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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 Governing Body failed to provide oversight on the facility's Nursing Department when Staff failed to protect one (1) of 30 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), when staff did not provide appropriate physical response to an agitated (being upset, annoyed, angry, and physically disturbed) patient (Patient 1), in accordance with the facility's policy and procedure (P&P) regarding Patient Rights (a set of legal and ethical principles that protect and empower patients in healthcare settings. These rights ensure that patients receive safe, quality care while respecting their autonomy and dignity) and GB bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to the GB's accountability for the safety and quality of care, treatment, and services provided.

This deficient practice resulted in Patient 1 sustaining (suffering) a 1.5-inch-long laceration (a deep cut or tear in skin or flesh) on the head that required staples (using metal staples to close a cut or tear). (Refer to A-0063)

2. The facility failed to provide a safe environment of care, in accordance with the facility's policy regarding "Security of the Unit" and GB bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to the GB's accountability for the safety and quality of care, treatment, and services provided, for one (1) of 30 sampled patients (Patient 2), when Patient 2 was able to force open a locked door.

This deficient practice resulted in Patient 2, who was on an involuntary legal hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) and identified as a danger to others, eloping (escaping) from the facility. Patient 2 was unable to be located and his whereabouts remained unknown. (Refer to A-0063)

3. The facility failed to provide and maintain an appropriate level of observation and monitoring for two of 30 sampled patients, who required line of sight (a straight line along which an observer had unobstructed vision) and one-to-one (1:1, one staff [sitter] assigned to be with one patient) monitoring, per physician order and in accordance with the facility's policy and procedure on rounding (the process of regularly visiting patients to assess their condition) and monitoring, when nursing staff left both Patient 8 and Patient 9 in a closed room together, without any visual monitoring on 6/14/2025.

This deficient practice resulted in Patient 9 physically assaulting (to attack) Patient 8 on 6/14/2025. Patient 8 sustained a fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) and multiple bruises to the face and head following the assault. This deficient practice also had the potential in putting other patients at risk for injury due to lack of monitoring. (Refer to A-0063)

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 one of 30 sampled patient's (Patient 12) and/or Patient 12's representative, was provided with follow up of grievance (a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care) and or informed of any resolution of grievance as per facility's policy and procedure regarding "Complaint and Grievance Procedure."

This deficient practice resulted in Patient 12's and Patient 12's representative to not be provided with a resolution about their complaint, which may leave Patient 12 and/or Patient 12's representative being dissatisfied and feel ignored or dismissed for concerns raised regarding patient care. (Refer to A-0118)

2. The facility failed ensure one of 30 sampled patient's (Patient 12) representative's denial of visitation right was reevaluated and a justification for denial of visitation right provided, in accordance with the facility's policy and procedure regarding "Visitation."

This deficient practice resulted in Patient 12's representative (FM 3) not being allowed to exercise his right to visit Patient 12 causing potential distress to Patient 12 and/or Patient 12's representative. (Refer to A-0217)

3. The facility failed to ensure two of 30 sampled patients' (Patient 22 and Patient 23) family representatives were informed of the use of restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) on Patient 22 and Patient 23, in accordance with the facility's policy and procedure regarding "Seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) and Restraint" and "Notification of Seclusion and/or Restraint Episode."

This deficient practice resulted in family representatives not being informed of the treatment provided at the facility including understanding the risk and benefits of the treatment (use of physical restraint on Patient 22 and Patient 23) and being able to help make informed decision (making healthcare choices based on a clear understanding of the available options, potential benefits, risks, and alternatives, as well as their own values and preferences) pertaining to Patient 22 and Patient 23's care. (Refer to A-0131)

4. The facility failed to provide a safe environment of care, in accordance with the facility's policy regarding "Security of the Unit" and Governing Body (GB) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to the GB's accountability for the safety and quality of care, treatment, and services provided, for one (1) of 30 sampled patients (Patient 2), when Patient 2 was able to force open a locked door.

This deficient practice resulted in Patient 2, who was on an involuntary legal hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) and identified as a danger to others, eloping (escaping) from the facility. Patient 2 was unable to be located and his whereabouts remained unknown. (Refer to A-0144)

5. The facility failed to ensure its nursing staff protected one (1) of 30 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), when staff failed to provide an appropriate physical response to an agitated (being upset, annoyed, angry, and physically disturbed) patient (Patient 1), in accordance with the facility's policy & procedure (P&P) regarding Patient Rights (a set of legal and ethical principles that protect and empower patients in healthcare settings. These rights ensure that patients receive safe, quality care while respecting their autonomy and dignity).

This deficient practice resulted in Patient 1 sustaining (suffering) a 1.5-inch-long laceration (a deep cut or tear in skin or flesh) on the head that required staples (using metal staples to close a cut or tear). (Refer to A-0145)

6. The facility failed to protect one of 30 sampled patients (Patient 10) from abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) and respond to an alleged physical abuse in a timely manner, in accordance with the facility's policy regarding "Patient Rights" and "Employee to Patient physical abuse," when the Behavioral Health Worker (BHW 10) put hands on Patient 10 inappropriately, and pushed Patient 10 in the room. The Registered Nurse (RN 5) also failed to assess Patient 10's left eyebrow wound and escalate the alleged abuse to the charge nurse and the house supervisor and notify the attending physician, after Patient 10 reported the alleged abuse on 4/20/2025.

This deficient practice resulted in Patient 10 sustaining a left eyebrow wound and delay in treatment and care due to a delay in notifying the physician. This deficient practice also resulted in BHW 10 not being removed from the facility immediately, thus putting Patient 10 and other patients at risk for further abuse. (Refer to A-0145)

7. The facility failed to ensure nursing staff obtained a physician order, in accordance with the facility's policy regarding "Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and Restraints," for one of 30 sampled patients (Patient 9), when nursing staff performed physical 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) by putting hands on Patient 9 and placed Patient 9 in locked seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) on 6/20/2025.

This deficient practice resulted in Patient 9 being physically restrained by BHU staff and placed on locked seclusion without a physician order which led to violation of Patient 9's rights to be free from restraint/seclusion. This deficient practice also had the potential to result in unnecessary restraint/seclusion including the risk of psychological harm for Patient 9. (Refer to A-0168)

8. The facility failed to ensure the physician signed off on the telephone orders received for two of 30 sampled patients (Patient 22 and Patient 23) within 24 hours, when 4 point (both arms and legs) restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) were applied on Patient 22 and Patient 23, in accordance with the facility's policy regarding "Seclusion and Restraint."

This deficient practice had the potential to result in unnecessary restraints for Patient 22 and Patient 23, including the lack of appropriate monitoring of potential risks of restraints use such as skin breakdown (injury to the skin caused by prolonged pressure or friction [force]). (Refer to A-0168)

9. The facility failed to ensure one of 30 sampled patient's (Patient 22) 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) monitoring was conducted every 15 minutes, in accordance with the facility's policy and procedure regarding "Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and Restraint," when Registered Nurse (RN) 6 placed (Patient 22) on 4-point (both ankles and wrist) restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) and Patient 22 was administered Thorazine (medication used to treat mental health condition and regulates a patient's mood) 100 milligrams (mg, a unit of measurement) and Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect) 50 mg via intramuscular (IM, into the muscles), while on 4 point restraints.

This deficient practice had the potential for inadequate oversight/monitoring of Patient 22's response to the use of restraints, which can lead to complications such as poor circulation (a medical condition where blood flow to parts of the body is reduced or inadequate), injury and/or death. (Refer to A-0175)

10. 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 three of 30 sampled patients (Patients 8, 9 and 20), in accordance with the federal regulations regarding physician notification after the completion of the face-to-face evaluation.

This deficient practice had the potential to result in Patients 8, 9 and 20 not receiving evaluation from physicians to determine appropriate treatment and care and also had the potential for unnecessary seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and 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) use. (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 Assurance and Performance Improvement (QAPI) was met, as evidenced by:

1. The facility's Quality Assurance Performance Improvement team (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) failed to implement corrective action and mechanisms in a timely manner, to ensure there was proper observation or monitoring provided for patients who are placed on line of sight (a straight line along which an observer had unobstructed vision) and one to one (1:1, one staff [sitter] assigned to be with one patient) monitoring in the Behavioral Health Unit (BHU, (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) after there was patient to patient altercation between two of 30 sampled patients (Patient 8 and Patient 9), which was identified on 6/14/2025.

This deficient practice had the potential to put other patients at risk for injury or harm. (Refer to A-0286)

2. The facility's Governing Body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure that the facility's Quality Assurance 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) Committee, reviewed and addressed the facility's Policy and Procedure (P&P) pertaining to "Seclusion (involuntary [without permission] confinement of a patient in a room or area from which the patient is physically prevented from leaving) and 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)," to ensure that the P&P was aligned with facility's current practice and be able to comply with federal regulations, when the P&P did not indicate that a Registered Nurse could perform face to face assessment on patients following the initial application of seclusion/restraints other than the physician, and the P&P did not also indicate that a Registered Nuse 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 three (3) of 30 sampled patients (Patients 8, 9, and 20).

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-0309)

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

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

1. The facility failed to ensure nursing staff provided and maintained an appropriate level of observation and monitoring for two of 30 sampled patients who required line of sight (a straight line along which an observer had unobstructed vision) and one-to-one (1:1, one staff [sitter] assigned to be with one patient) monitoring, per physician order and in accordance with the facility's policy and procedure on rounding (the process of regularly visiting patients to assess their condition) and monitoring, when nursing staff left both Patient 8 and Patient 9 in a closed room together, without any visual monitoring on 6/14/2025.

This deficient practice resulted in Patient 9 physically assaulting (to attack) Patient 8 on 6/14/2025. Patient 8 sustained a fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) and multiple bruises to the face and head following the assault. This deficient practice also had the potential in putting other patients at risk for injury due to lack of monitoring. (Refer to A-0395)

2. The facility failed to conduct a comprehensive assessment upon admission, that included assessing a patient's risk of suicide (killing self), homicide (killing others), or violence (assault towards others), for one of 30 sampled patients (Patient 4), in accordance with the facility's policy regarding "Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Nursing Standards of Care."

This deficient practice had the potential to result in harm to Patient 4 and other patients on the unit due to lack of assessment. (Refer to A-0395)

3. The facility failed to ensure its nursing staff adhered to policy and procedure regarding staff conduct, when a Registered Nurse (RN) 1 pursued an inappropriate relationship with one (1) of 30 sampled patients (Patient 3) after their (Patient 3) discharge from the facility.


This deficient practice had the potential to compromise professional boundaries and undermine the therapeutic integrity of care provided during the inpatient stay. (Refer to A-0398)

4. The facility failed to ensure patients' family members were informed of seclusion (apart from others) and/or restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) episodes for two of 30 sampled patients (Patient 22 and Patient 23), in accordance with the facility's policy and procedures regarding "Seclusion and Restraint," and "Notification of Patient Admission and Subsequent Events," when Patient 22 and Patient 23 were placed on 4-point (both arms and legs) restraints in the seclusion room (is a room where a person is involuntarily confined alone).

This deficient practice had the potential to negatively affect Patient 22 and Patient 23's wishes for treatment and care that they would receive in the facility, when there is lack of designated patients' family member's participation in the care process. (Refer to A-0398)

5. The facility failed to ensure one of 30 sampled patient's (Patient 22) restraint monitoring intervention, was implemented and conducted every 15 minutes, in accordance with the facility's policy and procedure regarding "Seclusion and Restraint," when Registered Nurse (RN) 6 placed Patient 22 on 4 point (both ankles and wrists) restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely). Subsequently, Patient 22 received Thorazine (medication used to treat mental health condition and regulates your mood) 100 milligram (mg, a unit of measurement) and Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect) 50 mg via intramuscular (IM, into the muscles).

This deficient practice had potential for negative consequences for Patient 22's safety due to lack of oversight (absence or inadequacy of monitoring) to identify adverse effects of restraint use such as poor circulation (blood flow), injury and/or death. (Refer to A-0398)

6. The facility failed to ensure nursing staff adhered to the facility's policy and procedure regarding "Rounding, Observation and Monitoring of Patients," when staff did not perform the 15- minute rounding (observing patient location and behavior) for one of 30 sampled patients (Patient 21).
This deficient practice had the potential for Patient 21's safety to not be monitored and care needs to not be addressed. (Refer to A-0398)

7. The facility failed to ensure nursing staff adhered to the facility's policy and procedure regarding notification of the physician for change of condition for one of 30 sampled patients (Patient 10), when Patient 10 reported a bleeding left eyebrow to the Registered Nurse (RN) 5, but RN 5 did not notify the attending physician.

This deficient practice resulted in delay for Patient 10 to receive diagnostic exams including a computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) scan of head thus have the potential to delay treatment and care. (Refer to A-0398)

8. The facility failed to ensure corrections to the medical records were documented appropriately, for one of 30 sampled patients (Patient 5), in accordance with the facility's policy regarding documentation and corrections in the medical record, when staff wrote on top of original documentation, which obscured the original documentation for Patient 5's location on 4/30/2025 from 5:45 p.m. to 6:30 p.m.

This deficient practice had the potential to result in inaccurate information and may lead to incorrect treatment plans which may harm the patient. (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 failed to ensure the Condition of Participation (CoP) for Infection Prevention and Control and Antibiotic Stewardship (a set of coordinated strategies aimed at optimizing antibiotic use to improve patient outcomes, reduce antibiotic resistance, and minimize healthcare costs) Program was met, as evidenced by:

1. The facility failed to ensure for one of 30 sampled patients (Patient 16), the facility's policy and procedure (P&P) for infection control was implemented when, Patient 16's intravenous tubing (known as "piggyback," a flexible tube that administers medication) was not labeled with a date for change of IV (Intravenous, into the vein) tubing, and IV site was not dated.

This deficient practice had the potential to result in Patient 16 being exposed to infections such as phlebitis (infection of the veins) and/or bloodstream infection caused by prolonged use of IV tubing and IV insertion site. (Refer to A-0749)

2. The facility failed to ensure one of three sampled campuses (Campus 1) Behavioral Health Unit (BHU), was kept clean and free of flies, in accordance with the facility's policy regarding Infection control and prevention.

This deficient practice had the potential to cause infections through contaminated areas and objects, which could negatively impact the patients' and staff's overall health. (Refer to A-0750)

3. The facility failed to ensure its staff followed infection control policy and procedure (P&P), when the annual tuberculosis (TB, a serious infectious bacterial disease that primary affects the lung, is spread through the air, and can stay in the air for several hours) screening, was missing for one (1) of 10 sampled employees (Registered Nurse [RN] 5).

This deficient practice had the potential to put the facility's staff and patients at risk for acquiring (catching) TB. (Refer to A-0776)

4. The facility failed to ensure its staff followed infection control policy and procedure (P&P), when evidence of either influenza (the flu, a contagious viral disease that affects the lungs and is spread through coughing and sneezing) vaccination administration or declination, was missing for one (1) of 10 sampled employees (Behavioral Health Worker [BHW] 10).

This deficient practice had the potential to put the facility's staff and patients at risk for acquiring influenza. (Refer to A-0776)

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

1. Staff failed to protect one (1) of 30 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury) when staff did not provide appropriate physical response to an agitated (being upset, annoyed, angry, and physically disturbed) patient (Patient 1), in accordance with the facility's policy and procedure (P&P) regarding Patient Rights (a set of legal and ethical principles that protect and empower patients in healthcare settings. These rights ensure that patients receive safe, quality care while respecting their autonomy and dignity) and GB bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to the GB's accountability for the safety and quality of care, treatment, and services provided.

This deficient practice resulted in Patient 1 sustaining (suffering) a 1.5-inch-long laceration (a deep cut or tear in skin or flesh) on the head that required staples (using metal staples to close a cut or tear).

2. The facility failed to provide a safe environment of care, in accordance with the facility's policy regarding "Security of the Unit" and GB bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to the GB's accountability for the safety and quality of care, treatment, and services provided, for one (1) of 30 sampled patients (Patient 2), when Patient 2 was able to force open a locked door.

This deficient practice resulted in Patient 2, who was on an involuntary legal hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) and identified as a danger to others, eloping (escaping) from the facility. Patient 2 was unable to be located and his whereabouts remained unknown.

3. The facility failed to provide and maintain an appropriate level of observation and monitoring for two of 30 sampled patients who required line of sight (a straight line along which an observer had unobstructed vision) and one-to-one (1:1, one staff [sitter] assigned to be with one patient) monitoring, per physician order and in accordance with the facility's policy and procedure on rounding (the process of regularly visiting patients to assess their condition) and monitoring, when nursing staff left both Patient 8 and Patient 9 in a closed room together, without any visual monitoring on 6/14/2025.

This deficient practice resulted in Patient 9 physically assaulting (to attack) Patient 8 on 6/14/2025. Patient 8 sustained a fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) and multiple bruises to the face and head following the assault. This deficient practice also had the potential in putting other patients at risk for injury due to lack of monitoring.

Findings:

1. During a review of Patient 1's "Face Sheet (front page of the chart that contains a summary of basic information about the patient)," not dated, the Face Sheet indicated Patient 1 was admitted to the facility's behavioral health service (treatment for mental health conditions and behaviors that impact overall well-being, including emotional, psychological, and social aspects) on 5/20/2025.

During a review of Patient 1's "Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves])," dated 5/20/2025, the 5150 hold paperwork indicated Patient 1 was detained for being a danger to herself and gravely disabled due to appearing paranoid (intense and irrational distrust and suspicion of others), internally preoccupied (focusing on things they are thinking or hearing inside their head instead of engaging with the world around them), not talking, and spitting.

During a review of Patient 1's "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment)- (5250 hold paperwork, a regulation in the state of California that allows designated professionals to extend a 72-hour hold into 14 days if an individual is deemed a danger to themselves or others, or is gravely disabled due to a mental health condition)," dated 5/21/2025, the 5250 hold paperwork indicated Patient 1's involuntary legal hold was extended due to being a danger to herself and being gravely disabled.

During a review of Patient 1's "Progress Note," dated 5/23/2025 at 2:11 p.m., the Progress Note indicated, "[At 11:40 a.m.], [Patient 1 was] throwing soiled diaper at staff and being aggressive towards staff ... [At 11:45 a.m.], [Patient 1 was] found on floor bleeding from head with cut slash on back of head [approximately] 4 inches long. [Patient 1 was] found attempting to throw blood on staff ... Walked [Patient 1] to seclusion room (a bare, enclosed space used to contain a patient who is experiencing a behavioral emergency, typically when less restrictive measures have failed to ensure the safety of the patient or others) to assess patient, meanwhile 911 was called."

During an interview on 6/24/2025 at 3:17 p.m. with the Quality Coordinator (QC), the QC stated that on 5/23/2025, Patient 1 was discovered on the floor in her (Patient 1) room bleeding from her head. The QC stated that it was reported she (Patient 1) was banging her head. She (Patient 1) was unable to be assessed in her room due to throwing blood at the staff, so she was walked to the seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) room and assessed. 911 was called and Patient 1 was taken to an outside general acute care hospital (GACH, a type of hospital that provides short-term, inpatient medical and surgical care for acute [sudden or severe] health conditions) to have her head wound treated.

During an interview on 6/24/2025 at 3:27 p.m. with the Director of the BHU (Behavioral Health Unit, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at Campus 2 (DIR 1), DIR 1 stated that the staff thought Patient 1 was self-harming (hurting herself) until DIR 1 received an anonymous text message on 5/24/2025 indicating that Patient 1 had been pushed. DIR 1 stated Patient 1 was alone in her room with Behavioral Health Worker (BHW) 1, who was witnessed coming out of Patient 1's room and calling for help. DIR 1 further stated they (the administrative team conducting the internal investigation) determined that BHW 1 most likely pushed her (Patient 1).

During a concurrent observation and interview on 6/25/25 at 10:04 a.m. with the QC, the Nurse Manager of the Campus 2 (NM 1), and the Associate Administrator (AA), the video surveillance footage from 5/23/2025, was reviewed. The following events were observed at the indicated timestamps in the video:

1. 11:47 a.m.: BHW 1 was seen entering the hallway in Unit 1, speaking to a patient off-camera. BHW 1's body language indicated that she was upset or agitated (being upset, annoyed, angry and physically disturbed). QC confirmed this was BHW 1.
2. 11:48 a.m.: BHW 1 stood outside of Patient 1's room, looking inside. QC confirmed that was Patient 1's room.
3. 11:51 a.m.: BHW 1 appeared to be hit by something from inside Patient 1's room. BHW 1 then entered Patient 1's room.
4. 11:52 a.m.: BHW 2 entered Patient 1's room. BHW 2 then left the room with BHW 1 and both moved off-camera. BHW 1 then returned to Patient 1's room.
5. 11:53 a.m.: Multiple staff entered Patient 1's room.
6. 11:55 a.m.: Patient 1 was escorted out of her (Patient 1) room with three different staff. There was blood on Patient 1's gown and one staff was holding a towel to the back of Patient 1's head.

During an interview on 6/25/2025 at 11:25 a.m. with the QC, the QC stated that BHW 1 was agitated in the surveillance footage, that BHW 1 was uncooperative during the facility's internal investigation, and that there were also inconsistencies in BHW 1's story, specifically that Patient 1 suffered a single laceration which was not consistent with the report that she (Patient 1) had been "banging her head."

During an interview on 6/25/2025 at 3:38 p.m. with Behavioral Health Worker (BHW) 2, BHW 2 stated that on 5/23/2025, Patient 1 threw a diaper in the hallway. BHW 1 went to Patient 1's room and said something to her (Patient 1) that BHW 2 did not hear. BHW 1 then went to the nurses' station, then back to Patient 1's room; BHW 2 saw BHW 1 go inside and went in behind her (BHW 1). Upon entering, BHW 2 saw Patient 1 on the ground and holding her head, so BHW 2 blew her whistle which alerted the staff. BHW 2 asked BHW 1 what happened; she stated BHW 1 told her that Patient 1 "banged her head."

During a concurrent interview and record review on 6/25/2025 at 4:04 p.m. with the QC, the staffing assignment for 5/24/2025, was reviewed. The assignment indicated BHW 1 was scheduled to work the day after the incident with Patient 1. The QC stated Patient 1 returned to the facility from the outside GACH early in the morning on 5/24/2025; BHW 1 did not report to work that day (5/24/2025) to seek medical care for injuries sustained during the incident, and then once DIR 1 received the anonymous text, BHW 1 was placed on suspension later that day.

During a review of Patient 1's "Progress Note," dated 5/23/2025 at 6:45 p.m., the Progress Note indicated Patient 1's CT (computed tomography, a procedure that uses X-ray techniques to create detailed images of the body) of the head at the outside GACH was negative, and that staples were applied on the head laceration that was approximately 1.5 inches long.

During a review of BHW 1's "Personnel Action Report (PAR)," dated 6/2/2025, the PAR indicated BHW 1's employment at the facility was terminated involuntarily on 6/2/2025 for the reason "patient abuse."

During a review of the facility's list of "Governing Board of Directors," not dated, the list indicated the Chief Executive Officer (CEO) was a voting member of the GB.

During an interview on 6/27/2025 at 8:03 p.m. with the CEO, the CEO confirmed he (CEO) was a voting member of the GB. The CEO stated that "at the end of the day," oversight and accountability for the facility fell on the governing board. The CEO further stated that the GB was responsible for quality patient care and had the ultimate say over what occurred in the facility.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights," last reviewed 8/2022, the P&P indicated, "It is the policy of the Behavioral Health Unit to maintain and protect patients' fundamental human, civil, constitutional and statutory rights in accordance with federal and California laws ... In addition, LPS (the Lanterman-Petris-Short Act, a California law regulating involuntary mental health holds) grants all patients these irrevocable rights: ... 4. To be free from harm ... 18. To be free from verbal and physical abuse."

During a review of the facility's GB (Governing Body) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), approved by the GB on 10/19/2022, the bylaws indicated, "The Board of Directors shall, through its members: ... Establish and maintain that the Hospital or other health care related facility that will provide high-quality total care to patients suffering from illnesses, diseases or disabilities which require that patients receive comprehensive care ... Oversee the hospital's compliance with the laws and regulations of federal, state, and local governmental agencies and with the standard's rules and regulations of the various and other accrediting and approval agencies ... Maintain ultimate accountability for the safety and quality of care, treatment, and services provided."

2. During a review of Patient 2's "Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves])," dated 6/9/2025, the 5150 hold paperwork indicated Patient 2 was detained for being a danger to others due to lighting objects on fire while assaulting his (Patient 2) parents.

During a review of Patient 2's "Face Sheet (front page of the chart that contains a summary of basic information about the patient)," not dated, the Face Sheet indicated Patient 2 was admitted to the facility's behavioral health service (treatment for mental health conditions and behaviors that impact overall well-being, including emotional, psychological, and social aspects) on 6/10/2025.

