HospitalInspections.org

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Based on record review and interviews, the facility failed to meet the Condition of Participation of Patient Right's according to CFR 482.13. The facility failed to protect and promote each patient's rights which had the potential to place all patients of the Katmai unit (based on a census of 24) at risk for neglect.

Findings:

1. The facility failed to ensure care was received in a safe setting. Specifically, the facility failed to: 1) Accurately perform Close Observation Status Scale (COSS) every 15-minute (Q15min) patient safety checks for patients on the Katmai unit; and 2) Act and render aid for 1 Patient (#5), out of 1 patient reviewed, whose position of sleep placed the patient at increased risk to his/her safety. (Refer to A-0144).

2. The facility failed to ensure 1 Patient (#5), out of 1 patient reviewed, was free from neglect. Specifically, the facility failed to ensure:

a) The nightshift Licensed Nurses (LN's) (#'s 16 and 21) used appropriate medication administration expectations, and reassessment of medication administrations expectations; for 1 patient (#5), out of 1 patient reviewed;

b) The nightshift LN's (#'s 16 and 21) and Psychiatric Nursing Assistants (PNA's) (#'s 4, 7, 8, 11, and 12) followed the behavior plan for 1 patient (#5), out of 1 patient reviewed; and

c) The nightshift LN's (#'s 16 and 21) and PNA's (#'s 4, 7, 8, 11, and 12), as well as, the dayshift LN (#30) failed to act and render aid to Patient #5 whose position of sleep placed the patient at increased risk to his/her safety. (Refer to A-0145).

3. The facility failed to ensure chemical restraints were not used for 1 Patient (#5), out of 1 patient reviewed, which restricted the patient's behavior and freedom of movement within his/her room, which was an approved intervention in a treatment team-approved individualized behavior plan (an individualized behavior plan to address challenging behaviors and interventions staff can use to work through them). (Refer to A-0160).
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Based on record review and interview, the facility failed to meet the Condition of Participation of Nursing Services according to CFR 482.23. The facility failed to have an organized nursing service that provided safe and appropriate nursing services.

Findings:

1. The facility failed to ensure the nightshift Licensed Nurses (LN #'s 16 and 21) supervised and evaluated the nursing care provided for 1 Patient (#5), out of 1 patient reviewed.

Specifically, LN #16 and #21 failed to:

a) Appropriately assess and offer scheduled PO (by mouth) medications to Patient #5 prior to administering court ordered IM Back Up (IMBU - medications received by injection after PO medications were refused) medications;

b) Appropriately assess and offer PRN (as needed) medication to Patient #5 prior to administering court ordered IMBU medication;

c) Appropriately re-assess Patient #5, within the facility's standard timeframe, after each administration of IMBU medication was received; and

d) Appropriately completed an evaluation for Patient #5 after reports of concern of possible deterioration of physical status were reported by Psychiatric Nursing Assistants (PNA #'s 7 and 12). (Refer to A-0395).

2. The facility failed to ensure the nightshift Licensed Nurses (LN #s 16 and 21) prepare and administer medications in accordance with the orders of the practitioner and accepted standards of practice for 1 Patient (#5), out of 1 patient reviewed.

Specifically, LN #16 and LN #21 failed to:

a) Appropriately assess and offer scheduled PO (by mouth) medications to Patient #5 prior to administering court ordered IM Back Up (IMBU - medications received by injection after PO medications were refused) medications;

b) Appropriately administer PRN (as needed) medications, based on the written parameters within the medication orders;

c) Appropriately assess and offer PO PRN medication to Patient #5 prior to administering court ordered IMBU medication; and

d) Appropriately re-assess Patient #5, within the facility's standard timeframe, after each administration of IMBU medication was received. (Refer to A-0405)
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Based on record review and interview, the facility failed to ensure care was received in a safe setting. Specifically, the facility failed to:

1) Accurately perform Close Observation Status Scale (COSS - the level of observation required for safety) every 15-minute (Q15min) patient safety checks for patients on the Katmai unit; and

2) Act and render aid for 1 Patient (#5), out of 1 patient reviewed, whose position of sleep placed the patient at increased risk to his/her safety.

These failed practices: 1) increased the risk to patient safety for all patients of the Katmai unit (based on a census of 24); and 2) placed Patient #5 at risk for a deterioration of his/her physical status. Patient #5 passed away in the facility.

Findings:

COSS Patient Safety Checks

Review of video recordings, dated 3/27-28/25, revealed there were three separate hours on night shift where staff did not perform appropriate Q15min patient safety checks:

1) 3/27/25 from 9:00 PM to 10:00 PM: PNA #4 was assigned Q15min checks for this hour.

- At 9:02 PM, it was observed that PNA #4 pulled a chair out of a small group room known as the "fishbowl" and sat next to PNA #8 in the hall by the nurse's station. PNA #4 had the patient safety checklist clipboard in his/her hand. PNA #4, remained seated by the nursing station for the hour assigned without rising to complete any Q15min check rounds.

- At 9:42 PM, PNA #8 completed a safety check for Patient #5 (despite not being assigned).

Review of the unit's Q15min checklist, dated 3/27/25, revealed PNA #4 documented that he/she completed all four Q15min checks from 9:00 PM to 10:00 PM.

2) 3/27/25 from 10:00 PM to 11:00 PM: PNA #11 was assigned Q15min checks for this hour.

- There was no observation on the video review that PNA #11 completed any Q15min check rounds.

Review of the unit's Q15min checklist, dated 3/27/25, revealed PNA #11 documented that he/she completed all four Q15min checks from 10:00 PM to 11:00 PM.

During an interview on 4/30/25 at 2:47 PM, the Director of Risk Management stated PNA #11 did not perform the Q15min checks on 3/27/25 from 10:00 to 11:00 PM.

3) 3/28/25 from 2:00 AM to 3:00 AM: PNA #4 was assigned Q15min checks for this hour.

- At 1:57 AM, it was observed that PNA #4 completed a safety check for Patient #5.

- At 2:01 AM, it was observed that PNA #4 sat in the hall by the nurse's station with the patient safety checklist clipboard in his/her hand. PNA #4 remained seated by the nursing station for the remaining hour assigned without rising to complete any Q15min check rounds.

Review of the unit's Q15min checklist, dated 3/28/25, revealed PNA #4 documented that he/she physically completed all four Q15min checks at 2:15 AM, 2:30 AM, and 2:45 AM.

During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that PNA #4's Q15min deficiencies were noted during the facility's investigation, video review, and interview. The DON further stated it was determined PNA #4 falsified the Q15min check documentation during the 9:00 PM to 10:00 PM and 2:00 AM to 3:00 AM timeframes.

During an interview on 4/30/25 at 11:17 AM, the Director of Quality Assurance and Performance Improvement (QAPI) stated PNA #11 did not perform the Q15min checks from 10:00 PM to 11:00 PM.

Act and Render Aid

Patient #5

Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5's court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment.

Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension.

Review of the most recent "Petition for Court Approval of Administration of Psychotropic Medication," dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: ". . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . ."

Further review revealed that Patient #5 was on 1st Degree COSS, which required Patient #5 to have an every-15-minute observation and engagement for patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety).

Patient #5's Treatment Plan

Review of Patient #5's "Multidisciplinary Master Treatment Plan," dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: "Disturbance of Thought: "[Patient #5] shows active disturbance of though and oppositional behavior."

Further review revealed identified interventions to address Patient #5's "disturbance of thought" that included:

- "LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level," initiated on 11/6/23;
- "RN will prompt [Patient #5] to comply with safety behavior," initiated on 1/30/24;
- "Psychology will develop behavior plan to guide staff response to challenging behaviors," initiated on 9/11/24; and
- "Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes," initiated 11/6/24.

Patient #5's Challenging Behaviors

During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5's history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor.

The DON further stated that Patient #5's behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as "normal" for Patient #5.

During an interview on 4/30/25 at 10:21 AM, Patient #5's Provider stated that Patient #5's behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted.

Patient #5's Provider stated that these behaviors had been present since his/her 2020 admission.

Patient #5's Behavior Plan

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans were initiated when a patient's behavior became increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times.

Review of Patient #5's behavior plan, last updated 3/25/25, revealed:

- "Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an 'episode.'"

- ". . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . ."

- ". . . If you notice [Patient #5] is about to have an "episode," walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball."

- "Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an "episode." Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5's] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, "hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn't flood." Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress."

During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime.

Incident on 3/28/25

During an interview on 4/30/25 at 9:58 AM, the DON and Director of QAPI stated that on the evening of 3/27/25 and through the early morning on 3/28/25, Patient #5 was up late in his/her bedroom exhibiting some of the behavior challenges they had been dealing with for an extended period of time: he/she moved back and forth from the bathroom to the bedroom area, later in the evening he/she was rolling around on the bedroom floor, excessively tapping on the floor, and making animal noises at times through the night.

The Director of QAPI stated that based on video review, it was observed and heard that at 1:13 AM, PNA #7, after having completed a patient safety check (a visual check on the patient's status for safety), told another PNA in the hall that Patient #5 was, "laying down on the table."

The "table" was a desk (measuring 2 feet, 11 1/2 inches long and 2 feet, 1/2 inch wide) that was in his/her bedroom. This desk was bolted to the back half of the left wall of the room and approximately 2 1/2 feet away from the back left corner of the room that connected to the back wall. In the space between desk and the back wall, Patient #5 had placed his/her weighted chair flush against the left wall (the front of the chair was against the left wall, with the back of the chair facing outward), which left approximately 3 inches between the chair and desk on the left side of the chair, and approximately 3 inches between the chair and back wall on the right side of the chair. The total length of the chair/desk space was 5 feet, 6 inches from the right arm rest of the chair to the far-left edge of the desk.

The Director of QAPI further stated that Patient #5 (who was 6 feet, 1/4 inches tall and weighed approximately 275.4 lbs.) initially was laying prone on the desk (flat on his/her stomach face down), with his/her head positioned towards the back wall, which caused his/her legs and upper shoulders and head to extend beyond the edges of the desk on either side.

As the night progressed, the Director of QAPI stated that Patient #5 began to move towards the back wall slowly inching his/her upper body onto the chair positioned between the desk and back wall, while his lower body remained on the desk. Eventually, Patient #5 had his/her head on the right armrest of the chair, closest to the back wall, with his/her face turned towards the left wall. Patient #5's left arm was tucked under his/her torso on the chair seat, and the right arm was draped over the back of the chair.

During an interview on 4/30/25 at 9:58 AM, the DON stated all staff on nightshift on 3/27-28/25 stated they had never seen Patient #5 sleep on the desk before, but they didn't think it was something alarming.

An observation on 4/30/25 at 2:38 PM, of Patient #5's bedroom, revealed that when the chair was placed between the desk and the back wall, the chair was at a lower elevation then the top of the desk. This would have caused Patient #5's upper body to be lower than his/her hips, buttocks, and legs which were still on the desk.

Further observation revealed that when the Director of QAPI positioned herself in the same prone position as Patient #5 was on 3/28/25, her torso was not supported when her head/neck was resting on the right armrest of the chair, which caused her chest to bow downward towards the seat of the chair placing the pressure of supporting her upper body on her head/neck.

Further observation revealed that when standing in the doorway of Patient #5's bedroom, a person's view would have been of Patient #5's buttocks, legs, and feet only, with a minimal view of Patient #5's back and back of head. If staff were to enter the room and stand in close proximity to Patient #5, there would have been no view of Patient #5's face or the rise and fall of Patient #5's front chest during respirations, which was face down in the chair.

During an interview on 5/1/25 at 10:45 AM, when asked what the expectation for nurses and PNAs would be if a patient was positioned, during rest or sleep, in a way that could place the patient at risk for safety, the Assistant Director of Nursing (ADON) stated the expectation would be to attempt to move the patient.

When asked what if the patient resisted, the ADON stated then repeated attempts should have been tried until the patient was positioned for safety. This could have achieved by trying to physically move the patient or communicate with the patient to achieve cooperation to move him/her into a safer position.

Review of the facility's video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 1:13 AM to 4:29 AM, revealed:

- From 1:13 AM to 1:57 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes. At 1:13 AM, PNA #7 entered Patient #5's bedroom. Patient #5 could be heard on the camera (but was not seen as there were no cameras in the bedroom) making vocal sounds that were not words. As PNA #7 exited the room and approached other PNA's in the hall, it could be heard on the video that PNA #7 stated, "[he's/she's] laying on down on the table."

PNA #7 completed patient safety checks at 1:25 AM and 1:43 AM by looking in the window of the closed bedroom door. PNA #4 completed the patient safety check at 1:57 AM by looking in the window of the closed bedroom door.

- From 2:00 AM to 3:00 AM, no patient safety checks were completed for Patient #5, or any other patient on the Katmai unit. PNA #4 was assigned to patient safety checks this hour and remained seated in the hallway through this time.

- From 3:00 AM to 3:56 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #11 completed checks at 3:00 AM, 3:15 AM, 3:29 AM, and 3:43 AM. During this last check at 3:43 AM, PNA #11 stood at the doorway for 24 seconds while observing Patient #5. At 3:56 AM, PNA #12 completed the patient safety check by standing in the doorway for 21 seconds while observing Patient #5.

- At 4:12 AM, PNA #12 completed the patient safety check by entering Patient #5's bedroom. PNA #12 turned on the bedroom light and was in the room for 70 seconds, then exited.

- At 4:29 AM, PNA #12 completed the patient safety check by entering Patient #5's bedroom. PNA #12 turned on the light and could be heard calling Patient #5's name several times. Shortly after this, PNA #12 came back out into the hallway and called PNA #7 into the room with him/her. PNA #7 was observed to quickly leave the bedroom and go into the nurse's station to get the nurses. PNA #7 could be heard on the video recording saying, "[he's/she's] not moving." At 4:32 AM, PNA #12 told nurses, "[he/she] was breathing earlier" when they met him/her at Patient #5's doorway. All staff entered Patient #5's bedroom. Staff could be heard calling Patient #5's name. PNA #11 said, "let me get a pillow for [his/her] head" and left to retrieve a pillow. After some time, staff exited the room, LN #16 could be heard saying, "[he/she] was holding onto something."

During an interview on 4/30/25 at 12:37, the DON and Director of QAPI stated that when they interviewed the staff during their investigation after 3/28/25, all staff stated that at 4:29 AM when they entered the room, Patient #5 was positioned mostly on the desk with his/her head on the armrest of the chair closest to the desk and they attempted to reposition Patient #5 for safety and comfort. LN #16 and LN #21 both stated in their interviews that they checked Patient #5's pulse and stated he/she was breathing at this time. The DON and Director of QAPI stated that during staff interviews the staff stated, when the repositioning was attempted Patient #5 resisted to move by forcing his/her upper body down.

The DON further stated that when PNA #7 was interviewed, he/she stated when he/she left Patient #5's bedroom at 4:29 AM to get the nurses, he/she asked the nurses to come check Patient #5 to see if he/she was breathing. When asked if PNA #7 had ever before requested nurses to come check a resident for breathing during a patient safety check, PNA #7 stated, "no."

Review of Patient #5's nursing note, written by LN #21 and dated 3/28/25 at 5:08 AM, revealed: ". . . Pt finally fall asleep around [2:00 AM] when checked. Pt was laying on the table and drippled on the chair, was prompted to get into [his/her] bed for more comfort but ignored instructions. Pt was breathing and no distress noted. No further incident for the remaining of the shift. ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . ."

Further review revealed no documentation of the pulse check, or the rate assessed, that the LNs reported completing at 4:29 AM. No other assessment information was documented, nor was there any other documentation from the LNs on 3/28/25.

During an interview on 4/30/25 at 12:39 AM, when asked what the expectation would be for an LN who was asked to come assess a patient for breathing, the Lead Educator stated the expectation would be to complete a head-to-toe assessment and call medical staff if needed.

Further review of the facility video recording, dated 3/28/25 from 4:38 AM to 7:14 AM, revealed:

- At 4:38 AM, PNA #7 completed a patient safety check for Patient #5 by standing in the doorway.

- At 4:45 AM, PNA #12 completed a patient safety check for Patient #5. PNA #12 entering Patient #5's bedroom. PNA #12 turned on the bedroom light and was in the room for 37 seconds, then exited.

- From 4:59 AM to 5:41 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #12 completed the check at 4:59 AM, PNA #8 completed the checks at 5:11 AM, 5:28 AM, and 5:41 AM.

- At 5:54 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and was in the room for 1 minute, 50 seconds, then exited.

- At 6:01 AM, PNA #7 completed the patient safety check for Patient #5 by looking in the window of the closed bedroom door.

- At 6:11 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and could be heard calling Patient #5's name. PNA #7 was in the room for 1 minute, then exited.

- At 6:29 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #7 turned on the bedroom lights and was in the room for 35 seconds, then exited.

- At 6:47 AM, PNA #7 completed a patient safety check for Patient #5 by entering the room. PNA #12 could be heard on the video recording saying, "[Patient #5] is going to be sore in the morning."

- At 6:59 AM, PNA #12 completed the patient safety check for Patient #5 by looking in the window of the closed bedroom door.

Shift change was conducted at 7:00 AM

- At 7:10 AM, PNA #7 completed a patient safety check round with dayshift PNA #9 and PNA #10. Both dayshift PNAs laughed at Patient #5's position on the desk and chair. PNA #10 called out Patient #5's name. PNA #9 stated, "You don't see that every day." PNA #9 asked, "did the nurses know about it?" and left to get the dayshift LN #30 to look at Patient #5. When LN #30 looked into Patient #5's bedroom from the hall, he/she laughed out loud, shook his/her head, and walked away back towards the nurse's station. At 7:12 AM, PNA #9 could be heard on the video saying, "This should be a meme."

During an interview on 6/2/25 at 9:51 AM, when asked what state of dress Patient #5 was in, the Risk Manager stated Patient #5's pants were down past his/her buttocks.

- At 7:13 AM, dayshift PNA #13 looked into Patient #5's room, turned back to the PNAs with a disapproving look, and entered Patient #5's bedroom. PNA #10 also entered the room and closed the door. PNA #13 left the room to go get LN #30 back into Patient #5's bedroom and could be heard saying, "you better get a pulse."

- At 7:14 AM, PNA #13 called on the radio to have the front desk announce a Code Blue to Katmai unit. "Code Blue Katmai Unit" could be heard on the overhead page system. Staff immediately brought the crash cart. Other staff members entered the unit to assist, including the Assistant Director of Nursing (ADON).

Review of the facility provided "Emergency [and] Disaster Treatment Form" (A code blue documentation sheet), dated 3/28/25, revealed:

- 7:17 AM: "Start CPR [cardiopulmonary resuscitation]"
- 7:17 AM: "Attaching AED [automated external defibrillator]. No pulse. O2 [Oxygen] pulled. Suction pulled. O2 applied . . . calling 911. Asked for a [second] O2 tank. Not getting air in ("locked up")."
- 7:20 AM: "No shock advised. [Second] O2 tank connected."
- 7:21 AM: "Suction in mouth used. Continuing CPR [and] rescue breaths. Continues to be stiff. Can feel pulse in neck with CPR. Pt cold to the touch."
- 7:24 AM: "No pulse. AED - no shock advised. No pulse. EMS arrived . . ."

Further observation of the facility video recording revealed EMS arrived on Katmai unit at 7:25 AM.

