HospitalInspections.org

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 a safe environment in the facility's Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders), when there was no proper rounding (the process of regularly visiting patients to assess their condition) conducted, every 15 minutes (Q15min), for 15 of 46 sampled patients (Patients 1-15), in the BHU, to check on the patients' location, behavior, and environmental or personal safety, on 8/26/2025 from 11:00 p.m. to 8/27/2025 at 7:00 a.m., in accordance with the facility's policy regarding rounding, observation, and monitoring patients, who were admitted to the BHU.

This deficient practice had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, psychological trauma and/or death. In addition, this deficient practice resulted in Patient 1 alleging of being sexually assaulted (an act of sexual abuse in which one intentionally sexually touches another person without that person's consent) by Patient 2 without the facility's knowledge on when and how it happened. (Refer to A-0144)

2. The facility failed to ensure a safe environment in the facility's Behavioral Health Unit (BHU) when there was no proper line of sight (a straight line along which an observer had unobstructed vision) and Q (every) 15 minutes rounding, conducted for 21 of 46 sampled patients (Patient 2, Patient 7, Patient 16 -35), on 9/6/2025 from 6:00 p.m. to 9:30 p.m., in accordance with the facility's policy regarding rounding, observation, and monitoring patients, who are admitted to the BHU.

This deficient practice potentially placed 21 patients' safety at risk for self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done), violence, and/or death. (Refer to A-0144)

3. The facility failed to ensure one (1) of 46 sampled patients (Patient 1) was free from all forms abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility's policy on patient rights (a subset of human rights), when an allegation of sexual assault was made by Patient 1 on 8/27/2025.

This deficient practice had the potential for Patient 1 and other patients in the Behavioral Health Unit (BHU) to experience physical injury, psychological trauma, fear, or anxiety (persistent worry or fear), and may lose trust in healthcare providers and institutions. (Refer to A-0145)

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

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

1. The facility failed to ensure adequate supervision of the facility's Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) staff that included Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and the Behavioral health Technicians (BHTs), to ensure consistent and accurate Q (every) 15-minute patient rounding (the process of regularly visiting patients to assess their condition) for 15 of 46 sampled patients (Patients 1-15), in accordance with the facility's policy regarding "Rounding, Observation, and Monitoring of Patients."

This deficient practice had the potential to place patients at risk for suicide (thoughts of taking one's own life), self-harm, assault (an intentional act that causes a reasonable fear of immediate harmful or offensive contact, even if no physical contact actually occurs), or undetected medical emergencies, by leaving patients unsupervised for extended periods. (A-0395)

2. The facility failed to ensure nursing staff adequately assessed a patient's care needs and addressed, in a timely manner, one of 46 sampled patient's (Patient 39) low blood pressure (measures the amount of force needed to move blood throughout the body and to the organs), by calling for a Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration), in accordance with the facility's policy regarding calling a RRT and policy on Standards of Nursing Practice pertaining to the nursing care process. Patient 39 had a persistently low blood pressure for over 3 hours in the Telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm), on 5/26/2025, before being transferred to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries).

This deficient practice resulted in Patient 39 having a delay in further evaluation and treatment, when Patient 39 remained in the Telemetry unit for more than three hours before being transferred to the Intensive Care Unit (ICU), which could have led to further complications and/or death. (Refer to A-0395)

3. The facility failed to ensure nursing staff adhered to the facility's policy and procedure regarding "Rounding, Observation and Monitoring of Patients," and the facility's charting/documentation policy, when staff did not perform and accurately document the Q (every) 15-minute rounding (observing patient location and behavior), for 15 of 46 sampled patients (Patients 1-15), from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m.

This deficient practice had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, psychological trauma and/or death. In addition, this deficient practice resulted in Patient 1 alleging of being sexually assaulted (an act of sexual abuse in which one intentionally sexually touches another person without that person's consent) by Patient 2 without the facility's knowledge on when and how it happened. (Refer to A-0398)

4. The facility failed to ensure a concern of low blood pressure (measures the amount of force needed to move blood throughout the body and to the organs) lasting over several hours (3 hours), for one of 46 sampled patients (Patient 39), was escalated by using a Rapid Response Team (RRT, group of individuals [may include a nurse, respiratory therapist, physician] that responds to concerning or emergency situations and can provide additional evaluations and interventions), in accordance with the facility's policy and procedure regarding "Rapid Response Team (RRT)."

This deficient practice resulted in Patient 39, remaining in the Telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm), with persistent low blood pressure for more than three hours, before being transferred to a higher level of care (a more intensive and comprehensive level of medical health treatment), which delayed treatment and could have worsened Patient 39's condition. (Refer to A-0398)

4. The facility failed to ensure an Oxygen Tank (a device to provide respiratory [to breathe] support) was stored and readily available for immediate use on one of two sampled crash carts (Cart #1, a set of trays on wheels used in hospital for transportation and dispensing emergency medications and equipment), in the Emergency Department (ED, a specialized hospital unit that provides 24/7 unscheduled medical care for acute [sudden in onset], severe, and life-threatening injuries and illnesses), which may impact 46 of 46 sampled patients, in accordance with the facility's policy regarding crash cart equipment and medications.

This deficient practice had the potential to result in endangering patients' life by delaying the ability to provide respiratory support (medical interventions that assist a patient's breathing when they are unable to do so adequately on their own. Example: providing oxygen therapy from an oxygen tank) in an emergency, which may result in patient harm and/or death. (Refer to A-0398)

5. The facility failed to ensure staff followed the facility's "Peripheral Inserted Central Catheter: Assisting, Insertion, Care and Removal Policy," for 2 of 46 sampled patients (Patient 44 and Patient 45), when staff did not provide proper PICC line (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is positioned in a location at the superior vena cava [a large, significant vein responsible for returning deoxygenated blood collected from the body to the heart], and used for intravenous treatment that is required over a long period) care by not changing Patient 44's soiled PICC line dressing and not properly securing Patient 45's PICC line with a securement device.

This deficient practice had the potential for Patient 44 and Patient 45 to develop blood stream infections (when bacteria or other pathogens enter the blood stream causing infection) due to improper maintenance and care of PICC line. (Refer to A-0398)

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

Based on observation, interview and record review, the facility's Governing Body (GB, the group of individuals legally responsible for overseeing the hospital, including ensuring that policies are followed, resources are provided, and patient safety is protected) failed to:

1. Ensure oversight on the 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 so that a comprehensive action plan to assure a safe environment and that patients remain free of abuse (intentional maltreatment of an individual that may cause physical or psychological injury), was implemented. The action plan implemented immediately after the alleged incident of sexual abuse on 8/27/2025, involving one (1) of 46 sampled patients, included incomplete in-service regarding proper patient rounding (not all staff working received in-service since 8/28/2025), and the in-service plan did not include the role of the RN and Charge nurse to ensure compliance (of Licensed Vocational Nurses [LVNs] and Behavioral Health Technicians [BHTs]) with patient rounding (the process of regularly visiting patients to assess their condition).

The QAPI team did not also implement proper auditing process to determine if rounding is being done consistently and accurately, in accordance with the facility's policy regarding rounding and observation of patients, the facility's patient safety plan and the facility's Governing Body Bylaws (the facility's formal written rules that define its purpose, powers, and responsibilities. These bylaws require the Governing body to maintain ultimate accountability for the safety and quality of care, oversee hospital compliance with all laws and regulations, and ensure that the facility policies are implemented effectively to protect patients).

This deficient practice had the potential to cause serious harm or death when high-risk patients (patients who may be at risk of harm themselves, harming others, or experiencing a sudden medical emergency) are left unchecked for extended periods, thus increasing the risk of suicide (thoughts of taking one's own life) , self-harm, assault (to attack), or undetected medical emergencies.

2. Ensure oversight on the Nursing Department to ensure that staff (RNs, LVNs [Licensed Vocational Nurses], BHTs [Behavioral health Technicians]) working in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) were completing line-of-sight (a straight line along which an observer had unobstructed vision) and Q15 minutes (every 15 minutes) patient rounding, in accordance with the facility's policy regarding patient rounding, for 15 of 46 sampled patients (Patients 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15) on 8/27/2025 and 21 of 46 sampled patients (Patient 2, Patient 17, Patients 16-34) on 9/6/2025.

This deficient practice resulted in a sexual assault allegation involving Patients 1 (alleged victim) and 2 (alleged perpetrator) on 8/27/2025. This deficient practice also had the potential to cause serious harm or death when high-risk patients (patients who may be at risk of harm themselves, harming others, or experiencing a sudden medical emergency) are left unchecked for extended periods, thus increasing the risk of suicide (thoughts of taking one's own life) , self-harm, assault (to attack), or undetected medical emergencies.

Findings:

1. During a review of Patient 1's "Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Progress Note," dated 8/27/2025, the psychiatric progress note indicated, "This morning the patient (Patient 1) was anxious (feeling tense, on edge, restless, fearful), rambling at times, fixated on discharge. He (Patient 1) endorsed being sexually assaulted by his roommate (Patient 2), police department came to interview and Sexual Assault Response Team (SART, provides emotional support, advocacy, and access to victim assistance services) nurse made recommendations made by medical and nursing staff."

During a review of Patient 1's "Progress Notes Report," dated 8/27/2025, the record indicated Patient 1's "Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person's emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell)." The record further indicated at 8:53 a.m., on 8/27/2025, Patient 1 "Approached primary nurse and claimed that he (Patient 1) was raped by his (Patient 1) roommate (Patient 2) last night."

During a concurrent observation, interview and video footage review on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the video footage, dated 8/26/2025 from 11:00 p.m. to 7:00 a.m. on 8/27/2025, was reviewed. The following was observed:

-At 11:30 p.m., on 8/26/2025, BHT 2 was seen sitting in a chair in the hallway, no patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was observed.
-At 12:00 a.m., on 8/27/2025, no rounding was observed.
-At 12:30 a.m., BHT 2 was seen sleeping on a chair and no rounding conducted
-At 12:40 a.m., BHT 2 was seen sleeping on a chair and was being awoken by an unknown patient.
-At 12:44 a.m., BHT 2 was seen sitting in chair and filling out paperwork, no rounding was completed on the patients.
-At 1:30 a.m., Patient 2 was seen leaving his room (room shared by Patient 1 and Patient 2) to go into the activity room then back to his (Patient 2) room.
-At 2:00 a.m., BHT 3 was seen sitting in chair and no rounding was completed.
-At 2:13 a.m., Patient 2 was seen going in and out of his (Patient 2) room.
-At 4:00 a.m., BHT 2 was not in his chair in the hallway he was assigned to watch. No staff member was seen in the hallway rounding or monitoring the hallway. BHT 2 returned to his chair at 6:00 a.m.
-At 6:15 a.m., BHT 2 was seen sitting in chair and no rounding was completed.

During the same interview on 9/9/2025 at 12:59 p.m. with the DBHU, the DBHU confirmed that no rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation, to be conducted every 15 minutes, was for the staff to open the patients' door, check for patients' breathing and ensure the patients were safe. DBHU said that patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was done for patient safety, and anything can occur if not done correctly (referring to the patient rounding). The DBHU also confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU further stated Charge Nurses (RNs) were expected to round every 4 hours and licensed (RNs and LVNs) staff every 2 hours.

During a record review of the facility's documents titled, "Inservice Roster: Topic Rounding, Observation and Monitoring of Patients," dated 8/28/2025, 8/29/2025-8/30/2025 and 9/9/2025, the in-service roster indicated that 68 out of a total of 131 Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) staff members had been in-serviced regarding the BHU's policy titled, "Rounding, Observation, and Monitoring of Patients."

During a record review of the facility's document titled, "Behavioral Health Unit staffing sheet," dated 9/10/2025, the document indicated the following:
-For the 7AM to 7PM shift, a total of 10 out of 14 BHU staff members have attended the in-service regarding patient rounding.
-For the 7PM to 7AM shift, a total of 5 out of 19 BHU staff members have attended the in-service regarding patient rounding.
During a concurrent observation, interview and record review on 9/10/2025 at 2:16 p.m. with the Informational Technology Technician (ITT), and the Director of Behavioral health Unit (DBHU), the video footage dated 9/06/2025 from 6:00 p.m. to 9:30 p.m., was observed and reviewed. The Video Footage of 21 Patients (Patient 2, Patient 7, Patient 16 to Patient 34) indicated that all 21 patients were not rounded on/monitored consistently and accurately (despite the in-services regarding patient rounding that were conducted by the facility). Behavioral Health Technician (BHT) 4, BHT 5 and Licensed Vocational Nurse (LVN) 1 were observed using their phone, not properly rounding on patients, not opening patient's doors, skipping rooms, and no RN oversight, was observed. This was confirmed by the Director of BHU (DBHU).

During an interview on 9/9/2025 at 3:57 p.m. with the DBHU, the DBHU stated that in-service training for patient rounding was still on going and not all BHU staff have completed the in-service.

During an interview on 9/11/2025 at 9 a.m. with the Quality Risk Management Director (QRMD), the QRMD stated the following: The facility provided in-service training, on 8/28/2025, for patient rounding every 15 minutes, after the first CDPH (California Department of Public Health, a regulatory agency) surveyor initially investigated the allegation of sexual abuse made by Patient 1 on 8/27/2025. The QRMD stated the night shift staff were not conducting their rounds every 15 minutes. The QRMD also stated that even though patient rounding training had been provided, staff were still not conducting the rounds properly.

