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Based on interview and record review the facility failed to ensure the Condition of Participation for Governing Body was met as evidenced by:

1. The facility's Governing Body failed to ensure Medical Staff followed the facility's "Medical Staff Bylaws, Rules and Regulations," when Physician Orders were incomplete for one of 30 sampled patients (Patient 6) and telephone orders were not signed within 48 hours for one of 30 sampled patients (Patient 4). These deficient practices had the potential for any staff to fill out physician's orders including unsigned physician's orders, which may result in inaccurate orders carried out thus resulting in patient harm. (Refer to A-0047)

2. The facility's Governing Body failed to ensure oversight on the Nursing Department to ensure that the standard of care on patient safety was implemented for one of 30 sampled patients (Patient 8), when Patient 8 was found unresponsive (not reacting or unable to react in a normal way when touched, spoken to, etc.), pulseless, not breathing, and when Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was not initiated immediately and the automatic external defibrillator (AED, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) was not applied on Patient 8. This deficient practice resulted in a delay in life-saving measures, which may have contributed to Patient 8's death. (Refer to A-0063)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe setting and contributed to Patient 8's death.

Based on interview and record review, the facility's Governing Body (responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure Medical Staff followed the facility's "Medical Staff Bylaws, Rules and Regulations," when Physician Orders were incomplete for one of 30 sampled patients (Patient 6) and telephone orders were not signed within 48 hours for one of 30 sampled patients (Patient 4). This deficient practice had the potential for any staff to fill out physician's orders including unsigned physician's orders, which may result in inaccurate orders carried out thus resulting in patient harm.

Findings:

1. During an interview and record review on 7/10/2024 at 11:39 a.m. with the Chief Nursing Officer (CNO), the CNO verified that Patient 6's "Physician's Order," dated 7/3/2024 and timed at 7:48 a.m., was signed by a physician. However, there were no orders documented. The CNO stated the physician should have entered orders in the electronic medical record, and orders on the chart (paper chart) should not be blank. The CNO verified that any staff could just fill out the orders that were signed by the physician.

During a review of Patient 6's "Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 7/2/2024, the Evaluation indicated the following: Patient 6 was admitted to the facility on 7/2/2024 on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric condition) due to increasing thoughts of suicide (taking one's own life) ... Patient 6 admitted he (Patient 6) has been hearing a lot of voices telling him to kill himself ...

During a review of Patient 6's "Physician Order," the Physician order form indicated that the order was dated 7/3/2024 at 7:48 a.m. and signed by a physician. The Physician's order form did not contain any orders. All areas that needed to be checked off and filled out by the physician were blank and unsigned. Areas indicated Patient 6's level of precautions, supervision level, primary treatment focus, diet, PRN (as needed) medications, including medications such as Tylenol (over the counter pain reliever and fever reducer) and Benadryl (a sleep aid).

During a review of the facility's "Medical Staff Bylaws, Rules & Regulations," undated, the Medical Staff Bylaws, Rules & Regulations indicated the following: All orders for treatment and/or medications shall be in writing ... All orders dictated over the telephone shall be signed by the nurse per the name of the practitioner. The responsible practitioner shall sign such orders with date and time at the next visit, within forty-eight (48) hours. Orders must be written clearly, legibly, and completely ...

2. During an interview and record review on 7/10/2024 at 12:25 p.m. with the Chief Nursing Officer (CNO), the CNO verified that Patient 4's Telephone order dated 6/25/2024 was not signed, dated, or timed by the Physician (1). The CNO stated telephone orders should be signed within 48 hours.

During a review of Patient 4's "Initial Psychiatric Evaluation," dated 6/25/2024, the Evaluation indicated the following: Patient 4 was admitted to the facility on 6/24/2024 on a 5585 (a minor who is put on an involuntary 72-hour hold [for psychiatric treatment and evaluation]) for a danger to self ... "As I (Physician 1) started talking to her (Patient 4) ... she (Patient 4) jumped up and started banging her head against the wall ...I (Physician 1) have ordered Thorazine (treats mental health conditions by regulating mood) ...to sedate (to put to sleep or calm down) her (Patient 4) ..."

During a review of Patient 4's telephone order titled, "Hospital Seclusion (confinement of a patient alone in a room in which the patient is physically prevented from leaving/Restraint (a device that limits a patient's movement) Order," dated 6/25/2024 at 11:20 a.m., the order included, "Thorazine (a medication used to treat certain mental/mood disorders) 100 milligrams (mg, a unit of measurement) IM (in the muscle) x 1 Now to improve function." Charge Nurse (CN) 2 signed the telephone order. Physician 1 did not sign, date, or time the telephone order. This absence of a signature, date or time on the telephone order was verified by the CNO during an interview.

During a review of the facility's "Medical Staff Bylaws, Rules & Regulations," undated, the Medical Staff Bylaws, Rules & Regulations indicated the following: All orders for treatment and/or medications shall be in writing ...All orders dictated over the telephone shall be signed by the nurse per the name of the practitioner. The responsible practitioner shall sign such orders with date and time at the next visit, within forty-eight (48) hours. Orders must be written clearly, legibly, and completely ...

Based on interview and record review, the facility's Governing Body (responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure oversight on the Nursing Department to ensure that the standard of care on patient safety was implemented for one of 30 sampled patients (Patient 8), when Patient 8 was found unresponsive (not reacting or unable to react in a normal way when touched, spoken to, etc.), pulseless, not breathing, and when Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was not initiated immediately and the automatic external defibrillator (AED, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) was not applied on Patient 8.

This deficient practice resulted in a delay in life-saving measures, which may have contributed to Patient 8's death.

Findings:

During a review of Patient 8's "Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 4/17/2024, the Psychiatric Evaluation indicated Patient 8 was admitted to the facility on an involuntary hold (a legal process in which someone is unwillingly hospitalized), on 4/17/2024, with a diagnosis of schizoaffective disorder (a mood disorder where someone may experience depression, mania [extreme euphoria-intense feeling of excitement/happiness or irritability]).

During a review of Patient 8's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/18/2024, the H&P indicated Patient 8 had diagnosis of headaches, somatic complaints (an extreme focus on physical symptoms causing major emotional distress and problems functioning), obesity (weighing 100 pounds over the recommended weight), and tachycardia (increased heart rate).

During a concurrent record review on 7/9/2024 at 1:10 p.m. with Nurse Manager 2 (NM 2), Patient 8's "Progress Note," dated 4/22/2024 at 1:10 p.m., was reviewed. The progress note indicated the following: Registered Nurse (RN) note ... at 8:37 a.m., "paramedics declared that time of death was 8:37 a.m..."

During a concurrent interview and record review on 7/10/2024 at 1:32 p.m. with Mental Health Technician 2 (MHT 2), MHT 2 stated the following: On 4/22/2024, MHT 2 was assigned to perform patient observations ("rounding- best practice intervention of checking in on patients to meet patient care needs") every 15 minutes to check for patient behavior, location, position, and breathing. During rounding, staff were required to enter the patient room and check for rise and fall of the chest. Following rounding at approximately 8:00 a.m., MHT 2 was asked by Mental Health Technician 1 (MHT 1) to check Patient 8 in his (Patient 8's) room, because he (Patient 8) was not moving or responding. MHT 2 tapped Patient 8 (on the body) and there was no response. MHT 1 left Patient 8's room to notify Charge Nurse 1 (CN 1) Patient 8 was unresponsive (not reacting or unable to react in a normal way when touched, spoken to, etc.), while MHT 2 stayed with Patient 8.
CN 1 arrived to Patient 8's room and attempted to obtain a set of vital signs (a measurement of blood pressure, temperature, pulse, respiratory rate, and oxygen saturation [measures the amount of oxygen circulating in the blood]). CN 1 observed Patient 8 was not breathing, called a code blue (hospital announcement means that someone is having a medical emergency, usually cardiac arrest [absent or abnormal heart activity] or respiratory arrest [absent breathing]) and Cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was initiated.

During a review of Patient 8's "Patient Observation Record," dated 4/22/2024 at 8:00 a.m., the patient Observation Record indicated Patient 8 was sleeping in his (Patient 8's) room on his (Patient 8's) back. MHT 2 confirmed his (MHT 2's) initials and documentation on Patient 8's 8:00 a.m. patient observation record. MHT 2 stated the following: During 7:45 a.m. and 8:00 a.m. rounding, MHT 2 did not go completely into Patient 8's room to check Patient 8's breathing, instead he (MHT 2) stood at the doorway. Patient 8 was breathing during 7:45 a.m. and 8:00 a.m. rounds. MHT 2 should have completely entered Patient 8's room while rounding to ensure the safety of the patient. MHT 2 should have called a code blue, when Patient 8 was found unresponsive. Any staff could call a code blue for a patient that was not breathing.

During an interview on 7/10/2024 at 2:40 p.m. with MHT 1, MHT 1 stated the following: On 4/22/2024 at approximately 7:30 a.m., MHT 1 was waking patients up for breakfast. At approximately 7:40 a.m., MHT 1 entered Patient 8's room and knocked on the door and wall to wake Patient 8. Patient 8 did not respond and was not arousable (cannot be woken up). Patient 8 "did not look right, he (Patient 8) looked sickly." MHT 1 did not check for breathing or a pulse. MHT 1 continued with waking other patients then returned to Patient 8's room. MHT 1 knocked on the wall and touched Patient 8's arm. Patient 8 remained unresponsive. MHT 1 attempted to simultaneously count respirations and obtain Patient 8's blood pressure on the vital signs machine (a device that measures blood pressure, temperature, pulse, respiratory rate, and oxygen saturation), which was unreadable. MHT 1 was unsure if Patient 8 was breathing and MHT 1 notified MHT 2 to come to Patient 8's room to verify if the patient was breathing. MHT 1 and MHT 2 were unsure if the patient was breathing, and MHT 1 went to get CN 1. CN 1 performed a sternal rub (rubbing the knuckles of a closed fist firmly and vigorously on the patient's chest), and Patient 8 was unarousable. CN 1 verified the patient was pulseless and a code blue was called. MHT 1 started chest compressions (the act of applying pressure to someone's chest to help blood flow through the heart in an emergency) and CPR. The AED (Automated Electrical Defibrillator, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) was not applied to Patient 8 during the code. It is the responsibility of the code blue lead to instruct someone to apply the AED.

During the same interview on 7/10/2024 at 2:40 p.m. with MHT 1, MHT 1 further stated the following: If a patient is unresponsive, it is important to get the nurse immediately, so the nurse is aware something has changed with the patient. The nurse has more training and can assess the patient. Vital signs should not be obtained before notifying the nurse, when a patient is unresponsive. When Patient 8 was unresponsive, the nurse should have been notified right away so there was no delay in care.

During a concurrent interview and record review on 7/11/2024 at 9:20 a.m. with Nurse Manager 1 (NM 1), NM 1 stated the following: All direct patient care staff are CPR certified. If a patient is unresponsive, anyone can check a pulse and start CPR. If unlicensed staff find a patient unresponsive, they should shout for help to get licensed staff- so not leave the patient. The licensed nurse should be notified immediately when a patient is unresponsive to avoid further decompensation (the inability of an organ such as the heart to maintain its function) or loss of life. If vital signs are obtained prior to notifying the nurse, there would be a delay in care. It is not best practice to use the vital signs machine during a code blue. The Charge Nurse is responsible and oversees the code blue. The AED should be applied if a patient is pulseless and not breathing. If the AED is unavailable, a carotid (major blood vessel that provides the brain's blood supply) or radial pulse (pulse between the wrist bone and the thumb side of the wrist). should be checked after every 5 rounds of CPR. It is important to apply the AED because it will give prompts (instructions) and measure whether the patient requires a shock. "Patient condition at departure or end of code: deceased."

During a review of Patient 8's "Code Blue/Medical Emergency Documentation," dated 4/22/2024, the documentation indicated the following: Patient 8 was "found not breathing, pulseless, not responding." A code blue was called at 8:04 a.m. The AED was not applied.