During an interview on 4/30/25 at 1:12 PM, the Director of QAPI stated that when LN #30 entered the room, he/she and other staff moved Patient #5 off the desk and placed him/her on the floor. The Director of QAPI stated once Patient #5 was on the floor they could see that Patient #5's face and his/her tongue was hanging out of his/her mouth and his/her jaw was stiff and closed around his/her tongue. Also, Patient #5's left arm remained tucked close to his/her chest because it was stiff and did not move. The Director of QAPI stated LN #30 initiated CPR and three rounds of CPR were attempted by facility staff, but no shock was advised with the AED that facility staff had placed during CPR.

The Director of QAPI further stated that when EMS arrived, they attempted two rounds of CPR and again no shock was advised. EMS determined Patient #5 was deceased and stopped CPR efforts.

During an interview on 5/1/25 at 10:45 AM, the ADON stated that when she entered Patient #5's room, responding to the Code Blue announcement, Patient #5 was on the floor dressed in a T-shirt and boxers. The ADON stated staff said they had to pull the boxers up because Patient #5's genitals were exposed when they laid him/her on the floor. The ADON stated Patient #5's tongue was out a little bit, and blood was seen around his/her mouth and a little on his/her nose (which the ADON suspected was probably from his/her mouth, because it was not coming from inside his/her nose). The ADON stated she attempted to use the AMBU bag to help with respirations, while LN #30 was performing CPR, however Patient #5's neck was stiff, and she was not able to tilt his/her head back or open his/her jaw. The ADON stated Patient #5 was cool and clammy when touched and Patient #5's t-shirt was wet. The ADON stated she suspected this wetness was urine, because it had an odor, but this was never confirmed. The ADON stated she remembered it being wet because the shirt was cut off when the AED was applied during CPR efforts.

Further review of the facility video recording, dated 3/28/25 from 7:56 AM to 10:17 AM, revealed:

- At 7:56 AM, Anchorage Police Department arrived on Katmai unit.

- At 7:59 AM, EMS left the Katmai unit.

- At 9:36 AM, Medical Examiner arrived on Katmai unit.

- At 10:17 AM, Medical Examiner departed with Patient #5.

Policy Review

Review of the facility's policy "Patient Rights," effective 1/29/24, revealed: "Procedure: Except as otherwise provided . . . a patient has rights that include the following . . . to be treated with consideration and recognition of the patient's dignity and individuality. . . to receive care in a safe, respectful, and the least restrictive setting and environment . . ."

Review of the facility's nursing department procedure "PNA Responsibilities," effective 8/19/24, revealed: ". . . Employees are responsible for knowing and following Hospital Policy [and] Procedures (P&P) and Nursing Department Procedures (NDP) . . . Rounds: Unit round are to be made at the beginning of each shift and no less than every fifteen (15) minutes throughout the remainder of the shift to identify potential risks and to assure that a therapeutic and safe environment is maintained. All patients admitted to API [Alaska Psychiatric Institute] are monitored on Q15 checks (24/7) [24 hours a day, 7 days a week] during their hospitalization including all Close Observation Status Scale Orders (COSS) are monitored Q15 minutes . . . The staff member responsible for making the round is required to take a radio, the Patient Location Checklist, and a pen with them when they do rounds. They are responsible to: Do not just count heads, account for each patient according to their status . . . Staff are required to check on the physical well-being of the patients as well as their physical presence on the Unit. When the patient is in bed, sleeping, observe respirations (chest rising and falling) and listen for the patient's breathing . . . Patient Care . . . Treat patients with dignity and respect at all times . . . Be alert for signs and/or symptoms that suggest a patient's physical status may be deteriorating or at risk of evolving into a medical emergency. Notify the Charge Nurse if any concerns . . . Between rounds . . . Maintain and ensure patient safety . . . Document observations and incidents as they occur; describe in detail your observations and patient behavior . . ."

Review of the facility's nursing department procedure "Nurse Responsibilities," effective 10/12/23, revealed: ". . . Employees are responsible for knowing and following Hospital Policy [and] Procedures (P&Ps) and Nursing Department Procedures (NDPs) . . . Unit Rounds are to be made at the beginning of each shift and each patient will be monitored on Routine Q15 minute checks (24/7) [24 hours a day, 7 days a week] during hospitalization to identify potential risks and to assure that a therapeutic and safe environment is maintained. Rounds are generally done by the PNA staff but may be done by a Nurse. The Nurse is responsible for weeing these are done regularly. The Nurse is responsible to assess every patient assigned to the unit at least once during their shift and not rely solely on the PNA to evaluate a patient's well-being. The staff member responsible for making the round is required to take a radio, the Patient Location Checklist, and a pen with them when they do rounds . . .Staff is required to check on the physical well being of the patients as well as their physical presence on the Unit. When the patient is in bed, sleeping, observe respirations (chest rising and falling) and listen for the patient's breathing . . . Patient Care: Treat patients with dignity and respect at all times. Know the location and activity of each patient on [1st degree] COSS at all times . . . Monitor each patient for signs and/or symptoms that suggest their physical status is deteriorating or at risk of evolving into a medical emergency . . . Between rounds . . . The Nurse is responsible for seeing that the PNAs carry out duties appropriately, chart correctly and perform to expectations . . . RN retains accountability for duties delegated to PNA staff . . . Ensure that significant interactions with patients are noted in the patient record and passed along in report. Document observations and incidents as they occur; chart accurately on patient noting incidents and behavior in detail . . ."

Review of the facility's policy "Close Observation Status Scale (COSS)," last reviewed 2/13/23, revealed: "Purpose: To delineate Alaska Psychiatric Institute's (API) policy for the ordering and performing of close observation for the protection of individual patients and others . . . COSS Observation Requirements: 1st Degree COSS: 15-minute observation and engagement checks, noted on the Patient Location Checklist . . ."

Review of the facility's nursing department procedure "Patient Safety Checklist," effective 7/1/24, revealed: ". . . All patients will be monitored through Q15 [every 15] minute checks throughout their hospitalization regardless of COSS. Security and Q15min [minutes] checks are completed to identify potential risks and to assure that a therapeutic and safe environment is maintained . . . Patient safety checklists are made by night staff for the next 24-hour period with the first check beginning at 0700 [7:00 AM]. All patients are listed on the patient safety checklist . . . The unit charge nurse or designated staff member will assign a staff member on the unit assignment sheet hourly to complete and record Q15min safety checks. Staff may not be assigned to another task when assigned to Q15min checks. Q15min rounds are completed for all patients regardless of COSS status. The staff member that records the safety check is responsible for physically identifying the patient and verifying the presence and safety of the patient for that round. Completing a round means you have physically checked and are verifying the physical presence and wellbeing of the patient on the unit. When a patient is in bed staff are to verify they witness respirations (chest rise and fall) and can hear breathing . . . Staff are to notify the RN [Registered Nurse] immediately if there are any irregularities in the patient's breathing or safety concerns . . . Staff assigned to safety checks is expected to be alert for potential safety hazards and take cor

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Based on record review and interview, the facility failed to ensure 1 Patient (#5), out of 1 patient reviewed, was free from neglect. Specifically, the facility failed to ensure:

1) The nightshift Licensed Nurses (LN's) (#'s 16 and 21) used appropriate medication administration expectations, and reassessment of medication administrations expectations; for 1 patient (#5), out of 1 patient reviewed;

2) The nightshift LN's (#'s 16 and 21) and Psychiatric Nursing Assistants (PNA's) (#'s 4, 7, 8, 11, and 12) followed the behavior plan for 1 patient (#5), out of 1 patient reviewed; and

3) The nightshift LN's (#'s 16 and 21) and PNA's (#'s 4, 7, 8, 11, and 12), as well as, the dayshift LN (#30) failed to act and render aid to Patient #5 whose position of sleep placed the patient at increased risk to his/her safety.

These failed practices placed Patient #5 at risk for: 1) adverse reactions to medications; 2) escalated behavior that was not addressed with least restrictive measures; and 3) a deterioration of his/her physical status. Patient #5 passed away in the facility.

Findings:

Patient #5

Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5's court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment.

Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension.

Review of the most recent "Petition for Court Approval of Administration of Psychotropic Medication," dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: ". . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . ."

Further review revealed that Patient #5 was on 1st Degree Close Observation Status Scale (COSS - the level of observation required for safety), which required Patient #5 to have an every-15-minute observation and engagement patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety).

Patient #5's Treatment Plan

Review of Patient #5's "Multidisciplinary Master Treatment Plan," dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: "Disturbance of Thought: "[Patient #5] shows active disturbance of though and oppositional behavior."

Further review revealed identified interventions to address Patient #5's "disturbance of thought" that included:

- "LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level," initiated on 11/6/23;
- "RN will prompt [Patient #5] to comply with safety behavior," initiated on 1/30/24;
- "Psychology will develop behavior plan to guide staff response to challenging behaviors," initiated on 9/11/24; and
- "Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes," initiated 11/6/24.

Patient #5's Challenging Behaviors

During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5's history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor.

The DON further stated that Patient #5's behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as "normal" for Patient #5.

During an interview on 4/30/25 at 10:21 AM, Patient #5's Provider stated that Patient #5's behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted.

Patient #5's Provider stated that these behaviors had been present since his/her 2020 admission.

Patient #5's Behavior Plan

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans are initiated when a patient's behavior becomes increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times.

Review of Patient #5's behavior plan, last updated 3/25/25, revealed:

- "Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an 'episode.'"

- ". . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . ."

- ". . . If you notice [Patient #5] is about to have an "episode," walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball."

- "Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an "episode." Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5's] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, "hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn't flood." Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress."

During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime.

Patient #5's Medication Regimen

Review of Patient #5's ordered medications, for March 2025, revealed he/she was on psychotropic medications ordered by the court. Further review revealed these medications also had a "shot" form of medication if Patient #5 refused to take his/her medications by mouth, called an IMBU (intramuscular, or IM, back up). These were ordered by the courts to aid in Patient #5's consistent treatment. These medications included:

Scheduled Medications

1) "Clozapine [an antipsychotic medication used to treat schizophrenia] 300mg [milligrams] PO [by mouth] QHS [every night scheduled for 9:00 PM] for schizophrenia." This order started on 1/21/25.

Further review revealed: "Court ordered: If refused give haloperidol [Haldol - an antipsychotic medication used to treat schizophrenia] IMBU."

1a) "Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO clozapine . . ." This order started on 12/5/23 and remained in effect.

2) "Divalproex [Depakote - An anticonvulsant used to treat some psychiatric illnesses] 1,250mg PO BID [twice a day: once in morning at 9:00 AM, once at night at 9:00 PM] for mood disorder secondary to schizophrenia." This order was started on 1/21/25.

Further review revealed: "Court ordered: If refused give lorazepam [Ativan - A benzodiazepine medication used to treat anxiety] IMBU."

3) "Clonazepam [An anti-epileptic drug used to treat seizure disorders] 2mg tablet PO 1300 [every day at 1:00 PM] for agitation secondary to schizophrenia." This order started on 2/25/25.

Further review revealed: "Court ordered: If patient refuses, provide IMBU lorazepam."

2a and 3a) "Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . Divalproex . . . [and] clonazepam . . ." This order started on 9/30/24 and remained in effect.

PRN Medications:

4) "Haloperidol 10mg tablet PO Q4HPRN [every 4 hours as needed] for agitation." This order started on 12/20/23.

Further review revealed: "Court ordered: If refused give haloperidol IMBU."

4a) "Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . haloperidol PRN . . ." This order started on 12/5/23 and remained in effect.

5) "Lorazepam 2mg tablet PO Q4HPRN for moderate anxiety or moderate agitation." This order started on 2/6/25.

Further review revealed: "Court ordered: If refused give Lorazepam IMBU."

5a) "Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO lorazepam PRN . . ." This order started on 9/30/24 and remained in effect.

6) "Chlorpromazine [Thorazine - An antipsychotic medication used to treat psychotic disorders such as schizophrenia] 100mg PO Q6HPRN [every 6 hours as needed] for severe agitation." This order started on 12/24/24.

Further review revealed: "Court ordered: If refused give chlorpromazine IMBU."

6a) "Chlorpromazine 50mg/2mL ampule - 100mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO chlorpromazine PRN." This order started on 12/24/24 and remained in effect.

Medication Administrations #1 for nightshift on 3/27/25

Review of Patient #5's electronic Medication Administration Record (eMAR), dated 3/27/25, revealed:

- At 7:12 PM, Licensed Nurse (LN) #16 documented that Patient #5 refused Lorazepam 2mg PO PRN for moderate anxiety or moderate agitation.

Further review revealed there was no documentation that the IMBU Lorazepam medication was given due to this PO refusal, which was instructed in the order.

- At 7:13 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Clozapine 300mg PO medication (107 minutes prior to scheduled time).
- At 7:14 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Divalproex 1,250mg PO medication (106 minutes prior to scheduled time).
- At 7:23 PM, LN #21 documented that Patient #5 received Lorazepam 2mg IM, PRN IMBU for refusal of court ordered PO Divalproex medication.
- At 7:25 PM, LN #21 documented that Patient #5 received Haloperidol 10mg IM, PRN IMBU for refusal of court ordered PO Clozapine medication.

Video Review of Medication Administrations #1

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 6:00 PM to 7:19 PM, revealed:

- From 6:00 PM to 6:16 PM, Patient #5 was in the unit's TV room watching basketball. He/she had calm movements during this time: he/she sat in a chair at times, stood and stretched and walked around the room at times; and made motions as if he/she was shooting a basketball at a hoop.

- At 6:16 PM, Patient #5 left the TV room and entered his/her bedroom.

During an interview on 6/2/25 at 9:24 AM, while reviewing the video, the Risk Manager stated that Patient #5 was exhibiting no aggression, and this was his/her baseline behavior.

- From 6:16 PM to 7:06 PM, Patient #5 remained in his/her room. Staff completed every-15-minute safety checks: they approached Patient #5's bedroom door, which was closed, and looked in the window and listened.

- At 7:02 PM, PNA #4 approached Patient #5's bedroom door, cracked the door, and then closed it. Further observation revealed PNA #4 instructed the staff at the nurse's station to turn off Patient #5's water.

During an interview on 6/2/25 at 9:25 AM, while reviewing the video, the Risk Manager stated that individual patient room's water supplies could be turned off at the nurse's station. When asked about Patient #5's behavior plan, and needing to speak to Patient #5 about exceeding the water limit of 30 minutes, the Risk Manager stated after reviewing the video, PNA #4 did not follow the behavior plan and talk with Patient #5 prior to turning the water off. The Risk Manager stated Patient #5 had a history of escalating when the water was turned off.

- At 7:06 PM, PNA #11 approached Patient #5's room to complete a safety check.

- At 7:10 PM, PNA #11 approached Patient #5's room to complete a safety check. On the video, Patient #5 could be heard making animal noises from within his/her room area.

- At 7:11 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5's room to offer medications in pill form. The LNs and the Nurse Supervisor left the room without giving the medications.

During an interview on 6/2/25 at 9:26 AM, while reviewing the video, the Risk Manager stated Patient #5 refused the medications by mouth.

- From 7:11 PM to 7:19 PM, Patient #5 could be heard on the camera making animal noises from within his/her room.

- At 7:19 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5's room and administered IMBU medications. The LNs and the Nurse Supervisor left the room shortly after this.

Reassessment of Medications Administration #1

Review of Patient #5's eMAR, dated 3/27/25, revealed:

- At 8:42 PM, LN #21 documented a reassessment for Patient #5's response to the IMBU medications Lorazepam and Haloperidol (79 minutes after its administration). LN #21 documented they were both "Medication effectiveness for clinical indication: effective."

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 7:19 PM to 9:00 PM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment.

During an interview on 4/30/25 at 12:08 PM, the DON stated no nursing assessment was completed after Patient #5 received Lorazepam and Haloperidol IM injections. The DON further stated nurses were to complete an assessment after 15 minutes of administration of the IM injections.

Medication Administrations #2 for Nightshift on 3/27/25

Review of Patient #5's eMAR, dated 3/27/25, revealed:

- At 11:50 PM, LN #21 documented that Patient #5 refused Chlorpromazine 100mg PO PRN for severe agitation.
- At 11:51 PM, LN #21 documented that Patient #5 received Chlorpromazine 100mg IM, PRN IMBU for refusal of PO Chlorpromazine medication.

Video Review of Medication Administration #2

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 10:00 PM to 11:50 PM, revealed there was no indication of "severe agitation" from Patient #5. During this time frame, Patient #5 was in his/her bedroom and was only heard making animal noises once at 11:43 PM, which only lasted for less than 1 minute. Further observation revealed PNA staff appeared calm, sitting in the halls, and no nurse ever approached Patient #5 to assess his/her level of agitation. No nurse offered Patient #5 the PO form of chlorpromazine prior to the administration IMBU medication. Also, no de-escalation techniques were seen attempted, and no distraction choices or preferred activities from Patient #5's behavior plan were attempted.

Further observation of the video recording revealed at 11:49 PM, LNs #16 and #21 entered Patient #5's bedroom with 2 IM syringes and a SHARPS container (a red hard plastic container in which to put used syringes in), along with PNA's #7 and #11, and exited shortly after.

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated it was the expectation for all nurses to offer patients PO forms of medication before IM or IMBU forms were used. Meaning that nurses were to approach patients, communicate with them while offering medications. Also explore alternative ways for the patients to agree to take PO medications prior to IM or IMBU being used.

When asked if there was any policy that defined mild-to moderate-to severe agitation for nurses to use as a guide, the ADON stated it is the nurse's discretion to determine what those terms mean. When asked what she thought "severe agitation" meant, the ADON stated it would mean to the point of causing potential harm to self or others.

During an interview on 5/1/25 at 11:35 AM, when asked how nurses were taught how to recognize mild-to moderate-to severe agitation, the Director of QAPI stated there was no training in orientation to help nurses recognize what those terms look like behavior-wise. The Director of QAPI further stated that nurses were taught what these terms meant in nursing schooling.

The Director of QAPI further stated that when Patient #5 was rolling around on the floor, it meant he/she was agitated, and it warranted PRN medication.

During an interview on 6/2/25 at 1:14 PM, when asked if Patient #5 was following his/her behavior plan (to be in his/her room during an episode), the ADON and Director of QAPI agreed Patient #5 was following the plan.

When asked if any staff member working on 3/27/25 used the interventions in the behavior plan to help distract Patient #5 and help to calm him/her, the Director of QAPI stated the video recording showed that no staff member followed the behavior plan interventions listed.

Reassessment of Medication Administration #2

Further review of Patient #5's eMAR, revealed that on 3/28/25 at 12:07 AM, LN #21 documented a reassessment for Patient #5's response to the IMBU Chlorpromazine (16 minutes after its administration): "Pt [patient] still agitated unable to respond to verbal prompts. Pt was laying on the floor in bed area at this time. Ongoing monitoring for effectiveness. Medication effectiveness for clinical indication: somewhat effective."

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 11:30 PM to 3/28/25 12:30 AM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment.

During an interview on 4/30/25 at 11:30 AM, the DON, Director of QAPI, and Lead Educator all agreed that LN #21 never completed this reassessment of medication. The Lead Educator stated it was the expectation that nurses completed a reassessment of PRN medication within 15 minutes of administration by physically assessing the patient.

During an interview on 5/1/25 at 9:27 AM, the Director of Risk Management stated from 3/27/25 at 11:49 PM to 3/28/25 at 4:29 AM no nurse returned to Patient #5's room.