During an interview on 9/11/2025 at 10:07 a.m. with DBHU, DBHU stated when he (DBHU) comes in around 7:00 a.m. to 8:00 a.m., he (DBHU) requests a copy of the rounding sheets to make sure they're filled. He checks the rounding sheets with the video snippets and did not keep track of the videos he watched. DBHU stated he ensured the RNs were rounding by trying to look at specific times and at 15-minute portions. DBHU stated he (DBHU) did not have time to review a whole time period such as an hour, and the least amount of time he (DBHU) watched was 15 minutes. DBHU stated if he (DBHU) had more time he would watch another time period for 15 minutes. DBHU stated he trusted that he (DBHU) would see the staff conduct patient rounds. DBHU stated he ensured weekend staff was rounding by reinforcing rounding to all staff.

During the same interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU confirmed that BHT 1's and BHT 2's Q 15-minutes patient rounding documentation for dates from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., was falsified. The DBHU stated that all documentation should be accurate and in the case of the patient rounding documented from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., the documentation of rounding was not accurate (it was contrary to what was observed in the video footage).

During an interview on 9/11/2025 at 10:16 a.m. with the Director of the Behavioral Health Unit (DBHU), the DBHU stated the following: DBHU was informed by nursing staff on 8/27/2025, that 2 sheriffs were in his (DBHU) office investigating an allegation of a sexual assault made by Patient 1's significant other. DBHU spoke with the Quality Risk Management Coordinator (QRMC) and proceeded to go into the room with Patient 1 and the two Sheriffs. The DBHU, the QRMC and a social worker were present when the Sheriffs were interviewing Patient 1 on 8/27/2025. The DBHU asked Patient 1 a few questions, while the Sheriffs interviewed Patient 1. The DBHU did not conduct his (DBHU) own independent investigation. DBHU verified that no rounds (Q15 min) were conducted that night, 8/26/2025 from 11 p.m. to 8/27/2025 at 7 a.m., by the Behavioral Health Technicians (BHT) and Registered Nurses (RNs). The BHT falsified the rounding sheets and BHTs acknowledged it (the falsified data of Q 15-minute rounding). Medical records were supposed to be accurate. The DBHU asked the charge nurses to make sure rounding was being done on time. The DBHU requested a copy of the rounding sheet to make sure they were all filled out. The DBHU stated he (DBHU) audits the patient rounding by cross checking the rounding sheet and watching a 15-minute snippet of the video footage (on patient rounding) the next morning. The DBHU only watches for 15 minutes and does not keep a log or keep track of the audits on patient rounding.

During an interview on 9/12/2025 at 3:18 p.m. with the Chief Executive Officer (CEO), the CEO stated the following: The Governing Body (GB, the group of individuals legally responsible for overseeing the hospital, including ensuring that policies are followed, resources are provided, and patient safety is protected) was not aware there were issues with patient safety rounds, or inaccurate documentation of the safety rounds. The Governing Body was only aware after the alleged incident between Patient 1 and Patient 2 which occurred on 8/27/2025. The CEO also said that video surveillance of patient rounding was sporadically reviewed and only reviewed if an incident occurred. The CEO stated QAPI (Quality Assurance and Performance Improvement, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) should communicate with the GB regarding any patient safety issues and QAPI should ensure action plans are effective and in place. The CEO further stated the Governing Body had authority for overall operations of the hospital, including patient safety.

During an interview on 9/12/2025 at 4:17 p.m. with Quality Risk Management Director (QRMD), QRMD stated the whole hospital was involved in ensuring patient safety and all patient care departments (such as the Nursing Department) report to the QAPI department quarterly, and the data (QAPI initiatives such as CLABSIs and any patient safety issues) was then reported by the QAPI to the Medical Executive Committee (represents the medical staff, oversees quality of care, ensures professional conduct, and makes key recommendations to the hospital's administration and board of directors) and the Governing Body because the GB had oversight over QAPI (the committee in which the QRMD is part of and responsible for performance improvement activities, track adverse patient events and other patient safety issues, analyze the causes, implement preventive action plans, and audit mechanisms to ensure compliance and continuous improvement). QRMD stated the Patient rounding video footage for the whole night (on 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m.), was not thoroughly reviewed or analyzed in its entirety, because it was not under their (referring to the QAPI) scope of work (The QRMD relied on the DBHU to complete the video footage review on patient rounding. This lack of coordinated effort between the DBHU and the QRMD does not align with the facility's "patient safety plan" regarding creating procedures for responding to system or process failures and the facility's "patient safety plan" that indicated "All hospital departments, programs, and services participate in the patient safety program").

During a review of the facility's "Governing Board of Directors Bylaws (the facility's formal written rules that define its purpose, powers, and responsibilities. These bylaws require the Governing Body to maintain ultimate accountability for the safety and quality of care, oversee hospital compliance with all laws and regulations, and ensure that the facility policies are implemented effectively to protect patients)," dated 02/08/2024. The facility's GB bylaws indicated, "The purpose of the Hospital Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care, and provide for organizational management, and planning of the Hospital. The Governing Board has ultimate responsibility and legal authority for safety and quality of care, treatment, and services rendered in the Hospital.

During a review of the facility's policy and procedure (P&P) titled, "Patient Safety Plan," dated 9/2025, the P&P indicated, "The Patient Safety Plan is a framework to establish and maintain a safe patient care environment. It expands the organization-wide support for risk management, performance improvement, information management, education, human resources, and patient rights by implementing patient safety standards, measuring, monitoring their effectiveness, and creating a "culture of safety" as part of the overall quality program ...The scope of the patient safety program includes the full range of safety issues, from potential or no-harm errors (sometimes referred to as near misses, close calls, or good catches) to hazardous conditions and sentinel events. All hospital departments, programs, and services participate in the patient safety program. As part of the patient safety program, the hospital creates procedures for responding to system or process failures."

2. During a review of Patient 1's "Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Progress Note," dated 8/27/2025, the psychiatric progress note indicated, "This morning the patient (Patient 1) was anxious (feeling tense, on edge, restless, fearful), rambling at times, fixated on discharge. He (Patient 1) endorsed being sexually assaulted by his roommate (Patient 2), police department came to interview and Sexual Assault Response Team (SART, provides emotional support, advocacy, and access to victim assistance services) nurse made recommendations made by medical and nursing staff."

During a review of Patient 1's "Progress Notes Report," dated 8/27/2025, the record indicated Patient 1's "Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person's emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell)." The record further indicated at 8:53 a.m., on 8/27/2025, Patient 1 "Approached primary nurse and claimed that he (Patient 1) was raped by his roommate (Patient 2) last night."

During a review of Patient 1's "Progress Note," dated 8/28/2025 and timed at 11:20 a.m., the record indicated Patient 1 was discharged from the facility on 8/28/2025 at 11:15 a.m. Patient 1 was accompanied by family and both verbalized understanding of discharge instructions.

During a review of Patient 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 8/24/2025, the H&P indicated Patient 2 was admitted to the facility on 8/23/2025. The H&P also indicated Patient 2 had major depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable) and suicidal ideations (thoughts of taking one's own life).

During a review of Patient 2's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 2 was placed under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient's location and activity) and was on suicide/self-harm and fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) precautions. On 8/26/2025 at 2:30 p.m., Patient 2 was noted to be anxious.

During a review of Patient 2's "Psychiatric Discharge Note," dated 8/28/2025 and timed 1718 (5:18 p.m.), the record indicated Patient 2 was discharged home on 8/28/2025.

During a review of Patients 1 and 2's document titled, "BHU Q (every) 15 Minute Roundings and Observation Form," dated 8/26/2025, the form indicated from times 2300 (11:00 p.m.) to 0700 (7:00 a.m.), Patients 1 and 2's behavior was documented asleep/breathing.

During a concurrent observation, interview and video footage review on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the video footage, dated 8/26/2025 from 11:00 p.m. to 7:00 a.m. on 8/27/2025, was reviewed. The following was observed:
-At 11:30 p.m., on 8/26/2025, BHT 2 was seen sitting in a chair in the hallway, no patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was observed.
-At 12:00 a.m., on 8/27/2025, no rounding was observed.
-At 12:30 a.m., BHT 2 was seen sleeping on a chair and no rounding conducted
-At 12:40 a.m., BHT 2 was seen sleeping on a chair and was being awoken by an unknown patient.
-At 12:44 a.m., BHT 2 was seen sitting in chair and filling out paperwork, no rounding was completed on the patients.
-At 1:30 a.m., Patient 2 was seen leaving his room (room shared by Patient 1 and Patient 2) to go into the activity room then back to his (Patient 2) room.
-At 2:00 a.m., BHT 3 was seen sitting in chair and no rounding was completed.
-At 2:13 a.m., Patient 2 was seen going in and out of his room.
-At 4:00 a.m., BHT 2 was not in his chair in the hallway he was assigned to watch. No staff member was seen in the hallway rounding or monitoring the hallway. BHT 2 returned to his chair at 6:00 a.m.
-At 6:15 a.m., BHT 2 was seen sitting in chair and no rounding was completed.

During the same interview on 9/9/2025 at 12:59 p.m. with the DBHU, the DBHU confirmed that no rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation, to be conducted every 15 minutes, was for the staff to open the patients' door, check for patients' breathing and ensure the patients were safe. DBHU said that patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was done for patient safety, and anything can occur if not done correctly (referring to the patient rounding). The DBHU also confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU further stated Charge Nurses (RNs) were expected to round every 4 hours and licensed (RNs and LVNs) staff every 2 hours.

During an interview on 9/9/2025 at 3:57 p.m. with the DBHU, the DBHU stated that in-service training regarding patient rounding compliance was still on going and not all BHU staff have completed the in-service. The DBHU stated that the goal was to have all staff in-serviced as soon as possible.

During an interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU confirmed that BHT 1's and BHT 2's Q 15-minutes patient rounding documentation for dates from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., was falsified. The DBHU stated that all documentation should be accurate and in the case of the patient rounding documented from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., the documentation of rounding was not accurate (it was contrary to what was observed in the video footage). The DBHU said he (DBHU) asked the charge nurses to make sure rounding was being done on time. The DBHU requested a copy of the rounding sheet to make sure they were all filled out. The DBHU stated he (DBHU) audits the patient rounding by cross checking the rounding sheet and watching a 15-minute snippet of the video footage (on patient rounding) the next morning. The DBHU only watches for 15 minutes and does not keep a log or keep track of the audits on patient rounding.
During the same interview on 9/11/2025 at 10:07 a.m. the DBHU stated the following: DBHU was informed by nursing staff on 8/27/2025, that 2 sheriffs were in his (DBHU) office investigating an allegation of a sexual assault made by Patient 1's significant other. DBHU spoke with the Quality Risk Management Coordinator (QRMC) and proceeded to go into the room with Patient 1 and the two Sheriffs. The DBHU, the QRMC and a social worker were present when the Sheriffs were interviewing Patient 1 on 8/27/2025. The DBHU asked Patient 1 a few questions, while the Sheriffs interviewed Patient 1. The DBHU did not conduct his (DBHU) own independent investigation. The DBHU stated that Patient 1 repeatedly verbalized "I just want to go home."

During the same interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU confirmed that BHT 1's and BHT 2's Q 15-minutes patient rounding documentation for dates from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., was falsified. The DBHU stated that all documentation should be accurate and in the case of the patient rounding documented from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., the documentation of rounding was not accurate (it was contrary to what was observed in the video footage).

During a concurrent observation, interview and record review on 9/10/2025 at 2:16 p.m. with the Informational Technology Technician (ITT), and the Director of Behavioral health Unit (DBHU), the video footage dated 9/06/2025 from 6:00 p.m. to 9:30 p.m., was observed and reviewed. The Video Footage of 21 Patients (Patient 2, Patient 7, Patient 16 to Patient 34) indicated that all 21 patients were not rounded on/monitored consistently and accurately (despite the in-services regarding patient rounding that were conducted by the facility). Behavioral Health Technician (BHT) 4, BHT 5 and Licensed Vocational Nurse (LVN) 1 were observed using their phone, not properly rounding on patients, not opening patient's doors, skipping rooms, and no RN oversight, was observed. This was confirmed by the Director of BHU (DBHU).

During a concurrent interview and record review on 9/10/2025 at 3:02 p.m. with the Clinical Analyst Information Technology (CAIT) and Registered Nurse (RN) 4, Patient 1's "Electronic Medical Record," undated, was reviewed. CAIT confirmed that Patient 1 was discharged on 8/28/2025 at 11:15 a.m.

During an interview on 9/10/2025 at 3:20 p.m. with RN 4 and CAIT, Patient 2's "Electronic Medical Record," undated, was reviewed. CAIT confirmed that Patient 2 was discharged on 8/28/2025 at 11:35 a.m.

During an interview on 9/11/2025 at 10:07 a.m. with the DBHU, the DBHU stated he (DBHU) checked the rounding sheets with the video snippets and did not keep track of the videos he watched and trusted he (DBHU) would see the staff conducting patient rounds. DBHU stated he (DBHU) ensured weekend staff were rounding by reinforcing patient rounding to all staff.

During the same interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU stated he (DBHU) did not see the actual Sexual Assault Response Team report ([SART report- document detailing a forensic medical exam of a sexual assault victim]). DBHU was told by the SART nurse that it did not seem like there was abuse, and that the alleged victim (Patient 1) did not want to file any charges. DBHU stated he (DBHU) did not have the official report from the forensic nurse confirming whether or not the allegation occurred.

