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Based on review of facility policies, review of facility documents, review of medical records (MR), and interviews with staff (EMP), it was determined that the hospital failed to ensure that patients received care in a safe setting. This deficiency had the potential to impact all 83 patients at the facility.


On October 7, 2024 at 11:28 AM, as a result of this failure, Immediate Jeopardy (IJ) was identified. The immediate interventions implemented by the facility included staff re-education, review and assessment of all current patients precautions and observation levels, along with implementing appropriate precautions and monitoring when needed, reviewing staffing schedules and obtaining additional staff whenever a provider identifies the need. The IJ was removed on October 8, 2024 at 2:02 PM after the State Survey Agency completed onsite verification that the facility implemented the corrective actions addressing the IJ.

Cross Reference:

482.13(c)(2) Patient Rights: Receive care in a safe setting

Based on observations, review of medical records (MR), review of facility policies and documents, and interviews with staff (EMP), it was determined that the facility failed to provide care in a safe setting as evidenced by failing to ensure that appropriate interventions were implemented for patients who demonstrated physical aggression towards a peer; failing to ensure safety observations were conducted as ordered; and failing to ensure that a unit locker containing PPE (personal protective equipment), a potential ligature risk, was secure. These deficiencies had the potential to impact all 83 patients within the facility.

Findings include:

Review of facility policy "Homicidal Patient Risk Reduction Guidelines" issued September 2023, last revised September 2023, revealed, "...Mental Health Professionals have a duty to protect individuals who are being threatened... verbally...with bodily harm by a patient. Patients...that...are a danger to others should be managed in such a way as to minimize the threat of injury or harm...1:1 Observation may be implemented if a patient is exhibiting extremely aggressive behaviors...which include...A history of attempting to harm others, which produced or could have produced serious physical harm while in an intensive treatment setting..."

Review of facility policy "Level of Observation/Rounds", issued January 2017, last revised January 2019, revealed, "...The physician shall order one of two levels of observation at time of admission...and may change the level...if the patient's condition warrants a change...If...the patient's condition changes and the Charge Nurse's clinical assessment indicated the patient requires a higher level of observation, the RN [registered nurse] may implement, and then call the primary physician to obtain an order to place the patient on a 1:1...Any patient placed on 1:1 shall be assigned an identified staff member... MHTs [mental health technicians] ...identify and report any findings while conducting observation rounds ... Ensure doors that are to be locked are, on [sic] fact, locked..."

Review of facility document "Dover Behavioral Health System Medical Staff Bylaws", no date, revealed, "...each applicant to the Allied Health Professional (AHP) Staff...obligates himself to provide his patients...with continuous and timely care...The Prerogatives of an AHP shall be to...write orders within scope of their license...and in accordance with...the Facility's Policies and Procedures..."


I. Failure to Implement Appropriate Interventions

Review of MR6 "Psychiatric Assessment" signed by EMP16 on 5/22/2024 at 3:41 PM revealed, "...Patient is acutely psychotic...intermittently becoming aggressive and loud but is easily redirectable...is verbally aggressive, but not violent at this time...Patient will be admitted...Q 15-minute safety check will suffice..."

Review of MR6 "Final Ancillary Orders (non-med)" revealed that Patient #6 was ordered every 15-minute observations with precautions for self-harm and aggression/homicide on 5/22/2024 at 1 PM.

Review of facility incident report revealed that on 5/28/2024 at 4:20 AM, Patient #5 was ambulating down the hall when Patient #6 pushed her/him to the floor. Patient #5's head began to bleed, a laceration was assessed, the area was cleansed with normal saline solution and Patient #5 was sent to the acute care hospital for evaluation and treatment.

Review of MR6 "Daily Physician Progress Notes" dated 5/27/2024 through 5/30/2024 revealed that patient was paranoid, manic, psychotic, loud, aggressive, agitated and refusing medication.

Review of MR6 "Daily Nursing Progress Notes" dated 5/23/2024 through 5/29/2024 revealed that patient was irritable, delusional, paranoid, agitated, verbally aggressive towards peers and staff, and refusing medications.

Review of MR6 revealed a copy of a notarized letter, dated 5/30/2024, addressed to "Your Honor, State of Delaware" and signed by EMP16. The letter revealed, "...Pt has refused to consent voluntary to take medication...Pt is imminently danger [sic] to...self and others...has physically assaulted... peer and...is currently on 1:1 for safety. Patient has been verbally aggressive towards peers and staff..."

