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Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for governing body (GB, the leadership group responsible for oversight of the facility operations and patient safety) was met, when the facility's governing body failed to fulfill its responsibilities to ensure that all patients received care in accordance with the facility's policies and procedures, and nationally recognized standards of practice as evidenced by:

1. The Governing Body failed to ensure its nursing staff adhered to its internal policies and procedures "Code Blue (emergency call for cardiac [heart] or respiratory arrest [stop breathing]) and Transferring Patients to the Emergency Room," and did not follow current American Heart Association (AHA) Basic Life Support (BLS) guidelines (nationally procedures for emergency resuscitation [emergency effort to restore breathing or heartbeat], including chest compressions [pressing on the chest to pump], airway support [keeping breathing passages open], and use of a defibrillator [a device that delivers an electric shock to restart or correct the heart's rhythm] during a cardiac arrest [heart stop] or other life-threatening conditions) for one (1) of 43 sampled patients (Patient 1).

This deficient practice resulted in the lack of timely and effective emergency response for a patient (Patient 1) who was found unresponsive (not responding to verbal command, touch, or pain). This deficient practice also increased the likelihood of poor patient outcomes or death during medical emergencies. (Refer to A-0063)

2. The Governing Body failed to ensure oversight in maintaining a safe environment for de-escalation (is a method to prevent potential violence), in accordance with the facility's policy on "Patient Precautions," for one (1) of 43 sampled patients (Patient 6), who had a known history of violent and unpredictable behavior and was brought into an unsecured and hazardous area (South Cafeteria). The cafeteria was not designed for patients for de-escalation and the cafeteria contained furniture and items that could be used as weapons (metal-legged chairs, hard plastic objects).

This deficient practice resulted in patient care areas not being assessed for safety prior to use, which contributed to an actual physical injury (laceration to the head) to the Director of Admission (DOA). The lack of oversight also had the potential to cause further harm to patients and staff if unsafe areas continue to be used for behavioral crisis (a situation where an individual's mental or emotional state becomes so severe that it poses a threat to their own safety or the safety of others) interventions. (Refer to A-0063)

3. The Governing Body failed to ensure oversight on the Nursing Services Department to ensure accurate 15-minute Patient rounding (a regular, systematic process where healthcare professionals assess patients) and documentation of the patient rounding were completed, in accordance with the facility's policy on supervision of patients/patient rounds, for 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43).

This deficient practice resulted in the inability to ensure accurate monitoring of patients with behavioral health needs, increasing the risk of undetected self-harm (hurting themselves), aggression (behavior aimed at harming others physically), or medical deterioration. Inaccurate rounding may also result in delayed or missed interventions with potentially severe consequences. (Refer to A-0063)

4. The Governing Body failed to ensure timely authentication of restraint (any physical restraint that is a mechanical or personal restriction that immobilizes or reduces the ability of an individual to move his or her arms, legs, or head freely) orders, in accordance with the facility's policy on restraints, for one (1) of 43 sampled patients (Patient 29).

This deficient practice resulted in the inability to ensure that restraints were used under proper medical authority. The absence of physician verification may lead to unauthorized restraint use, which poses a risk to patient rights and dignity. (Refer to A-0063)

5. The Governing Body failed to ensure that the legal admission status (the circumstances under which a patient was admitted and treated. It essentially determines whether the patient is voluntarily seeking help or is being admitted involuntarily) was documented and honored, for two (2) of 43 sampled patients (Patient 23 and Patient 30), in accordance with the facility's guidelines on "Rights for Individuals in Mental Health Facilities."

This deficient practice resulted in the inability to ensure patients' legal rights were upheld. Detaining a patient without proper documentation violates patient autonomy (their right to make decisions about their care). (Refer to A-0063)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment. In addition, the cumulative effect of these systemic failures placed patients at risk for physical harm, psychological trauma (a deeply distressing or overwhelming experience that can have significant and lasting negative effects on a person's mental health and well-being), violation of rights, and preventable medical emergencies. These deficient practices demonstrated that the facility leadership did not provide effective oversight or ensure that appropriate care practices were implemented and followed.

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 provide a certification review hearing (also known as probable cause hearing, a legal proceeding with a specific purpose related to involuntary psychiatric holds to determine if there is sufficient legal justification [probable cause] to continue holding an individual involuntarily for intensive treatment due to a mental disorder), in a timely manner, for three of 43 sampled patients (Patients 23, 24 and 28), in accordance with facility's policy and procedures regarding certification review hearing as well as state regulations when:

1.a. The facility failed to provide proof of signed voluntary admission for Patient 23. This deficient practice resulted in Patient 23 not receiving a certification review hearing on 5/23/2025 and had a potential to result in detaining Patient 23 unnecessarily. (Refer to A-0129)

1.b. The social services staff did not request and arrange a certification review hearing for Patient 24 after a 5250-hold (14 Days Involuntary Intensive Treatment) was placed on 1/7/2025. This deficient practice resulted in Patient 24 not receiving a certification review hearing and had a potential to result in detaining Patient 24 unnecessarily. (Refer to A-0129)

1.c. The social services staff was delayed in requesting a certification review hearing for Patient 28 after a 5250-hold was placed on 7/18/2025. This deficient practice delayed Patient 28 in receiving a certification review hearing and had potential to result in detaining Patient 28 unnecessarily. (Refer to A-0129)

2. The facility failed to provide a safe environment of care in accordance with the facility's policy titled "Patient Precautions," and the facility's Governing Body (GB, responsible for setting policies, ensuring quality of care, and managing the hospital's financial health. Essentially, they act as the legal and ethical guardians of the institution and its mission) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization pertaining to the GB's accountability for the safety and quality of care, treatment, and services provided), when one (1) of 43 sampled patients (Patient 6), who had a known history of violent and unpredictable behavior, was brought into an unsecured and hazardous area (South Cafeteria). The cafeteria was not designed for patients for de-escalation (is a method to prevent potential violence) and the cafeteria contained furniture and items that could be used as weapons (metal-legged chairs, hard plastic objects).

This deficient practice resulted in Patient 6 accessing and picking up a chair with metal legs and throwing the chair at the Director of Admission (DOA), causing a head laceration (a pattern of injury in which blunt forces tear the skin and underlying tissues). As a result, staff-initiated Code 10 (a call for all trained personnel to respond to a dangerous situation) for Patient 6 and a Code Blue (hospital announcement means that an individual is having a medical emergency) for the Director of Admission who suffered a head laceration. Following this event, Patient 6 engaged in another violent episode, during which he (Patient 6) assaulted a second staff member (MHT, Mental Health Technician 5), resulting in a broken nose. (Refer to A-0144)

3. The facility failed to monitor 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43) in the Psychiatric Intensive Care (relating to acute mental or behavior illness) Unit, every 15 minutes, in accordance with the facility's policy and procedure regarding supervision of patients and patient rounds, who are admitted to the behavior or mental health unit.

This deficient practice placed 20 patients' safety at risk, such as self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence. (Refer to A-0144)

4. The facility failed to ensure the physician authenticated a telephone restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order within 24 hours for one of 43 sampled patients (Patient 29), in accordance with the facility's policy and procedure regarding restraints use, when Patient 29 was placed on physical restraint (type of physical restraint, a manual or physical method of holding the patient against patient's will that restricts freedom of movement or normal access to one's body) on 7/16/2025.

This deficient practice resulted in a lack of physician verification of physical restraints use on Patient 29 and had the potential to result in unnecessary restraint use for Patient 29. (Refer to A-0168)

5. The facility failed to ensure its nursing staff notified physician, within 30 minutes, after a face-to-face evaluation (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) was performed for one of 43 sampled patients (Patient 6) on 7/14/2025 and 7/22/2025, in accordance with the facility's policy and procedure regarding restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)/seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving).

This deficient practice had the potential to result in Patient 6's physician not knowing Patient 6's response to restraint and had the potential to lead to Patient 6 not receiving additional treatment or care as needed. (Refer to A-0182)

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

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

1. The facility failed to ensure nursing staff assessed and documented the blood sugar level for one of 43 sampled patients (Patient 1), in accordance with the facility's policy regarding Nursing Assessment and Reassessment of Patients, when Patient 1's blood sugar (body's source of energy) was not assessed and when Patient 1 received Metformin (medication used to control blood sugar) without a corresponding blood sugar level checked.

This deficient practice had the potential for Patient 1 to not receive the appropriate monitoring and interventions and may contribute to Patient 1's change of condition such as hypoglycemia (low blood sugar) and/or death. (Refer to A-0395)

2. The facility failed to ensure for one of 43 sampled patients (Patient 13), nursing staff supervised care and adhered to the facility's policy titled, "Supervision of Patients/Patient Rounds (a regular, systematic process where healthcare professionals assess patients)," when Patient 13's "Round Sheet" did not have the Registered Nurse's (RN) signature to validate that a patient rounding was completed.

This deficient practice had the potential for Patient 13's care to not have the proper oversight by an RN, which may result in patient harm if the rounding was not accurately performed. (Refer to A-0398)

3. The facility failed to conduct a suicide (thoughts of taking one's own life) screening (a procedure that uses a standardized instrument or protocol, like a set of questions, to quickly identify individuals who may be at risk for suicide), daily, for one of 43 sampled patients (Patient 15), in accordance with the facility's policy and procedure regarding suicide screening.

This deficient practice resulted in two missed suicide screenings and had the potential for suicide risk to be unidentified for Patient 15, which may result in patient harm and/or death. (Refer to A-0398)

4. The facility failed to ensure its nursing staff adhered to its internal policies and procedures "Code Blue (Emergency overhead announcement for medical resuscitation) and Transferring Patients to the Emergency Room," and did not follow current American Heart Association (AHA) Basic Life Support (BLS) guidelines (nationally procedures for emergency resuscitation [emergency effort to restore breathing or heartbeat], including chest compressions [pressing on the chest to pump], airway support [keeping breathing passages open], and use of a defibrillator [a device that delivers an electric shock to restart or correct the heart's rhythm] during cardiac arrest [heart stop] or other life-threatening conditions) for one (1) of 43 sampled patients (Patient 1).

This deficient practice resulted in the failure to provide timely and appropriate resuscitation (emergency efforts to restore breathing or heartbeat) for Patient 1 and placed other patients at risk for delayed or inadequate emergencies during future medical emergencies. (Refer to A-0398)

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

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

1. The facility failed to ensure that medical records for 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43), were accurately written or documented, in accordance with the facility's policy regarding "Supervision of Patients / Patient Rounds." The patient rounds (a systematic process where a healthcare team member checks on a patient regularly) conducted, every 15 minutes, in the Intensive Treatment Unit, were inaccurately documented in the medical record for 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43).

This deficient practice led to the inaccurate documentation on 12/20/2025 at 9:45 p.m., that 20 patients had been visualized by a staff, when in fact, the round was not conducted at that time. This deficient practice also placed 20 patients' safety at risk for self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence. (Refer to A-0438)

2. The facility failed to ensure staff completed and retained a record of voluntary admission for one of 43 sampled patients (Patient 23), when staff claimed Patient 23 had signed voluntary admission on 5/23/2025 to justify admission and continued hospitalization.

This deficient practice resulted in confusion regarding Patient 23's legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) including an incomplete medical record to reflect Patient 23's proper legal status for the admission, which had the potential to violate patient's right regarding voluntary treatment. (Refer to A-0449)

3. The facility failed to ensure all physician orders were dated, timed and authenticated by the ordering physician, in a timely manner (within 24 hours), for one of 43 sampled patients (Patient 29), in accordance with the facility's policy and procedure regarding restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)/seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving).

This deficient practice resulted in a lack of physician verification of order and incomplete medical records. (Refer to A-0454)

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

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

1. The facility failed to ensure a patient's legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) was correctly reflected on one of 43 sampled patient's (Patient 30) medical record, after Patient 30 signed a voluntary admission on 7/7/2025.

This deficient practice resulted in confusion on Patient 30's legal status and led to unnecessary hold placement (putting a patient in an involuntary admission) on 7/15/2025, which violated Patient 30's right regarding voluntary treatment. (Refer to A-1622)

2. The facility failed to ensure to develop an individualized treatment plan (a document that outlines an individual's assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) for one of 43 sampled patients (Patient 24) to address Patient 24's past trauma as sexual abuse victim, in accordance with the facility's policy regarding "Interdisciplinary Patient-Centered Care Planning."

This deficient practice resulted in Patient 24 feeling anxious around male staff conducting patient rounding (a regular, systematic process where healthcare professionals assess patients) at nighttime during Patient 24's course of hospitalization. (Refer to A-1640)

3. The facility failed to ensure its multidisciplinary team (a group of professionals including physicians, nurses, social workers and therapists who collaborate to provide comprehensive and coordinated patient care) set a long-term goal when developing a treatment plan (a document that outlines an individual's assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) for two of 43 sampled patients (Patients 24, and 25), in accordance with the facility's policy regarding treatment plans.

This deficient practice had the potential to result in failure in evaluating patient's care progress and response to treatment, which may lead to a premature or a delayed discharge. (Refer to A-1642)

4. The facility failed to ensure the medication consent record for one (1) of 43 sampled patients (Patient 5), was completed, in such a way to assure that all active therapeutic efforts were included, in accordance with the facility's policy titled "Informed Consent For Psychotropic Medications (medications that affect the brain and can alter mood, awareness, thoughts, feelings, or behavior)." Specifically, the facility failed to ensure that the medication consent form for a sedation-hypnotic medication (Ambien, a medication used to treat insomnia [difficulty falling or staying asleep]) included: the dosing range, name and signature of the treating practitioner, the diagnosis, the intended benefits and outcomes of the medication, and documentation of the possibility that the medication may require adjustment.

This deficient practice resulted in a medication being administered to Patient 5 without a fully completed and physician signed medication consent form. The medical record did not contain documentation that the physician explained the medication's risks, benefits, or purpose to Patient 5. This lack of documentation may interfere with the treatment team's ability to assess informed consent, track treatment planning, and ensure proper authorization. This deficient practice also had the potential to affect other patients if medications were administered without a complete and accurately documented consent process. (Refer to A-1650)

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

Based on observation, interview, and record review, the facility's Governing Body (the legal responsible leadership group for hospital operations and patient safety) failed to ensure oversight in compliance with the facility's own policies and procedures for the care of patients as follows:

1. The Governing Body failed to ensure its nursing staff adhered to its internal policies and procedures "Code Blue (emergency call for cardiac [heart] or respiratory arrest [stop breathing]) and Transferring Patients to the Emergency Room," and did not follow current American Heart Association (AHA) Basic Life Support (BLS) guidelines (nationally procedures for emergency resuscitation [emergency effort to restore breathing or heartbeat], including chest compressions [pressing on the chest to pump], airway support [keeping breathing passages open], and use of a defibrillator [a device that delivers an electric shock to restart or correct the heart's rhythm] during a cardiac arrest [heart stop] or other life-threatening conditions) for one (1) of 43 sampled patients (Patient 1).

