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Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. The deficient practice was evidenced by the hospital failing to ensure the patient care area was free of ligature risks (See Tag A0144).

Based on observation, record review and interview, the hospital failed to ensure the patient received care in a safe setting. The deficient practice was evidenced by the hospital failing to ensure the patient care area was free of ligature risks.
Findings:

A review of hospital policy, "PC-1020: Ligature Risk," effective 08/02/2023 and no revisions, revealed in part: "Policy: (The hospital) is committed to maintaining a safe and therapeutic environment for all patients, including those with psychiatric conditions. This Ligature Risk Policy aims to identify, assess, and mitigate potential hazards relate to ligature points that could pose a risk of self-harm or harm to others. This policy applies to all areas within the hospital, including patient rooms, common areas, bathrooms, and outdoor spaces. Procedure: 1. Ligature Assessment: a. A comprehensive ligature risk assessment will be conducted throughout the hospital by a multidisciplinary team, including representatives from nursing, psychiatry, facility management, and safety officers. b. The ligature risk assessment will be repeated annually and whenever there are significant changes to the hospital's environment. 2. Ligature Risk Mitigation: a. All identified high-risk ligature points will be promptly addressed, either by removal, replacement, or modification of the item to minimize the risk. d. any existing ligature-resistant fixtures and equipment will be regularly inspected and maintained to ensure their effectiveness."

Observations during a hospital walk-thru on 12/18/2024 from 1:00 PM to 2:15 PM revealed the toilets in 14 (f - p, r - t) of 20 (a - t) patient restrooms have an open space between the toilet bowl and the wall and contain non-secured toilet seats creating ligature risks and the potential for injurious behavior. Further observation revealed sleigh bed style bed frames (plastic head board and foot board attached to the floor and are connected via an above floor plastic platform for mattress placement) in 16 (a - p) of 20 (a - t) patient bedrooms. This style frame creates multiple ligature risk and the potential for injurious behaviors.

In an interview on 12/182024 and present during the hospital walk-thru, S2DON confirmed the above mentioned findings.

Based on record review and interview, the hospital's Governing Body failed to ensure the Quality Assurance and Performance Improvement (QAPI) Program reflects the complexity of the hospital's organization and services, which includes all hospital departments and services, including services furnished under contract or arrangement, within its QAPI Program. This deficient practice was evidenced by the hospital failing to ensure Plant Operations including Environment of Care and Preventative Maintenance were part of the hospital's QAPI Program to ensure these services are tracked and analyzed to promote quality improvement and patient safety.
Findings:

A review of the hospital's, "Performance Improvement Plan," effective 07/2012 and no revision, revealed in part, no documentation related to Plant Operations including Environment of Care and Preventative Maintenance being on the, "Performance Improvement Master List of Indicators" as part of the hospitals QAPI Program to ensure these services are tracked and analyzed.

In an interview on 12/18/2024 at 3:10 PM, S1CEO confirmed the hospital's current QAPI Program does not track and analyze Plant Operations.

Based on record review, observation and an interview, the hospital failed to ensure the medical record was complete for 1 (#3) of 3 (#1-#3) patients' medical records reviewed.
Findings:

Review of the hospital's policy titled number "HIM-17: Documentation Completion Time Frames" last revised in June of 2023, indicated the following, in part:
"Purpose: To ensure timely and accurate entries in the medical record.
Policy: Health record documentation will be completed in an ongoing manner throughout the inpatient stay. All dictated and handwritten reports on patients will immediately be placed on the patients' charts. When data entries are not completed by the time of discharge the following time frames and definitions will apply:
- incomplete status: any record incomplete within 30 days of discharge
- delinquent status: any record incomplete beyond 30 days of discharge
Health Record Completion Time Frames: Document Type, Completion Time & Authentication, Verbal Orders, Within 10 days of order written, Discharge Summary, Within 30 days of discharge.
Procedure:
Each medical record shall be completed within 30 days after discharge or the patient, or the record becomes delinquent."

