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The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.12 Governing Body as evidenced by the following:

1. The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.13 Patient's Rights (Refer to A-0115) as evidenced by the following:

A. Based on interview and record review, the facility failed to provide Notification of Patient Rights for five of 47 sampled patients (Patient 4, Patient 5, Patient 8, Patient 9, and Patient 10). This failure had the potential to result in Patient 4, Patient 5, Patient 8, Patient 9, and Patient 10, and/or guardians to be unaware of their rights. (Refer to A-0116)

B. Based on interview and record review, the facility failed to ensure medical consultation was completed according to physician order for one of 47 sampled patients (Patient 21). This failure resulted in treatment not provided. (Refer to A-0129)

C. Based on interview, and record review the facility failed to ensure patients, designated representative, and/or guardians were provided informed medication consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention ) for 12 of 47 sampled Patients (Patient 4, Patient 7, Patient 19, Patient 20, Patient 21, Patient 23, Patient 38, Patient 41, Patient 42, Patient 34, Patient 37, and Patient 35). This failure resulted in treatment without informed consent. (A-0131)

D. Based on interview and record review, the facility failed to obtain information regarding Advance Directives (AD-a legal document that indicates a person's wishes for medical treatment) for nine of 47 sampled patients (Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 38, Patient 41, Patient 40, and Patient 42). This failure had the potential for staff to be unaware of the patient's and/or legal representative's wishes for treatment. (Refer to A-0132)

E. Based on interview and record review the facility failed to follow their policy & procedure (P&P) titled, "Code Gray-Management of Assaultive/Combative Behavior." This failure resulted in two staff (RN [Registered Nurse] 25 and MHW [Mental Health Worker] 15) being injured, violation of the right to receive care in a safe therapeutic environment for nine of nine sampled patients (Patient 18, Patient 21, Patient 22, Patient 36, Patient 43, Patient 44, Patient 45, Patient 46, and Patient 47). (Refer to A-0144)

F. Based on observation, interview, and record review, the facility failed to:
1. protect three of 47 sampled patients (Patient 14, Patient 16, and Patient 19) from physical abuse. This failure resulted in Patient 14, Patient 16, and Patient 19 being physically abused by other patients.

2. Protect one of 47 sampled patients (Patient 39) from sexual abuse. This failure put Patient 39 at risk for sexual abuse. (Refer to A-0145)

G. Based on interview and record review the facility failed to ensure accuracy one of 47 sampled patients (Patient 23) medical record. This failure resulted in a violation of Patient 23's right to privacy and confidentiality. (Refer to A-0147)

H. Based on interview and record review, the facility failed to follow it's policy and procedure titled, "Use of Seclusion and Restraint" for one of 47 sampled patients (Patient 21). This failure resulted in the violation of patients rights to be free from unnecessary restraints and had the potential for unmet care needs. (Refer to A-0201)

I. Based on interview and record review, the facility failed to ensure three of 24 sampled employees (Registered Nurse (RN) 14 and mental health worker (MHW) 10, and MHW 12) had current educational training and demonstrated knowledge in cardiopulmonary resuscitation (CPR-life saving intervention during medical emergency). This failure had the potential to contribute to adverse events. (Refer to A-0206)

J. Based on interview and record review the facility failed to ensure completion of annual evaluation was done for 12 of 13 (Quality Risk Manager (QRM), Mental Health Worker (MHW) 12, Registered Nurse (RN) 7, RN 18, RN 20, RN 19, RN 21, MHW 11, RN 8, RN 6, RN 1, and RN 21) sampled staff. These failures had the potential to result in staff not qualified to provide quality care to patients.(Refer to A-0208)

K. Based on observation, interview, and record review the facility failed to ensure the patients were allowed visitation for one of 32 sampled patients (Patient 19). This failure resulted in a violation of Patient 19's rights to have visitors, and the potential for other patient's to not have the right of visitation. (Refer to A-0217)

2. The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.21 Quality Assessment and Performance Improvement Program (Refer to A-0263) as evidenced by the following:

A. Based on interview and record review, the facility failed to have an effective Quality Assessment Performance Improvement (QAPI) program when 10 of 10 sampled staff (Registered Nurse [RN] 3, RN 4, Housekeeper [HKP] 1, Mental Health Worker [MHW] 1, MHW 2, RN 6, RN 7, RN 8, RN 9, Director of Plant Operations [DPO]) interviewed were not aware and/or did not participate in the facility's QAPI activities. This failure had the potential to result in the facility being unable to identify opportunities for improvement due to staff being unaware and not participating in the facility's QAPI program. (Refer to A-0283)

B. Based on interview and record review, the facility failed to develop and implement Performance Improvement (PI) projects. This failure resulted in the facility's inability to ensure quality health care in a safe environment is provided to all patients being treated in the facility. (Refer to A-0297)

C. Based on interview and record review, the facility failed to conduct a facility annual quality assessment to identify and prioritize opportunities for performance improvement (PI). This failure resulted in missed opportunities for performance improvement. (Refer to A-0309)

3. Based on interview and record review, the facility failed to develop, implement and evaluate a comprehensive care plan for two of 47 sampled patients (Patient 42, Patient 34). This failure had the potential for unmet patients care needs. (Refer to A-0396)

4. Based on interview and record review, the facility failed to ensure physician's verbal orders were used infrequently, were signed by the physician with date and time of order and signed timely according to the facility's policy and procedure for seven of 47 sampled patients (Patient 1, Patient 2, Patient 6, Patient 34, Patient 35, Patient 37, Patient 42). These failures had the potential for miscommunication that could result in errors and in unmet care needs. (Refer to A-0407)

5. Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP)/Infection Control Nurse was qualified. This failure had the potential to result in unsafe infection control practices to all patients, staff, and visitors. (Refer to A-0748)

6. Based on interview and record review, the facility failed to ensure continuity of care for three of 47 sampled patients (Patient 18, Patient 21, Patient 22) when the nurses failed to document in the patients' medical record information of the discharge. This failure had the potential to affect continuity of care upon discharge. (Refer to A-0813)

7. Based on observation, interview, and record review, the facility failed to provide patient centered therapeutic activities per posted "Weekly Activities Schedule" for all patients. This failure has the potential for adverse patient outcomes. (Refer to A-1720)

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Governing Body.

The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.13 Patient's Rights as evidenced by the following:

1. Based on interview and record review, the facility failed to provide Notification of Patient Rights for five of 47 sampled patients (Patient 4, Patient 5, Patient 8, Patient 9, and Patient 10).

This failure had the potential to result in Patient 4, Patient 5, Patient 8, Patient 9, and Patient 10, and/or guardians to be unaware of their rights. (Refer to A-0116)

2. Based on interview and record review, the facility failed to ensure medical consultation was completed according to physician order for one of 47 sampled patients (Patient 21).

This failure resulted in treatment not provided. (Refer to A-0129)

3. Based on interview, and record review the facility failed to ensure patients, designated representative, and/or guardians were provided informed medication consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention ) for 12 of 47 sampled Patients (Patient 4, Patient 7, Patient 19, Patient 20, Patient 21, Patient 23, Patient 38, Patient 41, Patient 42, Patient 34, Patient 37, and Patient 35).

This failure resulted in treatment without informed consent. (A-0131)

4. Based on interview and record review, the facility failed to obtain information regarding Advance Directives (AD-a legal document that indicates a person's wishes for medical treatment) for nine of 47 sampled patients (Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 38, Patient 41, Patient 40, and Patient 42).

This failure had the potential for staff to be unaware of the patient's and/or legal representative's wishes for treatment. (Refer to A-0132)

5. Based on interview and record review the facility failed to follow their policy & procedure (P&P) titled, "Code Gray-Management of Assaultive/Combative Behavior."

This failure resulted in two staff (RN [Registered Nurse] 25 and MHW [Mental Health Worker] 15) being injured, violation of the right to receive care in a safe therapeutic environment for nine of nine sampled patients (Patient 18, Patient 21, Patient 22, Patient 36, Patient 43, Patient 44, Patient 45, Patient 46, and Patient 47). (Refer to A-0144)

6. Based on interview and record review the facility failed to ensure accuracy one of 47 sampled patients (Patient 23) medical record.

This failure resulted in a violation of Patient 23's right to privacy and confidentiality. (Refer to A-0147)

7. Based on interview and record review, the facility failed to follow it's policy and procedure titled, "Use of Seclusion and Restraint" for one of 47 sampled patients (Patient 21).

This failure resulted in the violation of patients rights to be free from unnecessary restraints and had the potential for unmet care needs. (Refer to A-0201)

8. Based on interview and record review, the facility failed to ensure three of 24 sampled employees (Registered Nurse (RN) 14 and mental health worker (MHW) 10, and MHW 12) had current educational training and demonstrated knowledge in cardiopulmonary resuscitation (CPR-life saving intervention during medical emergency).

This failure had the potential to contribute to adverse events. (Refer to A-0206)

9. Based on interview and record review the facility failed to ensure completion of annual evaluation was done for 12 of 13 (Quality Risk Manager (QRM), Mental Health Worker (MHW) 12, Registered Nurse (RN) 7, RN 18, RN 20, RN 19, RN 21, MHW 11, RN 8, RN 6, RN 1, and RN 21) sampled staff.

These failures had the potential to result in staff not qualified to provide quality care to patients.(Refer to A-0208)

10. Based on observation, interview, and record review the facility failed to ensure the patients were allowed visitation for one of 47 sampled patients (Patient 19).

