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Based on observation, 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 facility's Governing Body failed to ensure oversight on the Nursing Department to ensure that staff (RNs, LVNs [Licensed Vocational Nurses], MHWs [Mental Health Workers]) working in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), accurately and consistently performed Q15 minutes (every 15 minutes) patient rounding (a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety )/and monitoring, in accordance with the facility's policy regarding patient rounding for 25 of 76 involuntary (5150 hold; 72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) and voluntary hold (when a patient agrees to be admitted to a psychiatric unit for treatment, a decision they make on their own or with their guardian's consent) sampled patients (Patients 1, 2, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 42, 43, 44). On 6/5/2025 (at 2:20 p.m.), an altercation occurred between two patients: Patient 1 and Patient 2, in the locked Behavioral Health Unit (BHU), 5th floor (Campus 1). The incident was unwitnessed by both licensed (RN, LVN) and unlicensed healthcare personnel (MHW) assigned to the unit and tasked to conduct Q15-minute patient rounding at the time.

This deficient practice resulted in inadequate monitoring and created a significant safety risk for all patients in the Behavioral Health Unit (BHU) at Campus 1 for several hours by placing them in an unsafe environment, thereby increasing the risk of self-harm, harm to others, or even death. In addition, this deficient practice potentially resulted in Patient 1 and Patient 2 not being adequately monitored, which led to an unwitnessed altercation. During the incident, Patient 1 sustained a neurological deficit (a possible subdural hematoma, a form of traumatic brain injury involving bleeding) and a confirmed displaced fracture of the right femoral neck, which is a break in the upper part of the thigh bone, just below the ball of the hip joint. (Refer to A-0063)

2. The facility's Governing Body failed to Ensure oversight over the Nursing Department to ensure that there was a process for nursing staff to escalate and advocate for one (1) of 76 sampled patients (Patient 18) to receive proper medical attention in a timely manner, when Patient 18 reported swallowing a foreign object (a non-food item is ingested and gets lodged in the gastrointestinal [GI, includes mouth, esophagus- a passage from throat to stomach, stomach and intestines] tract) on 9/6/2025. Patient 18 was sent out to emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) on 9/8/2025 ( 2 days later) and had esophagogastroduodenoscopy (EGD, a medical procedure using a thin, lighted tube [endoscope] to examine the lining of the esophagus, stomach, and the first part of the small intestine) to retrieve the foreign object.

This deficient practice resulted in Patient 18 suffering from having a foreign object lodged in Patient 18's throat for two (2) days. This deficient practice also had the potential to put other patients with similar symptoms at risk for not receiving care in a timely fashion thus compromising patient care and safety. (Refer to A-0063)

3. The facility's Governing Body failed to ensure oversight over the Nursing Department to ensure alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) cases were investigated and reported to the healthcare regulatory agencies (establishes and enforces standards and guidelines to ensure the safety, quality, and efficacy of healthcare services and products) in a timely manner, in accordance with the facility's policy and procedure regarding abuse reporting, for one of 76 patients (Patient 19), when Patient 19 reported an alleged physical abuse to Registered Nurse 1 (RN 1) on 4/23/2025.

This deficient practice compromised the safety of Patient 19 when the facility failed to initiate an investigation, did not remove the alleged staff members from duty, and potentially placed Patient 19 at further risk of abuse. Additionally, it compromised the safety of other patients who may have been at risk for further abuse. (refer to A-0063)

4. The facility's Governing Body failed to ensure that the facility's policy and procedure (P&P) regarding face-to-face assessments (an in person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), conducted after initiation of 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) or seclusion (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior) in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), was in alignment with Federal regulatory requirements, when the P&P did not indicate that a Registered Nurse must consult a physician after face-to-face assessment was completed. The physician was not consulted after a face-to- face assessment was completed for two (2) of 76 sampled patients (Patients 7 and 12).

This deficient practice had the potential for inconsistent practices, non-compliance with laws and regulations, and patient harm due to the P&P not reflecting up to date best practices. (Refer to A-0063)

5. The facility's Governing Body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital's overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) failed to ensure oversight on its contracted services in relation to their performance measures, when the facility's Quality Assessment and Performance Improvement committee (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), under the direction of the Governing Body failed to identify quality and performance issues for contracted services, implement corrective or improvement actions, and ensure ongoing monitoring and sustainability of implemented corrective actions, when there was a delay in obtaining a head computed tomography scan (CT scan, a medical imaging procedure that creates detailed cross-sectional images of the body), performed by a contracted company, for one of 76 sampled patients (Patient 1). On 6/5/2025, Patient 1 was involved in a patient-to-patient altercation with Patient 2. As a result, Patient 1 sustained a hip fracture and exhibited neurological deficits (impairment in the function of the nervous system) as was manifested by trembling (shaking) of arms and legs, right pupil sluggish response, right upper eyelid drooping (sagging), and left-hand grip weakness. thus, requiring a STAT (immediately) CT scan, but was not carried out by the contracted radiology company as ordered by the physician.

This deficient practice resulted in a delay in obtaining a head (CT) scan for Patient 1. The delay in diagnostic imaging potentially contributed to a delay in diagnosis for Patient 1. Furthermore, the facility's failure to assess and monitor the performance of contracted services, such as CT imaging, through its QAPI program, presented a missed opportunity to identify, analyze, correct, and monitor systemic issues related to delayed diagnostic performance times, placing all patients requiring contracted imaging services at risk. (Refer to A-0083)

6. The facility's Governing Body failed to ensure appropriate oversight on its contracted services (refer to specialized tasks performed by external, independent providers for a specific fee, outlined in a formal agreement that details the scope, timeline, and payment terms) staff in order to provide safe patient care, in accordance with the facility's contract agreement and the policy on Patient Rights, for one of 76 sampled patients (Patient 7), when a security guard (SG 1), from a contracted company, hit Patient 7 on 10/13/2024.

This deficient practice resulted in Patient 7 being physically abused (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by SG 1 and resulted in bruises on the cheek. This deficient practice also had the potential for psychological trauma for Patient 7. (Refer to A-0084)

7. The facility's Governing Body failed to ensure oversight over its contracted services by failing to maintain a current contract, in accordance with the facility's policy titled, "Vendor Agreements," for one of three sampled contracted services (CS 1, refer to specialized tasks performed by external, independent providers for a specific fee, outlined in a formal agreement that details the scope, timeline, and payment terms) when the contract expired since June 2024.

This deficient practice resulted in CS 1 providing services to the facility's patients without a current contract which may lead to the provision of services outside the contract agreement and substandard quality of care to patients that may result in patient harm and/or death. (Refer to A-0085)

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

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

1. The facility failed to ensure that patients received care in a safe environment when Q 15-minute (every fifteen-minute) observation patient rounding (a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety)/monitoring, was not correctly and consistently performed for 56 of 76 sampled 5150 (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) patients (Patient 1, Patient 2, Patient 14, Patient 15, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 42, Patient 43, Patient 44, Patient 45, Patient 46, Patient 47, Patient 48, Patient 49, Patient 50, Patient 51, Patient 52, Patient 54, Patient 55, Patient 56, Patient 57, Patient 58, Patient 59, Patient 60, Patient 61, Patient 62, Patient 63, Patient 64, Patient 65, Patient 66, Patient 67, Patient 68, Patient 72, Patient 73, Patient 74, Patient 75, Patient 76), in accordance with the facility's policy on patient rounding for both 5150 and voluntary hold (when a patient agrees to be admitted to a psychiatric unit for treatment, a decision they make on their own or with their guardian's consent) patients.

This deficient practice resulted in 5150 patients in the BHU (Behavioral health Unit, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) unit in Campus 1 and Campus 2 inadequately monitored for hours and had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, and potentially can result to death. Patient 1 and Patient 2 had an unwitnessed altercation in which Patient 1 sustained a subdural hematoma (a form of traumatic brain injury involving bleeding) and a displaced fracture (broken bone) of the right femoral neck (the narrow, connecting part of the femur (thigh bone) that links the ball-shaped head of the femur to the long shaft of the bone) thus needed to be transferred out for higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]). (Refer to A-0144)

2. The facility failed to protect one of 76 sampled patients (Patient 19) from alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), failed to investigate the abuse allegations, and to identify or remove the alleged perpetrator (a staff member) from the environment, in accordance with the facility's policy regarding abuse reporting, when Patient 19 reported to the Registered Nurse (RN) 1 that the night shift staff choked and placed Patient 19 in 4-point (both wrists and ankles) 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) on 4/23/2025.

This deficient practice resulted in the facility not conducting an investigation and removing the alleged staff members from working duties and potentially placing Patient 19 and other patients at risk for further abuse. (Refer to A-0145)

3. The facility failed to investigate thoroughly and report to the appropriate regulatory agencies an incident of alleged physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by the facility's security guard (SG 1) which occurred on 10/13/2024, for one of 76 sampled patients (Patient 7), in accordance with the facility's policy regarding abuse investigation and reporting.

This deficient practice resulted in a delay in involving regulatory agencies in investigating the abuse allegation and could potentially put other patients in an unsafe environment and be at risk of being abused. (Refer to A-0145)

4. The facility failed to report to appropriate regulatory agencies an allegation of sexual abuse (sexual conduct or a sexual act forced upon a woman, man or child without their consent), in accordance with the facility's policy regarding abuse reporting, for one of 76 sampled patients (Patient 8), after Patient 8 reported an alleged sexual abuse on 8/29/2024.

This deficient practice resulted in a delay in involving regulatory agencies in investigating the abuse allegation and could potentially put other patients in an unsafe environment and be at risk of being abused. (Refer to A-0145)

5. The facility failed to ensure nursing staff consulted the physician after a face to face assessment (an in person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) was performed by Registered Nurses (RNs) for two of 76 sample patients (Patient 7 and 12), in accordance with the federal regulation regarding physician notification after the completion of the face-to-face assessment.

This deficient practice had the potential to result in Patient 7 and Patient 12 not receiving evaluation from physicians to determine appropriate treatment, care and intervention. (Refer to A-0182)

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

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

1. The facility failed to ensure its 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) team collected, tracked and trend data on critical patient safety indicators, implement comprehensive action plan, and measure the success of actions taken and track performance to ensure improvements are sustained, when the QAPI team failed to collect data on all patient abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) incidents and report the data to the QAPI quarterly meeting, in accordance with the facility's performance improvement plan.

The facility did not retain any abuse data for 2024 including two (2) of 76 sampled patients' (Patient 7 and Patient 8) abuse allegation incidents and did not report abuse data to QAPI committee in 2024 and 2025. The facility also failed to capture an alleged physical abuse incident for one of 76 sampled patients (Patient 19) which happened on 4/23/2025, when Patient 19 reported being choked and restrained (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) by staff.

This deficient practice resulted in the facility's QAPI team's inability to analyze abuse data, identify and address potential problems which had the potential to affect quality of patient care and safety. This deficient practice also resulted in the facility's QAPI team's inability to monitor state regulatory compliance with reporting patient abuse to regulatory agencies as required. (Refer to A-0273)

2. The facility's Quality Assurance 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) program team failed to ensure that an ongoing program showed measurable improvements in indicators for patient safety and/or adverse events, when the facility's QAPI team failed to thoroughly investigate, report to the regulatory agencies, measure, analyze, and track adverse patient events (any unintended or undesirable occurrence, symptom, or condition that arises during medical treatment and may result in harm) such as incidents of alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), for three (3) of 76 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 19), in accordance with the facility's performance improvement plan, when:

2.a. The facility failed to ensure that a thorough internal investigation was conducted following the reported patient-to-patient altercation involving Patient 1 and Patient 2 that took place on 6/5/2025. The Quality Assurance and Performance Improvement (QAPI) team did not review available video footage and was unable to provide proof demonstrating that a structured method was used to identify the underlying causes of the adverse event and to implement measures to prevent recurrence, as required by the hospital's Performance Improvement Plan.

This deficient practice had the potential to result in a missed opportunity to identify and correct systemic failures, such as staff possibly not performing Q15-minute safety checks (routine observations conducted every 15 minutes to monitor and document each patient's condition and behavior, with the goal of identifying risks and intervening early to ensure safety) and failing to recognize and intervene to prevent Patient 1 from striking Patient 2. As a result of the altercation, Patient 1 sustained a hip fracture (break in the bone) and exhibited neurological changes, including trembling (shaking) of the arms and legs, sluggish (reduced or delayed) response of the right pupil, right upper eyelid drooping (sagging), and left-hand grip weakness. The facility's failure to address these issues potentially created an ongoing risk for other patients in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders). (Refer to A-0286)

2.b. The facility failed to ensure that abuse allegations (any suspected or alleged incident of physical abuse, abandonment, abduction, deprivation, financial abuse, mental suffering, neglect, exploitation, or mistreatment of an elder or dependent adult by a person responsible for their care) involving Patient 3 and nursing staff (Licensed Vocational Nurse - LVN 1), was promptly reported to the California Department of Public Health (CDPH, the department that works to protect the public's health), within 24 hours, in accordance with the facility's policy and procedure (P&P) regarding "Abuse Mandated Reporting," when abuse allegations were made regarding LVN 1, who was witnessed slapping Patient 3 twice during medication pass on 1/19/2024.

This deficient practice had the potential to result in continued risk of harm to Patient 3. In addition, it delayed external regulatory review and the opportunity for oversight, which may compromise patient safety when an investigation is not immediately undertaken to ensure that corrective action plans are implemented and that the facility is taking adequate steps to reduce the risk of a similar future event. (Refer to A-0286)

2.c. The facility failed to ensure that allegations of abuse (suspected or alleged incidents of physical abuse, abandonment, abduction, deprivation, financial abuse, mental suffering, neglect, exploitation, or mistreatment of an elder or dependent adult-must be reported immediately or as soon as practically possible by phone and followed by a written report (SOC 341) within 24 hours) involving Patient 19 was promptly investigated and reported to the California Department of Public Health (CDPH), in accordance with the facility's policy and procedure titled "Abuse Mandated Reporting." The allegation involved Patient 19 reporting to Registered Nurse (RN) 1 that night shift staff had choked and placed Patient 19 in four-point restraints (involve securing all four of a patient's limbs-both arms and both legs-to a bed or stretcher using soft or leather straps).

This deficient practice resulted in a delay in recognizing and responding to abuse allegations involving Patient 19, which compromised the patient's safety and well-being. In addition, it reflected the facility's failure to demonstrate an effective internal reporting system and oversight mechanisms intended to protect patients from the harm of abuse. (Refer to A-0286)

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

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

1. The facility failed to promptly evaluate and provide immediate medical intervention and treatment, in accordance with the facility's policy and procedure regarding plan for provision of care pertaining to safe, effective, timely care and treatment, when one of 76 sampled patient (Patient 18), a Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient (Patient 18), swallowed a foreign object (any item that does not belong in the body).

This deficient practice resulted in Patient 18's claim of swallowing a razor (sharp blade instrument) not validated and evaluated by nursing staff until two days later (on 9/8/2025) after Patient 18's initial claim (9/6/2025) of having swallowed a razor, which led to Patient 18 being transferred to another facility and undergoing a procedure for removal of the foreign object. This deficient practice also had the potential of Patient 18 losing a large amount of blood and damage to his esophagus (canal that connect the throat to the stomach), which may result in further serious injury or even death. (Refer to A-0395)

2. The facility failed to ensure nursing staff adhered to the facility's policy and procedure regarding "Every 15 Min (minute) Rounds, Patient," and the facility's charting/documentation policy, when staff did not consistently perform and accurately document the Q (every) 15?minute rounding (observing patient location and behavior), for 62 of 76 sampled patients (Patient 1, Patient 2, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44, Patient 14, Patient 15, Patient 16, Patient 45, Patient 46, Patient 47, Patient 48, Patient 49, Patient 50, Patient 51, Patient 52, Patient 53, Patient 54, Patient 55, Patient 56, Patient 57, Patient 58, Patient 59, Patient 60, Patient 61, Patient 62, Patient 63, Patient 64, Patient 65, Patient 66, Patient 67, Patient 68, Patient 69, Patient 70, Patient 71, Patient 72, Patient 73, Patient 74, Patient 75 and Patient 76), on 9/19/2025 from 1:00 a.m. to 2:30 a.m. in Campus 1, on 9/13/2025 from time period 1:20 a.m. to 4:58 a.m. in Campus 2, and on 9/19/2025 from time period of 1:00 a.m. to 2:15 a.m. in Campus 2.

This deficient practice had potentially placed the patients in an unsafe environment, at risk of self?harm, or harm to others, psychological trauma and/or death. (Refer to A-0398)

3. The facility failed to ensure implementation of a safe transfer to a higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]), in accordance with the facility's policy regarding Higher level of care transfer of patients to another facility, when one of 76 sampled patients (Patient 18), was transferred to another hospital for evaluation and treatment, in a hospital van which was not equipped with lifesaving equipment or a licensed staff capable of providing emergency service, after Patient 18 swallowed a foreign object (any item that does not belong in the body).

This deficient practice had the potential for inadequate medical support and compromised monitoring of Patient 18 who was at risk of losing a large amount of blood and damage to his esophagus (canal that connect throat to stomach), which had the potential to result in harm, serious injury or even death. (Refer to A-0398)

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

Based on observation, interview and record review, the facility's Governing Body (the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital's overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) failed to:

1. Ensure oversight on the Nursing Department to ensure that staff (RNs, LVNs [Licensed Vocational Nurses], MHWs [Mental Health Workers]) working in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), accurately and consistently performed Q15 minutes (every 15 minutes) patient rounding (a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety )/and monitoring, in accordance with the facility's policy regarding patient rounding for 25 of 76 involuntary (5150 hold; 72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) and voluntary hold (when a patient agrees to be admitted to a psychiatric unit for treatment, a decision they make on their own or with their guardian's consent) sampled patients (Patients 1, 2, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 42, 43, 44). On 6/5/2025 (at 2:20 p.m.), an altercation occurred between two patients: Patient 1 and Patient 2, in the locked Behavioral Health Unit (BHU), 5th floor (Campus 1). The incident was unwitnessed by both licensed (RN, LVN) and unlicensed healthcare personnel (MHW) assigned to the unit and tasked to conduct Q15-minute patient rounding at the time.

This deficient practice resulted in inadequate monitoring and created a significant safety risk for all patients in the Behavioral Health Unit (BHU) at Campus 1 for several hours, by placing them in an unsafe environment, thereby increasing the risk of self-harm, harm to others, or even death. In addition, this deficient practice potentially resulted in Patient 1 and Patient 2 not being adequately monitored, which led to an unwitnessed altercation. During the incident, Patient 1 sustained a neurological deficit (a possible subdural hematoma, a form of traumatic brain injury involving bleeding) and a confirmed displaced fracture of the right femoral neck, which is a break in the upper part of the thigh bone, just below the ball of the hip joint.


2. Ensure oversight over the Nursing Department to ensure that there was a process for nursing staff to escalate and advocate for one (1) of 76 sampled patients (Patient 18) to receive proper medical attention in a timely manner, when Patient 18 reported swallowing a foreign object (a non-food item is ingested and gets lodged in the gastrointestinal [GI, includes mouth, esophagus- a passage from throat to stomach, stomach and intestines] tract) on 9/6/2025. Patient 18 was sent out to emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) on 9/8/2025 ( 2 days later) and had esophagogastroduodenoscopy (EGD, a medical procedure using a thin, lighted tube [endoscope] to examine the lining of the esophagus, stomach, and the first part of the small intestine) to retrieve the foreign object.

This deficient practice resulted in Patient 18 suffering from having a foreign object lodged in Patient 18's throat for two (2) days. This deficient practice also had the potential to put other patients with similar symptoms at risk for not receiving care in a timely fashion thus compromising patient care and safety.

3. Ensure oversight over the Nursing Department to ensure alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) cases were investigated and reported to the healthcare regulatory agencies (establishes and enforces standards and guidelines to ensure the safety, quality, and efficacy of healthcare services and products) in a timely manner, in accordance with the facility's policy and procedure regarding abuse reporting, for one of 76 patients (Patient 19), when Patient 19 reported an alleged physical abuse to Registered Nurse 1 (RN 1) on 4/23/2025.

This deficient practice compromised the safety of Patient 19 when the facility failed to initiate an investigation, did not remove the alleged staff members from duty, and potentially placed Patient 19 at further risk of abuse. Additionally, it compromised the safety of other patients who may have been at risk for further abuse.

4. Ensure that the facility's policy and procedure (P&P) regarding face-to-face assessments (an in person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]), conducted after initiation of 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) or seclusion (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior) in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), was in alignment with Federal regulatory requirements, when the P&P did not indicate that a Registered Nurse must consult a physician after face-to-face assessment was completed. The physician was not consulted after a face-to- face assessment was completed for two (2) of 76 sampled patients (Patients 7 and 12).

This deficient practice had the potential for inconsistent practices, non-compliance with laws and regulations, and patient harm due to the P&P not reflecting up to date best practices.


Findings:

1. During a review of Patient 1's History and Physical (H&P, a comprehensive clinical document that includes a patient's medical history and findings from a physical examination), dated 6/4/2025, the H&P indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) due to being "agitated (feeling of uneasiness and severe restlessness) and aggressive." The H&P also indicated that Patient 1 was placed on assaultive (safety measures implemented for patients who exhibit or are at risk of exhibiting violent or aggressive behavior) and homicidal precautions (safety interventions used when a patient expresses or demonstrates thoughts, intentions, or behaviors indicating a risk of harming others).

During a review of Patient 1's "Behavioral Admission Assessment," dated 6/4/2025, the record indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU) at 2:45 p.m. on a 5150 Hold (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to others and being gravely disabled (GD, a condition in which a person, due to a mental health disorder, is unable to provide for their basic personal needs such as food, clothing, or shelter)." The record also stated that Patient 1 required "line of sight observation," meaning continuous visual monitoring by staff to ensure immediate intervention if needed, and was placed on 15-minute Close Observation Level II, which involved staff checking on the patient every 15 minutes due to a history of threatening and/or assaultive behavior within the past 30 days.

During a review of Patient 1's "Behavioral Health Daily Nursing Assessment," dated 6/5/2025, the record indicated that on 6/5/2025 Patient 1 continued to remain on 15-minute Close Observation Level II (patient was monitored every 15 minutes due to concerns about potential harm to self or others) and also had assault/aggression precautions in place (implemented due to the patient exhibiting, or being at risk of exhibiting, aggressive or violent behavior; includes increased supervision, environmental safety measures, and use of de-escalation techniques [methods used to reduce the intensity of a conflict or agitation in a person through calm, verbal, and non-verbal communication]).

During a review of Patient 2's History and Physical (H&P), dated 6/3/2025, The H&P indicated that Patient 2 was admitted to the Behavioral Health Unit (BHU) on 6/3/2025 for agitation and aggressive behavior.

During a review of Patient 2's Psychiatric Evaluation, dated 6/3/2025, the record indicated that Patient 2 was admitted on a 5150 Involuntary Hold. The record also indicated that the Hold was initiated due to danger to others after Patient 2 became "increasingly aggressive at the nursing home (a residential facility that provides 24-hour medical and personal care for individuals, who are unable to live independently due to illness, disability, or cognitive decline)."

During a review of Patient 2's "Nursing Progress Note," dated 6/5/2025 at 3:43 p.m., the note indicated that Patient 2 was involved in an altercation with another patient (Patient 1) and stated that he (Patient 2) was defending himself after Patient 1 struck him in the face, specifically on the left cheek and/or jaw.

During a review of Patient 2's "Rounds Sheet, dated 6/5/2025, the sheet indicated that Patient 2 was documented as either lying or sitting in his "BR" (bedroom) for the entire time from 7:00 a.m. to 7:00 p.m.

During a concurrent interview and record review on 9/30/2025 at 3:02 p.m. with the Chief Nursing Officer (CNO), Patient 1's medical record titled, "Nursing Progress Notes," dated 6/5/2025, was reviewed. The CNO stated that, according to the documentation, Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards. The CNO confirmed that the fall was unwitnessed (as per nursing notes documentation), and that Rapid Response Team (RRT, a team of healthcare professionals, often including a critical care nurse and a respiratory therapist, who are quickly dispatched to provide immediate care to a patient who shows signs of acute deterioration within a hospital) was called at 2:20 p.m. on 6/5/2025 after Patient 1 was assessed to have weakness in the lower extremities (both legs), drooping (excessive sagging) on the left side of face, and left arm weakness.

During a review of Patient 1's "Nursing Progress Notes," dated 6/5/2025 at 2:20 p.m., the note indicated the following: on 6/5/2025, Patient 1 was actually witnessed by an EVS (Environmental Services- trained cleaning support staff) worker who witnessed Patient 1 walking in the hallway, attempting to strike another patient (Patient 2). In response, Patient 2 pushed Patient 1, causing Patient 1 to fall backwards and sit down on the floor. A Rapid Response Team (RRT) was called, and Patient 1 was assessed to have bilateral (both) lower extremity weakness and was noted to be losing balance while standing. The note also stated that Patient 1 was transferred to a medical-surgical floor (a general hospital unit for adult patients who need care for a variety of illnesses and surgical recovery, but do not require intensive or highly specialized care) for further evaluation).

During a review of Patient 1's nursing note, dated 6/5/2025 at 2:20 p.m., the note indicated that Patient 1 sustained an unwitnessed fall (meaning the patient had experienced a fall that was not observed by staff or others, and the exact circumstances were unknown).

During further review of Patient 1's nursing notes documentation, dated 6/5/2025 at 2:35 p.m. (late entry), the note indicated that Patient 1 was status post (after) unwitnessed fall, and that Patient 1 began showing signs of facial drooping (sagging) on the left side, along with bilateral (both sides) leg tremors (involuntary, rhythmic shaking or trembling movements in the legs).

During a review of Patient 1's "Nursing Progress Note," dated 6/5/2025 at 4:30 p.m., the note indicated that on 6/5/2025 at 4:00 p.m., Patient 1 was observed with increasing shaking of the left leg and bilateral lower extremities. The note also indicated that during the physician's bedside assessment, Patient 1 was noted to have a bump on the right side of the head, with no bleeding. The note also indicated the following at 4;30 p.m. on 6/5/2025: the family was informed that, due to the fall, Patient 1 had possible fracture of the right hip ... and the physician recommended transferring Patient 1 to a higher level of care, as the patient continued to experience shaking and had a head injury with a possible subdural hematoma (a type of brain bleed that occurs when blood collects in the brain, often caused by head trauma and potentially life-threatening if not treated promptly).