During an interview on 7/11/2024 at 10:02 a.m. with Charge Nurse 1 (CN 1), CN 1 stated the following: On 4/22/2024, at 8:03 a.m., CN 1 was notified by MHT 1 that Patient 8 was not breathing. CN 1 and MHT 1 entered Patient 8's room. MHT 1 told CN 1 that vital signs were attempted and unable to be obtained, prior to notifying CN 1. MHT 1 told CN 1 that he (MHT 1) also called MHT 2 into Patient 8's room, prior to notifying CN 1. CN 1 attempted painful stimuli by performing a sternal rub and pressing the nail bed, Patient 8 was unresponsive. CN 1 did not immediately check a pulse. CN 1 attempted to obtain a blood pressure and was unable to obtain a reading. MHT 1 performed a pulse check and Patient 8 was pulseless. CN 1 stated to call a Code Blue and MHT 1 started compressions. CN 1 left Patient 8's room to call the code blue and obtain emergency equipment including the AED. CN 1 did not instruct MHT 1 or MHT 2 to call the code blue. When CN 1 returned to Patient 8's room with the emergency equipment, the code blue team (emergency response team, rendering lifesaving measures) arrived and CPR was in progress. The AED was not applied to patient 8. During the code, the vital signs machine was used to measure blood pressure and heart rate. A physical carotid pulse was not obtained during the code. The paramedics arrived and took over the code blue. After 30 minutes of CPR, the patient died.

During an interview on 7/12/2024 at 4:30 p.m. with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Risk Management and Performance Improvement (DRPI), and Director of Clinical Services Regional Compliance (DRC), the CEO stated the following: The Governing Board provides broad oversight and is responsible for the entire facility. Oversight includes staff competency (the application and demonstration of appropriate knowledge, skills and behavior in the clinical setting). The Governing Board was aware of Patient 8's death, but an action plan with corrective actions was not presented to the Governing Board. It was the responsibility of the Governing Board to take immediate action once an adverse (a harmful and negative outcome that happens when a patient has been provided with medical care)/sentinel event (a patient safety event that results in death, permanent harm, or severe temporary harm) was identified. The DRPI stated there was a gap because the Governing Board was not given an action plan for Patient 8's death.

During a review of the facility's policy and procedure (P&P) titled, "Code Blue and Transferring Patients to the Emergency Room," revised 3/2022, the policy indicated: "Policy: [the facility] provides for the medical needs of all patients requiring emergency medical evaluation or treatment ... Procedure: 1. The staff member who finds/witnesses the medical emergency will immediately call for help and to have a Code Blue paged overhead ... The staff member will not leave the patient alone ... 2. The staff from the unit housing the patient will bring the ...AED ... 3. The staff will assess the patient's condition and provide immediate intervention based on the patient's presentation and symptoms ... d) If the patient is not breathing and has no pulse, initiate cardiopulmonary resuscitation (CPR) ...

During a review of the facility's policy and procedure (P&P) titled, "Medical Emergencies and Acute Change in Condition," revised 3/2022, the policy indicated: "Purpose: It is our policy to provide safe and competent care to all patients experiencing medical emergencies or an acute change in condition ... 2. Breathing Problems ... b) If the following symptoms are demonstrated, it could indicate a significant medical problem and the RN should be notified immediately ... d. If the rate of breathing is too rapid or too slow, if breath sounds are diminished (lessened)/absent ... c) If the patient is found in cardiac/respiratory arrest (heart stops/not breathing), 911 and Code Blue will be called immediately ...

During a review of the facility's policy and procedure (P&P) titled, "Supervision of Patients/Patient Rounds," revised 7/2021, the policy indicated: "Purpose: To establish a process for supervising patients as a means to diminish the risk of harm and/or injury ... Conducting General Supervision via Rounds Process ... 8. Observe patients in bed resting or sleeping by: Looking for the rise and fall of the chest ... 12. Identify and report any findings while conducting observation rounds: Report any findings to the Charge Nurse ..."

Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Patient's Rights was met as evidenced by:

1. The facility failed to ensure that two of 30 sampled patients (Patients 21 and 30) and their (Patient 21 and 30) designated representatives were informed of the patients' (Patient 21 and 30) condition, in accordance with the facility's policy and procedure regarding the appropriate use of involuntary commitment (the legal process in which a person is confined in a psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] hospital because of a treatable mental disorder, against his or her wishes) when:

1.a. Patient 21's designated representative was not informed of the patient's (Patient 21) condition when Patient 21 was put on a psychiatric 14-day hold (a certification also known as 5250 hold, for intense treatment for a period of involuntary hospitalization for up to 14 days due to mental disorder) on 7/1/2024.

1.b. Patient 30 and the patient's (Patient 30) designated representative was not informed of the patient's (Patient 30) condition when Patient 30 was put on a 5250 hold on 4/27/2024.

These deficient practices resulted in the patients (Patient 21 and 30) and the patients' designated representative not able to exercise the right to make informed decisions (a decision that patients or their designated representatives can make once they have all the information related to the decision topic) regarding the patients' care. (Refer to A-0131)


2. The facility failed to initiate Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) immediately and apply the automatic external defibrillator (AED, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) for one of 30 sampled patients (Patient 8), when Patient 8 was found unresponsive (not reacting or unable to react in a normal way when touched, spoken to, etc.), pulseless, and not breathing, in accordance with the facility's policy and procedure regarding Code Blue (hospital announcement means that someone is having a medical emergency, usually cardiac arrest [absent or abnormal heart activity] or respiratory arrest [absent breathing]) and Change of Condition. This deficient practice resulted in a delay in life-saving measures, which may have contributed to Patient 8's death. (Refer to A-0144).

3. The facility failed to ensure the safety for one of 30 sampled patients (Patient 12), identified to be at risk for self-harm (hurting oneself), when Patient 12 took six (6) unspecified pills and cut wrist with a hairbrush while admitted to the facility, in accordance with the facility's policy and procedure regarding Medication Administration. This deficient practice resulted in Patient 12 being transferred to another hospital for treatment, after the patient (Patient 12) self-harmed. (Refer to A-0144)

4. The facility failed to check for the presence of one of six emergency equipment (emergency bag that contains medications, etc.) daily on one of six units (Del Sol [Adult Inpatient]), in accordance with the facility's protocol regarding Emergency Medical Equipment Daily Checklist and the facility's policy and procedure regarding medical emergencies. This deficient practice had the potential for emergency equipment not to be readily available in the event of a medical emergency and compromise patient safety. (Refer to A-0144)

5. The facility failed to conduct patient rounding (best practice intervention of checking in on patients to meet patient care needs) every 15 minutes for one of 30 sampled patients (Patient 6) in accordance with the facility's policy and procedure regarding supervision of patients. This deficient practice had the potential for the whereabouts of patients to be unknown and had the potential for harm, injury, medical emergency, or elopement (a patient who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected). (Refer to A-0144)

6. The facility failed to Ensure one of 30 sampled patients (Patient 21, a child [the facility considered patients in the age group of 5 years old to 12 years old as child]) was not left alone with Patient 2, an adolescent patient (the facility considered patients in the age group of 13 years old to 17 years old as adolescent) inside the Youth Services Unit's Day room (activity room) with no staff supervision, in accordance with the facility's policy and procedure regarding supervision of patients. This deficient practice had the potential for the patients, who were admitted with behavioral issues, to inflict self-harm or harm to others. (Refer to A-0144)

7. The facility failed to ensure there was continuous observation and direct line of vision (a level of observation in which the patient remains in staff view) for two of 30 sampled patients (Patient 27 and 28) in a group setting in accordance with the facility's policy and procedure (P&P) "Supervision of Patients/Patient Rounds." This deficient practice had the potential for the patients, who were admitted with behavioral issues, to inflict self-harm or harm to others. (Refer to A-0144)

8. The facility failed to ensure patient safety, in accordance with the facility's policy and procedure regarding patient precautions, for one of 30 sampled patients (Patient 17) when Patient 17 was involved in two physical altercations with Patients 18 and 19 within a 24-hour period. This deficient practice resulted in Patient 17 suffering a laceration (wound produced by tearing of soft body tissue) to the forehead that required sutures (stitch made to join the open parts of the wound) and had the potential for further psychological harm (harm that causes mental or emotional trauma). (Refer to A-0144)

9. The facility failed to provide proper supervision for two of 30 sampled patients (Patients 18 and 19), both of whom had a known history of aggression towards staff and other patients, to ensure that both patients (Patient 18 and Patient 19) did not physically attack Patient 17 twice, in accordance with the facility's policy and procedure regarding supervision of patients.

This deficient practice resulted in Patients 18 and 19 physically attacking Patient 17 twice within a 24-hour time frame. Patient 17 had to be transferred to a General Acute Care Hospital (GACH) Emergency Room (ER, responsible for the provision of medical care to patients arriving at the hospital in need of immediate treatment) for evaluation. Patient 17 suffered a laceration (wound produced by tearing of soft body tissue) to the forehead that required sutures (stitch made to join the open parts of the wound) after the first altercation and the laceration re-opened after the second altercation. (Refer to A-0145)

10. The facility failed to provide annual Abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse) Training for five of six staff (Charge Nurses [CN) 1, 2, and Mental Health Technicians [MHT] 1, 2, 4), in accordance with the facilities policies and procedures regarding abuse training.

This deficient practice had the potential for staff not to be able to identify signs and symptoms of abuse or take appropriate actions in the event a patient is identified to be a victim of abuse, which may result in patient harm. (Refer to A-0145)

11. The facility failed to ensure that an age appropriate sleeping arrangement and therapeutic environment was provided for one of 30 sampled patients (Patient 21), in accordance with the facility's policy and procedure regarding therapeutic environment when, Patient 21 was placed in a seclusion room (PRA - Private room Areas, a room used when a patient is being actively secluded/separated from other patients due to an aggressive behavior) at night to sleep.

This deficient practice resulted in Patient 21 not having an age-appropriate room and furnishings which could negatively affect the patient's emotional well-being and quality of care received. (Refer to A-0162)

12. The facility failed to ensure that one of 30 sampled patients (Patient 21), was assessed and monitored, in accordance with the facility's policy and procedure regarding Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion (confinement of a patient alone in a room in which the patient is physically prevented from leaving), when Patient 21 was placed on chemical restraints (a drug given to a person to control their behavior or restrict their movement). Patient 21 was administered Benadryl (medication used with sedation effects [a state of calmness or sleepiness]) and Thorazine (medication used to manage mental illness or behavior disorders).

This deficient practice had the potential to cause a delay in determining Patient 21's change of condition and/or provision of emergent treatment needed as a result of chemical restraint, which can lead to worsening of patient's condition and/or death. (Refer to A-0175)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe setting, potentially placing patients at risk for a delay in care and treatments, abuse, self-harm, harm to others, and/or death.

Based on interview and record review, the facility failed to ensure that two of 30 sampled patients (Patients 21 and 30) and their (Patient 21 and 30) designated representatives were informed of the patients' (Patient 21 and 30) condition, in accordance with the facility's policy and procedure regarding the appropriate use of involuntary commitment (the legal process in which a person is confined in a psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] hospital because of a treatable mental disorder, against his or her wishes) when:

1. Patient 21's designated representative was not informed of the patient's (Patient 21) condition when Patient 21 was put on a psychiatric 14-day hold (a certification also known as 5250 hold, for intense treatment for a period of involuntary hospitalization for up to 14 days due to mental disorder) on 7/1/2024.

2. Patient 30 and the patient's (Patient 30) designated representative was not informed of the patient's (Patient 30) condition when Patient 30 was put on a 5250 hold on 4/27/24.

These deficient practices resulted in the patients (Patient 21 and 30) and the patients' designated representative not able to exercise the right to make informed decisions (a decision that patients or their designated representatives can make once they have all the information related to the decision topic) regarding the patients' care.

Findings:

1. During a review of Patient 21's "Face Sheet (a document containing a patient's medical and demographic information)," undated, the face sheet indicated Patient 21 was admitted to the facility on 6/28/2024.

During a review of Patient 21's "72 hour hold (5585, a law that allows for the involuntary detention of someone with a mental illness in a psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] hospital for up to 72 hours)," dated 6/28/2024, the hold indicated Patient 21 was a danger to himself and others. Patient 21 was agitated, violent and trying to jump out of a moving car. Patient 21 had an open case with Department of Children and Family Services (DCFS - agency that oversees Los Angeles County's 24/7 child abuse and neglect hotline and responds to the immediate needs of any child at risk).

During a review of Patient 21's "5250 hold (5250-hold, allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric evaluation and treatment)," dated 7/1/2024, the 5250 hold form indicated Patient 21 continued to be a danger to self and others, "aggressive, assaulted peers."

