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Based on observations and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by:
1) failure to document the correct level of observation being performed per provider order for 5 (#R1-#R5) of 12 (#R1-#R12) close observation check sheets reviewed; and
2) failure to ensure current glucometer control solutions met the safety needs of the patients.
Findings:

1) Failure to document the correct level of observation being performed per provider order for 5 (#R1-#R5) of 12 (#R1-#R12) close observation check sheets reviewed.

Review of hospital policy number BH1032, titled "Observation Precautions," last revised 11/12/2024, revealed in part: "PURPOSE: To promote safety and ensure the patient is being treated in the least restrictive environment that is clinically permitted. POLICY: It is the policy of Universal Behavioral Health Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient's status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner. PROCEDURE: The licensed independent practitioner (LIP) shall order the patient the appropriate observation status at time of admission. Any change in the patient's observation status shall require a LIPs order. The Charge Registered Nurse is responsible for assigning the staff members to perform designated special observation status for each patient on his/her assigned unit. DOCUMENTATION: The LIP shall either verbally or in writing, issue an order for required observation status. The Charge Registered Nurse will be responsible for staff assignments on the MHT Unit Assignment Form. RN or LPN shall make rounds every 2 hours and sign the Observation Sheet to ensure that MHT's are observing their assigned patient, filling the form out correctly and not charting ahead. Documentation shall be completed in a timely manner such that an employee does not document ahead of time, nor does the employee document in such a fashion as to "catch up" the MHT Observation Sheet. The safety of patients and accuracy of documentation requires strict adherence to this policy and procedure."

Observations during a tour of the hospital on 08/21/2025 from 9:14 AM - 9:40 AM revealed 12 patients on Unit B. Review of the Unit Assignments revealed that Unit B had 11 patients on Q 15 minute observations and 1 patient on one to one observations. Review of the Close Observation sheets for Patient's #R1-#R5 revealed an observation of Level 1 (1:1 Observation) marked as their observation status. Further review failed to reveal the correct observation of Level II (Q 15 minutes) as being marked per provider order.

In an interview on 08/21/2025 at 9:23 AM, S1DON confirmed that the Close Observation sheets for Patient's #R1-#R5 were completed incorrectly, and verified that Level II should have been marked. S1DON further confirmed that Patient's #R1-#R5 had orders for Q 15 minute observations and were not on 1:1 observations.

2) Failure to ensure current glucometer control solutions met the safety needs of the patients.

Observations during a tour of the hospital on 08/21/2025 from 9:14 AM - 9:40 AM revealed Even Care Proview Glucose Control Solutions vials being opened and not properly labeled with an open date and beyond use date (expiration date). This would present a risk for harm or injury to a patient related to treatment being rendered based on the results of a capillary blood glucose reading via a glucometer that has not been properly quality control tested. The undocumented vials were as follows:

Unit A: Even Care Proview Glucose Control Solution #1 vial and Even Care Proview Glucose Control Solution #2 vial had an open date of 07/27/2025. Further review of the Even Care Proview Glucose Control Solutions failed to reveal a beyond use date (expiration date) marked on either opened vial.

In an interview on 08/21/2025 at 9:29 AM, S1DON confirmed the above mentioned findings.

Based on observations, record reviews, and interviews, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by:
1) failure of the Registered Nurse to supervise staff to ensure timely observation rounds were performed for 4 (#R1-#R4) of 12 (#R1-#R12) Patient Observation Check Sheets reviewed; and
2) failure of the Registered Nurse to document an assessment each shift for 1 (#1) of 3 (#1-#3) patient medical records reviewed.
Findings:

1) Failure of the Registered Nurse to supervise staff to ensure timely observation rounds were performed for 4 (#R1-#R4) of 12 (#R1-#R12) Patient Observation Check Sheets reviewed.

Review of hospital policy number BH1032, titled "Observation Precautions," last revised 11/12/2024, revealed in part: "PURPOSE: To promote safety and ensure the patient is being treated in the least restrictive environment that is clinically permitted. POLICY: It is the policy of Universal Behavioral Health Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient's status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner. Status guidelines as follows: 2. Level II: Q15 Minute Observation: Patients shall be visualized every fifteen (15) minutes by a staff member. Visual observation every 15 minutes by assigned staff prior to documenting patient location and behavior. Assigned staff members visualize patients on observation every 15 minutes or more often as indicated by patient behavior. DOCUMENTATION: The LIP shall either verbally or in writing, issue an order for required observation status. The Charge Registered Nurse will be responsible for staff assignments on the MHT Unit Assignment Form. RN or LPN shall make rounds every 2 hours and sign the Observation Sheet to ensure that MHT's are observing their assigned patient, filling the form out correctly and not charting ahead. Documentation shall be completed in a timely manner such that an employee does not document ahead of time, nor does the employee document in such a fashion as to "catch up" the MHT Observation Sheet. The safety of patients and accuracy of documentation requires strict adherence to this policy and procedure."

Observations during a walk-through on 08/21/2025 revealed the following on Unit B:

Review of Patient #R1-#R4 Observation Sheets for Unit B revealed the last documented observation as performed was at 8:30 AM. Further review failed to reveal documented evidence that Q15 minute observations were performed at 8:45 AM, 9:00 AM, or 9:15 AM on Patient #R1-#R4.

In an interview on 08/21/2025 at 9:23 AM, S1DON confirmed the above mentioned findings.

2) Failure of the Registered Nurse to document an assessment each shift for 1 (#1) of 3 (#1-#3) patient medical records reviewed.