This deficient practice resulted in the lack of timely and effective emergency response for a patient (Patient 1) who was found unresponsive (not responding to verbal command, touch, or pain). This deficient practice also increased the likelihood of poor patient outcomes or death during medical emergencies.

2. The Governing Body failed to ensure oversight in maintaining a safe environment for de-escalation (is a method to prevent potential violence), in accordance with the facility's policy on "Patient Precautions," for one (1) of 43 sampled patients (Patient 6), who had a known history of violent and unpredictable behavior and was brought into an unsecured and hazardous area (South Cafeteria). The cafeteria was not designed for patients for de-escalation and the cafeteria contained furniture and items that could be used as weapons (metal-legged chairs, hard plastic objects).

This deficient practice resulted in patient care areas not being assessed for safety prior to use, which contributed to an actual physical injury (laceration to the head) to the Director of Admission (DOA). The lack of oversight also had the potential to cause further harm to patients and staff if unsafe areas continue to be used for behavioral crisis (a situation where an individual's mental or emotional state becomes so severe that it poses a threat to their own safety or the safety of others) interventions.

3. The Governing Body failed to ensure oversight on the Nursing Services Department to ensure accurate 15-minute Patient rounding (a regular, systematic process where healthcare professionals assess patients) and Documentation of the patient rounding completed, in accordance with the facility's policy on supervision of patients/patient rounds, for 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43).

This deficient practice resulted in the inability to ensure accurate monitoring of patients with behavioral health needs, increasing the risk of undetected self-harm (hurting themselves), aggression (behavior aimed at harming others physically), or medical deterioration. Inaccurate rounding may also result in delayed or missed interventions with potentially severe consequences.

4. The Governing Body failed to ensure timely authentication of restraint (any physical restraint that is a mechanical or personal restriction that immobilizes or reduces the ability of an individual to move his or her arms, legs, or head freely) orders, in accordance with the facility's policy on restraints, for one (1) of 43 sampled patients (Patient 29).

This deficient practice resulted in the inability to ensure that restraints were used under proper medical authority. The absence of physician verification may lead to unauthorized restraint use, which poses a risk to patient rights and dignity.

5. The Governing Body failed to ensure that the legal admission status (the circumstances under which a patient was admitted and treated. It essentially determines whether the patient is voluntarily seeking help or is being admitted involuntarily) was documented and honored, for two (2) of 43 sampled patients (Patient 23 and Patient 30), in accordance with the facility's guidelines on "Rights for Individuals in Mental Health Facilities."

This deficient practice resulted in the inability to ensure patients' legal rights were upheld. Detaining a patient without proper documentation violates patient autonomy (their right to make decisions about their care).

Findings:

1. During a review of Patient 1's "Daily Progress Note," dated 12/20/2024, the note indicated, Patient 1 had medical history including: Diabetes (a chronic condition that leads to elevated blood sugar) with diagnoses of schizoaffective (a mental health condition that combines symptoms of both schizophrenia [a mental health condition combining symptoms of schizophrenia [characterized by significant disturbances in thought, perception, emotion, and behavior] and a mood disorder like), and bipolar (a mental illness marked by extreme mood swings from highs [mania] to lows [depression]) disorder.

During a review of Patient 1's medical record document titled, "Code Blue (emergency call for cardiac [heart] or respiratory arrest [stop breathing])/Medical Emergency Documentation," dated 12/20/2024, the record indicated the following:
-Code Blue (Emergency overhead announcement for medical resuscitation) was called at 10:03 p.m.
-No AED (Automated External Defibrillator, a portable electronic device that analyzes heart rhythms and delivers an electrical shock to help restore a normal heartbeat in cases of sudden cardiac arrest [heart stops beating]) was applied.
-No Blood glucose (Blood sugar) check, despite Patient 1's diabetes diagnosis.
-Documentation indicated "mouth sweep (inserting fingers into the mouth to remove a blockage- should only be done if the object is visible), Heimlich maneuver (abdominal thrusts to relieve choking-should only be used when there are signs of choking), with no documented evidence that the patient was choking or had a visible obstruction.

During an interview on 7/22/2025 at 3:41 p.m. with RN 11, RN 11stated they were unsure whether to apply the AED if the patient was unresponsive but had a pulse.

During a concurrent observation and interview on 7/22/2025 at 12:13 p.m. with the Assistant Chief Nursing Officer/ Clinical Educator (ACNO), in Unit ABC, the crash cart (a mobile cart containing emergency resuscitation equipment) was found lacking a suction machine (device used in hospitals to remove fluids and secretions from a patient's body, primarily the airway). The ACNO confirmed the facility did not have suction equipment available for use during a Code Blue.

During a concurrent interview and surveillance video observation and review on 7/24/2025 at 10:08 a.m. with the Director of Risk Management (DRM), the video footage, dated 12/20/2024, showed the following:
-At 10:01:00 p.m., Registered Nurse (RN) 9 and Certified Nurse Assistant (CNA, Certified nursing assistants provide basic care to patients) 1 entered Patient 1's room.
-At 10:02:00 p.m., RN 9 and CNA 1 exited the room.
-At 10:02:36 p.m., CNA 1 re-entered Patient 1's room
-At 10:03:00 p.m., RN 9 returned, and Code Blue was called.

During the same interview on 7/24/2025 at 10:08 a.m. with the Director of Risk Management (DRM), the DRM confirmed there was a two -minute delay between discovery of the unresponsive patient (Patient 1) and the initiation of emergency procedures (such as calling a code blue).

During an interview on 7/25/2025 at 5:58 p.m. with Registered Nurse (RN) 1, RN 1 stated the facility did not have a suction equipment installed on the unit (Unit ABC). RN 1 stated there was a training conducted on suction machines a month prior, but confirmed the equipment was still unavailable during medical emergencies, leaving staff without a method to clear a patient's airway when needed.

During an interview with the Chief Executive Officer (CEO, is the top administrator of a hospital or a network of hospitals. They are responsible for the overall management and strategic direction of the organization, including its operations, finances, and quality of care) on 7/25/2025 at 6:30 p.m., the CEO stated that the Governing Body was responsible for oversight of patient safety, financial matters, regulatory compliance, environmental safety, policy approval, and credentialing of medical providers.

During a review of the facility's policy and procedure (P&P) titled, "Code Blue and Transferring Patients to the Emergency Room," dated June 2025, the P&P indicated, "The staff member who finds/witnesses the medical emergency will immediately call for help and have a Code Blue paged overhead. The Code Blue will be paged overhead three times, including the location. The staff member will not leave the patient alone. The staff from the unit housing the patient will bring the vital signs machine, accu-check machine (used to check blood sugar), AED, oxygen tank, emergency crash carts, and any other pertinent equipment/supplies, based on the situation ..."

During a review of the facility's policy and procedure (P&P) titled, "Medical Emergencies and Acute Change in Condition," dated May 2025, the P&P indicated, "An RN may initiate a 911 call prior to calling the physician and House Supervisor ... Airway Problems: If the patient is coughing or can speak, stay with the patient and encourage continued coughing ... If the patient continues to cough ineffectively and appears to be in increasing distress, the object may be totally obstructing the airway. Call 911 and initiate a Code Blue. If the patient cannot speak or breathe, perform abdominal thrusts, call 911, and initiate a Code Blue."

During a review of the American Heart Association (AHA) 2020 Guidelines for CPR and Emergency Cardiovascular Care, Part 3 - Part 8: Adult Basic and Advance Life Support," indicated the following:
-"Initiate CPR immediately; do not leave the victim unattended."
-"Apply AED to all unresponsive patients regardless of the presence of a pulse, to analyze heart rhythm and guide next steps."
-"Suction equipment should be readily available in hospital settings where cardiac arrest may occur."
-"The Heimlich maneuver (abdominal thrusts) and finger sweeps should only be used when a foreign body airway obstruction is clearly present."

During review of the facility's Bylaws (provide a framework for the hospital's operations, ensuring accountability, quality of care, and adherence to legal and ethical standards) of the Board of Governors, dated 4/1/2020, indicated, "The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity's governing corporate documents and as authorized by the Corporate Governing Body."

2. During a review of Patient 6's "Daily Progress Note," dated 7/18/2025, the note indicated Patient 6's diagnoses included psychosis (a mental health condition where a person loses touch with reality), schizophrenia (a mental illness affecting thought, emotion, and behavior), and documented high risk for "self-harm or harm to others." The note also indicated Patient 6 had a history of assaultive behavior (refers to actions or behaviors that involve physical aggression, threats, or actions intended to cause physical harm or injury to another person).

During a surveillance video review of the South Cafeteria, on 7/23/2025 at 11:30 a.m. (video dated 7/22/2025 at 2:42 p.m.), in the presence of the Director of Quality and DQPI), the following events were observed:
-Nurse Manager (NM) escorted Patient 6 to the South Cafeteria and provided a soda as part of a calming strategy.
- Patient 6 approached the soda machine, served himself, and sat with NM 1.
- A second Staff member (Staff 1) entered the cafeteria and sat at the opposite end of the room.
-Patient 6 suddenly stood up and chased Staff 1 around the table.
- Patient 6 then picked up a metal chair with metal legs and threw it at the Director of Admission (DOA), striking him (DOA) in the forehead and causing a head laceration (a deep cut or tear in the skin).
- The DOA clutched his (DOA) head, and staff-initiated Code 10 (call for emergency trained responders) for Patient 6, and a Code Blue (medical emergency alert) for DOA (due to head laceration).

During an interview on 7/23/2025 at 4:20 p.m. with the Director of Plant Operation and Safety officer (DPO), DPO stated the cafeteria chairs were made of metal and it was not appropriate to bring an agitated patient to that environment.

During a concurrent interview and record review on 7/25/2025 at 8:45 p.m. with the Director of Plant Operations and Safety Officer (DPO, the staff member in charge of facility safety and maintenance), the facility's "Environmental Rounds," checklist was reviewed and there was no checklist for the facility's cafeterias. The DPO stated that monthly EOC rounds were conducted to identify safety hazards. However, DPO confirmed that the South Cafeteria, which contained chairs with metal legs (items that could be used as weapons), was not included in the routine EOC rounding. The DPO stated that EOC rounds were conducted monthly to identify safety hazards. However, the South Cafeteria which contained chairs with metal legs was not included because it was considered a "non-patient care area." The DPO also confirmed that patients routinely used the cafeteria for meals and, in some cases, for de-escalation (a behavioral intervention used to calm agitated (feeling worried, uneasy, or disturbed, and showing this through restlessness or physical behavior) patients without using physical restraint or medication). The DPO stated the cafeteria would now be added to future EOC rounds.

During an interview with the Chief Executive Officer (CEO, is the top administrator of a hospital or a network of hospitals. They are responsible for the overall management and strategic direction of the organization, including its operations, finances, and quality of care) on 7/25/2025 at 6:30 p.m., the CEO stated that the Governing Body was responsible for oversight of patient safety, financial matters, regulatory compliance, environmental safety, policy approval, and credentialing of medical providers.

During a review of the facility's policy and procedure (P&P) titled, "Patient Precautions," dated 7/2025, the P&P indicated, "All patients are assessed for risks of suicide (thoughts of taking one's own life)/self-harm, assault (refers to actions or behaviors that involve physical aggression, threats, or actions intended to cause physical harm or injury to another person), fall (an unexpected event where a patient unintentionally comes to rest on the ground or a lower level, like a bed or chair, during their hospital stay) ...and elopement (when a patient leaves the healthcare facility without authorization or notice) upon admission. All patients are also re-assessed for the same risk factors on a daily basis throughout their hospitalization to determine if there are any changes in their level of risk. Patients will also be re¿assessed for risk whenever there is an abrupt change in their behavior or mental status. Once risk factors are identified, the physician will determine appropriate precautions for each patient ... All patients identified to be on Assault Precautions will have the following measure initiated: May be restricted to the unit ... Monitor closely and ensure that vulnerable patients are monitored for safety ...Monitor and assess for environmental risks, including contraband, property damage, and items that could be used as weapons ... If an assault occurs: RN will assess and consult with attending psychiatrist for additional interventions including but not limited to: Change in observation level ... 1 :1 therapy ..."

During a review of the facility's Bylaws (provide a framework for the hospital's operations, ensuring accountability, quality of care, and adherence to legal and ethical standards) of the Board of Governors, dated 4/1/2020, indicated, "The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity's governing corporate documents and as authorized by the Corporate Governing Body."

3. During a video surveillance observation and review on 7/24/2025 at 10:08 a.m. with the Chief Nursing Officer (CNO) and the Director of Risk Management (DRM), a video footage of the Intensive Treatment Unit, dated 12/20/2024, was reviewed. The video footage on 12/20/2024 starting at 9 p.m. and ending at 11 p.m. indicated patient rounds (a systematic process where a healthcare team member checks on a patient regularly) were not performed for 20 Patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43), at 9:45 p.m. This video footage was in contrast with what staff documented that the 20 patients in the Intensive Treatment Unit (ITU) were checked during the required 15-minute safety rounds on 12/20/2024. During an interview on 7/24/2025 at 1:53 a.m., with the Chief Executive Officer (CEO), the CEO stated he (CEO) was aware that patient rounds had not been conducted on 12/20/2025 at 9:45 p.m., and verified that the Rounding Sheets for Patient 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43) had been "falsification" of a document.

During a review of "Round Sheet," dated 12/20/2024, for Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43, the Round Sheets indicated that rounds had been conducted at 9:45 p.m. The CNO and the CEO verified that the documentation was inaccurate.

During an interview with the Chief Executive Officer (CEO, is the top administrator of a hospital or a network of hospitals. They are responsible for the overall management and strategic direction of the organization, including its operations, finances, and quality of care) on 7/25/2025 at 6:30 p.m., the CEO stated that the Governing Body was responsible for oversight of patient safety, financial matters, regulatory compliance, environmental safety, policy approval, and credentialing of medical providers.

During a review of the facility's policy and procedure (P&P) titled, "Supervision of Patients/Patient Rounds," dated 7/2025, the P&P indicated the following: All patients who require supervision and rounds, are conducted continuously with each patient's location and behavior documented every 15 minutes. The staff assigned to the initial rounds will ensure that the Round Sheets for all patients on every 15-minute rounding are completed thoroughly and accurately.