During a review of Patient 2's "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment)- (5250 hold paperwork, a regulation in the state of California that allows designated professionals to extend a 72-hour hold into 14 days if an individual is deemed a danger to themselves or others, or is gravely disabled due to a mental health condition)," dated 6/11/2025, the 5250 hold paperwork indicated Patient 2's involuntary legal hold was extended due to being a danger to others and being gravely disabled.

During a review of Patient 2's "Progress Note," dated 6/11/2025 at 1:57 p.m., the Progress Note indicated Patient 2 was agitated (being upset, annoyed, angry, and physically disturbed), irritable, making "attempts to go AWOL (Absent Without Leave, leaving the facility without authorization)," and verbalizing a desire to leave.

During a review of Patient 2's "Behavioral Health Acuity [the severity or intensity of a patient's health condition] Assessment," dated 6/11/2025 at 2:00 p.m., the Assessment indicated Patient 2 was placed on elopement precautions (strategies or protocols to prevent patients from leaving a health care facility without authorization).

During a review of Patient 2's "Individual Observations" flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 6/11/2025 to 6/12/2025, the flowsheet indicated Patient 2 was asleep and in his (Patient 2) room from 10:14 p.m. to 1:30 a.m.

During a review of Patient 2's "Progress Note," dated 6/12/2025 at 6:42 a.m., the Progress Note indicated, "At approximately [1:40 a.m.], [Patient 2] came out of the room wrapped with the blanket to the nurse station responding to internal stimuli, pacing around the unit making nonsensical statement, disorganized and guarded, and continue talking to self. [Patient 2] was pacing around the back of the unit and suddenly [Behavioral Health Worker] called for help. [Patient 2] already make advance toward the exit door, ran left across the office and exit to the side door to [the street]. Staff unable to pursue the patient on the street. Police were called to report the incident."

During a concurrent observation and interview with the Director (DIR 1) of the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at the facility's offsite campus (Campus 2) on 6/24/2025 at 11:13 a.m., the double doors leading to Unit 2 on Campus 2, were observed. There was a keypad on the wall to the right side of the double doors; DIR 1 entered a code to unlock the doors. DIR 1 stated these doors had a lock that was magnetized for up to 1200 pounds.

During an interview on 6/24/2025 at 3:07 p.m. with the Quality Coordinator (QC) , the QC stated that on 6/12/2025 after midnight, Patient 2 was agitated and pacing the hall of Unit 2. Two staff, Charge Nurse (CN, the lead Registered Nurse on a shift) 4 and Behavioral Health Worker (BHW) 7 attempted to redirect Patient 2 away from the doors exiting out of Unit 2 (fire double doors without an alarm which should be opened only with a code). While CN 4 went to get more help, Patient 2 charged through the fire double doors of Unit 2. The doors were equipped with a magnetic lock rated at 1200 pounds (the amount of force necessary to force the lock open). The QC stated that instead of calling a "Code Green (a hospital-wide call for help when a patient elopes)," the staff decided to follow Patient 2 to try and stop him. DIR 1 stated that Patient 2 escaped onto the street and staff called the police. The facility did not know what happened to Patient 2 after he eloped.

During a concurrent observation and interview on 6/24/2025 at 3:09 p.m. with the QC, the QC demonstrated the path Patient 2 took to escape the facility. After exiting Unit 2, which had a fire door that should have been opened only with a code, Patient 2 made a right into the Partial Hospitalization Program (PHP, an intensive form of outpatient mental health treatment that offers a structured therapeutic environment during the day while allowing patients to return home in the evenings) unit, which was unlocked. Inside the PHP unit, to the right, there was an exit door onto the street.

During a concurrent observation and interview on 6/25/2025 at 9:26 a.m. with the QC, the Nurse Manager of Campus 2's BHU (NM 1), and the Associate Administrator (AA), the surveillance footage from 5/23/2025, was reviewed. The security camera was pointed at the double doors of Unit 2. The following events were observed at the indicated timestamps in the video:

1. 1:42 a.m.: The doors (Unit 2's doors) were shown with nobody present, including staff. Patient 2 then appeared on camera and walked toward the double doors. The QC confirmed that this was Patient 2. NM 1 stated that prior to this clip, Charge Nurse (CN) 4 was trying to talk to Patient 2 and left to get support.
2. 1:43:05 a.m.: Patient 2 attempted to open the door (Unit 2's doors) twice by pressing on the push bar using his right shoulder and back.
3. 1:43:14 a.m.: Patient 2 was standing by the door (Unit 2's doors). BHW 7 approached Patient 2 from off-camera, talking to him.
4. 1:43:15 a.m.: Patient 2 used his shoulder and back to open the door (Unit 2's doors); Patient 2 exited the unit. BHW 7 followed Patient 2 out of the doors. The AA stated there was no alarm when that door opened.
5. 1:43:47 a.m.: Multiple staff followed Patient 2 and BHW 7 out of the doors.

During an interview on 6/25/2025 at 2:16 p.m. with the Lead Maintenance Worker (LMW), the LMW stated that the doors in the BHU were equipped with a magnetic lock rated for 1200 pounds of force, which was required to force open the magnet lock. All the doors on Campus 2 were previously upgraded on 9/11/2024 from 600 pounds to 1200 pounds due to an elopement. The LMW stated he did not think it was possible for someone to apply 1200 pounds of force to open that door.

During an interview on 6/26/2025 at 9:45 a.m. with DIR 1, DIR 1 stated elopement precautions or specific interventions (strategies and actions implemented by nurses and other healthcare staff to achieve a goal) that staff should take when a patient was on elopement precautions were not listed in any of the facility's policy and procedures (P&P). DIR 1 further stated, "It [elopement precautions] just means to be 'on high alert.'"

During an interview on 6/26/2025 at 10:38 a.m. with the Associate Administrator (AA), the AA stated it was never acceptable for a patient to elope from the unit.

During a concurrent interview and record review on 6/26/2025 at 11:51 a.m. with the AA and QC, a report from the outside vendor that supplied the door, dated 6/26/2025, was reviewed. The report indicated, "It was found that the exit device's concealed vertical rod was intermittently failing to fully latch. The issue prevented the maglock from properly securing the door ... It is recommended to implement a quarterly preventative maintenance schedule to ensure continued reliable operation of the door hardware." The AA and QC confirmed that the Unit 2 doors (which Patient 2 managed to open) were broken.

During an interview on 6/26/2025 at 3:36 p.m. with the Nurse Manager of Campus 2's BHU (NM 1), NM 1 stated that BHU staff were provided with a whistle to use to call for help without leaving the patient. NM 1 confirmed the whistle was not used when Patient 2 was attempting to elope.

During an interview on 6/27/2025 at 7:22 p.m. with the Director of Performance Improvement and Quality (DQM), the DQM confirmed that there was no procedure in place at the time of the incident to regularly check the magnetic lock and door latch. The DQM also confirmed that in 2024, the magnetic locks on all the doors in Campus 2 were upgraded from a 600-pound rating to a 1200-pound rating due to an elopement as the patient at that time was able to open the door despite it being locked.

During a review of the facility's list of "Governing Board of Directors," not dated, the list indicated the Chief Executive Officer (CEO) was a voting member of the GB.

During an interview on 6/27/2025 at 8:03 p.m. with the Chief Executive Officer (CEO), the CEO stated that "at the end of the day," oversight and accountability for the facility fell on the governing board. The CEO further stated that the GB was responsible for quality patient care and had the ultimate say over what occurs in the facility.

During a review of the facility's policy and procedure (P&P) titled, "Security of the Unit," last reviewed 10/2021, indicated, "It is the policy of the Behavioral Health Unit to operate as a locked unit, in order to maintain safety and security of the treatment environment."

During a review of the facility's GB bylaws, approved by the GB on 10/19/2022, the bylaws indicated, "The Board of Directors shall, through its members: ... Establish and maintain that the Hospital or other health care related facility that will provide high-quality total care to patients suffering from illnesses, diseases or disabilities which require that patients receive comprehensive care ... Oversee the hospital's compliance with the laws and regulations of federal, state, and local governmental agencies and with the standard's rules and regulations of the various and other accrediting and approval agencies ... Maintain ultimate accountability for the safety and quality of care, treatment, and services provided."

3. 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 4/16/2025, the Psych Eval indicated, Patient 8 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) with diagnosis including but not limited to schizoaffective disorder (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]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 8's "Consultation Report," dated 4/16/2025, the "Consultation Report" indicated, Patient 8 had past medical history of pseudoseizures (event that mimic seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness] but are not caused by abnormal electrical activity in the brain) and autism (neurodevelopmental disorder characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication).

During a review of Patient 9'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 6/5/2025, the Psych Eval indicated, Patient 9 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) with diagnoses including but not limited to 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days 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 (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 8's "Progress Note Non-Physician (nurses progress notes)," dated 6/14/2025, the "Progress Note Non-Physician" indicated, "Patient (Patient 8) was attacked by his (Patient 8's) roommate (Patient 9) approximately 1830 (6:30 p.m.). Patient (Patient 8) was witnessed falling back out of his (Patient 8's) room into the hallway noted hitting the back of his (Patient 8's) head ... Patient (Patient 8) unable to follow command for PERRLA (Pupils equal, round, and reactive to light and accommodation, standard eye exam to check the health of eyes and the nervous system). Right pupil 3 mm (millimeters, unit of measure) reactive to light. Left pupil nonreactive (the pupil [the black circle in the center of the eye] doesn't constrict [get smaller] in response to light or when focusing on a near object). Rapid Response (a system designed to quickly address a patient's sudden clinical deterioration before it escalates into a medical emergency) was called at 1838 (6:38 p.m.) ... [physician] was notified ... CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head, transfer to telemetry floor [room number]. Pending report." The "Progress Note Non-Physician" also indicated Patient 8 was transferred to facility's telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor at 7:31 p.m.

During an interview on 6/24/2025 at 12 p.m. with Patient 8, Patient 8 stated he (Patient 8) was in the room, and someone attacked him (Patient 8). Patient 8 stated, "he hit my face to my left eye."

During an interview on 6/24/2025 at 3:10 p.m. with the Nurse Manager (NM 2) of BHU, NM 2 stated the following: there were different levels of monitoring aside from standard every 15-minute rounding in BHU. A specific staff was assigned to a specific patient who needed one to one (1:1, one staff [sitter] assigned to be with one patient) monitoring and the staff had to stay with the patient within arm's length. For patients who needed line of sight (a straight line along which an observer had unobstructed vision) monitoring, staff would need to keep a close eye on the patients and maintain visual on the patients outside their regular every 15-minute rounding.

During an interview on 6/25/2025 at 10:02 a.m. with the Director of Performance Improvement/ Quality (DQM), DQM stated Patient 8 and Patient 9 were both in the same room when the incident happened on 6/14/2025.

During a concurrent observation and interview on 6/25/2025 at 10:03 a.m. with DQM, the facility's security video footage, dated 6/14/2025, was reviewed. The security video footage with no audio indicated the following:

-At 6:23:27 p.m. a Behavioral Health Worker (BHW 5) was seen sitting in the hallway;
-At 6:23:30 p.m. BHW 5 heard something and walked toward Patient 8 and Patient 9's room. BHW 5 looked at the window on the door, then opened the door and walked in;
-At 6:23:47 p.m. Patient 8 walked out from the room, limping, then fell to the floor in the middle of hallway;
-At 6:25:45 p.m. Patient 9 was taken out by two BHWs out from the room.

During the same interview on 6/25/2025 at 10:03 a.m. with DQM, DQM confirmed the identities of BHW 5, Patient 8 and Patient 9. DQM also stated there was an altercation between Patient 8 and Patient 9 in the room (with the closed door).

During a review of Patient 8's "Progress Note Non-Physician (nurses progress notes)," dated 6/14/2025, the "Progress Note Non-Physician" indicated, "2005 (8:05 p.m.) patient (Patient 8) on unit (Telemetry unit) ... Patient (Patient 8) has multiple bruises to his (Patient 8's) face and head."

During an interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated on 6/14/2025, he (BHW 5) was sitting in the hallway and saw Patient 8 and Patient 9 went to the room. BHW 5 stated, "I heard feet shuffling in the room. I got up, peeked into the window and saw Patient 9 was on top of Patient 8 on the ground hitting Patient 8. Patient 9 was aggressive to Patient 8."

During the same interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated he (BHW 5) was not aware Patient 9 was under line-of-sight monitoring. BHW 5 also stated Patient 8 was on one to one (1:1) monitoring that day but his (Patient 8's) assigned sitter was flexed earlier that day due to overstaffing and no one was assigned to replace the sitter. BHW 5 stated there was no line of sight for both patients (Patient 8 and Patient 9) because the door was closed.

During an interview on 6/25/2025 at 2:29 p.m. with the Charge Nurse (CN 3) of BHU, CN 3 stated the following: the charge nurse of the unit was responsible for making assignment for the shift. There was no specific person assigned to perform line of sight. Any staff not assigned as 1:1 monitoring would be watching patients who required line of sight monitoring. The staff would need to see those patients at all times. CN 3 also stated a physician order was required for starting and discontinuing any line of sight and 1:1 monitoring.

During a concurrent interview and record review on 6/25/2025 at 2:52 p.m. with the Nurse Manager (NM 2) of BHU, the facility's Campus 1 BHU assignment, "[Unit] AM Shift Assignment," dated 6/14/2025 AM shift, was reviewed. The "[Unit] AM Shift Assignment" indicated, Patient 8 was 1:1 monitoring and Patient 9 was on line of sight monitoring. The "[Unit] AM Shift Assignment" did not indicate which nursing staff was assigned to Patient 8 and Patient 9 to perform the 1:1 monitoring and line of sight monitoring. NM 2 stated she (NM 2) could not tell which staff was assigned to perform line of sight monitoring because it was not written on the assignment.

During a concurrent interview and record review on 6/25/2025 at 3:29 p.m. with the Quality and Performance Improvement Supervisor (QPS), Patient 8's "Order Information for: Patient Monitoring (physician order)," dated 6/12/2025, was reviewed. The physician order indicated Patient 8 was placed on 1:1 sitter observation. QPS stated the order was active at the time of incident. QPS stated the order was discontinued on 6/14/2025 at 8:19 p.m.

During a concurrent interview and record review on 6/25/2025 at 3:30 p.m. with QPS, Patient 9's "Order Information for: Patient Monitoring (physician order)," dated 6/10/2025, was reviewed. The physician order indicated, Patient 9 was placed on line-of-sight observation. QPS stated the order was active and only discontinued on 6/20/2025.

During an interview on 6/27/2025 at 7:43 p.m. with the Director of Performance Improvement/Quality (DQM), DQM sta

Based on interview and record review, the facility failed to ensure one of 30 sampled patient's (Patient 12) and/or Patient 12's representative, was provided with follow up of grievance (a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care) and or informed of any resolution of grievance as per facility's policy and procedure regarding "Complaint and Grievance Procedure."

This deficient practice resulted in Patient 12's and their representative to not be provided with a resolution about their complaint, which may leave Patient 12 and/or Patient 12's representative being dissatisfied and feel ignored or dismissed for concerns raised regarding patient care.

Findings:

During a review of Patient 12's "Face Sheet (a document containing a patient's medical and demographic information)," undated, the face sheet indicated Patient 12 was admitted to the facility on 3/12/2025 at 6:58 p.m., with a medical diagnosis of psychosis (mental condition in which thought, and emotions are affected, and reality is affected).

During a phone interview on 6/25/2025 at 9:00 a.m. with Patient 12's representative (FM 3), FM 3 stated, he (FM 3) emailed a written complaint to the facility on 3/16/2025 with no response after a follow up email to the facility. FM 3 further stated he (FM 3) received no phone call or mail response from facility regarding his complaint.

During an interview on 6/25/2025 at 3:20 p.m. with the Patient Relations Manager (PRM), PRM stated, he (PRM) received Patient 12's FM 3's complaint, forwarded it to the unit Manager and the Director of Quality for investigation. PRM further stated he (PRM) was not sure of the result of the investigation or the resolution of Patient 12's FM3's complaint and does not remember speaking to Patient 12's FM3.

During a review of the facility's "Grievance Documentation Form," dated 3/16/2025, 3/17/2025, 3/23/2025 and 3/27/2025, the record indicated the following:
-on 3/16/2025 Patient 12's FM3 filed a complaint and agreed to a phone call with PRM.
-on 3/17/2025 Patient 12's FM 3 sent a follow up email to PRM requesting a response.
-on 3/23/2025 Patient 12's FM 3 sent a follow up email to PRM requesting a response.
-on 3/27/2025 Patient 12's FM 3 sent a follow up email to PRM stating he feels ignored and requesting resolution to concerns.

During a concurrent interview and record review on 6/25/2025 at 4:00 p.m. with the PRM, the "The Acknowledgement Letter," dated 3/24/2025 and the "Response/Closing Letter," dated 4/8/2025, were reviewed. "The Acknowledgement Letter" indicated the letter was sent to Patient 12's assisted living facility (provides housing and personal care services to individuals who need help with daily activities but do not require the level of care offered in a nursing home) under Patient 12's name and the "Response/Closing Letter" was returned to facility (where FM 3 filed a complaint) from Patient 12's Assisted living facility. The PRM stated letters were not sent to FM 3.

During a review of the facility's policy and procedures (P&P) titled, "Complaint and Grievance Procedure," revised 6/2024, indicated, "Every employee upon receipt of a complaint or grievance should acknowledge the patient's/family's concern and explains the process for resolution. Step by step grievance: ...3. The Patient relation manager will mail a letter acknowledging and resolving the grievance within 7 days of receipt. If grievance requires greater than 7 days for investigation or resolution, an acknowledgement letter may be sent informing the complainant that the facility requires more time to investigate the matter. A final response letter will be mailed to the complainant no later than 30 days of receiving grievance."

Based on interview and record review, the facility failed to ensure two of 30 sampled patients' (Patient 22 and Patient 23) family representatives were informed of the use of restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) on Patient 22 and Patient 23, in accordance with the facility's policy and procedure regarding "Seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) and Restraint" and "Notification of Seclusion and/or Restraint Episode."

This deficient practice resulted in family representatives not being informed of the treatment provided at the facility including understanding the risk and benefits of the treatment (use of physical restraint on Patient 22 and Patient 23) and being able to help make informed decision (making healthcare choices based on a clear understanding of the available options, potential benefits, risks, and alternatives, as well as their own values and preferences) pertaining to Patient 22 and Patient 23's care.

Findings:

1. During a review of Patient 22's medical record titled, "History and Physical Exam (H&P, a formal and complete assessment of the patient and the problem)," dated 6/13/2025, the H&P indicated Patient 22 was admitted for chief of complaint of status post (after) fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) with dizziness.

During a review of Patient 22's medical record titled, "Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 6/13/2025, the psychiatric evaluation indicated Patient 22 was brought in from medical floor on 5250 hold (an involuntary psychiatric hold that extends beyond the initial 72 hour hold in California) for gravely disability (unable to care for one's self) and danger to self (to harm one's self).

During a concurrent interview and record review on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22's "Orders," dated 6/16/2025, was reviewed. The Orders indicated Patient 22 had a physician's order for restraint for 4 hours, use of keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraints, and danger to others (to harm others). The HS 1 stated the use of keyed polyurethane restraints indicated that Patient 22 was placed in a seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) room.

During the same interview on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22's "Notification of seclusion and/or restraint episode consent form," dated 6/12/2025, was reviewed. The consent form indicated Patient 22 had requested to notify family member (FM) 1 of episode of seclusion and/or restraint use. HS 1 stated there was no documentation in Patient 22's clinical record that FM 1 was notified about Patient 22's restraint use, and placement in the seclusion room. HS 1 further stated the family member should have been notified per Patient 22's request according to the consent form and that Patient 22's wish should have been honored.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," reviewed in 6/2023, the P&P indicated, "A family member will be contacted by phone to notify the seclusion/restraint episode and patient condition, after obtaining the patient's consent."

During a review of the facility's policy and procedure (P&P) titled, "Notification of Patient Admission and Subsequent Events," reviewed in 10/2021, the P&P indicated, "It is the policy of Behavioral Unit to make reasonable attempts to notify any person designated by a patient admitted for mental health services in the following areas ...Notification of Seclusion and/or Restraint Episode."

2. During a review of Patient 23's "History and Physical (H&P)," dated 5/9/2025, the H&P indicated Patient 23 was admitted for chief complaint, "Patient endorses suicidal ideation (thoughts of taking one's own life)."

During a concurrent interview and record review on 6/25/2025 at 3:48 p.m. with the House Supervisor (HS) 1, Patient 23's "Orders," dated 5/12/2025, was reviewed. The HS 1 stated Patient 23 had a physician restraint order which indicated "4 hours [restraint use], keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure), danger to others."

During a concurrent interview and record review on 6/26/2025 at 10:00 a.m. with the House Supervisor (HS) 2, Patient 23's "Notification of Seclusion and/or Restraint episode," dated 5/8/2025, was reviewed. The HS 2 stated Patient 23's notification of seclusion and restraint consent form was signed by Patient 23 on admission. HS 2 further stated there was no documentation that the nurse informed Patient 23's family member (FM) 2 regarding Patient 23 being on restraint and being placed in the seclusion room.

During the same interview on 6/26/2025 at 10:00 a.m. with the House Supervisor (HS) 2, HS 2 stated [the use of] restraint was a "higher level of intervention," and it was important to notify the family (Patient 23) in case of injury or if anything were to happen.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," reviewed in 6/2023, the P&P indicated, "A family member will be contacted by phone to notify the seclusion/restraint episode and patient condition, after obtaining the patient's consent."

During a review of the facility's policy and procedure (P&P) titled, "Notification of Patient Admission and Subsequent Events," reviewed in 10/2021, the P&P indicated, "It is the policy of Behavioral Unit to make reasonable attempts to notify any person designated by a patient admitted for mental health services in the following areas ...Notification of Seclusion and/or Restraint Episode."

Based on observation, interview, and record review, the facility failed to provide a safe environment of care, in accordance with the facility's policy regarding "Security of the Unit" and Governing Body (GB) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization) pertaining to the GB's accountability for the safety and quality of care, treatment, and services provided, for one (1) of 30 sampled patients (Patient 2), when Patient 2 was able to force open a locked door.

This deficient practice resulted in Patient 2, who was on an involuntary legal hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) and identified as a danger to others, eloping (escaping) from the facility. Patient 2 was unable to be located and his whereabouts remained unknown.

On 6/26/2025 at 4:37 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Performance Improvement and Quality (DQM), Associate Administrator (AA), the Director (DIR 1) of the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at the facility's offsite campus (Campus 2), and Quality Coordinator (QC). The facility failed to provide a safe environment for care when Patient 2 was able to force open a locked door. This led to Patient 2, who was on an involuntary legal hold (a legal process where a person is held against their will in a mental health facility for evaluation and treatment due to concerns about their mental state and potential risk to themselves or others) and identified as a danger to others, eloping (escaping) from the facility. Patient 2 was unable to be located and his whereabouts remained unknown.

On 6/24/2025 at 3:07 p.m., the QC stated that on 6/12/2025 after midnight, Patient 2 was agitated and pacing the hall of Unit 2. Two staff, Charge Nurse (CN, the lead Registered Nurse on a shift) 4 and Behavioral Health Worker (BHW) 7 attempted to redirect Patient 2 away from the doors exiting out of Unit 2 (fire double doors without an alarm which should be opened only with a code). While CN 4 went to get more help, Patient 2 charged through the double doors of Unit 2. The doors were equipped with a magnetic lock rated for 1200 pounds (the amount of force necessary to force the lock open). The QC stated that instead of calling a "Code Green (a hospital-wide call for help when a patient elopes)," the staff decided to follow Patient 2 to try and stop him (Patient 2). DIR 1 stated that Patient 2 escaped onto the street and staff called the police. The facility did not know what happened to Patient 2 after he eloped.

On 6/27/2025 at 11:11 p.m., the IJ was removed in the presence of the CEO via telephone, DQM, AA, QC, and DIR 1. The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that for immediate action taken by the facility, the facility contacted an outside vendor to repair the door to Unit 2 on 6/18/2025; the vendor returned to confirm the door was repaired on 6/24/2025 and 6/25/2025. Assessment of all locked doors, including the latching mechanism, was added to the plant operations team's preventative maintenance tasks, occurring Monday to Friday. In addition, nursing staff were now responsible as of 6/27/2025 to conduct door checks every shift by pushing on the door to ensure it was locked. Any instances of the door being unlocked would be immediately escalated to plant operations for intervention, and a staff member would be stationed at the door until the door was confirmed to be working properly.

Education began on 6/27/2025 with all nursing staff on duty at all three of the facility's campuses (Campus 1, Campus 2, Campus 3) and would continue every shift until all nursing staff completed training. The topics included observing patients for unsafe behaviors such as eyeing the door and hovering around the door, consulting with the physician for enhanced monitoring, and calling a "Code Green" when a patient eloped to ensure all staff were notified and could assist with locating and/or retrieving the patient prior to exiting the campus.

