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Based on observation, record review, and interview, the psychiatric hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The psychiatric hospital failed to protect and promote each patient's rights as evidenced by:
1) Failure to ensure the patient /patient representative was included in the development and implementation of the patient's plan of care for 1 (#2) of 3 (#1- #3) patients reviewed for care plan participation (see Findings Tag A0130);
2) Failure to monitor Patient #2 on 1:1 observation per physician order and hospital policy (see Findings Tag A0144);
3) Failure to monitor and observe 7 (#3, #R15, #R43 - #R47) of 14 (#3, #R15, #R42 - #R53) patients per Precautions ordered by the physician (see Findings Tag A0144);
4) Failure to monitor and observe patients as assigned by the Registered Nurse (see Findings Tag A0144); and
5) Failure to ensure 1 (S9MHT) of 4 (S7MHT, S8MHT, S9MHT, S10MHT) unlicensed direct care workers had a criminal background check performed by a Louisiana State Police approved vendor (see Findings Tag A0144).

Based on record review and interview, the psychiatric hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care. This deficient practice was evidenced by failure to ensure the patient /patient representative was included in the development and implementation of the patient's plan of care for 1 (#2) of 3 (#1- #3) patients reviewed for care plan participation.
Findings:

A review of hospital policy # CS-02, titled "Treatment Planning; Integrated Multidisciplinary," last revised 07/01/2024, revealed in part: "Policy: The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessment process. The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, measureable goals and objectives based on assessed needs and identified by the patient, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care. Procedure: 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). If the patient is unable and/or unwilling to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient's medical record."

Review of Patient #2's medical record revealed an admission date of 02/04/2025 with Major Depressive Disorder and Suicidal Ideation.

Review of Patient #2's medical document titled "Interdisciplinary Treatment Plan Master Sheet" initiated on 02/04/2025, failed to reveal evidence of Patient #2's signature or Patient #2 representative's signature indicating participation in her plan of care. Further review also failed to reveal documentation why the patient did not participate in the treatment plan.

In an interview on 02/06/2025 at 9:18 AM, S4LPNQ confirmed the Interdisciplinary Treatment Plan Master for Patient #2 failed to reveal patient/patient representative signatures indicating participation in their plan of care. S4LPNQ also confirmed there is no documentation about the reason Patient #2 did not participate in their treatment plan.

Based on observation, record review, and interview, the psychiatric hospital failed to ensure patients received care in a safe setting. This deficient practice was as evidenced by:
1) Failure to monitor Patient #2 on 1:1 observation per physician order and hospital policy;
2) Failure to monitor and observe 7 (#3, #R15, #R43 - #R47) of 14 (#3, #R15, #R42 - #R53) patients per Precautions ordered by the physician;
3) Failure to monitor and observe patients as assigned by the Registered Nurse; and
4) Failure to ensure 1 (S9MHT) of 4 (S7MHT, S8MHT, S9MHT, S10MHT) unlicensed direct care workers had a criminal background check performed by a Louisiana State Police approved vendor.
Findings:

1) Failure to monitor Patient #2 on 1:1 observation per physician order and hospital policy

A review of the psychiatric hospital policy, "Levels of Observations," Policy Number: CS-23, effective 01/11/2026 and last revised 03/01/2023, revealed in part: "Policy: Three levels of observation are utilized: every 15-minute (Q15 minute) observation; Line of Sight (Constant Observation); and one-to-one observation. The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order. Observation Levels: one-to-one observation - The staff will ensure the patient is visually within sight and within arms -reach of a staff member at all times and in all circumstances. See Appendix A for more information. Procedure: 4. One-to-one Observations: Assigns a nursing staff to perform one-to-one and ensures staff have relief for all breaks. Ensures that staff members are in arms reach of a patient at all times. Appendix A: 1:1 Observation is defined as: keeping the patient under direct observation within one arm's reach of the patient at all times. This includes use of bathroom and bathing. Protocol for 1:1 Observation: 1. Staff is to remain within arm's length of patients at all times."

Observations during a walk-through of the hospital on 02/05/2025 from 8:45 AM to 10:00 AM revealed 2 MHT's (S9MHT, S10MHT) sitting at a table along the exterior wall of Room "h." The entry door to Room "h" was closed. It was identified by S4LPNQ that Patient #2 was assigned to Room "h" and currently on 1:1 observation. S9MHT and S10MHT were positioned in chairs facing Room "t" (dayroom) where Patient #2's entry door is located and neither were in a position which would have allowed a visual observation of Patient #2 if the door was open. Patient #2 was laid in Bed B of Room "h" and appeared to be sleeping.