During review of the facility's Bylaws (provide a framework for the hospital's operations, ensuring accountability, quality of care, and adherence to legal and ethical standards) of the Board of Governors, dated 4/1/2020, indicated, "The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity's governing corporate documents and as authorized by the Corporate Governing Body."

4. During a review of Patient 29's face sheet (face sheet, document provides patient's demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, "Patient Demographic Profile," dated 7/14/2025, the face sheet indicated Patient 29 was an involuntary admission with admitting diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions).

During a concurrent interview and record review on 7/25/2025 at 4:41 p.m. with the Director of Risk Management (DRM), Patient 29's physical restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order titled, "Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving)/Restraint/Chemical Restraint (use of medications to control a patient's behavior or restrict freedom of movement) Order," dated 7/16/2025, was reviewed. The physician restraint order indicated a telephone order was obtained for use of Physical Restraint on Patient 29 on 7/16/2025 at 2:12 p.m. The physician restraint order also indicated physician did not sign off on the order. DRM stated the order was missing a physician's signature.

During an interview on 7/25/2025 at 7:10 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: a physician order was required when putting a patient on restraint. The physician was required to authenticate the order within 24 hours. It would be considered as restraining patient without physician order because the physician did not sign off on the order (telephone order).

During an interview with the Chief Executive Officer (CEO, is the top administrator of a hospital or a network of hospitals. They are responsible for the overall management and strategic direction of the organization, including its operations, finances, and quality of care) on 7/25/2025 at 6:30 p.m., the CEO stated that the Governing Body was responsible for oversight of patient safety, financial matters, regulatory compliance, environmental safety, policy approval, and credentialing of medical providers.

During a review of the facility's policy and procedure (P&P) titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion," dated 7/2025, the P&P indicated, "Restraints or seclusion shall be used in emergency situations only and requires an order from a physician ... the physician shall authenticate the telephone/verbal order within 24 hours."

During review of the facility's Bylaws (provide a framework for the hospital's operations, ensuring accountability, quality of care, and adherence to legal and ethical standards) of the Board of Governors, dated 4/1/2020, indicated, "The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity's governing corporate documents and as authorized by the Corporate Governing Body."

5.a. During a review of Patient 23's "Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated 5/17/2025, the Psych Eval indicated, Patient 23 was admitted to the facility with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a concurrent interview and record review on 7/25/2025 at 2:45 p.m. with the Director of Clinical Services (DCS), Patient 23's "Certification Review Hearing (also known as probable cause hearing, a legal proceeding with a specific purpose related to involuntary psychiatric holds to determine if there is sufficient legal justification [probable cause] to continue holding an individual involuntarily for intensive treatment due to a mental disorder) Record," dated 5/23/2025, was reviewed. The "Certification Review Hearing Record" indicated, "the hearing was not held. Reason: patient (Patient 23) has signed VOL (voluntary admission) per [staff]." DCS stated the hearing was not held because Patient 23 signed for voluntary admission.

During an interview on 7/25/2025 at 2:46 p.m. with DCS, DCS stated the following: there was no voluntary admission form found in Patient 23's medical record. A patient would sign the voluntary admission form when changing legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) from involuntary to voluntary. The Psychiatrist (physician specializes in mental health) would then sign the voluntary admission form to confirm the voluntary admission. Patient 23 remained as involuntary admission during the hospital stay and did not receive a certification review hearing. DCS also stated it was important to have accurate medical record to reflect patient's legal status. Without the proof of voluntary admission form, there would be confusion on patient's legal status.

During an interview with the Chief Executive Officer (CEO, is the top administrator of a hospital or a network of hospitals. They are responsible for the overall management and strategic direction of the organization, including its operations, finances, and quality of care) on 7/25/2025 at 6:30 p.m., the CEO stated that the Governing Body was responsible for oversight of patient safety, financial matters, regulatory compliance, environmental safety, policy approval, and credentialing of medical providers.

During a review of the facility's patient handbook titled, "Rights for Individuals in Mental Health Facilities," dated 7/2018, the patient handbook indicated, "If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold. You may be represented at this hearing by a patient's rights advocate or another person of your choice. You can also request to have family members to help explain your circumstances."

During review of the facility's Bylaws (provide a framework for the hospital's operations, ensuring accountability, quality of care, and adherence to legal and ethical standards) of the Board of Governors, dated 4/1/2020, indicated, "The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity's governing corporate documents and as authorized by the Corporate Governing Body."

5.b. During a review of Patient 30's "Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 6/30/2025, the Psych Eval indicated, Patient 30 was admitted to the facility with diagnoses including but not limited to major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), severe, recurrent (repeat), with psychosis (a severe mental disorder with hallucinations [an experience involving the apparent perception of something not present]) and post-traumatic stress disorder (PTSD, an anxiety disorder that develops after experiencing stressful, frightening or distressing events).

During a concurrent interview and record review on 7/25/2025 at 3:11 p.m. with DCS, Patient 30's involuntary hold notice titled, "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code," dated 7/15/2025, the involuntary hold notice indicated, Patient 30 was placed on a 30-day hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 30 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for gravely disability due to being "irritable, labile (a tendency to be unpredictable), still working on a viable safety plan for discharge." DSC stated this hold was unnecessary because Patient 30 was already on voluntary status since 7/7/2025.

During a review of the facility's patient handbook titled, "Rights for Individuals in Mental Health Facilities," dated 7/2018, the patient handbook indicated, "If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold."

During an interview with the Chief Executive Officer (CEO, is the top administrator of a hospital or a network of hospitals. They are responsible for the overall management and strategic direction of the organization, including its operations, finances, and quality of care) on 7/25/2025 at 6:30 p.m., the CEO stated that the Governing Body was responsible for oversight of patient safety, financial matters, regulatory compliance, environmental safety, policy approval, and credentialing of medical providers.

During review of the facility's Bylaws (provide a framework for the hospital's operations, ensuring accountability, quality of care, and adherence to legal and ethical standards) of the Board of Governors, dated 4/1/2020, indicated, "The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. The primary purposes of the Hospital are to own and operate a behavioral health care facility and to perform such other activities for such other purposes as authorized by the Corporate Entity's governing corporate documents and as authorized by the Corporate Governing Body."

Based on interview and record review, the facility failed to provide a certification review hearing (also known as probable cause hearing, a legal proceeding with a specific purpose related to involuntary psychiatric holds to determine if there is sufficient legal justification [probable cause] to continue holding an individual involuntarily for intensive treatment due to a mental disorder), in a timely manner, for three of 43 sampled patients (Patients 23, 24 and 28), in accordance with facility's policy and procedures regarding certification review hearing as well as state regulations when:

1. The facility failed to provide proof of signed voluntary admission for Patient 23. This deficient practice resulted in Patient 23 not receiving a certification review hearing on 5/23/2025 and had a potential to result in detaining Patient 23 unnecessarily.

2. The social services staff did not request and arrange a certification review hearing for Patient 24 after a 5250-hold (14 Days Involuntary Intensive Treatment) was placed on 1/7/2025. This deficient practice resulted in Patient 24 not receiving a certification review hearing and had potential to result in detaining Patient 24 unnecessarily.

3. The social services staff was delayed in requesting a certification review hearing for Patient 28 after a 5250-hold was placed on 7/18/2025. This deficient practice delayed Patient 28 in receiving a certification review hearing and had potential to result in detaining Patient 28 unnecessarily.

Findings:

1. During a review of Patient 23's "Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated 5/17/2025, the Psych Eval indicated, Patient 23 was admitted to the facility with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 23's face sheet (face sheet, document provides patient's demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, "Patient Demographic Profile," dated 5/25/2025, the face sheet indicated Patient 23 was an involuntary admission from 5/17/2025 to 5/24/2025.

During an interview on 7/25/2025 at 11:22 a.m. with the Director of Clinical Services (DCS), DCS stated the following: social services staff would file a request for certification review hearing the next business day with court after a patient was placed on 5250-hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment). The hearing would be scheduled by the court within four (4) days. The court would then determine whether there was probable cause (sufficient legal justification) existing to detain the patient for involuntary detainment for psychiatric treatment.

During a review of Patient 23's involuntary hold notice titled, "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code," dated 5/19/2025, the involuntary hold notice indicated Patient 23 was placed on 14-day hold due to danger to himself or herself on 5/19/2025.

During a concurrent interview and record review on 7/25/2025 at 2:45 p.m. with DCS, Patient 23's "Certification Review Hearing Record," dated 5/23/2025, was reviewed. The "Certification Review Hearing Record" indicated, "the hearing was not held. Reason: patient (Patient 23) has signed VOL (voluntary admission) per [staff]." DCS stated the hearing was not held because Patient 23 signed for voluntary admission.

During an interview on 7/25/2025 at 2:46 p.m. with DCS, DCS stated the following: there was no voluntary admission form found in Patient 23's medical record. A patient would sign the voluntary admission form when changing legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) from involuntary to voluntary. The Psychiatrist (physician specializes in mental health) would then sign the voluntary admission form to confirm the voluntary admission. Patient 23 remained as involuntary admission during the hospital stay and did not receive a certification review hearing.

During a review of the facility's policy and procedure (P&P) titled, "Certification Review Hearings," dated 5/2025, the P&P indicated, "In accordance with [state] Welfare and Institution Code (WIC) 5256.4 and 5276, every patient detained under these articles shall have a certification hearing within 4 days of the initiation of that certification ... Procedure ... The process of Probable Cause Hearings is as follows: A. All patients on a 5250 or a 5270.15 must be provided a copy of the completed Notice of Certification on the date it is issued by the physician who executes the Certification. The Physician or designee must inform the patients that: 1. He or she will have a certification review hearing within four (4) days to determine whether or not there is "probable cause" to detain him or her ... the social worker must ... 3. Complete "Mental Health Court Notification of Holds" form (CLIN-078) notifying the Superior Court Department 95 of the initiation of the certification and patient's request to have family member or support person present. A. This form is to be completed within 24 hours (excluding weekends, holidays and court furlough days) of the initiation of the certification."

During a review of the facility's patient handbook titled, "Rights for Individuals in Mental Health Facilities," dated 7/2018, the patient handbook indicated, "If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold. You may be represented at this hearing by a patients' rights advocate or another person of your choice. You can also request to have family members present to help explain your circumstances."

2. During a review of Patient 24's "Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated 1/5/2025, the Psych Eval indicated, Patient 24 was admitted to the facility on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), depressed (mood disorder that causes a persistent feeling of sadness and loss of interest in life) type, without psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality), posttraumatic stress disorder (PTSD, an anxiety disorder that develops after experiencing stressful, frightening or distressing events) and diabetes (high blood sugar).

During an interview on 7/25/2025 at 11:22 a.m. with the Director of Clinical Services (DCS), DCS stated the following: social services staff would file a request for certification review hearing the next business day with court after a patient was placed on 5250-hold. The hearing would be scheduled by the court within four (4) days. The court would then determine whether there was probable cause (sufficient legal justification) existing to detain the patient for involuntary detainment for psychiatric treatment.

During a review of Patient 24's involuntary hold notice titled, "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code," dated 1/7/2025, the involuntary hold notice indicated, Patient 24 was placed on 14-day hold due to danger to himself or herself and gravely disabled (inability to care for one's self) on 1/7/2025.

During an interview on 7/25/2025 at 3:12 p.m. with DCS, DCS stated social services staff did not send a request of certification review hearing for Patient 24. Patient 24 did not receive a certification review hearing during the hospitalization.

During a review of the facility's policy and procedure (P&P) titled, "Certification Review Hearings," dated 5/2025, the P&P indicated, "In accordance with [state] Welfare and Institution Code (WIC) 5256.4 and 5276, every patient detained under these articles shall have a certification hearing within 4 days of the initiation of that certification ... Procedure ... The process of Probable Cause Hearings is as follows: A. All patients on a 5250 or a 5270.15 must be provided a copy of the completed Notice of Certification on the date it is issued by the physician who executes the Certification. The Physician or designee must inform the patients that: 1. He or she will have a certification review hearing within four (4) days to determine whether or not there is "probable cause" to detain him or her ... the social worker must ... 3. Complete "Mental Health Court Notification of Holds" form (CLIN-078) notifying the Superior Court Department 95 of the initiation of the certification and patient's request to have family member or support person present. A. This form is to be completed within 24 hours (excluding weekends, holidays and court furlough days) of the initiation of the certification."

During a review of the facility's patient handbook titled, "Rights for Individuals in Mental Health Facilities," dated 7/2018, the patient handbook indicated, "If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold. You may be represented at this hearing by a patients' rights advocate or another person of your choice. You can also request to have family members present to help explain your circumstances."

3. During a review of Patient 28's "Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated 7/18/2025, the Psych Eval indicated, Patient 28 was admitted to the facility with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), chronic, paranoid type (having excessive or irrational distrust and suspicion of others, often believing that they are plotting against you or trying to harm you), with acute (new onset) exacerbation (worsening).

During an interview on 7/25/2025 at 11:22 a.m. with the Director of Clinical Services (DCS), DCS stated the following: social services staff would file a request for certification review hearing the next business day with court after a patient was placed on 5250-hold. The hearing would be scheduled by the court within four (4) days. The court would then determine whether there was probable cause (sufficient legal justification) existing to detain the patient for involuntary detainment for psychiatric treatment.

During a review of Patient 28's involuntary hold notice titled, "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code," dated 7/18/2025, the involuntary hold notice indicated, Patient 28 was placed on 14-day hold due to danger to himself or herself and gravely disabled, on 7/18/2025.

During an interview on 7/25/2025 at 5:13 p.m. with DCS, DCS stated social service staff submitted a request for certification review hearing for Patient 28 on 7/23/2025. DCS stated it was two (2) days late (should be on 7/21/2025). DCS stated it could cause delay in scheduling certification review hearing for Patient 28.

During a review of the facility's policy and procedure (P&P) titled, "Certification Review Hearings," dated 5/2025, the P&P indicated, "In accordance with [state] Welfare and Institution Code (WIC) 5256.4 and 5276, every patient detained under these articles shall have a certification hearing within 4 days of the initiation of that certification ... Procedure ... The process of Probable Cause Hearings is as follows: A. All patients on a 5250 or a 5270.15 must be provided a copy of the completed Notice of Certification on the date it is issued by the physician who executes the Certification. The Physician or designee must inform the patients that: 1. He or she will have a certification review hearing within four (4) days to determine whether or not there is "probable cause" to detain him or her ... the social worker must ... 3. Complete "Mental Health Court Notification of Holds" form (CLIN-078) notifying the Superior Court Department 95 of the initiation of the certification and patient's request to have family member or support person present. A. This form is to be completed within 24 hours (excluding weekends, holidays and court furlough days) of the initiation of the certification."