During an interview on 10/1/2025 at 1:31 p.m. with the House Supervisor (HS 1), HS 1 stated that typically the facility conducted daily audit for the completeness of Q 15-Minute rounding sheets (a clinical documentation tool used by healthcare staff to record patient observations at regular intervals [every 15 minutes], designed to monitor patient location, behavior, and safety status, and to ensure staff accountability and timely intervention when needed) to verify staff compliance with patient rounding. However, the HS 1 also said that the paper documentation for patient rounding was not reviewed concurrently with video footage to determine whether the documented patient rounding matched what was observed through the facility's video surveillance cameras.

During a concurrent interview and record review on 10/1/2025 at 2:06 p.m. with the Chief Nursing Officer (CNO), Patient 1's "Patient Rounding Sheet, dated 6/5/2025 (covering the time from 7:00 a.m. to 4:30 p.m.), was reviewed. The rounding sheet indicated that Patient 1 was not agitated during this time frame (7 a.m. to 4;30 p.m.) and was consistently documented as either lying or sitting in their (Patient 1) bedroom. Specifically:
-At 1:00 p.m., Patient 1 was documented as either lying or sitting
-At 2:15 p.m., Patient 1 was again documented as either lying or sitting
-This same documentation pattern continued through 2:45 p.m.
-The Chief Nursing Officer (CNO) verified that this documentation was possibly inaccurate, noting that the Rapid Response Team was called at 2:20 p.m., and Patient 1 was found in the hallway by Patient 2's room, yet no deviation or incident was reflected in the rounding sheet during that time.

During further interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM stated that the administration was no longer certain whether the entire incident (between Patient 1 and Patient 2) had been witnessed by the Environmental Service (EVS) worker. The ADM confirmed that nursing staff and mental health workers did not witness the altercation between the two patients (Patient 1 and Patient 2). The ADM also stated that he (ADM) could not verify whether staff were conducting Q15-minute patient rounding on that day (6/5/2025). The ADM said, "They (referring to the facility staff) should have done it (referring to the Q 15-minute rounding)- this is the expectation," and noted that staff verbally confirmed they were conducting their rounds. However, the ADM also confirmed that the video footage, on 6/5/2025, was never reviewed to verify whether staff actions aligned with what was documented and reported on the day of the incident between Patient 1 and Patient 2.

During a concurrent observation, interview and video footage review on 10/1/2025 at 11:00 a.m. with Nurse Manager (NM 1) of BHU and Medical-Surgical (Med/Surg), the video footage dated 9/19/2025, from 1:00 a.m. to 2:30 a.m., was reviewed. The following events were observed at the indicated timestamp in the video:

9/19/2025 at 1:00 a.m.
-No staff seen conducting patient rounding in any of the video angles.

9/19/2025 at 1:15 a.m.
-No staff seen conducting patient rounding, in any video of the angles.

9/19/2025 at 1:30 a.m.
-No staff seen conducting patient rounding in any of the video angles

9/19/2025 at 1:45 a.m.
-no staff seen doing rounding, one patient seen in wheelchair going down hallway with no staff present (camera angle 6)

9/19/2025 at 2:00 a.m.
-two staff members seen rounding patient rooms 1, 2, 3 and 4 (camera angle 4) but not seen checking other rooms. Confirmed with NM1 that one was licensed staff (RN) and the other individual was the resource nurse.

9/19/2025 at 2:15 a.m.
-two staff members sitting in chairs in BHU hallway on Camera angles 6 and 7. Not getting up to conduct rounding on patients. NM 1 was unable to identify the two staff members.

9/19/2025 at 2:30 a.m.
-Same two staff members sitting in chairs in BHU hallway, not getting up to conduct rounding as seen in camera angles 6 and 7. NM 1 was unable to identify the two staff members

During an interview on 10/1/2025 at 11:47 a.m. with NM 1, NM 1 stated the expectation was for staff to do Q 15-minute rounding to check on the patients, ensure safety and known location. Purpose of rounding was to know the location of the patients and make sure the patient was safe. "It allows us to notice any changes in behaviors, so that staff can address them accordingly." NM 1 verified that rounding was only completed once for 4 rooms (rooms 1,2, 3, and 4) but not the whole unit within the 1.5 hour of video reviewed for Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44.

During a concurrent interview and record review on 10/1/2025 at 2:02 p.m. with NM 1, Patient 20's "Patient Rounds Sheet" dated 9/18/2025, was reviewed. NM 1 stated that the rounding sheet began on 9/18/2025 at 7:00 a.m. and ended on 9/19/2025 at 6:45 a.m. NM 1 stated that all patient rounding sheets being reviewed started around the same time (7 a.m. to 6:45 a.m.), which captures the entire 24 hours.

During an interview on 10/3/2025 at 3:44 p.m. with NM 1, NM 1 stated that, after reviewing the video footage and discussing the matter with the Chief Nursing Officer (CNO), it appeared that staff were documenting Q15-minute checks as completed, despite not actually performing them. NM 1 emphasized the importance of holding staff accountable and acknowledged that this practice falls under the category of falsification of records.

During an interview on 9/30/2025 at 11:35 a.m. with the Charge Nurse (CN) 4, CN 4 stated that licensed nurses were required to conduct patient rounds every hour and document on the patient's rounding sheet. CN 4 stated that licensed nurses could also help the MHW (Mental health Worker) with conducting Q15-minute rounding.

During an interview on 10/1/2025 at 2:12 p.m. with the Chief Nursing Officer (CNO), the CNO confirmed that Q15 (every 15 minutes) patient safety checks should be conducted to:
-Ensure patient safety,
-Confirm responsiveness,
-Assess patient behavior,
-Document patient activity.

During an interview on 10/1/2025 at 3:17 p.m. with the Chief Nursing Officer (CNO) and the Hospital Administrator (ADM), the CNO stated that the incident (involving Patients and 2) was investigated internally and that all key team members were interviewed, including the Environmental Services (EVS) worker who witnessed the altercation between Patient 1 and Patient 2 in the hallway. The ADM confirmed that, because of the EVS worker's statement regarding the witnessed fall and the altercation between the two patients (Patient 1 and Patient 2), the facility had no reason to review the video footage to verify what happened during the incident.

During an interview on 10/3/2025 at 3:34 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following regarding Q-15 Minutes rounding: "Q15-minute safety checks are conducted to monitor each patient's condition and behavior at regular 15-minute intervals. The purpose is to identify any signs of agitation, frustration, or behaviors that may indicate a risk to the patient or others. These checks are preventive in nature and allow staff to intervene early and provide therapeutic support as needed. We use this time to assess whether patients are escalating and to respond in a way that promotes safety and de-escalation. While staff are expected to document these checks accurately, it's also important to verify that the documentation aligns with actual observations, such as through video review when available."

During an interview on 10/6/2025 at 10:55 a.m. with the Chief Executive Officer (CEO), Hospital Administrator (ADM), and the Chief Nursing Officer (CNO), the CEO stated that he (CEO) was a voting member of the Governing Body (GB), responsible for participating in decisions regarding hospital operations and quality oversight. The Hospital Administrator and the CNO stated that they were non-voting members of the GB, attending meetings and contributing to discussions but not participating in formal decision-making or voting processes.

During an interview on 10/6/2025 at 10:56 a.m. with the Chief Executive Officer (CEO), the CEO stated that the Governing Board (GB) serves as the ultimate resource, responsible for overseeing operations, ensuring that policies and procedures were properly implemented, and maintaining compliance with regulatory agencies. The CEO also emphasized that the responsibility for ensuring overall patient quality of care and safety lies with the Governing Board.

During an interview on 10/6/2025 at 11:42 a.m. with the Chief Executive Officer (CEO), the CEO stated that Q15-minute rounding was something that must be done thoroughly and consistently, emphasizing its importance in maintaining visual monitoring for the patients served, particularly due to the volatility of behavioral health patients. The CEO was not aware that Q15-minute rounding was not being conducted in the Behavioral Health Unit (BHU) and acknowledged that it was something that needed to be implemented.

During an interview on 10/6/2025 at 11:44 a.m. with the Chief Nursing Officer (CNO), the CNO stated that Q15-minute rounding was considered "a given" in the Behavioral Health Unit (BHU). The CNO described the Q15-minutes rounding as an automatic process and a standard practice for BHU nurses. The CNO said that leadership had been focused on quality improvement projects on the medical-surgical floors and expressed trust in staff to perform the rounding as expected. However, the CNO acknowledged that there was no audit process in place to ensure that the rounding was actually being completed.

During a review of the facility's Bylaws (formal documents that establish the operational framework, governance structure, and strategic direction of a hospital and its medical staff. They define the hospital's purpose, set policies, ensure compliance with laws and accreditation standards, and outline the relationship between the governing body and the medical staff. Key functions include managing hospital finances and resources, selecting and evaluating leadership, and ensuring quality and patient safety ), dated 5/2019, the Bylaws indicated the following: "Governing Board is a committee appointed by the Facility. As the hospital's Governing Body, it is responsible for setting policy, ensuring quality patient care, and supporting institutional planning and management. Its actions align with the hospital's mission to deliver safe, compassionate, and cost-effective care that upholds patient dignity. The Governing Board reports directly to the Board of Directors, which retains ultimate oversight."

During a review of the facility's Bylaws, dated 5/2019, the Bylaws indicated the following: "The Governing Board, through the Administrator, shall provide whatever administrative assistance is reasonably necessary to support and facilitate the implementation and ongoing operations of these quality review and evaluation activities. These quality review and evaluation activities shall ensure that the same level of overall quality and appropriateness of care is provided to all patients of the Hospital.Monitoring and evaluating the quality and appropriateness of patient care through a valid and reliable quality assessment program."

During a review of the facility's policy and procedure (P&P) titled, "Every 15 Min Rounds, Patient," last revised 3/2025, the P&P indicated the following: "It is the policy of [the facility] Behavioral Health Services to monitor the safety/locations of all patients on a continuing basis. Such rounds will be conducted at 15-minute intervals. Patients requiring additional observation will be evaluated individually, and physician orders will be generated to address the safety/needs of the patient ...Floor staff will conduct patient rounds at 15-minute intervals, including the location of the patient and his/her condition, and will verify completion of such rounds by their initial and signature. In order to accurately monitor safety and condition of patients at night and/or during non-wakeful times, staff will visually observe chest movement of the patient to ascertain respiratory effort."

During a review of the Facility's policy and procedure (P&P) titled, "Observation Levels System," dated 3/2025, the P&P indicated, "It is the policy of [the facility] to initiate and provide the appropriate observation level of patient's behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient's Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress .... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress." B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient's Observation Rounds sheet every 15 minutes ..."

2. During a review of Patient 18's Behavioral Health History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/6/2025 at 1445 (2:45 p.m.), the H&P indicated, Patient 18 was admitted to the facility's Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) on 5150-hold (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to self (DTS) stating he (Patient 18) wanted to run into traffic and a danger to others (DTO) for wanting to hurt people in Mexico.

During a review of Patient 18's "Nursing Progress Notes," dated 9/6/2025 at 1808 (6:08 p.m.), the Nursing Progress Notes indicated Patient 18 reported to nurse (RN 1) he swallowed a razor, Nurse Practitioner (NP 1) was notified, and order was given to monitor Patient 18 and send to emergency department if with symptoms.

During a review of Patient 18's "Nursing Progress Notes," dated 9/7/2025 at 1608 (4:08 p.m.), the Nursing Progress Notes indicated Patient 18 stated, "you never did anything about the razor I swallowed yesterday." There was no record of a nurse notifying the physician regarding Patient 18's statement on 9/7/2025.

During a review of Patient 18's "Nursing Progress Notes," dated 9/8/2025 at 7:46 a.m., the Nursing Progress Notes indicated Patient 18 stated he (Patient 18) swallowed a razor that he hid inside his "butt."

During a review of Patient 18's "Nursing Progress Notes," dated 9/8/2025 at 1828 (6:28 p.m.), the Nursing Progress Notes indicated Patient 18 stated he (Patient 18) was going to swallow a razor and also stated he swallowed a razor "send me to ER (emergency room/emergency department) now." The notes also indicated that Patient 18 was observed spitting out small amount of serosanguinous drainage (pink or light red color) from mouth.

During a review of Patient 18's" Discharge Summary (a comprehensive medical document created when a patient leaves a hospital or other care setting, detailing the reason for admission, the care received, key findings, and post [after]-discharge instructions)," dated 9/9/2025, the discharge summary indicated Patient 18 was transferred to another facility (on 9/8/2025) for swallowing a foreign object and was later admitted at the receiving facility.

During an interview on 10/2/2025 at 11:00 a.m. with RN 1, RN 1 stated Patient 18 reported swallowing a razor on 9/6/2025. RN 1 stated she (RN 1) reported it to NP 1 on the floor and was told to monitor Patient 18 and send Patient 18 to ER if something was abnormal. RN 1 further stated no order for x-ray (a diagnostic imaging procedure that uses a small dose of high-energy radiation to create pictures of the inside of the body) was given on 9/6/2025.

During an interview on 10/1/2025 at 10:48 a.m. with Registered Nurse 3 (RN 3), RN 3 stated that on 9/8/2025, Patient 18 went to the nursing station and reported he (Patient 18) swallowed something, "we (staff) were not sure if he (Patient 18) did, later he (Patient 18) started spitting out blood and we (staff) called the Nurse Practitioner (NP 2) and patient was sent to Emergency Department via facility van."

During a review of Patient 18's "Operative Report," dated 9/9/2025, the Operative Report indicated, Patient 18 underwent Esophagogastroduodenoscopy (EGD, medical procedure that allows doctors to examine throat, stomach and small intestine) on 9/9/2025 with "a huge metallic foreign body ... very thick metal ... measured about 6 cm in length, 2 cm in width," removed from the esophagus (canal connecting the throat to the stomach).

During an interview on 10/1/2025 at 12:24 p.m. with the Behavioral Health Unit Manager (NM 3), NM 3 stated that for a patient who reports they swallowed a razor, staff should have called 911 because "we (staff) do not know what is going on with patient internally."

During an interview on 10/1/2025 at 1:33 p.m. with BHU manager (NM 3), NM 3 stated Charge Nurse or primary nurse should assess patient, call the doctor, and send patient to ER for evaluation to verify patient did not swallow anything. "We (staff) cannot ignore what patients say, in this case patient (Patient 18) should have been sent to higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]) to verify what he (Patient 18) was saying."

During an interview on 10/1/2025 at 3:13 p.m. with house supervisor (HS 3), HS 3 stated she (HS 3) was doing rounds on 9/8/2025 and overheard Patient 18 report to Charge Nurse (CN) 6 that he (Patient 18) swallowed a razor.

During an interview on 10/1/2025 at 3:56 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: when a patient reported to a nurse that he or she had swallowed a foreign object, the nurse should assess and notify the physician right away. Depending on the symptoms, the nurse may call 911 for emergency (patient's bleeding or unstable vital signs) or send the patient to emergency department for higher level of care. The CNO stated, "Nurse should take the report seriously and not to make any assumption."

During an interview on 10/1/2025 at 4:27 p.m. with Chief of Staff (COS, head of all medical staff), COS

Based on interview and record review, the facility's Governing Body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital's overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) failed to ensure oversight on its contracted services in relation to their performance measures, when the facility's Quality Assessment and Performance Improvement committee (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), under the direction of the Governing Body failed to identify quality and performance issues for contracted services, implement corrective or improvement actions, and ensure ongoing monitoring and sustainability of implemented corrective actions, when there was a delay in obtaining a head computed tomography scan (CT scan, a medical imaging procedure that creates detailed cross-sectional images of the body), performed by a contracted company, for one of 76 sampled patients (Patient 1). On 6/5/2025, Patient 1, was involved in a patient-to-patient altercation with Patient 2. As a result, Patient 1 sustained a hip fracture and exhibited neurological deficits (impairment in the function of the nervous system) as was manifested by trembling (shaking) of arms and legs, right pupil sluggish response, right upper eyelid drooping (sagging), and left-hand grip weakness. thus, requiring a STAT (immediately) CT scan, but was not carried out by the contracted radiology company as ordered by the physician.

This deficient practice resulted in a delay in obtaining a head (CT) scan for Patient 1. The delay in diagnostic imaging potentially contributed to a delay in diagnosis for Patient 1. Furthermore, the facility's failure to assess and monitor the performance of contracted services, such as CT imaging, through its QAPI program, presented a missed opportunity to identify, analyze, correct, and monitor systemic issues related to delayed diagnostic performance times, placing all patients requiring contracted imaging services at risk.

Findings:

During a review of Patient 1's History and Physical (H&P, a comprehensive clinical document that includes a patient's medical history and findings from a physical examination), dated 6/4/2025, the H&P indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU) due to being "agitated (a feeling of uneasiness and severe restlessness) and aggressive." The H&P also indicated that Patient 1 was placed on assaultive (safety measures implemented for patients who exhibit or are at risk of exhibiting violent or aggressive behavior) and homicidal precautions (safety interventions used when a patient expresses or demonstrates thoughts, intentions, or behaviors indicating a risk of harming others).

During a review of Patient 2's Psychiatric Evaluation, dated 6/3/2025, the record indicated that Patient 2 was admitted on a 5150 Involuntary Hold (a legal provision under the State law, that allows for the involuntary detention of an individual for up to 72 hours when they are deemed a danger to themselves, others, or are gravely disabled [a condition in which a person, due to a mental health disorder, is unable to provide for their basic personal needs such as food, clothing, or shelter ] due to a mental health disorder). The record also indicated that the 5150 Hold was initiated due to danger to others after Patient 2 became "increasingly aggressive at the nursing home (a residential facility that provides 24-hour medical and personal care for individuals, who are unable to live independently due to illness, disability, or cognitive decline)," from which Patient 2 was transferred from.

During a concurrent interview and record review on 9/30/2025 at 3:02 p.m. with the Chief Nursing Officer (CNO), Patient 1's medical record titled, "Nursing Progress Notes," dated 6/5/2025, was reviewed. The CNO stated that, according to the documentation, Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards. The CNO confirmed that the fall was unwitnessed (as per nursing notes documentation), and that Rapid Response Team (RRT, a team of healthcare professionals, often including a critical care nurse and a respiratory therapist, who are quickly dispatched to provide immediate care to a patient who shows signs of acute deterioration within a hospital) was called at 2:20 p.m. after Patient 1 was assessed to have weakness in the lower extremities (both legs), drooping (excessive sagging) on the left side of face, and left arm weakness.

During a concurrent interview and record review on 10/1/2025 at 2:34 p.m. with the Nurse Manager of the Behavioral Health Unit (NM 2), Patient 1's physician orders dated 6/4/2025 and 6/5/2025 were reviewed. The records indicated that Patient 1 had two (2) Computed Tomography (CT, a medical imaging procedure that creates detailed cross-sectional images of the body) orders placed, specifically:

-6/4/2025 at 5:21 p.m. - Order for CT head to rule out injury (due to a possible self-inflicted injury to the head)
-6/5/2025 at 3:32 p.m. - STAT CT head due to fall (unwitnessed fall after a patient-to-patient altercation between Patient 1 and Patient 2)
-The NM 2 said she (NM 2) was unaware of the timeframe for performing CT diagnostic imaging and would need to refer to the policy. NM 2 also stated that the CT head ordered on 6/4/2025 resulted on 6/5/2025 at 2:01 p.m., and the STAT (immediately) CT head ordered on 6/5/2025, was never completed. The NM 2 also said, that according to documentation in Patient 1's nursing notes, dated 6/5/2025, Patient 1 was transferred to a higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]) on 6/5/2025 at 4:46 p.m. via 9-1-1 to rule out (r/o) stroke (brain attack) or subdural hematoma (a collection of blood that accumulates in the brain).

During an interview on 10/2/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM stated that during the internal investigation of the incident between Patient 1 and Patient 2, the team did not identify delays in CT scan imaging. The ADM said that CT was a contracted third-party provider and there was no actual timeframe for CT order timeliness. The ADM said that typically the facility was not going to wait for a CT scan if the patient was showing signs of worsening, and the patient (Patient 1) was transferred to a higher level of care.

During an interview on 10/2/2025 at 3:37 p.m. with the Chief Nursing Officer (CNO), the CNO said that CT scan orders (a third-party, contracted service) must be called in by the staff to schedule, and the CT provider would typically inform the nurses of the earliest time they are available to perform the CT. The CNO also said that timeframe was not specified in the contract.

During the interview on 10/3/2025, at 1:59 p.m. with the Vice President of Operations (VPO), the VPO confirmed that the contract titled, "Hospital Diagnostic Services Agreement," was current and valid. The VPO further verified that this agreement represented the formal arrangement between the hospital and the diagnostic imaging service provider responsible for delivering on-site Computed Tomography (CT) services at the hospital. The VPO also confirmed that the hospital's governing board was the final approving authority for this contract (the governing board holds the ultimate decision-making power to authorize and execute the contract).

During an interview on 10/3/2025 at 2:01 p.m. with the Vice President of Operations (VPO), the VPO said that each contracted service should have its own performance improvement process and report data to the Quality Council (part of the QAPI program), then to the Medical Executive Committee (MEC, a body of physicians responsible for governing the hospital's medical staff, focusing on quality of care, professional conduct, and the effectiveness of medical activities), and finally to the Governing Body (GB).

During an interview on 10/3/2025 at 3:36 p.m. with the Vice President of Operations (VPO), the Hospital Administrator (ADM), Chief Nursing Officer (CNO), and both Nurse Managers of the Behavioral Health Unit (NM 1 and NM 2), the CNO and the ADM stated the following regarding QAPI and performance monitoring for CT diagnostic imaging contracted services:

- The facility did not have a formal QAPI program specifically for CT imaging turnaround times. No issues had been ever reported or identified regarding CT order delays. Monitoring is limited to CT requests and result reporting.
-The VPO said that performance improvement for CT diagnostic procedures included identifying delays and notifying physicians. The CNO and NM 1 then also said that since CT imaging was contracted out, STAT (done immediately, without delay) orders may not always be fulfilled immediately, and physicians must be informed when a CT cannot be performed as requested, so the physician can transfer out the patient, instead. The CNO then said that delays in both STAT and routine CT orders could impact patient care, particularly in time-sensitive cases like stroke (brain attack). In such situations, timely imaging was critical for diagnosis and treatment decisions.

During a follow-up interview on 10/3/2025 at 4:20 p.m. with Hospital Administrator (ADM), Chief Nursing Officer (CNO), Nurse Managers (NM 1 and NM 2) of Behavioral Health Unit (BHU), the CNO and NM 1 said that there had been past instances where physicians ordered CT scans and experienced delays in timely monitoring. The CNO said that these delays prompted discussions focused on improving communication between nursing staff and the radiology department. The NM 1 also confirmed that no formal tracking data or measurable outcomes were available to assess improvement, although stated that improvement in turn-around times for radiology tests, had been achieved. The CNO said that since nursing staff was responsible for bedside care, nursing staff faced challenges in monitoring QAPI measures addressing any possible performance issues with CT imaging. The NM 1 and CNO both said that in the past nursing staff achieved improved timeliness of CT orders by instructing nurses to directly communicate with the radiology department and notify physicians when a STAT order might be delayed due to the involvement of a third-party radiology contractor to allow physicians to make timely decisions, including transferring the patient if necessary, rather than waiting for CT scan completions.

During an interview on 10/6/2025 at 10:55 a.m. with the Chief Executive Officer (CEO), Hospital Administrator (ADM), and Chief Nursing Officer (CNO), the CEO stated that he (CEO) was a voting member of the Governing Body (GB), responsible for participating in decisions regarding hospital operations and quality oversight. The Hospital Administrator and the CNO stated that they were non-voting members of the GB, attending meetings and contributing to discussions but not participating in formal decision-making or voting processes.

During an interview on 10/6/2025 at 11:30 a.m. with the Chief Executive Officer (CEO), the CEO stated the following: the facility's governing body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital's overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) ultimately provided oversight for all contracted services. The contracted services were required to follow the facility's policies and procedures.

During a review of the agreement titled, "Hospital Diagnostic Service Agreement," dated 2/2024, the agreement indicated that "the CT diagnostic [Brand] company does not provide emergency services. It is willing to make accommodations to the Facility and to provide services within 6 hours of the time of the request of said service, and at additional cost (STAT) service fee."

During a review of the facility's policy and procedure (P&P) titled, "Contract Services," dated 3/2022, the P&P indicated the following, "The Governing Board must approve all contractual agreements that involve provision of care, treatment, and services. The contracts clearly describe the type and scope of the contractor's services, and performance measure expectations are included. Leaders monitor contracted services by evaluating these services in relation to their performance measures. The governing body reviews the performance of contract services on an annual basis."

During a review of the facility's Bylaws (foundational documents that outline the hospital's structure, purposes, and the medical staff's organization and responsibilities ), dated 5/2019, the Bylaws indicated the Governing Board is a committee appointed by the Facility. As the hospital's Governing Body, it is responsible for setting policy, ensuring quality patient care, and supporting institutional planning and management. Its actions align with the hospital's mission to deliver safe, compassionate, and cost-effective care that upholds patient dignity. The Governing Board reports directly to the Board of Directors, which retains ultimate oversight.

During a review of the facility's Bylaws, dated 5/2019, the Bylaws indicated the following: "The Governing Board, through the Administrator, shall provide whatever administrative assistance is reasonably necessary to support and facilitate the implementation and ongoing operations of these quality review and evaluation activities. These quality review and evaluation activities shall ensure that the same level of overall quality and appropriateness of care is provided to all patients of the Hospital. Monitoring and evaluating the quality and appropriateness of patient care through a valid and reliable quality assessment program."

Based on interview and record review, the facility's governing body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital's overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) failed to ensure appropriate oversight on its contracted services (refer to specialized tasks performed by external, independent providers for a specific fee, outlined in a formal agreement that details the scope, timeline, and payment terms) staff in order to provide safe patient care, in accordance with the facility's contract agreement and the policy on Patient Rights, for one of 76 sampled patients (Patient 7), when a security guard (SG 1), from a contracted company, hit Patient 7 on 10/13/2024.

This deficient practice resulted in Patient 7 being physically abused (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by SG 1 and resulted in bruises on the cheek. This deficient practice also had the potential for psychological trauma for Patient 7.

Findings:

During a review of Patient 7's "Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 10/12/2024, the Psych Eval indicated Patient 7 was admitted to the facility on 10/11/2024 due to increased agitation (feeling of irritability or severe restlessness) with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), paranoid type (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions).

During a review of Patient 7's "Interdisciplinary Team Progress Notes Nursing (nursing notes)," dated 10/13/2024, the notes indicated, on 10/13/2024 at 10:40 p.m., Patient 7 had increased aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) behavior verbally and physically towards staff ... called other staff member to help intervene with patient (Patient 7) behavior ... Patient (Patient 7) stayed in bed still irritable and continue to be aggressive towards staff. Patient (Patient 7) attempted to swing at staff ..."

