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Based on observation, interview, and record review, the facility failed to meet the Condition of Participation (CoP) for Governing Body as evidenced by:

1. The facility's Governing Body (a group of people who are legally responsible for the management and direction of an organization) failed ensure that the Quality Assurance Performance Improvement (is a data driven and proactive approach to quality improvement) Department analyze the cause, and develop a correction plan to address a delay of care for one of 30 sampled patients (Patient 1) who had a decline in condition (worsening of symptoms) after sustaining a fall (an unplanned change in position where a patient lands on the floor or another lower surface) on 5/2/2024 at 10:15 a.m. Nursing staff documented Patient 1 was alert prior to the fall and after the fall from 5/2/2024 at 10:00 p.m., Patient 1 was lethargic (a symptom that involves an unusual decrease in consciousness), was manifesting confusion (symptoms that involve disruptions in memory, ability to think and focus, awareness), and disorientation (the condition of having lost one's sense of direction) and yet, there was no notification to physician or call for Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to immediately assess and treat the patient) that was done by nursing staff.

This deficient practice had the potential for reoccurrence of a patient's decline in condition (when clinical symptoms worsen) not being addressed immediately by staff thus leading to life-threatening events such as cardiac arrest (when the heart stops beating), etc. and compromising patient safety. (Refer to A-0063)

2. The Governing Body failed to ensure the Nursing Services Department ensure nursing staff notified the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) Physician (a person trained to treat life-threatening or limb-threatening illnesses or injuries) (Campus 1) that one of 30 sampled patients (Patient 3) had psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), sustained a head injury, and was refusing medical care.

This deficient practice resulted in Patient 3 being discharged from the ED, without being seen and medically cleared by an ED Physician for a possible head injury (post-assault [when an individual inflicts physical contact that causes bodily harm and/or injury]) and without being evaluated for psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), which could have resulted in unresolved psychosis and complications from a brain bleed such as death. (Refer to A-0063)

3. The Governing Body failed to ensure the facility's Security Services Department ensure one of 30 sampled patients (Patient 3) was free from abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when the security guard (SO 1) physically assaulted (when someone physically attacks another person causing bodily harm) Patient 3.

This deficient practice resulted in Security Officer 1 (SO 1) punching Patient 3 in the face ten times and Patient 3 suffering a head laceration (a deep cut or tear in skin or flesh) above the left eye. (Refer to A-0063)

4. The facility failed to protect Patient 3 from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) from a contracted service from a security guard (SO)1. This deficient practice resulted in Security Officer 1 (SO 1) punching Patient 3 in the face ten times and Patient 3 suffering a head laceration (a deep cut or tear in skin or flesh). (Refer to A-0083)

5. The facility allowed contracted staff to continue to work at the facility despite one Security guard (SO3) not having received CPI (CPI, a non-violent training program that teaches how to identify, prevent, and respond to crises) training, and two security guards (SO 1 and SO 2) with expired CPI training.

This deficient practice resulted in SO 1 not using appropriate de-escalation technique (methods used to reduce the intensity of a volatile situation) and punched Patient 3 ten times in the face resulting in Patient 3's injury.
This deficient practice also had the potential for SO 2 and SO 3 to forget how to use a safe and appropriate de-escalation technique, which may result in other physical altercations with patients that may lead to patient abuse. (Refer to A-0083)

6. The facility failed to ensure the Security Services, a contracted service (a service that is performed by an independent contractor or service provider, under a formal, legally binding agreement), had a valid and un-expired contract agreement to provide and maintain a safe care environment in the facility.

This deficient practice had the potential for the contracted security services staff to not uphold their job requirements and responsibilities as required by the facility, placing the patients at risk for an unsafe care environment. (Refer to A-0083)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview and record review, the facility's Governing Body failed to ensure the following:

1. The facility's Governing Body (a group of people who are legally responsible for the management and direction of an organization) failed ensure that the Quality Assurance Performance Improvement (is a data driven and proactive approach to quality improvement) Department analyze the cause, and develop a correction plan to address a delay of care for one of 30 sampled patients (Patient 1) who had a decline in condition (worsening of symptoms) after sustaining a fall (an unplanned change in position where a patient lands on the floor or another lower surface) on 5/2/2024 at 10:15 a.m. Nursing staff documented Patient 1 was alert prior to the fall and after the fall from 5/2/2024 at 10:00 p.m., Patient 1 was lethargic (a symptom that involves an unusual decrease in consciousness), was manifesting confusion (symptoms that involve disruptions in memory, ability to think and focus, awareness), and disorientation (the condition of having lost one's sense of direction) and yet, there was no notification to physician or call for Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to immediately assess and treat the patient) that was done by nursing staff.

This deficient practice had the potential for reoccurrence of a patient's decline in condition (when clinical symptoms worsen) not being addressed immediately by staff thus leading to life-threatening events such as cardiac arrest (when the heart stops beating), etc. and compromising patient safety.

2. The Governing Body failed to ensure the Nursing Services Department ensure nursing staff notified the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) Physician (a person trained to treat life-threatening or limb-threatening illnesses or injuries) (Campus 1) that one of 30 sampled patients (Patient 3) had psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), sustained a head injury, and was refusing medical care.

This deficient practice resulted in Patient 3 being discharged from the ED, without being seen and medically cleared by an ED Physician for a possible head injury (post-assault [when an individual inflicts physical contact that causes bodily harm and/or injury]) and without being evaluated for psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), which could have resulted in unresolved psychosis and complications from a brain bleed such as death.

3. The Governing Body failed to ensure the facility's Security Services Department ensure one of 30 sampled patients (Patient 3) was free from abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when the security guard (SO 1) physically assaulted (when someone physically attacks another person causing bodily harm) Patient 3.

This deficient practice resulted in Security Officer 1 (SO 1) punching Patient 3 in the face ten times and Patient 3 suffering a head laceration (a deep cut or tear in skin or flesh) above the left eye.

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/30/2024, the "H&P" indicated, Patient 1, "presenting from skilled nursing facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care and rehabilitation services to patients) secondary to anemia (a condition marked by a deficiency of red blood cells [transports oxygen and nutrients throughout the body]) with a history of hyponatremia (low sodium [essential nutrient for body fluids] level in the blood) otherwise asymptomatic (showing no symptoms) alert awake (a state of active attention characterized by high sensory awareness) denies any chest pain, no emesis (vomiting), diarrhea (loose stools) ..."

During a concurrent interview and record review on 10/29/2024 at 3:59 p.m. with the Director of Medical Surgical (DMS), Patient 1's "Progress Notes (the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during treatment)," dated 5/2/2024, was reviewed. The progress note indicated on 5/2/2024 at 10:13 a.m., Certified Nursing Attendant (CNA, an entry-level role that provides vital support to both patients and nurses) 1 "reports finding pt (Patient 1) sitting on the floor leaning against the wall, disoriented (having lost one's sense of time, place, or identity) to situation... Pt (Patient 1) reports losing balance and falling towards the wall onto a sitting position."

During a concurrent interview and record review on 10/29/2024 at 4:30 p.m. with the DMS, Patient 1's "Progress Notes," dated 5/3/2024 at 8:00 a.m., was reviewed. The progress notes indicate Patient 1 was "drowsy and lethargic (a symptom that involves an unusual decrease in consciousness); eyes are not open to pain, but pt (Patient 1) is grunting (to make a short, low sound instead of speaking) and moving hands to sternal rub (a technique to test an unconscious person's responsiveness)." The DMS verified that there was no progress note by any physician that Patient 1 was assessed for a change in condition (drowsy and lethargic, eyes do not open to pain) until 5/3/2024 at 10:59 p.m., when a progress note by MD 1, date of service/time was 5/3/2024 at 10:59 p.m. indicated, "24 hour event: rapid response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to immediately assess and treat the patient) was called on the patient (Patient 1) at approximately 6 p.m. neurologically (the branch of medicine that deals with problems affecting the brain) twitching in all extremities was noted and neurology was called."

During a concurrent interview and record review on 10/29/2024 at 4:30 p.m. with the DMS, Patient 1's "Neurological Assessment (evaluates brain and functioning)," dated from 4/24/2024 through 5/3/2024 was reviewed and indicated the following:

- On 4/29/2024 at 9:16 p.m. (date of admission to the facility), Patient 1's level of consciousness (LOC, is a state of awareness, alertness, and wakefulness) was identified as alert.
- On 4/30/2024 at 9:08 a.m., Patient 1's level of consciousness was identified as alert.
- On 5/1/2024 at 8:00 a.m., Patient 1's level of consciousness was identified as alert.
- On 5/1/2024 at 10:00 p.m., Patient 1's level of consciousness was identified as alert.
- On 5/2/2024 at 10:15 a.m. (when Patient 1 had an unwitnessed fall [an unplanned change in position where a patient lands on the floor or another lower surface] inside the patient room), Patient 1's level of consciousness was identified as lethargic (a symptom that involves an unusual decrease in consciousness), marked by confusion (symptoms that involve disruptions in memory, ability to think and focus, awareness), and disorientation (the condition of having lost one's sense of direction).
- On 5/2/2024 at 10:00 p.m., Patient 1's level of consciousness was identified as lethargic, confusion/disorientation.
- On 5/3/2024 at 8:00 a.m., Patient 1's level of consciousness was identified as lethargic; the right and left pupils are brisk and regular (normal pupil behavior).
- On 5/3/2024 at 10:00 p.m. Patient 1's level of consciousness was identified as obtunded (diminished responsiveness); the right and left pupils are sluggish (abnormalities of pupils' behavior correlate with an underlying serious problem with brain functioning).

During an interview and record review with the DMS on 10/29/2024 at 4:55 p.m. Patient 1's "Neurological Assessment," was reviewed. DMS verified that Patient 1 had a condition change. The DMS stated, "The nurse (RN 1) should have notified the doctor and monitored the patient more frequently than every 4 hours." The DMS verified that the neurological assessment indicated Patient 1's condition declined from 5/2/2024 at 10:15 a.m. (when Patient 1 fell) and continued to decline, over 24 hours, until 5/3/2024 at 6:00 p.m. when a Rapid Response was called.

During a review of Patient 1's Computed Tomography scan (CT scan, a medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body's internal structures), dated 5/3/2024 at 6:31 p.m., the CT scan results indicated, Patient 1 had "Large acute (sudden and severe in onset) right frontoparietal (area of the front and near the upper back area in the skull) subdural hematoma (a buildup of blood on the surface of the brain) measuring about 2 cm (centimeter, a unit of measurement) in maximum thickness. Extensive edema (swelling caused by too much fluid trapped), mass effect and shift (a shift in the midline is when the natural centerline of the brain is pushed to the right or left due to fluid buildup) of the midline (line that divide the brain evenly in two) to the right-side measuring about 10 mm (millimeter, a unit of measurement)."

During a concurrent interview and record review on 10/29/2024 at 4:45 p.m. with the DMS, Patient 1's "flow sheet (track patient health data over a period of time)," for vitals dated from 5/3/2024 at 8:00 a.m., at 1200 p.m., and at 7:15 p.m., was reviewed. Patient 1's vital signs (measurements of the body's most basic functions, such as temperature, pulse rate, respiration rate, and blood pressure) were as follows:

On 5/3/2024 at 8:00 a.m., Patient's 1 blood pressure (BP, measures the blood pushing against the blood vessel walls when the heart beats) was elevated, 179/92. The blood pressure was not addressed. DMS confirmed that PRN (as needed) Hydralazine (prescribed medication used to treat high blood pressure) that was prescribed to administered if the systolic BP (the first number in measurement of the pressure the blood pressure) over 160s, was not given. The DMS verified that the BP was not reassessed until (4 hours later) at 12:00 p.m., when the systolic BP continued to be elevated at 160. The DMS confirmed that the elevated BP was also not addressed at 12 p.m. On 5/3/2024 at 7:15 p.m., Patient 1's BP increased to 205/100.

During an interview and record review with the DMS on 10/29/2024 at 5:00 p.m., Patient 1's "Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient) Team Assessment" report, was reviewed. The report indicated a rapid response started at 6:13 p.m. on 5/3/2024. The report indicated, Patient 1 was lethargic (a symptom that involves an unusual decrease in consciousness) and with AMS (altered mental status, a change in mental function), CT scan was ordered and confirmed subdural hematoma (a type of bleeding near the brain that can happen after a head injury)." Patient 1 had to be intubated (placing a tube into the patient windpipe to aid in breathing).

During an interview on 10/30/2024 at 9:56 a.m. with Registered Nurse (RN, nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 1, RN 1 stated, on 5/2/2024 at 8:00 a.m., CNA 1 reported that she found Patient 1 on the floor. RN 1 stated on 5/3/2024, he (RN 1) was precepting (provides supervision during clinical practice) for RN 2. RN 1 stated he (RN 1) was responsible to review RN 2' assessment of Patient 1 and sign off on documentation completed by RN 2.
During the same interview on 10/30/2024 at 9:56 a.m. with RN 1, RN 1 further stated that on 5/3/2024 at 8:00 a.m., Patient 1 required a sternal rub (a technique to test an unconscious person's responsiveness). RN 1 stated a sternal rub was done to apply some pain to see if the patient (Patient 1) would respond. RN 1 confirmed that he (RN 1) was not able to get Patient 1 to respond verbally, Patient 1 was grunting and moving hands. RN 1 stated, "When patient has a condition change, the MD (physician) should have been notified, and a rapid response should be called immediately."

During an interview on 10/30/2024 at 9:56 a.m. with Registered Nurse (RN) 2, RN 2 stated, "In the (Medical Surgical) unit, the CNA would take patients' blood pressure, and the RN will review the BP within an hour." RN 2 stated when a blood pressure was abnormal, the CNA would inform the RN immediately. RN 2 stated, "I do not recall if the CNA (CNA 1) notified of Patient 1's blood pressure of 179."

During a concurrent interview and record review on 11/1/2024 at 4:00 p.m. with the Director of Performance Improvement/Risk Manager (DPIQ), the facility's "Quality Council (a group of senior management within given operational units who plan, implement, facilitate and monitor the quality process)" minutes (an official record of actions the board or committee took at a meeting), dated 6/18/2024, was reviewed. The minutes indicated the presentation was regarding cases that were reported to the California Department of Public Health (CDPH). The first case was in regard to Patient 1 incident. The minutes indicated, "Patient fall resulted hematoma (a collection of blood within the skull) and transferred out for higher level of care. All appropriate documentation was provided to the surveyor. We do not foresee any issues. We identified an issue internally with the care plan and will look into that." DPIQ stated after the investigation was completed there was identification of a need for rounding. DPIQ confirmed that there was no corrective plan presented in the Quality Council meeting.

During a concurrent interview and record review on 11/1/1024 at 5:07 p.m. with the Improvement/Associate Administrator (AA), the facility's "Governing Board of Directors Meeting Minutes (a log of recording that acts as an official log of corporate deliberations and helps facilitate an organization's books and obligations)" for July 2024, was reviewed. The AA stated what was presented to the governing body (GB) was the patient fell; there was fall intervention in place, which was a falling star signage and a yellow armband. AA stated what was reported was the "false," such as there was no fall care plan in place and there was no two times assessment for pain. AA stated we presented the "false," but did not present the "fixed." The corrective plan (a document that outlines the steps to address the root cause of a problem) was not presented to the Governing Body. AA stated that the responsibility to assure the incident of delay in care for a subdural hematoma (type of bleeding near the brain that can happen after a head injury) for Patient 1 being identified and thoroughly investigated and that a corrective plan was developed and presented to GB was the responsibility of the Quality Assurance Performance Improvement (QAPI, a data-driven and proactive approach to quality improvement), and the body that had oversight was the GB.

During a review of the facility's policy and procedure (P&P) titled, "Governing Board," dated September 2023, the P&P indicated, "To state the composition, structure, and membership of the Governing Board of [name of facility] ...The Governing Board identifies those responsible for the provision of care, treatment, and services. The Governing Board is ultimately responsible for the quality of care provided by (Name of the Facility). To fulfill this function the Governing Board assures: Effective functioning of activities related to performance improvement by providing a mechanism which shall be defined in the Performance Improvement Plan ... Risk management functions related to patient care and safety."

During a review of the facility's "Governing Board of Directors Bylaws of (name of the facility)," dated October 2024, the Bylaws indicated, "The purpose for the establishment and operation of the Board of Directors is to serve as the governing body of the Hospital, and in connection therewith, the Board of Directors shall be responsible for the operation of the Hospital."

2. During a review of Patient 3's Face Sheet, dated 8/12/2024, the Face Sheet indicated Patient 3 was registered to the facility (Campus 1) Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) on 8/12/2024 at 2:00 a.m., with a chief complaint of psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not).

During an interview on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement and Quality Management (DPIQ), the DPIQ stated the following: On 8/12/2024 at approximately 2:56 a.m., the physical altercation (physical aggression that may or may not result in an injury) between Security Officer 1 (SO 1) and Patient 3 occurred in the facility's new Emergency Department that was still under construction at the time. SO 1 was working in the new ED at the entrance. Patient 3 tried to rip off the construction barrier on the wall. Patient 3 was agitated (a state of severe restlessness or uneasiness) and got into a verbal altercation (a verbal argument) with SO 1, then Patient 3 spat on SO 1. SO 1 and Patient 3 got into a physical altercation. Patient 3 was taken by staff inside the Emergency Room. The DPIQ validated SO 1 punching Patient 3 to the head (10 times) and that the verbal interactions on facility video between SO 1 and Patient 3 appeared to be a verbal argument prior to the physical altercation.

During a concurrent interview and record review on 10/30/2024 at 3:30 p.m. with the Director of Emergency Department (DED), Patient 3's medical record, was reviewed. The DED verified the following from the medical record: The Medical Screening Exam (MSE, an exam performed by a physician to determine whether a medical condition exist) and physician note were missing from the medical record. There was no notification to the ED Physician from nursing staff about Patient 3's physical altercation (with SO 1), head laceration (a deep cut or tear in skin or flesh), auditory hallucinations (when someone hears voices or noises that don't exist in reality) and refusal of medical care. Patient 3 left the facility in the custody of the police without being seen by an ED Physician and without receiving medical clearance (the process of evaluating someone's health condition to determine if they are fit for a specific activity or procedure) for psychosis or a head injury (post [after] physical assault).

During the same interview on 10/30/2024 at 3:30 p.m., the DED stated the following: Patient 3 was seen in the Emergency Department on 8/12/2024 following a physical altercation with a member of facility security staff (SO 1). There should have been a notification from nursing staff to the ED Physician that Patient 3 was having auditory hallucinations, had a head laceration following a physical altercation, and was refusing care. It was important to notify the ED Physician so that patient (Patient 3) could get the appropriate medical care. Patient 3 should not have left without being seen by a physician and being medically cleared for psychosis or a head injury (post physical assault). Nursing staff documented refusal of care, but the ED physician should have documented Patient 3's refusal to be seen in Patient 3's medical record.

During an interview on 10/31/2024 at 3:22 p.m. with the Emergency Department (ED) Physician, Medical Doctor 4 (MD 4), MD 4 stated the following: After the triage nurse triaged a patient (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) in the ED, the ED physician sees the patient and performs a MSE. A patient who presents with a head laceration, possible danger to others (condition of a person whose behavior or significant threats support a reasonable expectation that there is a substantial risk that he will inflict physical harm upon another person in the near future) and is identified as having auditory hallucinations, must be seen by a physician and must be medically cleared for psychosis or a head injury (post physical assault), by a physician prior to being discharged.

During the same interview on 10/31/2024 at 3:22 p.m. with MD 4, MD 4 said a patient presenting with auditory hallucinations should be evaluated by the ED physician to determine a need for a Psychiatric Emergency Team (PET, a team of licensed mental health clinicians) evaluation. When patients are discharged in the custody of the police, the ED Physician must medically clear all patients to ensure they do not have a medical event after they leave the ED. For head trauma, the standard of care treatment is to have a Computed Tomography (CT, a medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body's internal structures) scan completed to rule out a brain bleed, because a brain bleed can stop someone from breathing and kill them.