Review of MR6 "Physician's Orders" revealed, "...5/30/24...1030 [10:30 AM] ...Will have 1:1 while awake, pt aggressive, physical towards peer, refusing meds..."

Interview was conducted on 10/4/2024 from 10:59 AM to 11:16 AM with EMP16, staff psychiatrist. EMP16 was questioned about the rationale for not ordering a "1:1 while awake" level of observation for Patient #6 on 5/28/2024, the day Patient #6 assaulted Patient #5. EMP16 replied, "There were some staff shortages on the unit, we try to talk to the patient and calm them down. I would have liked to put the patient on 1:1." EMP16 could not remember who in nursing administration told him/her about the West Unit being short staffed on the 7a-3p shift on 5/28/2024, the day of the incident. EMP16 admitted that he/she did not write the 1:1 order that day for Patient #6 because of the short staffing on the unit. EMP16 confirmed that the 1:1 should have been ordered for Patient #6 on 5/28/2024 after the incident with Patient #5, per hospital policy.

Review of facility document titled, "Dover Behavioral Health System-Staffing Model 2024", no date, revealed a staffing grid for the East, North, South and West Units. The document also revealed, "...The combination of Nurses and MHT's [Mental Health Technicians] may also be adjusted based on the needs of the unit...West...4:1 Ratio on Days/Evenings..."

On 10/4/2024, in reviewing West Unit staffing for the 5/28/2024 7a-3p shift, EMP4 stated that the unit had a census of 33 patients with no 1:1 cases. Staffing was 1 RN, 1 LPN, and 5 MHT's, which was one MHT short for the 7a-3p shift. This finding was confirmed with EMP4 at 1:45PM.

Review of MR12 "Patient Demographic Profile" revealed that Patient #12 was admitted on 6/2/2024 at 6:20 AM and discharged on 7/3/2024 at 6:20 PM.

Review of MR10 "Patient Demographic Profile" revealed that Patient #10 was admitted on 5/22/2024 at 8:26 PM and discharged on 6/10/2024 at 5:30 PM.

Review of MR10 "Psychiatric Assessment" revealed, "...Patient is acutely psychotic, paranoid...patient has been noncompliant to...medication and decompensated...Patient will be admitted...Q [every] 15-minute safety check will suffice; however, patient is currently in the [sic] seclusion because of agitation and aggression..."

Review of facility incident reports revealed that on 6/4/2024 at 8:45 AM, Patient #12 was sitting in his/her wheelchair at the nurses' station when Patient #10 pushed and slammed the wheelchair into the double doors which caused Patient #12 to hit his/her head and fall out of the wheelchair. Patient #12 sustained a bruise and raised area to the forehead and complained of pain. Patient #12 was sent to the acute care hospital to be evaluated for a possible head injury. The reports described Patient #10 as being angry and agitated at the time of the incident.

Review of MR10 "Daily Physician Progress Notes" dated 5/29/2024 through 6/5/2024 revealed that the patient was delusional, irritated, angry, agitated and aggressive.

Review of MR10 "Daily Physician Progress Note" dated 6/4/24 at 8:30 AM revealed, "...Pt aggressive, agitated yesterday, push [sic] the wheelchair & other peer got injured...Recommend 1:1..."

Review of MR10 "Daily Nursing Progress Notes" dated 5/26/2024 through 6/5/2024 revealed that patient was irritable, unpredictable, intrusive, paranoid, delusional, manic, argumentative, and violent.

In an interview conducted on 10/7/2024 from 11:07 AM to 11:17 AM with EMP16, staff psychiatrist, EMP16 was questioned about the rationale for not ordering a 1:1 level of observation for Patient #10 after the incident of physical aggression with Patient #12 on 6/4/2024. EMP16 replied, "[Patient #10] did not want to be a 1:1. After the incident, the patient did not remember it. Patient stated...cannot do 1:1 because it is a trauma for [him/her] ...I think I should have done that, put [him/her] on a 1:1 based on the patient and...behavior."

Nursing staff also failed to initiate a 1:1 level of observation for Patient #6 and Patient #10, based on each patient's documented behaviors and hospital policy. These findings were confirmed with EMP1 and EMP4 during an interview on 10/8/2024 from 9:32 AM to 10:29 AM.



