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Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Governing Body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) was met, as evidenced by:

1. The Governing Body failed to ensure oversight to protect one (1) of 39 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility's policy regarding abuse prevention and Governing Body bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), by allowing an agitated (being upset, annoyed, angry and physically disturbed) patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3's) room with two other patients (Patients 1 and 2) present, on 4/9/2025.

This deficient practice resulted in Patient 2 being triggered by Patient 3's aggressive behavior, thus assaulting (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1, and led to Patient 1 sustaining midface fractures (broken bones). (Refer to A-0063)

2. The Governing Body failed to ensure oversight to ensure nursing staff complied with adherence to the facility's policies and procedures regarding seclusion (involves the involuntary confinement of a patient in a room or area from which they cannot freely exit), restraint (devices or techniques used to limit a patient's movement, typically to prevent harm to themselves or others), and physical hold (type of physical restraint, a manual or physical method of holding the patient against patient's will that restricts freedom of movement or normal access to one's body), to ensure that the facility's staff delivered safe and quality care to four (4) of 39 sampled patients (Patient 2, Patient 5, Patient 19, and Patient 24), as evidenced by:

2.a. The facility failed to ensure seclusion and restraint physician orders were obtained, in accordance with the facility's policy regarding restraints use, for two of 39 sampled patients (Patient 2 and Patient 5), after Patient 2 was placed in a seclusion, and Patient 5 was restrained in a physical hold (a manual restraint or manual hold used to restrict a patient's movement for safety reasons, performed according to established techniques and protocols).

This deficient practice had the potential to compromise Patient 2's and Patient 5's safety by increasing their (Patient 2 and Patient 5) risk for injury, trauma, and psychological distress. In addition, this deficient practice had the potential to result in restraints use without physician order and physician's oversight and direction which may lead to unnecessary restraints use, risk for injury related to restraints use and not keeping patients free from restraints. (Refer to A-0063)
2.b. The facility failed to ensure physical hold (a manual restraint or manual hold used to restrict a patient's movement for safety reasons, performed according to established techniques and protocols), was implemented, in accordance with the established correct techniques for staff, when performing physical holds on two of 39 sampled patients (Patient 19 and Patient 24). This deficient practice had the potential to compromise Patient 19's and Patient 24's safety such as risk for injury and impacting Patient 19's and Patient 24's dignity and right to receive care in a safe setting and therapeutic environment. (Refer to A-0063)

3. The Governing Body failed to ensure oversight so that established strategies (Example: Use of ABC [Antecedent-Behavior-Consequence] tool [an assessment to identify patient triggers such as phone call with family member] and discussion of the identified triggers during treatment planning) to diminish seclusion and restraint (S&R) use at the facility, especially on the DDMI (Developmental Disability and Mental Illness-Dual Diagnosis, unit (DDMI unit is an inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness), were implemented, monitored and documented to ensure staff compliance and adherence with established strategies for one of 58 DDMI sampled patients (Patient 27).

This deficient practice had the potential to result in continued overuse of seclusion and restraint (S&R) methods, increasing the risk for physical and psychological harm to all patients in the facility including Patient 27, undermining patient safety and violating patient rights. (Refer to A-0063)

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

Based on observation, 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 that one of one sampled medication cart (med cart #11, a portable storage unit used to organize and store medication for easy access by authorized staff in a medication room) in the medication room, located on 5 South unit (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis, individuals who have both a developmental disability and a mental illness] patients), and was used for 24 of 24 sampled patients, always remained locked, as required by the facility's policy for maintaining medication safety and administration.

This deficient practice had the potential to results in patient and staff safety violations, including unauthorized access to medication, medication theft, misuse, and tampering (altering or modifying a medication or its packaging without authorization), which could lead to medication errors, overdose, or other safety breaches, including violating the facility's policies designed to prevent medication mishandling and safeguard patients' safety. (Refer to A-0144)

2. The facility failed to ensure its nursing staff protected one (1) of 39 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility's policy regarding abuse prevention, when staff allowed an agitated patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3's) room with two other patients (Patients 1 and 2) present, on 4/9/2025.

This deficient practice resulted in Patient 2 being triggered by Patient 3's aggressive behavior, thus assaulting (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1, and led to Patient 1 sustaining midface fractures (broken bones) on 4/9/2025. (Refer to A-0145)

3. The facility failed to ensure that one of 39 sampled patient's (Patient 27), electronic medical record (EMR, a digital collection of a patient's medical information, including their health history, diagnoses, medications, allergies, immunizations, and treatment plans), was protected, in accordance with the facility's policy regarding confidentiality, when a nurse did not log out from Patient 27's digital chart and left for lunch, thereby exposing Patient 27's medical record to unauthorized personnel.

This deficient practice had the potential to violate Patient 27's right (Patient Rights- the fundamental entitlements and protections that individuals have when receiving medical care) to confidentiality and privacy, increasing the risk of unauthorized access to sensitive medical information, which could lead to privacy violations, identity theft, and misuse of personal health data. (Refer to A-0146)

4. The facility failed to ensure a physical hold (a manual restraint or manual hold used to restrict a patient's movement for safety reasons, performed according to established techniques and protocols) restraint, was properly implemented, in accordance with the established correct techniques for staff, when performing physical holds on two of 39 sampled patients (Patient 19 and Patient 24) when:

4.a. A mental health worker (MHW) 1 leaned his (MHW 1's) right elbow onto Patient 19's upper back during a physical hold on 4/22/2024. This deficient practice had the potential to result in hurting Patient 19 and affecting Patient 19's breathing. (Refer to A-0167)

4.b. A mental health worker (MHW 1) hyperextended (occurs when the elbow joint bends backward beyond its normal range of motion) Patient 24's left arm during a physical hold on 3/19/2024 in a seclusion room (a room or area where a person is involuntarily confined, meaning they are physically prevented from leaving), when Patient 24 was held against the wall, with two mental health workers on each side. This deficient practice had the potential to compromise Patient 24's safety by increasing Patient 24's risk of injury, such as nerve damage or musculoskeletal harm (any injury or disorder affecting the body's musculoskeletal system, including muscles, bones, joints, ligaments, and tendons) such as dislocation of the shoulder. (Refer to A-0167)

5. The facility failed to ensure that the use of restraint (devices or methods used to restrict a patient's movement, either physically or through medication) or seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior), was in accordance with a physician's order and the facility's policy regarding seclusion/restraints use, for four of 39 sampled patients (Patients 2, 5,19, 25) when:

5.a. Patient 2 was placed in seclusion without a physician order for three hours and five minutes. This deficient practice had the potential to put Patient 2 at risk for injury. (Refer to A-0168)

5.b. Patient 5 was placed in a physical hold (type of physical restraint, a manual or physical method of holding the patient against patient's will that restricts freedom of movement or normal access to one's body) without a physician order for approximately five seconds. This deficient practice had the potential to put patient 19 at risk for injury. (Refer to A-0168)

5.c. Patient 19 was physically restrained without a physician order on 4/22/2024. This deficient practice had the potential to put Patient 19 at risk for unnecessary seclusion and/or restraints and at risk for injury. (Refer to A-0168)

5.d. Patient 25 was documented to have been placed in seclusion eight (8) times from 3/12/2024 through 11/20/2024, of those eight episodes, Patient 25 was in seclusion without a physician's order for seclusion and for one out of eight episodes, lacked an order for physical restraints. This deficient practice had the potential to place Patient 25 at risk of harm/injury and unnecessary seclusion or restraints use. (Refer to A-0168)

6. The facility failed to ensure for five of five (5) sampled staff (Mental Health Worker 1, Mental Health Worker 6, Mental Health Worker 7, Charge Nurse 2, and Charge Nurse 3), a training and demonstration of competency on restraint (methods or devices used to restrict a person's movement or ability to move freely), seclusion (the involuntary confinement of a patient alone in a room from which they are physically prevented from leaving) and physical hold (a situation where a patient's movement is involuntarily restricted by staff, often to prevent harm to themselves or others), were successfully completed and documented, in accordance with the facility's "Behavioral Restraint and Seclusion Assessment of Competency," document.

This deficient practice had the potential to negatively affect patients receiving care. Specifically, incomplete training and documentation of completion could result in staff's lack of a clear understanding of the appropriate circumstances and procedures for utilizing restraints, seclusion, and physical holds, which can lead to inappropriate or unsafe use, increasing the risk of physical and psychological harm to patients including risk of injury to staff. (Refer to A-0208)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare 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 that a Registered Nurse (RN) provided supervision over the physical hold (a manual method used to restrict a person's movement or hold them immobile, often to prevent harm to themselves or others), for two of 39 sampled patients (Patient 19 and Patient 24), ensuring that correct physical restraining techniques were utilized, in accordance with the facility's policy regarding seclusion (the involuntary confinement of a patient alone in a room from which they are physically prevented from leaving) and restraints (methods or devices used to restrict a person's movement or ability to move freely) use, when:

1.a. Mental Health Worker (MHW 1) hyperextended Patient 24's left arm during a physical hold on 3/19/2024 in a seclusion room (a room or area where a person is involuntarily confined, meaning they are physically prevented from leaving), when Patient 24 was pinned against the wall, with two mental health workers on each side. This deficient practice had the potential to compromise Patient 24's safety by increasing Patient 24's risk of injury, such as nerve damage or musculoskeletal harm such as dislocation of the shoulder. (Refer to A-0395)

1.b. Mental Health Worker (MHW 1) leaned the right elbow against the back of Patient 19 during a physical hold on 4/22/2024, while clinical staff prepared the restraints for Patient 19 to be restrained shortly after. This deficient practice had the potential to result in causing Patient 19's difficulty breathing and injury. (Refer to A-0395)

2. The facility failed to ensure one of 39 sampled patient's (Patient 13) wound assessment (a systematic evaluation of a wound to determine its characteristics, stage, and healing progress), was completed and documented, in accordance with the facility's policy regarding assessment and reassessment.

This deficient practice had the potential to result in an inadequate assessment of the wound, which may lead to delayed healing and increased risk of infection, and/or delayed recognition of wound complications, potentially resulting in inappropriate or insufficient treatment to Patient 13's wounds. (Refer to A-0395)

3. The facility failed to ensure one of 39 sampled patient's (Patient 10) treatment plans (a structured, individualized document that outlines the care team objectives, intervention and the strategies to achieve specific health goals) regarding hypothyroid issues (a condition where the thyroid gland doesn't produce enough thyroid hormones [regulates growth and development]) and hypertension (high blood pressure), were developed and implemented upon admission, in accordance with the facility's policy regarding treatment planning.

This deficient practice had the potential of failing to implement clinically appropriate individualized goals and interventions to address Patient 10's care needs and risks, which may result in complications such as uncontrolled hypertension and prolonged hospital stay. (Refer to A-0396)

4. The facility failed to ensure that one of one sampled medication cart (med cart #11, a portable storage unit used to organize and store medication for easy access by authorized staff in a medication room), in the medication room, located on 5 South unit (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis, individuals who have both a developmental disability and a mental illness] patients), and is used for 24 of 24 sampled DDMI patients, always remained locked, as required by the facility's policy for maintaining medication safety and administration.

This deficient practice had the potential to result in patient and staff safety violations, including unauthorized access to medication, medication theft, misuse, and tampering (altering or modifying a medication or its packaging without authorization), which could lead to medication errors, overdose, or other safety breaches, including violating the facility's policies designed to prevent medication mishandling and safeguard patients' safety. (Refer to A-0398)

5. The facility failed to ensure its nursing staff protected one (1) of 39 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility's policy regarding abuse prevention, when staff allowed an agitated patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3's) room with two other patients (Patients 1 and 2) present, on 4/9/2025.

This deficient practice resulted in Patient 2 being triggered by Patient 3's aggressive behavior, thus assaulting (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1, and led to Patient 1 sustaining midface fractures (broken bones) on 4/9/2025. (Refer to A-0398)

6. The facility failed to ensure that a proper (minimum arm's length distance) Q (every) 15 minute observation (safety checks conducted every 15 minutes to ensure the well-being of patients) and close proximity observation, was completed for the safety and security of 12 of 39 sampled patients (Patients 7, 8, 30 ,31 ,32, 33, 34, 35, 36, 37, 38 and 39), in accordance with the facility's policy regarding observation and monitoring, when Registered Nurse (RN) 1, who was assigned to conduct Q-15 minute observation, did not enter the patients' rooms to make direct visual contact with the patients.

This deficient practice had the potential of failing to prevent harm to patients, including self-harm, suicide (the act of intentionally causing one's own death), and elopement (escape). (Refer to A-0398)

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

Based on interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Special Medical Record Requirements for Psychiatric Hospitals was met, as evidenced by:

1. The facility failed to ensure two of 39 sampled patient's (Patient 25 and Patient 27) behavioral plan (a personalized plan developed to address and manage specific behaviors, outlining strategies, goals, and intervention), included a behavioral analysis for after seclusion/restraint episodes and incorporated into the behavioral plan with short-term and long-terms goals aimed at reducing the frequency of seclusions and restraints (Seclusion restraint refers to the practice of isolating someone in a locked room or using physical, mechanical, or chemical means to restrict their movement and freedom of movement) episodes, in accordance with the facility's policy regarding treatment planning.

This deficient practice had the potential to result in poorly addressed triggers (specific events or stimuli that lead to behaviors such as aggression) and/or behaviors for Patient 25 and Patient 27, increasing their risk of repeated restraint episodes, injury, or escalation of aggression, compromising Patient 25's and Patient 27's safety, dignity, and overall well-being. In addition, the lack of behavioral analysis and individualized behavioral treatment plan could hinder effective intervention, delay behavior reduction, and impair ongoing progress in managing challenging behaviors for Patient 25 and Patient 27. (Refer to A-1640)

2. The facility failed to ensure that nursing staff documented that attempts were made to treat two of 39 sampled (Patient 24 and Patient 25), in the least restrictive manner, before placing Patient 24 and Patient 25 in physical restraints, in accordance with the facility's policy regarding restraints use.

This deficient practice had the potential to result in unnecessary use of restrictive interventions for Patient 24 and Patient 25, placing both patients at increased risk of injury and/or psychological trauma, and failure to promote dignity, thus violating Patient 24 and Patient 25 rights (the fundamental entitlements and protections that individuals have when receiving medical care). (Refer to A-1650)

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

Based on interview and record review, the facility's governing body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to provide oversight to ensure the facility's staff protects patients and provides safe and quality patient care when:

1. Staff failed to protect one (1) of 39 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility's policy regarding abuse prevention and Governing Body bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), by allowing an agitated (being upset, annoyed, angry and physically disturbed) patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3's) room with two other patients (Patients 1 and 2) present on 4/9/2025.

This deficient practice resulted in Patient 2 being triggered by Patient 3's aggressive behavior, assaulting (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1, and led to Patient 1 sustaining midface fractures (broken bones).

2. There was no oversight to ensure nursing staff complied with adherence to the facility's policies and procedures regarding seclusion (involves the involuntary confinement of a patient in a room or area from which they cannot freely exit), restraint (devices or techniques used to limit a patient's movement, typically to prevent harm to themselves or others), and physical hold (type of physical restraint, a manual or physical method of holding the patient against patient's will that restricts freedom of movement or normal access to one's body), to ensure that the facility's staff delivered safe and quality care to four (4) of 39 sampled patients (Patient 2, Patient 5, Patient 19, and Patient 24), as evidenced by:

2.a. The facility failed to ensure seclusion and restraint physician orders were obtained, in accordance with the facility's policy regarding restraints use, for two of 39 sampled patients (Patient 2 and Patient 5), after Patient 2 was placed in a seclusion, and Patient 5 was restrained in a physical hold.
This deficient practice had the potential to compromise Patient 2's and Patient 5's safety by increasing their (Patient 2 and Patient 5) risk for injury, trauma, and psychological distress. In addition, this deficient practice had the potential to result in restraints use without physician order and physician's oversight and direction which may lead to unnecessary restraints use, risk for injury related to restraints use and not keeping patients free from restraints.

2.b. The facility failed to ensure physical hold (a manual restraint or manual hold used to restrict a patient's movement for safety reasons, performed according to established techniques and protocols) was implemented, in accordance with the established correct techniques for staff, when performing physical holds on two of 39 sampled patients (Patient 19 and Patient 24). This deficient practice had the potential to compromise Patient 19's and Patient 24's safety such as risk for injury and impacting Patient 19's and Patient 24's dignity and right to receive care in a safe setting and therapeutic environment.

3. The facility failed to ensure that established strategies (Example: Use of ABC [Antecedent-Behavior-Consequence] tool [an assessment to identify patient triggers such as phone call with family member] and discussion of the identified triggers during treatment planning) to diminish seclusion and restraint (S&R) use at the facility, especially on the DDMI (Developmental Disability and Mental Illness-Dual Diagnosis, unit (DDMI unit is an inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness), were implemented, monitored and documented to ensure staff compliance and adherence with established strategies for one of 58 DDMI sampled patients (Patient 27).
This deficient practice had the potential to result in continued overuse of seclusion and restraint (S&R) methods, increasing the risk for physical and psychological harm to all patients in the facility including Patient 27, undermining patient safety and violating patient rights.

Findings:

1. During a review of Patient 1's "Face Sheet (front page of the chart that contains a summary of basic information about the patient)," dated 3/31/2025, the Face Sheet indicated Patient 1 was admitted to the facility on 3/31/2025 at 10:30 a.m. under a 5150 legal hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of himself]).

During a review of Patient 1's "Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold paperwork)," dated 3/30/2025, the 5150-hold paperwork indicated Patient 1 was detained for being gravely disabled due to auditory hallucinations (hearing sounds, noises, or voices that are not there) and abnormal behavior.

During a review of Patient 2's Face Sheet dated 4/8/2025, the Face Sheet indicated Patient 2 was admitted to the facility on 4/8/2025 at 10:08 p.m. under a 5150 legal hold.

During a review of Patient 2's 5150 hold paperwork, dated 4/8/2025, the 5150 hold paperwork indicated Patient 2 was detained for being a danger to others when he was found "challenging people to a fight without provocation" in the community.

During a review of Patient 3's "Face Sheet," dated 3/28/2025, the Face Sheet indicated Patient 3 was admitted to the facility on 3/28/2025 at 12:55 p.m. voluntarily (of his own free will).

During a review of Patient 3's "Psychiatric (treatment or care for a mental health disorder or illness) and Mental Status Examination (PMSE, a formal and complete assessment of the patient and the problem related to mental health)," dated 3/29/2025 at 10:23 a.m., the PMSE indicated Patient 3 sought voluntary admission due to suicidal thoughts (thinking about killing himself).

During a review of Patient 4's "Face Sheet," dated 4/8/2025, the Face Sheet indicated Patient 4 was admitted to the facility on 4/8/2025 at 10:50 a.m. under a 5150 legal hold.