During a concurrent interview and record review on 7/10/2024 at 2:37 p.m., with Nurse Administrator Program Specialist (NAPS), the NAPS stated after 5585, if the psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) determines the patient was not stable and needed to extend the treatment plan, then 5250 would be initiated. The NAPS stated the psychiatrist or the nurse must inform the patient and the patient's designated representative regarding the 5250 hold. In the same interview on 7/10/2024 at 2:37 p.m., the NAPS stated Patient 21's record did not have documentation of Patient 21 and/or Patient 21's designated representative being notified of the 5250 hold.

During a review of the facility's policy and procedure (P&P) titled, "Appropriate Use of Involuntary Commitment (the legal process in which a person is confined in a psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] hospital because of a treatable mental disorder, against his or her wishes)," revised in 3/2022, the P&P indicated, "The attending psychiatrist must then read and present a copy of the Notice of Certification for Additional 14 Day to the patient on the date it is issued. The physician must inform the patient that he/she may designate any person whom he/she wishes to be informed of this certification. The Social Worker must:
Inform patient of his legal right to judicial review by Writ of Habeas Corpus (orders the custodian of an individual in custody to produce the individual before the court to make an inquiry concerning his/her detention) with representation by counsel at any time during this 14-day period and explain that no hearing will be held unless requested by the patient..."


2. During a review of Patient 30's History and Physical (H&P, a formal and complete assessment of the patient and the problem), the H&P indicated Patient 30, who was under the care of DCFS (Department of Children and Family Services, agency that oversees Los Angeles County's 24/7 child abuse and neglect hotline and responds to the immediate needs of any child at risk), was admitted on 4/23/2024 for 5585 hold (involuntary 72 hour hold for minors) due to Suicidal Ideation (SI, thoughts of causing one's own death) with a plan to overdose (taking too much of a substance such as medications).

The H&P further indicated, Patient 30's medical history included major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities) and substance abuse (a state of psychological and/or physical dependence on the use of drugs or other substances such as alcohol).

During a review of Patient 30's medical record, the record indicated the following:

- On 4/25/2024, Patient 30 was on a 5585 hold;

- On 4/26/2024, Patent 30's admission status was changed to voluntary admission; and,

- On 4/27/2024, Patient 30 was put on 5250 hold (for intense treatment for a period of involuntary hospitalization for up to 14 days due to mental disorder).

During a concurrent interview and record review on 7/10/2024 at 3:01 p.m., with the Nurse Administrator Program Specialist (NAPS), the NAPS stated it is the physician's decision to put the patient on 5250 hold. The NAPS stated the patient and the patient's designated representative must be notified of the hold to comply with the patient's rights (a subset of human rights such as the right to be informed of the treatment plan). The NAPS verified there was no documentation the DCSF, Patient 30's designated representative, was notified when Patient 30 was put on 5250 hold.

During a concurrent interview and record review on 7/10/2024 at 3:45 p.m., with NM 2, NM 2 stated there was no 5250 advisement (written notification of an involuntary hold) provided to Patient 30 or Patient 30's designated representatives.

During a review of the facility's policy and procedure (P&P) titled, "Appropriate Use of Involuntary Commitment (the legal process in which a person is confined in a psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] hospital because of a treatable mental disorder, against his or her wishes)," revised in 3/2022, the P&P indicated, "The attending psychiatrist must then read and present a copy of the Notice of Certification for Additional 14 Day to the patient on the date it is issued. The physician must inform the patient that he/she may designate any person whom he/she wishes to be informed of this certification. The Social Worker must:
Inform patient of his legal right to judicial review by Writ of Habeas Corpus (orders the custodian of an individual in custody to produce the individual before the court to make an inquiry concerning his/her detention) with representation by counsel at any time during this 14-day period and explain that no hearing will be held unless requested by the patient ..."

Based on observation, interview and record review, the facility failed to:

1. Initiate Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) immediately and apply the automatic external defibrillator (AED, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) for one of 30 sampled patients (Patent 8), when Patient 8 was found unresponsive (not reacting or unable to react in a normal when touched, spoken to, etc.), pulseless, and not breathing, in accordance with the facility's policy and procedure regarding Code Blue (hospital announcement means that someone is having a medical emergency, usually cardiac arrest [absent or abnormal heart activity] or respiratory arrest [absent breathing]) and Change of Condition.

This deficient practice resulted in a delay in life-saving measures, which may have contributed to Patient 8's death.

2. Ensure the safety for one of 30 sampled patients (Patient 12), identified at risk for self-harm (hurting oneself), when Patient 12 took six (6) unspecified pills and cut wrist with a hairbrush while admitted in the facility, in accordance with the facility's policy and procedure regarding Medication Administration.

This deficient practice resulted Patient 12 being transferred to another hospital for treatment, after the patient (Patient 12) self-harmed.

3. Check for the presence of one of six emergency equipment (emergency bag that contains medications, etc.) daily on one of six units (Del Sol [Adult Inpatient]), in accordance with the facility's protocol regarding Emergency Medical Equipment Daily Checklist and the facility's policy and procedure regarding medical emergencies.

This deficient practice had the potential for emergency equipment not to be readily available in the event of a medical emergency and compromise patient safety.

4. Conduct patient rounding (best practice intervention of checking in on patients to meet patient care needs) every 15 minutes for one of 30 sampled patients (Patient 6) in accordance with the facility's policy and procedure regarding supervision of patients.

This deficient practice had the potential for the whereabouts of patients to be unknown and had the potential for harm, injury, medical emergency, or elopement (a patient who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected).

5. Ensure one of 30 sampled patients (Patient 21, a child [the facility considered patients in the age group of 5 years old to 12 years old as child]) was not left alone with Patient 2, an adolescent patient (the facility considered patients in the age group of 13 years old to 17 years old as adolescent) inside the Youth Services Unit's Day room (activity room) with no staff supervision, in accordance with the facility's policy and procedure regarding supervision of patients.

This deficient practice had the potential for the patients, who were admitted with behavioral issues, to inflict self-harm or harm to others.

6. Ensure there was continuous observation and direct line of vision (a level of observation in which the patient remains in staff view) for two of 30 sampled patients (Patient 27 and 28) in a group setting in accordance with the facility's policy and procedure regarding "Supervision of Patients/Patient Rounds."

This deficient practice had the potential for the patients, who were admitted with behavioral issues, to inflict self-harm or harm to others.

7. Ensure patient safety, in accordance with the facility's policy and procedure regarding patient precautions, for one of 30 sampled patients (Patient 17) when Patient 17 was involved in two physical altercations with Patients 18 and 19 within a 24-hour period.

This deficient practice resulted in Patient 17 suffering a laceration (wound produced by tearing of soft body tissue) to the forehead that required sutures (stitch made to join the open parts of the wound) and had the potential for further psychological harm (harm that causes mental or emotional trauma).


On 7/11/2024 at 4:07 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Divisional Clinical Services-Regulatory Compliance (DRC) , Director of Risk Management and Performance Improvement (DRPI), and Regional Vice President (RVP). Patient 8's medical history included schizoaffective disorder (a mood disorder where someone may experience depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities], mania [extreme euphoria- intense feeling of excitement/happiness or irritability], and hallucinations [sensing things such as visions, sounds or smells that seem real but are not] or delusions [a fixed false belief based on an inaccurate interpretation of an external reality despite evidence to the contrary]), headaches, obesity (weighing 100 pounds over the recommended weight) and dyspepsia (upset stomach). On 4/22/2024, Patient 8 was administered the medications Vistaril (a medication used to relieve itching caused by allergic skin reactions with sedative effects [can cause sleepiness, calms a person down, etc.]) 50mg (milligram, a unit of measurement) by mouth at 12:43 a.m. for anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure), and Trazodone (a medication used to treat depression and anxiety) 50mg (milligram, a unit of measurement) by mouth at 12:50 a.m. for insomnia (inability to sleep). Following administration of medications (Vistaril and Trazodone), there was no reassessment (re-evaluation of a patient's health status) of vital signs (includes temperature, heart rate, respiratory rate, blood pressure and pain level) and physical condition for Patient 8, per policy and procedure.

On 4/22/2024 at 7:40 a.m., Patient 8 was unarousable (cannot be woken up) when Mental Health Technician 1 (MHT 1, provides care for people who have mental health conditions) tried to wake Patient 8 for breakfast by knocking on the bedroom door and wall. MHT 1 did not attempt to touch Patient 8 or check for breathing at this time. MHT 1 left Patient 8's bedroom and continued to wake other patients for breakfast, and once completed, went back to Patient 8's room for a second attempt to try to wake Patient 8 by knocking on the wall and touching Patient 8's arm. Patient 8 remained unarousable. MHT 1 left Patient 8's room to gather the vital signs machine (a device that measures blood pressure, temperature, pulse, respiratory rate, and oxygen saturations), and when MHT 1 returned to patient 8's room, attempted to obtain a blood pressure for Patient 8. The vital signs machine read an error message. MHT 1 then called a second MHT (MHT 2) passing by in the hallway into the bedroom, to verify if Patient 8 was breathing. Mental Health Technician 2 (MHT 2) verified Patient 8 did not appear to be breathing. MHT 1 left Patient 8's bedroom to find Charge Nurse 1 (CN 1). MHT 2 remained at the bedside with Patient 8. Cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was not initiated at this time. At 8:03 a.m., CN 1 was notified by MHT 1 that Patient 8 was unresponsive and not breathing. CN 1 entered Patient 8's bedroom and performed painful stimuli by performing a sternal rub (rubbing the knuckles of a closed fist firmly and vigorously on the patient's chest) and applying pressure to the nailbeds. Patient 8 was unresponsive to painful stimuli (a technique used to determine the consciousness level of a person who is not responding to normal interaction, voice commands or gentle physical stimuli). CN 1 attempted to obtain Patient 8's blood pressure and was unable to obtain a reading on the vital signs machine. MHT 1 performed a pulse check and Patient 8 was pulseless. CN 1 started to call a code blue (hospital announcement means that someone is having a medical emergency, usually cardiac arrest [absent or abnormal heart activity] or respiratory arrest [absent breathing]) and MHT 1 started chest compressions (the act of applying pressure to someone's chest to help blood flow through the heart in an emergency). CN 1 left Patient 8's bedroom to call the code blue and obtain emergency equipment (life-saving equipment) to include the automatic external defibrillator (AED, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm), instead of instructing MHT 1 or MHT 2 to call a code blue and obtain the emergency equipment. When CN 1 returned to Patient 8's room, the code blue team arrived. CPR was in progress. The AED brought by CN 1 was never applied to Patient 8, and a pulse check was not reassessed during the code. During the code blue, the vital signs machine was used to measure blood pressure and heart rate. The paramedics arrived and took over the code blue and CPR. After 30 minutes of CPR, Patient 8 expired.

On 7/12/2024 at 7:41 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), DRC, DRPI, and RVP, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. The IJ Removal Plan included the following:

1. Immediate training of licensed staff, Registered Nurses (RN), Licensed Vocational Nurses (LVN), and Licensed Psychiatric Technicians (LPT), related to the reassessment of patients after PRN (as needed) medication administration to include physical condition, effectiveness, and vital signs within one hour. This will be documented in the electronic health record by the licensed nurse.

2. Immediate training of nursing staff including RNs, LVNs, LPTs, and MHTs, related to medical emergencies and acute changes in condition (a sudden, clinically important deviation from a patient's baseline in physical, cognitive [thinking and understanding], behavioral, or functional [activity or tasks] abilities) including responsiveness to code blue. Direct patient care staff will be current in CPR. When a patient is found unresponsive, staff will immediately initiate CPR, yell for the nurse, call a code blue and immediately initiate CPR. The Nurse Manager and/or Nurse Supervisor will instruct code blue drills (hands-on-training) one per month per shift (3 shifts) with direct patient care staff. The Nurse Manager and/or Nurse Supervisor will evaluate code blue drills and identify training needs. Training needs are immediately addressed with staff. When a patient is unresponsive, the licensed nurse will remain with the patient and delegate the MHT to call code blue and get the emergency equipment. Patient observations are every 15 minutes, minimally. During patient observations, the staff will observe patients in bed for at least three respirations and whether the patient has moved from previous sleeping position.