During an interview on 9/12/2025 at 11:58 a.m. with Quality Risk Management Director (QRMD), QRMD stated Patients 1 and 2 were discharged and the facility could not continue with the investigation after Patients 1 and 2 were discharged.

During an interview on 9/12/2025 at 4:17 p.m. with Quality Risk Management Director (QRMD), QRMD stated the whole hospital was involved in ensuring patient safety and all patient care departments (such as the Nursing department) report to the QAPI department quarterly, and the data (QAPI initiatives such as CLABSIs and any patient safety issues) was then reported by QAPI to the Medical Executive Committee (represents the medical staff, oversees quality of care, ensures professional conduct, and makes key recommendations to the hospital's administration and board of directors) and the Governing Body because the GB had oversight over QAPI (the committee in which the QRMD is part of and responsible for performance improvement activities, track adverse patient events and other patient safety issues, analyze the causes, implement preventive action plans, and audit mechanisms to ensure compliance and continuous improvement). QRMD stated the Patient rounding video footage for the whole night (on 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m.), was not thoroughly reviewed or analyzed in its entirety, because it was not under their (referring to the QAPI) scope of work (The QRMD relied on the DBHU [from the Nursing Department] to complete the video footage review on patient rounding. This lack of coordinated effort between the DBHU and the QRMD does not align with the facility's "patient safety plan" regarding creating procedures for responding to system or process failures and the facility's "patient safety plan" that indicated "All hospital departments, programs, and services participate in the patient safety program").

During a review of the facility's "Governing Board of Directors Bylaws (the facility's formal written rules that define its purpose, powers, and responsibilities. These bylaws require the Governing body to maintain ultimate accountability for the safety and quality of care, oversee hospital compliance with all laws and regulations, and ensure that the facility policies are implemented effectively to protect patients)," dated 02/08/2024. The facility's GB bylaws indicated, "The purpose of the Hospital Governing Board is to recommend and implement Hospital policy, promote patient safety and performance improvement, provide quality patient care, and provide for organizational management, and planning of the Hospital. The Governing Board has ultimate responsibility and legal authority for safety and quality of care, treatment, and services rendered in the Hospital.

During a review of the facility's policy and procedure (P&P) titled, "Patient Safety Plan," dated 9/2025, the P&P indicated, "The Patient Safety Plan is a framework to establish and maintain a safe patient care environment. It expands the organization-wide support for risk management, performance improvement, information management, education, human resources, and patient rights by implementing patient safety standards, measuring, monitoring their effectiveness, and creating a "culture of safety" as part of the overall quality program...The scope of the patient safety program includes the full range of safety issues, from potential or no-harm errors (sometimes referred to as near misses, close calls, or good catches) to hazardous conditions and sentinel events. All hospital departments, programs, and services participate in the patient safety program. As part of the patient safety program, the hospital creates procedures for responding to system or process failures."

During a review of the facility's policy and procedure (P&P) titled, "Rounding, Observation and Monitoring of Patients," dated 09/2022, the P&P indicated, "It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... 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. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ..."

Based on observation, interview and record review, the facility failed to ensure a safe environment in the facility's Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) when:

1. There was no proper rounding (the process of regularly visiting patients to assess their condition) conducted, every 15 minutes (Q 15-min), for 15 of 46 sampled patients (Patients 1-15), in the BHU, to check on the patients' location, behavior, and environmental or personal safety, on 8/26/2025 from 11:00 p.m. to 8/27/2025 at 7:00 a.m., in accordance with the facility's policy regarding rounding, observation, and monitoring patients, who are admitted to the BHU.

This deficient practice had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, psychological trauma and/or death. In addition, this deficient practice resulted in Patient 1 alleging of being sexually assaulted (an act of sexual abuse in which one intentionally sexually touches another person without that person's consent) by Patient 2 without the facility's knowledge on when and how it happened.

2. There was no proper line of sight (a straight line along which an observer had unobstructed vision) and Q (every) 15 minutes rounding, conducted for 21 of 46 sampled patients (Patient 2, Patient 7, Patient 16 -35), on 9/6/2025 from 6:00 p.m. to 9:30 p.m., in accordance with the facility's policy regarding rounding, observation, and monitoring patients, who are admitted to the BHU.

This deficient practice placed 21 patients' safety at risk for self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done), violence, and/or death.

Findings:

1. During a review of Patient 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 8/21/2025, the H&P indicated Patient 1 was admitted to the facility on 8/20/2025. The H&P also indicated Patient 1 had a chief complaint of suicidal ideation (thoughts of taking one's own life) with plan to jump off into traffic. Patient 1 had a history of depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable). Patient 1 was placed under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient's location and activity) for suicide/self-harm and fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) precautions.

During a review of Patient 1's document titled, "Behavioral Health Unit Roundings (the process of regularly visiting patients to assess their condition) and Observation Form," dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated that Patient 1's behaviors included being agitated (feeling of irritation and restlessness) at 7:45 a.m. and anxious (feeling tense, on edge, restless, fearful) from 8 a.m. to 8:45 a.m.

During a review of Patient 1's "Progress Notes Report," dated 8/27/2025, the record indicated Patient 1's "Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person's emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell)." The record further indicated at 8:53 a.m., Patient 1 "Approached primary nurse and claimed that he (Patient 1) was raped by his roommate (Patient 2) last night."

During a review of Patient 1's "Progress Note," dated 8/28/2025 and timed at 11:20 a.m., the record indicated Patient 1 was discharged from the facility on 8/28/2025 at 11:15 a.m. Patient 1 was accompanied by family and both (Patient 1 and Patient 1's family) verbalized understanding of discharge instructions.

During a review of Patient 2's H&P, dated 8/24/2025, the H&P indicated Patient 2 was admitted to the facility on 8/23/2025. The H&P also indicated Patient 2 had major depression and suicidal ideations.

During a review of Patient 2's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 2 was placed under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient's location and activity) and was on suicide/self-harm and fall (an unintentional descent of a patient to the ground, floor, or another lower surface) precautions. On 8/26/2025 at 2:30 p.m., Patient 2 was noted to be anxious.

During a review of Patient 2's "Psychiatric Discharge Note," dated 8/28/2025 and timed 1718 (5:18 p.m.), the record indicated Patient 2 was discharged home on 8/28/2025.

During a review of Patient 3's H&P, dated 8/25/2025, the H&P indicated Patient 3 was admitted to the facility on 8/25/2025. The H&P also indicated Patient 3 had depression with suicidal ideations.

During a review of Patient 3's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 3 was on standard observation and was on suicide/self-harm and fall precautions (a set of preventive measures to prevent patient injuries, such as bruises, fractures [broken bones], and even death, by reducing the frequency and severity of falls).

During a review of Patient 4's H&P, dated 8/25/2025, the H&P indicated Patient 4 was admitted to the facility on 8/24/2025. The H&P also indicated Patient 4 was on a 5150 (72-hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for suicidal and homicidal ideations (thoughts of killing others). The H&P indicated Patient 4 was placed under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 4's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 at 8 a.m. and 12 p.m., the document indicated Patient 4 was hopeless/helpless and socially withdrawn. On 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 4 was in a depressed mood.

During a review of Patient 5's H&P, dated 8/24/2025, the H&P indicated Patient 5 was admitted to the facility on 8/23/2025 for schizophrenia (person loses touch with reality, experiencing things like false beliefs [delusions], seeing or hearing things that aren't there [hallucinations]), disorganized thinking and speech, and withdrawal from others. The H&P indicated Patient 5 was placed on a 5150 hold for being a danger to others and hearing voices.

During a review of Patient 5's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 5 was on standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 6's H&P, dated 8/24/2025, the H&P indicated Patient 6 was admitted to the facility on 8/23/2025 for anxiety. The H&P also indicated Patient 6 had a chief complaint of being a danger to others and mental breakdown.

During a review of Patient 6's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025, the H&P indicated that on 8/26/2025, Patient 6 was placed under 1:1 (healthcare individual stays with the patient as a safety precaution) Arms-Length observation (a staff member remains within arm's reach of the patient at all times, providing immediate intervention and care, especially when a patient poses a risk to themselves or others due to mental distress or health concerns) until 2:01 p.m. On 8/26/2025 at 2:01 p.m., Patient 6 was placed under Line of Sight (direct view of patient) observation. On 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., Patient 6 was on suicide/self-harm and fall precautions. The roundings and observation form further indicated that on 8/26/2025, Patient 6 was anxious at 9:30 a.m., 9:45 a.m., 11 a.m., 11:15 a.m., and 12:45 p.m. In addition, Patient 6 was also agitated and hostile at 8 a.m. and hostile at 12 p.m. on 8/26/2025.

During a review of Patient 7's H&P, dated 8/22/2025, the H&P indicated Patient 7 was admitted to the facility on 8/24/2025. The H&P also indicated Patient 7's chief complaint was major depression with suicide ideations with plan to overdose on fentanyl (pain killer medication).

During a review of Patient 7's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 7 was under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 8's H&P, dated 8/22/2025, the H&P indicated Patient 8 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 8 presented with suicidal ideations and major depressive disorder.

During a review of Patient 8's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 8 was placed under standard observation and on suicide/self-harm precautions.

During a review of Patient 9's H&P, dated 8/22/2025, the H&P indicated Patient 9 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 9 presented with suicidal ideations with plan to overdose.

During a review of Patient 9's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 9 was placed under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 10's H&P, dated 8/21/2025, the H&P indicated Patient 10 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 10 had depression.

During a review of Patient 10's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 10 was placed under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 11's H&P, dated 8/21/2025, the H&P indicated Patient 11 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 11 had suicidal ideations and had a history of schizoaffective disorder (impaired ability to distinguish reality from what is not real).

During a review of Patient 11's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 11 was placed under standard observation and on suicide/self-harm and fall precautions.
The roundings and observation form also indicated Patient 11's behavior was intrusive at 7:45 a.m., 8 a.m., 8:15 a.m., and 8:30 a.m. on 8/27/2025.

During a review of Patient 12's H&P, dated 8/22/2025, the H&P indicated Patient 12 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 12 was brought by an outside acute care hospital (a healthcare facility that provides short-term, intensive medical and surgical care for patients with acute illnesses or injuries) with complaints of "hurting others with a plan to shoot them."

During a review of Patient 12's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 12 was under standard observation and under suicide/self-harm and fall precautions. The roundings and observation form also indicated Patient 12 was agitated (feeling of irritation and restlessness) on 8/26/2025 at 8 a.m., and anxious at 8:15 a.m. and 9:15 a.m. on 8/26/2025.

During a review of Patient 13's H&P, dated 8/21/2025, the H&P indicated Patient 13 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 13 was gravely disabled (unable to take care of themselves) and a danger to others.

During a review of Patient 13's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 13 was under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 14's H&P, dated 8/20/2025, the H&P indicated Patient 14 was admitted to the facility on 8/20/2025. The H&P further indicated Patient 14 had suicidal ideations.

During a review of Patient 14's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 14 was under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 15's H&P, dated 8/22/2025, the H&P indicated Patient 15 was admitted to the facility on 8/19/2025. The H&P further indicated Patient 15 had suicidal ideations and a history of schizophrenia.

During a review of Patient 15's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the roundings and observation form indicated Patient 15 was under standard observation and on suicide/self-harm and fall precautions.

During a review of Patients' 1-15's document titled, "BHU Q 15 Minute Roundings and Observation Form," dated 8/26/2025, the document indicated from times 2300 (11:00 p.m.) on 8/26/2025 to 0700 (7:00 a.m.) on 8/27/2025, Patients' 1-15's behavior was documented asleep/breathing.
During an interview on 9/9/2025 at 10:03 a.m. with Behavioral Health Technician (BHT) 1, BHT 1 stated "we (BHT) observe patients every 15 minutes (Q15), and check for patients' breathing, location and patients' behaviors." BHT 1 stated if a patient was asleep "we (BHT) observe a rise and fall of the chest to ensure breathing." BHT 1 stated that the importance of rounding was to ensure that patients were safe.

During a concurrent observation, interview and video footage review on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the video footage, dated 8/26/2025 from 11:00 p.m. to 7:00 a.m. on 8/27/2025, was reviewed. The following was observed:
-At 11:30 p.m., on 8/26/2025, BHT 2 was seen sitting in a chair in the hallway, no patient rounding was observed.

-At 12:00 a.m., on 8/27/2025, no rounding was observed.

-At 12:30 a.m., BHT 2 was seen sleeping on a chair and no rounding conducted

-At 12:40 a.m., BHT 2 was seen sleeping on a chair and was being awoken by an unknown patient.

-At 12:44 a.m., BHT 2 was seen sitting in chair and filling out paperwork, no rounding was completed on the patients.

-At 1:30 a.m., Patient 2 was seen leaving his room (room shared by Patient 1 and Patient 2) to go into the activity room then back to his (Patient 2) room.

-At 2:00 a.m., BHT 3 was seen sitting in chair and no rounding was completed.

-At 2:13 a.m., Patient 2 was seen going in and out of his room.

-At 4:00 a.m., BHT 2 was not in his (BHT 2) chair in the hallway he (BHT 2) was assigned to watch. No staff member was seen in the hallway rounding or monitoring the hallway. BHT 2 returned to his (BHT 2) chair at 6:00 a.m.

