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Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met as evidenced by:

1. The facility failed to ensure one of 30 sampled patients (Patient 28), was provided information regarding the Condition of Admission (COA, a contract that outlines the patient's obligations to the hospital, such as paying for services, providing informed consent [A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment], and understanding the hospital's arrangements).

This deficient practice had the potential for Patient 28 not being able to fully understand and exercise rights as a patient, which may lead to Patient 28's inability to effectively make decisions regarding own care and treatment in the facility. (Refer to A-0117)

2. The facility failed to ensure patient safety, in accordance with the facility's policy regarding patient supervision, for one of 30 sampled patients (Patient 1), when Patient 1 was involved in two separate physical altercations (a confrontation or fight involving physical contact or force, potentially resulting in injury) with Patients 2 and 3 within a 30-minute time period. Patient 1 was physically attacked by Patients 2 and 3.

This deficient practice resulted in Patient 1 suffering a hematoma (a collection of blood that pools outside of a blood vessel, often forming a lump or bruise-like area, due to a broken blood vessel) to the forehead and required a transfer to the acute care hospital for further evaluation and treatment. (Refer to A-0144)

3. The facility failed to ensure that one of 30 sampled patients (Patient 1), was free from all forms of abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse), when preventive mechanisms/methods to prevent the re-occurrence of abuse were not implemented, in accordance with the facility's policy regarding patient rights in mental health facilities and patient supervision. Patient 1 was involved in two separate incidents of altercations (physical and verbal) within a 30-minute time span.

This deficient practice resulted in Patient 1 suffering a hematoma (a collection of blood that pools outside of a blood vessel, often forming a lump or bruise-like area, due to a broken blood vessel) to the forehead, which required a transfer to the acute care hospital for further evaluation and treatment. This deficient practice also had the potential for other patients not to feel safe and secure in the healthcare environment. (Refer to A-0145)

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

Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met as evidenced by:

1. The facility failed to ensure for two of 30 sampled patients (Patient 11 and Patient 21), the following:

1.a. Patient's 11 treatment plan/care plan (a document that outlines a patient's healthcare needs, goals, and the interventions and treatments planned to achieve those goals, serving as a roadmap for their care and facilitating communication among the healthcare team) regarding Hepatitis B (a viral infection that causes inflammation of the liver), was developed and implemented within (8) hours of admission, in accordance with the facility's policy regarding care planning.

This deficient practice had the potential for Patient 11's condition to remain unmonitored and untreated and also had the potential for proper infection protocol not to be implemented which can result in the spread of infection among patients, staff and visitors. (Refer to A-0396)

1.b. Patient 21's treatment plan/care plan regarding suicide (thoughts of taking one's own life) and major depression (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), was reviewed, re-assessed, and updated to determine if the treatment goal was met or if there was a need to modify the treatment plan, in accordance with the facility's policy regarding care planning.

This deficient practice had the potential for Patient 21's patient care needs and progress to not be identified and monitored which can lead to a delay in modifying the treatment plan and implementation of necessary interventions resulting in poor patient outcomes (Example: increased risk of suicide and worsened mood disorders). (Refer to A-0396)

2. The facility failed to report a physical abuse (deliberately aggressive or violent behavior by one person toward another that results in bodily injury) incident in a timely manner (within five days), for one of 30 sampled patients (Patient 1), in accordance with the facility's policy and procedure titled, "Serious Event Notification."

This deficient practice had the potential to result in a delay in investigation, potentially placing patients at risk of not receiving necessary care and treatment. (Refer to A-0398)

3. The facility failed to ensure one of 30 sampled patients (Patient 21), was appropriately assessed and monitored for Detoxification (a set of interventions aimed at managing acute intoxication [a potentially life-threatening condition resulting from consuming a large amount of alcohol in a short period, leading to impaired bodily functions and potentially coma or death] and withdrawal)/Withdrawal symptoms (include cravings, sleep problems, headaches, nausea [an urge to vomit] and feeling restless or agitated), in accordance with the facility's policy regarding "Management of Detox Patients."

This deficient practice had the potential for Patient 21's care needs not to be addressed in a timely manner, which may result in Patient 21's worsening withdrawal symptoms leading to complications such as seizures (sudden, temporary disruptions in brain electrical activity that can cause changes in behavior, movement, sensation, and awareness) or even death. (Refer to A-0398)

4. The facility failed to ensure one of one sampled crash cart (Crash Cart #1, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) located in the Del Sol Unit and the CTC Unit (Crisis Treatment Center, Adult Psychiatric Unit), was equipped with a full oxygen tank (used to provide oxygen support when performing cardiopulmonary resuscitation [CPR, an emergency life?saving procedure performed when the heart stops beating]) to be used for 36 of 36 sampled patients during an emergency situation requiring oxygen support, in accordance with the facility's "Emergency Medical Equipment Daily Checklist."