During the same interview on 10/31/2024 at 3:22 p.m. with MD 4, MD 4 stated if a patient refuses care, staff notifies the ED physician, and the ED physician must explain and document that the risk and benefits (risks and benefits of healthcare-relevant decisions) have been explained to the patient. Documentation of the MSE or refusal in the MD progress note should be completed within 24 hours of seeing the patient. The ED Physician has the ultimate responsibility for the patient, and the interdisciplinary team (a group of healthcare professionals with various areas of expertise who work together toward the goals of their patients), such as the Charge Nurse or Registered Nurse, should communicate changes or refusals to the ED physician.

During a review of Patient 3's "ED note - Nursing (ED nursing note)," dated 8/12/2024 at 2:45 a.m., the ED nursing note indicated, "patient (Patient 3) was brought in by [staff] in cuffs (a device used to secure a person's wrists or ankles to limit their movement) into chair in emergency department (ED), patient (Patient 3) was yelling and screaming, threatening all staff and refusing care ... [staff] was able to see cut above [Patient 3's] left eye, cleaned and dressed with 4 X 4's dressing (a topical dressing for local management of bleeding wounds such as cuts, lacerations and abrasions) refusing triage and Medical Doctor (MD) exam, vital signs (measurements of the body's most basic functions, such as temperature, pulse rate, respiration rate, and blood pressure) and other care, kept screaming, in police department custody."

During a review of patient 3's "ED note - Nursing (ED nursing note)," dated 8/12/2024 at 3:21 a.m., the ED nursing note indicated the following: "Patient (Patient 3) complained of auditory hallucination ... unwitnessed altercation but patient (Patient 3) has laceration above left eye... called [local] police department immediately... police department arrived and took patient into custody."

During an interview on 10/31/2024 at 4:35 p.m. with the DPIQ, the DPIQ stated the following: Once Patient 3 was taken into custody by the police, the facility was unaware of what happened to Patient 3.

During an interview on 11/1/2024 at 5:14 p.m. with the Performance Improvement Associate Administrator (AA), the AA stated the following: He (AA) was a Governing Board (a group of people who are legally responsible for the management and direction of an organization) member for the facility. Patient 3's event was identified as an adverse event (an undesirable medical outcome that occurs in a patient as a result of medical care or treatment). Patient 3's adverse event was reported to the Governing Board in an emergency meeting. The facility did not keep meeting minutes (a formal written record of a meeting's discussions, decisions, and actions) for the emergency Governing Board meeting, but there should have been meeting minutes. He (AA) would be responsible for presenting Patient 3's adverse event Root Cause Analysis (RCA, a structured process for identifying the underlying causes of a problem or event, and then developing solutions to prevent it from happening again) Corrective Action Plan (a document that outlines the steps to address the root cause of a problem) to the Governing Board for approval and that was not done. Patient 3's adverse event was not discussed or presented during the last Governing Board meeting on October 22, 2024. Adverse events should be brought to the attention of the Governing Board immediately, even if the RCA was not completed. It was important for Patient 3's adverse event and RCA Corrective Action Plan to be reported to the Governing Board because the Governing Board needs to approve the Corrective Active Plan to ensure it was appropriate. The Governing Board had the ultimate responsibility for patient safety to provide oversight and input as necessary. The AA verified there were no meeting minutes to validate the Governing Board was aware of Patient 3's adverse event. There was no documentation of the Governing Board's oversight for Patient 3's RCA Corrective Action Plan to ensure the RCA Action Plan was appropriate and patient safety was upheld.

During a review of the facility's policy and procedure (P&P) titled, "Physician Notification," dated 3/2023, the P&P indicated the following: "The physician of record will be notified regarding patient issues in a timely manner ... The physician of record and or hospitalist will be notified of patient's change in condition."

During a review of the facility's policy and procedure (P&P) titled, "Patient Right to Refuse Care," dated 4/2018, the P&P indicated the following: " ...In the event that a patient refuses care or services, the physician should be notified. it is the physician's responsibility to explain the consequences of refusal and to present alternatives if any are appropriate ..."

During a review of the facility's policy and procedures (P&P) titled, "Medical Screening Examinations," dated 2/2020, the P&P indicated the following: " ...Any patient who presents to [the facility] requesting emergency services is entitled to and will receive a Medical Screening Examination performed by licensed providers for the determination of whether an emergency condition exists .... Emergency Medical Condition: A medical condition manifesting itself by acute (sudden and severe in onset) symptoms of sufficient severity, (including severe pain, psychiatric disturbances and/or symptoms) such that the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily functions or serious dysfunction or serious dysfunction of any bodily organ ..."

During a review of the facility's policy and procedures (P&P) titled, "Emergency Department Standards of Practice and Care," dated 8/2020, the P&P indicated: " ...Important Aspects of Patient Care: ...E. Assessment and patient needs are communicated to the healthcare provider(s) who is responsible for the care and treatment of the patient: 1. Members of the multidisciplinary team ... 3. Progress/nursing notes ..."

During a review of the facility's policy and procedures (P&P) titled, "Standard of Care Procedures," dated 10/2020, the P&P indicated: " ...Procedure: ...M. Head injuries 1. A patient who arrives at the Emergency Department with a head injury will be evaluated for the following care: ...Notify the Emergency Department Physician ..."

During a review of the facility's policy and procedures (P&P) titled, "Triage," dated 8/2020, the P&P indicated: "...Policy: ...B. Triage assessment and the assignment of an acuity rating do not fulfill the legal requirement of the patient receiving a medical screening examination (MSE) by the physician. C. The Emergency Medical Treatment and Active Labor Act (EMTALA) requires medical screening of individuals seeking emergency care to determine whether an emergency medical condition exists. Stabilization of the patient, to the best of the hospital's capabilities, is required prior to discharge or transfer ..."

During a review of the facility's policy and procedure (P&P) titled, "Governing Board," dated September 2023, the P&P indicated, "To state the composition, structure, and membership of the Governing Board of [name of facility] ...The Governing Board identifies those responsible for the provision of care, treatment, and services. The Governing Board is ultimately responsible for the quality of care provided by (Name of the Facility). To fulfill this function the Governing Board assures: Effective functioning of activities related to performance improvement by providing a mechanism which shall be defined in the Performance Improvement Plan ... Risk management functions related to patient care and safety."

During a review of the facility's "Governing Board of Directors Bylaws of (name of the facility)," dated October 2024, the Bylaws indicated, "The purpose for the establishment and operation of the Board of Directors is to serve as the governing body of the Hospital, and in connection therewith, the Board of Directors shall be responsible for the operation of the Hospital."

3. During a review of Patient 3's Face Sheet, dated 8/12/2024, the Face Sheet indicated Patient 3 was Registered to the facility (Campus 1) Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries), on 8/12/2024 at 2:00 a.m., with a chief complaint of psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not).

During an observation and interview on 10/29/2024 at 3:21 p.m. with the Security Officer 3 (SO 3). The SO 3 was observed by the entrance of the Emergency Department (Campus 1) entrance. The SO 3 stated he (SO 3) was employed by the facility for 3 months and he (SO 3) did not receive Crisis Prevention Intervention (CPI, a non-violent training program that teaches how to identify, prevent, and respond to crises) training.

During a concurrent interview and record review on 10/29/2024 at 3:30 p.m. with the Security Officer 2 (SO 2), the SO 2 stated the following: If a patient was agitated (a state of severe restlessness or uneasiness) or aggressive (ready or likely to attack or confront), CPI techniques should be used to de-escalate (reduce the intensity of (a conflict or potentially violent situation) the patient. He (SO 2) was due for a new CPI training. SO 2 verified his (SO 2) CPI card was expired and that the expiration date listed on the CPI card was 2/15/2024.

During an interview on 10/29/2024 at 4:05 p.m. with the Security Manager (SM), the SM stated the following: Security Officer staff are required to have CPI training within 60 days of hire, or they are unable to work. If a patient is aggressive, the security staff should not take the patient down [to the floor], they should only physically intervene if facility staff calls for back-up assistance. Security should never physically assault a patient. It is important for staff to be CPI trained to understand proper use of de-escalation techniques and restraints (direct physical contact that prevents or significantly restricts someone's freedom of movement) when dealing with aggressive or combative (ready or eager to fight) patients. All security staff are required to have CPI training. Security staff must maintain current CPI certification and renew CPI annually.

During a review of facility (Campus 1) video footage (no audio) on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement Quality Management (DPIQ), the DPIQ verified the following on the video footage:

- At 2:56 a.m. Patient 3 walked into the hallway where Security Officer 1 (SO 1) was posted. No other staff or persons were present. Patient 3 exited the facility doors and entered again and began walking the hallway past SO 1.

- At 2:57 a.m., Patient 3 started touching the wall. SO 1 approached Patient 3 and there was a verbal interaction. SO 1 walked with Patient 3 to a corner and Patient 3 was no longer observed on camera. SO 1 followed Patient 3 to the corner and performed multiple kicking motions towards Patient 3's direction.

- At 2:58 a.m., SO 1 and Patient 3 were visibly arguing face to face, less than one arm's length away. SO 1 pushed

Based on interview and record review, the Governing Body failed to ensure patient care and services rendered under contract with an outside entity (Security Services) were provided in a safe and effective manner, for one of 30 sampled patients (Patients 3), when:

1. The facility failed to protect Patient 3 from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) from contracted service from the security guard (SO)1. This deficient practice resulted in Security Officer 1 (SO 1) punching Patient 3 in the face ten times and Patient 3 suffering a head laceration (a deep cut or tear in skin or flesh).

2.a. The facility allowed contracted staff to continue to work at the facility despite one Security guard (SO3) not having received CPI (CPI, a non-violent training program that teaches how to identify, prevent, and respond to crises) training, and two security guards (SO 1 and SO 2's) with expired CPI training.

This deficient practice resulted in SO 1 not using appropriate de-escalation technique (methods used to reduce the intensity of a volatile situation) and punched Patient 3 ten time in the face resulting in Patient 3's injury. This deficient practice also had the potential for SO 2 and SO 3 to forget how to use a safe and appropriate de-escalation technique, which may result in other physical altercations with patients that may lead to patient abuse.

2.b. The facility failed to ensure the Security Services, a contracted service (a service that is performed by an independent contractor or service provider, under a formal, legally binding agreement), had a valid and un-expired contract agreement to provide and maintain a safe care environment in the facility.

This deficient practice had the potential for the contracted security services staff to not uphold their job requirements and responsibilities as required by the facility, placing the patients at risk for an unsafe care environment.

Findings:

1. During a review of Patient 3's Face Sheet, dated 8/12/2024, the Face Sheet indicated Patient 3 was Registered to the facility (Campus 1) Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries), on 8/12/2024 at 2:00 a.m., with a chief complaint of psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not).

During a concurrent interview and record review on 10/29/2024 at 3:30 p.m. with the Security Officer 2 (SO 2), the SO 2 stated the following: If a patient was agitated (a state of severe restlessness or uneasiness) or aggressive (ready or likely to attack or confront), CPI techniques should be used to de-escalate (reduce the intensity of a conflict or potentially violent situation) the patient. During an interview on 10/29/2024 at 4:05 p.m. with the Security Manager (SM), the SM stated the following: Security Officer staff are required to have CPI training within 60 days of hire, or they are unable to work. If a patient is aggressive, the security staff should not take the patient down [to the floor], they should only physically intervene if facility staff calls for back-up assistance. Security should never physically assault a patient. It is important for staff to be CPI trained to understand proper use of de-escalation techniques and restraints (direct physical contact that prevents or significantly restricts someone's freedom of movement) when dealing with aggressive or combative (ready or eager to fight) patients. All security staff are required to have CPI training. Security staff must maintain a current CPI certification and renew CPI annually.

During a review of facility (Campus 1) video footage (no audio) on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement Quality Management (DPIQ), the DPIQ verified the following on the video footage:

- At 2:56 a.m. Patient 3 walked into the hallway where Security Officer 1 (SO 1) was posted. No other staff or persons were present. Patient 3 exited the facility doors and entered again and began walking the hallway past SO 1.

- At 2:57 a.m., Patient 3 started touching the wall. SO 1 approached Patient 3 and there was a verbal interaction. SO 1 walked with Patient 3 to a corner and Patient 3 was no longer observed on camera. SO 1 followed Patient 3 to the corner and performed multiple kicking motions towards Patient 3's direction.

- At 2:58 a.m., SO 1 and Patient 3 were visibly arguing face to face, less than one arm's length away. SO 1 pushed Patient 3 away using his (SO 1's) arm. Patient 3 punched SO 1 and there was a physical altercation where SO 1 wrestled (grabbed and pushed using body weight and slammed to the ground) Patient 3 to the ground. SO 1 punched Patient 3 in the face multiple times (using blunt force with SO 1's right first), while Patient 3 was on the floor with SO 1 restraining him (Patient 3) by placing his (SO 1's) body weight on Patient 3. There was blood on the floor.

- At 2:59 a.m., Patient 3 remained restrained on the floor by SO 1, with SO 1's knee on patient 3's lower body and arm on Patient 3's upper body. SO 1 removed hand cuffs from pocket to apply to Patient 3.

During an interview on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement and Quality Management (DPIQ), the DPIQ validated the punching by SO1 on Patient 3 and that the verbal interactions on facility video between SO 1 and Patient 3 appeared to be an argument prior to the physical altercation.

During an interview on 10/30/2024 at 2:11 p.m. with the Security Manager (SM), the SM stated the following: On 8/12/2024, SO 1 and Patient 3 were involved in a physical altercation. Patient 3 was agitated, pulling things off the wall and SO 1 intervened aggressively. SO 1 started kicking Patient 3. Patient 3 was in SO 1's face and punched him (SO 1). SO 1 tackled Patient 3 to the ground then punched him (Patient 3) multiple times in the face. SO 1 was at fault for the physical altercation (a confrontation, tussle or physical aggression that may or may not result in injury) and physically assaulting Patient 3. SO 1 did not follow CPI guidelines. SO 1 should have made attempts to de-escalate Patient 3. SO 1 should not have placed Patient 3 in handcuffs, this is not CPI protocol. SO 1 should have called for back-up on the radio (provided to all security staff) or called a code gray (a hospital emergency response that indicates a dangerous or combative person in the hospital, or criminal activity), when Patient 1 was agitated and combative. It was staff to patient abuse when SO 1 tackled Patient 3 to the floor and punched him (Patient 3) in the face. Following the facility investigation which started 8/12/2024, SO 1 was suspended at the start of the next shift at 3:30 p.m. SO 1 did not return to work and was terminated for not utilizing proper CPI techniques, when SO 1 did not de-escalate Patient 3 and physically abused Patient 3.

During a review of the facility's policy and procedures (P&P) titled, "Management of Violent Patients," dated 5/2022, the P&P indicated the following: " ...IV. Procedure: A. Utilizing current Assault Prevention Techniques/Training, any or all of the following measures may be taken: ...b. Conditions which may lead to violence: ...vi. Psychiatric Disorders (a mental illness that involves significant changes in a person's thoughts, emotions, or behaviors that are difficult to control) ... 2. a. ...vii. Staff should alert hospital security as soon as possible of anytime a patient starts to escalate (becomes more intense or serious) or becomes violent. b. Patients who are agitated but cooperative may be amendable to verbal de-escalation techniques: i. Respect personal space- Maintain a distance of two arm's lengths and provide personal space for easy exit for either party; ii. Do not be provocative- Keep your hands relaxed, maintain a non-confrontational body posture, and do not stare at the patient ..."

During a review of the facility's policy and procedure (P&P) titled, "Assaultive Behavior," dated 10/2021, the P&P indicated the following: " ...D. A patient who strikes at or actually strikes another person, including patients, visitors or staff, will be assessed for seclusion and/or restraints. A Code Gray must be called, to secure additional assistance, if needed ..."

During a review of the facility's policy and procedure (P&P) titled, "Code Gray," dated 10/2021, the P&P indicated the following: " ...A. In the event of a psychiatric emergency (defined as an aggressive patient who does not respond to verbal limits and/or is posing a safety risk) the charge nurse will be alerted. She/he will make the determination whether a Code Gray is to be paged ..."

During a review of the facility's policy and procedure (P&P) titled, "Governing Board," dated September 2023, the P&P indicated, "To state the composition, structure, and membership of the Governing Board of [name of facility] ...The Governing Board identifies those responsible for the provision of care, treatment, and services. The Governing Board is ultimately responsible for the quality of care provided by (Name of the Facility). To fulfill this function the Governing Board assures: Effective functioning of activities related to performance improvement by providing a mechanism which shall be defined in the Performance Improvement Plan ... Risk management functions related to patient care and safety."

During a review of the facility's "Governing Board of Directors Bylaws of (name of the facility)," dated October 2024, the Bylaws indicated, "The purpose for the establishment and operation of the Board of Directors is to serve as the governing body of the Hospital, and in connection therewith, the Board of Directors shall be responsible for the operation of the Hospital."


2.a. During a review of Patient 3's "Emergency Documentation," dated 8/12/2024 at 3:21 a.m., the Emergency Documentation indicated: "patient (Patient 3) was having auditory hallucinations ...unwitnessed altercation but patient (3) has laceration (a deep cut or tear in skin or flesh) above left eye ... [SO 1] placed patient (3) in cuffs ..."

During a concurrent interview and record review on 10/30/2024 at 5:21 p.m. with the Director of Performance Improvement and Quality Management (DPIQ), the DPIQ verified the following: SO 1's Crisis Prevention Intervention (CPI, a non-violent training program that teaches how to identify, prevent, and respond to crises) card expired 7/5/2023. SO 2's CPI card expired 2/15/2024 and renewed 10/30/2024 (after the survey team identified SO 2 was working without CPI training on 10/29/2024). SO 3 was a new hire (hired 7/1/2024) working without CPI training on 10/29/2024. The DPIQ stated the following: CPI for security staff should be completed within 60 days of hire and maintained per policy. SO 1 was a Lead Security Officer. There was no CPI policy. The DPIQ provided a booklet titled "Crisis Prevention Institute: Non-violent Crisis Intervention Training."

During a review of the document provided by the facility titled, "Position description: Security Officer," no date, the document indicated the following: " ...Qualifications: Must complete CPI within 60 days of hire ..."

During a review of the document provided by the facility titled, "Position description: Lead Security Officer," no date, the document indicated the following: " ...Qualifications: Must complete CPI within 60 days of hire ..."

During a review of the booklet provided by the facility titled "Crisis Prevention Institute: Non-violent Crisis Intervention Training," no date, the Booklet indicated the following: "Manage your own emotional responses to distress behavior; Use the Decision Making Matrix in the moment of Risk Behavior to determine Safety Interventions that represent a reasonable, proportionate, least restrictive, and last resort course of action; Use safety intervention strategies to maximize safety and minimize harm to self or others ..."

During a review of the facility's policy and procedures (P&P) titled, "Management of Violent Patients," dated 5/2022, the P&P indicated the following: " ...IV. Procedure: A. Utilizing current Assault Prevention Techniques/Training, any or all of the following measures may be taken: ...b. Conditions which may lead to violence: ...vi. Psychiatric Disorders (a mental illness that involves significant changes in a person's thoughts, emotions, or behaviors that are difficult to control) ... 2. a. ...vii. Staff should alert hospital security as soon as possible of anytime a patient starts to escalate (becomes more intense or serious) or becomes violent. b. Patients who are agitated but cooperative may be amendable to verbal de-escalation techniques: i. Respect personal space- Maintain a distance of two arm's lengths and provide personal space for easy exit for either party; ii. Do not be provocative- Keep your hands relaxed, maintain a non-confrontational body posture, and do not stare at the patient ..."

During a review of the facility's policy and procedure (P&P) titled, "Assaultive Behavior," dated 10/2021, the P&P indicated the following: " ...D. A patient who strikes at or actually strikes another person, including patients, visitors or staff, will be assessed for seclusion and/or restraints. A Code Gray must be called, to secure additional assistance, if needed ..."