II. Failure to Conduct Safety Observations as Ordered

Review of MR5 "Final Ancillary Orders (non-med)" revealed, "...Observations-15-minute checks... Start Time: 5/17/24 12:00 [12 PM] ..."

Review of MR5 medical record (MR) revealed no evidence of a "Patient Observation Record" for 5/29/2024.

This finding was confirmed with EMP2 on 10/8/2024 at 1:58 PM.


Review of MR10 "Final Ancillary Orders (non-med)" revealed, "...Observations-15-minute checks...Start Time: 5/22/24 22:00 [10:00 PM] ..."

Review of MR10 medical record (MR) revealed no evidence of a "Patient Observation Record" for 6/6/2024.

This finding was confirmed with EMP2 on 10/8/2024 at 1:58 PM.


Review of MR12 "Final Ancillary Orders (non-med)" revealed, "... Observations-15-minute checks...Start Time: 6/2/2024 10:00 [10:00 AM] ..."

Review of MR12 medical record (MR) revealed no evidence of a "Patient Observation Record" for 6/6/2024.

This finding was confirmed with EMP2 on 10/8/2024 at 1:58 PM.



III. Failure to Securely Store Items that Posed Potential Ligature Risks

During a flash tour of the East Unit on 10/2/2024 from 10:06 AM to 10:55 AM, Locker 1426 B was found unsecured. The locker contained personal protective equipment including disposable gowns and disposable face shields, which could be considered potential ligature risks. During an interview on 10/3/2024 at 4:35 PM, EMP6, Corporate Director, confirmed, that per the "Level of Observation/Rounds" policy, "Patient observation policy can apply to all doors."

This finding was confirmed with EMP7 on 10/2/2024 at 10:18 AM.

Based on medical record review (MR), review of facility policies, review of facility documents, review of facility video surveillance, and interviews with staff (EMP), it was determined that the hospital failed to maintain an organized nursing service as evidenced by: failure to ensure patient observations were completed as ordered (A395); failure to supervise and evaluate nursing care (A395); failure to ensure patient progress notes contained the date, time, and signature of the responsible discipline (A398); failure to ensure that nursing staff carried out a physician's order (A398); and failure to ensure that medications were administered in accordance with acceptable standards of practice (A405). These deficiencies had the potential to impact all 83 patients at the facility.

On October 8, 2024, at 12:30 PM, as a result of this failure, Immediate Jeopardy (IJ) was identified. The immediate interventions implemented by the facility included re-education of medication administration with step-by-step instructions and return demonstration competencies, and daily monitoring. The IJ was removed on October 9, 2024, at 9:14 AM after the State Survey Agency completed onsite verification that the facility implemented the corrective actions addressing the IJ.



Cross Reference:
482.23(b)(3) RN Supervision of Nursing Care
482.23(b)(6) Supervision of Contract Staff
482.23(c) Preparation and Administration of Drug

Based on observations, review of medical records (MR), review of facility policies, review of facility documents, and interviews with staff (EMP), it was determined that the facility failed to complete ordered patient observations and failed to supervise and evaluate the nursing care for 17 out of 21 patients sampled (MR1, MR2, MR3, MR4, MR5, MR7, MR8, MR10, MR12, MR14, MR15, MR16, MR17, MR18, MR19, MR20, and MR 21).

Findings include:

Review of facility job description, "Charge Nurse (RN [registered nurse] III)", updated July 27, 2018, revealed, " ...Timely review of the Patient Observation Round sheets for each patient to ensure all levels of observation and precautions are accounted for and sign and date round sheets twice per shift ..."

Review of facility policy "Level of Observation/Rounds" issued January 2017, last revised January 2019, revealed, "...The Charge Nurse reviews and signs the Patient Observation Rounds sheet a minimum of 2x per shift...MHTs [mental health technicians] ...Observe each patient, a minimum of every 15 minutes...and document observation on the patient form..."


I. 15-Minute Observations

Patient #2 ordered Q (every) 15-minute checks on 9/9/2024 at 1 AM.

Review of MR2 "Patient Observation Record", dated 9/11/2024, revealed no documentation of a 15-minute patient observation at 11:15 AM, as ordered.

This finding was confirmed with EMP4 on 10/8/2024 at 9:53 AM.



