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Based on observation, administrative interviews, and administrative document reviews, the hospital did not ensure the Patient Rights, in a manner sufficient to ensure behavioral health quality and patient safety, when it did not:

1) Ensure clear expectations for safety was established for all facility staff and patients. (Cross Reference A-145);

2) Ensure the right for freedom from abuse was coordinated, responded to, investigated and reported by the facility for all patients. (Reference A-145); and,

3) Ensure patients' right for Informed Consent and response to Grievances for all patients. (Reference A-123, A-131).

The cumulative effect of these systemic problems resulted in a decrease in patient safety and the facility's inability to ensure the provision of quality health care in a safe environment, when: Patient-to-Patient Assaults and Staff-Patient Assaults were not effectively reported, investigated, assessed and monitored to ensure patient safety; when Patient Rights for Informed Consent for administration of anti-psychotic medications were not completed; and, when Patient Grievances and Complaints were not responded to in time-dependent manner.

Based on interview and record review, the facility failed to send written letters of grievance resolutions, according to the facility policy and procedure, to three patients:

1.) Patient I, one of 23 unsampled patients;
2.) Patient H, one of 23 unsampled patients; and,
3.) Patient 5, one of 12 sampled patients.

This failure resulted in violation of patient rights and possible missed opportunities for improvement of patient care.

Findings:

1. Patient I's Face Sheet (demographic information), undated, indicated Patient I was admitted to the facility on 8/02/24, and was discharged from the facility on 8/04/24.

During a review of the facility Grievance Log, it indicated the facility received a grievance from Patient I, dated 8/4/24, at 10:30 a.m. Patient I reported not getting the help needed to get around, sustaining a big bruise on the side of her leg from not getting help taking clothes off and taking a shower.

During a review of the facility Grievance Log Follow-up form, dated 8/20/24 at 4 p.m., Patient I was contacted and reported the following: a. She had bruises from getting in and out of bed; b. She was told she would have 1:1 care; c. Her son talked to the doctor and was told Patient I was not med [medication] compliant and did not attend groups; and, d. Staff acted "snobby" as if they did not like their jobs.

During an interview on 9/12/24 at 9:10 a.m. with Patient Ambassador (PA), the PA stated by the time she received Patient I's grievance/complaint, Patient I had been discharged from the facility. The PA further stated she did not send a resolution letter to Patient I.

During an interview on 9/12/24 at 10:34 a.m., with Risk Manager (RM), the RM stated she could provide no documentation of a follow-up resolution letter that addressed Patient I's grievance, but the facility should have sent a letter with resolution to Patient I.

During a review of the facility's policy and procedure (P&P) titled, "Grievance and Complaints," dated 5/26/22, the P&P indicated, "III. Definitions... Grievance: The written or verbal report of issues that cannot be addressed immediately, may concern an alleged violation of patient rights... Complaints that are not resolved prior to the patient's discharge and all grievances will be acknowledged in writing... A resolution letter shall be sent within 30 calendar days and shall include: a. The name of the hospital contact person b. A description of the nature of the concern c. The actions taken to investigate the concern d. Results of actions taken e. Date of completion of the grievance process."


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2. During a review of Patient H's Facesheet (demographics), undated, the Facesheet indicated Patient H was admitted on 7/26/24, with admitting diagnosis of unspecified psychosis (a group of symptoms that causes a person to lose touch with reality, disrupting their thoughts and perceptions) and was discharged on 8/1/24.

During a review of the Grievance Log entry for Patient H's complaint, dated 8/1/24, the entry indicated Patient H submitted a written complaint alleging that Mental Health Technician (MHT), "[name] shaved my vagina in my sleep and injected me with something attached to syringe and needle and cut my hair and stuck something in my vagina." The entry also indicated the complaint was resolved on 8/2/24.

During a review of the Complaint / Grievance Summary, undated, the form indicated a follow-up call to Patient H was attempted on 8/6/24, but did not indicate a resolution letter was sent.

During an interview on 9/12/24 at 3:25 p.m., with the Risk Manager (RM), the RM stated the facility was unable to find evidence that a resolution letter was sent after the grievance was resolved.

During a review of the facility's policy and procedure (P&P) titled, "Grievance and Complaints," dated 5/26/22, the P&P indicated, "III. Definitions... Grievance: The written or verbal report of issues that cannot be addressed immediately, may concern an alleged violation of patient rights... Complaints that are not resolved prior to the patient's discharge and all grievances will be acknowledged in writing... A resolution letter shall be sent within 30 calendar days and shall include: a. The name of the hospital contact person b. A description of the nature of the concern c. The actions taken to investigate the concern d. Results of actions taken e. Date of completion of the grievance process."


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3. During a review of Patient 5's Facesheet (demographics), [undated], the Facesheet indicated Patient 5 was admitted to the facility on 3/4/2024, and discharged on 3/11/2024. The Facesheet further indicated, Patient 5's admitting diagnoses included major depressive disorder. In addition, the Facesheet indicated, Patient 5 had previously been admitted to the facility on, 11/3/2023 through 12/5/2023.

During a review of Patient 5's, "Psychiatric Progress Note," dated 3/6/2024 at 8:24 a.m., the "Psychiatric Progress Note," indicated Patient 5 reported she was raped during her last admission (11/30/2023 through 12/5/2023) and had not reported the incident when it happened. The progress note further indicated during the Psychiatrist's assessment, "[Patient 5] saw the man who she says raped her... he just passed by."

During a review of Patient 5's, "Interdisciplinary Progress Note (IDN)," dated 3/6/2024 at 12:14 p.m., completed by Licensed Clinical Social Worker (LCSW), the IDN indicated, "Pt (Patient 5) reported a sexual assault incident occurred last time she was admitted here." The IDN indicated LCSW had notified the Department of Social Services and Risk Management (RM) of the incident.

During an interview on 9/11/2024 at 2:20 p.m., with the RM, the RM stated a patient complaint that could be resolved during the hospitalization, such as lost personal belongings, would be considered a complaint. The further stated, "If we were unable to resolve the complaint, we would consider it a grievance... I think it's our practice to follow up grievances with a letter." The RM stated she was unable to find documented evidence that a grievance resolution letter had been sent to Patient 5 after discharge.

During a review of the facility's policy and procedure (P&P) titled, "GRIEVANCE AND COMPLAINTS," dated 5/26/2022, the P&P indicated, "III. Definitions... Grievance: The written or verbal report of issues that cannot be addressed immediately, may concern an alleged violation of patient rights. Complaints that are not resolved prior to the patient's discharge and all grievances will be acknowledged in writing. A resolution letter shall be sent within 30 calendar days and shall include: a. The name of the hospital contact person. b. A description of the nature of the concern. c. The actions taken to investigate the concern. d. Results of actions taken. e. Date of completion of the grievance process."

Based on interview and record review, the facility failed to ensure Informed Consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a medical treatment) regarding psychotropic medications (drugs that affect a person's mental state) were obtained, per the facility's policy and procedure, for four of 12 sampled patients (Patient 1, 6, 7, 8) and five of 25 unsampled patients (Patient A, B, C, D, E).

1. Sampled Patient 6 and Patient 7's Informed Consent forms were incomplete.
2. Sampled Patient 1's Informed Consent form was incomplete.
3. Unsampled Patient A, B, C, D, and E's Informed Consent forms were incomplete.
4. Sampled Patient 8's Informed Consent form was incomplete.

These failures had the potential to violate patients' rights to make informed decisions regarding their treatment based on a complete Informed Consent process.

Findings:

1.a. During a review of the Patient 6's Facesheet (demographics), undated, the Facesheet indicated Patient 6 was admitted on 8/30/24, with admitting diagnoses of major depressive disorder, and recurrent and severe psychotic symptoms.

During a concurrent interview and record review on 9/10/24 at 2:28 p.m. with Nurse Manager EE, Patient 6's Informed Consent form, dated 8/30/24, was reviewed. The psychotropic medication Informed Consent form for the administration of the following medications did not include a max (maximum) dosage and was not signed by a psychiatrist: Lithium, Seroquel, Klonopin. Nurse Manager EE stated all psychotropic medications needed to have a signed Informed Consent forms and max dosage for each psychotropic medication listed. Nurse Manager EE verified Patient 6's Informed Consent form was not properly filled out.