During a review of the facility's policy and procedure (P&P) titled, "Code Gray," dated 10/2021, the P&P indicated the following: " ...A. In the event of a psychiatric emergency (defined as an aggressive patient who does not respond to verbal limits and/or is posing a safety risk) the charge nurse will be alerted. She/he will make the determination whether a Code Gray is to be paged ..."

During a review of the facility's policy and procedure (P&P) titled, "Employee File Requirements," dated 11/2022, the P&P indicated the following: " ...All staff whose job description requires Crisis Prevention and Intervention (CPI) must complete the recertification training no later than the end of the month in which it expires. New hires have 60 days from the date of hire to complete the training ..."
During a review of the facility's policy and procedure (P&P) titled, "Governing Board," dated September 2023, the P&P indicated, "To state the composition, structure, and membership of the Governing Board of [name of facility] ...The Governing Board identifies those responsible for the provision of care, treatment, and services. The Governing Board is ultimately responsible for the quality of care provided by (Name of the Facility). To fulfill this function the Governing Board assures: Effective functioning of activities related to performance improvement by providing a mechanism which shall be defined in the Performance Improvement Plan ... Risk management functions related to patient care and safety."

During a review of the facility's "Governing Board of Directors Bylaws of (name of the facility)," dated October 2024, the Bylaws indicated, "The purpose for the establishment and operation of the Board of Directors is to serve as the governing body of the Hospital, and in connection therewith, the Board of Directors shall be responsible for the operation of the Hospital."

2.b. During a concurrent interview and record review on 11/1/2024 at 10:45 a.m. with Executive Director of Human Resources (HRD), the HRD stated Security Officer 3 (SO 3) was a contracted employee with a hire date of 7/1/2024. The HRD stated SO 3's job description (a written document that outlines the responsibilities and qualifications for a job position) was not in the employee's file.

During a concurrent interview and record review, on 11/1/2024 at 11:13 a.m., with the HRD, the HRD stated SO 2 was a contracted employee with a hire date of 1/6/2023. The HRD stated SO 2's job description was not in the employee's file.

During a concurrent interview and record review on 11/1/2024 at 12:16 p.m. with the HRD, the HRD provided the "Security Service Agreement," Contract with a start of service date on 1/15/2020, and a termination date of 12/31/2023. The HRD stated "that is the last contract we have on file." The HRD verified that the security service agreement contract was expired since 12/31/2023.

During a concurrent interview on 11/1/2024 at 12:53 p.m. with the Director of Performance Improvement/Risk Manager (DPIQ), the DPIQ stated the Executive Director of Support Services (EDSS) was responsible in reviewing the security contract.

During an interview on 11/1/2024 at 2:50 p.m. with the HRD, the HRD confirmed SO 2 and SO 3 did not have the security officer job description.

During an interview on 11/1/2024 at 5:40 p.m. with the Performance Improvement Associate Administrator (AA), the AA stated the facility's Governing Body (GB) had the ultimate responsibility and authority in the hospital including oversight of contracted services. The AA stated it was important to have a valid contract with the contracted services (Security Services) to ensure there was accountability in providing patient safety. The AA stated the facility's GB had oversight regarding ensuring there was no expired Security Services contract because providing patient safety was their responsibility.

During a concurrent interview and record review on 11/1/2024 at 7:16 p.m. with the Executive Director of Human Resources (HRD), HRD stated the importance of having the job description for the contracted security officers in the HR records was to have a list of the expectations, responsibilities, obligations of the contracted security staff. HRD stated it was important to know the role that the security officer will be performing in the facility under the terms of the contractual agreement.

During a review of the facility's policy and procedure (P&P) titled, "Organizational Performance Improvement Plan," reviewed on 04/2024, the P&P indicated, "The organizational program, established by the medical staff, with support and approval from the Governing Board, has the responsibility for monitoring every aspect of patient care and service (including contracted services), from the time the patient enters the hospital through diagnosis, treatment, recovery
and discharge in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to continuously improve and facilitate positive patient outcomes ..."

During a review of the facility's policy and procedure (P&P) titled, "Independent Contractors and Contracting Arrangements," revised on 08/2020, the P&P indicated, "Purpose to ensure that all independent contractors and employees of contractors who perform duties within [Name of the facility] are qualified to perform such duties; are consistently performing in a competent manner; ...1. Description of duties. 2. Current licensure and Certification... 4. Resume documenting experience to perform duties. 5. Attendance document from General Hospital Orientation and if appropriate, annual re-orientation. 6. 90 day and annual evaluation of performance done by contracting [name of facility] manager .... Companies that provide labor within [Name of Facility] are required to keep the above records for review at any time by [name of facility] or regulatory agency, except for insurance certificates that are kept in Administration. All required documentation must be current. Failure to provide current licensure or certification will result in immediate suspension of the contract pending investigation... No employee of a contracting company may perform duties for which they do not have current proof of competency ... [Name of facility] reviews all contracting company's employee records performing duties at [name of facility] on an annual basis. Representative of [name of Facility] may review contracting company's records at any time with or without notice."

Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights as evidenced by:

1. The facility failed to ensure the staff removed a ligature (a thing used for tying) risk item for one of 30 sampled patients (Patient 9), in accordance with the facility's policy and procedure regarding contrabands (any item that is prohibited or could be dangerous to patients, staff or visitors. Example: Belts and shoelaces), when Patient 9 was allowed to wear a sweater with a drawstring in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders).

This deficient practice resulted in putting Patient 9 and other patients in an unsafe environment when the drawstring (considered as a contraband) could be used to harm self or others. (Refer to A-0144)

2. The facility failed to ensure one of 30 sampled patients (Patient 20), who was at risk for suicide (a mental state in which it is likely that a person will try to end their own life), was monitored every 15 minutes, in accordance with the facility's policy and procedure regarding rounding (visit patients to assess their needs, review their care, and ensure safety) on and monitoring patients.

This deficient practice had the potential to result in an unsafe care due to lack of purposeful rounding, which may lead to Patient 20 harming self that could cause injury and/or death. (Refer to A-0144)

3. The facility failed to ensure one of 30 sampled patients (Patient 3) was free from abuse (the improper treatment of a person), when Patient 3 was physically assaulted (when someone physically attacks another person causing bodily harm) by facility staff.

This deficient practice resulted in Security Officer 1 (SO 1) punching Patient 3 in the face ten times and Patient 3 suffering a head laceration (a deep cut or tear in skin or flesh) above the left eye. (Refer to A-0145)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

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

1. Ensure the staff removed a ligature (a thing used for tying) risk item for one of 30 sampled patients (Patient 9) accordance with the facility's policy and procedure regarding contrabands (any item that is prohibited or could be dangerous to patients, staff or visitors. Example: Belts and shoelaces), when Patient 9 was allowed to wear a sweater with a drawstring in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders).

This deficient practice resulted in putting Patient 9 and other patients in an unsafe environment when the drawstring (considered as a contraband) could be used to harm self or others.

2. Ensure one of 30 sampled patients (Patient 20), who was at risk for suicide (a mental state in which it is likely that a person will try to end their own life), was monitored every 15 minutes, in accordance with the facility's policy and procedure regarding rounding (visit patients to assess their needs, review their care, and ensure safety) on and monitoring patients.

This deficient practice had the potential to result in an unsafe care due to lack of purposeful rounding, which may lead to Patient 20 harming self that could cause injury and/or death.

Findings:

1. During a review of Patient 9's "Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated 10/24/2024, the Psych Eval indicated, Patient 9 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] evaluation and treatment) due to being gravely disabled (inability to care self) with admitting diagnosis of paranoid schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). The Psych Eval also indicated Patient 9 had auditory (hearing) hallucinations (when someone hears voices or noises that don't exist in reality) of evil voices commanding her (Patient 9) to kill someone.

During a concurrent observation and interview on 10/30/2024 at 9:07 a.m. with the Charge Nurse (CN) 4 of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) in Patient 9's room, Patient 9 was observed lying in bed wearing a white sweater. There was a drawstring on the hood of Patient 9's white sweater. CN 4 stated Patient 9 should not have any clothing with drawstring in it because it was dangerous. CN 4 stated drawstring was not allowed in the BHU because it would pose a ligature (a thing used for tying or binding tightly) risk on patients.

During a concurrent interview and record review on 10/30/2024 at 9:39 a.m. with the Registered Nurse (RN) 7, Patient 9's "Patient Valuables/ Belongings (belongings list, inventory of a patient's belongings brought to the hospital)," dated 10/24/2024, was reviewed. The belongings list indicated, "clothing description with white sweater, grey graphic tee, and cheetah pants." RN 7 stated staff would look for any drawstring or any items on patient's clothing upon admission that could possibly pose a risk for harm. RN 7 stated if there was drawstring on the clothing, the drawstring should be cut or removed from the unit and kept in the contraband room. RN 7 stated, "Drawstring was a definite 'No' on the floor because of the ligature risk."

During an interview on 11/1/2024 at 9:35 a.m. with the Nurse Manager (NM) 1 of Behavioral Health Unit, NM 1 stated drawstring on clothing was considered as contraband (prohibited items) and it was a ligature risk because patients could use the drawstring to harm self or others.

During a review of the facility's policy and procedure (P&P) titled, "Identification and Securing of Contraband," dated 5/2021, the P&P indicated, "To preserve the safety of patients, employees and visitors of the hospital by identifying and preventing prohibited items (contraband) from entering the hospital facilities ... What to do with contraband: immediately dispose, place in personal vehicle of patient/visitor or place in [facility] locker. Identified contraband will not be allowed to be brought into the facility ... hanging risk (ropes, electrical wires ...string/rope/cord longer than eight inches)."

2. During a review of Patient 20's "Consultation Report," dated 10/29/2024, the report indicated Patient 20 was admitted to the facility with a diagnosis of Suicidal ideation (a mental state in which it is likely that a person will try to end their own life or feeling that people would be better off without them).

During a review of Patient 20's "Columbia-Suicide Severity Rating Scale (CSSRS, a suicidal ideation and behavior rating scale intended to help establish a person's immediate risk of suicide.)," dated 10/29/2024, Patient 20's CSSRS indicated Patient 20 had a low suicidal risk.

During an interview on 10/29/2024 at 2:06 p.m. with Charge Nurse 3 (CN 3), CN 3 stated the patients that were admitted in the Behavioral Health Unit (BHU, a specialize unit that provides services for people with mental health) would be monitored every 15 minutes. CN 3 said the Behavioral Health Worker (BHW) would do patient rounding (visit patients to assess their needs, review their care, and ensure safety) every 15 minutes and would document the patient's location and the patient's behavior observed during the patient rounding.

During an interview on 10/30/2024 at 9:09 a.m. with Mental Health Worker 1 (MHW 1 [also known as BHW]), MHW 1 stated, "Rounds (patient rounding) are every 15 minutes." MHW 1 stated they document the location and behavior of the patient. MHW 1 stated hazards (example: contrabands such as shoelaces, belts, etc.) in the room that could harm the patient were being checked too during the patient's rounding.

During a concurrent interview and record review on 10/31/2024 at 11:46 a.m. with Nurse Manager 1 (NM 1), NM 1 verified Patient 20 had a physician's order, dated 10/29/2024 at 4:33 pm, for 15 minutes rounding monitoring for suicide, harm to self.

During a concurrent interview and record review on 10/31/2024 at 11:55 a.m. with Nurse Manager 1 (NM 1), NM 1 verified Patient 20's "Individual Observation Record," had missed documentation of patient rounding every 15 minutes on the following dates and times:

-Patient 20 was monitored on 10/29/2024 at 5:02 p.m., the next monitoring was at 5:29 pm (a total of 27 minutes since Patient 20 was last seen);

-Patient 20 was monitored on 10/30/2024 at 12:00 a.m., the next monitoring was at 12:29 a.m. (a total of 29 minutes since Patient 20 was last seen);

-Patient 20 was monitored on 10/30/2024 at 5:31 a.m., the next monitoring was at 5:59 a.m. (a total of 28 minutes since Patient 20 was last seen);

-Patient 20 was monitored on 10/30/24 at 3:05 a.m., the next monitoring was at 3:29 a.m. (a total of 24 minutes since Patient 20 was last seen);

-Patient 20 was monitored on 10/30/2024 at 2:00 p.m., the next monitoring was at 2:28 p.m. (a total of 28 minutes since Patient 20 was last seen);

- Patient 20 was monitored on 10/31/2024 at 12:34 a.m., the next monitoring was at 12:59 a.m. (a total of 25 minutes since Patient 20 was last seen);

-Patient 20 was monitored on 10/31/2024 at 3:01 a.m., the next monitoring was at 3:29 a.m. (a total of 28 minutes since Patient 20 was last seen); and,

-Patient 20 was monitored on 10/31/2024 at 8:59 a.m., the next monitoring was at 9:29 a.m. (a total of 30 minutes since Patient 20 was last seen).

During the same interview on 10/31/2024 at 11:55 a.m. with Nurse Manager (NM) 1, NM 1 stated patient rounding every 15 minutes was important to monitor for patient safety. NM 1 stated, "Anything can happen in 15 minutes, patient can hurt the roommate, spontaneously die, make weapons ...It is important to check for patient's chest rise and fall, location, and demeanor." NM 1 said the BHW were responsible for doing the 15-minute patient rounding and documenting the rounds. NM 1 stated when a patient needs further intervention the RN would assess the patient.

During a review of the facility's policy and procedure (P&P) titled, "Rounding, Observation and Monitoring of Patients," dated 10/2021, the P&P indicated the following:

- "It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety."

- "The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient's whereabouts and ensure a safe environment."

- "Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes."

- "All patients on the BHU are at a minimum under standard observation."

Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled patients (Patient 3) was free from abuse (the improper treatment of a person), when Patient 3 was physically assaulted (when someone physically attacks another person causing bodily harm) by facility staff.

This deficient practice resulted in Security Officer 1 (SO 1) punching Patient 3 in the face ten times and Patient 3 suffering a head laceration (a deep cut or tear in skin or flesh) above the left eye.

On 10/31/2024 at 1:07 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Director of Performance Improvement and Quality Management (DPIQ), Associate Administrator (AA), the Chief Nursing Officer (CNO), and the Chief Executive Officer (CEO).

The facility was informed that facility nursing staff failed to ensure Patient 3 was free from abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when Security Officer 1 (SO 1) physically assaulted (physical attack that causes physical harm/injury) Patient 3. Patient 3 suffered a left eye laceration (post [after] assault) and had to be treated in the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries). SO 1 did not follow hospital policy, when Crisis Prevention and Intervention Program (CPI, strategies for de-escalating [reduce the intensity] violent, hostile [aggressive], or anxious [feeling of fear or uneasiness] behavior) techniques were not used to de-escalate Patient 3 who was agitated (a feeling of irritability or severe restlessness). Additionally, SO 1 did not have an active CPI Certification at the time of Patient 3's physical assault by SO 1, as required per hospital policy.

On 11/1/2024 at 6:05 p.m., the facility submitted an acceptable Immediate Jeopardy Removal Plan (IJRP, includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). The IJRP included the following:

1. Memorandum to all staff
A memorandum addressing the critical importance of maintaining Crisis Prevention and Intervention (CPI) certification for all staff. Any lapse in CPI certification will result in immediate suspension until recertification is completed. Directors have been instructed to monitor and verify the certification status of their team members to ensure compliance and minimize operational disruptions.

2. Suspension of all staff who have direct interaction with patients
Effective 11/01/2024, any staff member with an expired CPI certification will be placed on immediate suspension until they complete recertification. To facilitate this, additional CPI training session have been scheduled for the upcoming week alongside the regular scheduled CPI training sessions. These extra training sessions will ensure ample opportunity for all staff who needed recertification to fulfill this requirement.

3. Immediate Education on De-escalation Techniques
Education immediately commenced on 11/01/2024 for hospital staff. Education will continue daily for staff until all scheduled staff have been trained. The following topics were included in the training:

A. Behaviors that may indicate or pose a threat to the safety of staff, other patients and visitors include:
- Provocative behavior (intended to cause a reaction such as anger or annoyance)
- Angry demeanor
- Loud, aggressive speech
- Tense posturing (e.g., gripping arm rails tightly, clenching fists)
- Frequently changing body position, pacing
- Aggressive acts (e.g., pounding walls, throwing objects, hitting oneself)
- Staff should alert hospital security as soon as possible of anytime a patient starts to escalate or becomes violent.

B. De-escalation techniques include:
- Respect personal space-Maintain a distance of two arm's lengths and provide space for easy exit for either party.
- Do not be provocative - Keep your hands relaxed, maintain a non-confrontational body posture, and do not stare at the patient.
- Establish Verbal contact -The first person to contact the patient should be the leader.
- Speak slowly and calmly.
- Use concise, simple language - elaborate and technical terms are hard for an impaired person to understand.
- Identify feelings and desires -"What are you hoping for?"
- Listen closely to what the patient is saying-After listening, restate what the patient said to improve mutual understanding (e.g., "tell me if I have this right ... ").
- Agree or agree to disagree -(a) agree with clear specific truths; (b) agree in general: "Yes, everyone should be treated respectfully"; (c) agree with minority situations: "There are others who would feel like you."

C. If the patient is assaultive and presenting a physical danger, do not fight the patient and seek safe shelter. Immediately call for help (code grey) or by yelling for staff and/or dialing 3111. When a safe number of staff are present and if less restrictive means are ineffective (verbal de-escalation), as decided by the lead RN, or physician, staff will swarm the patient and each will work to restrain (to limit the movement of a patient to keep them safe or prevent them from harming others) the patient utilizing CPI techniques.

On 11/1/2024 at 9:44 p.m., the IJ was removed, in the presence of the DPIQ, the AA, and the CNO, after the elements of the IJRP were verified onsite, by the survey team, through observation, interviews and record reviews.

Findings:

During a review of Patient 3's Face Sheet, dated 8/12/2024, the Face Sheet indicated Patient 3 was Registered to the facility (Campus 1) Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries), on 8/12/2024 at 2:00 a.m., with a chief complaint of psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not).

During an observation and interview on 10/29/2024 at 3:21 p.m. with the Security Officer 3 (SO 3). The SO 3 was observed by the entrance of the Emergency Department (Campus 1) entrance. The SO 3 stated he (SO 3) was employed by the facility for 3 months and he (SO 3) did not receive Crisis Prevention Intervention (CPI, a non-violent training program that teaches how to identify, prevent, and respond to crises) training.

During a concurrent interview and record review on 10/29/2024 at 3:30 p.m. with the Security Officer 2 (SO 2), the SO 2 stated the following: If a patient was agitated (a state of severe restlessness or uneasiness) or aggressive (ready or likely to attack or confront), CPI techniques should be used to de-escalate (reduce the intensity of (a conflict or potentially violent situation) the patient. He (SO 2) was due for a new CPI training. SO 2 verified his (SO 2) CPI card was expired and that the expiration date listed on the CPI card was 2/15/2024.

During an interview on 10/29/2024 at 4:05 p.m. with the Security Manager (SM), the SM stated the following: Security Officer staff were required to have CPI training within 60 days of hire, or they were unable to work. If a patient was aggressive, the security staff should not take the patient down [to the floor], they should only physically intervene if facility staff called for back-up assistance. Security should never physically assault a patient. It was important for staff to be CPI trained to understand proper use of de-escalation techniques and restraints (direct physical contact that prevents or significantly restricts someone's freedom of movement) when dealing with aggressive or combative (ready or eager to fight) patients. All security staff were required to have CPI training. Security staff must maintain current CPI certification and renew CPI annually.

During a review of facility (Campus 1) video footage (no audio) on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement Quality Management (DPIQ), the DPIQ verified the following on the video footage:

At 2:56 a.m. Patient 3 walked into the hallway where Security Officer 1 (SO 1) was posted. No other staff or persons were present. Patient 3 exited the facility doors and entered again and began walking the hallway past SO 1.