An immediate review of S9MHT and S10MHT observation flowsheets, revealed S10MHT was currently monitoring and in possession of 7 (#2, #R28 - #R33) of 15 (#2, #R28 - #R41) patient's Observation Check Sheet/Graphic Flowsheets. This included the 1:1 Observation patient #2. S9MHT was currently monitoring and in possession of 8 (#R34 - #R41) of 15 (#2, #R28 - #R41) patient's Observation Check Sheet/Graphic Flowsheets. The reviewed Observation Check Sheet/Graphic Flowsheets revealed S10MHT was currently observing a 1:1 patient and 6 other patients which, per hospital policy is not protocol. This type of practice placed Patient #2 at risk for potential self-injurious behavior.

A review of Patient #2's medical record revealed physician orders for 1:1 Observation with a rationale of "Danger to Self." Further, Patient #2's prescribed precaution levels included, "Suicide/Self Harm Precautions."

In an interview on 02/05/2025 and present during this walk-through, S2DON and S4LPNQ confirmed the above mentioned findings and further confirmed, Patient #2 was not being observed and monitored per hospital policy.

2) Failure to monitor and observe 7 (#3, #R15, #R43 - #R47) of 14 (#3, #R15, #R42 - #R53) patients per Precautions ordered by the physician

A review of the psychiatric hospital policy, "Elopements," Policy Number: CS-04, effective 01/11/2016 and last revised 01/01/2025, revealed in part: "Purpose: To identify those at risk for elopement and to prevent the occurrence. Procedure: 2. For patients who are screened or assessed to be at risk for elopement, the physician is notified and an order for elopement precautions is obtained. The prescribed level of observation is implemented immediately. 5. Elopement prevention strategies and interventions include, but not limited to: Initiate 1:1 or Line of sight observation level. Limit/restrict outdoor privileges (requires physician order which must be renewed every 24 hours). Ensure all staff practice door safety by ensuring all doors on and off the unit are closed and appropriately latched/locked before leaving the door area. Redirect patients away from immediate proximity of doors. Staff vigilance during outdoor time by walking the inside perimeter of fencing to stay between patients and fence. Always having two or more staff present when patients are off the locked unit within the facility. Ensure no items such as chairs, benches, garbage cans, etc. are in the outdoor courtyard that could be used to leverage patient over fencing. Direct patients away from fence during outdoor times."

A review of the psychiatric hospital policy, "Fall Assessment/Re-Assessment and Precautions," Policy Number: AS-12, effective 01/11/2016 and last revised 11/16/2022, revealed in part: "Purpose: To screen patient's potential for falling and decrease the risk of injury. Procedure: 5. Interventions shall include: Mandatory fall precautions - Interventions for patients "at risk for falls" (must implement all below): Apply yellow fall risk arm band; Provide nonskid slipper socks or ensure appropriate skid-proof footwear is used; Provide patient education; Initiate Fall Risk treatment plan. Additional fall precautions - (must select at least 2 additional interventions from below that are appropriate to the patient's individual needs): Bed alarm; Chair alarm; Ambulate with staff assistance; Ensure assistive devices (ex: eyeglasses, hearing aids) are available; Keep pathways clear; Line of Sight observation level; 1:1 observation level; Reclining chair, Assist with ADLs."

A review of the psychiatric hospital policy, "Suicide/Homicide Risk Assessment," Policy Number: AS-19, effective 01/11/2016 and last revised 11/01/2023, revealed in part: "Purpose: The purpose of this policy is to ensure an effective method for suicide/homicide screening, assessment, monitoring, and treatment of patients at risk for suicide/homicide. Policy: Prevention techniques will be accomplished by a comprehensive approach that identifies and mitigates process and system level issues contained within the hospital environment that can contribute to self-harm. Direct Care Staff who conduct suicide screening, assessment, or re-assessment will be trained and successfully pass competency test on the screening and/or assessment process and screening/assessment tools as part of new hire orientation and annually thereafter. Procedure: Inpatient: 3. All direct care staff needs to be aware of suicidal/homicide/violence risks. Suicide, homicide, and/or violence precautions will be noted in the medical record. 5. The following Risk Levels and Interventions will be used in the assessment to mitigate any suicide/homicide/violence risk: Levels of risk and appropriate interventions (Inpatient): Suicidal Risk Stratification: HIGH Suicide Risk: Suicidal ideation with intent or intent with plan in the last month or suicidal behavior within the past 3 months. Suicidal Intervention: HIGH Suicide Risk: Stay patient, initiate 1:1 observation, and notify provider to obtain order. Patient may be placed on lower level of observation based on clinical judgement of the Medical Staff and the documented justification. Initiate a "Potential for Self-Harm" treatment plan. Maintain a SAFE environment & evaluate personal belongings for ligature risk. Develop Safety Plan with suicide resources for discharge planning. Notify multidisciplinary team of patient's "high suicide risk" status. Suicidal Risk Stratification: MODERATE Suicide Risk: Suicidal ideation with method, WITHOUT plan, intent or behavior in the past month Or Suicidal behavior more than 3 months ago Or Multiple risk factors and few protective factors. Suicidal Intervention: MODERATE Suicide Risk: Implement q15 min observation. Place patient close to nurses' station with roommate, if possible. Initiate a "Potential for Self-Harm" treatment plan. Maintain a SAFE environment & evaluate personal belongings for ligature risk. Develop Safety Plan with suicide resources for discharge planning. Notify multidisciplinary team of patient's "moderate suicide risk" status. Suicidal Risk Stratification: LOW Suicide Risk: Wish to die or Suicidal Ideation WITHOUT method, intent, plan, or behavior Or Modifiable risk factors and strong protective factors Or No reported history of Suicidal Ideation or Behavior. LOW Suicide Risk: Implement q15 min observation. Continue to monitor for changes in suicidal ideation or behavior."