This deficient practice had the potential for oxygen supplies to not be readily available in case of an emergency and had the potential to result in a delayed emergency care needed by patients, which may lead to patient harm and/or death. (Refer to A-0398)

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

Based on interview, and record review, the facility failed to ensure one of 30 sampled patients (Patient 28), was provided information regarding the Condition of Admission (COA, a contract that outlines the patient's obligations to the hospital, such as paying for services, providing informed consent [A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment], and understanding the hospital's arrangements).

This deficient practice had the potential for Patient 28 not being able to fully understand and exercise rights as a patient, which may lead to Patient 28's inability to effectively make decisions regarding own care and treatment in the facility.

Findings:

During a review of Patient 28's "Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help the treatment team develop a treatment plan)," dated 03/04/2025, the document indicated that Patient 28 was a 57 years old male who was admitted on 03/04/2025 for danger to self and grave disability (a severe mental health condition that renders an individual unable to provide for their basic needs, such as food, clothing, and shelter) hold. The psychiatric evaluation also indicated Patient 28 was previously diagnosed with a history of mood disorder (a mental health condition that primarily affects a person's emotional state, characterized by persistent and intense changes in mood, energy levels, and behavior, often including periods of extreme sadness [depression] or excessive happiness [mania]). Patient 28's psychiatric evaluation also indicated Patient 28's mental status was alert and oriented to person, place, time and situation.

During a concurrent interview and record review on 3/14/2025 at 11:09 a.m. with the Intake Director (ID 1), Patient 28's medical record titled, "Condition of Admission (COA- a contract that outlines the patient's obligations to the hospital, such as paying for services, providing informed consent [A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment], and understanding the hospital's arrangements)," dated 3/04/2025, was reviewed. Patient 1's COA record indicated "Refused, Sleeping." ID 1 stated the following: confirmed documentation done by staff was inappropriate and staff should have followed up with patient (Patient 28) to ensure patient (Patient 28) understood his (Patient 28) COA and affirm understanding by signing the COA form.

During the same interview on 3/14/2025 at 11:09 a.m. with the Intake Director (ID 1), ID 1 stated the facility did not have a policy on Condition of Admission and the facility will start developing a policy for it. ID 1 also said that it was the responsibility of the intake staff to obtain the signature of the patients for the COA to ensure that the patient understood what the COA was for and provide the patient the opportunity to ask questions.
During an interview on 3/14/2025 at 2:45 p.m. with the Director of Performance Improvement (DPI 1), DPI 1 stated and confirmed that the facility had no policy for Condition of Admission.

Based on interview and record review, the facility failed to ensure patient safety, in accordance with the facility's policy regarding patient supervision, for one of 30 sampled patients (Patient 1), when Patient 1 was involved in two separate physical altercations (a confrontation or fight involving physical contact or force, potentially resulting in injury) with Patients 2 and 3 within a 30-minute time period., Patient 1 was physically attacked by Patients 2 and 3.

This deficient practice resulted in Patient 1 suffering a hematoma (a collection of blood that pools outside of a blood vessel, often forming a lump or bruise-like area, due to a broken blood vessel) to the forehead and required a transfer to the acute care hospital for further evaluation and treatment.

Findings:

During a review of Patient 1's Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help the treatment team develop a treatment plan), dated 8/28/2023, the psychiatric evaluation indicated that Patient 1 was admitted to the facility on 8/27/2023 on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric condition) for danger to self and others and a diagnosis of disruptive mood dysregulation disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts). The psychiatric evaluation also indicated that Patient 1 was to be discharged to an outpatient facility on 8/28/2023.

During a review of Patient 1's Progress notes, dated 8/28/2023 and timed at 13:13 (1:13 p.m.), Patient 1's Progress Notes indicated that Patient 1 was transferred to an acute hospital for evaluation and that Patient 1 complained of left shoulder pain and loss of consciousness (neither awake nor aware of the external environment).

During a review of Patient 1's document titled, "Out of Hospital Consultation Report," dated 8/28/2023, the report indicated Patient 1 was sent to the acute care hospital for hematoma (a collection of blood that pools outside of a blood vessel, often forming a lump or bruise-like area, due to a broken blood vessel) on the forehead due to altercation (physical altercation- a confrontation or fight involving physical contact or force, potentially resulting in injury) and to rule out (to eliminate or exclude something from consideration) head trauma (a tissue injury that occurs more or less suddenly due to violence or an accident).