This failure resulted in a violation of Patient 19's rights to have visitors, and the potential for other patient's to not have the right of visitation. (Refer to A-0217)

The cumulative effect of these systemic practices resulted in the facility's inability to ensure the provision of quality health care in a safe environment in compliance with the Condition of Participation for Patient Rights.

Based on interview and record review, the facility failed to provide Notification of Patient Rights for five of 47 sampled patients (Patient 4, Patient 5, Patient 8, Patient 9, and Patient 10). This failure had the potential to result in Patient 4, Patient 5, Patient 8, Patient 9, and Patient 10, and/or guardians to be unaware of their rights.

Findings:

During a concurrent interview and record review on 5/25/23, at 1:39 p.m., with Quality Risk Director (QRD), Patient 5's MR was reviewed. MR indicated, Patient 5 was admitted to the facility on 4/11/23. QRD was unable to find documentation of notification of patient rights provided to Patient 5 and/or guardian and stated, "None."

During a concurrent interview and record review on 5/25/23, at 2 p.m., with QRD, Patient 4's medical record (MR) was reviewed. MR indicated, Patient 4 was admitted to the facility on 5/13/23. QRD was unable to find documentation of notification of patient rights provided to Patient 4 and/or guardian and stated, "There's none."

During a concurrent interview and record review on 5/25/23, at 3:30 p.m., with QRD, Patient 8's MR was reviewed. MR indicated, Patient 8 was admitted to the facility on 5/24/23. QRD was unable to find documentation of notification of patient rights provided to Patient 8 and/or guardian and stated, "Not here."

During a concurrent interview and record review on 5/25/23, at 3:42 p.m., with QRD, Patient 9's MR was reviewed. MR indicated, Patient 9 was admitted to the facility on 5/23/23. QRD was unable to find documentation of notification of patient rights provided to Patient 9 and/or guardian and stated, "None."

During a concurrent interview and record review on 5/25/23, at 3:55 p.m., with QRD, Patient 10's MR was reviewed. MR indicated, Patient was admitted to the facility on 5/22/23. QRD was unable to find documentation of notification of patient rights provided to Patient 10 and/or guardian and stated, "Notification of Patient's rights should be provided to patient or guardian on admission."

QRD was unable to provide Notification of Patient Rights policy.

Based on interview and record review, the facility failed to ensure medical consultation was completed according to physician order for one of 47 sampled patients (Patient 21). This failure resulted in treatment not provided.

Findings:

During a concurrent interview and record review, on 5/26/23, at 11:20 a.m., with Registered Nurse (RN) 1, Patient 21's physician order dated 8/24/23, indicated, "Med [medical] consult to check on pain on left wrist" was reviewed. RN 1 stated, there was no documentation in Patient 21's medical record that the medical consultation was provided.

During an interview on 5/30/23, at 9:10 a.m., with Medical Doctor (MD) 1, MD 1 stated, the expectation is for the physician orders to be followed and completed.

During a review of the facility's policy and procedure (P&P) titled, "Medical Consultation/Physical Examinations," dated 7/27/22, indicated, "The nurse or designee will contact the physician's office to notify him/her of the consultation, the physician requesting the consult and location of the patient. . . On completion of the medical consultation, the date and time will be entered . . . in the progress note."

During a review of the facility's P&P titled, "CONDITIONS OF ADMISSION AND ASSIGNMENT OF BENEFITS," undated, indicated, "The patient is under the care and supervision of his/her attending physician and it is the responsibility of the hospital and its nursing staff to carry out the instructions of such physicians."

Based on interview, and record review the facility failed to ensure patients, designated representative, and/or guardians were provided informed medication consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention ) for 12 of 47 sampled Patients (Patient 4, Patient 7, Patient 19, Patient 20, Patient 21, Patient 23, Patient 38, Patient 41, Patient 42, Patient 34, Patient 37, and Patient 35). This failure resulted in treatment without informed consent.

Findings:

1. During a concurrent interview and record review on 5/25/23, at 2 p.m., with Quality and Risk Director (QRD). Patient 4's medical record (MR) was reviewed and indicated on 5/15/23, medical doctor (MD) 2 ordered Haldol (helps to restore the balance of certain natural substances in the brain and treat behavioral issues) 2 milligrams (mg - unit of measure). On 5/19/23, MD 2 ordered Haldol 2 mg and Ativan (used to treat anxiety) 1 mg. Medication Administration Record (MAR) dated 5/15/23, at 8:20 a.m., Registered Nurse (RN) 17 administered Haldol 2 mg by mouth, and on 5/19/23, at 4 p.m., RN 18 administered Haldol 2 mg and Ativan 1 mg. QRD reviewed Patient 4's MR twice and was unable to find informed consent and stated, "No consents. We should have an informed consent before administering psych [psychotropic] meds [medications]."

2. During a concurrent interview and record review on 5/25/23, at 3 p.m., with QRD, Patient 7's MR was reviewed. MR indicated on 5/20/23, at 8:30 a.m., MD 2 ordered Abilify (works by changing the activity of certain natural substances in the brain) 2 mg by mouth, and was administered on 5/21/23, at 9 a.m., and on 5/23/23, at 9 a.m. by RN 17. On 5/23/23, at 9:18 a.m. MD 2 ordered by phone "Trazodone [for depression] 50 mg PO [By mouth] PRN [as needed] Q [Every] HS [Hour of sleep], and was administered on 5/19/23. Informed consents for Abilify and Trazodone were not signed by MD 2. QRD reviewed Patient 7's MR and stated, "Informed consents should be signed by the doctor."


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3. During an interview on 5/18/23, at 7 p.m., with Guardian (GR) 2, GR 2 stated, the nurse's called "after" the medications were given to Patient 21.

During an interview on 5/18/23, at 7:30 p.m., with Patient 21, Patient 21 stated, when she was upset the nurses would give her an injection or pill and call GR 2 after.

During a concurrent interview and record review, on 5/26/23, at 11:16 a.m., with RN 1, Patient 21's "Medication Information & Consent (MIC) (ANTIPSYCHOTIC/NEUROLEPTIC)" form was reviewed, and indicated on 3/17/23, 3/19/23, and 4/1/23, a telephone consent was listed on one consent form with one Physician signature dated on 3/19/23. RN 1 stated, Patient 21's anti-psychotic/neuroleptic medication consent form must be verified each time consent is provided by the physician and the nurse standard is to verify the consent process is completed with separate consent forms. RN 1 stated, the expectation is to follow the policy and procedure and standards of practice. RN 1 stated, there was no documentation the physician informed Patient 21's guardian.

During a concurrent interview and record review, on 5/26/23, at 11:18 a.m., with RN 1, Patient 21's PO was reviewed and indicated, on 3/19/23 and 4/1/23, Zyprexa (a medication that alters mood and behavior) was administered. RN 1 stated, there was no informed consent for Zyprexa in Patient 21's medical record.

4. During an interview on 5/19/23, at 2:18 p.m., with Patient 19's GR 1. GR 1 stated, the facility was unsafe and gave medications without consent. GR 1 stated, the facility nursing staff called her (GR 1) about the medication for Patient 19, and not the doctor.

During an interview on 5/25/23, at 2 p.m., with RN 12, RN 12 stated, two nurses call to obtain an informed consent for medications from GR, and when the patient is in "crisis" danger to self (DTS) or danger to others (DTO) we don't call.

During a concurrent interview and record review on 5/26/23, at 11:14 a.m., with RN 1, Patient 19's "MIC (MOOD STABILIZERS)" form, dated 3/14/23, was reviewed and indicated a telephone consent with an undated doctor signature. RN 1 stated, an informed consent is the responsibility of the doctor. RN 1 stated, there was no documentation the physician informed Patient 19's guardian.

5. During a concurrent interview and record review, on 5/26/23, at 11:21 a.m.,with RN 1, Patient 20's "MIC (Minor Tranquilizers and Sleeping Medication)" consent form was reviewed and indicated on 3/9/23, the refusal box was marked indicating the medication Vistaril (medication that decreases anxiety and alters behavior) refusal. Patient 20's MAR, indicated on 3/16/23 and 3/20/23, Vistaril was administred. RN 1 stated, Vistaril was administered without an informed consent.

6. During a concurrent interview and record review, 5/23/23, at 5:10 p.m., with QRD, Patient 23's "MIC (ANTIDEPRESSANTS)" form for Trintellix (a medication for mood elevation) dated 5/23/23, the form indicated no signature by MD. The MAR, dated 5/23/23 indicated Trintellix was administered. RN 1 stated, Trintellix was administered without informed consent.

7. During a concurrent interview and record review, on 5/24/23, at 2:15 p.m., with RN 20, Patient 38's "MIC for Abilify", dated 5/8/23 was reviewed. The MIC indicated there is no signature by the physician on consent. RN 20 stated, "MD [medical director] did not sign the consent form."

During a concurrent interview and record review, on 5/24/23, at 2:16 p.m., with RN 20, Patient 38's "MIC for Zoloft (Treats several mental health condition), dated 5/8/23 was reviewed. The MIC indicated there is no signature by the physician on consent. RN 20 stated, "MD did not sign the consent form."

8. During a concurrent interview and record review, on 5/24/23, at 2:30 p.m., with RN 20, Patient 41's MIC for Wellbutrin (Treats depression), dated 5/2/23 was reviewed. The MIC indicated there is no signature by the physician on consent. RN 20 stated, there is no signature from MD.