II. Nursing Supervision of Patient Safety Observations

The Patient Observation Rounds sheet contains a section for registered nurses to sign for supervising the observations in 4-hour time slots (12:00 AM - 4:00 AM; 4:00 AM - 8:00 AM, etc.).


Review of MR1 "Patient Observation Record" revealed no evidence of nursing signatures to indicate a nurse supervised the observation rounds on the following dates and times:

9/23/2024: 8 AM to 4 PM (4 hours)
9/25/2024: 12 AM to 4 PM (16 hours)
9/26/2024: 8 AM to 4 PM (8 hours)

These findings were confirmed during an interview conducted on 10/8/2024 between 9:35 AM-9:42 AM with EMP4.


Review of MR2 "Patient Observation Record" revealed no evidence of nursing signatures to indicate a nurse supervised the observation rounds on the following dates and times:

9/8/2024: 8 PM-12 AM (4 hours)
9/10/2024: 12 AM-8 AM (8hours) and 8 PM-12 AM (4 hours)
9/12/2024: 8AM-4PM (8 hours)
9/13/2024: 8AM-12 PM (4 hours)
9/14/2024: 12 AM-12AM (24 hours)
9/15/2024: 4 PM-12 AM (8 hours)
9/16/2024: 12 PM-4 PM (4 hours)
9/19/2024: 4 PM-12 AM (8 hours)
9/20/2024: 8AM-4 PM (8 hours)
9/23/2024: 8 AM-4 PM (8 hours)
9/25/2024: 12 AM-4 PM (16 hours)
9/26/2024: 8 AM-4 PM (8 hours) and 8 PM-12 AM (4 hours)

These findings were confirmed during an interview conducted on 10/8/2024 from 9:51 AM-9:57 AM.


Review of MR3 "Patient Observation Record" revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times:

9/10/24: 8 PM-12 AM (4 hours)
9/14/24: 12 PM-4PM (4 hours)
9/18/24: 8 AM-4 PM (8 hours)
9/19/24: 4 PM-12 AM (8 hours)
9/20/24: 8 AM-4 PM (8 hours)
9/23/24: 8 AM-4 PM (8 hours)
9/24/24: 8 AM-4 PM (8 hours)
9/25/24: 12 PM-4 PM (4 hours)
9/26/24: 8 AM-4 PM (8 hours)
9/27/24: 8 AM-4 PM (8 hours)
9/29/24: 8 AM-4 PM (8 hours)

These findings were confirmed by EMP4 on 10/8/24 at 9:30AM.


Review of MR4 "Patient Observation Record" revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times:

9/10/24: 8 AM-12 AM (16 hours)
9/12/24: 8 AM-4 PM (8 hours)
9/14/24: 12 PM-4 PM (4 hours)
9/18/24: 8 AM-4 PM (8 hours)
9/19/24: 4 PM-12 AM (8 hours)
9/20/24: 8 AM-4 PM (8 hours)
9/23/24: 8 AM-12 AM (16 hours)
9/24/24: 8 AM-4 PM (8 hours)
9/25/24: 12 AM-8 AM (8 hours)
9/27/24: 8 AM-4 PM (8 hours)
9/29/24: 8 AM-4 PM (8 hours)

These findings were confirmed with EMP4 on 10/8/24 at 9:30AM.


Review of MR5 "Patient Observation Record" revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times:

5/19/2024: 8 AM-12 PM (4 hours)

This finding was confirmed with EMP4 on 10/8/2024 at 10:07 AM.


Review of MR7 "Patient Observation Record" revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times:

9/19/2024: 4:00 PM-12:00 AM (8 hours)
9/20/2024: 8:00 AM-4:00 PM (8 hours)
9/25/2024: 12:00 AM-4:00 PM (16 hours)
9/26/2024: 8:00 AM-4:00 PM (8 hours)
9/29/2024: 8:00 AM-4:00 PM (8 hours)
10/1/2024: 12:00 AM-8:00 PM (20 hours)

These findings were confirmed during an interview conducted on 10/8/2024 between 9:35 AM-9:42 AM with EMP4.


Review of MR8 "Patient Observation Record" revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times:

9/21/24: 12 PM-4 PM (4 hours)
9/25/24: 12 AM-8 AM (8 hours)
9/26/24: 8 AM-4 PM (8 hours)
9/28/24: 12 PM-12 AM (12 hours)

These findings were confirmed with EMP4 on 10/8/24 at 930AM.


