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Based on policy and procedure review, medical record reviews, safety rounding sheets review and staff interviews the nursing staff failed to obtain an order for recommended medications following an ED (emergency department) visit for 1 of 4 patients that went to the ED (#16); and failed to conduct a patient room search per physician order and document contraband searches per facility policy for 1 of 1 (Patient #1) sampled record with contraband search per physician orders.

The findings include:

1. Review of policy "Sexual Aggression and Victimization Prevention and Precautions", revised 03/2025 was received from facility staff on October 14, 2025, at approximately 0900. The policy stated ..." discovery of sexual allegation between patient/patient ...immediately separate patients, secure the area, preserve evidence, initiate investigation, prepare patients for transport to ER (emergency room) complete incident report ...".

Closed medical record review was conducted on October 14, 2025. Patient #16 was admitted to the facility on 07/15/2025 with a diagnosis of psychosis and SI (suicidal ideation) involuntary. It was noted that Patient #16 was sexually active with Patient #4 in the admissions lobby bathroom prior to being admitted to the facility. Medical treatment plan was reviewed and identified a patient with high-risk alerts for sexual precautions due to bathroom incident. Patient #16 was on 15 min checks per policy. Patient #16 was sent out to an emergency department (ED) for evaluation and treatment. Review of the ED discharge instructions for Patient #16 included the following labs CBC (complete blood count), CMP (complete metabolic panel), HIV antigen/antibody with reflex, magnesium level, syphilis screen, eGFR (measures how the kidneys are doing), and hCG (pregnancy test). The following medications were given in the ED Truvada (medication used to treat pre-exposure prophylaxis to prevent HIV) 200 mg (milligrams) -300 mg take 1 tablet by mouth daily; and raltegravir (medication used to treat HIV infection) 400 mg take 1 table by mouth 2 times a day. Review of the discharge summary revealed - pick up these medications at the named outpatient pharmacy. Further medical record revealed these medications were not given to the patient at the facility during the hospitalization.

Interview with MD #5 on 10/14/2025 at 1525 revealed, "it looks like we didn't start it, the medicine wasn't started here, we missed it".
Interview with RN #6 on 10/15/2025 at 1800 revealed, "I remember assessing her and I admitted her to the unit, I called the physician and she was sent out to the ED to be evaluated, I thought she would come back with a cream, I don't remember any other medicines ...usually I look at the discharge summary and call the nurse practitioner on call and I put medicines in the system once I talk to them and get an order".



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2. Review on 10/16/2025 of the facility policy titled "Contraband Search Guidelines" revised 5/2022, revealed "... "IV. Room Search - Room searches will be done for specific patient rooms when there is reasonable cause to believe the patient may possess an item, which is potentially dangerous. ... A room search will be conducted in the following manner: a. A minimum of two staff members will conduct the search. b. Inform the patient(s) of the search and the reason for the search beforehand. c. The patient has the right to be present during the search of their rooms, unless contraindicated. Patient will not participate in the search. d. Examine all chairs, cushions, beds, dressers, stands, closets and/or other furniture; Check under, behind and on top of furniture and under mattresses and in bed linens. e. Examine light and lamp fixtures, wall grills and covers, heating and air conditioning units. f. Examine all bathroom fixtures and fitting as well as cabinets, sinks, paper dispensers, etc. g. Check patient drawers, linens, suitcases, folded and dirty clothing, shoes, purses/bags, and anything else which something could be hidden. Articles such as books, purses, and hygiene articles should also be thoroughly inspected. Keep in mind that people intending to hide something can sometimes be very resourceful. Each and any place, which can be used to hide potentially dangerous articles. h. All articles and items should be returned to their original place after examined. i. documentation in the patient's medical record will be completed when a room search is performed. this documentation should include the reasons for conducting the search, the results of the search, the disposition of any dangerous materials found and the patient's response. ..."

Closed medical record review on 10/14/2025 for Patient #1 revealed a 15-year-old female involuntary admitted to the facility on 06/23/2025 at 1850 with a diagnosis of Major Depressive Disorder and suicidal ideations. Review of the medical record for Patient #1 revealed a physician order written on 07/17/2025 at 0400 (no stop date/time) for "Contraband searches of patient's room and person at least once per shift." Review of the medical record revealed no documented evidence of room searches conducted from 07/17/2025 through 07/23/2025. The record review revealed a physician order written on 07/24/2025 at 1225 (no stop date/time) for "Contraband searches of patient's room and person at least once per shift." Review of the medical record revealed no documented evidence of room searches conducted from 07/24/2025 through 08/08/2025 (date of discharge).

Review of the 7 AM and 7 PM environmental safety rounding sheets, conducted by nurses and/or mental health technicians, for the adolescent female unit from 07/17/2025 through 08/08/2025 (date of discharge) revealed no documented 7 AM shift safety round checks on 07/17/2025, 07/18/2025, 07/19/2025, 07/20/2025, 07/21/2025, 07/24/2025, 07/25/2025, 07/27/2025, 07/28/2025, 07/29/2025, 07/31/2025, 08/01/2025, 08/02/2025, 08/03/2025, 08/05/2025, 08/06/2025, and 08/07/2025 (17 of 22 contraband searches). Further review of the safety rounding sheets revealed no documented 7 PM shift safety round checks on 07/17/2025, 07/19/2025, 07/20/2025, 07/24/2025, 07/25/2025, 07/31/2025, and 08/01/2025 (7 of 22 contraband searches). Review of the safety rounding sheets dated 07/22/2025 revealed the 7 AM and 7 PM safety rounds were conducted by the same mental health technician with no documentation of the nurse review signature. Review of the shift safety rounding sheets dated 07/23/2025, 07/26/2025 and 08/07/2025 (3 of 22 contraband searches) revealed no nurse review signature documented for the 7 AM shift safety rounds.