During a review of the facility's patient handbook titled, "Rights for Individuals in Mental Health Facilities," dated 7/2018, the patient handbook indicated, "If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold. You may be represented at this hearing by a patients' rights advocate or another person of your choice. You can also request to have family members present to help explain your circumstances."

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

1. Provide a safe environment of care in accordance with the facility's policy titled, "Patient Precautions" and the facility's Governing Body (GB, responsible for setting policies, ensuring quality of care, and managing the hospital's financial health. Essentially, they act as the legal and ethical guardians of the institution and its mission) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization pertaining to the GB's accountability for the safety and quality of care, treatment, and services provided), when one (1) of 43 sampled patients (Patient 6), who had a known history of violent and unpredictable behavior, was brought into an unsecured and hazardous area (South Cafeteria). The cafeteria was not designed for patients for de-escalation (is a method to prevent potential violence) and the cafeteria contained furniture and items that could be used as weapons (metal-legged chairs, hard plastic objects).

This deficient practice resulted in Patient 6 accessing and picking up a chair with metal legs and throwing the chair at the Director of Admission (DOA), causing a head laceration (a pattern of injury in which blunt forces tear the skin and underlying tissues). As a result, staff-initiated Code 10 (a call for all trained personnel to respond to a dangerous situation) for Patient 6 and a Code Blue (hospital announcement means that an individual is having a medical emergency) for the Director of Admission who suffered a head laceration. Following this event, Patient 6 engaged in another violent episode, during which he (Patient 6) assaulted a second staff member (MHT, Mental Health Technician 5), resulting in a broken nose.

2. Monitor twenty (20) of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43) in the Psychiatric Intensive Care (relating to acute mental or behavior illness) Unit, every 15 minutes, in accordance with the facility's policy and procedure regarding supervision of patients and patient rounds, who are admitted to the behavior or mental health unit.

This deficient practice placed 20 patients' safety at risk, such as self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence.

On 7/24/2025 at 5:47 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient), in the presence of the Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Regional Vice President (RVP), and the Director of Quality and Performance Improvement Compliance Officer (DQPI). The facility failed to provide a safe environment by not providing appropriate safety measures by bringing Patient 6 who was in an aggressive (ready or likely to attack or confront) state, who had known history of violent and unpredictable behavior into an unsecured area (South cafeteria) not designed for de-escalation (the process of reducing the intensity of a conflict or crisis, typically through communication and strategic actions, to prevent or minimize harm to all parties involved), with access to potential weapons (chairs, metal legs, and hard plastic objects). The facility lacked adequate risk assessment and failed to implement a safe intervention plan, appropriate use of seclusion, and observation. This deficient practice resulted in a staff injury (head laceration to the Director of Admission) and a subsequent violent episode causing a broken nose to another staff member (MHT, Mental Health Technician) 5. This deficient practice created an ongoing and immediate threat of harm not only to staff, but to all patients in the facility.

During a review of Patient 6' "Daily Progress Note," dated 7/18/2025, the note indicated Patient 6 diagnoses included psychosis (a mental health condition where a person loses touch with reality), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), capacity for self-harm or harm to others was high, and had prior aggression behavior (violent or threatening actions toward others).

On 7/22/2025, at 2:42 p.m., surveillance video showed that staff brought Patient 6 into the South cafeteria to calm Patient 6 down (a process called de-escalation). However, the cafeteria was not a secure area and contained removable wooden chairs with metal legs and other hard objects (such as hard food trays) that could be used as weapons. While in the cafeteria, Patient 6 became physically aggressive. The video showed Patient 6 chasing a staff member (DOA, Director of Admission) and throwing a chair at the DOA, hitting the DOA in the head and causing a laceration (a deep cut). After the incident, Patient 6 was taken back to a shared room in the unit with other patients, and no additional supervision-such as one-to-one observation (having a staff member assigned to watch one patient closely at all times)- was put in place. Shortly after, Patient 6 assaulted another staff member (MHT, Mental Health Technician) 5, resulting in a nasal fracture (a broken nose). During an Interview on 7/24/225 at 3:34 p.m. with Nurse Manger (NM) 1, NM 1 confirmed that the cafeteria was regularly used to calm down agitated patients, even though it was not a ligature-free area (a space that does not contain items that could be used for self-harm or harm others). NM 1 also confirmed that the chairs and furniture in the cafeteria were unsafe for this purpose.

On 7/25/2025 at 9:06 p.m., the IJ was removed in the presence of the RVP via phone, CNO, CEO, DQPI, Chief Operating Officer (COO), Division of Director of Clinical Services (DDCS) via phone, Director of Pharmacy (DP), Director of Clinical Services/ licensed marriage family therapist (DCS), and Director of Plant Operation (DPO). The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed by the survey team while onsite through observation, interview, and record review. The IJ Removal Plan indicated:

1. All metal chairs in the cafeteria were immediately removed and replaced with blunt-edged plastic chairs. The cafeteria will no longer be used for patient de-escalation.
2. The "Patient Precautions" policy was modified to include that any patient in an agitated state will be assessed by unit RN or House Supervisor to determine adequate risk and a safe intervention plan that may include not being allowed to go to cafeteria.
3. Risk assessment (existing nursing re-assessment when change in behavior or condition) will be reviewed with the treatment team, consisting of physician, nurse and social worker for implementation of an alternative plan that will assist in de-escalation of patients demonstrating increased aggression.
4. De-escalation efforts with agitated/aggressive patients will be implemented on the unit in an area without plastic chairs or in the courtyard that is secured by being devoid of sharp objects, objects that can be lifted and thrown, and peripheral doors closed, restricting access back on to the unit and affording the patient with less stimulation. The patient will return to the unit when assessed to be in a calm and safe state.
5. Alternative treatment plans that address de-escalation of an aggressive patient may include removing the patient from the milieu to decrease stimulation accompanied by two clinical staff members trained in Handle with Care, and preferably those with the most rapport with patient, onto an area without plastic chairs or in the courtyard that is secured by being devoid of sharp objects, objects that can be lifted and thrown, and peripheral doors closed, restricting access back on to the unit and affording the patient with less stimulation. The patient will return to the unit when assessed to be in a calm and safe state.
6. The Patient Precautions policy was reviewed and revised to include restriction of agitated and assaultive patients to the Unit when not responding to de-escalation techniques. For the safety of other patients and staff, the agitated/assaultive patient may require seclusion to decrease danger to others.
7. All RNs, LVNs, LPNs and Mental Health Workers were trained in the revised Patient Precautions policy. Training was initiated on 7/24/25 to include all scheduled nursing staff on the night shift and conducted by the CNO, ACNO, or designee. Training will continue on 7/25/25 with day shift nursing staff and on all shifts until training is completed. Staff that do not attend this training will not be scheduled to work until training is completed.

Findings:

1. During a review of Patient 6's "Daily Progress Note," dated 7/18/2025, the note indicated Patient 6's diagnoses included psychosis (a mental health condition where a person loses touch with reality), schizophrenia (a mental illness affecting thought, emotion, and behavior), and documented high risk for "self-harm or harm to others." The note also indicated Patient 6 had a history of assaultive behavior (refers to actions or behaviors that involve physical aggression, threats, or actions intended to cause physical harm or injury to another person).

During a surveillance video review of the South Cafeteria on 7/23/2025 at 11:30 a.m. (video dated 7/22/2025 at 2:42 p.m.), in the presence of the Director of Quality and DQPI), the following events were observed:
-Nurse Manager (NM) escorted Patient 6 to the South Cafeteria and provided a soda as part of a calming strategy.
- Patient 6 approached the soda machine, served himself, and sat with NM 1.
- A second Staff member (Staff 1) entered the cafeteria and sat at the opposite end of the room.
-Patient 6 suddenly stood up and chased Staff 1 around the table.
- Patient 6 then picked up a metal chair with metal legs and threw it at the Director of Admission (DOA), striking him (DOA) in the forehead and causing a head laceration (a deep cut or tear in the skin).
- The DOA clutched his (DOA) head, and staff-initiated Code 10 (call for emergency trained responders) and a Code Blue (medical emergency alert).

During an observation on 7/22/2025 at 5:30 p.m., with the Chief Executive Officer (CEO) at the South cafeteria. The cafeteria contained 12 dining tables, each with multiple removable chairs that had metal legs. Additionally, a stack of approximately 30 large plastic trays was observed on an open shelf that was accessible to anyone present in the cafeteria, including patients.

During an interview on 7/22/2025 at 3:12 p.m. with Registered Nurse (RN) 6, RN 6 stated that staff commonly used the cafeteria, courtyard, or dayroom to calm agitated (feeling worried, uneasy, or disturbed, and showing this through restlessness or physical behavior) patients.

During an interview on 7/23/2025 at 3:34 p.m. with Nurse Manger (NM)1, NM 1 stated Patient 6 was upset with a staff on the unit and was getting agitated. NM 1 stated she (NM 1) offered to take Patient 6 to the cafeteria to get a soda to de-escalate the situation. NM 1 stated that during the middle of the conversation with her (NM 1), Patient 6 got up and went toward Staff 1. NM 1 stated Patient 6 had a history of aggression and especially toward male staff and was unpredictable. NM1 stated designated areas to take patients for de-escalation were the two courtyards, the 2-day rooms, and the South Cafeteria. NM 1 also confirmed that Patient 6 hit DOA on the head with the chair. NM 1 stated the chairs in the cafeteria were of concern regarding safety.

During the same interview on 7/23/2025 at 3:34 p.m. with Nurse Manager (NM) 1, NM1 stated after the incident, Patient 6 was taken back to the room where other patients were housed. Additionally, Patient 6 was aggressive towards another staff member (MHT 5), assaulted the staff (MHT 5), and broke his (MHT 5's) nose. Patient 6 was not isolated from others and was not assigned a sitter (caregiver who provides continuous supervision to a patient) or a line-of-sight monitoring (staff to have continuous visual of the patient).
NM1 stated Patient 6 was on "Assault Precaution (monitor and assess for environmental risks, including contraband (anything that can be used as a weapon such as lighters, razors, and knives), property damaged, and items that could be used as a weapons). NM 1 stated the reason a sitter was not assigned to Patient 6 was because Patient 6 may hit the sitter. NM 1 confirmed that Patient 1's monitoring situation did not change after Patient 6 assaulted the DOA in the cafeteria, such as placing Patient 6 into an observation room or obtaining an order for a line-of-sight observation.

During an interview on 7/23/2025 at 4:20 p.m. with the Director of Plant Operation (DPO), DPO stated the cafeteria chairs were made of metal and it was not appropriate to bring an agitated patient to that environment.

During a review of the facility's policy and procedure (P&P) titled, "Patient Precautions," dated 7/2025, the P&P indicated, "It is the policy of (name of the facility) to identify and assess risk factors of all patients in order to provide care in a safe and therapeutic milieu. All patients are assessed for risks for suicide (thoughts of taking one's own life)/self-harm, assault (refers to actions or behaviors that involve physical aggression, threats, or actions intended to cause physical harm or injury to another person), fall (an unexpected event where a patient unintentionally comes to rest on the ground or a lower level, like a bed or chair, during their hospital stay), seizures (a sudden, uncontrolled electrical disturbance in the brain, which can cause changes in behavior, movements, or consciousness), sexual aggression, sexual victimization (any unwanted or non-consensual sexual experiences), medical issues, detoxification (a set of interventions aimed at managing acute intoxication and withdrawal), and elopement (when a patient leaves the healthcare facility without authorization or notice) upon admission. All patients are also re-assessed for the same risk factors on a daily basis throughout their hospitalization to determine if there are any changes in their level of risk. Patients will also be re¿assessed for risk whenever there is an abrupt change in their behavior or mental status. Once risk factors are identified, the physician will determine appropriate precautions for each patient ... All patients identified to be on Assault Precautions will have the following measure initiated: May be restricted to the unit ... Monitor closely and ensure that vulnerable patients are monitored for safety ... Be aware of potentially escalating situations and will assume the patient will not be in control of his/her behavior. Staff will pay attention to phone calls or meetings with the physician where upsetting news may be communicated. Assess the patient every shift for signs of aggression or agitation, such as verbal and physical outbursts, including punching walls, slamming doors, throwing things, and pacing with clenched fists or jaw. Staff will promptly notify the Charge Nurse of any such behavior. Aim to separate the patient from others in the milieu if the agitation/aggression is directed at a specific person(s) ... Monitor and assess for environmental risks, including contraband, property damage, and items that could be used as weapons ... If an assault occurs: RN will assess and consult with attending psychiatrist for additional interventions including but not limited to: Change in observation level ... 1 :1 therapy ..."

During a review of the facility's GB (Governing Body, responsible for setting policies, ensuring quality of care, and managing the hospital's financial health. Essentially, they act as the legal and ethical guardians of the institution and its mission.) bylaws (a set of rules and regulations that establish the internal structure, operations, and decision-making processes of an organization), approved by the GB on 4/1/2020, the bylaws indicated, " The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital ..."

During a review of the facility's policy and procedure (P&P) titled, "Environmental of Care Committee, dated 1/2024, the P&P indicated, "The administration and senior leadership of the facility are responsible for safety and security of (name of the facility) ... The Environment of Care Committee shall have full authority to intervene in any matter affecting the immediate safety or security of the facility, and ensure a safe environment for patients, visitors, or staff ... Seven key activities of the EOC Committee: Hazard Identification - Identifying hazards and unsafe practices in the healthcare environment ..."

2. During a concurrent interview and record review on 7/24/2025 at 10:08 a.m., with the Chief Nursing Officer (CNO) and the Director of Risk Management (DRM), a Video footage of the Intensive Treatment Unit, dated 12/20/2024, was reviewed. The video footage on 12/20/2025 starting at 9 p.m. and ending at 11 p.m. indicated patient rounds (a systematic process where a healthcare team member checks on a patient regularly) were not performed for 20 Patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43), at 9:45 p.m. The CNO and the DRM verified that patient rounds had not been completed.

During an interview on 7/24/2025 at 10:35 a.m. with the Chief Nursing Officer (CNO), the CNO stated patient rounds should be done every 15 minutes for all patients. Staff should enter patients and document patients' location and behavior and ensure the patients were safe. If patients were sleeping, staff should enter patients' rooms and observe for rise and fall of the chest.

During a review of Patient 17's Initial Psychiatric History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/16/2025, the H&P indicated the following: Patient was admitted to the facility due to increased bizarre behavior, delusions (fixed, false beliefs that conflict with reality) of paranoia (a mental state characterized by excessive distrust and suspicion of others, often without reason), believed that she (Patient 17) was being followed. Problem areas: Poor coping skills and danger to self.