-At 6:15 a.m., BHT 2 was seen sitting in chair and no rounding was completed.

During the same interview on 9/9/2025 at 12:59 p.m. with the DBHU, the DBHU confirmed that no patient rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation, to be conducted every 15 minutes, was for the staff to open the patients' door, check for patients' breathing and ensure the patients were safe. DBHU said that patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was done for patient safety, and anything can occur if not done correctly (referring to the patient rounding). The DBHU also confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU further stated Charge Nurses (RNs) were expected to round every 4 hours and licensed staff (RNs and LVNs) every 2 hours.

During a review of the facility's policy and procedure (P&P) titled, "Rounding, Observation and Monitoring of Patients," dated 09/2022, the P&P indicated, "It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... 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. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ..."

2. During a review of Patient 2's H&P, dated 8/24/2025, the H&P indicated Patient 2 was admitted to the facility on 8/23/2025. The H&P indicated also Patient 2 had major depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable) and suicidal ideations (thoughts of taking one's own life).

During a review of Patient 2's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the roundings and observation form indicated Patient 2 was placed under standard observation and was on suicide/self-harm and fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) precautions.

During a review of Patient 7's H&P, dated 8/22/2025, the H&P indicated Patient 7 was admitted to the facility on 8/22/2025. The H&P also indicated Patient 7's chief complaint was major depression with suicidal ideations with plan to overdose on fentanyl (pain killer medication).

During a review of Patient 7's document titled "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending 9/07/2025 at 7:00 a.m., the document indicated Patient 7 was under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient's location and activity) and was on suicide/self-harm and fall precautions.

During a review of Patient 16's H&P, dated 8/28/2025, the H&P indicated Patient 16 was admitted to the facility on 8/28/2025. The H&P also indicated Patient 16 had psychosis (a mental health condition that causes a person to lose touch with reality), visual hallucination (sensory experiences of seeing things that are not actually present) and paranoid ideation (a pattern of thinking characterized by persistent and unfounded beliefs that one is being persecuted, harmed, or deceived).

During a review of Patient 16's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 16 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 17's H&P, dated 8/19/2025, the H&P indicated Patient 17 was admitted to the facility on 8/19/2025. The H&P also indicated Patient 17's chief complaint was major depression with suicidal ideations and plan to hang self with blanket wrapped around neck.

During a review of Patient 17's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 17 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 18's H&P, dated 9/03/2025, the H&P indicated Patient 18 was admitted to the facility on 9/03/2025. The H&P indicated Patient 18's chief complaint was paranoid delusion (a false belief that is firmly held despite clear evidence to the contrary), schizophrenia, depression with suicidal ideation to kill self with a knife.

During a review of Patient 18's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 18 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 19's H&P, dated 8/31/2025, the H&P indicated Patient 19 was admitted to the facility on 8/31/2025. The H&P indicated Patient 19 had chief complaint of depression and suicidal.

During a review of Patient 19's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 19 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 20's H&P, dated 9/02/2025, the H&P indicated Patient 20 was admitted to the facility on 9/02/2025. The H&P also indicated Patient 20 was a danger to self, with Shizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and mood disorders, such as depression or mania [a state of abnormally elevated mood, energy, and activity that lasts for an extended period]) and anxiety (a common mental health condition characterized by excessive and persistent worry, fear, and unease).

During a review of Patient 20's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 20 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 21's H&P, dated 9/02/2025, the H&P indicated Patient 21 was admitted to the facility on 9/02/2025. The H&P also indicated Patient 21's chief complaint was auditory hallucination (sensory experiences where a person hears sounds that are not present in the external environment) telling Patient 21 to kill self and suicidal ideation.

During a review of Patient 21's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 21 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 22's H&P, dated 1/29/2025, the H&P indicated Patient 22 was admitted to the facility on 1/30/2025. The H&P also indicated Patient 22's chief complaint was schizophrenia and wanting to hurt others.

During a review of Patient 22's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 22 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 23's H&P, dated 9/05/2025, the H&P indicated Patient 23 was admitted to the facility on 9/05/2025. The H&P also indicated Patient 23's chief complaint was depressive disorder and suicidal ideation with a plan to overdose with pills.

During a review of Patient 23's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 23 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 24's H&P, dated 9/01/2025, the H&P indicated Patient 24 was admitted to the facility on 9/01/2025. The H&P also indicated Patient 24's chief complaint was gravely disabled (unable to take care of themselves) with homicidal ideation (thoughts of killing others) and wanting to hurt others.

During a review of Patient 24's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 24 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 25's H&P, dated 9/02/2025, the H&P indicated Patient 25 was admitted to the facility on 9/02/2025. The H&P also indicated Patient 25's chief complaint was depression and suicidal ideations with plan to jump in front of a car.

During a review of Patient 25's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 25 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 26's H&P, dated 8/20/2025, the H&P indicated Patient 26 was admitted to the facility on 9/02/2025. The H&P also indicated Patient 26's chief complaint was anxiety and suicidal ideations with a plan to walk into traffic.

During a review of Patient 26's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 26 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 27's H&P, dated 8/31/2025, the H&P indicated Patient 27 was admitted to the facility on 8/31/2025. The H&P also indicated Patient 27's chief complaint was depression and suicidal ideation to kill self in any way.

During a review of Patient 27's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 27 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 28's H&P, dated 9/02/2025, the H&P indicated Patient 28 was admitted to the facility on 9/02/2025. The H&P also indicated Patient 28 was gravely disabled with anxiety and hallucination, and positive for suicidal ideation.

During a review of Patient 28's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 28 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 29's H&P, dated 8/18/2025, the H&P indicated Patient 29 was admitted to the facility on 8/18/2025. The H&P also indicated Patient 29 was a danger to self with suicidal ideation and plan to overdose and run into traffic.

During a review of Patient 29's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 29 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 30's H&P, dated 9/02/2025, the H&P indicated Patient 30 was admitted to the facility on 9/02/2025. The H&P also indicated Patient 30 was a danger to self and others and with positive suicidal ideation.

During a review of Patient 30's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 30 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 31's H&P, dated 9/06/2025, the H&P indicated Patient 31 was admitted to the facility on 9/06/2025. The H&P also indicated Patient 31's chief complaint was schizophrenia, danger to self and others with positive suicidal ideation.

During a review of Patient 31's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 31 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 32's H&P, dated 8/29/2025, the H&P indicated Patient 32 was admitted to the facility on 8/29/2025. The H&P also indicated Patient 32's chief complaint was schizophrenia, with positive suicidal ideation to hurt self by jumping in front of a van.

During a review of Patient 32's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 32 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 33's H&P, dated 9/04/2025, the H&P indicated Patient 33 was admitted to the facility on 9/04/2025. The H&P also indicated Patient 33's chief complaint was depression with auditory hallucination to hurt self.

During a review of Patient 33's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 33 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 34's H&P, dated 9/03/2025, the H&P indicated Patient 34 was admitted to the facility on 9/03/2025. The H&P also indicated Patient 34's chief complaint was major depressive disorder with substance abuse (harmful or excessive use of substances, such as alcohol, drugs, and medications), and danger to self and others.

During a review of Patient 34's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 9/06/2025 starting at 7:15 a.m. and ending on 9/07/2025 at 7:00 a.m., the document indicated Patient 34 was placed under standard observation and was on suicide/self-harm and fall precautions.

During a concurrent observation, interview and review of video footage on 9/10/2025 at 2:16 p.m. with the Informational Technology Technician (ITT), and the DBHU, the video footage dated 9/06/2025 from 6:00 p.m. to 9:30 p.m., was observed and reviewed. The following was observed:

- At 6:15 p.m. - No Behavioral Health Technician was observed making 15-minute rounds on patients in the (Behavioral Health Unit) BHU.

- At 7:15 p.m. - No Behavioral Health Technician was observed making 15-minute rounds on patients in the BHU.

- At 7:20 p.m. - BHT 4 observed not completing 15-minute rounding to all assigned patients. BHT 4 observed skipping 15-minute rounding and not opening patient doors to check on patients.

- At 7:34 p.m. - BHT 4 observed not completing 15-minute rounding to all assigned patients. BHT 4 observed skipping 15-minute rounding and not opening doors to check on patients.

- At 8:04 p.m. - BHT 4 observed not completing 15-minute rounding to all assigned patients. BHT 4 observed skipping 15-minute rounding and not opening doors to check on patients.

- At 8:19 p.m. - BHT 4 observed not completing 15-minute rounding to all assigned patients. BHT 4 observed skipping 15-minute rounding and not opening doors to check on patients.

- At 8:34 p.m. - BHT 4 observed not completing 15-minute rounding to all assigned patients. BHT 4 observed skipping 15-minute rounding and not opening doors to check on patients.

- At 8:44 p.m. - Licensed Vocational Nurse (LVN) 1 and BHT 4 sitting in chair with cell phone in hand. Observed watching their (LVN 1 and BHT 4) cell phone and not completing their 15-minute rounding on all patients assigned to make rounds on.

- At 8:49 p.m. - BHT 4 observed not completing 15-minute rounding to all assigned patients. BHT 4 observed skipping 15-minute rounding and not opening doors to check on patients.

- At 9

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

1. Ensure one (1) of 46 sampled patients (Patient 1) was free from all forms abuse (intentional maltreatment of an individual that may cause physical or psychological injury), in accordance with the facility's policy on patient rights (a subset of human rights), when an allegation of sexual assault (an act of sexual abuse in which one intentionally sexually touches another person without that person's consent) was made by Patient 1 on 8/27/2025.

This deficient practice had the potential for Patient 1 and other patients in the Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) to experience physical injury, psychological trauma, fear, or anxiety (a common mental health condition characterized by excessive and persistent worry, fear, and unease), and may lose trust in healthcare providers and institutions.

On 9/11/2025 at 1:30 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Nursing Officer (CNO), Quality of Risk Management coordinator (QRC), Quality Risk Management Director (QRMD) and the Manager of Risk and Regulatory. The facility failed to ensure the following: Ensure 15 sampled patients' (Patients 1-15) location, behavior, and environmental or personal safety, were checked, in the Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) on 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., when an allegation of sexual assault (an act of sexual abuse in which one intentionally sexually touches another person without that person's consent) was made by Patient 1; When Registered Nurses in the behavioral health unit (BHU) were not observed conducting every 4 hour (Q4h) patient rounds (the process of regularly visiting patients to assess their condition) nor did they (RNs) ensure behavioral health technicians (BHT) performed patient rounds every 15 minutes, in accordance with the facility's policy and procedure regarding patient rounding; Ensure proper rounding was conducted, by BHTs 4 and 5, for 21 sampled patients (Patient 2, Patient 16 -35), on 9/6/2025 from 6:00 p.m. to 9:30 p.m. These deficient practices resulted in all patients being inadequately monitored for eight (8) hours from 8/26/2025 at 11 p.m. to 7 a.m. on 8/27/2025 and three (3) hours on 9/6/2025 from 6 p.m. to 9 p.m., and had potentially placed patients in an unsafe environment, at risk of self-harm, or harm to others, and potentially can result to death if not corrected. In addition, Patient 1 alleged being sexually assaulted by Patient 2 without the facility's knowledge on when and how it happened.

During a review of Patient 1's "Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Progress Note," dated 8/27/2025, the psychiatric progress note indicated, "This morning the patient (Patient 1) was anxious (feeling tense, on edge, restless, fearful), rambling at times, fixated on discharge (to go home). He (Patient 1) endorsed being sexually assaulted by his roommate (Patient 2), police department came to interview and Sexual Assault Response Team (SART, provides emotional support, advocacy, and access to victim assistance services) nurse made recommendations made by medical and nursing staff."

During a review of Patient 1's "Progress Notes Report," dated 8/27/2025, the record indicated Patient 1's "Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person's emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell)." The record further indicated at 8:53 a.m., on 8/27/2025, Patient 1 "Approached primary nurse and claimed that he (Patient 1) was raped by his roommate (Patient 2) last night."

During an interview on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), the Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the DBHU confirmed that no rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation for patient rounding, every 15 minutes, was for the staff to open the patients' rooms' door, check for patients' breathing and ensure the patients were safe. DBHU also said that patient rounding was done for patient safety, and anything can occur if not done correctly. DBHU confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU stated BHTs were required to round every 15 minutes, while Charge Nurses (Registered Nurses, RNs) were expected to round every 4 hours and licensed staff (RNs and LVNs) every 2 hours.

During a concurrent observation, interview and record review on 9/10/2025 at 2:16 p.m. with the Informational Technology Technician (ITT), and the DBHU, the video footage dated 9/06/2025 from 6:00 p.m. to 9:30 p.m., was observed and reviewed. The video footage indicated inadequate rounding by BHT 4 who was seen standing by the patients' door and not entering each of the patients' rooms (Patient 2, Patient 16 -35). This observation was confirmed by the DBHU.

During a review of the facility's policy and procedure (P&P) titled, "Inpatient Rights and Responsibilities of Patients," revised 08/2023, the P&P indicated "All personnel shall observe and respect these patient rights: 13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including government agencies of neglect or abuse."

During a review of the facility's policy and procedure (P&P) titled, "Rounding, Observation and Monitoring of Patients," dated 09/2022, the P&P indicated, "It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... 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. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ..."