During an interview on 9/12/24 at 1:55 p.m., with the Psychiatrist, the Psychiatrist stated verbal and written Informed Consent forms needed to be completed before psychotropic medications were ordered and administered.

During an interview on 9/12/24 at 2:13 p.m., with Psychiatrist BB, Psychiatrist BB stated Informed Consent forms for psychotropic medications should include the name of the medication, dosing, explanation of side effects, and signatures of patient and psychiatrist.

During a review of Patient 6's Medication Administration Record (MAR), dated 8/30/24 to 9/11/24, the MAR indicated Patient 6 was administered the first dose of the following medications on the corresponding dates:
A. Clonazepam (Klonopin) on 8/30/24, for agitation;
B. Lithium on 8/30/24, for mood; and,
C. Quetiapine (Seroquel) 8/30/24, for psychosis (a group of symptoms that cause a person to lose touch with reality, disrupting their thoughts and perceptions).

During a review of the facility's policy and procedure (P&P) titled, "Consent for Medications, Treatments and Procedures," dated 5/26/22, the P&P indicated, "The purpose of this policy is to provide a process for obtaining consent for patients in accordance with state law. [Name of facility] requires informed consent for psychotropic medication... the attending psychiatrist will be responsible for the consent procedure for psychotropic medication. The consent form must include the medication and dosage ranges ... This will be documented on the consent form prior to psychotropic meds being given."

1.b. During a review of the Patient 7's Facesheet (demographics), undated, the Facesheet indicated, Patient 7 was admitted on 9/3/24, with an admitting diagnosis of major depressive disorder and was discharged on 9/9/24.

During a concurrent interview and record review on 9/10/24 at 2:28 p.m., with Nurse Manager EE, Patient 7's Informed Consent form, dated 8/30/24, was reviewed. The psychotropic medication Informed Consent form for the administration of the following medications did not include a max dosage and was not signed by a psychiatrist: Lithium, Seroquel, Klonopin. Nurse Manager EE stated all psychotropic medications needed to have a signed Informed Consent form and max dosage for each psychotropic medication listed. Nurse Manager EE verified Patient 7's Informed Consent form was not properly filled out.

During an interview on 9/12/24 at 1:55 p.m., with the Psychiatrist, the Psychiatrist stated verbal and written Informed Consent forms needed to be completed before psychotropic medications were ordered and administered.

During an interview on 9/12/24 at 2:13 p.m., with Psychiatrist BB, Psychiatrist BB stated Informed Consent forms for psychotropic medications should include the name of the medication, dosing, explanation of side effects, and signatures of patient and psychiatrist.

During a review of Patient 7's Medication Administration Record (MAR), dated 9/3/24 to 9/9/24, the MAR indicated Patient 7 was administered the first dose of the following medications on the corresponding dates:
A. Aripiprazole on 9/3/24, for, "major depressive disorder, single episode, unspecified;"
B. Benztropine on 9/3/24, for EPS (group of side effects that can result from taking antipsychotic drugs);
C. Duloxetine on 9/3/24, for, "major depressive disorder, single episode, unspecified;"
D. Gabapentin on 9/3/24, for Anxiety;
E. Trazodone on 9/5/24, for insomnia; and,
F. Hydroxyzine on 9/8/24, for mild anxiety.

During a review of the facility's policy and procedure (P&P) titled, "Consent for Medications, Treatments and Procedures," dated 5/26/22, the P&P indicated, "The purpose of this policy is to provide a process for obtaining consent for patients in accordance with state law. [Name of facility] requires informed consent for psychotropic medication... the attending psychiatrist will be responsible for the consent procedure for psychotropic medication. The consent form must include the medication and dosage ranges ... This will be documented on the consent form prior to psychotropic meds being given."


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2. During a review of Patient 1's clinical record, indicated Patient 1 was admitted on 9/4/2024, for a diagnosis of Psychosis (a mental disorder that causes people lose contact with reality).

During a review of Patient 1's, "Informed Consent for the Administration of Psychotropic Medications," dated, 9/4, indicated, " ... 2. My physician is proposing the following medications (Medication Name, Max dose):

Depakote (for the treatment of bipolar);

Haldol (for severe aggression); and,

Lithium (for the treatment of bipolar)."

The psychiatrist signature was left blank, and there was no max dose documented.

During an interview on 9/10/2024, at 2:35 PM with Psychiatrist CC, Psychiatrist CC stated she did not sign the Informed Consent for psychotropic medication for Patient 1. Psychiatrist CC further stated she had a face-to-face conversation with Patient 1 and received a verbal consent but did not document it in the clinical record. Psychiatrist CC stated she was not aware she had to complete the max dose on the Informed Consent.

During a review of the facility's policy and procedure titled, "Consent for Medications, Treatments and Procedures, dated, 5/26/2022, indicated, " ... II Procedure: 1. Medication: a. The attending psychiatrist will be responsible for the consent procedure for psychotropic medication. The consent form must include the medication and dosage ranges. The consent procedure may be done in person with the patient or by a 3-way phone conversation between the patient, physician and nurse and parents/legal guardian for patients under 18 years of age ... This will be documented on the consent form prior to psychotropic meds being given."


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3. Unsampled Patients A, B, C, D, E did not have completed Informed Consent forms in their medical records.

During a review of Patient A's Face Sheet, undated, it indicated Patient A was admitted on 9/04/24, with an admitting diagnosis of unspecified psychosis (a group of symptoms that cause a person to lose touch with reality and have difficulty distinguishing what is real and what is not).

During a review of Patient A's Medication Administration Record (MAR), the MAR indicated Patient A was administered the following medications:
1. Olanzapine DT tab, 5 mg (medication to prevent psychosis or antipsychotic)

During a record review of Patient A's medical record, there was no Informed Consent form located in Patient 5's medical record.

During a review of Patient B's Face Sheet, undated, it indicated Patient B was admitted on 8/23/24, with an admitting diagnosis of major depressive disorder.

During a review of Patient B's MAR indicated Patient B was administered the following medications:
1. Fluoxetine capsule 80 mg (anti-depressive medication), on 8/29/24, and daily thereafter through 9/10/24; and,
2. Trazadone tablet 50 mg (anti-insomnia), on 8/26/24, and daily thereafter through 9/9/24.

During a record review of Patient B's medical record, Patient B's Informed Consent form was not signed by the prescribing MD nor was the medication strength and dosage written on the form.

During a review of Patient C's Face Sheet, undated, it indicated Patient C was admitted on 8/23/24, with an admitting diagnosis of major depressive disorder.

During a review of Patient C's MAR, it indicated Patient C was administered the following medications:
1. Divalproex sodium ERT ER 500 mg (mood stabilizer), twice a day on 8/23/24, and twice daily thereafter through 9/10/24;
2. Trazadone tablet 50 mg, at bedtime (for insomnia) daily on 8/25/24, and daily thereafter through 9/5/24; and,
3. Hydroxyzine pamaote 50 mg (for anxiety) every six hours as needed for mild anxiety, on 8/26/24, 9/2/24, and 9/5/24.

During a record review of Patient C's medical record, Patient C's Informed Consent form was not signed by the prescribing MD, nor was the medication strength and dosage written on the form.

During a review of Patient D's Face Sheet, undated, it indicated Patient D was admitted on 8/13/24, with an admitting diagnosis of unspecified psychosis.

During a review of Patient D's MAR, it indicated Patient D was administered the following medications:
1. Risperdone tablet 1 mg (for mood) twice a day, daily on 8/14/24 and 8/15/24;
2. Lorazepam tablet 2 mg (as needed for emergent [symptoms]), on 8/15/24;
3. Haloperidol solution 5 mg (for emergent [symptoms]), on 8/15/24;
4. Ativan solution 2 mg (for emergency [symptoms]), on 8/15/24; and,
5. Risperdone tablet 2 mg (for mood), twice a day, on 8/16/24, and twice daily thereafter through 8/20/24.

During a record review of Patient D's medical record, Patient D's Informed Consent form was not signed by the prescribing MD, nor was the medication strength and dosage written on the form.

During a review of Patient E's Face Sheet, undated, it indicated Patient E was admitted on 9/09/24, with an admitting diagnosis of unspecified psychosis.