- At 2:57 a.m., Patient 3 started touching the wall. SO 1 approached Patient 3 and there was a verbal interaction. SO 1 walked with Patient 3 to a corner and Patient 3 was no longer observed on camera. SO 1 followed Patient 3 to the corner and performed multiple kicking motions towards Patient 3's direction.

- At 2:58 a.m., SO 1 and Patient 3 were visibly arguing face to face, less than one arm's length away. SO 1 pushed Patient 3 away using his (SO 1's) arm. Patient 3 punched SO 1 and there was a physical altercation where SO 1 wrestled (grabbed and pushed using body weight and slammed to the ground) Patient 3 to the ground. SO 1 punched Patient 3 in the face multiple times (using blunt force with SO 1's right first), while Patient 3 was on the floor with SO 1 restraining him (Patient 3) by placing his (SO 1's) body weight on Patient 3. There was blood on the floor.

- At 2:59 a.m., Patient 3 remained restrained on the floor by SO 1, with SO 1's knee on patient 3's lower body and arm on Patient 3's upper body. SO 1 removed hand cuffs from pocket to apply to Patient 3.

During an interview on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement and Quality Management (DPIQ), the DPIQ stated the following: The physical altercation between SO 1 and Patient 3 occurred 8/12/2024 in the facility's new Emergency Department (ED) that was still under construction at the time. SO 1 was working in the new ED at the entrance. Patient 3 tried to rip off the construction barrier on the wall. Patient 3 was agitated and got into a verbal altercation (a verbal argument) with SO 1, then Patient 3 spat at SO 1. SO 1 and Patient 3 got into a physical altercation. The DPIQ validated the punching by SO1 on Patient 3 and that the verbal interactions on facility video between SO 1 and Patient 3 appeared to be an argument prior to the physical altercation.

During an interview on 10/30/2024 at 2:11 p.m. with the Security Manager (SM), the SM stated the following: On 8/12/2024, SO 1 and Patient 3 were involved in a physical altercation. Patient 3 was agitated, pulling things off the wall and SO 1 intervened aggressively. SO 1 started kicking Patient 3. Patient 3 was in SO 1's face and punched him (SO 1). SO 1 tackled Patient 3 to the ground then punched him (Patient 3) multiple times in the face. SO 1 was at fault for the physical altercation (a confrontation, tussle or physical aggression that may or may not result in injury) and physically assaulting Patient 3.
SO 1 did not follow CPI guidelines. SO 1 should have made attempts to deescalate Patient 3. SO 1 should not have placed Patient 3 in handcuffs, this is not CPI protocol. SO 1 should have called for back-up on the radio (provided to all security staff) or called a code gray (a hospital emergency response that indicates a dangerous or combative person in the hospital, or criminal activity), when Patient 1 was agitated and combative. It was staff to patient abuse when SO 1 tackled Patient 3 to the floor and punched him (Patient 3) in the face. Following the facility investigation which started 8/12/2024, SO 1 was suspended at the start of the next shift at 3:30pm. SO 1 did not return to work and was terminated for not utilizing proper CPI techniques, when SO 1 did not de-escalate Patient 3 and physically abused Patient 3.

During a concurrent interview and record review on 10/30/2024 at 5:21 p.m. with the DPIQ, the DPIQ verified the following: SO 1's CPI card expired 7/5/2023. SO 2's CPI card expired 2/15/2024 and renewed 10/30/2024 (after the survey team identified SO 2 was working without CPI training on 10/29/24). SO 3 was a new hire (hired 7/1/2024) working without CPI training on 10/29/24. The DPIQ stated the following: CPI for security staff should be completed within 60 days of hire and maintained per policy. SO 1 was a Lead Security Officer. There was no CPI policy. The DPIQ provided a booklet titled "Crisis Prevention Institute: Non-violent Crisis Intervention Training."

During a review of Patient 3's "Emergency Documentation," dated 8/12/2024 at 3:21 a.m., the document indicated: "patient (Patient 3) was having auditory hallucinations (when someone hears voices or noises that don't exist in reality) ...unwitnessed altercation but patient (3) has laceration above left eye ... [SO 1] placed patient (3) in cuffs ..."

During a review of the document provided by the facility titled, "Position description: Security Officer," no date, the document indicated the following: " ...Qualifications: Must complete CPI within 60 days of hire ..."

During a review of the document provided by the facility titled, "Position description: Lead Security Officer," no date, the document indicated the following: " ...Qualifications: Must complete CPI within 60 days of hire ..."

During a review of the booklet provided by the facility titled "Crisis Prevention Institute: Non-violent Crisis Intervention Training," no date, the booklet indicated the following: "Manage your own emotional responses to distress behavior; Use the Decision Making Matrix in the moment of Risk Behavior to determine Safety Interventions that represent a reasonable, proportionate, least restrictive, and last resort course of action; Use safety intervention strategies to maximize safety and minimize harm to self or others ..."

During a review of the facility's policy and procedure (P&P) titled, "Management of Violent Patients," dated 5/2022, the P&P indicated the following: " ...IV. Procedure: A. Utilizing current Assault Prevention Techniques/Training, any or all of the following measures may be taken: ...b. Conditions which may lead to violence: ...vi. Psychiatric Disorders (a mental illness that involves significant changes in a person's thoughts, emotions, or behaviors that are difficult to control) ... 2. a. ...vii. Staff should alert hospital security as soon as possible of anytime a patient starts to escalate (becomes more intense or serious) or becomes violent. b. Patients who are agitated but cooperative may be amendable to verbal de-escalation techniques: i. Respect personal space- Maintain a distance of two arm's lengths and provide personal space for easy exit for either party; ii. Do not be provocative- Keep your hands relaxed, maintain a non-confrontational body posture, and do not stare at the patient ..."

During a review of the facility's policy and procedures (P&P) titled, "Assaultive Behavior," dated 10/2021, the P&P indicated the following: " ...D. A patient who strikes at or actually strikes another person, including patients, visitors or staff, will be assessed for seclusion and/or restraints. A Code Gray (a hospital emergency response that indicates a dangerous or combative person in the hospital, or criminal activity) must be called, to secure additional assistance, if needed ..."

During a review of the facility's policy and procedures (P&P) titled, "Code Gray ," dated 10/2021, the P&P indicated the following: " ...A. In the event of a psychiatric emergency (defined as an aggressive patient who does not respond to verbal limits and/or is posing a safety risk) the charge nurse will be alerted. She/he will make the determination whether a Code Gray is to be paged ..."
During a review of the facility's policy and procedures (P&P) titled, "Employee File Requirements," dated 11/2022, the P&P indicated the following: " ...All staff whose job description requires Crisis Prevention and Intervention (CPI) must complete the recertification training no later than the end of the month in which it expires. New hires have 60 days from the date of hire to complete the training ..."

Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Quality Assurance and Performance Improvement (QAPI) as evidenced by:

1. The facility's Quality Assurance and Performance Improvement (QAPI, a data driven and proactive approach to quality care) Committee failed to
ensure that an adverse event (an undesirable or harmful outcome) involving one of 30 sampled patients (Patient 1), was analyzed to determine the cause of the event and then develop and implement preventive actions to ensure patient safety and prevent re-occurrence, in accordance with the facility's policy and procedure regarding Organizational Performance Improvement Plan. Patient 1 received delayed intervention for a head bleed with a decline in condition (after an unwitnessed fall) which included symptoms of lethargy (a symptom that involves an unusual decrease in consciousness), confusion, eyes not opening to painful stimuli, all of which were not reported by nursing staff to the physician.

This deficient practice had the potential to result in life-threatening situations and jeopardize patients' safety, which may lead to death, when the events that led to Patient 1's delayed care are not analyzed for the causes, and preventive actions to prevent re-occurrence of the same incident involving a decline in patient's condition, are not properly addressed. (Refer to A-0286)

2. The facility's Quality Assurance and Performance Improvement (QAPI, a data driven and proactive approach to quality care) Committee failed to keep track of its abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) reports record made to the regulatory agency, when one of 30 sampled patient's (Patient 7) report of an alleged physical abuse for being hit 15 times by two staff on 4/7/2017, was not available for review.

This deficient practice had the potential for the facility not being able to identify abuse patterns, intervene early to protect potential victims, and develop prevention strategies to improve patient care. This deficient practice also had the potential to result in putting the facility non-compliant with mandatory reporting requirement of State and Federal regulatory agency and delay the investigation process by State regulatory agency. (Refer to A-0286)

3. The facility failed to ensure 10 out of 28 policy and procedure (P&P) sampled, were reviewed and addressed by Quality Assurance Performance Improvement (QAPI, a data-driven and proactive approach to quality improvement program) Committee, to ensure these P&Ps were not outdated and that P&Ps were reviewed by the facility's governing body every three years.

This deficient practice had the potential for inconsistent practices, non-compliance with laws and regulations, and patient harm due to outdated policies that might not reflect up to date best practices. (Refer to A-0309)

The cumulative effect of these deficient practices resulted in the facility's inability to deliver quality health care in a safe environment.

Based on observation, interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI, a data driven and proactive approach to quality care) Committee failed to:

1. Ensure that an adverse event (an undesirable or harmful outcome) involving one of 30 sampled patients (Patient 1), was analyzed to determine the cause of the event and then develop and implement preventive actions to ensure patient safety and prevent re-occurrence, in accordance with the facility's policy and procedure regarding Organizational Performance Improvement Plan. Patient 1 received delayed intervention for a head bleed with a decline in condition (after an unwitnessed fall) which included symptoms of lethargy (a symptom that involves an unusual decrease in consciousness), confusion, eyes not opening to painful stimuli, all of which were not reported by nursing staff to the physician.

This deficient practice had the potential to result in life-threatening situations and jeopardize patients' safety, which may lead to death, when the events that led to Patient 1's delayed care were not analyzed for the causes and preventive actions to prevent re-occurrence of the same incident involving a decline in patient's condition were not properly addressed.

2. Keep track of its abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) reports record made to the regulatory agency, when one of 30 sampled patient's (Patient 7) report of an alleged physical abuse for being hit 15 times by two staff on 4/7/2017, was not available for review.

This deficient practice had the potential for the facility not being able to identify abuse patterns, intervene early to protect potential victims, and develop prevention strategies to improve patient care. This deficient practice also had the potential to result in putting the facility non-compliant with mandatory reporting requirement of state regulatory agency and delay the investigation process by state regulatory agency.

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/30/2024, the "H&P" indicated, Patient 1, "presenting from skilled nursing facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care and rehabilitation services to patients) secondary to anemia (a condition marked by a deficiency of red blood cells [transports oxygen and nutrients throughout the body]) with a history of hyponatremia (low sodium [essential nutrient for body fluids] level in the blood) otherwise asymptomatic (showing no symptoms) alert awake (a state of active attention characterized by high sensory awareness) denies any chest pain, no emesis (vomiting), diarrhea (loose stools) ..."

During a concurrent interview and record review on 10/29/2024 at 3:59 p.m. with the Director of Medical Surgical (DMS), Patient 1's "Progress Notes (the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during treatment)," dated 5/2/2024, was reviewed. The progress note indicated on 5/2/2024 at 10:13 a.m., Certified Nursing Attendant (CNA, an entry-level role that provides vital support to both patients and nurses) 1 "reports finding pt (Patient 1) sitting on the floor leaning against the wall, disoriented (having lost one's sense of time, place, or identity) to situation... Pt (Patient 1) reports losing balance and falling towards the wall onto a sitting position."

During a concurrent interview and record review on 10/29/2024 at 4:30 p.m. with the DMS, Patient 1's "Progress Notes," dated 5/3/2024 at 8:00 a.m., was reviewed. The progress notes indicate Patient 1 was "drowsy and lethargic (a symptom that involves an unusual decrease in consciousness); eyes are not open to pain, but pt (Patient 1) is grunting (to make a short, low sound instead of speaking) and moving hands to sternal rub (a technique to test an unconscious person's responsiveness)."
The DMS verified that there was no progress note by any physician that Patient 1 was assessed for a change in condition (drowsy and lethargic, eyes do not open to pain) until 5/3/2024 at 10:59 p.m., when a progress note by MD 1, date of service/time was 5/3/2024 at 10:59 p.m. indicated, "24 hour event: rapid response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to immediately assess and treat the patient) was called on the patient (Patient 1) at approximately 6 p.m. neurologically (the branch of medicine that deals with problems affecting the brain) twitching in all extremities was noted and neurology was called."

During a review of Patient 1's Computed Tomography (CT scan, a medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body's internal structures) scan, dated 5/3/2024 at 6:31 p.m., CT scan results indicated, Patient 1 had "Large acute (sudden and severe in onset) right frontoparietal (area of the front and near the upper back area in the skull) subdural hematoma (a buildup of blood on the surface of the brain) measuring about 2 cm (centimeter, a unit of measurement) in maximum thickness. Extensive edema (swelling caused by too much fluid trapped), mass effect and shift (a shift in the midline is when the natural centerline of the brain is pushed to the right or left due to fluid buildup) of the midline (line that divide the brain evenly in two) to the right-side measuring about 10 mm (millimeter, a unit of measurement)."

During an interview and record review with the DMS on 10/29/2024 at 4:55 p.m. Patient 1's "Neurological Assessment," was reviewed. DMS verified that Patient 1 had a condition change. The DMS stated, "The nurse (RN 1) should have notified the doctor and monitored the patient (Patient 1) more frequently than every 4 hours."

During a concurrent interview and record review on 10/29/2024 at 4:45 p.m. with the DMS, Patient 1's "flow sheet (track patient health data over a period of time)," for vitals dated from 5/3/2024 at 8:00 a.m., at 12:00 p.m., and at 7:15 p.m., was reviewed. Patient 1's vital signs were as follows:

On 5/3/2024 at 8:00 a.m., Patient's 1 blood pressure (BP, measures the blood pushing against the blood vessel walls when the heart beats) was elevated, 179/92. The blood pressure was not addressed. DMS confirmed that PRN (as needed) Hydralazine (prescribed medication used to treat high blood pressure) that was prescribed to be administered if the systolic BP (the first number in measurement of the pressure the blood pressure) was over 160s, was not given.

The DMS verified that the BP was not reassessed until (4 hours later) at 12:00 p.m., when the systolic BP continued to be elevated at 160. The DMS confirmed that the elevated BP was also not addressed at 12:00 p.m. On 5/3/2024 at 7:15 p.m., Patient 1's BP increased to 205/100.

During an interview and record review with the DMS on 10/29/2024 at 5:00 p.m., Patient 1's "Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient) Team Assessment" report indicated a rapid response started at 6:13 p.m. on 5/3/2024. The report indicated, Patient 1 was lethargic (a symptom that involves an unusual decrease in consciousness) and with AMS (altered mental status, a change in mental function), CT scan was ordered and confirmed subdural hematoma (a type of bleeding near the brain that can happen after a head injury)." Patient 1 had to be intubated (placing a tube into the patient windpipe to aid in breathing).

During an interview on 10/30/2024 at 9:56 a.m. with Registered Nurse (RN, nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 1, RN 1 stated, on 5/2/2024 at 8:00 a.m., CNA 1 reported that she (CNA 1) found Patient 1 on the floor. RN 1 stated on 5/3/2024 he (RN 1) was precepting (provides supervision during clinical practice) for RN 2. RN 1 stated he (RN 1) was responsible to review RN 2' assessment of Patient 1 and sign off on documentation completed by RN 2. RN 1 further stated that on 5/3/2024 at 8:00 a.m., Patient 1 required a sternal rub (a technique to test an unconscious person's responsiveness). RN 1 stated a sternal rub was done to apply some pain to see if the patient (Patient 1) will respond. RN 1 confirmed that he (RN 1) was not able to get Patient 1 to respond verbally, Patient 1 was grunting (to make a short, low sound instead of speaking) and moving hands. RN 1 stated, "When patient has a condition change, the MD (physician) should have been notified, and a rapid response should be called immediately."

During an interview on 10/30/2024 at 9:56 a.m. with Registered Nurse (RN) 2, RN 2 stated, "In the (Medical Surgical) unit, the CNA would take patients' blood pressure, and the RN will review the BP within an hour." RN 2 stated when a blood pressure is abnormal, the CNA will inform the RN immediately. RN 2 stated, "I do not recall if the CNA (CNA 1) notified of Patient 1's blood pressure of 179."

During a concurrent interview and record review on 10/30/2024 at 4:00 p.m. with the Director of Medical Surgical (DMS), Patient 1's "Assessment" flowsheet (track patient health data over a period of time), was reviewed. The flowsheet indicated Patient 1 was identified on the Morse Scores (Assessment tool that predicts the likelihood that a patient will fall (an unplanned change in position where a patient lands on the floor or another lower surface): ranging from 0-24 indicate no risk, 25-50 indicate low risk and higher than 50 indicate high risk) at 50 which was high fall risk. DMS stated the individualized fall prevention for Patient 1 was "the bed was in low position, wheels (bed) are locked, and the patient (Patient 1) was restrained." After reviewing with DMS purpose of restraint in the hospital setting, DMS stated, "the patient (Patient 1) was also on hourly rounding."

During a concurrent interview and record review on 10/30/2024 at 4:15 p.m. with the Director of Medical Surgical (DMS), Patient 1's electronic medical record titled, "Hourly Rounding (purposeful rounding by staff with the goal to protect patients and promote patient safety on the 4 P's: Pain, Potty, Positioning, and possessions)," was reviewed. The Hourly Rounding form indicated, "Rounding every hour from 6 a.m. - 10 p.m. and rounding every two hours from 10 p.m. -6 a.m." The form had staff's initials hourly and every two hours for night shift (10 p.m. -6 a.m.) on 4/30/2024 and 5/1/2024, but on 5/2/2024 (date that Patient 1 fell), the form was left blank. The form had Patient 1's identification labeled with date of birth, medical record number, physician name and other identification numbers. DMS stated although she (DMS) did not see a deficiency in practice that staff did not complete hourly rounding on 5/2/2024, which was the date that Patient 1 fell, DMS stated staff should have signed the form and initiated a fall care plan (provides a framework for evaluating and providing patient care needs related to the nursing process). DMS further stated the purpose of hourly rounding was to "make sure that staff are going in the room and checking on patients."

During an interview on 11/1/2024 at 11:39 a.m. with Director of Performance Improvement/Risk Manager (DPIQ), DPIQ validate that although the facility's Medical Surgical (provides caring, to all patients for illness, surgery or testing and observation) and telemetry (patients undergo continuous heart monitor) unit are implementing the hourly rounding process, DPIQ stated "there is no policy or procedure regarding hourly rounding process because this is something that nursing established." DPIQ further stated, the Quality Assurance Performance department does not know who or when the "Hourly Rounding" process was established.

During a concurrent interview and record review on 11/1/2024 at 4:00 p.m. with Director of Performance Improvement/Risk Manager (DPIQ), the facility's "Quality Council" minutes, dated 6/18/2024, was reviewed. The minutes indicated the presentation was regarding cases that were reported to the California Department of Public Health (CDPH). The first case was in regard to Patient 1's fall. The minutes indicated, "Patient fall resulted hematoma (a collection of blood within the skull) and transferred out for higher level of care (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which the patient originates). All appropriate documentation was provided to the surveyor. We do not foresee any issues. We identified an issue internally with the care plan and will look into that." There was no corrective plan documented in the Quality Council minutes. DPIQ stated after the investigation was completed there was identification of a need for rounding. DPIQ confirmed that there was no corrective plan presented in the Quality Council meeting.