During a review of Patient 17's "Round Sheet," dated 12/20/2024, the Round Sheet (indicates the patient's location and behavior and completed every 15 minutes monitoring by staff) indicated Patient 17 was being monitored for safety, every 15 minutes. There was no documentation for rounding at 10 p.m.

During a review of Patient 18's Initial Psychiatric History and Physical, dated 7/09/2024, the H&P indicated the following: Patient (Patient 18) was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for Grave Disability (a person who is unable to care for their basic needs due to a mental health disorder). Patient 18 had schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).

During a review of Patient 18's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 18 was being monitored for assault (refers to actions or behaviors that involve physical aggression, threats, or actions intended to cause physical harm or injury to another person)/aggression, and safety, every 15 minutes. There was no documentation for rounding at 10 p.m.

During a review of Patient 19's Initial Psychiatric History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/24/2024, the H&P indicated the following: Patient19 was admitted to the facility on a 5150 Hold (72-hour involuntary hold) for Grave Disability. Patient 19 had a seizure disorder (uncontrolled jerking, loss of consciousness, blank stares caused by electrical activity in the brain).

During a review of Patient 19's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 19 was being monitored for falls (an unexpected event where a patient unintentionally comes to rest on the ground or a lower level, like a bed or chair, during their hospital stay), seizures, and safety, every 15 minutes. There was no documentation for rounding at 10 p.m.

During a review of Patient 20's Psychiatric Initial History and Physical, dated 9/24/2024, the H&P indicated the following: Patient 20 was admitted to the facility on a 5150 Hold due to increasing bizarre and disorganized behavior, and hearing voices telling him (Patient 20) to hurt himself.

During a review of Patient 20's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 20 was being monitored for suicide (killing self), every 15 minutes. There was no documentation for rounding at 10 p.m.

During a review of Patient 21's Initial Psychiatric History and Physical, dated 8/09/2024, the H&P indicated the following: Patient 21 was admitted to the facility on a 5150 Hold for danger to self and grave disability.

During a review of Patient 21's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 21 was being monitored for suicide, sexual aggression, and elopement (when a patient leaves the healthcare facility without authorization or notice), every 15 minutes. There was no documentation for rounding at 10 p.m.

During a review of Patient 22's Initial Psychiatric History and Physical, dated 12/16/2024, the H&P indicated the following: Patient 22 was admitted to the facility on a 5150 Hold for danger to others. Patient 22 came in agitated and aggressive towards grandparents.

During a review of Patient 22's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 22 was being monitored for assault/aggression, every 15 minutes. There was no documentation for rounding at 10 p.m.

During a review of Patient 26's Initial Psychiatric History and Physical, dated 7/10/2024, the H&P indicated the following: Patient 21 was admitted to the facility under conservatorship (a legal process where a court appoints someone to manage the affairs of an individual who is unable to care for themselves) under the Surge Program (a program intended for former inmates who are too dangerous to be released into the community).

During a review of Patient 26's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 26 was being monitored, every 15 minutes, for assault/aggression and sexual aggression. There was no documentation for rounding at 10 p.m.

During a review of Patient 31's Initial Psychiatric History and Physical, dated 12/18/2024, the H&P indicated the following: Patient 31 was admitted to the facility on a 5150 Hold due to increasing agitation (feeling worried, uneasy, or disturbed, and showing this through restlessness or physical behavior) and threatening behavior.

During a review of Patient 31's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 31 was being monitored, every 15 minutes, for assault/aggression, and elopement. There was no documentation for rounding at 10 p.m.

During a review of Patient 32's Initial Psychiatric History and Physical, dated 12/11/2024, the H&P indicated the following: Patient 32 was admitted to the facility on a 5150 Hold for grave disability.

During a review of Patient 32's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 32 was being monitored for assault/aggression, every 15 minutes. There was no documentation for rounding at 10 p.m.

During a review of Patient 33's Initial Psychiatric History and Physical, dated 12/19/2024, the H&P indicated the following: Patient 33 was admitted to the facility on a 5150 Hold after making threats to hurt herself and others.

During a review of Patient 33's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 33 was being monitored, every 15 minutes, for suicide, and assault/aggression. There was no documentation for rounding at 10 p.m.

During a review of Patient 34's Initial Psychiatric History and Physical, dated 12/15/2024, the H&P indicated the following: Patient 34 was admitted to the facility on a 5150 Hold due to increased agitation and threatening behavior.

During a review of Patient 34's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 34 was being for monitored, every 15 minutes, for assault/-aggression, and safety. There was no documentation for rounding at 10 p.m.

During a review of Patient 35's Initial Psychiatric History and Physical, dated 12/09/2024, the H&P indicated the following: Patient 35 was admitted to the facility on a 5150 Hold because he endorsed active suicidal ideations (thought of killing self), homicidal ideation (thoughts of hurting or killing others) with no plan.

During a review of Patient 35's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 35 was being monitored, every 15 minutes. for suicide, and assault/ aggression. There was no documentation for rounding at 10 p.m.

During a review of Patient 36's Initial Psychiatric History and Physical, dated 12/16/2024, the H&P indicated the following: Patient 36 was admitted to the facility on a 5150 Hold for being gravely disabled.

During a review of Patient 36's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 36 was being monitored, every 15 minutes, for sexual aggression and safety. There was no documentation for rounding at 10 p.m.

During a review of Patient 37's Initial Psychiatric History and Physical, dated 12/17/2024, the H&P indicated the following: Patient 37 had a history of schizophrenia and was admitted to the facility with increased confusion, delusions (false beliefs) of paranoia (fear and distrust in others).

During a review of Patient 37's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 37 was being monitored, every 15 minutes, for suicide and assault/aggression. There was no documentation for rounding at 10 p.m.

During a review of Patient 38's Initial Psychiatric History and Physical, dated 12/20/2024, the H&P indicated the following: Patient 38 was admitted to the facility on a 5150 Hold because he (Patient 38) endorsed auditory hallucinations (hearing voices that are not present).

During a review of Patient 38's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 38 was being monitored, every 15 minutes, for assault/aggression. There was no documentation for rounding at 10 p.m.

During a review of Patient 39's Initial Psychiatric History and Physical, dated 12/20/2024, the H&P indicated the following: Patient 39 had schizophrenia and presented to the facility due to increased agitation, and aggressive behavior.

During a review of Patient 39's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 39 was being monitored, every 15 minutes, for suicide, assault/aggression and safety. There was no documentation for rounding at 10 p.m.

During a review of Patient 40's Initial Psychiatric History and Physical, dated 12/20/2024, the H&P indicated the following: Patient 40 was admitted to the facility due to increased bizarre and disorganized behavior. Patient 40 was on a 5150 Hold for danger to self, danger to others, and grave disability.

During a review of Patient 40's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 40 was being monitored, every 15 minutes, for suicide, assault/ aggression and safety. There was no documentation for rounding at 10 p.m.

During a review of Patient 41's Initial Psychiatric History and Physical, dated 12/19/2024, the H&P indicated the following: Patient 41 was on a 5150 Hold due to increasing disorganized behavior and agitation.

During a review of Patient 41's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 41 was being monitored, every 15 minutes, for assault/aggression, falls, and safety. There was no documentation for rounding at 10 p.m.

During a review of Patient 42's Initial Psychiatric History and Physical, dated 12/18/2024, the H&P indicated the following: Patient 42 was admitted on a 5150 Hold for danger to self.

During a review of Patient 42's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 42 was being monitored, every 15 minutes, for suicide. There was no documentation for rounding at 10 p.m.

During a review of Patient 43's Initial Psychiatric History and Physical, dated 12/18/2024, the H&P indicated the following: Patient 43 was admitted on a 5150 Hold for danger to self and others.

During a review of Patient 43's "Round Sheet," dated 12/20/2024, the Round Sheet indicated Patient 43 was being monitored, 15 minutes, for suicide, assault/aggression. There was no documentation for rounding at 10 p.m.

During a review of the facility's policy and procedure (P&P) titled, "Supervision of Patients/ Patient Rounds," dated 7/2025, the P&P indicated the following: It is the policy of the Hospital that patients be supervised to diminish the risk of harm and/or injury. All patients require supervision and rounds are conducted continuously with each patient's location and behavior documented every 15 minutes ...Observe each patient, a minimum of every 15 minutes and document observation (location and behavior) on the patient Rounds Sheet at time of observation ...Observe patients in bed or sleeping by: Looking for the rise of the chest; Making sure that the patient has moved from his/her previous sleeping position. Visually observe patients when behind closed doors by: Knocking on bedroom and bathroom doors; Announce that they are stepping into the room for rounds; Open the door and visually observe the safety of the patient.

Based on interview and record review, the facility failed to ensure the physician authenticated a telephone restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order within 24 hours for one of 43 sampled patients (Patient 29), in accordance with the facility's policy and procedure regarding restraints use, when Patient 29 was placed on physical restraint (type of physical restraint, a manual or physical method of holding the patient against patient's will that restricts freedom of movement or normal access to one's body) on 7/16/2025.

This deficient practice resulted in the lack of physician verification of physical restraints use on Patient 29 and had the potential to result in unnecessary restraint use for Patient 29.

Findings:

During a review of Patient 29's face sheet (face sheet, document provides patient's demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, "Patient Demographic Profile," dated 7/14/2025, the face sheet indicated Patient 29 was an involuntary admission with admitting diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions).

During a concurrent interview and record review on 7/25/2025 at 4:41 p.m. with the Director of Risk Management (DRM), Patient 29's physical restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order titled, "Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving)/Restraint/Chemical Restraint (use of medications to control a patient's behavior or restrict freedom of movement) Order," dated 7/16/2025, was reviewed. The physician restraint order indicated a telephone order was obtained for use of Physical Restraint on Patient 29 on 7/16/2025 at 2:12 p.m. The physician restraint telephone order also indicated physician did not sign off on the order. DRM stated the order was missing a physician's signature.

During an interview on 7/25/2025 at 7:10 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: a physician order was required when putting a patient on restraint. The physician was required to authenticate the order within 24 hours. It would be considered as restraining patient without physician order because the physician did not sign off on the order (telephone order).

During a review of the facility's policy and procedure (P&P) titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion," dated 7/2025, the P&P indicated, "Restraints or seclusion shall be used in emergency situations only and requires an order from a physician ... the physician shall authenticate the telephone/verbal order within 24 hours."

Based on interview and record review, the facility failed to ensure its nursing staff notified physician, within 30 minutes, after a face-to-face evaluation (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) was performed for one of 43 sampled patients (Patient 6) on 7/14/2025 and 7/22/2025, in accordance with the facility's policy and procedure regarding restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)/seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving).

This deficient practice had the potential to result in Patient 6's physician not knowing Patient 6's response to restraint and had the potential to lead to Patient 6 not receiving additional treatment or care as needed.

Findings:

During a review of Patient 6's "Daily Progress Note," dated 7/18/2025, the note indicated Patient 6's diagnoses included psychosis (a mental health condition where a person loses touch with reality), schizophrenia (a mental illness affecting thought, emotion, and behavior), and documented high risk for "self-harm or harm to others." The note also indicated Patient 6 had a history of assaultive behavior (refers to actions or behaviors that involve physical aggression, threats, or actions intended to cause physical harm or injury to another person).

During an interview on 7/24/2025 at 3:53 p.m. with Registered Nurse (RN) 2, RN 2 stated the RN would perform face-to-face evaluation (an in-person assessment performed by physician, licensed practitioner or trained Registered Nurse [RN]) after applying physical hold (type of physical restraint, a manual or physical method of holding the patient against patient's will that restricts freedom of movement or normal access to one's body) on patient to assess patient's response to restraints and intervention. RN 2 further stated, normally the RN would only call physician back if something abnormal was identified during the face-to-face evaluation for further orders.

During a review of Patient 6's physician order titled, "Seclusion/Restraint/Chemical Restraint (use of medications to control a patient's behavior or restrict freedom of movement) Order," dated 7/14/2025, the physician order indicated a physician order was obtained on 7/14/2025 at 8 p.m. when Patient 26 was placed on physical restraint on 7/14/2025 at 7:50 p.m.

During a concurrent interview and record review on 7/25/2025 at 5:35 p.m. with the Director of Risk Management (DRM), Patient 26's "Post Intervention Face to Face Evaluation (face-to-face evaluation)" form, dated 7/14/2025, was reviewed. The face-to-face evaluation indicated Registered Nurse (RN) 13 completed the face-to-face evaluation on 7/14/2025 at 8:45 p.m. and notified physician on 7/14/2025 at 8 p.m. DRM stated the physician notification time was incorrect. DRM stated the time did not reflect RN 13 had called the physician after performing face-to-face evaluation for Patient 26. RN 13 called the physician before completing the face-to-face evaluation of the restraint use.

During a review of Patient 6's physician order titled, "Seclusion/Restraint/Chemical Restraint Order," dated 7/22/2025, the physician order indicated a physician order was obtained on 7/22/2025 at 3:30 p.m. when Patient 26 was placed on physical restraint on 7/22/2025 at 3:08 p.m.

During an interview on 7/25/2025 at 11:34 a.m. with Registered Nurse (RN 1), RN 1 stated nurse would need to call the physician after face-to-face evaluation to let physician know about the patient and if interventions were effective or not.

During a concurrent interview and record review on 7/25/2025 at 5:37 p.m. with the Director of Risk Management (DRM), Patient 26's "Post Intervention Face to Face Evaluation (face-to-face evaluation)" form, dated 7/22/2025, was reviewed. The face-to-face evaluation indicated RN 2 completed the face-to-face evaluation on 7/22/2025 at 3:45 p.m. and notified physician on 7/22/2025 at 3:18 p.m. DRM stated the physician notification time was inaccurate. DRM stated based on document, RN 2 did not call the physician after performing face-to-face evaluation for Patient 26. RN 2 called the physician before the face-to-face evaluation of restraint use was completed.

During a review of the facility's policy and procedure (P&P) titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion," dated 7/2025, the P&P indicated, "Face to Face Evaluation by the physician, licensed independent practitioner, or trained RN: within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized LIP (Nurse Practitioner), or trained RN ... The evaluation will be documented in the medical record to include the following: 1. The date and time of the evaluation 2. An assessment of the patient's immediate situation 3. An evaluation of the patient's reaction to the intervention 4. An assessment of the patient's medical and behavioral condition ... 5. An assessment of the need to continue or terminate the restraint/seclusion ... If the evaluation is conducted by a trained RN, he/she must consult with the attending physician or other LIP responsible for the patient's care as soon as possible (within 30 minutes) after the evaluation. This consultation should include a discussion of the findings of the 1-hour evaluation, the need for other interventions or treatments, and the need continue or discontinue the use of restraint/seclusion."