Patient #1
A review of Patient #1's medical record revealed Patient #1 was admitted on 08/03/2025 at 4:45 AM and discharged on 08/13/2025 at 11:09 AM. Further review of the nursing assessments in Patient #1's medical record failed to reveal documented evidence of a nursing assessment on 08/10/2025 for the 7 AM-7 PM shift.

In an interview on 08/21/2025 at 2:55 PM, S2DRM confirmed that a nursing shift assessment is to be completed for each shift on each patient. S2DRM verified the 7 AM-7 PM nursing shift assessment was not documented on 08/10/2025 for Patient #1.

Based on record review and interview, the hospital failed to ensure social service records included all interviews with patients, family members and others, assessment of home plans, family attitudes, and community resource contacts as well as a social history. This deficiency was evidenced by failing to ensure changes to discharge plan were updated for 1 (#1) of 3 (#1-#3) patient medical records reviewed.
Findings:

Review of hospital policy number BH6010, titled "Social Services," last revised 02/24/2025, revealed in part: "POLICY: Social work contact with the patient, family and significant others shall occur during, or as soon as possible, after patient admission within 72 hours to be initiated. Continuity of care is an important social work principle and may be demonstrated through case management and a major role in discharge planning. Activities, in conjunction with the patient's wishes, may include contact with patient's family, identifying and assisting in referral of the patient to community-based agency(ies) at the time of discharge. Social service staff responsibilities shall include, but not limited to: Participating in discharge planning; arranging for follow-up care; developing mechanisms for exchange of appropriate information with sources outside the facility."

Review of hospital policy number BH1303, titled "Discharge of Patients," last revised 03/25/2025, revealed in part: "PROCEDURE: Social Services shall notify the family or caretaker of the discharge order."

Review of hospital policy number BH1301, titled "Discharge and Transition of Care Planning of Patients with Social Services," last revised 03/25/2025, revealed in part: "POLICY: Patients shall be advised of recommendations for programs and services in the community, and with the consent of the patient/family, appropriate referrals shall be made by the Social Worker/Discharge Planner. The Social Worker/Discharge Planner shall attempt to find adequate and appropriate living arrangements for all patients discharged from the behavioral health facility. Based on input from the patient, family/significant other, providers, and members of the multidisciplinary team, a discharge plan shall be developed. PROCEDURE: Information shall be obtained from the patient and/or family member, providers, medical records, and other information available to assist in transitioning the patient to the most relevant level of care. Information to form a plan may include: Patient's optimal level of functioning outside of the facility. Patient's current support system. Potential for out-of-home placement shall be assessed and appropriate level of care options for long-term care shall be explored with the patient and family. The patient/family shall be given an aftercare plan, which includes discharge referral information. DOCUMENTATION: The Social Worker/Discharge Planner shall document the discharge summary on the discharge summary form utilized by the multidisciplinary team. This summary shall report the patient's: Patient/family involvement and response to treatment interventions if applicable."

Patient #1
Review of Patient #1's medical record revealed Patient #1 was admitted on 08/03/2025 at 4:45 AM with diagnoses of Schizophrenia, Bipolar 1 Disorder, Cannabis Use Disorder, and Psychosis. Patient #1 was discharged on 08/13/2025 at 11:09 AM.

Review of Patient #1's Psychosocial Assessment signed by S7SW on 08/05/2025 at 3:48 PM revealed in part the following:
Admission Criteria: Altered Thought Process Violent/Homicidal
Relationships: Describe current relationship with other family members: Patient states relationship with family is "good."
Housing: Resides with: Homeless (Patient was residing with sister. Patient refuses to return).
Collateral Contact: See Initial Discharge Planning and Collateral Contact Note
Summary: LMSW met with patient to complete PSA and obtain collateral information. Patient reports living with his sister. Patient states he wants to discharge to a group home. Patient gave brother's information for collateral contact. Patient reports his brother will provide him transportation at discharge. Patient to be discharged once mood has stabilized, improved thought process, medication compliance, and improved insight and judgement.

Review of Patient #1's Discharge Planning Log signed by S8SW on 08/14/2025 at 1:44 PM revealed in part the following:
08/05/2025 at 12:39 PM
Discharge location: Group Home
Collateral contact/Support Identified: YES
Collateral/support involved in discharge plan: YES

08/07/2025 at 1:49 PM - 3 Day Post Initial Discharge Plan Completion
Any changes to initial discharge plan: NO
Discussed barriers/recommendations with client/collateral contact: YES

08/13/2025 at 1:55 PM - Follow Up with Discharge Plan (if applicable)
Any changes to initial discharge plan: NO

Review of Patient #1's Discharge Planner Note signed by S8SW on 08/13/2025 at 2:26 PM revealed in part the following:
Chief Complaint: Psychosis
1) Client's current presentation: Appropriate Mood and actively participating in discharge discussion.
4) Is identified collateral contact/support aware of discharge plan and in agreement: YES
7) Collateral/support contact verbalized understanding of current discharge plan/crisis safety plan: YES
Discharge plan was discussed with client and/or collateral contact day of discharge. Confirmed discharge location and follow up care scheduled and/or recommended after discharge. Client/collateral contact will be provided a printed copy of discharge plans and aftercare appointments along with discharge medication list.

Review of Patient #1's medical records failed to reveal documentation that contact with Patient #1's collateral was obtained. Further review of failed to reveal documented evidence that the collateral contact/support was notified and in agreement with the discharge plan for Patient #1.

In an interview on 08/21/2025 at 1:20 PM, S3DSS confirmed that they were unable to make contact with the collateral contact/support for Patient #1 prior to discharging the patient. S2DRM and S3DSS verified that the above mentioned social worker documentation revealed that the collateral contact/support was contacted and aware of the discharge plan for Patient #1. S3DSS further stated that the collateral/support contact documentation was incorrect.