During a review of the facility's policy and procedure (P&P) titled, "Organizational Performance Improvement Plan," dated April 2024, the P&P indicated, "The purpose of the Organizational Performance Improvement Plan at (name of the facility) is to ensure that the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk ...Organizational Goals of Performance Improvement: The primary goal of the Organizational Performance Improvement Plan is to continually and systematically plan, design, measure, assess and improve performance of hospital wide key functions and processes relative to patient care; and to improve healthcare outcomes while reducing and preventing medical/health care errors. To achieve this goal, the plan strives to ...The status of identified problems and action plans is tracked to assure improvement or problem resolution at the department and organization levels. Information from departments/services and the findings of discrete performance improvement activities and adverse patient events are used to detect trends, patterns of performance or potential problems that affect more than one department/service ... Important key aspects of care to the health and safety of patients are identified. Included are those that ...place patients at risk of serious consequences of deprivation of substantial benefit if care is not provided correctly or not provided when indicated; or care provided is not indicated, or those tending to produce problems for patients, their families or staff ... The following methodology known as the FOCUS-PDCA approach to performance improvement is utilized by (name of the facility) to find, organize, clarify, understand and select the process for improvement - to Plan, Do, Check and Act."

2. During a review of Patient 7's Face sheet (face sheet, document provides patient's demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance), undated, the face sheet indicated, "Patient 7 was admitted to the facility on 4/4/2017 with chief complaint of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration)."

During a review of Patient 7's Progress Notes Non-Physicians (nursing progress notes), dated 4/7/2017, the nursing progress notes indicated, "in the morning, patient (Patient 7) came to nurse's station stating he (Patient 7) wants to file a report. He (Patient 7) stated, 'staff jumped me (Patient 7) last night!' he (Patient 7) said he (Patient 7) was hit 15 times by two staff. Red spatter found on mattress and wall. Patient (Patient 7) has redness on left side of head and swelling left orbit (bony cavity that contains the eye)." The nursing progress notes also indicated physician was notified after Patient 7's report.

During a concurrent interview and record review on 11/1/2024 at 4:53 p.m. with the Director (DBHU) of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders), Mental Health Worker (MHW) 6's "Employee Warning Notice (disciplinary record, facility's disciplinary record with its employee)," dated 4/7/2017, was reviewed. The disciplinary record indicated, MHW 6 was placed on suspension on 4/7/2017 due to alleged abuse report. DBHU stated it was the facility's process to put the staff on investigatory suspension when the staff was involved in an alleged abuse until investigation was over.

During an interview on 11/1/2024 at 5:09 p.m. with the Director (DBHU) of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders), DBHU stated the following: from facility's internal investigation, Patient 7 had aggressive behavior despite staff attempt to de-escalate (reduce the intensity of a conflict or potentially violent situation). Three Mental Health Workers (MHW 6, 7, and 8) had to use hands on per Crisis Prevention Institute (CPI, a program that teaches people how to prevent and respond to crises) protocol to restrain (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) Patient 7 on his (Patient 7's) bed. Patient 7's nurse was called in to talk to Patient 7. DBHU stated that Patient 7's nurse should have performed assessment on Patient 7 after the assaultive behavior (violent behavior that could cause physical harm) for any injury. Patient 7's nurse should have notified the physician about the incident for any further instruction. DBHU stated Patient 7's nurse did not document the incident, assessment or notification to Patient 7's physician. Patient 7 was found with injury at left side of head and swelling at left eye next morning by following shift nurse.

During an interview on 11/1/2024 at 5:15 p.m. with DBHU, DBHU stated any alleged abuse case would be reported to Quality Department which will handle the reporting to state regulatory agency. DBHU stated she (DBHU) did not know if reporting to the state regulatory agency was done for Patient 7.

During an interview on 11/1/2024 at 8:35 p.m. with the Director of Performance Improvement Quality Management (DPIQ), DPIQ stated the facility should report all alleged physical abuse to state regulatory agency. DPIQ stated she (DPIQ) did not know if Patient 7's alleged abuse case was ever reported to the state regulatory agency since it was in 2017.

During a review of the facility's policy and procedure titled, "Mandated Adverse Event Reporting to the [state] Department of Public Health," dated 12/2023, the P&P indicated, "to comply with the mandated reporting requirements of [state] Health and Safety Code 1279.1(b) and to support the improvement of patient safety and quality improvement initiatives ... it shall be the policy of the organization to report an adverse event ... to the [state] department of Public Health no later than five days after the event has been detected ... an adverse event as defined under the Code includes any of the following ... criminal events including the following ... the death or significant injury of a patient or staff member resulting from a physical assault that occurs within or on the grounds ... it will be the responsibility of the Quality Management Department to develop and submit the report to [state] department of Public Health, as well as serve as liaison with [state] department of Public Health during the subsequent investigation process."

Based on interview and record review, the facility failed to ensure 10 out of 28 policy and procedure (P&P) sampled, were reviewed and addressed by Quality Assurance Performance Improvement (QAPI, a data-driven and proactive approach to quality improvement program) Committee, to ensure these P&Ps were not outdated and that P&Ps were reviewed by the facility's governing body every three years.

This deficient practice had the potential for inconsistent practices, non-compliance with laws and regulations, and patient harm due to outdated policies that might not reflect up to date best practices.

Findings:

During a concurrent interview and record review on 11/1/2024 at 5:07 p.m. with the Performance Improvement /Associate Administrator (AA), the facility's policy and procedures (10 outdated P&Ps), were reviewed. AA stated, "P&Ps should be reviewed every three years by governing body." The P&Ps that were reviewed and were validated to be outdated by AA were the following:

- Facility's policy and procedures (P&P) titled, "Skin Assessment," dated 11/2020, the P&P indicated the policy was last reviewed 11/2020.

- Facility's policy and procedures (P&P) titled, "Patient Valuables and Belongings," dated 8/2020, the P&P indicated the policy was last reviewed 8/2020.

- Facility's policy and procedures (P&P) titled, "Identification and Securing of Contraband (any item that is prohibited or could be dangerous to patients, staff or visitors)," dated 5/2021, the P&P indicated the policy was last reviewed 5/2021.

- Facility's policy and procedures (P&P) titled, "Rounding (visit patients to assess their needs, review their care, and ensure safety), Observation and Monitoring of Patients," dated 5/2021, the P&P indicated the policy was last reviewed 10/2021.

- Facility's policy and procedures (P&P) titled, "Medical Screening Examinations (MSE, the initial exam performed when a patient presents to a dedicated emergency department and requests care)," dated 2/2020, the P&P indicated the policy was last reviewed 2/2020.

- Facility's policy and procedures (P&P) titled, "Psychiatric Evaluation (a clinical assessment of a person's mental health)/Medical Clearance (the process of evaluating someone's health condition to determine if they are fit for a specific activity or procedure) of Emergency Department (ED) patients," dated 6/2020, the P&P indicated the policy was last reviewed 6/2020.

- Facility's policy and procedures (P&P) titled, "Patient Right to Refuse Care," dated 4/2018, the P&P indicated the policy was last reviewed 4/2018.

- Facility's policy and procedures (P&P) titled, "Emergency Department: Standards of Care Procedures," dated 10/2020, the P&P indicated the policy was last reviewed 10/2020.

- Facility's policy and procedures (P&P) titled, "Standards of Practice and Care," dated 6/2020, the P&P indicated the policy was last reviewed 6/2020.

- Facility's policy and procedures (P&P) titled, "Transportation of the ED Patient," dated 5/2021, the P&P indicated the policy was last reviewed 5/2021.

During a review of the facility's policy and procedure (P&P) titled, "Governing Board," dated September 2023, the P&P indicated, "Governing Board -Responsibilities: Establishing mechanisms designed to ensure adherence to relevant statutory and regulatory requirements. Formulating, periodically reviewing, revising, and approving key policies in collaboration with organizational leaders.
a. Policies will be reviewed and approved within established time frames.
b. The Board will require collaboration among organizational leaders in establishment and/or revision of such policies."

Based on observation, interview and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by:

1. The facility failed to ensure one of 30 sampled Patients (Patient 1), Patient 1's decline in condition, becoming lethargic (a symptom that involves an unusual decrease in consciousness) and unresponsive to pain (the patient does not respond spontaneously) with abnormal changes in the vital signs (increased blood pressure, when the force of blood flowing through the blood vessels continues to be higher than 130/80 mm Hg, millimeters of mercury, a unit of measurement), after sustaining an unwitnessed fall (an unplanned change in position where a patient lands on the floor or a lower surface) the day before, was communicated in a timely manner to the physicians, in accordance with the facility's policy and procedure regarding assessment and physician notification.

This deficient practice resulted in delayed intervention for Patient 1's brain bleed and resulted in a call for Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest [heart stop], or death). This deficient practice also resulted in Patient 1 intubation (surgically inserting a tube into the patient's windpipe to aid in breathing) and being transferred to the intensive care unit (ICU, for critically ill or injured patients that is staffed by specially trained medical personnel) in the same facility, and then being transferred out to a higher level of care (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which a patient originates) facility for surgery. (Refer to A-0395)

2. The facility failed to ensure for two of 30 sampled patients (Patients 25 and 28), the following:

2.a. Patient 25's pressure injury (PI, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the right and left buttock had a wound care treatment order and wound care treatment provided, in accordance with the facility's policy and procedure.

This deficient practice resulted in Patient 25's delayed treatment which may result in Patient 25's PI to deteriorate and for the patient to suffer from pain and wound infection. (Refer to A-0395)

2.b. Patient 28's high blood pressure (BP, amount of force blood uses to move through the body, with a normal range less than 120/80 mmHg]) readings were not communicated to the physician in accordance with the facility's policy and procedure regarding physician notification.

This deficient practice had the potential to cause a delay in determining Patient 28's change of condition and/or a delay in the provision of emergent treatment needed which could worsen Patient 28's condition that may result in complications such as stroke (clot in the brain), and/or death. (Refer to A-0395)

3. The facility failed to ensure nursing staff develop and implement a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for high fall (an unplanned change in position where a patient lands on the floor or a lower surface) risk prevention and care for one of thirty (30) sampled patients (Patient 1), in accordance with the facility's policy and procedures regarding care plan development.

This deficient practice had the potential to result in Patient 1's treatment and care goals not being met by not identifying the patient's needs and risks for potential fall. (Refer to A-0396)

4. The facility failed to ensure one of 30 sampled patient's (Patients 16), individualized nursing care plans (provides a means of communication among health care providers) to address Patient 16's issues regarding Hypertension (high blood pressure) and Skin Impairment (damaged skin), was developed and implemented, in accordance with the facility's policy and procedure regarding care plan development.

This deficient practice had the potential to result in delayed provision of care to the patient by not identifying Patients 16's needs and risks. (Refer to A-0396)

5. The facility failed to notify the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) Physician (a person trained to treat life-threatening or limb-threatening illnesses or injuries) (Campus 1) that one of 30 sampled patients (Patient 3) had psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), a head injury (sustained after a fall [an unexpected descent to the floor or another lower surface with or without injury to the patient]), and was refusing medical care.

This deficient practice resulted in Patient 3 being discharged from the Emergency Department (ED), without being seen and cleared by an ED Physician for a possible head injury (post [after]-assault [when an individual inflicts physical contact that causes bodily harm and/or injury]) and without being evaluated for psychosis, which could have resulted in unresolved psychosis and complications from a brain bleed such as death. (Refer to A-0398)

6. The facility failed to ensure one of 30 sampled Patients (Patient 1), who was identified as high risk for fall, received "hourly rounding (purposeful rounding by staff with the goal to protect patients and promote patient safety on the 4 P's: Pain, Potty, Positioning, and possessions)," in accordance with the facility's procedure regarding rounding and monitoring of patients.

This deficient practice likely resulted in Patient 1's fall (an unexpected descent to the floor or onto another surface with or without injury to the patient) on 5/2/2024 at 10:15 a.m. and sustaining a head bleed, which required transfer to a high-level care (a hospital capable of providing diagnostic or interventional care beyond the capacity of the hospital from which a patient originates) facility for surgery. (Refer to A-0398)

7. The facility failed to ensure nursing staff assessed a patient and notified a physician in a timely manner, regarding an injury involving one of 30 sampled patients (Patient 7), after a hands-on protocol (using one or both hands to immobilize a patient) per Crisis Prevention Institute (CPI, a program that teaches people how to prevent and respond to crises) was used to restrain (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) Patient 7 to his (Patient 7) bed on 4/6/2017 (night shift).

This deficient practice resulted in delay of treatment and care as physician was contacted only the next morning when Patient 7 was found with redness on left side of head and swelling in the left orbit (the bony cavity of the skull that houses the left eye). (Refer to A-0398)

8. The facility failed to ensure nursing staff removed a ligature (a thing used for tying) risk item, in accordance with the facility's policy and procedure regarding contrabands (any item that is prohibited or could be dangerous to patients, staff or visitors. Example: Belts and shoelaces, etc.), for one of 30 sampled patients (Patient 9), when Patient 9 was allowed to wear a sweater with a drawstring in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders).

This deficient practice resulted in putting Patient 9 and other patients' safety at risk when the drawstring could be used as a ligature to harm self or others. (Refer to A-0398)

9. The facility failed to ensure for three of 30 sampled patients (Patients 25, 24, and 23), Patients 25, 24, and 23's nursing care provided by the Licensed Vocational Nurse (LVN, an entry level health care provider who is responsible for basic nursing care under the direction of a registered nurse) was supervised by the Registered Nurse (RN, a licensed professional responsible for providing patient care, education and support to the patient), in accordance with the facility's policy and procedure regarding RN oversight, when the LVNs' patient care documentation was not reviewed and verified by the RNs to indicate the care was completed, accurate, and provided under the RNs' supervision.

This deficient practice had the potential for Patients 25, 24, and 23 to receive incomplete and inaccurate care which may cause negative impact on the overall provision of care and may lead to patient harm and/or death. (Refer to A-0398)

10. The facility failed to ensure one of 30 sampled Patient's (Patient 1) PRN (as needed) medication, Hydralazine (prescribed medication used to treat high blood pressure) was administered as ordered by the physician and in accordance with the facility's policy and procedure regarding medication administration.

This deficient practice had the potential to result in worsening of Patient 1's condition with further increase in blood pressure that may result in complications such as seizure (abnormal electrical activity in the brain that can cause changes in behavior, movements, and levels of consciousness [describes a person's awareness and understanding of what is happening in their surroundings), stroke (a clot in the brain), and/or death. (A-0405)

11. The facility failed to ensure nursing staff performed safe medication administration for one of 30 sampled patients (Patient 10), in accordance to the facility's policy and procedure regarding medication administration, when a Licensed Vocational Nurse (LVN) 1 allowed Patient 10 walk away with two medication ointment in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders).

This deficient practice had the potential to result in Patient 10 not receiving prescribed medication correctly. This deficient practice may also cause additional complications such as Patient 10 swallowing it or giving the medication to other patients in BHU who might end up using the medications inappropriately. (Refer to A-0405)

12. The facility failed to ensure one of 30 sampled patient's (Patient 14) Valproic acid (also known as Depakene, medication used to treat seizure disorders (abnormal electrical activity in the brain that can cause changes in behavior, movements, and levels of consciousness [describes a person's awareness and understanding of what is happening in their surroundings], mental/mood conditions, and to prevent migraine headaches), was administered in accordance with the physician's order.

This deficient practice had the potential for Patient 14's behavioral condition such as agitation (a feeling of irritability and severe restlessness) to remain unresolved and may also lead to prolonged hospitalization. (Refer to A-0405)

The cumulative effect of these deficient practices resulted in the facility's inability to deliver quality health care in a safe environment.

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

1. Ensure one of 30 sampled Patients (Patient 1), Patient 1's decline in condition, becoming lethargic (a symptom that involves an unusual decrease in consciousness) and unresponsive to pain (the patient does not respond spontaneously) with abnormal changes in the vital signs (increased blood pressure, when the force of blood flowing through the blood vessels continues to be higher than 130/80 mm Hg, millimeters of mercury, a unit of measurement), after sustaining an unwitnessed fall (an unplanned change in position where a patient lands on the floor or a lower surface) the day before, was communicated in a timely manner to the physicians in compliance with the facility's policy and procedure regarding assessment and physician notification.

This deficient practice resulted in delayed intervention for Patient 1's brain bleed and resulted in a call for Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest [heart stop], or death). This deficient practice also resulted in Patient 1 intubation (surgically inserting a tube into the patient's windpipe to aid in breathing) and being transferred to the intensive care unit (ICU, for critically ill or injured patients that is staffed by specially trained medical personnel) in the same facility, and then being transferred out to a higher level of care (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which a patient originates) facility for surgery.

2. Ensure for two of 30 sampled patients (Patients 25 and 28), the following:

2.a. Patient 25's pressure injury (PI, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the right and left buttock had a wound care treatment order and wound care treatment provided in accordance with the facility's policy and procedure.

This deficient practice resulted in Patient 25's delayed treatment which may result in Patient 25's PI to deteriorate and for the patient to suffer from pain and wound infection.

2.b. Patient 28's high blood pressure (BP, amount of force blood uses to move through the body, with a normal range less than 120/80 mmHg]) readings were not communicated to the physician in accordance with the facility's policy and procedure regarding physician notification.

This deficient practice had the potential to cause a delay in determining Patient 28's change of condition and/or a delay in the provision of emergent treatment needed which could worsen Patient 28's condition that may result in complications such as stroke (clot in the brain), and/or death.

On 10/30/2024 at 5:21 p.m., the survey team called an immediate jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Performance Improvement Associate Administrator (AA), and the Director of Performance Improvement/Risk Manager (DPIQ).

The IJ was related to the facility's failure to ensure that Patient 1's decline in condition, such as becoming lethargic (a symptom that involves an unusual decrease in consciousness) and unresponsive to pain (the patient does not respond spontaneously) with abnormal changes in the vital signs (increased blood pressure, when the force of blood flowing through the blood vessels continues to be too high), after sustaining an unwitnessed fall the day before, was not communicated to the physicians in compliance with the facility's policy and procedure.

This failure resulted in delayed intervention for Patient 1's brain bleed and resulted in a call for Rapid Response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest [heart stops beating], or death). Also, resulted in Patient 1's intubation (surgically inserting a tube into the patient's windpipe to aid in breathing) and being transferred to the intensive care unit (ICU, for critically ill or injured patients that is staffed by specially trained medical personnel) in the same facility, and then being transferred out to a higher level of care (a hospital capable of providing diagnostic or interventional care beyond the capacity of the hospital from which the patient originates) facility for surgery.

On 11/1/2024 at 1:16 p.m., while onsite, the IJ was removed after verifying and confirming the facility's implementation of the IJ Removal Plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) through observation, interview, and record review, in the presence of the following facility members: Chief Nursing Officer (CNO), Performance Improvement Associate Administrator (AA), and the Director of Performance Improvement/Risk Manager (DPIQ).

The IJ Removal Plan included the following:

1. Multidisciplinary Leadership Team Meeting & Policy Updates
On 10/30/2024, the following leaders met to discuss the clinician notification process:
- Chief Executive Officer
- Chief Nursing Officer
- Associate Administrator
- Director of Medical/Surgical Services
- Quality Director.

During the meeting, it was identified there was a need to update two policies to provide staff with guidance on timely physician notification, documentation, and data required to ensure patient safety and prevent clinical deterioration (a sudden or serious worsening of a patient's condition).

Policy #1: Physician Notification
The below nursing education elements will be reflected in "Physician Notification"
A. The primary attending physician will immediately be notified of patient's change in condition.
B. Include details in your communication with the provider (e.g., vitals, symptoms observed, time the decline was observed, any relative context, etc.)

Policy #2: Documentation Patient Care Record
The below nursing education elements will be reflected in the "Documentation Patient Care Record."
A. Patients are immediately reassessed whenever a significant change in condition or in vital signs (blood pressure, heart rate, temperature, respiratory rate, or oxygen saturation) occurs outside the baseline for the patient.
B. When a significant change occurs, the attending physician shall be immediately contacted and notification documented along with any pertinent details (e.g., vitals, symptoms observed, time the decline observed, any relative context, etc.).

2. Nursing Education
Education was started for both night and day shift on the morning of 10/31/2024 to ensure staff have a comprehensive understanding of the updates. Education will continue daily for staff until all scheduled staff have been trained. The following have been used in the nursing education to ensure timely communication and intervention when necessary. Strict adherence is required to ensure patient safety and prevent clinical deterioration.