Findings:

During a review of Patient 2's "Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves])," dated 6/9/2025, the 5150 hold paperwork indicated Patient 2 was detained for being a danger to others due to lighting objects on fire while assaulting his (Patient 2) parents.

During a review of Patient 2's "Face Sheet (front page of the chart that contains a summary of basic information about the patient)," not dated, the Face Sheet indicated Patient 1 was admitted to the facility's behavioral health service (treatment for mental health conditions and behaviors that impact overall well-being, including emotional, psychological, and social aspects) on 6/10/2025.

During a review of Patient 2's "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment)- (5250 hold paperwork, a regulation in the state of California that allows designated professionals to extend a 72-hour hold into 14 days if an individual is deemed a danger to themselves or others, or is gravely disabled due to a mental health condition)," dated 6/11/2025, the 5250 hold paperwork indicated Patient 2's involuntary legal hold was extended due to being a danger to others and being gravely disabled.

During a review of Patient 2's "Progress Note," dated 6/11/2025 at 1:57 p.m., the Progress Note indicated Patient 2 was agitated (being upset, annoyed, angry, and physically disturbed), irritable, making "attempts to go AWOL (Absent Without Leave, leaving the facility without authorization)," and verbalizing a desire to leave.

During a review of Patient 2's "Behavioral Health Acuity (the severity or intensity of a patient's health condition) Assessment," dated 6/11/2025 at 2:00 p.m., the Assessment indicated Patient 2 was placed on elopement precautions (strategies or protocols to prevent patients from leaving a health care facility without authorization).

During a review of Patient 2's "Individual Observations" flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 6/11/2025 to 6/12/2025, the flowsheet indicated Patient 2 was asleep and in his (Patient 2) room from 10:14 p.m. to 1:30 a.m.

During a review of Patient 2's "Progress Note," dated 6/12/2025 at 6:42 a.m., the Progress Note indicated, "At approximately [1:40 a.m.], [Patient 2] came out of the room wrapped with the blanket, to the nurse station responding to internal stimuli, pacing around the unit making nonsensical statement, disorganized and guarded, and continue talking to self. [Patient 2] was pacing around the back of the unit and suddenly [Behavioral Health Worker] called for help. [Patient 2] already make advance toward the exit door, ran left across the office and exit to the side door to [the street]. Staff unable to pursue the patient on the street. Police were called to report the incident."

During a concurrent observation and interview on 6/24/2025 at 11:13 a.m. with the Director (DIR 1) of the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at the facility's offsite campus (Campus 2), the double doors leading to Unit 2 on Campus 2, were observed. There was a keypad on the wall to the right side of the double doors; DIR 1 entered a code to unlock the doors. DIR 1 stated these doors had a lock that was magnetized for up to 1200 pounds.

During an interview on 6/24/2025 at 3:07 p.m. with the Quality Coordinator (QC), the QC stated that on 6/12/2025 after midnight, Patient 2 was agitated and pacing the hall of Unit 2. Two staff, Charge Nurse (CN, the lead Registered Nurse on a shift) 4 and Behavioral Health Worker (BHW) 7 attempted to redirect Patient 2 away from the doors exiting out of Unit 2 (fire double doors without an alarm which should be opened only with a code). While CN 4 went to get more help, Patient 2 charged through the fire double doors of Unit 2. The doors were equipped with a magnetic lock rated for 1200 pounds (the amount of force necessary to force the lock open). The QC stated that instead of calling a "Code Green (a hospital-wide call for help when a patient elopes)," the staff decided to follow Patient 2 to try and stop him (Patient 2). DIR 1 stated that Patient 2 escaped onto the street and staff called the police. The facility did not know what happened to Patient 2 after he eloped.

During a concurrent observation and interview on 6/24/2025 at 3:09 p.m. with the QC, the QC demonstrated the path Patient 2 took to escape the facility. After exiting Unit 2, which had a fire door that should have been opened only with a code, Patient 2 made a right into the Partial Hospitalization Program (PHP, an intensive form of outpatient mental health treatment that offers a structured therapeutic environment during the day while allowing patients to return home in the evenings) unit, which was unlocked. Inside the PHP unit, to the right, there was an exit door onto the street.

During a concurrent observation and interview on 6/25/2025 at 9:26 a.m. with the QC, the Nurse Manager of Campus 2's BHU (NM 1), and the Associate Administrator (AA), the surveillance footage from 5/23/2025, was reviewed. The security camera was pointed at the double doors of Unit 2. The following events were observed at the indicated timestamps in the video:

1. 1:42 a.m.: The doors (Unit 2's doors) were shown with nobody present, including staff. Patient 2 then appeared on camera and walked toward the double doors. The QC confirmed that this was Patient 2. NM 1 stated that prior to this clip, Charge Nurse (CN) 4 was trying to talk to Patient 2 and left to get support.
2. 1:43:05 a.m.: Patient 2 attempted to open the door (unit 2's doors) twice by pressing on the push bar using his right shoulder and back.
3. 1:43:14 a.m.: Patient 2 was standing by the door (Unit 2's doors). BHW 7 approached Patient 2 from off-camera, talking to him.
4. 1:43:15 a.m.: Patient 2 used his shoulder and back to open the door (Unit 2's doors); Patient 2 exited the unit (Unit 2). BHW 7 followed Patient 2 out of the doors. The AA stated there was no alarm when that door opened.
5. 1:43:47 a.m.: Multiple staff followed Patient 2 and BHW 7 out of the doors.

During an interview on 6/25/2025 at 2:16 p.m. with the Lead Maintenance Worker (LMW), the LMW stated that the doors in the BHU were equipped with a magnetic lock rated for 1200 pounds of force, which was required to force open the magnet lock. All the doors on Campus 2 were previously upgraded on 9/11/2024 from 600 pounds to 1200 pounds due to an elopement. The LMW stated he did not think it was possible for someone to apply 1200 pounds of force to open that door.

During an interview on 6/26/2025 at 9:45 a.m. with DIR 1, DIR 1 stated elopement precautions or specific interventions (strategies and actions implemented by nurses and other healthcare staff to achieve a goal) that staff should take when a patient was on elopement precautions were not listed in any of the facility's policies or procedures. DIR 1 further stated, "It [elopement precautions] just means to be 'on high alert.'"

During an interview on 6/26/2025 at 10:38 a.m. with the Associate Administrator (AA), the AA stated it was never acceptable for a patient to elope from the unit.

During a concurrent interview and record review on 6/26/2025 at 11:51 a.m. with the AA and QC, a report from the outside vendor that supplied the door, dated 6/26/2025, was reviewed. The report indicated, "It was found that the exit device's concealed vertical rod was intermittently failing to fully latch. The issue prevented the maglock from properly securing the door. ... It is recommended to implement a quarterly preventative maintenance schedule to ensure continued reliable operation of the door hardware." The AA and QC confirmed that the Unit 2 doors were broken.

During an interview on 6/26/2025 at 3:36 p.m. with the Nurse Manager of Campus 2's BHU (NM 1), NM 1 stated that BHU staff were provided a whistle to use to call for help without leaving the patient. NM 1 confirmed the whistle was not used when Patient 2 was attempting to elope.

During an interview on 6/27/2025 at 7:22 p.m. with the Director of Performance Improvement and Quality (DQM), the DQM confirmed that there was no procedure in place at the time of the incident to regularly check the magnetic lock and door latch. The DQM also confirmed that in 2024, the magnetic locks on all the doors in Campus 2 were upgraded from a 600-pound rating to a 1200-pound rating due to an elopement as the patient at that time was able to open the door despite it being locked.

During a review of the facility's policy and procedure (P&P) titled, "Security of the Unit," last reviewed 10/2021, the P&P indicated, "It is the policy of the Behavioral Health Unit to operate as a locked unit, in order to maintain safety and security of the treatment environment."

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

1. Ensure its nursing staff protected one (1) of 30 sampled patients (Patient 1) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury), when staff failed to provide an appropriate physical response to an agitated (being upset, annoyed, angry, and physically disturbed) patient (Patient 1), in accordance with the facility's policy & procedure (P&P) regarding Patient Rights (a set of legal and ethical principles that protect and empower patients in healthcare settings. These rights ensure that patients receive safe, quality care while respecting their autonomy and dignity).

This deficient practice resulted in Patient 1 sustaining (suffering) a 1.5-inch-long laceration (a deep cut or tear in skin or flesh) on the head that required staples (using metal staples to close a cut or tear).

2. Protect one of 30 sampled patients (Patient 10) from abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) and respond to an alleged physical abuse in a timely manner, in accordance with the facility's policy regarding "Patient Rights" and "Employee to Patient physical abuse," when the Behavioral Health Worker (BHW 10) put hands on Patient 10 inappropriately, and pushed Patient 10 in the room. The Registered Nurse (RN 5) also failed to assess Patient 10's left eyebrow wound and escalate the alleged abuse to the charge nurse and the house supervisor and notify the attending physician, after Patient 10 reported the alleged abuse on 4/20/2025.

This deficient practice resulted in Patient 10 sustaining a left eyebrow wound and delay in treatment and care due to a delay in notifying the physician. This deficient practice also resulted in BHW 10 not being removed from the facility immediately, thus putting Patient 10 and other patients at risk for further abuse.

On 6/25/2025 at 5:12 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Director of Performance Improvement and Quality (DQM), Associate Administrator (AA), Nurse Manager (NM 1) of the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at the facility's offsite campus (Campus 2), and Quality Coordinator (QC). The facility failed to ensure its nursing staff protected psychiatric patients (someone receiving treatment or care for a mental health disorder or illness) from physical abuse (intentional maltreatment of an individual that may cause physical or psychological injury) when staff failed to provide an appropriate physical response to an agitated (being upset, annoyed, angry and physically disturbed) patient (Patient 1). This led to Patient 1 sustaining (suffering) a 1.5-inch-long laceration (a deep cut or tear in skin or flesh) on the head that required staples (using metal staples to close a cut or tear).

On 6/24/2025 at 3:17 p.m., the Quality Coordinator (QC) stated that on 5/23/2025, Patient 1 was discovered on the floor in her (Patient 1) room bleeding from her head. 911 was called and Patient 1 was taken to an outside hospital to have her head wound treated. On 6/24/2025 at 3:27 p.m., the Director of the BHU at Campus 2 (DIR 1) stated that the staff thought Patient 1 was self-harming until DIR 1 received an anonymous text message on 5/24/2025 indicating that Patient 1 had been pushed. Patient 1 was alone in her room with Behavioral Health Worker (BHW) 1, who was witnessed coming out of Patient 1's room and calling for help. DIR 1 stated they determined that BHW 1 most likely pushed her (Patient 1). On 6/25/2025 at 11:25 a.m., the QC stated that BHW 1 was agitated in the surveillance footage, that BHW 1 was uncooperative during the facility's internal investigation, and that there were also inconsistencies in BHW 1's story, specifically that Patient 1 suffered a single laceration which was not consistent with the report that she (Patient 1) had been banging her head. BHW 1's Personnel Action Report indicated that BHW 1's employment at the facility was terminated involuntarily on 6/2/2025 for the reason "patient abuse."

On 6/27/2025 at 11:10 p.m., the IJ was removed in the presence of the CEO via telephone, DQM, AA, QC, and DIR 1. The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that for immediate action taken by the facility, the alleged staff member was suspended on 5/24/2025 and terminated on 6/2/2025.

Education began on 6/27/2025 with all nursing staff on duty at all three of the facility's campuses (Campus 1, Campus 2, Campus 3) and would continue every shift until all nursing staff completed training. The topics included de-escalation (the methods and actions taken to decrease the severity of a conflict, whether of physical, verbal or another nature) techniques, appropriate patient approach, skills such as safe restraining, calming techniques, and notifying other staff, post-event staff responsibilities, and the rights of mental health patients.

The IJ Removal Plan also included distributing the annual de-escalation training schedule to all nursing staff to ensure training was completed timely as well as random daily leadership rounds to verify staff were engaging with patients in a respectful and therapeutic manner, following established policies and procedures, and maintaining appropriate boundaries.

Findings:

1. During a review of Patient 1's "Face Sheet (front page of the chart that contains a summary of basic information about the patient)," not dated, the Face Sheet indicated Patient 1 was admitted to the facility's behavioral health service (treatment for mental health conditions and behaviors that impact overall well-being, including emotional, psychological, and social aspects) on 5/20/2025.

During a review of Patient 1's "Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment- (5150 hold paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves])," dated 5/20/2025, the 5150 hold paperwork indicated Patient 1 was detained for being a danger to herself and gravely disabled due to appearing paranoid (intense and irrational distrust and suspicion of others), internally preoccupied (focusing on things they are thinking or hearing inside their head instead of engaging with the world around them), not talking, and spitting.

During a review of Patient 1's "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment)- (5250 hold paperwork, a regulation in the state of California that allows designated professionals to extend a 72-hour hold into 14 days if an individual is deemed a danger to themselves or others, or is gravely disabled due to a mental health condition)," dated 5/21/2025, the 5250 hold paperwork indicated Patient 1's involuntary legal hold was extended due to being a danger to herself and being gravely disabled.

During a review of Patient 1's "Progress Note," dated 5/23/2025 at 2:11 p.m., the Progress Note indicated, "[At 11:40 a.m.], [Patient 1 was] throwing soiled diaper at staff and being aggressive towards staff ... [At 11:45 a.m.], [Patient 1 was] found on floor bleeding from head with cut slash on back of head [approximately] 4 inches long. [Patient 1 was] found attempting to throw blood on staff ... Walked [Patient 1] to seclusion room to assess patient, meanwhile 911 was called."

During an interview on 6/24/2025 at 3:17 p.m. with the Quality Coordinator (QC), the QC stated that on 5/23/2025, Patient 1 was discovered on the floor in her (Patient 1) room bleeding from her head. The QC stated that it was reported she (Patient 1) was banging her head. She (Patient 1) was unable to be assessed in her room due to throwing blood at the staff, so she was walked to the seclusion (the involuntary confinement of a patient alone in a room or area, preventing them from leaving, to manage violent or self-destructive behavior) room and assessed. 911 was called and Patient 1 was taken to an outside general acute care hospital (GACH, a type of hospital that provides short-term, inpatient medical and surgical care for acute [sudden or severe] health conditions) to have her head wound treated.

During an interview on 6/24/2025 at 3:27 p.m. with the Director of the BHU at Campus 2 (DIR 1), DIR 1 stated that the staff thought Patient 1 was self-harming (hurting herself) until DIR 1 received an anonymous text message on 5/24/2025 indicating that Patient 1 had been pushed. DIR 1 stated Patient 1 was alone in her (Patient 1) room with Behavioral Health Worker (BHW) 1, who was witnessed coming out of Patient 1's room and calling for help. DIR 1 further stated they (facility administrative staff involved in the incident investigation) determined that BHW 1 most likely pushed her (Patient 1).

During a concurrent observation and interview on 6/25/2025 at 10:04 a.m. with the QC, the Nurse Manager of the Campus 2 (NM 1), and the Associate Administrator (AA), the video surveillance footage from 5/23/2025 was reviewed. The following events were observed at the indicated timestamps in the video:

1. 11:47 a.m.: BHW 1 was seen entering the hallway in Unit 1, speaking to a patient off-camera. BHW 1's body language indicated that she (BHW 1) was upset or agitated. QC confirmed this was BHW 1.
2. 11:48 a.m.: BHW 1 stood outside of Patient 1's room, looking inside. QC confirmed that was Patient 1's room.
3. 11:51 a.m.: BHW 1 appeared to be hit by something from inside Patient 1's room. BHW 1 then entered Patient 1's room.
4. 11:52 a.m.: BHW 2 entered Patient 1's room. BHW 2 then left the room with BHW 1 and both moved off-camera. BHW 1 then returned to Patient 1's room.
5. 11:53 a.m.: Multiple staff entered Patient 1's room.
6. 11:55 a.m.: Patient 1 was escorted out of her room with three different staff. There was blood on Patient 1's gown and one staff was holding a towel to the back of Patient 1's head.

During an interview on 6/25/2025 at 11:25 a.m. with the QC, the QC stated that BHW 1 was agitated in the surveillance footage, that BHW 1 was uncooperative during the facility's internal investigation, and that there were also inconsistencies in BHW 1's story, specifically that Patient 1 suffered a single laceration which was not consistent with the report that she (Patient 1) had been "banging her head."

During an interview on 6/25/2025 at 3:38 p.m. with the Behavioral Health Worker (BHW) 2, BHW 2 stated that on 5/23/2025, Patient 1 threw a diaper in the hallway. BHW 1 went to Patient 1's room and said something to her (Patient 1) that BHW 2 did not hear. BHW 1 then went to the nurses' station, then back to Patient 1's room; BHW 2 saw BHW 1 go inside (Patient 1's room) and went in behind her (BHW 1). Upon entering, BHW 2 saw Patient 1 on the ground and holding her (Patient 1) head, so BHW 2 blew her whistle which alerted the staff. BHW 2 asked BHW 1 what happened; she (BHW 2) stated BHW 1 told her (BHW 2) that Patient 1 "banged her head."

During a concurrent interview and record review on 6/25/2025 at 4:04 p.m. with the QC, the staffing assignment for 5/24/2025, was reviewed. The assignment indicated BHW 1 was scheduled to work the day after the incident with Patient 1. The QC stated Patient 1 returned to the facility from the outside GACH early in the morning on 5/24/2025; BHW 1 did not report to work that day to seek medical care for injuries sustained during the incident, and then once DIR 1 received the anonymous text, BHW 1 was placed on suspension later that day.

During a review of Patient 1's "Progress Note," dated 5/23/2025 at 6:45 p.m., the Progress Note indicated Patient 1's CT (computed tomography, a procedure that uses X-ray techniques to create detailed images of the body) of the head at the outside GACH was negative, and that staples were applied on the head laceration that was approximately 1.5 inches long.

During a review of BHW 1's "Personnel Action Report (PAR)," dated 6/2/2025, the PAR indicated BHW 1's employment at the facility was terminated involuntarily on 6/2/2025 for the reason "patient abuse."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights," last reviewed 8/2022, the P&P indicated, "It is the policy of the Behavioral Health Unit to maintain and protect patients' fundamental human, civil, constitutional and statutory rights in accordance with federal and California laws ... In addition, LPS (the Lanterman-Petris-Short Act, a California law regulating involuntary mental health holds) grants all patients these irrevocable rights: ... 4. To be free from harm ... 18. To be free from verbal and physical abuse."

2. During a review of Patient 10'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 4/16/2025, the Psych Eval indicated, Patient 10 was a 77-year-old 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) with diagnosis including but not limited to schizoaffective disorder (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]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a concurrent observation and interview on 6/26/2025 at 9:37 a.m. with the Director of Performance Improvement/Quality (DQM), the facility's security video footage dated 4/20/2025, was reviewed. The security video indicated the following:

-At 11:26 p.m.: Patient 10 was seen standing by the doorway of his (Patient 10's) room holding a pair of green pants;
-At 11:27 p.m.: a Behavioral Health Worker (BHW 10) was seen walking towards Patient 10 and handed Patient 10 a diaper. Patient 10 and BHW 10 exchanged some conversation;
-At 11:27:25 p.m.: BHW 10 put hands on Patient 10's left shoulder area and right arm and pushed Patient 10 into the room. Both BHW 10 and Patient 10 went into the room;
-At 11:27:41 p.m.: BHW 11 was seen walking down the hallway and looked into Patient 10's room but did not go inside;
-At 11:27:49 p.m.: BHW 10 came out of Patient 10's room;
-At 11:27:56 p.m.: Patient 10 walked to the doorway and pointed at his (Patient 10) left eye to BHW 11

During the same interview on 6/26/2025 at 9:37 a.m. with the Director of Performance Improvement/Quality (DQM), DQM confirmed the Patient 10, BHW 10 and BHW 11 identities in the video surveillance footage. DQM also stated the following: what BHW 10 did (putting hands on Patient 10 and the act of pushing Patient 10 into the room) was inappropriate. Patient 10 was not aggressive. The hands on (Patient 10) was not necessary.

During a review of Patient 10's "Progress Note Non-Physician (nursing progress notes)," dated 4/20/2025, the "Progress Note Non-Physician," indicated, at 3:17 a.m., Patient 10 went to nursing station with bleeding at corner of (Patient 10's) left eyebrow, Patient 10 informed Registered Nurse (RN) 5 that "I got my pants wet and requested for another pair. The BHW (Behavioral Health Worker 10) put his hand on me, held me tight on my neck, and pushed me back from the door of my room to my bed. I hit myself somewhere, not sure if it was on my bed or on the wall. I had a scar on my left eyebrow since I was 9 years old. I started bleeding where the scar is." The "Progress Note Non-Physician," also indicated RN 5 spoke with BHW 10 with BHW 10 stating, "This guy came talking shit to me. He put his hand on me and I tried to defend on myself by pulling my arm away from him and he (Patient 10) lost his balance."

During an interview on 6/26/2025 at 9:44 a.m. with DQM, the DQM stated the following: Patient 10 accused BHW 10 of having caused the injury. It would be considered as an alleged physical abuse. Patient 10's primary nurse (RN 5) did not escalate the reported alleged physical abuse to the charge nurse or the house supervisor that night. BHW 10 should have been removed immediately (from patient care) after the alleged abuse for the safety of the patient. However, BHW 10 stayed and worked throughout the remainders of the shift. The incident was discovered the next day.

During an interview on 6/26/2025 at 11:32 a.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated RN 5 was terminated because RN 5 did not assess Patient 10's wound (left eyebrow) when it was reported, did not call the physician for Patient 10's change of condition, did not escalate the incident to charge nurse or house supervisor, and did not offer Patient 10 the opportunity to file a police report. NM 2 further stated BHW 10 was also terminated because BHW 10 had placed hands on Patient 10, causing Patient 10 to slip and got hurt.

During an interview on 6/27/2025 at 9:48 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3, DIR 3 stated the following: BHW 11 heard yelling and went to the room (Patient 10's room) that day. He (BHW 11) noted there was a cut on Patient 10's (left eyebrow), but he (BHW 11) thought BHW 10 told the nurse already, so he (BHW 11) did not report. DIR 3 stated education was given to BHW 11 about "see something say something."

During a review of RN 5's "Personnel Action Report," dated 4/24/2025, the "Personnel Action Report" indicated reason for termination as "involuntary - neglect of patient care," with effective date on 4/24/2025.

During an interview on 6/27/2025 at 4:45 p.m. with the Director of Infection Control (DIR) 4, DIR 4 stated BHW 10 was terminated by the facility on 4/24/2025.

During an interview on 6/27/2026 at 10:55 p.m. with the Charge Nurse (CN) 5 of BHU, CN 5 stated when the alleged abuse involved a staff member, the staff member should be sent home right away to ensure patient safety. CN 5 stated if the alleged staff member was not sent home, he or she might hurt other patients, putting other patients at risk for injury.

During a review of the facility's policy and procedure (P&P) titled, "Employee to Patient Physical Abuse," dated 8/2024, the P&P indicated, "It is an expectation that [the facility] will provide high quality patient care, in a compassionate manner and in a safe environment. Any employee who mistreats a patient, either verbally or physically, or witnesses any abuse or mistreatment of a patient and who failed to promptly report the incident to their immediate supervisor will be subject to appropriate disciplinary action ...Definitions: physical abuse: the use of physical force resulting in pain, discomfort or injury, including slapping, hitting burning, rough handling ... Investigation Process: A. The Charge Nurse will initiate investigation and when allegations include descriptions of the physical environment or if an investigation of the physical environment may provide useful information to an investigation to an investigator the Charge Nurse shall preserve the scene ...D. The Director of the BHU will notify the accused employee that he/she is subject to an abuse investigation and place that individual(s) on administrative leave immediately until the investigation is completed."

During a review of the facility's policy and procedure (P&P) titled, "Patient to Patient Physical Abuse," dated 8/2024, the P&P indicated, "Policy: Staff shall take seriously all statements from patients claiming to be victims of physical abuse and respond supportively and non-judgmentally ... Procedure ... A. Attend to the immediate first aid needs of victim; including psychological/ emotional support. B. Any patient who alleges that he or she has been physical abuse shall be offered immediate protection from the assailant and referred for a medical examination and/or a clinical assessment of the potential for negative symptoms. C. Patient have the right to call the Police. D. Immediate notification to the following: 1. Charge Nurse 2. Director of BHU or designee 3. Security (if needed) 4. Police (if applicable) 5. Medical Physician 6. Quality/Risk Management designee 7. Family - if the patient provided consent to do so."

During a review of the facility's policy and procedure (P&P) titled, "Adult & Elder Abuse," dated 10/2021, the P&P indicated, "To establish policy for BHU employees that are mandated reporters to ensure that elder abuse is reported in accordance with current law ... It is the responsibility of all health care professionals at [the facility] to report any suspected incidents of Dependent Adult/Elder Neglect and Abuse ... Definitions: A. Elder: Any person 65 years of age or older."