During a review of Patient E's MAR, it indicated Patient E was prescribed the following medications:
1. Haloperidol tablet 5 mg (as needed for severe aggression), start on 9/9/24, end on 10/8/24;
2. Hydroxyzine pamoate 50 mg (as needed for mild anxiety), start on 9/9/24, end on 10/8/24; and,
3. Trazadone tablet 50 mg (as needed for insomnia), start on 9/9/24, end on 10/8/24.

During a record review of Patient E's medical record, there was no Informed Consent form located in Patient E's medical record.

During an interview on 9/12/24 at 2:45 p.m. with the Nurse Educator (NE), the NE acknowledged the missing documents and appropriate signatures. The NE stated Informed Consents for psychotropic medications should be signed by the patient or Responsible Party, the nurse and the MD who prescribed the medication, and the medication strength and dosage should be noted on the form as well.

During an interview on 9/12/24 at 3 p.m., with the Chief Nursing Officer (CNO), the CNO stated Informed Consent forms should be completed for each patient with medication strength, dosage and signatures by patient/Responsible Party, nurse and MD prescriber.

During a review of the facility's policy and procedure (P&P) titled, "Consent for Medications, Treatments and Procedures," dated 5/26/2022, the P&P indicated, "The purpose of this policy is to provide a process for obtaining consent for patients in accordance with state law. [Name of facility] requires informed consent for psychotropic medication... the attending physician will be responsible for the consent procedure for psychotropic medication. The consent form must include the medication and dosage ranges..."


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4. During a review of Patient 8's Facesheet (demographics), [undated], the Facesheet indicated Patient 8 was admitted to the facility on 8/6/2024. Patient 8's admitting diagnosis was unspecified psychosis (a loss of grasp on reality).

During a review of Patient 8's, "Physician Medication Orders," dated 8/6/2024 through 9/10/2024, the, "Physician Medication Orders," indicated on 8/21/2024, Patient 8 was prescribed Risperdal (antipsychotic medication), 1 milligram (mg) by mouth daily, by Psychiatrist CC. In addition, the physician medication orders indicated the indication for Risperdal was, "psychosis."

During a review of Patient 8's, "INFORMED CONSENT FORM FOR THE ADMINISTRATION OF PSYCHOTROPIC MEDICATION (S)," dated 8/21/2024, the Informed Consent form indicated, "2. My physician is proposing the following medications (Medication Name, Maximum dose): Risperdal." Review of the Informed Consent form indicated, the medication Risperdal was handwritten in the designated space without a maximum dose. Review of the Informed Consent form indicated, "We discussed how the proposed medication(s) may be helpful in my treatment...We talked about the possible risks and benefits of my medication(s)... black box warnings... common side effects." Further review of the Informed Consent form indicated the space at the bottom of the Informed Consent, where the Psychiatrist was to sign, date, and time the document, was left blank.

During an interview on 9/10/2024 at 9:30 a.m., with Nurse Manager EE (NM EE), for Units 400 and 500, NM EE stated the Psychiatrist was supposed to sign the Informed Consent forms.

During a concurrent interview and record review on 9/12/2024 at 9:40 a.m., with Pharmacist DD, Patient 8's, "Medication Administration Record (MAR)," dated, 8/21/2024 through 9/12/2024, was reviewed. Pharmacist DD stated on 8/21/2024, Patient 8 was administered Risperdal 1 mg daily. On 8/24/2024, the Risperdal was increased, and Patient 8 was administered 2 mg. Pharmacist DD further stated on 8/26/2024, the Risperdal dosage was increased, and Patient 8 was administered 3 mg twice a day, which was the current dose Patient 8 was receiving. In addition, Pharmacist DD stated the maximum dosing range for Risperdal was up to 16 mg/day.

During an interview on 9/12/2024 at 1:40 p.m., with Psychiatrist CC, Psychiatrist CC stated she would stop by Health Information Management and sign the Informed Consent forms after the patients were discharged. Psychiatrist CC stated, "The Informed Consent forms should be signed before starting treatment."

During a review of the facility's policy and procedure (P&P) titled, "Consent for Medications, Treatments and Procedures," dated 5/26/2022, the P&P indicated, "The purpose of this policy is to provide a process for obtaining consent for patients in accordance with state law. [Name of facility] requires informed consent for psychotropic medication... the attending physician will be responsible for the consent procedure for psychotropic medication. The consent form must include the medication and dosage ranges."

Based on observation, interview and record review, the facility failed to ensure three sampled patients (Sampled Patient 2, Sampled Patient 5, Sampled Patient 9), and 11 Unsampled Patients (Unsampled Patient R, Unsampled Patient AA, Unsampled Patient Q, Unsampled Patient N, Unsampled Patient O, Unsampled Patient P, Unsampled Patient G, Unsampled Patient T, Unsampled Patient U, Unsampled Patient V, Unsampled Patient H) received the right to be free from all forms of abuse, when:

1. Two Sampled Patients (Sampled Patient 5 and Sampled Patient 9) and three Unsampled Patients (Unsampled Patient O, Unsampled Patient R, Unsampled Patient T) were slapped, punched and had their heads slammed on a table on 2/24/24, 3/31/24, 4/5/24, 7/11/24.

2. Three Sampled Patients (Sampled Patient 2, Sampled Patient 5 and Sampled Patient 9), and 11 Unsampled Patients (Unsampled Patient R, Unsampled Patient AA, Unsampled Patient Q, Unsampled Patient N, Unsampled Patient O, Unsampled Patient P, Unsampled Patient T, Unsampled Patient U, Unsampled Patient V, Unsampled Patient G, and Unsampled Patient H), who lodged allegations of sexual and physical abuse, which were not thoroughly investigated, documented or reported to the California Department of Public Health within 24 hours.

These incidents resulted in patients experiencing split lips, headaches, dizziness, pain, fear, and anger and had the potential to contribute to longer hospitalizations due to depression, increased assaultive behaviors, re-hospitalization, lack of trust, and the potential for additional psycho-social harm and suicide.

Findings:

1. During a concurrent interview and video record review, on 9/11/24, at 1:15 p.m., with the Performance Improvement Analyst (PIA), the video indicated an assaultive incident on 3/31/24, at 3:55 p.m., in Unit 100 Day Room. The video indicated 12 adolescent patients were seated at tables and chairs. The video indicated at 3:55 p.m., a Mental Health Technician walked out of the room. The video indicated at 3:56 p.m., Unsampled Patient P walked to Unsampled Patient O, who was sitting at the table. The video indicated Unsampled Patient P punched Unsampled Patient O two times, from behind, with right- and left-handed closed fists. The video indicated Unsampled Patient O was punched on both sides of her head, ears and face. The video indicated Unsampled Patient O held her head, did not move, and sobbed. The PIA stated, "It looked like [Unsampled Patient O] was in shock. This was a significant event considering her vulnerable state." She stated Unsampled Patient O looked, "Distraught," and, "[Unsampled Patient P] looked menacing." The video indicated staff entered the Day Room and removed Unsampled Patient P. The video indicated an observation of one staff who recreated the incident by demonstrating how Unsampled Patient P punched Unsampled Patient O with both closed fists. The video indicated an observation Patient O was sobbing uncontrollably, her shoulders were shaking, her face appeared with her mouth open, sobbing and crying with an expression of fear (Open mouth, with the lips tight, the mouth flattens into a sideways oval. The corners of the mouth pull back and the lips might cover the front teeth. A quivering mouth).