On 9/12/2025 at 4:59 p.m., the IJ was removed in the presence of the Chief Executive Officer (CEO), CNO, Quality Risk Management Director, Quality of Risk Management Coordinator (QRC) and the Director of the Behavioral Health Unit (DBHU), after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews and record reviews. The acceptable IJ Removal Plan included the following: Enhanced round frequency where Charge Nurses/Resource Nurses were expected to round with the BHTs every top of the hour. Education on proper round procedures on the Behavioral Health Unit and Nursing leadership oversight began on 9/11/2025. Key points in the education included: Proper rounding of visual confirmation of patient and patient engagement, and a competency demonstration to verify proper rounding techniques. Staff members must complete education prior to their next scheduled BHU shift. Leadership oversight included: Hourly rounding conducted by the charge nurse to ensure rounds have been completed and documented by the BHTs will be done on each shift, the Director of Nursing (DON) reviewing both BHTs and Charge Nurses rounding logs. Other leadership interventions included the increase in the frequency of random spot checking of security footage.

Findings:

During a review of Patient 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 8/21/2025, the H&P indicated Patient 1 was admitted to the facility on 8/20/2025. The H&P also indicated Patient 1 had a chief complaint of suicidal ideation (thoughts of taking one's own life) with plan to jump off into traffic. Patient 1 had a history of depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable). Patient 1 was placed under standard observation (every 15 minutes) for suicide/self-harm and fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) precautions.

During a review of Patient 1's document titled, "Behavioral Health Unit Roundings (the process of regularly visiting patients to assess their condition) and Observation Form," dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated that Patient 1's behaviors included being agitated (feeling of irritation and restlessness) at 7:45 a.m. and anxious (feeling tense, on edge, restless, fearful) from 8 a.m. to 8:45 a.m.

During a review of Patient 1's "Progress Notes Report," dated 8/27/2025, the record indicated Patient 1's "Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person's emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell)." The record further indicated at 8:53 a.m., Patient 1 "Approached primary nurse and claimed that he (Patient 1) was raped by his roommate (Patient 2) last night."

During a review of Patient 1's "Progress Note," dated 8/28/2025 and timed at 11:20 a.m., the record indicated Patient 1 was discharged from the facility on 8/28/2025 at 11:15 a.m. Patient 1 was accompanied by family and both (Patient 1 and Patient 1's family) verbalized understanding of discharge instructions.

During a review of Patient 2's H&P, dated 8/24/2025, the H&P indicated Patient 2 was admitted to the facility on 8/23/2025. The H&P also indicated Patient 2 had major depression and suicidal ideations.

During a review of Patient 2's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 2 was placed under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient's location and activity) and was on suicide/self-harm and fall precautions. On 8/26/2025 at 2:30 p.m., Patient 2 was noted to be anxious.

During a review of Patient 2's "Psychiatric Discharge Note," dated 8/28/2025 and timed 1718 (5:18 p.m.), the record indicated Patient 2 was discharged home on 8/28/2025.

During a review of Patients' 1-15's document titled, "BHU Q (every) 15 Minute Roundings and Observation Form," dated 8/26/2025, the form indicated from times 2300 (11:00 p.m.) to 0700 (7:00 a.m.), Patients' 1-15's behavior was documented asleep/breathing.

During an interview on 9/9/2025 at 10:03 a.m. with Behavioral Health Technician (BHT) 1, BHT 1 stated "we (BHT) observe patients every 15 minutes (q15), and check for patient breathing, location and patients' behaviors." BHT 1 stated if a patient was asleep "we (BHT) observe a rise and fall of the chest to ensure breathing." BHT 1 stated that the importance of rounding was to ensure that patients were safe.

During a concurrent observation, interview and video footage review on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the video footage, dated 8/26/2025 from 11:00 p.m. to 7:00 a.m. on 8/27/2025, was reviewed. The following was observed:

-At 11:30 p.m., on 8/26/2025, BHT 2 was seen sitting in a chair in the hallway, no patient rounding (the process of regularly visiting patients to assess their condition) was observed.

-At 12:00 a.m., on 8/27/2025, no rounding was observed.

-At 12:30 a.m., BHT 2 was seen sleeping on a chair and no rounding conducted

-At 12:40 a.m., BHT 2 was seen sleeping on a chair and was being awoken by an unknown patient.

-At 12:44 a.m., BHT 2 was seen sitting in chair and filling out paperwork, no rounding was completed on the patients.

-At 1:30 a.m., Patient 2 was seen leaving his room (room shared by Patient 1 and Patient 2) to go into the activity room then back to his (Patient 2) room.

-At 2:00 a.m., BHT 3 was seen sitting in chair in the hallway and no rounding was completed.

-At 2:13 a.m., Patient 2 was seen going in and out of his room.

-At 4:00 a.m., BHT 2 was not in his (BHT 2) chair in the hallway he (BHT 2) was assigned to watch. No staff member was seen in the hallway rounding or monitoring the hallway. BHT 2 returned to his chair at 6:00 a.m.

-At 6:15 a.m., BHT 2 was seen sitting in chair and no rounding was completed.

During the same interview on 9/9/2025 at 12:59 p.m. with the DBHU, the DBHU confirmed that no rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation, to be conducted every 15 minutes, was for the staff to open the patients' door, check for patients' breathing and ensure the patients were safe. DBHU said that patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was done for patient safety, and anything can occur if not done correctly (referring to the patient rounding). The DBHU also confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU further stated Charge Nurses (Registered Nurses, RNs) were expected to round every 4 hours and licensed staff (RNs and LVNs [Licensed Vocational Nurses]) every 2 hours.

During an interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU confirmed that BHT 1's and BHT 2's Q 15-minutes patient rounding documentation for dates from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., was falsified. The DBHU stated that all documentation should be accurate and in the case of the patient rounding documented from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., the documentation of rounding was not accurate (it was contrary to what was observed in the video footage). The DBHU said he (DBHU) asked the charge nurses to make sure rounding was being done on time. The DBHU stated he (DBHU) requested a copy of the rounding sheet to make sure they were all filled out. The DBHU stated he (DBHU) audits the patient rounding by cross checking the rounding sheet and watching a 15-minute snippet of the video footage (on patient rounding) the next morning. The DBHU only watches for 15 minutes and does not keep a log or keep track of the audits on patient rounding.

During the same interview on 9/11/2025 at 10:07 a.m. with the DBHU, the DBHU stated the following: DBHU was informed by nursing staff on 8/27/2025, that 2 sheriffs were in his (DBHU) office investigating an allegation of a sexual assault (an act of sexual abuse in which one intentionally sexually touches another person without that person's consent) made by Patient 1's significant other. DBHU spoke with the Quality Risk Management Coordinator (QRMC) and proceeded to go into the room with Patient 1 and the two Sheriffs. The DBHU, the QRMC and a social worker were present when the Sheriffs were interviewing Patient 1 on 8/27/2025. The DBHU asked Patient 1 a few questions, while the Sheriffs interviewed Patient 1. The DBHU did not conduct his (DBHU) own independent investigation. The DBHU stated that Patient 1 repeatedly verbalized "I just want to go home."

During a record review of the facility's documents titled, "Inservice Roster: Topic Rounding, Observation and Monitoring of Patients," dated 8/28/2025, 8/29/2025-8/30/2025 and 9/9/2025, the in-service roster indicated that 68 out of a total of 131 Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) staff members had been in-serviced regarding the BHU's policy titled, "Rounding, Observation, and Monitoring of Patients."

During a record review of the facility's document titled, "Behavioral Health Unit staffing sheet" dated 9/10/2025, the document indicated the following:
-For the 7AM to 7PM shift, a total of 10 out of 14 BHU staff members have attended the in-service regarding patient rounding.
-For the 7PM to 7AM shift, a total of 5 out of 19 BHU staff members have attended the in-service regarding patient rounding.

During an interview on 9/9/2025 at 3:57 p.m. with the DBHU, the DBHU stated that in-service training for patient rounding was still on going and not all BHU staff have completed the in-service. The DBHU stated that the goal was to have all staff in-serviced as soon as possible.

During an interview on 9/11/2025 at 9 a.m. with the Quality Risk Management Director (QRMD), the QRMD stated the following: The facility provided in-service training, on 8/28/2025, for patient rounding every 15 minutes, after the first CDPH (California Department of Public Health, a regulatory agency) surveyor initially investigated the allegation of sexual abuse made by Patient 1 on 8/27/2025. The QRMD stated the night shift staff were not conducting their rounds every 15 minutes. The QRMD also stated that even though training on patient rounding had been provided, staff were still not conducting the patient rounds properly.

During a review of the facility's policy and procedure (P&P) titled, "Inpatient Rights and Responsibilities of Patients" revised 08/2023, the P&P indicated "All personnel shall observe and respect these patient rights: 13. Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment. You have the right to access protective and advocacy services including government agencies of neglect or abuse."

During a review of the facility's policy and procedure (P&P) titled, "Rounding, Observation and Monitoring of Patients," dated 9/2022, the P&P indicated, "It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... 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. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ..."

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

1. Ensure adequate supervision of the facility's Behavioral Health Unit (BHU, inpatient unit that provides treatment and therapy for people who have mental, emotional and behavioral disorders) staff that included Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and the Behavioral health Technicians (BHTs), to ensure consistent and accurate Q (every) 15-minute patient rounding (the process of regularly visiting patients to assess their condition) for 15 of 46 sampled patients (Patients 1-15), in accordance with the facility's policy regarding "Rounding, Observation, and Monitoring of Patients."

This deficient practice had the potential to place patients at risk for suicide (thoughts of taking one's own life), self-harm, assault (an intentional act that causes a reasonable fear of immediate harmful or offensive contact, even if no physical contact actually occurs), or undetected medical emergencies, by leaving patients unsupervised for extended periods.

2. Ensure nursing staff adequately assessed a patient's care needs and addressed, in a timely manner, one of 46 sampled patient's (Patient 39) low blood pressure (measures the amount of force needed to move blood throughout the body and to the organs), by calling for a Rapid Response Team (RRT, a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration), in accordance with the facility's policy regarding calling a RRT and policy on Standards of Nursing Practice pertaining to the nursing care process. Patient 39 had a persistently low blood pressure for over 3 hours in the Telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm), on 5/26/2025, before being transferred to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries).

This deficient practice resulted in Patient 39 having a delay in further evaluation and treatment, when Patient 39 remained in the Telemetry unit for more than three hours before being transferred to the Intensive Care Unit (ICU), which could have led to further complications and/or death.

Findings:

1. During a review of Patient 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 8/21/2025, the H&P indicated Patient 1 was admitted to the facility on 8/20/2025. The H&P also indicated Patient 1 had a chief complaint of suicidal ideation (thoughts of taking one's own life) with plan to jump off into traffic. Patient 1 had a history of depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable). Patient 1 was placed under standard observation (every 15 minutes) for suicide/self-harm and fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) precautions.

During a review of Patient 1's document titled, "Behavioral Health Unit Roundings (the process of regularly visiting patients to assess their condition) and Observation Form," dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated that Patient 1's behaviors included being agitated (feeling of irritation and restlessness) at 7:45 a.m. and anxious (feeling tense, on edge, restless, fearful) from 8 a.m. to 8:45 a.m.

During a review of Patient 1's "Progress Notes Report," dated 8/27/2025, the record indicated Patient 1's "Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person's emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell)." The record further indicated at 8:53 a.m., Patient 1 "Approached primary nurse and claimed that he (Patient 1) was raped by his roommate (Patient 2) last night."

During a review of Patient 1's "Progress Note," dated 8/28/2025 and timed at 11:20 a.m., the record indicated Patient 1 was discharged from the facility on 8/28/2025 at 11:15 a.m. Patient 1 was accompanied by family and both (Patient 1 and Patient 1's family) verbalized understanding of discharge instructions.

During a review of Patient 2's H&P, dated 8/24/2025, the H&P indicated Patient 2 was admitted to the facility on 8/23/2025. The H&P also indicated Patient 2 had major depression and suicidal ideations.

During a review of Patient 2's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 2 was placed under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient's location and activity) and was on suicide/self-harm and fall precautions. On 8/26/2025 at 2:30 p.m., Patient 2 was noted to be anxious.

During a review of Patient 2's "Psychiatric Discharge Note," dated 8/28/2025 and timed 1718 (5:18 p.m.), the record indicated Patient 2 was discharged home on 8/28/2025.

During a review of Patient 3's H&P, dated 8/25/2025, the H&P indicated Patient 3 was admitted to the facility on 8/25/2025. The H&P also indicated Patient 3 had depression with suicidal ideations.

During a review of Patient 3's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 3 was on standard observation and was on suicide/self-harm and fall precautions (a set of preventive measures to prevent patient injuries, such as bruises, fractures [broken bones], and even death, by reducing the frequency and severity of falls).

During a review of Patient 4's H&P, dated 8/25/2025, the H&P indicated Patient 4 was admitted to the facility on 8/24/2025. The H&P also indicated Patient 4 was on a 5150 (72-hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for suicidal and homicidal ideations (thoughts of killing others). The H&P indicated Patient 4 was placed under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 4's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 at 8 a.m. and 12 p.m., the document indicated Patient 4 was hopeless/helpless and socially withdrawn. On 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., Patient 4 was in a depressed mood.