During a review of Patient 4's 5150 hold paperwork, dated 4/8/2025, the 5150 hold paperwork indicated Patient 4 was detained for being gravely disabled due to abnormal behavior.

During a review of Patient 1's "Progress Notes," dated 4/9/2025 at 4:35 a.m., the Progress Notes indicated, "Around [4:10 a.m.], patient (Patient 1) came out of his (Patient 1) room [with] heavy bleeding from both nostrils. [Patient 1 was] confused, unable to provide accurate information regarding what exactly happened, but stated 'I'm sorry, someone punched me'." The Progress Notes further indicated Patient 1 was sent to General Acute Care Hospital (GACH) 1's Emergency Department (a hospital department that provides immediate care for patients with urgent medical conditions) at 4:33 a.m.

During a review of Patient 1's "Progress Notes," dated 4/9/2025 at 1:51 p.m., the Progress Notes indicated Patient 1 was scheduled to be transferred to GACH 2 at 2:00 p.m. for possible oral facial (face and mouth) surgery.

During a review of Patient 2's "Progress Notes," dated 4/9/2025 at 4:47 a.m., the Progress Notes indicated, "[Patient 1] ran out of his room with his nose bleeding. [Patient 2] stated he did not know who punched him."

During a review of Patient 2's "Progress Notes," dated 4/9/2025 at 3:48 p.m., the Progress Notes indicated, "[Patient 2] states, 'I hit the other guy earlier.'"

During a review of Patient 1's "CT (computed tomography, a procedure that uses X-ray techniques to create detailed images of the body) Maxillofacial (upper jaw and face) Scan" report from GACH 2, dated 4/9/2025 at 8:26 p.m., the report indicated Patient 1 sustained bilateral (both) Le Fort I (a type of facial fracture that occurs horizontally through the maxilla [upper jaw], above the roots of the teeth), right possible Le Fort II fractures (a pyramidal shaped fracture along the nasal bridge and causes separation of the midface from the skull base), and bilateral maxillary sinus fractures (a break in the bones that make up the maxillary sinus [the air-filled cavities in the cheek bones]) of the anterior (front) and posterolateral (at the back and to the side) walls.

During an interview with the Director of Quality Improvement and Risk Management (DQ) on 6/9/2025 at 1:51 p.m., the DQ stated that on 4/9/2025 at around 4:00 a.m., Patient 1 came out of his (Patient 1) room with his nose bleeding and stated that somebody punched him. The DQ further stated that the only other person in the room was his roommate, Patient 2, but at the time, he (Patient 2) denied knowing what happened.

During an interview with the Nurse Manager (NM 1) for North and South ICU (Intensive Care Unit, a specialized hospital department that provides critical care to patients with life-threatening conditions) on 6/11/2025 at 10:16 a.m., NM 1 confirmed that Patients 1, 2, and 3 were roomed in together in the same room (Room A). NM 1 further stated that on 4/9/2025 after midnight, there was a "fight" between Patients 3 and 4 in the hallway; during the fight, another altercation between Patient 1 and Patient 2 occurred in Room A, unwitnessed by staff.

During a concurrent interview and video surveillance review with the Nurse Manager (NM 1) for North and South ICU on 6/12/2025 at 9:34 a.m., two video clips of security footage from 4/9/2025, were reviewed. NM 1 stated these videos occurred at approximately 4:00 a.m. on 4/9/2025 as there were no time stamps on the footage. The following events were observed from the first clip:
a. At the beginning of the video clip, Patient 4 was standing in the hallway.
b. Patient 3 emerged from his room. Staff stepped in between Patients 3 and 4. One minute and 12 seconds into the video Patient 3 swung his left arm at Patient 4. Additional staff responded to the incident.
c. One minute and 30 seconds in, staff brought Patient 3 back to Room A. Four staff were observed entering Room A with Patient 3.
d. Two minutes and 49 seconds in, staff removed Patient 3 from Room A.

During the same interview on 6/12/2025 at 9:34 a.m. with the Nurse Manager (NM 1) for North and South ICU, NM 1 stated Patient 3 was in his (Patient 3) room (Room A, where Patients 1 and 2 were staying), with staff present, for one minute and 19 seconds, based on the time elapsed in the video. NM 1 further stated that staff removed Patient 3 from his room and brought him to the seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) room to administer emergency medications (medications given to manage severe mental health symptoms such as agitation).

During the same video surveillance review on 6/12/2025 at 9:34 a.m. with the Nurse Manager (NM 1) for North and South ICU, the following events were reviewed from the second clip:
a. Two minutes and 19 seconds into the video, staff brought Patient 3 out of Room A.
b. Two minutes and 44 seconds in, Mental Health Worker (MHW) 2 closed the door to Room A.
c. Three minutes and 40 seconds in, House Supervisor (HS) 1, who was standing in the hallway, appeared to hear something coming from Room A and opened the door.
d.Three minutes and 44 seconds in, Patient 1 emerged from Room A dripping blood on the floor. Staff took him (Patient 1) to the nurses' station. Patient 2 was seen standing in the doorway of Room A.
-NM 1 stated Patients 1 and 2 were left alone in Room A for 56 seconds, based on the time elapsed in the video.

During an interview with NM 1 on 6/12/2025 at 9:50 a.m., NM 1 stated that the facility's staff were responsible for the patients. NM 1 further stated that agitated (a state of restlessness or uneasiness) patients should not be in a room with other patients and staff should remove the roommates as best as they could because there was potential that the roommates could get triggered, agitated, or get hurt.

During an interview with NM 1 on 6/12/2025 at 10:24 a.m., NM 1 stated Patient 2 was a newly admitted patient and had not yet been seen by a physician. The staff was not familiar with Patient 2 and did not know what would trigger Patient 2 and what Patient 2's behavior would be. NM 1 further stated the staff should have maintained vigilance until the staff got to know Patient 2 more.

During an interview with the Chief Executive Officer (CEO) and the Associate Administrator of Hospital Operations (AAO) on 6/13/2025 at 2:28 p.m., the CEO confirmed he (CEO) was on the GB and stated that the GB had overall responsibility for the facility, for the quality of care provided by the facility to its patients, and for patient safety. The CEO confirmed the GB was also responsible for ensuring the facility followed state and federal regulations. The CEO and the AAO confirmed that patient-to-patient altercation incidents were discussed during the GB meetings but were not sure if the incident between Patients 1 and 2 was discussed at the last meeting on May 5, 2025. The GB meeting minutes for May 5 were not available for review.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold Policy," last reviewed 10/2023, indicated, "The clinical staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation (reduction of the intensity of a conflict or potentially violent situation) preferences from the initial assessment prior to [seclusion/restraint], including ... C. Separating patient from group or community ... E. Offering the use of the quiet room to decrease stimuli and regain control."

During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention, Screening, Identification, Training, Protection, Investigation, and Reporting," last reviewed 10/2023, indicated, "It is the policy of [Name of Facility] to protect our patients from all types of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients, or visitors ... A critical part of protecting patients from abuse is preventing abuse from occurring in the first place."

During a review of the facility's Governing Body (GB) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), approved by the GB on 5/6/2024, the bylaws indicated, "The primary responsibility and goal of the Board of Directors (the 'Board') is to further the role and purpose of the Hospital by providing oversight of the Hospital and advice to the Corporation, thereby facilitating institutional management and planning, the establishment of policies and the maintenance of quality patient care services, all in a manner that is responsive to and meets the needs of the community area, consistent with our mission and the advancement of our vision for the organization. The Board serves as the governing body of the Hospital and retains ultimate responsibility for the Hospital's compliance with all applicable federal, state, and local laws and regulations."

2.a. During an interview on 6/13/2025 at 2:28 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: the governing body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) had the overall responsibility of the facility, for the quality of care provided by the facility to its patients, and for patient safety. GB was responsible to ensure the facility complied with all federal, state, and local regulations as well as the facility's policies and procedures (P&P). GB meetings were held quarterly to discuss topics including but not limited to Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) and patient safety. GB would monitor the facility's QAPI activities and meet with the facility's leadership team if there were any quality or patient safety issues.

During an interview on 6/13/2025 at 2:55 p.m. with the Director of Quality Improvement and Risk Management (DQ), the DQ stated the following regarding the previously identified issues with nursing staff not obtaining and/or documenting physician orders for seclusions/restraints and/or physical hold (Restraint is the restriction of an individual's movement using physical force, a mechanical device, or medication to manage behavior. Seclusion is the involuntary confinement of an individual in a room or area from which they cannot freely leave. Physical hold, also known as physical restraint, is a method of restricting freedom of movement by physically holding an individual) being implemented on patients in the facility:

-"After the last Centers for Medicare and Medicaid Services (CMS, responsible for creating health and safety guidelines for hospitals and healthcare facilities, including introducing and enforcing clinical and quality programs ) survey conducted in January 2025, the facility identified that nursing staff was not compliant with obtaining and documenting orders for physical restraints, seclusions, or physical holds. In response, we provided facility-wide education through in-service trainings to all staff [in February 2025]. Nursing leaderships was tasked with collecting data and monitoring staff compliance to ensure that orders for seclusions and restraints were documented in patients' electronic medical records (EMRs, digital version of paper chart). I (DQ) receive the data from nursing leadership monthly, compile it, and present the compliance rate as percentages (%). Our goal was to achieve at least 95% compliance, but we were only successful in meeting the goal in February and March of 2025. Our YDT (Year Data Target, the period from the start of the year to the current date) for 2025, is currently under 95%. Nursing leadership is ultimately responsible to ensure compliance..."

During a review of Patient 2's Face Sheet (front page of the chart that contains a summary of basic information about the patient), dated 4/8/2025, the Face Sheet indicated Patient 2 was admitted to the facility on 4/8/2025 at 10:08 p.m. under a 5150 legal hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to care for themselves]).

During a review of Patient 2's "Seclusion and Restraints Assessment Packet (S&R Assessment)," dated 4/9/2025, the S&R Assessment indicated Patient 2 was placed in seclusion because he (Patient 2) "punched his roommate unwitnessed by staff [and was] irritable, testing limits, minimizing [the] situation, appearing very unpredictable and uncooperative, [and] non-redirectable." The S&R Assessment further indicated Patient 2 was in seclusion for three hours and five minutes, entering at 4:45 a.m. and then released at 7:50 a.m.

During a concurrent interview and record review with Nurse Manager (NM) 1 on 6/12/2025 at 2:41 p.m., Patient 2's medical record, was reviewed. NM 1 confirmed that there was no physician order present in the medical record for Patient 2's seclusion on 4/9/2025 from 4:45 a.m. to 7:50 a.m. and that there should be one [physician order] present.

During a review of Patient 5's Face Sheet dated 6/4/2025, the Face Sheet indicated Patient 5 was admitted to the facility on 6/4/2025 at 7:55 p.m. on a 5150 legal hold.

During a concurrent interview and video surveillance review with Nurse Manager (NM) 1 on 6/12/2025 at 1:59 p.m., the security video footage from 6/6/2025, was reviewed. The video indicated that at 8:01 p.m. [on 6/6/2025] two staff members were holding Patient 5 in the hallway for approximately five seconds, each staff member holding each patient's [Patient 5's] arm. NM 1 confirmed this was a physical hold and stated the staff members were trying to prevent Patient 5 from leaving with the visitor.

During a concurrent interview and record review with Nurse Manager (NM) 1 on 6/13/2025 at 9:28 a.m., Patient 5's medical record, was reviewed. NM 1 confirmed there was no physician order in Patient 5's medical record for the physical hold observed in the security video (dated 6/6/2025). NM 1 stated that physical holds were a form of restraint to prevent the patient from moving, and that there should have been an order for the physical hold.

During an interview with Nurse Manager (NM) 1 on 6/13/2025 at 11:10 a.m., NM 1 stated that nurses could initiate seclusion or restraint, but the physician needed to order it as well to ensure that it was the appropriate or necessary intervention.

During an interview on 6/13/2025 at 2:55 p.m. with the Director of Quality and Risk Management (DQ), the DQ stated the following regarding the timely physician order for seclusion and restraint (S&R, the requirement is that a healthcare provider must provide a documented order before instigating seclusion or restraints, or almost immediately after, in accordance with regulatory and facility's policy): "Obtaining a seclusion and restraint order within minutes of initiation, and ensuring that a physical hold order is present during any period of seclusion or restraint are among the performance metrics that are being monitored and audited."

During the same concurrent interview and record review on 6/13/2025 at 2:55 p.m. with the Director of Quality and Risk Management (DQ), the DQ presented the performance measurement report (a document that tracks and analyzes various metrics to assess the quality, efficiency, and overall performance of the hospital) and stated that the results for these audits were discussed during the typical Safety Committee meetings, and the facility was actively monitoring the compliance rate with these measures, and nursing leadership was responsible for ensuring that staff adhered to these protocols and achieve compliance. The DQ did not provide a comment on the fact that compliance rates for the identified two performance metrics-obtaining a S&R order within minutes of initiation and having physical hold order during S&R-were below the 95% target.

During a concurrent interview and record review on 6/13/2025 at 2:55 p.m. with the CEO and the Associate Administrator of Operations (AAO), the facility's "Board of Directors Meeting Minutes (GB minutes, the official record of discussions, decisions, and actions taken by the hospital's governing body)," dated 2/3/2025, were reviewed. The GB minutes indicated there was a discussion regarding the usage of seclusion and restraint during the period of October to December 2024. AAO stated the GB meeting minutes did not reflect any discussion regarding compliance monitoring of seclusion and restraint use by staff in accordance with facility's policy and procedure. The AAO also stated the GB met in May 2025 [GB meets quarterly] but the GB meeting minutes from that meeting were not available for review at this time.

During an interview on 6/13/2025 at 3:38 p.m. with the Chief Nursing Officer, CNO stated, "Our compliance rates are not great," and then said that the house supervisor was responsible for collecting the data and inputting it into the shared files where the Director of Quality (DQ) can access the data and compile it (data collected to show nursing compliance with obtaining S&R order within minutes of initiation and having physical hold order during S&R) to produce compliance percentage (%) rates. The CNO verified that the facility's compliance rates with the two metrics were not optimal (not the best or satisfactory) and said that additional monitoring efforts may need to be implemented to ensure better compliance.

During a review of the facility's "Bylaws of Governing Board of [the facility] (GB Bylaws)," dated 5/2024, the GB Bylaws indicated, "The primary responsibility and goal of the Board of Directors (the 'Board" [GB]) is to further the role and purpose of the Hospital by providing oversight of the Hospital and advice to the Corporation, thereby facilitating institutional management and planning, the establishment of policies and the maintenance of quality patient care services, all in a manner that is responsive to and meets the needs of the community area, consistent with our mission and the organization. The Board serves as the governing body of the Hospital and retains ultimate responsibility for the Hospital's compliance with all applicable federal, state, and local laws and regulations. The Board shall receive and evaluate periodic reports from the Medical Staff and its officers .... oversee performance improvement (QAPI) ... regarding the provision of quality patient care at the Hospital and establish policies regarding such matters."

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold Policy," dated 10/2023, the P&P indicated, "Definition ... Restraints: A. Physical Restraint/Hold: Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body ... Procedure ... 4. The physician or Registered Nurse (RN) can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the seclusion/restraints (S/R), and document on the Seclusion/Restraint Order form as follows: A. Time Limits: 1) Adults 18 and older up to four (4) hours; 2) Youth 9 - 17 up to two (2) hours ... B. The physician's orders specify the reason for restraint and seclusion usage, the type of restraint, and their duration. The S/R can be ordered for less than above stated maximum. The length of the S/R is limited by the continued need for the intervention rather than then length of the order ... C. In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained Registered Nurse may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes."

2.b. During an interview on 6/12/2025, at 2:40 p.m., with the Director of Quality (DQ) and the Director for DDMI (Developmental Disability and Mental Illness-Dual Diagnosis (DDMI, inpatient unit that provides treatment and therapy for people who have developmental delay with mental illness) unit (Dir 1), the DQ said that no person was assigned to watch the video footage of all recordings for patients who were ordered for seclusion, restraints, or physical hold. There had been no practice of reviewing all videos involving restraints or seclusions. Dir 1 said that nobody was specifically assigned to monitor staff during the application of restraints or seclusions because it was not feasible, as all staff were trained on the unit to apply restraints, and the expectation was that staff were performing their job appropriately without constant oversight.

During a review of Patient 19's "Annual Psychiatric Assessment (a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 5/9/2024, the "Annual Psychiatric Assessment" indicated, Patient 19 was admitted to the facility's adult locked Developmental Delay and Mental Illness (DDMI, inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness) with bipolar (a mental illness that causes unusual shifts in mood, energy, and concentration) type schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) and mild intellectual disability (a disability that affects the acquisition of knowledge and skills).

During a concurrent interview and record review on 6/11/2025 at 11:47 a.m. with the Program Director (DIR 1) of DDMI, a facility's video clip of security footage, with no audio, timestamp dated on 4/22/2024, was reviewed. The video clip showed the following:

-At 4:51 p.m.: Patient 19 was walking around and banging the wall in the seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) room;

-At 5:21 p.m.: multiple clinical staff came into the seclusion room. A Mental Health Worker (MHW) 1 brought Patient 19 to face the wall and leaned his (MHW 1's) right elbow onto Patient 19's upper back while another clinical staff was holding Patient 19's left arm. Other clinical staff were preparing restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) devices on the restraint bed for Patient 19.

During the same interview on 6/11/2025 at 11:47 a.m. with DIR 1, DIR 1 stated the following: MHW 1 performed physical hold (type of physical restraint, a manual or physical method of holding the patient against patient's will that restricts freedom of movement or normal access to one's body) on Patient 19 incorrectly. MHW 1 was leaning too much with his (MHW 1's) elbow onto Patient 19. There was potential that Patient 19 could get hurt by hitting the wall. DIR 1 also stated MHW 1 was terminated.

During an interview on 6/12/2025 at 10:36 a.m. with Nurse Manager (NM) 1, NM 1 stated leaning elbow onto patient was incorrect NCI (Nonviolent Crisis Intervention, behavior management system designed to help to de-escalate [reduce the intensity of a conflict or potentially violent situation] and manage disruptive or out-of-control individuals in a safe and non-harmful way) technique. NM 1 stated the incorrect technique could restrict patient's breathing and cause patient harm.

During a review of Patient 24's "Annual Psychiatric Assessment (APA, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 1/22/2024, the APA indicated that Patient 24 was a DDMI patient (DDMI-Developmental Disability and Mental Illness -dual diagnosis), who was admitted to the facility on 1/22/2024 due to being danger to self (threatening to kill self) and others, and had history of autism (a neurodevelopmental condition that affects how people interact with the world, particularly in social communication and interaction, and in the presence of restricted and repetitive behaviors, interests, or activities), ADHD (Attention-Deficit/Hyperactivity Disorder, is a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and impulsivity), anxiety (a common emotion characterized by feelings of fear, worry, unease, and apprehension) and ODD (Oppositional Defiant Disorder, a pattern of defiant, angry, and irritable behavior, including arguing, refusing to comply, and intentionally annoying others).