During a review of the facility's policy and procedure (P&P) titled, "Patients' Rights," dated 8/2022, the P&P indicated, "It is the policy of the Behavioral Health Unit to maintain and protect patients' fundamental human, civil, constitutional and statutory rights in accordance with federal and [state] laws ... Procedure ... LPS grants all patients these irrevocable rights ... 4. To be free from harm, including unnecessary or excessive physical restraint, isolation, medication abuse or neglect."

During a review of the facility's policy and procedure (P&P) titled, "Physician Notification," dated 10/2024, the P&P indicated, "the attending physician will be notified regarding patient issue in a timely manner ... the primary attending physician will immediately be notified of patient's change in condition."

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

1. Ensure nursing staff obtained a physician order, in accordance with the facility's policy regarding "Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and Restraints," for one of 30 sampled patients (Patient 9), when nursing staff performed physical 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) by putting hands on Patient 9 and placed Patient 9 in locked seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) on 6/20/2025.

This deficient practice resulted in Patient 9 being physically restrained by BHU staff and placed on locked seclusion without a physician order which led to violation of Patient 9's rights to be free from restraint/seclusion. This deficient practice also had the potential to result in unnecessary restraint/seclusion including the risk of psychological harm for Patient 9.

2. Ensure the physician signed off on the telephone orders received for two of 30 sampled patients (Patient 22 and Patient 23) within 24 hours, when 4 point (both arms and legs) restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) were applied on Patient 22 and Patient 23, in accordance with the facility's policy regarding "Seclusion and Restraint."

This deficient practice had the potential to result in unnecessary restraints for Patient 22 and Patient 23, including the lack of appropriate monitoring and reassessment for further use of restraints including potential risks of restraints use such as skin breakdown (injury to the skin caused by prolonged pressure or friction [force]).

Findings:

1. During a review of Patient 9's "Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated 6/5/2025, the Psych Eval indicated, Patient 9 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) with diagnoses including but not limited to 5250-hold (allows an adult experiencing a mental health crisis to be involuntarily detained for maximum of 14 days 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 (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (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]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 9's "Progress Note Non-Physician (nursing progress notes)," dated 6/14/2025, the "Progress Note Non-Physician" indicated, "at 1830 (6:30 p.m.), BHW (behavioral health worker [BHW 5]) doing rounds (the process of regularly visiting patients to assess their condition) and heard a commotion in room (Patient 9's room shared with another patient [Patient 8]). BHW (BHW 5) witnessed Patient (Patient 9) sitting on top of roommate (Patient 8), hitting him (Patient 8) in the face ... Patient (Patient 9) was detained by BHW ... escorted to seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) room, two men assist for decrease stimulation."

During an interview on 6/24/2025 at 12:49 p.m. with the Charge Nurse (CN) 1 at BHU, CN 1 stated nurses needed to obtain a physician order when putting a patient in seclusion and/or 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).

During a concurrent observation and interview on 6/25/2025 at 10:44 a.m. with the Nurse Manager (NM) 2 of BHU, the facility's security video footage, dated 6/14/2025, was reviewed. The security video footage indicated, at 6:25 p.m., Patient 9 was walking with two BHWs, one BHW on each of Patient 9's side grabbing Patient 9's arm, from Patient 9's room to the hallway. NM 2 stated the two BHWs put hands on Patient 9 and took Patient 9 to the seclusion room.

During an interview on 6/25/2025 at 2:05 p.m. with the Behavioral Health Worker (BHW) 5, BHW 5 stated he (BHW 5) and another BHW took Patient 9 to the seclusion room after Patient 9 hit Patient 8 in the room (room shared by Patient 9 and Patient 8).

During a concurrent interview and record review on 6/26/2025 at 10:41 a.m. with NM 2, Patient 9's "physician orders," dated 6/14/2025, was reviewed. The physician order indicated there were no physician orders relating to seclusion and physical hold (any manual and physical method of holding a patient against patient's will that restricts freedom of movement or normal access to one's body) given on 6/14/2025. NM 2 stated it would be considered as physical restraints when the two BHWs were holding Patient 9's arm and walked him (Patient 9) to the seclusion room. NM 2 stated there was no order for the physical hold in Patient 9's medical record.

During a concurrent interview and record review on 6/27/2025 at 10:13 a.m. with the Director (DIR) 3 of BHU for Campus 1 and 3, Patient 9's "Individual Observation Record (15-min rounding record)," dated 6/14/2025, was reviewed. The "Individual Observation Record" indicated, Patient 9 was in "locked seclusion" from 6:53 p.m. to 9:18 p.m. (almost 2 hours 30 minutes). DIR 3 stated a physician order was required when placing a patient in locked seclusion.

During an interview on 6/27/2025 at 10:18 a.m. with NM 2, NM 2 stated the following: there was no physician order for locked seclusion on 6/14/2025. Patient 9 was placed in seclusion without a physician order. It was a violation of patients' rights.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 6/2023, the P&P indicated, "Policy ... The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient ... Procedure ... B. Types of Restraints and Orders 1. Safety a. 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 ... Seclusion: Seclusion refers to the involuntary confinement of a person alone in a room where the person is physically prevented from leaving ... Patient care for behavioral restraints: i. All orders for behavioral modification restraints/seclusion shall be dated and times and shall include: ii. Type of restraint iii. The behavior necessitating the use of restraint/seclusion iv. Length of time the restraint/seclusion may be utilized ... 3. Orders a. Only a physician or Registered Nurse may write a restraints order. In clear case of emergency, the RN may authorize the use of restraints and obtain a telephone order from physician within one hour of application of restraints."

2. During a review of Patient 22's medical record titled, "History and Physical Exam (H&P, a formal and complete assessment of the patient and the problem)," dated 6/13/2025, the H&P indicated Patient 22 was admitted for chief complaint of status post (after) fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) with dizziness.

During a review of Patient 22's medical record titled, "Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 6/13/2025, the psychiatric eval indicated Patient 22 was brought in from medical floor on a 5250 hold (an involuntary psychiatric hold that extends beyond the initial 72 hour hold in California) for grave disability (someone is unable to provide for their basic personal needs due to a mental disorder) and danger to self (a person is not able to care for him/herself or likely to inadvertently place him/herself in a position of danger).

During a concurrent interview and record review on 6/25/2025 at 3:48 p.m. with the House Supervisor (HS) 1, Patient 22's "Orders," dated 6/16/2025, was reviewed. The orders indicated Patient 22 had a physician's telephone order for 4-point restraints (both arms and legs), to be used for 4 hours, keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraints use for being a danger to others, ordered on 6/16/2025 at 9:06 a.m. The HS 1 stated Patient 22's restraint telephone order was not signed off by the ordering physician within 24 hours (6/17/25 at 9:06 a.m.) and had no follow up documented.

During the same interview on 6/25/2025 at 3:48 p.m. with HS 1, HS 1 stated telephone orders should have been signed off by the physician and it was important for physicians to sign off telephone orders to verify/confirm they had given the orders.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraints," reviewed in 6/2023, the P&P indicated, "Only a physician or Registered Nurse may write a restraints order. In clear case of emergency, the RN may authorize the use of restraints and obtain a telephone order from physician within one hour (1 hour for behavioral restraint) of application of restraints. The physician must authenticate order within 24 hours of implementation."

During a review of the facility's Medical Staff Bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), dated November 2023, the Medical Staff Bylaws indicated, "Basic responsibilities of medical staff membership ...preparing and completing in timely and accurate manner, the medical records for all the patients to whom they provide care in the hospital including compliance with electronic health (EHR) policies and protocols."

3. During a review of Patient 23's medical record titled, "History and Physical (H&P)," dated 5/9/2025, the H&P indicated Patient 23 was admitted for chief complaint, "Patient endorses suicidal ideation (thoughts of taking one's own life)."

During a concurrent interview and record review on 6/26/2025 at 10:00 a.m. with the House Supervisor (HS) 2, Patient 23's telephone "Orders," dated 5/12/2025, was reviewed. The HS 2 stated Patient 23's telephone "Orders" was given on 5/12/2025 at 1:32 p.m. for 4-point restraints, for 4 hours duration, use of keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraints for being a danger to others. However, the telephone order was not signed off by the ordering physician.

During the same interview on 6/26/2025 at 10:00 a.m. with the House Supervisor (HS) 2, the HS 2 stated it was important for the physician to cosign (sign jointly with another or others) or sign off the telephone order to know patient was on restraint, to follow up with patient afterwards, adjust plan of care, verify the fact that restraint orders was placed and a validation of physician order.

During a review of the facility's policy and procedures (P&P) titled, "Seclusion and Restraints," reviewed in 6/2023, the P&P indicated, "Only a physician or Registered Nurse may write a restraints order. In clear case of emergency, the RN may authorize the use of restraints and obtain a telephone order from physician within one hour (1 hour for behavioral restraint) of application of restraints. The physician must authenticate order within 24 hours of implementation."

During a review of the facility's Medical Staff Bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), dated November 2023, the Medical Staff Bylaws indicated, " Basic responsibilities of medical staff membership ...preparing and completing in timely and accurate manner, the medical records for all the patients to whom they provide care in the hospital including compliance with electronic health (EHR) policies and protocols."

Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled patient's (Patient 22) 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) monitoring was conducted every 15 minutes, in accordance with the facility's policy and procedure regarding "Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and Restraint," when Registered Nurse (RN) 6 placed (Patient 22) on 4 point (both ankles and wrist) restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) and Patient 22 was administered Thorazine (medication used to treat mental health condition and regulates a patient's mood) 100 milligrams (mg, a unit of measurement) and Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect) 50 mg via intramuscular (IM, into the muscles), while on 4 point restraints.

This deficient practice had the potential for inadequate oversight/monitoring of Patient 22's response to the use of restraints, which can lead to complications such as poor circulation (a medical condition where blood flow to parts of the body is reduced or inadequate), injury and/or death.

Findings:

During a review of Patient 22's medical record titled, "History and Physical Exam (H&P, a formal and complete assessment of the patient and the problem)," dated 6/13/2025, the H&P indicated Patient 22 was admitted for chief of complaint of status post (after or following) fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) with dizziness.

During a review of Patient 22's medical record titled, "Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 6/13/2025, the psychiatric evaluation indicated Patient 22 was brought in from medical floor on a 5250 hold (an involuntary psychiatric hold that extends beyond the initial 72 hour hold in California) for grave disability (someone is unable to provide for their basic personal needs due to a mental disorder) and danger to self.

During an observation and interview on 6/24/2025 at 11:51 a.m. with the Director of Behavioral Unit (DIR) 1 in Campus 2 Unit 2 seclusion (involuntary confinement of a person alone in a room where the person is physically prevented from leaving) room, there was a bed and a camera inside. DIR 1 stated seclusion room criteria included a patient on 4-point restraint, and someone will stay in the room with the patient.

During a concurrent observation and interview on 6/24/2025 at 12:19 p.m. with DIR 1 in Campus 2 Unit 1, there was a female staff sitting outside the room of Patient 22. DIR 1 stated Patient 22 had a 1:1 sitter (is a caregiver who provides direct observation and support to a patient).

During a concurrent interview and record review on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22's telephone "Order" dated 6/16/2025, was reviewed. The HS 1 stated Patient 22 had a telephone order for 4-point restraints (both arms and legs) restraint, with 4 hours duration, and use of keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraints for being a danger to others. HS 1 further stated, keyed polyurethane restraints would be applied in the seclusion room.

During the same interview on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22's "Progress Notes Non-Physician" and "Medication Order," dated 6/16/2025, were reviewed. HS 1 stated, Patient 22's progress notes indicated Patient 22 was placed on 4-point restraints. HS 1 also stated Patient 22 received Thorazine (medication used to treat mental health condition and regulates a patient's mood) 100 milligrams (mg, a unit of measurement) and Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect) 50 mg via IM (intramuscular, into the muscles) route, on 6/16/2025 at 8:16 a.m.

During a concurrent observation, interview and record review on 6/26/2025 at 2:45 p.m. with the Associate Administrator (AA), in the conference room, the security footage from 6/16/2025, was reviewed. The following events were observed at the indicated timestamps in the video:
1. 7:53 a.m.: Staff brought Patient 22 to the seclusion room unrestrained at this time
2. 7:58 a.m.: Patient 22 was put on 4-point restraints applied to both ankles and wrists

During a concurrent observation, interview, and record review on 6/26/2025 at 3:07 p.m. with the AA, the DIR 1 and the Quality Coordinator (QC), in the conference room, the security footage from 6/16/2025, was reviewed. The following events were observed at the indicated timestamps in the video and confirmed by the AA, the Dir 1, and the QC:

1. 8:15 a.m.: Patient 22 received injection medications to right deltoid (triangular shoulder muscle) and to left buttocks
2. 8:18 a.m.: RN 6 (primary nurse) left the room
3. 8:26 a.m.-8:52 a.m. - Patient 22 was observed alone in the room with no staff
4. 8:53 a.m. RN 6 entered the room and quickly stepped out of the room

During an interview on 6/27/2025 at 8:44 a.m. with Registered Nurse (RN) 7, the RN 7 stated that for restraint monitoring conducted every 15 minutes, the RN would check for circulation (the continuous movement of blood though-out the body) by physically checking the pulse, ensuring restraint was not too tight cutting circulation, and check skin discolorations (a change in the original color). RN 7 said it was important to check patients on restraints as change of condition could happen especially when they (the patients) were on medications as well.

During a concurrent observation, interview, and record review on 6/27/2025 at 9:02 a.m. with the AA, the DIR 1 and the Quality Coordinator (QC), in the conference room, the security footage from 6/16/2025, was reviewed. The following events were observed at the indicated timestamps in the video and confirmed by the AA, the Dir 1, and the QC:

1. 8:53:57 RN 6 entered the room and walked out of the room at 8:54:00 (3 seconds)
2. 8:54-9:25 a.m. Patient alone in the room, no staff present
3. 9:26:23 -Behavior Mental Worker step in and out of the room
4. 9:28:50-9:29:26 a.m.: RN 6 went near the Patient 22 and just looked at her.
5. 9:30 -10:13:24 a.m.: RN 6 entered the room, approached the patient and appeared to be talking with Patient 22.
6. 10:14:10: RN 6 still in the room, started to unlock and to remove the keyed polyurethane restraint on Patient 22's ankles and wrists. Subsequently, other facility staff entered the room

During the same interview on 6/27/2025 at 9:02 a.m. with DIR 1, DIR 1 stated a more thorough assessment could have been done for Patient 22 to address safety concerns, that an adverse event (an undesirable medical occurrence associated with the use of a drug or treatment) can occur for patients on 4-point restraints and being medicated, and circulation can be compromised. DIR 1 acknowledged RN 6 was seen with Patient 22 at 8:53 a.m., 9:28 a.m. and 10:13 a.m. DIR 1 also acknowledged the time gaps (a period of time between two events or moments) Patient 22 was not monitored while being restrained in the seclusion room.

During the same concurrent interview and record review on 6/27/2025 at 9:02 a.m. with DIR 1, Patient 22's "Progress Note Non-Physician," dated 6/16/2025, was reviewed. DIR 1 stated Patient 22's progress notes did not reflect what was done (referring to the monitoring) for the patient according to the video footage observed (gaps in monitoring instead of the standard every 15-minute monitoring frequency) and that the expectation would be the documentation should match what staff were doing for the patient.

During a review of facility's policy and procedure (P&P) titled, "Seclusion and Restraint," reviewed in 6/2023, the P&P indicated, "Patients in behavioral modification restraint shall be monitored continually by staff on face to face basis at arms length for duration of seclusion, when audiovisuals are not available ...Patient in seclusion only shall be monitored continually by staff on face to face basis for the first hour. This is followed by observation at intervals not greater than every fifteen (15) minutes and continuous monitoring visual equipment in close proximity to the patient ...The flow sheet will include type of restraint, LOC and circulation checks every 15 minutes ..."

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 three of 30 sampled patients (Patients 8, 9 and 20), in accordance with the federal regulations regarding physician notification after the completion of the face-to-face evaluation.

This deficient practice had the potential to result in Patients 8, 9 and 20 not receiving evaluation from physicians to determine appropriate treatment and care and also had the potential for unnecessary seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and 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) use.

Findings:

1. 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 4/16/2025, the Psych Eval indicated, Patient 8 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) with diagnosis including but not limited to schizoaffective disorder (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]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 8's "Order Information for: Restraints (physician order)," dated 6/10/2025, the "Order Information for: Restraints" indicated keyed (a special key is needed to unlock the restraint device) polyurethane (a type of polymers [man-made materials] that is durable and resistant to wear and tear) restraints was ordered on 6/10/2025 at 9:01 p.m. with reason for danger to self or others.

During an interview on 6/24/2025 at 12:45 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated nurse would perform a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour after initiation of seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and/or 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). CN 3 also stated there was no follow up call with the physician after the face-to-face assessment was completed unless there were any abnormal findings identified.

During an interview on 6/24/2025 at 12:56 p.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated nurses would only call physician if there was any issue identified during the face-to-face assessment.

During a concurrent interview and record review on 6/26/2025 at 10:44 a.m. with the Nurse Manager (NM) 2 of BHU, Patient 8's "Progress Notes Non-Physician (nursing progress notes)," dated 6/10/2025, was reviewed. The "Progress Notes Non-Physician" indicated, Patient 8 was placed on 4-point (both wrists and both ankles) restraints which started at 8:52 p.m., the Registered Nurse (RN) 11 performed face-to-face assessment at 9:30 p.m. The "Progress Notes Non-Physician" did not indicate any communication with physician after the face-to-face assessment. NM 2 stated RN 11 did not call physician after face-to-face assessment.

During a concurrent interview and record review on 6/27/2025 at 10:31 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and NM 2, the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 6/2023, was reviewed. The P&P indicated, "The physician must conduct a face-to-face assessment of the patient's need for restraints or seclusion within one hour after the initiation of the intervention ... 4. Evaluations, Documentations and Monitoring a. Behavioral Restraints i. A physician or other licensed independent practitioner must see (face to face) and evaluate the need for seclusion and restraints within one hour after the initiation of this intervention, the evaluation must be documented in the patient medical record." The P&P did not indicate any procedures relating to having a Registered Nurse to perform face to face assessment. DIR 3 stated the following: the facility's current practice allowed nurses to perform the face-to-face assessments for patients on seclusion and/or restraints. Current practice did not align with policy. DIR 3 confirmed the facility's P&P did not cover face-to-face assessment completed by nurses and did not give directions to nurses what to follow.

During a concurrent interview and record review on 6/27/2025 at 10:33 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and 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." DIR 3 and NM 2 both stated they (DIR 3 and NM 2) were not aware of this regulation. DIR 3 stated the current practice did not follow the regulations. DIR 3 also stated nurses should assess the patient, then call and inform the physician about the assessment so that the physician could determine and update the treatment plan for the patient.

2. During a review of Patient 9'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 6/5/2025, the Psych Eval indicated, Patient 9 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) with diagnoses including but not limited to 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days 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 (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 9's "Progress Note Non-Physician (nursing progress notes)," dated 6/14/2025, the "Progress Note Non-Physician" indicated, "at 1830 (6:30 p.m.), BHW (behavioral health worker [BHW 5]) doing rounds and heard a commotion in room (Patient room shared by patient 9 and Patient 8). BHW (BHW 5) witness Patient (Patient 9) sitting on top of roommate (Patient 8), hitting him (Patient 8) in the face ... Patient (Patient 9) was detained by BHW ... escorted to seclusion room, two men assist for decrease stimulation ... [physician] informed of patient status and ordered Benadryl (usually used for allergic reaction, can cause drowsiness) 50 milligrams (mg, unit of measure) IM (Intramuscular injection, delivering medication directly into the muscle tissue), Haldol (medication to treat schizophrenia [(mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] agitation [being upset, annoyed, angry and physically disturbed]) 5 mg IM, Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 2 mg IM STAT (as soon as possible). IM delivered as ordered."

During an interview on 6/24/2025 at 12:45 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated nurse would perform a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour after initiation of seclusion and/or restraints. CN 3 also stated there was no follow up call with the physician after the face-to-face assessment was completed unless there were any abnormal findings identified.

During an interview on 6/24/2025 at 12:56 p.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated nurses would only call physician if there was any issue identified during the face-to-face assessment.

During a concurrent interview and record review on 6/26/205 at 10:19 a.m. with NM 2, Patient 9's "Progress Note Non-Physician (nursing progress notes)," dated 6/14/2025, was reviewed. The "Progress Note Non-Physician" indicated, "Face to Face ... at 1930 (7:30 p.m.) Face to Face evaluation completed ... Patient (Patient 9) has even and unlabored breaths (normal, effortless breathing) and is calm during face-to-face evaluation ... Patient (Patient 9) is calm at this time." NM 2 stated the face-to-face assessment was performed by the Registered Nurse (RN) 9 and RN 9 did not need to call the physician after face-to-face assessment because there was no need.

During a concurrent interview and record review on 6/27/2025 at 10:20 a.m. with NM 2, Patient 9's Individual Observation Record (15-min rounding record)," dated 6/14/2025, was reviewed. The "Individual Observation Record" indicated, Patient 9 was in "locked seclusion" from 6:53 p.m. to 9:18 p.m. (almost 2 hours 30 minutes) with behavior described as "cooperative." The "Individual Observation Record" also indicated RN 10 documented Patient 9 was calm and cooperative at 8 p.m. NM 2 stated the seclusion should have been discontinued at earlier time because Patient 9 was calm and cooperative. NM 2 stated the seclusion was not necessary.

During a concurrent interview and record review on 6/27/2025 at 10:31 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and NM 2, the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 6/2023, was reviewed. The P&P indicated, "The physician must conduct a face-to-face assessment of the patient's need for restraints or seclusion within one hour after the initiation of the intervention ... 4. Evaluations, Documentations and Monitoring a. Behavioral Restraints i. A physician or other licensed independent practitioner must see (face to face) and evaluate the need for seclusion and restraints within one hour after the initiation of this intervention, the evaluation must be documented in the patient medical record." The P&P did not indicate any procedures relating to having a Registered Nurse to perform face to face assessment. DIR 3 stated the following: the facility's current practice allowed nurses to perform the face-to-face assessments for patients on seclusion and/or restraints. Current practice did not align with policy. DIR 3 confirmed the facility's P&P did not cover face-to-face assessment completed by nurses and did not give directions to nurses what to follow.

During a concurrent interview and record review on 6/27/2025 at 10:33 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and 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." DIR 3 and NM 2 both stated they (DIR 3 and NM 2) were not aware of this regulation. DIR 3 stated the current practice did not follow the regulations. DIR 3 also stated nurses should assess the patient, then call and inform the physician about the assessment so that the physician could determine and update the treatment plan for the patient.

3. During a review of Patient 20's "Psychiatric Evaluation (Psych Eval, a formal assessment of the patient done by a Psychiatrist [physician who specializes in mental health])," dated 6/17/2025, the Psych Eval indicated, Patient 20 was admitted to the facility on a 5150 hold (allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for being a danger to others. The Psych Eval also indicated Patient 20 was hearing voices and had a history of schizophrenia (mental illness affecting how someone behaves, feels, and thinks).

During an interview on 6/24/2025 at 11:40 a.m. with Licensed Vocational Nurse 2 (LVN) 2, LVN 2 stated Patient 20 was trying to hit staff in the day room (activity room), was given emergency medications and placed on 4 point restraints (physical device applied to the person's wrists and ankles to limit movement) in the seclusion room (involuntary [without permission] confinement of a patient alone in a room or area from which the patient is physically prevented from leaving).

During an interview on 6/24/2025 at 12:48 p.m. with Nurse Manager (NM) 2 and Charge Nurse (CN) 1, CN 1 stated when a patient was placed on restraints, the nurse would call the physician for a restraint order. CN 1 also stated the nurse sees the patient immediately after restraint application and will complete a "Face to Face" assessment within an hour. NM 2 stated the nurses were not required to call the physician after (completing the face-to-face assessment), unless there was something abnormal (unusual) with the patient.

During a review of Patient 20's "Progress Note Non-Physician (nursing progress note)," dated 6/24/2025, the progress note indicated, "At around 0830 (8:30) a.m., Patient (Patient 20) was knocking hard on the back door of the nursing station, the patient's 1:1 sitter (individual who stays with the patient as a safety precaution) redirected (guide an individual's thoughts and behavior to a different action) him (Patient 20) not to do it and patient (Patient 20) became aggressive (behavior that is forceful and potentially hostile or threatening) and doing a fist fight to the 1:1 sitter ...wanted to fight with the staff, doing a fist, approaching the staff, staff got hit on the face with the patient's fist ...ordered to place patient on seclusion and restraint (4-point restraints). Ordered, Haldol (medication used to treat schizophrenia [(mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] and agitation [being upset, annoyed, angry and physically disturbed]) 5 milligrams (mg- a unit of measure), Ativan (medication used for relaxation) 2 mg, Benadryl (medication used to cause sleepiness) 50 mg. Per pharmacy, out of stock for Ativan, replaced with Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 2 mg... order noted and carried out." Patient 20 was placed on 4-point restraints in the seclusion room and received intramuscular (IM, injection in the muscle) medications.