A review of the psychiatric hospital policy, "Sexual Acting Out (SAO) Identification and Precautions," Policy Number: CS-44, effective 12/19/2022 and no revisions, revealed in part: "Purpose: To provide staff with a framework for identifying patients who are at risk for exhibiting sexually inappropriate behavior and to provide for the implementation of precautions to ensure the safety of all patients. Policy: Definitions: Sexual Precautions: Sexual Precautions are defined as intensified levels of staff awareness and attention to patient safety/security related to sexual acting out behaviors. Sexual Precautions require varying levels of observing patients and the initiation of specific protocols and supplemental documentation, when warranted. Procedure: 4. The RN/LVN/LPN ensures all patient orders for SAO Precautions are recorded and posted. 5. The RN ensures the SAO Precaution level is communicated on the hand off report and all staff are aware of the SAO Order. Sexual Acting Out (SAO Precautions: 1. LOS or 1:1 or 15 minute observation based on clinical assessment; 2. Assess location of patient rooms based on vulnerability of the patient population in particular at-risk patients; 3. Determine if level of SAO risk requires that a patient requires his/her patient room; 4. Room visible from the nurses' station or patient lounge when possible; 5. Door open when patient is his/her room; 8. Ensure all staff members are aware of SAO behavior (including volunteers, students); 9. Ensure two staff members are present when the patient needs assistance in his/her room or isolated areas; 10. Monitor relationships, interactions, not passing, whispering, etc., among patients. 11. Screen reading materials, ensure appropriate media is viewed on the unit; 12. Visitor restrictions if appropriate."

A review of the psychiatric hospital policy, "Seizure Precautions," Policy Number: NSG-40, effective 01/11/2016 and last revised 02/01/2023, revealed in part: "Purpose: To identify patients at risk for seizure activity, implement precautions to prevent injury, and provide immediate interventions for patients during seizure activity. Seizure Precautions (Inpatient): 4. Seizure precautions may include: Ensure patient showers instead of bath & utilize shower chair (always have personnel in near proximity in case assistance is needed); Assess room for hard edges, un-necessary furniture, etc. that may cause injury if seizure occurs (remove un-necessary furniture, consider padding hard edges); Include risk for seizures in shift report; include risk of seizures in multi-disciplinary treatment plan; Ensure suction equipment, airway management equipment, and oxygen are in proximity and available for use; Prevent individual patient's known triggers once identified (i.e. bright lights, television, or specific foods)."

A review of the before mentioned policies include patient interventions to be performed and/or monitored in relation to the prescribed Precaution level.

Observations during a walk-through of the hospital on 02/05/2025 from 8:45 AM to 10:00 AM revealed S7MHT sitting at a table in Room "s." S7MHT was currently monitoring and documenting observations on 8 (#3, #R15, #R42 - #R47) of 14 (#3, #R15, #R42 - #R43) patients' Observation Check Sheet/Graphic Flowsheets. A review of these Observation Check Sheet/Graphic Flowsheets was performed with S7MHT.

In an interview on 02/05/2025 at 9:00AM, S7MHT confirmed she was currently assigned to Patients #3, #R15 and #R42 - #R47. S7MHT further confirmed, she was unaware of the before mentioned patients having any ordered Precautions.

In an interview on 02/05/2025 and present during this walk-through, S2DON and S4LPNQ confirmed the above mentioned findings.