During an interview on 10/3/2025 at 11:09 a.m. with the House Supervisor (HS 5), HS 5 stated the following: on 10/13/2024 at night, she (HS 5) received a report involving Patient 7 being physically abused (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by a security guard (SG 1). HS 5 spoke with SG 1. SG 1 tried to intervene as Patient 7 was being aggressive. SG 1 admitted to HS 5 that he (SG 1) hit Patient 7 because he (SG 1) got mad (at Patient 7) and retaliated. HS 5 assessed Patient 7 and noted Patient 7 had bruises on his (Patient 7's) cheek. The incident was also witnessed by other staff (Patient 7's primary nurse and two other Mental Health Workers). SG 1 was sent home immediately. The incident was reported to department nurse manager (NM 1) and the Chief Nursing Officer (CNO) for investigation and report. HS 5 also stated she (HS 5) did not see SG 1 working anymore since then.

During a review of SG 1's termination letter issued by facility's security guard contracted services (CS 3), dated 10/17/2024, the termination letter indicated SG 1 was terminated on 10/17/2024 due to a serious incident that occurred involving a patient (Patient 7) on 10/13/2024. The termination letter also indicated, "this type of conduct is unacceptable and goes against the values and policies of [the organization] ... it has been determined that immediate termination is the appropriate course of action."

During an interview on 10/3/2025 at 2:07 p.m. with the Chief Executive Officer (CEO 2) for facility's security guard contracted services (CS 3), CEO 2 stated SG 1 was terminated after confirming the incident with Patient 7 for physical abuse. CEO 2 stated all contracted staff should follow facility's policies and procedures.

During an interview on 10/6/2025 at 11:30 a.m. with the Chief Executive Officer (CEO), the CEO stated the following: the facility's governing body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital's overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) ultimately provided oversight for all contracted services. The contracted services were required to follow the facility's policies and procedures.

During a review of the facility's contract with CS 3 titled, "Cardio-Pulmonary Ancillary Services," dated 8/1/2022, the "Cardio-Pulmonary Ancillary Services" indicated, "Compliance ... 4.1. Cooperation with Compliance Efforts of Hospital. [CS 3] agrees to cooperate with [the facility] as necessary so that [the facility] and [CS 3] meet all requirements imposed by law or ordinance or established by the rules and regulations of any federal state or local agency ...to set standards governing the operation of [the facility] and the activities of [CS3] ... 4.2 Compliance with Law. In the performance of their respective responsibilities and obligations hereunder, [the facility] and [CS 3] shall comply with the requirements of all federal, state and local laws, regulations and ordinances and policies and procedures and Governing Bylaws applicable to their respective organizations and activities."

During a review of the facility's policy and procedure (P&P) titled, "Patient's Rights," dated 5/2025, the P&P indicated, "This policy applies to all employees, medical staff, volunteers, contractors and students providing care or services within [the facility] ... Patient Rights ... All patients receiving care at [the facility] have the rights to ... 6. Safety ... Receive care in a safe environment, free from all forms of abuse, harassment, or restraints that are not medically necessary."

Based on observation, interview and record review, the facility's governing body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital's overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) failed to ensure oversight over its contracted services by failing to maintain a current contract, in accordance with the facility's policy titled, "Vendor Agreements," for one of three sampled contracted services (CS 1, refer to specialized tasks performed by external, independent providers for a specific fee, outlined in a formal agreement that details the scope, timeline, and payment terms) when the contract expired since June 2024.

This deficient practice resulted in CS 1 providing services to the facility's patients without a current contract which may lead to the provision of services outside the contract agreement and substandard quality of care to patients that may result in patient harm and/or death.

Findings:

During a concurrent observation and interview on 10/1/2025 at 8:33 a.m. with the facility's contracted service (CS 1) clinic physician (MD 1) at the CS 1 clinic, CS 1 clinic was open with clinic staff presently working. MD 1 stated he (MD 1) provided medical screening for patients at the clinic and determined if the patients were medically cleared to be admitted to the facility as inpatients.

During an interview on 10/1/2025 at 10:45 a.m. with the House Supervisor (HS 2), HS 2 stated the following: the facility was contracted with CS 1. The facility would receive admissions from CS 1 clinic after patients were medically cleared by the CS 1 physicians.

During an interview on 10/3/2025 at 1:54 p.m. with the Vice President of Operation (VPO), VPO stated she (VPO) was responsible for reviewing all facility's contracts on an annual basis to ensure contracts were current (up to date) and all contract requirements were met. VPO stated she (VPO) reported to the facility's Chief Executive Officer (CEO) directly and would get CEO's approval if there were any changes or updates in contract agreement that needed to be made.

During a concurrent interview and record review on 10/3/2025 at 2:08 p.m. with VPO, the facility's contract with CS 1 titled, "Service Agreement," dated 10/20/2023, was reviewed. The "Service Agreement" indicated, "Term and Termination: a. Term. The initial term of this Agreement ("Initial Term") shall be 12 MONTHS commencing on the Effective Date 6/1/2023. At the end of the Initial Term, the Agreement may be renewed or extended for any period upon the mutual written agreement of the Parties." VPO stated the following: She (VPO) thought the contract agreement was "auto-renew (automatic renewal)." The VPO also said the contract expired in June 2024 and was no longer active. There was no written renewal statement with CS 1. VPO also stated the governing body oversaw all contract services.

During an interview on 10/6/2025 at 11:33 a.m. with the Chief Executive Officer (CEO), the CEO stated the following: he (CEO) was part of the Governing Body (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital's overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health). The GB was responsible for providing oversight for all contract services. Contract must be current, or it was not relevant. There would be areas of service oversight and not accounted for, should the contract be not reviewed appropriately by the facility. All services must be reviewed, communicated, clearly spelled out, and updated in the contract agreement by the controller (GB's designee) and with the GB's approval. The GB was under the assumption that the contract with CS 1 was on auto-renew. GB was not aware the contract with CS 1 had expired (since June 2024).

During a review of the facility's policy and procedure (P&P) titled, "Vendor Agreements," dated 3/2025, the P&P indicated, "All agreements entered into on behalf of the organization must be properly authorized, reviewed, documented, and maintained in accordance with applicable laws, regulations, and organizational procedures."

Based on observation, interview and record review, the facility failed to ensure that patients received care in a safe environment when Q 15-minute (every fifteen-minute) observation patient rounding (a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety)/monitoring, was not correctly and consistently performed for 56 of 76 sampled 5150 (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) patients (Patient 1, Patient 2, Patient 14, Patient 15, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 42, Patient 43, Patient 44, Patient 45, Patient 46, Patient 47, Patient 48, Patient 49, Patient 50, Patient 51, Patient 52, Patient 54, Patient 55, Patient 56, Patient 57, Patient 58, Patient 59, Patient 60, Patient 61, Patient 62, Patient 63, Patient 64, Patient 65, Patient 66, Patient 67, Patient 68, Patient 72, Patient 73, Patient 74, Patient 75, Patient 76), in accordance with the facility's policy on patient rounding for both 5150 and voluntary hold (when a patient agrees to be admitted to a psychiatric unit for treatment, a decision they make on their own or with their guardian's consent) patients.

This deficient practice resulted in 5150 patients in the BHU (Behavioral health Unit, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) unit in Campus 1 and Campus 2 inadequately monitored for hours and had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, and potentially can result to death. Patient 1 and Patient 2 had an unwitnessed altercation in which Patient 1 sustained a subdural hematoma (a form of traumatic brain injury involving bleeding) and a displaced fracture (broken bone) of the right femoral neck (the narrow, connecting part of the femur (thigh bone) that links the ball-shaped head of the femur to the long shaft of the bone) thus needed to be transferred out for higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]).

On 10/2/2025 at 2:31 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the Chief Nursing Officer (CNO), Manager of Medical-Surgical and Behavioral Health Unit (NM 1), Hospital Administrator (ADM), Manager of Behavioral Health Unit (NM 2 [from Campus 2]), Director of Behavioral Health Unit (DIR 1 [from Campus 2]), and Manager of Behavioral Health Unit (NM 3 [from Campus 2]). The facility failed to ensure that Q-15 (every fifteen-minute) observation patient rounding (a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety )/monitoring, was correctly and consistently performed for 56 of 76 sampled 5150 (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) patients (Patient 1, Patient 2, Patient 14, Patient 15, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 42, Patient 43, Patient 44, Patient 45, Patient 46, Patient 47, Patient 48, Patient 49, Patient 50, Patient 51, Patient 52, Patient 54, Patient 55, Patient 56, Patient 57, Patient 58, Patient 59, Patient 60, Patient 61, Patient 62, Patient 63, Patient 64, Patient 65, Patient 66, Patient 67, Patient 68, Patient 72, Patient 73, Patient 74, Patient 75, Patient 76), in accordance with the facility's policy on patient rounding for both 5150 and voluntary hold patients. This deficient practice resulted in 5150 patients in the BHU (Behavioral health Unit, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) unit in Campus 1 and Campus 2 being inadequately monitored for hours and had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, and potentially can result to death. Patient 1 and Patient 2 had an unwitnessed altercation in which Patient 1 sustained a subdural hematoma (a form of traumatic brain injury involving bleeding) and a displaced fracture (broken bone) of the right femoral neck (the narrow, connecting part of the femur (thigh bone) that links the ball-shaped head of the femur to the long shaft of the bone) thus needed to be transferred out for higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]).

Patient 1 was admitted to the BHU (locked) unit on 6/4/2025 due to "agitated (feeling of uneasiness and severe restlessness), aggressive" behavior and for increasing and assaultive behavior (actions likely to cause physical harm or danger to another person) towards staff, and was placed on a 5150 hold for DTO (danger to self)/GD (Grave Disability [a situation where a person is unable to provide for their basic needs due to a mental health disorder]).

Patient 2 was admitted to the BHU unit on 6/3/2025 due to agitation and increasingly aggressive behavior, and was placed on a 5150 involuntary hold for danger to others.

During a review of Patient 1's "Nursing Progress Note," dated 6/5/2025 at 4:30 p.m., the note indicated that a physician who was at Patient 1's bedside noted a head bump on Patient 1's right head on 6/5/2025. There was no other documented evidence that Patient 1 was admitted already with a head bump on 6/4/2025

On 6/5/2025 at 2:20 p.m., an altercation occurred between Patient 1 and Patient 2 in the locked Behavioral Health Unit (BHU), 5th floor (Campus 1). Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards and later was confirmed that Patient 1 sustained a right hip fracture (a break in the upper portion of the right femur (thighbone, specifically where it connects to the hip joint on the right side of the body). Patient 1 was also later assessed to show signs and symptoms of neurological deficit (an impairment or loss of function in the nervous system): weakness in the lower extremities (refers to a reduction in muscle strength in the legs, which can affect a person's ability to stand, walk, maintain balance, or perform daily activities), drooping on the left side of face (a unilateral sagging or weakness of the facial muscles, typically on one side of the face), and left arm weakness and was transferred to a higher level of care. There was also no video footage available for review of the incident that happened on 6/5/2025 because the facility only kept the video footages for 10 days in Campus 1. The incident was unwitnessed (as documented in the nursing progress notes) by both licensed (RN [Registered nurse], LVN [licensed Vocational Nurse]) and unlicensed (MHW [Mental Health Worker]) healthcare personnel assigned to the unit at the time.

During the time frame of the incident (on 6/5/2025 between Patients 1 and 2), the Q15-minute observation log on 6/5/2025, indicated that Patient 1 was not agitated (feeling of uneasiness and severe restlessness) and was consistently documented as either lying or sitting in his (Patient 1) room. The Chief Nursing Officer (CNO) verified that this documentation was possibly inaccurate, noting that the altercation occurred at 2:20 p.m. on 6/5/2025, yet no deviation or incident was reflected in the rounding sheet during that time. The CNO also confirmed that the video footage of the incident involving Patient 1 and Patient 2 was not reviewed by the facility during the internal investigation to verify whether the Q15-minute observation documentation accurately reflected the patients' actual activity and behavior at the time of the incident.

During a concurrent observation, interview and video footage review on 10/1/2025 at 11:00 a.m. with Nurse Manager (NM 1) of BHU and Medical-Surgical (Med/Surg) Unit, the video footage, dated 9/19/2025 from 1:00 a.m. to 2:30 a.m., was reviewed. The following events were observed at the indicated timestamp in the video:

9/19/2025 at 1:00 a.m.
-No staff seen conducting patient rounding in any of the video angles.

9/19/2025 at 1:15 a.m.
-No staff seen conducting patient rounding, in any video of the angles.
9/19/2025 at 1:30 a.m.
-No staff seen conducting patient rounding in any of the video angles

9/19/2025 at 1:45 a.m.
-no staff seen doing rounding, one patient seen in wheelchair going down hallway without staff presence (camera angle 6)

9/19/2025 at 2:00 a.m.
-two staff members seen rounding in Patient rooms 1, 2, 3 and 4 (camera angle 4) but not seen checking other patient rooms. Confirmed with NM 1 that one was a licensed staff (RN) and the other individual was the resource nurse.

9/19/2025 at 2:15 a.m.
-two staff members sitting in chairs in the BHU hallway on Camera angles 6 and 7. Not getting up to conduct rounding on patients. NM 1 was unable to identify the two staff members.

9/19/2025 at 2:30 a.m.
-Same two staff members sitting in chairs in BHU hallway, not getting up to conduct patient rounding seen in camera angles 6 and 7, NM 1 was unable to identify the two staff members

During a concurrent observation, interview, and record review on 10/1/2025 at 12:40 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility's security footage of Campus 2 BHU unit (Unit C) on 9/13/2025, from time period 1:20 a.m. to 4:58 a.m., was observed and reviewed. It was observed and was confirmed by NM 2 that there was no patient rounding by facility staff between the hours of 1:20 a.m. to 4:58 a.m. on 9/13/2025.

During a concurrent observation, interview, and record review on 10/1/2025 at 1:10 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility's security footage of Campus 2 BHU unit (Unit S) on 9/19/2025, from time period of 1:00 a.m. to 2:15 a.m., was observed and reviewed. It was observed and verified by NM 2 that facility staff were not entering the patient rooms during patient rounding to check on patients.

During an interview on 10/1/2025 at 11:47 a.m. with NM 1, NM 1 stated the expectation was for staff to do Q 15-minute rounding to check on the patients, ensure safety and known location. Purpose of rounding was to know the location of the patients and make sure the patient was safe. "It allows us to notice any changes in behaviors, so that staff can address them accordingly." NM 1 verified that rounding was only completed once for 4 rooms (rooms 1,2, 3, and 4) but not the whole unit within the 1.5 hour of video reviewed for Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44.

During an interview on 10/1/2025 at 2:12 p.m. with the Chief Nursing Officer (CNO), the
CNO confirmed that Q15 (every 15 minutes) patient safety checks should be conducted to:
ensure patient safety, confirm responsiveness, assess patient behavior, and document patient activity.

During an interview on 10/1/2025, at 1:31 p.m. with House Supervisor (HS 1), HS 1 stated they do daily audit for the completeness of the Q 15-minute rounding sheet to verify staff compliance with rounding. However, the paper documentation for rounding was not done concurrently with a review of the video footages to determine if the paper documentation matches what was observed on the rounding being done as seen through the video surveillance cameras.

During an interview on 10/2/2025 at 9:13 a.m. with the Nurse Manager (NM 2) of BHU and Med/Surg, NM 2 stated she (NM 2) never did any concurrent security video review to compare what the BHU staff did and what was documented for the behavioral health unit (BHU). NM 2 stated, "We wanted to believe the employees that what they wrote was what they did (referring to the documented Q 15-minute rounding by staff)."

During a review of the Facility's policy and procedure (P&P) titled, "Observation Levels System," dated 3/2025, the P&P indicated, "It is the policy of [the facility] to initiate and provide the appropriate observation level of patient's behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient's Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress ... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress." B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient's Observation Rounds sheet every 15 minutes ..."

On 10/6/2025 at 2:50 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), ADM, CNO, NM 1, NM 3 and DIR 1, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The acceptable IJ Removal plan included the following: On 10/2/2025 the facility added additional MHW staffing to the BHU units at both campuses (Campus 1 and Campus 2) to assist with the provision of alternate rounding schedules, monitoring patients' behavior and condition, staffing will be based on acuity (the severity and complexity of a patient's medical condition. It is a measure of the patient's healthcare needs and the intensity of nursing care required). On 10/2/2025, new staff workflow interventions were implemented, a 'Buddy System' where staff pairings were assigned and designed to overlap coverage and ensure accountability for staff to complete rounds, the buddy system will be indicated on the staff assignment sheet. On 10/2/2025 re-education began for licensed nurses, Certified Nurse Assistants (CNA) and MHWs regarding the facility's policy on Q 15-minute rounding, emphasis on awareness of the patients location, behavior and safety, in order to provide a safe environment for all patients away from any harm, any non-compliance would result in disciplinary action. Leadership oversight included: the house supervisor/designee will make unannounced visits to each unit, every shift to ensure staff are conducting observational rounds every 15 minutes and audit the document titled, "Patient Observation Rounds Sheet Q15 minutes" focusing on accuracy and completion of the documents in accordance with the facility's policy. The House Supervisor/Designees will address any findings immediately for corrective actions. The house supervisor/designee will perform random video review at least every 4 hours around the clock to ensure licensed nurses, CNAs, MHWs are rounding every 15 minutes for patient's locations, behavior and safety, a log will be maintained by Nurse Managers. The Quality Risk Coordinator created a Performance Improvement Indicator in the Quality Assessment and Performance Improvement (QAPI) dashboard to incorporate every 15-minute rounds data to present at the quality meetings. Hospital Administration will review data monthly, and present to the quality meeting for any further recommendations if necessary

Findings:

1.a. During a review of Patient 1's History and Physical (H&P, a comprehensive clinical document that includes a patient's medical history and findings from a physical examination), dated 6/4/2025, the H&P indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) due to being "agitated (feeling of uneasiness and severe restlessness) and aggressive." The H&P also indicated that Patient 1 was placed on assaultive (safety measures implemented for patients who exhibit or are at risk of exhibiting violent or aggressive behavior) and homicidal precautions (safety interventions used when a patient expresses or demonstrates thoughts, intentions, or behaviors indicating a risk of harming others).

During a review of Patient 1's "Behavioral Admission Assessment," dated 6/4/2025, the record indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU) at 2:45 p.m. on a 5150 Hold (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to others and being gravely disabled (GD, a condition in which a person, due to a mental health disorder, is unable to provide for their basic personal needs such as food, clothing, or shelter)." The record also stated that Patient 1 required "line of sight observation," meaning continuous visual monitoring by staff to ensure immediate intervention if needed, and was placed on 15-minute Close Observation Level II, which involved staff checking on the patient every 15 minutes due to a history of threatening and/or assaultive behavior within the past 30 days.

During a review of Patient 1's "Behavioral Health Daily Nursing Assessment," dated 6/5/2025, the record indicated that on 6/5/2025 Patient 1 continued to remain on 15-minute Close Observation Level II (patient was monitored every 15 minutes due to concerns about potential harm to self or others) and also had assault/aggression precautions in place (implemented due to the patient exhibiting, or being at risk of exhibiting, aggressive or violent behavior; includes increased supervision, environmental safety measures, and use of de-escalation techniques [methods used to reduce the intensity of a conflict or agitation in a person through calm, verbal, and non-verbal communication]).

During a review of Patient 2's History and Physical (H&P), dated 6/3/2025, The H&P indicated that Patient 2 was admitted to the Behavioral Health Unit (BHU) on 6/3/2025 for agitation and aggressive behavior.

During a review of Patient 2's Psychiatric Evaluation, dated 6/3/2025, the record indicated that Patient 2 was admitted on a 5150 Involuntary Hold. The record also indicated that the Hold was initiated due to danger to others after Patient 2 became "increasingly aggressive at the nursing home (a residential facility that provides 24-hour medical and personal care for individuals, who are unable to live independently due to illness, disability, or cognitive decline)."

During a review of Patient 2's "Nursing Progress Note," dated 6/5/2025 at 3:43 p.m., the note indicated that Patient 2 was involved in an altercation with another patient (Patient 1) and stated that he (Patient 2) was defending himself after Patient 1 struck him in the face, specifically on the left cheek and/or jaw.

During a review of Patient 2's "Rounds Sheet, dated 6/5/2025, the sheet indicated that Patient 2 was documented as either lying or sitting in his "BR" (bedroom) for the entire time from 7:00 a.m. to 7:00 p.m.

During a concurrent interview and record review on 9/30/2025 at 3:02 p.m. with the Chief Nursing Officer (CNO), Patient 1's medical record titled, "Nursing Progress Notes," dated 6/5/2025, was reviewed. The CNO stated that, according to the documentation, Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards. The CNO confirmed that the fall was unwitnessed (as per nursing notes documentation), and that Rapid Response Team (RRT, a team of healthcare professionals, often including a critical care nurse and a respiratory therapist, who are quickly dispatched to provide immediate care to a patient who shows signs of acute deterioration within a hospital) was called at 2:20 p.m. on 6/5/2025 after Patient 1 was assessed to have weakness in the lower extremities (both legs), drooping (excessive sagging) on the left side of face, and left arm weakness.

During a review of Patient 1's "Nursing Progress Notes," dated 6/5/2025 at 2:20 p.m., the note indicated the following: on 6/5/2025, Patient 1 was actually witnessed by an EVS (Environmental Services- trained cleaning support staff) worker who witnessed Patient 1 walking in the hallway, attempting to strike another patient (Patient 2). In response, Patient 2 pushed Patient 1, causing Patient 1 to fall backwards and sit down on the floor. A Rapid Response Team (RRT) was called, and Patient 1 was assessed to have bilateral (both) lower extremity weakness and was noted to be losing balance while standing. The note also stated that Patient 1 was transferred to a medical-surgical floor (a general hospital unit for adult patients who need care for a variety of illnesses and surgical recovery, but do not require intensive or highly specialized care) for further evaluation).

During a review of Patient 1's nursing note, dated 6/5/2025 at 2:20 p.m., the note indicated that Patient 1 sustained an unwitnessed fall (meaning the patient had experienced a fall that was not observed by staff or others, and the exact circumstances were unknown).

During further review of Patient 1's nursing notes documentation, dated 6/5/2025 at 2:35 p.m. (late entry), the note indicated that Patient 1 was status post (after) unwitnessed fall, and that Patient 1 began showing signs of facial drooping (sagging) on the left side, along with bilateral (both sides) leg tremors (involuntary, rhythmic shaking or trembling movements in the legs).

During a review of Patient 1's "Nursing Progress Note," dated 6/5/2025 at 4:30 p.m., the note indicated that on 6/5/2025 at 4:00 p.m., Patient 1 was observed with increasing shaking of the left leg and bilateral lower extremities. The note also indicated that during the physician's bedside assessment, Patient 1 was noted to have a bump on the right side of the head, with no bleeding. The note also indicated the following at 4;30 p.m. on 6/5/2025: the family was informed that, due to the fall, Patient 1 had possible fracture of the right hip ... and the physician recommended transferring Patient 1 to a higher level of care, as the patient continued to experience shaking and had a head injury with a possible subdural hematoma (a type of brain bleed that occurs when blood collects in the brain, often caused by head trauma and potentially life-threatening if not treated promptly).

During an interview on 10/1/2025 at 1:31 p.m. with the House Supervisor (HS 1), HS 1 stated that typically the facility conducted daily audit for the completeness of Q 15-Minute rounding sheets (a clinical documentation tool used by healthcare staff to record patient observations at regular intervals [every 15 minutes], designed to monitor patient location, behavior, and safety status, and to ensure staff accountability and timely intervention when needed) to verify staff compliance with patient rounding. However, the HS 1 also said that the paper documentation for patient rounding was not reviewed concurrently with video footage to determine whether the documented patient rounding matched what was observed through the facility's video surveillance cameras.

During a concurrent interview and record review on 10/1/2025 at 2:06 p.m. with the Chief Nursing Officer (CNO), Patient 1's "Patient Rounding Sheet, dated 6/5/2025 (covering the time from 7:00 a.m. to 4:30 p.m.), was reviewed. The rounding sheet indicated that Patient 1 was not agitated during this time frame (7 a.m. to 4;30 p.m.) and was consistently documented as either lying or sitting in their (Patient 1) bedroom. Specifically:
-At 1:00 p.m., Patient 1 was documented as either lying or sitting
-At 2:15 p.m., Patient 1 was again documented as either lying or sitting
-This same documentation pattern continued through 2:45 p.m.
-The Chief Nursing Officer (CNO) verified that this documentation was possibly inaccurate, noting that the Rapid Response Team was called at 2:20 p.m., and Patient 1 was found in the hallway by Patient 2's room, yet no deviation or incident was reflected in the rounding sheet during that time.

During further interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM stated that the administration was no longer certain whether the entire incident (between Patient 1 and Patient 2) had been witnessed by the Environmental Service (EVS) worker. The ADM confirmed that nursing staff and mental health workers did not witness the altercation between the two patients (Patient 1 and Patient 2). The ADM also stated that he (ADM) could not verify whether staff were conducting Q15-minute patient rounding on that day (6/5/2025). The ADM said, "They (referring to the facility staff) should have done it (referring to the Q 15-minute rounding)- this is the expectation," and noted that staff verbally confirmed they were conducting their rounds. However, the ADM also confirmed that the video footage, on 6/5/2025, was never reviewed to verify whether staff actions aligned with what was documented and reported on the day of the incident between Patient 1 and Patient 2.

During a concurrent observation, interview and video footage review on 10/1/2025 at 11:00 a.m. with Nurse Manager (NM 1) of BHU and Medical-Surgical (Med/Surg), the video footage dated 9/19/2025, from 1:00 a.m. to 2:30 a.m., was reviewed. The following events were observed at the indicated timestamp in the video:

9/19/2025 at 1:00 a.m.
-No staff seen conducting patient rounding in any of the video angles.

9/19/2025 at 1:15 a.m.
-No staff seen conducting patient rounding, in any video of the angles.

9/19/2025 at 1:30 a.m.
-No staff seen conducting patient rounding in any of the video angles

9/19/2025 at 1:45 a.m.
-no staff seen doing rounding, one patient seen in wheelchair going down hallway with no staff present (camera angle 6)

9/19/2025 at 2:00 a.m.
-two staff members seen rounding patient rooms 1, 2, 3 and 4 (camera angle 4) but not seen checking other rooms. Confirmed with NM1 that one was licensed staff (RN) and the other individual was the resource nurse.