Review of MR10 "Patient Observation Record" revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times:

5/28/2024: 4 PM-12 AM (8 hours)
5/29/2024: 4 PM-12 AM (8 hours)

These findings were confirmed with EMP4 on 10/8/2024 at 10:19 AM.


Review of MR12 "Patient Observation Record" revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times:

6/5/2024: 8 PM- 12 AM (4 hours)
6/16/2024: 4 PM-12 AM (8 hours)

These findings were confirmed with EMP4 on 10/8/2024 at 10:28 AM.


Flash tour of the East Unit conducted on 10/2/2024 from 10:06 AM-10:55 AM.

Review of MR14, MR15, MR16, MR17, MR18, MR19, MR20 and MR21 "Patient Observation Record" revealed no evidence of nursing signatures to indicate a nurse supervised the patient observation rounds on the following dates and times:

10/2/2024: 12 AM-8 AM (8 hours)

These findings were confirmed by EMP4 on 10/2/24 at 10:42AM.

Based on medical record review (MR), review of facility policies, review of facility documents, and interviews with staff (EMP), it was determined that, for 4 out of 21 patients sampled (MR2, MR5, MR6, and MR12), the facility failed to ensure patient progress notes contained the date, time, and signature of the responsible discipline, and failed to ensure that nursing staff carried out a physician's order.

Findings include:

Review of facility policy "Chart Documentation Requirements" issued April 2007, last reviewed April 2024, revealed, "...Each entry is to be dated and timed, with the discipline writing the note identified...NSG =Nursing...MHT=Mental Health Technician..."

Review of facility document "Registered Nurse (Level I), last reviewed July 27, 2018, revealed, "Essential Job Duties: ...Transcribe and carry out physician orders..."

I. Progress Notes Missing Date, Time, and Signature of Responsible Discipline

Review of MR2's "Progress Record" revealed two (2) notes written on 9/15/24 at the following two (2) times: 8:00 AM and 11:00 AM. These notes revealed no evidence of the writer's signature and discipline.

Review of MR2's "Progress Record" for the admission dates of 9/8/2024 through 9/26/2024 revealed five (5) notes with no evidence of a date, or the writer's signature and discipline.

These findings were confirmed with EMP4 on 10/8/2024 between 9:45 AM-9:55 AM.


Review of MR5's "Progress Record" revealed a note dated 5/28/24 at 4:53 AM. The note revealed no evidence of the writer's signature and discipline.

This finding was confirmed with EMP4 on 10/8/2024 at 10:06 AM.


Review of MR6's "Progress Record" revealed four (4) notes written on 5/31/24 by a MHT [mental health technician] at the following four (4) times: 12:00 PM, 2:00 PM, 4:00 PM, and 6:00 PM. These four notes revealed no evidence of the writer's signature.

These findings were confirmed with EMP4 on 10/8/2024 at 10:05 AM.



II. Failure of Nursing Staff to Carry Out Physician's Order

Review of facility incident reports revealed that on 6/4/2024 at 8:45 AM, Patient #12 was sitting in a wheelchair at the nurses' station when Patient #10 pushed and slammed the wheelchair into the double doors which caused Patient #12 to hit his/her head and fall out of the wheelchair. Patient #12 sustained a bruise and raised area to the forehead and complained of pain. Patient #12 was sent out to the acute care hospital to be evaluated for a possible head injury.

Review of MR12's "Physician Orders" revealed, "...6/4/24 1500 [3:00 PM] ...Orders to transfer to East Unit..."

Hospital census reports reviewed for 6/3/2024 through 6/5/2024 revealed that Patient #10 and Patient #12 were on the West Unit.

Review of MR12's "Patient Observation Records" dated 6/5/2024, 6/7/2024, 6/8/2024, 6/9/2024 and 6/10/2024, revealed that Patient #12 was in Room 1150A on the West Unit.

Review of MR10's "Patient Demographic Profile" revealed that Patient #10 was discharged on 6/10/2024 at 5:30 PM.

Review of MR12's "Patient Demographic Profile" revealed Patient #12 was discharged on 7/3/2024 at 6:20 PM.