A review of Patients #3, #R15 and #R42 - #R47 medical records for physician ordered Precautions revealed:

Patient #3: Elopement Precautions Continuous, Request Type: Routine, Status: Open, Start: 02/04/2025 1:00 PM, End Date: not avaialble; Fall Precautions Continuous, Request Type: Routine, Status: Open, Start 02/04/2025 1:00 PM, End Date: not avaialble; and Suicide/Self Harm Precautions Continuous, Request Type: Routine, Status: Open, Start 02/04/2025 1:00 PM, End Date: not avaialble.

Patient #R15: Elopement Precautions Continuous, Request Type: Routine, Status: Open, Start: 01/25/2025 12:00 PM, End Date: not avaialble; and Fall Precautions Continuous, Request Type: Routine, Status: Open, Start 01/25/2025 12:00 PM, End Date: not avaialble.

Patient #R42 no ordered Precautions.

Patient #R43: Fall Precautions Continuous, Request Type: Routine, Status: Open, Start 01/31/2025 5:00 PM, End Date: not avaialble; and Violence/Homicide Precautions Continuous, Request Type: Routine, Status: Open, Start 01/31/2025 5:00 PM, End Date: not avaialble.

Patient #44: Fall Precautions Continuous, Request Type: Routine, Status: Open, Start 01/29/2025 6:00 PM, End Date: not avaialble..

Patient #45: Elopement Precautions Continuous, Request Type: Routine, Status: Open, Start: 01/27/2025 3:00 PM, End Date: not avaialble.; Fall Precautions Continuous, Request Type: Routine, Status: Open, Start 01/27/2025 3:00 PM, End Date: not avaialble; Suicide/Self Harm Precautions Continuous, Request Type: Routine, Status: Open, Start: 01/27/2025 3:00 PM, End Date: not avaialble; and Violence/Homicide Precautions Continuous, Request Type: Routine, Status: Open, Start 01/27/2025 3:00 PM, End Date: not avaialble.

Patient #45: Elopement Precautions Continuous, Request Type: Routine, Status: Open, Start: 01/28/2025 1:00 PM, End Date: not avaialble; and Patient #45: Violence/Homicide Precautions Continuous, Request Type: Routine, Status: Open, Start: 01/28/2025 1:00 PM, End Date: not avaialble..

Patient #46: Elopement Precautions Continuous, Request Type: Routine, Status: Open, Start: 01/29/2025 4:00 PM, End Date: not avaialble; and Fall Precautions Continuous, Request Type: Routine, Status: Open, Start 01/29/2025 4:00 PM, End Date: not avaialble.

A review of the before mentioned medical records revealed orders for precautions on 7 (#3, #R15, #R43 - #R47) of 8 (#3, #R15, #R42 - #R47) medical records. S7MHT was unaware of the ordered Precautions on the patients she was observing and monitoring which jeopardized their safety and well-being.

In an interview on 02/05/2025 at 1:30 PM S3DQ confirmed the above mentioned findings during medical record review and further confirmed the MHT's should be aware of the patient's Precautions.

3) Failure to monitor and observe patients as assigned by the Registered Nurse

A review of the psychiatric hospital policy, "Levels of Observations," Policy Number: CS-23, effective 01/11/2026 and last revised 03/01/2023, revealed in part: "Policy: Three levels of observation are utilized: every 15-minute (Q15 minute) observation; Line of Sight (Constant Observation); and one-to-one observation. The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order. Observation Levels: one-to-one observation - The staff will ensure the patient is visually within sight and within arms -reach of a staff member at all times and in all circumstances. See Appendix A for more information. Procedure: 4. One-to-one Observations: Assigns a nursing staff to perform one-to-one and ensures staff have relief for all breaks. Ensures that staff members are in arms reach of a patient at all times. Appendix A: 1:1 Observation is defined as: keeping the patient under direct observation within one arm's reach of the patient at all times. This includes use of bathroom and bathing. Protocol for 1:1 Observation: 1. Staff is to remain within arm's length of patients at all times."

A review of the psychiatric hospital policy, "Nursing Assignments," Policy Number: NSG-05, effective 01/11/2016 and last revised 06/01/2023, revealed in part: "Purpose: To ensure a safe, therapeutic milieu and delivery of quality care by designating specific duties to appropriate staff members. To ensure the assignment of nursing staff without regard to race, color, disability, or national origin of ether staff or patients. Policy: It is the charge nurse's responsibility to complete the nursing assignment sheet at the onset of every shift. All nursing staff member are held accountable for duties assigned. Charge nurses will supervise assignments and ensure completion of all delegated duties. Procedure: In-Patient: 1. The charge nurse will determine the nursing care assignments for the shift based on patient acuity, and capabilities and scope of practice of available staff. Every patient will be assigned to a specific staff person. 2. All nursing staff team members will be notified of their assigned responsibilities and the shift assignment will be posted. 3. The charge nurse is involved with and responsible for supervising and evaluating the care of all patients. Patient care assignments area commensurate with the qualifications of the nursing staff member assigned. 5. Agency/contracted nursing personnel will receive training and competency assessment/documentation prior to receiving a patient care assignment."