During a concurrent interview and record review on 6/26/2025 at 9:56 a.m. with CN 3, Patient 20's two "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)" orders, both dated 6/24/2025, were reviewed. Patient 20 had an order placed at 8:32 a.m. for "Emergency Medication Administration" for being a "Danger to others." Patient 20 also had a second order placed at 8:55 a.m. for the use of "Keyed Polyurethane (type of restraint that is applied to the person's wrists and ankles and uses a key and lock for application)" restraints for being a "Danger to others."

During a concurrent interview and record review on 6/26/2025 at 9:56 a.m. with CN 3, Patient 20's "Medication Administration Record (MAR)," dated 6/24/2025, was reviewed. The MAR indicated, on 6/24/2025 at 8:44 a.m. Patient 20 received Haldol (medication used to treat schizophrenia [(mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] and agitation [being upset, annoyed, angry and physically disturbed]) 5 milligrams (mg, a unit of measure) Intramuscular (IM, injection into the muscle), Benadryl (medication used to cause sleepiness) 50 mg IM and Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 2 mg.

During an interview on 6/26/2025 at 10:25 a.m. with CN 3, CN 3 stated if the patient was in the seclusion room or on restraints, the nurse did not have to call the doctor again unless there was a change in condition.

During an interview on 6/26/2025 at 10:42 a.m. with CN 3, CN 3 stated the physician did not document a "Face to Face" assessment after Patient 20 was placed on 4-point restraints in the seclusion room on 6/24/2025.

During a concurrent interview and record review on 6/26/2025 at 3:35 p.m. with CN 3, Patient 20's "Progress Note Physician," dated 6/24/2025 and 6/25/2025, were reviewed. CN 3 stated the Progress notes did not indicate the incident (use of 4-point restraints and seclusion room placement of patient 20) that occurred on 6/24/2025. The Progress notes did not also indicate the completion of a face-to-face assessment by the physician following the initiation of seclusion/restraints on Patient 20.

During a concurrent interview and record review on 6/27/2025 at 10:31 a.m. with the Director (DIR) 3 of the Behavioral Health Unit (BHU) and Nurse Manager (NM) 2, the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 6/2023, was reviewed. DIR 3 stated their practice was for the nurses to perform the face-to-face assessments for patients who are placed on seclusion/restraints. DIR 3 acknowledged their policy did not cover face to face assessments completed by nurses.

During a concurrent interview and record review on 6/27/2025 at 10:33 a.m. with the DIR 3 and NM 2, the "Code of Federal Regulation Title 42, 'Condition of Participation: Patient's Rights, §482.13(e)(14),'" dated 2/2020, was reviewed. DIR 3 acknowledged they (facility staff) were not following the regulation on the nurses consulting the physician for a face-to-face evaluation within 1 hour following the application of seclusion/restraints.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 6/2023, the P&P indicated, "The physician must conduct a face-to -face assessment of the patient's need for restraint or seclusion within one hour after the initiation of the intervention."

Based on interview and record review, the facility failed to ensure one of 30 sampled patient's (Patient 12) representative's denial of visitation right was reevaluated and a justification for denial of visitation right provided, in accordance with the facility's policy and procedure regarding "Visitation."

This deficient practice resulted in Patient 12's representative (FM 3) not being allowed to exercise his right to visit Patient 12 causing potential distress to Patient 12 and/or representative.

Findings:

During a review of Patient 12's "Face Sheet (a document containing a patient's medical and demographic information)," undated, the face sheet indicated Patient 12 was admitted to the facility on 3/12/2025 at 6:58 p.m., with a medical diagnosis of psychosis (mental condition in which thought, and emotions are affected and reality is affected).

During a phone interview on 6/25/2025 at 9:00 a.m. with Patient 12's representative (FM 3), FM 3 stated, he (FM 3) was escorted out of facility unit after complaining regarding Patient 12's care and was not allowed to visit.

During an interview on 6/25/2025 at 2:26 p.m. with Charge Nurse (CN) 1, CN 1 stated a denial of right for family visitation required a doctor's order and must be renewed every day after reassessment of the need for the order. The CN further stated denial of right for family visitation could be requested when family was being abusive to patient, causing harm or being aggressive to patient.

During a concurrent interview and record review on 6/25/2025 at 3:00 p.m. with the CN 1, Patient 12's "Nursing Progress Note," dated 3/15/2025, was reviewed. The record indicated that at 4:26 p.m., Patient 12's FM 3 was escorted out of the facility and a physician order was acquired for denial of rights for visitation for Patient 12's FM 3. The CN 1 stated, Patient 12's FM 3 was verbally aggressive towards staff thus, requiring restricting Patient 12's FM 3's visitation rights.

During a record review of Patient 12's "Denial of Rights" physician order, dated 3/15/2025, the record indicated a verbatim order for denial of rights for Patient 12's representative's visitations.

During a concurrent interview and record review on 6/25/2025 at 3:00 p.m. with the CN 1, Patient 12's "Nursing Progress Note," dated 3/16/2025, was reviewed. The record indicated the denial of visitation rights for Patient 12's FM 3 was requested to be renewed, but with no documented indication or rationale (reason) for continuation of order. The CN stated, the indication should be based on nurse's assessment need for the order.

During a record review of Patient 12's "Denial of Rights" physician order, dated 3/16/2025, the record indicated a verbatim order for denial of rights for Patient 12's FM 3 visitations.

During an interview on 6/25/2025 at 3:15 p.m. with the Behavioral Health Unit Nurse Manager (NM) 2, NM 2 stated, the facility did not need to indicate or document in the patient's chart the rationale for renewing a denial of rights of visitation order because it involved the patient's representative (FM 3), not the patient.

During a review of the facility's policy and procedure (P&P) titled, "Visitation," reviewed 10/2021, the P&P indicated, "Any restriction of visitors imposed by the treatment staff must be ordered by the attending psychiatrist and a justified for good cause (means there is a valid and legally acceptable reason for an action or inaction. It implies that the reason is substantial, reasonable, and sufficient to warrant the specific action) [documented] documented in the medical record. The patient will be informed of the restriction, as well as the rationale. Such restrictions will be reviewed every 24 hours by the attending psychiatrist and documented in the medical record."

Based on observation, interview and record review, the facility's Quality Assurance Performance Improvement team (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) failed to implement corrective action and mechanisms in a timely manner, to ensure there was proper observation or monitoring provided for patients who are placed on line of sight (a straight line along which an observer had unobstructed vision) and one to one (1:1, one staff [sitter] assigned to be with one patient) monitoring in the Behavioral Health Unit (BHU, (inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) after there was patient to patient altercation between two of 30 sampled patients (Patient 8 and Patient 9), which was identified on 6/14/2025.

This deficient practice had the potential to put other patients at risk for injury or harm.

Findings:

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 4/16/2025, the Psych Eval indicated, Patient 8 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) with diagnosis including but not limited to schizoaffective disorder (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]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 8's "Consultation Report," dated 4/16/2025, the "Consultation Report" indicated, Patient 8 had past medical history of pseudoseizures (event that mimic seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness] but are not caused by abnormal electrical activity in the brain) and autism (neurodevelopmental disorder characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication).

During a review of Patient 9'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 6/5/2025, the Psych Eval indicated, Patient 9 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) with diagnoses including but not limited to 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days 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 (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and had symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 8's "Progress Note Non-Physician (nurses progress notes)," dated 6/14/2025, the "Progress Note Non-Physician" indicated, "Patient (Patient 8) was attacked by his (Patient 8's) roommate (Patient 9) approximately 1830 (6:30 p.m.). Patient (Patient 8) was witnessed falling back out of his (Patient 8's) room into the hallway noted hitting the back of his (Patient 8's) head ... Patient (Patient 8) unable to follow command for PERRLA (Pupils equal, round, and reactive to light and accommodation, standard eye exam to check the health of eyes and the nervous system). Right pupil 3 mm (millimeters, unit of measure) reactive to light. Left pupil nonreactive (the pupil [the black circle in the center of the eye] doesn't constrict [get smaller] in response to light or when focusing on a near object). Rapid Response (a system designed to quickly address a patient's sudden clinical deterioration before it escalates into a medical emergency). Rapid Response (a system designed to quickly address a patient's sudden clinical deterioration before it escalates into a medical emergency) was called at 1838 (6:38 p.m.) ... [physician] was notified ... CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head, transfer to telemetry floor [room number]. Pending report." The "Progress Note Non-Physician" also indicated Patient 8 was transferred to the facility's telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor at 7:31 p.m.

During an interview on 6/24/2025 at 12 p.m. with Patient 8, Patient 8 stated he (Patient 8) was in the room (Patient room shared by Patient 9 and Patient 8), and someone attacked him (Patient 8). Patient 8 stated, "he (Patient 9) hit my face to my left eye."

During an interview on 6/24/2025 at 3:10 p.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated the following: there were different levels of monitoring aside from standard every 15-minutue rounding in BHU. A specific staff was assigned to a specific patient who needed one to one (1:1, one staff [sitter] assigned to be with one patient) monitoring and the staff had to stay with the patient within arm's length. For patients who needed line of sight (a straight line along which an observer had unobstructed vision) monitoring, staff would need to keep a close eye on the patients and maintain visual on the patients outside their (referring to the staff) regular every 15-minute rounding.

During an interview on 6/25/2025 at 10:02 a.m. with the Director of Performance Improvement/ Quality (DQM), DQM stated Patient 8 and Patient 9 were both in the same room when the incident happened on 6/14/2025.

During a concurrent observation and interview on 6/25/2025 at 10:03 a.m. with DQM, the facility's security video footage dated 6/14/2025, was reviewed. The security video footage with no audio indicated the following:

-At 6:23:27 p.m. a Behavioral Health Worker (BHW 5) was seen sitting in the hallway;
-At 6:23:30 p.m. BHW 5 heard something and walked toward Patient 8 and Patient 9's room. BHW 5 looked at the window on the door, then opened the door and walked in;
-At 6:23:47 p.m. Patient 8 walked out from the room, limping then fell to the floor in the middle of hallway;
-At 6:25:45 p.m. Patient 9 was taken out by two BHWs from the room (room shared by Patient 9 and Patient 8).

During the same interview on 6/25/2025 at 10:03 a.m. with DQM, DQM confirmed the identities of BHW 5, Patient 8 and Patient 9. DQM also stated there was an altercation between Patient 8 and Patient 9 in the room.

During a review of Patient 8's "Progress Note Non-Physician (nurses progress notes)," dated 6/14/2025, the "Progress Note Non-Physician" indicated, "2005 (8:05 p.m.) patient (Patient 8) on unit (Telemetry unit) ... Patient (Patient 8) has multiple bruises to his (Patient 8's) face and head."

During an interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated on 6/14/2025, he (BHW 5) was sitting in the hallway and saw Patient 8 and Patient 9 enter the room (the patient room shared by patient 9 and Patient 8). BHW 5 stated, "I heard feet shuffling in the room. I got up, peeked into the window and saw Patient 9 was on top of Patient 8 on the ground hitting Patient 8. Patient 9 was aggressive to Patient 8."

During the same interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated he (BHW 5) was not aware Patient 9 was under line-of-sight monitoring. BHW 5 also stated Patient 8 was on one to one (1:1) monitoring that day (6/14/2025) but his (Patient 8's) assigned sitter was flexed earlier that day due to overstaffing and no one was assigned to replace the sitter. BHW 5 stated there was no line of sight for both patients (Patient 8 and Patient 9) because the door (to both patients' [Patient 9 and Patient 8] room) was closed.

During an interview on 6/25/2025 at 2:29 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated the following: the charge nurse of the unit was responsible for making assignment for the shift. There was no specific person assigned to perform line of sight. Any staff not assigned as 1:1 monitoring would be watching patients who required line of sight monitoring. The staff would need to see those patients at all times. CN 3 also stated a physician order was required for starting and discontinuing any line of sight and 1:1 monitoring.

During a concurrent interview and record review on 6/25/2025 at 2:52 p.m. with the Nurse Manager (NM) 2 of BHU, the facility's Campus 1 BHU assignment, "[Unit] AM Shift Assignment," dated 6/14/2025 AM shift, was reviewed. The "[Unit] AM Shift Assignment" indicated, Patient 8 was on 1:1 monitoring and Patient 9 was on line of sight monitoring. The "[Unit] AM Shift Assignment" did not indicate which nursing staff was assigned to Patient 8 and Patient 9 to perform the 1:1 monitoring and line of sight monitoring. NM 2 stated she (NM 2) could not tell which staff was assigned to perform line of sight monitoring because it was not written on the assignment.

During a concurrent interview and record review on 6/25/2025 at 3:29 p.m. with the Quality and Performance Improvement Supervisor (QPS), Patient 8's "Order Information for: Patient Monitoring (physician order)," dated 6/12/2025, was reviewed. The physician order indicated Patient 8 was placed on 1:1 sitter observation. QPS stated the order was active at time of incident. QPS stated the order was discontinued on 6/14/2025 at 8:19 p.m.

During a concurrent interview and record review on 6/25/2025 at 3:30 p.m. with QPS, Patient 9's "Order Information for: Patient Monitoring (physician order)," dated 6/10/2025, was reviewed. The physician order indicated Patient 9 was placed on line-of-sight observation. QPS stated the order was active and only discontinued on 6/20/2025.

During an interview on 6/27/2025 at 7:43 p.m. with the Director of Performance Improvement/ Quality (DQM), DQM stated the following: 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 met and performed a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution) for the incident (physical assault on Patient 8). The incident was still in discussion. Nothing was implemented.

During a review of the facility's policy and procedure (P&P) titled, "Mandated Adverse Event Reporting to the California Department of Public Health," dated 12/2023, the P&P indicated, "The Committee will identify systems, issues, and events that negatively affect the process of care in a case or could potentially impact the care of the other patients. If necessary, a thorough and credible root-cause analysis will be completed on all identified adverse events and the results with corrective actions will be forwarded to the appropriate medical staff committee for critical evaluation and then to the Medical Executive Committee and Governing Board for final approval ... the Committee will meet and review the case, conducts interviews, prepared records of findings and action plans, assigned responsibilities for action steps to clinical or hospital departments, set deadlines for completion, refers system issues and/or hospital-wide issues to the appropriate responsible services or individuals, ensure the reporting of action plan results, and report the findings and actions taken as the result of the adverse event review to the appropriate Medical Staff Department Committee and Medical Executive Committee."

During a review of the facility's policy and procedure (P&P) titled, "Organizational Performance Improvement Plan," dated 4/2025, the P&P indicated, "The purpose of the Organizational Performance Improvement Plan at [the facility] is to ensure that the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk."

Based on interview and record review, the facility's Governing Body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure that the facility's Quality Assurance 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) Committee, reviewed and addressed the facility's Policy and Procedure (P&P) pertaining to "Seclusion (involuntary [without permission] confinement of a patient in a room or area from which the patient is physically prevented from leaving) and 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)," to ensure that the P&P was aligned with facility's current practice and be able to comply with federal regulations, when the P&P did not indicate that a Registered Nurse could perform face to face assessment on patients following the initial application of seclusion/restraints other than the physician, and the P&P did not also indicate that a Registered Nuse 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 three (3) of 30 sampled patients (Patients 8, 9, and 20).

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 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 4/16/2025, the Psych Eval indicated, Patient 8 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) with diagnosis including but not limited to schizoaffective disorder (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]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 8's "Order Information for: Restraints (physician order)," dated 6/10/2025, the "Order Information for: Restraints" indicated keyed (a special key is needed to unlock the restraint device) polyurethane (a type of polymers [man-made materials] that is durable and resistant to wear and tear) restraints was ordered on 6/10/2025 at 9:01 p.m. with reason for danger to self or others.

During an interview on 6/24/2025 at 12:45 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated nurse would perform a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour after initiation of seclusion and/or restraints. CN 3 also stated there was no follow up call with the physician after the face-to-face assessment was completed unless there were any abnormal findings identified.

During an interview on 6/24/2025 at 12:56 p.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated nurses would only call physician if there was any issue identified during the face-to-face assessment.

During a concurrent interview and record review on 6/26/2025 at 10:44 a.m. with the Nurse Manager (NM) 2 of BHU, Patient 8's "Progress Notes Non-Physician (nursing progress notes)," dated 6/10/2025, was reviewed. The "Progress Notes Non-Physician" indicated, Patient 8 was placed on 4-point (both wrists and both ankles) restraints which started at 8:52 p.m., the Registered Nurse (RN 11) performed face-to-face assessment at 9:30 p.m. The "Progress Notes Non-Physician" did not indicate any communication with physician after the face-to-face assessment. NM 2 stated RN 11 did not call physician after face-to-face assessment.

During a concurrent interview and record review on 6/27/2025 at 10:31 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and NM 2, the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 6/2023, was reviewed. The P&P indicated, "The physician must conduct a face to face assessment of the patient's need for restraints or seclusion within one hour after the initiation of the intervention ... 4. Evaluations, Documentations and Monitoring a. Behavioral Restraints i. A physician or other licensed independent practitioner must see (face to face) and evaluate the need for seclusion and restraints within one hour after the initiation of this intervention, the evaluation must be documented in the patient medical record." The P&P did not indicate any procedures relating to having a Registered Nurse to perform face to face assessment. DIR 3 stated the following: the facility's current practice allowed nurses to perform the face-to-face assessments for patients on seclusion and/or restraints. Current practice did not align with policy. DIR 3 confirmed the facility's P&P did not cover face-to-face assessment completed by nurses and did not give directions to nurses what to follow.

During a concurrent interview and record review on 6/27/2025 at 10:33 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and 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." DIR 3 and NM 2 both stated they (DIR 3 and NM 2) were not aware of this regulation. DIR 3 stated the current practice did not follow the regulations. DIR 3 also stated nurses should assess the patient, then call and inform the physician about the assessment (face-to-face assessment after initiation of seclusion/restraint) so that the physician could determine and update the treatment plan for the patient.

During an interview on 6/27/2025 at 6:58 p.m. with the Director of Performance Improvement and Quality (DQM), DQM stated the following: QAPI provided oversight for facility's policies and procedures process and management. The department directors and managers were responsible for the update of the policies in accordance with regulations, standards of care and current practice. It was a collaborative effort between QAPI committee and the department.

During an interview on 6/27/2025 at 7:16 p.m. with DQM, DQM stated when policies do not align with facility's current practice and follow federal regulations, it would put the facility out of compliance and there would be potential for patient safety issue.

During an interview on 6/27/2025 at 8:09 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: GB (Governing Body, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) relied on QAPI and the Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) to report quality of care and patient safety issues but at the end of the day, the oversight and accountability of the facility fell on the governing board. The CEO also stated GB was responsible for providing oversight on overall quality of care and patient safety.

During a review of the facility's policy and procedure (P&P) titled, "Psychiatric Nursing Standards of Care," dated 10/2021, the P&P indicated, "It is the policy of the Behavioral Health Unit that all nursing services rendered will be consistent with established nursing standards ... Role of the Registered Nurse: the Registered Nurse shall directly provide the planning, supervision, implementation, and evaluation of the nursing care provided to each patient. Nursing care may be directed to other licensed nursing staff or unlicensed nursing staff..."

During a review of the facility's policy and procedure (P&P) titled "Organizational Performance Improvement Plan," dated 4/2025, the P&P indicated, "The purpose of the Organization Performance Improvement Plan at [the facility] is to ensure the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk ... The primary goal of the Organizational Performance Improvement Plan is to continually and systemically plan, design, measure, assess and improve performance of hospital-wide key functions and processes relative to patient care; and to improve healthcare outcomes while reducing and preventing medical/health care errors ... provide for a hospital-wide program that assures the facility designs processes (with special emphasis on design of new or revisions in established services) well and systematically measures, assesses and improves its performance to achieve optimal patient health outcomes in a collaborative, cross-departmental, interdisciplinary approach."

During a review of the facility's "Governing Board of Directors Bylaws of [the facility] (GB Bylaws)," approved by the GB on 10/19/2022, the GB Bylaws indicated, "The Board of Directors shall, through its members: ... Establish and maintain that the Hospital or other health care related facility that will provide high-quality total care to patients suffering from illnesses, diseases or disabilities which require that patients receive comprehensive care ... Oversee the hospital's compliance with the laws and regulations of federal, state, and local governmental agencies and with the standard's rules and regulations of the various and other accrediting and approval agencies ... Maintain ultimate accountability for the safety and quality of care, treatment, and services provided."

2. During a review of Patient 9'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 6/5/2025, the Psych Eval indicated, Patient 9 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) with diagnoses including but not limited to 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days 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 (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 9's "Progress Note Non-Physician (nursing progress notes)," dated 6/14/2025, the "Progress Note Non-Physician" indicated, "at 1830 (6:30 p.m.), BHW (behavioral health worker [BHW 5]) doing rounds and heard a commotion in room (the patient room shared by Patient 9 and Patient 8). BHW (BHW 5) witness Patient (Patient 9) sitting on top of roommate (Patient 8), hitting him (Patient 8) in the face ... Patient (Patient 9) was detained by BHW ... escorted to seclusion room, two men assist for decrease stimulation ... [physician] informed of patient status and ordered Benadryl (usually used for allergic reaction, can cause drowsiness) 50 milligrams (mg, unit of measure) IM (Intramuscular injection, delivering medication directly into the muscle tissue), Haldol (medication to treat schizophrenia and acute [new onset] agitation [being upset, annoyed, angry and physically disturbed)] 5 mg IM, Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 2 mg IM STAT (as soon as possible). IM delivered as ordered."

During an interview on 6/24/2025 at 12:45 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated nurse would perform a face-to-face assessment (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) within an hour after initiation of seclusion and/or restraints. CN 3 also stated there was no follow up call with the physician after the face-to-face assessment was completed unless there were any abnormal findings identified.

During an interview on 6/24/2025 at 12:56 p.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated nurses would only call physician if there was any issue identified during the face-to-face assessment.

During a concurrent interview and record review on 6/26/205 at 10:19 a.m. with NM 2, Patient 9's "Progress Note Non-Physician (nursing progress notes)," dated 6/14/2025, was reviewed. The "Progress Note Non-Physician" indicated, "Face to Face ... at 1930 (7:30 p.m.) Face to Face evaluation completed ... Patient (Patient 9) has even and unlabored breaths (normal, effortless breathing) and is calm during face-to-face evaluation ... Patient (Patient 9) is calm at this time." NM 2 stated the face-to-face assessment was performed by the Registered Nurse (RN) 9 and RN 9 did not need to call the physician after face-to-face assessment because there was no need.

During a concurrent interview and record review on 6/27/2025 at 10:20 a.m. with NM 2, Patient 9's Individual Observation Record (15-min rounding record)," dated 6/14/2025, was reviewed. The "Individual Observation Record" indicated, Patient 9 was in "locked seclusion" from 6:53 p.m. to 9:18 p.m. (almost 2 hours 30 minutes) with behavior documented as "cooperative." The "Individual Observation Record" also indicated RN 10 documented Patient 9 was calm and cooperative at 8 p.m. NM 2 stated the seclusion should have been discontinued at earlier time because Patient 9 was calm and cooperative. NM 2 stated the seclusion was not necessary.

During a concurrent interview and record review on 6/27/2025 at 10:31 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and NM 2, the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 6/2023, was reviewed. The P&P indicated, "The physician must conduct a face-to-face assessment of the patient's need for restraints or seclusion within one hour after the initiation of the intervention ... 4. Evaluations, Documentations and Monitoring a. Behavioral Restraints i. A physician or other licensed independent practitioner must see (face to face) and evaluate the need for seclusion and restraints within one hour after the initiation of this intervention, the evaluation must be documented in the patient medical record." The P&P did not indicate any procedures relating to having a Registered Nurse to perform face to face assessment. DIR 3 stated the following: the facility's current practice allowed nurses to perform the face-to-face assessments for patients on seclusion and/or restraints. Current practice did not align with policy. DIR 3 confirmed the facility's P&P did not cover face-to-face assessment completed by nurses and did not give directions to nurses what to follow.

During a concurrent interview and record review on 6/27/2025 at 10:33 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3 and 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." DIR 3 and NM 2 both stated they (DIR 3 and NM 2) were not aware of this regulation. DIR 3 stated the current practice did not follow the regulations. DIR 3 also stated nurses should assess the patient, then call and inform the physician about the assessment so that the physician could determine and update the treatment plan for the patient.

During an interview on 6/27/2025 at 6:58 p.m. with the Director of Performance Improvement and Quality (DQM), DQM stated the following: QAPI provided oversight for facility's policies and procedures process and management. The department directors and managers were responsible for the update of the policies in accordance with regulations, standards of care and current practice. It was a collaborative effort between QAPI committee and the department.

During an interview on 6/27/2025 at 7:16 p.m. with DQM, DQM stated when policies do not align with the facility's current practice and follow federal regulations, it would put the facility out of compliance and there would be potential patient safety issue.