During a review of Patient 2's Initial Psychiatric Evaluation, dated 8/23/2023, Patient 2 was admitted to the facility on 8/22/2023 on a 5585 (a minor [anyone under the age of 18] who is put on an involuntary 72-hour hold [for psychiatric treatment and evaluation]) and diagnosis of disruptive mood dysregulation disorder and attention deficit hyperactivity disorder (a condition that makes it hard to focus, sit still, and control impulses, often causing difficulties in daily life).

During a review of Patient 2's Progress notes, dated 8/28/2023 and timed at 1430 (2:30 p.m.), the progress notes indicated that Patient 2 became verbally aggressive and attempted to throw a chair at Patient 1 which was blocked by a facility staff. Patient 1 was then put in a physical restraint technique (PRT-technique used to hold an aggressive patient. Example: holding a patient's arms or legs) for 10 seconds and then was released. Patient 2 physically attacked Patient 1 again while lining up to exit the facility's cafeteria. Patient 3 (who was also in the line) intervened and began to attack Patient 1 as well. Patient 2 was placed in a PRT and then released.

During a review of Patient 3's Initial Psychiatric Evaluation, dated 8/18/2023, Patient 3's psychiatric evaluation indicated Patient 3 was admitted to the facility with the diagnosis of unspecified schizophrenic (chronic mental disorder characterized by a combination of positive [like hallucinations and delusions] and negative symptoms, and disorganized thinking and behavior) spectrum and substance-induced psychosis (state where someone experiences a significant disconnect from reality, often involving hallucinations [seeing or hearing things that aren't there] and delusions [holding false beliefs]).

During a review of Patient 3's Progress note, dated 8/28/2023 and timed at 1400 (2:00 p.m.), Patient 3's Progress note indicated that Patient 3 tried to intervene in the altercation between Patient 1 and Patient 2 but was pushed in the process. Patient 3 then pushed Patient 1 to the floor and began to hit Patient 1 repeatedly. Patient 3 was placed in PRT and redirected outside to the courtyard.

During an interview on 3/10/2025 at 2:10 p.m. with Mental Health Technician 1 (MHT 1), MHT 1 stated that safety of the patients is a priority. MHT 1 also said "When an altercation (either physical or verbal) occurs between two patients, we separate the individuals and if needed we will call a Code 10. Code 10 is where staff from other units come and help with the situation."

During a concurrent interview and record review on 3/11/2025 at 2:42 p.m. with Registered Nurse (RN) 1, Patient 1's Progress note dated 8/23/2023, timed at 1430 (2:30 p.m.), was reviewed. The Progress note indicated that Patient 1 was involved in two separate altercations with Patient 2 and Patient 3 in the facility's cafeteria. The progress note indicated that Patient 1 and Patient 2 were involved in a verbal altercation that resulted in Patient 2 attempting to throw a chair at Patient 1 (First altercation). The second altercation between Patient 1 and Patient 2 occurred while lining up in the facility's cafeteria, where Patient 3 was also involved with the kicking and punching of Patient 1. The Patients (Patients 1, 2 and 3) involved were separated, and a "Code 10 (all trained staff needed to assist in handling an acutely agitated or assaultive patient)," was called. RN 1 stated that the MHT should have called a "Code 10" during the first altercation (which was not done. The Code 10 was only called after the second altercation occurred).

During an interview on 3/13/2025 at 10:27 a.m. with Mental Health Technician (MHT) 2, MHT 2 stated that a RN should have been notified of the first incident between Patient 1 and Patient 2 (referring to the verbal altercation) and that either the aggressor or victim needed to be pulled from the environment to prevent another incident from happening. MHT 2 stated she (MHT 2) remembered the incident vaguely and just remembered protecting Patient 1 from the altercation.

During an interview on 3/13/2025 at 11:58 a.m. with Nurse Manager (NM) 1, NM 1 stated that if a PRT was initiated by a staff member, a RN needed to assess the situation and be the one to end the PRT. NM1 stated that if a RN was involved with the first incident (verbal altercation between Patient 1 and Patient 2) or notified about the first incident, incident 2 (when Patient 1 was kicked and punched) might not have occurred.

During a review of the facility's document titled, "Mental Health Technician 1 (MHT 1), dated 7/2020, the document indicated MHT must ensure safety of patient at all times and consistently provide supervision for assigned patients. The document also indicated that to notify charge/staff nurses of patients with potential risk of injury due to falls, self-destructive, or assaultive behaviors.

During a review of the facility's policy and procedure (P&P) titled, "Supervision of Patients/Patient Rounds," revised 01/2025, the P&P indicated "when staff are observing patients during mealtimes in the off-unit cafeterias, observe for possible elopement, removal of contraband (any item that is prohibited within the facility. Example: knives, razors, illegal drugs) and/or sharp items (intended to cut or penetrate the skin- Example: needles, lancets, etc.), and any unsafe behavior."