Review of Patient #5's nursing note, written by LN #21 dated 3/28/25 at 5:08 AM, revealed: "Behaviors related to COSS [Close Observation Status Scale] status: Pt was elevated in bed area at shift change and was offered HS [night] med [medications] earlier by declined and started [his/her] 'seizure like shaking.' Received IMBU for refusing court order PO. Pt was making weird sound in bed area and was observed laying on the floor. Pt didn't show any improvement from [his/her] conditions and continued to scream at bed area. Pt received another IMBU Thorazine for refusal of PO meds for agitation. Pt was still tapping the floor and not responding to prompts for hours. Pt finally fall asleep around [2:00 AM] when checked . . . ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . ."

Patient #5's Aggressive Behavior

During an interview on 4/30/25 at 9:58 AM, the DON stated how staff interact with patients and unit culture has been a concern since February 2025.

During an interview on 4/30/25 at 11:00 AM, the Patient #5's Provider stated consoling and encouraging was the best therapy for Patient #5's during his/her episodes.

During an interview on 5/1/25 at 10:21 AM, when asked to describe what Patient #5's "severe agitation" would look like, Patient #5's Provider stated this would typically be non-redirectable behavior of disrobing, running out of his/her room, and being physically aggressive towards staff.

When asked if rolling on the floor, tapping, and making animal noises in Patient #5's bedroom area would be considered "severe agitation" and warrant PRN medication, Patient #5's Provider stated, "No. The treatment team made the decision to be as least restrictive as possible with [Patient #5]."

The Director of QAPI was in the room during this interview and asked Patient #5's Provider, "What if Patient #5 was rolling on the floor and making animal noises for hours?" Patient #5's Provider stated, "No, as long as [he/she] was in [his/her] room it would not warrant PRN medication."

An observation on 5/1/25 at 10:37 AM, once this interview was completed and Patient #5's Provider and the Director of QAPI left the room. Raised voices could be heard in the hallway, one of the voices heard was the Director of QAPI, although the articulation of the speech, or what was actually said, was not clear. Shortly after this, Patient #5's Provider returned to the room and stated Patient #5's lengthy behavior of rolling around on the floor and making animal noises could be considered agitation.

Incident on 3/28/25

During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) and Director of QAPI stated that on the evening of 3/27/25 and through the early morning on 3/28/25, Patient #5 was up late in his/her bedroom exhibiting some of the behavior challenges they had been dealing with for an extended period of time: he/she moved back and forth from the bathroom to the bedroom area, later in the evening he/she was rolling around on the bedroom floor, excessively tapping on the floor, and making animal noises at times through the night.

The Director of QAPI stated that based on video review, it was observed and heard that at 1:13 AM, PNA #7, after having completed a patient safety check (a visual check on the patient's status for safety), told another PNA in the hall that Patient #5 was, "laying down on the table."

The "table" was a desk (measuring 2 feet, 11 1/2 inches long and 2 feet, 1/2 inch wide) that was in his/her bedroom. This desk was bolted to the back half of the left wall of the room and approximately 2 1/2 feet away from the back left corner of the room that connected to the back wall. In the space between desk and the back wall, Patient #5 had placed his/her weighted chair flush against the left wall (the front of the chair was against the left wall, with the back of the chair facing outward), which left approximately 3 inches between the chair and desk on the left side of the chair, and approximately 3 inches between the chair and back wall on the right side of the chair. The total length of the chair/desk space was 5 feet, 6 inches from the right arm rest of the chair to the far-left edge of the desk.

The Director of QAPI further stated that Patient #5 (who was 6 feet, 1/4 inches tall and weighed approximately 275.4 lbs.) initially was laying prone on the desk (flat on his/her stomach face down), with his/her head positioned towards the back wall, which caused his/her legs and upper shoulders and head to extend beyond the edges of the desk on either side.

As the night progressed, the Director of QAPI stated that Patient #5 began to move towards the back wall slowly inching his/her upper body onto the chair positioned between the desk and back wall, while his lower body remained on the desk. Eventually, Patient #5 had his/her head on the right armrest of the chair, closest to the back wall, with his/her face turned towards the left wall. Patient #5's left arm was tucked under his/her torso on the chair seat, and the right arm was draped over the back of the chair.

During an interview on 4/30/25 at 9:58 AM, the DON stated all staff on nightshift on 3/27-28/25 stated they had never seen Patient #5 sleep on the desk before, but they didn't think it was something alarming.

An observation on 4/30/25 at 2:38 PM, of Patient #5's bedroom, revealed that when the chair was placed between the desk and the back wall, the chair was at a lower elevation then the top of the desk. This would have caused Patient #5's upper body to be lower than his/her hips, buttocks, and legs which were still on the desk.

Further observation revealed that when the Director of QAPI positioned herself in the same prone position as Patient #5 was on 3/28/25, her torso was not supported when her head/neck was resting on the right armrest of the chair, which caused her chest to bow downward towards the seat of the chair placing the pressure of supporting her upper body on her head/neck.

Further observation revealed that when standing in the doorway of Patient #5's bedroom, a person's view would have been of Patient #5's buttocks, legs, and feet only, with a minimal view of Patient #5's back and back of head. If staff were to enter the room and stand in close proximity to Patient #5, there would have been no view of Patient #5's face or the rise and fall of Patient #5's front chest during respirations, which was face down in the chair.

During an interview on 5/1/25 at 10:45 AM, when asked what the expectation for nurses and PNAs would be if a patient was positioned, during rest or sleep, in a way that could place the patient at risk for safety, the Assistant Director of Nursing (ADON) stated the expectation would be to attempt to move the patient.

When asked what if the patient resisted, the ADON stated then repeated attempts should be tried until the patient is positioned for safety. This could be trying to physically move the patient or communicate with the patient to achieve cooperation to move into a safer position.

Review of the facility's video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 1:13 AM to 4:29 AM, revealed:

- From 1:13 AM to 1:57 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes. At 1:13 AM, PNA #7 entered Patient #5's bedroom. Patient #5 could be heard on the camera (but was not seen as there were no cameras in the bedroom) making vocal sounds that were not words. As PNA #7 exited the room and approached other PNA's in the hall, it could be heard on the video that PNA #7 stated, "[he's/she's] laying on down on the table."

PNA #7 completed patient safety checks at 1:25 AM and 1:43 AM by looking in the window of the closed bedroom door. PNA #4 completed the patient safety check at 1:57 AM by looking in the window of the closed bedroom door.

- From 2:15 AM to 2:53 AM, no patient safety checks were completed for Patient #5, or any other patient on the Katmai unit. PNA #4 was assigned to patient safety checks this hour and remained seated in the hallway through this time.

- From 3:00 AM to 3:56 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #11 completed checks at 3:00 AM, 3:15 AM, 3:29 AM, and 3:43 AM. During this last check at 3:43 AM, PNA #11 stood at the doorway for 24 seconds while observing Patient #5. At 3:56 AM, PNA #12 completed the patient safety check by standing in the doorway for 21 seconds while observing Patient #5.

- At 4:12 AM, PNA #12 completed the patient safety check by entering Patient #5's bedroom. PNA #12 turned on the bedroom light and was in the room for 70 seconds, then exited.

- At 4:29 AM, PNA #12 completed the patient safety check by entering Patient #5's bedroom. PNA #12 turned on the light and could be heard calling Patient #5's name several times. Shortly after this, PNA #12 came back out into the hallway and called PNA #7 into the room with him/her. PNA #7 was observed to quickly leave the bedroom and go into the nurse's station to get the nurses. PNA #7 could be heard on the video recording saying, "[he's/she's] not moving." At 4:32 AM, PNA #12 told nurses, "[he/she] was breathing earlier" when they met him/her at Patient #5's doorway. All staff entered Patient #5's bedroom. Staff could be heard calling Patient #5's name. PNA #11 said, "let me get a pillow for [his/her] head" and left to retrieve a pillow. After some time, staff exited the room, LN #16 could be heard saying, "[he/she] was holding onto something."

During an interview on 4/30/25 at 12:37, the DON and Director of QAPI stated that when they interviewed the staff during their investigation after 3/28/25, all staff stated that at 4:29 AM when they entered the room, Patient #5 was positioned mostly on the desk with his/her head on the armrest of the chair closet to the desk and they attempted to reposition Patient #5 for safety and comfort. LN #16 and LN #21 both stated in their interviews that they checked Patient #5's pulse and stated he/she was breathing at this time. The DON and Director of QAPI stated that during staff interviews the staff stated, when the repositioning was attempted Patient #5 resisted to move by forcing his/her upper body down.

The DON further stated that when PNA #7 was interviewed, he/she stated when he/she left Patient #5's bedroom at 4:29 AM to get the nurses, he/she asked the nurses to come check Patient #5 to see if he/she was breathing. When asked if PNA #7 had ever before requested nurses to come check a resident for breathing during a patient safety check, PNA #7 stated, "no."

Review of Patient #5's nursing note, written by LN #21 and dated 3/28/25 at 5:08 AM, revealed: ". . . Pt finally fall asleep around [2:00 AM] when checked. Pt was laying on the table and drippled on the chair, was prompted to get into [his/her] bed for more comfort but ignored instructions. Pt was breathing and no distress noted. No further incident for the remaining of the shift. ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . ."

Further review revealed no documentation of the pulse check, or the rate assessed, that the LNs reported completing at 4:29 AM. No other assessment information was documented, nor was there any other documentation from the LNs on 3/28/25.

During an interview on 4/30/25 at 12:39 AM, when asked what the expectation would be for an LN who was asked to come as

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Based on record review and interview, the facility failed to ensure chemical restraints were not used for 1 Patient (#5), out of 1 patient reviewed, which restricted the patient's behavior and freedom of movement within his/her room, which was an approved intervention in a treatment team-approved behavior plan (an individualized behavior plan to address challenging behaviors and interventions staff can use to work through them). This failed practice violated the patient's right to be free from restraints, of any form.

Findings:

Patient #5

Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5's court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment.

Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension.

Review of the most recent "Petition for Court Approval of Administration of Psychotropic Medication," dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: ". . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . ."

Further review revealed that Patient #5 was on 1st Degree Close Observation Status Scale (COSS - the level of observation required for safety, ranging from 1st degree to 3rd degree. The higher the degree number, the closer the observation interval), which required Patient #5 to have an every-15-minute observation and engagement patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety).

Patient #5's Treatment Plan

Review of Patient #5's "Multidisciplinary Master Treatment Plan," dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: "Disturbance of Thought: "[Patient #5] shows active disturbance of though and oppositional behavior."

Further review revealed identified interventions to address Patient #5's "disturbance of thought" that included:

- "LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level," initiated on 11/6/23;
- "RN will prompt [Patient #5] to comply with safety behavior," initiated on 1/30/24;
- "Psychology will develop behavior plan to guide staff response to challenging behaviors," initiated on 9/11/24; and
- "Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes," initiated 11/6/24.

Patient #5's Challenging Behaviors

During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5's history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor.

The DON further stated that Patient #5's behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as "normal" for Patient #5.

During an interview on 4/30/25 at 10:21 AM, Patient #5's Provider stated that Patient #5's behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted.

Patient #5's Provider stated that these behaviors had been present since his/her 2020 admission.

Patient #5's Behavior Plan

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans are initiated when a patient's behavior becomes increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times.

Review of Patient #5's behavior plan, last updated 3/25/25, revealed:

- "Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an 'episode.'"

- ". . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . ."

- ". . . If you notice [Patient #5] is about to have an "episode," walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball."

- "Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an "episode." Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5's] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, "hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn't flood." Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress."

During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime.

Patient #5's Medication Regimen

Review of Patient #5's ordered medications, for March 2025, revealed he/she was on psychotropic medications ordered by the court. Further review revealed these medications also had a "shot" form of medication if Patient #5 refused to take his/her medications by mouth. These were ordered by the courts to aid in Patient #5's consistent treatment. These medications included:

Scheduled Medications:

1) "Clozapine [an antipsychotic medication used to treat schizophrenia] 300mg [milligrams] PO [by mouth] QHS [every night scheduled for 9:00 PM] for schizophrenia." This order started on 1/21/25.

Further review revealed: "Court ordered: If refused give haloperidol [Haldol - an antipsychotic medication used to treat schizophrenia] IMBU [IM, or shot, back up]."

1a) "Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO clozapine . . ." This order started on 12/5/23 and remained in effect.

2) "Divalproex [Depakote - An anticonvulsant used to treat some psychiatric illnesses] 1,250mg PO BID [twice a day: once in morning at 9:00 AM, once at night at 9:00 PM] for mood disorder secondary to schizophrenia." This order was started on 1/21/25.

Further review revealed: "Court ordered: If refused give lorazepam [Ativan - A benzodiazepine medication used to treat anxiety] IMBU."

3) "Clonazepam [An anti-epileptic drug used to treat seizure disorders] 2mg tablet PO 1300 [every day at 1:00 PM] for agitation secondary to schizophrenia." This order started on 2/25/25.

Further review revealed: "Court ordered: If patient refuses, provide IMBU lorazepam."

2a and 3a) "Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . Divalproex . . . [and] clonazepam . . ." This order started on 9/30/24 and remained in effect.

PRN Medications:

4) "Haloperidol 10mg tablet PO Q4HPRN [every 4 hours as needed] for agitation." This order started on 12/20/23.

Further review revealed: "Court ordered: If refused give haloperidol IMBU."

4a) "Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . haloperidol PRN . . ." This order started on 12/5/23 and remained in effect.

5) "Lorazepam 2mg tablet PO Q4HPRN for moderate anxiety or moderate agitation." This order started on 2/6/25.

Further review revealed: "Court ordered: If refused give Lorazepam IMBU."

5a) "Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO lorazepam PRN . . ." This order started on 9/30/24 and remained in effect.

6) "Chlorpromazine [Thorazine - An antipsychotic medication used to treat psychotic disorders such as schizophrenia] 100mg PO Q6HPRN [every 6 hours as needed] for severe agitation." This order started on 12/24/24.

Further review revealed: "Court ordered: If refused give chlorpromazine IMBU."

6a) "Chlorpromazine 50mg/2mL ampule - 100mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO chlorpromazine PRN." This order started on 12/24/24 and remained in effect.

Medication Administrations #1 for nightshift on 3/27/25

Review of Patient #5's electronic Medication Administration Record (eMAR), dated 3/27/25, revealed:

- At 7:12 PM, Licensed Nurse (LN) #16 documented that Patient #5 refused Lorazepam 2mg PO PRN for moderate anxiety or moderate agitation.

Further review revealed there was no documentation that the IMBU Lorazepam medication was given due to this PO refusal, which was instructed in the order.

- At 7:13 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Clozapine 300mg PO medication (107 minutes prior to scheduled time).
- At 7:14 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Divalproex 1,250mg PO medication (106 minutes prior to scheduled time).
- At 7:23 PM, LN #21 documented that Patient #5 received Lorazepam 2mg IM, PRN IMBU for refusal of court ordered PO Divalproex medication.
- At 7:25 PM, LN #21 documented that Patient #5 received Haloperidol 10mg IM, PRN IMBU for refusal of court ordered PO Clozapine medication.

Video Review of Medication Administrations #1

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 6:00 PM to 7:19 PM, revealed:

- From 6:00 PM to 6:16 PM, Patient #5 was in the unit's TV room watching basketball. He/she had calm movements during this time: he/she sat in a chair at times, stood and stretched and walked around the room at times; and made motions as if he/she was shooting a basketball at a hoop.

- At 6:16 PM, Patient #5 left the TV room and entered his/her bedroom.

During an interview on 6/2/25 at 9:24 AM, while reviewing the video, the Risk Manager stated that Patient #5 was exhibiting no aggression, and this was his/her baseline behavior.

- From 6:16 PM to 7:06 PM, Patient #5 remained in his/her room. Staff completed every-15-minute safety checks: they approached Patient #5's bedroom door, which was closed, and looked in the window and listened.

- At 7:02 PM, PNA #4 approached Patient #5's bedroom door, cracked the door, and then closed it. Further observation revealed PNA #4 instructed the staff at the nurse's station to turn off Patient #5's water.

During an interview on 6/2/25 at 9:25 AM, while reviewing the video, the Risk Manager stated that individual patient room's water supplies could be turned off at the nurse's station. When asked about Patient #5's behavior plan, and needing to speak to Patient #5 about him/her exceeding the water limit of 30 minutes, the Risk Manager stated after reviewing the video, PNA #4 did not follow the behavior plan and talk with Patient #5 prior to turning the water off. The Risk Manager stated Patient #5 had a history of escalating when the water was turned off.

- At 7:06 PM, PNA #11 approached Patient #5's room to complete a safety check.

- At 7:10 PM, PNA #11 approached Patient #5's room to complete a safety check . On the video, Patient #5 could be heard making animal noises from within his/her room area.

- At 7:11 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5's room to offer medications in pill form. The LNs and the Nurse Supervisor left the room without giving the medications.

During an interview on 6/2/25 at 9:26 AM, while reviewing the video, the Risk Manager stated Patient #5 refused the medications by mouth.

- From 7:11 PM to 7:19 PM, Patient #5 could be heard on the camera making animal noises from within his/her room.

- At 7:19 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5's room and administered IMBU medications. The LNs and the Nurse Supervisor left the room shortly after this.

Reassessment of Medications Administration #1

Review of Patient #5's eMAR, dated 3/27/25, revealed:

- At 8:42 PM, LN #21 documented a reassessment for Patient #5's response to the IMBU medications Lorazepam and Haloperidol (79 minutes after its administration). LN #21 documented they were both "Medication effectiveness for clinical indication: effective."

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 7:19 PM to 9:00 PM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment.

During an interview on 4/30/25 at 12:08 PM, the DON stated no nursing assessment was completed after Patient #5 received Lorazepam and Haloperidol IM injections. The DON further stated nurses were to complete an assessment after 15 minutes of administration of the IM injections.

Medication Administrations #2 for Nightshift on 3/27/25

Review of Patient #5's eMAR, dated 3/27/25, revealed:

- At 11:50 PM, LN #21 documented that Patient #5 refused Chlorpromazine 100mg PO PRN for severe agitation.
- At 11:51 PM, LN #21 documented that Patient #5 received Chlorpromazine 100mg IM, PRN IMBU for refusal of PO Chlorpromazine medication.

Video Review of Medication Administration #2

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 10:00 PM to 11:50 PM, revealed there was no indication of "severe agitation" from Patient #5. During this time frame, Patient #5 was in his/her bedroom and was only heard making animal noises once at 11:43 PM, which only lasted for less than 1 minute. Further observation revealed PNA staff appeared calm, sitting in the halls, and no nurse ever approached Patient #5 to assess his/her level of agitation. No nurse offered Patient #5 the PO form of chlorpromazine prior to the administration IMBU medication. Also, no de-escalation techniques were seen attempted, and no distraction choices or preferred activities from Patient #5's behavior plan were attempted.

Further observation of the video recording revealed at 11:49 PM, LNs #16 and #21 entered Patient #5's bedroom with 2 IM syringes and a SHARPS container (a red hard plastic container in which to put used syringes in), along with PNA's #7 and #11, and exited shortly after.

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated it was the expectation for all nurses to offer patients PO forms of medication before IM or IMBU forms were used. Meaning that nurses were to approach patients, communicate with them while offering medications. Also explore alternative ways for the patients to agree to take PO medications prior to IM or IMBU being used.