Based on interview and record review, the facility failed to ensure its Quality Assessment and Performance Improvement (QAPI) program (a hospital-wide quality improvement system designed to monitor and improve safety and care) addressed environmental safety hazards (unsafe physical conditions that may cause injury or harm) in areas regularly accessed by patients. This deficient practice affected one (1) of the 43 sampled patients (Patient 6), when Patient 6 picked up a metal-legged chair in the cafeteria and threw it at the Director of Admission (DOA), causing a head injury.

This deficient practice resulted in head injury for DOA and resulted in a lack of structured safety oversight in patient-used areas, particularly for patients with known behavioral risks. The absence of proper monitoring and environmental risk assessments contributed to unsafe conditions and had the potential to affect the health and safety of other patients and staff throughout the facility.

Findings:

During a concurrent interview and record review on 7/25/2025 at 5:25 p.m. with the Director of Quality and Performance Improvement (DQPI, a hospital leader responsible for quality and safety monitoring), the facility performance improvement project (PI, a structured, ongoing effort to enhance the quality and efficiency of healthcare services), was reviewed. The DQPI confirmed that monthly QAPI meetings were held. The facility had active PI projects (targeted safety initiatives) including fall prevention, medication safety, and infection control. However, the DQPI stated there were no PI projects addressing environmental safety in areas such as cafeterias. The DQPI stated that reports were collected from monthly Environmental of Care (EOC) rounds (routine facility safety inspections), but confirmed that there were no incident reports related to movable furniture. DQPI could not confirm that the South Cafeteria was included in the EOC rounds, nor was it monitored through QAPI activities or included in adverse event (an undesirable outcome or occurrence that results from medical care) tracking or improvement efforts related to behavioral or environmental risks.

During a concurrent interview and record review on 7/25/2025 at 8:45 p.m. with the Director of Plant Operations and Safety Officer (DPO, the staff member in charge of facility safety and maintenance), the facility's "Environmental Rounds," checklist was reviewed and there was no checklist for the facility's cafeterias. The DPO stated that monthly EOC rounds were conducted to identify safety hazards. However, DPO confirmed that the South Cafeteria, which contained chairs with metal legs (items that could be used as weapons), was not included in the routine EOC rounding. The DPO stated that EOC rounds were conducted monthly to identify safety hazards. However, the South Cafeteria which contained chairs with metal legs was not included because it was considered a "non-patient care area." The DPO also confirmed that patients routinely used the cafeteria for meals and, in some cases, for de-escalation (a behavioral intervention used to calm agitated (feeling worried, uneasy, or disturbed, and showing this through restlessness or physical behavior) patients without using physical restraint or medication). The DPO stated the cafeteria would now be added to future EOC rounds.

During a surveillance video review of the South Cafeteria, on 7/23/2025 at 11:30 a.m. (video dated 7/22/2025 at 2:42 p.m.), it was observed that Patient 6, who had a documented history of violent and unpredictable behavior was brought into the South Cafeteria for de-escalation, despite the area not being assessed for safety or designed to manage behavioral emergencies.

During a surveillance video review of the South Cafeteria, on 7/23/2025 at 11:30 a.m. (video dated 7/22/2025 at 2:42 p.m.), in the presence of the Director of Quality and DQPI), the following events were observed:

-Nurse Manager (NM) 1 escorted Patient 6 to the South Cafeteria and provided a soda as part of a calming strategy.
- Patient 6 approached the soda machine, served himself, and sat with NM 1.
- A second Staff member (Staff 1) entered the cafeteria and sat at the opposite end of the room.
-Patient 6 suddenly stood up and chased Staff 1 around the table.
- Patient 6 then picked up a metal chair with metal legs and threw it at the Director of Admission (DOA), striking him (DOA) in the forehead and causing a head laceration (a deep cut or tear in the skin).
- The DOA clutched his (DOA) head, and staff initiated Code 10 (call for emergency trained responders) for Patient 6 and a Code Blue (medical emergency alert) for DOA (due to a head laceration).

During a review of the facility's policy and procedure (P&P) titled, "Quality Assurance & Performance Improvement (QAPI) 2025," dated 2/27/2025, the P&P indicated, "The plan is used as a guide to design, measure, assess and improve organizational performance; identify, minimize, and prevent organizational risks and ensure delivery of safe patient care ... The 2025 Plan addresses patient-focused and organization-wide processes and functions that have the greatest potential to improve patient safety and outcomes ... To enhance, maintain and continually improve the quality and safety of patient care through departmental/service measurement and assessment of patient care, resolution of problems and on-going pursuit of opportunities to improve patient care ... To promote safety and prevent untoward occurrences through systematic monitoring of the treatment environment to reduce facility and medical liability. The Environment of Care (EOC) Committee serves to assess and mitigate risks to safety in the physical environment. EOC Rounds are conducted to gather data on the environment and remedy any issues. The Committee monitors performance by identifying metrics for safety, handling hazardous waste materials, fire safety, equipment inspections and utilities."

Based on interview and record review, the facility failed to ensure nursing staff assessed and documented the blood sugar level for one of 43 sampled patients (Patient 1), in accordance with the facility's policy regarding Nursing Assessment and Reassessment of Patients when Patient 1's blood sugar (body's source of energy) was not assessed and when Patient 1 received Metformin (medication used to control blood sugar) without a corresponding blood sugar level checked.

This deficient practice had the potential for Patient 1 to not receive the appropriate monitoring and interventions and may contribute to Patient 1's change of condition such as hypoglycemia (low blood sugar) and/or death.

Findings:

During a review of Patient 1's "Discharge Summary," dated 12/26/2024, the Discharge Summary indicated Patient 1 was admitted to the facility on a 5150 hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for grave disability (unable to take care of basic needs). Patient 1's medical history included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (an abnormally high concentration of fat particles in the blood), alcohol abuse (alcohol use that can negatively affect how someone thinks and acts) and polysubstance (more than one drug use and/or alcohol or tobacco use) abuse. The record further indicated Patient 1 expired (died) on 12/20/2024.

During a review of Patient 1's "Progress Note," dated 12/20/2024, the Progress Note did not indicate Patient 1 refused blood sugar checks and any notification to other nurses and Patient 1's physician. The record further indicated at 10:00 p.m., "Patient (Patient 1) was found unresponsive (not responding to verbal command, touch, or pain) ..."

During a concurrent interview and record review on 7/23/2025 at 3:40 p.m. with the Assistant Chief Nursing Officer (ACNO), Patient 1's "Electronic Health Record (EHR, digital version of paper chart)," undated, was reviewed. The record indicated on 11/11/2024, Patient 1 had an order for Insulin (injectable medication used to control diabetes) sliding scale (blood sugar level determines how much medication should be given) to be given as needed. The record further indicated on 12/12/2024, Patient 1 had an order for Metformin (medication used to control diabetes) 500 milligrams [mg, a unit of measure]) twice a day to be taken by mouth.

During a concurrent interview and record review on 7/23/2025 at 3:40 p.m. with the Assistant Chief Nursing Officer (ACNO), Patient 1's "Electronic Health Record," undated, was reviewed. The EHR indicated on 10/12/2024, Patient 1 had an order for blood glucose (sugar levels and the body's primary source of energy from food) monitoring four times a day, at 7:30 a.m., 11:30 a.m., 4:30 p.m., and at 9:00 p.m. for hypoglycemic (low blood sugar) checks.

During a concurrent interview and record review on 7/23/2025 at 3:40 p.m. with the ACNO, Patient 1's "EHR," undated, was reviewed. The record indicated the following:

-On 12/19/2024 at 4:30 p.m. and 9:00 p.m., Patient 1's blood sugar check was marked as not completed. ACNO stated Patient 1's blood sugar was not checked.
-On 12/20/2024 at 12:20 p.m., Patient 1's medication response after receiving 4 units (amount, a unit of measure for insulin based on the blood sugar level) of Humalog (type of injectable insulin given to given control blood sugar) was documented as "effective." ACNO stated there was not another blood sugar recheck at that time.
-On 12/20/2024 at 4:30 p.m., Patient 1's blood sugar level was marked as "complete" and did not show a value. The ACNO stated this was the last blood sugar check because Patient 1 refused the 9:00 p.m. check.

During a concurrent interview and record review on 7/23/2025 at 3:40 p.m. with the ACNO, Patient 1's "EHR," undated, indicated the following:
-On 12/19/2024 at 9:00 a.m. and 4:47 p.m., Patient 1 received Metformin 500 mg.
-On 12/20/2024 at 9:25 a.m. and 4:46 p.m., Patient 1 received Metformin 500 mg.
-On 12/20/2024 at 11:48 a.m., Patient 1 received 4 units (amount, a unit of measure for insulin based on the blood sugar level) of Humalog (type of injectable insulin given).
-On 12/20/2024 at 12:20 p.m., Patient 1's medication response was documented as "effective." ACNO stated there was not another blood sugar recheck at that time.
-On 12/20/2024 at 4:46 p.m., Patient 1 received Metformin 500 mg.

During an interview on 7/24/2025 at 3:43 p.m. with the Licensed Practical Technician (LPT), LPT stated patients should not get Metformin if they refused their blood sugar check. LPT stated if a patient was given Metformin (medication used to control diabetes) 500 milligrams [mg, a unit of measure]) without a blood sugar check, the blood sugar can go too low and cause problems.

During an interview on 7/24/2025 at 3:33 p.m. with the LPT, LPT stated if patient refused to have a blood sugar check using a glucometer (machine used to check blood sugar), the reason why it was needed to be monitored, should be explained to the patient. LPT stated if the patient still refused, another nurse who had a better rapport (friendly relationship) with the patient should try and explain the purpose to them. LPT further stated if the patient still refused, the issue should be brought to the charge nurse to let them know what happened.

During a review of the facility's policy and procedure (P&P) titled, "Nursing Assessment and Reassessment of Patients," dated 7/2025, indicated, "The assessment includes the collection and analysis of data about the patient to determine the need for any additional information, the patient's care needs, and the care to be provided ...Reassessment is done to determine the patient's response to treatment and need for further interventions."

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

1. Ensure for one of 43 sampled patients (Patient 13), nursing staff supervised care and adhered to the facility's policy titled, "Supervision of Patients/Patient Rounds (a regular, systematic process where healthcare professionals assess patients)," when Patient 13's "Round Sheet" did not have the Registered Nurse's (RN) signature to validate that a patient rounding was completed.

This deficient practice had the potential for Patient 13's care to not have the proper oversight by an RN, which may result in patient harm if the rounding was not accurately performed.

2. Conduct a suicide (thoughts of taking one's own life) screening (a procedure that uses a standardized instrument or protocol, like a set of questions, to quickly identify individuals who may be at risk for suicide), daily, for one of 43 sampled patients (Patient 15), in accordance with the facility's policy and procedure regarding suicide screening.

This deficient practice resulted in two missed suicide screenings and had the potential for suicide risk to be unidentified for Patient 15, which may result in patient harm and/or death.

3. Ensure its nursing staff adhered to its internal policies and procedures "Code Blue (Emergency overhead announcement for medical resuscitation) and Transferring Patients to the Emergency Room," and did not follow current American Heart Association (AHA) Basic Life Support (BLS) guidelines (nationally procedures for emergency resuscitation [emergency effort to restore breathing or heartbeat], including chest compressions [pressing on the chest to pump], airway support [keeping breathing passages open], and use of a defibrillator [a device that delivers an electric shock to restart or correct the heart's rhythm] during cardiac arrest [heart stop] or other life-threatening conditions) for one (1) of 43 sampled patients (Patient 1).

This deficient practice resulted in the failure to provide timely and appropriate resuscitation (emergency efforts to restore breathing or heartbeat) for Patient 1 and placed other patients at risk for delayed or inadequate emergencies during future medical emergencies.

Findings:

1. During a review of Patient 13's "Initial Psychiatric (focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 7/18/2025, the record indicated Patient 13 was admitted to the facility for depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life), anxiety (a group of mental disorders characterized by significant feelings of fear), and had a history of self-harm.

During an interview on 7/24/2025 at 11:59 a.m. with the Director of Risk Management (DRM), the DRM stated the "Number one thing for safety is patient rounding (checking for patient's behavior and location every 15 minutes)."

During a concurrent interview and record review on 7/25/2025 at 5:48 p.m. with the DRM, Patient 13's "Round Sheet (indicates the patient's location and behavior and completed every 15 minutes monitoring by staff)," dated 7/20/2025 to 7/21/2025, was reviewed. The Round Sheet contained several areas for staff to mark what the patient was doing and where; the position the patient was sleeping in; precautions to take if the patient was aggressive, tried to harm themselves, and other behaviors; observation level (every 15 minutes or 1:1 [someone is with the patient at all times]). The record also indicated two areas for staff to sign: the "Registered Nurse (RN) Oversight" section and another area for staff to write their initial, name, and title.

During the same concurrent interview and record review on 7/25/2025 at 5:48 p.m. with the DRM, Patient 13's "Round Sheet (indicates the patient's location and behavior and completed every 15 minutes by staff)," dated 7/20/2025 to 7/21/2025, was reviewed. The Round Sheet further indicated, there was only one signature from 2300 (11:00 p.m.) to 0300 (3:00 a.m.) in the "Registered Nurse (RN) Oversight" section. The sections with the timeframes of 0300-0700 (7:00 a.m.), 0700-1100 (11:00 a.m.), 1100-1500 (11:00 a.m. to 3:00 p.m.), 1500-1900 (3:00 p.m. to 7:00 p.m.), and 1900-2300 (7 p.m. to 11 p.m.), were left blank. DRM stated, the nurse should round twice a shift, and the RNs should initial next to the staff's signature who was assigned to do rounds at a specific time. DRM acknowledged the RNs should have identified themselves in the "RN Oversight" section.

During a review of the facility's policy and procedure (P&P) titled, "Supervision of Patients/Patient Rounds," dated 7/2025, indicated, "The Charge Nurse will also provide oversight of the Rounds process at least one more time each shift. He/she will complete another set of Rounds or initial next to the time at which oversight was provided. He/she will be monitoring to ensure the Rounds Sheet information (name, precautions, etc.) is complete and accurate, as well as ensuring the staff are completing it properly and in a timely manner."

2. During a concurrent interview and record review on 7/25/2025 at 2:45 p.m. with the Chief Nursing Officer (CNO), the CNO reviewed Patient 15's CSSRS (Columbia-Suicide Severity Rating Scale, a suicide risk assessment tool) assessments. The CNO stated CSSRS assessments should be completed upon admission and every day in order to implement interventions, if necessary. The CNO verified that Patient 15's CSSRS assessment was not completed on 6/24/2025 and on 6/27/2025.