3. Immediate training of nursing staff of AED use. AED training will include indications for use, checking for patient responsiveness, ensuring the AED is turned on, proper application of defibrillator pads, following AED prompts, and what to do if a shock (an electric current used to restart the heart) is advised. Staff will use the AED when the patient has a lack of circulation indicated by unconsciousness, absence of normal breathing, and absence of pulse. The nurse will turn the AED on and follow AED prompts (directions) based on what the nurse sees and hears. The patient will be checked for responsiveness, by shaking the patient and shouting "are you ok?," and electrode pads (adhere to the chest of an individual who needs defibrillation [an electric current used to restart the heart]) will be applied to the patient's bare chest. While the AED is analyzing, do not touch the patient. The nurse will follow the directions if shock is advised. If shock is advised, the nurse will advise staff to stand clear and not to touch the patient. The shock will be delivered by pressing the "heart" button. Once the shock is delivered, follow prompts to resume CPR. The nurse will continue to follow AED prompts; CPR for 5 cycles, stop CPR, analyzing, advisement of shock followed by CPR. Additionally, licensed staff will be trained when to reassess a patient's pulse during a code blue, using the carotid (major blood vessel that provides the brain's blood supply) or radial pulse (pulse between the wrist bone and the thumb side of the wrist).

Findings:

1. During a review of Patient 8's "Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 4/17/2024, the Psychiatric Evaluation indicated Patient 8 was admitted to the facility on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric [relating to mental illness or treatment] condition), on 4/17/2024, with a diagnosis of schizoaffective disorder (a mood disorder where someone may experience depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities], mania [extreme euphoria- intense feeling of excitement/happiness or irritability], and hallucinations [sensing things such as visions, sounds or smells that seem real but are not] or delusions [a fixed false belief based on an inaccurate interpretation of an external reality despite evidence to the contrary).

During a review of Patient 8's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/18/2024, the H&P indicated Patient 8 had diagnosis of headaches, somatic complaints (an extreme focus on physical symptoms causing major emotional distress and problems functioning), obesity (weighing 100 pounds over the recommended weight) and tachycardia (increased heart rate).

During a concurrent record review on 7/9/2024 at 1:10 p.m. with Nurse Manager 2 (NM 2), Patient 8's "Progress Note," dated 4/22/2024 at 1:10 p.m., was reviewed. The progress note indicated the following: Registered Nurse (RN) note ... at 8:37 a.m., paramedics declared that time of death was 8:37 a.m..." on 4/22/2024.

During a concurrent interview and record review on 7/10/2024 at 1:32 p.m. with Mental Health Technician 2 (MHT 2), MHT 2 stated the following: On 4/22/2024, MHT 2 was assigned to perform patient observations ("rounding [best practice intervention of checking in on patients to meet patient care needs]") every 15 minutes to check for patient behavior, location, position, and breathing. During rounding, staff were required to enter the patient room and check for rise and fall of the chest which MHT 2 did not do. Following rounding at approximately 8:00 a.m., MHT 2 was asked by Mental Health Technician 1 (MHT 1) to check Patient 8 in his (Patient 8's) room, because he (Patient 8) was not moving or responding. MHT 2 tapped Patient 8 (on the body) and there was no response. MHT 1 left Patient 8's room to notify Charge Nurse 1 (CN 1) that Patient 8 was unresponsive, while MHT 2 stayed with Patient 8. CN 1 arrived to Patient 8's room and attempted to obtain a set of vital signs (a measurement of blood pressure, temperature, pulse, respiratory rate, and oxygen saturation). CN 1 observed Patient 8 was not breathing, called a code blue (hospital announcement means that someone is having a medical emergency, usually cardiac arrest [absent or abnormal heart activity] or respiratory arrest [absent breathing]) and Cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) was initiated.

During a review of Patient 8's "Patient Observation Record," dated 4/22/2024 at 8:00 a.m., the Patient Observation Record indicated Patient 8 was sleeping in his (Patient 8's) room on his (Patient 8's) back. MHT 2 stated the following: MHT 2 did not go completely into Patient 8's room to check Patient 8's breathing, instead he (MHT 2) stood at the doorway. MHT 2 said he (MHT 2) should have completely entered Patient 8's room and he (MHT 2) had no reason not to completely enter the room. MHT 2 should have called a code blue, when Patient 8 was found unresponsive. Any staff could call a code blue for a patient that was not breathing.

During an interview on 7/10/2024 at 2:40 p.m. with MHT 1, MHT 1 stated the following: On 4/22/2024 at approximately 7:30 a.m., MHT 1 was waking patients up for breakfast. At approximately 7:40 a.m., MHT 1 entered Patient 8's room and knocked on the door and wall to wake Patient 8. Patient 8 did not respond and was not arousable (unable to wake up). Patient 8 "did not look right, he (Patient 8) looked sickly." MHT 1 did not check for breathing or a pulse. MHT 1 continued with waking other patients then returned to Patient 8's room. MHT 1 knocked on the wall and touched Patient 8's arm. Patient 8 remained unresponsive. MHT 1 attempted to simultaneously count respirations and obtain Patient 8's blood pressure on the vital signs machine (a device that measures blood pressure, temperature, pulse, respiratory rate, and oxygen saturation), which was unreadable. MHT 1 was unsure if Patient 8 was breathing and MHT 1 notified MHT 2 to come to Patient 8's room to verify if the patient was breathing. MHT 1 and MHT 2 were unsure if the patient was breathing, and MHT 1 went to get CN 1. CN 1 performed a sternal rub (rubbing the knuckles of a closed fist firmly and vigorously on the patient's chest), and Patient 8 was unarousable. CN 1 verified the patient (Patient 8) was pulseless and a code blue was called. MHT 1 started chest compressions (the act of applying pressure to someone's chest to help blood flow through the heart in an emergency) and CPR (Cardiopulmonary Resuscitation, an emergency lifesaving procedure performed when the heart stops beating). The AED (Automated External Defibrillator, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) was not applied to Patient 8 during the code. It was the responsibility of the code blue lead to instruct someone to apply the AED.

During the same interview on 7/10/2024 at 2:40 p.m. with MHT 1, MHT 1 further stated the following: If a patient was unresponsive, it was important to get the nurse immediately, so the nurse was aware something had changed with the patient. The nurse had more training and can assess the patient. Vital signs should not be obtained before notifying the nurse, when a patient was unresponsive. When Patient 8 was unresponsive, the nurse should have been notified so there was no delay in care.

During a concurrent interview and record review on 7/11/2024 at 9:20 a.m. with Nurse Manager 1 (NM 1), NM 1 stated the following: All direct patient care staff are CPR certified. If a patient is unresponsive, anyone can check a pulse and start CPR. If unlicensed staff find a patient unresponsive, they should shout for help to get licensed staff- so as not to leave the patient. The licensed nurse should be notified immediately when a patient is unresponsive to avoid further decompensation (worsening of symptoms) or loss of life. If vital signs are obtained prior to notifying the nurse, there would be a delay in care. It is not best practice to use the vital signs machine during a code blue. The Charge Nurse is responsible and oversees the code blue. The AED should be applied if a patient is pulseless and not breathing. If the AED is unavailable, a carotid or radial pulse should be checked after every 5 rounds of CPR. It is important to apply the AED because it will give prompts (instructions) and measure whether the patient requires a shock (to deliver a dose of electric current to the heart).

During a review of Patient 8's "Code Blue/Medical Emergency Documentation," dated 4/22/2024, the document indicated the following: Patient 8 was "found not breathing, pulseless, not responding." A code blue was called at 8:04 a.m., 14 minutes after MHT 1 initially observed Patient 8 unresponsive. The AED was not applied. "Patient condition at departure or end of code: deceased."

During an interview on 7/11/2024 at 10:02 a.m. with Charge Nurse 1 (CN 1), CN 1 stated the following: On 4/22/2024, at 8:03 a.m. CN 1 was notified by MHT 1 that Patient 8 was not breathing. CN 1 and MHT 1 entered Patient 8's room. MHT 1 told CN 1 that vital signs were attempted and unable to be obtained, prior to notifying CN 1. MHT 1 told CN 1 that he (MHT 1) also called MHT 2 into Patient 8's room, prior to notifying CN 1. CN 1 attempted painful stimuli by performing a sternal rub and pressing the nail bed, Patient 8 was unresponsive. CN 1 did not immediately check a pulse. CN 1 attempted to obtain a blood pressure and was unable to obtain a reading. MHT 1 performed a pulse check and Patient 8 was pulseless. CN 1 stated to call a Code Blue and MHT 1 started compressions. CN 1 left Patient 8's room to call the code blue and obtain emergency equipment including the AED. CN 1 did not instruct MHT 1 or MHT 2 to call the code blue. When CN 1 returned to Patient 8's room with the emergency equipment, the code blue team (emergency response team, rendering lifesaving measures) arrived and CPR was in progress. The AED was not applied to patient 8. During the code, the vital signs machine was used to measure blood pressure and heart rate. A physical carotid (arteries located on either side of the neck) pulse was not obtained during the code. The paramedics arrived and took over the code blue. After 30 minutes of CPR, the patient died.

During a review of the facility's policy and procedure (P&P) titled "Code Blue and Transferring Patients to the Emergency Room," revised 3/2022, the P&P indicated: "Policy: [the facility] provides for the medical needs of all patients requiring emergency medical evaluation or treatment ... Procedure: 1. The staff member who finds/witnesses the medical emergency will immediately call for help and to have a Code Blue paged overhead ... The staff member will not leave the patient alone ... 2. The staff from the unit housing the patient will bring the ...AED ... 3. The staff will assess the patient's condition and provide immediate intervention based on the patient's presentation and symptoms ... d) If the patient is not breathing and has no pulse, initiate cardiopulmonary resuscitation (CPR) ..."

During a review of the facility's policy and procedure (P&P) titled, "Medical Emergencies and Acute (severe and sudden in onset) Change in Condition," revised 3/2022, the policy indicated: "Purpose: It is our policy to provide safe and competent care to all patients experiencing medical emergencies or an acute change in condition ... 2. Breathing Problems ... b) If the following symptoms are demonstrated, it could indicate a significant medical problem and the RN should be notified immediately ... d. If the rate of breathing is too rapid or too slow, if breath sounds are diminished (lessened)/absent ... c) If the patient is found in cardiac/respiratory arrest (heart stops/not breathing), 911 and Code Blue will be called immediately ..."

During a review of the facility's policy and procedure (P&P) titled, "Supervision of Patients/Patient Rounds," revised 7/2021, the P&P indicated: "Purpose: To establish a process for supervising patients as a means to diminish the risk of harm and/or injury ... Conducting General Supervision via Rounds Process (best practice intervention of checking in on patients to meet patient care needs) ... 8. Observe patients in bed resting or sleeping by: Looking for the rise and fall of the chest ... 12. Identify and report any findings while conducting observation rounds: Report any findings to the Charge Nurse ..."

2. During a review of Patient 12's "Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 5/29/2024, the Psychiatric Evaluation indicated Patient 12 was admitted to the facility on a voluntary hold (a process in which someone is willingly hospitalized), on 5/29/2024, with diagnoses of attention deficit hyperactivity disorder (ADHD, a condition that causes inattention and hyperactivity), suicide (the act of taking one's own life) attempts and self-harm (injury to oneself) by cutting self.

During a concurrent interview and record review on 7/11/2024 at 4:46 p.m. the with Nurse Manager 2 (NM 2), Patient 12's medical record was reviewed. The NM 2 verified that on 6/3/2024, Patient 12 cut her (Patient 12's) own wrist with a broken brush and took six (6) pills of unknown type and origin inside the patient's (Patient 12) room. The NM 2 further verified that Patient 12's contraband (prohibited items) check was completed on admission, and the patient was not identified to have contraband. The NM 2 stated the following: Contraband included medications. Patient 12 should not have been in the possession of pills. Per policy, Patient 12 should have received all medications witnessed by licensed staff, followed by a mouth check, to ensure the medications were swallowed. Mouth checks should have been performed for Patient 12, per policy, to prevent cheeking (storage of pills in the cheek of the mouth) of medications. Since it was unknown what pills were taken, Patient 12 could have had a reaction to the pills or an overdose (an excessive and dangerous dose of a medication/drug). Since the hairbrush was provided by the facility, Patient 12 should have had personal care items, such as a hairbrush, used only in the direct observation of facility staff. Once the hairbrush was no longer in use by Patient 12, the item should have been locked away with Patient 12's personal items in a locked storage room. Patient 12 should not have been left alone with the hairbrush because it could have been used to further self-harm or harm others.