During a review of Patient 5's H&P, dated 8/24/2025, the H&P indicated Patient 5 was admitted to the facility on 8/23/2025 for schizophrenia (person loses touch with reality, experiencing things like false beliefs [delusions], seeing or hearing things that aren't there [hallucinations]), disorganized thinking and speech, and withdrawal from others. The H&P indicated Patient 5 was placed on a 5150 hold for being a danger to others and hearing voices.

During a review of Patient 5's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 5 was on standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 6's H&P, dated 8/24/2025, the H&P indicated Patient 6 was admitted to the facility on 8/23/2025 for anxiety. The H&P also indicated Patient 6 had a chief complaint of being a danger to others and mental breakdown.

During a review of Patient 6's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025, the H&P indicated that on 8/26/2025, Patient 6 was placed under 1:1 (healthcare individual stays with the patient as a safety precaution) Arms-Length observation (a staff member remains within arm's reach of the patient at all times, providing immediate intervention and care, especially when a patient poses a risk to themselves or others due to mental distress or health concerns) until 2:01 p.m. On 8/26/2025 at 2:01 p.m., Patient 6 was placed under Line of Sight (direct view of patient) observation. On 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., Patient 6 was on suicide/self-harm and fall precautions. The roundings and observation form further indicated that on 8/26/2025, Patient 6 was anxious at 9:30 a.m., 9:45 a.m., 11 a.m., 11:15 a.m., and 12:45 p.m. In addition, Patient 6 was agitated (feelings of restlessness and irritability) and hostile at 8 a.m. and also hostile at 12 p.m. on 8/26/2025.

During a review of Patient 7's H&P, dated 8/22/2025, the H&P indicated Patient 7 was admitted to the facility on 8/24/2025. The H&P also indicated Patient 7's chief complaint was major depression with suicide ideations with plan to overdose on fentanyl (pain killer medication).

During a review of Patient 7's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 7 was under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 8's H&P, dated 8/22/2025, the H&P indicated Patient 8 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 8 presented with suicidal ideations and major depressive disorder.

During a review of Patient 8's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 8 was placed under standard observation and on suicide/self-harm precautions.

During a review of Patient 9's H&P, dated 8/22/2025, the H&P indicated Patient 9 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 9 presented with suicidal ideations with plan to overdose.

During a review of Patient 9's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 9 was placed under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 10's H&P, dated 8/21/2025, the H&P indicated Patient 10 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 10 had depression.

During a review of Patient 10's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 10 was placed under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 11's H&P, dated 8/21/2025, the H&P indicated Patient 11 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 11 had suicidal ideations and had a history of schizoaffective disorder (impaired ability to distinguish reality from what is not real).

During a review of Patient 11's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 11 was placed under standard observation and on suicide/self-harm and fall precautions.
The roundings and observation form also indicated Patient 11's behavior was intrusive (actions or thoughts that are unwanted, distressing, and often repetitive) at 7:45 a.m., 8 a.m., 8:15 a.m., and 8:30 a.m. on 8/27/2025.

During a review of Patient 12's H&P, dated 8/22/2025, the H&P indicated Patient 12 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 12 was brought by an outside acute care hospital (a healthcare facility that provides short-term, intensive medical and surgical care for patients with acute illnesses or injuries) with complaints of "hurting others with a plan to shoot them."

During a review of Patient 12's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 12 was under standard observation and under suicide/self-harm and fall precautions. The roundings and observation form also indicated Patient 12 was agitated on 8/26/2025 at 8 a.m., and anxious at 8:15 a.m. and 9:15 a.m. on 8/26/2025.

During a review of Patient 13's H&P, dated 8/21/2025, the H&P indicated Patient 13 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 13 was gravely disabled (unable to take care of themselves) and a danger to others.

During a review of Patient 13's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 13 was under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 14's H&P, dated 8/20/2025, the H&P indicated Patient 14 was admitted to the facility on 8/20/2025. The H&P further indicated Patient 14 had suicidal ideations.

During a review of Patient 14's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 14 was under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 15's H&P, dated 8/22/2025, the H&P indicated Patient 15 was admitted to the facility on 8/19/2025. The H&P further indicated Patient 15 had suicidal ideations and a history of schizophrenia.

During a review of Patient 15's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the roundings and observation form indicated Patient 15 was under standard observation and on suicide/self-harm and fall precautions.

During an interview on 9/9/2025 at 10:03 a.m. with Behavioral Health Technician (BHT) 1, BHT 1 stated "we (BHT) observe patients every 15 minutes (Q 15), and check for patients' breathing, location and patients' behaviors." BHT 1 stated if a patient was asleep "we (BHT) observe a rise and fall of the chest to ensure breathing." BHT 1 stated that the importance of rounding was to ensure that patients were safe.

During a concurrent observation, interview and video footage review on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the video footage, dated 8/26/2025 from 11:00 p.m. to 7:00 a.m. on 8/27/2025, was reviewed. The following was observed:

-At 11:30 p.m., on 8/26/2025, BHT 2 was seen sitting in a chair in the hallway, no patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was observed.

-At 12:00 a.m., on 8/27/2025, no rounding was observed.

-At 12:30 a.m., BHT 2 was seen sleeping on a chair and no rounding conducted

-At 12:40 a.m., BHT 2 was seen sleeping on a chair and was being awoken by an unknown patient.

-At 12:44 a.m., BHT 2 was seen sitting in chair and filling out paperwork, no rounding was completed on the patients.

-At 1:30 a.m., Patient 2 was seen leaving his room (room shared by Patient 1 and Patient 2) to go into the activity room then back to his (Patient 2) room.

-At 2:00 a.m., BHT 3 was seen sitting in chair and no rounding was completed.

-At 2:13 a.m., Patient 2 was seen going in and out of his room.

-At 4:00 a.m., BHT 2 was not in his chair in the hallway he was assigned to watch. No staff member was seen in the hallway rounding or monitoring the hallway. BHT 2 returned to his chair at 6:00 a.m.

-At 6:15 a.m., BHT 2 was seen sitting in chair and no rounding was completed.

During the same interview on 9/9/2025 at 12:59 p.m. with the DBHU, the DBHU confirmed that no rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation, to be conducted, every 15 minutes, was for the staff to open the patients' door, check for patients' breathing and ensure the patients were safe. DBHU said that patient rounding was done for patient safety, and anything can occur if not done correctly (referring to the patient rounding). The DBHU also confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU further stated Charge Nurses (RNs) were expected to round every 4 hours and licensed staff (RNs and LVNs) every 2 hours.

During an interview on 9/12/2025 at 4:30 p.m. with Registered Nurse (RN) 3, RN 3 stated Charge Nurses have oversight of the staff, especially BHTs. RN 3 also stated that all staff have responsibility in ensuring patient safety by conducting proper patient rounding.

During a review of the facility's policy and procedure (P&P) titled, "Rounding, Observation and Monitoring of Patients," dated 09/2022, the P&P indicated, "It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... 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. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ..."

During a review of the facility's document titled, "Position Description: Behavioral Health Technician," dated 7/2024, the document indicated The Behavioral Health Technician supports licensed staff in providing safe and therapeutic patient care as delegated and in adherence to policies and procedures. The document also indicated that Essential Functions included observing and monitoring patients' progress and reports observations to appropriate staff.

2. During a review of Patient 39 ' s "History and Physical (H&P)," dated 5/25/2025, the H&P indicated Patient 39 was admitted to the facility ' s telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm) for altered mental status (different level of thinking, communicating, than what is normal for someone). Patient 39 ' s medical history included stroke (loss of blood flow to a part of the brain) and pseudo (fake) - seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness [loss of awareness of oneself and the surroundings due to a temporary reduction in blood flow to the brain]).

During a review of Patient 39 ' s "Intensivist Consult Note," dated 5/27/2025, the record indicated Patient 39 was admitted to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) for hypotension (low blood pressure below the normal range of 120/90 millimeters of mercury [mmHg, a unit of measurement]). The note further indicated Patient 39 ' s "Condition was further complicated when she received all her (Patient 39) home medications, including antipsychotics (medications used to treat and manage mental health conditions) and antihypertensives (medications used to lower and control blood pressure), at one time. Subsequently, she Patient 39) became hypotensive with blood pressure dropping into the sixties. Treatment was initiated with intravenous (IV, into the vein) fluid resuscitation (to bring up) and a Levophed (Norepinephrine, medication used to raise blood pressure) infusion. The patient is currently improving with these interventions."

During a concurrent interview and record review on 9/11/2025 at 3:26 p.m. with Registered Nurse (RN) 12 and the Clinical Analyst Information Technology (CAIT), Patient 39 ' s "Daily Focus Assessment Report," dated 5/26/2025, was reviewed. The report indicated at 8:00 a.m. on 5/26/2025, Patient 39 was "Awake/Alert, Oriented to Person, Time, Place, and Situation, Spontaneous Eye Opening, Appropriate Verbal Response, Obeys Commands, Clear Speech ...Glasgow Coma Scale (GCS, level of awareness with a maximum level of 15 indicating full awareness) 15/15." RN 12 and the CAIT confirmed that at at 9:00 p.m., Patient 39 was "Lethargic (slow to respond), nonverbal" and had a GCS score of 4/15 for "Eyes to painful stimuli, verbal: none, motor: none."

During a concurrent interview and record review on 9/11/2025 at 3:26 p.m. with RN 12 and CAIT, Patient 39 ' s "Vitals (Vital Signs, include temperature, heart rate, respiratory rate, blood pressure) Inquiry," dated 5/26/2025, was reviewed. The record indicated the following on 5/26/2025:

-At 4:45 p.m., Patient 39 ' s Blood Pressure (BP) was 85/46 (Normal is 120/90 millimeters of mercury [mmHg, a unit of measurement) in the telemetry unit;

-At 6:01 p.m., Patient 39 ' s BP was 89/44

-At 7:00 p.m., Patient 39 ' s BP was 90/50

-At 7:27 p.m., Patient 39 ' s BP was 61/38

-At 7:43 p.m., Patient 39 ' s BP was 89/44

-At 7:46 p.m., Patient 39 ' s BP was 126/107

-At 7:57 p.m., Patient 39 ' s BP was 87/34

-At 7:58 p.m., Patient 39 ' s BP was 77/40

-At 8:22 p.m., Patient 39 ' s BP was 54/33

-At 9:00 p.m., Patient 39 ' s BP was 72/38 in the ICU

-At 9:05 p.m., Patient 39 ' s BP was 80/59, and at 9:15 p.m. increased to 155/98.

During the same concurrent interview and record review on 9/11/2025 at 3:26 p.m. with RN 12 and CAIT, Patient 39 ' s "Progress Notes Report," dated 5/26/2025, was reviewed. The report indicated at 5:30 p.m. on 5/26/2025, Patient 39 ' s BP was 90/55 (taken more than half an hour after the first low BP reading from 4:45 p.m.). Another entry at 8:05 p.m. indicated Patient 39 ' s "fluid challenge (Normal saline, fluids that go into the vein to balance the body ' s fluids and help with blood pressure given) and Albumin (medication used to help raise blood pressure) unsuccessful. Pt (Patient 39) is arousable (to be able to be stimulated, awakened, or excited from a state of sleep, unconsciousness, or a lack of response), but drowsy (feel sleepy and sluggish). Endorsed to (name of RN) night shift RN." A later entry at 8:17 p.m. indicated at 8:15 p.m., Patient 39 ' s BP was 74/44, and "MD (medical doctor) ordered to transfer patient to ICU ...patient transferred."

During further concurrent interview and record review on 9/11/2025 at 3:26 p.m. with Registered Nurse (RN) 12 and the Clinical Analyst IT (CAIT), Patient 39 ' s "Medication Administration Record (MAR)," dated 5/26/2025, was reviewed. The MAR indicated Patient 39 received Albumin (medication used to raise blood pressure) and two liters (a unit of measure) of Normal Saline in the telemetry unit. The MAR further indicated Patient 39 received Norepinephrine (Levophed, IV medication used to raise blood pressure and requires close monitoring) in the ICU after being transferred from the Telemetry unit.

During the same concurrent interview and record review on 9/11/2025 at 3:26 p.m. with RN 12 and CAIT, Patient 39 ' s "Electronic Medical Record," undated, was reviewed. CAIT confirmed that Patient 39 was transferred to the Intensive Care Unit (ICU, where patients are closely monitored) on 5/26/2025 at 8:28 p.m. CAIT also confirmed that Patient 39 remained in the telemetry unit, with low blood pressure, for over three hours prior to being transferred to the ICU.

During the same interview on 9/11/2025 at 3:26 p.m. with RN 12, RN 12 stated RRT would be called when there was a change in a patient ' s status (condition) or BP, and anyone can call for a RRT. RN 12 also stated she (RN 12) thought it would have been appropriate to have called a rapid response for Patient 39.

During an interview on 9/12/2025 at 2:09 p.m. with the Chief Nursing Officer (CNO), the CNO stated, "Nurses can call (RRT) if they need assistance and there ' s no harm to call a rapid response." CNO also stated, "The purpose of a rapid response was to get interventions to help the patient."

During a review of the facility ' s policy and procedure (P&P) titled, "Standard of Nursing Practice," dated 7/2022, the P&P indicated, "It is the policy of (name of facility) to provide all patients with a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process.The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse ' s decision-making."

During a review of the facility ' s policy and procedure (P&P) titled "Rapid Response Team (RRT)," dated 12/2014, the P&P indicated:

"Purpose: To improve patient outcomes by providing expert assessment, early intervention and stabilization for patients and to prevent clinical deterioration and/or arrest.