During a concurrent interview and record review, on 5/24/23, at 2:31 p.m., with RN 20, Patient 41's MIC for Ativan, dated 5/8/23 was reviewed. The MIC indicated there is no signature by the physician on consent. RN 20 stated, "MD did not sign the consent form."

During a concurrent interview and record review, on 5/24/23, at 2:32 p.m., with RN 20, Patient 41's MIC for Depakote (Helps with mental health condition), dated 5/8/23 was reviewed. The MIC indicated there is no signature by the physician on consent. RN 20 stated, "MD did not sign the consent form."

During a concurrent interview and record review, on 5/24/23, at 2:33 p.m., with RN 20, Patient 41's MIC for Neurontin (to manage some seizures), dated 5/8/23 was reviewed. The MIC indicated there is no signature by the physician on consent. RN 20 stated, "MD did not sign the consent form."

During a concurrent interview and record review, on 5/24/23, at 2:31 p.m., with RN 20, Patient 41's MIC for Caplyta (treats depression), dated 5/17/23 was reviewed. The MIC indicated MD signed the consent on 5/23/23 (six days later). RN 20 stated, MD signed consent on 5/23/23.

9. During a concurrent interview and record review, on 5/24/23, at 3:15 p.m., with RN 20, Patient 42's MIC for Zyprexa, dated 4/25/23 was reviewed. The MIC indicated MD signed the consent on 5/3/23 (eight days later). RN 20 stated, MD signed consent on 5/3/23.

During a concurrent interview and record review, on 5/24/23, at 3:15 p.m., with RN 20, Patient 42's MIC for Prozac (treat major depressive disorder), dated 4/17/23 was reviewed. The MIC indicated MD signed the consent on 5/3/23 (16 days later). RN 20 stated, MD signed consent on 5/3/23.

10. During a concurrent interview and record review, on 5/25/23, at 3:45 p.m., with RN 21, Patient 34's "MIC for Decanote", dated 5/16/23 was reviewed. The MIC indicated there is no signature by the physician on consent. RN 21 stated, MD has not signed the consents.

During a concurrent interview and record review, on 5/25/23, at 3:46 p.m., with RN 21, Patient 34's "MIC for Trazadone", dated 5/16/23 was reviewed. The MIC indicated there is no signature by the physician on consent. RN 21 stated, MD has not signed the consents.

11. During a concurrent interview and record review, on 5/25/23, at 10:40 a.m., with RN 21, Patient 37's "MIC for Trazadone", dated 5/5/23 was reviewed. The MIC indicated MD signed the consent on 5/12/23 and medication as given on 5/5/23. RN 21 stated, MD signed the consent on 5/12/23.

During a concurrent interview and record review, on 5/25/23, at 10:42 a.m., with RN 21, Patient 37's "MIC for Abilify", dated 5/5/23 was reviewed. The MIC indicated medication was given on 5/5/23, and MD signed the consent on 5/12/23 (seven days later). RN 21 stated, MD signed the consent on 5/12/23.

12. During a concurrent interview and record review, on 5/25/23, at 1:50 p.m., with RN 21, Patient 35's "MIC for Lexapro (Treats depression)", dated 5/3/23 was reviewed. The MIC indicated medication was given on 5/3/23, and MD signed the consent on 5/16/23 (13 days later). RN 21 stated, MD signed the consent on 5/16/23.

During a concurrent interview and record review, on 5/25/23, at 1:50 p.m., with RN 21, Patient 35's "MIC for Trazadone", dated 5/3/23 was reviewed. The MIC indicated medication was given on 5/3/23, and MD signed the consent on 5/16/23 (13 days later). RN 21 stated, MD signed the consent on 5/16/23.

During an interview on 5/25/23, at 10:40 a.m., with RN 21, RN 21 stated, "Nurses are explaining consents to family and patients."

During a review of the facility's policy and procedure (P&P) titled, "CONDITIONS OF ADMISSION AND ASSIGNMENT OF BENEFITS," undated, indicated, "It is the responsibility of the patient's physician. . . to obtain the patient's informed consent . . . hospital services rendered to the patient under the general and special instructions of the physician."

During a review of the facility's P&P titled, "PATIENT RIGHTS-HOSPITAL WIDE," dated 9/22, indicated, "Have all patient's rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient."

During a review of the facility's P&P titled "Informed Consents" dated 7/27/22, the P&P indicated, ". . . Obtaining Informed Consent: It is the anesthesiologist and /or treating physician's responsibility to obtain the informed consent. Hospital personnel cannot be involved in providing information that is necessary for informed consent - only the physician and/ or anesthesiologist can provide the information. Informed consent form is prepared by the attending physician or operating physician and is discussed with the patient by the physician . . ."

During a review of the facility's P&P titled, "Consent to Psychotropic Medication" dated 2022, the P&P indicated, "To ensure that the patient has received specific information regarding the nature and effect to antipsychotic medications, to enable him/her to make an informed decision. To ensure that the patient has signed the Consent to Receive Psychopharmacological Medication Form prior to administering the medication(s) to the patient. The patient must be provided with sufficient information by the physician prescribing the medication, in order to make an informed consent."

Based on interview and record review, the facility failed to obtain information regarding Advance Directives (AD-a legal document that indicates a person's wishes for medical treatment) for nine of 47 sampled patients (Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 38, Patient 41, Patient 40, and Patient 42). This failure had the potential for staff to be unaware of the patient's and/or legal representative's wishes for treatment.

Findings:

1. During a concurrent interview and record review on 5/25/23, at 1:39 p.m., with QRD, Patient 5's MR was reviewed. MR indicated Patient 5 was admitted to the facility on 4/11/23. QRD was unable to find documentation of AD. QRD reviewed Patient 5's MR and was unable to find AD documentation. QRD stated "None"

2. During a concurrent interview and record review on 5/25/23, at 2 p.m., with Quality Risk Director (QRD), Patient 4's medical record (MR) was reviewed. MR indicated Patient 4 was admitted to the facility on 5/13/23. QRD reviewed the file twice but was unable to find documentation of AD and stated, "None"

3. During a concurrent interview and record review on 5/24/23, at 2:15 p.m., with RN 20, Patient 38's MR was reviewed. MR indicated Patient was admitted to the facility on 5/04/23. RN 20 was unable to find documentation of AD. RN 20 reviewed Patient 38's MR several times and was unable to find AD documentation. RN 20 stated there was no AD in patient' chart.

4. During a concurrent interview and record review on 5/24/23, at 2:30 p.m., with RN 20, Patient 41's MR was reviewed. MR indicated Patient was admitted to the facility on 5/06/23. RN 20 was unable to find documentation of AD. RN 20 reviewed Patient 41's MR several times and was unable to find AD documentation. RN 20 stated there was no AD in patient' chart.

5. During a concurrent interview and record review on 5/24/23, at 3:15 p.m., with RN 20, Patient 42's MR was reviewed. MR indicated Patient was admitted to the facility on 4/12/23. RN 20 was unable to find documentation of AD. RN 20 reviewed Patient 42's MR several times and was unable to find AD documentation. RN 20 stated there was no AD in patient' chart.

6. During a concurrent interview and record review on 5/25/23, at 3:30 p.m., with QRD, Patient 8's MR was reviewed. MR indicated Patient 8 was admitted to the facility on 5/24/23. QRD was unable to find documentation of AD and stated, "Not here."

7. During a concurrent interview and record review on 5/25/23, at 3:42 p.m., with QRD, Patient 9's MR was reviewed. MR indicated Patient 9 was admitted to the facility on 5/23/23. QRD was unable to find documentation of AD. QRD stated, "None."

8. During a concurrent interview and record review on 5/25/23, at 3:55 p.m., with QRD, Patient 10's MR was reviewed. MR indicated Patient was admitted to the facility on 5/22/23. QRD was unable to find documentation of AD. QRD reviewed Patient 10's MR several times and was unable to find AD documentation. QRD stated an advance directive should have been completed on admission.

9. During a concurrent interview and record review on 5/24/23, at 4 p.m., with RN 20, Patient 40's MR was reviewed. MR indicated Patient was admitted to the facility on 5/4/23. RN 20 was unable to find documentation of AD. RN 20 reviewed Patient 40's MR several times and was unable to find AD documentation. RN 20 stated there was no AD in patient' chart.

During a review of the hospital's policy and procedure (P&P) titled, "PATIENT RIGHTS-HOSPITAL WIDE" (undated), the P&P indicated, "8. Formulate advance directives . . . All patient's rights apply to the person who has legal responsibility to make decisions regarding medical care on your behalf."

Based on interview and record review the facility failed to follow their policy & procedure (P&P) titled, "Code Gray-Management of Assaultive/Combative Behavior." This failure resulted in two staff (RN [Registered Nurse] 25 and MHW [Mental Health Worker] 15) being injured, violation of the right to receive care in a safe therapeutic environment for nine of nine sampled patients (Patient 18, Patient 21, Patient 22, Patient 36, Patient 43, Patient 44, Patient 45, Patient 46, and Patient 47).

Findings:

During an interview, on 4/4/23, at 12:03 p.m., with Quality Risk Director (QRD), QRD stated, "Patient 18 was the "ringleader" and Patient 20 were both yelling at each other trying to get out of their assigned units. QRD stated, the facility was not effective in deescalating the situation.