During a concurrent interview and record review on 6/12/2025 at 12:37 p.m. with the director of DDMI (Development Disability & Mental Illness -Dual Diagnosis) program (Dir 1), Patient 24's restraint and seclusion (R&S, interventions used in the treatment and management of disruptive and violent behaviors in psychiatry), video footage (no audio, timestamp dated 3/19/2024, was reviewed. The video footage demonstrated the following:

-At 5:15 p.m., Patient 24 was held against the wall, restrained by two mental health workers (MHW 1 and MHW 2). MHW 1 was positioned on the left side of Patient 24, holding Patient 24's left arm, hyper-extending the arm backwards and slightly upward (meaning the arm was pulled or extended beyond its normal range of motion). Patient 24 was pinned against the wall in a physical hold, for about a minute, while staff prepared the 5-point physical restraints (refer to a type of physical restraint that uses a combination of restraints on the

Based on observation, interview and record review, the facility failed to ensure that one of one sampled medication cart (med cart #11, a portable storage unit used to organize and store medication for easy access by authorized staff in a medication room) in the medication room, located on 5 South unit (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis, individuals who have both a developmental disability and a mental illness] patients), and was used for 24 of 24 sampled patients, always remained locked, as required by the facility's policy for maintaining medication safety and administration.

This deficient practice had the potential to results in patient and staff safety violations, including unauthorized access to medication, medication theft, misuse, and tampering (altering or modifying a medication or its packaging without authorization), which could lead to medication errors, overdose, or other safety breaches, including violating the facility's policies designed to prevent medication mishandling and safeguard patients' safety.

Findings:

During an observation on 6/10/2025 at 11:27 a.m. in the medication room on 5 South (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis] patients), with two nurse managers (NM 1 and NM 3), medication cart # 11 (a portable storage unit used to organize and dispense medications for the unit's patients), was observed to be located within the medication room. The cart was found to be unlocked. NM 3 stated that the medication cart must be kept locked when not in use, even when it is parked in the locked medication room.

During the same interview on 6/10/2025 at 11:27 a.m. with Nurse Manager (NM) 3, NM 3 said that usually, the key to the cart remained with the assigned medication nurse for the day, but all licensed personnel also had the key to access the medication room. NM 3 also said that EVS (Environmental Services) personnel, responsible for cleanliness and sanitation, had access to the medication room as well, and may enter it at any time. NM 3 stated that an unlocked medication cart can pose a risk of unauthorized access to patients' medications. NM 1 then also said that the medication nurse was on a lunch break at the time of the observation [on 6/10/2025 at 11:28 a.m.].

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration and Documentation," dated 10/2023, the P&P indicated that the medication room and the medication cart must be locked when unattended by licensed nursing staff.

Based on interview and record review, the facility failed to ensure its nursing staff protected one (1) of 39 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility's policy regarding abuse prevention, when staff allowed an agitated patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3's) room with two other patients (Patients 1 and 2) present, on 4/9/2025.
This deficient practice resulted in Patient 2 being triggered by Patient 3's aggressive behavior, thus assaulting (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1, and led to Patient 1 sustaining midface fractures (broken bones) on 4/9/2025.

On 6/12/2025 at 3:52 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Associate Administrator of Operations (AAO), Chief Nursing Officer (CNO), Director of Quality Improvement and Risk Management (DQ), Program Director (DIR 1) of Developmental Delay and Mental Illness (DDMI, inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness), Director of Social Services (DIR 2), Nurse Manager (NM 1) for North and South ICU (intensive care unit, inpatient unit that provides treatment and therapy for adults who have mental, emotional and behavioral disorders), Nurse Manger (NM 2) for Central and Infection Control Practitioner, and Nurse Manager (NM 3) for East ICU and Youth (inpatient unit that provides treatment and therapy for adolescents who have mental, emotional and behavioral disorders).
The facility failed to ensure its nursing staff protected psychiatric patients (someone receiving treatment or care for a mental health disorder or illness) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury) when staff allowed an agitated (being upset, annoyed, angry and physically disturbed) patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3's) room with two other patients (Patient 1 and 2) present on 4/9/2025. This led to Patient 2 being triggered (activated) by Patient 3's aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) behavior. As a result, Patient 2 assaulted (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1 and led to Patient 1 sustaining (suffering) midface (central part of the face, between upper eyelids and the upper lips, including the cheeks and the nose) fractures (broken bones) on 4/9/2025.

A review of facility's security footage indicated the following: on 4/9/2025 at around 4 a.m., there was a patient-to-patient altercation (Patient 3 and Patient 4) when Patient 3 was seen swinging his (Patient 3's) left arm to Patient 4. Nursing staff responded, separated both patients (Patient 3 and 4) and brought Patient 3 to his room (Room A). Patient 1 and Patient 2 were in same room (Room A) with Patient 3. Patient 3 was in Room A for 1 minute and 19 seconds, with multiple staff present, before staff brought Patient 3 back out of Room A. 25 seconds after Patient 3 left Room A, a Mental Health Worker (MHW) 1 looked in to Room A for about four (4) seconds then closed the door to Room A. Patient 1 and Patient 2 were left alone in Room A at this time for 56 seconds. Then a House Supervisor heard something, opened the door of Room A and Patient 1 came out of Room A, visibly bleeding with blood dripping on the floor. Patient 2 was seen standing by the door of Room A. Patient 1 reported to nursing staff that someone punched him (Patient 1). Patient 2 reported to nursing staff that he (Patient 2) hit Patient 1. Patient 1 was sent to a general acute care hospital after the incident and received a computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) maxillofacial (the area of the head, neck, face, and jaws) scan. On 4/9/2025, the CT scan indicated Patient 1 sustained bilateral (both) Le Fort I (Le Fort I fracture is a type of facial fracture that occurs horizontally through the maxilla [upper jaw], above the roots of the teeth), right possible Le Fort II fractures (a pyramidal shaped fracture along the nasal bridge and causes separation of the midface from the skull base), and bilateral maxillary sinus fractures (a break in the bones that make up the maxillary sinus [the air-filled cavities in the cheek bones]) of the anterior (front) and posterolateral (at the back and to the side) walls. During an interview on 6/12/2025 at 9:50 a.m. with the Nurse Manager (NM 1) for North and South ICU, NM 1 stated staff should remove the roommates as best as they could because there was potential the roommates could get triggered, agitated and get hurt.

On 6/13/2025 at 4:43 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), Associate Administrator of Operations (AAO), Chief Nursing Officer (CNO), Director of Quality Improvement and Risk Management (DQ), Program Director (DIR 1) of DDMI, Director of Social Services (DIR 2), Nurse Manager (NM 1) for North and South ICU, Nurse Manger (NM 2) for Central and Infection Control Practitioner, Nurse Manager (NM 3) for East ICU and Youth, and Director of Human Resources (HRD). The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that for immediate action taken by the facility, starting 6/12/2025, in the event of an incident of patient aggression, clinical staff would separate patients immediately and the aggressor(s) was to be placed in a separate area(s) away from other patients to maintain safety of all patients from direct harm by the aggressor(s) and also from being triggered to act out themselves. Clinical staff would debrief any patients who could be triggered by the incident and report any patients that were triggered and who might need further assessment/interventions to the Registered Nurse (RN) as soon as feasible after the incident when the aggressor(s) had been removed from the area. The RN would assess the patients involved in the incident as well as patients triggered by the incidents for the need for further interventions and take appropriate action as needed as soon as feasible after the incident when the patients were re-directable. The RN would document the assessment on the "Assault/ Violence Risk (Broset Violence Checklist [a 6-item tool used to predict the risk of imminent violence within 24 hours in individuals] Assessment) on the daily nursing flowchart. Patient might only be returned to the milieu (a person's social environment) once it had been determined to be safe to do so.

Education began on 6/12/2025 with all clinical staff including nursing, social services, activity therapy and behavioral team that were on duty on 6/12/2025 PM shift (3 p.m. to 11 p.m.). This education was also repeated before the shift started for the NOC shift (11 p.m. to 7 a.m.) and would continue to be repeated on all shifts at the beginning of each shift until all scheduled staff had been educated. Any staff that were not scheduled, on vacation or on a leave, would be educated upon their return. The education included an educational memorandum titled "Protecting Patients After Patient Aggression/Altercation." Staff were required to sign an acknowledgement of receipt they received the memo and understood its content.

The IJ removal plan also included monitoring activities to ensure there was a dedicated staff member assigned to monitor the hallway to ensure patient safety. The House Supervisor/Nurse Manager during the shift would complete the monitoring tool titled "Post Patient to Patient Altercation Monitoring Tool" to ensure its compliance after each incident occurred.

Findings:

During a review of Patient 1's "Face Sheet (front page of the chart that contains a summary of basic information about the patient)," dated 3/31/2025, the Face Sheet indicated Patient 1 was admitted to the facility on 3/31/2025 at 10:30 a.m. under a 5150 legal hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of himself]).

During a review of Patient 1's "Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold paperwork)," dated 3/30/2025, the 5150 hold paperwork indicated Patient 1 was detained for being gravely disabled due to auditory hallucinations (hearing sounds, noises, or voices that are not there) and abnormal behavior.

During a review of Patient 2's Face Sheet, dated 4/8/2025, the Face Sheet indicated Patient 2 was admitted to the facility on 4/8/2025 at 10:08 p.m. under a 5150 legal hold.

During a review of Patient 2's 5150 hold paperwork, dated 4/8/2025, the 5150 hold paperwork indicated Patient 2 was detained for being a danger to others when he (Patient 2) was found "challenging people to a fight without provocation" in the community.

During a review of Patient 3's "Face Sheet," dated 3/28/2025, the Face Sheet indicated Patient 3 was admitted to the facility on 3/28/2025 at 12:55 p.m. voluntarily (of his own free will).

During a review of Patient 3's "Psychiatric (treatment or care for a mental health disorder or illness) and Mental Status Examination (PMSE, a formal and complete assessment of the patient and the problem related to mental health)," dated 3/29/2025 at 10:23 a.m., the PMSE indicated Patient 3 sought voluntary admission due to suicidal thoughts (thinking about killing himself).

During a review of Patient 4's "Face Sheet," dated 4/8/2025, the Face Sheet indicated Patient 4 was admitted to the facility on 4/8/2025 at 10:50 a.m. under a 5150 legal hold.

During a review of Patient 4's 5150 hold paperwork, dated 4/8/2025, the 5150 hold paperwork indicated Patient 4 was detained for being gravely disabled due to abnormal behavior.

During a review of Patient 1's "Observation Record," dated 4/9/2025, the Record indicated Patient 1 was awake and in his room from 2:15 a.m. to 4:00 a.m.

During a review of Patient 2's "Observation Record," dated 4/9/2025, the Record indicated Patient 2 was awake and in his room from 2:30 a.m. to 4:00 a.m.

During an interview with the Director of Quality and Risk Management (DQ) on 6/9/2025 at 1:51 p.m., the DQ stated that on 4/9/2025 at around 4:00 a.m., Patient 1 came out of his (Patient 1) room with his nose bleeding and stated that somebody punched him. The DQ further stated that the only other person in the room was his roommate, Patient 2, but at the time, he (Patient 2) denied knowing what happened.

During an interview with Nurse Manager (NM) 1 on 6/11/2025 at 10:16 a.m., NM 1 confirmed that Patients 1, 2, and 3 were roomed in together in the same room (Room A). NM 1 further stated that on 4/9/2025 after midnight, there was a "fight" between Patients 3 and 4 in the hallway; during the fight, another altercation between Patient 1 and Patient 2 occurred in Room A, unwitnessed by staff.

During a concurrent interview and video surveillance review with Nurse Manager (NM) 1 on 6/12/2025 at 9:34 a.m., two video clips of security footage from 4/9/2025, were reviewed. NM 1 stated these videos occurred at approximately 4:00 a.m. on 4/9/2025 as there were no time stamps on the footage. The following events were observed from the first clip:

1. At the beginning of the video clip, Patient 4 was standing in the hallway.
2. Patient 3 emerged from his room. Staff stepped in between Patients 3 and 4. One minute and 12 seconds into the video Patient 3 swung his left arm at Patient 4. Additional staff responded to the incident.
3. One minute and 30 seconds in, staff brought Patient 3 back to Room A (where Patients 1 and 2 were staying). Four staff were observed entering Room A with Patient 3.
4. Two minutes and 49 seconds in, staff removed Patient 3 from Room A.

During the same interview on 6/12/2025 at 9:34 a.m. with Nurse Manager (NM) 1, NM 1 stated Patient 3 was in his room, with staff present, for one minute and 19 seconds, based on the time elapsed in the video. NM 1 further stated that staff removed Patient 3 from his room and brought him to the seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) room to administer emergency medications (medications given to manage severe mental health symptoms such as agitation).

During the same video surveillance review on 6/12/2025 at 9:34 a.m., the following events were reviewed from the second clip:
1. Two minutes and 19 seconds into the video, staff brought Patient 3 out of Room A.
2. Two minutes and 44 seconds in, Mental Health Worker (MHW) 2 closed the door to Room A.
3. Three minutes and 40 seconds in, House Supervisor (HS) 1, who was standing in the hallway, appeared to hear something coming from Room A and opened the door.
4.Three minutes and 44 seconds in, Patient 1 emerged from Room A dripping blood on the floor. Staff took him (Patient 1) to the nurses' station. Patient 2 was seen standing in the doorway of Room A.
-NM 1 stated Patients 1 and 2 were left alone in Room A for 56 seconds, based on the time elapsed in the video.

During an interview with Nurse Manager (NM) 1 on 6/12/2025 at 9:50 a.m., NM 1 stated that the facility's staff were responsible for the patients. NM 1 further stated that agitated patients should not be in a room with other patients, and staff should remove the roommates as best as they could because there was potential that the roommates could get triggered, agitated, or get hurt.

During an interview with Nurse Manager (NM) 1 on 6/12/2025 at 10:24 a.m., NM 1 stated Patient 2 was a newly admitted patient and had not yet been seen by a physician. The staff was not familiar with Patient 2 and did not know what would trigger Patient 2 and what Patient 2's behavior would be. NM 1 further stated the staff should have maintained vigilance until the staff got to know Patient 2 more.

During a review of Patient 1's "Progress Notes," dated 4/9/2025 at 4:35 a.m., the Progress Notes indicated, "Around [4:10 a.m.], patient [Patient 1] came out of his room [with] heavy bleeding from both nostrils. [Patient 1 was] confused, unable to provide accurate information regarding what exactly happened, but stated 'I'm sorry, someone punched me'." The Progress Notes further indicated Patient 1 was sent to General Acute Care Hospital (GACH) 1's Emergency Department (a hospital department that provides immediate care for patients with urgent medical conditions) at 4:33 a.m.

During a review of Patient 1's "Progress Notes," dated 4/9/2025 at 1:51 p.m., the Progress Notes indicated Patient 1 was scheduled to be transferred to GACH 2 at 2:00 p.m. for possible oral facial (face and mouth) surgery.

During a review of Patient 2's "Progress Notes," dated 4/9/2025 at 4:47 a.m., the Progress Notes indicated, "[Patient 1] ran out of his room with his nose bleeding. [Patient 2] stated he (Patient 2) did not know who punched him."

During a review of Patient 2's "Progress Notes," dated 4/9/2025 at 3:48 p.m., the Progress Notes indicated, "[Patient 2] states, ['I hit the other guy earlier.']"

During a review of Patient 1's "CT (computed tomography, a procedure that uses X-ray techniques to create detailed images of the body) Maxillofacial (upper jaw and face) Scan" report from GACH 2, dated 4/9/2025 at 8:26 p.m., the report indicated Patient 1 sustained bilateral (both) Le Fort I (a type of facial fracture that occurs horizontally through the maxilla [upper jaw], above the roots of the teeth), right possible Le Fort II fractures (a pyramidal shaped fracture along the nasal bridge and causes separation of the midface from the skull base), and bilateral maxillary sinus fractures (a break in the bones that make up the maxillary sinus [the air-filled cavities in the cheek bones]) of the anterior (front) and posterolateral (at the back and to the side) walls.

During a review of Patient 1's "ENT (a physician that specializes in medical conditions of the ear, nose, throat, and neck) Consultation Note," from GACH 2, dated 4/10/2025 at 4:04 a.m., the Note indicated the ENT physician recommended conservative non-operative management (no surgery required) and cleared Patient 1 to return to the facility (where Patient 1 got punched by Patient 2).

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold Policy," last reviewed 10/2023, indicated, "The clinical staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preferences from the initial assessment prior to [seclusion/restraint], including ... C. Separating patient from group or community ... E. Offering the use of the quiet room to decrease stimuli and regain control."

During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention, Screening, Identification, Training, Protection, Investigation, and Reporting," last reviewed 10/2023, indicated, "It is the policy of College Hospital to protect our patients from all types of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients, or visitors ... A critical part of protecting patients from abuse is preventing abuse from occurring in the first place."

Based on observation, interview and record review the facility failed to ensure that one of 39 sampled patient's (Patient 27), electronic medical record (EMR, a digital collection of a patient's medical information, including their health history, diagnoses, medications, allergies, immunizations, and treatment plans), was protected, in accordance with the facility's policy regarding confidentiality, when a nurse did not log out from Patient 27's digital chart and left for lunch, thereby exposing Patient 27's medical record to unauthorized personnel.

This deficient practice had the potential to violate Patient 27's right (Patient Rights- the fundamental entitlements and protections that individuals have when receiving medical care) to confidentiality and privacy, increasing the risk of unauthorized access to sensitive medical information, which could lead to privacy violations, identity theft, and misuse of personal health data.

Findings:

During an observation on 6/10/2025 at 11:27 a.m. in the medication room on 5 South (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis] patients), with two nurse managers (NM 1 and NM 3), a computer (nursing workstation) was observed to be located on top of the medication room cart (cart# 11) inside the locked medication room. Personal information of Patient 27 was visible on the screen, displaying the digital record of the medication administration record (MAR), including details of the last documented medications administered. NM 3 proceeded to log out Patient 27's digital record and stated that this was confidential information, and nurses should log out of the patient's chart to protect patient's confidential medical information from unauthorized use. NM 1 stated that a nurse who was logged into Patient 27's electronic medical record (EMR, a digital collection of a patient's medical information, including their health history, diagnoses, medications, allergies, immunizations, and treatment plans) was on lunch at the time of the observation.

During an interview on 6/10/2027 at 11:28 a.m. with nurse manager (NM) 3, NM 3 said that all licensed personnel also had the key to access the medication room. NM 3 also said that EVS (Environmental Services personnel, responsible for cleanliness and sanitation), had access to the medication room at well, and may enter it at any time.