Based on interview and record review, the facility failed to ensure that one of 30 sampled patients (Patient 1) was free from all forms of abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse), when preventive mechanisms/methods to prevent the re-occurrence of abuse were not implemented, in accordance with the facility's policy regarding patient rights in mental health facilities and patient supervision. Patient 1 was involved in two separate incidents of altercations (physical and verbal) within a 30-minute time span.

This deficient practice resulted in Patient 1 suffering a hematoma (a collection of blood that pools outside of a blood vessel, often forming a lump or bruise-like area, due to a broken blood vessel) to the forehead which required a transfer to the acute care hospital for further evaluation and treatment. This deficient practice also had the potential for other patients not to feel safe and secure in the healthcare environment.

Findings:

During a review of Patient 1's Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help to the treatment team develop a treatment plan), dated 8/28/2023, the evaluation indicated that Patient 1 was admitted to the facility on 8/27/2023 on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric condition) for danger to self and others and a diagnosis of disruptive mood dysregulation disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts). The psychiatric evaluation also indicated that Patient 1 was to be discharged to an outpatient facility on 8/28/2023.

During a review of Patient 1's Progress notes dated 8/28/2023 and timed at 13:13 (1:13 p.m.), Patient 1's Progress notes indicated that Patient 1 was transferred to an acute hospital for evaluation (following the second physical altercation involving Patients 2 and 3) and that Patient 1 complained of left shoulder pain and loss of consciousness (neither awake nor aware of the external environment).

During a review of Patient 1's document titled, "Out of Hospital Consultation Report," dated 8/28/2023, the document indicated Patient 1 was sent to the acute care hospital for hematoma (a collection of blood that pools outside of a blood vessel, often forming a lump or bruise-like area, due to a broken blood vessel) on the forehead due to altercation (referring to the physical altercation [a confrontation or fight involving physical contact or force, potentially resulting in injury] involving Patients 1, 2 and 3) and to rule out (to eliminate or exclude something from consideration) head trauma (a tissue injury that occurs more or less suddenly due to violence or an accident).

During a review of Patient 2's Initial Psychiatric Evaluation, dated 8/23/2023, Patient 2's psychiatric evaluation indicated Patient 2 was admitted to the facility on 8/22/2023 on a 5585 (a minor [anyone under the age of 18] who is put on an involuntary 72-hour hold [for psychiatric treatment and evaluation]) and a diagnosis of disruptive mood dysregulation disorder and attention deficit hyperactivity disorder (a condition that makes it hard to focus, sit still, and control impulses, often causing difficulties in daily life).

During a review of Patient 2's Progress notes, dated 8/28/2023 and timed at 1430 (2:30 p.m.), the progress notes indicated that Patient 2 became verbally aggressive and attempted to throw a chair at Patient 1 which was blocked by facility staff. Patient 2 was then put in a physical restraint technique (PRT-technique used to hold an aggressive patient. Example: holding a patient's arms or legs) for 10 seconds and then was released. Patient 2 physically attacked Patient 1 again while lining up to exit the facility's cafeteria. Patient 3 intervened and began to attack Patient 1. Patient 2 was then placed in a PRT and released.

During a review of Patient 3's Initial Psychiatric Evaluation, dated 8/18/2023, Patient 3's psychiatric evaluation indicated Patient 3 was admitted to the facility with a diagnosis of unspecified schizophrenic (chronic mental disorder characterized by a combination of positive [like hallucinations and delusions] and negative symptoms, and disorganized thinking and behavior) spectrum and substance-induced psychosis (state where someone experiences a significant disconnect from reality, often involving hallucinations [seeing or hearing things that aren't there] and delusions [holding false beliefs]).

During a review of Patient 3's Progress note, dated 8/28/2023 and timed at 1400 (2:00 p.m.), Patient 3's Progress note indicated that Patient 3 tried to intervene in the altercation between Patient 1 and Patient 2 but was pushed in the process. Patient 3 then pushed Patient 1 to the floor and began to hit Patient 1 repeatedly. Patient 3 was placed in PRT and redirected outside to the courtyard.

During a concurrent interview and record review on 3/14/2025 at 10:44 a.m. with the Director of Risk Management (DRM), the facility's policy and procedure (P&P) titled, "Assessment and Reporting Abuse (any action or failure to act which causes unreasonable suffering, misery, or harm to the patient. Includes physical abuse, neglect, sexual abuse, emotional and financial abuse)," dated 10/2001, was reviewed. The DRM stated the abuse can be any physical contact between patient to patient or patient to staff. The DRM then stated that according to the facility's P&P physical abuse includes any non-accidental physical trauma cause by the caretaker, spouse or cohabitant and that it may include burning, beating, branding, punching, etc.