During a concurrent interview and record review, on 4/4/23, at 1:35 p.m., with Quality Risk Manager (QRM), the "facility video surveillance unit 500" dated 4/2/23, was reviewed and indicated, on 4/2/23, at 8:09 p.m., Patient 18 hit the nurses station window with a closed fist, and then repeatedly hit RN 25's face and head. MHW 15 and RN 25 were at the entrance/exit double doors adjacent to the dayroom when Patient 21 hit MHW 15. There were six patients in the hallway (Patient 36, Patient 43, Patient 44, Patient 45, Patient 46, and Patient 47 including Patient 18, Patient 21, and Patient 22. At 9:22 p.m. a police officer entered 500 unit.

During an interview, on 4/4/23, at 3:55 p.m., with administrator on call (AOC), AOC stated, on 4/2/23, at 8 p.m. a call was received from RN 12, and while on the phone AOC heard loud banging and yelling. At 8:24 p.m. AOC stated another call was received from RN 12 with "a fearful " that patients in the 500 unit were "rioting," and asked to call the police. AOC stated, the incident was "chaotic and not safe."

During an interview, on 5/3/23, at 3:50 p.m., with MHW 7, MHW 7, stated on 4/2/23, at 6:30 p.m. the environment in unit 500 was unsafe and was escalating. MHW 7, Patient 18 and Patient 20 were trying to "get at each other." MHW 7 stated, Patient 18 repeatedly said he was going to "target" Patient 20, and if anyone got in his way he was going to "beat their ass." MHW 7 stated the uninvolved patients should have been moved to another unit. MHW 7 stated the "chaos" went on for hours, and the code gray (the management of assaultive and combative behavior) situation was not under control until the police arrived.

During an interview, on 5/25/23, at 1:32 p.m., with RN 12, RN 12 stated Patient 18, Patient 21, and Patient 22 were "attacking staff" and the others patients could not be escorted off unit because it was a "chaotic" environment.

During a concurrent interview and record review, on 5/26/23, at 12:23 p.m., with RN 1, the facility P&P, titled "Code Gray- Management of Assaultive/Combative behavior," dated 7/27/22, was reviewed, the P&P indicated, "PROCEDURE. . . Make every attempt to decrease the stimulus and isolate the patient from other patients. A staff member should be responsible for removing the other patients from the immediate environment and remaining with them to decrease their anxiety." RN 1 stated the removal of all patients when situation escalates is standard procedure to provide a safe environment.

During a review of the facility's P&P, titled "Code Gray-Management of Assaultive/Combative behavior," dated 7/27/22, indicated, "PURPOSE: To provide a safe environment for the Mental Health Unit's patients and staff . . . To ensure that emergency procedures are followed . . . the event that a patient escalates and becomes assaultive/combative, all safety measures shall be provided to the patient, other patients and staff . . . decrease the stimulus and isolate the patient from other patients. A staff member should be responsible for removing the other patients from the immediate environment and remaining with them to decrease their anxiety."

During a review of the facility's competency test titled "Milieu Management Competency," undated, indicated, "1. Basic features of healthy milieu include the following except: [answer] c. Chaos. . . 7. What is our primary goal when providing care to our patient? [answer] b. safety 8. You are in the hallway and heard banging sound, what should you do first? [answer] a. Check and ensure patient's safety. Call for help"

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

1. Protect three of 47 sampled patients (Patient 14, Patient 16, and Patient 19) from physical abuse. This failure resulted in Patient 14, Patient 16, and Patient 19 being physically abused by other patients.

2. Protect one of 47 sampled patients (Patient 39) from sexual abuse. This failure put Patient 39 at risk for sexual abuse.

Findings:

1a. During a concurrent interview and record review, on 3/30/23, at 12:52 p.m., with Quality Risk Director (QRD), the "facility surveillance video unit 600", dated 3/18/23 was reviewed. QRD stated, the "facility surveillance video unit 600" indicated, Patient 18 and Patient 20 assaulted Patient 19, causing Patient 19's hair pulled and a broken nose injury. The video record indicated, Patient 19 sitting in a chair using the unit telephone and Patient 20 come out of the dayroom and pull Patient 19's hair and Patient 18 punch Patient 19 in the face.

During an interview on 3/30/23, at 2:38 p.m., with Registered Nurse (RN) 8, RN 8 stated, Patient 19 was on the phone with Guardian (GR) because Patient 19 did not like it on the unit, and wanted to go home. Patient 18 and Patient 20 would call her profanity, "Bitch" and didn't like her. Patient 19 had very thin hair, and Patient 19 didn't like her hair to be touched. RN 8 stated, Patient 19 was a younger adolescent on the unit and small. RN 8 stated, that Patient 20 pulled Patient 19's hair and Patient 18 punched Patient 19's face breaking Patient 19's nose. RN 8 stated, that there was a lot of blood and Patient 19 was on the phone with Guardian when Patient 19 was attacked.

During an interview on 5/19/23, at 1:45 p.m., with Guardian (GR), GR stated, on 3/18/23, she (GR) was talking on the phone with Patient 19, and she (GR) heard yelling from other Patients on the unit. GR stated, Patient 19 started to cry and told her (GR) that Patient 19's hair was pulled and wanted GR to come to pick her up. GR stated, Patient 19 screamed in pain and the phone call ended.

During a concurrent interview and record review, on 5/26/23, at 11:56 a.m., with RN 1, the facility "Nursing Staff Assignment AM 3/18/23" document was reviewed. RN 1 stated, the facility "Nursing Staff Assignment AM 3/18/23" indicated, Patient 19 was assigned a Mental Health Worker (MHW) for every 5-minute observations with a higher care need (level 4) and the "Observation Rounds/Precautions" flowsheet, dated 3/18/23, indicated Patient 19 was monitored every 10 minutes. RN 1 stated, the "Observation Rounds/Precautions" flowsheet should match Patient 19's higher care needs (level 4) every 5 minutes monitoring and the injury could have been prevented with the increased observation.

During a concurrent interview and record review, on 5/26/23, at 11:58 p.m., with RN 1, Patient 18's "Nursing Shift notes," dated 3/17/23, were reviewed and indicated, Patient 18 had conflict with female patients, hyperverbal, poor concentration, impaired decision making ability, and at risk for homicide (intention to harm others) due to easily irritable, impulsive (action without thinking) behavior, refusing activities, angry, and anxious (a profound sense of worry). RN 1 stated, Patient 18 had signs of DTO.

During a concurrent interview and record review on 5/26/23, at 12 p.m., with RN 1, Patient 20's "Physician Order", dated 3/14/23, was reviewed. RN 1 stated, Patient 20 had a physician order for danger to others (DTO) precautions, and Patient 20's "Observation Rounds/Precautions" flowsheet's, dated 3/14/23, 3/15/23, 3/16/23, 3/17/23, and 3/18/23 indicated no implementation of DTO precautions.

1b. During a concurrent interview and record review, on 5/26/23, at 5:47 p.m., with QRD, the "facility surveillance video unit 500," dated 3/31/23, was reviewed. QRD stated, Patient 14 was assaulted by Patient 18 and Patient 20. The "facility surveillance video unit 500" indicated, Patient 14 was sitting in the hallway when Patient 18 kicked Patient 14's face and head, and Patient 20 punched Patient 14's face and head. On the video RN 11 is observed with his hands in his pockets in the unit hallway watching the assault. QRD stated, RN 11's in-action was that, "He failed."

1c. During an interview on 5/23/23, at 2:27 p.m., with RN 3, RN 3 stated, that Patient 17 was a new admission, and had the contraband from intake onto the unit. RN 3 stated Patient 17 had an object in his hand before the property destruction, and Patient 16 was cut with the weapon.

During an interview, on 5/23/23, at 4:45 p.m., with RN 5, RN 5 stated, patients are checked for contraband during admission and on the unit, and the patients do hide contraband. RN 5 stated, contraband searches are for safety purpose to find any item that can be used as a weapon.

During an interview and concurrent record review, on 5/30/23, at 12:15 p.m., with Quality Risk Manager (QRM), QRM reviewed Patient 17's Medical Chart and stated, Patient 17's chart did not have a contraband search document.

During an interview on 5/30/23, at 4:43 p.m., with RN 26, RN 26, stated the expectation is to have a contraband search to be done for safety and ensure items that are potential for use to harm self or others are not on the patient care unit.

During a concurrent interview and record review, on 5/30/23, at 5:03 p.m., with QRM, QRM reviewed the "facility surveillance video unit 600," dated 5/17/23 and stated, Patient 16 was assaulted by Patient 17. The "facility surveillance video unit 600," indicated, Patient 17 in the hallway with a toothbrush in his hand and his arm motion towards Patient 16. QRM stated, Patient 17 had a toothbrush in his hand and a toothbrush is considered contraband.

2. During a review of Master Treatment Plan (MTP), undated, the MTP indicated, Patient 38 was identified as Sexually acting out on 5/7/23.

During an interview on 5/30/23, at 10:20 a.m., with RN 21, RN 21 stated, Patient 38 was identified as sexually acting out on 5/7/23.

During an interview on 5/30/23, at 10:21 a.m., with RN 21, RN 21 stated, Patient 39 was admitted on 5/8/23 in Patient 38's room. They both were roommates.