Observations during a walk-through of the hospital on 02/05/2025 from 8:45 AM to 10:00 AM revealed 2 MHT's (S9MHT, S10MHT) sitting at a table along the exterior wall of Room "h." An immediate review of S9MHT and S10MHT observation flowsheets, revealed S10MHT was currently monitoring and in possession of 7 (#2, #R28 - #R33) of 15 (#2, #R28 - #R41) patient's Observation Check Sheet/Graphic Flowsheets. This included the 1:1 Observation Patient #2. S9MHT was currently monitoring and in possession of 8 (#R34 - #R41) of 15 (#2, #R28 - #R41) patient's Observation Check Sheet/Graphic Flowsheets. The reviewed Observation Check Sheet/Graphic Flowsheets revealed S10MHT was currently observing a 1:1 patient and 6 other patients which, per hospital policy is not protocol.

A review of the hospital's 7A-7P Assignment Sheet, dated 02/05/2025, revealed in part, S10MHT was assigned Patients #2 and #R34 - #R40 and S9MHT was assigned Patients #R41 and #R28 - #R33. The hospital's 7A-7P Assignment Sheet, dated 02/05/2025 did not match the MHT/patient assignments being performed. The change in patient assignment without the charge nurse's involvement could jeopardized the safety and well-being of patients.

In an interview on 02/05/2025 and present during this walk-through, S2DON and S4LPNQ confirmed the above mentioned findings.

In an interview on 02/05/2025 at 2:45 PM, S3DQ confirmed the above mentioned findings.

In an interview on 02/06/2025 at 8:25 AM, S5RN confirmed the above mentioned findings and further confirmed she had made the assignment on 02/05/2025, however S9MHT and S10MHT had changed their assignments.

4) Failure to ensure 1 (S9MHT) of 4 (S7MHT, S8MHT, S9MHT, S10MHT) unlicensed direct care workers had a criminal background check performed by a Louisiana State Police approved vendor

Pursuant to La. R.S. 40:1203.7, Authorized Agencies must be domiciled in the state of Louisiana and must be certified by the LA Secretary of State's office. Authorized Agents must also be certified by the Bureau of Criminal Identification and Information (Bureau). Companies that perform background check services that are not domiciled in Louisiana nor certified through the Secretary of State's office and the Bureau are not authorized to request or receive criminal history information stored in Louisiana Computerized Criminal History (LACCH) database. The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the State's designated repository for criminal history information pursuant to the laws cited in La. R.S. 15:575 et seq. Any criminal event that is documented by the submission of fingerprints to the State is stored in the Louisiana Computerized Criminal History (LACCH) database. The Bureau may only release criminal history information stored in LACCH for noncriminal justice purposes when authorized by law. The Bureau is authorized to release criminal history information stored in LACCH to those employers and Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2

A review of hospital policy, "Selections of Employees," Policy Number: HR 01.02, effective 01/11/2016 and revised 09/01/2024, revealed in part, "Purpose: To establish consistent recruiting, hiring and retention policies that comply with all federal, state, and local laws and/or regulation in order to attract and retain the most qualified employees. Procedure: Employee Background Checks: In addition to thorough reference checks, additional background checks are required utilizing an approved company vendor prior to extending an offer of employment.

A review of personnel files revealed S9MHT's prior to hire criminal background check being performed by an unapproved vendor - DISA.

In an interview on 02/06/2025 at 9:15 AM, S12HR confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by:
1) failure of the Registered Nurse to document patient observations every 2 hours per hospital policy;
2) failure of the Registered Nurse to assign Observation Levels for 4 (Patient #1, R2-R4) of 28 (Patient #1, R1-R27) patient Observation Check Sheets reviewed; and
3) failure of the Registered Nurse to document the nursing shift assessment on 1 (#1) of 3 (#1-#3) patient's medical records reviewed.
Findings:

Review of the hospital policy # CS-23, titled "Level of Observation," last revised, 03/01/2023, revealed in part: "Observation Levels: -Every 15 minutes- The staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. -Line of Sight (Constant Observation)- The staff member will ensure the patient is visually within sight at all times. -One-to-one Observation- The staff will ensure the patient is visually within sight and within arms-reach of a staff member at all times and in all circumstances. Procedure: 1. The initial patient observation level is determined and ordered by the physician upon patient admission. The decision to utilize one of the observation levels is made based on the patient's needs and presenting symptomology. 3. Staff members utilize the close observation checklist form (Q15 check sheet) to document the ongoing observation and location of the patient. The observing staff initials the 15-minute increments on the form to indicate the patient was observed. This form or vital sign form will also be utilized for 1:1 monitoring when stricter level of monitoring is ordered and will be notated as such on the top of the form. The staff member signs the signature line at the bottom of the form to validate their initials and credentials. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section(s) of the form. Every 15 Minute Observation: RN assigns staff members to q15-minute observations, Line of Sight or one-to-one observation based on physician/NPP orders and assigns breaks and meal-time relief."

1) Failure of the Registered Nurse to document patient observations every 2 hours per policy.

Review of the Patient #1's Observation Check Sheet dated 01/24/2025, revealed the Registered Nurse failed to review and sign that the patient observations were completed every 2 hours within the timeframes below:
01/25/2025 between 3:15 AM - 6:45 AM.

In interview on 02/05/2025 at 2:00 PM, S4LPNQ confirmed that the RN did not document that observations were performed every 2 hours per hospital policy.

Review of the Patient Observation Check Sheets dated 01/26/2025, revealed the Registered Nurse failed to review and sign that the patient observations were completed every 2 hours for 5 (Patient #1, R1-R3) of 28 (Patient #1, R1-R27) patient Observation Check Sheets reviewed within the timeframes below:

Review of Patient #1's Observation Check Sheet dated 01/26/2025, revealed RN observations were not documented every 2 hours on 01/26/2025 between 7:00 AM - 6:45 PM.

Review of R1's Observation Check Sheet dated 01/26/2025, revealed RN observations were not documented every 2 hours on 01/26/2025 between 7:00 AM - 6:45 PM.

Review of R2's Observation Check Sheet dated 01/26/2025, revealed RN observations were not documented every 2 hours on 01/26/2025 between 7:00 AM - 6:45 PM.

Review of R3's Observation Check Sheet dated 01/26/2025, revealed RN observations were not documented every 2 hours on 01/26/2025 between 7:00 AM - 6:45 PM.

Review of R4's Observation Check Sheet dated 01/26/2025, revealed RN observations were not documented every 2 hours on 01/26/2025 between 7:00 AM - 6:45 PM.

In interview on 02/05/2025 at 2:05 PM, S4LPNQ confirmed that the RN did not document that observations were performed every 2 hours per hospital policy on the above mentioned patients.

2) Failure of the Registered Nurse to assign Observation Levels for 4 (Patient #1, R2-R4) of 28 (Patient #1, R1-R27) patient Observation Check Sheets reviewed.

A review of the Patient Observation Check Sheet for Patient #1 dated 01/26/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse.

A review of the Patient Observation Check Sheet for R2 dated 01/26/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse.

A review of the Patient Observation Check Sheet for R3 dated 01/26/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse.

A review of the Patient Observation Check Sheet for R4 dated 01/26/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse.

In interview on 02/05/2025 at 2:05 PM, S4LPNQ confirmed that the RN did not document that observations were performed every 2 hours per hospital's policy on the above mentioned patients.

3) Failure of the Registered Nurse to document the nursing shift assessment on 1 (#1) of 3 (#1-#3) patient's medical records reviewed.

A review of hospital policy # NSG-02, titled "Documentation," last revised 01/01/2023, revealed in part: "Policy: Inpatient nursing personnel document patient's progress every 12-hour shift, incorporating the elements of the nursing process and patient's treatment goals and progress within the patient's medical record. Inpatient: Daily: The Registered Nurse (RN) documents or review the LPN/LVN documentation on the Nursing Shift Assessment a minimum of once per shift. 1. All notes must be related to the patient's problems on the treatment plan."

Review of Patient #1's medical record failed to reveal a nursing shift assessment documented on 01/20/2025 for night shift.

In an interview on 02/05/2025 at 3:31 PM, S4LPNQ confirmed that the nurse failed to document a shift assessment on the night of 01/20/2025 per hospital policy.