During a review of the facility's handbook titled, "Rights for Individuals in Mental Health Facilities," revised July 2018, the handbook (page 22) indicated that patients have the right to be free from abuse, neglect, or harm, including unnecessary or excessive restraint (devices that limit a patient's movement), isolation (supervised confinement of a patient away from other patients) or medication. The handbook also indicated that patients have the right to be free from potentially harmful situations or conditions.

During a review of the facility's policy and procedure (P&P) titled, "Supervision of Patients/Patient Rounds," revised 01/2025, the P&P indicated when staff are observing patients during mealtimes in the off-unit cafeterias, observe for possible elopement, removal of contraband (any item that is prohibited within the facility. Example: knives, razors, illegal drugs) and/or sharp items (intended to cut or penetrate the skin- Example: needles, lancets, etc.), and any unsafe behavior.

Based on interview, and record review, the facility failed to ensure for two of 30 sampled patients (Patient 11 and Patient 21), the following:

1. Patient's 11 treatment plan/care plan (a document that outlines a patient's healthcare needs, goals, and the interventions and treatments planned to achieve those goals, serving as a roadmap for their care and facilitating communication among the healthcare team) regarding Hepatitis B (a viral infection that causes inflammation of the liver) was developed and implemented within (8) hours of admission, in accordance with the facility's policy regarding care planning.

This deficient practice had the potential for Patient 11's condition to remain unmonitored and untreated and also had the potential for proper infection protocol not to be implemented which can result in the spread of infection among patients, staff and visitors.

2. Patient 21's treatment plan/care plan regarding suicide (thoughts of taking one's own life) and major depression (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), was reviewed, re-assessed, and updated to determine if the treatment goal was met or if there was a need to modify the treatment plan, in accordance with the facility's policy regarding care planning.

This deficient practice had the potential for Patient 21's patient care needs and progress to not be identified and monitored which can lead to a delay in modifying the treatment plan and implementation of necessary interventions resulting in poor patient outcomes (Example: increased risk of suicide and worsened mood disorders).

Findings:

1. During a review of Patient 11's "Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help to the treatment team develop a treatment plan)," dated 03/03/2025, the document indicated that Patient 11 was a 39 years old male who was admitted on 03/01/2025 for Schizophrenia (a chronic [persists for a long time] mental illness characterized by disruptions in thought, perception, emotion, and behavior). Patient 11's psychiatric evaluation also indicated that Patient 11 had a past medical problem of Hepatitis B (a viral infection that causes inflammation of the liver).

During a concurrent interview and record review on 3/10/2025 at 2:40 p.m. with Registered Nurse (RN) 3, Patient 11's medical record titled, "Chronic/Stable Psychiatric & Medical Problem List," undated, was reviewed. Patient 11's record did not indicate Hepatitis B was on the problem list. RN 3 stated that Patient 11 was admitted with Hepatitis B as one of his (Patient 11) past medical problems. RN 3 said the admitting nurse failed to note and include Hepatitis B in the treatment plan problem list, so that it can be discussed in the patient's weekly treatment rounds. RN 3 also stated the weekly treatment rounds was when members of multidisciplinary teams (comprises professionals from various disciplines who collaborate to provide comprehensive care and support for patients or clients, focusing on coordinated, patient-centered care) meet to review a patient progress, develop personalized care plans (a document that outlines a patient's healthcare needs, goals, and the interventions and treatments planned to achieve those goals, serving as a roadmap for their care and facilitating communication among the healthcare team. ), and address potential risks to improve patient outcomes.

During a review of the facility's Policy and Procedure (P&P) titled, "Interdisciplinary Patient - Centered Care Planning," (Policy No.: PC-13), with revised date of May 2024, the P&P indicated the following:

Policy: It is policy to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patient's progress and determine if any modifications are needed.
Each patient's written Treatment Plan must include:
-Substantiated diagnosis(es)
-Identification of problems to be treated and the specific behavioral manifestations of those problems in the patient
-Short-term and long-term goals for each active problem, developed with patient input
-The specific treatment modalities with individualized patient focus
-The responsibilities of each member of the treatment team
Procedure:
Developing the Treatment Plan
1. The Nurse completing the Nursing Assessment or designee shall develop the Initial Treatment Plan within eight (8) hours of admission. The nurse will utilize the problems and specific behavioral manifestations identified in the initial assessment and nursing assessment to develop clinically appropriate and individualized goals and interventions which will be included in the Initial Treatment Plan.
a. Any medical problems or diagnoses that are not receiving treatment will be listed on the Treatment Plan cover sheet/problem list as deferred with justification provided. If the medical problem requires active treatment, it will either be included in the plan as a "Chronic/Stable" medical problem if only routine care is provided or on a separate problem sheet if more than routine care is indicated.
b. At the time of the development of the Interdisciplinary Master Treatment Plan (MTP), the Initial Treatment Plan will be considered resolved, with psychiatric problems either moved to the MTP or fully resolved and medical problems moved to the MTP.