When asked if there was any policy that defined mild-to moderate-to severe agitation for nurses to use as a guide, the ADON stated it is the nurse's discretion to determine what those terms mean. When asked what she thought "severe agitation" meant, the ADON stated it would mean to the point of causing potential harm to self or others.

During an interview on 5/1/25 at 11:35 AM, when asked how nurses were taught how to recognize mild-to moderate-to severe agitation, the Director of QAPI stated there was no training in orientation to help nurses recognize what those terms look like behavior-wise. The Director of QAPI further stated that nurses were taught what these terms meant in nursing schooling.

The Director of QAPI further stated that when Patient #5 was rolling around on the floor, it meant he/she was agitated, and it warranted PRN medication.

During an interview on 6/2/25 at 1:14 PM, when asked if Patient #5 was following his/her behavior plan (to be in his/her room during an episode), the ADON and Director of QAPI agreed Patient #5 was following the plan.

When asked if any staff member working on 3/27/25 used the interventions in the behavior plan to help distract Patient #5 and help to calm him/her, the Director of QAPI stated the video recording showed that no staff member followed the behavior plan interventions listed.

Reassessment of Medication Administration #2

Further review of Patient #5's eMAR, revealed that on 3/28/25 at 12:07 AM, LN #21 documented a reassessment for Patient #5's response to the IMBU Chlorpromazine (16 minutes after its administration): "Pt [patient] still agitated unable to respond to verbal prompts. Pt was laying on the floor in bed area at this time. Ongoing monitoring for effectiveness. Medication effectiveness for clinical indication: somewhat effective."

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 11:30 PM to 3/28/25 12:30 AM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment.

During an interview on 4/30/25 at 11:30 AM, the DON, Director of QAPI, and Lead Educator all agreed that LN #21 never completed this reassessment of medication. The Lead Educator stated it was the expectation that nurses completed a reassessment of PRN medication within 15 minutes of administration by physically assessing the patient.

During an interview on 5/1/25 at 9:27 AM, the Director of Risk Management stated from 3/27/25 at 11:49 PM to 3/28/25 at 4:29 AM no nurse returned to Patient #5's room.

Review of Patient #5's nursing note, written by LN #21 dated 3/28/25 at 5:08 AM, revealed: "Behaviors related to COSS [Close Observation Status Scale] status: Pt was elevated in bed area at shift change and was offered HS [night] med [medications] earlier by declined and started [his/her] 'seizure like shaking.' Received IMBU for refusing court order PO. Pt was making weird sound in bed area and was observed laying on the floor. Pt didn't show any improvement from [his/her] conditions and continued to scream at bed area. Pt received another IMBU Thorazine for refusal of PO meds for agitation. Pt was still tapping the floor and not responding to prompts for hours. Pt finally fall asleep around [2:00 AM] when checked . . . ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . ."

Patient #5's Aggressive Behavior

During an interview on 4/30/25 at 9:58 AM, the DON stated how staff interact with patients and unit culture has been a concern since February 2025.

During an interview on 4/30/25 at 11:00 AM, the Patient #5's Provider stated consoling and encouraging was the best therapy for Patient #5's during his/her episodes.

During an interview on 5/1/25 at 10:21 AM, when asked to describe what Patient #5's "severe agitation" would look like, Patient #5's Provider stated this would typically be non-redirectable behavior of disrobing, running out of his/her room, and being physically aggressive towards staff.

When asked if rolling on the floor, tapping, and making animal noises in Patient #5's bedroom area would be considered "severe agitation" and warrant PRN medication, Patient #5's Provider stated, "No. The treatment team made the decision to be as least restrictive as possible with [Patient #5]."

The Director of QAPI was in the room during this interview and asked Patient #5's Provider, "What if Patient #5 was rolling on the floor and making animal noises for hours?" Patient #5's Provider stated, "No, as long as [he/she] was in [his/her] room it would not warrant PRN medication."

An observation on 5/1/25 at 10:37 AM, once this interview was completed and Patient #5's Provider and the Director of QAPI left the room. Raised voices could be heard in the hallway, one of the voices heard was the Director of QAPI, although the articulation of the speech, or what was actually said, was not clear. Shortly after this, Patient #5's Provider returned to the room and stated Patient #5's lengthy behavior of rolling around on the floor and making animal noises could be considered agitation.

During an interview on 6/2/25 at 1:16 PM, the Education Coordinator stated the definition of a chemical restraint was to cause sedation to limit or stop a behavior. When asked about the facility's policy on chemical restraint, the Education Coordinator stated the facility did not use chemical restraints, and was considered prohibited, and this was trained to all staff.

Review of the facility's policy "Patient Rights," effective 1/29/24, revealed: "Procedure: Except as otherwise provided . . . a patient has rights that include the following . . . to be free from physical or chemical restraints . . . to be treated with consideration and recognition of the patient's dignity and individuality . . . to be free from unnecessary or excessive medications . . . to receive care in a safe, respectful, and the least restrictive setting and environment . . ."

Review of the facility's policy "Medication Orders, Preparation, and Administration," effective 5/19/22, revealed: ". . . A complete order indicates the following . . . PRN . . . orders require "clear intent" which implies the inclusion of the indication for use and/or precise instructions for PRN medications: The use of "PRN" with medication orders must be qualified to include the frequency and the specific symptom(s) of therapeutic indication for which the drug is to be used. The PRN therapeutic indication shall be clear and unique (no two medications shall have the same PRN indication) . . . Medication Administration Time Requirements . . . All scheduled medications are administered 90 minutes prior to or 90 minutes after the scheduled time . . . The Patient shall be monitored for their perception of side effects and the effectiveness of the medication(s). Necessary assessments and re-assessments shall be completed . . . All medications administered for any type of pain, all PRN medications, all 1st doses and all one time orders . . . require follow up documentation/reassessment: IM Medications - 30 minutes . . ."

Review of the facility's policy "Management of Patient Behavior," effective 7/1/24, revealed: ". . . Policy: API will provide the least restrictive and non-violent therapeutic environment for the care of its patients, will treat all patients with dignity and respect, and will ensure the safety and well-being of all patients, staff, and visitors . . . In situations where a patient exhibits behavior that are or have the imminent potential to be harmful to themselves or others, staff will intervene in the least restrictive manner effective to assist the patient to regain emotional control and to mitigate the danger of the situation. The following describes the therapeutic measure that may be used by staff during the escalation of dangerous patient behavior, from least restrictive to most restrictive: Non-verbal interventions; verbal interventions; Physical interventions to guide and direct a patient; and Physical interventions which restrict a patient's movement . . . Management of Patient Behavior: API's procedures safely and therapeutically manage and improve that behavior(s) of a patient manifesting from the patient's emotional or behavioral disorder. These procedures include de-escalation of a patient through the progression of non-verbal, verbal, and physical interventions necessary to manage a patient's behaviors safely and therapeutically. As a last resort, the interventions may include seclusion, physical holds/restraints, and mechanical restraints . . . Individual Behavior Plans (IBP): Refer to P&P [Policy and Procedure] PC-050-05.05 Treatment Planning . . ."

Review of the facility policy "Treatment Planning," effective 1/22/25, revealed: ". . . Individual Behavioral Plans: If the patient demonstrates unsafe behaviors that do not respond to other intervention on the Treatment Plan, the Treatment Team may recommend the patient receive an assessment and an Individualized Behavioral Plan (IBP) . . . The IBP will specifically target maladaptive behaviors and document adaptive/replacement behaviors and interventions . . . The Clinical Services MHC [Mental Health Clinician] will educate team members on the implementation of the IBP and specific behavioral strategies . . . The IBP will be attached to the Daily Nursing Communication Report for each patient, every day, to be reviewed by staff as they receive report and arrive on the unit . . ."
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Based on record review and interview, the facility failed to ensure the nightshift Licensed Nurses (LN #'s 16 and 21) supervised and evaluated the nursing care provided for 1 Patient (#5), out of 1 patient reviewed. Specifically, LN #16 and #21 failed to:

1) Appropriately assess and offer scheduled PO (by mouth) medications to Patient #5 prior to administering court ordered IM Back Up (IMBU - medications received by injection after PO medications were refused) medications;

2) Appropriately assess and offer PRN (as needed) medication to Patient #5 prior to administering court ordered IMBU medication;

3) Appropriately re-assess Patient #5, within the facility's standard timeframe, after each administration of IMBU medication was received; and

4) Appropriately completed an evaluation for Patient #5 after reports of concern of possible deterioration of physical status were reported by Psychiatric Nursing Assistants (PNA #'s 7 and 12).

These failed practices, to not appropriately assess the patient's care needs, health status/condition, and response to interventions, placed Patient #5 at risk for a compromised airway and deterioration of physical status, which had the potential to increase the risk of respiratory distress, and harm, up to and including death.

Findings:

Patient #5

Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5's court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment.

Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension.

Review of the most recent "Petition for Court Approval of Administration of Psychotropic Medication," dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: ". . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . ."

Further review revealed that Patient #5 was on 1st Degree Close Observation Status Scale (COSS - the level of observation required for safety, ranging from 1st degree to 3rd degree. The higher the degree number, the closer the observation interval), which required Patient #5 to have an every-15-minute observation and engagement patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety).

Patient #5's Treatment Plan

Review of Patient #5's "Multidisciplinary Master Treatment Plan," dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: "Disturbance of Thought: "[Patient #5] shows active disturbance of though and oppositional behavior."

Further review revealed identified interventions to address Patient #5's "disturbance of thought" that included:

- "LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level," initiated on 11/6/23;
- "RN will prompt [Patient #5] to comply with safety behavior," initiated on 1/30/24;
- "Psychology will develop behavior plan to guide staff response to challenging behaviors," initiated on 9/11/24; and
- "Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes," initiated 11/6/24.

Patient #5's Challenging Behaviors

During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5's history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor.

The DON further stated that Patient #5's behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as "normal" for Patient #5.

During an interview on 4/30/25 at 10:21 AM, Patient #5's Provider stated that Patient #5's behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted.

Patient #5's Provider stated that these behaviors had been present since his/her 2020 admission.

Patient #5's Behavior Plan

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans are initiated when a patient's behavior becomes increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times.

Review of Patient #5's behavior plan, last updated 3/25/25, revealed:

- "Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an 'episode.'"

- ". . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . ."

- ". . . If you notice [Patient #5] is about to have an "episode," walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball."

- "Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an "episode." Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5's] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, "hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn't flood." Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress."

During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime.

Patient #5's Medication Regimen

Review of Patient #5's ordered medications, for March 2025, revealed he/she was on psychotropic medications ordered by the court. Further review revealed these medications also had a "shot" form of medication if Patient #5 refused to take his/her medications by mouth. These were ordered by the courts to aid in Patient #5's consistent treatment. These medications included:

Scheduled Medications:

1) "Clozapine [an antipsychotic medication used to treat schizophrenia] 300mg [milligrams] PO [by mouth] QHS [every night scheduled for 9:00 PM] for schizophrenia." This order started on 1/21/25.

Further review revealed: "Court ordered: If refused give haloperidol [Haldol - an antipsychotic medication used to treat schizophrenia] IMBU [IM, or shot, back up]."

1a) "Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO clozapine . . ." This order started on 12/5/23 and remained in effect.

2) "Divalproex [Depakote - An anticonvulsant used to treat some psychiatric illnesses] 1,250mg PO BID [twice a day: once in morning at 9:00 AM, once at night at 9:00 PM] for mood disorder secondary to schizophrenia." This order was started on 1/21/25.

Further review revealed: "Court ordered: If refused give lorazepam [Ativan - A benzodiazepine medication used to treat anxiety] IMBU."

3) "Clonazepam [An anti-epileptic drug used to treat seizure disorders] 2mg tablet PO 1300 [every day at 1:00 PM] for agitation secondary to schizophrenia." This order started on 2/25/25.

Further review revealed: "Court ordered: If patient refuses, provide IMBU lorazepam."

2a and 3a) "Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . Divalproex . . . [and] clonazepam . . ." This order started on 9/30/24 and remained in effect.

PRN Medications:

4) "Haloperidol 10mg tablet PO Q4HPRN [every 4 hours as needed] for agitation." This order started on 12/20/23.

Further review revealed: "Court ordered: If refused give haloperidol IMBU."

4a) "Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . haloperidol PRN . . ." This order started on 12/5/23 and remained in effect.

5) "Lorazepam 2mg tablet PO Q4HPRN for moderate anxiety or moderate agitation." This order started on 2/6/25.

Further review revealed: "Court ordered: If refused give Lorazepam IMBU."

5a) "Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO lorazepam PRN . . ." This order started on 9/30/24 and remained in effect.

6) "Chlorpromazine [Thorazine - An antipsychotic medication used to treat psychotic disorders such as schizophrenia] 100mg PO Q6HPRN [every 6 hours as needed] for severe agitation." This order started on 12/24/24.

Further review revealed: "Court ordered: If refused give chlorpromazine IMBU."

6a) "Chlorpromazine 50mg/2mL ampule - 100mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO chlorpromazine PRN." This order started on 12/24/24 and remained in effect.

Medication Administrations #1 for nightshift on 3/27/25

Review of Patient #5's electronic Medication Administration Record (eMAR), dated 3/27/25, revealed:

- At 7:12 PM, Licensed Nurse (LN) #16 documented that Patient #5 refused Lorazepam 2mg PO PRN for moderate anxiety or moderate agitation.

Further review revealed there was no documentation that the IMBU Lorazepam medication was given due to this PO refusal, which was instructed in the order.

- At 7:13 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Clozapine 300mg PO medication (107 minutes prior to scheduled time).
- At 7:14 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Divalproex 1,250mg PO medication (106 minutes prior to scheduled time).
- At 7:23 PM, LN #21 documented that Patient #5 received Lorazepam 2mg IM, PRN IMBU for refusal of court ordered PO Divalproex medication.
- At 7:25 PM, LN #21 documented that Patient #5 received Haloperidol 10mg IM, PRN IMBU for refusal of court ordered PO Clozapine medication.

Video Review of Medication Administrations #1

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 6:00 PM to 7:19 PM, revealed:

- From 6:00 PM to 6:16 PM, Patient #5 was in the unit's TV room watching basketball. He/she had calm movements during this time: he/she sat in a chair at times, stood and stretched and walked around the room at times; and made motions as if he/she was shooting a basketball at a hoop.

- At 6:16 PM, Patient #5 left the TV room and entered his/her bedroom.

During an interview on 6/2/25 at 9:24 AM, while reviewing the video, the Risk Manager stated that Patient #5 was exhibiting no aggression, and this was his/her baseline behavior.

- From 6:16 PM to 7:06 PM, Patient #5 remained in his/her room. Staff completed every-15-minute safety checks: they approached Patient #5's bedroom door, which was closed, and looked in the window and listened.

- At 7:02 PM, PNA #4 approached Patient #5's bedroom door, cracked the door, and then closed it. Further observation revealed PNA #4 instructed the staff at the nurse's station to turn off Patient #5's water.

During an interview on 6/2/25 at 9:25 AM, while reviewing the video, the Risk Manager stated that individual patient room's water supplies could be turned off at the nurse's station. When asked about Patient #5's behavior plan, and needing to speak to Patient #5 about him/her exceeding the water limit of 30 minutes, the Risk Manager stated after reviewing the video, PNA #4 did not follow the behavior plan and talk with Patient #5 prior to turning the water off. The Risk Manager stated Patient #5 had a history of escalating when the water was turned off.

- At 7:06 PM, PNA #11 approached Patient #5's room to complete a safety check.

- At 7:10 PM, PNA #11 approached Patient #5's room to complete a safety check. On the video, Patient #5 could be heard making animal noises from within his/her room area.

- At 7:11 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5's room to offer medications in pill form. The LNs and the Nurse Supervisor left the room without giving the medications.

During an interview on 6/2/25 at 9:26 AM, while reviewing the video, the Risk Manager stated Patient #5 refused the medications by mouth.

- From 7:11 PM to 7:19 PM, Patient #5 could be heard on the camera making animal noises from within his/her room.

- At 7:19 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5's room and administered IMBU medications. The LNs and the Nurse Supervisor left the room shortly after this.

Reassessment of Medications Administration #1

Review of Patient #5's eMAR, dated 3/27/25, revealed:

- At 8:42 PM, LN #21 documented a reassessment for Patient #5's response to the IMBU medications Lorazepam and Haloperidol (79 minutes after its administration). LN #21 documented they were both "Medication effectiveness for clinical indication: effective."

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 7:19 PM to 9:00 PM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment.

During an interview on 4/30/25 at 12:08 PM, the DON stated no nursing assessment was completed after Patient #5 received Lorazepam and Haloperidol IM injections. The DON further stated nurses were to complete an assessment after 15 minutes of administration of the IM injections.

Medication Administrations #2 for Nightshift on 3/27/25

Review of Patient #5's eMAR, dated 3/27/25, revealed:

- At 11:50 PM, LN #21 documented that Patient #5 refused Chlorpromazine 100mg PO PRN for severe agitation.
- At 11:51 PM, LN #21 documented that Patient #5 received Chlorpromazine 100mg IM, PRN IMBU for refusal of PO Chlorpromazine medication.

Video Review of Medication Administration #2

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 10:00 PM to 11:50 PM, revealed there was no indication of "severe agitation" from Patient #5. During this time frame, Patient #5 was in his/her bedroom and was only heard making animal noises once at 11:43 PM, which only lasted for less than 1 minute. Further observation revealed PNA staff appeared calm, sitting in the halls, and no nurse ever approached Patient #5 to assess his/her level of agitation. No nurse offered Patient #5 the PO form of chlorpromazine prior to the administration IMBU medication. Also, no de-escalation techniques were seen attempted, and no distraction choices or preferred activities from Patient #5's behavior plan were attempted.

Further observation of the video recording revealed at 11:49 PM, LNs #16 and #21 entered Patient #5's bedroom with 2 IM syringes and a SHARPS container (a red hard plastic container in which to put used syringes in), along with PNA's #7 and #11, and exited shortly after.

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated it was the expectation for all nurses to offer patients PO forms of medication before IM or IMBU forms were used. Meaning that nurses were to approach patients, communicate with them while offering medications. Also explore alternative ways for the patients to agree to take PO medications prior to IM or IMBU being used.

When asked if there was any policy that defined mild-to moderate-to severe agitation for nurses to use as a guide, the ADON stated it is the nurse's discretion to determine what those terms mean. When asked what she thought "severe agitation" meant, the ADON stated it would mean to the point of causing potential harm to self or others.

During an interview on 5/1/25 at 11:35 AM, when asked how nurses were taught how to recognize mild-to moderate-to severe agitation, the Director of QAPI stated there was no training in orientation to help nurses recognize what those terms look like behavior-wise. The Director of QAPI further stated that nurses were taught what these terms meant in nursing schooling.

The Director of QAPI further stated that when Patient #5 was rolling around on the floor, it meant he/she was agitated, and it warranted PRN medication.

During an interview on 6/2/25 at 1:14 PM, when asked if Patient #5 was following his/her behavior plan (to be in his/her room during an episode), the ADON and Director of QAPI agreed Patient #5 was following the plan.

When asked if any staff member working on 3/27/25 used the interventions in the behavior plan to help distract Patient #5 and help to calm him/her, the Director of QAPI stated the video recording showed that no staff member followed the behavior plan interventions listed.