Physician Notification:
1. Identify a decline in patient clinical condition or abnormal vitals:
Monitor patients for any signs of clinical decline, such as changes in mental status, and significant changes in vital signs (blood pressure, heart rate, temperature, respiratory rate, or oxygen saturation) outside the baseline for the patient. Reassessment is required within 60 minutes and if vital signs remain significant further reassessments and level of care to be determined by the physician.

2. Notify the physician:
Immediately contact the physician responsible for the patient's care upon identifying any of the following:
- Deterioration in the patient's condition
- Abnormal vital signs
Include specific details in your communication:
- Vitals or symptoms observed.
- The time the decline or abnormality was noticed.
- Any relevant context (e.g., falls, recent procedures, etc.).
If the attending does not respond within 20 minutes by phone and the need is urgent, the staff will contact the following medical staff in the order listed below:
- Consulting physician listed in patient record
- Department medical director
- Chief Medical Officer
- Chief of staff
If at any time, the patient's status continues to decline, a rapid response protocol should be initiated.

Documentation Patient Care Record:
1. Document the licensed provider notification:
Record each notification in the patient's medical record, including:
- Time of notification: When you contacted the physician.
- Method (e.g., phone, in-person).
- Details of nursing assessment of patient condition (as stated above).
- Physician's response: Record the orders provided or the physician's response.
- Next steps: carry out physician orders and additional monitoring required.

3. Physician memorandum (memo) was created on 10/30/2024 and distributed to all medical staff members the following day. The memo references the hospital's Rules & Regulations Section 5.1, outlining the requirement for progress notes to accurately reflect providers' patient assessments. Additionally, the memo emphasizes that documentation must include the results of these assessments, noting any significant changes in patient condition or level of care. 4. EHR (Electronic Health Record) Cerner Standing Communication Order: Verify Change in Condition - Completed 11/01/2024A new standing communication order has been implemented for all new admissions, triggering a required task at 0500 and 1700. At these times, the required task will prompt nursing staff to verify whether there was a change in the patient's condition during the shift. If "yes" is selected, the physician notification form will automatically appear and will be required to be completed by the RN. In addition, an automatic report will generate daily showcasing whether or not the required task was completed. Moreover, this report will be sent to directors daily for leadership oversight and follow-up. Beginning 11/01/2024, in-person education on the new EHR verification of change in condition process will occur daily for licensed staff until all scheduled staff have been trained.

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/30/2024, the "H&P" indicated, Patient 1, "presenting from skilled nursing facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care and rehabilitation services to patients) secondary to anemia (a condition marked by a deficiency of red blood cells [transport oxygen and nutrients throughout the body]) with a history of hyponatremia (low sodium [an essential nutrient necessary for blood pressure control and body fluids] level in the blood) otherwise asymptomatic (showing no symptoms) alert awake (a state of active attention characterized by high sensory awareness) denies any chest pain, no emesis (vomiting), diarrhea (loose stools) ..."

During a concurrent interview and record review on 10/29/2024 at 3:59 p.m. with the Director of Medical Surgical (DMS), Patient 1's "Progress Notes (the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during treatment)," dated 5/2/2024, was reviewed. The progress note indicated on 5/2/24 at 10:13 a.m., Certified Nursing Attendant (CNA, an entry-level role that provides vital support to both patients and nurses) 1 "reports finding pt (Patient 1) sitting on the floor leaning against the wall, disoriented (having lost one's sense of time, place, or identity) to situation... Pt (Patient 1) reports losing balance and falling towards the wall onto a sitting position."

During a concurrent interview and record review on 10/29/2024 at 4:30 p.m. with the DMS, Patient 1's "Progress Notes," dated 5/3/2024 at 8:00 a.m., was reviewed. The progress notes indicate Patient 1 was"drowsy and lethargic (a symptom that involves an unusual decrease in consciousness); eyes are not open to pain, but pt (Patient 1) is grunting (short, low sound instead of speaking) and moving hands to sternal rub (a technique to test an unconscious person's responsiveness)."
The DMS verified that there was no progress note by any physician that Patient 1 was assessed for a change in condition (drowsy and lethargic, eyes do not open to pain) until 5/3/2024 at 10:59 p.m., when a progress note by MD 1, date of service/time was 5/3/2024 at 10:59 p.m. indicated, "24 hour event: rapid response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest [heart stop], or death) was called on the patient (Patient 1) at approximately 6 p.m. neurologically (the branch of medicine that deals with problems affecting the brain) twitching in all extremities was noted and neurology was called."

During a concurrent interview and record review on 10/29/2024 at 4:30 p.m. with the DMS, Patient 1's "Neurological Assessment (evaluates brain and functioning)," dated from 4/24/2024 through 5/3/2024, was reviewed and indicated the following:

- On 4/29/2024 at 9:16 p.m. (date of admission to the facility), Patient 1's level of consciousness (LOC, is a state of awareness, alertness, and wakefulness) was identified as alert.

- On 4/30/2024 at 9:08 a.m., Patient 1's level of consciousness was identified as alert.

- On 5/1/2024 at 8:00 a.m., Patient 1's level of consciousness was identified as alert.

- On 5/1/2024 at 10:00 p.m., Patient 1's level of consciousness was identified as alert.

- On 5/2/2024 at 10:15 a.m. (when Patient 1 had an unwitnessed fall inside the patient room), Patient 1's level of consciousness was identified as lethargic (a symptom that involves an unusual decrease in consciousness), confusion (symptoms that involve disruptions in memory, ability to think and focus, awareness), and disorientation (the condition of having lost one's sense of direction).

- On 5/2/2024 at 10:00 p.m., Patient 1's level of consciousness was identified as lethargic, confusion/disorientation.

- On 5/3/2024 at 8:00 a.m., Patient 1's level of consciousness was identified as lethargic; the right and left pupils are brisk and regular (normal pupil behavior).

- On 5/3/2024 at 10:00 p.m. Patient 1's level of consciousness was identified as obtunded (diminished responsiveness); the right and left pupils are sluggish (abnormalities of pupils' behavior correlate with an underlying serious problem with brain functioning).

During an interview and record review on 10/29/2024 at 4:55 p.m. with the DMS, Patient 1's "Neurological Assessment," was reviewed. DMS verified that Patient 1 had a condition change. The DMS stated, "The nurse (RN 1) should have notified the doctor and monitor the patient more frequently than every 4 hours." The neurological assessment indicated Patient 1's condition declined from 5/2/2024 at 10:15 a.m. (when Patient 1 fell) and continued to decline, over 24 hours, until 5/3/2024 at 6:00 p.m. when a Rapid Response was called.

During a review of Patient 1's Computerized Tomography scan (CT scan, a medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body's internal structures), dated 5/3/2024 at 6:31 p.m., the CT scan results indicated, Patient 1 had "Large acute (sudden and severe in onset) right frontoparietal (area of the front and near the upper back area in the skull) subdural hematoma (a buildup of blood on the surface of the brain) measuring about 2 cm (centimeter, a unit of measurement) in maximum thickness. Extensive edema (swelling caused by too much fluid trapped), mass effect and shift (a shift in the midline is when the natural centerline of the brain is pushed to the right or left due to fluid buildup) of the midline (line that divide the brain evenly in two) to the right-side measuring about 10 mm (millimeter, a unit of measurement)."

During a concurrent interview and record review on 10/29/2024 at 4:45 p.m. with the DMS, Patient 1's "flow sheet (track patient health data over a period of time)," for vitals dated from 5/3/2024 at 8:00 a.m., at 1200 p.m., and at 7:15 p.m., were reviewed. Patient 1's vital signs were as follows:

- On 5/3/2024 at 8:00 a.m., Patient's 1 blood pressure (BP, measures the blood pushing against the blood vessel walls when the heart beats) was elevated, 179/92. The blood pressure was not addressed. DMS confirmed that PRN (as needed) Hydralazine (prescribed medication used to treat high blood pressure) that was prescribed to be administered if the systolic BP (the first number in measurement of the pressure the blood pressure) over 160s, was not given.

- The DMS verified that the BP was not reassessed until (4 hours later) at 12:00 p.m., when the systolic BP continued to be elevated at 160. The DMS confirmed that the elevated BP was not addressed again. On 5/3/2024 at 7:15 p.m., Patient 1's BP increased to 205/100.

During an interview and record review with the DMS on 10/29/2024 at 5:00 p.m., Patient 1's "Rapid Response Team Assessment" report indicated a rapid response started at 6:13 p.m. on 5/3/2024. The report also indicated, Patient 1 was lethargic and with AMS (altered mental status, a change in mental function), CT scan was ordered, and confirmed subdural hematoma (a type of bleeding near the brain that can happen after a head injury)." Patient 1 had to be intubated (placing a tube into the patient windpipe to aid in breathing).

During an interview on 10/30/2024 at 9:56 a.m. with Registered Nurse (RN, nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 1, RN 1 stated, on 5/2/2024 at 8:00 a.m., CNA 1 reported that she (CNA 1) found Patient 1 on the floor. RN 1 stated on 5/3/2024 he (RN 1) was precepting (provides supervision during clinical practice) for RN 2. Stated he (RN 1) was responsible to review RN 2' assessment of Patient 1 and sign off on documentation completed by RN 2. RN 1 further stated that on 5/3/2024 at 8:00 a.m., Patient 1 required a sternal rub. RN 1 stated a sternal rub was done to apply some pain to see if the patient (Patient 1) will respond. RN 1 confirmed that he (RN 1) was not able to get Patient 1 to respond verbally, Patient 1 was grunting and moving hands. RN 1 stated, "When patient has a condition change, the MD (physician) should have been notified, and a rapid response should be called immediately."

During an interview on 10/30/2024 at 9:56 a.m. with Registered Nurse (RN) 2, RN 2 stated, "In the (Medical Surgical) unit, the CNA would take patients' blood pressure, and the RN will review the BP within an hour." RN 2 stated when a blood pressure was abnormal, the CNA will inform the RN immediately. RN 2 stated, "I do not recall if the CNA (CNA 1) notified of Patient 1's blood pressure of 179."

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Re-assessment," dated March 2023, the P&P indicated, "To ensure that all patients receive the appropriate assessment (including Initial/screening and reassessment) provided by qualified individuals within the organizational setting. The assessment process will be a continuous collaborative effort with all departments functioning as a team. Patient assessment is a multidisciplinary function. The importance of input by various members of the health care team is valued and supported by the organization ... Reassessment will occur at points in time when there are changes in the level of care, the patient's condition, and/or the patient's diagnosis ... Reassessment procedures determine and document the patient's response to the care provided."

During a review of the facility's policy and procedure (P&P) titled, "Physician Notification," dated March 2023, the P&P indicated, "The physician of record (POR) will be notified regarding patient issues in a timely manner ... The POR and/or hospitalist will be notified of patient's change in condition."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated July 2023, the P&P indicated, "Medications not eligible for scheduled dosing times are medications that require exact or precise timing of administration, based on diagnosis type, treatment requirements, or therapeutic goals: Medications prescribed on an as needed basis ...Medications are administered only with legitimate and appropriate orders ... Before administering a medication, the authorized individual administering the medication will complete the following: Verify that the medication selected for administration is correct based on the medication order and product label ... For as needed (prn) medications, the nurse will assess the patient condition and document the need for the medication prior to administration. The patient will be monitored for patient response appropriately, and reassessment will occur per hospital policy."

2.a. During a review of Patient 25's "History and Physical Exam (H&P, a full, complete assessment of a patient's medical history and current condition)," dated 10/17/2024, the H&P indicated Patient 25 was discharged from the medical unit (a hospital floor/unit used to provide medical examinations, treatments, medical services or procedures to the patients) and was admitted to the Behavioral Health Unit (BHU, unit that provides services for patients with mental health and substance abuse issues) on a 5150 hold (California law that allows a person to be involuntary detained for up to 72 hours for psychiatric evaluation and treatment) for grave disability (unable to provide for their basic needs like food, clothing, shelter due to a mental health disorder). The H&P further indicated Patient 25's medication regimen from the medical unit was to be continued in the BHU.

During a review of Patient 25's "Nurse Admission Report," dated 10/16/2024, the report indicated Patient 25 had Pressure Injury (PI, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the right and left buttocks.

During a concurrent interview and record review on 10/30/2024 at 11:10 a.m., with Charge Nurse 1 (CN 1), CN 1 verified Patient 25's "Wound Care Nurse Progress Note," dated 10/14/2024, was from Patient 25's admission in the medical unit. The note indicated Patient 25 had a right ischium (bony part of the buttock) unstageable pressure injury (full thickness skin and tissue loss where the base of the wound is covered by dead tissue) measuring 7.0 x (by) 4.0 x 1.0 centimeter (cm-a unit of measurement) and a left ischium unstageable PI measuring 3.0 x 3.0 cm. CN 1 stated Patient 25 had a pending wound care consult for the BHU admission (Patient 25 had been admitted to BHU for a total of 16 days).

During the same interview and record review on 10/30/2024 at 11:10 a.m. with CN 1, CN 1 verified that the BHU physician entered a "Wound Care Order," for Patient 25 on 10/16/2024. The order indicated for Patient 25 to have Leptospermum honey (Medihoney, natural immunomodulatory and antimicrobial agent) 4"x5" wound patch, 1 topical (applied directly to a part of the body) dressing every 24 hours for 30 days. CN 1 verified there was no instruction on where the Medihoney wound patch would be applied. CN 1 stated the wound care order should specify the wound site for wound treatment.

During concurrent interview and record review on 10/30/2024 at 11:30 a.m., with CN 1, Patient 25's "Nursing Progress Notes," dated 10/17/2024, 10/18/2024, and 10/29/2024, were reviewed. The notes indicated the following:

- On 10/17/2024, Patient 25's "wound treatment on sacrum (lower back) done as ordered."
There was no documented evidence wound treatment was provided to Patient 25's PI on the right and left buttocks.

- On 10/18/2024, Patient 25's "wound treatment done as ordered."
There was no documented evidence wound treatment was provided to Patient 25's PI on the right and left buttocks.

- On 10/29/2024, Patient 25's "wound treatment on sacrum done as ordered."
There was no documented evidence wound treatment was provided to Patient 25's PI on the right and left buttocks.

- CN 1 stated wound care treatment was important to ensure wound healing and prevent wound deterioration.

During a concurrent interview and record review on 10/31/2024 at 11:20 a.m. with the Wound Care Nurse (WCN, Registered Nurse who specializes in the treatment of wounds), the WCN stated Patient 25's record indicated the nurses were documenting wound treatment with the wrong wound location and following a physician's order with no specified treatment location. The WCN stated it was not the standard practice of care.

During the same interview and record review on 10/31/2024 at 11:20 a.m., the WCN confirmed that Patient 25's wound care order on 10/16/2024, did not specify the wound location for treatment. The WCN stated the nurses should have called the physician for order clarification.

During a review of the facility's policy and procedure (P&P) titled, "Documentation, Patient Care Record," revised 7/2020, the P&P indicated, "Patient care delivered will be continually evaluated. Response to and outcome of the care provided will be documented throughout the shift."

During a review of the facility's policy and procedure (P&P) titled, "Physician Notification," revised 8/2015, the P&P indicated, "The physician of record (POR) will be notified regarding patient issues in a timely manner..."

2.b. During a review of Patient 28's "History and Physical Exam (H&P, a full, complete assessment of a patient's medical history and current condition)," dated 10/26/2024, the H&P indicated, Patient 28 was admitted to the facility for right eyebrow laceration (a cut or tear in the skin) and hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) after an unwitnessed fall (an unplanned descent of a patient to the floor or onto a lower surface). Patient 28 had a history of high blood pressure.

During a concurrent interview and record review on 10/31/2024 at 3:46 p.m. with the Intensive Care Manager (ICM), the ICM verified Patient 28's "Vital Signs Flowsheet," dated 10/26/2024, had the following blood pressure (BP) readings:

-At 1:00 a.m., Patient 28's BP on admission was 128/76;

-At 4:55 a.m., Patient 28's BP was 129/79;

-At 6:00 a.m., Patient 28's BP was 154/74;

-At 7:54 a.m., Patient 28's BP was 159/101;

-At 8:00 a.m., Patient 28's BP was 175/142; and,

-At 9:27 a.m., Patient 28's BP was 171/89.

- The ICM stated there was no documented evidence of Patient 28's high BP readings on 10/26/2024 from 6 a.m. through 9:27 a.m., were addressed. The ICM stated Patient 28's high BP should have been reported to Patient 28's physician.

During a review of the facility's policy and procedure (P&P) titled, "Physician Notification," revised 8/2015, the P&P indicated, "The physician of record (POR) will be notified regarding patient issues in a timely manner. The POR and/or hospitalist will be notified of patient's change in condition."

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

1. Ensure nursing staff develop and implement a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for high fall (an unplanned change in position where a patient lands on the floor or a lower surface) risk prevention and care for one of thirty (30) sampled patients (Patient 1) in accordance with the facility's policy and procedures regarding care plan development.

This deficient practice had the potential to result in Patient 1's treatment and care goals not being met by not identifying the patient's needs and risks for potential fall.

2.Ensure one of 30 sampled patient's (Patients 16), individualized nursing care plans (provides a means of communication among health care providers) to address Patient 16's issues regarding Hypertension (high blood pressure) and Skin Impairment (damaged skin), was developed and implemented, in accordance with the facility's policy and procedure regarding care plan development.

This deficient practice had the potential to result in delayed provision of care to the patient by not identifying Patients 16's needs and risks.

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/30/2024, the "H&P" indicated, Patient 1, "presenting from skilled nursing facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care and rehabilitation services to patients) secondary to anemia (a condition marked by a deficiency of red blood cells [transports oxygen and nutrients throughout the body]) with a history of hyponatremia (low sodium [essential nutrient to help control blood pressure and body fluids] level in the blood) otherwise asymptomatic (showing no symptoms) alert awake (a state of active attention characterized by high sensory awareness) denies any chest pain, no emesis (vomiting), diarrhea (loose stools) ..."

During a concurrent interview and record review on 10/29/2024 at 3:59 p.m. with the Director of Medical Surgical (DMS), Patient 1's "Progress Notes (the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during treatment)," dated 5/2/2024, was reviewed. The progress note indicated on 5/2/24 at 10:13 a.m., Certified Nursing Attendant (CNA, an entry-level role that provides vital support to both patients and nurses) 1 "reports finding pt (Patient 1) sitting on the floor leaning against the wall, disoriented (having lost one's sense of time, place, or identity) to situation... Pt (Patient 1) reports losing balance and falling towards the wall onto a sitting position."

During a concurrent interview and record review on 10/30/2024 at 4:00 p.m. with the Director of Medical Surgical (DMS), Patient 1's "Assessment" flowsheet (track patient health data over a period of time), the flowsheet indicated Patient 1 was identified on the Morse Scores (Assessment tool that predicts the likelihood that a patient will fall: falling from 0-24 indicate no risk, 25-50 indicate low risk and higher than 50 indicate high risk) at 50 which is high fall risk.

During a review of Patient 1's Computed Tomography Scan (CT scan, medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body's internal structures), dated 5/3/2024 at 6:31 p.m., the CT scan results indicated, Patient 1 had "Large acute (sudden and severe in onset) right frontoparietal (area of the front and near the upper back area in the skull) subdural hematoma (a buildup of blood on the surface of the brain) measuring about 2 cm (centimeter, a unit of measurement) in maximum thickness. Extensive edema (swelling caused by too much fluid trapped), mass effect and shift (a shift in the midline is when the natural centerline of the brain is pushed to the right or left due to fluid buildup) of the midline (line that divide the brain evenly in two) to the right-side measuring about 10 mm (millimeter, a unit of measurement)."