2. During a review of Patient 21's "Initial Psychiatric Evaluation," dated 03/10/2025, the document indicated that Patient 21 was a 59 years old female who was admitted on 03/09/2025 for feeling suicidal (thoughts of taking one's own life). The psychiatric evaluation also indicated Patient 21 was previously diagnosed with major depression (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life).

During a concurrent interview and record review on 3/13/2025 at 11:09 a.m. with Nurse Manager (NM) 1, Patient 21's medical record titled, "Multidisciplinary Treatment Plan," dated 3/09/2025, was reviewed. Patient 21's Multidisciplinary Treatment Plan record indicated the staff did not evaluate Patient 21's care plan goals. NM 1 stated the following: Confirmed achieved dates (completion date of goals indicated in the treatment plan that helps indicate if the identified problem was resolved or if there was a need to revise the treatment plan) were not done for Patient 21's treatment goals. No documentation from staff that treatment goals were achieved/met/or reviewed. NM 1 also said it was important to complete the achieve dates (dates the treatment goals were met) for the care plan per policy and NM 1 will educate the staff to make sure they complete the care plan's achieved treatment goal dates.

During a review of the facility's Policy and Procedure titled, "Interdisciplinary Patient - Centered Care Planning," (Policy No.: PC-13), with revised date of May 2024, the P&P indicated the following:
Policy: It is policy to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patient's progress and determine if any modifications are needed.
2. Resolving, Discontinuing or Continuing Goals and Interventions
a. During the treatment plan review, the treatment team will evaluate if goals have been met by established target dates. Once a goal has been resolved, the date will be identified on the treatment plan.
b. If the goal has not been met, the team needs to either reevaluate the target date and establish a new one or re-evaluate the appropriateness of the goal.
c. Staff members, upon discharge, shall either document on remaining goals the date if resolved or "ongoing" meaning that the problem has not yet been resolved.

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

1. Report a physical abuse (deliberately aggressive or violent behavior by one person toward another that results in bodily injury) incident in a timely manner (within five days), for one of 30 sampled patients (Patient 1), in accordance with the facility's policy and procedure titled, "Serious Event Notification."

This deficient practice had the potential to result in a delay in investigation, potentially placing patients at risk of not receiving necessary care and treatment.

2. Ensure one of 30 sampled patients (Patient 21), was appropriately assessed and monitored for Detoxification (a set of interventions aimed at managing acute intoxication [a potentially life-threatening condition resulting from consuming a large amount of alcohol in a short period, leading to impaired bodily functions and potentially coma or death] and withdrawal)/Withdrawal symptoms (include cravings, sleep problems, headaches, nausea [an urge to vomit] and feeling restless or agitated), in accordance with the facility's policy regarding "Management of Detox Patients."

This deficient practice had the potential for Patient 21's care needs not to be addressed in a timely manner, which may result in Patient 21's worsening withdrawal symptoms leading to complications such as seizures (sudden, temporary disruptions in brain electrical activity that can cause changes in behavior, movement, sensation, and awareness) or even death.

3. Ensure one of one sampled crash cart (Crash Cart #1, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) located in the Del Sol Unit and the CTC Unit (Crisis Treatment Center, Adult Psychiatric Unit), was equipped with a full oxygen tank (used to provide oxygen support when performing cardiopulmonary resuscitation [CPR, an emergency life?saving procedure performed when the heart stops beating]) to be used for 36 of 36 sampled patients during an emergency situation requiring oxygen support, in accordance with the facility's "Emergency Medical Equipment Daily Checklist."

This deficient practice had the potential for oxygen supplies to not be readily available in case of an emergency and had the potential to result in a delayed emergency care needed by patients, which may lead to patient harm and/or death.

Findings:

1. During a review of Patient 1's Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation (first interview between physician and patient to help identify disorders and help to the treatment team develop a treatment plan), dated 8/28/2023, Patient 1's psychiatric evaluation indicated that Patient 1 was admitted to the facility on 8/27/2023 on a 5150 (an involuntary 72-hour hold for the treatment of a psychiatric condition) for danger to self and others and a diagnosis of disruptive mood dysregulation disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outbursts). The document also indicated that Patient 1 was to be discharged to an outpatient facility on 8/28/2023.