9/19/2025 at 2:15 a.m.
-two staff members sitting in chairs in BHU hallway on Camera angles 6 and 7. Not getting up to conduct rounding on patients. NM 1 was unable to identify the two staff members.

9/19/2025 at 2:30 a.m.
-Same two staff members sitting in chairs in BHU hallway, not getting up to conduct rounding as seen in camera angles 6 and 7. NM 1 was unable to identify the two staff members

During an interview on 10/1/2025 at 11:47 a.m. with NM 1, NM 1 stated the expectation was for staff to do Q 15-minute rounding to check on the patients, ensure safety and known location. Purpose of rounding was to know the location of the patients and make sure the patient was safe. "It allows us to notice any changes in behaviors, so that staff can address them accordingly." NM 1 verified that rounding was only completed once for 4 rooms (rooms 1,2, 3, and 4) but not the whole unit within the 1.5 hour of video reviewed for Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44.

During a concurrent interview and record review on 10/1/2025 at 2:02 p.m. with NM 1, Patient 20's "Patient Rounds Sheet" dated 9/18/2025, was reviewed. NM 1 stated that the rounding sheet began on 9/18/2025 at 7:00 a.m. and ended on 9/19/2025 at 6:45 a.m. NM 1 stated that all patient rounding sheets being reviewed started around the same time (7 a.m. to 6:45 a.m.), which captures the entire 24 hours.

During an interview on 10/3/2025 at 3:44 p.m. with NM 1, NM 1 stated that, after reviewing the video footage and discussing the matter with the Chief Nursing Officer (CNO), it appeared that staff were documenting Q15-minute checks as completed, despite not actually performing them. NM 1 emphasized the importance of holding staff accountable and acknowledged that this practice falls under the category of falsification of records.

During an interview on 9/30/2025 at 11:35 a.m. with the Charge Nurse (CN) 4, CN 4 stated that licensed nurses were required to conduct patient rounds every hour and document on the patient's rounding sheet. CN 4 stated that licensed nurses could also help the MHW (Mental health Worker) with conducting Q15-minute rounding.

During an interview on 10/1/2025 at 2:12 p.m. with the Chief Nursing Officer (CNO), the CNO confirmed that Q15 (every 15 minutes) patient safety checks should be conducted to:
-Ensure patient safety,
-Confirm responsiveness,
-Assess patient behavior,
-Document patient activity.

During an interview on 10/1/2025 at 3:17 p.m. with the Chief Nursing Officer (CNO) and the Hospital Administrator (ADM), the CNO stated that the incident (involving Patients and 2) was investigated internally and that all key team members were interviewed, including the Environmental Services (EVS) worker who witnessed the altercation between Patient 1 and Patient 2 in the hallway. The ADM confirmed that, because of the EVS worker's statement regarding the witnessed fall and the altercation between the two patients (Patient 1 and Patient 2), the facility had no reason to review the video footage to verify what happened during the incident.

During an interview on 10/3/2025 at 3:34 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following regarding Q-15 Minutes rounding: "Q15-minute safety checks are conducted to monitor each patient's condition and behavior at regular 15-minute intervals. The purpose is to identify any signs of agitation, frustration, or behaviors that may indicate a risk to the patient or others. These checks are preventive in nature and allow staff to intervene early and provide therapeutic support as needed. We use this time to assess whether patients are escalating and to respond in a way that promotes safety and de-escalation. While staff are expected to document these checks accurately, it's also important to verify that the documentation aligns with actual observations, such as through video review when available."

During a review of Patient 20's Psychiatric Evaluation (a comprehensive mental health assessment, conducted by a psychologist or psychiatrist, that uses interviews, tests, and observations to understand a person's emotional, behavioral, and cognitive state), dated 9/11/2025 and timed 17:56 (5:56 p.m.), the record indicated Patient 20 was admitted to the facility on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisi

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

1. Protect one of 76 sampled patients (Patient 19) from alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), failed to investigate the abuse allegations, and to identify or remove the alleged perpetrator (a staff member) from the environment, in accordance with the facility's policy regarding abuse reporting, when Patient 19 reported to the Registered Nurse (RN) 1 that the night shift staff choked and placed Patient 19 in 4-point (both wrists and ankles) 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) on 4/23/2025.

This deficient practice resulted in the facility not conducting an investigation and removing the alleged staff members from working duties and potentially placing Patient 19 and other patients at risk for further abuse.

2. Investigate thoroughly and report to the appropriate regulatory agencies an incident of alleged physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by the facility's security guard (SG 1) which occurred on 10/13/2024, for one of 76 sampled patients (Patient 7), in accordance with the facility's policy regarding abuse investigation and reporting.

This deficient practice resulted in a delay in involving regulatory agencies in investigating the abuse allegation and could potentially put other patients in an unsafe environment and be at risk of being abused.

3. Report to appropriate regulatory agencies an allegation of sexual abuse (sexual conduct or a sexual act forced upon a woman, man or child without their consent), in accordance with the facility's policy regarding abuse reporting, for one of 76 sampled patients (Patient 8), after Patient 8 reported an alleged sexual abuse on 8/29/2024.

This deficient practice resulted in a delay in involving regulatory agencies in investigating the abuse allegation and could potentially put other patients in an unsafe environment and be at risk of being abused.

On 10/3/2025 at 12:10 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 Nursing Officer (CNO), Manager of Medical-Surgical and Behavioral Health Unit (NM 1), Hospital Administrator (ADM), Manager of Behavioral Health Unit (NM 2, from Campus 2), Director of Behavioral Health Unit (DIR 1, from Campus 2), and the Manager of Behavioral Health Unit (NM 3, from Campus 2). The facility failed to protect Patient 19 from alleged abuse, failed to investigate the abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) allegations, and to identify and remove the alleged perpetrator (a staff member) from the environment, in accordance with the facility's policy and procedure titled, "Abuse/Mandated Reporting," when Patient 19 reported of an alleged physical abuse by staff members to Registered Nurse 1. This deficient practice resulted in the facility not conducting an investigation and removing the alleged staff members from working duties and potentially placing other patients at risk for further abuse.

During a review of Patient 19's History & Physical (H&P), dated 4/21/2025, the H&P indicated that Patient 19 was admitted to the facility's Behavioral Health Unit (BHU) on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) hold due to increased aggression and at risk for assaultive behavior (actions likely to cause physical harm or danger to another person).

During a review of Patient 19's "Nursing Progress Notes," dated 4/23/2025 and timed at 14:58 (2:58 p.m.), the notes indicated that according to the patient (Patient 19), he (Patient 19) was awakened around the morning of (4/23/2025) at 0100 (1:00 a.m.) by noises from his (Patient 19) roommate. When he (Patent 19) got up to check on the situation, he (Patient 19) was instructed by the night shift staff to return to his (Patient 19) bed immediately. The patient (Patient 19) stated while he (Patient 19) was preparing his bed, staff members approached him (Patient 19), choked him (Patient 19), and escorted him to the seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). He (Patient 19) further reported he (Patient 19) was choked again and placed in a 4-point (both wrists and ankles) 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) for approximately 4 to 5 hours around 0100 (1:00 a.m.) on 4/23/2025. He (Patient 19) was reported released from the restraints around 0600 (6:00 a.m.) that morning (4/23/2025). The notes also indicated that the house supervisor (HS 4) and nursing manager (NM 3) were both informed of the incident.

During a review of Patient 19's "Nursing Progress Notes," dated 5/11/2025 , the notes indicated Patient 19 was discharged to an Independent Living facility (a community designed for active adults and seniors who can live independently but want to be part of a community with amenities like housekeeping, transportation, and social activities, while also having security and maintenance-free living).

During a concurrent interview and record review on 10/2/2025 at 10:47 a.m. with Registered Nurse (RN) 1, Patient 19's "Nursing Progress Notes," dated 4/23/2025 and timed at 14:58 (2:58 p.m.), was reviewed. RN 1 confirmed she (RN 1) wrote the progress note and notified the house supervisor (HS 4) and nurse manager (NM 3) regarding the incident involving Patient 19. RN 1 stated that everyone was a mandated reporter, and an alleged abuse must be escalated appropriately.

During an interview on 10/2/2025 at 1:59 p.m. with the Nurse Manager (NM) 3 of BHU and the Director (DIR 1) of BHU, NM 3 stated this was the first time the facility administrative team heard of Patient 19's alleged abuse. NM 3 stated that RN 1 "never reported this to me (NM 3) and if it was, I (NM 3) would have started an investigation." DIR 1 stated when an alleged abuse incident occurred and involved staff, "we put the alleged staff member on suspension while an investigation is being conducted." DIR 1 stated since "we (the facility) did not know about the incident regarding patient (Patient 19), there was no investigation conducted and was never reported to the proper authorities." DIR 1 stated since the allegation was not reported, "we (facility) were unable to identify the perpetrator."

During an interview on 10/3/2025 at 10:19 a.m. with House Supervisor 4 (HS 4), stated that she (HS 4) was unaware of the alleged abuse. HS 4 stated when RN 1 became aware of the alleged abuse, RN 1 should have notified "myself (HS 4) and I (HS 4) should file an incident report. The incident report then will go to the nurse manager and performance improvement team for them to investigate."
Patient 19 was discharged from the facility on 5/1/2025 and the abuse allegation was still not investigated as of 10/2/2025.

During a review of the facility's policy and procedure (P&P) titled, "Abuse/Mandated Reporting," revised date 3/2025, the P&P indicated all suspected cases must be investigated immediately. Any individual (employee, volunteer, or associate) who reasonably believes or has knowledge that a patient's health or welfare has been, is, or will be adversely affected by abuse or neglect must report it within 24 hours to Administration.

During a review of the facility's policy and procedure (P&P) titled, "Incident/Occurrence Reporting," revised 5/3/2025, indicated employees who witness or are aware of an unusual occurrence are responsible for completing an Incident Report at the time they become aware of the occurrence.

On 10/6/2025 at 2:52 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), ADM, CNO, NM 1, NM 3 and DIR 1, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews and record reviews. The acceptable IJ Removal Plan included the following: On 10/3/2025 an immediate investigation of the alleged abuse allegations was conducted by the facility. On 10/3/2025 a re-education began for all staff members including leadership regarding the facility's policy on abuse, with emphasis on the following key points: 1. Staff has to report to his/her immediate floor supervisor, staff summons extra help to the incident site to triage (conduct a preliminary assessment to determine the urgency of treatment needed) the situation and ensure patient safety. Onsite MD must be notified. 2. Immediate supervisor reports the incident to the resource nurse/charge nurse and converse with the house supervisor. 3. House supervisor ensures the data collection immediately and requests an immediate meeting with CNO, Administrator, CEO, and etc. 4. House Supervisor will notify the treating physicians. 5. Administrator/Designee reports serious injury within 24 hours to the appropriate regulatory agencies if it is an urgent or emergency threat to the health and safety of the patient. 6. Reports of elder abuse must be made by the Administrator/designee by telephone and followed up with a written report within 2 working days using form SOC-341 (official form used to report suspected abuse to appropriate authorities). On 10/3/2025, the facility implemented the use of an inter-shift hand off tool (Patients who express a significant change in status during shift must have physician notified in a timely manner. House supervisor/designee will ensure complaint presented is acted upon promptly) to ensure patients' complaints are attended to timely and acted upon appropriately. Unit manager/designee will audit the inter-shift hand off tool daily to ensure compliance.

Findings:

1. During a review of Patient 19's History & Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/21/2025, the H&P indicated that Patient 19 was admitted to the facility's Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) hold due to increased aggression and at risk for assaultive behavior (actions likely to cause physical harm or danger to another person).

During a review of Patient 19's "Nursing Progress Notes," dated 4/23/2025 and timed at 14:58 (2:58 p.m.), the Nursing Progress Notes indicated that according to the patient (Patient 19), he (Patient 19) was awakened around the morning of (4/23/2025) 0100 (1:00 a.m.) by noises from his (Patient 19) roommate. When he (Patent 19) got up to check on the situation, he (Patient 19) was instructed by the night shift staff to return to his bed immediately. The patient (Patient 19) stated while he (Patient 19) was preparing his bed, staff members approached him (Patient 19), choked him (Patient 19), and escorted him to the seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). He (Patient 19) further reported he (Patient 19) was choked again and placed in 4-point (both wrists and ankles) 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) for approximately four (4) to five (5) hours around 0100 (1:00 a.m.). He (Patient 19) was reported released from the restraints around 0600 (6:00 a.m.) that morning (4/23/2025). The Nursing Progress notes also indicated that the house supervisor and nursing manager were both informed of the incident.

During a review of Patient 19's "Nursing Progress Notes" dated 5/11/2025, the notes indicated Patient 19 was discharged to an Independent Living facility (a community designed for active adults and seniors who can live independently but want to be part of a community with amenities like housekeeping, transportation, and social activities, while also having security and maintenance-free living).

During concurrent interview and record review on 10/2/2025 at 10:47 a.m. with Registered Nurse (RN) 1, Patient 19's "Nursing Progress Notes," dated 4/23/2025 and timed at 14:58 (2:58 p.m.), was reviewed. RN 1 confirmed she (RN 1) wrote the progress note and notified the house supervisor and nurse manager (NM 3) regarding the incident involving Patient 19. RN 1 stated that everyone was a mandated reporter, and an alleged abuse must be escalated appropriately.

During an interview on 10/2/2025 at 1:59 p.m. with the Nurse Manager (NM) 3 of BHU and the Director (DIR 1) of BHU, NM 3 stated this was the first time of the administrative team hearing of Patient 19's alleged abuse. NM 3 stated that RN 1 "never reported this to me (NM 3) and if it was, I (NM 3) would have started an investigation." DIR 1 stated when an alleged abuse incident occurred and involved staff, "we put the alleged staff member on suspension while an investigation is being conducted." DIR 1 stated since "we (the facility) did not know about the incident regarding the patient (Patient 19), there was no investigation conducted and was never reported to the proper authorities." DIR 1 stated since the allegation was not reported to the facility administrative team, "we (facility) were unable to identify the perpetrator."

During an interview on 10/3/2025 at 10:19 a.m. with House Supervisor 4 (HS 4), HS 4 stated that she (HS 4) was unaware of the alleged abuse incident. HS 4 stated when RN 1 became aware of the alleged abuse, RN 1 "should have notified myself (HS 4) and I (HS 4) should file an incident report. The incident report then will go to the nurse manager and performance improvement team for them to investigate."

During a review of the facility's policy and procedure (P&P) titled, "Abuse/Mandated Reporting," dated 03/2025, the P&P indicated that:
"Under applicable laws, the facility requires any person with reasonable cause to suspect abuse, neglect, or exploitation to report it to the appropriate regulatory agency.
Key Procedures:
Prioritize cases of suspected sexual assault, physical abuse, or neglect.
Immediate investigation is required for all suspected cases.
Reports must be made within 24 hours to Administration.
Law enforcement must be notified when applicable.
Who Must Report:
All healthcare practitioners and facility employees are mandated reporters.
Staff must notify their immediate supervisor and department manager, who will coordinate with the CNO or Administrator (Abuse Coordinator).
Reporting Process:
Document the incident in the patient's progress notes (include date, time, source, and quotes).
Generate an incident report.
Notify supervisor and Quality & Risk Department.
Report to authorities via phone and written report within required timeframes.
Administrative Responsibilities:
Leadership (CEO, CNO, Administrator, etc.) will review and determine reportability.
Investigation results must be reported to management and regulatory agencies within 5 working days.

During a review of the facility's policy and procedure (P&P) titled, "Incident/Occurrence Reporting," revised 5/3/2025, the P&P indicated employees who witness or are aware of an unusual occurrence are responsible for completing an Incident Report at the time they become aware of the occurrence.

2. During a review of Patient 7's "Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 10/12/2024, the Psych Eval indicated Patient 7 was admitted to the facility on 10/11/2024 due to increased agitation (feeling of irritability or severe restlessness) with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), paranoid type (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions).

During a review of Patient 7's "Interdisciplinary Team Progress Notes Nursing (nursing notes)," dated 10/13/2024, the notes indicated, on 10/13/2024 at 10:40 p.m., "patient (Patient 7) had increased aggressive (behavior that is forceful, assertive, and potentially hostile or threatening) behavior verbally and physically towards staff ... called other staff member to help intervene with patient (Patient 7) behavior ... Patient (Patient 7) stayed in bed still irritable and continue to be aggressive towards staff. Patient (Patient 7) attempted to swing at staff ..."

During an interview on 10/3/2025 at 11:09 a.m. with the House Supervisor (HS 5), HS 5 stated the following: on 10/13/2024 at night, she (HS 5) received a report involving Patient 7 being physically abused (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by a security guard (SG 1). HS 5 spoke with SG 1. SG 1 tried to intervene as Patient 7 was being aggressive. SG 1 admitted to HS 5 that he (SG 1) hit Patient 7 because he (SG 1) got mad (at Patient 7) and thus retaliated. HS 5 assessed Patient 7 and noted Patient 7 had bruises on his (Patient 7's) cheek. The incident was also witnessed by other staff (Patient 7's primary nurse and two other Mental Health Workers). SG 1 was sent home immediately. The incident was reported to department nurse manager (NM 1) and the Chief Nursing Officer (CNO) for investigation and report. HS 5 also stated she (HS 5) did not see SG 1 working anymore since then.

During an interview on 10/3/2025 at 11:29 a.m. with NM 1, NM 1 stated the following: she (NM 1) recalled the incident (involving Patient 7). There was a meeting about the incident, but she (NM 1) was not involved in the investigation. The management team conducted the investigation. The investigation was handled by the previous Quality Director. NM 1 stated the incident was a physical assault resulting in injury (of Patient 7) and should have been reported to the State health department and adult protective services (a government-run social services program that investigates and responds to reports of abuse, neglect, self-neglect, and financial exploitation of vulnerable adults, including older adults and adults with disabilities) within 24 hours.

During an interview on 10/3/2025 at 1:30 p.m. with NM 1, NM 1 stated there was an in-service provided to staff about abuse training after the incident (on 10/13/2024). NM 1 stated she (NM 1) could not provide any evidence if an investigation was conducted. NM 1 also stated she (NM 1) was unable to provide any evidence that this abuse incident was reported to any regulatory agencies including the state health department and adult protective services.

During an interview on 10/3/2025 at 1:43 p.m. with Chief Nursing Officer (CNO), CNO stated she (CNO) was unable to determine if the abuse incident was reported to the state health department and adult protective services. CNO further stated the facility must report to the regulatory agencies so that the agencies could investigate further. CNO stated, "we need to make sure we protect the patients. It is required to report any alleged abuse in order to protect the elderly and mentally ill patients. We have people (regulatory agencies) to monitor and ensure the laws are followed."

During a review of SG 1's termination letter issued by facility's security guard contracted services (CS 3), dated 10/17/2024, the termination letter indicated SG 1 was terminated on 10/17/2024 due to a serious incident that occurred involving a patient (Patient 7) on 10/13/2024. The termination letter also indicated, "this type of conduct is unacceptable and goes against the values and policies of [the organization] ... it has been determined that immediate termination is the appropriate course of action."

During an interview on 10/3/2025 at 2:07 p.m. with the Chief Executive Officer (CEO 2) for the facility's security guard contracted services (CS 3), CEO 2 stated SG 1 was terminated after the incident of physical abuse with Patient 7 was confirmed through the facility's internal investigation.

During a review of the facility's policy and procedure (P&P) titled, "Abuse-Management of Suspected Child, Adult, Disabled Person or Elderly Abuse, Neglect," dated 3/2022, the P&P indicated, "This policy and procedure assure mechanism for identifying, investigating, and mandatory reporting of any mistreatment, abuse, neglect, involuntary seclusion, or misappropriation of property of [the facility] patients ... A. Reportable concerns and procedural steps of suspected abuse/neglect ... 3. All cases of suspected abuse/neglect must be reported to authorities. A person, including an employee, volunteer, or other person associated with the department, who reasonably cause a person to believe that the physical or mental health or welfare of a patient of the department who is receiving medical services has been, is or will be adversely affected by abuse or neglect by any person shall, provide a mandatory report of information supporting the belief to the department of health, or the appropriate health care regulatory agency, by telephone, in writing, or by personal visit within 24-26 hours of alleged event ... 5. All reports received by any local or state law enforcement agency shall be referred to the appropriate department providing protective regulatory services ... If the perpetrator(s) of the alleged abuse, neglect, mistreatment, or misappropriation of property have been identified as a healthcare worker then he/she should be immediately removed from the patient(s) care until an investigation is completed. The allegation of abuse is to be reported to [state health department] within 36 hours of the alleged event."

During a review of the facility's policy and procedure (P&P) titled, "Patient's Rights," dated 5/2025, the P&P indicated, "This policy applies to all employees, medical staff, volunteers, contractors and students providing care or services within [the facility] ... Patient Rights ... All patients receiving care at [the facility] have the rights to ... 6. Safety ... Receive care in a safe environment, free from all forms of abuse, harassment, or restraints that are not medically necessary."

3. During a review of Patient 8's "Psychiatric Evaluation (Psych Eval)," dated 8/29/2024, the Psych Eval indicated, Patient 8 was admitted to the facility on 8/28/2024 with agitated (feeling of irritability or severe restlessness) behavior and diagnosis of schizoaffective disorder (a mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]). The Psych Eval also indicated Patient 8 came from a nursing care facility (a nursing facility with the staff and equipment to give skilled nursing care and skilled rehabilitative services and other related health services).

During a concurrent interview and record review on 10/2/2025 at 12:58 p.m. with the Nurse Manager (NM 1) of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) and Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery), Patient 8's "Interdisciplinary Progress Note Nursing (nursing notes)," dated 8/29/2024, was reviewed. The nursing notes indicated, on 8/29/2024 at 4:09 p.m., Patient 8 reported to Registered Nurse (RN) 6 that Patient 8 did not want to go back to the nursing care facility because "she (Patient 8) had a man come into her (Patient 8) room at 2 a.m. (unknown date) and she was striking at him because she (Patient 8) was defending herself due to her feeling that she was going to be harassed (experiencing persistent and unwanted behavior that troubles, annoys, or creates an intimidating, hostile, or degrading environment." The nursing notes also indicated RN 6 notified social worker, and NM 1. NM 1 stated she (NM 1) spoke with Patient 8, gathered information after RN 6 reported the incident and determined it was an alleged sexual abuse (sexual conduct or a sexual act forced upon a woman, man or child without their consent) involving the nursing care facility where Patient 8 came from. NM 1 stated this incident was reportable to the state health department and adult protective services.

During an interview on 10/3/2025 at 1:43 p.m. with Chief Nursing Officer (CNO), CNO stated she (CNO) was unable to determine if the abuse incident was reported to state health department and adult protective services. CNO further stated the facility must report to the regulatory agencies so that the agencies could investigate further. CNO stated, "we need to make sure we protect the patients. It is required to report any alleged abuse in order to protect the elderly and mentally ill patients. We have people (regulatory agencies) to monitor and ensure the laws are followed."

During a review of the facility's policy and procedure (P&P) titled, "Abuse-Management of Suspected Child, Adult, Disabled Person or Elderly Abuse, Neglect," dated 3/2022, the P&P indicated, "This policy and procedure assure mechanism for identifying, investigating, and mandatory reporting of any mistreatment, abuse, neglect, involuntary seclusion, or misappropriation of property of [the facility] patients ... A. Reportable concerns and procedural steps of suspected abuse/neglect ... 3. All cases of suspected abuse/neglect must be reported to authorities. A person, including an employee, volunteer, or other person associated with the department, who reasonably cause a person to believe that the physical or mental health or welfare of a patient of the department who is receiving medical services has been, is or will be adversely affected by abuse or neglect by any person shall, provide a mandatory report of information supporting the belief to the department of health, or the appropriate health care regulatory agency, by telephone, in writing, or by personal visit within 24-26 hours of alleged event ... 5. All reports received by any local or state law enforcement agency shall be referred to the appropriate department providing protective regulatory services ... If the perpetrator(s) of the alleged abuse, neglect, mistreatment, or misappropriation of property have been identified as a healthcare worker then he/she should be immediately removed from the patient(s) care until an investigation is completed. The allegation of abuse is to be reported to [state health department] within 36 hours of the alleged event."

Based on interview and record review, the facility failed to ensure nursing staff consulted the physician after a face to face assessment (an in person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) was performed by Registered Nurses (RNs) for two of 76 sample patients (Patient 7 and 12), in accordance with the federal regulation regarding physician notification after the completion of the face-to-face assessment.


This deficient practice had the potential to result in Patient 7 and Patient 12 not receiving evaluation from physicians to determine appropriate treatment, care and intervention.

Findings:

1. During a review of Patient 7's "Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 10/12/2024, the Psych Eval indicated Patient 7 was admitted to the facility on 10/11/2024 due to increased agitation (feeling of irritability or severe restlessness) with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), paranoid type (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions).

During a review of Patient 7's "Emergency Medication Intervention (EMI) Assessment and Re-assessment (EMI form)," dated 10/11/2024, the EMI form indicated Patient 7 received Haldol (medication to treat schizophrenia [a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions] and acute [new onset] agitation [feeling of irritability or severe restlessness]) 5 milligrams (mg, unit of measure), Ativan (medication used to anxiety and produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 1 mg, and Benadryl (medication usually used for allergic reaction, can cause drowsiness) 50 mg intramuscular (IM, delivering medication directly into the muscle tissue) injections on 10/11/2024 at 2:15 p.m. due to being combative and agitated toward staff by throwing punches on the floor.

During a concurrent interview and record review 10/2/2025 at 1:40 p.m. with the Nurse Manager (NM) 1 of Behavioral Health Unit (BHU, (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) and Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery), Patient 7's EMI form, dated 10/11/2024, was reviewed. The EMI form indicated a face-to-face assessment was completed on 10/11/2024 at 3:15 p.m. and there was no notification made to physician after face-to-face assessment was completed. NM 1 stated the Registered Nurses (RN) did not call Patient 7's physician after the completion of the face-to-face assessment on 10/11/2024.

During an interview on 10/2/2025 at 1:46 p.m. with NM 1, NM 1 stated the following: emergency medication were injections given to patients when patients' behavior was imminent danger (a situation where a hazard exists that could reasonably be expected to cause death or serious physical harm immediately or before the danger can be eliminated) to self and/or others. The purpose of the medications was to control the patient's behavior and maintain patient's safety. It was a type of behavioral restraint (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). Trained RN must perform face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour after medication administration to evaluate the patient. Nurses would notify physicians only if there was change of condition such as the patient being not arousable or medications were ineffective. It was not the facility's policy to notify the physician every time a face-to-face assessment was completed.