Philosophy:

A. The Rapid Response Team (RRT) shall be used to create a culture where hospital staff, especially nurses, are encouraged to ask for help if they are uncertain about a patient ' s condition or desired intervention.

B. The Team is also a vehicle to enhance the knowledge and assessment skills of front-line staff and helps to create a supportive environment.

Policy:

C. Criteria for calling the Team may include but are not limited to one or more of the following ...Changes in SBP (<90 mmHg) ...Acute mental status change ..."

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

1. Ensure nursing staff adhered to the facility's policy and procedure regarding "Rounding, Observation and Monitoring of Patients," and the facility's charting/documentation policy, when staff did not perform and accurately document the Q (every) 15-minute rounding (observing patient location and behavior), for 15 of 46 sampled patients (Patients 1-15), from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m.

This deficient practice had potentially placed the patients in an unsafe environment, at risk of self-harm, or harm to others, psychological trauma and/or death. In addition, this deficient practice resulted in Patient 1 alleging of being sexually assaulted (an act of sexual abuse in which one intentionally sexually touches another person without that person's consent) by Patient 2 without the facility's knowledge on when and how it happened.

2. Ensure a concern of low blood pressure (measures the amount of force needed to move blood throughout the body and to the organs) lasting over several hours (3 hours), for one of 46 sampled patients (Patient 39), was escalated by using a Rapid Response Team (RRT, group of individuals [may include a nurse, respiratory therapist, physician] that responds to concerning or emergency situations and can provide additional evaluations and interventions), in accordance with the facility's policy and procedure regarding "Rapid Response Team (RRT)."

This deficient practice resulted in Patient 39, remaining in the Telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm), with persistent low blood pressure for more than three hours, before being transferred to a higher level of care (a more intensive and comprehensive level of medical health treatment), which delayed treatment and could have worsened Patient 39's condition.

3. Ensure an Oxygen Tank (a device to provide respiratory [to breathe] support) was stored and readily available for immediate use on one of two sampled crash carts (Cart #1, a set of trays on wheels used in hospital for transportation and dispensing emergency medications and equipment), in the Emergency Department (ED, a specialized hospital unit that provides 24/7 unscheduled medical care for acute [sudden in onset], severe, and life-threatening injuries and illnesses), which may impact 46 of 46 sampled patients, in accordance with the facility's policy regarding crash cart equipment and medications.

This deficient practice had the potential to result in endangering patients' life by delaying the ability to provide respiratory support (medical interventions that assist a patient's breathing when they are unable to do so adequately on their own. Example: providing oxygen therapy from an oxygen tank) in an emergency, which may result in patient harm and/or death.

4. Ensure staff followed the facility's "Peripheral Inserted Central Catheter: Assisting, Insertion, Care and Removal Policy," for 2 of 46 sampled patients (Patient 44 and Patient 45), when staff did not provide proper PICC line (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is positioned in a location at the superior vena cava [a large, significant vein responsible for returning deoxygenated blood collected from the body to the heart], and used for intravenous treatment that is required over a long period) care by not changing Patient 44's soiled PICC line dressing and not properly securing Patient 45's PICC line with a securement device.

This deficient practice had the potential for Patient 44 and Patient 45 to develop blood stream infections (when bacteria or other pathogens enter the blood stream causing infection) due to improper maintenance and care of PICC line.

Findings:

1. During a review of Patient 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 8/21/2025, the H&P indicated Patient 1 was admitted to the facility on 8/20/2025. The H&P also indicated Patient 1 had a chief complaint of suicidal ideation (thoughts of taking one's own life) with plan to jump off into traffic. Patient 1 had a history of depression (persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable). Patient 1 was placed under standard observation (direct visual contact with patients and confirm they are in no danger or distress every 15 minutes, must document patient's location and activity) for suicide/self-harm and fall (an unintentional event that results in a person coming to rest on the ground, floor, or a lower level) precautions.

During a review of Patient 1's document titled, "Behavioral Health Unit Roundings (the process of regularly visiting patients to assess their condition) and Observation Form," dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated that Patient 1's behaviors included being agitated (feeling of irritation and restlessness) at 7:45 a.m. and anxious (feeling tense, on edge, restless, fearful) from 8 a.m. to 8:45 a.m.

During a review of Patient 1's "Progress Notes Report," dated 8/27/2025, the record indicated Patient 1's "Behavior guarded (restrained way of acting due to a fear of being hurt, vulnerable, or exposed, often stemming from past trauma), isolative (avoiding social interactions), paranoid (unfounded distrust and suspicion of others), and suspicious. Affect (the observable expression of a person's emotions) anxious, irritable, labile (rapid and unpredictable changes in mood, emotions), avoidant and needy. Mood anxious and dysphoric (uneasy or unhappy or unwell)." The record further indicated at 8:53 a.m., Patient 1 "Approached primary nurse and claimed that he (Patient 1) was raped by his roommate (Patient 2) last night."

During a review of Patient 1 "Progress Note" dated 8/28/2025 and timed at 11:20 a.m., the record indicated was discharged from the facility on 8/28/2025 at 11:15 a.m. Patient 1 was accompanied by family and both (Patient 1 and Patient 1's family) verbalized understanding of discharge instructions.

During a review of Patient 2's H&P, dated 8/24/2025, the H&P indicated Patient 2 was admitted to the facility on 8/23/2025. The H&P also indicated Patient 2 had major depression and suicidal ideations.

During a review of Patient 2's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 2 was placed under standard and was on suicide/self-harm and fall precautions. On 8/26/2025 at 2:30 p.m., Patient 2 was noted to be anxious.

During a review of Patient 2's "Psychiatric Discharge Note," dated 8/28/2025 and timed 1718 (5:18 p.m.), the record indicated Patient 2 was discharged home on 8/28/2025.

During a review of Patient 3's H&P, dated 8/25/2025, the H&P indicated Patient 3 was admitted to the facility on 8/25/2025. The H&P also indicated Patient 3 had depression with suicidal ideations.

During a review of Patient 3's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., the document indicated Patient 3 was on standard observation and was on suicide/self-harm and fall precautions (a set of preventive measures to prevent patient injuries, such as bruises, fractures [broken bones], and even death, by reducing the frequency and severity of falls).

During a review of Patient 4's H&P, dated 8/25/2025, the H&P indicated Patient 4 was admitted to the facility on 8/24/2025. The H&P also indicated Patient 4 was on a 5150 (72-hour involuntary hold; allows an adult experiencing a mental health crisis to be evaluated and treated without their permission for 72 hours) for suicidal and homicidal ideations (thoughts of killing others). The H&P indicated Patient 4 was placed under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 4's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 at 8 a.m. and 12 p.m., the document indicated Patient 4 was hopeless/helpless and socially withdrawn. On 8/26/2025 starting at 7:15 a.m. and ending on 8/27/2025 at 7:00 a.m., Patient 4 was in a depressed mood.

During a review of Patient 5's H&P, dated 8/24/2025, the H&P indicated Patient 5 was admitted to the facility on 8/23/2025 for schizophrenia (person loses touch with reality, experiencing things like false beliefs [delusions], seeing or hearing things that aren't there [hallucinations]), disorganized thinking and speech, and withdrawal from others. The H&P indicated Patient 5 was placed on a 5150 hold for being a danger to others and hearing voices.

During a review of Patient 5's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 5 was on standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 6's H&P, dated 8/24/2025, the H&P indicated Patient 6 was admitted to the facility on 8/23/2025 for anxiety. The H&P also indicated Patient 6 had a chief complaint of being a danger to others and mental breakdown.

During a review of Patient 6's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025, the H&P indicated that on 8/26/2025, Patient 6 was placed under 1:1 (healthcare individual stays with the patient as a safety precaution) Arms-Length observation until 2:01 p.m. On 8/26/2025 at 2:01 p.m., Patient 6 was placed under Line of Sight (direct view of patient) observation. On 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., Patient 6 was on suicide/self-harm and fall precautions. The roundings and observation form further indicated that on 8/26/2025, Patient 6 was anxious at 9:30 a.m., 9:45 a.m., 11 a.m., 11:15 a.m., and 12:45 p.m. In addition, Patient 6 was agitated (feelings of restlessness and irritability) and hostile at 8 a.m. and was hostile at 12 p.m. on 8/26/2025.

During a review of Patient 7's H&P, dated 8/22/2025, the H&P indicated Patient 7 was admitted to the facility on 8/24/2025. The H&P also indicated Patient 7's chief complaint was major depression with suicide ideations with plan to overdose on fentanyl (pain killer medication).

During a review of Patient 7's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 7 was under standard observation and was on suicide/self-harm and fall precautions.

During a review of Patient 8's H&P, dated 8/22/2025, the H&P indicated Patient 8 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 8 presented with suicidal ideations and major depressive disorder.

During a review of Patient 8's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 8 was placed under standard observation and on suicide/self-harm precautions.

During a review of Patient 9's H&P, dated 8/22/2025, the H&P indicated Patient 9 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 9 presented with suicidal ideations with plan to overdose.

During a review of Patient 9's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 9 was placed under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 10's H&P, dated 8/21/2025, the H&P indicated Patient 10 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 10 had depression.

During a review of Patient 10's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 10 was placed under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 11's H&P, dated 8/21/2025, the H&P indicated Patient 11 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 11 had suicidal ideations and had a history of schizoaffective disorder (impaired ability to distinguish reality from what is not real).

During a review of Patient 11's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025, starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 11 was placed under standard observation and on suicide/self-harm and fall precautions.
The roundings and observation form also indicated Patient 11's behavior was intrusive (actions or thoughts that are unwanted, distressing, and often repetitive) at 7:45 a.m., 8 a.m., 8:15 a.m., and 8:30 a.m. on 8/27/2025.

During a review of Patient 12's H&P, dated 8/22/2025, the H&P indicated Patient 12 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 12 was brought by an outside acute care hospital (a healthcare facility that provides short-term, intensive medical and surgical care for patients with acute illnesses or injuries) with complaints of "hurting others with a plan to shoot them."

During a review of Patient 12's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 12 was under standard observation and under suicide/self-harm and fall precautions. The roundings and observation form also indicated Patient 12 was agitated on 8/26/2025 at 8 a.m., and anxious at 8:15 a.m. and 9:15 a.m. on 8/26/2025.

During a review of Patient 13's H&P, dated 8/21/2025, the H&P indicated Patient 13 was admitted to the facility on 8/21/2025. The H&P also indicated Patient 13 was gravely disabled (unable to take care of themselves) and a danger to others.

During a review of Patient 13's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 13 was under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 14's H&P, dated 8/20/2025, the H&P indicated Patient 14 was admitted to the facility on 8/20/2025. The H&P further indicated Patient 14 had suicidal ideations.

During a review of Patient 14's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the document indicated Patient 14 was under standard observation and on suicide/self-harm and fall precautions.

During a review of Patient 15's H&P, dated 8/22/2025, the H&P indicated Patient 15 was admitted to the facility on 8/19/2025. The H&P further indicated Patient 15 had suicidal ideations and a history of schizophrenia.

During a review of Patient 15's document titled, "Behavioral Health Unit Roundings and Observation Form," dated 8/26/2025 starting at 7:15 a.m. and ending 8/27/2025 at 7:00 a.m., the roundings and observation form indicated Patient 15 was under standard observation and on suicide/self-harm and fall precautions.

During a review of Patients 1-15 document titled "BHU Q15 Minute Roundings and Observation Form" dated 8/26/2025 indicated from times 2300 (11:00 p.m.) to 0700 (7:00 a.m.) Patients 1-15 behavior was asleep/breathing (AB).

During an interview on 9/9/2025 at 10:03 a.m. with Behavioral Health Technician (BHT) 1, BHT 1 stated "we (BHT) observe patients every 15 minutes (q15), and check for patients' breathing, location and patients' behaviors." BHT 1 stated if a patient was asleep "we (BHT) observe a rise and fall of the chest to ensure breathing." BHT 1 stated that the importance of rounding was to ensure that patients were safe.

During a concurrent observation, interview and video footage review o on 9/9/2025 at 12:59 p.m. with the Informational Technology Technician (ITT), Quality Risk Management Coordinator (QRC) and the Director of Behavioral Health Unit (DBHU), the video footage, dated 8/26/2025 from 11:00 p.m. to 7:00 a.m. on 8/27/2025, was reviewed. The following was observed:

-At 11:30 p.m., on 8/26/2025, BHT 2 was seen sitting in a chair in the hallway, no patient rounding (the process of regularly visiting/monitoring patients to assess their condition) was observed.

-At 12:00 a.m., on 8/27/2025, no rounding was observed.

-At 12:30 a.m., BHT 2 was seen sleeping on a chair and no rounding conducted

-At 12:40 a.m., BHT 2 was seen sleeping on a chair and was being awoken by an unknown patient.

-At 12:44 a.m., BHT 2 was seen sitting in chair and filling out paperwork, no rounding was completed on the patients.

-At 1:30 a.m., Patient 2 was seen leaving his room (room shared by Patient 1 and Patient 2) to go into the activity room then back to his (Patient 2) room.

-At 2:00 a.m., BHT 3 was seen sitting in chair and no rounding was completed.

-At 2:13 a.m., Patient 2 was seen going in and out of his room.