During a concurrent interview with the PIA, and video record review, on 9/11/24, at 1:40 p.m., a video indicated Unit 500 Hallway on 7/10/24 at 7:39 a.m. The video indicated a Mental Health Technician seated on the left side of the hallway across from Unsampled Patient N's doorway. The video indicated a second Mental Health Technician standing outside Unsampled Patient N's doorway. The video indicated the positions of the Mental Health Technicians directly across from one another, reduced the walkway access distance of the hallway. The video indicated Sampled Patient 9, seated directly under the telephone, located three doors away from Unsampled Patient N's doorway. The video indicated on 7/10/24 at 7:39 a.m., Unsampled Patient N was in the doorway of his room. At the same time, the seated Mental Health Technician on the left side of the hallway, was talking to a third patient, and the walkway past Unsampled Patient N's doorway was constricted by three people, directly across from one another. The video indicated at 7:39.38 a.m., Unsampled Patient N walked out of his room into the hallway, when Sampled Patient 9 stood up and walked down the hallway, in an attempt to walk past the two Mental Health Technicians and Unsampled Patient N. The video indicated Sampled Patient 9 was forced to walk past Unsampled Patient N, within striking range, because of the placement of the two Mental Health Technicians on both sides of the hallway. The video indicated Unsampled Patient N walking towards Sampled Patient 9, and threw two punches with his right and left closed fists, to the right side of Sampled Patient 9's face. The PIA stated no actions were noted to be taken until after Unsampled Patient N had thrown his first punch and made contact with Sampled Patient 9's face. The video indicated at 7:40.58 a.m., the Mental Health Technician, behind Unsampled Patient N, had pulled him back into his room. The video indicated Sampled Patient 9 appeared upset and agitated, he checked his face and mouth with his fingers. The PIA stated, "He looked upset like he was checking for blood or an injury and ran back to his room." She stated Unsampled Patient N had a reputation for assaultive and dangerous actions. She stated, "If I was a patient I would stay away from him."

During a concurrent interview, video record review, and record review on 9/11/24, at 1:50 p.m., with the PIA, the video indicated Unit 300's Day Room on 2/24/24 at 11:09.32 a.m. The video showed only Unsampled Patient T's legs, Unsampled Patient U and Unsampled Patient V, in the upper right side of the video. The video was not able to indicate the entire Unit 300 Day Room, which resulted in an observation of all the Unsampled Patients from the waist down only. The PIA stated the camera did not provide observation of the entire Day Room. She stated the video had been reviewed by Administration and had not been re-adjusted to provide a view of the entire room. A review of a document titled "CAMERA REVIEW of EVENTS - IR PE-24-53590," indicated Unsampled Patient U wore, "plaid paints in wheelchair / knee brace." Unsampled Patient V wore, "red shirt, gray pants, dark purple hair." The PIA reviewed the video and stated, "You can see [Unsampled Patient U] get up and walk to where [Unsampled Patient T] was seated in the corner." The video indicated on 2/24/24, at 11:09.32 a.m., Unsampled Patient V's legs, seated in a wheelchair, wearing a leg brace. At 11:09.55 a.m., the video showed Unsampled Patient V stand up and walk in the direction of Unsampled Patient T, where she lunged in the direction of Unsampled Patient T. The video captured a disturbance occurred. The PIA stated, "There appears to be more than one assault occurring, but you can't clearly see the actions as the bodies aren't visible on video." The video indicated at 11:10.29 a.m., seven facility staff members entered the Day Room, 34 seconds after the start of the assaultive incident. The PIA stated she remembered this incident, and there were three patients involved in the assault of Unsampled Patient T. She stated, "I spoke with her mother, and she was very upset and wanted [Unsampled Patient T] discharged." The PIA stated Unsampled Patient T's mother had, "Heard from her daughter that she was assaulted." The PIA stated she did not know what the Policy and Procedure for reporting to parents, guardians, or the California Department of Public Health were.

During an interview and concurrent record review with the RM on 9/12/24 at 2:15 p.m., she stated the facility investigation into the Facility-Reported Incident for Unsampled Patient Q's allegations of being touched on her breasts by Unsampled Patient R, that occurred on 4/5/24 and 4/7/24, indicated the facility had concluded the allegation of inappropriate touching by Unsampled Patient R to Unsampled Patient Q, had not occurred.

During the concurrent interview and medical record review with the RM, on 9/12/24, at 2:30 p.m., Unsampled Patient's R medical record was reviewed, and she stated it indicated an additional witnessed patient-to-patient assault incident between Unsampled Patient AA and Unsampled Patient R, on 4/4/24, that resulted in Unsampled Patient R getting a bloody lip. The RM stated both incidents were not on the facility Occurrence List. She stated both of the incidents were not documented in the facility risk system titled, "Risk Connect," (An email reporting system used by staff to report actual observations or allegations of abuse to the Risk Department). She stated there was no document found in the facility risk management system of how the assault on Unsampled Patient R on 4/5/24, was investigated or resolved. The RM stated there was no documentation that indicated this incident was reported to the facility risk management, or reported in the morning flash meeting, and she stated she could not find documentation that indicated he was assessed by nursing or the physician. She stated the current system was not effective at documenting, tracking or following-up with abuse allegations. She stated the facility should have filed reports to Children Protective Services and self-reported to California Department of Public Health. The RM stated she did not know what the definition of harm was, but stated the facility did not consider an assault, that did not require a trip to the Emergency Room, rising to the level of being reported to the California Department of Public Health.

During the concurrent interview and medical record review with the RM, on 9/12/24, at 2:30 p.m., Unsampled Patient AA's medical record was reviewed, and it indicated on a document titled, "General Progress Notes," dated 4/5/24 at 4 p.m., "Patient was doing a group therapy in the day room when all of a sudden he punched one of the patient on the face and his lip was bleeding." The RM stated there was no documentation of the incident in Unsampled Patient R's medical record about being punched by Unsampled Patient AA on 4/4/24. She stated there was no documentation in the Unusual Reporting tool titled, "Risk Aware." She stated she was unable to find any documentation this incident was investigated, and it was not reported to the California Department of Public Health or Child Protective Services. She stated there was no investigation file in the Risk Department files. She stated, "We only send reports for a patient injury level that get sent out to the Emergency Room for assessment." She stated, "Only if an injury is sustained by a patient, like bloody nose, do we report it as an Unusual Occurrence." She stated she did not know what the Center for Medicare Services' (CMS) definition of harm or injury was. She stated Unsampled Patient R did have a bloody lip, and it should have been reported.

A review of an investigation document for Unsampled Patient O, titled "California Healthcare Event and Reporting Tool," indicated "Date of Incident: 3/31/24.....Reported Date: 4/4/2024." The incident was not reported to the California Department of public health until four days after the incident occurred.

A review of the facility document titled, "Occurrence Report Summary," indicated "DATE OF INCIDENT: 3/31/24.....DATE Received: 4/1/24.....Summary of Event: Unsampled Patient P approached Unsampled Patient O from behind in the 100 Day Room and pushed her head against the table two times and then hits her two times as staff run over and intervene. Outcome: RN Assessment Data: Pt was hit on her head by another pt in an unprovoked attack. She was complaining of headache, dizziness & left arm pain."

A review of a document for Unsampled Patient O, titled, "FACESHEET," indicated she was a 17 year-old female, admitted 3/27/24, discharged 4/1/24, with admitting diagnoses that included Major Depressive Disorder (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts), recurrent severe without psychotic features, Suicidal Ideation's, and Anxiety Disorder.

A review of a document for Unsampled Patient O titled, "Psychiatric Progress Notes," dated 3/31/24, indicated, "This afternoon, patient was struck unprovoked by peer. ...She was complaining of headache, dizziness & left arm pain. Medical Hospitalist notified and recommend transfer to ER for evaluation."

A review of a document for Unsampled Patient O, titled, "Psychiatric Progress Note," dated 4/1/24, indicated, "Patient seen on rounds today and discussed with staff. Yesterday patient attacked peer unprovoked, including striking her head on the table in the dayroom."

A review of a document for Unsampled Patient O, titled, "Psychiatric Progress Note," dated 4/2/24, indicated, "The patient is unable to care for physical or psychiatric needs. The patient is at risk for decompensation and readmission to the hospital ... Patient recently attacked peer unprovoked. "

A review of a document for Unsampled Patient O, titled, "General Progress Note," dated 4/1/24, indicated, "Pt was hit on her head by another pt in an unprovoked attack. She was complaining of headache, dizziness & left arm pain."

A review of a document for Unsampled Patient P, titled, "Nursing Progress Notes," dated 4/1/24, indicated, "Patient stated that she is having flashbacks to the assault on 3/31/24, when she closes her eyes. Patient stated that she still has a headache and that her body is sore."

A review of a document for Sampled Patient 9, titled, "Face Sheet," indicated he was a 51 year-old male admitted 6/28/24, and discharged 7/18/24, with diagnoses that included Unspecified Psychosis (A severe mental condition in which thought and emotions are so affected that contact is lost with external reality), Suicidal Ideation's, and Homelessness.