During a review of Patient 1's Progress notes, dated 8/28/2023 and timed at 13:13 (1:13 p.m.), Patient 1's Progress notes indicated that Patient 1 was transferred to an acute hospital for evaluation (following the second physical altercation [a confrontation or fight involving physical contact or force, potentially resulting in injury] involving Patients 2 and 3) and that Patient 1 complained of left shoulder pain and loss of consciousness (neither awake nor aware of the external environment).

During a review of Patient 2's Initial Psychiatric Evaluation, dated 8/23/2023, Patient 2's psychiatric evaluation indicated Patient 2 was admitted to the facility on 8/22/2023 on a 5585 (a minor [anyone below 18 years old] who is put on an involuntary 72-hour hold [for psychiatric treatment and evaluation]) and a diagnosis of disruptive mood dysregulation disorder and attention deficit hyperactivity disorder (a condition that makes it hard to focus, sit still, and control impulses, often causing difficulties in daily life).

During a review of Patient 2's Progress notes, dated 8/28/2023 and timed at 1430 (2:30 p.m.), the progress notes indicated that Patient 2 became verbally aggressive and attempted to throw a chair at Patient 1 which was blocked by facility staff. Patient 1 was then put in a physical restraint technique (PRT-technique used to hold an aggressive patient. Example: holding a patient's arms or legs) for 10 seconds and then was released from PRT. Patient 2 physically attacked Patient 1 again while lining up to exit the facility's cafeteria. Patient 3 intervened and began to attack Patient 1 as well. Patient 2 was placed in a PRT and then released from PRT.

During a review of Patient 3's Initial Psychiatric Evaluation, dated 8/18/2023, Patient 3's psychiatric evaluation indicated Patient 3 was admitted to the facility with a diagnosis of unspecified schizophrenic (chronic mental disorder characterized by a combination of positive [like hallucinations and delusions] and negative symptoms, and disorganized thinking and behavior) spectrum and substance-induced psychosis (state where someone experiences a significant disconnect from reality, often involving hallucinations [seeing or hearing things that aren't there] and delusions [holding false beliefs]).

During a review of Patient 3's Progress note, dated 8/28/2023 and timed at 1400 (2:00 p.m.), Patient 3's Progress note indicated that Patient 3 tried to intervene in the altercation (physical) between Patient 1 and Patient 2 but was pushed in the process. Patient 3 then pushed Patient 1 to the floor and began to hit Patient 1 repeatedly. Patient 3 was placed in PRT and redirected outside to the courtyard.

During a review of the facility's fax confirmation sheet, dated 9/12/2023, the fax confirmation sheet indicated that the incident between Patients 1, 2, and 3, was reported to the Department on 9/12/2023 at 4:09 p.m. (The physical altercation happened on 8/28/2023).

During a concurrent interview and record review on 3/14/2025 at 9:37 a.m. with the Director of Risk Management (DRM), Patient 1's Progress Note, dated 8/28/2023 and timed at 1313 (1:13 p.m.,), was reviewed. The progress note indicated that Patient 1 was transferred to the acute care hospital (after the second incident of physical altercation) and the Progress note also indicated that Patient 1 was complaining of left shoulder pain and "loss of consciousness." The DRM stated that the incident between Patients 1, 2 and 3 was a reportable event due to Patient 1's loss of consciousness.

During an interview on 3/14/2025 at 3:37 p.m., with the Regional Vice President (RVP), the RVP stated that the facility reported the incident between Patients 1, 2, and 3 but the report was "late." (The incident happened on 8/28/2023 but the facility reported the incident to the Department on 9/12/2023).

During a review of the facility's policy and procedure (P&P) titled, "Serious Event Notifications," dated 11/17/2022, the P&P indicated it is the policy of the facility to comply with all regulatory reporting requirements and to identify and communicate all serious events to internal and external stakeholders in a standardized manner to improve patient care and to promote safe facility practices. The P&P also indicated that the facility will notify the regulatory agency no later than five days after the adverse event has been detected.

2. During a review of Patient 21's "Initial Psychiatric Evaluation," dated 03/10/2025, Patient 21's psychiatric evaluation indicated that Patient 21 was a 59 years old female who was admitted on 03/09/2025 for feeling suicidal (thoughts of taking one's own life). The psychiatric evaluation also indicated Patient 21 was previously diagnosed with major depression (a common and serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life).

During a review of Patient 21's "Multidisciplinary Treatment Plan Substance Abuse (The use of illegal drugs or the use of prescription or over-the-counter drugs or alcohol for purposes other than those for which they are meant to be used, or in excessive amounts)/Detox (a set of interventions aimed at managing acute intoxication and withdrawal)," record, dated 3/09/2025, the record indicated that Patient 21 was on behavioral manifestation/observation for mixed drinks binge for 1 month daily with a goal to identify 3 coping skills to use to prevent relapse (a return to substance use or addictive behaviors after a period of abstinence or improvement).