During a review of the facility's policy and procedure (P&P) titled, "Managing Inappropriate Sexual Behaviors for Inpatient Hospitalization" dated 2022, the P&P indicated, "In high-risk patient understands the hospital policy but does not agree or cannot follow the policy and the patient is demonstrating inappropriate sexual behavior a treatment plan maybe developed and implemented as appropriate to the patient's behaviors and may include, but is not limited to the following: Placement in private room (no roommate)."

During a review of the facility policy and procedure titled, "Assault Precautions", dated 7/27/22, indicated, "PURPOSE: To decrease episodes of patient escalation by recognizing patient specific risk factors, escalation triggers and effective de-escalation techniques. . . When risk factors are identified, assault precautions are to be added to the patient's treatment plan and be considered when determining room assignment. . . Physicians are to be notified when preventative techniques are not effective. . . Risk Assessment- History of violence . . . Current thoughts, plans or threats of violence, Involuntary status, Displayed aggression. . . Acute symptoms of illness. . . Predisposing Situations- When a patient is afraid, Following the denial of a real or perceived privilege, Perceived loss of control, Following a conflict or argument . . . Treatment Plan-Indicate assault precautions on the treatment plan . . . Triggers should be identified on the treatment plan, Patient-identified de-escalators should be identified on the treatment plan ... Signs of Escalation."

During a review of the facility's P&P, titled "Code Gray -Management of Assaultive/Combative behavior," dated 7/27/22, indicated, "PURPOSE: To provide a safe environment for the Mental Health Unit's patients and staff . . . To ensure that emergency procedures are followed . . . the event that a patient escalates and becomes assaultive/combative, all safety measures shall be provided to the patient, other patients and staff . . . decrease the stimulus and isolate the patient from other patients. A staff member should be responsible for removing the other patients from the immediate environment and remaining with them to decrease their anxiety."

During a review of the facility's "Contraband Competency Test," undated, indicated, "4. Who is responsible for contraband checks on the patient living units? [Answer] d. Nurse & MHW . . . 5. A patient can be placed on the unit without a contraband check? [Answer] c. Never . . . 7. What constitutes a proper reason for a contraband search? [Answer] e. all of the above . . . d. Patient not returning all hygiene products."

During a review of the facility's "Contraband Acknowledgement," undated, indicated, "Items Identified as Contraband at [facility]: Sharp objects. . . pencils, pens, plastic silverware, plastic plates, or any other sharp or pointed object that could inflict harm."

During a review of the facility policy and procedure (P&P) titled, "Abuse: Identifying, Reporting, and Facility Initiated Investigations" dated 7/27/22, indicated, "All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form. . . d. monitoring of patients with special needs or behaviors that may require additional resources to safely manage, without neglecting the care needs of any other patient on the unit . . . A. Abuse: refers to the willful infliction injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish but not limited to staff neglect or indifference to infliction of injury or intimidation of one patient by another. . . C. Verbal Abuse: defined as the use of oral, written or gestured language that willfully includes dispersing and derogatory term to patients . . . within their hearing distance, regardless of their age, ability to comparand, or disability. . . E. Physical Abuse: includes hitting, slapping, pinching, pushing and , kicking or any aggressive behavior in the direction of the patient. H. Neglect: failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Based on interview and record review the facility failed to ensure accuracy one of 47 sampled patients (Patient 23) medical record. This failure resulted in a violation of Patient 23's right to privacy and confidentiality.

Findings:

During a concurrent interview and record review, on 5/25/23, at 5:03 p.m., with Quality Risk Director (QRD), Patient 23's medical record (MR) was reviewed and indicated Patient 33's "Nursing Day Shift Notes," dated 5/23/23 was in Patient 23's MR. QRD stated, Patient 33's "Nursing Day Shift Notes" should not be in Patient 23's MR.

During a review of the facility policy and procedure (P&P) titled, "PATIENT RIGHTS-HOSPITAL WIDE," dated 9/29/22, indicated, "Confidential treatment of all communications and records pertaining to the care and the stay in the hospital."

During a review of the facility P&P titled, "Hospital Plan for the Provision of Patient Care," dated 2/22/22, indicated, "Clinical departments. . . will operationalize a departmental plan of care to promote continuity of care and promote consistency in the quality of services to consumers."

Based on interview and record review, the facility failed to follow it's policy and procedure titled, "Use of Seclusion and Restraint" for one of 47 sampled patients (Patient 21). This failure resulted in the violation of patients rights to be free from unnecessary restraints and had the potential for unmet care needs.

Findings:

During an interview, on 5/18/23, at 7:05 p.m., with Guardian (GR) 2, GR 2 stated, Patient 21's Medical Doctor (MD) 2 and the nursing staff never involved GR 2 in Patient 21's care. GR 2 stated, the nursing staff called GR 2, when "they had already injected [Patient 21] with medication."

During an interview, on 5/18/23, at 7:12 p.m., with Patient 21, Patient 21 stated, she was injected with medications, her family was not called, and she did not have a mental health worker (MHW) assigned only to her.

During an interview, on 5/18/23, at 7:30 p.m., with Patient 21, Patient 21, stated she was not her regular self and was receiving so many medications. Patient 21 stated, anytime she was upset the staff would give her a pill or an injection. Patient 21 stated, she had to always have her guard up because she didn't trust the staff the way they treated her and other patients.

During a concurrent interview and record review, on 5/26/23, at 11:19 a.m., with RN 1, Patient 21's medical record was reviewed and the following was noted:

1. Patient 21's "Physician Orders [PO]", dated 3/31/23, at 4 p.m., indicated, "Haldol [stabilize mood and reduces extremes in behavior] 5 mg [milligrams is a unit of measure] IM [intramuscular-medication injection into the muscle] Lorazepam [stabilize mood and reduces extremes in behavior] 2 mg IM Benadryl [induce drowsiness and slows behavior] 50 mg IM x 1 now PRN [as needed] agitation TORB[telephone order readback] MD 2 RN 11 [Signature]" MD 2 signature dated 4/3/23. RN 1 stated, Patient 21's PO should have been clarified because the medications should be ordered with parameters and not as needed.


2. Patient 21's, "Nursing Progress Notes", dated 3/31/23, no time, RN 11 documented, "Pt [patient] placed into PRT [physical restraint hold] and then seclusion due to aggression towards peers and banging on the walls, unable to respond to redirection Pt [patient] received IM meds [without] hold but was still unable to respond to redirection MD [medical doctor] guardian notified." RN 1 stated, the entry indicated the GR was notified after the medication was administered.

3. Patient 21's, "Observation Rounds/Precautions" flowsheet's indicated, no 1:1 monitoring care intervention was implemented before or after the use of restraint medications, PRT, and seclusion for agitation according to the facility's policy and procedure (P&P).

4. Patient 21's, "Child Daily Contact", dated 3/31/23, was reviewed and RN 1 stated, Patient 21's GR 2 was notified about the "action" of PRT, medication administration, and seclusion after it was implemented.

During an interview on 5/26/23, at 11:51 a.m., with RN 1, RN 1 stated, the expectation was to involve the family and/or guardian in care of patients.

During a review of the facility's P&P titled, "Use of Seclusion and Restraint", dated 7/27/2022, indicated, "Restraint for behavior management . . . the term "restraint" includes. . . a drug that is being used as a restraint. . . A drug used, as a restraint, is a medication used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment for the patients' medical and psychiatric condition. . . The use of a restraint . . . must be Selected only when less restrictive measures have been found to be ineffective to protect the patient or others from harm. . . Orders for the use of . . . restraint must never be written as . . . an as needed basis. . . PRN."

During a review of the facility's P&P titled, "Rounds of Patient Observation", dated 3/12/2021, indicated, "Guidelines for 1:1 Seclusion, Restraint or Emergency Use of Meds, Patient failed other levels of observations, unsafe at lower level of care. . . Guidelines for 10 Minute Observations Minimum observation level for all children and adolescents ages that are inpatient."

During a review of the facility's P&P titled, Multidisciplinary Treatment Planning," dated 3/25/22, indicated, "Treatment Plan Review/Revision. . . The plan shall be revised. . . following any major event such as physical hold. . . The changes are discussed with. . . guardian."

Based on interview and record review, the facility failed to ensure three of 24 sampled employees (Registered Nurse (RN) 14 and mental health worker (MHW) 10, and MHW 12) had current educational training and demonstrated knowledge in cardiopulmonary resuscitation (CPR-life saving intervention during medical emergency). This failure had the potential to contribute to adverse events.

Findings:

During a concurrent interview and record review, on 5/24/23 , at 4:30 p.m., with Human Resources Director (HRD), HRD reviewed RN 14 and MHW 10 employee records, and stated, RN 14 and MHW 10 do not have BLS certification and should have it.


46958

During a concurrent interview and record review, on 5/25/23, at 11:10 AM, with Human Resources Assistant (HRA), the employee record for MHW 12 was reviewed. The CPR, automated external defibrillator (AED), and Basic First Aid (CABFA) certifications, dated 2/21 was reviewed. The CABFA indicated, expired since 2/2023. HRA stated, CPR card has been expired since 2/2023, and "We don't have any recent one on file."

During a review of the facility's job description titled, "Registered Nurse," dated 5/4/22, indicated, "Required Licenses- Current CA-RN license, CPR . . . Adheres to . . . compliance standards."

During a review of the facility's job description titled, "Mental Health Worker," dated 5/4/22, indicated, "Job requirements ... Current CPR Certificate."