Patient #12 was never transferred to the East Unit as ordered on 6/4/2024, after the incident with Patient #10. Patient #12 and Patient #10 both remained on the West Unit through 6/10/2024, when Patient #10 was discharged.

This finding was confirmed with EMP4 on 10/8/2024 at 10:24 AM.

Based on review of facility policies, review of medical records (MR), and interviews with staff (EMP), it was determined that the hospital failed to ensure that medications were administered in accordance with hospital policy. This deficiency had the potential to impact all 83 patients within the facility.

Findings include:

Review of facility policy "Medication Management", issued August 2007, last revised May 6, 2022, stated, " ...Procedure ...The nurse will identify the patient using the two (2) of the following approved patient identifiers ...Asking the patient to state their name ...Using the patient picture located in the MAR ...date of birth ...The nurse will inspect the patient's mouth to ensure ingestion of the medication ..."

I. Patient identifiers

Interview on October 2, 2024 between 10:20 AM and 10:35 AM with EMP5, indicated that his/her standard of practice is to administer medications without the use of two (2) patient identifiers. EMP5 indicated that they know all the kids, so they do not need to ask their name when they come up to get their medications. EMP5 stated that he/she works primarily on the adolescent unit, and this is his/her standard practice when administering medications.

During an interview on October 2, 2024 at 10:50 AM with EMP6, this finding was confirmed. EMP6 stated that he/she provided immediate remedial education to EMP5 after witnessing the above statements.

II. Mouth checks

Review of MR1, Progress Record", dated September 26, 2024, stated, "Pt [patient] was walking the hallway ...Pt fell to floor c/o [complained of] chest pain. Rapid response called. Pt was pale, clammy, diaphoretic ...Pt stated...took an orange and white capsule that was in [his/her] room....While waiting on transport pt stated...had also cheeked [his/her] meds from the day before which...was trazadone, ASA, and Melatonin ...Pharmacy had identified there is one pt in adolescent unit taking orange and white capsule and identified that capsule to be Vyvanse ..."

Review of MR1, "Physician Medication Orders", revealed an order for lisdexamfetamine (Vyvanse) oral 30 mg capsule daily to start on 9/26/2024.

Review of MR1, "Medication Administration Record", revealed that the patient received scheduled dose of Vyvanse on 9/26/24 at 12:41 PM.

Review of facility video surveillance for 9/25/24 between 8:21 PM and 10:00 PM, revealed, at 8:21 PM, Patient #1 received his/her scheduled melatonin at the medication window. After taking the medications he/she appeared to have a small unidentifiable object between his fingers. No mouth check was completed by the nurse administering the medication. At 9:59 PM, Patient #1 walks to the nursing station door to receive his/her scheduled medication. No mouth check was completed by the nurse administering the medication. As Patient #1 walks away from the nursing station holding cups of water, he/she opens their mouth and spits the medication into the cup of water.

Review of facility video surveillance for 9/26/24 between 12:39 PM and 12:45 PM, revealed, at 12:39 PM, Patient #1 arrives to the nursing station and the nurse hands him/her a medication cup and a cup of water. As soon as he/she takes the medication, he/she spits the medication into his water cup. He/she then appears to drink the water from the cup. Patient #1 hands the medication cup and the water cup back to the nurse, who appears to glance in the cup, and then dispose of it. No mouth check was completed.

Interview on October 3, 2024 between 10:26 AM and 11:00 AM, with EMP4, revealed the hospital recognized the need for staff re-education relating to medication administration, specifically, the need to ensure that patients are not holding medications in their mouths. EMP4 stated that all staff received education regarding appropriate medication administration and signed an attestation. EMP4 provided evidence that all active nursing staff received the education.

Review of facility video surveillance from October 8, 2024 between 8:50 AM and 9:30 AM on the South Unit, revealed no mouth checks were completed for patients that received medications during that timeframe.

Review of facility video surveillance from October 8, 2024 between 8:10 AM and 8:30 AM on the North Unit, revealed no mouth checks were completed for patients that received medications during that timeframe.

During an interview on October 8, 2024 at 11:47 AM with EMP3, the above findings were confirmed.

During an interview on October 8, 2024, between 10:40 AM and 10:44 AM with EMP4, it was stated that all nurses were expected to complete mouth checks with every med pass. It was also stated that no monitoring was currently being done by the facility to ensure that the recent education provided to staff on completing mouth checks had improved compliance.