During a review of Patient 27's Psychiatric (treatment or care for a mental health disorder or illness) and Mental Status Examination," dated 5/27/2025 (an annual psychiatric mental examination for 5/26/2025), was reviewed. The Psychiatric and Mental Status Examination report indicated Patient 27 was admitted on 1/17/2024 on a 5150 hold (a legal procedure where a person can be involuntarily detained for up to 72 hours in a psychiatric facility for evaluation and stabilization if they are deemed to be a danger to themselves or others, or gravely disabled due to a mental health disorder) because of running into traffic and noncompliance with medications.

During a review of the facility's policy and procedure (P&P) titled, "Confidentiality," dated 10/2023, the P&P indicated the following, "All nursing staff shall keep all patient information private. Neither written nor verbal information may be shared with staff not involved in the patient's treatment nor any other person."

Based on interview and record review, the facility failed to ensure physical hold (a manual restraint or manual hold used to restrict a patient's movement for safety reasons, performed according to established techniques and protocols) restraint, was properly implemented, in accordance with the established correct techniques for staff, when performing physical holds on two of 39 sampled patients (Patient 19 and Patient 24) when:

1. A mental health worker (MHW) 1 leaned his (MHW 1's) right elbow onto Patient 19's upper back during a physical hold on 4/22/2024. This deficient practice had the potential to result in hurting Patient 19 and affecting Patient 19's breathing.

2. A mental health worker (MHW 1) hyperextended (occurs when the elbow joint bends backward beyond its normal range of motion) Patient 24's left arm during a physical hold on 3/19/2024 in a seclusion room (a room or area where a person is involuntarily confined, meaning they are physically prevented from leaving), when Patient 24 was held against the wall, with two mental health workers on each side. This deficient practice had the potential to compromise Patient 24's safety by increasing Patient 24's risk of injury, such as nerve damage or musculoskeletal harm such as dislocation of the shoulder.

Findings:

1. During a review of Patient 19's "Annual Psychiatric Assessment (a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 5/9/2024, the "Annual Psychiatric Assessment" indicated, Patient 19 was admitted to the facility's adult locked Developmental Delay and Mental Illness (DDMI, inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness) with bipolar (a mental illness that causes unusual shifts in mood, energy, and concentration) type schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations [a false perception of objects or events involving your senses: sight, sound, smell, touch and taste] and/or delusions [a fixed, false belief that is not amenable to change even when presented with contradictory evidence]) and mild intellectual disability (a disability that affects the acquisition of knowledge and skills).

During a concurrent interview and record review on 6/11/2025 at 11:47 a.m. with Program Director (DIR 1) of DDMI, a facility's video clip of security footage, with no audio, timestamp dated on 4/22/2024, was reviewed. The video clip showed the following:
-At 4:51 p.m.: Patient 19 was walking around and banging the wall in the seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) room;
-At 5:15 p.m.: a clinical staff came to talk to Patient 19;
-At 5:20 p.m.: Patient 19 continued pacing and banging the wall in the seclusion room;
-At 5:21 p.m.: multiple clinical staff came into the seclusion room. A Mental Health Worker (MHW) 1 brought Patient 19 to face the wall and leaned his (MHW 1's) right elbow onto Patient 19's upper back while another clinical staff was holding Patient 19's left arm. Other clinical staff were preparing restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) devices on the restraint bed for Patient 19.

During the same interview on 6/11/2025 at 11:47 a.m. with Program Director (DIR 1) of DDMI, DIR 1 stated the following: MHW 1 performed physical hold (type of physical restraint, a manual or physical method of holding the patient against patient's will that restricts freedom of movement or normal access to one's body) on Patient 19 incorrectly. MHW 1 was leaning too much with his (MHW 1's) elbow onto Patient 19. There was potential that Patient 19 could get hurt by hitting the wall. DIR 1 also stated MHW 1 was terminated.

During an interview on 6/12/2025 at 10:36 a.m. with Nurse Manager (NM) 1, NM 1 stated leaning elbow onto patient was incorrect NCI (Nonviolent Crisis Intervention, behavior management system designed to help to de-escalate [reduce the intensity of a conflict or potentially violent situation] and manage disruptive or out-of-control individuals in a safe and non-harmful way) technique. It could restrict patient's breathing with excessive force and cause patient harm. It was important for clinical staff to use correct NCI trained technique to safely handle the patient through physical intervention.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold," dated 10/2023, the P&P indicated, "Seclusion and restraints (S/R) interventions are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others ... S/R procedures are considered to be unusual, high-risk events that warrant timely assessment and continuous monitoring ... The leadership team has developed S/R training and competencies that are required for all clinical staff prior to patient intervention ... the facility's approved method of non-violent crisis intervention (NCI) are additional competency requirements. The use of non-violent crisis prevention techniques to ensure patient and staff safety are consistent with established standards ... Procedure ... 7. The Registered Nurse (RN), in collaboration with unit staff, evaluates the patient's behavior and implements appropriate NCI techniques to maintain patient and staff safety for escort to seclusion room, placement on transport gurney, and/or restraint bed. 8. If physical restraint is indicated, a minimum of two (2) but preferably four (4) NCI trained staff must participate in the physical hold application."

During a review of the educational material developed by the Crisis Prevention Institution (CPI, a global organization that provides evidence-based training focused on de-escalation and crisis intervention) titled, "Non-Violent Crisis Intervention Training," dated 2023, the educational material indicated, "Safety Interventions - Holding Skills ... Holding: A restrictive safety intervention necessary to restrict a person's range of movement to prevent the infliction of harm to self or others ... keep upright. Avoid leaning or bending the person forward."

2. During a review of Patient 24's "Annual Psychiatric Assessment (APA, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 1/22/2024, the APA indicated that Patient 24 was a DDMI patient (DDMI-Developmental Disability and Mental Illness -dual diagnosis), who was admitted to the facility on 1/22/2024 due to being danger to self (threatening to kill self) and others, and had history of autism (a neurodevelopmental condition that affects how people interact with the world, particularly in social communication and interaction, and in the presence of restricted and repetitive behaviors, interests, or activities), ADHD (Attention-Deficit/Hyperactivity Disorder, is a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and impulsivity), anxiety (a common emotion characterized by feelings of fear, worry, unease, and apprehension) and ODD (Oppositional Defiant Disorder, a pattern of defiant, angry, and irritable behavior, including arguing, refusing to comply, and intentionally annoying others).

During a concurrent interview and review on 6/12/2025 at 12:37 p.m. with the director of DDMI (Development Disability & Mental Illness -Dual Diagnosis) program (Dir 1), Patient 24's restraint and seclusion (S&R, interventions used in the treatment and management of disruptive and violent behaviors in psychiatry), video footage (no audio), timestamp dated 3/19/2024, was reviewed. The video footage indicated the following:

-At 5:15 p.m., Patient 24 was held against the wall, restrained by two mental health workers (MHW 1 and MHW 2). MHW 1 was positioned on the left side of Patient 24, holding Patient 24's left arm, hyper-extending the arm backwards and slightly upward (meaning the arm was pulled or extended beyond its normal range of motion). Patient 24 was pinned against the wall in a physical hold, for about a minute, while staff prepared the 5-point physical restraints (refer to a type of physical restraint that uses a combination of restraints on the body to limit movement., involving restraints on all four limbs (wrists and ankles) and an additional restraint around the torso, pelvis, or thighs) to secure the patient on the bed).

-At 5:17 p.m. Patient 24 was restrained in 5-point restraints

During the same interview on 6/12/2025 at 12:37 p.m. with the director of DDMI (Development Disability & Mental Illness -Dual Diagnosis) program (Dir 1), Dir 1 said that hyperextension of the arm was an incorrect level of restriction applied by MHW 1 when applying a physical hold. Dir 1 also said that MHW 1 was terminated in 2024 but could not recall the specific reason for the termination. Dir 1 also said that MHW 1 could have easily dislocated Patient 24's arm and verified that this technique was not in accordance with the NCI (The Crisis Prevention Institute's Nonviolent Crisis Intervention [NCI] certification program which is designed to provide participants with the knowledge and skills required to respond early and effectively to prevent or defuse a behavioral escalation) training provided by the facility to staff.

During a review of Mental Health Worker (MHW 1) 1's "Behavioral Restraint and Seclusion Assessment of Competency - MHW," dated 10/03/2024, the record indicated that MHW 1 only demonstrated understanding and competence on the application and use of restraint or seclusion safely, including (1) Less restrictive alternative, (2) Physical Holding Techniques, (3) Physical Intervention Techniques, and (4) Application and Removal of Mechanical Restraints, through verbal or written test, there was no validation completed through simulation (the use of realistic models, scenarios, and technologies to replicate real-life medical situations in a controlled environment) and observation. The record also indicated that the employee must adequately demonstrate competency related to the use of seclusion and/or restraint during an actual episode as observed by an assessor (a qualified staff who evaluate the quality and safety use of restrictive practices, physical hold, including physical and mechanical restraints, and seclusion).

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold," dated 10/2023, the P&P indicated that: "A. Physical Restraint/Hold: any manual or physical method of holding the patient against the a patient's will that restricts freedom of movement or normal access to one's body."

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Treatment Plan/Patient and Staff Debriefing/Staff Training and Competency," dated 10/2023, the P&P indicated that: "Staff members who are authorized to apply restraint or seclusion are trained in all (restraint, seclusion, physical hold, de-escalation techniques) techniques, plus the safe use of restraint, including physical holding techniques, take down procedures, and the application and removal of mechanical restraints..."

During a review of the educational material developed by the Crisis Prevention Institution (CPI, a global organization that provides evidence-based training focused on de-escalation and crisis intervention) titled, "Non-Violent Crisis Intervention Training," dated 2023, the educational material indicated the following regarding safety interventions-Holding Skills: "CPI focuses on nonviolent crisis intervention, emphasizing verbal and non-verbal de-escalation techniques to manage potentially dangerous situations. Physical interventions, like those involving arm movements, are only considered as a last resort and should be performed safely with minimal force...utilizing techniques such as the person's arms are against their own body or holding on the insight of the wrist and/or elbows..."

Based on interview and record review, the facility failed to ensure that the use of restraint (devices or methods used to restrict a patient's movement, either physically or through medication) or seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior), was in accordance with a physician's order and the facility's policy regarding seclusion/restraints use, for four of 39 sampled patients (Patients 2, 5,19, 25) when:

1. Patient 2 was placed in seclusion without a physician order for three hours and five minutes. This deficient practice had the potential to put Patient 2 at risk for injury.

2. Patient 5 was placed in a physical hold (type of physical restraint, a manual or physical method of holding the patient against patient's will that restricts freedom of movement or normal access to one's body) without a physician order for approximately five seconds. This deficient practice had the potential to put patient 19 at risk for injury.

3. Patient 19 was physically restrained without a physician order on 4/22/2024. This deficient practice had the potential to put Patient 19 at risk for unnecessary seclusion and/or restraints and at risk for injury.

4. Patient 25 was documented to have been placed in seclusion eight (8) times from 3/12/2024 through 11/20/2024, of those eight episodes, Patient 25 was in seclusion without a physician's order for seclusion and for one out of eight episodes, lacked an order for physical restraints. This deficient practice had the potential to place Patient 25 at risk of harm and unnecessary seclusion or restraints use.

Findings:

1. During a review of Patient 2's Face Sheet (front page of the chart that contains a summary of basic information about the patient), dated 4/8/2025, the Face Sheet indicated Patient 2 was admitted to the facility on 4/8/2025 at 10:08 p.m. under a 5150 legal hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to care for themselves]).

During a review of Patient 2's "Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold paperwork)," dated 4/8/2025, the 5150 hold paperwork indicated Patient 2 was detained for being a danger to others when he (Patient 2) was found "challenging people to a fight without provocation" in the community.

During a review of Patient 2's Progress Notes, dated 4/9/2025 at 4:47 a.m., the Progress Notes indicated, "[Patient 1] ran out of his (Patient 1) room with his nose bleeding. [Patient 2] stated he did not know who punched him (Patient 1) ... [Patient 2] is put into locked seclusion (the involuntary confinement of a patient alone in a locked room, preventing them from leaving, to manage violent or self-destructive behavior) at [4:50 a.m.]"

During a review of Patient 2's "Seclusion and Restraints Assessment Packet (S&R Assessment)," dated 4/9/2025 at 7:50 a.m., the S&R Assessment indicated Patient 2 was placed in seclusion because he "punched his roommate (Patient 1) unwitnessed by staff [and was] irritable, testing limits, minimizing [the] situation, appearing very unpredictable and uncooperative, [and] non-redirectable." The S&R Assessment further indicated Patient 2 was in seclusion for three hours and five minutes, entering at 4:45 a.m. and then released at 7:50 a.m.

During a concurrent interview and record review with Nurse Manager (NM) 1 on 6/12/2025 at 2:41 p.m., Patient 2's medical record, was reviewed. NM 1 confirmed that there was no physician order present in the medical record for Patient 2's seclusion on 4/9/2025 from 4:45 a.m. to 7:50 a.m. and that there should be one present (physician order).

During an interview with Nurse Manager (NM) 1 on 6/13/2025 at 11:10 a.m., NM 1 stated that nurses could initiate seclusion or restraint, but the physician needed to order it as well to ensure that it was the appropriate or necessary intervention.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold Policy," last reviewed 10/2023, the P&P indicated, "The Physician or RN can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the S/R [seclusion/restraint], and document on the Seclusion/Restraint Order as follows: ... B. The physician's orders specify the reason for the restraint and seclusion usage, the type of restraint, and their duration. ... C. In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained RN may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes."

2. During a review of Patient 5's Face Sheet, dated 6/4/2025, the Face Sheet indicated Patient 5 was admitted to the facility on 6/4/2025 at 7:55 p.m. on a 5150 legal hold.

During a review of Patient 5's 5150 hold paperwork, dated 6/4/2025, the paperwork indicated Patient 5 was placed on a 5150 legal hold for being a danger to herself due to erratic and suicidal (thoughts of taking one's own life) behavior.

During a review of Patient 5's "Emergency Use of Medications Assessment Flowsheet," dated 6/6/2025 at 8:40 p.m., the Flowsheet indicated, "At [7:30 p.m.], [Patient 5] had a visit from [Visitor]. [Patient 5] was calm with [Visitor]. At [8:00 p.m.], when [Visitor] was about to leave, [Patient 5] was being defiant and refusing to go back to room, stating 'I'm leaving with [Visitor].' [Patient 5] was educated on how [Patient 5] cannot leave at this moment due to [Patient 5] being on involuntary hold. [Patient 5] refused to understand and locked arms with [Visitor]. 1 to 1 therapeutic communication was used. [Patient 5] was reoriented to reality and to comply with visits and to go back into the room. [Patient 5] refused to let go of [Visitor] and stated, 'I'm going with [Visitor], don't touch me or I will fight.' Code grey (an emergency situation involving a combative or aggressive patient) was called, patient was asked to walk back to the room."

During a concurrent interview and video surveillance review with Nurse Manager (NM) 1 on 6/12/2025 at 1:59 p.m., the security video from 6/6/2025, was reviewed. The video indicated at 8:01 p.m., two staff members were holding Patient 5 in the hallway for approximately five seconds, one holding each arm. NM 1 confirmed this was a physical hold and stated they (the two staff members) were trying to prevent Patient 5 from leaving with the visitor.

During a concurrent interview and record review with Nurse Manager (NM) 1 on 6/13/2025 at 9:28 a.m., Patient 5's medical record, was reviewed. NM 1 confirmed there was no physician order for the physical hold observed in the security video. NM 1 stated that physical holds were a form of restraint, was used to prevent the patient from moving, and that there should have been an order for the physical hold.

During an interview with Nurse Manager (NM) 1 on 6/13/2025 at 11:10 a.m., NM 1 stated that nurses can initiate seclusion or restraint, but the physician needs to order it as well to ensure that it was the appropriate or necessary intervention.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold Policy," last reviewed 10/2023, the P&P indicated, "Restraint: Physical Restraint/Hold: Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body ... The Physician or RN can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the S/R, and document on the Seclusion/Restraint Order as follows: ... B. The physician's orders specify the reason for the restraint and seclusion usage, the type of restraint, and their duration. ... C. In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained RN may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes."

3. During a review of Patient 19's "Annual Psychiatric Assessment (a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 5/9/2024, the "Annual Psychiatric Assessment" indicated, Patient 19 was admitted to the facility's adult locked Developmental Delay and Mental Illness (DDMI, inpatient unit that provides treatment and therapy for people who have developmental delay with mental illness) with bipolar (a mental illness that causes unusual shifts in mood, energy, and concentration) type schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) and mild intellectual disability (a disability that affects the acquisition of knowledge and skills).

During a concurrent interview and record review on 6/11/2025 at 11:47 a.m. with Program Director (DIR 1) of DDMI, a facility's video clip of security footage with no audio, timestamp dated on 4/22/2024, was reviewed. The video clip showed the following:

-At 4:51 p.m.: Patient 19 was walking around and banging the wall in the seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) room;
-At 5:15 p.m.: a clinical staff came to talk to Patient 19;
-At 5:20 p.m.: Patient 19 continued pacing and banging the wall in the seclusion room;
-At 5:21 p.m.: multiple clinical staff came into the seclusion room. A Mental Health Worker (MHW) 1 brought Patient 19 to face the wall and leaned his (MHW 1's) right elbow onto Patient 19's upper back while another clinical staff was holding Patient 19's left arm. Other clinical staff were preparing restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) devices on the restraint bed for Patient 19.

During the same interview on 6/11/2025 at 11:47 a.m. with Program Director (DIR 1) of DDMI, DIR 1 stated the clinical staff performed physical hold on Patient 19 prior to placing Patient 19 on 5-point restraints.

During a concurrent interview and record review on 6/12/2025 at 2:31 p.m. with Nurse Manager (NM) 2, Patient 19's physician order, dated 4/22/2024, was reviewed. The physician order indicated there was a seclusion and a 5-point restraint ordered on 4/22/2024. NM 2 stated there should be a separate physician order for physical hold when staff were putting hands on patient. NM 2 stated there was no physical hold order for the seclusion/restraints episode on 4/22/2024.

During an interview on 6/13/2025 at 10:43 a.m. with Director (DIR 1) of DDMI, DIR 1 stated the following: nursing staff must obtain a physician order when putting patients on seclusion, physical hold and restraint so physician would know what was going on with the patient, the physician could then decide and agree with the interventions and give direction if any interventions was needed. Without a physician order, it would be considered as holding patient illegally without physician's permission.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold Policy," dated 10/2023, the P&P indicated, "Definition ... Restraints: A. Physical Restraint/Hold: Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body ... Procedure ... 4. The physician or Registered Nurse (RN) can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the seclusion/restraints (S/R), and document on the Seclusion/Restraint Order form as follows: A. Time Limits: 1) Adults 18 and older up to four (4) hours; 2) Youth 9 - 17 up to two (2) hours ... B. The physician's orders specify the reason for restraint and seclusion usage, the type of restraint, and their duration. The S/R can be ordered for less than above stated maximum. The length of the S/R is limited by the continued need for the intervention rather than then length of the order ... C. In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained Registered Nurse may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes."