During an interview on 6/27/2025 at 8:09 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: GB relied on QAPI and the Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) to report quality of care and patient safety issues, but at the end of the day, the oversight and accountability of the facility fell on the governing board. The CEO also stated the GB was responsible for providing oversight on overall quality of care and patient safety.

During a review of the facility's policy and procedure (P&P) titled, "Psychiatric Nursing Standards of Care," dated 10/2021, the P&P indicated, "It is the policy of the Behavioral Health Unit that all nursing services rendered will be consistent with established nursing standards ... Role of the Registered Nurse: the Registered Nurse shall directly provide the planning, supervision, implementation, and evaluation of the nursing care provided to each patient. Nursing care may be directed to other licensed nursing staff or unlicensed nursing staff..."

During a review of the facility's policy and procedure (P&P) titled "Organizational Performance Improvement Plan," dated 4/2025, the P&P indicated, "The purpose of the Organization Performance Improvement Plan at [the facility] is to ensure the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk ... The primary goal of the Organizational Performance Improvement Plan is to continually and systemically plan, design, measure, assess and improve performance of hospital-wide key functions and processes relative to patient care; and to improve healthcare outcomes while reducing and preventing medical/health care errors ... provide for a hospital-wide program that assures the facility designs processes (with special emphasis on design of new or revisions in established services) well and systematically measures, assesses and improves its performance to achieve optimal patient health outcomes in a collaborative, cross-departmental, interdisciplinary approach."

During a review of the facility's "Governing Board of Directors Bylaws of [the facility] (GB Bylaws)," approved by the GB on 10/19/2022, the GB Bylaws indicated, "The Board of Directors shall, through its members: ... Establish and maintain that the Hospital or other health care related facility that will provide high-quality total care to patients suffering from illnesses, diseases or disabilities which require that patients receive comprehensive care ... Oversee the hospital's compliance with the laws and regulations of federal, state, and local governmental agencies and with the standard's rules and regulations of the various and other accrediting and approval agencies ... Maintain ultimate accountability for the safety and quality of care, treatment, and services provided."

3. During a review of Patient 20's "Psychiatric Evaluation (Psych Eval, a formal assessment of the patient done by a Psychiatrist [physician who specializes in mental health])," dated 6/17/2025, the Psych Eval indicated, Patient 20 was admitted to the facility on a 5150 hold (allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for being a danger to others. The Psych Eval also indicated Patient 20 was hearing voices and had a history of schizophrenia (mental illness affecting how someone behaves, feels, and thinks).

During an interview on 6/24/2025 at 11:40 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Patient 20 was trying to hit staff in the day room (activity room), was given emergency medications and placed on 4 point restraints (physical device applied to the person's wrists and ankles to limit movement) in the seclusion room (involuntary [without permission] confinement of a patient alone in a room or area from which the patient is physically prevented from leaving).

During an interview on 6/24/2025 at 12:48 p.m. with Nurse Manager (NM) 2 and Charge Nurse (CN) 1, CN 1 stated when a patient was placed on restraints, the nurse would call the physician for a restraint order. CN 1 also stated the nurse sees the patient immediately after restraint application and will complete a "Face to Face" assessment within an hour. NM 2 stated the nurses were not required to call the physician after (completing the face-to-face assessment), unless there was something abnormal (unusual) with the patient.

During a review of Patient 20's "Progress Note Non-Physician (nursing progress note)," dated 6/24/2025, the progress note indicated, "At around 0830 (8:30) a.m., Patient (Patient 20) was knocking hard on the back door of the nursing station, the patient's 1:1 sitter (individual who stays with the patient as a safety precaution) redirected (guide an individual's thoughts and behavior to a different action) him (Patient 20) not to do it and patient (Patient 20) became aggressive (behavior that is forceful and potentially hostile or threatening) and doing a fist fight to the 1:1 sitter...wanted to fight with the staff, doing a fist, approaching the staff, staff got hit on the face with the patient's fist ...ordered to place patient on seclusion and restraint (4-point restraints). Ordered, Haldol (medication used to treat schizophrenia [(mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] and agitation [being upset, annoyed, angry and physically disturbed]) 5 milligrams (mg- a unit of measure), Ativan (medication used for relaxation) 2 mg, Benadryl (medication used to cause sleepiness) 50 mg. Per pharmacy, out of stock for Ativan, replaced with Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 2 mg... order noted and carried out." Patient 20 was placed on 4 point restraints in the seclusion room and had received intramuscular (IM, injection in the muscle) medications.

During a concurrent interview and record review on 6/26/2025 at 9:56 a.m. with CN 3, Patient 20's two "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)" orders, both dated 6/24/2025, were reviewed. Patient 20 had an order placed at 8:32 a.m. for "Emergency Medication Administration" for being a "Danger to others." Patient 20 also had a second order placed at 8:55 a.m. for the use of "Keyed Polyurethane (type of restraint that is applied to the person's wrists and ankles and uses a key and lock for application)" restraints for being a "Danger to others."

During a concurrent interview and record review on 6/26/2025 at 9:56 a.m. with CN 3, Patient 20's "Medication Administration Record (MAR)," dated 6/24/2025, was reviewed. The MAR indicated, on 6/24/2025 at 8:44 a.m., Patient 20 received Haldol (medication used to treat schizophrenia [(mental illness affecting how someone behaves, feels, and thinks] and acute [new onset] and agitation [being upset, annoyed, angry and physically disturbed]) 5 milligrams (mg , a unit of measure) Intramuscular (IM, injection into the muscle), Benadryl (medication used to cause sleepiness) 50 mg IM and Versed (medication used to produce drowsiness and has sedation [a state of calmness or drowsiness induced by drugs] effect) 2 mg.

During an interview on 6/26/2025 at 10:25 a.m. with CN 3, CN 3 stated if the patient was in the seclusion room or on restraints, the nurse did not have to call the doctor again unless there was a change in condition.

During an interview on 6/26/2025 at 10:42 a.m. with CN 3, CN 3 stated the physician did not document a "Face to Face" assessment.

During a concurrent interview and record review on 6/26/2025 at 3:35 p.m. with CN 3, Patient 20's "Progress Note Physician," dated 6/24/2025 and 6/25/2025, were reviewed. CN 3 stated the Progress notes did not indicate the incident (use of 4-point restraints and seclusion room placement of patient 20) that occurred on 6/24/2025. The Progress notes did not also indicate the completion of a face-to-face assessment by the physician following the initiation of seclusion/restraints on Patient 20.

During a concurrent interview and record review on 6/27/2025 at 10:33 a.m. with the Director (DIR) 3 of Behavioral Health and Nurse Manager (NM) 2, the "Code of Federal Regulation Title 42, 'Condition of Participation: Patient's Rights, §482.13(e)(14),'" dated 2/2020, was reviewed. DIR 3 acknowledged they (facility staff) were not following the regulation on the nurses consulting the physician for a face-to-face evaluation within 1 hour of the completion of a face-to-face evaluation by a Registered Nurse, and was not what was practiced (the notification of the physician).

During an interview on 6/27/2025 at 6:58 p.m. with the Director of Performance Improvement and Quality (DQM), DQM stated the following: QAPI provided oversight for the facility's policies and procedures, process, and management. The department directors and managers were responsible for the update of the policies in accordance with regulations, standards of care, and current practice. It was a collaborative effort between QAPI committee and the department.

During an interview on 6/27/2025 at 7:16 p.m. with DQM, DQM stated that when policies did not align with the facility's current practice and follow federal regulations, it would put the facility out of compliance and there would be potential for patient safety issue.

During a review of the facility's policy and procedure (P&P) titled, "Seclusion and Restraint," dated 6/2023, the P&P indicated, "The physician must conduct a face-to-face assessment of the patient's need for restraint or seclusion within one hour after the initiation of the intervention."

During an interview on 6/27/2025 at 8:09 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: GB relied on QAPI and the Medical Executive Committee (MEC, responsible for making important medical and clinical decisions, overseeing medical staff and addressing various healthcare-related issued within the hospital) to report quality of care and patient safety issues but at the end of the day, the oversight and accountability of the facility fell on the governing board/Governing Body. The CEO also stated the GB was responsible for providing oversight on overall quality of care and patient safety.

During a review of the facility's policy and procedure (P&P) titled, "Psychiatric Nursing Standards of Care," dated 10/2021, the P&P indicated, "It is the policy of the Behavioral Health Unit that all nursing services rendered will be consistent with established nursing standards ... Role of the Registered Nurse: the Registered Nurse shall directly provide the planning, supervision, implementation, and evaluation of the nursing care provided to each patient. Nursing care may be directed to other licensed nursing staff or unlicensed nursing staff..."

During a review of the facility's policy and procedure (P&P) titled "Organizational Performance Improvement Plan," dated 4/2025, the P&P indicated, "The purpose of the Organization Performance Improvement Plan at [the facility] is to ensure the Governing Board, medical staff and professional service staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care and services in an environment of minimal risk ... The primary goal of the Organizational Performance Improvement Plan is to continually and systemically plan, design, measure, assess and improve performance of hospital-wide key functions and processes relative to patient care; and to improve healthcare outcomes while reducing and preventing medical/health care errors ... provide for a hospital-wide program that assures the facility designs processes (with special emphasis on design of new or revisions in established services) well and systematically measures, assesses and improves its performance to achieve optimal patient health outcomes in a collaborative, cross-departmental, interdisciplinary approach."

During a review of the facility's "Governing Board of Directors Bylaws of [the facility] (GB Bylaws)," approved by the GB on 10/19/2022, the GB Bylaws indicated, "The Board of Directors shall, through its members: ... Establish and maintain that the Hospital or other health care related facility that will provide high-quality total care to patients suffering from illnesses, diseases or disabilities which require that patients receive comprehensive care ... Oversee the hospital's compliance with the laws and regulations of federal, state, and local governmental agencies and with the standard's rules and regulations of the various and other accrediting and approval agencies ... Maintain ultimate accountability for the safety and quality of care, treatment, and services provided."

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


1. Ensure nursing staff provided and maintained an appropriate level of observation and monitoring for two of 30 sampled patients who required line of sight (a straight line along which an observer had unobstructed vision) and one-to-one (1:1, one staff [sitter] assigned to be with one patient) monitoring, per physician order and in accordance with the facility's policy and procedure on rounding (the process of regularly visiting patients to assess their condition) and monitoring, when nursing staff left both Patient 8 and Patient 9 in a closed room together, without any visual monitoring on 6/14/2025.

This deficient practice resulted in Patient 9 physically assaulting (to attack) Patient 8 on 6/14/2025. Patient 8 sustained a fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) and multiple bruises to the face and head following the assault. This deficient practice also had the potential in putting other patients at risk for injury due to lack of monitoring.

2. Conduct a comprehensive assessment upon admission, that included assessing a patient's risk of suicide (killing self), homicide (killing others), or violence (assault towards others) for one of 30 sampled patients (Patient 4), in accordance with the facility's policy regarding "Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Nursing Standards of Care." This deficient practice had the potential to result in harm to Patient 4 and other patients on the unit due to lack of assessment.

On 6/26/2025 at 3:05 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 Director of Performance Improvement and Quality (DQM), Associate Administrator (AA), Quality Coordinator, Director (DIR 1) of Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at facility's offsite campus (Campus 2), and Nurse Manager (NM 1) of BHU at Campus 2. The facility failed to ensure nursing staff provided and maintained appropriate level of observation and monitoring for patients requiring line of sight (a straight line along which an observer had unobstructed vision) and one-to-one (1:1, one staff [sitter] assigned to be with one patient) monitoring per physician order when nursing staff left both Patient 8 and Patient 9 in a closed room together, without any visual monitoring on 6/14/2025. This resulted in Patient 9 physically assaulting (attack) Patient 8 in the room. Patient 8 sustained a fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) and multiple bruises to the face and head following the assault.

On 6/25/2025 at 1:45 p.m., the Behavioral Health Worker (BHW) 5 stated that on 6/14/2025, he (BHW 5) was in the hallway and heard feet shuffling in the room where Patient 8 and Patient 9 were both in. He (BHW 5) went into the room and found Patient 9 was on top of Patient 8 on the ground hitting Patient 8. BHW 5 also stated the following: he (BHW 5) was not aware Patient 9 was under line-of-sight monitoring. Patient 8 was on 1:1 monitoring that day, but the sitter was flexed (sent home) earlier that day due to overstaffing and no one was assigned to replace the sitter. There was no line of sight for both patients (Patient 8 and Patient 9) because the door was closed.

On 6/27/2025 at 11:09 p.m., the IJ was removed in the presence of DQM, AA, QC, DIR 1, and with the CEO via telephone. The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated that for immediate action taken by the facility, education began on 6/25/2025 night shift with all BHU Mental Health Workers, Registered Nurses, Charge Nurses, and Staffing Coordinators at all three campuses (Campus 1, Campus 2 and Campus 3) and would continue every shift until all relevant staff have been trained. The education included reinforcing compliance with physician monitoring order and the facility's policy related to monitoring for different levels of monitoring: standard level (every 15-minute rounding), line of sight and one-to-one (1:1).

The IJ Removal Plan also listed the responsibilities of Charge Nurse, Registered Nurse, Behavior Health Workers, and Staffing Coordinators to ensure adequate staffing and monitoring is provided and maintained for all line of sight (a straight line along which an observer had unobstructed vision) and 1:1 monitoring patients. The BHU leadership would perform daily morning reviews of all line-of-sight and 1:1 patients to confirm appropriateness of level of monitoring, active physician order in place and staff assignment instituted appropriately.

Findings:

1. 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 4/16/2025, the Psych Eval indicated, Patient 8 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) with diagnosis including but not limited to schizoaffective disorder (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]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 8's "Consultation Report," dated 4/16/2025, the "Consultation Report" indicated, Patient 8 had past medical history of pseudoseizures (event that mimic seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness] but are not caused by abnormal electrical activity in the brain) and autism (neurodevelopmental disorder characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication).

During a review of Patient 9'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 6/5/2025, the Psych Eval indicated, Patient 9 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) with diagnoses including but not limited to 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days 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 (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 8's "Progress Note Non-Physician (nurses progress notes)," dated 6/14/2025, the "Progress Note Non-Physician" indicated, "Patient (Patient 8) was attacked by his (Patient 8's) roommate (Patient 9) approximately 1830 (6:30 p.m.). Patient (Patient 8) was witnessed falling back out of his (Patient 8's) room into the hallway, noted hitting the back of his (Patient 8's) head ... Patient (Patient 8) unable to follow command for PERRLA (Pupils equal, round, and reactive to light and accommodation, standard eye exam to check the health of eyes and the nervous system). Right pupil 3 mm (millimeters, unit of measure) reactive to light. Left pupil nonreactive (the pupil [the black circle in the center of the eye] doesn't constrict [get smaller] in response to light or when focusing on a near object). Rapid Response (a system designed to quickly address a patient's sudden clinical deterioration before it escalates into a medical emergency) was called at 1838 (6:38 p.m.) ... [physician] was notified ... CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head, transfer to telemetry floor [room number]. Pending report." The "Progress Note Non-Physician" also indicated Patient 8 was transferred to facility's telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor at 7:31 p.m.

During an interview on 6/24/2025 at 12 p.m. with Patient 8, Patient 8 stated he (Patient 8) was in the room, and someone attacked him (Patient 8). Patient 8 stated, "he hit my face to my left eye."

During an interview on 6/24/2025 at 3:10 p.m. with the Nurse Manager (NM) 2 of BHU, NM 2 stated the following: there were different levels of monitoring aside from standard every 15-minutue rounding in BHU. A specific staff was assigned to a specific patient who needed one to one (1:1, one staff [sitter] assigned to be with one patient) monitoring and the staff had to stay with the patient within arm's length. For patients who needed line of sight (a straight line along which an observer had unobstructed vision) monitoring, staff would need to keep a close eye on the patients and maintain visual on the patients outside their regular every 15-minute rounding.

During an interview on 6/25/2025 at 10:02 a.m. with the Director of Performance Improvement/ Quality (DQM), DQM stated Patient 8 and Patient 9 were both in the same room when the incident happened on 6/14/2025.

During a concurrent observation and interview on 6/25/2025 at 10:03 a.m. with DQM, the facility's security video footage dated 6/14/2025, was reviewed. The security video footage with no audio indicated the following:

-At 6:23:27 p.m. a Behavioral Health Worker (BHW 5) was seen sitting in the hallway;
-At 6:23:30 p.m. BHW 5 heard something and walked toward Patient 8 and Patient 9's room. BHW 5 looked at the window on the door, then opened the door and walked in;
-At 6:23:47 p.m. Patient 8 walked out from the room, limping then fell to the floor in the middle of hallway;
-At 6:25:45 p.m. Patient 9 was taken out by two BHWs out from the room.

During the same interview on 6/25/2025 at 10:03 a.m. with DQM, DQM confirmed the identities of BHW 5, Patient 8 and Patient 9. DQM also stated there was an altercation between Patient 8 and Patient 9 in the room.

During a review of Patient 8's "Progress Note Non-Physician (nurses progress notes)," dated 6/14/2025, the "Progress Note Non-Physician" indicated, "2005 (8:05 p.m.) patient (Patient 8) on unit (Telemetry unit) ... Patient (Patient 8) has multiple bruises to his (Patient 8's) face and head."

During an interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated on 6/14/2025, he (BHW 5) was sitting in the hallway and saw Patient 8 and Patient 9 went to the room. BHW 5 stated, "I heard feet shuffling in the room. I got up, peeked into the window and saw Patient 9 was on top of Patient 8 on the ground hitting Patient 8. Patient 9 was aggressive to Patient 8."

During the same interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated he (BHW 5) was not aware Patient 9 was under line-of-sight monitoring. BHW 5 also stated Patient 8 was on one to one (1:1) monitoring that day but his (Patient 8's) assigned sitter was flexed earlier that day due to overstaffing and no one was assigned to replace the sitter. BHW 5 stated there was no line of sight for both patients (Patient 8 and Patient 9) because the door was closed.

During an interview on 6/25/2025 at 2:29 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated the following: the charge nurse of the unit was responsible for making assignment for the shift. There was no specific person assigned to perform line of sight. Any staff not assigned as 1:1 monitoring would be watching patients who required line of sight monitoring. The staff would need to see those patients at all times. CN 3 also stated a physician order was required for starting and discontinuing any line of sight and 1:1 monitoring.

During a concurrent interview and record review on 6/25/2025 at 2:52 p.m. with the Nurse Manager (NM) 2 of BHU, the facility's Campus 1 BHU assignment, "[Unit] AM Shift Assignment," dated 6/14/2025, was reviewed. The "[Unit] AM Shift Assignment" indicated, Patient 8 was 1:1 monitoring and Patient 9 was on line-of-sight monitoring. The "[Unit] AM Shift Assignment" did not indicate which nursing staff was assigned to Patient 8 and Patient 9 to perform the 1:1 monitoring and line of sight monitoring. NM 2 stated she (NM 2) could not tell which staff was assigned to perform line of sight monitoring because it was not written on the assignment.

During a concurrent interview and record review on 6/25/2025 at 3:29 p.m. with the Quality and Performance Improvement Supervisor (QPS), Patient 8's "Order Information for: Patient Monitoring (physician order)," dated 6/12/2025, was reviewed. The physician order indicated Patient 8 was placed on 1:1 sitter observation. QPS stated the order was active at the time of incident. QPS stated the order was discontinued on 6/14/2025 at 8:19 p.m.

During a concurrent interview and record review on 6/25/2025 at 3:30 p.m. with QPS, Patient 9's "Order Information for: Patient Monitoring (physician order)," dated 6/10/2025, was reviewed. The physician order indicated Patient 9 was placed on line of sight observation. QPS stated the order was active and only discontinued on 6/20/2025.

During a review of the facility's policy and procedure (P&P) titled, "Rounding, Observation and Monitoring of Patients," dated 10/2021, the P&P indicated, "The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient's whereabouts and ensure a safe environment ... Observation levels are designed to provide the right level of observation, precaution and oversight commensurate with physician and RN assessment of the safety needs of the patient in alignment with the current behavior and symptoms they are demonstrating ... Three levels of staff monitoring are provided ... Level II - moderate - line of sight ... Policy - A level of observation wherein the patient remains in staff view at all times. A specific staff member is assigned, and the line of observation is maintained by staff in person and not through video monitoring ... Level III - intensive - one to one ... Policy - consists of one to one staff observation with a patient never farther away than arm's length. The patient remains within arm's length at all times ... The RN is responsible for obtaining an MD order for an observation level that is line of sight or 1 to 1 ... When the patient's status permits, the RN will notify the MD and get an order to down-grade the observation status to that of "least restrictive" in a manner to maintain the patient in an optimal level of safety."

During a review of the facility's policy and procedure (P&P) titled, "Psychiatric Nursing Standards of Care," dated 10/2021, the P&P indicated, "It is the policy of the Behavioral Health Unit that all nursing services rendered will be consistent with established nursing standards ... Role of the Registered Nurse: the Registered Nurse shall directly provide the planning, supervision, implementation, and evaluation of the nursing care provided to each patient. Nursing care may be directed to other licensed nursing staff or unlicensed nursing staff..."

2. During a review of Patient 4's "Psych (Psychiatric, a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Nurse Admit Note," dated 4/16/2025 at 11:38 p.m., the Psych Nurse Admit Note indicated Patient 4 was admitted to the facility on 4/16/2025 at 10:10 p.m.

During a review of Patient 4's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/17/2025, the H&P indicated the following: Patient 4 with a past medical history including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responses, and social interactions), presents on voluntary status for auditory hallucinations (sensory experiences that seem real but are created by the mind, not by an eternal stimulus) but unable to elaborate further. Patient 4 was also observed responding to internal stimuli (anything that can trigger a physical or behavioral change), talking to unseen others.

During a review of Patient 4's nursing notes titled, "BH (Behavior Health) History," dated 4/17/2025 at 12:11 a.m., the nursing notes indicated the following: Patient 4's reason for admission: Stabilization (the process of preventing a patient's condition from worsening, particularly during an emergency or while awaiting further treatment). Admission was voluntary for being gravely disabled (a person who is unable to provide for their basic needs due to a mental health disorder).

During a concurrent interview and record review on 6/24/2025 at 3:30 p.m. with the House Supervisor (HS) 1, HS 1 stated the following: Patient 4 was admitted under voluntary status for responding to internal stimuli on 4/16/2025 at 10:10 p.m. HS 1 stated a comprehensive nursing assessment should be done on all patients within two hours of admission to the facility. Patient assessments should include assessments for suicidal ideations (thoughts of killing self), homicidal ideations (thoughts of killing others), and assault ideations (thought of violence to others). HS 1 was asked to review Patient 4's initial nursing assessment. HS 1 verified that Patient 1 had not been assessed for suicidal, homicidal, or assault ideations upon admission within two hours, as indicated in the facility's policy regarding psychiatric nursing standards of care. HS 1 stated it was important to conduct these assessments to develop plans of care and to provide appropriate treatment for patients.

During a concurrent interview and record review on 6/25/2025 at 11:13 a.m. with Registered Nurse (RN) 2, RN 2 stated the following: All patients should be assessed for suicidal, homicidal and assault ideations upon admission. RN 2 verified that these assessments were not documented for Patient 4 in the initial or comprehensive nursing assessment dated 4/17/2025.

During a review of the facility's policy and procedure (P&P) titled, "Psychiatric Nursing Standards of Care," dated 10/2021, the P&P indicated the following: A comprehensive nursing assessment will be initiated within two hours of patient admission. The assessment will include physical, psychological, social and cultural factors that impact upon daily care of the patient. Also include in the assessment will be the patient's self-destructive and violence potential ...

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

1. Ensure its nursing staff adhered to policy and procedure regarding staff conduct, when a Registered Nurse (RN) 1 pursued an inappropriate relationship with one (1) of 30 sampled patients (Patient 3) after their discharge from the facility.

This deficient practice had the potential to compromise professional boundaries and undermine the therapeutic integrity of care provided during the inpatient stay.

2.Ensure patients' family members were informed of seclusion (apart from others) and/or restraint (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely) episodes for two of 30 sampled patients (Patient 22 and Patient 23), in accordance with the facility's policy and procedures regarding "Seclusion and Restraint," and "Notification of Patient Admission and Subsequent Events," when Patient 22 and Patient 23 were placed on 4-point (both arms and legs) restraints in the seclusion room (is a room where a person is involuntarily confined alone).

This deficient practice had the potential to negatively affect Patient 22 and Patient 23's wishes for treatment and care they would receive in the facility, when there is lack of designated patients' family member's participation in the care process.

3. Ensure one of 30 sampled patient's (Patient 22) restraint monitoring intervention, was implemented and conducted every 15 minutes, in accordance with the facility's policy and procedure regarding "Seclusion and Restraint," when Registered Nurse (RN) 6 placed Patient 22 on 4 point (both ankles and wrists) restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability to a patient to move his or her arms, legs, body, or head freely). Subsequently, Patient 22 received Thorazine (medication used to treat mental health condition and regulates your mood) 100 milligram (mg, a unit of measurement) and Benadryl (antihistamine [medication that treat allergy symptoms] that can have a calming or sedative effect) 50 mg via intramuscular (IM, into the muscles).