During a review of Patient 12's "Multidisciplinary Treatment Plan (a unified group approach in a healthcare setting where the responsibility of plans of treatment and delivery of care does not lie on a single person but a group of qualified professionals)," dated 5/30/2024, the Multidisciplinary Treatment Plan indicated a treatment plan for "self-injurious (hurting oneself) behavior." The treatment plan further indicated the following information: "Long term goals/discharge (leaving the hospital) criteria: Patient will demonstrate no dangerous/self-harm behavior for 2 days prior to discharge- target date 6/4/2024 ..."

During a review of Patient 12's "Suicide/Self Injury Risk Assessment," dated 6/1/2024, the assessment indicated the "suicide/self-injury risk assessment" had indicators for suicide or self-harm.

During a review of Patient 12's progress notes, dated 6/3/2024 at 8:30 p.m., the progress notes indicated the following: "At approximately 4:00 p.m., patient (Patient 12) was witnessed by staff ingesting [taking] six unknown pills. Patient (Patient 12) also had broken brush by her bed that she (Patient 12) verbalized going to use (broken brush) for self-harm ...ordered to send her to the [hospital] Emergency Room (ER, the department of a hospital that provides immediate treatment for acute illnesses and trauma) for further evaluation ... transfer[ed] to ER for evaluation ... Left arm laceration (cut) caused by broken brush ..."

During a review of Patient 12's "Nursing Orders," dated 6/3/2024 at 5:00 p.m., the Nursing Orders indicated a Nurse Practitioner's order to "transfer to the emergency department (ED, the department of a hospital that provides immediate treatment for acute illnesses and trauma)."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," revised 7/2019, the policy indicated: "Policy: Medications shall be prepared and administered in a safe and timely manner by a licensed nursing staff ... 14. After giving the patient oral (by mouth) medications, observe him/her until he/she has swallowed it. Ask the patient to open his/her mouth to verify proper consumption and prevent cheeking of medications ..."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," revised 3/2022, the P&P indicated: "Policy: Certain items are unsafe on the units and are considered contraband ... Procedure: Upon admission, a patient search is conducted by nursing to assess for contraband and itemize personal property ... The following items are considered CONTRABAND and are NOT allowed on the Units ... All medications ..."

3. During an observation on 7/8/2024 at 3:16 p.m. in Del Sol (Adult Inpatient unit), with Nurse Manager (NM) 2, an Emergency Bag (contains emergency medical equipment), a backboard (placed on a person's back while person is receiving chest compressions [the act of applying pressure to someone's chest to help blood flow through the heart in an emergency], to increase the quality of chest compressions, when a person's heart stops), and automatic external defibrillator (AED, a machine that analyzes a person's heart rhythm and delivers an electric shock if indicated) were observed.

Concurrently, during an interview and review of a Checklist titled, "Emergency Medical Equipment Daily Checklist," on 7/8/2024 at 3:16 p.m., NM 2 verified that there was no evidence that emergency equipment was checked on 6/20/2024, 6/21/2024, 6/30/2024, and 7/7/2024. NM 2 stated nursing staff should check emergency equipment daily and document the date on the Checklist daily to ensure emergency equipment is available during a medical emergency.

During a review of a Checklist in Del Sol Unit titled, "Emergency Medical Equipment Daily Checklist," dated 6/2024, the Checklist indicated missing documentation of emergency equipment being checked on 6/20/2024, 6/21/2024, and 6/30/2024.

During a review of a Checklist in Del Sol Unit titled, "Emergency Medical Equipment Daily Checklist," dated 7/2024, the Checklist indicated missing documentation of emergency equipment being checked on 7/07/2024.

During a review of the facility's policy and procedure (P&P) titled, "Medical Emergencies and Acute Change in Condition," dated 2/2017, the P&P indicated, "It is our policy to provide safe and competent care to all patients experiencing medical emergencies or acute change in condition (a sudden, clinically important deviation from a patient's baseline in physical, cognitive [thinking and understanding], behavioral, or functional [activity or tasks] abilities)."

4. During a concurrent interview and record review, on 7/10/2024 at 11:39 a.m., with the Chief Nursing Officer (CNO), the CNO verified that Patient 6's "Patient Observation Record & Milieu Group," dated 7/3/2024, was missing documentation for observing (rounding) Patient 6 every 15 minutes, between 1 p.m., and 3:29 p.m. The CNO stated rounding should be conducted every 15 minutes for the safety of the patients.

During an interview, on 7/10/2024 at 3:22 p.m. with Registered Nurse (RN) 1, RN 1 stated patient rounds should be conducted every 15 minutes to verify the location and behaviors of patients.

During a review of Patient 6's "Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 7/2/2024, the Evaluation indicated the following: Patient 6 was admitted to the facility on 7/2/2024 on a 5150 hold (an involuntary 72-hour hold for the treatment of a psychiatric [relating to mental illness or treatment] condition) due to increasing thoughts of suicide (taking one's own life) ... Patient 6 admitted he (Patient 6) had been hearing a lot of voices telling him to kill himself ...
During a review of Patient 6's "Patient Observation Record & Milieu Groups," dated 7/3/2024, the Patient Observation Record indicated Patient 6 was on Suicide Precautions (monitoring patients for high-risk behaviors of suicide). There was no documentation of Patient 6's behavior or location from 1 p.m., to 3:29 p.m.

During a review of the facility's policy and procedure (P&P) titled, "Patient Precautions," dated 2/2010, the P&P indicated the following: "Suicide ...All patients identified to be on Suicide Precautions will have the following measures initiated: Indicate the suicide precautions on the patient's rounds sheet ...May be restricted to the unit ...Staff will monitor for high risk behaviors, including but not

Based on interview and record review, the facility failed to:

1. Provide proper supervision for two of 30 sampled patients (Patients 18 and 19), both of whom had a known history of aggression towards staff and other patients, to ensure that both patients (Patient 18 and Patient 19) did not physically attack Patient 17 twice, in accordance with the facility's policy and procedure regarding supervision of patients.

This deficient practice resulted in Patients 18 and 19 physically attacking Patient 17 for a second time within a 24-hour time frame. Patient 17 had to be transferred to a General Acute Care Hospital (GACH) Emergency Room (ER, responsible for the provision of medical care to patients arriving at the hospital in need of immediate treatment) for evaluation. Patient 17 suffered a laceration (wound produced by tearing of soft body tissue) to the forehead that required sutures (stitch made to join the open parts of the wound) after the first altercation and the laceration was re-opened after the second altercation.

2. Provide annual Abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse) Training for five of six staff (Charge Nurses [CN) 1, 2, and Mental Health Technicians [MHT] 1, 2, 4), in accordance with the facilities policies and procedures regarding abuse training.

This deficient practice had the potential for staff not to be able to identify signs and symptoms of abuse or take appropriate actions in the event a patient is identified to be a victim of abuse, which may result in patient harm.

Findings:

1. During a review of Patient 18's face sheet (document that gives a patient's information at a quick glance), the face sheet indicated that Patient 18 was admitted to the facility on 11/6/2023 at 3:45 p.m., with the diagnosis of oppositional defiant disorder (frequent and ongoing patter of anger, irritability, arguing and defiance toward parents and other authority figures).

During a review of Patient 18's Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help to the treatment team develop a treatment plan), dated 11/6/2023, the evaluation indicated Patient 18 was admitted for danger to self and also meeting the criteria for danger to others as well.

During a review of Patient 18's psychiatric progress note (physician progress notes written by psychiatric doctor [physician who specializes in mental, emotional and behavioral disorders]), dated 11/11/2023, the progress report indicated Patient 18 remains unpredictable, has thoughts of self-harm and very aggressive.

During a review of Patient 18's progress notes dated for 11/11/2023 and 11/12/2023 timed at 11:00 p.m., and at 6:45 a.m., the progress notes indicated that Patient 18 was involved in two physical altercations involving Patient 17.

During a review of Patient 19's face sheet (document that gives a patient's information at a quick glance), the face sheet indicated that Patient 19 was admitted to the facility on 11/3/2023 with the diagnosis of major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities).

During a review of Patient 19's psychiatric progress note (physician progress notes written by psychiatric doctor [physician who specializes in mental, emotional and behavioral disorders]) dated 11/11/2023, the progress note indicated that Patient 19 has anger management issues, very reckless, easily agitated and verbally aggressive.

During a review of Patient 19's progress note dated for 11/11/2023 and 11/12/2023 timed at 10:30 p.m., and 6:45 a.m., the progress note indicated that Patient 19 was involved in a physical altercation with Patient 17.

During a review of Patient 19's physician order (orders written by physicians to direct care and treatment), dated for 11/12/2023 and timed at 7:00 a.m., the physician order indicated Patient 19 had a 1:1 (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) order (the 1:1 order was written after the second altercation involving Patient 17).

During a review of Patient 17's Face sheet (document that gives a patient's information at a quick glance), the Face sheet indicated Patient 17 was admitted to the facility on 11/09/2023 at 3:30 p.m. with the diagnoses of major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities).

During a review of Patient 17's progress note dated 11/11/2023 and timed at 10:30 p.m., the progress note indicated that patient 17 was involved in an altercation (first physical altercation) that resulted in Patient 17 being transferred to the GACH (General Acute Care Hospital) ER (Emergency Room, responsible for the provision of medical care to patients arriving at the hospital in need of immediate treatment) for further evaluation.

During a review of Patient 17's Post (after) ER Visit Reassessment document, dated 11/12/2023 and timed at 1:23 a.m., the document indicated Patient 17 returned from the ER. Patient 17 suffered a laceration (wound produced by tearing of soft body tissue) to the forehead that required sutures (stitch made to join the open parts of the wound) after the first altercation on 11/11/2023 at 10:30 p.m.

During a review of Patient 17's Physician Order dated 11/12/2023 and timed at 7:00 a.m., the physician order indicated that patient 17 was to be transferred to the GACH ER for another evaluation (after the second altercation on 11/12/23 at 6:45 a.m.).

During a review of Patient 17's progress note dated 11/12/2023 and timed at 2:00 p.m., the progress noted indicated that patient 17 was transferred to another facility from the GACH ER.

During an interview with Nurse Manager (NM) 3 on 7/11/2024 at 10:02 a.m., NM 3 stated that when an altercation occurs, a 1:1 order can be ordered by the physician, it depends on the "situation." NM 3 stated that 1:1 is done for the safety of not only patients but for staff also. NM 3 stated if the aggressor had a history of previous 1:1 orders, then the aggressor would be put on a 1:1 after the altercation.

During a record review on 7/12/2024 at 11:02 a.m., with Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Risk Management and performance improvement (DRPI) and NM 1 and 2, the facility's video recording (no audio, recording of the second altercation) dated 11/12/2023 was reviewed, beginning at 6:27 a.m., the video captured Patient 18 and 19 walking into Patient 17's room. Patient 17's room was verified by NM 2 and Patients 18 and 19 were verified by NM 1. Approximately 25 seconds, roommate of Patient 17 was seen exiting the room with Patient 18 and 19 following shortly after. Staff was then seen running into Patient 17's room.

During a concurrent interview and record review on 7/12/2024 with NM 2 at 3:22 p.m., the medical charts for Patient's 18 and 19 was reviewed. NM 2 stated that Patient 18 had a known history of being aggressive and having orders of 1:1 in the past. NM 2 stated that a Physician order for 1:1 was ordered on 11/10/2023 but only for Day time. NM 2 stated that is done because that is when patients "act out the most." NM 2 stated that a 1:1 for all shifts was ordered for both Patients 18 and 19 after the physical altercation which happened the second time on 11/12/2023. NM 2 stated that after the first incident (on 11/11/2023) with Patient 17, both Patients 18 and 19 should have been put on a 1:1 in order to protect the safety of other patients and staff. NM 2 stated that safety is a priority for everyone.

During a review of the facility's policy and procedure (P&P) titled, "Patient Precautions," revised 2/2022, the P&P indicated that it was the policy of the facility to identify and assess risk factors of all patients in order to provide care in a safe and therapeutic milieu. The P&P also indicated that patients would also be re-assessed for risk whenever there was an abrupt change in their behavior or mental status.

During a review of the facility's P&P titled, "Supervision of Patients/Patient Rounds," revised 7/2021, the P&P indicated that patients be supervised to diminish the risk of harm and/or injury. The policy also indicated that patients who were assessed to be at imminent risk of harm to self or others, a 1:1 level of supervision may be assigned.