4. During a review of Patient 25's "Psychiatric and Mental Status Examination (PMSE, a comprehensive assessment performed by a psychiatrist to diagnose and treat mental health conditions, while a mental status examination [MSE] is a structured way to observe and document a patient's current psychological state during a clinical encounter)," dated 3/12/2024, the PMSE indicated that Patient 25 was admitted on a 5150 (a temporarily hold for evaluation and crisis intervention- involuntary 72-hour psychiatric hospitalization of an individual who, due to a mental health disorder, is deemed a danger to themselves, a danger to others, or gravely disabled) due to danger to others. The PMSE also indicated that Patient 25 had history of autism (neurodevelopmental condition that affects how individuals interact with the world, particularly in social communication and interaction, and in their patterns of behavior and interests) and explosive disorder (a mental health condition characterized by sudden and frequent episodes of impulsive, aggressive, violent behavior or angry verbal outbursts).

During a review of Patient 25's electronic medical record (EMR, digital version of paper chart), the "Behavioral Restraint/Seclusion Order Assessment," dated 3/12/2024 through 11/12/2024, was reviewed. The records indicated that Patient 25 had eight (8) episodes of restraint and seclusions.

During a concurrent interview and record review on 6/11/2025 at 11:30 a.m. with Nurse Manager (NM 1), Patient 25's electronic medical record (EMR) titled, "Behavioral Restraint/Seclusion Order Assessment," dated 3/12/2024 through 11/12/2024, was reviewed. The record indicated that Patient 25 was placed in seclusion/restraints 8 times since the admission to the facility on 3/12/2024:
-3/15/2024-Patient 25 was placed on physical hold at 5:10 p.m., seclusion at 5:10 p.m., and physical restraints at 5:10 p.m. No order for physical restraints was placed in Patient 25's EMR.

-3/24/2024-Patient 25 was placed on physical hold at 3:45 p.m., seclusion at 3:55 p.m., and restraints at 3:55 p.m. No physician's order for seclusion was placed in Patient 25's EMR

-3/30/2024-Patient 25 was placed on physical hold at 10:15 a.m., seclusion at 10:18 a.m., and restraints at10:18 a.m. No physician's order for seclusion was found to be placed in Patient 25's EMR.

-4/13/2024-Patient 25 was placed on physical hold at 6:15 p.m., seclusion at 11:14 a.m., and restraints at 6:15 p.m. No physician's order for seclusion was documented in Patient 25's EMR.

-4/28/2024-Patient 25 was placed on physical hold at 8:10 a.m., seclusion at 8:20 a.m., and restraints at 8:20 a.m. No physician's order for seclusion was found in Patient 25's EMR.

-5/5/2024-Patient 25 was placed on physical hold at 10:05 a.m., seclusion at 10:10 a.m., and restraints at 10:10 a.m. No physician's order for seclusion was documented in Patient 25's EMR.

-5/12/2024-Patient 25 was placed on physical hold at 2:25 p.m., seclusion 2:45 p.m., and restrained at 2:45 p.m. No order for seclusion was placed in Patient 25's EMR.

-8/4/2024 -Patients 25 was placed on physical hold at 3:05 p.m., seclusion at 3:10 p.m., and restraints at 3:10 p.m. No order for seclusion was found to be placed in Patient 25's EMR
-Seven out of eight (8) reviewed episodes of Patient 25 being in seclusion from 3/12/2024 through 11/12/2024, lacked corresponding physician's orders for seclusion and one out of eight (8) reviewed episodes of Patient 25 being in restraints, lacked an order for physical restraints. NM 1 stated that a separate order for a physical hold, seclusion and restraint was required and should be placed within minutes after placing a patient in physical hold, seclusion or restraints, in accordance with the facility's policy regarding seclusion and restraints use.

During an interview on 6/12/2025 at 3:19 p.m. with Nurse Manager (NM) 1, NM 1 said that all orders for physical restraints/seclusions, or physical holds must be obtained and documented within minutes after placing the patient in seclusion, restraints, or a physical hold. NM 1 also said that there should be no more gaps in documentation when it comes to placing these orders and added that the facility had already implemented extensive education on this requirement, and compliance was continuously monitored through ongoing audits.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold Policy," dated 10/2023, the P&P indicated, "Definition ... Restraints: A. Physical Restraint/Hold: Any manual or physical method of holding the patient against the patient's will that restricts freedom of movement or normal access to one's body ... Procedure ... 4. The physician or Registered Nurse (RN) can initiate the need for restrictive intervention, obtain a written or telephonic order from the physician for the seclusion/restraints (S/R), and document on the Seclusion/Restraint Order form as follows: A. Time Limits: 1) Adults 18 and older up to four (4) hours; 2) Youth 9 - 17 up to two (2) hours ... B. The physician's orders specify the reason for restraint and seclusion usage, the type of restraint, and their duration. The S/R can be ordered for less than above stated maximum. The length of the S/R is limited by the continued need for the intervention rather than then length of the order ... C. In an emergency, the Nursing Supervisor, Shift Supervisor, or a trained Registered Nurse may initiate a S/R as a protective measure provided that a physician order is obtained immediately within minutes."

Based on interview and record review, the facility failed to ensure for five of five (5) sampled staff (Mental Health Worker 1, Mental Health Worker 6, Mental Health Worker 7, Charge Nurse 2, and Charge Nurse 3), a training and demonstration of competency on restraint (methods or devices used to restrict a person's movement or ability to move freely), seclusion (the involuntary confinement of a patient alone in a room from which they are physically prevented from leaving) and physical hold (a situation where a patient's movement is involuntarily restricted by staff, often to prevent harm to themselves or others), were successfully completed and documented, in accordance with the facility's "Behavioral Restraint and Seclusion Assessment of Competency," document.

This deficient practice had the potential to negatively affect patients receiving care. Specifically, incomplete training and documentation of completion could result in staff's lack of a clear understanding of the appropriate circumstances and procedures for utilizing restraints, seclusion, and physical holds, which can lead to inappropriate or unsafe use, increasing the risk of physical and psychological harm to patients including risk of injury to staff.

Findings:

During a review of Mental Health Worker 1's (MHW 1) "Behavioral Restraint and Seclusion Assessment of Competency - MHW," dated 03/07/2024, the record indicated that MHW 1 only demonstrated understanding and competence on the application and use of restraint (methods or devices used to restrict a person's movement or ability to move freely) or seclusion (the involuntary confinement of a patient alone in a room from which they are physically prevented from leaving) safely, including (1) Less restrictive alternative, (2) Physical Holding Techniques, (3) Physical Intervention Techniques, and (4) Application and Removal of Mechanical Restraints through simulation (a retraining exercise that mimics real-life scenarios in a controlled environment to demonstrate proper techniques and responses), there was no validation completed through verbal or written test and observation.

The record also indicated that it was required that the employee must adequately demonstrate competency related to the use of seclusion and/or restraint during an actual episode as observed by an assessor (a qualified staff who evaluate the quality and safety use of restrictive practices, physical hold, including physical and mechanical restraints, and seclusion). It also indicated that there was no other competency plan required for MHW 1. This was validated by Nurse Manager (NM) 1 on 6/13/2025.

During a review of Mental Health Worker 6's (MHW 6) "Behavioral Restraint and Seclusion Assessment of Competency - MHW," dated 03/12/2025, the record indicated that MHW 6 only demonstrated understanding and competence on the application and use of restraint or seclusion safely, including (1) Less restrictive alternative, (2) Physical Holding Techniques, (3) Physical Intervention Techniques, and (4) Application and Removal of Mechanical Restraints through verbal or written test, there was no validation completed through simulation and observation. The record also indicated that there was no other competency plan required for MHW 6. This was validated by Nurse Manager (NM) 1 on 6/13/2025.
During a review of Mental Health Worker 7's (MHW 7) "Behavioral Restraint and Seclusion Assessment of Competency - MHW," dated 10/03/2024, the record indicated that MHW 7 only demonstrated understanding and competence on the application and use of restraint or seclusion safely, including (1) Less restrictive alternative, (2) Physical Holding Techniques, (3) Physical Intervention Techniques, and (4) Application and Removal of Mechanical Restraints through verbal or written test, there was no validation completed through simulation and observation. The record also indicated that the employee must adequately demonstrate competency related to the use of seclusion and/or restraint during an actual episode as observed by an assessor (a qualified staff who evaluate the quality and safety use of restrictive practices, physical hold, including physical and mechanical restraints, and seclusion). It also indicated that there was no other competency plan required for MHW 7. This was validated by Nurse Manager (NM) 1 on 6/13/2025.

During a review of Charge Nurse 2's (CN 2) "Behavioral Restraint and Seclusion Assessment of Competency - RN," dated 05/20/2025, the record indicated that CN 2 only demonstrated understanding and competence on the application and use of restraint or seclusion safely, including (1) Less restrictive alternative, (2) Physical Holding Techniques, (3) Physical Intervention Techniques, and (4) Application and Removal of Mechanical Restraints through simulation, there was no validation completed thru verbal or written test and observation. It also indicated that there was no other competency plan required for CN 2. This was validated by Nurse Manager (NM) 1 on 6/13/2025.
During a review of Charge Nurse 3's (CN 3) "Behavioral Restraint and Seclusion Assessment of Competency - RN," dated 06/13/2024, the record indicated that CN 3 only demonstrated understanding and competence on the application and use of restraint or seclusion safely, including (1) Less restrictive alternative, (2) Physical Holding Techniques, (3) Physical Intervention Techniques, and (4) Application and Removal of Mechanical Restraints through verbal or written test and simulation, there was no validation completed thru observation. The record also indicated that the employee must adequately demonstrate competency related to the use of seclusion and/ or restraint during an actual episode as observed by an assessor (a qualified staff who evaluate the quality and safety use of restrictive practices, physical hold, including physical and mechanical restraints, and seclusion). It also indicated that there was no other competency plan required for CN 3. This was validated by NM 1 on 6/13/2025.
During an interview on 06/13/2025 at 2:54 p.m. with Nurse Manager (NM) 1, NM1 stated that it was an expectation that when training and validating staff competency on restraint, seclusion and physical hold, staff must demonstrate competency via verbalization and/or written test, simulation and observation. The employee must also demonstrate the use of seclusion and restraint during an actual episode as observed by an assessor.

During a concurrent interview and record review on 06/13/2025 at 3:33 p.m. with the Chief Nursing Officer (CNO), Mental Health Worker 1's (MHW 1) "Behavioral Restraint and Seclusion Assessment of Competency - MHW,"- dated 03/07/2024, Mental Health Worker 6's (MHW 6) "Behavioral Restraint and Seclusion Assessment of Competency - MHW,"- dated 03/12/2025, Mental Health Worker 7's (MHW 7) "Behavioral Restraint and Seclusion Assessment of Competency - MHW,"- dated 10/03/2024, Charge Nurse 2's (CN 2) "Behavioral Restraint and Seclusion Assessment of Competency - RN,"- dated 05/20/2025 and Charge Nurse 3's (CN 3) "Behavioral Restraint and Seclusion Assessment of Competency - RN,"- dated 06/13/2024, were reviewed. The Chief Nursing Officer (CNO) concurred that five of five (5) sampled staff's (Mental Health Worker 1, Mental Health Worker 6, Mental Health Worker 7, Charge Nurse 2, and Charge Nurse 3), training documentation and demonstration of competency on restraint, seclusion and physical hold were incomplete. CNO stated that there was a recent change in the "Behavioral Restraint and Seclusion Assessment of Competency" form, and there may have been confusion as to how it was supposed to be completed and documented.

During a review of the facility's "Behavioral Restraint and Seclusion Assessment of Competency," document, undated, the document indicated that the assessor will initial and date the competency assessment form only after the following indicators were met by staff:
-The employee has adequately (via verbalization, simulation, and/or written test) demonstrated the use of seclusion and/or restraint for his/her job classification
-The employee has adequately demonstrated competency related to the use of seclusion and/or restraint during actual episode as observed by Assessor.

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

1. Ensure that a Registered Nurse (RN) provided supervision over the physical hold (a manual method used to restrict a person's movement or hold them immobile, often to prevent harm to themselves or others), for two of 39 sampled patients (Patient 19 and Patient 24), ensuring that correct physical restraining techniques were utilized, in accordance with the facility's policy regarding seclusion (the involuntary confinement of a patient alone in a room from which they are physically prevented from leaving) and restraints (methods or devices used to restrict a person's movement or ability to move freely) use, when:

1.a. Mental Health Worker (MHW 1) hyperextended Patient 24's left arm during a physical hold on 3/19/2024 in a seclusion room (a room or area where a person is involuntarily confined, meaning they are physically prevented from leaving), when Patient 24 was pinned against the wall, with two mental health workers on each side. This deficient practice had the potential to compromise Patient 24's safety by increasing Patient 24's risk of injury, such as nerve damage or musculoskeletal harm such as dislocation of the shoulder.

1.b. Mental Health Worker (MHW 1) leaned the right elbow against the back of Patient 19 during a physical hold on 4/22/2024, while clinical staff prepared the restraints for Patient 19 to be restrained shortly after. This deficient practice had the potential to result in causing Patient 19's difficulty breathing and injury.

2. Ensure one of 39 sampled patient's (Patient 13) wound assessment (a systematic evaluation of a wound to determine its characteristics, stage, and healing progress), was completed and documented, in accordance with the facility's policy regarding assessment and reassessment.

This deficient practice had the potential to result in an inadequate assessment of the wound, which may lead to delayed healing and increased risk of infection, and/or delayed recognition of wound complications, potentially resulting in inappropriate or insufficient treatment to Patient 13's wounds.

Findings:

1.a. During a review of Patient 24's "Annual Psychiatric Assessment (APA, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 1/22/2024, the APA indicated that Patient 24 was a DDMI patient (DDMI-Developmental Disability and Mental Illness dual diagnosis), who was admitted to the facility on 1/22/2024 due to being danger to self (threatening to kill self) and others, and had history of autism (a neurodevelopmental condition that affects how people interact with the world, particularly in social communication and interaction, and in the presence of restricted and repetitive behaviors, interests, or activities), ADHD (Attention-Deficit/Hyperactivity Disorder, is a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and impulsivity),anxiety (a common emotion characterized by feelings of fear, worry, unease, and apprehension) and ODD (Oppositional Defiant Disorder, a pattern of defiant, angry, and irritable behavior, including arguing, refusing to comply, and intentionally annoying others).

During a concurrent interview and record review on 6/12/2025 at 12:37 p.m. with the director of DDMI (Development Disability & Mental Illness -Dual Diagnosis] program (Dir 1), Patient 24's restraint and seclusion (S&R, interventions used in the treatment and management of disruptive and violent behaviors in psychiatry) video footage (no audio), timestamp dated 3/19/2024, was reviewed. The video footage indicated the following:

-At 5:15 p.m., Patient 24 was held against the wall, restrained by two mental health workers (MHW 1 and MHW 2). MHW 1 was positioned on the left side of Patient 24, holding Patient 24's left arm, hyper-extending the arm backwards and slightly upward (meaning the arm was pulled or extended beyond its normal range of motion). Patient 24 was pinned against the wall in a physical hold, for about a minute, while staff prepared the 5-point physical restraints (refer to a type of physical restraint that uses a combination of restraints on the body to limit movement., involving restraints on all four limbs (wrists and ankles) and an additional restraint around the torso, pelvis, or thighs) to secure the patient (Patient 24) on the bed).

-At 5:16 p.m., shift supervisor (CN 1) approached the two MHWs (MHW 1 and MHW 2) while the MHW's had Patient 24 pinned against the wall, and MHW 1 hyperextended Patient 24's arm (pulling or bending the arm beyond its normal range of motion). CN 1 appeared to try to look at Patient 24 and/or speak with the patient [Patient 24] (video footage had no sound) but then stepped aside to assist with preparing to apply the physical restraints on the bed.

-At 5:17 p.m., Patient 24 was restrained using 5-point restraints.

During the same interview on 6/12/2025 at 12:37 p.m. with the Director of DDMI (Development Disability & Mental Illness -Dual Diagnosis] program (Dir 1), Dir 1 said that hyperextension of the arm was an incorrect level of restriction applied by MHW 1 when applying a physical hold. Dir 1 also said that MHW 1 was terminated in 2024 but could not recall the specific reason for the termination. Dir 1 also said that MHW 1 could have easily dislocated Patient 24's arm and verified that this technique was not in accordance with the NCI (The Crisis Prevention Institute's Nonviolent Crisis Intervention [NCI] certification program which is designed to provide participants with the knowledge and skills required to respond early and effectively to prevent or defuse a behavioral escalation) training provided by the facility to staff.

During an interview on 6/13/2025 at 2:40 p.m. with the Director of DDMI (Development Disability & Mental Illness -Dual Diagnosis] program (Dir 1), the Dir 2 said the following: "There is no staff specifically assigned to monitor or supervise staff (mental Health workers, licensed vocational nurses, and registered nurses) performing a physical hold or applying restraints. This is not feasible, as all staff members are trained on the unit to apply restraints and perform physical hold safely. The expectation is that staff are doing their job correctly and in accordance with established protocols, ensuring patient safety and proper restraint use without the need for constant supervision."

During an interview on 6/13/2025 at 3:01 p.m. with the Chief Nursing Officer (CNO), the CNO stated that in the past, she (the CNO) reviewed the video footage (3/19/2024) which showed Patient 24 in a physical hold and then restrained, and she (the CNO) confirmed that no corrective actions were identified following the review of the footage. The CNO further mentioned that the footage was only reviewed to assess the need for restraint application and to observe the technique used during the physical hold (specifically, hyperextension of the left arm while pinned to the wall by the Mental Health Worker [MHW 1]). The CNO said that the review of the video footage did not include an assessment of the restraint technique itself to identify or recommend corrective actions.

During a review of the educational material developed and provided to staff by the facility titled, "Restraints and Seclusion," (date not specified), the educational material indicated the following: "A registered nurse is responsible for supervising the Licensed Vocational Nurses (LVNs) and Mental Health Workers (MHW), for the safe use of restraints, which includes proper physical holding techniques..."

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold," dated 10/2023, the P&P indicated that: "A. Physical Restraint/Hold: any manual or physical method of holding the patient against a patient's will that restricts freedom of movement or normal access to one's body."