A review of a facility investigation document for Sampled Patient 9, titled, "Occurrence Report Summary," indicated, "DATE OF INCIDENT: 7/10/24, DATE RECEIVED 7/11/24, Summary of Event: Unsampled Patient N punched Sampled Patient 9 in face both sides approximately 4 times unprovoked in hallway.....Investigation: ...The hallway monitor, MHT, is seated across the hall from Unsampled Patient N's room and the chair blocked part of the hallway forcing patients to walk closer to Unsampled Patient N's door on their way to the day room. The 1:1 staff member was standing next to Unsampled Patient N in the hall when the peer, Sampled Patient 9, entered Unsampled Patient N's strike zone."

A review of a document titled, "California Healthcare Event and Reporting Tool," indicated "Date of Incident: 7/10/24, Time of Incident 7:44 AM....Reported Date: 7/11/24 Time of Incident 5:43 PM. (34 hours after the video taped assault on Sampled Patient 9).

A review of a document for Sampled Patient 9 titled, "General Progress Note," dated 7/10/24, indicated, "Patient was assaulted by peer....Tylenol administered for pain. Transferred to Unit 400 for safety."

A review of a document for Sampled Patient 9 titled, "Nursing Progress Note," dated 7/11/24, indicated, "Pt reports he is still having some pain in his jaw after a peer assaulted him earlier in the day. Pt taking (medication) for pain."

A review of a document for Sampled Patient 9 titled, "General Progress Note," dated 7/10/24, indicated, "Patient was assaulted by peer."

A review of a document for Sampled Patient 9 titled, "Interdisciplinary Progress Note," dated 7/10/24, indicated, "Met with patient to follow up on patient's request to press charges on another patient who assaulted him....Patient reported being 'okay' following the attack but complained of pain to his jaw. Nursing confirmed that patient would be receiving an x-ray on his jaw."

A review of a document for Unsampled Patient N titled, "Face Sheet," indicated he was a 26 year-old male admitted 8/12/22, and discharged 8/26/24, with diagnoses that included Unspecified psychosis (Delusions that cannot be clearly determined or characterized) and Schizophrenia (A serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality).

A review of a document for Unsampled Patient N, titled, "General Progress Note," dated 7/10/24, indicated, "Patient came out of his room and punched a peer in the face four times that was walking by.....A manual hold was initiated to bring the patient to a quiet room, was administered Ativan, and was placed in seclusion."

A review of a facility document titled, "CAMERA REVIEW of EVENTS - IR PE-24-53590," dated 3/14/24, indicated, "Date of event: 2/24/24, Time of event: 11:15:40.....Nature of event: Assaultive Episode, Manual Hold, Seclusion." The document did not indicate if the incident was escalated, reported in Flash or Closed.

A review of a investigation document for Unsampled Patient T, of an online Self-Reported Adverse Event Document, indicated the facility reported this assaultive event occurred on 2/24/24, and reported it to the California Department of Public Health on 2/29/24. The document indicated, "14-year-old female patient approached 17-year-old female peer and started to punch her. She was struck several times as staff intervened. Patient examined by Hospitalist for soft tissue injury, recommended oral analgesic and ice applied to site."

A review of a document for Unsampled Patient T, titled, "Facesheet," indicated, "Admit date 2/23/24.....Discharge Date 2/24/24." Unsampled Patient T was admitted with diagnoses that included Major Depressive Disorder." Unsampled Patient T was admitted from an acute care hospital after a suicide attempt that included slicing her arms from her wrist to her elbow.

A review of a document for Unsampled Patient T, titled General Progress Note," dated 3/14/24, indicated, "Late Entry: Patient assaulted by several peers in the day room on the morning of 2/25/24. Patient reports she was feeling frustrated by the antagonistic activity and jeering by several peers. Patient reports she was making efforts to Ignore. Per patient, one of the peers walked over and stood beside the patient and started to bang the wall right next to the patient's head. Patient reported that she was unable to, 'take it anymore' and yelled for them to stop. Peers began punching the patient......Hospitalist conducted a thorough neuro and physical examination, concluding that patient sustained minor soft tissue bruising behind her right ear."

A review of a document for Unsampled Patient T, titled. "Medical Consult," dated 2/24/24, indicated, "Subjective: Patient complains of pain in back of head following being struck on back of head numerous times with fists by another patient. She was also stuck a few times in the face and had her hair pulled. This happened earlier this morning. Her only current complaint is about the pain in the back of her head on the right. Objective Head: There is mild skin redness behind the right ear and tenderness of the right mastoid (Behind the ear) process. Assessment: Soft tissue injury s/p (Status post) assault."

A review of a document for Unsampled Patient T, titled, "Discharge Summary," dated 2/25/24, indicated, "Patient was attacked by other patients on the unit leading to patient's mother wanting to remove her from the hospital AMA (Against Medical Advice.)."

A review of a document for Unsampled Patient V, titled, "Facesheet," indicated she was admitted 2/23/24 and discharged 3/1/24. Unsampled Patient V was admitted with diagnoses that included Major Depressive Disorder, Suicidal Ideation's.

A review of a document for Unsampled Patient V, titled, "General Progress Note," dated 2/24/24, indicated, "Pt observed by staff threatening a peer and making statements such as, 'I better not catch you slipping.' Pt began to punch that peer multiple times in the head. Pt was escorted to the quiet room and placed in a manual hold at 1115 (11:15 a.m.). Pt placed in seclusion at 1117 (11:17 a.m.). Pt began punching the walls in the quiet room and making holes in the wall. Pt continued to have aggressive and assaultive behavior in seclusion. Emergent meds given ..."

During a record review of Unsampled Patient Q's medical record, a document titled, "Face Sheet," indicated she had been admitted on 3/30/24, and discharged 4/10/24. It indicated she was a 14 year-old female, with diagnoses that included Major Depressive Disorder and Suicidal Ideation's. A document titled, "General Progress Note," dated 4/4/24, indicated, "Around 7:24 p.m., patient was attacked by another peer on the unit. No injuries noted to patient....She reported she was feeling very anxious and unsafe due to being on the same unit as the peer that attacked her. She also felt that there was so much chaos which was making her anxiety worse." A document titled, "Nursing Shift Risk Assessment," dated 4/5/24, indicated, "Patient reported having thoughts of wanting to harm self-due to feeling unsafe on unit."

During a record review of Unsampled R's medical record, a document titled, "Face Sheet," indicated he had been admitted on 2/12/24, and discharged 4/9/24. It indicated he was a 14 year-old male who had diagnoses that included bipolar disorder (A mental condition marked by alternating period of elation and depression) and Autistic Disorder (A developmental disorder that included characteristics of impaired development in social interaction communication, and behavior).

Review of a document for Unsampled Patient R, titled, "General Progress Note," dated 4/5/24 at 5:03 p.m., indicated, "Patient is in a group therapy doing some slimy thing when all of a sudden patient was punch [sic] in the face by another patient in front of him, both immediately got separated. No manual taken place. Patient calms down and was redirectable. Tried to contact his social worker (sic) but no answer VM (Voicemail) was left and a call back number."

A review of Unsampled R's document titled, "General Progress Note," dated 4/6/24 indicated, "Patient is in a group therapy doing some slimy thing when all of a sudden patient was punch [sic] in the face by another patient in front of him, both immediately got separated, no manual taken. Patient calms down and was redirectable. Tried to contact his social worker but no answer VM (Voicemail) was left and a call back number.....Was Parent / Guardian notified? Yes Date / Time of notification: 4/5/24 at 5 p.m." RM reviewed the medical record for Unsampled Patient AA and stated a document titled, "General Progress Notes," dated 4/5/24, indicated, "Patient (Unsampled Patient AA) was doing a group therapy in the day room when all of a sudden he punch [sic] one of the patient (Unsampled Patient R) on the face and his lip was bleeding."

During a record review of Unsampled Patient AA's medical record, a document titled, "Face Sheet," indicated he had been admitted on 3/26/24, and discharged 4/13/24. Patient AA had diagnoses that included Psychosis and Schizophrenia. A document titled, "Psychiatric Progress Note," dated 4/7/24, indicated, "The patient reports he had an incident one day ago with a peer where he has been getting agitated with a peer and asked him to stop but he wouldn't listen, so he proceeded to punch him in the face and pushed him afar from him."