-At 4:00 a.m., BHT 2 was not in his chair in the hallway he was assigned to watch. No staff member was seen in the hallway rounding or monitoring the hallway. BHT 2 returned to his chair at 6:00 a.m.

-At 6:15 a.m., BHT 2 was seen sitting in chair and no rounding was completed.

During the same interview on 9/9/2025 at 12:59 p.m. with the DBHU, the DBHU confirmed that no rounding was completed for Patients 1-15 between the hours of 8/26/2025 at 11:00 p.m., through 8/27/2025 at 7:00 a.m. DBHU stated that the expectation, to be conducted every 15 minutes, was for the staff to open the patients' door, check for patients' breathing and ensure the patients were safe. DBHU said that patient rounding was done for patient safety, and anything can occur if not done correctly (referring to the patient rounding). The DBHU also confirmed there was no RN observed rounding between the hours of 11:00 p.m. on 8/26/2025 to 7:00 a.m. on 8/27/2025. DBHU further stated Charge Nurses (RNs) were expected to round every 4 hours and licensed staff (RNs and LVNs) every 2 hours. DBHU also confirmed that staff were falsifying documentation of patient rounding.

During an interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU confirmed that BHT 1's and BHT 2's Q 15-minutes patient rounding documentation for dates from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., was falsified. The DBHU stated that all documentation should be accurate and in the case of the patient rounding documented from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., the documentation of rounding was not accurate (it was contrary to what was observed in the video footage).

During the same interview on 9/11/2025 at 10:07 a.m. with DBHU, the DBHU confirmed that BHT 1's and BHT 2's Q 15-minutes patient rounding documentation for dates from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., was falsified. The DBHU stated that all documentation should be accurate and in the case of the patient rounding documented from 8/26/2025 at 11 p.m. to 8/27/2025 at 7 a.m., the documentation of rounding was not accurate (it was contrary to what was observed in the video footage). The DBHU said he (DBHU) asked the charge nurses to make sure rounding was being done on time. The DBHU also said he (DBHU) requested a copy of the rounding sheet to make sure they were all filled out. The DBHU stated he (DBHU) audits the patient rounding by cross checking the rounding sheet and watching a 15-minute snippet of the video footage (on patient rounding) the next morning. The DBHU only watches for 15 minutes and does not keep a log or keep track of the audits on patient rounding.

During the same interview on 9/11/2025 at 10:07 a.m., the DBHU stated the following: DBHU was informed by nursing staff on 8/27/2025, that 2 sheriffs were in his (DBHU) office investigating an allegation of a sexual assault made by Patient 1's significant other. DBHU spoke with the Quality Risk Management Coordinator (QRMC) and proceeded to go into the room with Patient 1 and the two Sheriffs. The DBHU, the QRMC and a social worker were present when the Sheriffs were interviewing Patient 1 on 8/27/2025. The DBHU asked Patient 1 a few questions, while the Sheriffs interviewed Patient 1. The DBHU did not conduct his (DBHU) own independent investigation. The DBHU stated that Patient 1 repeatedly verbalized "I just want to go home."

During a review of the facility's policy and procedure (P&P) titled, "Rounding, Observation and Monitoring of Patients," dated 09/2022, the P&P indicated, "It is the policy of the BHU to perform rounds on all patients in an orderly fashion that facilitates an adequate process to observe and monitor patients according to the risk of each patient and to ensure safety measures are implemented as necessary to promote an environment of safety ... 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. Patient rounds are assigned to nursing staff and made at a minimum of every fifteen (15) minutes ...Level 1 - Minimal- Standard. a. All patients on the BHU are at a minimum under standard observation. Standard observations may not be completed standing in a doorway or at a distance particularly for patients that may be sleeping. It is expected that staff will look into the room ..."

During a review of the facility's policy and procedure (P&P) titled, "Documentation (Charting) Policy," revised 07/2022, the P&P indicated the following: Purpose: To provide a concise, complete and accurate record of treatments, symptoms and observation to assist physicians in diagnosing and prescribing, assist nurses and ancillary departments in planning care and to maintain a legal record ...Procedure: 2. All charting must be complete and accurate.

2. During a review of Patient 39's "History and Physical (H&P)," dated 5/25/2025, the H&P indicated Patient 39 was admitted to the facility's telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm) for altered mental status (different level of thinking, communicating, than what is normal for someone). Patient 39's medical history included stroke (loss of blood flow to a part of the brain) and pseudo (fake) - seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness [loss of awareness of oneself and the surroundings due to a temporary reduction in blood flow to the brain]).

During a review of Patient 39's "Intensivist Consult Note," dated 5/27/2025, the record indicated Patient 39 was admitted to the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries) for hypotension (low blood pressure below the normal range of 120/90 millimeters of mercury [mmHg, a unit of measurement]). The note further indicated Patient 39's "Condition was further complicated when she received all her (Patient 39) home medications, including antipsychotics (medications used to treat and manage mental health conditions) and antihypertensives (medications used to lower and control blood pressure), at one time. Subsequently, she (Patient 39) became hypotensive with blood pressure dropping into the sixties. Treatment was initiated with intravenous (IV, into the vein) fluid resuscitation (to bring up) and a Levophed (Norepinephrine, medication used to raise blood pressure) infusion. The patient (Patient 39) is currently improving with these interventions."

During a concurrent interview and record review on 9/11/2025 at 3:26 p.m. with Registered Nurse (RN) 12 and the Clinical Analyst Information Technology (CAIT), Patient 39's "Daily Focus Assessment Report," dated 5/26/2025, was reviewed. The record indicated at 8:00 a.m. on 5/26/2025, Patient 39 was "Awake/Alert, Oriented to Person, Time, Place, and Situation, Spontaneous Eye Opening, Appropriate Verbal Response, Obeys Commands, Clear Speech ...Glasgow Coma Scale (GCS, level of awareness with a maximum level of 15 indicating full awareness) 15/15." RN 12 and the CAIT said that at 9:00 p.m., Patient 39 was "Lethargic (slow to respond), nonverbal" and had a GCS score of 4/15 for "Eyes to painful stimuli, verbal: none, motor: none."

During a concurrent interview and record review on 9/11/2025 at 3:26 p.m. with RN 12 and CAIT, Patient 39's "Vitals (Vital Signs, includes temperature, heart rate, respiratory rate, blood pressure) Inquiry," dated 5/26/2025, was reviewed. The record indicated the following on 5/26/2025:

-At 4:45 p.m., Patient 39's Blood Pressure (BP) was 85/46 (normal: 120/90 millimeters of mercury [mmHg, a unit of measurement]) in the telemetry unit;
-At 6:01 p.m., Patient 39's BP was 89/44
-At 7:00 p.m., Patient 39's BP was 90/50
-At 7:27 p.m., Patient 39's BP was 61/38
-At 7:43 p.m., Patient 39's BP was 89/44
-At 7:46 p.m., Patient 39's BP was 126/107
-At 7:57 p.m., Patient 39's BP was 87/34
-At 7:58 p.m., Patient 39's BP was 77/40
-At 8:22 p.m., Patient 39's BP was 54/33
-At 9:00 p.m., Patient 39's BP was 72/38 in the Intensive Care Unit (ICU, a specialized hospital unit that provides round-the-clock, intensive medical care to patients with life-threatening illnesses or injuries)
-At 9:05 p.m., Patient 39's BP was 80/59, and at 9:15 p.m. increased to 155/98 in the ICU.

During the same concurrent interview and record review on 9/11/2025 at 3:26 p.m. with RN 12 and CAIT, Patient 39's "Progress Notes Report," dated 5/26/2025, was reviewed. The report indicated that at 5:30 p.m. on 5/26/2025, Patient 39's BP was 90/55 (taken more than half an hour after the first low BP reading from 4:45 p.m.). Another entry at 8:05 p.m. indicated Patient 39's "fluid challenge (Normal saline, fluids that go into the vein to balance the body's fluids and help with blood pressure given) and Albumin (medication used to help raise blood pressure) unsuccessful. Pt (Patient 39) is arousable (to be able to be stimulated, awakened, or excited from a state of sleep, unconsciousness, or a lack of response), but drowsy (feel sleepy and sluggish). Endorsed to (name of RN) night shift RN." A later entry at 8:17 p.m. indicated at 8:15 p.m., Patient 39's BP was 74/44, "MD ordered to transfer patient to ICU ...patient transferred."

During further interview and record review on 9/11/2025 at 3:26 p.m. with Registered Nurse (RN) 12 and Clinical Analyst IT (CAIT), Patient 39's "Medication Administration Record," undated, was reviewed. The record indicated the following:

-On 5/26/2025 at 6:30 p.m. and at 7:18 p.m., Patient 39 received one liter (a unit of measure) of Normal Saline (a total of two liters) in the telemetry unit.
-On 5/26/2025 at 7:44 p.m., Patient 39 received Albumin (medication used to help balance the body's fluid levels and blood pressure) in the telemetry unit.
-On 5/26/2025 at 9:30 p.m., Patient 39 received Norepinephrine (medication that goes into the vein to raise blood pressure) in the ICU.

During the same concurrent interview and record review on 9/11/2025 at 3:26 p.m. with RN 12 and CAIT, Patient 39's "Electronic Medical Record," undated, was reviewed. CAIT confirmed Patient 39 was transferred to the Intensive Care Unit on 5/26/2025 at 8:28 p.m from the telemetry unit (a unit where patients require continuous monitoring of heart rate and rhythm). CAIT also confirmed Patient 39 remained in the Telemetry floor with low blood pressure for over three hours prior to being transferred to ICU.

During the same interview on 9/11/2025 at 3:26 p.m. with RN 12, RN 12 stated RRT would be called when there was a change in a patient's status (condition) or BP, and anyone can also call for a RRT. RN 12 further stated she (RN 12) thought it would have been appropriate for staff to have called a rapid response for Patient 39 on 5/26/2025.

During an interview on 9/12/2025 at 2:09 p.m. with the Chief Nursing Officer (CNO), the CNO stated, "Nurses can call if they need assistance and there's no harm to call a rapid response." CNO also stated, "The purpose of a rapid response was to get interventions to help the patient."

During a review of the facility's policy and procedure (P&P) titled, "Rapid Response Team (RRT)," dated 12/2014, the P&P indicated the following:

"Purpose: To improve patient outcomes by providing expert assessment, early intervention and stabilization for patients and to prevent clinical deterioration and/or arrest (cardiac or respiratory arrest [when the heart stops beating or when the patient stops breathing]).
Philosophy:
A. The Rapid Response Team (RRT) shall be used to create a culture where hospital staff, especially nurses, are encouraged to ask for help if they are uncertain about a patient's condition or desired intervention.
B. The Team is also a vehicle to enhance the knowledge and assessment skills of front-line staff and helps to create a supportive environment.
Policy:
C. Criteria for calling the Team may include but are not limited to one or more of the following ...Changes in SBP (<90 mmHg) ...Acute mental status change ..."

3. During a concurrent observation and interview on 9/9/2025 at 10:54 a.m. with the Emergency Room Director (ER/ICUD), in the emergency room department, one of two crash carts (crash cart #1, a set of trays on wheels used in hospital for transportation and dispensing emergency medications and equipment) was missing an oxygen tank (O2).
This observation was confirmed by the ER/ICUD. The ER/ICUD also stated that the O2 tank should be with the crash cart and should be readily available for use in case of an emergency. The ER/ICUD further stated that Charge Nurses were responsible for checking the crash cart every shift and use the crash cart checklist as guidance and if there was a missing item (such as a full oxygen tank), then the missing item should be replaced.

During a review of the facility's policy and procedure (P&P) titled, "Crash Cart Equipment and Medications," revised 02/2024, the P&P indicated, "Emergency carts and external equipment are to be checked a minimum of once each calendar day by the Charge Nurse or assigned licensed nurse ...Check for: O2 Cylinder present and at 1,000 psi or greater."

4.a. During a review of Patient 44's "Face Sheet (a document that summarizes a patient's essential medical information in a concise and easy-to-read format)," dated 9/06/2025, the Face Sheet indicated Patient 44 was admitted to the facility unit on 9/06/2025 at 14:13 (2:13 p.m.) p.m.

During a review of Patient 44's "History and Physical (H&P)," dated 9/06/2025, the "H&P" indicated the following: Patient 44 with a history of Tachycardia (abnormal fast heartbeats), Dementia (a general term for a group of conditions that cause a gradual decline in memory, thinking, reasoning, and language), Pulmonary Edema (condition where excess fluid accumulates in the lungs, making it difficult to breathe), and Code Blue (signals a life-threatening medical emergency, typically cardiac [the heart stops beating] or respiratory arrest [patient stops breathing], requiring immediate resuscitation [to revive] from a specially trained medical team).

During a review of Patient 44's PICC (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is positioned in a location at the superior vena cava [a large, significant vein responsible for returning deoxygenated blood collected from the body to the heart], and used for intravenous treatment that is required over a long period) Insertion Documentation, dated 9/7/2025, the "PICC Insertion Documentation" indicated the following: Patient 44 had a PICC line inserted to the left upper arm.

During a concurrent observation and interview on 9/09/2025 at 10:27 a.m., with Charge Nurse (CN 2) and Registered Nurse (RN 1), in Patient 44's room, Patient 44 had a PICC line to the left upper arm with transparent dressing soiled with blood, covering the insertion site and unable to see through the dressing. RN 1 stated the following: She (RN 1) did not assess the PICC line dressing today (9/9/2025