Reassessment of Medication Administration #2

Further review of Patient #5's eMAR, revealed that on 3/28/25 at 12:07 AM, LN #21 documented a reassessment for Patient #5's response to the IMBU Chlorpromazine (16 minutes after its administration): "Pt [patient] still agitated unable to respond to verbal prompts. Pt was laying on the floor in bed area at this time. Ongoing monitoring for effectiveness. Medication effectiveness for clinical indication: somewhat effective."

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 11:30 PM to 3/28/25 12:30 AM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment.

During an interview on 4/30/25 at 11:30 AM, the DON, Director of QAPI, and Lead Educator all agreed that LN #21 never completed this reassessment of medication. The Lead Educator stated it was the expectation that nurses completed a reassessment of PRN medication within 15 minutes of administration by physically assessing the patient.

During an interview on 5/1/25 at 9:27 AM, the Director of Risk Management stated from 3/27/25 at 11:49 PM to 3/28/25 at 4:29 AM no nurse returned to Patient #5's room.

Review of Patient #5's nursing note, written by LN #21 dated 3/28/25 at 5:08 AM, revealed: "Behaviors related to COSS [Close Observation Status Scale] status: Pt was elevated in bed area at shift change and was offered HS [night] med [medications] earlier by declined and started [his/her] 'seizure like shaking.' Received IMBU for refusing court order PO. Pt was making weird sound in bed area and was observed laying on the floor. Pt didn't show any improvement from [his/her] conditions and continued to scream at bed area. Pt received another IMBU Thorazine for refusal of PO meds for agitation. Pt was still tapping the floor and not responding to prompts for hours. Pt finally fall asleep around [2:00 AM] when checked . . . ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . ."

Patient #5's Aggressive Behavior

During an interview on 4/30/25 at 9:58 AM, the DON stated how staff interact with patients and unit culture has been a concern since February 2025.

During an interview on 4/30/25 at 11:00 AM, the Patient #5's Provider stated consoling and encouraging was the best therapy for Patient #5's during his/her episodes.

During an interview on 5/1/25 at 10:21 AM, when asked to describe what Patient #5's "severe agitation" would look like, Patient #5's Provider stated this would typically be non-redirectable behavior of disrobing, running out of his/her room, and being physically aggressive towards staff.

When asked if rolling on the floor, tapping, and making animal noises in Patient #5's bedroom area be considered "severe agitation" and warrant PRN medication, Patient #5's Provider stated, "No. The treatment team made the decision to be as least restrictive as possible with [Patient #5]."

The Director of QAPI was in the room during this interview and asked Patient #5's Provider, "What if Patient #5 was rolling on the floor and making animal noises for hours?" Patient #5's Provider stated, "No, as long as [he/she] was in [his/her] room it would not warrant PRN medication."

An observation on 5/1/25 at 10:37 AM, once this interview was completed and Patient #5's Provider and the Director of QAPI left the room. Raised voices could be heard in the hallway, one of the voices heard was the Director of QAPI, although the articulation of the speech, or what was actually said, was not clear. Shortly after this, Patient #5's Provider returned to the room and stated Patient #5's lengthy behavior of rolling around on the floor and making animal noises could be considered agitation.

Incident on 3/28/25

During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) and Director of QAPI stated that on the evening of 3/27/25 and through the early morning on 3/28/25, Patient #5 was up late in his/her bedroom exhibiting some of the behavior challenges they had been dealing with for an extended period of time: he/she moved back and forth from the bathroom to the bedroom area, later in the evening he/she was rolling around on the bedroom floor, excessively tapping on the floor, and making animal noises at times through the night.

The Director of QAPI stated that based on video review, it was observed and heard that at 1:13 AM, PNA #7, after having completed a patient safety check (a visual check on the patient's status for safety), told another PNA in the hall that Patient #5 was, "laying down on the table."

The "table" was a desk (measuring 2 feet, 11 1/2 inches long and 2 feet, 1/2 inch wide) that was in his/her bedroom. This desk was bolted to the back half of the left wall of the room and approximately 2 1/2 feet away from the back left corner of the room that connected to the back wall. In the space between desk and the back wall, Patient #5 had placed his/her weighted chair flush against the left wall (the front of the chair was against the left wall, with the back of the chair facing outward), which left approximately 3 inches between the chair and desk on the left side of the chair, and approximately 3 inches between the chair and back wall on the right side of the chair. The total length of the chair/desk space was 5 feet, 6 inches from the right arm rest of the chair to the far-left edge of the desk.

The Director of QAPI further stated that Patient #5 (who was 6 feet, 1/4 inches tall and weighed approximately 275.4 lbs.) initially was laying prone on the desk (flat on his/her stomach face down), with his/her head positioned towards the back wall, which caused his/her legs and upper shoulders and head to extend beyond the edges of the desk on either side.

As the night progressed, the Director of QAPI stated that Patient #5 began to move towards the back wall slowly inching his/her upper body onto the chair positioned between the desk and back wall, while his lower body remained on the desk. Eventually, Patient #5 had his/her head on the right armrest of the chair, closest to the back wall, with his/her face turned towards the left wall. Patient #5's left arm was tucked under his/her torso on the chair seat, and the right arm was draped over the back of the chair.

During an interview on 4/30/25 at 9:58 AM, the DON stated all staff on nightshift on 3/27-28/25 stated they had never seen Patient #5 sleep on the desk before, but they didn't think it was something alarming.

An observation on 4/30/25 at 2:38 PM, of Patient #5's bedroom, revealed that when the chair was placed between the desk and the back wall, the chair was at a lower elevation then the top of the desk. This would have caused Patient #5's upper body to be lower than his/her hips, buttocks, and legs which were still on the desk.

Further observation revealed that when the Director of QAPI positioned herself in the same prone position as Patient #5 was on 3/28/25, her torso was not supported when her head/neck was resting on the right armrest of the chair, which caused her chest to bow downward towards the seat of the chair placing the pressure of supporting her upper body on her head/neck.

Further observation revealed that when standing in the doorway of Patient #5's bedroom, a person's view would have been of Patient #5's buttocks, legs, and feet only, with a minimal view of Patient #5's back and back of head. If staff were to enter the room and stand in close proximity to Patient #5, there would have been no view of Patient #5's face or the rise and fall of Patient #5's front chest during respirations, which was face down in the chair.

During an interview on 5/1/25 at 10:45 AM, when asked what the expectation for nurses and PNAs would be if a patient was positioned, during rest or sleep, in a way that could place the patient at risk for safety, the Assistant Director of Nursing (ADON) stated the expectation would be to attempt to move the patient.

When asked what if the patient resisted, the ADON stated then repeated attempts should be tried until the patient is positioned for safety. This could be trying to physically move the patient or communicate with the patient to achieve cooperation to move into a safer position.

Review of the facility's video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 1:13 AM to 7:15 AM, revealed:

- From 1:13 AM to 1:57 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes. At 1:13 AM, PNA #7 entered Patient #5's bedroom. Patient #5 could be heard on the camera (but was not seen as there were no cameras in the bedroom) making vocal sounds that were not words. As PNA #7 exited the room and approached other PNA's in the hall, it could be heard on the video that PNA #7 stated, "[he's/she's] laying on down on the table."

PNA #7 completed patient safety checks at 1:25 AM and 1:43 AM by looking in the window of the closed bedroom door. PNA #4 completed the patient safety check at 1:57 AM by looking in the window of the closed bedroom door.

- From 2:15 AM to 2:53 AM, no patient safety checks were completed for Patient #5, or any other patient on the Katmai unit. PNA #4 was assigned to patient safety checks this hour and remained seated in the hallway through this time.

- From 3:00 AM to 3:56 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #11 completed checks at 3:00 AM, 3:15 AM, 3:29 AM, and 3:43 AM. During this last check at 3:43 AM, PNA #11 stood at the doorway for 24 seconds while observing Patient #5. At 3:56 AM, PNA #12 completed the patient safety check by standing in the doorway for 21 seconds while observing Patient #5.

- At 4:12 AM, PNA #12 completed the patient safety check by entering Patient #5's bedroom. PNA #12 turned on the bedroom light and was in the room for 70 seconds, then exited.

- At 4:29 AM, PNA #12 completed the patient safety check by entering Patient #5's bedroom. PNA #12 turned on the light and could be heard calling Patient #5's name several times. Shortly after this, PNA #12 came back out into the hallway and called PNA #7 into the room with him/her. PNA #7 was observed to quickly leave the bedroom and go into the nurse's station to get the nurses. PNA #7 could be heard on the video recording saying, "[he's/she's] not moving." At 4:32 AM, PNA #12 told nurses, "[he/she] was breathing earlier" when they met him/her at Patient #5's doorway. All staff entered Patient #5's bedroom. Staff could be heard calling Patient #5's name. PNA #11 said, "let me get a pillow for [his/her] head" and left to retrieve a pillow. After some time, staff exited the room, LN #16 could be heard saying, "[he/she] was holding onto something."

During an interview on 4/30/25 at 12:37, the DON and Director of QAPI stated that when they interviewed the staff during their investigation after 3/28/25, all staff stated that at 4:29 AM when they entered the room, Patient #5 was positioned mostly on the desk with his/her head on the armrest of the chair closest to the desk and they attempted to reposition Patient #5 for safety and comfort. LN #16 and LN #21 both stated in their interviews that they checked Patient #5's pulse and stated he/she was breathing at this time. The DON and Director of QAPI stated that during staff interviews the staff stated, when the repositioning was attempted Patient #5 resisted to move by forcing his/her upper body down.

The DON further stated that when PNA #7 was interviewed, he/she stated when he/she left Patient #5's bedroom at 4:29 AM to get the nurses, he/she asked the nurses to come check Patient #5 to see if he/she was breathing. When asked if PNA #7 had ever before requested nurses to come check a resident for breathing during a patient safety check, PNA #7 stated, "no."

Review of Patient #5's nursing note, written by LN #21 and dated 3/28/25 at 5:08 AM, revealed: ". . . Pt finally fall asleep around [2:00 AM] when checked. Pt was laying on the table and drippled on the chair, was prompted to get into [his/her] bed for more comfort but ignored instructions. Pt was breathing and no distress noted. No further incident for the remaining of the shift. ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . ."

Further review revealed no documentation of the pulse check, or the rate as

.
Based on record review and interview, the facility failed to ensure the nightshift Licensed Nurses (LN #s 16 and 21) prepare and administer medications in accordance with the orders of the practitioner and accepted standards of practice for 1 Patient (#5), out of 1 patient reviewed. Specifically, LN #16 and LN #21 failed to:

1) Appropriately assess and offer scheduled PO (by mouth) medications to Patient #5 prior to administering court ordered IM Back Up (IMBU - medications received by injection after PO medications were refused) medications;

2) Appropriately administer PRN (as needed) medications, based on the written parameters within the medication orders;

3) Appropriately assess and offer PO PRN medication to Patient #5 prior to administering court ordered IMBU medication; and

4) Appropriately re-assess Patient #5, within the facility's standard timeframe, after each administration of IMBU medication was received.

This failed practice violated the court-approved petition for court ordered medications, denied Patient #5 the choice of potentially accepting PO medications, and placed the patient at risk for adverse drug reactions.

Findings:

Patient #5

Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5's court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment.

Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension.

Review of the most recent "Petition for Court Approval of Administration of Psychotropic Medication," dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: ". . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . ."

Further review revealed that Patient #5 was on 1st Degree Close Observation Status Scale (COSS - the level of observation required for safety, ranging from 1st degree to 3rd degree. The higher the degree number, the closer the observation interval), which required Patient #5 to have an every-15-minute observation and engagement patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety).

Patient #5's Treatment Plan

Review of Patient #5's "Multidisciplinary Master Treatment Plan," dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: "Disturbance of Thought: "[Patient #5] shows active disturbance of though and oppositional behavior."

Further review revealed identified interventions to address Patient #5's "disturbance of thought" that included:

- "LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level," initiated on 11/6/23;
- "RN will prompt [Patient #5] to comply with safety behavior," initiated on 1/30/24;
- "Psychology will develop behavior plan to guide staff response to challenging behaviors," initiated on 9/11/24; and
- "Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes," initiated 11/6/24.

Patient #5's Challenging Behaviors

During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5's history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor.

The DON further stated that Patient #5's behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as "normal" for Patient #5.

During an interview on 4/30/25 at 10:21 AM, Patient #5's Provider stated that Patient #5's behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted.

Patient #5's Provider stated that these behaviors had been present since his/her 2020 admission.

Patient #5's Behavior Plan

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans are initiated when a patient's behavior becomes increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times.

Review of Patient #5's behavior plan, last updated 3/25/25, revealed:

- "Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an 'episode.'"

- ". . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . ."

- ". . . If you notice [Patient #5] is about to have an "episode," walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball."

- "Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an "episode." Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5's] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, "hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn't flood." Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress."

During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime.

Patient #5's Medication Regimen

Review of Patient #5's ordered medications, for March 2025, revealed he/she was on psychotropic medications ordered by the court. Further review revealed these medications also had a "shot" form of medication if Patient #5 refused to take his/her medications by mouth. These were ordered by the courts to aid in Patient #5's consistent treatment. These medications included:

Scheduled Medications:

1) "Clozapine [an antipsychotic medication used to treat schizophrenia] 300mg [milligrams] PO [by mouth] QHS [every night scheduled for 9:00 PM] for schizophrenia." This order started on 1/21/25.

Further review revealed: "Court ordered: If refused give haloperidol [Haldol - an antipsychotic medication used to treat schizophrenia] IMBU [IM, or shot, back up]."

1a) "Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO clozapine . . ." This order started on 12/5/23 and remained in effect.

2) "Divalproex [Depakote - An anticonvulsant used to treat some psychiatric illnesses] 1,250mg PO BID [twice a day: once in morning at 9:00 AM, once at night at 9:00 PM] for mood disorder secondary to schizophrenia." This order was started on 1/21/25.

Further review revealed: "Court ordered: If refused give lorazepam [Ativan - A benzodiazepine medication used to treat anxiety] IMBU."

3) "Clonazepam [An anti-epileptic drug used to treat seizure disorders] 2mg tablet PO 1300 [every day at 1:00 PM] for agitation secondary to schizophrenia." This order started on 2/25/25.

Further review revealed: "Court ordered: If patient refuses, provide IMBU lorazepam."

2a and 3a) "Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . Divalproex . . . [and] clonazepam . . ." This order started on 9/30/24 and remained in effect.

PRN Medications:

4) "Haloperidol 10mg tablet PO Q4HPRN [every 4 hours as needed] for agitation." This order started on 12/20/23.

Further review revealed: "Court ordered: If refused give haloperidol IMBU."

4a) "Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . haloperidol PRN . . ." This order started on 12/5/23 and remained in effect.

5) "Lorazepam 2mg tablet PO Q4HPRN for moderate anxiety or moderate agitation." This order started on 2/6/25.

Further review revealed: "Court ordered: If refused give Lorazepam IMBU."

5a) "Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO lorazepam PRN . . ." This order started on 9/30/24 and remained in effect.

6) "Chlorpromazine [Thorazine - An antipsychotic medication used to treat psychotic disorders such as schizophrenia] 100mg PO Q6HPRN [every 6 hours as needed] for severe agitation." This order started on 12/24/24.

Further review revealed: "Court ordered: If refused give chlorpromazine IMBU."

6a) "Chlorpromazine 50mg/2mL ampule - 100mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO chlorpromazine PRN." This order started on 12/24/24 and remained in effect.

Medication Administrations #1 for nightshift on 3/27/25

Review of Patient #5's electronic Medication Administration Record (eMAR), dated 3/27/25, revealed:

- At 7:12 PM, Licensed Nurse (LN) #16 documented that Patient #5 refused Lorazepam 2mg PO PRN for moderate anxiety or moderate agitation.

Further review revealed there was no documentation that the IMBU Lorazepam medication was given due to this PO refusal, which was instructed in the order.

- At 7:13 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Clozapine 300mg PO medication (107 minutes prior to scheduled time).
- At 7:14 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Divalproex 1,250mg PO medication (106 minutes prior to scheduled time).
- At 7:23 PM, LN #21 documented that Patient #5 received Lorazepam 2mg IM, PRN IMBU for refusal of court ordered PO Divalproex medication.
- At 7:25 PM, LN #21 documented that Patient #5 received Haloperidol 10mg IM, PRN IMBU for refusal of court ordered PO Clozapine medication.

Video Review of Medication Administrations #1

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 6:00 PM to 7:19 PM, revealed:

- From 6:00 PM to 6:16 PM, Patient #5 was in the unit's TV room watching basketball. He/she had calm movements during this time: he/she sat in a chair at times, stood and stretched and walked around the room at times; and made motions as if he/she was shooting a basketball at a hoop.

- At 6:16 PM, Patient #5 left the TV room and entered his/her bedroom.

During an interview on 6/2/25 at 9:24 AM, while reviewing the video, the Risk Manager stated that Patient #5 was exhibiting no aggression, and this was his/her baseline behavior.

- From 6:16 PM to 7:06 PM, Patient #5 remained in his/her room. Staff completed every-15-minute safety checks: they approached Patient #5's bedroom door, which was closed, and looked in the window and listened.

- At 7:02 PM, PNA #4 approached Patient #5's bedroom door, cracked the door, and then closed it. Further observation revealed PNA #4 instructed the staff at the nurse's station to turn off Patient #5's water.

During an interview on 6/2/25 at 9:25 AM, while reviewing the video, the Risk Manager stated that individual patient room's water supplies could be turned off at the nurse's station. When asked about Patient #5's behavior plan, and needing to speak to Patient #5 about exceeding the water limit of 30 minutes, the Risk Manager stated after reviewing the video, PNA #4 did not follow the behavior plan and talk with Patient #5 prior to turning the water off. The Risk Manager stated Patient #5 had a history of escalating when the water was turned off.

- At 7:06 PM, PNA #11 approached Patient #5's room to complete a safety check.

- At 7:10 PM, PNA #11 approached Patient #5's room to complete a safety check . On the video, Patient #5 could be heard making animal noises from within his/her room area.

- At 7:11 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5's room to offer medications in pill form. The LNs and the Nurse Supervisor left the room without giving the medications.

During an interview on 6/2/25 at 9:26 AM, while reviewing the video, the Risk Manager stated Patient #5 refused the medications by mouth.

- From 7:11 PM to 7:19 PM, Patient #5 could be heard on the camera making animal noises from within his/her room.

- At 7:19 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5's room and administered IMBU medications. The LNs and the Nurse Supervisor left the room shortly after this.

Reassessment of Medications Administration #1

Review of Patient #5's eMAR, dated 3/27/25, revealed:

- At 8:42 PM, LN #21 documented a reassessment for Patient #5's response to the IMBU medications Lorazepam and Haloperidol (79 minutes after its administration). LN #21 documented they were both "Medication effectiveness for clinical indication: effective."

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 7:19 PM to 9:00 PM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment.

During an interview on 4/30/25 at 12:08 PM, the DON stated no nursing assessment was completed after Patient #5 received Lorazepam and Haloperidol IM injections. The DON further stated nurses were to complete an assessment after 15 minutes of administration of the IM injections.

Medication Administrations #2 for Nightshift on 3/27/25

Review of Patient #5's eMAR, dated 3/27/25, revealed:

- At 11:50 PM, LN #21 documented that Patient #5 refused Chlorpromazine 100mg PO PRN for severe agitation.
- At 11:51 PM, LN #21 documented that Patient #5 received Chlorpromazine 100mg IM, PRN IMBU for refusal of PO Chlorpromazine medication.