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Treatment Plan/ Patient and Staff Debriefing/ Staff Training and Competency," dated 10/2023, the P&P indicated, " c) Evaluate if appropriate techniques were used to de-escalate the patient and/or contain the incident; d) Identify alternative actions to prevent or minimize future need for S/R."

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold," dated 10/2023, the P&P indicated, "Seclusion and restraints (S/R) interventions are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others ... S/R procedures are considered to be unusual, high-risk events that warrant timely assessment and continuous monitoring ... The leadership team has developed S/R training and competencies that are required for all clinical staff prior to patient intervention ... the facility's approved method of non-violent crisis intervention (NCI) are additional competency requirements. The use of non-violent crisis prevention techniques to ensure patient and staff safety are consistent with established standards ... Procedure ... 7. The Registered Nurse (RN), in collaboration with unit staff, evaluates the patient's behavior and implements appropriate NCI techniques to maintain patient and staff safety for escort to seclusion room, placement on transport gurney, and/or restraint bed.

During a review of the educational material developed by the Crisis Prevention Institution (CPI, a global organization that provides evidence-based training focused on de-escalation and crisis intervention) titled, "Non-Violent Crisis Intervention Training," dated 2023, the educational material indicated, "Safety Interventions - Holding Skills ... Holding: A restrictive safety intervention necessary to restrict a person's range of movement to prevent the infliction of harm to self or others ... keep upright. Avoid leaning or bending the person forward."

1.b. During a review of Patient 19's "Annual Psychiatric Assessment (a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 5/9/2024, the "Annual Psychiatric Assessment" indicated, Patient 19 was admitted to the facility's adult locked Developmental Delay and Mental Illness (DDMI, inpatient unit that provide treatment and therapy for people who have developmental delay with mental illness) unit with bipolar (a mental illness that causes unusual shifts in mood, energy, and concentration) type schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) and mild intellectual disability.

During a concurrent interview and record review on 6/11/2025 at 11:47 a.m. with the Program Director (DIR 1) of DDMI, the facility's video clip of security footage, with no audio, timestamp dated on 4/22/2024, was reviewed. The video clip showed the following:

-At 4:51 p.m.: Patient 19 was walking around and banging the wall in the seclusion (any involuntary confinement of a patient alone in a room or area where he or she is physically prevented from leaving) room;
-At 5:15 p.m.: a clinical staff came to talk to Patient 19;
-At 5:20 p.m.: Patient 19 continued pacing and banging the wall in the seclusion room;
-At 5:21 p.m.: multiple clinical staff came into the seclusion room. A Mental Health Worker (MHW) 1 brought Patient 19 to face the wall and leaned his (MHW 1's) right elbow onto Patient 19's upper back while another clinical staff was holding Patient 19's left arm. Other clinical staff were preparing restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) devices on the restraint bed for Patient 19.

During the same interview on 6/11/2025 at 11:47 a.m. with the Program Director (DIR 1) of DDMI, DIR 1 stated the following: MHW 1 performed physical hold (type of physical restraint, a manual or physical method of holding the patient against patient's will that restricts freedom of movement or normal access to one's body) on Patient 19 incorrectly. DIR 1 stated MHW 1 was leaning too much with his (MHW 1's) elbow onto Patient 19. There was potential that Patient 19 could get hurt by hitting the wall. DIR 1 also stated there were multiple clinical staff including the Registered Nurse Shift Supervisor (RNS 2) present at that time, but no one checked on MHW 1 and identified MHW 1's incorrect holding technique.

During an interview on 6/12/2025 at 10:36 a.m. with Nurse Manager (NM) 1, NM 1 stated that leaning elbow onto patient was incorrect NCI (Nonviolent Crisis Intervention, behavior management system designed to help to de-escalate and manage disruptive or out-of-control individuals in a safe and non-harmful way) technique. It could restrict patient's breathing with excessive force and cause patient harm. NM 1 also said it was important to use correct NCI trained technique to safely handle the patients through physical intervention.

During a concurrent interview and record review on 6/13/2025 at 11:35 a.m. with DIR 1, Patient 19's "S&R (Seclusion and Restraints) Assessment Packet," dated 4/22/2025, was reviewed. The S&R Assessment Packet" indicated, Patient 19 was placed in a seclusion room at 4:50 p.m. and placed in restraints at 5:20 p.m. Patient 19 was released from seclusion and restraints at 6:20 p.m. The "S&R Assessment Packet" also indicated, a post S&R Staff Conference was conducted by RN Shift Supervisor (RNS) 2 at 5:20 p.m. with clinical staff including but not limited to Mental Health Worker (MHW) 1 and under section "Patterns - Are there any questions related to how staff responded to the incident (did staff follow policy & procedure? Are there any concerns relate to how staff responded to the incident?)," RNS 2 marked "yes" next to "were physical restraints applied appropriately?"

During the same interview on 6/13/2025 at 11:35 a.m. with DIR 1, DIR 1 stated the following: the post S&R Staff Conference was conducted by the Registered Nurse after each seclusion and/or restraints episode to identify and address any issue. Any issue identified would be brought to the staff's attention to correct and improve. DIR 1 stated RNS 2 did not identify that MHW 1 performed a physical hold incorrectly.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Treatment Plan/ Patient and Staff Debriefing/ Staff Training and Competency," dated 10/2023, the P&P indicated, "Purpose: debriefing both the patient and the staff has two purposes: 1. It is an attempt to learn if there was a cause or trigger to the episode requiring seclusion or restraint (S/R). This would allow for the modification of the patient's treatment plan with the intent that restraint or seclusion may be avoided for this patient in the future or, if not avoided completely, to identify how it could be handled more effectively. 2. The information is used in performance improvement activities ...Policy: Patients and staff involved in a seclusion and/or restraint episode are provided the opportunity to participate in a debriefing session as soon as possible and appropriate after the seclusion/restraint episodes, but always within 24 hours. Procedure ... 3. Debriefing of Staff: 1) The Shift Supervisor or designee conducts a debriefing of the staff who were immediately involved in the S/R as soon as possible after the incident but not to exceed right (8) hours. 2) The debriefing should, at a minimum: a) identify if any staff obtained injury during the intervention; b) identify precipitating triggers to behaviors which led to the S/R; c) Evaluate if appropriate techniques were used to de-escalate the patient and/or contain the incident; d) Identify alternative actions to prevent or minimize future need for S/R."

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold," dated 10/2023, the P&P indicated, "Seclusion and restraints (S/R) interventions are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others ... S/R procedures are considered to be unusual, high-risk events that warrant timely assessment and continuous monitoring ... The leadership team has developed S/R training and competencies that are required for all clinical staff prior to patient intervention ... the facility's approved method of non-violent crisis intervention (NCI) are additional competency requirements. The use of non-violent crisis prevention techniques to ensure patient and staff safety are consistent with established standards ... Procedure ... 7. The Registered Nurse (RN), in collaboration with unit staff, evaluates the patient's behavior and implements appropriate NCI techniques to maintain patient and staff safety for escort to seclusion room, placement on transport gurney, and/or restraint bed. 8. If physical restraint is indicated, a minimum of two (2) but preferably four (4) NCI trained staff must participate in the physical hold application."

During a review of the educational material developed by the Crisis Prevention Institution (CPI, a global organization that provides evidence-based training focused on de-escalation and crisis intervention) titled, "Non-Violent Crisis Intervention Training," dated 2023, the educational material indicated, "Safety Interventions - Holding Skills ... Holding: A restrictive safety intervention necessary to restrict a person's range of movement to prevent the infliction of harm to self or others ... keep upright. Avoid leaning or bending the person forward."

During a review of the educational material developed and provided to staff by the facility titled, "Restraints and Seclusion" (date not specified), the educational material indicated the following: "A registered nurse is responsible for supervising the Licensed Vocational Nurses (LVNs) and Mental Health Workers (MHW), for the safe use of restraints, which includes proper physical holding techniques..."

2. During a review of Patient's 13's "Medical history and Physical Examination (A formal and complete assessment of the patient and the problem)," dated 04/09/2025, the record indicated that Patient 13 was suicidal (thoughts of taking one's own life), and was placed on a hold (a legal procedure where a person can be involuntarily detained for up to 72 hours in a psychiatric facility for evaluation and stabilization if they are deemed to be a danger to themselves or others, or gravely disabled [unable to care for one's self] due to a mental health disorder) for danger to self.

During further review of Patient 13's "Medical history and Physical Examination," the record indicated that Patient 13 had self-induced laceration (a tear or cut in the skin and/or underlying tissue) on left forearm and bilateral thighs from a kitchen knife due to a recent breakup. Included in Patient 13's record under "Assessment and Plan," it indicated that the self-induced laceration of the left forearm and both thighs would be treated with topical antibiotics.

During a concurrent interview and record review on 06/13/2025 at 9:33 a.m. with Nurse Manager (NM) 3, Patient 13's medical record titled, "Patient Progress Notes," dated 04/09/2025 - 04/14/2025, was reviewed. The Patient Progress Notes for Patient 13 did not indicate that a wound assessment was completed. NM 3 stated that Patient 13 was admitted with cuts from a kitchen knife to her left forearm and bilateral thigh.

During the same interview on 06/13/2025 at 9:33 a.m. with Nurse Manager (NM) 3, NM 3 said that per policy, wound assessment must be completed and documented every shift. However, the progress note did not indicate that a wound assessment was completed every shift. NM 3 further said that wound assessment was important for monitoring progress, effective treatment and prevention of complications.

During a review of the facility's Policy and Procedure (P&P) titled, "Assessment and Reassessment," with last revised date of 10/2023, the P&P indicated that the "purpose of assessment and reassessment is to determine that the appropriate care, treatment, and services are being provided to meet the patient's changing needs; To evaluate the patient's response to these services; To respond to significant changes in the patient's status or condition. Each patient will be assessed/reassessed by a registered nurse each shift. It is the responsibility of the RN to analyze that data into an assessment and to make care. treatment, and service decisions based on that assessment. The content of the assessment/ reassessment includes medical issues, pain and infection control issues."

Based on interview and record review, the facility failed to ensure one of 39 sampled patient's (Patient 10) treatment plans (a structured, individualized document that outlines the care team objectives, intervention and the strategies to achieve specific health goals) regarding hypothyroid issues (a condition where the thyroid gland doesn't produce enough thyroid hormones [regulates growth and development]) and hypertension (high blood pressure), were developed and implemented upon admission, in accordance with the facility's policy regarding treatment planning.

This deficient practice had the potential of failing to implement clinically appropriate individualized goals and interventions to address Patient 10's care needs and risks, which may result in complications such as uncontrolled hypertension and prolonged hospital stay.

Findings:

During a review of Patient's 10 "Medical History and Physical Examination (a formal and complete assessment of the patient and the problem)," dated 1/02/2025, the record indicated that Patient 10 was brought in on a 5150 hold (a 72-hour involuntary psychiatric [mental health issues] hold that allows for the temporary detention of an individual deemed a danger to themselves or others, or gravely disabled [unable to care for one's self] due to a mental health disorder) after recently becoming very violent.

During a review of Patient's 10 "Psychiatric and Mental Status Examination," dated 1/01/2025, the record indicated that Patient 10 was admitted for increased aggression, with past medical history of hypothyroidism and hypertension. The record also indicated a plan to continue Patient 10's medication of Synthroid (a medication used to treat hypothyroidism) and metoprolol (a medication that lowers the blood pressure and heart rate).

During a review of Patient's 10 "Order Chronology," dated 12/31/2024 - 1/02/2025, the record indicated that Synthroid and Metoprolol medication was ordered to start on 01/01/2025

During a concurrent interview and record review on 6/12/2025 at 10:29 a.m. with Nurse Manager (NM) 3, Patient 10's medical record titled, "Master Problem List," with initial treatment date of 01/03/2025, was reviewed. The record indicated that a Hypothyroidism and Hypertension problems were not identified on admission and was only added to the problem list on 01/22/2025. NM 3 stated that, the admitting nurse should have identified and included hypothyroidism and hypertension in the interdisciplinary treatment plan and problem list on admission.

During the same interview on 6/12/2025 at 10:29 a.m. with Nurse Manager (NM) 3, NM 3 stated that a patient's treatment plan was reviewed and updated by the treatment team every 7 days. NM 3 also said that including identified medical problems in the treatment plan, was important because it served as a roadmap for both the patient and healthcare providers, ensuring a clear and effective approach to managing a patients' health and helped meet treatment goals.

During a review of the facility's Policy and Procedure (P&P) titled, "Interdisciplinary Treatment Planning," with last revised date of 10/2023, the P&P indicated the following:

-The initial preliminary treatment plan should be initiated with a physician's order upon admission.

-Within eight (8) hours of patient admission, the RN shall initiate the Interdisciplinary Treatment Plan, including the Master Problem List. The list shall include an admitting diagnosis and any active medical problems if specific interventions are required. Medical problems which are stable and do not require any change in intervention (i.e. hypothyroidism that is appropriately managed with a pre-admission medication regimen) will be identified as stable on the problem list.

-Within 72 hours (3 days) of admission. the Interdisciplinary Treatment Team shall fi.111her develop the patient's treatment plan based on a comprehensive assessment of the patient's presenting problems. physical health. emotional. social. and behavioral status. The Team will consist of the physician. the RN. the Social Worker and representatives from other clinical disciplines (i.e. Activity Therapy. Pharmacy) as appropriate. Attendance of the patient (or designee) in the treatment planning meeting is strongly encouraged. It is the responsibility of the Treatment Team to review and integrate pertinent data gathered through clinical assessments ( i.e. initial medical screening, admission assessment. risk assessment. history & physical. psychiatric evaluation. etc...) into the patient's individualized plan of care. Any changes in the patient's diagnosis will be identified.

-At least every 7 days. or as frequently as indicated by the patient's anticipated length of stay. acuity. and treatment issues. the Treatment Plan shall be reviewed and updated.

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

1. Ensure that one of one sampled medication cart (med cart #11, a portable storage unit used to organize and store medication for easy access by authorized staff in a medication room) in the medication room, located on 5 South unit (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis, individuals who have both a developmental disability and a mental illness] patients), and is used for 24 of 24 sampled patients, always remained locked, as required by the facility's policy for maintaining medication safety and administration.

This deficient practice had the potential to results in patient and staff safety violations, including unauthorized access to medication, medication theft, misuse, and tampering (altering or modifying a medication or its packaging without authorization), which could lead to medication errors, overdose, or other safety breaches, including violating the facility's policies designed to prevent medication mishandling and safeguard patients' safety.

2. Ensure its nursing staff protected one (1) of 39 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility's policy regarding abuse prevention, when staff allowed an agitated patient (Patient 3) after a patient-to-patient altercation (physical or verbal conflict between two or more patients) to return to his (Patient 3's) room with two other patients (Patients 1 and 2) present, on 4/9/2025.

This deficient practice resulted in Patient 2 being triggered by Patient 3's aggressive behavior, thus assaulting (attack, inflict [cause] immediate offensive physical contact or bodily harm to someone) Patient 1, and led to Patient 1 sustaining midface fractures (broken bones) on 4/9/2025.

3. Ensure that a proper (minimum arm's length distance) Q (every) 15 minute observation (safety checks conducted every 15 minutes to ensure the well-being of patients) and close proximity observation, was completed for the safety and security of 12 of 39 sampled patients (Patients 7, 8, 30 ,31 ,32, 33, 34, 35, 36, 37, 38 and 39), in accordance with the facility's policy regarding observation and monitoring, when Registered Nurse (RN) 1, who was assigned to conduct Q-15 minute observation, did not enter the patients' rooms to make direct visual contact with the patients.

This deficient practice had the potential of failing to prevent harm to patients, including self-harm, suicide (the act of intentionally causing one's own death), and elopement (escape).

Findings:

1. During an observation on 6/10/2025 at 11:27 a.m. in the medication room on 5 South (mixed [males and females] unit for DDMI [Developmental Disability and Mental Illness dual diagnosis] patients), with two nurse managers (NM 1 and NM 3), medication cart # 11 (a portable storage unit used to organize and dispense medications for the unit's patients), was observed to be located within the medication room. The cart was found to be unlocked. NM 3 stated that the medication cart must be kept locked when not in use, even when it is parked in the locked medication room.

During the same interview on 6/10/2025 at 11:27 a.m. with Nurse Manager (NM) 3, NM 3 said that usually, the key to the cart remained with the assigned medication nurse for the day, but all licensed personnel also had the key to access the medication room. NM 3 also said that EVS (Environmental Services) personnel, responsible for cleanliness and sanitation, had access to the medication room as well, and may enter it at any time. NM 3 stated that an unlocked medication cart can pose a risk of unauthorized access to patients' medications. NM 1 then also said that the medication nurse was on a lunch break at the time of the observation [on 6/10/2025 at 11:28 a.m.].

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration and Documentation," dated 10/2023, the P&P indicated that the medication room and the medication cart must be locked when unattended by licensed nursing staff ..."

2. During a review of Patient 1's "Face Sheet (front page of the chart that contains a summary of basic information about the patient)," dated 3/31/2025, the Face Sheet indicated Patient 1 was admitted to the facility on 3/31/2025 at 10:30 a.m. under a 5150 legal hold (a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of himself]).

During a review of Patient 1's "Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold paperwork)," dated 3/30/2025, the 5150 hold paperwork indicated Patient 1 was detained for being gravely disabled due to auditory hallucinations (hearing sounds, noises, or voices that are not there) and abnormal behavior.

During a review of Patient 2's Face Sheet, dated 4/8/2025, the Face Sheet indicated Patient 2 was admitted to the facility on 4/8/2025 at 10:08 p.m. under a 5150 legal hold.

During a review of Patient 2's 5150 hold paperwork, dated 4/8/2025, the 5150 hold paperwork indicated Patient 2 was detained for being a danger to others when he (Patient 2) was found "challenging people to a fight without provocation" in the community.

During a review of Patient 3's "Face Sheet," dated 3/28/2025, the Face Sheet indicated Patient 3 was admitted to the facility on 3/28/2025 at 12:55 p.m. voluntarily (of his own free will).

During a review of Patient 3's "Psychiatric (treatment or care for a mental health disorder or illness) and Mental Status Examination (PMSE, a formal and complete assessment of the patient and the problem related to mental health)," dated 3/29/2025 at 10:23 a.m., the PMSE indicated Patient 3 sought voluntary admission due to suicidal thoughts (thinking about killing himself).

During a review of Patient 4's "Face Sheet," dated 4/8/2025, the Face Sheet indicated Patient 4 was admitted to the facility on 4/8/2025 at 10:50 a.m. under a 5150 legal hold.

During a review of Patient 4's 5150 hold paperwork, dated 4/8/2025, the 5150 hold paperwork indicated Patient 4 was detained for being gravely disabled due to abnormal behavior.

During a review of Patient 1's "Observation Record," dated 4/9/2025, the Record indicated Patient 1 was awake and in his room from 2:15 a.m. to 4:00 a.m.