Based on observation, record review and interview, the psychiatric hospital failed to ensure a registered nurse assigned the nursing care of each patient to other personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. This deficient practice was evidenced by the MHTs changing their patient care assignments.
Findings:

A review of the psychiatric hospital policy, "Nursing Assignments," Policy Number: NSG-05, effective 01/11/2016 and last revised 06/01/2023, revealed in part: "Purpose: To ensure a safe, therapeutic milieu and delivery of quality care by designating specific duties to appropriate staff members. To ensure the assignment of nursing staff without regard to race, color, disability, or national origin of ether staff or patients. Policy: It is the charge nurse's responsibility to complete the nursing assignment sheet at the onset of every shift. All nursing staff member are held accountable for duties assigned. Charge nurses will supervise assignments and ensure completion of all delegated duties. Procedure: In-Patient: 1. The charge nurse will determine the nursing care assignments for the shift based on patient acuity, and capabilities and scope of practice of available staff. Every patient will be assigned to a specific staff person. 2. All nursing staff team members will be notified of their assigned responsibilities and the shift assignment will be posted. 3. The charge nurse is involved with and responsible for supervising and evaluating the care of all patients. Patient care assignments area commensurate with the qualifications of the nursing staff member assigned. 5. Agency/contracted nursing personnel will receive training and competency assessment/documentation prior to receiving a patient care assignment.

A review of the psychiatric hospital policy, "Levels of Observations," Policy Number: CS-23, effective 01/11/2026 and last revised 03/01/2023, revealed in part: "Policy: Three levels of observation are utilized: every 15-minute (Q15 minute) observation; Line of Sight (Constant Observation); and one-to-one observation. The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order. Observation Levels: one-to-one observation - The staff will ensure the patient is visually within sight and within arms -reach of a staff member at all times and in all circumstances. See Appendix A for more information. Procedure: 4. One-to-one Observations: Assigns a nursing staff to perform one-to-one and ensures staff have relief for all breaks. Ensures that staff members are in arms reach of a patient at all times. Appendix A: 1:1 Observation is defined as: keeping the patient under direct observation within one arm's reach of the patient at all times. This includes use of bathroom and bathing. Protocol for 1:1 Observation: 1. Staff is to remain within arm's length of patients at all times."

Observations during a walk-through of the hospital on 02/05/2025 from 8:45 AM to 10:00 AM revealed 2 MHT's (S9MHT, S10MHT) sitting at a table along the exterior wall of Room "h." An immediate review of S9MHT and S10MHT observation flowsheets, revealed S10MHT was currently monitoring and in possession of 7 (#2, #R28 - #R33) of 15 (#2, #R28 - #R41) patient's Observation Check Sheet/Graphic Flowsheets. This included the 1:1 Observation Patient #2. S9MHT was currently monitoring and in possession of 8 (#R34 - #R41) of 15 (#2, #R28 - #R41) patient's Observation Check Sheet/Graphic Flowsheets. The reviewed Observation Check Sheet/Graphic Flowsheets revealed S10MHT was currently observing a 1:1 patient and 6 other patients which, per hospital policy is not protocol.

A review of the hospital's 7A-7P Assignment Sheet, dated 02/05/2025, revealed in part, S10MHT was assigned Patients #2 and #R34 - #R40 and S9MHT was assigned Patients #R41 and #R28 - #R33. The hospital's 7A-7P Assignment Sheet, dated 02/05/2025 did not match the MHT/patient assignments being performed. The change in patient assignment without the charge nurse's involvement could jeopardized the safety and well-being of patients.

In an interview on 02/05/2025 and present during this walk-through, S2DON and S4LPNQ confirmed the above mentioned findings.

In an interview on 02/05/2025 at 2:45 PM, S3DQ confirmed the above mentioned findings.

In an interview on 02/06/2025 at 8:25 AM, S5RN confirmed the above mentioned findings and further confirmed she had made the assignment on 02/05/2025, however S9MHT and S10MHT had changed their assignments.

50453


Based on record review and interview, the hospital nursing staff failed to administer medications in accordance with the accepted standards of practice. This deficient practice is evidenced by:
1) failure of the nursing staff to administer medications within the appropriate timeframe per physician order in 1 (#2) of 3 (#1-#3) patient medical records reviewed; and
2) failure of nursing staff to notify the physician of an abnormal blood pressure per hospital policy.
Findings:

1) Failure of the nursing staff to administer medications within the appropriate timeframe per physician order in 1 (#2) of 3 (#1-#3) patient medical records reviewed.

Review of hospital policy # MM-01, titled "Medications," last revised: 12/01/2024, revealed in part: "Medication administration: Before administering a medication, the licensed independent practitioner or qualified individual administering the medication does the following: -Verifies that the medication is being administered at the proper time, in the prescribed dose, and by the correct route."