During a review of the facility's handbook titled "Rights for Individuals in Mental Health Facilities," revised July 2018, the handbook (page 22) indicated that patients have the right to be free from abuse, neglect, or harm, including unnecessary or excessive restraint (devices that limit a patient's movement), isolation (supervised confinement of a patient away from other patients) or medication. The handbook also indicated that patients have the right to be free from potentially harmful situations or conditions.

2. During a concurrent interview and personnel file review on 7/11/2024 at 4:29 p.m., with the Director of Human Resources (DHR), the DHR reviewed the personnel files and stated the following: Abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse) training should be provided upon hire and annually for staff, including Registered Nurses (RNs), and Mental Health Technicians (MHTs). The DHR stated the facility did not provide refresher abuse training last year (2023) during annual competencies (the application and demonstration of appropriate knowledge, skills and behavior in the clinical setting) for all staff including CN 2, MHT 1 and 2.

During a second concurrent interview and personnel file review on 7/12/2024 at 10:54 a.m., the DHR stated CN 1 and MHT 4 did complete annual abuse training.

During an interview on 7/12/2024 at 11:25 a.m. with the Director of Clinical Services (DCS), DCS stated she (DCS) provided abuse training to all staff upon hire and normally a refresher course was provided annually. The DCS stated that the facility did not ask her (DCS) to provide a refresher course in abuse training last year (2023) during the annual competency fair. The DCS stated abuse training should be provided annually to ensure staff are able to recognize signs and symptoms of abuse, and actions to take in the event abuse is identified.

During a review of personnel files on 7/12/2024, the personnel files review indicated the following: RN 1 and MHT 4 did not have evidence of abuse training. CN 1's last completed abuse training was on 11/6/2022. MHT 1's last completed abuse training was on 10/25/2022. This was verified by the DHR during an interview.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reporting of Abuse and Neglect," dated 10/2021, the P&P indicated the hospital treatment team will assess and reassess patients for signs and symptoms of abuse including: emotional, sexual, and fiduciary (financial) abuse, exploitation, neglect, and abandonment, upon intake, admission and throughout hospitalization.

During a review of the facility's policy and procedure (P&P) titled, "Staff Competency and Training," dated 8/1/2020, the P&P indicated the following ...On an annual basis, each employee is required to complete refresher training on the following topics, including Abuse/Neglect Identification and Reporting.

Based on observation, interview, and record review, the facility failed to ensure that an age appropriate sleeping arrangement and therapeutic environment was provided for one of 30 sampled patients (Patient 21), in accordance with the facility's policy and procedure regarding therapeutic environment when, Patient 21 was placed in a seclusion room (PRA - Private room Areas, a room used when a patient is being actively secluded/separated from other patients due to an aggressive behavior) at night to sleep.

This deficient practice resulted in Patient 21 not having an age-appropriate room and furnishings which could negatively affect the patient's emotional well-being and quality of care received.

Findings:

During a concurrent observation and interview, on 7/8/2024 at 2:05 p.m., with Nurse Manager 2 (NM 2), in Room 56, designated as one of the seclusion room (PRA - Private room Areas, a room used when a patient is being actively secluded/separated from other patients due to an aggressive behavior), was observed to have a bed with no fitted sheet or blanket on the mattress, there were no other furniture in the room. In addition, a camera was noted in the left corner of the room. NM 2 stated Patient 21 sleeps in the room (Room 56) at night to keep sleeping area separate from child (5-12 years old) and adolescent (13-17 years old) patients.

During an interview on 7/9/2024 at 9:38 a.m. with the Director of Clinical Services and Regional Compliance (DRC), the DRC stated seclusion room should not be used for sleeping.

During an interview on 7/9/2024 at 9:38 a.m. with the Chief Nursing Officer (CNO), the CNO stated Patient 21 sleeps in room 56 (seclusion room). The CNO agreed Room 56 was normally used for the patients needing to be separated from other patients for safety reasons. The CNO stated Patient 21 sleeps in Room 56 because the patient belongs to the child age group and should sleep in separate room from the adolescent patients.

During an interview on 7/9/2024 at 10:58 a.m., with Patient 21, in the presence of the Regional Vice President (RVP), Patient 21 stated he was scared of being alone in the room, pointing to room 56. Patient 21 stated he sleeps in Room 56 at night and "they (staff) don't check" on him (Patient 21).

During an interview on 7/10/2024 at 3:55 p.m., with Registered Nurse 1 (RN 1), RN 1 stated the seclusion rooms (Room 55 and 56) were used when a patient is having behavioral problems.

During a review of the facility's "Patient Observation Record & Milieu Groups (rounding sheet)," dated 7/8/2024, the record indicated from 12:00 a.m. until 7:00 a.m., Patient 21 was sleeping in the seclusion room (PRA - Private room Areas, a room used when a patient is being actively secluded/separated from other patients due to an aggressive behavior)).

During a concurrent interview and record review on 7/11/2024 at 2:21 p.m., with Nurse manager (NM) 2, the facility's policy and procedure (P&P) titled, "Supervision of Patients/Patient Rounds," dated 7/2021, was reviewed. The P&P indicated, "The Charge Nurse is responsible for ensuring the proper use of Private Room Areas (PRA's/Seclusion room). These areas may ONLY be used when a patient is being actively secluded or restrained, during which time they will have a minimum of 1:1 supervision (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) for the duration of emergency intervention." NM 2 stated she was not aware of the P&P regarding the use of PRA room.

During a review of the facility's policy and procedure (P&P) titled, "Therapeutic Environment," dated 3/2022, the P&P indicated, "It is the policy of facility that all patients are to have an appropriate environment in which to receive their treatment. This applies to privacy, personal space and age-appropriate furnishings. It is the responsibility of each Program Director to ensure that their unit meets the following: Space: adequate and separate personal area will be provided for patient belongings. Age-Appropriate Furnishings: each unit is to have furnishings, both indoor and outdoor, that are safe and encourage comfort and age-appropriate utilization."

Based on interview and record review, the facility failed to ensure that one of 30 sampled patients (Patient 21), was assessed and monitored, in accordance with the facility's policy and procedure regarding Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion (confinement of a patient alone in a room in which the patient is physically prevented from leaving), when Patient 21 was placed on chemical restraints (a drug given to a person to control their behavior or restrict their movement). Patient 21 was administered Benadryl (medication used with sedation effects [a state of calmness or sleepiness]) and Thorazine (medication used to manage mental illness or behavior disorders).

This deficient practice had the potential to cause a delay in determining Patient 21's change of condition and/or provision of emergent treatment needed as a result of chemical restraint, which can lead to worsening of patient's condition and/or death.

Findings:

During a review of Patient 21's "Face Sheet (a document containing a patient's medical and demographic information)," undated, the face sheet indicated Patient 21 was admitted to the facility on 6/28/2024.

During a review of Patient 21's "72 hour hold (5585, a law that allows for the involuntary detention of someone with a mental illness in a psychiatric [branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] hospital for up to 72 hours)," dated 6/28/2024, the hold indicated Patient 21 was a danger to himself and others. Patient 21 was agitated, violent and trying to jump out of a moving car. Patient 21 had an open case with Department of Children and Family Services (DCFS - agency that oversees Los Angeles County's 24/7 child abuse [any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse] and neglect hotline and responds to the immediate needs of any child at risk).

During a concurrent interview and record review on 7/11/2024 at 11:22 a.m., with Nurse Manager 2 (NM 2), Patient 21's "Medication Administration Record (MAR)," indicated a physician order of Benadryl (medication used with sedation effects [a state of calmness or sleepiness]) 50 milligram (mg, a unit of measurement) to be given intramuscularly (IM-in the muscle) one time for agitated behavior/aggressive behavior towards staff. Furthermore, the MAR indicated Patient 21 was administered Benadryl 50 mg IM on 6/28/2024 at 11:45 p.m. NM 2 stated Patient 21 was held down for a couple of minutes to be given the medication thus "purple packet (Facility Seclusion/restraint order) was filled out.

During a concurrent interview and record review on 7/11/2024 at 2:21 p.m. with NM 2, Patient 21's "Facility Seclusion/Restrained order," dated 6/28/2024, indicated Patient 21 was physically held down on 6/28/2024 at 11:45 p.m. until 11:47 p.m., and Benadryl 50 mg IM was given for improved mood/function. The assessment of patient range of motion, toileting/hygiene/food/vitals and assessment every 15 minutes after the administration of the Benadryl 50 mg IM was not completed with "n/a (not applicable)" written on the assessment record. NM 2 stated the assessment portion of the form was not necessary to fill out because physical hold was only for two minutes. NM 2 said medication used for the patient was considered a restraint, only if the patient falls sleep within an hour.

During a concurrent interview and record review on 7/11/2024 at 2:21 p.m., with Nurse Manager 2 (NM 2), Patient 21's MAR indicated a physician order of Thorazine (medication used to manage mental illness or behavior disorders) 25 mg to be given IM one time for agitation/aggression. Furthermore, the MAR indicated Patient 21 was administered Thorazine 25 mg IM on 6/29/2024 at 11:20 a.m.
In the same record review on 7/11/2024 at 2:21 p.m., with NM 2, Patient 21's "Facility Seclusion/Restrained order," dated 6/29/2024 indicated Patient 21 was physically held down on 6/29/2024 at 11:20 a.m. until 11:21 a.m. and was given Thorazine 25 mg IM for improved mood/function, "patient (Patient 21) hit a peer, was running around the unit throwing items at staff and peers. The nursing graphics portion which included assessment of patient range of motion, toileting/hygiene/food/vitals and assessment every 15 minutes was not completed with "n/a" written on the assessment document.

During a concurrent interview and record review on 7/11/2024 at 2:21 p.m. with NM 2, the facility's policy and procedure (P&P) titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion," revised 3/2022, was reviewed. NM 2 stated she was unaware of the policy on chemical restraint that, "administration of a medication for the purpose of controlling an acute episodic behavior, with the intent to restrict the patient's functioning or movement and/or to bring about sedation ..." required assessment and monitoring, and that was the reason the assessment and monitoring was not done. NM 2 agreed that the use of Benadryl and Thorazine for Patient 21's behavior was a chemical restraint and required monitoring and reassessment per policy.

During a review of the facility's policy and procedure (P&P) titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion," revised in 3/2022, the P&P indicated the following:
- Chemical (Medication) Restraint: The administration of a medication for the purpose of controlling an acute (severe and sudden in onset) episodic behavior, with the intent to restrict the patient's functioning or movement and/or to bring about sedation (a state of calmness or sleepiness).
- The RN immediately will assign a staff member, trained, and deemed competent in the usage and monitoring of seclusion and restraints to conduct continuous in person observation/monitoring for the duration of the seclusion/restraint episode.
- Documentation of each episode of restraint/seclusion include 15-minute assessment of the patient status, continuous monitoring of patient and care provided.

Based on interview and record review, the facility failed to formulate and implement a corrective action plan or action, when the facility identified deficiencies in the staff's responses when Patient 8 was found to be unresponsive (not reacting or unable to react in a normal way when touched, spoken to, etc.), pulseless, not breathing and subsequent death (refer to A-0144), as well as corrective action plan for follow-ups when issues were identified during Mock Codes (a simulation exercise with a mannequin/human patient simulator with no respiratory effort and/or no pulse), in accordance with the facility's Quality Assurance & Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) program.

This deficient practice had the potential for staff's inability to respond appropriately during a medical emergency such as in cases of pulseless patients or patients who are not breathing.

Findings:

During an interview on 7/12/2024 at 4:30 p.m. with the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Risk Management and Performance Improvement (DRPI), and Director of Clinical Services Regional Compliance (DRC), the CNO stated the following: A root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solutions) was performed for Patient 8's death. The RCA identified there were concerns with rounding, delayed implementation of live-saving measures, delayed notification of licensed staff, and not applying the AED (automatic external defibrillator, delivers an electric shock through the chest to the heart when it detects an abnormal rhythm) during the code blue (hospital announcement means that someone is having a medical emergency, usually cardiac arrest [absent or abnormal heart activity] or respiratory arrest [absent breathing]). The facility implemented an action plan to correct the identified concerns, but the action plan (a document that lists what steps must be taken to correct identified concerns) was not documented. The CNO and DRPI confirmed the action plan was not documented and they were unable to provide a copy to the survey team.