During a review of Patient 2's "Observation Record," dated 4/9/2025, the Record indicated Patient 2 was awake and in his room from 2:30 a.m. to 4:00 a.m.

During an interview with the Director of Quality and Risk Management (DQ) on 6/9/2025 at 1:51 p.m., the DQ stated that on 4/9/2025 at around 4:00 a.m., Patient 1 came out of his (Patient 1) room with his nose bleeding and stated that somebody punched him. The DQ further stated that the only other person in the room was his roommate, Patient 2, but at the time, he (Patient 2) denied knowing what happened.

During an interview with Nurse Manager (NM) 1 on 6/11/2025 at 10:16 a.m., NM 1 confirmed that Patients 1, 2, and 3 were roomed in together in the same room (Room A). NM 1 further stated that on 4/9/2025 after midnight, there was a "fight" between Patients 3 and 4 in the hallway; during the fight, another altercation between Patient 1 and Patient 2 occurred in Room A, unwitnessed by staff.

During a concurrent interview and video surveillance review with Nurse Manager (NM) 1 on 6/12/2025 at 9:34 a.m., two video clips of security footage from 4/9/2025, were reviewed. NM 1 stated these videos occurred at approximately 4:00 a.m. on 4/9/2025 as there were no time stamps on the footage. The following events were observed from the first clip:

-At the beginning of the video clip, Patient 4 was standing in the hallway.

-Patient 3 emerged from his room. Staff stepped in between Patients 3 and 4. One minute and 12 seconds into the video Patient 3 swung his left arm at Patient 4. Additional staff responded to the incident.

-One minute and 30 seconds in, staff brought Patient 3 back to Room A (where Patients 1 and 2 were staying). Four staff were observed entering Room A with Patient 3.

-Two minutes and 49 seconds in, staff removed Patient 3 from Room A.

During the same interview on 6/12/2025 at 9:34 a.m. with Nurse Manager (NM) 1, NM 1 stated Patient 3 was in his room, with staff present, for one minute and 19 seconds, based on the time elapsed in the video. NM 1 further stated that staff removed Patient 3 from his room and brought him to the seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) room to administer emergency medications (medications given to manage severe mental health symptoms such as agitation).

During the same video surveillance review on 6/12/2025 at 9:34 a.m., the following events were reviewed from the second clip:
-Two minutes and 19 seconds into the video, staff brought Patient 3 out of Room A.

-Two minutes and 44 seconds in, Mental Health Worker (MHW) 2 closed the door to Room A.

-Three minutes and 40 seconds in, House Supervisor (HS) 1, who was standing in the hallway, appeared to hear something coming from Room A and opened the door.

-Three minutes and 44 seconds in, Patient 1 emerged from Room A dripping blood on the floor. Staff took him (Patient 1) to the nurses' station. Patient 2 was seen standing in the doorway of Room A.

-NM 1 stated Patients 1 and 2 were left alone in Room A for 56 seconds, based on the time elapsed in the video.

During an interview with Nurse Manager (NM) 1 on 6/12/2025 at 9:50 a.m., NM 1 stated that the facility's staff were responsible for the patients. NM 1 further stated that agitated patients should not be in a room with other patients, and staff should remove the roommates as best as they could because there was potential that the roommates could get triggered, agitated, or get hurt.

During an interview with Nurse Manager (NM) 1 on 6/12/2025 at 10:24 a.m., NM 1 stated Patient 2 was a newly admitted patient and had not yet been seen by a physician. The staff was not familiar with Patient 2 and did not know what would trigger Patient 2 and what Patient 2's behavior would be. NM 1 further stated the staff should have maintained vigilance until the staff got to know Patient 2 more.

During a review of Patient 1's "Progress Notes," dated 4/9/2025 at 4:35 a.m., the Progress Notes indicated, "Around [4:10 a.m.], patient [Patient 1] came out of his room [with] heavy bleeding from both nostrils. [Patient 1 was] confused, unable to provide accurate information regarding what exactly happened, but stated 'I'm sorry, someone punched me'." The Progress Notes further indicated Patient 1 was sent to General Acute Care Hospital (GACH) 1's Emergency Department (a hospital department that provides immediate care for patients with urgent medical conditions) at 4:33 a.m.

During a review of Patient 1's "Progress Notes," dated 4/9/2025 at 1:51 p.m., the Progress Notes indicated Patient 1 was scheduled to be transferred to GACH 2 at 2:00 p.m. for possible oral facial (face and mouth) surgery.

During a review of Patient 2's "Progress Notes," dated 4/9/2025 at 4:47 a.m., the Progress Notes indicated, "[Patient 1] ran out of his room with his nose bleeding. [Patient 2] stated he (Patient 2) did not know who punched him."

During a review of Patient 2's "Progress Notes," dated 4/9/2025 at 3:48 p.m., the Progress Notes indicated, "[Patient 2] states, 'I hit the other guy earlier.'"

During a review of Patient 1's "CT (computed tomography, a procedure that uses X-ray techniques to create detailed images of the body) Maxillofacial (upper jaw and face) Scan" report from GACH 2, dated 4/9/2025 at 8:26 p.m., the report indicated Patient 1 sustained bilateral (both) Le Fort I (a type of facial fracture that occurs horizontally through the maxilla [upper jaw], above the roots of the teeth), right possible Le Fort II fractures (a pyramidal shaped fracture along the nasal bridge and causes separation of the midface from the skull base), and bilateral maxillary sinus fractures (a break in the bones that make up the maxillary sinus [the air-filled cavities in the cheek bones]) of the anterior (front) and posterolateral (at the back and to the side) walls.

During a review of Patient 1's "ENT (a physician that specializes in medical conditions of the ear, nose, throat, and neck) Consultation Note," from GACH 2, dated 4/10/2025 at 4:04 a.m., the Note indicated the ENT physician recommended conservative non-operative management (no surgery required) and cleared Patient 1 to return to the facility (where Patient 1 got punched by Patient 2).

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold Policy," last reviewed 10/2023, indicated, "The clinical staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preferences from the initial assessment prior to [seclusion/restraint], including ... C. Separating patient from group or community ... E. Offering the use of the quiet room to decrease stimuli and regain control."

During a review of the facility's policy and procedure (P&P) titled, "Abuse Prevention, Screening, Identification, Training, Protection, Investigation, and Reporting," last reviewed 10/2023, indicated, "It is the policy of College Hospital to protect our patients from all types of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients, or visitors ... A critical part of protecting patients from abuse is preventing abuse from occurring in the first place."

3. During a review of the facility's "Nursing Census," dated 2/18/2025, the Nursing Census indicated patients to their assigned rooms as follows: Patient 30 to Room 109-A, Patient 31 to Room 109-B, Patient 32 to Room 109-C, Patient 7 to Room 110-A, Patient 33 to Room 110-B, Patient 34 to Room 110-C, Patient 35 to Room 111-A , Patient 36 to Room 111-B, Patient 8 to Room 111-C, Patient 37 to Room 112-A, Patient 38 to Room 112-B, and Patient 39 to Room 112-C.

During a review of Patient 30's Mental Status Examination (MSE, a structured assessment used to evaluate a patient's current mental state), dated 2/09/2025, the MSE indicated that Patient 30 suffered from schizoaffective disorder bipolar type (a mental health condition characterized by a combination of schizophrenia [a chronic and severe mental disorder that disrupts a person's ability to think, feel, and behave clearly] symptoms and bipolar disorder [a mental health condition that causes extreme shifts in mood, energy, activity levels, and concentration] symptoms. It involves experiencing psychotic symptoms like hallucinations [a sensory perception that seems real but is not, occurring without external stimuli] or delusions [a fixed, false belief that is not amenable to change even when presented with contradictory evidence] alongside mood episodes of mania [a state of abnormally elevated, expansive, or irritable mood, often accompanied by increased energy, activity, and impaired judgment] and sometimes depression [a mood disorder characterized by persistent feelings of sadness, loss of interest in activities, and changes in thinking and behavior that interfere with daily life]).

During a review of Patient 31's MSE, dated 2/05/2025, the MSE indicated that Patient 31 was being readmitted on a 5150 (72-hour hold, a legal procedure that allows for the involuntary 72-hour psychiatric hold of an individual who is deemed a danger to themselves or others, or is gravely disabled [unable to care for one's self] due to a mental health disorder) after she (Patient 31) reported having active suicidal ideations (having thoughts, fantasies, or contemplations about ending one's life) with a plan to overdose (ingestion or application of a drug or other substance in quantities much greater than are recommended).

During a review of Patient 32's MSE, dated 2/16/2025, the MSE indicated that Patient 32 was brought in by family for psychiatric evaluation. Patient 32's MSE also indicated Patient 32 was placed on a 5150 hold for danger to others, with history of schizophrenia, had poor compliance with medication and was a poor historian, she (Patient 32) was also unable to provide any information.

During a review of Patient 7's MSE, dated 11/22/2024, the MSE indicated that Patient 7 brought in on a conservatorship (a legal arrangement where a court appoints someone [the conservator] to manage the financial and/or personal affairs of an individual [the conservatee] who is deemed unable to do so themselves due to incapacity. This typically involves adults who are unable to care for their own needs due to physical or mental limitations). Patient 7's MSE indicated that Patient 7 would not continue with her (Patient 7) medications and decompensated (to become worse) into now auditory hallucinations (when one perceives sounds that are not actually present in their environment), wanted to overdose on pills, and hit her (Patient 7) head against the wall.

During a review of Patient 33's MSE, dated 2/16/2025, the MSE indicated that Patient 33 was depressed and confused and had mood lability (rapid and unpredictable shifts in emotions). Patient 33'2 MSE further indicated "She (Patient 33) came in on a 5150 hold. She says she is very confused and disorganized. She says that she is suicidal but then she gets frustrated on interviews."

During a review of Patient 34's MSE, dated 2/17/2025, the MSE indicated that Patient 34 was being admitted to the hospital with increased depression, anxiety (a feeling of unease, fear or worry), frustration and feeling hopeless, helpless, and lack of motivation. Patient 34's MSE also indicated that "she has been struggling with the voices in her head telling her (Patient 34) to kill herself. She currently is having urge to end life by overdose or cut her wrist."

During a review of Patient 35's MSE, dated 2/17/2025, the MSE indicated that Patient 35 was having difficulty to cope with day-to-day responsibility, had not slept well for several days, and with decreased self-care.

During a review of Patient 36's MSE, dated 2/18/2025, the MSE indicated that Patient 36 lived alone, admitted on a 5150 after expressing thoughts of suicide.

During a review of Patient 8's MSE, dated 1/22/2025, the MSE indicated that Patient 8 came into the hospital on a 5150 hold. Patient 8's MSE indicated "she (Patient 8) was exhibiting symptoms of psychosis (a mental state where a person loses contact with reality, experiencing symptoms like hallucinations and delusions), she was hyper religious, holding her (Patient 8) hands in prayer, being selectively mute, acting very bizarre and confused. She is confused, disorganized. She has suicidal intent to overdose on medications."

During a review of Patient 37's MSE, dated 2/14/2025, the MSE indicated that Patient 37 was admitted on a 5150. Patient 37's MSE indicated Patient 37 had been self-medicating with Methamphetamines (a powerful and addictive stimulant drug that affects the central nervous system) and had thoughts about wanting to hurt himself (Patient 37) by cutting himself with a knife.

During a review of Patient 38's MSE, dated 2/11/2025, the MSE indicated that Patient 38 was admitted on a 5150 hold after assaulting his (Patient 38) mother following an argument regarding patient (Patient 38) not taking his (Patient 38) medication.

During a review of Patient 39's MSE, dated 2/11/2025, the MSE indicated that Patient 39 presented to the hospital on a 5150 hold for danger to others. The report indicated patient (Patient 39) became aggressive at the group home, where he was prior to admission to the hospital, and tried to hurt others with his (Patient 39) keys, swinging at staff because patient (Patient 39) believed that they (the staff) were talking bad about him (Patient 39) behind his back.

During a concurrent interview and record review on 6/11/2025 at 2:34 p.m. with Nurse Manager (NM) 1 a security footage from 2/18/2025, was reviewed. NM 1 stated these videos occurred at approximately 11:40 p.m. on 2/18/2025 in 1-South. The following was reviewed from the video:
-Registered Nurse (RN) 1 doing Q 15 observation rounding;
-RN 1 first went to room 110, opened the door, remained standing by the door, did not enter the patient room;
-RN 1 went to room 112, opened the door, remained standing by the door, did not enter the patient room;
-RN 1 went to room 111, shined a flashlight through the patient door window, did not open door to patient room;
-RN 1 then went to room 109, opened door, remained standing by the door, did not enter the patient room.

During the same interview on 6/11/2025 at 2:34 p.m. with Nurse Manager (NM) 1, NM 1 stated that RN 1 was doing the Q (every) 15-minute observation (safety checks conducted every 15 minutes to ensure the well-being of patients). NM 1 said RN 1 did not perform the Q 15-minute observation correctly. NM 1 further stated RN 1 should have walked into the room and be near the patient for the observation. NM 1 stated, in this case, RN 1 did not go into the patient rooms. It was an expectation when doing Q 15 observation that staff should go inside the room and have a close look at each patient as part of the safety check.

During a review of the facility's policy and procedure (P&P) titled, "Observation and Monitoring," last reviewed 10/2023, the P&P indicated the following:
-Q 15 MINUTE OBSERVATIONS are minimum level of observation for all patients.
-Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress.
-Staff will be vigilant for potential risk factors identified for specific patients (levels of precautions).
-Sleeping patients will be observed at close enough proximity to confirm they are in no physical distress. Staff will observe the patient at a minimum arm's length distance to ensure the ability to clearly see the patient's identity and respiration.

Based on interview and record review, the facility failed to ensure that nursing staff documented that attempts were made to treat two of 39 sampled (Patient 24 and Patient 25), in the least restrictive manner, before placing Patient 24 and Patient 25 in physical restraints, in accordance with the facility's policy regarding restraints use.

This deficient practice had the potential to result in unnecessary use of restrictive interventions for Patient 24 and Patient 25, placing both patients at increased risk of injury and/or psychological trauma, and failure to promote dignity, thus violating Patient 24 and Patient 25 rights (the fundamental entitlements and protections that individuals have when receiving medical care).

Findings:

1. During a review of Patient 24's "Annual Psychiatric Assessment (APA, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 1/22/2024, the APA indicated that Patient 24 was a DDMI patient (DDMI-Developmental Disability and Mental Illness dual diagnosis), who was admitted to the facility on 1/22/2024 due to being danger to self (threatening to kill self) and others, and had history of autism (a neurodevelopmental condition that affects how people interact with the world, particularly in social communication and interaction, and in the presence of restricted and repetitive behaviors, interests, or activities), ADHD (Attention-Deficit/Hyperactivity Disorder, is a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and impulsivity),anxiety (a common emotion characterized by feelings of fear, worry, unease, and apprehension) and ODD (Oppositional Defiant Disorder, a pattern of defiant, angry, and irritable behavior, including arguing, refusing to comply, and intentionally annoying others).

During a concurrent interview and review on 6/12/2025 at 12:37 p.m. with the Director of DDMI (Development Disability & Mental Illness -Dual Diagnosis) program (Dir 1), Patient 24's restraint and seclusion (S&R, interventions used in the treatment and management of disruptive and violent behaviors in psychiatry), video footage (no audio), timestamp dated 3/19/2024, was reviewed. The video footage demonstrated the following:

-At 5:13 p.m.-Patient 24 received chemical restraint (the use of medication to manage or restrict a person's behavior, freedom of movement, or ability to interact with their environment, when that medication is not part of their standard treatment for a diagnosed condition) and was released from the seclusion room. Patient 24 then got up from the bed, after clinical staff let go, and Patient 24 left the seclusion room (the isolation of a disturbed psychiatric patient in a robust locked room).

-At 5:15 p.m., Patient 24 was returned to the seclusion room, accompanied by multiple staff. Two Mental Health Workers (MHW 1 and MHW 2) were observed performing a physical hold (involves staff physically holding a person to restrict their movement or ability to access their body) on Patient 24, by restraining Patient 24 to the wall in the seclusion room.

-At 5:17 Patient 24 was applied the physical restraint (the use of a manual hold or device to restrict a person's movement, either by immobilizing their body or limiting their access to it. It's a form of restrictive practice, used as a last resort when less restrictive interventions have failed) and was left in the seclusion room with a 1:1 /sitter for observation (caregiver or staff member who provides constant, one-on-one supervision and support to a patient).

During the same interview on 6/12/2025 at 12:37 p.m. with the Director of DDMI (Development Disability & Mental Illness -Dual Diagnosis) program (Dir 1), the Dir 1 stated that the video footage did not show what happened to Patient 24 in the hallway after administration of the chemical restraint at 5:13 p.m. and before the patient (Patient 24) returned to the seclusion room at 5:17 p.m. The Dir 1 also said that he (Dir 1) would need to review Patient 24's medical record titled, "Restraint and Seclusion (S&R)" (assessment packet for nurses) to clarify the sequence of events.

During a concurrent interview and record review on 6/13/2025 at 10:51 a.m. with the Director of the DDMI unit (Dir 1), Patient 24' Restraint and Seclusion (S&R) form, dated 3/19/2025, was reviewed. The S&R form, indicated that Patient 24 was given 2 milligrams (mg, measuring unit of weight used for medication dosing) of Ativan (a medication used to sedate, calm, or treat anxiety [a feeling of unease], often given for agitation [a state of restlessness]) intramuscularly (IM, into the muscle). The S&R form did not contain any recorded explanation or documentation to justify the application of physical restraints at 5:17 p.m. on 3/19/2024, which were applied on Patient 24 about 2-3 minutes after administering Ativan IM.

During the same interview on 6/13/2025 at 10:51 a.m. with the Director of the DDMI unit (Dir 1), the Dir 1 said that when a chemical restraint (Ativan, emergency medication) was administered first, the patient was given time and let go by the staff (Patient 24 was released to the hallway at 5:13 p.m. after receiving 2 mg of Ativan IM). Dir 1 said that perhaps, Patient 24 started to act out or exhibited unsafe behavior, so additional measures such as bringing the patient (Patient 24) back into the seclusion room at 5:17 p.m. to apply physical restraints was necessary, depending on Patient 24's behavior. However, the Dir 1 stated, there was nothing documented in Patient 24's S&R form and the documentation was lacking a reasonable explanation for what happened in the hallway after the 2 mg of Ativan was given to Patient 24 at 5:13 p.m.