Video Review of Medication Administration #2

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 10:00 PM to 11:50 PM, revealed there was no indication of "severe agitation" from Patient #5. During this time frame, Patient #5 was in his/her bedroom and was only heard making animal noises once at 11:43 PM, which only lasted for less than 1 minute. Further observation revealed PNA staff appeared calm, sitting in the halls, and no nurse ever approached Patient #5 to assess his/her level of agitation. No nurse offered Patient #5 the PO form of chlorpromazine prior to the administration IMBU medication. Also, no de-escalation techniques were seen attempted, and no distraction choices or preferred activities from Patient #5's behavior plan were attempted.

Further observation of the video recording revealed at 11:49 PM, LNs #16 and #21 entered Patient #5's bedroom with 2 IM syringes and a SHARPS container (a red hard plastic container in which to put used syringes in), along with PNA's #7 and #11, and exited shortly after.

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated it was the expectation for all nurses to offer patients PO forms of medication before IM or IMBU forms were used. Meaning that nurses were to approach patients, communicate with them while offering medications. Also explore alternative ways for the patients to agree to take PO medications prior to IM or IMBU being used.

When asked if there was any policy that defined mild-to moderate-to severe agitation for nurses to use as a guide, the ADON stated it is the nurse's discretion to determine what those terms mean. When asked what she thought "severe agitation" meant, the ADON stated it would mean to the point of causing potential harm to self or others.

During an interview on 5/1/25 at 11:35 AM, when asked how nurses were taught how to recognize mild-to moderate-to severe agitation, the Director of QAPI stated there was no training in orientation to help nurses recognize what those terms look like behavior-wise. The Director of QAPI further stated that nurses were taught what these terms meant in nursing schooling.

The Director of QAPI further stated that when Patient #5 was rolling around on the floor, it meant he/she was agitated, and it warranted PRN medication.

During an interview on 6/2/25 at 1:14 PM, when asked if Patient #5 was following his/her behavior plan (to be in his/her room during an episode), the ADON and Director of QAPI agreed Patient #5 was following the plan.

When asked if any staff member working on 3/27/25 used the interventions in the behavior plan to help distract Patient #5 and help to calm him/her, the Director of QAPI stated the video recording showed that no staff member followed the behavior plan interventions listed.

Reassessment of Medication Administration #2

Further review of Patient #5's eMAR, revealed that on 3/28/25 at 12:07 AM, LN #21 documented a reassessment for Patient #5's response to the IMBU Chlorpromazine (16 minutes after its administration): "Pt [patient] still agitated unable to respond to verbal prompts. Pt was laying on the floor in bed area at this time. Ongoing monitoring for effectiveness. Medication effectiveness for clinical indication: somewhat effective."

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 11:30 PM to 3/28/25 12:30 AM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment.

During an interview on 4/30/25 at 11:30 AM, the DON, Director of QAPI, and Lead Educator all agreed that LN #21 never completed this reassessment of medication. The Lead Educator stated it was the expectation that nurses completed a reassessment of PRN medication within 15 minutes of administration by physically assessing the patient.

During an interview on 5/1/25 at 9:27 AM, the Director of Risk Management stated from 3/27/25 at 11:49 PM to 3/28/25 at 4:29 AM no nurse returned to Patient #5's room.

Review of Patient #5's nursing note, written by LN #21 dated 3/28/25 at 5:08 AM, revealed: "Behaviors related to COSS [Close Observation Status Scale] status: Pt was elevated in bed area at shift change and was offered HS [night] med [medications] earlier by declined and started [his/her] 'seizure like shaking.' Received IMBU for refusing court order PO. Pt was making weird sound in bed area and was observed laying on the floor. Pt didn't show any improvement from [his/her] conditions and continued to scream at bed area. Pt received another IMBU Thorazine for refusal of PO meds for agitation. Pt was still tapping the floor and not responding to prompts for hours. Pt finally fall asleep around [2:00 AM] when checked . . . ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . ."

Patient #5's Aggressive Behavior

During an interview on 4/30/25 at 9:58 AM, the DON stated how staff interact with patients and unit culture has been a concern since February 2025.

During an interview on 4/30/25 at 11:00 AM, the Patient #5's Provider stated consoling and encouraging was the best therapy for Patient #5's during his/her episodes.

During an interview on 5/1/25 at 10:21 AM, when asked to describe what Patient #5's "severe agitation" would look like, Patient #5's Provider stated this would typically be non-redirectable behavior of disrobing, running out of his/her room, and being physically aggressive towards staff.

When asked if rolling on the floor, tapping, and making animal noises in Patient #5's bedroom area be considered "severe agitation" and warrant PRN medication, Patient #5's Provider stated, "No. The treatment team made the decision to be as least restrictive as possible with [Patient #5]."

The Director of QAPI was in the room during this interview and asked Patient #5's Provider, "What if Patient #5 was rolling on the floor and making animal noises for hours?" Patient #5's Provider stated, "No, as long as [he/she] was in [his/her] room it would not warrant PRN medication."

An observation on 5/1/25 at 10:37 AM, once this interview was completed and Patient #5's Provider and the Director of QAPI left the room. Raised voices could be heard in the hallway, one of the voices heard was the Director of QAPI, although the articulation of the speech, or what was actually said, was not clear. Shortly after this, Patient #5's Provider returned to the room and stated Patient #5's lengthy behavior of rolling around on the floor and making animal noises could be considered agitation.

Review of the facility's policy "Medication Orders, Preparation, and Administration," effective 5/19/22, revealed: ". . . A complete order indicates the following . . . PRN . . . orders require "clear intent" which implies the inclusion of the indication for use and/or precise instructions for PRN medications: The use of "PRN" with medication orders must be qualified to include the frequency and the specific symptom(s) of therapeutic indication for which the drug is to be used. The PRN therapeutic indication shall be clear and unique (no two medications shall have the same PRN indication) . . . Medication Administration Time Requirements . . . All scheduled medications are administered 90 minutes prior to or 90 minutes after the scheduled time . . . The Patient shall be monitored for their perception of side effects and the effectiveness of the medication(s). Necessary assessments and re-assessments shall be completed . . . All medications administered for any type of pain, all PRN medications, all 1st doses and all one time orders . . . require follow up documentation/reassessment: IM Medications - 30 minutes . . ."

Review of the facility's policy "Deterioration of Physical Status, Medical Emergencies, and Code Blue Response," effective 8/12/24, revealed: "Purpose: To recognition of a deteriorating physical status is an interdisciplinary response that provides for early intervention and management of patients to decrease the risk for cardiopulmonary arrest and/or other adverse medical events . . . Procedure: Deteriorating Physical Status: Any API staff member, patient, visitor, or family member of patient may notify nursing staff of concern for deterioration in physical status of an API patient. The goal of the initial evaluation for deteriorating physical status is to identify and correct conditions before they progress to medically emergent of life-threatening status. Nursing staff response: If a patient exhibits early warning signs or symptoms, unit nursing staff will initiate an evaluation without delay using established criteria as guidelines (See Attachment: Criteria for Deteriorating Physical Status and Trigger for Response);

- If criteria are met: Nursing staff will assess severity of signs or symptoms and will determine if immediate consultation by in-house staff or emergent consultation at outside facility (emergency room) is indicated;

- If criteria are not present, but concern expressed by staff, family, etc.: Nursing staff will document concern, evaluation and follow-up using Situation Background Assessment Recommendation/Request (SBAR) [a format for note documentation] method including hand-off communication to on-coming shift. Nursing staff will provide verbal feedback to concerned party of increased vigilance for comprise of physical status . . . If at any time signs/symptoms progress towards meeting criteria, nursing will proceed with protocol for Deteriorating Physical Status . . ."

Further review of the policy attachment "Criteria for Deteriorating Physical Status and Trigger for Response," last updated 8/2022, revealed: Recognition of the following by staff and verification by Nursing staff should initiate contact with the medical Officer staff (MOS) or LIP [Provider] on call . . . Concern: Change in Respiratory Rate . . . Criteria: Respiratory rate is a change from baseline and less than 8 or greater than 28 . . . Response: Assess Vital Signs including Pulse Oximetry [oxygen saturation levels in the blood]; Loof for etiology (pain, infection, wheezing/rhonchi [noisy breath sounds]; Contact LIP/MOS to determine further level of care or work up . . . Concern: Altered Mental Status or Acute Chang in LOC [level of consciousness] or CNS [central nervous system] status . . . Criteria: Patient becomes somnolent, difficult to awaken, confused or obtunded or any other change in mental status or CNS status: ex. Pupil reaction, slurred speech, onset of unilateral limb or facial weakness; Response: Assess Vital Signs including Pulse Oximetry; Look for etiology (medication adverse effects, h/o [history of] stroke or embolism, h/o water intoxication); Contact LIP/MOS to determine further level of care or work up . . ."
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Based on record review and interview, the facility failed to ensure medical records were complete and accurate that described the patient's progress and response to medications and services, for 1 Patient (#5), out of 15 sampled patients.

Specifically, the facility failed to:

1) Appropriately assess and offer scheduled PO (by mouth) medications to Patient #5 prior to administering court ordered IM Back Up (IMBU - medications received by injection after PO medications were refused) medications;

2) Appropriately assess and offer PRN (as needed) medication to Patient #5 prior to administering court ordered IMBU medication;

3) Appropriately re-assess Patient #5, within the facility's standard timeframe, after each administration of IMBU medication was received; and

4) Appropriately completed an evaluation for Patient #5 after reports of concern of possible deterioration of physical status were reported by Psychiatric Nursing Assistants (PNA #'s 7 and 12).

This failed practice placed the patient at risk for incomplete medical records and caused an incomplete accounting of all interventions, care, and treatment provided, and responses from these medications and services. Patient #5 passed away in the facility.

Findings:

Patient #5

Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5's court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment.

Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension.

Review of the most recent "Petition for Court Approval of Administration of Psychotropic Medication," dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: ". . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . ."

Further review revealed that Patient #5 was on 1st Degree Close Observation Status Scale (COSS - the level of observation required for safety, ranging from 1st degree to 3rd degree. The higher the degree number, the closer the observation interval), which required Patient #5 to have an every-15-minute observation and engagement patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety).

Patient #5's Treatment Plan

Review of Patient #5's "Multidisciplinary Master Treatment Plan," dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: "Disturbance of Thought: "[Patient #5] shows active disturbance of though and oppositional behavior."

Further review revealed identified interventions to address Patient #5's "disturbance of thought" that included:

- "LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level," initiated on 11/6/23;
- "RN will prompt [Patient #5] to comply with safety behavior," initiated on 1/30/24;
- "Psychology will develop behavior plan to guide staff response to challenging behaviors," initiated on 9/11/24; and
- "Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes," initiated 11/6/24.

Patient #5's Challenging Behaviors

During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5's history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor.

The DON further stated that Patient #5's behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as "normal" for Patient #5.

During an interview on 4/30/25 at 10:21 AM, Patient #5's Provider stated that Patient #5's behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted.

Patient #5's Provider stated that these behaviors had been present since his/her 2020 admission.

Patient #5's Behavior Plan

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans are initiated when a patient's behavior becomes increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times.

Review of Patient #5's behavior plan, last updated 3/25/25, revealed:

- "Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an 'episode.'"

- ". . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . ."

- ". . . If you notice [Patient #5] is about to have an "episode," walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball."

- "Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an "episode." Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5's] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, "hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn't flood." Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress."

During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime.

Patient #5's Medication Regimen

Review of Patient #5's ordered medications, for March 2025, revealed he/she was on psychotropic medications ordered by the court. Further review revealed these medications also had a "shot" form of medication if Patient #5 refused to take his/her medications by mouth. These were ordered by the courts to aid in Patient #5's consistent treatment. These medications included:

Scheduled Medications:

1) "Clozapine [an antipsychotic medication used to treat schizophrenia] 300mg [milligrams] PO [by mouth] QHS [every night scheduled for 9:00 PM] for schizophrenia." This order started on 1/21/25.

Further review revealed: "Court ordered: If refused give haloperidol [Haldol - an antipsychotic medication used to treat schizophrenia] IMBU [IM, or shot, back up]."

1a) "Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO clozapine . . ." This order started on 12/5/23 and remained in effect.

2) "Divalproex [Depakote - An anticonvulsant used to treat some psychiatric illnesses] 1,250mg PO BID [twice a day: once in morning at 9:00 AM, once at night at 9:00 PM] for mood disorder secondary to schizophrenia." This order was started on 1/21/25.

Further review revealed: "Court ordered: If refused give lorazepam [Ativan - A benzodiazepine medication used to treat anxiety] IMBU."

3) "Clonazepam [An anti-epileptic drug used to treat seizure disorders] 2mg tablet PO 1300 [every day at 1:00 PM] for agitation secondary to schizophrenia." This order started on 2/25/25.

Further review revealed: "Court ordered: If patient refuses, provide IMBU lorazepam."

2a and 3a) "Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . Divalproex . . . [and] clonazepam . . ." This order started on 9/30/24 and remained in effect.

PRN Medications:

4) "Haloperidol 10mg tablet PO Q4HPRN [every 4 hours as needed] for agitation." This order started on 12/20/23.

Further review revealed: "Court ordered: If refused give haloperidol IMBU."

4a) "Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . haloperidol PRN . . ." This order started on 12/5/23 and remained in effect.

5) "Lorazepam 2mg tablet PO Q4HPRN for moderate anxiety or moderate agitation." This order started on 2/6/25.

Further review revealed: "Court ordered: If refused give Lorazepam IMBU."

5a) "Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO lorazepam PRN . . ." This order started on 9/30/24 and remained in effect.

6) "Chlorpromazine [Thorazine - An antipsychotic medication used to treat psychotic disorders such as schizophrenia] 100mg PO Q6HPRN [every 6 hours as needed] for severe agitation." This order started on 12/24/24.

Further review revealed: "Court ordered: If refused give chlorpromazine IMBU."

6a) "Chlorpromazine 50mg/2mL ampule - 100mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO chlorpromazine PRN." This order started on 12/24/24 and remained in effect.

Medication Administrations #1 for nightshift on 3/27/25

Review of Patient #5's electronic Medication Administration Record (eMAR), dated 3/27/25, revealed:

- At 7:12 PM, Licensed Nurse (LN) #16 documented that Patient #5 refused Lorazepam 2mg PO PRN for moderate anxiety or moderate agitation.

Further review revealed there was no documentation that the IMBU Lorazepam medication was given due to this PO refusal, which was instructed in the order.

- At 7:13 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Clozapine 300mg PO medication (107 minutes prior to scheduled time).
- At 7:14 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Divalproex 1,250mg PO medication (106 minutes prior to scheduled time).
- At 7:23 PM, LN #21 documented that Patient #5 received Lorazepam 2mg IM, PRN IMBU for refusal of court ordered PO Divalproex medication.
- At 7:25 PM, LN #21 documented that Patient #5 received Haloperidol 10mg IM, PRN IMBU for refusal of court ordered PO Clozapine medication.

Video Review of Medication Administrations #1

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 6:00 PM to 7:19 PM, revealed:

- From 6:00 PM to 6:16 PM, Patient #5 was in the unit's TV room watching basketball. He/she had calm movements during this time: he/she sat in a chair at times, stood and stretched and walked around the room at times; and made motions as if he/she was shooting a basketball at a hoop.

- At 6:16 PM, Patient #5 left the TV room and entered his/her bedroom.

During an interview on 6/2/25 at 9:24 AM, while reviewing the video, the Risk Manager stated that Patient #5 was exhibiting no aggression, and this was his/her baseline behavior.

- From 6:16 PM to 7:06 PM, Patient #5 remained in his/her room. Staff completed every-15-minute safety checks: they approached Patient #5's bedroom door, which was closed, and looked in the window and listened.

- At 7:02 PM, PNA #4 approached Patient #5's bedroom door, cracked the door, and then closed it. Further observation revealed PNA #4 instructed the staff at the nurse's station to turn off Patient #5's water.

During an interview on 6/2/25 at 9:25 AM, while reviewing the video, the Risk Manager stated that individual patient room's water supplies could be turned off at the nurse's station. When asked about Patient #5's behavior plan, and needing to speak to Patient #5 about him/her exceeding the water limit of 30 minutes, the Risk Manager stated after reviewing the video, PNA #4 did not follow the behavior plan and talk with Patient #5 prior to turning the water off. The Risk Manager stated Patient #5 had a history of escalating when the water was turned off.

- At 7:06 PM, PNA #11 approached Patient #5's room to complete a safety check.

- At 7:10 PM, PNA #11 approached Patient #5's room to complete a safety check. On the video, Patient #5 could be heard making animal noises from within his/her room area.

- At 7:11 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5's room to offer medications in pill form. The LNs and the Nurse Supervisor left the room without giving the medications.

During an interview on 6/2/25 at 9:26 AM, while reviewing the video, the Risk Manager stated Patient #5 refused the medications by mouth.

- From 7:11 PM to 7:19 PM, Patient #5 could be heard on the camera making animal noises from within his/her room.

- At 7:19 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5's room and administered IMBU medications. The LNs and the Nurse Supervisor left the room shortly after this.

Reassessment of Medications Administration #1

Review of Patient #5's eMAR, dated 3/27/25, revealed:

- At 8:42 PM, LN #21 documented a reassessment for Patient #5's response to the IMBU medications Lorazepam and Haloperidol (79 minutes after its administration). LN #21 documented they were both "Medication effectiveness for clinical indication: effective."

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 7:19 PM to 9:00 PM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment.

During an interview on 4/30/25 at 12:08 PM, the DON stated no nursing assessment was completed after Patient #5 received Lorazepam and Haloperidol IM injections. The DON further stated nurses were to complete an assessment after 15 minutes of administration of the IM injections.

Medication Administrations #2 for Nightshift on 3/27/25

Review of Patient #5's eMAR, dated 3/27/25, revealed:

- At 11:50 PM, LN #21 documented that Patient #5 refused Chlorpromazine 100mg PO PRN for severe agitation.
- At 11:51 PM, LN #21 documented that Patient #5 received Chlorpromazine 100mg IM, PRN IMBU for refusal of PO Chlorpromazine medication.

Video Review of Medication Administration #2

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 10:00 PM to 11:50 PM, revealed there was no indication of "severe agitation" from Patient #5. During this time frame, Patient #5 was in his/her bedroom and was only heard making animal noises once at 11:43 PM, which only lasted for less than 1 minute. Further observation revealed PNA staff appeared calm, sitting in the halls, and no nurse ever approached Patient #5 to assess his/her level of agitation. No nurse offered Patient #5 the PO form of chlorpromazine prior to the administration IMBU medication. Also, no de-escalation techniques were seen attempted, and no distraction choices or preferred activities from Patient #5's behavior plan were attempted.

Further observation of the video recording revealed at 11:49 PM, LNs #16 and #21 entered Patient #5's bedroom with 2 IM syringes and a SHARPS container (a red hard plastic container in which to put used syringes in), along with PNA's #7 and #11, and exited shortly after.

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated it was the expectation for all nurses to offer patients PO forms of medication before IM or IMBU forms were used. Meaning that nurses were to approach patients, communicate with them while offering medications. Also explore alternative ways for the patients to agree to take PO medications prior to IM or IMBU being used.

When asked if there was any policy that defined mild-to moderate-to severe agitation for nurses to use as a guide, the ADON stated it is the nurse's discretion to determine what those terms mean. When asked what she thought "severe agitation" meant, the ADON stated it would mean to the point of causing potential harm to self or others.