Review of Patient #2's medication administration record revealed the following order:
Hydroxyzine Pamoate (Vistaril) 50mg (1 capsule) by mouth, every 8 hours, PRN: Anxiety.
Further review of Patient #2's medication administration record revealed the following dates/times of administration:
02/05/2025 at 4:18 PM
02/05/2025 at 10:03 PM

Review of Patient #2's medical record failed to reveal nursing documentation that the provider was notified or that the provider approved the administration of the medication to be given early.

In an interview on 02/06/2025 at 9:03 AM, S4LPNQ confirmed the PRN medication was given early and not as prescribed by the provider. S4LPNQ also verified that there was no documentation by the nurse that the provider approved them to administer the medication early. At this time S3DQ also confirmed that the medication above was administered within 6 hours of each other and not within 8 hours as prescribed by the provider.

2) Failure of nursing staff to notify the physician of an abnormal blood pressure per hospital policy

A review of hospital policy, " Vital Signs Monitoring," Policy Number NSG-34, effective 01/11/2016 and last revised 12/01/2022, revealed in part, " Purpose: To ensure vital signs are accurately obtained and monitored as ordered by the physician/non-physician practitioner (NPP). Policy: It is the policy of the Hospital to effectively communicate all vital signs that fall outside of the "within normal limits" parameters in a timely manner to licensed and independent practitioners as established by acceptable nursing practice. Vital signs include Blood Pressure (B/P), Pulse (P), Respirations (R), and Temperature (T). Procedure: 4. Normal vital signs are: Blood Pressure: Adults - <120/80. 6. The RN will notify the physician or NPP of abnormal vital signs and assessments based on nursing judgement and critical thinking. Parameters and patient's baseline are used as a guide in judgement and assessment on reporting of vital signs to physician/NPP. Reporting ranges may vary according to symptomology and history of individual's baseline.

A review of Patient #2's medical record revealed a History and Physical performed by S11FNP on 02/01/2025 at 1:15 pm and indicated a prior medical history of hypertension, vascular dementia, cerebral vascular accident, heart failure, coronary artery disease and Stage 3 chronic kidney disease. A review of Patient #2's daily vital sign record revealed a B/P of 183/77 on 02/02/2025 at 4:01 AM. The prior B/P reading on 02/01/2024 at 10:18 PM was 155/78. The latter of the 2 readings does fall within Patient #2's baseline, however the 183/77 would be outside of the patient's baseline and considered abnormal. A review of the medication administration record revealed clonidine HCL 0.1mg was administered by mouth on 02/04/2025 at 4:04 AM with a follow up of, "effective 108/56" at 6:04 AM. The medical record did not reveal any documentation of the physician or NPP being contacted regarding this abnormal B/P.

In an interview on 02/10/2025 at 3:00 PM, S3DQ confirmed the above mentioned findings.

Based on observation and interview, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair.
Findings:

Observations during a tour on 02/05/2025 8:45 AM - 10:02 AM revealed the following:
- Room a - room p revealed 2 sets of shelves containing large amounts of grey, fuzzy substance resembling dust.
- Room q revealed a mattress with 2 large tears in the mattress.

In an interview during the hospital tour, S2DON and S4LPNQ confirmed the above mentioned findings.

Based on observation and interview, the hospital failed to ensure the infection prevention program included surveillance of the facility to identify and mitigate identified sources with potential for transmission of infection. This deficient practice was evidenced by failing to ensure the hospital maintained a sanitary environment to prevent infection.
Findings:

A review of hospital policy # IC-05.04, titled "Separation of Clean and Dirty Supplies," last revised 01/01/2025, revealed in part: "Procedure: The clean and dirty utility areas are separated into two different rooms. The rooms must be clean and tidy at all times. Sterile and clean items can be stored in the same room, but each category should be located in separate areas, i.e., individual shelves, individual cabinets, individual bins. Any supplies which have been used on or by a patient are considered dirty/soiled. Disposable patient care items are assigned to and used for only one patient are discarded or sent with the patient upon transfer or discharge. Single use items are discarded after each use."

Observations of room r during a tour on 02/05/2025 8:45 AM - 10:02 AM revealed the following used supplies:
- Medline Remedy Cleanse No-Rinse Foam Cleaner, quantity 2
- Medline Skin Integrity Cleanser, quantity 2
- Sparkle Fresh Toothpaste, quantity 2
- Moisturize Body Lotion, quantity 2
- Anti-perspirant, quantity 1
- Shaving Cream can, quantity 3

In an interview on 02/05/2025 at 9:11 AM, S2DON and S4LPNQ confirmed the above mentioned findings. S2DON and S4LPNQ also confirmed that opened/used supplies should not be stored in room r and should have been discarded.