Based on interview and record review the facility failed to ensure completion of annual evaluation was done for 12 of 13 (Quality Risk Manager (QRM), MHW 12, Registered Nurse (RN) 7, RN 18, RN 20, RN 19, RN 21, MHW 11, RN 8, RN 6, RN 1, and RN 21) sampled staff. These failures had the potential to result in staff not qualified to provide quality care to patients.

Findings:

During a concurrent interview and record review, on 5/24/23, at 4:30 p.m., with Human Resources Director (HRD), HRD reviewed the employment record (ER) for QRM. The ER indicated the annual performamnce evaluation was not completed for 2022. HRD stated, there's no not completed since QRD hired 8/23/21.




46958


During a concurrent interview and record review, on 5/25/23, at 11:20 a.m., with Human Resources Assistant (HRA), ER for RN 7, dated Feb 2016 was reviewed. The ER indicated, no annual evaluation done after 2021 for RN 7. HRA stated, Last one was done in year 2021 and there is none after that.

During a concurrent interview and record review, on 5/25/23, at 11:45 a.m., with HRA, The ER for RN 18, dated 11/6/2017 was reviewed. The ER indicated, no annual evaluation done for 2022 for RN 18. HRA stated, there was no evaluation done for year 2018, 2019, 2021, 2022.

During a concurrent interview and record review, on 5/25/23, at 11:55 a.m., with HRA, the ER for RN 20, dated 12/31/21 was reviewed. The ER indicated, no annual evaluation done for RN 20. HRA stated, there is no evaluation in her file.

During a concurrent interview and record review, on 5/25/23, at 12:10 a.m., with HRA, the ER for RN 19, dated 8/2/21 was reviewed. The ER indicated, no annual evaluation done for 2022 for RN 19. HRA stated, No evaluation was found for year 2022.

During a concurrent interview and record review, on 5/25/23, at 12:20 p.m., with HRA, the ER for RN 21, dated 2016 was reviewed. The ER indicated, no annual evaluation done after 2019 for RN 21. HRA stated, No evaluations are done after 2019.

During a concurrent interview and record review, on 5/25/23, at 12:30 p.m., with HRA, the ER for MHW 11, dated 4/2018 was reviewed. The ER indicated, no annual evaluation done after 2019 for MHW 11. HRA stated, Last evaluation was done in year of 2019 and none done after that.

During a concurrent interview and record review, on 5/25/23, at 4:08 p.m., with HRD, RN 8's ER was reviewed and indicated, annual performance evaluation was not completed for 2022.
HRD stated, "not completed for year 2022."

During a concurrent interview and record review, on 5/25/23, at 4:20 p.m., with HRD, RN 6's ER was reviewed and indicated, annual performance evaluation was not completed for 2018 and 2022. HRD stated, "all annual performance evaluation not completed in year 2022."

During a concurrent interview and record review, on 5/25/23, at 4:48 p.m., with HRD, RN 1's ER was reviewed and indicated, annual performance evaluation was not completed for 2018, 2019 and 2022. HRD stated, "I don't know what happened."

During a concurrent interview and record review, on 5/25/23, at 5 p.m., with HRD, RN 21's ER was reviewed and indicated, annual performance evaluation was not completed for 2017, 2018, 2021, 2022. HRD stated, "I know all staff were not evaluated in 2022, but I don't know why this one were not completed every year."

During a review of the facility P&P, titled, "Conditions of Employment", dated 5/2/22, indicated, "PURPOSE: To ensure [facility] employs properly qualified individuals, and to communicate certain information and expectations to employees and to maintain the necessary records associated with employment. POLICY: [Facility] has established certain employment conditions. . . to. . . maintain their employment. . . completion of. . . certain tests necessary to maintaining a safe. . . workplace and a work environment free of infection and communicable disease; annual reexaminations associated with infection control. . . Completion of any applicable competency or proficiency test. . . The completion of the appraisal period."

Based on observation, interview, and record review the facility failed to ensure the patients were allowed visitation for one of 32 sampled patients (Patient 19). This failure resulted in a violation of Patient 19's rights to have visitors, and the potential for other patient's to not have the right of visitation.

Findings:

During an observation and record review on 5/23/23, at 8:04 a.m., the facility visitation guidelines sign on the reception wall was observed, and indicated Covid-19 vaccination as a listed requirement for in-person visitation.

During an interview, on 5/19/23, at 2:15 p.m., with Guardian (GR), indicated that during Patient 19's hospitalization at the facility, GR was not allowed to visit because GR was not vaccinated for Covid-19 according to facility guidelines.

During a concurrent interview and record review on 5/23/23, at 4:38 p.m., with Receptionist, Receptionist reviewed the facility document titled, "As of July 11, 2022, New Visitation Guidelines . . . For in-person visitation . . . All visitors must provide proof of full vaccination or a negative COVID test performed 72 hours prior to the visit" and stated that the patient's approved visitors are screened over the phone and follow Covid guidelines.

During a concurrent interview and record review, on 5/24/23, at 2 p.m., with the business office manager (BOM), BOM reviewed Patient 19's March 2023 approved visitor, and GR was not listed as an approved visitor.

During an interview on 5/26/23, at 1:06 p.m., with Infection Control Epidemiologist (ICE), ICE stated, she is aware of the current recommendation and all facilities letters (AFL's) regarding Covid-19 guidelines and the facility visitation guidelines are not accurate.

During a review of the "California Department of Public Health [CDPH] AFL[All Facilities Letter 21-31.2, updated 1/23/23, the AFL indicated, "Visitor Limitation Guidance at General Acute Care Hospitals (GACH). . . This AFL announces that, effective September 17, 2022. . . Visitors are no longer required to show proof of vaccination or a negative test to have indoor visitation."

During a review of the facility's policy and procedure (P&P) titled, "Patient's Rights-Mental Health Unit," undated, indicated, "Each person admitted voluntarily or involuntarily has the following rights: 3. To see visitors each day."

During a review of the facility's P&P titled, "Patient Rights Hospital Wide," undated, indicated "A patient's right shall include but not limited to. . . visitors. . . At a minimum, the hospital shall include any person living in the household."

The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.21 Quality Assessment and Performance Improvement Program as evidenced by the following:

1. Based on interview and record review, the facility failed to have an effective Quality Assessment Performance Improvement (QAPI) program when 10 of 10 sampled staff (Registered Nurse [RN] 3, RN 4, Housekeeper [HKP] 1, Mental Health Worker [MHW] 1, MHW 2, RN 6, RN 7, RN 8, RN 9, Director of Plant Operations [DPO]) interviewed were not aware and/or did not participate in the facility's QAPI activities.

This failure had the potential to result in the facility being unable to identify opportunities for improvement due to staff being unaware and not participating in the facility's QAPI program. (Refer to A-0283)

2. Based on interview and record review, the facility failed to develop and implement Performance Improvement (PI) projects.

This failure resulted in the facility's inability to ensure quality health care in a safe environment is provided to all patients being treated in the facility. (Refer to A-0297)

3. Based on interview and record review, the facility failed to conduct a facility annual quality assessment to identify and prioritize opportunities for performance improvement (PI).

This failure resulted in missed opportunities for performance improvement. (Refer to A-0309)

The cumulative effect of these systemic practices resulted in the facility's inability to ensure quality health care, in compliance with the condition of Participation for Quality Assessment and Performance Improvement Program.

Based on interview and record review, the facility failed to have an effective Quality Assessment Performance Improvement (QAPI) program when 10 of 10 staff (Registered Nurse [RN] 3, RN 4, Housekeeper [HKP] 1, Mental Health Worker [MHW] 1, MHW 2, RN 6, RN 7, RN 8, RN 9, Director of Plant Operations [DPO]) interviewed were not aware and/or did not participate in the facility's QAPI activities. This failure had the potential to result in the facility being unable to identify opportunities for improvement due to staff being unaware and not participating in the facility's QAPI program.

Findings:

During an interview on 5/23/23, at 9:10 a.m., with RN 3, RN 3 stated, "I don't know that they have Quality projects here. They don't tell us. We just come to work and work hard. There's no projects [PI] that I know of."

During an interview on 5/23/23, at 9:14 a.m., with RN 4, RN 4 stated, "I don't know anything about Quality or QAPI projects here, maybe that's for full time only."

During an interview on 5/23/23, at 9:22 a.m., with HKP 1, HKP 1 stated, "We don't have any hospital project. I don't know any hospital issues. I don't participate. I'm just a housekeeper here and my job is to clean. My manager doesn't tell me anything or any project or issues."

During an interview on 5/23/23, at 9:34 a.m., with MHW 1, MHW 1 stated, "There's no hospital project here. I do not know Quality group or [PI]. We don't have that here. Nobody participates in any projects. Well, they don't communicate with us anyway."

During an interview on 5/23/23, at 9:53 a.m., with MHW 2, MHW 2 stated, "I don't know any hospital projects, they don't communicate with us ..."

During an interview on 5/23/23, at 9:59 a.m., with RN 6, RN 6 was unable to explain what a QAPI program is and PI activities.

During an interview on 5/23/23, at 10:05 a.m., with RN 7, RN 7 stated, she did not know Quality or QAPI, or performance improvement. RN 7 stated she did not participate in any projects. One issue the facility can improve in is staffing. To staff according to the patient's needs. RN 7 stated that sometimes they put two patients that need one-on-one [supervision] in one room for one Mental Health Worker (MHW) to supervise.