During a review of Patient 8's "Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 4/17/2024, the Psychiatric Evaluation indicated Patient 8 was admitted to the facility on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric condition), on 4/17/2024, with a diagnosis of schizoaffective disorder (a mood disorder where someone may experience depression [a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities], mania [extreme euphoria or irritability], and hallucinations [sensing things such as visions, sounds or smells that seem real but are not] or delusions [a fixed false belief based on an inaccurate interpretation of an external reality despite evidence to the contrary).

During a review of Patient 8's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/18/2024, the H&P indicated Patient 8 had diagnosis of headaches, somatic complaints (an extreme focus on physical symptoms causing major emotional distress and problems functioning), obesity (weighing 100 pounds over the recommended weight) and tachycardia (increased heart rate).

During a review of Patient 8's "Code Blue/Medical Emergency Documentation," dated 4/22/2024 at 8:04 a.m., the documentation indicated the following: Patient 8 was "found not breathing, pulseless, not responding." A code blue was called at 8:04 a.m. The AED was not applied. Transferred care of Patient (8) to EMS (Emergency Medical Services) at 8:14 a.m. Patient (8) condition at departure or at the end of the code: Deceased.

During a review of Patient 8's "Discharge Summary (a narrative document for communicating clinical information about what happened to a patient in the hospital)," dated 5/4/2024 at 7:42 a.m., the Discharge Summary indicated the following: On March 22, 2024 at 8:14 a.m., Patient (8) was found unconscious and not responding ...Paramedics took over the emergency situation and Patient (8) didn't make it. Outcome of hospitalization: Patient (8) expired.

During an interview and record review on 7/12/2024 at 5:05 p.m. with Nurse Manager (NM) 2, NM 2 stated the following: Mock Codes (a simulation exercise with a mannequin/human patient simulator with no respiratory effort and/or no pulse) were conducted on 5/1/2024. The response of staff to the Mock code was analyzed and it was determined that the staff did not bring the AED and the staff was not able to utilize the equipment correctly. NM 2 verified there was no documentation of follow-up actions aimed at ensuring the staff would bring the AED and know how to utilize the AED during a Code (Code Blue, a medical emergency, usually cardiac [heart] or respiratory arrest). There should be follow up.

During a review of a facility document titled, "Nursing Administration Evaluation and Analysis of Code Blue Response," dated 5/1/2024 at 1:27 p.m., the document indicated the following:
3. Did staff bring the appropriate equipment (AED, oxygen tanks etc ...), No ...
6. Were the staff members able to utilize all equipment correctly? No ...
If any "No" answers, describe: "Staff did not bring appropriate equipment to the code. Nursing Manager educated staff on necessary equipment to bring.

During a review of a facility document titled, "Nursing Administration Evaluation and Analysis of Code Blue Response," dated 5/1/2024at 10:30 p.m., indicated the following:
14. Were proper notifications completed (physician, Internist, family/support)? No.
If any "No" answers, describe: "MOCK: Interventions Take to Correct: blank (no documentation of corrective interventions).

During a review of the facility's Quality Assurance & Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) program, dated 2024, the QAPI indicated the following: The QAPI program is designed to provide a coordinated, objective, and systemic approach to organization-wide performance improvement activities ...The Performance Improvement Committee ...is responsible to oversee and accomplish the following ...Ensure that a comprehensive assessment and root cause analysis is initiated when data analysis indicates undesirable variations in performance. Assure that appropriate actions are implemented to effectively resolve identified problems or improve existing processes.

Based on interview and record review the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:

1. The facility failed to perform a reassessment (reevaluation of a patient's health status) for one of 30 sampled patients (Patient 8) within one hour after PRN (as needed) medications Vistaril (a medication used to relieve itching caused by allergic skin reactions with sedative [cause drowsiness or sleepiness] effects) and Trazodone (a medication used to treat depression and anxiety) were administered to Patient 8. This deficient practice had the potential to cause irregular heart rhythms, when Vistaril and Trazodone were taken together, resulting in patient harm or death. (Refer to A-0395)

2. The facility failed to complete an admission assessment (a process where a nurse gathers, sorts, and analyzes a patient's health information) for one of 30 sampled patients (Patient 8), in accordance with the facility's policy and procedure regarding Assessment and reassessment. This deficient practice had the potential for delayed provision of medical care and treatment of identified concerns, resulting in patient harm and/or death. (Refer to A-0395)

3. The facility failed to ensure two of 30 sampled patients (Patients 25 and 28) vital signs (VS, includes blood pressure, heart rate, respiration [breathing], and temperature) were assessed and documented in accordance with the physician's order and the facility's policy and procedure regarding Vital Signs assessment and documentation.

This deficient practice had the potential to cause a delay in determining Patients' 25 and 28's change of condition and/or a delay in the provision of emergent treatment needed which could worsen the patients' condition and may result in death. (Refer to A-0395)

4. The facility failed to ensure that two of 30 sampled patients (Patients 29 and 30's) Colombia Suicide Severity Rating Scale (CSSRS - suicidal risk assessment tool) assessment were completed daily in accordance with the facility's policy and procedure regarding Nursing Assessment and Reassessment.

This deficient practice had the potential for Patients' 29 and 30's assessment and reassessment to be inaccurate and may cause delay in the provision of medical care and treatment that could result in patient harm and or death. (Refer to A-0395)

5. The facility failed to ensure four of six sampled clinical staff (Registered Nurse [RN] 1, Mental Health Technicians [MHT] 1, MHT 4, and Charge Nurse (CN) 1), were evaluated to ensure the staff were competent in their respective positions, in accordance with the facility's policy and procedure regarding staff competency (the application and demonstration of appropriate knowledge, skills and behavior in the clinical setting) and training.

This deficient practice had the potential for staff's inability to perform the essential functions of their respective positions, which may compromise patient safety when necessary patient care interventions are not performed appropriately. (Refer to A-0397)

6. The facility failed to ensure two of 30 sampled patients' (Patients 29 and 30) nursing assessment (involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected) was completed in accordance with the facility's guideline regarding Changes to Nursing Admit Assessment and Nursing Progress Notes when, Patient 29 and 30's daily assessment, completed by the Licensed Psychiatric Technician (LPT), did not have a Registered Nurse (RN) co-signature to indicate the LPT's assessment was verified by the RN.

This deficient practice had the potential for Patients' 29 and 30's nursing assessment to be inaccurate and may cause delay in the provision of medical care and treatment that could result in patient harm and or death. (Refer to A-0398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality care in a safe environment, potentially putting patients at risk for harm.

Based on interview and record review, the facility failed to:

1. Perform a reassessment (reevaluation of a patient's health status) for one of 30 sampled patients (Patient 8) within one hour after PRN (as needed) medications Vistaril (a medication used to relieve itching caused by allergic skin reactions with sedative [cause drowsiness or sleepiness] effects) and Trazodone (a medication used to treat depression and anxiety) were administered to Patient 8. This deficient practice had the potential to cause irregular heart rhythms, when Vistaril and Trazodone were taken together, resulting in patient harm or death.

2. Complete an admission assessment (a process where a nurse gathers, sorts, and analyzes a patient's health information) for one of 30 sampled patients (Patient 8), in accordance with the facility's policy and procedure regarding Assessment and reassessment. This deficient practice had the potential for delayed provision of medical care and treatment of identified concerns, resulting in patient harm and/or death.

3. Ensure two of 30 sampled patients (Patients 25 and 28) vital signs (VS, includes blood pressure, heart rate, respiration (breathing), and temperature) were assessed and documented in accordance with the physician's order and the facility's policy and procedure regarding Vital Signs assessment and documentation.

This deficient practice had the potential to cause a delay in determining Patients' 25 and 28's change of condition and/or a delay in the provision of emergent treatment needed which could worsen the patients' condition and may result in death.

4. Ensure that two of 30 sampled patients (Patients 29 and 30's) Colombia Suicide Severity Rating Scale (CSSRS - suicidal risk assessment tool) assessment were completed daily in accordance with the facility's policy and procedure regarding Nursing Assessment and Reassessment.

This deficient practice had the potential for Patients' 29 and 30's assessment and reassessment to be inaccurate and may cause delay in the provision of medical care and treatment that could result in patient harm and or death.


Findings:

1. During a review of Patient 8's "Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 4/17/2024, the Psychiatric Evaluation indicated Patient 8 was admitted to the facility on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric condition), on 4/17/2024, with a diagnosis of schizoaffective disorder (a mood disorder where someone may experience depression, mania [extreme euphoria- intense feeling of excitement/happiness or irritability]).

During a review of Patient 8's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/18/2024, the H&P indicated Patient 8 had diagnosis of headaches, somatic complaints (an extreme focus on physical symptoms causing major emotional distress and problems functioning), obesity (weighing 100 pounds over the recommended weight) and tachycardia (increased heart rate).

During a review of Patent 8's "Physician Medication Orders," dated 4/18/2024, the physician orders indicated an order for Trazodone (a medication used to treat depression and anxiety) 50 milligrams (mg, a unit of measurement) by mouth, as needed, at bedtime.

During a review of Patent 8's "Physician Medication Orders," dated 4/18/2024, the physician orders indicated an order for Vistaril (a medication used to relieve itching caused by allergic skin reactions with sedative [cause drowsiness or sleepiness] effects) 50 mg by mouth, as needed, every 6 hours.

During a concurrent interview and record review on 7/10/2024 at 3:48 p.m. with the Nurse Manager 2 (NM 2), Patient 8's medical record titled "Medication Administration Record (MAR, a report detailing the drugs administered to a patient)," was reviewed. The MAR indicated on 4/22/2024 at 12:43 a.m., Patient 8 received as needed dose of Vistaril (a medication used to relieve itching caused by allergic skin reactions with sedative effects) 50 mg (milligram, a unit of measurement) by mouth for anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure). At 12:50 a.m. on 4/22/2024, Patient 8 received as needed dose of Trazodone (a medication used to treat depression and anxiety) 50 mg (milligram, a unit of measurement) by mouth for insomnia (inability to sleep). The NM 2 verified this was Patient 8's first dose of Trazodone and Vistaril. The NM further verified the Vistaril and Trazodone were never reassessed and documented by the licensed nurse. The NM 2 said that all medications given required reassessment within an hour of administration, per policy. The NM 2 said that it was important to reassess Patient 8 to assess if the medication was effective and if there were any adverse side effects (unwanted undesirable effects that are possibly related to a medication). The NM 2 further stated that it was important to reassess Patient 8 after the first dose of medications because there was a likelihood the patient can have a reaction.

During a review of the facility's policy and procedure (P&P) titled, "Monitoring of Medication Effects on Patients," revised 3/2022, the P&P indicated: "Policy: The effects of medications of patients will be monitored by appropriate clinical staff throughout the patient's treatment ... members of the treatment team will document the patient's response to medication therapy in progress notes. In addition to the clinician's observations, notation will be made of the patient's perception of the effectiveness of medications ... Procedure: ...2. The RN will record observations regarding patient behavior and symptoms in the daily nursing assessment. Response to PRN (as needed) medications will be recorded in the medical record, including the patient's perception of effectiveness ... 3. The patient's response to the first dose(s) of a medication new to the patient while he or she is under the direct care of the hospital will be recorded in the medical record."

2. During a concurrent interview and record review on 7/9/2024 at 1:10 p.m. with the Nurse Manager 2 (NM 2), Patient 8's medical record titled "Nursing Admission Assessment (a process where a nurse gathers, sorts, and analyzes a patient's health information)- ADULTS (age 18+)," the NM 2 verified the following nursing assessment sections were incomplete and marked as not applicable ("N/A"): substance abuse assessment, potential for sexual victimization (being the recipient of a sexually aggressive act), sexually aggressive behavior (a person engaging in sexual behavior with someone who does not or cannot consent to engage in that behavior), homicidal/violence/aggression risk assessment (screens for someone who is dangerous because they are likely to harm or kill someone), psychological trauma (a person's experience of emotional distress resulting) history, elopement (an act or instance of a patient in care leaving a hospital, care facility, or safe area independently without notifying anyone) risk assessment, and heightened risk associated with potential restraint (devices that limit a patient's movement)/seclusion (confinement of a patient alone in a room in which the patient is physically prevented from leaving) intervention.