During a concurrent interview and record review with NM 1 on 10/2/2025 at 1:55 p.m., the Code of Federal Regulation Title 42 (federal regulations), "Condition of Participation: Patient's Rights," dated 2/2020, was reviewed. The federal regulations indicated, "§482.13(e)(14) - - If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient soon as possible after the completion of the 1 hour face-to-face evaluation." NM 1 stated she (NM 1) was not aware of this regulation. NM 1 further stated physicians should be updated on patient's response to the emergency medication injections so the physician could determine how the medication improved the patient's behavior and adjust the treatment plan for patients as needed.

During an interview on 10/2/2025 at 8:44 a.m. with Nurse Manager (NM) 2, NM 2 stated it was not indicated in the facility's policy to notify the physician after a face-to-face assessment was completed by a Registered Nurse (as required by the Federal regulation).

During a concurrent interview and record review on 10/6/2025 at 2:53 p.m. with the Chief Nursing Officer (CNO), Hospital Administrator (ADM), and the Nurse Manager (NM) 1, the facility's policy and procedure (P&P) pertaining to "Restraint and Seclusion Policy," effective 3/2019, was reviewed. The CNO and NM 1 verified that the facility's P&P did not align with the federal regulations (regarding the notification of a physician after a RN completes a face-to-face assessment). ADM stated it was the governing body's responsibility to oversee the facility's policy implementation and compliance of staff.

During a review of the facility's policy and procedure (P&P) titled, "Psychotropic Medications (drugs that affect the brain and central nervous system [the body's main processing center, consisting of the brain and spinal cord] to treat mental health disorders)," dated 10/2024, the P&P indicated, "Emergency Medication Intervention (EMI) injections shall be assessed and reassessed by nursing staff in eHR (electronic health record, digital version of paper charting) including initial assessment, vital signs, conclusion assessment, and patient behavior face to face interview."

During a review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Policy," dated 4/2025, the P&P indicated, "Assessment and Monitoring of Restraint (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)/Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) ... a. Restraint used for the management of violent behavior: One-hour face-to-face assessment: A responsible licensed independent practitioner, qualified registered nurse or physician assistant shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of restraint or seclusion. Registered nurses or physician assistants who perform such assessment shall be trained and have demonstrated competence in the management of violent behavior ..."

2. During a review of Patient 12's, "Psychiatric Initial Evaluation, dated 9/20/2025, the psychiatric eval indicated Patient 12 was admitted to the facility's behavioral health unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) on 9/20/2025 on 5150-hold (72 hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for danger to others (DTO, a person who poses a substantial likelihood of inflicting serious bodily harm on another person) increased aggression, threats, and instigating fight with staff.

During a review of Patient 12's "Emergency Medication and Restraint Order Sheet," dated 9/25/2025, the emergency medication and restraint order sheet indicated Patient 12 had physician's order for the following:
-Restraint order -hard restraints (physical or mechanical devices that are rigid and difficult to remove, designed to immobilize a person's body or limbs. They are typically made of durable materials like padded leather or heavy-duty plastic with locking mechanisms, and are used in situations where soft restraints are insufficient to prevent self-harm or escape) -not to exceed four hours, 4 point (both wrists and ankles) and seclusion - not to exceed four hours.
-Medication order - Ativan 2 milligrams via IM (intramuscular, into the muscle), Haldol 10 milligrams via IM, and Benadryl 50 milligrams via IM.

During a concurrent interview and record review on 10/1/2025 at 11:08 a.m. with the Medical Records Management (MRM) 1 and the Nurse Manager (NM) 2, Patient 12's "Emergency Medication Intervention (EMI, involve the use of sedative medication [drug that slows brain activity to calm a person] to quickly calm and manage patient experiencing acute agitation) notes," dated 9/25/2025, was reviewed. NM 2 stated Patient 12 was placed in seclusion room and placed on 4-point (both arms and legs) restraint (any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) at 7:30 p.m. NM 2 also said Patient 12 and received via IM route Haldol 10 milligrams, Ativan 2 milligrams and Benadryl 50 milligrams at 7:55 p.m. on 9/25/2025.

During a concurrent interview and record review on 10/2/2025 at 8:44 a.m. with Nurse Manager (NM) 2, Patient 12's "Seclusion/Restraint face to face assessment by L.I.P/H.S. (Licensed Independent Practitioner/House Supervisor)," was reviewed. NM 2 stated face to face assessment, dated 9/25/2025, was signed by House Supervisor (HS) 6, a Registered Nurse. NM 2 verified the physician was not notified by the RN after face-to-face assessment was completed because the date and time of physician notification was left blank in the seclusion/restraint face to face assessment form. NM 2 also stated it was not indicated in the facility's policy to notify the physician after a face-to-face assessment was completed by a Registered Nurse (as required by the Federal regulation).

During the same concurrent interview and record review on 10/2/2025 at 8:44 a.m. with NM 2, the Code of Federal Regulation Title 42 (federal regulations), "Condition of Participation: Patient's Rights," dated 2/2020, was reviewed. The federal regulations indicated, "§482.13(e)(14) - - If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient soon as possible after the completion of the 1 hour face-to-face evaluation." NM 2 stated the facility's policy did not reflect the federal regulations (which required the notification of a physician after a face-to-face assessment was completed by a RN), and it was important for their (the facility's) policy to match the regulations. NM 2 stated it was important for the nurse to inform the physician that face-to-face assessment was conducted, to report any abnormal findings, ensure patient safety, determine if restraint use was tolerated well or whether restraint should be continued. NM 2 stated there should always be a coordination among healthcare disciplines (such as between the physician and the Registered Nurse) regarding the plan of care, change in plan of care or in making adjustments in treatment plan.

During a concurrent interview and record review on 10/6/2025 at 2:53 p.m. with the Chief Nursing Officer (CNO), Hospital Administrator (ADM), and the Nurse Manager (NM) 1, the facility's policy and procedure (P&P) pertaining to "Restraint and Seclusion Policy," effective 3/2019, was reviewed. The CNO and NM 1 verified that the facility's P&P did not align with the federal regulations (regarding the notification of a physician after a RN completes a face-to-face assessment). ADM stated it was the governing body's responsibility to oversee the facility's policy implementation and compliance of staff.

During a review of the facility's policy and procedure (P&P) titled, "Psychotropic Medications (drugs that affect the brain and central nervous system [the body's main processing center, consisting of the brain and spinal cord] to treat mental health disorders)," dated 10/2024, the P&P indicated, "Emergency Medication Intervention (EMI) injections shall be assessed and reassessed by nursing staff in eHR (electronic health record, digital version of paper charting) including initial assessment, vital signs, conclusion assessment, and patient behavior face to face interview."

During a review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Policy," dated 4/2025, the P&P indicated, "Assessment and Monitoring of Restraint (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)/Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) ... a. Restraint used for the management of violent behavior: One-hour face-to-face assessment: A responsible licensed independent practitioner, qualified registered nurse or physician assistant shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of restraint or seclusion. Registered nurses or physician assistants who perform such assessment shall be trained and have demonstrated competence in the management of violent behavior ..."

Based on interview and record review, the facility failed to ensure its 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) team collected, tracked and trend data on critical patient safety indicators, implement comprehensive action plan, and measure the success of actions taken and track performance to ensure improvements are sustained, when the QAPI team failed to collect data on all patient abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) incidents and report the data to the QAPI quarterly meeting, in accordance with the facility's performance improvement plan.

The facility did not retain any abuse data for 2024 including two (2) of 76 sampled patients' (Patient 7 and Patient 8) abuse allegation incidents and did not report abuse data to QAPI committee in 2024 and 2025. The facility also failed to capture an alleged physical abuse incident for one of 76 sampled patients (Patient 19) which happened on 4/23/2025, when Patient 19 reported being choked and restrained (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) by staff.

This deficient practice resulted in the facility's QAPI team's inability to analyze abuse data, identify and address potential problems which had the potential to affect quality of patient care and safety. This deficient practice also resulted in facility's QAPI team's inability to monitor state regulatory compliance with reporting patient abuse to regulatory agencies as required.

Findings:

During an interview on 10/2/2025 at 9:34 a.m. with the Chief Nursing Officer (CNO), the CNO stated the facility did not have any record of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) cases reported to the state regulatory agency for 2024.

During an interview on 10/3/2025 at 4:57 p.m. with the Chief Executive Officer (CEO), the CEO stated the facility lost all patient abuse related data for 2024 after the previous Director of Quality left. The CEO said the facility did not retain any patient abuse record for 2024.

During a review of Patient 8's "Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 8/29/2024, the Psych Eval indicated, Patient 8 was admitted to the facility on 8/28/2024 with agitated (feeling of irritability or severe restlessness) behavior and diagnosis of schizoaffective disorder (a mental illness that affects mood and has symptoms of hallucinations [a false perception that can involve any of the five senses: sight, hearing, touch, smell, or taste] and/or delusions [a belief that is not based in reality and is held with absolute certainty despite evidence to the contrary]). The Psych Eval also indicated Patient 8 came from a nursing care facility (a nursing facility with the staff and equipment to give skilled nursing care and skilled rehabilitative services and other related health services).

During a concurrent interview and record review on 10/2/2025 at 12:58 p.m. with the Nurse Manager (NM 1) of Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) and Medical Surgical (Med-Surg, general patient population hospitalized for various causes such as illness and surgery), Patient 8's "Interdisciplinary Progress Note Nursing (nursing notes)," dated 8/29/2024, was reviewed. The nursing notes indicated, on 8/29/2024 at 4:09 p.m., Patient 8 reported to Registered Nurse (RN) 6 that Patient 8 did not want to go back to the nursing care facility because "she (Patient 8) had a man come into her (Patient 8's) room at 2 a.m. (unknown date) and she (Patient 8) was striking at him because she (Patient 8) was defending herself (Patient 8) due to her (Patient 8's) feeling that she (Patient 8) was going to be harassed (experiencing persistent and unwanted behavior that troubles, annoys, or creates an intimidating, hostile, or degrading environment." The nursing notes also indicated RN 6 notified the social worker, and NM 1. NM 1 stated she (NM 1) spoke with Patient 8, gathered information after RN 6 reported the incident and determined it was an alleged sexual abuse (sexual conduct or a sexual act forced upon a woman, man or child without their consent) involving the nursing care facility where Patient 8 came from. NM 1 stated this incident was reportable to the state health department and adult protective services (a government-run social services program that investigates and responds to reports of abuse, neglect, self-neglect, and financial exploitation of vulnerable adults, including older adults and adults with disabilities).

During a review of Patient 7's "Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 10/12/2024, the Psych Eval indicated, Patient 7 was admitted to the facility on 10/11/2024 due to increased agitation (feeling of irritability or severe restlessness) with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), paranoid type (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions).

During an interview on 10/3/2025 at 11:09 a.m. with the House Supervisor (HS 5), HS 5 stated the following: on 10/13/2024 at night, she (HS 5) received a report involving Patient 7 being physically abused (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by a security guard (SG 1). HS 5 spoke with SG 1. SG 1 tried to intervene as Patient 7 was being aggressive. SG 1 admitted to HS 5 that he (SG 1) hit Patient 7 because he (SG 1) got mad (at Patient 7) and retaliated. HS 5 assessed Patient 7 and noted Patient 7 had bruises on his (Patient 7's) cheek. The incident was also witnessed by other staff (Patient 7's primary nurse and two other Mental Health Workers). SG 1 was sent home immediately. The incident was reported to department nurse manager (NM 1) and the Chief Nursing Officer (CNO) for investigation and report.

During an interview on 10/3/2025 at 1:43 p.m. with Chief Nursing Officer (CNO), CNO stated she (CNO) was unable to see if the abuse incidents (Patient 7 and 8) were reported to state health department and adult protective services. CNO further stated the facility must report to the regulatory agencies so that the agencies could investigate further. CNO stated, "we need to make sure we protect the patients. It is required to report any alleged abuse in order to protect the elderly and mentally ill patients. We have people (regulatory agencies) to monitor and ensure the laws are followed."

During a review of the facility's QAPI (Quality Assessment and Performance Improvement, 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) minutes (a formal record of the committee's discussions, data analysis, and action plans to enhance patient care), dated 7/24/2024, 10/23/2024, 1/22/2025, 4/23/2025 and 7/23/2025, the QAPI minutes indicated there was no patient abuse data mentioned in all five (5) QAPI minutes.

During an interview on 10/3/2025 at 3:03 p.m. with the Hospital Administrator (ADM), the ADM stated the following: the QAPI team consisted of all members including physicians, Chief Executive Officer (CEO), Hospital Administrator (ADM), Chief Nursing Officer (CNO), and department managers. The QAPI team would identify issues and implement them into the QAPI Program by setting benchmarks and goals. The facility had issue with keeping track of abuse data and reporting previously. Starting March 2025, each department manager was responsible for investigating any alleged abuse cases and reported to ADM. ADM stated the facility was 100% compliant with the abuse reporting policy with all the abuse cases reported in 2025.

During an interview on 10/3/2025 at 3:23 p.m. with the Hospital Administrator (ADM), the ADM stated the following: the facility would report abuse data in QAPI meetings quarterly so the QAPI team could ask questions and take action as needed. The Quality Council data would then be reported to the Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issues within the hospital) and to the Governing Board meetings quarterly. ADM stated, "we want to make sure patient safety is number one priority."

During a concurrent interview and record review on 10/3/2025 at 3:30 p.m. with ADM, the facility's QAPI meeting minutes, dated 7/23/2025, was reviewed. The QAPI meeting minutes indicated data reported for second quarter (April to June) of 2025 and did not indicate any abuse data being reported. ADM confirmed the QAPI minutes did not have any abuse data. ADM stated, "it was an oversight."

During a concurrent interview and record review on 10/3/2025 at 3:35 p.m. with the Chief Nursing Office (CNO), the facility's "Quality Council (includes all the data collected by each department for quality improvement for second quarter [April to June] of 2025) report," dated 7/23/2025, was reviewed. The "Quality Council" report indicated there was no abuse data mentioned for second quarter of 2025. CNO confirmed the abuse data was not included in Quality Council report.

During a review of Patient 19's History & Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/21/2025, the H&P indicated, Patient 19 was admitted to the facility's Behavioral Health Unit (BHU) on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) hold due to increased aggression and at risk for assaultive behavior (a range of actions that are intended to harm or intimate others).

During a review of Patient 19's "Nursing Progress Notes," dated 4/23/2025, the "Nursing Progress Notes" indicated Patient 19 reported to Registered Nurse (RN) 1 that "he (Patient 19) was awakened around this morning (4/23/2025) 0100 (1:00 a.m.) by noises from his (Patient 19's) roommate. When he (Patent 19) got up to check on the situation, he (Patient 19) was instructed by the night shift staff to return his (Patient 19's) bed immediately. The patient (Patient 19) stated while he (Patient 19) preparing his (Patient 19's) bed, staff members approached him (Patient 19), choked him (Patient 19), and escorted him (Patient 19) to the seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). He (Patient 19) further reported he (Patient 19) was choked again and placed in 4-point (both wrists and ankles) 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) for approximately 4 to 5 hours around 0100 (1:00 a.m.). He (Patient 19) was reported released from the restraints around 0600 (6:00 a.m.) that morning. The house supervisor and nursing manager were both informed of the incident."

During an interview on 10/6/2025 at 11:20 a.m. with ADM, ADM stated he (ADM) was not aware of the alleged abuse case that happened on 4/23/2025 involving Patient 19 until 10/3/2025 (during the Federal survey). ADM stated the case was currently under investigation. ADM stated, "no, we are not 100% compliant (referring to instances of abuse investigations and referral/reporting to regulatory agencies)." The ADM stated the facility was required to investigate any alleged abuse case immediately and report the abuse to regulatory agencies. ADM further stated failure to report could cause safety issues and concern.

During a review of the facility's QAPI Plan titled, "2025 Hospital Performance Improvement Plan QAPI," dated 1/2025, the QAPI Plan indicated, "The primary goal is to provide a comprehensive Performance Improvement Program that will coordinate and integrate ALL performance improvement activities hospital wide to assure that the highest achievable safe and quality of care is delivered to patients. Being consistent in identifying and solving problems will minimize duplication, reduce medical liability, and encourage productive interrelationships ... The Governing Board (GB, the board of directors or board of trustees, is the group of individuals responsible for overseeing the hospital's overall strategic direction, policies, and operations. They ensure the hospital operates efficiently, ethically, and in compliance with regulations, ultimately aiming to improve patient care and community health) specifies the following for each department PI (Performance Improvement) plan ... 2. The Governing Board will receive no less than quarterly reports relating to Performance Improvement activities. 3. Data will be collected at least quarterly ... Quality Council is the multidisciplinary Medical Staff committee tasked with implementation of the hospital-wide PI process with direct reporting responsibility to the Governing Board ... The Quality Council/Patient Safety Committee has the responsibility to perform the following functions ... performance improvement activities will track and trend data on critical patient safety indicators including, but not limited to, [accreditation organization's] National patient Safety Goals, medical errors and adverse events and provide feedback and education throughout the hospital. The hospital shall measure the success of actions taken and track performance to ensure improvements are sustained ... Measuring and Monitoring Performance ... the organization collects data on measures as outlined by regulatory agencies ... and as needed to evaluate the services provided by the organization and contracted services. At a minimum, the organization collects data on these measures ... local, state, and federal requirements/regulatory compliance."

Based on interview and record review, the facility's Quality Assurance 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) program team failed to ensure that an ongoing program showed measurable improvements in indicators for patient safety and/or adverse events, when the facility's QAPI team failed to thoroughly investigate, report to the regulatory agencies, measure, analyze, and track adverse patient events (any unintended or undesirable occurrence, symptom, or condition that arises during medical treatment and may result in harm) such as incidents of alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), for three (3) of 76 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 19), in accordance with the facility's performance improvement plan, when:

1. The facility failed to ensure that a thorough internal investigation was conducted following the reported patient-to-patient altercation involving Patient 1 and Patient 2 that took place on 6/5/2025. The Quality Assurance and Performance Improvement (QAPI) team did not review available video footage and was unable to provide proof demonstrating that a structured method was used to identify the underlying causes of the adverse event and to implement measures to prevent recurrence, as required by the hospital's Performance Improvement Plan.

This deficient practice had the potential to result in a missed opportunity to identify and correct systemic failures, such as staff possibly not performing Q15-minute safety checks (routine observations conducted every 15 minutes to monitor and document each patient's condition and behavior, with the goal of identifying risks and intervening early to ensure safety) and failing to recognize and intervene to prevent Patient 1 from striking Patient 2. As a result of the altercation, Patient 1 sustained a hip fracture (break in the bone) and exhibited neurological changes, including trembling (shaking) of the arms and legs, sluggish (reduced or delayed) response of the right pupil, right upper eyelid drooping (sagging), and left-hand grip weakness. The facility's failure to address these issues potentially created an ongoing risk for other patients in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders).

2. The facility failed to ensure that abuse allegations (any suspected or alleged incident of physical abuse, abandonment, abduction, deprivation, financial abuse, mental suffering, neglect, exploitation, or mistreatment of an elder or dependent adult by a person responsible for their care) involving Patient 3 and nursing staff (Licensed Vocational Nurse - LVN 1) were promptly reported to the California Department of Public Health (CDPH, the department that works to protect the public's health), within 24 hours, in accordance with the facility's policy and procedure (P&P) regarding "Abuse Mandated Reporting," when abuse allegations were made regarding LVN 1, who was witnessed slapping Patient 3 twice during medication pass on 1/19/2024.

This deficient practice had the potential to result in continued risk of harm to Patient 3. In addition, it delayed external regulatory review and the opportunity for oversight, which may compromise patient safety when an investigation is not immediately undertaken to ensure that corrective action plans are implemented and that the facility is taking adequate steps to reduce the risk of a similar future event.

3.The facility failed to ensure that allegations of abuse (suspected or alleged incidents of physical abuse, abandonment, abduction, deprivation, financial abuse, mental suffering, neglect, exploitation, or mistreatment of an elder or dependent adult-must be reported immediately or as soon as practically possible by phone and followed by a written report (SOC 341) within 24 hours) involving Patient 19 was promptly investigated and reported to the California Department of Public Health (CDPH), in accordance with the facility's policy and procedure titled "Abuse Mandated Reporting." The allegation involved Patient 19 reporting to Registered Nurse (RN) 1 that night shift staff had choked and placed Patient 19 in four-point restraints (involve securing all four of a patient's limbs-both arms and both legs-to a bed or stretcher using soft or leather straps).

This deficient practice resulted in a delay in recognizing and responding to abuse allegations involving Patient 19, which compromised the patient's safety and well-being. In addition, it reflected the facility's failure to demonstrate an effective internal reporting system and oversight mechanisms intended to protect patients from the harm of abuse.

Findings:

1. During an interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), ADM confirmed that on 6/5/2025 at 2:20 p.m., an altercation occurred between Patient 1 and Patient 2 in the locked Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders), 5th floor (Campus 1). Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards and later was confirmed that Patient 1 sustained a right hip fracture (a break in the upper portion of the right femur (thighbone), specifically where it connects to the hip joint on the right side of the body). Patient 1 was also later assessed to show signs and symptoms of neurological deficit (define): weakness in the lower extremities (refers to a reduction in muscle strength in the legs, which can affect a person's ability to stand, walk, maintain balance, or perform daily activities), drooping on the left side of face (a unilateral sagging or weakness of the facial muscles, typically on one side of the face), and left arm weakness and was transferred to a higher level of care (refers to a healthcare setting that provides more advanced, specialized, or intensive medical services). There was also no video footage available for review of the incident that happened on 6/5/2025 because the facility kept the video footages for only 10 days in Campus 1. The incident was unwitnessed (as documented in the nursing progress notes) by both licensed (RN, LVN [licensed vocational nurse]) and unlicensed (MHW [mental health worker]) healthcare personnel assigned to the unit at the time.

During a concurrent interview and record review on 9/30/2025 at 3:02 p.m. with the Chief Nursing Officer (CNO), Patient 1's medical record titled, "Nursing Progress Notes," dated 6/5/2025, was reviewed. The CNO stated that, according to the documentation, Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards. The CNO confirmed that the fall was unwitnessed (as per nursing notes documentation), and that Rapid Response Team (RRT, a team of healthcare professionals, often including a critical care nurse and a respiratory therapist, who are quickly dispatched to provide immediate care to a patient who shows signs of acute deterioration within a hospital) was called at 2:20 p.m. after Patient 1 was assessed to have weakness in the lower extremities (both legs), drooping (excessive sagging) on the left side of face, and left arm weakness.

During a concurrent interview and record review on 10/1/2025 at 2:06 p.m., with the Chief Nursing Officer (CNO), Patient 1's "Patient Rounding (a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety) Sheet, dated 6/5/2025 (covering the time from 7:00 a.m. to 4:30 p.m.), was reviewed. The documentation indicated that Patient 1 was not agitated (feeling of irritability or severe restlessness) during this time frame and was consistently documented as either lying or sitting in their (Patient 1) bedroom. Specifically:

-At 1:00 p.m., Patient 1 was documented as either lying or sitting
-At 2:15 p.m., Patient 1 was again documented as either lying or sitting
-This same documentation pattern continued through 2:45 p.m.
-The Chief Nursing Officer (CNO) verified that this documentation was possibly inaccurate, noting that the Rapid Response Team was called at 2:20 p.m. and Patient 1 was found in the hallway by Patient 2's room, yet no deviation or incident was reflected in the rounding sheet during that time.

During an interview conducted on 10/1/2025 at 2:06 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following about the incident involving Patient 1 striking Patient 2 that occurred in the hallway on 6/5/2025: The initial investigation was conducted by the House Supervisor, the resource nurse, and the primary nurse. A Root Cause Analysis (RCA, a systematic process for identifying the underlying, fundamental causes of a problem to prevent it from happening again) was later completed by the CNO, a physician (MD 2), and the Hospital Administrator (ADM). The CNO acknowledged that patient-to-patient altercations fell under the category of alleged abuse and were subject to mandated reporting requirements. When asked whether the case was investigated, the CNO confirmed that an investigation took place, during which staff were interviewed, the patient (Patient 1) was assessed, and both the family and physicians were notified. The CNO stated that it was determined the patients were fighting, based on a witness account (EVS [Environmental Service Worker] worker statement) indicating that one patient (Patient 1) attacked the other patient (Patient 2), resulting in one patient (Patient 1) falling to the floor. However, the CNO also confirmed that video footage of the incident was never reviewed. Additionally, although a mental health worker was reportedly present on the unit that day, the CNO could not recall specific details about their involvement.

During an interview on 10/1/2025 at 3:17 p.m. with the Chief Nursing Officer (CNO) and the Hospital Administrator (ADM), the CNO stated that the incident was investigated internally and that all key team members were interviewed, including the Environmental Services (EVS) worker who witnessed the altercation between Patient 1 and Patient 2 in the hallway. The ADM confirmed that, because of the EVS worker's statement regarding the witnessed fall and the altercation between the two patients (Patient 1 and Patient 2), the facility had no reason to review the video footage.

During further interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM stated that the administration was no longer certain whether the entire incident (between Patient 1 and Patient 2) had been witnessed by the Environmental Service (EVS) worker. The ADM confirmed that nursing staff and mental health workers did not witness the altercation between the two patients (Patient 1 and Patient 2). The ADM also stated that he (ADM) could not verify whether staff was conducting Q15-minute checks on that day. The ADM said, "They should have done it (referring to the Q15-minute patient rounds) - this is the expectation," and noted that staff verbally confirmed they were conducting their rounds. However, the ADM also confirmed that the video footage was never reviewed to verify whether staff actions aligned with what was documented and reported on the day of the incident between Patient 1 and Patient 2.

During a follow-up interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM stated that following the Root Cause Analysis (RCA) of the incident involving Patient 1 and Patient 2, it was determined that Patient 1 had exhibited a sudden change in behavior. In response to the incident, the facility evaluated management practices and provided staff training on de-escalation and early recognition of behavioral changes. Although the ADM stated that all staff received in-service training, the facility was unable to provide documentation of those trainings. The RCA process document provided was dated 10/1/2025 (the incident happened on 6/5/2025), and the ADM admitted that the facility did not routinely retain RCA records and that he (ADM) had typed the document on the day it was requested.