During an interview on 5/23/23, at 10:11 a.m., with RN 8, RN 8 was unable to explain QAPI and PI projects. RN 8 stated, "We have a problem with the way Administration staffed the unit. They don't give us enough staff. We don't have a break nurse. How can we go for a break."

During an interview on 5/23/23, at 10:35 a.m., with RN 9, RN 9 stated, "I don't know any hospital projects. They don't tell us."


47095

During an interview on 5/24/23, at 2:46 p.m., with the Director of Plant Operations (DPO), DPO stated, "I wasn't part of any meeting [QAPI] and RCA."

During concurrent interview and record review on 5/30/23, at 12:10 p.m., with Quality and Risk Director (QRD), QRD was unable to provide documentation of QAPI and PI staff training and communication with staff.

Based on interview and record review, the facility failed to develop and implement Performance Improvement (PI) projects. This failure resulted in the facility's inability to ensure quality health care in a safe environment is provided to all patients being treated in the facility.

Findings:

During a concurrent interview and record review, on 5/30/23, at 8:43 a.m., with Medical Doctor (MD) 1, MD 1 stated, "I am the Medical Director and Chairperson of the Governing body, Medical Staff, and QAPI [Quality Assessment and Performance Improvement] Committee. We are trying to revamp [Give new and improved form, structure, or appearance] to the adolescent behavioral program which is very important for the patients but it's not documented. We discussed about working on it. It is not a QAPI project, it should be. I know psyche eval [Psychiatric evaluation-Assessment and reassessment of mental health illness and its treatments] is a problem too." MD 1 added, "We don't have a good QAPI program because of the fast turnover of people in management. We always have new CEO [Chief Executive Officer, Top position and responsible for implementing existing plans and policies], CFO [Chief Financial Officer, Senior executive responsible to financial affairs of the organization], CNO [Chief Nursing Officer, experienced nurse with responsibilities related to patient care]. There was a time we did not have CEO or CNO. That's the biggest problem here, so things don't work and look chaotic. We have the same issues, 2 years ago and last year about informed consent and is still a problem." MD 1 was unable to provide document evidence of QAPI PI projects approved by QAPI Committee and Governing body. MD 1 stated, "We don't have documents of PI projects."

During an interview on 5/30/23, at 9:46 a.m., with CNO, CNO stated, "I am a consultant CNO, I started three weeks ago. I don't understand their processes and I haven't seen their [facility's] QAPI binder and plan. My assessment[is] they [the facility] need a manager to work with the staff to hardwire the processes and consistency. There's no foundation to support the QAPI. I don't know of any PI projects. I know staffing is an issue and the need for manager position between CNO and staff. My last day is on June 20 [2023]."

During an interview on 5/30/23, at 11:24 a.m., with Corporate Director of Quality and Risk (CDQR), CDQR stated, "[CEO] told me about our QAPI issues and I agree it's not effective, we should have worked on last year's findings [2022 survey deficiencies] as PI projects. What's happening is they write POC [Plan of Correction] for the sake of writing it but not well completed. I wrote some parts of POC."

During a concurrent interview and record review, on 5/31/23, at 12:10 p.m., with Quality and Risk Director (QRD). QRD was not able to provide an approved QAPI Plan for 2023. QRD provided a blank QAPI plan approval page and stated, "It's blank without signatures." No further information was provided.

Based on interview and record review, the facility failed to conduct a facility annual quality assessment to identify and prioritize opportunities for performance improvement (PI). This failure resulted in missed opportunities for performance improvement.

Findings:

During a concurrent interview and record review, on 5/30/23, at 8:57 a.m., with Medical Director and Quality Assessment Performance Improvement (QAPI), (MD) 1, MD 1 was unable to provide documentation of a facility assessment. MD 1 stated, "We don't do facility assessment, that's the right thing to do. CNO [CNO-Chief Nursing Officer] should do that. We don't have documents to show you."

During a concurrent interview and record review, on 5/30/23, at 8:43 a.m.- 9:45 a.m., with MD 1, MD 1 stated, "I am the Medical Director and Chairperson of the Governing body, Medical Staff, and QAPI Committee. We are trying to revamp [Give new and improved form, structure, or appearance] the adolescent behavioral program which is very important for the patients but it's not documented, we discussed about working on it. It is not a QAPI project, it should be."

During a concurrent interview and record on 5/30/23, at 12:10 p.m., with Quality and Risk Director (QRD), the facility's QAPI Program Plan dated 2023 was reviewed. The QAPI Plan approval page indicated no signatures of approval by QRD, Chief Executive Officer, Quality Council, PI Committee Chair, and Board of Governors. QRD was not able to provide a QAPI Plan approved by the governing body and stated, "It's not signed [which would acknowledge approval]."

Based on interview and record review, the facility failed to develop, implement and evaluate a comprehensive care plan for two of 47 sampled patients (Patient 42, Patient 34). This failure had the potential for unmet patients care needs.

Findings:

During a concurrent interview and record review, on 5/24/23, at 3:15 p.m., with Registered Nurse (RN) 20, the Master Treatment Plan (MTP) for Patient 42, dated 4/14/23 was reviewed. The MTP indicated was initiated on 4/14/23. There was no update/revisions to the MTP. RN 20 stated the MTP was not updated.

During a concurrent interview and record review, on 5/25/23, at 3:15 p.m., with RN 21, MTP for Patient 34, dated 5/8/23 was reviewed. The MTP indicated it was initiated on 5/8/23 and Patient 34 was discharged on 5/23/23. There was no update/revisions to the MTP from the time the MTP was initiated until the patient was discharged 15 days later. RN 21 stated the MTP was not updated.

During an interview on 5/24/23, at 3:20 p.m., with RN 20, RN 20 stated, the MTPs should be revised every seven days.

During the review of the facility's policy and procedure (P&P) titled " Hospital Plan for the Provision of Patient Care" dated 2/22/2022, the P&P indicated, "Nursing care for each patient is under the supervision of a Registered Nurse with specific aspects of care delegated to competent staff. Each patient is assessed by a Registered Nurse at the time of entry to the facility with ongoing assessments with each patient contact to determine further needs."

During the review of the facility's P&P titled "Multidisciplinary Treatment Planning" dated 3/25/2022, the P&P indicated, " Treatment Plan Review/Revision: The treatment and discharge plan is reviewed and revised no later than 7 days after the development of the Multidisciplinary Treatment Plan (MTP), and every 7 days thereafter, communicate with changes in the patient's status and/or condition . . ."

Based on interview and record review, the facility failed to ensure physician's verbal orders were used infrequently, were signed by the physician with date and time of order and signed timely according to the facility's policy and procedure for seven of 47 sampled patients (Patient 1, Patient 2, Patient 6, Patient 34, Patient 35, Patient 37, Patient 42). These failures had the potential for miscommunication that could result in errors and in unmet care needs.

Findings:

1. During a concurrent interview and record review on 5/24/23, at 3 p.m., with Quality and Risk Director (QRD), Patient 1's "Physician Orders [PO]" were reviewed. The following was noted:

a. PO dated 3/15/23, at 9:35 p.m., indicated "Zyprexa [Treats several mental health conditions and helps regulate mood, behaviors and thoughts] 10 milligram (mg - unit of measure) x 1 [One time] now. TORB [Telephone Order Read Back] Doctor: [MD 1] (Registered Nurse [RN] 28's Signature)" MD 1's signature was without a date or time.

b. PO dated 3/16/23, at 7:50 p.m., indicated "Thorazine [Mood stabilizer] 100 mg x 1 IM [Intramuscular injection] for agitation, and at 8:10 pm Transfer to Unit 300 due to unit needs. TORB Doctor: [MD 1] [RN 28's Signature]." MD 1's signature was without date or time.

c. PO dated 3/20/23, at 6:25 a.m., indicated "Change 1:1 [one staff assigned to supervise one patient] level of observation to Q [every] 5 minutes level of observation . . . TORB Doctor: [MD 1] [RN 29's Signature]." MD 1's signature was without date and time.

d. PO dated 3/20/23, at 12 p.m., indicated, "1:1 level of observation for patient safety. High risk for elopement. Transfer to ER ... TORB Doctor: [MD 1] [RN 30's signature]." MD 1's signature was without a date or time.

e. PO dated 3/25/23, at 6:10 p.m., indicated, "Thorazine 100 mg IM now" TORB Doctor: [MD 1] [RN 22's signature]." MD 1's signature was without a date or time.

f. PO dated 3/26/23, at 1:30 p.m., indicated, "Thorazine 100 mg IM now" TORB Doctor: [MD 1] [RN 31's signature]." MD 1's signature was without a date or time.

2. During a concurrent interview and record review on 5/24/23, at 3 p.m., with Quality and Risk Director (QRD), Patient 2's PO were reviewed. The following were noted:

a. PO dated 3/22/23, at 10:20 a.m., indicated, "Lithium Carbonate [stabilize the mood and reduce extremes in behavior] TORB Doctor: [MD 1] [RN 17's Signature]." MD 1's signature was without a date or time.

b. PO dated 4/23/23, indicated, "Suicide Precaution, Assault Precaution TORB Doctor: [MD 3]." MD 3's electronic signature dated 5/2/23, was nine days after the TORB.