This deficient practice had potential for negative consequences for Patient 22's safety due to lack of oversight (absence or inadequacy of monitoring) to identify adverse effects of restraint use such as poor circulation (blood flow), injury and/or death.

4.Ensure nursing staff adhered to the facility's policy and procedure regarding "Rounding, Observation and Monitoring of Patients," when staff did not perform the 15- minute rounding (observing patient location and behavior) for one of 30 sampled patients (Patient 21).

This deficient practice had the potential for Patient 21's safety to not be monitored and care needs to not be addressed.

5. Ensure nursing staff adhered to the facility's policy and procedure regarding notification of the physician for change of condition for one of 30 sampled patients (Patient 10), when Patient 10 reported a bleeding left eyebrow to the Registered Nurse (RN) 5, but RN 5 did not notify the attending physician.

This deficient practice resulted in delay for Patient 10 to receive diagnostic exams including a computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) scan of head thus have the potential to delay treatment and care.

6. Ensure corrections to the medical records were documented appropriately, for one of 30 sampled patients (Patient 5), in accordance with the facility's policy regarding documentation and corrections in the medical record, when staff wrote on top of original documentation which obscured the original documentation for Patient 5's location on 4/30/2025 from 5:45 p.m. to 6:30 p.m.

This deficient practice had the potential to result in inaccurate information and may lead to incorrect treatment plans which may harm the patient.

Findings:

1. During a review of Patient 3's "Face Sheet (front page of the chart that contains a summary of basic information about the patient)," not dated, the Face Sheet indicated Patient 3 was admitted to the facility's behavioral health service (treatment for mental health conditions and behaviors that impact overall well-being, including emotional, psychological, and social aspects) on 5/8/2025.

During a review of Patient 3's "Application For Up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment (5150 hold paperwork, a regulation in the state of California that allows designated professionals such as police officers or mental health clinicians to detain a person involuntarily [without their consent or permission] in a designated facility for up to 72 hours for mental health evaluation and treatment if they are deemed to be a danger to themselves, to others, or gravely disabled [unable to take care of themselves])," dated 5/8/2025, the 5150 hold paperwork indicated Patient 3 was detained due to being unable to care for herself.

During a review of Patient 3's "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment)- (5250 hold paperwork, a regulation in the state of California that allows designated professionals to extend a 72-hour hold into 14 days if an individual is deemed a danger to themselves or others, or is gravely disabled due to a mental health condition)," dated 5/11/2025, the 5250 hold paperwork indicated Patient 1's involuntary legal hold was extended due to being unable to care for herself.

During a review of the facility's staffing assignments for Campus 2, the assignments indicated RN 1 was assigned to care for Patient 3 on 5/16/2025, 5/17/2025, and 5/18/2025.

During a review of Patient 3's "Discharge Summary (a comprehensive document summarizing a patient's hospital stay, including their condition upon admission, the care they received, diagnoses, treatments, and follow-up instructions)," dated 5/21/2025 at 9:34 a.m., the Discharge Summary indicated Patient 3 was discharged from the facility on 5/21/2025.

During an interview on 6/24/2025 at 3:30 p.m. with the Director (DIR) 1 of the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) at the facility's offsite campus (Campus 2) and the Quality Coordinator (QC), DIR 1 stated that on 6/1/2025, the house supervisor on shift at the time received a phone call from Patient 3 alleging RN 1 had an inappropriate relationship with her (Patient 3). The house supervisor notified DIR 1, who called Patient 3 back; after speaking with her (Patient 3), DIR 1 placed RN 1 on suspension. The QC stated RN 1 denied having a sexual relationship with Patient 3 while she (Patient 3) was admitted to the facility but admitted to having inappropriate contact with Patient 3 after her (Patient 3) discharge from the facility once presented with evidence. DIR 1 stated RN 1 admitted to sending Patient 3 money, visiting Patient 3 while she (Patient 3) was admitted to a different facility, and gifting Patient 3 a vape (electronic cigarette that can either be nicotine or marijuana).

During a concurrent interview and record review on 6/25/2025 at 11:36 a.m. with the QC, mobile phone screenshots provided by Patient 3 to the facility, were reviewed. One screenshot was of a text message conversation between Patient 3 and a contact listed as RN 1, undated. The other screenshot appeared to be receipt of money via a mobile phone app from a contact listed as RN 1 on 5/25/2025, 5/26/2025, and 5/30/2025. The QC stated RN 1 confirmed that the text messages were from him, that RN 1 sent Patient 3 money, and that RN 1 gave Patient 3 "contraband (illegal goods)."

During an interview on 6/26/2025 at 11:13 a.m. with DIR 1, DIR 1 confirmed RN 1 was terminated for violation of code of conduct and for having inappropriate boundaries with patients. DIR 1 stated this was a violation of nursing ethics and "you don't do that."

During a review of RN 1's "Personnel Action Report (PAR)," dated 6/3/2025, the PAR indicated RN 1's employment at the facility was terminated involuntarily on 6/3/2025 for the reason "inappropriate relationship with patient."

During a review of the facility's policy and procedure (P&P) titled, "Staff Conduct," last reviewed 10/2021, the P&P indicated, "Expectations will include, but not necessarily be limited to the following: ... 7. Staff should not provide patients with drugs, alcohol, cigarettes, (other than during specified smoke breaks) or other personal and/or prohibited items. ... 9. Any form of unauthorized socialization with a patient within two (2) years of hospitalization is prohibited. Staff may resume their relationship with the patient in a fashion that is consistent with the relationship prior to hospitalization."

2.a. During a review of Patient 22's medical record titled, "History and Physical Exam (H&P, a formal and complete assessment of the patient and the problem)," dated 6/13/2025, the H&P indicated Patient 22 was admitted for chief of complaint of status post (after) fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) with dizziness.

During a review of Patient 22's medical record titled, "Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 6/13/2025, the psychiatric evaluation indicated Patient 22 was brought in from medical floor on a 5250 hold (an involuntary psychiatric hold that extends beyond the initial 72 hour hold in California) for grave disability (unable to care for one's self) and danger to self.

During a concurrent interview and record review on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22's, "Orders," dated 6/16/2025, was reviewed. The Orders indicated Patient 22 had a physician's order for 4-point (bilateral arms and bilateral legs) restraints for 4 hours, use of keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure), for being a danger to others. The HS 1 stated keyed polyurethane indicated Patient 22 was placed in seclusion (involuntary [without permission] confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) room.

During the same interview on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22's, "Notification of seclusion and/or restraint episode consent form," dated 6/12/2025, was reviewed. The consent form indicated Patient 22's request for the facility staff to notify Patient 22's family member (FM) 1 regarding any episode of seclusion and/or restraint use. HS 1 stated there was no documentation in Patient 22's clinical record that FM 1 was notified of restraints use and placement in seclusion room of patient 22. HS 1 further stated the family member should have been notified because Patient 22 requested according to the form and Patient 22's wish should have been honored.

During a review of the facility's policy and procedures (P&P) titled, "Seclusion and Restraint," reviewed in 6/2023, the P&P indicated, "A family member will be contacted by phone to notify the seclusion/restraint episode and patient condition, after obtaining the patient's consent."

During a review of the facility's policy and procedure (P&P) titled, "Notification of Patient Admission and Subsequent Events," reviewed in 10/2021, the P&P indicated, "It is the policy of Behavioral Unit to make reasonable attempts to notify any person designated by a patient admitted for mental health services in the following areas ...Notification of Seclusion and/or Restraint Episode."

2.b. During a review of Patient 23's "History and Physical (H&P)," dated 5/9/2025, the H&P indicated Patient 23 was admitted for chief complaint, "Patient endorses suicidal ideation (thoughts of taking one's own life)."

During a concurrent interview and record review on 6/25/2025 at 3:48 p.m. with the House Supervisor (HS) 1, Patient 23's "Orders," dated 5/12/2025, were reviewed. The HS 1 stated Patient 23 had a physician restraint order for 4 hours and use of keyed polyurethane restraints due to being a danger to others.

During a concurrent interview and record review on 6/26/2025 at 10:00 a.m. with the House Supervisor (HS) 2, Patient 23's "Notification of Seclusion and/or Restraint episode" dated 5/8/2025, was reviewed. The HS 2 stated Patient 23's notification of seclusion and restraint consent form was signed by Patient 23 on admission. HS 2 further stated there was no documentation the nurse had informed the family member (FM) 2 regarding Patient 23 being on restraint and having been placed in the seclusion room.

During the same interview on 6/26/2025 at 10:00 a.m. with the House Supervisor (HS) 2, HS 2 stated the use of restraints was higher level of intervention, and it was important to notify the patient's family in case of an injury or if anything were to happen.

During a review of the facility's policy and procedures (P&P) titled, "Seclusion and Restraint," reviewed in 6/2023, the P&P indicated, "A family member will be contacted by phone to notify the seclusion/restraint episode and patient condition, after obtaining the patient's consent."

During a review of the facility's P&P titled, "Notification of Patient Admission and Subsequent Events," reviewed in 10/2021, the P&P indicated, "It is the policy of Behavioral Unit to make reasonable attempts to notify any person designated by a patient admitted for mental health services in the following areas ...Notification of Seclusion and/or Restraint Episode."

3. During a review of Patient 22's medical record titled, "History and Physical Exam (H&P)," dated 6/13/2025, the H&P indicated Patient 22 was admitted for chief of complaint of status post fall with dizziness.

During a review of Patient 22's medical record titled, "Psychiatric Evaluation," dated 6/13/2025, the psychiatric evaluation indicated Patient 22 was brought in from medical floor on a 5250 hold (an involuntary psychiatric hold that extends beyond the initial 72 hour hold in California) for grave disability (someone is unable to provide for their basic personal needs due to a mental disorder) and danger to self.

During a concurrent observation and interview on 6/24/2025 at 11:51 a.m. with the Director of Behavioral Unit (DIR) 1 in Campus 2 Unit 2 seclusion room, there was a bed and a camera inside. DIR 1 stated seclusion room criteria included patient on restraint, and someone (assigned facility staff) will stay with the patient in the room.

During a concurrent observation and interview on 6/24/2025 at 12:19 p.m. with DIR 1 in Campus 2 Unit 1, there was a female staff sitting outside the room of Patient 22. DIR 1 stated Patient 22 had a 1:1 sitter (is a caregiver who provides direct observation and support to a patient).

During a concurrent interview and record review on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22's "Order," dated 6/16/2025, was reviewed. The HS 1 stated Patient 22 had an order for 4-point restraints, for 4 hours duration, and use of keyed polyurethane (a type of restraint that utilizes a key-lock mechanism for closure) restraints due to being a danger to others. HS 1 further stated, keyed polyurethane restraints would be applied only in the seclusion room (is a room where a person is involuntarily confined alone).

During the same interview and record review on 6/25/2025 at 2:11 p.m. with the House Supervisor (HS) 1, Patient 22's, "Progress Notes Non-Physician" and Medication Order," dated 6/16/2025, were reviewed. HS 1 stated, Patient 22's progress notes indicated Patient 22 was put on 4-point (both arms and legs) restraints. HS 1 also said Patient 22 received Thorazine and Benadryl via IM on 6/16/2025 at 8:16 a.m.

During an observation on 6/26/2025 at 2:45 p.m. with the Associate Administrator (AA), in the conference room, the security footage from 6/16/2025, was reviewed. The following events were observed at the indicated timestamps in the video:
1. 7:53 a.m.: Staff brought Patient 22 to the seclusion room unrestrained at this time
2. 7:58 a.m.: Patient 22 was put on restraints applied to both ankles and wrist

During a concurrent observation, interview, and record review on 6/26/2025 at 3:07 p.m. with the AA, the Director of the Behavioral Health Unit (DIR) 1 and the Quality Coordinator (QC)., in the conference room, the security footage from 6/16/2025 was reviewed. The following events were observed at the indicated timestamps in the video:
1. 8:15 a.m.: Patient 22 received injection medications to right deltoid (triangular shoulder muscle) and to left buttocks
2. 8:18 a.m.: RN 6 (primary nurse) left the room
3. 8:26 a.m.-8:52 a.m. - Patient 22 was observed alone in the room with no staff
4. 8:53 a.m. RN 6 entered the room and quickly stepped out of the room

During an interview on 6/27/2025 at 8:44 a.m. with the Registered Nurse (RN) 7, the RN 7 stated for restraint monitoring every 15 minutes, the RN would check for circulation (the continuous movement of blood though-out the body) by physically checking the pulse, ensuring the restraint was not too tight cutting off circulation, and check skin discolorations. RN 7 also said it was important to check patients on restraint because there could be changes of condition especially when they (the patients) were medicated as well.

During a concurrent observation, interview, and record review on 6/27/2025 at 9:02 a.m. with AA, DIR 1 and the Quality Coordinator (QC), in the conference room, the security footage from 6/16/2025, was reviewed. The following events were observed at the indicated timestamps in the video:
1. 8:53:57 a.m. RN 6 entered the room and walked out of the room at 8:54:00 (3 seconds)
2. 8:54-9:25 a.m. Patient alone in the room, no staff present
3. 9:26:23 -Behavior Mental Worker step in and out of the room
4. 9:28:50-9:29:26 a.m.: RN 6 went near the Patient 22 and just looked at her.
5. 9:30 -10:13:24 a.m.: RN 6 entered the room, approached the patient and appeared to be talking with Patient 22.
6. 10:14:10: RN 6 still in the room started to unlock and remove the keyed polyurethane restraint to ankles and wrist. Subsequently, other facility staff entered the room

During the same interview on 6/27/2025 at 9:02 a.m. with DIR 1, DIR 1 stated a more thorough assessment could have been done for Patient 22 for safety concerns, an adverse event can occur, and circulation can be compromised. DIR 1 acknowledged RN 6 was seen with Patient 22 at 8:53 a.m., 9:28 a.m. and 10:13 a.m. DIR 1 acknowledged the time gaps Patient 22 was not monitored while restrained in the seclusion room.

During the same interview on 6/27/2025 at 9:02 a.m. with DIR 1, Patient 22's, "Progress Note Non-Physician," dated 6/16/2025, was reviewed. DIR 1 stated Patient 22's progress notes did not reflect what was done for the patient according to the video footage observed and the expectation would be documentation matched what they (the staff) were doing for the patient.

During a review of facility's policy and procedure (P&P) titled, "Seclusion and Restraint," reviewed in 6/2023, the P&P indicated, "Patients in behavioral modification restraint shall be monitored continually by staff on face to face basis at arms-length for duration of seclusion, when audiovisuals are not available ...Patient in seclusion only shall be monitored continually by staff on face to face basis for the first hour. This is followed by observation at intervals not greater than every fifteen (15) minutes and continuous monitoring visual equipment in close proximity to the patient ...The flow sheet will include type of restraint, LOC and circulation checks every 15 minutes ..."

4. During a review of Patient 21'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 5/9/2025, the Psych Eval indicated Patient 21 was admitted to the facility on a 5150 hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for grave disability (individual cannot provide their own food, clothing, and shelter because of a mental health disorder). Patient 21 had a history of suicidal ideation (thoughts of self-harm) and urinary tract infection (UTI, an infection in the bladder/urinary tract).

During an interview on 6/24/2025 at 12:23 p.m. with Behavioral Health Worker (BHW) 4, BHW 4 stated 15 minutes rounding was about checking on each patient's location, behaviors, and ensuring safety on the unit.

During a concurrent interview and record review on 6/27/2025 at 5:45 p.m. with Nurse Manager (NM) 2 and Director (DIR) 3 of the Behavioral Health Unit, Patient 21's "Individual Observation Record," dated 5/27/2025, was reviewed. NM 2 and DIR 3 acknowledged Patient 21's location and behaviors on 5/27/2025 from 5:00 p.m. to 5:29 p.m., and from 8:18 p.m. to 8:44 p.m., were missing and not documented. DIR 3 stated there should be every 15 minutes rounding done for Patient 21.

During a review of the facility's policy and procedure (P&P) titled, "Rounding, Observation and Monitoring of Patients," dated 10/2021, the P&P indicated, "All patients on the BHU (Behavioral Health Unit) are at a minimum under standard observation ...Policy-Assess and document at 15-minute intervals."

5. During a review of Patient 10'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 4/16/2025, the Psych Eval indicated, Patient 10 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) with diagnosis including but not limited to schizoaffective disorder (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]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a concurrent observation and interview on 6/26/2025 at 9:37 a.m. with the Director of Performance Improvement/Quality (DQM), the facility's security video footage dated 4/20/2025, was reviewed. The security video footage indicated the following:

-At 11:26 p.m.: Patient 10 was seen standing by the doorway of his (Patient 10's) room holding a pair of green pants;
-At 11:27 p.m.: a Behavioral Health Worker (BHW 10) was seen walking towards Patient 10 and handed Patient 10 a diaper. Patient 10 and BHW 10 exchanged some conversation;
-At 11:27:25 p.m.: BHW 10 put hands on Patient 10's left shoulder area and right arm and pushed Patient 10 into the room. Both BHW 10 and Patient 10 went into the room;
-At 11:27:41 p.m.: BHW 11 was seen walking down the hallway and looked into Patient 10's room but did not go inside;
-At 11:27:49 p.m.: BHW 10 came out of Patient 10's room;
-At 11:27:56 p.m.: Patient 10 walked to the doorway and pointed his left eye to BHW 11

During the same interview on 6/26/2025 at 9:37 a.m. with the Director of Performance Improvement/Quality (DQM), DQM confirmed Patient 10, BHW 10 and BHW 11's identities from the video surveillance footage. DQM stated Patient 10 came out of the room with laceration on the left eyebrow.

During the same interview on 6/26/2025 at 9:37 a.m. with the Director of Performance Improvement/Quality (DQM), DQM stated the facility conducted an internal investigation and identified care was delayed because RN 5 did not notify the attending physician regarding Patient 10's change of condition (left eyebrow wound). DQM stated, "the care was delayed." DQM further said Patient 10's physician was not notified that night. Physician was notified the next morning and a computed tomography (CT, a medical imaging technique to create detailed images of the inside of the body) scan of head was ordered.

During a review of Patient 10's "Progress Note Non-Physician (nursing progress notes)," dated 4/20/2025, the "Progress Note Non-Physician," indicated, at 3:17 a.m., Patient 10 went to the nursing station with bleeding at the corner of left eyebrow, Patient 10 informed RN 5 that "I got my pants wet and requested for another pair. The BHW (Behavioral Health Worker 10) put his hand on me, held me tight on my neck, and pushed me back from the door of my room to my bed. I hit myself somewhere, not sure if it was on my bed or on the wall. I had a scar on my left eyebrow since I was 9 years old. It started bleeding where the scar is."

During an interview on 6/26/2025 at 11:32 a.m. with Nurse Manager (NM) 2 of BHU, NM 2 stated RN 5 did not assess Patient 10's wound (left eyebrow) when it was reported, and did not call the physician for Patient 10's change of condition.

During an interview on 6/27/2025 at 9:48 a.m. with the Director (DIR) 3 of BHU for Campus 1 and Campus 3, DIR 3 stated the following: BHW 11 heard yelling and went to the room that day. He (BHW 11) noted there was a cut on Patient 10 but he (BHW 11) thought BHW 10 told the nurse already, so he (BHW 11) did not report.

During a review of the facility's policy and procedure (P&P) titled, "Physician Notification," dated 10/2024, the P&P indicated, "the attending physician will be notified regarding patient issue in a timely manner ... the primary attending physician will immediately be notified of patient's change in condition."

6. During a review of Patient 5's "History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/27/2025, the H&P indicated the following: Patient 5 with a history of alcohol use disorder, seizure disorder (sudden burst of electrical activity in the brain), and psychosis (disconnection from reality). Patient 5 was brought in by ambulance from the streets after having a witnessed tonic-clonic seizure (a type of seizure that involves a loss of consciousness [a state where an individual loses awareness of themselves and their surroundings] and violent muscle contractions [the process where muscle fibers shorten to generate force, allowing for movement and other functions]) for about 5 minutes.

During a review of a document for Patient 5 titled, "BHU (Behavior Health Unit) Rounding & Observation," dated 4/30/2025, the document indicated Patient 5's locations. Location Code: PR (indicates Patient Room), H (indicates Hallway), and SR (indicates Seclusion Room):

-At 5:45 p.m. and 6 p.m., Location: The letter "H" was handwritten, in dark black ink, on top of original writing in lighter black ink. Two originally handwritten letters were obscured by the letter "H" and not legible.
-At 6:15 p.m. and 6:30 p.m., Location: The letter "S" was handwritten, in dark black ink, on top of the original writing of two letters in a lighter black ink. One of the original letters was obscured by the letter "S" and other original letter was "R".

During a concurrent interview and record review on 6/25/2025 at 2:16 p.m. with the Nurse Manager (NM) 1 for Campus 2, NM 1 reviewed Patient 5's rounding documentation titled, "BHU (Behavior Health Unit) Rounding & Observation," dated 4/30/2025, and verified that there was previous writing underneath the "H" documented at 5:45 p.m. and 6 p.m., and the "S" documented at 6:15 p.m. and 6:30 p.m. The letters "H" and "S" appeared to be written on top of the letters "PR," at 5:45 p.m., 6 p.m., 6:15 p.m., and 6:30 p.m. NM 1 stated that if a staff wanted to correct documentation, the staff needed to draw a line through the error, write error and initials of the staff making the correction, then write the correct documentation. The NM verified there was writing on top of existing writing and that the facility's policy regarding documentation and corrections was not followed.

During a review of the facility's policy and procedure (P&P) titled, "Documentation, Corrections," dated 2/2023, the P&P indicated the following: When an error is made ... corrections are allowed. All medical record entries are made as soon as possible after care, treatment or services provided. A medical record entry is never made in the medical record in advance of the care, treatment or service provided to the patient. Pre-dating or back dating an entry in the medical record is prohibited.
Procedure: Corrections to the paper medical record are made following the process stated below:
1. Handwritten entries are made with permanent black ink ...
2. All entries in the medical record must be legible, dated, timed, and authenticated.
3. Do not write over original medical record entry to obscured what was originally written ...
4. Erasers and use of correction fluid or tape ...are prohibited.
5. Corrections of entries are done, as follows:
a. Draw a SINGLE line through the mistake ...
b. Write ERROR next to the single lined through mistake, then write the time, date, and sign/titled.
c. Document the correct information above the error ...
d. Use the current time, date, and then time, date, and sign/title for the new entry.

Based on observation, interview, and record review, the facility failed to ensure for one of 30 sampled patients (Patient 16), the facility's policy and procedure (P&P) for infection control was implemented when, Patient 16's intravenous tubing (known as "piggyback," a flexible tube that administers medication) was not labeled with a date for change of IV (Intravenous, into the vein) tubing, and IV site was not dated.

This deficient practice had the potential to result in Patient 16 being exposed to infections such as phlebitis (infection of the veins) and/or bloodstream infection caused by prolonged use of IV tubing and IV insertion site.

Finding:

During a review of Patient 16's "Face Sheet (a document containing a patient's medical and demographic information)," undated, the face sheet indicated Patient 16 was admitted to the facility on 6/23/2025 at 6:56 p.m., with a medical diagnosis of lactic acidosis (a condition causing blood to be acidic).

During an observation on 6/25/2025 at 11:00 a.m., in Patient 16's room 211, Patient 16's IV (Intravenous, into the vein) insertion site was observed with no insertion date label and the IV tubing piggyback (method of administering medication through an existing intravenous [IV]) line) antibiotic had no tubing label for change of tubing.

During a concurrent observation and interview on 6/25/2025 at 11:12 a.m. with Patient 16's registered Nurse (RN) 8 in room 211, RN 8 confirmed that Patient 16's IV insertion site had no insertion date label, and the IV piggyback tubing had no label sticker to indicate the next change of tubing. RN 8 stated the IV insertion site to the left antecubital (area on the inside of the elbow) should be labeled with insertion date and nurse initials and the IV piggyback should have a label with date of next tubing change. RN 8 also said these are all measures to prevent infection. RN 8 further stated the IV tubing, and IV insertion site were changed every three days unless contraindicated and documented.

During an interview on 6/26/2025 at 8:55a.m. with the Director of Medical/Surgical floor (DIR) 2, the DIR 2 stated, the standard of care for patients with IV access was for the insertion site to be assessed every shift for patency (condition of being open), date of insertion and documented in the patients' medical record. DIR 2 also said that for IV piggyback medication tubing, they need to be labeled with next change of tubing date. DIR 2 further stated IV tubing should be changed every 72 hours for infection prevention.