A review of Patient #3's discharge record revealed he was discharged from the hospital on 11/12/2024. Further review revealed Patient #3's Admission Orders dated 11/10/2024 at 5:15 PM and Discharge Orders dated 11/12/2024 at 10:00 AM were not signed by the physician.

On 12/18/2024 at 4:20 PM, an observation was made during record review of Patient #3's discharge record of where the physician needed to sign admission and discharge orders being marked with flagged stickie tabs on the right long edge of the page. The admission order sheets had a date of 11/10/2024 and the discharge order sheets had a date of 11/12/2024.

On 12/18/2024 at 4:22 PM, an interview was conducted with S2DON. He confirmed both the admission and discharge order sheets had not been signed and dated by the physician. He confirmed without the signatures, the medical record was not complete due to the missing signatures. He confirmed Patient #3 had discharged more than 30 days ago from the hospital and the medical record should have been completed by this time with all provider signatures and dates properly documented.

Based on record review, observation and an interview, the hospital failed to ensure the medical record was complete for 1 (#3) of 3 (#1-#3) patients' medical records reviewed.
Findings:

Review of the hospital's policy titled number "PC-1407: Verbal/Phone Orders" effective July 10th, 2012, indicated the following in part:
"Objective: To maintain a high level of accuracy and safety in following physician's or Licensed Independent Practitioner's (LIP) orders.
Procedure: 8. All phone orders are to be signed during the next physician or LIP face to face with patient or within 10 days."

Review of the hospital's policy titled number "HIM-17: Documentation Completion Time Frames" last revised in June of 2023, indicated the following, in part:
"Purpose: To ensure timely and accurate entries in the medical record.
Policy: Health record documentation will be completed in an ongoing manner throughout the inpatient stay. All dictated and handwritten reports on patients will immediately be placed on the patients' charts. When data entries are not completed by the time of discharge the following time frames and definitions will apply:
- incomplete status: any record incomplete within 30 days of discharge
- delinquent status: any record incomplete beyond 30 days of discharge
Health Record Completion Time Frames: Document Type, Completion Time & Authentication, Verbal Orders, ithin 10 days of order written, Discharge Summary, Within 30 days of discharge.

A review of Patient #3's discharge record revealed he was discharged from the hospital on 11/12/2024. Further review revealed Patient #3's Admission Orders dated 11/10/2024 at 5:15 PM and Discharge Orders dated 11/12/2024 at 10:00 AM were not signed by the physician.

On 12/18/2024 at 4:20 PM, an observation was made during record review of Patient #3's discharge record of where the physician needed to sign admission and discharge orders being marked with flagged stickie tabs on the right long edge of the page. The admission order sheets had a date of 11/10/2024 and the discharge order sheets had a date of 11/12/2024.

On 12/18/2024 at 4:22 PM, an interview was conducted with S2DON. He confirmed both the admission and discharge order sheets had not been signed and dated by the physician. He confirmed the admission and discharge orders did not have a physician's signature and were TORB/VORBs. He confirmed all TORB/VORBs must be signed by the provider within 10 days and Patient #3's admission and discharge orders were not.

Based on observation and interview, the hospital failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are ensured. This deficient practice was evidenced by the hospital failing to ensure the ventilation system's return and exit vents were routinely cleaned and free of brown and grey substances.
Findings:

Observations during a hospital walk-thru on 12/18/2024 from 1:00 PM to 2:15 PM revealed the hospital's ventilation system having vents being discolored brown, with a rough surface resembling rust located at the main entry of the unit and the hallway vents at Rooms "g" and "k." Further observations revealed a grey, fuzzy substance resembling dust accumulation on 2 vents located at Room "v" next to the nurses' station.

In an interview on 11/24/2024 and present during the hospital walk-thru, S1CEO confirmed the above mentioned findings.