During an interview on 5/1/25 at 11:35 AM, when asked how nurses were taught how to recognize mild-to moderate-to severe agitation, the Director of QAPI stated there was no training in orientation to help nurses recognize what those terms look like behavior-wise. The Director of QAPI further stated that nurses were taught what these terms meant in nursing schooling.

The Director of QAPI further stated that when Patient #5 was rolling around on the floor, it meant he/she was agitated, and it warranted PRN medication.

During an interview on 6/2/25 at 1:14 PM, when asked if Patient #5 was following his/her behavior plan (to be in his/her room during an episode), the ADON and Director of QAPI agreed Patient #5 was following the plan.

When asked if any staff member working on 3/27/25 used the interventions in the behavior plan to help distract Patient #5 and help to calm him/her, the Director of QAPI stated the video recording showed that no staff member followed the behavior plan interventions listed.

Reassessment of Medication Administration #2

Further review of Patient #5's eMAR, revealed that on 3/28/25 at 12:07 AM, LN #21 documented a reassessment for Patient #5's response to the IMBU Chlorpromazine (16 minutes after its administration): "Pt [patient] still agitated unable to respond to verbal prompts. Pt was laying on the floor in bed area at this time. Ongoing monitoring for effectiveness. Medication effectiveness for clinical indication: somewhat effective."

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 11:30 PM to 3/28/25 12:30 AM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment.

During an interview on 4/30/25 at 11:30 AM, the DON, Director of QAPI, and Lead Educator all agreed that LN #21 never completed this reassessment of medication. The Lead Educator stated it was the expectation that nurses completed a reassessment of PRN medication within 15 minutes of administration by physically assessing the patient.

During an interview on 5/1/25 at 9:27 AM, the Director of Risk Management stated from 3/27/25 at 11:49 PM to 3/28/25 at 4:29 AM no nurse returned to Patient #5's room.

Review of Patient #5's nursing note, written by LN #21 dated 3/28/25 at 5:08 AM, revealed: "Behaviors related to COSS [Close Observation Status Scale] status: Pt was elevated in bed area at shift change and was offered HS [night] med [medications] earlier by declined and started [his/her] 'seizure like shaking.' Received IMBU for refusing court order PO. Pt was making weird sound in bed area and was observed laying on the floor. Pt didn't show any improvement from [his/her] conditions and continued to scream at bed area. Pt received another IMBU Thorazine for refusal of PO meds for agitation. Pt was still tapping the floor and not responding to prompts for hours. Pt finally fall asleep around [2:00 AM] when checked . . . ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . ."

Patient #5's Aggressive Behavior

During an interview on 4/30/25 at 9:58 AM, the DON stated how staff interact with patients and unit culture has been a concern since February 2025.

During an interview on 4/30/25 at 11:00 AM, the Patient #5's Provider stated consoling and encouraging was the best therapy for Patient #5's during his/her episodes.

During an interview on 5/1/25 at 10:21 AM, when asked to describe what Patient #5's "severe agitation" would look like, Patient #5's Provider stated this would typically be non-redirectable behavior of disrobing, running out of his/her room, and being physically aggressive towards staff.

When asked if rolling on the floor, tapping, and making animal noises in Patient #5's bedroom area be considered "severe agitation" and warrant PRN medication, Patient #5's Provider stated, "No. The treatment team made the decision to be as least restrictive as possible with [Patient #5]."

The Director of QAPI was in the room during this interview and asked Patient #5's Provider, "What if Patient #5 was rolling on the floor and making animal noises for hours?" Patient #5's Provider stated, "No, as long as [he/she] was in [his/her] room it would not warrant PRN medication."

An observation on 5/1/25 at 10:37 AM, once this interview was completed and Patient #5's Provider and the Director of QAPI left the room. Raised voices could be heard in the hallway, one of the voices heard was the Director of QAPI, although the articulation of the speech, or what was actually said, was not clear. Shortly after this, Patient #5's Provider returned to the room and stated Patient #5's lengthy behavior of rolling around on the floor and making animal noises could be considered agitation.

Incident on 3/28/25

During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) and Director of QAPI stated that on the evening of 3/27/25 and through the early morning on 3/28/25, Patient #5 was up late in his/her bedroom exhibiting some of the behavior challenges they had been dealing with for an extended period of time: he/she moved back and forth from the bathroom to the bedroom area, later in the evening he/she was rolling around on the bedroom floor, excessively tapping on the floor, and making animal noises at times through the night.

The Director of QAPI stated that based on video review, it was observed and heard that at 1:13 AM, PNA #7, after having completed a patient safety check (a visual check on the patient's status for safety), told another PNA in the hall that Patient #5 was, "laying down on the table."

The "table" was a desk (measuring 2 feet, 11 1/2 inches long and 2 feet, 1/2 inch wide) that was in his/her bedroom. This desk was bolted to the back half of the left wall of the room and approximately 2 1/2 feet away from the back left corner of the room that connected to the back wall. In the space between desk and the back wall, Patient #5 had placed his/her weighted chair flush against the left wall (the front of the chair was against the left wall, with the back of the chair facing outward), which left approximately 3 inches between the chair and desk on the left side of the chair, and approximately 3 inches between the chair and back wall on the right side of the chair. The total length of the chair/desk space was 5 feet, 6 inches from the right arm rest of the chair to the far-left edge of the desk.

The Director of QAPI further stated that Patient #5 (who was 6 feet, 1/4 inches tall and weighed approximately 275.4 lbs.) initially was laying prone on the desk (flat on his/her stomach face down), with his/her head positioned towards the back wall, which caused his/her legs and upper shoulders and head to extend beyond the edges of the desk on either side.

As the night progressed, the Director of QAPI stated that Patient #5 began to move towards the back wall slowly inching his/her upper body onto the chair positioned between the desk and back wall, while his lower body remained on the desk. Eventually, Patient #5 had his/her head on the right armrest of the chair, closest to the back wall, with his/her face turned towards the left wall. Patient #5's left arm was tucked under his/her torso on the chair seat, and the right arm was draped over the back of the chair.

During an interview on 4/30/25 at 9:58 AM, the DON stated all staff on nightshift on 3/27-28/25 stated they had never seen Patient #5 sleep on the desk before, but they didn't think it was something alarming.

An observation on 4/30/25 at 2:38 PM, of Patient #5's bedroom, revealed that when the chair was placed between the desk and the back wall, the chair was at a lower elevation then the top of the desk. This would have caused Patient #5's upper body to be lower than his/her hips, buttocks, and legs which were still on the desk.

Further observation revealed that when the Director of QAPI positioned herself in the same prone position as Patient #5 was on 3/28/25, her torso was not supported when her head/neck was resting on the right armrest of the chair, which caused her chest to bow downward towards the seat of the chair placing the pressure of supporting her upper body on her head/neck.

Further observation revealed that when standing in the doorway of Patient #5's bedroom, a person's view would have been of Patient #5's buttocks, legs, and feet only, with a minimal view of Patient #5's back and back of head. If staff were to enter the room and stand in close proximity to Patient #5, there would have been no view of Patient #5's face or the rise and fall of Patient #5's front chest during respirations, which was face down in the chair.

During an interview on 5/1/25 at 10:45 AM, when asked what the expectation for nurses and PNAs would be if a patient was positioned, during rest or sleep, in a way that could place the patient at risk for safety, the Assistant Director of Nursing (ADON) stated the expectation would be to attempt to move the patient.

When asked what if the patient resisted, the ADON stated then repeated attempts should be tried until the patient is positioned for safety. This could be trying to physically move the patient or communicate with the patient to achieve cooperation to move into a safer position.

Review of the facility's video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 1:13 AM to 7:15 AM, revealed:

- From 1:13 AM to 1:57 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes. At 1:13 AM, PNA #7 entered Patient #5's bedroom. Patient #5 could be heard on the camera (but was not seen as there were no cameras in the bedroom) making vocal sounds that were not words. As PNA #7 exited the room and approached other PNA's in the hall, it could be heard on the video that PNA #7 stated, "[he's/she's] laying on down on the table."

PNA #7 completed patient safety checks at 1:25 AM and 1:43 AM by looking in the window of the closed bedroom door. PNA #4 completed the patient safety check at 1:57 AM by looking in the window of the closed bedroom door.

- From 2:15 AM to 2:53 AM, no patient safety checks were completed for Patient #5, or any other patient on the Katmai unit. PNA #4 was assigned to patient safety checks this hour and remained seated in the hallway through this time.

- From 3:00 AM to 3:56 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #11 completed checks at 3:00 AM, 3:15 AM, 3:29 AM, and 3:43 AM. During this last check at 3:43 AM, PNA #11 stood at the doorway for 24 seconds while observing Patient #5. At 3:56 AM, PNA #12 completed the patient safety check by standing in the doorway for 21 seconds while observing Patient #5.

- At 4:12 AM, PNA #12 completed the patient safety check by entering Patient #5's bedroom. PNA #12 turned on the bedroom light and was in the room for 70 seconds, then exited.

- At 4:29 AM, PNA #12 completed the patient safety check by entering Patient #5's bedroom. PNA #12 turned on the light and could be heard calling Patient #5's name several times. Shortly after this, PNA #12 came back out into the hallway and called PNA #7 into the room with him/her. PNA #7 was observed to quickly leave the bedroom and go into the nurse's station to get the nurses. PNA #7 could be heard on the video recording saying, "[he's/she's] not moving." At 4:32 AM, PNA #12 told nurses, "[he/she] was breathing earlier" when they met him/her at Patient #5's doorway. All staff entered Patient #5's bedroom. Staff could be heard calling Patient #5's name. PNA #11 said, "let me get a pillow for [his/her] head" and left to retrieve a pillow. After some time, staff exited the room, LN #16 could be heard saying, "[he/she] was holding onto something."

During an interview on 4/30/25 at 12:37, the DON and Director of QAPI stated that when they interviewed the staff during their investigation after 3/28/25, all staff stated that at 4:29 AM when they entered the room, Patient #5 was positioned mostly on the desk with his/her head on the armrest of the chair closest to the desk and they attempted to reposition Patient #5 for safety and comfort. LN #16 and LN #21 both stated in their interviews that they checked Patient #5's pulse and stated he/she was breathing at this time. The DON and Director of QAPI stated that during staff interviews the staff stated, when the repositioning was attempted Patient #5 resisted to move by forcing his/her upper body down.

The DON further stated that when PNA #7 was interviewed, he/she stated when he/she left Patient #5's bedroom at 4:29 AM to get the nurses, he/she asked the nurses to come check Patient #5 to see if he/she was breathing. When asked if PNA #7 had ever before requested nurses to come check a resident for breathing during a patient safety check, PNA #7 stated, "no."

Review of Patient #5's nursing note, written by LN #21 and dated 3/28/25 at 5:08 AM, revealed: ". . . Pt finally fall asleep around [2:00 AM] when checked. Pt was laying on the table and drippled on the chair, was prompted to get into [his/her] bed for more comfort but ignored instructions. Pt was breathing and no distress noted. No further incident for the remaining of the shift. ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . ."

Further review revealed no documentation of the pulse check, or the rate assessed, that the LNs reported completing at 4:29 AM

.
Based on record review and interview, the facility failed to ensure medical records contained nursing notes, reports of treatments, vital signs, and other information necessary to monitor the patient's condition for 1 Patient (#5), out of 15 sampled residents. This failed practice placed the patient at risk for incomplete medical records and an incomplete accounting of all interventions, care, and treatment provided, including responses to these services. Patient #5 passed away in the facility.

Findings:

Patient #5

Record review on 4/4/25, 4/30/25-5/1/25, and 6/2/25 revealed Patient #5 was admitted to the facility on 2/27/20, under court-ordered commitment, due to being gravely disabled (a condition in which a person as a result of mental illness is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, and personal safety as to render serious accident, illness, or death highly probable if care by another in not taken). Patient #5's court orders for commitment remained active throughout his/her admission, as well as court ordered medications for treatment.

Further review revealed Patient #5 had diagnoses that included schizophrenia (a chronic mental disorder characterized by symptoms of hallucinations, delusions, and disorganized speech, such as a pattern of speaking that in incoherent, illogical, or difficult to follow), antisocial personality disorder (a mental health condition characterized by a consistent disregard for right and wrong, along with a lack of regard for the rights and feelings of others), obesity, and hypertension.

Review of the most recent "Petition for Court Approval of Administration of Psychotropic Medication," dated 1/17/25, revealed Patient #5 was not able to make clear judgements or participate in making treatment decisions: ". . . The patient is incapable of giving or withholding informed consent because: The patient does not have the capacity to assimilate relevant facts and to appreciate and understand their situation with regard to those facts. The patient does not appreciate that they have a mental disorder or impairment, although evidence so indicates. The patient does not have the capacity to participate in treatment decisions by means of a rational thought process . . ."

Further review revealed that Patient #5 was on 1st Degree Close Observation Status Scale (COSS - the level of observation required for safety), which required Patient #5 to have an every-15-minute observation and engagement patient safety check (staff were to physically visualize Patient #5 and assess his/her status for safety).

Patient #5's Treatment Plan

Review of Patient #5's "Multidisciplinary Master Treatment Plan," dated 3/18/25, revealed there was only one identified acute need, or problem identified, that was being addressed for his/her diagnoses of Schizophrenia: "Disturbance of Thought: "[Patient #5] shows active disturbance of though and oppositional behavior."

Further review revealed identified interventions to address Patient #5's "disturbance of thought" that included:

- "LIP [Licensed Independent Practitioner] will prescribe, titrate and monitor psychiatric medications and dosages to a therapeutic level," initiated on 11/6/23;
- "RN will prompt [Patient #5] to comply with safety behavior," initiated on 1/30/24;
- "Psychology will develop behavior plan to guide staff response to challenging behaviors," initiated on 9/11/24; and
- "Decrease shower times (<30 mins [less than 30 minutes]) to reduce idiosyncratic [peculiar or individual reactions to an idea or action] episodes," initiated 11/6/24.

Patient #5's Challenging Behaviors

During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) stated that the facility, for the last two years, had been assessing Patient #5's history of behaviors that resembled seizure-like behaviors - eyes rolling up into head for prolonged periods; tapping fingers/hands on walls, floors, and items; make animal sounds; and rolling on the floor.

The DON further stated that Patient #5's behavior also included sleeping in unusual places and positions. Patient #5 would sleep in running showers, under tables, and at times on the floor in the bathroom with his/her head resting on the toilet seat or on the floor with feet inside the toilet. The DON stated that these behaviors were present for so long that they were perceived as "normal" for Patient #5.

During an interview on 4/30/25 at 10:21 AM, Patient #5's Provider stated that Patient #5's behavior was very inconsistent, and at times appeared volitional (voluntary) where staff could offer Patient #5 food, and he/she would stop the behavior. At other times it appeared not volitional. The intensity of the behavior was very inconsistent as well, where Patient #5 would exhibit the behaviors without aggression, and other times he/she would remove his/her clothes, run out of his/her room, and attempt to attack staff. Shadow boxing was a precursor for aggressive behavior as well. These behaviors were being monitored, and a neurology consult with MRI scan was conducted, however no abnormalities were noted.

Patient #5's Provider stated that these behaviors had been present since his/her 2020 admission.

Patient #5's Behavior Plan

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated behavior plans are initiated when a patient's behavior becomes increasingly challenging. The Provider would discuss with the treatment team to make a behavior plan based around these challenging behaviors. The ADON further stated once the behavior plan was made the nurses and PNAs on the floor would implement the behavior plan, as it would direct them on how to work with the patient when challenging behaviors were exhibited, by offering preferable activities during these challenging times.

Review of Patient #5's behavior plan, last updated 3/25/25, revealed:

- "Our goal is to support [Patient #5] through [his/her] difficult days . . . We have noticed that when [he/she] gets bored, [his/her] anxiety increases, and [he/she] is more likely to have an 'episode.'"

- ". . . [Patient #5] can utilize [his/her] personal iPad and Bluetooth headphones in [his/her] bedroom only. He may not keep the iPad or headphones in [his/her] room overnight and must return them to the nursing station by [9:00 PM] . . ."

- ". . . If you notice [Patient #5] is about to have an "episode," walk [him/her] to the med [medication] window for PRNs [as needed medications] and try and distract [him/her] by playing cards, going on a mall walk [walking a main hallway outside of the individual units] and listening to music, or engage [him/her] in other preferred activities. Preferred activities/topics: sports statistics - mainly NBA [National Basketball Association] stats, playing card games, listening to loud music and going for a mall walk, going to the gym or outside to play basketball."

- "Unless it becomes a safety issue, please prompt [Patient #5] to remain in [his/her] room and listen to music when [he/she] is experiencing an "episode." Do not remove [his/her] belongings from [his/her] room or disrupt [him/her] other than the regular Q15 checks . . . If it becomes a safety issue or [he/she] exits [his/her] room disrobed, direct [him/her] to return to [his/her] room or to the [seclusion room] for a [voluntary time out] or seclusion. Please do not turn off [his/her] water unless there is a safety concern ([ex.] fire alarm goes off, hallway or room begins flooding) remember that water is a coping skill for [him/her]! When you take this away you could increase [his/her] anxiety . . . UPDATE 3/25/25: Due to maintenance flooding concerns, please limit [Patient #5's] showers to 30 minutes. When [his/her] time is up, please knock on [his/her] door and politely state, "hey [Resident #5], your shower has been on for over 30 minutes, we will have to turn the water off so the hallway doesn't flood." Do NOT turn [his/her] water off prior to having a conversation with [him/her]. This can cause unnecessary distress."

During an interview on 5/1/25 at 11:18 AM, the Nurse Manager for the Katmai unit stated that preferable activities that worked well with Patient #5 on his/her behavior plan were showers, music, iPad and headphones, and gym time. When asked if Patient #5 could use his/her iPad and headphones after 9:00 PM, the Nurse Manager for the Katmai unit stated these were not always returned at 9:00 PM and Patient #5 could use them if needed anytime.

Patient #5's Medication Regimen

Review of Patient #5's ordered medications, for March 2025, revealed he/she was on psychotropic medications ordered by the court. Further review revealed these medications also had a "shot" form of medication if Patient #5 refused to take his/her medications by mouth, called an IMBU (intramuscular, or IM, back up). These were ordered by the courts to aid in Patient #5's consistent treatment. These medications included:

Scheduled Medications

1) "Clozapine [an antipsychotic medication used to treat schizophrenia] 300mg [milligrams] PO [by mouth] QHS [every night scheduled for 9:00 PM] for schizophrenia." This order started on 1/21/25.

Further review revealed: "Court ordered: If refused give haloperidol [Haldol - an antipsychotic medication used to treat schizophrenia] IMBU."

1a) "Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO clozapine . . ." This order started on 12/5/23 and remained in effect.

2) "Divalproex [Depakote - An anticonvulsant used to treat some psychiatric illnesses] 1,250mg PO BID [twice a day: once in morning at 9:00 AM, once at night at 9:00 PM] for mood disorder secondary to schizophrenia." This order was started on 1/21/25.

Further review revealed: "Court ordered: If refused give lorazepam [Ativan - A benzodiazepine medication used to treat anxiety] IMBU."

3) "Clonazepam [An anti-epileptic drug used to treat seizure disorders] 2mg tablet PO 1300 [every day at 1:00 PM] for agitation secondary to schizophrenia." This order started on 2/25/25.

Further review revealed: "Court ordered: If patient refuses, provide IMBU lorazepam."