During a review of Patient 15's Face Sheet (document provides patient's demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance), the Face Sheet indicated Patient 15 was admitted to the facility on 6/22/2025 at 11:30 a.m., and discharged on 6/27/2025 at 1:51 p.m.

During a review of Patient 15's Initial Psychiatric Evaluation, dated 3/21/2025, the psychiatric evaluation indicated Patient 15 presented to the hospital on a 5150 Hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) because she (Patient 15) was throwing things at staff, yelling, kicking, fighting, and being agitated (feeling worried, uneasy, or disturbed, and showing this through restlessness or physical behavior).

During a review of Patient 15's Daily Nursing Progress Notes, the Daily Nursing Progress Notes indicated the CSSRS screen was not completed on 6/24/2025 and 6/27/2025.

During a review of the facility's policy and procedure (P&P) titled, "Assessment for Suicide Risk Potential," dated 5/2025, the P&P indicated the following: It is the policy of the Hospital to create an environment of care that will foster the accurate identification and successful management of patients who are at an increased risk for suicide or self-destructive behaviors ...Nursing staff will screen all patients with an evidence-based tool who are admitted to the hospital that identify patient characteristics that may indicate an increased risk of suicide. As indicated by the screening tool, the identified intervention will be enacted ...Reassessment of suicidality will occur daily.

3. During a review of Patient 1's "Daily Progress Note," dated12/20/2024, the note indicated, Patient 1 had medical history including: Diabetes (a chronic condition that leads to elevated blood sugar) with diagnoses of schizoaffective (a mental health condition that combines symptoms of both schizophrenia [a mental health condition combining symptoms of schizophrenia [characterized by significant disturbances in thought, perception, emotion, and behavior] and a mood disorder like), and bipolar (a mental illness marked by extreme mood swings from highs [mania] to lows [depression]) disorder.

During a review of Patient 1's medical record document titled, "Code Blue (Emergency overhead announcement for medical resuscitation)/Medical Emergency Documentation," dated 12/20/2024, the document indicated the following:
-Code Blue (Emergency overhead announcement for medical resuscitation) was called at 10:03 p.m.
-No AED (Automated External Defibrillator, a portable electronic device that analyzes heart rhythms and delivers an electrical shock to help restore a normal heartbeat in cases of sudden cardiac arrest [heart stops beating]) was applied on Patient 1.
-No Blood glucose (blood sugar) check, despite Patient 1's diabetes diagnosis.
-Documentation indicated "mouth sweep (inserting fingers into the mouth to remove a blockage- should only be done if the object is visible), Heimlich maneuver (abdominal thrusts to relieve choking-should only be used when there are signs of choking), with no documented evidence that the patient was choking or had a visible obstruction.

During a concurrent observation and interview on 7/22/2025 at 12:13 p.m. with the Assistant Chief Nursing Officer/Clinical Educator (ACNO), in Unit ABC, the crash cart (a mobile cart containing emergency resuscitation equipment) was found lacking a suction machine (device used in hospitals to remove fluids and secretions from a patient's body, primarily the airway). The ACNO confirmed the facility did not have suction equipment available for use during a Code Blue.

During an interview on 7/22/2025 at 12:51 p.m. with charge nurse (Registered Nurse, a nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 10, RN 10 stated:
-staff were required to call a Code Blue immediately upon finding an unresponsive patient.
-Do not leave the patient
-Begin CPR (cardiopulmonary resuscitation, an emergency procedure that combines chest compressions, and rescue breathing to keep blood flowing). The AED should always be applied, even if the patient had a pulse, to allow the device to analyze the heart rhythm.
-Check the blood sugar to rule out hypoglycemia (low blood sugar), which can be treated with Glucagon (a hormone that raises blood sugar).
-Perform Heimlich maneuver (abdominal thrusts used to relieve choking) only if obvious choking signs were present
-Never perform a blind finger sweep (inserting a finger into the mouth without visualizing the obstruction)

During a concurrent interview and surveillance video review on 7/24/2025 at 10:08 a.m. with the Director of Risk Management (DRM), the video footage dated 12/20/2024 showed the following:
-At 10:01:00 p.m., Registered Nurse (RN) 9 and Certified Nurse Assistant (CNA, Certified nursing assistants provide basic care to patients) 1 entered Patient 1's room.
-At 10:02:00 p.m., RN 9 and CNA 1 exited the room.
-At 10:02:36 p.m., CNA 1 reentered Patient's room
-At 10:03:00 p.m., RN 9 returned, and Code Blue was called.

During the same interview on 7/24/2025 at 10:08 a.m. with the Director of Risk Management (DRM), the DRM confirmed there was a two -minute delay between discovery of the unresponsive patient and initiation of emergency procedures (such as calling a code blue).

During an interview on 7/22/2025 at 3:41 p.m. with RN 11, RN 11stated they were unsure whether to apply the AED if the patient was unresponsive but had a pulse.

During a concurrent observation and interview on 7/23/2025 at 2:47 p.m., with RN 12, in Unit CDE, the crash cart was again found to be missing a suction machine. RN 12 also stated uncertainty about AED use in an unresponsive patient with pulse but stated the AED "helps analyze heart rhythm."

During an interview with on 7/25/2025 at 5:58 p.m. with RN 1, RN 1 stated the facility did not have suction equipment installed on the unit. RN 1 stated training on suction machines a month prior was conducted but confirmed the equipment was still unavailable during medical emergencies, leaving staff without a method to clear a patient's airway when needed.

During a review of the facility's policy and procedure (P&P) titled, "Code Blue and Transferring Patients to the Emergency Room," dated June 2025, the P&P indicated, "The staff member who finds/witnesses the medical emergency will immediately call for help and have a Code Blue paged overhead. The Code Blue will be paged overhead three times, including the lo cation. The staff member will not leave the patient alone. The staff from the unit housing the patient will bring the vital signs machine, accu-check machine, AED, oxygen tank, emergency crash carts, and any other pertinent equipment/supplies, based on the situation ..."

During a review of the facility's policy and procedure (P&P) titled, "Medical Emergencies and Acute Change in Condition," dated May 2025, the P&P indicated, "An RN may initiate a 911 call prior to calling the physician and House Supervisor ... Airway Problems: If the patient is coughing or can speak, stay with the patient and encourage continued coughing ... If the patient continues to cough ineffectively and appears to be in increasing distress, the object may be totally obstructing the airway. Call 911 and initiate a Code Blue. If the patient cannot speak or breathe, perform abdominal thrusts, call 911, and initiate a Code Blue."

During a review of the American Heart Association (AHA) 2020 Guidelines for CPR and Emergency Cardiovascular Care, Part 3 - Part 8: Adult Basic and Advance Life Support," indicated the following:
-"Initiate CPR immediately; do not leave the victim unattended."
-"Apply AED to all unresponsive patients regardless of the presence of a pulse, to analyze heart rhythm and guide next steps."
-"Suction equipment should be readily available in hospital settings where cardiac arrest may occur."
-"The Heimlich maneuver (abdominal thrusts) and finger sweeps should only be used when a foreign body airway obstruction is clearly present."

Based on observation, interview, and record review, the facility failed to ensure that medical records for 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43) were accurately written or documented, in accordance with the facility's policy regarding "Supervision of Patients / Patient Rounds." The patient rounds (a systematic process where a healthcare team member checks on a patient regularly) conducted, every 15 minutes, in the Intensive Treatment Unit, were inaccurately documented in the medical record for 20 of 43 sampled patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43).

This deficient practice led to the inaccurate documentation on 12/20/2025 at 9:45 p.m., that 20 patients had been visualized by a staff, when in fact, the round was not conducted at that time. This deficient practice also placed 20 patients' safety at risk for self-harm, assault (an act that threatens physical harm to a person, whether or not actual harm is done) and violence.

Findings:

During an interview and record review on 7/24/2025 at 10:08 a.m., a Video footage, dated 12/20/2024 of the Intensive Treatment Unit, was reviewed. The following was observed on video surveillance with the Chief Nursing Officer (CNO) and the Director of Risk Management (DRM). The video footage on 12/20/2025 starting at 9 p.m. and ending at 11 p.m. indicated patient rounds (a systematic process where a healthcare team member checks on a patient regularly) were not performed for 20 Patients (Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43), at 9:45 p.m. The CNO and the DRM verified that patient rounds had not been completed. The CNO stated that the documentation for the rounds on 12/20/2025 at 9:45 p.m., was inaccurate, and did not reflect what was seen on video footage.

During an interview on 7/24/2025 at 1:53 a.m., with the Chief Executive Officer (CEO), the CEO stated he (CEO) was aware that patient rounds had not been conducted on 12/20/2025 at 9:45 p.m., and verified that the Rounding Sheets for Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43) had been "falsification" of a document.

During a review of "Round Sheet (indicates the patient's location and behavior and completed every 15 minutes by staff)," dated 12/20/2024, for Patients 17, 18, 19, 20, 21, 22, 26, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, and 43, the Round Sheets indicated that rounds had been conducted at 9:45 p.m. The CNO and the CEO verified that the documentation was inaccurate.
During a review of the facility's policy and procedure (P&P) titled, "Supervision of Patients / Patient Rounds," dated 7/2025, the P&P indicated the following: All patients require supervision and rounds are conducted continuously with each patient's location and behavior documented every 15 minutes. The staff assigned to the initial rounds will ensure that the Round Sheets for all patients on every 15 precaution(s) are completed thoroughly and accurately.

Based on interview and record review, the facility failed to ensure staff completed and retained a record of voluntary admission for one of 43 sampled patients (Patient 23), when staff claimed Patient 23 had signed voluntary admission on 5/23/2025 to justify admission and continued hospitalization.

This deficient practice resulted in confusion regarding Patient 23's legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) including an incomplete medical record to reflect Patient 23's proper legal status for the admission, which had the potential to violate patient's right regarding voluntary treatment.

Findings:

During a review of Patient 23's "Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated 5/17/2025, the Psych Eval indicated, Patient 23 was admitted to the facility with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 23's face sheet (face sheet, document provides patient's demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, "Patient Demographic Profile," dated 5/25/2025, the face sheet indicated Patient 23 was an involuntary admission from 5/17/2025 to 5/24/2025.

During a review of Patient 23's involuntary hold notice titled, "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code," dated 5/19/2025, the involuntary hold notice indicated Patient 23 was placed on 14-day hold (14 days involuntary intensive treatment) due to danger to himself or herself on 5/19/2025.

During a concurrent interview and record review on 7/25/2025 at 2:45 p.m. with the Director of Clinical Services (DCS), Patient 23's "Certification Review Hearing (also known as probable cause hearing, a legal proceeding with a specific purpose related to involuntary psychiatric holds to determine if there is sufficient legal justification [probable cause] to continue holding an individual involuntarily for intensive treatment due to a mental disorder) Record," dated 5/23/2025, was reviewed. The "Certification Review Hearing Record" indicated, "the hearing was not held. Reason: patient (Patient 23) has signed VOL (voluntary admission) per [staff]." DCS stated the hearing was not held because Patient 23 signed for voluntary admission.

During an interview on 7/25/2025 at 2:46 p.m. with DCS, DCS stated the following: there was no voluntary admission form found in Patient 23's medical record. A patient would sign the voluntary admission form when changing legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) from involuntary to voluntary. The Psychiatrist (physician specializes in mental health) would then sign the voluntary admission form to confirm the voluntary admission. Patient 23 remained as involuntary admission during the hospital stay and did not receive a certification review hearing. DCS also stated it was important to have accurate medical record to reflect patient's legal status. Without the proof of voluntary admission form, there would be confusion on patient's legal status.

During an interview on 7/25/2025 at 6:15 p.m. with the Chief Operating Officer (COO), the COO stated patients could sign a voluntary admission during an involuntary hospitalization. COO further stated the facility did not have a policy and procedure that speaks to the process of voluntary admission.

During a review of the facility's patient handbook titled, "Rights for Individuals in Mental Health Facilities," dated 7/2018, the patient handbook indicated, "If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold. You may be represented at this hearing by a patients' rights advocate or another person of your choice. You can also request to have family members present to help explain your circumstances."

Based on interview and record review, the facility failed to ensure all physician orders were dated, timed and authenticated by the ordering physician, in a timely manner (within 24 hours), for one of 43 sampled patients (Patient 29), in accordance with the facility's policy and procedure regarding restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body)/seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving).

This deficient practice resulted in a lack of physician verification of order and incomplete medical records.

Findings:

During a review of Patient 29's face sheet (face sheet, document provides patient's demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, "Patient Demographic Profile," dated 7/14/2025, the face sheet indicated Patient 29 was an involuntary admission with admitting diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions).

During a concurrent interview and record review on 7/25/2025 at 4:41 p.m. with the Director of Risk Management (DRM), Patient 29's physician restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) order titled, "Seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving)/Restraint/Chemical Restraint (use of medications to control a patient's behavior or restrict freedom of movement) Order," dated 7/16/2025, was reviewed. The physician restraint order indicated a telephone order was obtained for use of Physical Restraint on Patient 29 on 7/16/2025 at 2:12 p.m. The physician restraint order also indicated physician did not sign off the telephone order. DRM stated the order was missing physician's signature.

During an interview on 7/25/2025 at 7:10 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following: a physician order was required when putting a patient on restraint. The physician was required to authenticate the order within 24 hours. It would be considered as restraining patient without a physician order because the physician did not sign off on the order.

During a review of the facility's policy and procedure (P&P) titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion," dated 7/2025, the P&P indicated, "Restraints or seclusion shall be used in emergency situations only and requires an order from a physician ... the physician shall authenticate the telephone/verbal order within 24 hours."

Based on interview and record review, the facility failed to ensure its multidisciplinary team (a group of professionals including physicians, nurses, social workers and therapists who collaborate to provide comprehensive and coordinated patient care) set a long-term goal when developing a treatment plan (a document that outlines an individual's assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) for two of 43 sampled patients (Patients 24, and 25), in accordance with the facility's policy regarding treatment plans.

This deficient practice had the potential to result in failure in evaluating a patient's care progress and response to treatment, which may lead to a premature or a delayed discharge.

Findings:

1. During a review of Patient 24's "Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 1/5/2025, the Psych Eval indicated, Patient 24 was admitted to the facility on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), depressed (mood disorder that causes a persistent feeling of sadness and loss of interest in life) type, without psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality), posttraumatic stress disorder (PTSD, an anxiety disorder that develops after experiencing stressful, frightening or distressing events), and diabetes (high blood sugar).

During an interview on 7/25/2025 at 11:48 a.m. with the Registered Nurse (RN) 1, RN 1 stated each patient would have a treatment plan (a document that outlines an individual's assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) developed with short term and long-term goals set to each problem identified by the multi-disciplinary team (a group of professionals including physicians, nurses, social workers and therapists who collaborate to provide comprehensive and coordinated patient care). RN 1 further stated there must be set goals for a patient to meet before discharge.