During a review of the facility's policy and procedures (P&P) titled, "Intravenous Therapy," reviewed 2/2023, the P&P indicated, "The peripheral IV site is to be changed every 72 hours to prevent infection and phlebitis from occurring. If the site is not changed, document reason(s) in the medical record. IV tubing, including piggy-back tubing will be changed every 72 hours with the following exceptions: 1. TPN (Total Parenteral Nutrition, a method of feeding a patient intravenously (through a vein) when they cannot get adequate nutrition through their digestive system) /Lipids (a liquid preparation of fat used in intravenous infusions to provide calories and essential fatty acids to patients unable to obtain adequate nutrition through oral intake) change every 24 hours."

Based on observation and interview, the facility failed to ensure one of three sampled campuses (Campus 1) Behavioral Health Unit (BHU), was kept clean and free of flies, in accordance with the facility's policy regarding Infection control and prevention.

This deficient practice had the potential to cause infections through contaminated areas and objects, which could negatively impact the patients' and staff's overall health.

Findings:

During a concurrent observation and interview on 6/24/2025 at 12:34 p.m. with Behavioral Health Worker (BHW) 4, in the seclusion room (involuntary [without permission] confinement of a patient in a room or area from which the patient is physically prevented from leaving), BHW 4 stated he (BHW 4) saw juice stains and sticky areas on the floor. BHW 4 stated Environmental Services (EVS, department responsible for maintaining a clean working environment) usually came and clean the room. BHW 4 looked at the bed and stated, "I think it's juice on the mattress. It's dirty right now and it does have to be clean." BHW 4 stated there were wipes used to sanitize the bed, and anyone can go and clean the room.

During a concurrent observation and interview on 6/24/2025 at 12:37 p.m. with BHW 4, in the seclusion room bathroom, BHW 4 verified the toilet with brown stains was not clean. BHW 4 also stated he (BHW 4) saw a fly in the room, and that there were "A couple of flies here and there." BHW 4 stated he (BHW 4) noticed the flies this morning (6/24/2025) and did not notify anyone about the flies.

During a concurrent observation and interview on 6/24/2025 at 12:48 p.m. with Nurse Manager (NM) 2 and Charge Nurse (CN) 1, in another seclusion room, NM 2 and CN 1 verified there were stains on the wall. NM 2 stated, "The whole unit looks dirty."

During an interview on 6/26/2025 at 11:53 a.m. with the Director (DIR) 4 of Infection Control, DIR 4 stated she (DIR 4) did not hear of any flies in the units recently. DIR 4 stated the plan to remove pests was to meet with EVS to coordinate a cleaning effort to see if the patient's rooms, lounge, or patio areas had to be treated. DIR 4 said the nursing directors and charge nurses would take guidance from EVS, and effectiveness would be evaluated within 24 hours. DIR 4 stated flies could contaminate food surfaces and patient wounds.

During an interview on 6/27/2025 at 9:12 a.m. with the Environmental Services Manager (ESM), ESM stated he (ESM) was always made aware of flies and other pests. ESM stated he and his (ESM) staff were not called about the flies.

During an interview on 6/27/2025 at 5:20 p.m. with the Director of Behavioral Health (DIR) 3, DIR 3 stated humane care can be physical care and needs of the patient. DIR 3 stated "we should be on top of asking EVS to clean for soiled areas and after discharge, and for infection prevention." DIR 3 stated, the areas "Should definitely be kept clean." DIR 3 stated the danger of not having a clean environment "Could cause slips, falls, bugs, maybe another patient picking something up that should have been picked up by staff," and was part of infection control.

During a review of the facility's policy and procedure (P&P) titled, "Infection Prevention and Control Plan," dated 2/2025, the P&P indicated, "Develop and implement a preventative and corrective program designed to minimize infectious hazards, including reviewing and evaluating aseptic, isolation, and sanitation techniques ...Infection Prevention: The outcome objectives are to reduce the risk of preventable HAIs (Hospital Acquired Infections), reduce the risk of multi-drug resistant organisms, decrease patient suffering and inconvenience ..."

During a review of the facility's policy and procedure (P&P) titled, "Patients Rights," dated 8/2022, the "P&P" indicated, "In addition, LPS (Lanterman-Petris-Short Conservatorship, is a legal process in California where a court appoints someone to care for and make decisions for an individual deemed "gravely disabled" due to a mental disorder. This mechanism allows for involuntary mental health treatment and placement, including medication and living arrangements, when the individual cannot provide for their basic needs) grants all patients these irrevocable rights: To dignity, privacy and humane care."

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

1. Ensure its staff followed infection control policy and procedure (P&P) when the annual tuberculosis (TB, a serious infectious bacterial disease that primary affects the lung, is spread through the air, and can stay in the air for several hours) screening, was missing for one (1) of 10 sampled employees (Registered Nurse [RN] 5).

This deficient practice had the potential to put the facility's staff and patients at risk for acquiring (catching) TB.

2. Ensure its staff followed infection control policy and procedure (P&P), when evidence of either influenza (the flu, a contagious viral disease that affects the lungs and is spread through coughing and sneezing) vaccination administration or declination, was missing for one (1) of 10 sampled employees (Behavioral Health Worker [BHW] 10).

This deficient practice had the potential to put the facility's staff and patients at risk for acquiring influenza.

Findings:

1. During a concurrent interview and record review on 6/27/2025 at 3:33 p.m. with the Director of Infection Control (DIR) 4, Registered Nurse (RN) 5's employee health records, were reviewed. RN 5 had a positive QuantiFERON test (a blood test used to help detect TB infection) on 5/16/2019. The most recent TB (tuberculosis, a serious infectious bacterial disease that primary affects the lung, is spread through the air, and can stay in the air for several hours) symptom screening listed for RN 5, was on 10/12/2023. DIR 4 stated that RN 5 was noncompliant and did not complete their annual TB symptom (signs of having a disease) screening in 2024. Additionally, DIR 4 stated RN 5's employment at the facility was terminated on 4/24/2025.

During the same interview on 6/27/2025 at 3:33 p.m. with the Director of Infection Control (DIR) 4, DIR 4 stated it was important for the facility to know their employees' TB status because they wanted to be able to catch if their employees convert from negative to positive TB status (go from not having TB to having TB), or from latent TB (when TB bacteria is present in the body but the immune system keeps them under control, preventing that person from feeling sick or spreading TB to other people) to active TB (when the immune system can't keep TB from multiplying and growing in the body, so that person feels sick and can spread TB to other people); if they were showing symptoms, the employees could have potentially given TB to their co-workers or their patients.

During a review of the facility's policy and procedure (P&P) titled, "Employee Health Program," last reviewed 11/2024, the P&P indicated, "Annual Tuberculosis (TB) Screening: a. Employees with documented history of negative tuberculin skin test (TST) will undergo an annual TST and TB symptom questionnaire. b. Employees with documented history of positive TST will complete an annual TB symptom questionnaire."

2. During a concurrent interview and record review on 6/27/2025 at 4:45 p.m. with the Director of Infection Control (DIR) 4, BHW 10's employee health records, were reviewed. DIR 4 stated there was no evidence in the records that BHW 10 had either received the 2024 flu vaccine or declined it. Additionally, DIR 4 stated BHW 10's employment at the facility was terminated on 4/24/2025.

During the same interview on 6/27/2025 at 4:45 p.m. with the Director of Infection Control (DIR) 4, DIR 4 stated that it was still important for staff to sign a declination form so that they understood the risk they were taking on if they declined the vaccine, such as flu transmission to themselves, to other patients, and to other employees, and also so that employees understood that they must wear a mask if they declined the vaccine to prevent transmission of influenza.

During a review of the facility's policy & procedure (P&P) titled, "Healthcare Personnel Influenza Vaccination," last reviewed 5/2020, the P&P indicated, "All personnel will be required to either accept or decline the influenza vaccine annually in order to comply with California Health and Safety Code, Section 1288.5 and any local, state and federal laws ... All healthcare personnel will be offered the influenza vaccine annually at no cost. Healthcare personnel are defined as employees, contract staff, licensed independent practitioners, and volunteers at [the facility] ... Healthcare personnel who choose to decline the vaccine will sign a declination form and will be required to wear a surgical mask while in the Hospital Board designated Mask Zones from November 1st through April 30th of each year."
1

Based on interview and record review, the facility failed to provide adequate number of Behavioral Health Workers (BHW, same as Mental Health Workers, non-licensed staff helping with unit rounding and assist patients with daily activities) to perform line of sight (a straight line along which an observer had unobstructed vision) monitoring in the Behavioral Health Unit (inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), in accordance with the facility's policy on rounding and observation, for three of four sampled shifts (Shift 1, 2 and 3) at Unit S on 4/20/2025 and 6/14/2025.

This deficient practice had the potential to result in insufficient monitoring of patients in BHU and putting patients at risk for injury. On 4/20/2025, a Behavioral Health Worker (BHW 10) pushed Patient 10, and Patient 10 sustained a left eyebrow injury. On 6/14/2025, Patient 9 hit Patient 8 in the room. Patient 8 sustained a fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) and bruises on face and head following the assault (an intentional act that causes another person to reasonably fear imminent harmful or offensive contact).

Findings:

During an interview on 6/24/2025 at 3:10 p.m. with the Nurse Manager (NM 2) of BHU, NM 2 stated the following: there were different levels of monitoring aside from standard every 15-minutue rounding in BHU. A specific staff was assigned to a specific patient who needed one to one (1:1, one staff [sitter] assigned to be with one patient) monitoring and the staff had to stay with the patient within arm's length. For patients who needed line of sight (a straight line along which an observer had unobstructed vision) monitoring, staff would need to keep a close eye on the patients and maintain visual on the patients outside their regular every 15-minute rounding.

During an interview on 6/26/2025 at 3:41 p.m. with the Staffing Coordinator (SC), SC stated the following: she (SC) had been preparing staffing for BHU at Campus 1 for 2 years. Each unit would staff with three BHWs at minimal each shift and would staff up based on the acuity of the unit. Patients requiring one to one (1:1) monitoring and line of sight monitoring would be high acuity (the severity of a patient's illness or injury, and the level of care they require). One additional BHW would be added to each patient who was on 1:1 and/or line of sight monitoring. Staffing Coordinators would obtain census, number of patients on 1:1 and line of sight monitoring from the charge nurse when preparing for the staffing.

During a concurrent interview and record review on 6/26/2025 at 3:53 p.m. with SC, the facility's BHU "Unit S, AM Shift Assignment (Shift 1)," dated 4/20/2025, was reviewed. The "Unit S, AM Shift Assignment" indicated, there were five (5) BHWs staffed for census of 20 patients with 10 patients requiring line of sight monitoring. SC stated the following: based on the census and number of patients requiring line of sight, Unit S would need thirteen (13) BHWs to cover rounding and line of sight monitoring. 5 BHWs would not be enough to cover half of the patients who required line of sight monitoring.

During a concurrent interview and record review on 6/26/2025 at 3:55 p.m. with SC, the facility's BHU "Unit S, PM Shift Assignment (Shift 2)," dated 4/20/2025, was reviewed. The "Unit S, PM Shift Assignment" indicated, there was one licensed vocational nurse (LVN) working as BHW and three (3) BHWs staffed for census of 20 with 10 patients requiring line of sight monitoring. SC stated the following: based on the census and number of patients requiring line of sight, Unit S would need thirteen (13) BHWs to cover rounding and line of sight monitoring. With the one LVN who worked as BHW that night, there were only four (4) staff to do rounding and line of sight monitoring, which was not enough. SC further stated there was potential risk for patient hurting another patient, someone could get hurt and staff could feel stressed due to short staffing.

During a review of Patient 10'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 4/16/2025, the Psych Eval indicated, Patient 10 was a 77-year-old 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) with diagnosis including but not limited to schizoaffective disorder (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]) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 10's "Progress Note Non-Physician (nursing progress notes)," dated 4/20/2025, the "Progress Note Non-Physician," indicated, at 3:17 a.m., Patient 10 went to nursing station with bleeding at corner of left eyebrow, Patient 10 informed RN 5 that "I got my pants wet and requested for another pair. The BHW (Behavioral Health Worker 10) put his hand on me, held me tight on my neck, and pushed me back from the door of my room to my bed. I hit myself somewhere, not sure if it was on my bed or on the wall. I had a scar on my left eyebrow since I was 9 years old. It started bleeding where the scar is." The "Progress Note Non-Physician," also indicated RN 5 spoke with BHW 10 with BHW 10 stating, "This guy came talking shit to me. He put his hand on me, and I tried to defend myself by pulling my arm away from him. and he (Patient 10) lost his balance."

During a concurrent interview and record review on 6/26/2025 at 4:06 p.m. with SC, the facility's BHU "Unit S, AM Shift Assignment" (Shift 3), dated 6/14/2025, was reviewed. The "Unit S, AM Shift Assignment" indicated, there were five (5) BHWs staffed for census of 20 patients with 4 (four) patients requiring line of sight monitoring and two (2) patients requiring one to one monitoring. The "Unit S, AM Shift Assignment" also indicated four (4) BHWs were canceled and one BHW was flexed at 2 p.m. SC stated the following: based on the census and number of patients requiring line of sight, Unit S would need nine (9) BHWs to cover rounding, line of sight and 1:1 monitoring. SC further stated five (5) BHWs was not enough to cover all the line-of-sight monitoring. The four (4) BHWs should not have been canceled.

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 4/16/2025, the Psych Eval indicated, Patient 8 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) with diagnosis including but not limited to schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 8's "Consultation Report," dated 4/16/2025, the "Consultation Report" indicated, Patient 8 had past medical history of pseudoseizures (event that mimic seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness] but are not caused by abnormal electrical activity in the brain) and autism (neurodevelopmental disorder characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication).

During a review of Patient 9'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 6/5/2025, the Psych Eval indicated, Patient 9 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) with diagnoses including but not limited to a 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days 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 (harming self), danger to others (harming others), and grave disability (inability to care for oneself), and schizoaffective disorder (mental illness that affects mood and has symptoms of hallucinations and/or delusions) bipolar type (a mental illness that causes unusual shifts in mood, energy, and concentration).
During a review of Patient 9's "Order Information for: Patient Monitoring (physician order)," dated 6/10/2025, the physician order indicated, Patient 9 was placed on line of sight observation starting 6/10/2025.
During a review of Patient 8's "Order Information for: Patient Monitoring (physician order)," dated 6/12/2025, the physician order indicated, Patient 8 was placed on 1:1 sitter observation starting 6/12/2025.
During a review of Patient 8's "Progress Note Non-Physician (nurses progress notes)," dated 6/14/2025, the "Progress Note Non-Physician" indicated, "Patient (Patient 8) was attacked by his (Patient 8's) roommate (Patient 9) approximately 1830 (6:30 p.m.). Patient (Patient 8) was witnessed falling back out of his (Patient 8's) room into the hallway noted hitting the back of his (Patient 8's) head ... Patient (Patient 8) unable to follow command for PERRLA (Pupils equal, round, and reactive to light and accommodation, standard eye exam to check the health of eyes and the nervous system). Right pupil 3 mm (millimeters, unit of measure) reactive to light. Left pupil nonreactive (the pupil [the black circle in the center of the eye] doesn't constrict [get smaller] in response to light or when focusing on a near object). Rapid Response (a system designed to quickly address a patient's sudden clinical deterioration before it escalates into a medical emergency) was called at 1838 (6:38 p.m.) ... [physician] was notified ... CT (computed tomography, a medical imaging technique to create detailed images of the inside of the body) head, transfer to telemetry floor [room number]. Pending report." The "Progress Note Non-Physician" also indicated Patient 8 was transferred to the facility's telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) floor at 7:31 p.m.
During an interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated on 6/14/2025, he (BHW 5) was sitting in the hallway and saw Patient 8 and Patient 9 went to the room. BHW 5 stated, "I heard feet shuffling in the room. I got up, peeked into the window and saw Patient 9 was on top of Patient 8 on the ground hitting Patient 8. Patient 9 was aggressive to Patient 8."
During the same interview on 6/25/2025 at 1:45 p.m. with BHW 5, BHW 5 stated he (BHW 5) was not aware Patient 9 was under line-of-sight monitoring. BHW 5 also stated Patient 8 was on one to one (1:1) monitoring that day (6/14/2025), but his (Patient 8's) assigned sitter was flexed earlier that day due to overstaffing and no one was assigned to replace the sitter. BHW 5 stated there was no line of sight for both patients (Patient 8 and Patient 9) because the door was closed.
During an interview on 6/25/2025 at 2:29 p.m. with the Charge Nurse (CN) 3 of BHU, CN 3 stated the following: the charge nurse of the unit was responsible for making assignment for the shift. There was no specific person assigned to perform line of sight. Any staff not assigned as 1:1 monitoring would be watching patients who required line of sight monitoring. The staff would need to see those patients at all times. CN 3 also stated a physician order was required for starting and discontinuing any line of sight and 1:1 monitoring.
During a concurrent interview and record review on 6/25/2025 at 2:52 p.m. with the Nurse Manager (NM) 2 of BHU, the facility's Campus 1 BHU assignment, "Unit S, AM Shift Assignment," dated 6/14/2025, was reviewed. The "Unit S, AM Shift Assignment" indicated, Patient 8 was 1:1 monitoring and Patient 9 was on line of sight monitoring. The "[Unit] AM Shift Assignment" did not indicate which nursing staff was assigned to Patient 8 and Patient 9 to perform the 1:1 monitoring and line of sight monitoring. NM 2 stated she (NM 2) could not tell which staff was assigned to perform line of sight monitoring because it was not written on the assignment.
During an interview on 6/27/2025 at 9:37 a.m. with the Director (DIR) 3 of BHU, DIR 3 stated the BHU unit did not assign line of sight monitoring per patient per staff before. DIR 3 stated, "we did not have the staff." DIR 3 further stated there was no policy or staffing grid to guide the staffing coordinators on how to staff BHWs to the unit.
During a review of the facility's policy and procedure (P&P) titled, "Rounding, Observation and Monitoring of Patients," dated 10/2021, the P&P indicated, "The charge nurse is responsible for assigning BHU staff to make unit rounds in order to account for all patient's whereabouts and ensure a safe environment ... Observation levels are designed to provide the right level of observation, precaution and oversight commensurate with physician and RN assessment of the safety needs of the patient in alignment with the current behavior and symptoms they are demonstrating ... Three levels of staff monitoring are provided ... Level II - moderate - line of sight ... Policy - A level of observation wherein the patient remains in staff view at all times. A specific staff member is assigned and the line of observation is maintained by staff in person and not through video monitoring ... Level III - intensive - one to one ... Policy - consists of one to one staff observation with a patient never farther away than arm's length. The patient remains within arm's length at all times ... The RN is responsible for obtaining an MD order for an observation level that is line of sight or 1 to 1 ... When the patient's status permits, the RN will notify the MD and get an order to down-grade the observation status to that of "least restrictive" in a manner to maintain the patient in an optimal level of safety."
During a review of the facility's policy and procedure (P&P) titled, "Scope of Service," dated 10/2021, the P&P indicated, "Management of Patients ... 1. Nursing care is delivered based on acuity of the patient, skill level of the nurse and available resources ... Note: Augmentation of nursing resources, beyond core staffing will be based on the acuity of the patients and the nursing skill level."

Based on interview, and record review, the facility failed to ensure two of 30 sampled patients' (Patient 28 and Patient 29) inter-disciplinary treatment plan was developed and implemented when:

1. Patient 28's inter-disciplinary treatment plan (a structured, individualized document that outlines the care team objectives, intervention and the strategies to achieve specific health goals) for anemia (a condition where the body doesn't have enough healthy red blood cells or hemoglobin to carry sufficient oxygen to the body's tissues) was not developed and implemented by nursing staff within 8 hours of admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility's policy regarding Multidisciplinary treatment plan.

This deficient practice had the potential for the care needs and risks of Patient 28 to not be identified and addressed which may result in patient harm.

2. Patient 29's inter-disciplinary treatment plan (a structured, individualized document that outlines the care team objectives, intervention and the strategies to achieve specific health goals) for hypertension (high blood pressure) was not developed and implemented by nursing staff within 8 hours of admission (a process in healthcare that involves evaluating a patient's condition to identify problems, determine the need for interventions, and guide treatment plans), in accordance with the facility's policy regarding Multidisciplinary treatment plan.

This deficient practice had the potential for the care needs and risks of Patient 29 to not be identified and addressed which may result in patient harm.

Findings:

1. During a review of Patient 28'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 06/20/2025, the Psych eval record indicated that Patient 28 was placed on a 5150 hold (a 72-hour involuntary psychiatric hold) for being gravely disabled (GD, when a person is no longer able to provide for their own food, clothing, or shelter because of a mental health disorder). The Psych eval indicated Patient 28 was discovered with altered mental status (AMS, a change in a person's normal level of consciousness, awareness, or cognitive function [the mental processes that enable someone to perceive, process, and understand information, make decisions, and learn]), wandering around in public with his (Patient 28) pants down, and unable to meet basic needs independently for survival, and at risk for failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity). The Psych eval also indicated Patient 28 had a medical history of anemia (a condition where the body doesn't have enough healthy red blood cells or hemoglobin to carry sufficient oxygen to the body's tissues).

During a concurrent interview and record review on 06/27/2025 at 4:30 p.m. with Performance Improvement Registered Nurse (PIRN), Patient 28's medical record titled, "Interdisciplinary Master Treatment Plan," dated 06/23/2025, was reviewed. Patient 28's medical record indicated that a treatment plan for anemia was not developed and implemented. PIRN stated that the admitting nurse did not initiate a treatment plan for anemia. PIRN also said Patient 28 had history of anemia and was on ferrous sulfate (an iron supplement used to treat or prevent low blood levels of iron such as those caused by anemia) medication since admission.

During an interview on 6/27/2025 at 5:19 p.m. with the Director of Behavioral Health (DIR) 3, DIR 3 stated upon review of the facility's electronic medical record (EMR, a digital version of a patient's medical chart) system, it was found that the EMR in the behavioral health unit (BHU, a specialized unit that provide care for individuals with mental health conditions) did not have the option for the nurse to create an anemia treatment plan. DIR 3 said the BHU leadership would reach out to the information technology (the department responsible for managing and maintaining the facility's technology infrastructure, including software, and data) department to fix that problem.

During a review of the facility's Policy and Procedure titled, "Multidisciplinary Treatment Plan," with last revised date of 12/2023, the P&P indicated the following:

Policy: Each patient admitted to the Behavioral Health Unit at College Medical Center shall have an individualized written treatment plan which is based on interdisciplinary clinical assessments. The treatment planning process is continuous, beginning at the time of admission and continuing through discharge. Treatment planning takes place prior to the first treatment team meeting for the patient and is reviewed at the first treatment meeting and in regular treatment reviews. All members of the multidisciplinary treatment team shall be present during the meetings, including but not limited to nursing, social work, discharge planning, recreational therapy, the attending psychiatrist and the patient (if possible). Patients and families are involved in the treatment planning process by providing input and receiving ongoing feedback.

Procedure: Multi-disciplinary Treatment Team:
Within eight (8) hours of admission, nursing staff shall begin to develop a treatment plan based on an assessment of the patient's presenting problems, emotional, cultural, behavioral, physical, spiritual and sensory deficits.


2. During a review of Patient 29's "Consultation Report," dated 06/20/2025, the consultation report indicated that Patient 29's blood pressure was elevated, was anxious (a feeling of unease, worry, or fear), and currently on psychiatric hold with suicidal) thoughts of taking one's own life) gesture. Patient 29 had hypertension (high blood pressure) history.

During a concurrent interview and record review on 06/27/2025 at 4:40 p.m. with Performance Improvement Registered Nurse (PIRN), Patient 29's medical record titled, "Interdisciplinary Master Treatment Plan," dated 06/20/2025, was reviewed. Patient 29's medical record also indicated that a treatment plan for hypertension was not developed and implemented. PIRN stated that the admitting nurse did not initiate a treatment plan for hypertension. PIRN said Patient 29 had history of hypertension and was on medication for hypertension. PIRN stated the admitting nurse should have initiated a treatment plan for hypertension.

During a review of the facility's Policy and Procedure (P&P) titled, "Multidisciplinary Treatment Plan", with last revised date of 12/2023, the P&P indicated the following:

Policy: Each patient admitted to the Behavioral Health Unit at College Medical Center shall have an individualized written treatment plan which is based on interdisciplinary clinical assessments. The treatment planning process is continuous, beginning at the time of admission and continuing through discharge. Treatment planning takes place prior to the first treatment team meeting for the patient and is reviewed at the first treatment meeting and in regular treatment reviews. All members of the multidisciplinary treatment team shall be present during the meetings, including but not limited to nursing, social work, discharge planning, recreational therapy, the attending psychiatrist and the patient (if possible). Patients and families are involved in the treatment planning process by providing input and receiving ongoing feedback.

Procedure: Multi-disciplinary Treatment Team:
Within eight (8) hours of admission, nursing staff shall begin to develop a treatment plan based on an assessment of the patient's presenting problems, emotional, cultural, behavioral, physical, spiritual and sensory deficits.