During a review of Patient 21's "Final Ancillary Orders," dated 3/13/2025, the document indicated that Patient 21 had a nursing general order to complete the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-AR, a tool used to assess the severity of alcohol withdrawal symptoms) every four hours.

During a concurrent interview and record review on 3/13/2025 at 11:13 a.m. with Nurse Manager (NM) 1, Patient 21's medical record titled, "Detoxification/Withdrawal Assessment," dated 3/11/2025, was reviewed. The record indicated staff did not fully complete the assessment and documented Detoxification/Withdrawal Assessment symptoms at 0200 (2 a.m.) for Patient 21. NM 1 stated the following: Confirmed assessment was not done by staff and will educate staff on the importance of completing the assessment every fours, per Management of Detox Patients policy.

During a review of the facility's Policy and Procedure (P&P) titled, "Management of Detox Patients" (Policy No.: PC-15), with revised date of March 2022, the P&P indicated the following:
PURPOSE:
To outline the assessment and care of any patient whose primary diagnosis is substance abuse or any patient who reports regular use of addictive drugs or alcohol.
PROCEDURE:
I. Pre-Admission Screening:
The Intake Department will obtain substance abuse information and notify the unit staff of substance use history.
II. Assessment Upon Admission:
Upon arrival on the unit, the RN will complete an admission nursing assessment, including collecting information about alcohol/substance use (types, frequency/pattern of use, last use), completing an AUDIT-C tool, tobacco use screening, and assessment of withdrawal symptoms. The RN will assess vital signs, complete a body/skin check (L VN/LPT may complete this task), and perform a mental status examination, including assessing for level of consciousness, orientation, thought process, speech, behavior, and presence of hallucinations. The RN will also collect current and history information for each body system, including cardiovascular, respiratory, neurological, and gastrointestinal. The RN will obtain admission and detoxification orders from the psychiatrist and internist, as appropriate. Within 24 hours of admission, the psychiatrist will complete an admission assessment, and the internist will perform a History and Physical assessment.
Ill. Plan of Care:
Nursing staff will implement the interventions ordered by the physician, including administering medications routinely/as needed and obtaining vital signs and assessing for withdrawal symptoms Q4hours around the clock, including but not limited to nausea/vomiting, diarrhea, sweats, anxiety, tremors, and headache. The RN will review assessment data and notify the physician of significantly abnormal vital signs (as listed below) and/or emergency situations, including but not limited to, seizure activity, severe chest pain, and deterioration of mental status from baseline.

3. During a concurrent observation and interview on 3/10/2025 at 2:02 p.m. with the Charge Registered Nurse (CRN 1) and the Director of Risk Management (DRM 1), at the area between the Del Sol Unit and the CTC (Crisis Treatment Center) unit, a crash cart (a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency), was observed with an empty oxygen tank. CRN 1 and DRM 1 stated the following: Confirmed oxygen tank was empty. The night shift staff checks the crash cart and day shift staff does not check it. CRN 1 will let plant operator know to replace the empty oxygen tank. The crash cart was shared between two units (Del Sol and the CTC). CRN 1 was observed removing the empty oxygen tank from the crash cart.

During an interview on 3/10/2025 at 2:17 p.m. with the Charge Registered Nurse (CRN 1), CRN 1 stated the following: Crash cart was shared between two units. Staff need to immediately let the house supervisor know if the oxygen tank was empty to get it replaced and also let the nurses know from the other unit about the empty tank.

During an interview on 3/10/2025 at 3:13 p.m. with House Supervisor (HS 1), HS 1 stated the following: Did not get informed by staff about the empty oxygen tank today (3/10/2025). Will educate the staff to remove empty oxygen tank and replace with full oxygen tank incase there is a code (Code Blue- a medical emergency, specifically a cardiac [when the heart stops beating] or respiratory arrest [when breathing stops], that triggers immediate response from the resuscitation team to provide life-saving interventions) so Staff does not grab empty tank to use (during a code).

During an interview on 3/12/2025 at 3:36 p.m. with Nurse Manager (NM 2), NM 2 stated the following: Crash cart should not have empty oxygen tank, not safe for the patients when staff are not aware of using empty tank during a code, will educate staff on it. For an empty oxygen tank, immediately remove tank and replace it so that staff does not use the empty oxygen tank during an emergency.

During a review of the facility's "Emergency Medical Equipment Daily Checklist," dated March 2025, the Emergency Medical Equipment Daily Checklist indicated the following: Staff are to check the Oxygen Levels of the tank and "If oxygen tank is below 50%, Immediately notify Facilities at ext. 292 and the Nursing/Shift Supervisor."