During an interview and record review on 10/29/2024 at 5:00 p.m. with the Director of Medical Surgical (DMS), DMS , Patient 1's "Rapid Response Team Assessment" report, indicated a rapid response started at 6:13 p.m. on 5/3/2024. The report indicated, Patient 1 is lethargic and AMS (altered mental status, change in mental function), CT scan was ordered, and confirmed subdural hematoma (a type of bleeding near the brain that can happen after a head injury)." Patient 1 had to be intubated (placing a tube into the patient windpipe to aid in breathing).

During a concurrent interview and record review on 10/30/2024 at 10:10 a.m. with the Director of Medical Surgical (DMS), Patient1's "Care Plan," dated from date of admission 4/29/2024 through 5/4/2024, was reviewed. The DMS verified that there was no fall (an unplanned change in position where a patient lands on the floor or a lower surface) care plan initiated and implemented for Patient 1 throughout the hospital stayed and even after Patient 1 fell on 5/2/2024. DMS stated, "This is a deficiency here, they should have initiated the fall care plan, as that the patient fell."

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care," dated March 2023, the P&P indicated, "To create a nursing care plan for each patient within 24 hours of admission. It should be started by the patient's primary nurse who admits the patient. To provide the highest quality of care that is individualized and goal-directed based on the initial admission assessment from nursing and all appropriate disciplines. To evaluate patient's response to care goals and when indicated, to ensure that the plan and goals are revised. A Registered Nurse (RN) is responsible for initiating and developing an interdisciplinary plan of care within 24 hours of admission or as specified in unit specific standards. An RN and/or qualified individual from a discipline is responsible for: Identifying expected outcomes individualized to the patient. Problem identification is initiated by an RN or other qualified individuals based on direct observation of the patient and evaluation of data gathered by designated staff or family members. The RN is responsible for analyzing, synthesizing and evaluating data and identifying appropriate nursing diagnoses/patient problems. The LVN may assist with data collection. Problems identification and development of Plan of Care is: Individualized. An ongoing process throughout a patient's hospitalization ...The Plan of Care is reviewed every shift."

During a review of the facility's policy and procedure (P&P) titled, "Fall Assessment & Prevention Program," dated February 2023, the P&P indicated, "Fall Risk Score assigned to Patient and Protocols implemented per risk level: Normal = 0-44 and At Risk= 45 and above, Patients who are at High Risk for falls may utilize the Bed Alert System as a less restrictive measure and alternative to restraint while continuing to monitor for unauthorized ambulation ...Monitoring Risk Prevention Protocols: follow-up of all risk reduction interventions listed in the care plan should be performed to determine the effectiveness."

2. During a review of Patient 16's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/23/2024, the H&P indicated Patient 16 was admitted to the facility for Hypertension (HTN - high blood pressure) and Coronary Artery Disease (CAD-damage or disease in the heart's major blood vessels). The H&P further indicated Patient 16 had a wound on the left buttock.

2.a. During a concurrent interview and record review on 10/30/2024 at 10:58 a.m. with Nurse Manager 1 (NM 1), NM 1 verified Patient 16's care plan did not include plans for management of Patient 16's HTN. NM 1 stated Patient 16's care plan addressing HTN should have been initiated on admission.

During an interview on 10/31/2024 at 2:30 p.m. with the Director of Behavior Health Unit (DBHU), the DBHU stated it was the Registered Nurse's (RN) responsibility to initiate a care plan for the patient upon admission and to update the patient's care plan every shift. The DBHU stated the patients were expected to have an individualized care plan.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care," revised in 03/2023, the P&P indicated, "To create a nursing care plan for each patient, within 24 hours of admission. It should be started by the patient's primary nurse, or the nurse who admits the patient...A Registered Nurse (RN) is responsible for initiating and developing an interdisciplinary plan of care within 24 hours of admission or as specified in unit specific standards...Problems identification and development of Plan of Care is: a. Individualized, b. an ongoing process throughout a patient's hospitalization. The Plan of Care is developed interdisciplinary by all appropriate services based on their assessment findings."

2.b. During a concurrent interview and record review on 10/30/2024 at 2:22 p.m. with the Nurse Manager 1 (NM 1), NM1 verified Patient 16's "Integumentary flowsheet," dated 10/22/2024, indicated Patient 16 had a wound on the left buttock.

During a concurrent interview and record review on 10/31/2024 at 2:38 p.m. with NM 1, NM 1 verified Patient 16's care plan on "Skin Impairment" was only developed on 10/30/2024 (8 days after Patient 16's initial skin assessment of wound on the left buttock). NM 1 stated Patient 16's skin impairment care plan should have been initiated on 10/22/2024, when the patient's wound was first identified.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care," revised in 03/2023, the P&P indicated, "To create a nursing care plan for each patient, within 24 hours of admission. It should be started by the patient's primary nurse, or the nurse who admits the patient...A Registered Nurse (RN) is responsible for initiating and developing an interdisciplinary plan of care within 24 hours of admission or as specified in unit specific standards...Problems identification and development of Plan of Care is: a. Individualized, b. an ongoing process throughout a patient's hospitalization. The Plan of Care is developed interdisciplinary by all appropriate services based on their assessment findings."

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

1. Notify the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) Physician (a person trained to treat life-threatening or limb-threatening illnesses or injuries) (Campus 1) that one of 30 sampled patients (Patient 3) had psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), a head injury (sustained after a fall [an unexpected descent to the floor or another lower surface with or without injury to the patient]), and was refusing medical care.

This deficient practice resulted in Patient 3 being discharged from the Emergency Department (ED), without being seen and cleared by an ED Physician for a possible head injury (post [after]-assault [when an individual inflicts physical contact that causes bodily harm and/or injury]) and without being evaluated for psychosis, which could have resulted in unresolved psychosis and complications from a brain bleed such as death.

2. Ensure one of 30 sampled Patients (Patient 1), who was identified as high risk for fall, received "hourly rounding (purposeful rounding by staff with the goal to protect patients and promote patient safety on the 4 P's: Pain, Potty, Positioning, and possessions)," in accordance with the facility's procedure regarding rounding and monitoring of patients.

This deficient practice likely resulted in Patient 1's fall (an unexpected descent to the floor or onto another surface with or without injury to the patient) on 5/2/2024 at 10:15 a.m. and sustaining a head bleed, which required transfer to a high-level care (a hospital capable of providing diagnostic or interventional care beyon the capacity of the hospital from which a patient originates) facility for surgery.

3. Ensure nursing staff assessed a patient and notified a physician in a timely manner, regarding an injury involving one of 30 sampled patients (Patient 7), after a hands-on protocol (using one or both hands to immobilize a patient) per Crisis Prevention Institute (CPI, a program that teaches people how to prevent and respond to crises) was used to restrain (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) Patient 7 to his (Patient 7) bed on 4/6/2017 (night shift).

This deficient practice resulted in delay of treatment and care as physician was contacted only the next morning when Patient 7 was found with redness on left side of head and swelling in the left orbit (the bony cavity of the skull tha houses the left eye).

4. Ensure nursing staff removed a ligature (a thing used for tying) risk item, in accordance with the facility's policy and procedure regarding contrabands (any item that is prohibited or could be dangerous to patients, staff or visitors. Example: Belts and shoelaces, etc.), for one of 30 sampled patients (Patient 9), when Patient 9 was allowed to wear a sweater with a drawstring in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders).

This deficient practice resulted in putting Patient 9 and other patients' safety at risk when the drawstring could be used as a ligature to harm self or others.

5. Ensure for three of 30 sampled patients (Patients 25, 24, and 23), Patients 25, 24, and 23's nursing care provided by the Licensed Vocational Nurse (LVN, an entry level health care provider who is responsible for basic nursing care under the direction of a registered nurse) was supervised by the Registered Nurse (RN, a licensed professional responsible for providing patient care, education and support to the patient), in accordance with the facility's policy and procedure regarding RN oversight, when the LVNs' patient care documentation was not reviewed and verified by the RNs to indicate the care was completed, accurate, and provided under the RNs' supervision.

This deficient practice had the potential for Patients 25, 24, and 23 to receive incomplete and inaccurate care which may cause negative impact on the overall provision of care and may lead to patient harm and/or death.

On 11/1/2024 at 1:17 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Director of Performance Improvement and Quality Management (DPIQ), the Associate Administrator (AA), and the Chief Nursing Officer (CNO).

The facility was informed facility nursing staff failed to notify the Emergency Department (ED) Physician (a person trained to treat life-threatening or limb-threatening illnesses or injuries) that Patient 3 had psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not), head injury, and was refusing medical care. Patient 3 suffered an injury (status-post staff altercation and assault) to the face and was treated in the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) for a laceration (a deep cut or tear in skin or flesh) above the left eye. Patient 3 suffered a laceration to the head (head injury status post assault), had auditory hallucinations (when someone hears voices or noises that don't exist in reality), and refused medical care. Patient 3 was taken into custody by the police and removed from the facility prior to receiving a medical exam and medical clearance from possible emergency head injuries (the process of evaluating someone's health condition to determine if they are fit for a specific activity or procedure) by an ED Physician.

On 11/1/2024 at 8:31 p.m., the facility submitted an Immediate Jeopardy Removal Plan (IJRP, includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely) for review and approval. The IJRP included the following:
Immediate Education

The following education started on 11/01/2024 for emergency room staff. Education will continue every shift until all scheduled staff have been trained. The following points outline the procedures for ensuring that patients with psychosis and/or head trauma receive appropriate medical screening exam (MSE, an exam performed by a physician to determine whether a medical condition exist) and support, especially those at risk of harm or who may require additional supervision.

- The hospital must provide a triage (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) and Medical Screening Examination to any individual who presents themselves to the emergency department for the purposes of emergency care.
- If the patient is displaying signs of psychosis or has evidence of head trauma/injury they will be held in the department until they have the capacity (ability to make a decision) or they are evaluated (medical screening exam) by a physician who has the authority to order a Psychiatric Evaluation Team (PET, a team of licensed mental health clinicians) evaluation.
- If the patient refuses triage, medical screening exam, and/or is refusing care, the RN must immediately notify the physician face-to-face and update him/her on the patient's chief complaint and current status so they can discuss the risks & benefits with the patient.
- This notification must be documented in the patient's electronic medical record.
- The emergency room charge RN/appointed designee shall be notified of any refusal of care to ensure the correct process is followed.

On 11/1/2024 at 9:45 p.m. in the presence of the Director of Performance Improvement and Quality Management (DPIQ), the Associate Administrator (AA), and the Chief Nursing Officer (CNO), the facility was informed that the survey team was unable to accept the IJRP. The IJRP was missing information regarding the Emergency Department (ED) processes and standards of care to see, treat, and medically clear all patients presenting to the ED for treatment and care, and specifically treatment and care for patients presenting with psychosis and head injuries.

On 11/1/2024 at 9:47 p.m., the facility was placed on a 23-day fast track (a process that places a hospital or other provider on a termination track if deficiencies are found that pose an immediate jeopardy to patient health and safety).

On 11/6/2024, an acceptable IJRP was received from the facility.

On 11/11/2024 at 12:33 p.m., the IJ was removed in the presence of the Director of Quality and the CEO after all the elements of the IJRP were verified onsite through observation, interview, and record review.

Findings:

1. During a review of Patient 3's Face Sheet, dated 8/12/2024, the Face Sheet indicated Patient 3 was registered to the facility (Campus 1) Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) on 8/12/2024 at 2:00 a.m., with a chief complaint of psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not).

During an interview on 10/30/2024 at 11:05 a.m. with the Director of Performance Improvement and Quality Management (DPIQ), the DPIQ stated the following: On 8/12/2024 at approximately 2:56 a.m., the physical altercation (physical aggression that may or may not result in an injury) between Security Officer 1 (SO 1) and Patient 3 occurred in the facility's new Emergency Department that was still under construction at the time. SO 1 was working in the new ED at the entrance. Patient 3 tried to rip off the construction barrier on the wall. Patient 3 was agitated (a state of severe restlessness or uneasiness) and got into a verbal altercation (a verbal argument) with SO 1, then Patient 3 spat on SO 1. SO 1 and Patient 3 got into a physical altercation. Patient 3 was taken by staff inside the Emergency Room. The DPIQ validated SO 1 punching Patient 3 to the head (10 times) and that the verbal interactions on facility video between SO 1 and Patient 3 appeared to be a verbal argument prior to the physical altercation.

During a concurrent interview and record review on 10/30/2024 at 3:30 p.m. with the Director of Emergency Department (DED), Patient 3's medical record, was reviewed. The DED verified the following in the medical record: The Medical Screening Exam (MSE, an exam performed by a physician to determine whether a medical condition exist) and physician note was missing from the medical record. There was no notification to the ED Physician from nursing staff about Patient 3's physical altercation (with SO 1), head laceration (a deep cut or tear in skin or flesh), auditory hallucinations (when someone hears voices or noises that don't exist in reality) and refusal of medical care. Patient 3 left the facility in the custody of the police without being seen by an ED Physician and without receiving medical clearance (the process of evaluating someone's health condition to determine if they are fit for a specific activity or procedure) for psychosis or a head injury (post physical assault).

During the same interview on 10/30/2024 at 3:30 p.m., the DED stated the following: Patient 3 was seen in the Emergency Department on 8/12/2024 following a physical altercation with a member of facility security staff (SO 1). There should have been a notification from nursing staff to the ED Physician that Patient 3 was having auditory hallucinations, had a head laceration following a physical altercation, and was refusing care. It was important to notify the ED Physician so that patient (Patient 3) could get the appropriate medical care. Patient 3 should not have left without being seen by a physician and being medically cleared for psychosis or a head injury (post physical assault). Nursing staff documented refusal of care, but the ED physician should have documented Patient 3's refusal to be seen in Patient 3's medical record.

During an interview on 10/31/2024 at 3:22 p.m. with the Emergency Department (ED) Physician, Medical Doctor 4 (MD 4), MD 4 stated the following: After the triage nurse triaged a patient (the preliminary assessment of patients or casualties in order to determine the urgency of their need for treatment and the nature of treatment required) in the ED, the ED physician sees the patient and performs a MSE. A patient who presents with a head laceration, possible danger to others (condition of a person whose behavior or significant threats support a reasonable expectation that there is a substantial risk that he will inflict physical harm upon another person in the near future) and is identified as having auditory hallucinations must be seen by a physician and must be medically cleared for psychosis or a head injury (post physical assault), by a physician prior to being discharged.

During the same interview on 10/31/2024 at 3:22 p.m. with MD 4, MD 4 said a patient presenting with auditory hallucinations should be evaluated by the ED physician to determine a need for a Psychiatric Emergency Team (PET, a team of licensed mental health clinicians) evaluation. When patients are discharged in the custody of the police, the ED Physician must medically clear all patients to ensure they do not have a medical event after they leave the ED. For head trauma, the standard of care treatment is to have a Computed Tomography (CT, a medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body's internal structures) scan completed to rule out a brain bleed, because a brain bleed can stop someone from breathing and kill them.

During the same interview on 10/31/2024 at 3:22 p.m. with MD 4, MD 4 stated if a patient refuses care, staff notifies the ED physician, and the ED physician must explain and document that the risk and benefits (risks and benefits of healthcare-relevant decisions) have been explained to the patient. Documentation of the MSE or refusal in the MD progress note should be completed within 24 hours of seeing the patient. The ED Physician has the ultimate responsibility for the patient, and the interdisciplinary team (a group of healthcare professionals with various areas of expertise who work together toward the goals of their patients), such as the Charge Nurse or Registered Nurse, should communicate changes or refusals to the ED physician.

During an interview on 10/31/2024 at 4:35 p.m. with the DPIQ, the DPIQ stated the following: Once Patient 3 was taken into custody by the police, the facility was unaware of what happened to Patient 3.

During a review of Patient 3's "ED note - Nursing (ED nursing note)," dated 8/12/2024 at 2:45 a.m., the ED nursing note indicated, "patient (Patient 3) was brought in by [staff] in cuffs (a device used to secure a person's wrists or ankles to limit their movement) into chair in emergency department (ED), patient (Patient 3) was yelling and screaming, threatening all staff and refusing care ... [staff] was able to see cut above [Patient 3's] left eye, cleaned and dressed with 4 X 4's dressing (a topical dressing for local management of bleeding wounds such as cuts, lacerations and abrasions) refusing triage and Medical Doctor (MD) exam, vital signs (measurements of the body's most basic functions, such as temperature, pulse rate, respiration rate, and blood pressure) and other care, kept screaming, in police department custody."

During a review of patient 3's "ED note - Nursing (ED nursing note)," dated 8/12/2024 at 3:21 a.m., the ED nursing note indicated the following: "Patient (Patient 3) complained of auditory hallucination ... unwitnessed altercation but patient (Patient 3) has laceration above left eye... called [local] police department immediately... police department arrived and took patient into custody."

During a review of the facility's policy and procedure (P&P) titled, "Physician Notification," dated 3/2023, the P&P indicated the following: "The physician of record will be notified regarding patient issues in a timely manner ... The physician of record and or hospitalist will be notified of patient's change in condition."

During a review of the facility's policy and procedure (P&P) titled, "Patient Right to Refuse Care," dated 4/2018, the P&P indicated the following: " ...In the event that a patient refuses care or services, the physician should be notified. it is the physician's responsibility to explain the consequences of refusal and to present alternatives if any are appropriate ..."

During a review of the facility's policy and procedures (P&P) titled, "Medical Screening Examinations," dated 2/2020, the P&P indicated the following: " ...Any patient who presents to [the facility] requesting emergency services is entitled to and will receive a Medical Screening Examination performed by licensed providers for the determination of whether an emergency condition exists .... Emergency Medical Condition: A medical condition manifesting itself by acute (sudden and severe in onset) symptoms of sufficient severity, (including severe pain, psychiatric disturbances and/or symptoms) such that the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily functions or serious dysfunction or serious dysfunction of any bodily organ ..."

During a review of the facility's policy and procedures (P&P) titled, "Emergency Department Standards of Practice and Care," dated 8/2020, the P&P indicated: " ...Important Aspects of Patient Care: ...E. Assessment and patient needs are communicated to the healthcare provider(s) who is responsible for the care and treatment of the patient: 1. Members of the multidisciplinary team ... 3. Progress/nursing notes ..."

During a review of the facility's policy and procedures (P&P) titled, "Standard of Care Procedures," dated 10/2020, the P&P indicated: " ...Procedure: ...M. Head injuries 1. A patient who arrives at the Emergency Department with a head injury will be evaluated for the following care: ...Notify the Emergency Department Physician ..."

During a review of the facility's policy and procedures (P&P) titled, "Triage," dated 8/2020, the P&P indicated: "...Policy: ...B. Triage assessment and the assignment of an acuity rating do not fulfill the legal requirement of the patient receiving a medical screening examination (MSE) by the physician. C. The Emergency Medical Treatment and Active Labor Act (EMTALA) requires medical screening of individuals seeking emergency care to determine whether an emergency medical condition exists. Stabilization of the patient, to the best of the hospital's capabilities, is required prior to discharge or transfer ..."

2. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/30/2024, the "H&P" indicated, Patient 1, "presenting from skilled nursing facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care and rehabilitation services to patients) secondary to anemia (a condition marked by a deficiency of red blood cells [transports oxygen and nutrients throughout the body]) with a history of hyponatremia (low sodium [an essential nutrient that helps control blood pressure and body fluids] level in the blood) otherwise asymptomatic (showing no symptoms) alert awake (a state of active attention characterized by high sensory awareness) denies any chest pain, no emesis (vomiting), diarrhea (loose stools) ..."

During a concurrent interview and record review on 10/29/2024 at 3:59 p.m. with the Director of Medical Surgical (DMS), Patient 1's "Progress Notes (the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during treatment)," dated 5/2/2024, was reviewed. The progress note indicated on 5/2/2024 at 10:13 a.m., Certified Nursing Attendant (CNA, an entry-level role that provides vital support to both patients and nurses) 1 "reports finding pt (Patient 1) sitting on the floor leaning against the wall, disoriented (having lost one's sense of time, place, or identity) to situation... Pt (Patient 1) reports losing balance and falling towards the wall onto a sitting position."