During a follow-up interview on 10/1/2025 at 3:37 p.m., with the Hospital Administrator (ADM), the ADM stated that he (the ADM) could no longer confirm whether the entire altercation between Patient 1 and Patient 2 had been witnessed by the Environmental Services (EVS) worker. This uncertainty arose due to a reviewed statement documented by the Behavioral Health Unit (BHU) Nurse Manager (NM 1) on 6/5/2025 at 4:30 p.m., which referenced a physician's finding of a bump on the right side of Patient 1's head. The ADM acknowledged that he had not been aware of this possible head injury sustained by Patient 1 during the fall following the altercation. The ADM further confirmed that neither nursing staff nor mental health workers had witnessed the incident. The ADM also stated that he could not verify whether Q15-minute safety checks were conducted on the day of the incident, although staff verbally reported that they had completed their rounds. However, the ADM confirmed that video footage from the unit was never reviewed to validate whether staff actions aligned with documentation and verbal reports regarding the incident involving Patient 1 and Patient 2.

During an interview on 10/3/2025 at 3:34 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following regarding Q-15 Minutes rounding: "Q15-minute safety checks are conducted to monitor each patient's condition and behavior at regular 15-minute intervals. The purpose is to identify any signs of agitation, frustration, or behaviors that may indicate a risk to the patient or others. These checks are preventive in nature and allow staff to intervene early and provide therapeutic support as needed. We use this time to assess whether patients are escalating and to respond in a way that promotes safety and de-escalation. While staff are expected to document these checks accurately, it's also important to verify that the documentation aligns with actual observations, such as through video review when available."

During a review of the facility's "2025 Hospital Performance Improvement Plan-QAPI," dated 2025, the plan indicated that, "When a sentinel or significant adverse event occurs, the facility is required to immediately conduct a Root Cause Analysis (RCA) as outlined in its Sentinel Event policy. An action plan must then be developed to address the underlying system failures, and follow-up monitoring is incorporated to evaluate the effectiveness of the corrective actions. The results of the RCA are reported to the Medical Executive Committee and the Patient Safety Committee, which is a subcommittee of the Quality Council."

During a review of the facility's "2025 Hospital Performance Improvement Plan-QAPI," dated 2025, the plan indicated that the hospital's 2025 Performance Improvement Plan (QAPI) outlines a comprehensive, organization-wide approach to improving patient care and safety. It emphasizes the importance of tracking and analyzing data on critical patient safety indicators to identify trends, educate staff, and implement corrective actions. The plan requires that the effectiveness of these actions be measured over time to ensure that improvements are sustained. It also highlights the need to prioritize issues that have the greatest impact on patient outcomes and satisfaction. Hospital administration is responsible for implementing the plan and ensuring that all departments actively participate in performance improvement efforts. Department leaders are accountable for monitoring quality within their areas, identifying trends, and collaborating across departments to address systemic issues. The Quality Council, a multidisciplinary committee, oversees the hospital-wide improvement process and reports directly to the Governing Board. The plan further ensures that staff, physicians, and leadership receive the necessary education and support to engage in meaningful performance improvement activities. Overall, the goal is to create a culture of continuous improvement that enhances patient safety, reduces risk, and promotes high-quality care.

2. During a concurrent interview and record review conducted on 10/3/2025 at 12:36 p.m. with House Supervisor (HS 1), Patient 3's admissions to the facility for the year 2024 were reviewed. HS 1 stated that Patient 3 was not admitted to the facility in January 2024.

During an interview on 10/3/2025 at 11:32 a.m., with the Nurse Manager (NM 1) of the Medical-Surgical and Behavioral Health Units, NM 1 confirmed that the facility had no access to 2024 data to verify whether the abuse allegations involving Patient 3 were reported to the California Department of Public Health (CDPH, department that works to protect the public's health). NM 1 explained that the information was no longer available because the former Director of Quality had left the organization, and the facility was unsure whether the incident had ever been reported.

During a follow-up interview on 10/3/2025 at 1:40 p.m. with Nurse Manager (NM 1), NM 1 said the following: "The former Director of Quality did the investigation of the alleged abuse. I am not aware if she did or did not report the abuse allegations to California Department of Public Health (CDPH, department that works to protect the public's health). When the former Director of Quality got the call regarding the abuse, and once the investigation was done, we went to the patient, we wanted to make sure the patient was handled by a female CNA only. Another person said the nurse hit the patient. The former Quality Director did have the file for the case, and I am not aware if this was reported or not. I remember we discussed this with management. When she (former Director of Quality) resigned, she (former Director of Quality) did not perform proper endorsement of her cases."

During an interview conducted on 10/3/2025, at 1:52 p.m. with the QAPI team, which included the Hospital Administrator (ADM), Chief Nursing Officer (CNO), Nurse Manager (NM 2), Quality Coordinator (QC), and Manager of the Behavioral Health Unit (NM 2), NM 2 confirmed that Patient 3 was admitted to the facility for aggressive behavior and striking out. NM 2 said that Patient 3 was admitted to the Behavioral Health Unit on 1/19/2024 due to danger to self and placed on a 5150 hold (refers to the involuntary detention of an individual for up to 72 hours for psychiatric evaluation when they are deemed a danger to themselves, others, or are gravely disabled due to a mental health disorder). The NM 2 then said that Patient 3 was discharged on 1/25/2024.

During an interview on 10/2/2025 at 3:52 p.m. with the Chief Nursing Officer (CNO), the CNO provided documentation of an investigation into alleged abuse reported to the facility on 1/22/2024 by a staff member who witnessed Licensed Vocational Nurse (LVN 2) slapping Patient 3 twice during the morning medication pass on 1/19/2024.

During a review of the investigation into the alleged abuse incident, dated January 22, 2024, the facility's records indicated the following:
-"On January 22, 2025, at 10:30 a.m., the Human Resources (HR) Coordinator received an anonymous phone call reporting the following:
"I want to report an anonymous incident that on Friday, January 19 [2024], in the morning, in room number [#], LVN 2 was giving medication to the patient (Patient 3), and the patient did not want to take the medication. LVN 2 slapped the patient (Patient 3) twice."
-The record also indicated that Interviews were conducted with the following individuals:
LVN 2 (the alleged perpetrator)
A witness who observed LVN 2 punch Patient 3
Patient 3 (the alleged victim)
-The documentation also confirmed that LVN 2 was suspended on January 22, 2024, pending the outcome of the investigation.

During an interview on 10/3/2025 at 3:06 p.m. with the Hospital Administrator (ADM), Chief Nursing Officer (CNO), and both Nurse Managers of the Behavioral Health Unit (NM 1 and NM 2), the ADM stated that the position of Director of Quality is neither open nor currently occupied. The ADM explained that the QAPI team comprised of departmental managers, physicians, and the Chief Executive Officer (CEO) of the hospital. The ADM stated, "If there are issues that we identify, we incorporate them into our QAPI program, and we want to achieve the benchmark," referring to the facility's performance goals. As an example, the ADM described the abuse reporting process, stating that each department was responsible for mandated reporting, and that the facility followed procedures to ensure compliance. The ADM added, "We are currently at 100% for abuse reporting. We had two incidents, and we are in 100% compliance for reporting ... and we follow policy."

During a follow-up interview conducted on 10/3/2025 at 4:36 p.m. with the Chief Nursing Officer (CNO), the CNO stated: ""I don't have a tracking report (if the alleged abuse incident was reported to regulatory agencies) for this abuse case. It's supposed to be reported within 24 hours, since it's alleged abuse and the patient had no injury..."

During a review of the facility's Policy and Procedure (P&P) titled, "Abuse - Management of Suspected Child, Adult, Disabled Person or Elderly Abuse, Neglect," dated March 2022, the P&P indicated the following:
"-It is the policy of the facility, in accordance with applicable laws, that any person with reasonable cause to believe that an individual is experiencing abuse, exploitation, or neglect must report the information to the appropriate regulatory agency.
-Cases of suspected sexual assault, physical abuse, or neglect should be given priority.
-All reports received by local or state law enforcement must be referred to the appropriate protective regulatory services or county agency responsible for human rights protection.
-Individuals may report alleged violations to the Department of Health or the appropriate state healthcare regulatory agency by telephone, in writing, or in person.
-If the alleged perpetrator is a healthcare worker, they must be immediately removed from patient care duties until the investigation is completed.
-Allegations of abuse must be reported to CDPH within 36 hours of the alleged event."

During a review of the facility's "2025 Hospital Performance Improvement Plan-QAPI," dated 2025, the plan indicated that, "When a sentinel or significant adverse event occurs, the facility is required to immediately conduct a Root Cause Analysis (RCA) as outlined in its Sentinel Event policy. An action plan must then be developed to address the underlying system failures, and follow-up monitoring is incorporated to evaluate the effectiveness of the corrective actions. The results of the RCA are reported to the Medical Executive Committee and the Patient Safety Committee, which is a subcommittee of the Quality Council."

During a review of the facility's "2025 Hospital Performance Improvement Plan-QAPI," dated 2025, the plan indicated that the hospital's 2025 Performance Improvement Plan (QAPI) outlines a comprehensive, organization-wide approach to improving patient care and safety. It emphasizes the importance of tracking and analyzing data on critical patient safety indicators to identify trends, educate staff, and implement corrective actions. The plan requires that the effectiveness of these actions be measured over time to ensure that improvements are sustained. It also highlights the need to prioritize issues that have the greatest impact on patient outcomes and satisfaction. Hospital administration is responsible for implementing the plan and ensuring that all departments actively participate in performance improvement efforts. Department leaders are accountable for monitoring quality within their areas, identifying trends, and collaborating across departments to address systemic issues. The Quality Council, a multidisciplinary committee, oversees the hospital-wide improvement process and reports directly to the Governing Board. The plan further ensures that staff, physicians, and leadership receive the necessary education and support to engage in meaningful performance improvement activities. Overall, the goal is to create a culture of continuous improvement that enhances patient safety, reduces risk, and promotes high-quality care.

3. During a review of Patient 19's "Nursing Progress Notes," dated 4/23/2025 at 2:58 p.m., recorded by the registered nurse (RN 1), the note indicated that, according to Patient 19, "He (Patient 19) was awakened around 0100 (1:00 a.m.) that morning (4/23/2025) by noises from the roommate. When he (Patient 19) got up to check on the situation, he (Patient 19) was instructed by night shift staff to return to the bed immediately... Patient 19 then stated that while he (Patient 19) was preparing the bed, staff members approached him (Patient 19), choked him (Patient 19), and escorted him to the seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). He further reported that he was choked again and placed in 4-point restraints (A 4-point restraint is a medical or security measure that uses restraints on all four of a person's limbs-both wrists and both ankles-simultaneously to prevent movement. It is a restrictive intervention typically used only in emergencies when a person is an immediate danger to themselves, or others and less restrictive alternatives have failed) for approximately 4 to 5 hours starting around 0100 (1:00 a.m.). Patient 19 was reportedly released from the restraints around 0600 (6:00 a.m.) that morning (4/23/2025)." The House Supervisor (HS 4) and Nurse Manager (NM 3) were both documented as having been informed by RN 1 of the incident.

During a concurrent interview and record review on 10/2/2025 at 10:47 a.m. with Registered Nurse (RN 1), Patient 19's "Nursing Progress Notes," dated 4/23/2025 at 14:58 (2:58 p.m.), were reviewed. RN 1 confirmed that she (RN 1) authored the progress note and stated she (RN 19) had notified both the House Supervisor (HS 4) and Nurse Manager (NM 3). RN 1 said that all staff were mandated reporters (legally obligated to report. Failure to do so can result in criminal liability, including fines and jail time, as well as civil lawsuits) and that any alleged (said, without proof) abuse must be escalated appropriately.

During an interview on 10/2/2025 at 1:59 p.m. with Nurse Manager (NM 3) and the Director (DIR 1) of BHU, NM 3 stated this was the first time she had heard of Patient 19's alleged abuse. NM 3 stated, "RN 1 never reported this to me, and if she (RN 1) had, I would have started an investigation." DIR 1 stated that when an alleged abuse incident involving staff occurred, "we place the alleged staff member on suspension while an investigation is conducted." DIR 1 further stated that since the facility was unaware of the incident involving Patient 19, no investigation was conducted, and the incident was never reported to the appropriate authorities. As a result, the facility was unable to identify the alleged perpetrator.

During an interview on 10/3/2025 at 10:19 a.m. with House Supervisor 4 (HS 4), HS 4 stated that HS 4 was unaware of the alleged abuse claims. HS 4 said that when RN 1 became aware of the allegation (a claim made without proof), RN 1 should have notified the supervisor (HS 4) and "I (HS 4) should file an incident report. The incident report would then be forwarded to the Nurse Manager and Performance Improvement for investigation." Patient 19 was discharged from the facility on 5/1/2025, and as of 10/2/2025, the abuse allegation had not been investigated.

During an interview on 10/3/2025 at 11:32 a.m. with Nurse Manager (NM 1), NM 1 stated:
"We don't have the data from 2024 because our Director of Quality has left, and we no longer have access to that information. As a result, we implemented a new reporting process in 2025."

During an interview on 10/3/2025 at 3:06 p.m. with the Hospital Administrator (ADM), Chief Nursing Officer (CNO), and both Nurse Managers of the Behavioral Health Unit (NM 1 and NM 2), when asked about tracking abuse reporting incidents, the ADM said that the facility was tracking and maintaining records for both incident and abuse reporting (Patient 19's abuse allegation was not in the facility's tracking report). The ADM also said that the process followed the facility's new policy and chain of command: if a floor nurse observed a reportable incident, they notify the direct supervisor or resource nurse, who then informs the house supervisor. The nurse was expected to document the incident in the patient's progress notes, including direct statements from the patient. The same reporting process was followed at both campuses (Campus 1 and Campus 2) and the house supervisor should submit the incident report. The ADM verified that abuse reporting was handled separately from sentinel (a serious, unexpected occurrence in a healthcare setting that results in death, serious physical or psychological injury, or the risk thereof) or adverse event reporting. And also said that the abuse reporting policy was revised in March 2025 to make the process more concise and directive, and that the Administrator now served as the coordinator for the abuse reporting process.

During an interview on 10/3/2025 at 3:36 p.m. with the Hospital Administrator (ADM), Chief Nursing Officer (CNO), and both Nurse Managers of the Behavioral Health Unit (NM 1 and NM 2), the ADM stated that the position of Director of Quality was neither open nor currently occupied. The ADM explained that the QAPI team was comprised of departmental managers, physicians, and the Chief Executive Officer (CEO) of the hospital. The ADM stated, "If there are issues that we identify, we implement them into our QAPI program, and we want to achieve the benchmark," referring to the facility's performance goals. As an example, the ADM described the abuse reporting process, stating that each department was responsible for mandated reporting, and that the facility followed procedures to ensure compliance. The ADM added, "We are currently at 100% for abuse reporting. We had two incidents, and we are in 100% compliance for reporting ... and we follow policy."

During the same interview on 10/3/2025 at 3:36 p.m. with the Hospital Administrator (ADM), Chief Nursing Officer (CNO), and both Nurse Managers of the Behavioral Health Unit (NM 1 and NM 2), the CNO stated that while each department was responsible for collecting their patient safety data, abuse and adverse events were not measurable data. The CNO further stated that abuse cases do not fall under the scope of nursing metrics.

During a review of the facility's policy and procedure (P&P) titled "Abuse/Mandated Reporting," dated 3/2025, the P&P indicated, that "All suspected cases must be investigated immediately. Any individual (employee, volunteer, or associate) who reasonably believes or has knowledge that a patient's health or welfare has been, is, or will be adversely affected by abuse or neglect must report it within 24 hours to Administration... Law enforcement agencies must refer reports to the appropriate protective services agency. o If an alleged perpetrator is a healthcare worker, they must be immediately removed from patient care pending an investigation. [The Facility] prohibits retaliation against employees or individuals who report suspected violations in good faith... All healthcare practitioners and [The Facility] employees are mandated reporters. Employees must notify their immediate supervisors, Department Manager, who will collaborate with the CNO/Hospital Administrator/Designee (the Abuse Coordinator) in the final analysis of the reportable incident. The reporting process includes documenting the incident in the patient's progress notes with the date, time, source, and direct quotes; generating an incident report; notifying the supervisor and the Quality & Risk Department; and reporting the incident to authorities both by phone and in writing within the required timeframes. Admi

Based on interview and record review, the facility failed to promptly evaluate and provide immediate medical intervention and treatment, in accordance with the facility's policy and procedure regarding plan for provision of care pertaining to safe, effective, timely care and treatment, when one of 76 sampled patient (Patient 18), a Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient (Patient 18), swallowed a foreign object (any item that does not belong in the body).

This deficient practice resulted in Patient 18's claim of swallowing a razor (sharp blade instrument) not validated and evaluated by nursing staff until two days later (on 9/8/2025) after Patient 18's initial claim (9/6/2025) of having swallowed a razor, which led to Patient 18 being transferred to another facility and undergoing a procedure for removal of the foreign object. This deficient practice also had the potential of Patient 18 losing a large amount of blood and damage to his esophagus (canal that connect the throat to the stomach), which may result in further serious injury or even death.

On 10/2/2025 at 2:32 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 Nursing Officer (CNO), Manager of Medical Surgical and Behavioral Health Unit (NM 1), Hospital Administrator (ADM), Manager of Medical Surgical and Behavior Health Unit (NM 2), Facility Director of Behavior Health Unit (DIR 1) and Nurse Manager of Behavior Health Unit (NM 3). the facility failed to promptly evaluate and provide immediate medical intervention and treatment, in accordance with the facility's policy and procedure regarding plan for provision of care pertaining to safe, effective, timely care and treatment, when one of 76 sampled patient (Patient 18), a Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) patient (Patient 18), swallowed a foreign object (any item that does not belong in the body). This deficient practice resulted in Patient 18's claim of swallowing a razor (sharp blade instrument) not validated and evaluated by nursing staff until two days later (on 9/8/2025) after Patient 18's initial claim (9/6/2025) of having swallowed a razor, which led to Patient 18 being transferred to another facility and undergoing a procedure for removal of the foreign object. This deficient practice also had the potential of Patient 18 losing a large amount of blood and damage to his esophagus (canal that connect the throat to the stomach), which may result in further serious injury or even death.

During a review of Patient 18's (a BHU patient, on involuntary hold (involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] evaluation and treatment) Nursing Progress Notes, dated 9/6/2025 at 1808 (6:08 p.m.), indicated Patient 18 reported to nurse (RN 1) he (Patient 18) swallowed a razor, Nurse Practitioner (NP 1) was notified, and order was given to monitor and send to Emergency Department (ED) if with symptoms.

During a review of Patient 18's Nursing Progress Notes, dated 9/7/2025 at 1608 (4:08 p.m.) indicated Patient 18 stated, "you never did anything about the razor I swallowed yesterday (referring to 9/6/2025)." There was no record of a nurse notifying the physician regarding Patient 18's statement on 9/7/2025.

During a review of Patient 18's Nursing progress Notes, dated 9/8/2025 at 7:46 a.m. indicated Patient 18 stated he (Patient 18) swallowed a razor that he hid inside his (Patient 18) "butt."

During a review of Patient 18's Nursing progress notes, dated 9/8/2025 at 1828 (6:28 p.m.) indicated Patient 18 stated he (Patient 18) was going to swallow a razor and also stated he (Patient 18) swallowed a razor "send me to ER (Emergency Room) now." The notes also indicated Patient 18 was observed spitting out small amount of serosanguinous (pink or light red color) drainage from his mouth.

During a review of Patient 18's "Operative Report," dated 9/9/2025, the record indicated, Patient 18 underwent Esophagogastroduodenoscopy (EGD, medical procedure that allows the doctor to examine the inside of throat, stomach and small intestine) on 9/9/2025 with "a huge metallic foreign body ... very thick metal ... measured about 6 centimeter (cm, unit of measurement) in length, 2 cm in width" removed from the esophagus.

During a review of Patient 18's Discharge Summary (a comprehensive medical document created when a patient leaves a hospital or other care setting, detailing the reason for admission, the care received, key findings, and post [after]-discharge instructions), dated 9/9/2025, the discharge summary indicated Patient 18 was transferred to another facility (on 9/8/2025) for swallowing a foreign object and was later admitted at the receiving facility.

During an interview on 10/1/2025 at 1:33 p.m. with BHU manager (NM 3), NM 3 stated charge nurse or primary nurse should assess patient, call doctor, and send patient to ED for evaluation to verify patient did not swallow anything. "We (staff) cannot ignore what patients say, in this case patient (Patient 18) should have been sent to higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]) to verify what he was saying."

During an interview on 10/1/2025 at 3:56 p.m. with the Chief Nursing Officer (CNO), CNO stated when a patient reported to a nurse that he or she had swallowed a foreign object, the nurse should assess and notify the physician right away. Depending on the symptoms, the nurse may call 911 for emergency (patient's bleeding or unstable vital signs) or send the patient to emergency department for higher level of care. The CNO stated, "Nurse should take the report seriously and not to make any assumption."

On 10/6/2025 at 2:51 p.m. the IJ was removed in the presence of the CNO, NM 1, ADM, Chief Executive Officer (CEO), DIR 1 and NM 3, after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that immediate action taken by the facility were the following: starting 10/2/2025, Immediate Response -Nursing staff shall acknowledge and validate patient complaints, obtain vital signs (includes body temperature, heart rate, respiratory rate, blood pressure) and perform a focused assessment related to complaint. Document the patient's exact words and findings. Call the onsite physician, house supervisor and clinical Manager to reassess the patient situation/condition and contact treating physician. Additionally, the nurse must also call one of the facility's Governing Board physician members to make final determination whether patient will be transferred or not. Re-education of all Licensed staff on the topic of Patient Rights Facility policy, Contraband (any item that is prohibited because it poses a risk to the safety and security of patients, staff, or visitors. This includes a wide range of items that could be used for harm, escape, or intimidation, such as weapons, illegal drugs, lighters, and alcohol) Handling policy, Behavior Health Unit Criteria and SBAR (a communication tool used in nursing to update team about patient, it stands for Situation, Background, Assessment and recommendations)/Significant change. Transfer protocol/guidelines Policy established and inter shift hand off (the transfer of information, responsibility, and authority from one person or team to another as a shift ends and a new one begins) process for patients who present/express a significant change during shift the house supervisor will ensure complaint presented is acted upon timely and physician notified.

Findings:

During a review of Patient 18's Behavioral Health History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/6/2025 at 1445 (2:45 p.m.), the H&P indicated, Patient 18 was admitted to the facility's Behavioral Health Unit (BHU- inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders)) on 5150 (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) hold for danger to self (DTS) stating he (Patient 18) wanted to run into traffic and a danger to others (DTO) for wanting to hurt people in Mexico.

During a review of Patient 18's "Nursing Progress Notes," dated 9/6/2025 at 1808 (6:08 p.m.), the Nursing Progress Notes indicated Patient 18 reported to nurse (RN 1) he (Patient 18) swallowed a razor, Nurse Practitioner (NP 1) was notified, and an order was given by the NP 1 to monitor Patient 18 and send to emergency department if with symptoms.

During a review of Patient 18's "Nursing Progress Notes," dated 9/7/2025 at 1608 (4:08 p.m.), The Nursing Progress Notes indicated that Patient 18 stated, "you never did anything about the razor I swallowed yesterday (referring to 9/6/2025)." There was no record of a nurse notifying the physician regarding Patient 18's statement on 9/7/2025 (this was verified by Nurse Manager (NM) 3 during an interview on 10/2/2025 at 10:44 a.m.).

During a review of Patient 18's "Nursing Progress Notes," dated 9/8/2025 at 7:46 a.m., the Nursing progress Notes indicated Patient 18 stated he swallowed a razor that he hid inside his (Patient 18) "butt."

During a review of Patient 18's "Nursing Progress Notes," dated 9/8/2025 at 1828 (6:28 p.m.), the Nursing Progress Notes indicated Patient 18 stated he (Patient 18) was going to swallow a razor and also stated he swallowed razor "send me to ER (emergency room) now." The notes also indicated Patient 18 was observed spitting out small amount of serosanguinous (pink or light red color) drainage from his (Patient 18) mouth.

During a review of Patient 18's" Discharge Summary (a comprehensive medical document created when a patient leaves a hospital or other care setting, detailing the reason for admission, the care received, key findings, and post [after]-discharge instructions)," dated 9/9/2025, the discharge summary indicated Patient 18 was transferred to another facility (on 9/8/2025) for swallowing a foreign object and was later admitted at the receiving facility.

During an interview on 10/2/2025 at 11:00 a.m. with Registered Nurse (RN) 1, RN 1 stated Patient 18 reported swallowing a razor on 9/6/2025. RN 1 stated she (RN 1) reported it to NP 1 on the floor and was told to monitor Patient 18 and send Patient 18 to ER if something was abnormal. RN 1 further stated there was no order for x-ray (a diagnostic imaging procedure that uses a small dose of high-energy radiation to create pictures of the inside of the body) given on 9/6/2025.

During an interview on 10/1/2025 at 10:48 a.m. with Registered Nurse 3 (RN 3), RN 3 stated that on 9/8/2025, Patient 18 went to the nursing station and reported he (Patient 18) swallowed something, "we (staff) were not sure if he (Patient 18) did, later he (Patient 18) started spitting out blood and we (staff) called the Nurse Practitioner (NP 2) and patient (Patient 18) was sent to Emergency Department via facility van."

During an interview on 10/1/2025 at 12:24 p.m. with the Behavioral Health Unit Manager (NM 3), NM 3 stated that for a patient who reported they swallowed a razor, staff should have called 911 because "we (staff) do not know what is going on with patient internally."

During an interview on 10/1/2025 at 1:33 p.m. with BHU manager (NM 3), NM 3 stated Charge Nurse or primary nurse should have assessed the patient, called the doctor and sent patient to ER for evaluation to verify patient did not swallow anything. "We (staff) cannot ignore what patients say, in this case patient (Patient 18) should have been sent to higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]) to verify what he was saying."

During an interview on 10/1/2025 at 3:13 p.m. with house supervisor (HS 3), HS 3 stated she (HS 3) was doing rounds (patient rounds, a proactive nursing practice where staff check on patients at regular intervals to anticipate and address their needs. This strategy aims to improve patient safety) on 9/8/2025 and overheard Patient 18 report to Charge Nurse (CN) 6 that he (Patient 18) swallowed a razor.

During an interview on 10/1/2025 at 3:56 p.m. with the Chief Nursing Officer (CNO), CNO stated when a patient reported to a nurse that he or she had swallowed a foreign object, the nurse should assess and notify the physician right away. Depending on the symptoms, the nurse may call 911 for emergency (patient's bleeding or unstable vital signs) or send the patient to emergency department for higher level of care. CNO stated, "Nurse should take the report seriously and not to make any assumption."