3. During a concurrent interview and record review on 5/25/23, at 2:30 p.m., with QRD, Patient 6's PO were reviewed. The following were noted:

a. PO dated 3/14/23, at 11 p.m., indicated, "Give Seroquel [regulate mood, behaviors and thoughts] 200 mg for agitation TORB Doctor: [MD 1]." MD 1 did not sign the order.

b. PO dated 3/16/23, at 9:03 a.m., indicated, "Zyprexa 10 mg PO [By mouth] BID [Twice a day] TORB Doctor: [MD 4]. MD 4's signature was without a date or time.


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4. During a concurrent interview and record review, on 5/24/23, at 3:15 p.m., with RN 20, Patient 42's PO, dated 4/21/23, was reviewed. The PO indicated, Prozac 20 MG (milligram-units in measurement) by mouth to be given daily. The nurse obtained the PO by telephone. The physician did not sign the order. RN 20 stated the physician did not sign the order.

5. During a concurrent interview and record review, on 5/25/23, at 11 a.m., with RN 21, Patient 37's PO, dated 5/4/23, was reviewed. The PO indicated, to give Abilify 20 MG by mouth every hour of sleep. The nurse obtained the PO by telephone. The physician did not sign the order. RN 21 stated the physician did not sign the order until 5/12/23.

6. During a concurrent interview and record review, on 5/25/23, at 1:50 p.m., with RN 21, Patient 35's PO, dated 5/10/23, was reviewed. The PO indicated, "Discharge pt [patient] today. The nurse obtained the order by telephone and the order was not signed by the physician. RN 21 stated physician did not sign the order.

7. During a concurrent interview and record review, on 5/25/23, at 3:30 p.m., with RN 21, Patient 34's PO, dated 5/16/23 was reviewed. The PO indicated, "Give 14 units of insulin aspart [medication used to lower blood sugar] for 405 BS [blood sugar] x 1 now and check blood sugar after 1 hour." "Cancel 14 units of insulin Aspart and give 10 units for insulin Aspart for 327 for current blood sugar level and check blood sugar after 1 hour. " The nurse obtained the order by telephone. The physician was not signed by the physician. RN 21 stated the physician did not sign the order.

During a review of the facility's policy and procedure (P&P) titled "Ordering and Prescribing- General Requirements" dated 10/28/22, the P&P indicated, ". . . Verbal and Telephone Orders: Verbal and telephone orders are discouraged and are not used as the routine method of medication order communication."

During a review of the facility's P&P titled, "Verbal Medication Orders", dated 10/28/20, indicated, "PURPOSE To minimize the use of verbal orders . . . POLICY Verbal/telephone orders are reserved for use in situations when it is difficult for written . . . Documentation and Verification . . . Verbal/telephone orders for medications must include the following elements: Date and time the order is received, The name of the individual prescribing the medication. . . licensure (i.e., MD, DO, etc.) . . . name of the medication . . . Dose strength or concentration. . . Route of administration. . . Indication for use as needed PRN orders. . . Duration of therapy. . . any known allergies. . . Name and level of licensure of the individual receiving and documenting the order . . . RN [Registered Nurse]. Read Back and Confirm (RB&C) . . . order is verified for accuracy by reading the complete order back to the individual authorizing the order. Authenticating Verbal Orders Verbal/telephone orders must be co-signed/verified by a practitioner who is responsible for the care of the patient and is authorized to prescribe in accordance with state law and hospital policy. Verbal orders must be authenticated within the time-frame defined in the medical staff rules and regulations and as required by state law and regulations... within 24 hours."

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP)/Infection Control Nurse was qualified. This failure had the potential to result in unsafe infection control practices to all patients, staff, and visitors.

Findings:

During an interview on 5/26/23, at 1:20 p.m., with Registered Nurse (RN) 10, RN 10 stated, she has worked as an RN in California since 9/2021 and has not completed her Infection Preventionist (IP) training, although she acknowledges she is the IP/Infection Control Nurse.

During a concurrent interview and record review, on 5/30/23, at 4:45 p.m., with VP Accreditation and Regulatory (VPAR), VPAR reviewed RN 10's California RN license and the facility's job description, titled, "Clinical Educator/Infection Preventionist," dated 5/4/22. The job description indicated, "Minimum Work Experience: Three (3) years. " RN 10 was licensed in the state of CA in 9/2021. VPAR stated, RN 10 did not meet the years of experience as a RN in CA to qualify as the Infection Preventionist.

During a review of the facility's Job Description, titled "Clinical Educator/Infection Preventionist," dated 5/4/22, the job description indicated, "This position is the leader in infection prevention practices and ensure the implementation of programs, policies and procedures related to ensuring infection-free patient care experience. Knowledge of epidemiology and application of public health practices in acute hospital environment with goal of implementing effective and efficient procedures and policies to combat disease transmission among hospital patients and staff."

Based on interview and record review, the facility failed to ensure continuity of care for three of 47 sampled patients (Patient 18, Patient 21, Patient 22) when the nurses failed to document in the patients' medical record information of the discharge. This failure had the potential to affect continuity of care upon discharge.

Findings:

During an interview and concurrent record review on 4/4/23, at 2:46 p.m., with Quality Risk Director (QRD), Patient 18's medical record was reviewed. QRD stated, there was no discharge documentation in Patient 18's medical record.

During an interview and concurrent record review on 4/4/23, at 2:47 p.m., with QRD, Patient 21's medical record was reviewed. QRD stated, there was no discharge documentation in Patient 21's medical record.

During an interview and concurrent record review on 4/4/23, at 2:48 p.m., with QRD, Patient 22's medical record was reviewed. QRD stated, there was no discharge documentation in Patient 22's medical record.

During an interview on 4/4/23, at 2:49 p.m., with QRD, QRD stated, the expectation is for the discharge documentation to be completed.

During a review of the facility's policy and procedure (P&P) titled, "Discharge of Patients", dated 7/27/22, indicated, "Purpose to ensure a smooth transition to the next level of care and to ensure continuity of the treatment modalities selected for the patient. Documentation: In nursing notes ... complete all discharge forms."

During a review of the facility's P&P titled, "PATIENT RIGHTS-HOSPITAL WIDE", dated 9/29/23, indicated, "Be informed of continuing health care requirements following discharge from the hospital."

During a review of the facility's P&P, titled, "Assessment Nursing for Mental Health", dated 7/27/22, indicated, "The discharge progress notes shall include a mini-assessment of mental status and the overall condition of the patient at the time of discharge."

During a review of the facility's P&P, titled, "Transfer to Another Facility," dated 5/30/22, indicated, "PROCEDURE: The nurse will document the physician's order. . . The Nurse will assure copies of required transfer records are provided."

Based on observation, interview, and record review, the facility failed to provide patient centered therapeutic activities per posted "Weekly Activities Schedule" for all patients. This failure has the potential for adverse patient outcomes.

Findings:

During a concurrent observation and interview on 5/25/23, at 10:28 a.m. in the 600 unit, with Patient 27, Patient 27 is observed in the hallway and stated the facility does not allow him and other patients to go outside and he knows that he has rights. Patient 27 stated there is no outside patio time. Patient 27 stated, "This is no one's problem but the hospital. . . need more workers because it's hard dealing with your mind when you are stuck inside." Patient 27 stated, "This is like a prison." Patient 27 stated, the group activities are mainly coloring and crossword puzzles. Patient 27 stated his preferred activity is exercise and references the posted activities schedule at the end of the hallway. He stated, the facility is supposed to follow the activities schedule, but they do not follow the schedule.

During a concurrent interview and record review on 5/25/23, at 10:32 a.m., in the 600 unit, with Patient 27, Patient 27 reviewed the facility's identified and posted "Weekly Activities Schedule", dated Monday to Sunday, and stated there was no patio time this morning as indicated on the Weekly Activities Schedule. The Activity Schedule indicated gym time at 10 a.m. today, but there was no gym time and lunch time is at 11 a.m.

During a concurrent interview and record review on 5/25/23, at 10:40 a.m., with Registered Nurse (RN) 13, RN 13 reviewed the facility posted "Weekly Activities Schedule," and stated the patients are waiting to go off the unit to the gym. In order for the patients to go off the unit, there needs to be two designated staff to escort the patients and if any patients prefer to stay on the unit then a Mental Health Worker (MHW) needs to remain on the unit with the patients that choose to stay on the unit. RN 13 states the patients do not go outside and they would like to.

During an interview on 5/25/23, at 10:42 a.m., with MHW 6, MHW 6 stated, the patients want to go off unit and the administration have instructed the workers to keep the patients on the unit. MHW 6 stated, the reason for the patients to stay on the unit is because there has been a lot of escalations and "the escalations get worse before better because the patients want an outlet." MHW 6 stated the patients request to go outside and there used to be security and she does not know why there is no longer any security, when it is needed to help maintain order and safety.

During an interview on 5/25/23, at 10:44 a.m., with MHW 5, MHW 5 stated the patients are supposed to have the schedule followed, but without the supervision they cannot go off the unit. They also are not going to have group therapy as scheduled today from 10 a.m. to 11 a.m.

During a review of the facility's policy and procedure (P&P) titled, "Unit Rules and Expectations," undated, indicated, "14. Each designated unit has a schedule that will be adhered to."

During a review of the facility's P&P titled, "Protocol for Patio Breaks and Activities," dated 7/27/22, indicated, "SCOPE: Nursing, Social Services, Physicians, and Security Department. . . POLICY: Patients shall be afforded the right for outside recreational activities and breaks."