During a review of Patient 1's Computed Tomography scan (CT scan, a medical imaging technique that produces cross-sectional images of specific areas of the body to provide detailed imaging of the body's internal structures), dated 5/3/2024 at 6:31 p.m., the CT scan results indicated, Patient 1 had "Large acute (sudden and severe in onset) right frontoparietal (area of the front and near the upper back area in the skull) subdural hematoma (a buildup of blood on the surface of the brain) measuring about 2 cm (centimeter, a unit of measurement) in maximum thickness. Extensive edema (swelling caused by too much fluid trapped), mass effect and shift (a shift in the midline is when the natural centerline of the brain is pushed to the right or left due to fluid buildup) of the midline (line that divide the brain evenly in two) to the right-side measuring about 10 mm (millimeter, a unit of measurement)."

During a concurrent interview and record review on 10/30/2024 at 4:00 p.m. with the Director of Medical Surgical (DMS), Patient 1's "Assessment" flowsheet (track patient health data over a period of time), was reviewed. The flowsheet indicated Patient 1 was identified on the Morse Scores (Assessment tool that predicts the likelihood that a patient will fall (unplanned descent to the floor or another lower surface with or without injury to the patient): falling from 0-24 indicate no risk, 25-50 indicate low risk and higher than 50 indicate high risk) at 50 which is high fall risk. DMS stated the individualized fall prevention for Patient 1 is "the bed was in low position, wheels are locked, and the patient (Patient 1) was restrained. After reviewing with DMS purpose of restraint (devices that limit a patient's movement) in the hospital setting, DMS stated, "the patient (Patient 1) was also on hourly rounding."

During a concurrent interview and record review on 10/30/2024 at 4:15 p.m. with the Director of Medical Surgical (DMS), Patient 1's electronic medical record titled, "Hourly Rounding (purposeful rounding by staff with the goal to protect patients and promote patient safety on the 4 P's: Pain, Potty, Positioning, and possessions)," was reviewed. The Hourly Rounding form indicated, "Rounding every hour from 6 a.m. - 10 p.m. and rounding every two hours from 10 p.m. -6 a.m." The form had staff's initials hourly and every two hours for night shift (10 p.m. -6 a.m.) on 4/30/2024 and 5/1/2024, but on 5/2/2024 (date that Patient 1's fell), the form was left blank. The form had Patient 1's identification labeled with date of birth, medical record number, physician name and other identification numbers. DMS stated although she did not see a deficiency in practice that staff did not complete hourly rounding on 5/2/2024, on the date that Patient 1 fell, DMS stated staff should have signed the form and initiate a fall care plan. DMS further stated the purpose of hourly rounding was to "make sure that staff are going in the room and checking on patients."

During an interview on 11/1/2024 at 12:20 p.m. with Registered Nurse (RN) 5, RN 5 stated, "Hourly rounding is a standard process. Hourly rounding is completed to make sure everyone (patients) is safe and have their (patients) needs met, and to improve quality care for patients."

During an interview on 11/1/2024 at 12:20 p.m. with Registered Nurse (RN) 4, RN 4 stated, "Hourly rounding, the purpose is to monitor for safety and to see if they (patients) have change of condition. Hourly rounding is standard of care for all patients."

During an interview on 11/1/2024 at 12:20 p.m. with Registered Nurse (RN) 3, RN 3 stated, "Hourly rounding is standard of care that we do to prevents fall and make sure patients' need are addressed."

During an interview on 11/1/2024 at 11:39 a.m. with Director of Performance Improvement/Risk Manager (DPIQ), DPIQ validate that although the facility's Medical Surgical (provides caring, to all patients for illness, surgery or testing and observation) and telemetry (patients undergo continuous heart monitor) unit were implementing the hourly rounding process, DPIQ stated "there is no policy or procedure regarding hourly rounding process because this is something that nursing established." DPIQ further stated, the Quality Assurance Performance department does not know who or when the "Hourly Rounding" process was established.

3. During a review of Patient 7's Face sheet (face sheet, document provides patient's demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance), undated, the face sheet indicated, "Patient 7 was admitted to the facility on 4/4/2017 with chief complaint of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration)."

During a review of Patient 7's Progress Notes Non-Physicians (nursing progress notes), dated 4/7/2017, the nursing progress notes indicated, "in the morning patient (Patient 7) came to nurse's station stating he (Patient 7) wants to file a report. He (Patient 7) stated, 'staff jumped me (Patient 7) last night!' he (Patient 7) said he (Patient 7) was hit 15 times by two staff. Red spatter found on mattress and wall. Patient (Patient 7) has redness on left side of head and swelling left orbit (bony cavity in the skull that houses the left eye)." The nursing progress notes also indicated physician was notified after Patient 7's report on 4/7/2017.

During an interview on 11/1/2024 at 5:09 p.m. with the Director (DBHU) of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders), DBHU stated the following: from facility's internal investigation, Patient 7 had aggressive behavior despite staff attempt to de-escalate (reduce the intensity of a conflict or potentially violent situation). Three Mental Health Workers (MHW 6, 7, and 8) had to use hands on (using one or both hands to immobilize a patient) per Crisis Prevention Institute (CPI, a program that teaches people how to prevent and respond to crises) protocol to restrain (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) Patient 7 on his (Patient 7's) bed. Patient 7's nurse was called in to talk to Patient 7. DBHU stated that Patient 7's nurse should have performed assessment on Patient 7 after the assaultive behavior for any injury. Patient 7's nurse should have notified the physician about the incident for any further instruction. DBHU stated Patient 7's nurse did not document the incident, assessment or notification to Patient 7's physician. Patient 7 was found with injury on the left side of head and swelling on the left eye next morning by the next shift nurse (morning shift nurse who took over Patient 7's care).

During a review of the facility's policy and procedure (P&P) titled, "Assaultive Behavior," dated 10/2021, the P&P indicated, "It is the policy of the Behavioral Health Unit to take all precautions to prevent assaultive behavior on the unit. Should potentially assaultive behavior be evidenced, or should an assault occur, specific interventions will be implemented ... if an injury occurs, the following procedures will be employed: Patient injury: Nurse evaluates extent of patient injury. Physician is notified immediately [so] proper medical and supportive care will be ordered. Vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level) are recorded. Physician orders are implemented and immediate care if rendered as needed."

4. During a review of Patient 9's "Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated 10/24/2024, the Psych Eval indicated, Patient 9 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to being gravely disabled (inability to care self) with admitting diagnosis of paranoid schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). The Psych Eval also indicated Patient 9 had auditory (hearing) hallucinations (when someone hears voices or noises that don't exist in reality) of evil voices commanding her (Patient 9) to kill someone.

During a concurrent observation and interview on 10/30/2024 at 9:07 a.m. with the Charge Nurse (CN) 4 of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) in Patient 9's room, Patient 9 was observed laying in bed wearing a white sweater. There was a drawstring on the hood of Patient 9's white sweater. CN 4 stated Patient 9 should e not have any clothing with drawstring in it because it was dangerous. CN 4 stated drawstring was not allowed in the BHU because it would pose a ligature (a thing used for tying) risk on patients.

During a concurrent interview and record review on 10/30/2024 at 9:39 a.m. with the Registered Nurse (RN) 7, Patient 9's "Patient Valuables/ Belongings (belongings list, inventory of a patient's belongings brought to the hospital)," dated 10/24/2024, was reviewed. The belongings list indicated, "clothing description with white sweater, grey graphic tee, and cheetah pants." RN 7 stated staff would look for any drawstring or any items that could possibly harm patients on patient's clothing upon admission. RN 7 stated if there was a drawstring on a clothing, the drawstring should be cut or placed in the contraband room. RN 7 stated, "Drawstring was a definite 'No' on the floor because of the ligature risk."

During an interview on 11/1/2024 at 9:35 a.m. with the Nurse Manager (NM) 1 of Behavioral Health Unit, NM 1 stated nursing staff should perform initial check upon patients' admission to BHU for any contraband. NM 1 stated drawstring on clothing was considered as contraband and it was a ligature risk because patients could use the drawstring to harm self or others.

During a review of the facility's policy and procedure (P&P) titled, "Identification and Securing of Contraband," dated 5/2021, the P&P indicated, "To preserve the safety of patients, employees and visitors of the hospital by identifying and preventing prohibited items (contraband) from entering the hospital facilities ... What to do with contraband: immediately dispose, place in personal vehicle of patient/visitor or place in [facility] locker. Identified contraband will not be allowed to be brought into the facility ... hanging risk (ropes, electrical wires ...string/rope/cord longer than eight inches)."

5.a. During a review of Patient 25's "History and Physical Exam (H&P, a full and complete assessment of a patient's medical history and current condition)," dated 10/17/2024, the H&P indicated, Patient 25 was medically cleared (means someone was examined by a physician and deemed healthy enough for a particular task) and was admitted to the Behavioral Health Unit (BHU, unit that provides services for patients with mental health and substance abuse issues) on a 5150 hold (California law that allows a person to be involuntary detained for up to 72 hours for psychiatric evaluation and treatment) for grave disability (unable to provide for their basic needs like food, clothing, shelter due to a mental health disorder). Patient 25 also had a history of paraplegia (loss of movement and/or sensation, to some degree, of the legs).

During an interview on 10/29/2024 at 2:30 p.m. with the BHU

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

1. Ensure one of 30 sampled Patient's (Patient 1) PRN (as needed) medication, Hydralazine (prescribed medication used to treat high blood pressure)) was administered as ordered by the physician and in accordance with the facility's policy and procedure regarding medication administration.

This deficient practice had the potential to result in worsening of Patient 1's condition with further increase in blood pressure that may result in complications such as seizure (abnormal electrical activity in the brain that can cause changes in behavior, movements, and levels of consciousness [describes a person's awareness and understanding of what is happening in their surroundings]), stroke (a clot in the brain), and/or death.

2. Ensure nursing staff performed safe medication administration for one of 30 sampled patients (Patient 10), in accordance to the facility's policy and procedure regarding medication administration, when a Licensed Vocational Nurse (LVN) 1 allowed Patient 10 walk away with two medication ointment in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders).

This deficient practice had the potential to result in Patient 10 not receiving prescribed medication correctly. This deficient practice may also cause additional complications such as Patient 10 swallowing it or giving the medication to other patients in BHU who might end up using the medications inappropriately.

3. Ensure one of 30 sampled patient's (Patient 14) Valproic acid (also known as Depakene, medication used to treat seizure disorders (abnormal electrical activity in the brain that can cause changes in behavior, movements, and levels of consciousness [describes a person's awareness and understanding of what is happening in their surroundings], mental/mood conditions, and to prevent migraine headaches), was administered in accordance with the physician's order.

This deficient practice had the potential for Patient 14's behavioral condition such as agitation (a feeling of irritability and severe restlessness) to remain unresolved and may also lead to prolonged hospitalization.

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/30/2024, the "H&P" indicated, Patient 1, "presenting from skilled nursing facility (SNF, a type of inpatient facility that provides short or long-term skilled nursing care and rehabilitation services to patients) secondary to anemia (a condition marked by a deficiency of red blood cells [transports oxygen and nutrients throughout the body]) with a history of hyponatremia (low sodium [essential nutrient that regulates blood pressure and body fluids] level in the blood) otherwise asymptomatic (showing no symptoms) alert awake (a state of active attention characterized by high sensory awareness) denies any chest pain, no emesis (vomiting), diarrhea (loose stool) ..."

During a concurrent interview and record review on 10/29/2024 at 3:59 p.m. with the Director of Medical Surgical (DMS), Patient 1's "Progress Notes (the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during treatment)," dated 5/2/2024, was reviewed. The progress note indicated on 5/2/24 at 10:13 a.m., Certified Nursing Attendant (CNA, an entry-level role that provides vital support to both patients and nurses) 1 "reports finding pt (Patient 1) sitting on the floor leaning against the wall, disoriented (having lost one's sense of time, place, or identity) to situation... Pt (Patient 1) reports losing balance and falling towards the wall onto a sitting position."

During a concurrent interview and record review on 10/29/2024 at 4:30 p.m. with the DMS, Patient 1's "Progress Notes," dated 5/3/2024 at 8:00 a.m., was reviewed. The progress notes indicate Patient 1 was "drowsy and lethargic (a symptom that involves an unusual decrease in consciousness); eyes are not open to pain, but pt. (Patient 1) is grunting (to make a short low sound instead of speaking) and moving hands to sternal rub (a technique to test an unconscious person's responsiveness)."
The DMS verified that there was no progress note by physician that Patient 1 was assessed for a change in condition (drowsy and lethargic, eyes do not open to pain) until 5/3/2024 at 10:59 p.m., when a progress note by MD 1, date of service/time was 5/3/2024 at 10:59 p.m. indicated, "24 hour event: rapid response (when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest [heart stop], or death) was called on the patient (Patient 1) at approximately 6 p.m. neurologically (the branch of medicine that deals with problems affecting the brain) twitching in all extremities was noted and neurology was called."

During a concurrent interview and record review on 10/29/2024 at 4:45 p.m. with the DMS, Patient 1's "flow sheet (track patient health data over a period of time)," for vitals dated from 5/3/2024 at 8:00 a.m., at 12:00 p.m., and at 7:15 p.m., was reviewed. Patient 1's vital signs were as follows:

On 5/3/2024 at 8:00 a.m., Patient's 1 blood pressure (BP, measures the blood pushing against the blood vessel walls when the heart beats) was elevated, 179/92. The blood pressure was not addressed. DMS confirmed that PRN (as needed) Hydralazine (prescribed medication used to treat high blood pressure) that was prescribed to be administered if the systolic BP (the first number in measurement of the pressure the blood pressure) was over 160s, was not given.
The DMS verified that the BP was not reassessed until (4 hours later) at 12:00 p.m., when the systolic BP continued to be elevated at 160. The DMS confirmed that the elevated BP was not addressed again at 12:00 p.m. On 5/3/2024 at 7:15 p.m., Patient 1's BP increased to 205/100.

During a review of the facility's policy and procedure titled, "Medication Administration," dated July 2023 indicated, "Medications not eligible for scheduled dosing times are medications that require exact or precise timing of administration, based on diagnosis type, treatment requirements, or therapeutic goals: Medications prescribed on an as needed basis ...Medications are administered only with legitimate and appropriate orders ... Before administering a medication, the authorized individual administering the medication will complete the following: Verify that the medication selected for administration is correct based on the medication order and product label ... For as needed (prn) medications, the nurse will assess the patient condition and document the need for the medication prior to administration. The patient will be monitored for patient response appropriately, and reassessment will occur per hospital policy."

2. During a review of Patient 10's "Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 10/24/2024, the Psych Eval indicated, Patient 10 was admitted to the facility with 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to being gravely disabled (inability to care self).

During an observation on 10/30/2024 at 9:03 a.m. at the facility's (Campus 2) behavioral health unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) medication room, a Licensed Vocational Nurse (LVN) 1 gave two (2) paper medicine cups to Patient 10. Patient 10 walked away with two paper medicine cups in hand.

During an interview on 10/30/2024 at 9:04 a.m. with LVN 1, LVN 1 stated the following: he (LVN 2) gave two (2) ointment to Patient 10. The two medication ointments were Vitamin A & D topical (medication applied to the skin) ointment (medication to relieve dry skin) and Preparation H Rectal Ointment (medication to relieve swelling and pain caused by hemorrhoids [swollen veins in the anus or rectum). He (LVN 1) trusted Patient 10 to do it herself (Patient 10). LVN 1 stated he (LVN 1) would not know if Patient 10 would apply the ointment correctly because he (LVN 1) did not watch Patient 10 applying them. LVN 2 stated Patient 10 could have applied at a wrong site, swallow the ointment or give to other patients.

During a review of Patient 10's physician orders, undated, the physician orders indicated Patient 10's active medications including but not limited to the following: "Preparation H Rectal Ointment, 1 application rectally daily as needed for pain with start date of 10/25/2024 and Vitamin A & D topical ointment, 1 application topical twice a day as needed for dry skin with start date of 10/25/2024."

During a concurrent interview and record review on 10/30/2024 at 9:45 a.m. with the Registered Nurse (RN) 8, Patient 10's "Medication Administration Record (MAR, record of medications given to a patient)," dated 10/30/2024, was reviewed. The MAR indicated, Patient 10 received Preparation H Rectal Ointment at 9 a.m. and Vitamin A & D topical ointment at 9:03 a.m. RN 8 stated the nursing staff should take Patient 10 aside and observe Patient 10 apply the ointment to the correct area if she (Patient 10) would like to apply herself (Patient 10).

During an interview on 11/1/2024 at 9:30 a.m. with the Nurse Manager (NM) 1 of BHU, NM 1 stated nursing staff should not let patients walk out with medicine cups because there were medications inside. NM 1 stated the nursing staff should apply ointment for patients or observe patients applying. NM 1 stated there was risk for patients eating the ointment or giving to someone who did not need it.

During a concurrent interview and record review on 11/1/2024 at 10:14 a.m. with the Director of Pharmacy (PHARM), the facility's policy and procedure (P&P) titled, "Medication Administration," dated 7/2023, was reviewed. The P&P indicated, "To ensure medications are administered by authorized individuals in a safe and timely manner to meet the needs of the patient ... the authorized personnel will observe the patient take the medication and will stay with the patient until he/she has swallowed the medication." PHARM stated the P&P should be more extensive to include different routes including topical application but nursing staff should observe ointment was applied per physician order. PHARM stated it was not a complete medication administration if nursing staff did not observe the ointment being applied as ordered by physician.

3. During review of Patient 14's "Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated 8/13/2024, Patient 14 presented to the Facility Campus 3 (Campus 3) with increased bizarre and disorganized behavior, agitation (a feeling of irritability and severe restlessness) with thoughts of suicide (thoughts of ending one's own life).

During a concurrent interview and record review on 11/01/2024 at 9:33 a.m. with Charge Nurse 2 (CN 2), CN 2 verified Patient 14's, "Order Information," dated 10/06/2024 indicated a physician's order for Patient 14 to receive valproic acid (Depakene, medication used to treat seizure disorders [abnormal electrical activity in the brain that can cause changes in behavior, movements, and levels of consciousness which describes a person's awareness and understanding of what is happening in their surroundings], mental/mood conditions, and to prevent migraine headaches) 250 milligram/5 milliliter (mg/ml, a unit of measurement) by mouth 1000 mg twice a day after meals.

During the same interview and record review on 11/01/2024 at 9:33 a.m., CN 2 verified Patient 14's "Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient)," indicated Patient 14's Depakene scheduled dose on 10/28/2024 at 6:00 p.m. was omitted. CN 2 stated Patient 14's record did not have clinical documentation as to why Patient 14's Depakene was omitted. CN 2 further stated, Patient 14's Depakene was for mood stabilization and if omitted could cause Patient 14 to become agitated and frustrated.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," reviewed in 07/2023, the P&P indicated, "Time critical scheduled medication include: ...Psychotropic medications (drugs that affect the mind, behavior, and emotions) require timely administration to ensure patients and staff safety ...When medications eligible for a scheduled dosing time are not administered within the defined time period, the nurse will: i. Document the reason the dose was missed or delayed...Notify the prescribing/attending physician if the delay poses an immediate patient care issue and for time-critical medication...Medication errors that are the result or missed or late dose administration must be reported in accordance with hospital policy."

During a review of the facility's policy and procedure (P&P) titled, "Medication: Error Reporting," reviewed in 02/2023, the P&P indicated, "Medication error shall be reported and reviewed in accordance with this policy ...Examples of medication errors included but are not limited to: ...omission of a dose ...Reports to practitioner who ordered the drug. Medication errors shall be reported in a timely manner to the practitioner who ordered the drug...E. Recording errors in patient's record. The drug administered in error or omitted in error and the action taken shall be properly recorded in the patient's medical record...The facility shall review all medication error reports."