2a and 3a) "Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . Divalproex . . . [and] clonazepam . . ." This order started on 9/30/24 and remained in effect.

PRN Medications:

4) "Haloperidol 10mg tablet PO Q4HPRN [every 4 hours as needed] for agitation." This order started on 12/20/23.

Further review revealed: "Court ordered: If refused give haloperidol IMBU."

4a) "Haloperidol 5mg/mL [milliliter] Vial (10mg) - 10mg IM PRN [as needed] IM Back Up if PO refused . . . Court ordered: IMBU for refused PO . . . haloperidol PRN . . ." This order started on 12/5/23 and remained in effect.

5) "Lorazepam 2mg tablet PO Q4HPRN for moderate anxiety or moderate agitation." This order started on 2/6/25.

Further review revealed: "Court ordered: If refused give Lorazepam IMBU."

5a) "Lorazepam 2mg/mL (2mg) - 2mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO lorazepam PRN . . ." This order started on 9/30/24 and remained in effect.

6) "Chlorpromazine [Thorazine - An antipsychotic medication used to treat psychotic disorders such as schizophrenia] 100mg PO Q6HPRN [every 6 hours as needed] for severe agitation." This order started on 12/24/24.

Further review revealed: "Court ordered: If refused give chlorpromazine IMBU."

6a) "Chlorpromazine 50mg/2mL ampule - 100mg IM PRN IM Back Up if PO refused . . . Court ordered: IMBU for refused PO chlorpromazine PRN." This order started on 12/24/24 and remained in effect.

Medication Administrations #1 for nightshift on 3/27/25

Review of Patient #5's electronic Medication Administration Record (eMAR), dated 3/27/25, revealed:

- At 7:12 PM, Licensed Nurse (LN) #16 documented that Patient #5 refused Lorazepam 2mg PO PRN for moderate anxiety or moderate agitation.

Further review revealed there was no documentation that the IMBU Lorazepam medication was given due to this PO refusal, which was instructed in the order.

- At 7:13 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Clozapine 300mg PO medication (107 minutes prior to scheduled time).
- At 7:14 PM, LN #16 documented that Patient #5 refused his/her scheduled 9:00 PM Divalproex 1,250mg PO medication (106 minutes prior to scheduled time).
- At 7:23 PM, LN #21 documented that Patient #5 received Lorazepam 2mg IM, PRN IMBU for refusal of court ordered PO Divalproex medication.
- At 7:25 PM, LN #21 documented that Patient #5 received Haloperidol 10mg IM, PRN IMBU for refusal of court ordered PO Clozapine medication.

Video Review of Medication Administrations #1

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 6:00 PM to 7:19 PM, revealed:

- From 6:00 PM to 6:16 PM, Patient #5 was in the unit's TV room watching basketball. He/she had calm movements during this time: he/she sat in a chair at times, stood and stretched and walked around the room at times; and made motions as if he/she was shooting a basketball at a hoop.

- At 6:16 PM, Patient #5 left the TV room and entered his/her bedroom.

During an interview on 6/2/25 at 9:24 AM, while reviewing the video, the Risk Manager stated that Patient #5 was exhibiting no aggression, and this was his/her baseline behavior.

- From 6:16 PM to 7:06 PM, Patient #5 remained in his/her room. Staff completed every-15-minute safety checks: they approached Patient #5's bedroom door, which was closed, and looked in the window and listened.

- At 7:02 PM, PNA #4 approached Patient #5's bedroom door, cracked the door, and then closed it. Further observation revealed PNA #4 instructed the staff at the nurse's station to turn off Patient #5's water.

During an interview on 6/2/25 at 9:25 AM, while reviewing the video, the Risk Manager stated that individual patient room's water supplies could be turned off at the nurse's station. When asked about Patient #5's behavior plan, and needing to speak to Patient #5 about exceeding the water limit of 30 minutes, the Risk Manager stated after reviewing the video, PNA #4 did not follow the behavior plan and talk with Patient #5 prior to turning the water off. The Risk Manager stated Patient #5 had a history of escalating when the water was turned off.

- At 7:06 PM, PNA #11 approached Patient #5's room to complete a safety check.

- At 7:10 PM, PNA #11 approached Patient #5's room to complete a safety check. On the video, Patient #5 could be heard making animal noises from within his/her room area.

- At 7:11 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5's room to offer medications in pill form. The LNs and the Nurse Supervisor left the room without giving the medications.

During an interview on 6/2/25 at 9:26 AM, while reviewing the video, the Risk Manager stated Patient #5 refused the medications by mouth.

- From 7:11 PM to 7:19 PM, Patient #5 could be heard on the camera making animal noises from within his/her room.

- At 7:19 PM, LN #s 16 and #21, as well as Nurse Supervisor #3 entered Patient #5's room and administered IMBU medications. The LNs and the Nurse Supervisor left the room shortly after this.

Reassessment of Medications Administration #1

Review of Patient #5's eMAR, dated 3/27/25, revealed:

- At 8:42 PM, LN #21 documented a reassessment for Patient #5's response to the IMBU medications Lorazepam and Haloperidol (79 minutes after its administration). LN #21 documented they were both "Medication effectiveness for clinical indication: effective."

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 7:19 PM to 9:00 PM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment.

During an interview on 4/30/25 at 12:08 PM, the DON stated no nursing assessment was completed after Patient #5 received Lorazepam and Haloperidol IM injections. The DON further stated nurses were to complete an assessment after 15 minutes of administration of the IM injections.

Medication Administrations #2 for Nightshift on 3/27/25

Review of Patient #5's eMAR, dated 3/27/25, revealed:

- At 11:50 PM, LN #21 documented that Patient #5 refused Chlorpromazine 100mg PO PRN for severe agitation.
- At 11:51 PM, LN #21 documented that Patient #5 received Chlorpromazine 100mg IM, PRN IMBU for refusal of PO Chlorpromazine medication.

Video Review of Medication Administration #2

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 10:00 PM to 11:50 PM, revealed there was no indication of "severe agitation" from Patient #5. During this time frame, Patient #5 was in his/her bedroom and was only heard making animal noises once at 11:43 PM, which only lasted for less than 1 minute. Further observation revealed PNA staff appeared calm, sitting in the halls, and no nurse ever approached Patient #5 to assess his/her level of agitation. No nurse offered Patient #5 the PO form of chlorpromazine prior to the administration IMBU medication. Also, no de-escalation techniques were seen attempted, and no distraction choices or preferred activities from Patient #5's behavior plan were attempted.

Further observation of the video recording revealed at 11:49 PM, LNs #16 and #21 entered Patient #5's bedroom with 2 IM syringes and a SHARPS container (a red hard plastic container in which to put used syringes in), along with PNA's #7 and #11, and exited shortly after.

During an interview on 5/1/25 at 10:45 AM, the Assistant Director of Nursing (ADON) stated it was the expectation for all nurses to offer patients PO forms of medication before IM or IMBU forms were used. Meaning that nurses were to approach patients, communicate with them while offering medications. Also explore alternative ways for the patients to agree to take PO medications prior to IM or IMBU being used.

When asked if there was any policy that defined mild-to moderate-to severe agitation for nurses to use as a guide, the ADON stated it is the nurse's discretion to determine what those terms mean. When asked what she thought "severe agitation" meant, the ADON stated it would mean to the point of causing potential harm to self or others.

During an interview on 5/1/25 at 11:35 AM, when asked how nurses were taught how to recognize mild-to moderate-to severe agitation, the Director of QAPI stated there was no training in orientation to help nurses recognize what those terms look like behavior-wise. The Director of QAPI further stated that nurses were taught what these terms meant in nursing schooling.

The Director of QAPI further stated that when Patient #5 was rolling around on the floor, it meant he/she was agitated, and it warranted PRN medication.

During an interview on 6/2/25 at 1:14 PM, when asked if Patient #5 was following his/her behavior plan (to be in his/her room during an episode), the ADON and Director of QAPI agreed Patient #5 was following the plan.

When asked if any staff member working on 3/27/25 used the interventions in the behavior plan to help distract Patient #5 and help to calm him/her, the Director of QAPI stated the video recording showed that no staff member followed the behavior plan interventions listed.

Reassessment of Medication Administration #2

Further review of Patient #5's eMAR, revealed that on 3/28/25 at 12:07 AM, LN #21 documented a reassessment for Patient #5's response to the IMBU Chlorpromazine (16 minutes after its administration): "Pt [patient] still agitated unable to respond to verbal prompts. Pt was laying on the floor in bed area at this time. Ongoing monitoring for effectiveness. Medication effectiveness for clinical indication: somewhat effective."

Review of facility video recordings of the Katmai unit, dated 3/27/25 from 11:30 PM to 3/28/25 12:30 AM, revealed LN #21 was never seen approaching Patient #5 to make this reassessment.

During an interview on 4/30/25 at 11:30 AM, the DON, Director of QAPI, and Lead Educator all agreed that LN #21 never completed this reassessment of medication. The Lead Educator stated it was the expectation that nurses completed a reassessment of PRN medication within 15 minutes of administration by physically assessing the patient.

During an interview on 5/1/25 at 9:27 AM, the Director of Risk Management stated from 3/27/25 at 11:49 PM to 3/28/25 at 4:29 AM no nurse returned to Patient #5's room.

Review of Patient #5's nursing note, written by LN #21 dated 3/28/25 at 5:08 AM, revealed: "Behaviors related to COSS [Close Observation Status Scale] status: Pt was elevated in bed area at shift change and was offered HS [night] med [medications] earlier by declined and started [his/her] 'seizure like shaking.' Received IMBU for refusing court order PO. Pt was making weird sound in bed area and was observed laying on the floor. Pt didn't show any improvement from [his/her] conditions and continued to scream at bed area. Pt received another IMBU Thorazine for refusal of PO meds for agitation. Pt was still tapping the floor and not responding to prompts for hours. Pt finally fall asleep around [2:00 AM] when checked . . . ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . ."

Patient #5's Aggressive Behavior

During an interview on 4/30/25 at 9:58 AM, the DON stated how staff interact with patients and unit culture has been a concern since February 2025.

During an interview on 4/30/25 at 11:00 AM, the Patient #5's Provider stated consoling and encouraging was the best therapy for Patient #5's during his/her episodes.

During an interview on 5/1/25 at 10:21 AM, when asked to describe what Patient #5's "severe agitation" would look like, Patient #5's Provider stated this would typically be non-redirectable behavior of disrobing, running out of his/her room, and being physically aggressive towards staff.

When asked if rolling on the floor, tapping, and making animal noises in Patient #5's bedroom area would be considered "severe agitation" and warrant PRN medication, Patient #5's Provider stated, "No. The treatment team made the decision to be as least restrictive as possible with [Patient #5]."

The Director of QAPI was in the room during this interview and asked Patient #5's Provider, "What if Patient #5 was rolling on the floor and making animal noises for hours?" Patient #5's Provider stated, "No, as long as [he/she] was in [his/her] room it would not warrant PRN medication."

An observation on 5/1/25 at 10:37 AM, once this interview was completed and Patient #5's Provider and the Director of QAPI left the room. Raised voices could be heard in the hallway, one of the voices heard was the Director of QAPI, although the articulation of the speech, or what was actually said, was not clear. Shortly after this, Patient #5's Provider returned to the room and stated Patient #5's lengthy behavior of rolling around on the floor and making animal noises could be considered agitation.

Incident on 3/28/25

During an interview on 4/30/25 at 9:58 AM, the Director of Nursing (DON) and Director of QAPI stated that on the evening of 3/27/25 and through the early morning on 3/28/25, Patient #5 was up late in his/her bedroom exhibiting some of the behavior challenges they had been dealing with for an extended period of time: he/she moved back and forth from the bathroom to the bedroom area, later in the evening he/she was rolling around on the bedroom floor, excessively tapping on the floor, and making animal noises at times through the night.

The Director of QAPI stated that based on video review, it was observed and heard that at 1:13 AM, PNA #7, after having completed a patient safety check (a visual check on the patient's status for safety), told another PNA in the hall that Patient #5 was, "laying down on the table."

The "table" was a desk (measuring 2 feet, 11 1/2 inches long and 2 feet, 1/2 inch wide) that was in his/her bedroom. This desk was bolted to the back half of the left wall of the room and approximately 2 1/2 feet away from the back left corner of the room that connected to the back wall. In the space between desk and the back wall, Patient #5 had placed his/her weighted chair flush against the left wall (the front of the chair was against the left wall, with the back of the chair facing outward), which left approximately 3 inches between the chair and desk on the left side of the chair, and approximately 3 inches between the chair and back wall on the right side of the chair. The total length of the chair/desk space was 5 feet, 6 inches from the right arm rest of the chair to the far-left edge of the desk.

The Director of QAPI further stated that Patient #5 (who was 6 feet, 1/4 inches tall and weighed approximately 275.4 lbs.) initially was laying prone on the desk (flat on his/her stomach face down), with his/her head positioned towards the back wall, which caused his/her legs and upper shoulders and head to extend beyond the edges of the desk on either side.

As the night progressed, the Director of QAPI stated that Patient #5 began to move towards the back wall slowly inching his/her upper body onto the chair positioned between the desk and back wall, while his lower body remained on the desk. Eventually, Patient #5 had his/her head on the right armrest of the chair, closest to the back wall, with his/her face turned towards the left wall. Patient #5's left arm was tucked under his/her torso on the chair seat, and the right arm was draped over the back of the chair.

During an interview on 4/30/25 at 9:58 AM, the DON stated all staff on nightshift on 3/27-28/25 stated they had never seen Patient #5 sleep on the desk before, but they didn't think it was something alarming.

An observation on 4/30/25 at 2:38 PM, of Patient #5's bedroom, revealed that when the chair was placed between the desk and the back wall, the chair was at a lower elevation then the top of the desk. This would have caused Patient #5's upper body to be lower than his/her hips, buttocks, and legs which were still on the desk.

Further observation revealed that when the Director of QAPI positioned herself in the same prone position as Patient #5 was on 3/28/25, her torso was not supported when her head/neck was resting on the right armrest of the chair, which caused her chest to bow downward towards the seat of the chair placing the pressure of supporting her upper body on her head/neck.

Further observation revealed that when standing in the doorway of Patient #5's bedroom, a person's view would have been of Patient #5's buttocks, legs, and feet only, with a minimal view of Patient #5's back and back of head. If staff were to enter the room and stand in close proximity to Patient #5, there would have been no view of Patient #5's face or the rise and fall of Patient #5's front chest during respirations, which was face down in the chair.

During an interview on 5/1/25 at 10:45 AM, when asked what the expectation for nurses and PNAs would be if a patient was positioned, during rest or sleep, in a way that could place the patient at risk for safety, the Assistant Director of Nursing (ADON) stated the expectation would be to attempt to move the patient.

When asked what if the patient resisted, the ADON stated then repeated attempts should be tried until the patient is positioned for safety. This could be trying to physically move the patient or communicate with the patient to achieve cooperation to move into a safer position.

Review of the facility's video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 1:13 AM to 4:29 AM, revealed:

- From 1:13 AM to 1:57 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes. At 1:13 AM, PNA #7 entered Patient #5's bedroom. Patient #5 could be heard on the camera (but was not seen as there were no cameras in the bedroom) making vocal sounds that were not words. As PNA #7 exited the room and approached other PNA's in the hall, it could be heard on the video that PNA #7 stated, "[he's/she's] laying on down on the table."

PNA #7 completed patient safety checks at 1:25 AM and 1:43 AM by looking in the window of the closed bedroom door. PNA #4 completed the patient safety check at 1:57 AM by looking in the window of the closed bedroom door.

- From 2:15 AM to 2:53 AM, no patient safety checks were completed for Patient #5, or any other patient on the Katmai unit. PNA #4 was assigned to patient safety checks this hour and remained seated in the hallway through this time.

- From 3:00 AM to 3:56 AM, PNA staff completed patient safety checks for Patient #5 every 15 minutes by viewing Patient #5 from the doorway of the bedroom. PNA #11 completed checks at 3:00 AM, 3:15 AM, 3:29 AM, and 3:43 AM. During this last check at 3:43 AM, PNA #11 stood at the doorway for 24 seconds while observing Patient #5. At 3:56 AM, PNA #12 completed the patient safety check by standing in the doorway for 21 seconds while observing Patient #5.

- At 4:12 AM, PNA #12 completed the patient safety check by entering Patient #5's bedroom. PNA #12 turned on the bedroom light and was in the room for 70 seconds, then exited.

- At 4:29 AM, PNA #12 completed the patient safety check by entering Patient #5's bedroom. PNA #12 turned on the light and could be heard calling Patient #5's name several times. Shortly after this, PNA #12 came back out into the hallway and called PNA #7 into the room with him/her. PNA #7 was observed to quickly leave the bedroom and go into the nurse's station to get the nurses. PNA #7 could be heard on the video recording saying, "[he's/she's] not moving." At 4:32 AM, PNA #12 told nurses, "[he/she] was breathing earlier" when they met him/her at Patient #5's doorway. All staff entered Patient #5's bedroom. Staff could be heard calling Patient #5's name. PNA #11 said, "let me get a pillow for [his/her] head" and left to retrieve a pillow. After some time, staff exited the room, LN #16 could be heard saying, "[he/she] was holding onto something."

During an interview on 4/30/25 at 12:37, the DON and Director of QAPI stated that when they interviewed the staff during their investigation after 3/28/25, all staff stated that at 4:29 AM when they entered the room, Patient #5 was positioned mostly on the desk with his/her head on the armrest of the chair closet to the desk and they attempted to reposition Patient #5 for safety and comfort. LN #16 and LN #21 both stated in their interviews that they checked Patient #5's pulse and stated he/she was breathing at this time. The DON and Director of QAPI stated that during staff interviews the staff stated, when the repositioning was attempted Patient #5 resisted to move by forcing his/her upper body down.

The DON further stated that when PNA #7 was interviewed, he/she stated when he/she left Patient #5's bedroom at 4:29 AM to get the nurses, he/she asked the nurses to come check Patient #5 to see if he/she was breathing. When asked if PNA #7 had ever before requested nurses to come check a resident for breathing during a patient safety check, PNA #7 stated, "no."

Review of Patient #5's nursing note, written by LN #21 and dated 3/28/25 at 5:08 AM, revealed: ". . . Pt finally fall asleep around [2:00 AM] when checked. Pt was laying on the table and drippled on the chair, was prompted to get into [his/her] bed for more comfort but ignored instructions. Pt was breathing and no distress noted. No further incident for the remaining of the shift. ADDENDUM: Per video review, this writer RN is clarifying that I observed patient at [4:29 AM], not [2:00 AM] as previously documented . . ."

Further review revealed no documentation of the pulse check, or the rate assessed, that the LNs reported completing at 4:29 AM. No other assessment information was documented, nor was there any other documentation from the LNs on 3/28/25.

During an interview on 4/30/25 at 12:39 AM, when asked what the expectation would be for an LN who was asked to come assess a patient for breathing, the Lead Educator stated the expectation would be to complete a head-to-toe assessment and call medical staff if needed.

Review of the facility's video recording of the common hallway areas on Katmai unit, dated 3/28/25 from 4:38 AM to 7:14 AM, revealed:

- At 4:38 AM, PNA #7 completed a patient safety check for Patient #5 by standing in the doorway.

- At 4:45 AM, PNA #12 completed a patient safety check for Patient #5. PNA #12 entering Patient #5's bedroom. PNA #12 turned on the bedroom light and was in the room for 37 seconds, then exited.

- Fr