During an interview on 10/1/2025 at 4:27 p.m. with the Chief of Staff (COS), COS stated the following: when a patient reported he or she swallowed a foreign object, we need to believe the patient even though they have poor insight and judgement. When a patient reported he or she swallowed a foreign object, the provider needed to be notified, and examination performed on the patient. There should be a STAT (immediately) chest X ray and abdomen X ray to rule out the foreign object and to determine the next step for treatment. Once the foreign object was confirmed, the patient should be sent out to emergency department (ED) for medical intervention.

During an interview on 10/1/2025 at 4:45 p.m. with the Chief of Staff (COS), COS stated the following: for Patient 18's incident, Patient 18 was seen by a provider (NP 2) and sent out to an emergency department for EGD 48 hours later on 9/8/2025 (from the first time [9/6/2025] of Patient 18 reporting swallowing a foreign object). There would be an extensive discussion of this incident in the next MEC (Medical Executive Committee, acts as a representative of the medical staff. The committee proposes change and enacts policies, procedures, and other items in an effort to improve patient care and medical staff structure) meeting this month on the 22nd (10/22/2025). COS also stated, "We are trying to recognize this better so we can put a stop to this (referring to the delayed treatment for Patient 18)."

During an interview on 10/2/2025 at 10:44 a.m. with NM 3, NM 3 stated, there were no physician progress notes documented from 9/6/2025 to 9/8/2025 regarding Patient 18 having swallowed a foreign object.

During a review of Patient 18's "Operative Report" dated 9/9/2025, the Operative Report indicated, Patient 18 underwent Esophagogastroduodenoscopy (EGD-medical procedure that allows doctors to examine throat, stomach and small intestine) on 9/9/2025 with "a huge metallic foreign body ... very thick metal ... measured about 6 cm in length, 2 cm in width" removed from the esophagus (canal connecting the throat to the stomach).

During a review of the facility's policy and procedure (P&P) titled, "Patient's Rights," dated 3/2025, the P&P indicated, "Basic Rights. 1. The patient has a basic right to treatment. Provision of treatment is the physician's and hospital's fundamental responsibility to the patient ... B. Rights which May not Be Limited. 3. To humane care and treatment."

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for Provision of Care," dated 2022, the P&P indicated, "[the facility] is committed to assuring a single standard of culturally competent care to patients. Patient Services at [the facility] are delivered through organized and systemic process designed to ensure the delivery of safe, effective, timely care and treatment. Patients have access to the appropriate level of care based on their individual condition and needs."

During a review of the facility's "Medical Staff Bylaws", dated 10/2024, the Bylaws indicated "Basic Responsibilities of Medical Staff Membership ... (a) providing patients with quality of care meeting the professional standards of the medical staff of this hospital."

During a review of the facility's policy and procedure (P&P) titled, "Higher level of care transfer of patient to another facility," revised 3/2023, the P&P indicated, "If a patient has an emergency medical condition, (facility name) will provide the necessary stabilizing examination and treatment with its capabilities, if and when the hospital does not have the necessary capability to treat the patient, the hospital will make all required arrangement for transfer, including but not limited to: stabilizing, treating and monitoring the patient condition, performing any and all life saving measures that may be needed and are within our capabilities ...Clinical Situations based on. 3. Or any other clinical diagnosis requiring specialty services not offered at [the facility] will be stabilized and transferred expeditiously to high level of care receiving facility based on Emergency Medical Services.

During a review of the facility's policy and procedure (P&P) titled, "SBAR/Significant Change of Condition," dated 5/2025, the P&P indicated, "The facility must inform the patient, consult with the patient's physician and/or notify the patient's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include ... 1. Accidents ... b. potential to require physician intervention ... 2. Significant change in the patient's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include ... a. life-threatening conditions, or b. clinical complications."

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

1. Ensure nursing staff adhered to the facility's policy and procedure regarding " Every 15 Min (minute) Rounds, Patient," and the facility's charting/documentation policy, when staff did not consistently perform and accurately document the Q (every) 15?minute rounding (observing patient location and behavior), for 62 of 76 sampled patients (Patient 1, Patient 2, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44, Patient 14, Patient 15, Patient 16, Patient 45, Patient 46, Patient 47, Patient 48, Patient 49, Patient 50, Patient 51, Patient 52, Patient 53, Patient 54, Patient 55, Patient 56, Patient 57, Patient 58, Patient 59, Patient 60, Patient 61, Patient 62, Patient 63, Patient 64, Patient 65, Patient 66, Patient 67, Patient 68, Patient 69, Patient 70, Patient 71, Patient 72, Patient 73, Patient 74, Patient 75 and Patient 76), on 9/19/2025 from 1:00 a.m. to 2:30 a.m. in Campus 1, on 9/13/2025 from time period 1:20 a.m. to 4:58 a.m. in Campus 2, and on 9/19/2025 from time period of 1:00 a.m. to 2:15 a.m. in Campus 2.

This deficient practice had potentially placed the patients in an unsafe environment, at risk of self?harm, or harm to others, psychological
trauma and/or death.

2. Ensure implementation of a safe transfer to a higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]), in accordance with the facility's policy regarding Higher level of care transfer of patients to another facility, when one of 76 sampled patients (Patient 18), was transferred to another hospital for evaluation and treatment, in a hospital van which was not equipped with lifesaving equipment or a licensed staff capable of providing emergency service, after Patient 18 swallowed a foreign object (any item that does not belong in the body).

This deficient practice had the potential for inadequate medical support and compromised monitoring of Patient 18 who was at risk of losing a large amount of blood and damage to his esophagus (canal that connect throat to stomach), which had the potential to result in harm, serious injury or even death.

Findings:

1.a. During a review of Patient 1's History and Physical (H&P, a comprehensive clinical document that includes a patient's medical history and findings from a physical examination), dated 6/4/2025, the H&P indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) due to being "agitated (feeling of uneasiness and severe restlessness) and aggressive." The H&P also indicated that Patient 1 was placed on assaultive (safety measures implemented for patients who exhibit or are at risk of exhibiting violent or aggressive behavior) and homicidal precautions (safety interventions used when a patient expresses or demonstrates thoughts, intentions, or behaviors indicating a risk of harming others).

During a review of Patient 1's "Behavioral Admission Assessment," dated 6/4/2025, the record indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU) at 2:45 p.m. on a 5150 Hold (involuntary hold/involuntary detention at the facility to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for danger to others and being gravely disabled (GD, a condition in which a person, due to a mental health disorder, is unable to provide for their basic personal needs such as food, clothing, or shelter)." The record also stated that Patient 1 required "line of sight observation," meaning continuous visual monitoring by staff to ensure immediate intervention if needed, and was placed on 15-minute Close Observation Level II, which involved staff checking on the patient every 15 minutes due to a history of threatening and/or assaultive behavior within the past 30 days.

During a review of Patient 1's "Behavioral Health Daily Nursing Assessment," dated 6/5/2025, the record indicated that on 6/5/2025 Patient 1 continued to remain on 15-minute Close Observation Level II (patient was monitored every 15 minutes due to concerns about potential harm to self or others) and also had assault/aggression precautions in place (implemented due to the patient exhibiting, or being at risk of exhibiting, aggressive or violent behavior; includes increased supervision, environmental safety measures, and use of de-escalation techniques [methods used to reduce the intensity of a conflict or agitation in a person through calm, verbal, and non-verbal communication]).

During a review of Patient 2's History and Physical (H&P), dated 6/3/2025, The H&P indicated that Patient 2 was admitted to the Behavioral Health Unit (BHU) on 6/3/2025 for agitation and aggressive behavior.

During a review of Patient 2's Psychiatric Evaluation, dated 6/3/2025, the record indicated that Patient 2 was admitted on a 5150 Involuntary Hold. The record also indicated that the Hold was initiated due to danger to others after Patient 2 became "increasingly aggressive at the nursing home (a residential facility that provides 24-hour medical and personal care for individuals, who are unable to live independently due to illness, disability, or cognitive decline)."

During a review of Patient 2's "Nursing Progress Note," dated 6/5/2025 at 3:43 p.m., the note indicated that Patient 2 was involved in an altercation with another patient (Patient 1) and stated that he (Patient 2) was defending himself after Patient 1 struck him in the face, specifically on the left cheek and/or jaw.

During a review of Patient 2's "Rounds Sheet, dated 6/5/2025, the sheet indicated that Patient 2 was documented as either lying or sitting in his "BR" (bedroom) for the entire time from 7:00 a.m. to 7:00 p.m.

During a concurrent interview and record review on 9/30/2025 at 3:02 p.m. with the Chief Nursing Officer (CNO), Patient 1's medical record titled, "Nursing Progress Notes," dated 6/5/2025, was reviewed. The CNO stated that, according to the documentation, Patient 1 attempted to strike Patient 2, who was sitting at the door in the hallway. Patient 2 defended himself, stood up, and pushed Patient 1, who then fell backwards. The CNO confirmed that the fall was unwitnessed (as per nursing notes documentation), and that Rapid Response Team (RRT, a team of healthcare professionals, often including a critical care nurse and a respiratory therapist, who are quickly dispatched to provide immediate care to a patient who shows signs of acute deterioration within a hospital) was called at 2:20 p.m. on 6/5/2025 after Patient 1 was assessed to have weakness in the lower extremities (both legs), drooping (excessive sagging) on the left side of face, and left arm weakness.

During a review of Patient 1's "Nursing Progress Notes," dated 6/5/2025 at 2:20 p.m., the note indicated the following: on 6/5/2025, Patient 1 was actually witnessed by an EVS (Environmental Services- trained cleaning support staff) worker who witnessed Patient 1 walking in the hallway, attempting to strike another patient (Patient 2). In response, Patient 2 pushed Patient 1, causing Patient 1 to fall backwards and sit down on the floor. A Rapid Response Team (RRT) was called, and Patient 1 was assessed to have bilateral (both) lower extremity weakness and was noted to be losing balance while standing. The note also stated that Patient 1 was transferred to a medical-surgical floor (a general hospital unit for adult patients who need care for a variety of illnesses and surgical recovery, but do not require intensive or highly specialized care) for further evaluation).

During a review of Patient 1's nursing note, dated 6/5/2025 at 2:20 p.m., the note indicated that Patient 1 sustained an unwitnessed fall (meaning the patient had experienced a fall that was not observed by staff or others, and the exact circumstances were unknown).

During further review of Patient 1's nursing notes documentation, dated 6/5/2025 at 2:35 p.m. (late entry), the note indicated that Patient 1 was status post (after) unwitnessed fall, and that Patient 1 began showing signs of facial drooping (sagging) on the left side, along with bilateral (both sides) leg tremors (involuntary, rhythmic shaking or trembling movements in the legs).

During a review of Patient 1's "Nursing Progress Note," dated 6/5/2025 at 4:30 p.m., the note indicated that on 6/5/2025 at 4:00 p.m., Patient 1 was observed with increasing shaking of the left leg and bilateral lower extremities. The note also indicated that during the physician's bedside assessment, Patient 1 was noted to have a bump on the right side of the head, with no bleeding. The note also indicated the following at 4;30 p.m. on 6/5/2025: the family was informed that, due to the fall, Patient 1 had possible fracture of the right hip ... and the physician recommended transferring Patient 1 to a higher level of care, as the patient continued to experience shaking and had a head injury with a possible subdural hematoma (a type of brain bleed that occurs when blood collects in the brain, often caused by head trauma and potentially life-threatening if not treated promptly).

During an interview on 10/1/2025 at 1:31 p.m. with the House Supervisor (HS 1), HS 1 stated that typically the facility conducted daily audit for the completeness of Q 15-Minute rounding sheets (a clinical documentation tool used by healthcare staff to record patient observations at regular intervals [every 15 minutes], designed to monitor patient location, behavior, and safety status, and to ensure staff accountability and timely intervention when needed) to verify staff compliance with patient rounding. However, the HS 1 also said that the paper documentation for patient rounding was not reviewed concurrently with video footage to determine whether the documented patient rounding matched what was observed through the facility's video surveillance cameras.

During a concurrent interview and record review on 10/1/2025 at 2:06 p.m. with the Chief Nursing Officer (CNO), Patient 1's "Patient Rounding Sheet, dated 6/5/2025 (covering the time from 7:00 a.m. to 4:30 p.m.), was reviewed. The rounding sheet indicated that Patient 1 was not agitated during this time frame (7 a.m. to 4;30 p.m.) and was consistently documented as either lying or sitting in their (Patient 1) bedroom. Specifically:
-At 1:00 p.m., Patient 1 was documented as either lying or sitting
-At 2:15 p.m., Patient 1 was again documented as either lying or sitting
-This same documentation pattern continued through 2:45 p.m.
-The Chief Nursing Officer (CNO) verified that this documentation was possibly inaccurate, noting that the Rapid Response Team was called at 2:20 p.m., and Patient 1 was found in the hallway by Patient 2's room, yet no deviation or incident was reflected in the rounding sheet during that time.

During further interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM stated that the administration was no longer certain whether the entire incident (between Patient 1 and Patient 2) had been witnessed by the Environmental Service (EVS) worker. The ADM confirmed that nursing staff and mental health workers did not witness the altercation between the two patients (Patient 1 and Patient 2). The ADM also stated that he (ADM) could not verify whether staff were conducting Q15-minute patient rounding on that day (6/5/2025). The ADM said, "They (referring to the facility staff) should have done it (referring to the Q 15-minute rounding)- this is the expectation," and noted that staff verbally confirmed they were conducting their rounds. However, the ADM also confirmed that the video footage, on 6/5/2025, was never reviewed to verify whether staff actions aligned with what was documented and reported on the day of the incident between Patient 1 and Patient 2.

During a concurrent observation, interview and video footage review on 10/1/2025 at 11:00 a.m. with Nurse Manager (NM 1) of BHU and Medical-Surgical (Med/Surg), the video footage dated 9/19/2025, from 1:00 a.m. to 2:30 a.m., was reviewed. The following events were observed at the indicated timestamp in the video:

9/19/2025 at 1:00 a.m.
-No staff seen conducting patient rounding in any of the video angles.

9/19/2025 at 1:15 a.m.
-No staff seen conducting patient rounding, in any video of the angles.

9/19/2025 at 1:30 a.m.
-No staff seen conducting patient rounding in any of the video angles

9/19/2025 at 1:45 a.m.
-no staff seen doing rounding, one patient seen in wheelchair going down hallway with no staff present (camera angle 6)

9/19/2025 at 2:00 a.m.
-two staff members seen rounding patient rooms 1, 2, 3 and 4 (camera angle 4) but not seen checking other rooms. Confirmed with NM1 that one was licensed staff (RN) and the other individual was the resource nurse.

9/19/2025 at 2:15 a.m.
-two staff members sitting in chairs in BHU hallway on Camera angles 6 and 7. Not getting up to conduct rounding on patients. NM 1 was unable to identify the two staff members.

9/19/2025 at 2:30 a.m.
-Same two staff members sitting in chairs in BHU hallway, not getting up to conduct rounding as seen in camera angles 6 and 7. NM 1 was unable to identify the two staff members

During an interview on 10/1/2025 at 11:47 a.m. with NM 1, NM 1 stated the expectation was for staff to do Q 15-minute rounding to check on the patients, ensure safety and known location. Purpose of rounding was to know the location of the patients and make sure the patient was safe. "It allows us to notice any changes in behaviors, so that staff can address them accordingly." NM 1 verified that rounding was only completed once for 4 rooms (rooms 1,2, 3, and 4) but not the whole unit within the 1.5 hour of video reviewed for Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44.

During a concurrent interview and record review on 10/1/2025 at 2:02 p.m. with NM 1, Patient 20's "Patient Rounds Sheet" dated 9/18/2025, was reviewed. NM 1 stated that the rounding sheet began on 9/18/2025 at 7:00 a.m. and ended on 9/19/2025 at 6:45 a.m. NM 1 stated that all patient rounding sheets being reviewed started around the same time (7 a.m. to 6:45 a.m.), which captures the entire 24 hours.

During an interview on 10/3/2025 at 3:44 p.m. with NM 1, NM 1 stated that, after reviewing the video footage and discussing the matter with the Chief Nursing Officer (CNO), it appeared that staff were documenting Q15-minute checks as completed, despite not actually performing them. NM 1 emphasized the importance of holding staff accountable and acknowledged that this practice falls under the category of falsification of records.

During an interview on 9/30/2025 at 11:35 a.m. with the Charge Nurse (CN) 4, CN 4 stated that licensed nurses were required to conduct patient rounds every hour and document on the patient's rounding sheet. CN 4 stated that licensed nurses could also help the MHW (Mental health Worker) with conducting Q15-minute rounding.

During an interview on 10/1/2025 at 2:12 p.m. with the Chief Nursing Officer (CNO), the CNO confirmed that Q15 (every 15 minutes) patient safety checks should be conducted to:
-Ensure patient safety,
-Confirm responsiveness,
-Assess patient behavior,
-Document patient activity.

During an interview on 10/1/2025 at 3:17 p.m. with the Chief Nursing Officer (CNO) and the Hospital Administrator (ADM), the CNO stated that the incident (involving Patients and 2) was investigated internally and that all key team members were interviewed, including the Environmental Services (EVS) worker who witnessed the altercation between Patient 1 and Patient 2 in the hallway. The ADM confirmed that, because of the EVS worker's statement regarding the witnessed fall and the altercation between the two patients (Patient 1 and Patient 2), the facility had no reason to review the video footage to verify what happened during the incident.

During an interview on 10/3/2025 at 3:34 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following regarding Q-15 Minutes rounding: "Q15-minute safety checks are conducted to monitor each patient's condition and behavior at regular 15-minute intervals. The purpose is to identify any signs of agitation, frustration, or behaviors that may indicate a risk to the patient or others. These checks are preventive in nature and allow staff to intervene early and provide therapeutic support as needed. We use this time to assess whether patients are escalating and to respond in a way that promotes safety and de-escalation. While staff are expected to document these checks accurately, it's also important to verify that the documentation aligns with actual observations, such as through video review when available."

During a review of Patient 20's Psychiatric Evaluation (psych eval, a comprehensive mental health assessment, conducted by a psychologist or psychiatrist, that uses interviews, tests, and observations to understand a person's emotional, behavioral, and cognitive state), dated 9/11/2025 and timed 17:56 (5:56 p.m.), the record indicated Patient 20 was admitted to the facility on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) hold for grave disability (GD-unable to take care of oneself).

During a review of Patient 20's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 20 was sleeping, and respirations were present.

During a review of Patient 21's Psychiatric Evaluation, dated 9/12/2025 and timed 1801 (6:01 p.m.), the record indicated Patient 21 was admitted to the facility on a 5150 hold for GD due to increasing paranoid delusions (false beliefs that persist despite evidence to the contrary and are characterized by suspicion, mistrust, and persecution), yelling and screaming.

During a review of Patient 21's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 22 was sleeping and respirations were present.

During a review of Patient 22's Psychiatric Evaluation, dated 9/14/2025 at 1710 (5:10 p.m.), the record indicated Patient 22 was admitted to the facility on a 5150 hold for danger to self (DTS).

During a review of Patient 22's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 22 was sleeping, and respirations were present.

During a review of Patient 23's Psychiatric Evaluation, dated 9/18/2025, the record indicated that Patient 23 was admitted to the facility and was placed on a 5150 hold for Danger to others (DTO).

During a review of Patient 23's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 23 was sleeping, and respirations were present.

During a review of Patient 24's Psychiatric Evaluation, dated 9/18/20225, the record indicated that Patient 24 was admitted to the facility on 9/18/2025 and was placed on a 5150 hold for GD.

During a review of Patient 24's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 24 was sleeping, and respirations were present.

During a review of Patient 25's Psychiatric Evaluation, dated 9/16/2025, the record indicated Patient 25 was admitted to the facility on 9/16/2025 and was placed on a 5150 hold for DTO.

During a review of Patient 25's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 25 was sleeping, and respirations were present.

During a review of Patient 26's Psychiatric Evaluation, dated 9/13/2025, the record indicated that Patient 26 was admitted to the facility on 9/13/2025 and was placed on a 5150 hold for DTO.

During a review of Patient 26's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 26 was sleeping, and respirations were present.

During a review of Patient 27's Psychiatric Evaluation, dated 9/12/2025, the record indicated that Patient 27 was admitted to the facility on 9/12/2025 and was placed on a 5150 hold due to DTO.

During a review of Patient 27's "Patient Rounds Sheet," dated 9/18/2025,the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 27 was sleeping, and respirations were present.

During a review of Patient 28's Psychiatric Evaluation, dated 9/17/2025, the record indicated that Patient 28 was admitted to facility on a 5150 involuntary hold for DTS and GD.

During a review of Patient 28's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 28 was sleeping, and respirations were present.

During a review of Patient 29's psychiatric Evaluation, dated 9/18/2025, the record indicated that Patient 29 was admitted to the facility on 9/18/2025 and placed on 5150 for DTO.

During a review of Patient 29's "Patient Rounds Sheet," dated 9/18/2025,the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 29 was sleeping, and respirations were present.

During a review of Patient 30's Psychiatric Evaluation, dated 9/19/2025, the record indicated that Patient 30 was admitted to the facility on 9/18/2025 on a 5150 hold for DTO.

During a review of Patient 30's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 30 was sleeping at 0100 (1:00 a.m.), and lying or sitting from 0130 (1:30 a.m.) to 0200 (2:00 a.m.) and respirations were present.

During a review of Patient 31's Psychiatric Evaluation, dated 9/15/2025 and timed at 2017 (8:17 p.m.), the record indicated that Patient 31 was admitted to the facility on a 5150 hold due to DTO and GD.

During a review of Patient 31's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 31 was sleeping at 0115 (1:15 a.m.) to 0230 (2:30 a.m.), lying or sitting at 0100 (1:00 a.m.) and was walking or pacing at 0015 (1:15 a.m.) and respirations were present.

During a review of Patient 32's Psychiatric Evaluation, dated 9/14/2025 and timed at 2016 (8:16 p.m.), the record indicated Patient 32 was admitted to the facility on a 5150 due to DTO.

During a review of Patient 32's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 32 was sleeping, and respirations were present.

During a review of Patient 33's Psychiatric Evaluation, dated 9/16/2025 and timed at 0626 (6:26 a.m.), the record indicated Patient 33 was admitted to the facility on a 5150 hold due to DTO and GD.

During a review of Patient 33's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 33 was lying or sitting at 0100 (1:00 a.m.) and sleeping at 0115 (1:15 a.m.) to 0230 (2:30 a.m.) with respirations present.

During a review of Patient 34's Psychiatric Evaluation, dated 9/13/2025 and timed at 1806 (6:06 p.m.), the record indicated Patient 34 was admitted to the facility on 9/13/2025 and was placed on a 5150 due to DTS and DTO.

During a review of Patient 34's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 34 was sleeping, and respirations were present.

During a review of Patient 35's Psychiatric Evaluation, dated 9/16/2025, the record indicated that Patient 35 was admitted to the facility on 9/13/2025 and placed on a 5150 due to DTS and GD.

During a review of Patient 35's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 35 was sleeping, and respirations were present.

During a review of Patient 36's Psychiatric Evaluation, dated 9/18/2025 and timed at 1055 (10:55 a.m.), the record indicated that Patient 36 was admitted to the facility on 9/18/2025 on a 5150 hold due to GD.

During a review of Patient 36's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 36 was lying or sitting at 0115 (1:15 a.m.) and sleeping at 0100 (1:00 a.m.), 0130 (1:30 a.m.), 0145 (1:45 a.m.), 0200 (2:00 a.m.), 0215 (2:15 a.m.), and 0230 (2:30 a.m.) and respirations were present.

During a review of Patient 37's Psychiatric Evaluation, dated 9/12/2025 and timed at 1935 (7:35 p.m.), the record indicated that Patient 37 was admitted to the facility on 9/12/2025 on a 5150 hold for DTO.

During a review of Patient 37's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 37 was sleeping, and respirations were present.

During a review of Patient 38's Psychiatric Evaluation, dated 9/19/2025 and timed at 1331 (1:31 p.m.), the record indicated that Patient 38 was admitted to the facility on 9/19/2025 on a 5150 hold for DTO.

During a review of Patient 38's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 38 was lying or sitting and respirations were present.

During a review of Patient 39's Psychiatric Evaluation, dated 9/18/2025 and timed at 1340 (1:40 p.m.), the record indicated that Patient 39 was admitted to the facility on 9/18/2025 and placed on a 5150 hold due to GD.

During a review of Patient 39's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 39 was found sleeping, and respirations were present.

During a review of Patient 40's Psychiatric Evaluation, dated 9/16/2025 and timed at 0933 (9:33 a.m.), the record indicated that Patient 40 was admitted to the facility on 9/16/2025 on a 5150 involuntary hold for DTO and GD.

During a review of Patient 40's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 40 was sleeping, and respirations were present.

During a review of Patient 41's Psychiatric Evaluation dated 9/12/2025, the psych eval indicated Patient 41 was admitted to the facility on 9/12/2025 with agitation (a state of restless excitement and emotional upset, characterized by a feeling of being "stirred up," tense, confused, or irritable, often accompanied by physical actions like pacing or gesturing), mood lability (having rapid, intense, and unpredictable shifts in your emotions) and irritability (a feeling of being easily annoyed, frustrated, or angered, often by small or insignificant things.

During a review of Patient 41's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 41 was sleeping, and respirations were present.

During a review of Patient 42's Psychiatric Evaluation, dated 9/14/2025, the record indicated Patient 42 was admitted to the facility on 9/14/2025 on a 5150 hold due to DTO.

During a review of Patient 42's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 42 was sleeping, and respirations were present.

During a review of Patient 43's Psychiatric Evaluation, dated 9/19/2025 and timed at 1423 (2:43 p.m.), the record indicated that Patient 43 was admitted to the facility on 9/19/2025 on 5150 hold due to GD.

During a review of Patient 43's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 43 was sleeping, and respirations were present.

During a review of Patient 44's Psychiatric Evaluation, dated 9/18/2025 and timed at 1544 (3:44 p.m.), the record indicated that Patient 44 was admitted to the facility on 9/18/2025 on 5150 hold due to DTO.

During a review of Patient 44's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 44 was sleeping, and respirations were present.

During a review of the facility's policy and procedure (P&P) titled, "Every 15 Min (minute) Rounds, Patient," last revised 3/2025, the P&P indicated the following: "It is the policy of [the facility] Behavioral Health Services to monitor the safety/locations of all patients on a continuing basis. Such rounds will be conducted at 15-minute intervals. Patients requiring additional observation will be evaluated individually, and physician orders will be generated to address the safety/needs of the patient ...Floor staff will conduct patient rounds at 15-minute intervals, including the location of the patient and his/her condition, and will verify completion of such rounds by their initial and signature. In order to accurately monitor safety and condition of patients at night and/or during non-wakeful times, staff will visually observe chest movement of the patient to ascertain respiratory effort."