During an interview on 7/9/2024 at 1:10 p.m. with the Nurse Manager (NM) 2, the NM 2 further verified that the admission assessment was not endorsed (to hand over) to the licensed nurse for completion. The NM 2 stated the following: The admission assessment should be completed on admission by a licensed nurse and signed off by a Registered Nurse (RN). If a licensed nurse is unable to complete the admission assessment prior to the end of their (8 hour) shift, incomplete sections of the admission assessment should be endorsed to the licensed nurse on the next shift. The number of attempts to complete the admission assessment should be documented on page one to include the date, time, reason unable to complete and RN initials. The RN can endorse the admission assessment up to three times. For Patient 8's admission assessment, the incomplete sections should have not been marked "N/A," instead, the RN should have documented the reason the assessment was incomplete or the patient's refusal. It was important to complete the admission assessment to have a baseline of the Patient 8 on admission. Furthermore, Patient 8's admission assessment should have been completed and relayed to the physician, so the physician knows the patient's history to determine the course of treatment for their stay.

During a review of the facility's policy and procedure (P&P) titled "Nursing Assessment and Reassessment (reevaluation of a patient's health status) of Patients," revised 3/2022, the P&P indicated: "Assessment Policy: ...5. The Nursing Admission Assessment must be completed within eight (8) hours of admission by a Registered Nurse ... 6. The completion of the Nursing Admission Assessment is the responsibility of the shift during which the patient was admitted. If completion of the form is delayed because of the patient's condition, a notation to this effect is to be documented in the "Attempts made for completion" section ..."

3.a. During a review of Patient 25's "Face Sheet (a document containing a patient's medical and demographic information)," undated, the face sheet indicated Patient 25 was admitted to the facility on 7/03/2024 with a medical diagnosis of Major depressive disorder (a serious mood disorder that can affect how people feel, think, and behave).

During a concurrent interview and record review on 7/11/2024 at 8:57 a.m., with Nurse Manager 2 (NM 2), NM 2 stated Patient 25's "Vital flowsheet" did not have Vital Signs (VS, includes blood pressure, heart rate, respiration, and temperature) documented on 7/8/2024. NM 2 stated Patient 25's VS should be taken at least daily.

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs", revised 3/2022, the P&P indicated, "Vital signs (blood pressure, temperature, pulse, respirations) will be obtained at least once per day, documented, and evaluated by nursing staff in an appropriate manner to aid in diagnosis and treatment. All patients will have vital signs taken as part of the initial nursing assessment and daily thereafter until discharge, unless ordered more frequently by the physician..."


3.b. During a review of Patient 28's "Face Sheet (a document containing a patient's medical and demographic information)," undated, the face sheet indicated Patient 28 was admitted to the facility on 7/8/2024 with a medical diagnosis of major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities).

During a review of Patient 28's physician's order, dated 7/8/2024, the Physician's Order indicated Patient 28's Vital Signs (VS, includes blood pressure, heart rate, respiration, and temperature) to be taken every four hours.

During a concurrent interview and record review on 7/11/2024 at 10:01 a.m. with Nurse Manager (NM) 2, Patient 28's "Vital flowsheet" indicated the following:

- On 7/9/2014 at 6:30 a.m., Patient 28's VS were completed, the next VS taken was taken at 2:01 p.m. (7 hours and 30 minutes since the last VS were taken); and,

- On 7/10/2024 at 6:18 a.m. Patient 28's VS were completed, the next VS taken was at 11:48 a.m. (5 hours and 30 minutes since last VS were taken).

NM 2 stated Patient 28's vital signs should be taken as ordered by the physician (every 4 hours).

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs", revised 3/2022, the P&P indicated, "Vital signs (blood pressure, temperature, pulse, respirations) will be obtained at least once per day, documented, and evaluated by nursing staff in an appropriate manner to aid in diagnosis and treatment. All patients will have vital signs taken as part of the initial nursing assessment and daily thereafter until discharge, unless ordered more frequently by the physician..."

4.a. During a review of Patient 29's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/23/2024, the H&P indicated Patient 29 was admitted to the facility for Major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities).

During a concurrent interview and record review on 7/10/2024 at 11:18 a.m., with Nurse Manager 2 (NM 2), Patient 29's "Colombia Suicide Severity Rating Scale (CSSRS - a suicidal assessment tool) documentation was reviewed and indicated the following:

- Patient 29's initial "Colombia Suicide Severity Rating Scale (CSSRS - a suicidal assessment tool)," assessment dated 4/23/2024, indicated Patient 29's CSSRS was low risk for committing suicide (taking one's own life).

- Patient 29's daily CSSRS was not completed on 4/24/2024 and 4/29/2024. On both dates, there was no documentation to indicate if Patient 29 was assessed to be a low risk or high risk for suicide)

NM 2 verified Patient 29's CSSRS assessment was not completed on 4/24/2024 and 4/29/2024.

During a review of the facility's policy and procedure (P&P) titled, "Nursing Assessment and Reassessment," revised in 2/2024, the P&P indicated, "...each patient is assessed every 24 hours and as needed...RN will complete the CSSRS daily while patient remain on suicide precaution (interventions to prevent a patient from harming themselves such as frequent monitoring, etc.) ..."

4.b. During a review of Patient 30's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/23/2024, the H&P indicated Patient 30 was admitted to the facility on 4/23/2024 for Suicidal Ideations (SI, thoughts of ending one's own life) with a plan to overdose (taking too much of a substance such as medications). Patient 30's medical history included major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities) and substance abuse (a state of psychological and/or physical dependence on the use of drugs or other substances such as alcohol).

During a concurrent interview and record review on 7/10/2024 at 11:18 a.m., with Nurse Manager 2 (NM 2) Patient 30's "Colombia Suicide Severity Rating Scale (CSSRS - a suicidal assessment tool) documentation was reviewed and indicated the following:


- Patient 30's initial CSSRS assessment dated 4/23/2024, indicated Patient 30's CSSRS was high risk for suicide (taking one's own life); and,

- Patient 30's daily CSSRS was not completed on 4/24/2024 (3 p.m. to 11 p.m. shift) and 4/28/2024 (7 a.m. to 3 p.m. and 3 p.m. to 11 p.m. shift).

During an interview on 7/10/2024 at 3:45 p.m., with the Nurse Manager (NM) 2, NM 2 stated the Initial CSSRS had to be completed on all the patients upon admission and a daily CSSRS would be done on the patients who were identified with SI.

In the same interview, on 7/10/2024 at 3:45 p.m., NM 2 stated when the patients' daily CSSRS was not completed, the patient would not be assessed if he/she was still suicidal and could cause to harm self.

During a review of the facility's policy and procedure (P&P) titled, "Nursing Assessment and Reassessment," revised in 2/2024, the P&P indicated, "...each patient is assessed every 24 hours and as needed...RN will complete the CSSRS daily while patient remain on suicide precaution..."

Based on interview and record review, the facility failed to ensure four of six sampled clinical staff (Registered Nurse (RN) 1, Mental Health Technicians [MHT] 1, 4, and Charge Nurse (CN) 1) were evaluated to ensure the staff were competent in their respective positions, in accordance with the facility's policy and procedure regarding staff competency (the application and demonstration of appropriate knowledge, skills and behavior in the clinical setting) and training.

This deficient practice had the potential for staff's inability to perform the essential functions of their respective positions, which may compromise patient safety when necessary patient care interventions are not performed appropriately.

Findings:

During a concurrent interview and personnel file review on 7/11/2024 at 4:29 p.m. with the Director of Human Resources (DHR), the DHR reviewed the personnel files and stated the following: Competency (the application and demonstration of appropriate knowledge, skills and behavior in the clinical setting) evaluations should be performed annually to ensure staff are competent in their positions and should be documented in the "General/Unit/Program Specific Competency Checklist." DHR verified Registered Nurse (RN) 1 did not have evidence of any competency evaluations in the file. Mental Health Technician (MHT) 1's last competency was evaluated on 10/25/2022, was overdue for competency evaluation.

During a second concurrent interview and personnel file review on 7/12/2024 at 10:54 a.m. the DHR stated Charge Nurse (CN) 1's last competency was evaluated on 11/6/2022. Likewise, DHR verified Mental health Technician (MHT) 4 did not have evidence of any competency evaluation in the file.

During a review of a checklist titled, "General/Unit/Program Specific Competency Checklist, undated, the Checklist indicated an area to document if a staff is competent (MET) or not competent (Not Met) in the following, including; Facilitates accurate communication between caregivers ...i.e ...critical patient care information. Can identify signs of decompensation (worsening of symptoms). Able to describe the admission and assessment ...Regularly surveys surroundings for safety hazards ...Assures adequate patient safety by timely rounding or supervision ...Identifies patients in crisis, offers appropriate interventions ...Assesses patient's physical and emotional safety ...Assures that rounds are done and documented accurately.

During a review of the facility's policy and procedure (P&P) titled, "Staff Competency and Training," dated 8/1/2020, the P&P indicated the following. It is the policy of the Facility to hire individuals who are qualified to perform the essential functions of the position with or without reasonable accommodation.

Based on interview and record review, the facility failed to ensure two of 30 sampled patients' (Patient 29 and 30) nursing assessment (involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected) was completed in accordance with the facility's guideline regarding Changes to Nursing Admit Assessment and Nursing Progress Notes when, Patient 29 and 30's daily assessment, completed by the Licensed Psychiatric Technician (LPT), did not have a Registered Nurse (RN) co-signature to indicate the LPT's assessment was verified by the RN.

This deficient practice had the potential for Patients' 29 and 30's nursing assessment to be inaccurate and may cause delay in the provision of medical care and treatment that could result in patient harm and or death.

Findings:

1. During a review of Patient 29's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/23/2024, the H&P indicated Patient 29 was admitted to the facility for Major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities).

During a review of Patient 29's nursing assessment (involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected) form dated, 4/29/2024 (3 p.m. to 11 p.m. shift), the form indicated the assessment was completed and signed by Licensed Psychiatric Technician (LPT) 1. The RN signature box beneath the LPT 1 signature box was blank. There was no RN signature in the assessment form completed by LPT 1. The form indicated, "Medical requires RN co-signature if completed by LVN (Licensed Vocational Nurse)/LPT."

During an interview on 7/12/2024 at 10:35 a.m., with Nurse Manager (NM) 2, the NM 2 verified Patient 29's assessment on 4/29/2024 was completed by LPT 1. NM 2 stated an LVN/LPT should not do the patient's initial assessments and reassessments alone, the assessment completed by the LVN/LPT must be co-signed by a RN.

During a review of the facility's document titled, "Changes to Nursing Admit Assessment and Nursing Progress Notes", dated 9/5/2023, the documents indicated on page 2, "LVN/LPT's completed training to assist w/completion of nursing progress notes, including narrative w/ (with) RN co-signature."


2. During a review of Patient 30's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/23/2024, the H&P indicated Patient 30 was admitted to the facility on 4/23/2024 for Suicidal Ideations (SI, thoughts of causing one's own death) with a plan to overdose (taking too much of a substance such as medications). Patient 30's medical history included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities) and substance abuse (a state of psychological and/or physical dependence on the use of drugs or other substances such as alcohol).

During a review of Patient 30's daily nursing assessment (involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected) dated 4/28/2024 (3 p.m. to 11 p.m. shift), the form indicated the assessment was completed and signed by Licensed Psychiatric Technician (LPT) 1. The RN signature box beneath the LPT 1 signature box was blank. There was no RN signature in the assessment form completed by LPT 1. The form indicated, "Medical requires RN co-signature if completed by LVN (Licensed Vocational Nurse)/LPT."

During an interview on 7/12/2024 at 10:35 a.m., with Nurse Manager (NM) 2, the NM 2 verified Patient 30's assessment on 4/28/2024 was completed by LPT 1. NM 2 stated an LVN/LPT should not do the patient's initial assessments and reassessments alone, the assessment completed by the LVN/LPT must be co-signed by a RN.

In the same interview on 7/12/2024 at 10:35 a.m., with NM 2, the NM 2 stated there was a change of practice in the facility regarding "Nursing Admission Assessment and Daily Nurse Progress Notes." The NM 2 stated the change of practice allowed the LVN/Licensed Psychiatric Technician (LPT) to do assessments and RN to co-sign.

During a review of the facility's document titled, "Changes to Nursing Admit Assessment and Nursing Progress Notes", dated 9/5/2023, the documents indicated on page 2, "LVN/LPT's completed training to assist w/completion of nursing progress notes, including narrative w/ (with) RN co-signature."