2. During an interview on 9/10/24 at 9:15 a.m., the DSS stated she, "Guessed that she was the abuse coordinator for the facility." She stated her role as DSS was to oversee abuse training, and abuse workshops for reporting, for all facility staff. She stated all the incident reports were review by the RM, and she reported to Child Protective Services and Adult Protective Services. She stated staff should report abuse to the Supervisor who should then contact the Administrator on call. She stated the facility would never call the police unless the resident asked them to call the police. She stated Abuse Education was provided in computer classes, and the Mandated Reporter's responsibilities were covered. She stated, "I am the abuse coordinator and work with other departments to ensure we are meeting the expectations of regulatory standards." She stated abuse allegations or reports should be reported to Adult Protective Services and Children Protected Services in 24 hours or no later than 36 hours. She stated it was the RM's role to make the reporting decision. She stated, for state of California, all suspected cases of abuse and / or neglect should be reported as soon as possible with a follow-up letter sent to California Department of Public Health.

During an interview on 9/10/24 at 10:45 a.m., CNO and CEO stated the DSS was the Abuse Coordinator for the facility and responsible to understand the Mandated Reporting and training requirements for the facility. The CNO stated the DSS was responsible for reporting abuse incidents to Adult Protective Services or Children Protective Services, and the RM's team was responsible for regulatory requirements to report to California Department of Public Health. The CEO stated the RM and DSS were required to report directly to her. The CNO stated the facility provided monitoring for Abuse Prevention and Reporting by providing oversight for all the abuse and incident reports. She stated she had re-written the Abuse Policy and Procedure for the facility. She was asked to provide the resources for the Abuse Policy and Procedure and stated she had reviewed all the regulatory requirements but could not find language about abuse reporting requirements to the California Department of Public Health and timelines for reporting. The CNO stated the process for staff, when an observation of abuse or allegation of abuse occurred, was to have staff stay with the victim while another staff called the House Supervisor, who called the Nurse Manager. She stated, if it was an allegation of staff-to-patient abuse, the Supervisor was to suspend the employee until investigation was completed. If the allegation was a patient-to-patient abuse, the Supervisor was to place one of the patients on 1:1 [supervision], and the Supervisor was to document the details in the Facility Risk Connect reporting system. The CNO stated the investigation was to start with the accusation. She stated if it was discovered overnight, the staff were to keep the patients safe, but begin to interview witnesses. The CNO stated the investigation began when a report was populated in the facility reporting system. The CNO stated the Nurse was to interview the victim and document in the Progress Notes, and they were required to enter the information into the incident reporting system by the end of their shift. She stated the police were to be called right away if it was an accusation of sexual assault. She stated the DSS and RM were the ones who determined the competencies for the Abuse Prevention Reporting program for the facility. She stated the DSS and RM's role had changed recently, and they had not done a good job preparing them. She stated the expectation for the Abuse Program was not well understood for the DSS. The CEO stated, "We need to do more." The CNO stated the DSS was to be the coordinator for the training and not doing any investigations. She stated there was no job description for Abuse Coordinator. The CNO stated the Abuse information and data was reported to the Governing Body, and the last meeting was in May or June.

During an interview on 9/10/24 at 2:15 p.m., the RM stated she could not get the investigation packets for the Facility-Reported Incidents (FRI CA00893755, CA00887769, CA00909325, CA00893250) because the previous Risk Manager had a different process, and she could not find the documentation. She stated she had only recently functioned in the Risk Manager Role. She stated there was no facility abuse investigation packet for the incident that occurred on 2/24/24, that involved Unsampled Patient T's allegation of being assaulted by Unsampled Patient U. She stated there was no documentation of what the facility had done as a result of the assaultive incident, if it was substantiated, what was done by the facility to ensure it never happened again.

During an interview on 9/11/24 at 8:45 a.m., with Nurse Manager FF, he stated, if staff witnessed or heard about abuse, they reported it to the RM and documented in the online risk reporting program. He stated Nurses were supposed to interview the patients and report that information to the RM. He stated, if a patient expressed a complaint or grievance, the Patient Ambassador would come and start the grievance process.

During an interview with the RM and CNO on 9/11/23, at 2:31 p.m., a request was made for all facility Policies and Procedures for Abuse investigations (How the facility protected patients during an abuse investigation, how the facility substantiated or not, abuse allegations, how the facility proceeded, once an abuse allegation was substantiated, how the facility ensured it complied with Federal, State and local laws for its Abuse Program, how the facility ensured its abuse prevention and reporting process was effective, and for any evidence that all allegations of abuse were thoroughly investigated). The CNO stated the only Abuse Policy and Procedure they had did not include all of this requested information. She stated she was unsure what the Federal and State requirements were for reporting abuse allegations.

During a record review and interview on 9/12/24 at 12:20 p.m., RN BBB stated, during a review of Sampled Patient 9 and Unsampled Patient N's medical records, indicated, "The Safety of victim was not provided when Unsampled Patient N struck Sampled Patient 9."

During a concurrent interview and medical record review with the RM, on 9/12/24 at 2:05 p.m., she stated Unsampled Patient Q's medical record indicated documentation that mentioned Unsampled Patient Q had informed the Patient Ambassador of a patient-to-patient incident on 4/6/24. Unsampled Patient Q stated Unsampled Patient R had, "Touched her boobs," on 4/5/24, during an activity in the gymnasium. The RM stated the medical record indicated the Patient Ambassador provided Unsampled Patient Q with a Grievance Form to fill and submit. The RM stated the Mental Health Technician, assigned to the gym on the date of the patient-to-patient incident, were interviewed, and they all stated they did not witness the incident on 4/5/24, between Unsampled patient Q and Unsampled Patient R.

During an interview and concurrent record review with the RM on 9/12/24 at 2:15 p.m., the RM stated the facility reported an incident that involved Unsampled Patient R allegedly touching the breasts of Unsampled Patient Q on 4/5/24. She stated the facility had reported it to the California Department of Public Health on 4/8/24. She stated a facility document, titled, "Occurrence Report Summary," indicated, "DATE OF INCIDENT: 4/5/24 & 4/7/24 DATE RECEIVED: 4/8/24.....Summary of Event: Unsampled Patient Q accused Unsampled Patient R of touching her breasts in the gym on 4/5/24, buttocks in the gym on 4/7/24." She stated the document indicated the event was unwitnessed and investigated, but there was no indication if the facility determined whether the allegation was substantiated or not.

During further concurrent interview and medical record review with the RM, on 9/12/24 at 2:30 p.m., the RM stated the patient-to-patient incident documentation indicated a Patient Ambassador spoke with Unsampled Resident Q on 4/8/24, at 11:30 a.m., to provide a patient grievance follow-up. The RM stated the incident documentation indicated during that follow-up, Unsampled Resident Q stated on 4/7/24, at 4 p.m., another incident of patient-to-patient touching of Unsampled Patient Q's buttocks by Unsampled Patient R, in the Gymnasium. Review of the Unusual Occurrence Report indicated Mental Health Technicians were interviewed and indicated they did not witness any sexually acting out behavior by Unsampled Patient R. The documentation indicated that Unsampled Patient R was interviewed by two providers, who stated Unsampled Patient R had denied any allegations for the incidents on 4/7/24 and 4/8/24.

During the concurrent interview and medical record review with the RM, on 9/12/24, at 2:30 p.m., "No documentation of what happened with the grievance," was documented in the reporting system titled, "Risk Aware

Based on observation, interviews and record reviews, the hospital failed to ensure a safe and appropriate Discharge Planning Process as evidenced by failure to:

1. Have in effect a Discharge Planning Process that focuses on the patient goals and treatment preferences (Cross Reference A-802;

2. Ensure an effective transition of the patient from the hospital to post-discharge care (Cross Reference 802); and,

3. Reduce the factors leading to a preventable hospital readmissions.
(Cross Reference A-802)

The cumulative effect of these systemic problems resulted in the inability of the hospital's Discharge Planning process to safely discharge patients post-hospitalization.

Based on observation, interview and record review, the facility failed to ensure safe and appropriate discharge for two out of 27 Unsampled Patients (Patient L and Patient M).