During the same interview on 6/13/2025 at 10:51 a.m. with the director of DDMI unit (Dir 1), the Dir 1 stated that a form titled, "Emergency Use of Medication Assessment Flowsheet (a documentation form that records the assessment and justification administering emergency medication, including the reasons for restraint use)," was not completed by nursing staff on 3/19/2024 when 2 mg of Ativan IM was given to Patient 24 at 5:13 p.m. The Dir 1 said that the form should have been completed by nursing staff. The Dir 1 said that typically, the "Emergency Use of Medication Assessment Flowsheet," form was completed after administering any emergency medication; and the Restraint and Seclusion (S&R) form, was completed after utilizing physical restraints and/or seclusion.

During an interview on 6/13/2025 at 11:02 a.m. with the director of the DDMI unit (Dir 1), the Dir 1 said: "Nursing staff must document both the use of restraints and seclusion (S&R) and the Emergency use of Medication Assessment form (2 separate forms). Nurses should always attempt less restrictive measures with patients, and physical restraints should be used only as a last resort. The documentation should include a thorough explanation of the medication given and the reasons for administration, as well as the description of the behavior that prompted its use, what happened afterwards, and why the patient was physically restrained if physical restraint was still required. All of this should be documented in the patient's records. The nurse should specifically document the behavior that led to the use of physical restraints (after previously administering chemical restraint) and why the patient was not given enough time for the medication to take effect."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medications," dated 11/2024, the P& P indicated the following: " ...The clinical indications or "target symptoms" are to be listed in the emergency medication order ...the RN will document the clinical situation which led to the need for the use of emergency medication in the progress notes. The patient's response to the medication is to be documented by a licensed member of the nursing staff in the medical record ... The staff will encourage and assist the patient to return to the milieu as soon as possible .... The RN will document behaviors which led to the need for the use of emergency medication in the Emergency Use of Medication Assessment Flowsheet (form 6793) ...The monitoring of the patient will be documented in the form 6793 ..."

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold," dated 10/2023, the P&P indicated the following: "The Facility is committed to prevent, reduce, and eliminate S7R use through early identification and intervention of high-risk behaviors or events. S7R interventions are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others. Nonphysical interventions are the preferred method of intervention, and the use of S&R is considered to be an exception and not a standard of practice ..."

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold," dated 10/2023, the P&P indicated the following:
"The clinical staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preferences and information from the initial assessment prior to Seclusion and Restraint (S&R), including:
a. redirecting the patient's focus
b. employing verbal de-escalation
c. separating patient from group or community
d. engaging the patient in 1:1 activity to promote safe expression of feelings
e. offering the use of the quiet room to decrease stimuli and regain control
f. offering food or drink
g. administering medication as ordered by the physician to help patient more effectively function
h. documents the alternative attempted or the rationale for not using alternatives ..."

2. During a review of Patient 25's "Psychiatric and Mental Status Examination (PMSE, a comprehensive assessment performed by a psychiatrist to diagnose and treat mental health conditions, while a mental status examination [MSE] is a structured way to observe and document a patient's current psychological state during a clinical encounter )," dated 3/12/2024, the PMSE indicated that Patient 25 was admitted on a 5150 (a temporarily hold for evaluation and crisis intervention- involuntary 72-hour psychiatric hospitalization of an individual who, due to a mental health disorder, is deemed a danger to themselves, a danger to others, or gravely disabled [unable to care for one's self]) due to danger to others. The PMSE also indicated that Patient 25 had history of autism (neurodevelopmental condition that affects how individuals interact with the world, particularly in social communication and interaction, and in their patterns of behavior and interests) and explosive disorder (a mental health condition characterized by sudden and frequent episodes of impulsive, aggressive, violent behavior or angry verbal outbursts).

During a concurrent interview and record review on 6/11/2025 at 11:30 a. m. with Nurse Manager (NM 1), Patient 25's electronic medical record (EMR) titled, "Behavioral Restraint/Seclusion Order Assessment," dated 3/12/2024 through 11/12/2024, was reviewed. The record indicated that Patient 25 was placed in physical hold/seclusion/restraints 11 times since the admission to the facility on 3/12/2024 [through 11/20/2024]. The record also indicated that Patient 25 was given emergency medications (chemical restraint-the use of medication administered rapidly to quickly sedate or calm a patient experiencing severe agitation or behavior that poses a danger to themselves or others):

1. 3/30/2024-Patient 25 was placed in physical hold at 10:15 a.m., seclusion at 10:18 a.m., and restraints at 10:18 a.m. (Emergency medications given: Haldol 5 milligram [mg, a unit of measurement], Ativan 2 mg, and Benadryl 50 mg-no time of administration documented).

2. 4/13/2024-Patient 25 documented to be administered emergency medications (Haldol 5 milligrams [mg], Ativan 2 mg and Benadryl 50 mg given at 6:05 p.m.), then placed in a physical hold at 6:15 p.m., and restraints at 6:15 p.m. (restrained only 10 minutes after administering emergency medications)

3. 4/21/2024 -Patient 25 was placed in a physical hold at 5:55 p.m., seclusion 6:00 p.m., emergency medication (Ativan 2 mg, Haldol 10 mg, and Benadryl 50 mg) given at 6:10 p.m. (only 10 minutes prior to placing Patient 25 in physical restraints) and restraints at 6:20 p.m.

4. 4/28/2024-Patient 25 was placed in physical hold at 8:10 a.m., emergency medication (Ativan 1 mg, Haldol 5 mg, Benadryl 50 mg) at 8:14 a.m., seclusion at 8:20 a.m., and restraints at 8:20 a.m. (Patient 25 was placed in restraints only 6 minutes after administration of emergency medications).

5. 5/12/2024-Patient 25 was placed in physical hold at 2:25 p.m., seclusion 2:45 p.m., and restrained at 2:45 p.m.-emergency medication given (Haldol 10 mg, Ativan 2 mg, and Benadryl 50 mg) no time of administration documented.

6. 8/4/2024 -Patients 25 was placed in physical hold at 3:05 p.m., seclusion at 3:10 p.m., and restraints at 3:10 p.m.-emergency medication given (Ativan 2 mg, Zyprexa 10 mg), no time for administration documented.

During the same record review on 6/11/2025 at 11:30 a.m. with Nurse Manager (NM) 1, Patient 25's S&R records indicated that three (3) out of 6 seclusion and restraints (S&R) episodes involving the administration of chemical restraint/emergency medication, had no separately completed form titled, "Emergency Use of Medication Assessment Flowsheet (a documentation form that records the assessment and justification administering emergency medication, including the reasons for restraint use)," and three (3) out of 6 remaining (S&R) episodes involving the administration of emergency medications had no time of administration recorded. The S&R forms reviewed also contained no explanation as to why Patient 25 was restrained shortly after being given emergency medications, without allowing sufficient time for the medications to take effect. This information was verified with NM 1 during the record review.

During an interview on 6/13/2025 at 10:51 a.m. with the Director of DDMI unit (Dir 1), the Dir 1 stated that a form titled "Emergency Use of Medication Assessment Flowsheet," must be completed by nursing staff when emergency medications are administered to a patient. Dir 1 also said that if the emergency medication was administered after the patient was already restrained, then it's sufficient to document the time of administration in the same Seclusion and Restraint (S&R) form.

During an interview on 6/13/2025 at 11:02 a.m., with the Director of the DDMI unit (Dir 1), the Dir 1 said: "Nursing staff must document both the use of restraints and seclusion (S&R) and the Emergency use of Medication Assessment form (2 separate forms). Nurses should always attempt less restrictive measures first, and physical restraints should be used only as a last resort. The documentation should include a thorough explanation of the emergency medication given and the reasons for administration, as well as the description of the behavior that prompted its use, what happened afterwards, and why the patient was physically restrained if physical restraint was still required. All of this should be documented in the patient's records. The nurse should specifically document the behavior that led to the use of physical restraints (after previously administering chemical restraint) and why the patient was not given enough time for the medication to take effect.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medications," dated 11/2024, the P& P indicated the following: " ...The clinical indications or "target symptoms" are to be listed in the emergency medication order ...the RN will document the clinical situation which led to the need for the use of emergency medication in the progress notes. The patient's response to the medication is to be documented by a licensed member of the nursing staff in the medical record ... The staff will encourage and assist the patient to return to the milieu as soon as possible .... The RN will document behaviors which led to the need for the use of emergency medication in the Emergency Use of Medication Assessment Flowsheet (form 6793) ...The monitoring of the patient will be documented in the form 6793 ..."

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold," dated 10/2023, the P&P indicated the following: "The Facility is committed to prevent, reduce, and eliminate S&R use through early identification and intervention of high-risk behaviors or events. S&R interventions are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others. Nonphysical interventions are the preferred method of intervention, and the use of S&R is considered to be an exception and not a standard of practice ..."

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint Physical Hold," dated 10/2023, the P&P indicated the following:
"The clinical staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preferences and information from the initial assessment prior to Seclusion and Restraint (S&R), including:
a. redirecting the patient's focus
b. employing verbal de-escalation
c. separating patient from group or community
d. engaging the patient in 1:1 activity to promote safe expression of feelings
e. offering the use of the quiet room to decrease stimuli and regain control
f. offering food or drink
g. administering medication as ordered by the physician to help patient more effectively function
h. documents the alternative attempted or the rationale for not using alternatives ..."

Based on interview and record review, the facility failed to ensure two of 39 sampled patient's (Patient 25 and Patient 27) behavioral plan (a personalized plan developed to address and manage specific behaviors, outlining strategies, goals, and intervention), included a behavioral analysis for after seclusion/restraint episodes and incorporated into the behavioral plan with short-term and long-terms goals aimed at reducing the frequency of seclusions and restraints (Seclusion restraint refers to the practice of isolating someone in a locked room or using physical, mechanical, or chemical means to restrict their movement and freedom of movement) episodes, in accordance with the facility's policy regarding treatment planning.

This deficient practice had the potential to result in poorly addressed triggers (specific events or stimuli that lead to behaviors such as aggression) and/or behaviors for Patient 25 and Patient 27, increasing their risk of repeated restraint episodes, injury, or escalation of aggression, compromising Patient 25's and Patient 27's safety, dignity, and overall well-being. In addition, the lack of behavioral analysis and individualized behavioral treatment plan could hinders effective intervention, delay behavior reduction, and impair ongoing progress in managing challenging behaviors for Patient 25 and Patient 27.

Findings:

1. During a review of Patient 25's "Psychiatric and Mental Status Examination (PMSE, a comprehensive assessment performed by a psychiatrist to diagnose and treat mental health conditions, while a mental status examination [MSE] is a structured way to observe and document a patient's current psychological state during a clinical encounter )," dated 3/12/2024, the PMSE indicated that Patient 25 was admitted on a 5150 (a temporarily hold for evaluation and crisis intervention- involuntary 72-hour psychiatric hospitalization of an individual who, due to a mental health disorder, is deemed a danger to themselves, a danger to others, or gravely disabled [unable to care for one's self]) due to danger to others. The PMSE also indicated that Patient 25 had history of autism (neurodevelopmental condition that affects how individuals interact with the world, particularly in social communication and interaction, and in their patterns of behavior and interests) and explosive disorder (a mental health condition characterized by sudden and frequent episodes of impulsive, aggressive, violent behavior or angry verbal outbursts).

During a review of Patient 25's electronic medical record (EMR), the "Behavioral Restraint/Seclusion Order Assessment," dated 3/12/2024 through 3/12/2024 through 11/12/2024, was reviewed. The records indicated that Patient 25 had 11 episodes of seclusions and restraints (S&R, seclusion restraint refers to the practice of isolating someone in a locked room or using physical, mechanical, or chemical means to restrict their movement and freedom of movement).

During a concurrent interview and record review on 6/11/2026, at 11:00 a.m. with Nurse Manager (NM 1), Patient 25's electronic medical record (EMR) titled, "Behavioral Restraint/Seclusion Order Assessment," dated 3/12/2024 through 11/12/2024, was reviewed. The record indicated that Patient 25 was placed in physical hold (the act of staff physically holding a patient to restrict their movement)/seclusion/restraints on the following dates:

1. 3/15/2024-Patient 25 was placed in a physical hold at 5:10 p.m., seclusion at 5:10 p.m., and restraints (5-point restraints, restraints on all four limbs [wrists and ankles] and an additional restraint around the torso, pelvis or thighs) at 5:10 p.m.
2. 3/24/2024-Patient 25 was placed in a physical hold at 3:45 p.m., seclusion at 3:55 p.m., and restraints at 3:55 p.m.
3. 3/30/2024-Patient 25 was placed in a physical hold at 10:15 a.m., seclusion at 10:18 a.m., and restraints at10:18 a.m.
4. 4/9/2024 (no information provided)
5. 4/13/2024-Patient 25 documented to be placed in a physical hold at 6:15 p.m., seclusion at 11:14 a.m., and restraints at 6:15 p.m.
6. 4/20/2024 (no information provided)
7. 4/21/2024 -Patient 25 was placed in a physical hold at 5:55 p.m., seclusions 6:00 p.m., and restraints 6:20 p.m.
8. 4/28/2024-Patient 25 was placed in a physical hold at 8:10 a.m., seclusion at 8:20 a.m., and restraints at 8:20 a.m.
9. 5/5/2024-Patient 25 was placed in a physical hold at 10:05 a.m., seclusion at 10:10 a.m., and restraints at 10:10 a.m.
10. 5/12/2024-Patient 25 was placed in a physical hold at 2:25 p.m., seclusion 2:45 p.m., and restrained at 2:45 p.m.
11. 8/4/2024 -Patients 25 was placed in a physical hold at 3:05 p.m., seclusion at 3:10 p.m., and restraints at 3:10 p.m.

During the same concurrent interview and record review on 6/11/2026, at 11:00 a.m. with Nurse Manager (NM 1), NM 1 reviewed the Behavioral Weekly Progress Reports, 30-day Behavioral Progress Reports, and Interdisciplinary Treatment (IDT, a comprehensive plan of care developed collaboratively by a team of professionals from different disciplines to address a patient's mental health needs) Plans [a week after each restraint episode] developed for Patient 25 throughout the admission stay at the facility [3/12/2024-11/20/2024]. NM 1 said that these restraint episodes were not mentioned/included in any of the reviewed reports and IDT Plans for Patient 25.

During an interview on 6/13/2025 at 10:29 a.m. with the Behavioral Analyst (BA 1), the BA 1 said that the 30-Day Behavioral Progress Reports represent a functional behavioral assessment, with monthly goals primarily aimed at reducing challenging behaviors in patients with developmental disabilities in the DDMI unit. The BA 1 stated that restraints triggers were reviewed because "we want to know what led to the incident of restraints," but noted that including restraints triggers in these reports had not been the practice at the facility. The BA 1 also said that the behavioral therapists followed the standards from tools used in ABA therapy (Applied Behavior Analysis, a scientific approach to understanding and improving specific behaviors using reinforcement strategies, positive or negative, to promote adaptive behaviors and reduce problematic ones), and the facility did not have formal policies dictating how these reports should be documented.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Treatment Planning," dated 10/2023, the P&P indicated the following: "Each patient admitted to the hospital shall have a written treatment plan that is appropriate to the patient's specific assessed needs. The treatment plan should be revised and maintained on the patient's response to identified interventions... The treatment plan should be individualized to meet patient's unique needs and circumstances as identified through assessment data and... and shall be appropriate to the patients' needs, strengths, limitations, and goals... An interdisciplinary Treatment Team shall plan, review, and evaluate the treatment plan at least weekly, or as often as indicated...The Master Treatment Plan shall be initiated for each active problem... Contain long-term goal(s) ...and shot term goals ... have interventions that directly related to the goals..."

2. During a review of Patient 27's Psychiatric and Mental Status Examination (PMSE)," dated 5/27/2025 (an annual psychiatric mental examination for 5/26/2025), the PMSE indicated Patient 27 was admitted on 1/17/2024 on a 5150 hold (a legal procedure where a person can be involuntarily detained for up to 72 hours in a psychiatric facility for evaluation and stabilization if they are deemed to be a danger to themselves or others, or gravely disabled due to a mental health disorder) because of running into traffic and noncompliance with medications.

During a review of Patient 27's electronic medical record (EMR), the "Behavioral Restraint/Seclusion Order Assessment," dated 4/30/2025 through 6/2/2025, were reviewed. The records indicated that Patient 27 had 18 episodes of seclusions and restraints (S&R, seclusion restraint refers to the practice of isolating someone in a locked room or using physical, mechanical, or chemical means to restrict their movement and freedom of movement) since admission on 4/30/2025 through 6/2/2025.

During an interview on 6/13/2025 at 10:29 a.m. with the Behavioral Analyst (BA 1), the BA 1 said that the 30-Day Behavioral Progress Reports represented a functional behavioral assessment, with monthly goals primarily aimed at reducing challenging behaviors in patients with developmental disabilities in the DDMI unit. The BA 1 stated that restraints triggers were reviewed because "we want to know what led to the incident of restraints," but noted that including restraints triggers in these reports had not been the practice at the facility. The BA 1 also said that the behavioral therapists followed the standards from tools used in ABA therapy, and the facility did not have formal policies dictating how these reports should be documented.

During a concurrent interview and record review on 6/13/2025 at 3:10 p.m. with Nurse Manager (NM 1), Patient 27's electronic medical record (EMR, a digital collection of a patient's health information that is stored and managed electronically) titled, "Behavioral Restraint/Seclusion Order Assessment," dated 6/2/2025 and the "ABC Analysis" tool (refers to the systematic observation and recording of Antecedents (triggers), Behaviors, and Consequences to understand and modify behavior), was reviewed. The "Behavioral Restraint/Seclusion Order Assessment," dated 6/2/2025, indicated that Patient 27 was placed in a physical hold at 4:52 p.m. and then seclusion at 4:55 p.m. The ABC Analysis tool indicated no documentation of Patient 27 being in a physical hold on 6/2/2025 at 4:52 p.m. and being in seclusion at 4:55 p.m.

During the same concurrent interview and record review on 6/13/2025, at 3:10 p.m. with Nurse Manager (NM 1), NM 1 reviewed the Behavioral Weekly Progress Report [dated 6/4/2025], 30-day Behavioral Progress Reports, and the Interdisciplinary Treatment (IDT) Plan [dated 6/4/2025], developed for Patient 27 , and said that the S&R episodes on 6/2/2025 was not mentioned/included in any of the reviewed reports and IDT Plans for Patient 27.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Treatment Planning," dated 10/2023, the P&P indicated the following: "Each patient admitted to the hospital shall have a written treatment plan that is appropriate to the patient's specific assessed needs. The treatment plan should be revised and maintained on the patient's response to identified interventions... The treatment plan should be individualized to meet patient's unique needs and circumstances as identified through assessment data and... and shall be appropriate to the patients' needs, strengths, limitations, and goals... An interdisciplinary Treatment Team shall plan, review, and evaluate the treatment plan at least weekly, or as often as indicated...The Master Treatment Plan shall be initiated for each active problem... Contain long-term goal(s) ...and shot term goals ... have interventions that directly related to the goals..."