During a review of the facility's policy and procedure (P&P) titled, "Observation Levels System," dated 3/2025, the P&P indicated, "It is the policy of [the facility] to initiate and provide the appropriate observation level of patient's behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient's Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress .... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress." B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient's Observation Rounds sheet every 15 minutes ..."

1.b. During a concurrent observation, interview and record review on 10/1/2025 at 12:40 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility's security footage of Campus 2 BHU unit (Unit C), on 9/13/2025 from time period 1:20 a.m. to 4:58 a.m., was reviewed, the following events were observed:

-At 1:20 a.m., a Mental Health Worker (MHW) 8 was seen sitting outside unit seclusion room (a secure, private room used to involuntarily confine an individual alone to de-escalate a situation or modify behavior). The video displayed two (2) patient rooms (Room A and Room B) and a seclusion room.
-At 1:30 a.m., No staff seen rounding on patients
-At 1:45 a.m., No staff seen rounding
-At 2:00 a.m., No staff seen rounding
-At 2:15 a.m., No staff seen rounding
-At 2:23 a.m., a MHW went to the second room, left the room holding a blue blanket
-At 2:30 a.m., No staff seen rounding
-At 2:45 a.m., No staff seen rounding
-At 3:00 a.m., No staff seen rounding
-At 3:15 a.m., No staff seen rounding
-At 3:30 a.m., No staff seen rounding.
-At 3:45 a.m., MHW 8 got up and went to bathroom. No staff was seen to relieve MHW 8 while MHW 8 was away.
-At 4:15 a.m., a male patient in green gown was seen pacing in the dayroom and no staff was seen monitoring the area.
-At 4:58 a.m., a MHW went into a patient room (room A) and performed rounding. The MHW did not enter any other rooms.

During the same interview on 10/1/2025 at 12:40 p.m. with NM 2, NM 2 stated the following: there was no staff performing the Q 15-minute

Based on observation, interview and record review, the facility failed to ensure that 62 of 76 sampled patients' (Patients 1, 2, 14, 15, 16, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75 and 76) Q15-minute safety checks/rounding (routine observations conducted every 15 minutes to monitor and document each patient's condition and behavior, with the goal of identifying risks and intervening early to ensure patient safety), were accurately documented, in accordance with the facility's policy on patient rounds and accurate chart completion when:

1. The documented completion of rounds by staff for Patients 1 and 2, did not accurately reflect the actual rounding activities conducted, in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) in Campus 1.

This deficient practice had the potential to compromise the safety of Patient 1 and Patient 2 and may have contributed to harm sustained by Patient 1, who, during an attempt to strike Patient 2, fell backward, resulting in a hip fracture (break in the bone) and neurological deficit (an abnormality or impairment in the function of the nervous system when there is damage or disruption to the brain, spinal cord, nerves, or other components of the nervous system). Patient 1 was subsequently transferred to a higher level of care (a more intensive and specialized level of treatment for patients with complex medical needs, often beyond what is offered in a standard medical ward but not always requiring the most critical care of an Intensive Care Unit [ICU]).

2.a. There was no proper documentation of the Q15-minute rounds conducted for 25 patients (Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44) in the Behavioral Health Unit in Campus 1. The documentation did not match what was observed on video surveillance footage on 9/19/2025 from 1:00 a.m. to 2:30 a.m.

This deficient practice had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, psychological trauma and/or death.

2.b. There was no proper documentation of the Q15-minute rounds conducted for 35 patients (Patients 14, 15, 16, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75 and 76) in the BHU in Campus 2. The documentation did not match what was observed on video surveillance footage on 9/13/2025 from time period 1:20 a.m. to 4:58 a.m., and on 9/19/2025 from time period of 1:00 a.m. to 2:15 a.m.

This deficient practice had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, psychological trauma and/or death.

Findings:

1. During a review of Patient 1's History and Physical (H&P, a comprehensive clinical document that includes a patient's medical history and findings from a physical examination), dated 6/4/2025, the H&P indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU) due to being "agitated (feeling of uneasiness and severe restlessness) and aggressive." The H&P also indicated that Patient 1 was placed on assaultive (safety measures implemented for patients who exhibit or are at risk of exhibiting violent or aggressive behavior) and homicidal precautions (safety interventions used when a patient expresses or demonstrates thoughts, intentions, or behaviors indicating a risk of harming others).

During a review of Patient 1's "Behavioral Admission Assessment," dated 6/4/2025, the record indicated that Patient 1 was admitted to the Behavioral Health Unit (BHU) on a 5150 Hold (a legal provision under the State law, that allows for the involuntary detention of an individual for up to 72 hours when they are deemed a danger to themselves, others, or are gravely disabled due to a mental health disorder) for danger to others and being gravely disabled (GD, a condition in which a person, due to a mental health disorder, is unable to provide for their basic personal needs such as food, clothing, or shelter)." The record also indicated that Patient 1 required "line of sight observation," meaning continuous visual monitoring by staff to ensure immediate intervention if needed, and Patient 1 was also placed on 15-minute Close Observation Level II, which involved staff checking on the patient every 15 minutes due to a history of threatening and/or assaultive behavior within the past 30 days.

During a review of Patient 1's "Behavioral Health Daily Nursing Assessment," dated 6/5/2025, the record indicated that on 6/5/2025, Patient 1 continued to remain on 15-minute Close Observation Level II (patient was monitored every 15 minutes due to concerns about potential harm to self or others) and also had assault/aggression precautions in place (implemented due to the patient exhibiting, or being at risk of exhibiting, aggressive or violent behavior; includes increased supervision, environmental safety measures, and use of de-escalation techniques [methods used to reduce the intensity of a conflict or agitation in a person through calm, verbal, and non-verbal communication]).

During a review of Patient 1's "Nursing Progress Notes," dated 6/5/2025 at 2:20 p.m., the note indicated the following: On 6/5/2025, Patient 2 pushed Patient 1, causing Patient 1 to fall backwards and sit down on the floor. A Rapid Response Team (RRT, a team of healthcare professionals, often including a critical care nurse and a respiratory therapist, who are quickly dispatched to provide immediate care to a patient who shows signs of acute deterioration within a hospital) was called, and Patient 1 was assessed to have bilateral (both) lower extremity weakness and was noted to be losing balance while standing. The note also stated that Patient 1 was transferred to a medical-surgical floor (a general hospital unit for adult patients who need care for a variety of illnesses and surgical recovery, but do not require intensive or highly specialized care) for further evaluation.

During an interview on 10/1/2025 at 1:31 p.m. with the House Supervisor (HS 1), HS 1 stated that typically the facility conducted daily audit for the completeness of the Q15-minute rounding sheets (a clinical documentation tool used by healthcare staff to record patient observations at regular intervals [every 15 minutes], designed to monitor patient location, behavior, and safety status, and to ensure staff accountability and timely intervention when needed) to verify staff compliance with rounding. However, the HS 1 also said that the paper documentation for rounding was not reviewed concurrently with video footage to determine whether the documented rounding matched what was observed through the facility's video surveillance cameras.

During a concurrent interview and record review on 10/1/2025 at 2:06 p.m. with the Chief Nursing Officer (CNO), Patient 1's "Patient Rounding Sheet, dated 6/5/2025 (covering the time from 7:00 a.m. to 4:30 p.m.), was reviewed. The documentation indicated that Patient 1 was not recorded to be agitated during this time frame (dated 6/5/2025, covering the time from 7:00 a.m. to 4:30 p.m.) and was consistently documented as either lying or sitting in their (Patient 1) bedroom. Specifically:
-At 1:00 p.m., Patient 1 was documented as either lying or sitting
-At 2:15 p.m., Patient 1 was again documented as either lying or sitting
-This same documentation pattern continued through 2:45 p.m.
-The Chief Nursing Officer (CNO) verified that this documentation was possibly inaccurate, noting that the Rapid Response Team was called at 2:20 p.m. and Patient 1 was documented to be obtaining computed tomography (CT) scan (a medical imaging procedure that uses X-rays to create detailed cross-sectional images of the body) at 1:00 p.m. (while also documented to be in the room sitting or lying])and Patient 1 was also found in the hallway by Patient 2's room (between 2:00 to 2:20 p.m.), yet no deviation or incident was reflected in the rounding sheet dated 6/5/2025 during that time.

During an interview on 10/1/2025 at 2:12 p.m. with the Chief Nursing Officer (CNO), the CNO also confirmed that Q15 (every 15 minutes) patient safety checks should be conducted to:
-Ensure patient safety,
-Confirm responsiveness,
-Assess patient behavior,
-Document patient activity.

During further interview on 10/1/2025 at 3:37 p.m. with the Hospital Administrator (ADM), the ADM confirmed that nursing staff and mental health workers did not witness the altercation between the two patients (Patient 1 and Patient 2). The ADM also stated that he (ADM) could not verify whether staff were conducting Q15-minute checks on that day (6/5/2025). The ADM said, "They should have done it (referring to accurate patient rounding every 15 minutes) - this is the expectation," and noted that staff verbally confirmed they were conducting their rounds. However, the ADM also confirmed that the video footage pertaining to patient rounding on 6/5/2025, was never reviewed to verify whether staff actions aligned with what was documented and reported on the day of the incident between Patient 1 and Patient 2.

During an interview on 10/3/2025, at 3:34 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following regarding Q-15 Minutes rounding: "Q15-minute safety checks are conducted to monitor each patient's condition and behavior at regular 15-minute intervals. The purpose is to identify any signs of agitation, frustration, or behaviors that may indicate a risk to the patient or others. These checks are preventive in nature and allow staff to intervene early and provide therapeutic support as needed. We use this time to assess whether patients are escalating and to respond in a way that promotes safety and de-escalation. While staff are expected to document these checks accurately, it's also important to verify that the documentation aligns with actual observations, such as through video review when available."

During a review of Patient 2's Psychiatric Evaluation, dated 6/3/2025, the record indicated that Patient 2 was admitted on a 5150 Involuntary Hold. The record also indicated that the Hold was initiated due to danger to others after Patient 2 became "increasingly aggressive at the nursing home (a residential facility that provides 24-hour medical and personal care for individuals, who are unable to live independently due to illness, disability, or cognitive decline).

During a review of Patient 2's "Nursing Progress Note," dated 6/5/2025 at 3:43 p.m., the note indicated that Patient 2 was involved in an altercation with another patient (Patient 1) and stated that he (Patient 2) was defending himself after Patient 1 struck him in the face, specifically on the left cheek and/or jaw.

During a review of Patient 2's "Rounds Sheet, dated 6/5/2025, the sheet indicated that Patient 2 was documented as either lying or sitting in his "BR" (bedroom) for the entire time from 7:00 a.m. to 7:00 p.m.

During an interview on 10/3/2025 at 3:44 p.m. with the Manager of the Medical-Surgical and Behavioral Units (NM 1), NM 1 stated that, after reviewing the video footage on other dates of patient rounding and discussing the matter with the Chief Nursing Officer (CNO), it appeared that staff were documenting Q15-minute checks as completed, despite not actually performing them. NM 1 emphasized the importance of holding staff accountable and acknowledged that this practice falls under the category of falsification of records.

During a review of the facility's policy and procedure (P&P) titled, Chart Completion," last revised 9/2025, the P&P indicated the following: "To ensure that the medical records at (Facility) fully and accurately reflect a patient's care and are completed in accordance with federal and state law, the facility requires that types of treatment records shall be included in the medical record and are to be counted for the reporting purposes of the applicable accrediting agency..."

During a review of the facility's policy and procedure (P&P) titled, "Every 15 Min Rounds, Patient," last revised 3/2025, the P&P indicated the following: "It is the policy of [the facility] Behavioral Health Services to monitor the safety/locations of all patients on a continuing basis. Such rounds will be conducted at 15-minute intervals. Patients requiring additional observation will be evaluated individually, and physician orders will be generated to address the safety/needs of the patient ...Floor staff will conduct patient rounds at 15-minute intervals, including the location of the patient and his/her condition, and will verify completion of such rounds by their initial and signature. In order to accurately monitor safety and condition of patients at night and/or during non-wakeful times, staff will visually observe chest movement of the patient to ascertain respiratory effort."

During a review of the facility's policy and procedure (P&P) titled, "Observation Levels System," dated 3/2025, the P&P indicated, "It is the policy of [the facility] to initiate and provide the appropriate observation level of patient's behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient's Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress .... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress." B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient's Observation Rounds sheet every 15 minutes ..."

2.a. During a review of Patient 20's Psychiatric Evaluation (psych eval, a comprehensive mental health assessment, conducted by a psychologist or psychiatrist, that uses interviews, tests, and observations to understand a person's emotional, behavioral, and cognitive state), dated 9/11/2025 and timed 17:56 (5:56 p.m.), the record indicated Patient 20 was admitted to the facility on a 5150 (72?hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) hold for grave disability (GD-unable to take care of oneself).

During a review of Patient 20's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 20 was sleeping, and respirations were present.

During a review of Patient 21's Psychiatric Evaluation, dated 9/12/2025 and timed 1801 (6:01 p.m.), the record indicated Patient 21 was admitted to the facility on a 5150 hold for GD due to increasing paranoid delusions (false beliefs that persist despite evidence to the contrary and are characterized by suspicion, mistrust, and persecution), yelling and screaming.

During a review of Patient 21's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 22 was sleeping and respirations were present.

During a review of Patient 22's Psychiatric Evaluation, dated 9/14/2025 at 1710 (5:10 p.m.), the record indicated Patient 22 was admitted to the facility on a 5150 hold for danger to self (DTS).

During a review of Patient 22's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 22 was sleeping, and respirations were present.

During a review of Patient 23's Psychiatric Evaluation, dated 9/18/2025, the record indicated that Patient 23 was admitted to the facility and was placed on a 5150 hold for Danger to others (DTO).

During a review of Patient 23's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 23 was sleeping, and respirations were present.

During a review of Patient 24's Psychiatric Evaluation, dated 9/18/20225, the record indicated that Patient 24 was admitted to the facility on 9/18/2025 and was placed on a 5150 hold for GD.

During a review of Patient 24's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 24 was sleeping, and respirations were present.

During a review of Patient 25's Psychiatric Evaluation, dated 9/16/2025, the record indicated Patient 25 was admitted to the facility on 9/16/2025 and was placed on a 5150 hold for DTO.

During a review of Patient 25's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 25 was sleeping, and respirations were present.

During a review of Patient 26's Psychiatric Evaluation, dated 9/13/2025, the record indicated that Patient 26 was admitted to the facility on 9/13/2025 and was placed on a 5150 hold for DTO.

During a review of Patient 26's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 26 was sleeping, and respirations were present.

During a review of Patient 27's Psychiatric Evaluation, dated 9/12/2025, the record indicated that Patient 27 was admitted to the facility on 9/12/2025 and was placed on a 5150 hold due to DTO.

During a review of Patient 27's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 27 was sleeping, and respirations were present.

During a review of Patient 28's Psychiatric Evaluation, dated 9/17/2025, the record indicated that Patient 28 was admitted to facility on a 5150 involuntary hold for DTS and GD.

During a review of Patient 28's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 28 was sleeping, and respirations were present.

During a review of Patient 29's psychiatric Evaluation, dated 9/18/2025, the record indicated that Patient 29 was admitted to the facility on 9/18/2025 and placed on 5150 for DTO.

During a review of Patient 29's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 29 was sleeping, and respirations were present.

During a review of Patient 30's Psychiatric Evaluation, dated 9/19/2025, the record indicated that Patient 30 was admitted to the facility on 9/18/2025 on a 5150 hold for DTO.

During a review of Patient 30's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 30 was sleeping at 0100 (1:00 a.m.), and lying or sitting from 0130 (1:30 a.m.) to 0200 (2:00 a.m.) and respirations were present.

During a review of Patient 31's Psychiatric Evaluation, dated 9/15/2025 and timed at 2017 (8:17 p.m.), the record indicated that Patient 31 was admitted to the facility on a 5150 hold due to DTO and GD.

During a review of Patient 31's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 31 was sleeping at 0115 (1:15 a.m.) to 0230 (2:30 a.m.), lying or sitting at 0100 (1:00 a.m.) and was walking or pacing at 0015 (1:15 a.m.) and respirations were present.

During a review of Patient 32's Psychiatric Evaluation, dated 9/14/2025 and timed at 2016 (8:16 p.m.), the record indicated Patient 32 was admitted to the facility on a 5150 due to DTO.

During a review of Patient 32's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 32 was sleeping, and respirations were present.

During a review of Patient 33's Psychiatric Evaluation, dated 9/16/2025 and timed at 0626 (6:26 a.m.), the record indicated Patient 33 was admitted to the facility on a 5150 hold due to DTO and GD.

During a review of Patient 33's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 33 was lying or sitting at 0100 (1:00 a.m.) and sleeping at 0115 (1:15 a.m.) to 0230 (2:30 a.m.) with respirations present.

During a review of Patient 34's Psychiatric Evaluation, dated 9/13/2025 and timed at 1806 (6:06 p.m.), the record indicated Patient 34 was admitted to the facility on 9/13/2025 and was placed on a 5150 due to DTS and DTO.

During a review of Patient 34's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 34 was sleeping, and respirations were present.

During a review of Patient 35's Psychiatric Evaluation, dated 9/16/2025, the record indicated that Patient 35 was admitted to the facility on 9/13/2025 and placed on a 5150 due to DTS and GD.

During a review of Patient 35's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 35 was sleeping, and respirations were present.

During a review of Patient 36's Psychiatric Evaluation, dated 9/18/2025 and timed at 1055 (10:55 a.m.), the record indicated that Patient 36 was admitted to the facility on 9/18/2025 on a 5150 hold due to GD.

During a review of Patient 36's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 36 was lying or sitting at 0115 (1:15 a.m.) and sleeping at 0100 (1:00 a.m.), 0130 (1:30 a.m.), 0145 (1:45 a.m.), 0200 (2:00 a.m.), 0215 (2:15 a.m.), and 0230 (2:30 a.m.) and respirations were present.

During a review of Patient 37's Psychiatric Evaluation, dated 9/12/2025 and timed at 1935 (7:35 p.m.), the record indicated that Patient 37 was admitted to the facility on 9/12/2025 on a 5150 hold for DTO.

During a review of Patient 37's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 37 was sleeping, and respirations were present.

During a review of Patient 38's Psychiatric Evaluation, dated 9/19/2025 and timed at 1331 (1:31 p.m.), the record indicated that Patient 38 was admitted to the facility on 9/19/2025 on a 5150 hold for DTO.

During a review of Patient 38's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 38 was lying or sitting and respirations were present.

During a review of Patient 39's Psychiatric Evaluation, dated 9/18/2025 and timed at 1340 (1:40 p.m.), the record indicated that Patient 39 was admitted to the facility on 9/18/2025 and placed on a 5150 hold due to GD.

During a review of Patient 39's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 39 was found sleeping, and respirations were present.

During a review of Patient 40's Psychiatric Evaluation, dated 9/16/2025 and timed at 0933 (9:33 a.m.), the record indicated that Patient 40 was admitted to the facility on 9/16/2025 on a 5150 involuntary hold for DTO and GD.

During a review of Patient 40's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 40 was sleeping, and respirations were present.

During a review of Patient 41's Psychiatric Evaluation dated 9/12/2025, the psych eval indicated Patient 41 was admitted to the facility on 9/12/2025 with agitation (a state of restless excitement and emotional upset, characterized by a feeling of being "stirred up," tense, confused, or irritable, often accompanied by physical actions like pacing or gesturing), mood lability (having rapid, intense, and unpredictable shifts in your emotions) and irritability (a feeling of being easily annoyed, frustrated, or angered, often by small or insignificant things.

During a review of Patient 41's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 41 was sleeping, and respirations were present.

During a review of Patient 42's Psychiatric Evaluation, dated 9/14/2025, the record indicated Patient 42 was admitted to the facility on 9/14/2025 on a 5150 hold due to DTO.

During a review of Patient 42's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 42 was sleeping, and respirations were present.

During a review of Patient 43's Psychiatric Evaluation, dated 9/19/2025 and timed at 1423 (2:43 p.m.), the record indicated that Patient 43 was admitted to the facility on 9/19/2025 on 5150 hold due to GD.

During a review of Patient 43's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 43 was sleeping, and respirations were present.

During a review of Patient 44's Psychiatric Evaluation, dated 9/18/2025 and timed at 1544 (3:44 p.m.), the record indicated that Patient 44 was admitted to the facility on 9/18/2025 on 5150 hold due to DTO.

During a review of Patient 44's "Patient Rounds Sheet," dated 9/18/2025, the record indicated from 0100 (1:00 a.m.) to 0230 (2:00 a.m.), Patient 44 was sleeping, and respirations were present.

During an interview on 9/30/2025 at 11:35 a.m. with the Charge Nurse (CN) 4, CN 4 stated that licensed nurses were required to conduct patient rounds every hour and document on the patient's rounding sheet. CN 4 stated that licensed nurses could also help the MHW (Mental health Worker) with conducting Q15-minute rounding.

During a concurrent observation, interview and video footage review on 10/1/2025 at 11:00 a.m. with Nurse Manager (NM 1) of BHU and Medical-Surgical (Med/Surg), the video footage dated 9/19/2025, from 1:00 a.m. to 2:30 a.m., was reviewed. The following events were observed at the indicated timestamp in the video:

9/19/2025 at 1:00 a.m.
-No staff seen conducting patient rounding in any of the video angles.

9/19/2025 at 1:15 a.m.
-No staff seen conducting patient rounding, in any video of the angles.

9/19/2025 at 1:30 a.m.
-No staff seen conducting patient rounding in any of the video angles

9/19/2025 at 1:45 a.m.
-no staff seen doing rounding, one patient seen in wheelchair going down hallway with no staff present (camera angle 6)

9/19/2025 at 2:00 a.m.
-two staff members seen rounding patient rooms 1, 2, 3 and 4 (camera angle 4) but not seen checking other rooms. Confirmed with NM1 that one was licensed staff (RN) and the other individual was the resource nurse.

9/19/2025 at 2:15 a.m.
-two staff members sitting in chairs in BHU hallway on Camera angles 6 and 7. Not getting up to conduct rounding on patients. NM 1 was unable to identify the two staff members.

9/19/2025 at 2:30 a.m.
-Same two staff members sitting in chairs in BHU hallway, not getting up to conduct rounding as seen in camera angles 6 and 7. NM 1 was unable to identify the two staff members

During an interview on 10/1/2025 at 11:47 a.m. with NM 1, NM 1 stated the expectation was for staff to do Q 15-minute rounding to check on the patients, ensure safety and known location. Purpose of rounding was to know the location of the patients and make sure the patient was safe. "It allows us to notice any changes in behaviors, so that staff can address them accordingly." NM 1 verified that rounding was only completed once for 4 rooms (rooms 1, 2, 3, and 4) but not the whole unit within the 1.5 hour of video reviewed for Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37, Patient 38, Patient 39, Patient 40, Patient 41, Patient 42, Patient 43, Patient 44.

During a concurrent interview and record review on 10/1/2025 at 2:02 p.m. with NM 1, Patient 20's "Patient Rounds Sheet" dated 9/18/2025, was reviewed. NM 1 stated that the rounding sheet began on 9/18/2025 at 7:00 a.m. and ended on 9/19/2025 at 6:45 a.m. NM 1 stated that all patient rounding sheets being reviewed started around the same time (7 a.m. to 6:45 a.m.), which captures the entire 24 hours.

During an interview on 10/3/2025 at 3:44 p.m. with NM 1, NM 1 stated that, after reviewing the video footage and discussing the matter with the Chief Nursing Officer (CNO), it appeared that staff were documenting Q15-minute checks as completed, despite not actually performing them. NM 1 emphasized the importance of holding staff accountable and acknowledged that this practice falls under the category of falsification of records.

During a review of the facility's policy and procedure (P&P) titled, Chart Completion," last revised 9/2025, the P&P indicated the following: "To ensure that the medical records at [Name of Facility] fully and accurately reflect a patient's care and are completed in accordance with federal and state law, the facility requires that types of treatment records shall be included in the medical record and are to be counted for the reporting purposes of the applicable accrediting agency..."

During a review of the facility's policy and procedure (P&P) titled, "Every 15 Min (Minute) Rounds, Patient," last revised 3/2025, the P&P indicated the following: "It is the policy of [the facility] Behavioral Health Services to monitor the safety/locations of all patients on a continuing basis. Such rounds will be conducted at 15-minute intervals. Patients requiring additional observation will be evaluated individually, and physician orders will be generated to address the safety/needs of the patient ...Floor staff will conduct patient rounds at 15-minute intervals, including the location of the patient and his/her condition, and will verify completion of such rounds by their initial and signature. In order to accurately monitor safety and condition of patients at night and/or during non-wakeful times, staff will visually observe chest movement of the patient to ascertain respiratory effort."

During a review of the facility's policy and procedure (P&P) titled, "Observation Levels System," dated 3/2025, the P&P indicated, "It is the policy of [the facility] to initiate and provide the appropriate observation level of patient's behaviors exhibited and also the information provided at the time of admission, and throughout hospitalization. All patients will be routinely observed in compliance with physician/psychologist orders and prescribed protocols. Purpose: to provide the most appropriate patient observation level is maintained throughout hospitalization. To provide patient safety at all times ... Types of Observation Level A. Level I: every 15-minute checks, routine observation. Minimal level of observation for all patients. Staff will observe patient and document on the Patient's Observation Rounds Sheet Q15 minutes. Assigned staff will make direct contact with patients and confirm they are in no danger or distress .... Observation may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that the staff conducting the 15 minutes observation will enter the room, approach the patient and check their identify, respirations, and to ensure that they are not in any distress." B. Level II: every 15 minutes checks, routine observations with precautions and taking note of precautions ordered as well ...staff will observe patient and document on the Patient's Observation Rounds sheet every 15 minutes ..."

2.b. During a concurrent observation, interview and record review on 10/1/2025 at 12:40 p.m. with the Nurse Manager (NM) 2 of Behavioral Health Unit (BHU) and the Security Supervisor (SS)1, the facility's security footage of Campus 2 BHU unit (Unit C), on 9/13/2025 from time period 1:20 a.m. to 4:58 a.m., was reviewed, the following events were observed:

-At 1:20 a.m., a Mental Health Worker (MHW) 8 was se