1. Patient L was driven twice by Public Transporter NN to a building with no available resources or shelter. Patient L was taken back to the facility the first time and the second time was sent to the Emergency Department.

2. Patient M was driven by Public Transporter NN, after hours, to a closed chained-up building with no available resources or shelter. Patient M's family called the police and filed a Missing Person's report on Patient M. Patient M was found five days later and readmitted to the hospital.

These failures resulted in Patient L and Patient M both being immediately re-hospitalized after being discharged from the facility.

Findings:

1. During an interview on 9/8/24 at 4 PM, Family Member OO stated she launched the complaint with the State due to the facility just, "dumping my daughter at a closed building after dark using public transportation." Family Member OO stated she filed a police report because they could not find Patient M after they found out she was discharged from the facility. Family Member OO stated her daughter was finally found by the police down by the river. Family Member OO stated she was told by the police they took Patient M to the hospital, and the hospital assisted her in obtaining adequate resources and shelter after being discharged by the hospital.

During a review of Patient M's medical record, Facesheet with an admission date of 5/5/23, it indicated Patient M was admitted with a diagnosis of Schizophrenia (mental illness that causes one to be out of touch with reality). The Facesheet indicated a discharge date of 6/9/23 at 4:03 p.m.

During a review of Patient M's medical record, a Case Manager's Progress Note, dated 5/18/23, authored by Case Manager JJ, indicated the case manager called Patient M's sister who stated she could not allow Patient M to stay with her after discharge.

During a review of Patient M's medical record, a Case Manager's Progress Note, dated 5/28/23, authored by Case Manager JJ, indicated the case manager called Patient M's mother who stated she could not allow Patient M to stay with her after discharge.

During a review of Patient M's medical record, MD (Medical Doctor) KK's Progress Note, dated 6/4/23, indicated, "The patient continues to be gravely disabled, unable to provide food, shelter and clothing." Recommendation: "Continue discharge planning for psychiatric follow up as patient is homeless."

During a review of Patient M's medical record, DO (Doctor of Osteopathic) MM's Progress Note, dated 6/6/23, indicated, "estimated length of stay....dependent on placement."

During a review of Patient M's medical record, Psychiatric Progress Note, dated 6/9/23, authored by NP (Nurse Practitioner) LL, indicated, "Patient states she would like to go to a shelter today and advised case manager to see if we can discharge today to a shelter."

During a review of Patient M's medical record, Social Work Note, dated, "Late Entry: on 6/9/23," Social Worker QQ, indicated she, "let Patient M know there are no shelters for women in Sacramento that Social Worker QQ is aware of, and the only place she can go is to Resource Center RR.....Social Worker confirmed with the doctor it would be an AMA (against medical advice) discharge."

After multiple requests for the AMA paperwork Patient M signed, no paperwork signed by facility staff, medical doctor, or Patient M agreeing to an AMA discharge was received. During a review of Patient M's medical record, no AMA paperwork was noted.

During a review of Patient M's medical record, a DO order, authored by DO MM, dated 6/9/23, indicated, "Discharge Order: Date of Discharge: 6/9/23, diagnosis Schizophrenia, Discharge status Regular. No Notes."

During a review of Patient M's medical record, a DO Discharge Summary, authored by DO MM, dated 6/9/23, indicated on 6/9/23, Patient M stated she would like to go to a shelter and at that time she was discharged against medical advice." DO MM indicated, Aftercare Plan: "The patient is discharged to shelter." No AMA paperwork was included in the Discharge Summary.

During a review of the Patient M's medical record, a Discharge/Aftercare Plan signed by Social Worker QQ, dated 6/9/23, indicated, "Discharged to Resource Center RR....call 211 for more county services.....Patient to be picked up [by Public Transporter NN] on 6/9/23 at 4 p.m.

A request for Public Transport NN's documentation of transport times for Patient M's departure from the facility and arrival at Resource Center RR was made. A departure time for 6/9/23 at 4:03 p.m., was received. Resource Center RR was two hours and 45 minutes away from the facility, which would have been an arrival time of 6:45 p.m.

During an interview with Patient Advocate SS at Resource Center RR on 9/17/24 at 10 a.m., Patient Advocate SS was queried what services Resource Center RR provided to the public. Patient Advocate SS responded, "We only supply meals and showers for the homeless from 7 a.m. to 2 p.m." Patient Advocate SS stated she knew the Resource Center RR building was closed after 2 p.m. When queried, Patient Advocate SS, if there were any shelter services for men or women at Resource Center RR, and Patient Advocate SS responded, "We do not have any shelter services for men and very limited shelter services (16 Beds) for women at another location. There is a wait list to get into our women's shelter and there needs to be screening and prior approval for the bed in the women's shelter." Patient Advocate SS stated, "We do not take walk-ins."

During an interview with Case Manager JJ on 9/10/24 at 2:35 p.m., Case Manager JJ was queried if she had spoken with anyone at Resource Center RR to make arrangements for Patient M to stay at the women's shelter. Case Manager JJ stated she did not. Case Manager JJ was queried if she followed up with Resource Center RR to find out if Patient M had arrived at Resource Center RR. Case Manager JJ stated she did not, stated she just called Public Transporter NN to pick Patient M at 4 p.m. Case Manager JJ was queried if she was aware Patient M was dropped off at a closed building due to Resource Center RR having limited hours and closed at 2 p.m. Case Manager JJ stated she was not aware of the limited hours.

During an interview with the DSS (Director of Social Services) on 9/10/24 at 9:10 a.m., the DSS was queried about the facilities' resource list for their Homeless Patients. The DSS responded she utilized Resource Center RR and sometimes did send patients there. The DSS was queried if she knew what services Resource Center RR provided and stated she was aware patients could get meals and a shower but did not believe it was a shelter. The DSS was queried for some of the risks that a female with a diagnosis of schizophrenia faced if she was dropped off after dark at a closed building with no resources. The DSS stated she could get very cold, not have food, water, or shelter and that could affect her health. The DSS was queried whose responsible it was to keep her resources' list up-to-date and inform the facilities' Case Manager what resources were available at the Resource Centers. The DSS stated she tried to keep it up-to-date but admitted Resource RR escaped her, and she had not updated the Resource list in a while. The DSS was queried if she had oversight of her Case Manager's Discharge Planning, the DSS indicated she was responsible for the oversite of the Case Manager as she was the Director of Social Services.

2. Two complaints, dated, 3/13/24 and 3/14/24, were received from Adult Protective Services (APS). One complaint was from an APS Representative (APS UU) and the second complaint was from APS VV, regarding Patient L being dropped off at Resource Center RR, but the Discharge paperwork indicated he was supposed to be discharged to a shelter. APS VV indicated Transportation Driver TT contacted Sonoma County APS (at the direction of Sacramento APS) to report concern about this frail elder (Patient L), stating he was not comfortable leaving Patient L at a dining facility (Resource Center RR), when Patient L was supposed to be at a shelter and may even need more care than a shelter could provide. Patient L reported to Transportation Driver TT he refused to sign his Discharge paperwork. APS VV advised Transportation Driver TT to take Patient L to the nearest hospital Emergency Department.

During a review of Patient L's medical record, the Facesheet indicated Patient L was an 83-year-old male who was admitted to the facility on 2/9/24, and had a discharge date of 3/13/24.

During a review of Patient L's medical record, NP orders signed by NP LL, dated 2/9/24, indicated Patient L was admitted on 2/9/24, with a legal hold status of 5150 (regulation that indicates a patient can be held as an inpatient due to being a danger to self or others). Notes indicated, "Danger to Self and Gravely Disabled" (a condition where someone is unable to provide for their basic needs due to a mental health disorder).

During a review of Patient L's medical record, DO XX signed an order, dated, 2/24/24, for Patient L to be placed on a 5270 (a regulation hold that can extend a psychiatric hold for an additional 30 days. It's used to provide intensive treatment for people who are gravely disabled due to a mental disorder) legal hold status, Notes: "Danger to Self and Gravely Disabled."

During a review of Patient L's medical record, History and Physical, dated, 2/11/24, authored by MD YY, indicated his living situation as: "Homeless."