Interview on 10/16/2025 at 1339 with MHT #10 revealed the mental health technicians were expected to complete the environmental safety rounding sheets once a shift. The technicians checked for contraband such as pen, pencil, crayon, etc. The safety checklists were placed on a clipboard on the unit after completion and handed off to the on-coming shift. The interview revealed the violations sheet, census and environmental rounding sheets with the environmental sheets indicating what actions were taken. All three sheets were placed on the clipboard and kept on the unit in a notebook.

Interview on 10/17/2025 at 1300 with RN #9 and RN #4 revealed the staff were expected to document the environmental safety rounding sheets once each shift. The safety rounding sheets should be signed by the mental health technician and reviewed and signed by the Registered Nurse. The interview revealed that the staff were not expected to check the patient's clothing in the room. Interview revealed the staff failed to follow the facility policy for contraband checks in a patient room when ordered by the physician. Interview revealed the staff failed to follow the physician order to conduct contraband searches of patient's room and person at least once per shift.

Based on review of hospital policies, medical records and staff interviews, hospital staff failed to ensure a Master Treatment Plan (MTP) was completed and/or updated for 2 of 7 master treatment plans reviewed (Pt #1, Pt #21); and failed to include a medical diagnosis on the Master Treatment Plan (MTP) for 1 of 2 pregnant patient medical records reviewed (#19).

The findings include:

Review on 10/14/2025 of the hospital policy titled "Master Treatment Plan & Master Treatment Plan Update" revised 03/2023, revealed "Social Services staff: *is responsible for completing the Master Treatment Plan within 72 hours of admission... ... *is responsible for completing Master Treatment Plan Updates at a minimum of every 7-days from the date that the Master Treatment Plan is signed. ..."

Review on 10/25/2025 of the hospital policy titled "Documentation Requirements in the Medical Record" revised 02/2025 revealed, "... Treatment Plan ... 3. The multi-disciplinary treatment team shall develop the Master Treatment Plan within seventy-two (72) hours of admission... 3. ... based on a comprehensive assessment of the patient's presenting problems, physical health, emotional and behavioral status .... 15. The Treatment Plan shall be reviewed and updated as frequently as clinically indicated by the patient's anticipated length of stay and treatment issues, but at a minimum, reviewed weekly. ..."

1. Closed medical record review on 10/14/2025 for Patient #1 revealed a 15-year-old female involuntary admitted to the facility on 06/23/2025 at 1850 with a diagnosis of Major Depressive Disorder and suicidal ideations. Review of the medical record revealed the interdisciplinary treatment plan was documented and signed on 07/02/2025 (9 days after admission). Review of the medical record revealed the facility failed to document a master treatment plan within seventy-two (72) hours of admission. Patient #1 was transported and admitted to an acute-care hospital on 07/05/2025. Patient #1 was readmitted to the facility on 07/07/2025 after discharge from acute-care hospital. Review of the medical record for Patient #1 revealed the Patient was readmitted to the facility after discharge from the acute-care hospital on 07/07/2025 at 1456. The Master Treatment Plan was initiated on 07/08/2025, updated on 07/15/2025, 07/22/2025 and on 08/02/2025 (4 days late). Record review failed to reveal evidence of the seven (7) day Master Treatment Plan update on 07/29/2025. Patient #1 was discharged to the DSS legal guardian on 08/08/2025 at 1035.

Interview on 10/15/2025 at 1000 with RN #4 revealed that the initial master treatment plan should be completed within 72 hours of admission and updated every seven days.



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2. Review of an open medical record for Patient #21 revealed a 25-year-old male admitted on 10/10/2025 with a diagnosis of Schizophrenia with self-harm behaviors. Review revealed the Master Treatment Plan was dated 10/14/2025, 4 days after admission.

Interview on 10/14/2025 at 1515 with Therapist #3 revealed the Master Treatment Plan was late. Interview revealed "I did not have time. I had 6-8 MTP's to do."

Interview on 10/17/2025 at 1330 with DCS #1 revealed the MTP was late. The MTP should have been completed within 72 hours after admission. Interview revealed the policy was not followed.

3. Review of a closed medical record for Patient #19 revealed a 42-year-old female admitted on 07/25/2025 for psychosis. Review revealed Patient #19 was pregnant in the first trimester. Review of the Master Treatment Plan Master Problem List dated 07/28/2025 revealed no diagnosis listed in Acute Medical Problems/Medical Problems section. Review of the medical record revealed Patient #19 had been evaluated by the medical team on 07/26/2025 for "spotting and abdominal cramping."

Interview on 10/17/2025 at 1330 with DCS (Director of Clinical Services) #1 revealed the pregnancy should have been listed on the medical problems list. Interview revealed the policy was not followed.

NC00233226; NC00233899, NC00232603; NC00233712; NC00233733; NC00233655; NC00233229; NC00232086; NC00233883