During a review of Patient L's Nursing Admission Assessment, dated, 2/9/24, authored by RN ZZ, indicated, "Limitations: Gravely Disabled, Lack of insight to illness, multiple medical concerns, poor judgement, housing issues, poor concentration and unable to meet basic needs, impaired gait, transfer difficulty, standing/balance and generalized weakness."

During a review of Patient L's Psychiatric Progress Note, dated, 2/26/24, signed by DO XX, indicated, "Patient L is still incapable of providing his own food, shelter, and clothing due to his physical and mental limitations including memory issues.

During a review of Patient L's Psychiatric Progress Note, dated, 2/29/24, signed by DO XX, indicated, "Patient L is still incapable of providing his own food, shelter, and clothing due to his physical and mental limitations including memory issues."

During a review of Patient L's Psychiatric Progress Note, dated, 3/6/24, signed by DO XX, indicated, "Patient L is still incapable of providing his own food, shelter, and clothing due to his physical and mental limitations including memory issues, but we have been unable to find any placement for him here.....We will plan to plan to discharge him to a shelter."

During a review of Patient L's Discharge Summary, dated 3/6/24, signed by DO XX, indicated, "Housing may be an issue, so shelter has been arranged."

During a review of Patient L's MD orders, signed by DO XX, indicated, Discharge Patient L to a shelter.

During a review of Patient L's Discharge Summary dated 3/6/24, signed by DO XX, it was noted to not match the IDT Notes for discharge planning.

During a review of Patient L's Interdisciplinary Progress Note (IDT), dated 3/7/24, authored by Case Manager JJ, it indicated, Case Manager JJ called Loaves and Fishes, there was no answer as the call went into multiple loops of voicemail's, not allowing her to leave a message.

During a review of Patient L's Psychiatric Progress Note, dated, 3/7/24, signed by DO XX, indicated, "Patient reportedly discharged yesterday 3/6/24, and was taken by [Public Transporter NN], to the shelter in Sacramento, but they told him he could not stay there. Reportedly [Transporter NN] drove around to a bunch of different shelters without any luck and then took him to get pizza before driving him all the way back to the facility again. This was treated like he never left the hospital, and his hospitalization continues. [Patient L] reports the discharge needs to be delayed until he is feeling better. He reports we need to do better planning and find him a safe place to go."

During a review of Patient L's Nurses Notes, dated 3/11/24, authored by RN AAA, indicated, "Patient is disheveled and irritable, becomes agitated and raises his voice. Patient remains in wheelchair, ADL's (Activities of Daily Living), very poor."

During a review of Patient L's Psychiatric Progress Note, dated 3/12/24, signed by DO XX, indicated, "Apparently, they were unprepared for him yesterday when we tried to discharge him, but we will try to make them aware of his situation today. Hopefully this can all be set up today or tomorrow at the latest. If not, we will consider lateral transfer to our Sister Facility in Sacramento so they can contact APS."

During an interview with Case Manager JJ on 9/10/24 at 10:10 a.m., Case Manager JJ was queried if she had spoken with anyone from Resource Center RR to let them know Patient L would be arriving and needed placement in a shelter. Case Manager JJ stated she could not because every time she called Resource Center RR, she only got a voice mail and could not leave a message. Case Manager JJ was queried, when she also discharged Patient M to the same location nine months earlier, and the family contacted the facility due to Family Member OO filing a missing persons report on Patient M, why she would send another patient (Patient L) to the same Resource Center RR. Case Manager JJ stated she could not get through to anyone at Resource Center RR to make arrangements for either Patient L or Patient M. Case Manager JJ was queried why she would send Patient L, who needed a shelter to the same building address (Resource Center RR), where she already knew a week prior [Transportation Driver TT] had arrived the first time at Resource Center RR with Patient L and then contacted APS due to it not having a men's shelter, Case Manager JJ stated she was unaware of the extent of the resources at Resource Center RR and was merely following her DSS resource list for placement. Case Manager JJ asked if Patient L signed his Discharge paperwork and agreed to returning to the same place he was returned from a week ago, Case Manager JJ stated she could not remember the details. No further communication occurred with Case Manager JJ and no further documentation was offered for Patient L's Discharge paperwork.

During a review of the Patient L's medical record indicated no signed Discharge paperwork was found.

During an interview with the DSS on 9/10/24 at 10:45 a.m., the DSS was queried if the facility had filed an APS report on Patient L prior to sending him to Resource Center RR. The DSS stated, "Yes, there was an APS report filed by this facility on Patient L," then later indicated APS would not take the report, "so there was no APS report filed on Patient L by our facility." The DSS was queried what the risks were to discharging homeless patients to a building with no resources or shelter, the DSS responded, "They would probably be readmitted for health problems."

During an interview with the CNO (Chief Nursing Officer) on 9/10/24 at 11:45 a.m., the CNO was queried what a safe and appropriate discharge was for homeless patients (Patient L and Patient M). The CNO responded, "Contact the shelter ahead of time and make arrangements for placement."

During a review of the Case Manager's Job Description, the Job Description indicated the Case Manager reported to Director of Social Services. "Job Description: Provides quality case management and discharge planning services to all patients and their families. Serves as a member of interdisciplinary team supporting the organization's treatment program and philosophy, and assures the deliverance of quality treatment to patients and their families. Key Responsibilities: Ensures linkage to mental health/recovery services, and facilitates communication with the county. Completion of discharge aftercare plan, and provides daily placement and collateral documentation. Coordinates discharge packets and reviews them with patients and their families. Completes required documentation and progress notes on time and individualized per patient. Upholds the Organization's ethics and customer service standards."

During a review of the Director of Social Services (DSS) Job Description, the Job Description indicated, "The DSS reports to the CEO. Duties: Oversight, development and coordination of individualized discharge plan for the patient by utilizing treatment team and written chart information to determine the patient's aftercare needs. Access by phone or written correspondence family or community resources such as nursing homes, group homes, or private mental health practitioners to meet patient's aftercare needs. Attends regular treatment team meetings to provide social work perspectives for total case management of the patient by discussing progress notes charts and communicating any state or local agency legal requirement for case management with the interdisciplinary team."

During a review of the facility's policy and procedure titled, "Discharge Planning / Aftercare," revised 3/11/24, indicated, "Purpose: To help prepare all patients for their return to the community by connecting the patient with available community resources, treatment, shelter, and other supportive services, as appropriate. This policy also serves to specify the discharge planning procedures to ensure that discharge planning begins at the time of admission and is updated through the duration of the patient's hospitalization. After care planning facilitates the optimal transition for patients from the hospital to the community. Procedure: Discharge planning shall be initiated at the time of the psychosocial evaluation. The social services department shall discuss with the patient, family, guardian and / or outpatient provider, as appropriate, the tentative discharge plan, including resident, outpatient treatment, financial / vocational / situation evaluation) as well as any Social Services interventions that are needed. These recommendations include the various levels of care indicated to assure that patients are treated at the appropriate level of care. The clinicians shall assist in implementing appropriate clinical interventions including Assisting in coordinating necessarily follow up care. If any difficulties arise in coordinating appointments, then clinicians will reach out to outpatient providers to schedule and coordinate a meeting to discuss complex cases. In developing discharge/aftercare plans, the following is assessed, safety needs and planning, housing needs and placement issues. The social work staff shall assist in implementing appropriate Social Services interventions including Addressing any need for placement or appropriate living arrangements. A homeless patient is determined by Senate Bill 1152, as an individual who: Lacks a fixed and regular nighttime, residence. The patient will be offered transportation to his or her chose [sic] discharge destination. The Social Services department will coordinate a transportation plan and review it with the patient prior to discharge."

During a review of the facility's policy and procedure titled, "Against Medical Advice Intervention," dated, 5/26/22, indicated, "Purpose: To address patients requesting Against Medical Advice (AMA) discharges. Patient will sign AMA form. The attending will be contacted to see and evaluate the patient and provide an AMA discharge order, Patient will be encouraged to contact his/her family, significant other to inform them of the intent to leave. Complete the AMA request for Discharge information from. An AMA discharge is considered a treatment failure. Complete an incident report and attach copy of Request for AMA form. The RN House Supervisor will report AMA status of discharged patient at shift handoff-to provide data regarding the discharge. Indicate on 24-hour DON report by Nurse Manager/Supervisor. Notify DON/AOC prior to AMA discharge."