During a concurrent interview and record review on 7/25/2025 at 12:01 p.m. with RN 1, Patient 24's treatment plan titled, "Multidisciplinary Treatment Plan - Mood Swing/Labile (tendency to be unpredictable) Mood," dated 1/8/2025, was reviewed. The treatment plan indicated, "Problem Name: Mood Swings/Labile Mood with behavioral manifestations/observations: patient (Patient 24) mood fluctuates from calm to easily agitated." The treatment plan also indicated there was no long-term goal/discharge criteria listed. RN 1 stated the long-term goal was missing. RN 1 further stated, without the long-term goal, the treatment team could not measure if Patient 24's mood improved or not.

During an interview on 7/25/2025 at 2:56 p.m. with the Director of Clinical Services (DCS), DCS stated the following: there should be at least one long-term goal and one short-term goal set for each problem identified for patient in the treatment plan. Every patient should have a measurable set goal, otherwise the treatment team would not be able to measure a patient's progress and adjust interventions as needed to meet the set goals. Once the patient had met the goals, the patient would be ready for discharge.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Patient-Centered Care Planning," dated 5/2025, the P&P indicated, "It is the policy of [the facility] to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions ... Each patient's written Treatment Plan must include ... short-term and long-term goals for each active problem, developed with patient input ... Procedures: Developing the Treatment Plan ... 4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan ... the treatment team will complete the MTP (Master Treatment Plan) including ... b. completion of an individual problem sheet for each active psychiatric or medical problem. The problem sheets will include the problem, specific patient behavioral manifestations, long and short-term goals with target dates, and interventions for each appropriate discipline ... the following would be cause of conducting a review of the plan and developing a revision... the patient has successfully completed treatment goals ... the patient fails to reach treatment goals despite reasonable clinical care."

2. During a review of Patient 25's face sheet (face sheet, document provides patient's demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, "Patient Demographic Profile," dated 7/16/2025, the face sheet indicated, Patient 25 was admitted to the facility with diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), recurrent (repeat).

During an interview on 7/25/2025 at 11:48 a.m. with the Registered Nurse (RN) 1, RN 1 stated each patient would have a treatment plan developed with short term and long-term goals set to each problem identified by the multi-disciplinary team. RN 1 further stated there must be set goals for a patient to meet before discharge.

During an interview on 7/25/2025 at 2:56 p.m. with the Director of Clinical Services (DCS), the DCS stated the following: there should be at least one long-term goal and one short-term goal set for each problem identified for a patient in the treatment plan. Every patient should have a measurable set goal, otherwise the treatment team would not be able to measure a patient's care progress and adjust interventions as needed to meet the set goals. Once the patient had met the goals, the patient would be ready for discharge.

During a concurrent interview and record review on 7/25/2025 at 3:02 p.m. with the DCS, Patient 25's treatment plan titled, "Multidisciplinary Treatment Plan - Depressed Mood with Suicidality (ending one's own life)," dated 7/16/2025, was reviewed. The treatment plan indicated, "Problem Name: Depressed Mood with Suicidality with behavioral manifestations/observations: endorsed suicidal ideation with a plan to overdose (an excessive and dangerous dose of a drug)." The treatment plan also indicated there was no long-term goals/discharge criteria listed. DCS stated the following: the long-term goal was missing. It was the multidisciplinary team's responsibility to make sure there was at least one long-term goal listed on the active problem. There was nothing to measure and evaluate Patient 25's progress because there was no long-term goal.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Patient-Centered Care Planning," dated 5/2025, the P&P indicated, "It is the policy of [the facility] to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions ... Each patient's written Treatment Plan must include ... short-term and long-term goals for each active problem, developed with patient input ... Procedures: Developing the Treatment Plan ... 4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan ... the treatment team will complete the MTP (Master Treatment Plan) including ... b. completion of an individual problem sheet for each active psychiatric or medical problem. The problem sheets will include the problem, specific patient behavioral manifestations, long and short-term goals with target dates, and interventions for each appropriate discipline ... the following would be cause of conducting a review of the plan and developing a revision... the patient has successfully completed treatment goals ... the patient fails to reach treatment goals despite reasonable clinical care."

Based on observation, interview and record review, the facility failed to ensure the medication consent record for one (1) of 43 sampled patients (Patient 5), was completed, in such a way to assure that all active therapeutic efforts were included, in accordance with the facility's policy titled "Informed Consent For Psychotropic Medications (medications that affect the brain and can alter mood, awareness, thoughts, feelings, or behavior)." Specifically, the facility failed to ensure that the medication consent form for a sedation-hypnotic medication (Ambien, a medication used to treat insomnia [difficulty falling or staying asleep]) included: the dosing range, name and signature of the treating practitioner, the diagnosis, the intended benefits and outcomes of the medication, and documentation of the possibility that the medication may require adjustment.

This deficient practice resulted in a medication being administered to Patient 5 without a fully completed and physician signed medication consent form. The medical record did not contain documentation that the physician explained the medication's risks, benefits, or purpose to Patient 5. This lack of documentation may interfere with the treatment team's ability to assess informed consent, track treatment planning, and ensure proper authorization. This deficient practice also had the potential to affect other patients if medications were administered without a complete and accurately documented consent process.

Findings:

During a review of Patient 5's "Initial Psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders) Evaluation," dated 7/14/2025, indicated that Patient 5 was admitted for complaints of anxiety (a persistent feeling of worry or nervousness), depression (a mood disorder causing a persistent feeling of sadness or loss of interest), and thoughts of suicide (intending to take one's own life) through overdose (when you take more than the recommended amount of something, often a medicine or drug). Patient 5's psychiatric diagnosis included bipolar disorder (a mental health condition causing extreme mood swings including manic highs and depressive lows).

During a review of Patient 5's form titled, "Medication Consent For: Sedation (produce a state of calm or sleep), Hypnotics (used to induce and maintain sleep), and Anti-Anxiety Agents," dated 7/16/2025, the medication Ambien (a sedative-hypnotic used to treat insomnia [difficulty falling or staying asleep]) was listed. However, the consent form was missing the following required elements: Physician signature attesting that the risks, benefits, alternatives of hypnotics and anxiety agents, had been explained to Patient 5, dosing range, diagnosis, and Documentation that the medication might need adjustment.

During a review of Patient 5's Medication Administration Record, dated from 7/16/2025 through 7/22/2025, the record indicated, Ambien 10 milligrams (mg, a unit of measurement) oral tablet was documented as administered on the following dates:
o 7/16/2025 at 11:45 p.m.
o 7/17/2025 at 8:44 p.m.
o 7/18/2025 at 11:47 p.m.
o 7/20/2025 at 12:49 a.m.
o 7/21/2025 at 2:13 a.m.
o 7/22/2025 at 1:33 a.m.
o 7/23/2025 at 12:50 a.m.
o 7/24/2025 at 12:01 a.m.

During a concurrent interview and record review on 7/25/2025 at 8:05 p.m. with the Director of Quality and Performance Improvement Compliance Officer (DQPI), Patient 5's "Medication Consent For: Sedation, Hypnotics, and Anti-Anxiety Agents," dated 7/16/2025, was reviewed. The DQPI confirmed that the form lacked all required documentation including:
-the dosing range,
-the name and signature of the prescribing practitioner,
-the psychiatric diagnosis,
-the potential need for medication adjustment.

During a concurrent interview and record review on 7/25/2025 at 8:05 p.m. with the Chief Executive Officer (CEO), Patient 1's medication consent form, was reviewed. The CEO confirmed that the physician had not signed the consent form and that the witness signature was illegible.

During a review of the facility's Policy and Procedure (P&P) titled, "Informed Consent for Psychotropic Medication (medications that affect the brain and can alter mood, awareness, thoughts, feelings, or behavior)," dated June 2024, was reviewed. The P&P indicated: "Each medication ordered by the physician must have a distinct and separate medication consent form filled out by the physician or his designee in black ink. Dosing range must be documented, name and signature of the treating practitioner, the diagnosis, the benefits and intended outcomes, and the possibility that the medication would need to be adjusted."

During a review of the facility's Medical Staff Bylaws (a set of rules and regulations that govern the internal management of an organization), Rules, and Regulations, dated 1/23/2025, the bylaws indicated:
"Required consents for any and all treatments should be obtained ...All orders for treatment and/or medications shall be in writing ...The responsible practitioner shall sign such orders with date and time at the next visit, within 48 hours."

Based on interview and record review, the facility failed to ensure a patient's legal status (the circumstances under which the patient was admitted and/or is being treated - voluntary or involuntary, committed by court, evaluation and recertification are in accordance with state requirements) was correctly reflected on one of 43 sampled patient's (Patient 30) medical record, after Patient 30 signed a voluntary admission on 7/7/2025.

This deficient practice resulted in confusion on Patient 30's legal status and led to unnecessary hold placement (putting a patient in an involuntary admission) on 7/15/2025, which violated Patient 30's right regarding voluntary treatment.

Findings:

During a review of Patient 30's "Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 6/30/2025, the Psych Eval indicated, Patient 30 was admitted to the facility with diagnoses including but not limited to major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), severe, recurrent (repeat), with psychosis (a severe mental disorder with hallucinations [an experience involving the apparent perception of something not present]) and post-traumatic stress disorder (PTSD, an anxiety disorder that develops after experiencing stressful, frightening or distressing events).

During a review of Patient 30's involuntary hold notice titled, "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code," dated 7/1/2025, the involuntary hold notice indicated Patient 30 was placed on a 14-day hold (5250-hold, allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to danger to others, danger to himself or herself, and gravely disabled (inability to care for oneself).

During a concurrent interview and record review on 7/25/2025 at 3:07 p.m. with the Director of Clinical Services (DCS), Patient 30's "Request for Voluntary Admission (a patient consent form for voluntary admission)," dated 7/7/2025, was reviewed. The "Request for Voluntary Admission" indicated, Patient 30 signed for voluntary admission on 7/7/2025 and signed off by physician on 7/7/2025. DCS stated Patient 30's legal status should be "voluntary" starting 7/7/2025.

During a review of Patient 30's "Daily Progress Note," dated 7/14/2025, the "Daily Progress Note" indicated Patient 30's legal status as 5250 (5250-hold, allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 14 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment).

During a concurrent interview and record review on 7/25/2025 at 3:09 p.m. with DCS, Patient 30's face sheet (face sheet, document provides patient's demographic data including name, date of birth, emergency contact, admitting diagnosis and health insurance) titled, "Patient Demographic Profile," dated 7/15/2025, was reviewed. The face sheet indicated Patient 30's admission as involuntary status. DCS stated the face sheet was not updated. Patient 30 should be on voluntary status.

During a concurrent interview and record review on 7/25/2025 at 3:11 p.m. with DCS, Patient 30's involuntary hold notice titled, "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 Days Intensive Treatment) or 5270.15 (Additional 30 Days Intensive Treatment) of the Welfare and Institutions Code," dated 7/15/2025, the involuntary hold notice indicated, Patient 30 was placed on a 30-day hold (allows an adult experiencing a mental health crisis to be involuntary detained for maximum of 30 days to receive psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) for grave disability due to being "irritable, labile (a tendency to be unpredictable), still working on a viable safety plan for discharge." DSC stated this hold was unnecessary because Patient 30 was already on voluntary status since 7/7/2025.

During an interview on 7/25/2025 at 6:15 p.m. with the Chief Operating Officer (COO), COO stated patients could sign a voluntary admission during an involuntary hospitalization. COO further stated the facility did not have a policy and procedure that speaks to the process of voluntary admission.

During a review of the facility's patient handbook titled, "Rights for Individuals in Mental Health Facilities," dated 7/2018, the patient handbook indicated, "If you are held beyond 72 hours, you have the right to remain in the hospital for voluntary treatment. If you do not want to stay voluntarily, the facility where you are staying will conduct a certification review hearing within four (4) days of the end of your 72-hour hold."

Based on interview and record review, the facility failed to ensure to develop an individualized treatment plan (a document that outlines an individual's assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) for one of 43 sampled patients (Patient 24) to address Patient 24's past trauma as sexual abuse victim, in accordance with the facility's policy regarding "Interdisciplinary Patient-Centered Care Planning."

This deficient practice resulted in Patient 24 feeling anxious around male staff conducting patient rounding (a regular, systematic process where healthcare professionals assess patients) at nighttime during Patient 24's course of hospitalization.

Findings:

During a review of Patient 24's "Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 1/5/2025, the Psych Eval indicated, Patient 24 was admitted to the facility on 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) with diagnoses including but not limited to bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), depressed (mood disorder that causes a persistent feeling of sadness and loss of interest in life) type, without psychosis (severe mental condition involving abnormal thinking, perceptions, and loss of contact with reality), posttraumatic stress disorder (PTSD, an anxiety disorder that develops after experiencing stressful, frightening or distressing events) and diabetes (high blood sugar). The Psych Eval also indicated, "Her (Patient 24's) father sexually abused her (Patient 24) when she (Patient 24) was a child ... Patient (Patient 24) complains of high anxiety (a feeling of fear and uneasiness), racing thoughts, insomnia (inability to sleep), labile (tendency to be unpredictable) mood, lack of motivation, feelings of hopelessness and worthlessness."

During a concurrent interview and record review on 7/25/2025 at 11:57 a.m. with the Registered Nurse (RN) 1, Patient 24's nursing admission assessment titled, "Nursing Admission Assessment - ADULTS (age 18+)," dated 1/5/2025, was reviewed. The nursing admission assessment indicated Patient 24 was a victim of sexual abuse and with history of psychological trauma due to sexual abuse. The nursing admission assessment also indicated Patient 24 was depressed for 30 years after this trauma.
RN 1 stated this would trigger the primary nurse to develop a treatment plan (a document that outlines an individual's assessed needs and the specific support or care required to meet those needs, ensuring the right level of care is provided) with problem of "sexually acting out - victim" to address Patient 24's trauma related to sexual abuse. RN 1 further stated it was important to identify past trauma because it would shape the interventions of the treatment plan.

During a concurrent interview and record review on 7/25/2025 at 12:01 p.m. with RN 1, Patient 24's treatment plan titled, "Initial and Master Treatment Plan," dated 1/5/2025, was reviewed. The treatment plan indicated, "depressed mood with suicidality (thoughts of taking one's own life)" and "mood swings" as Patient 24's active problems. RN 1 stated the treatment plan to address the problem of "sexually acting out - victim" was missing. RN 1 stated this could result in staff being unaware of what interventions and adjustments in patient care that are needed to be provided to Patient 24 to avoid triggering the trauma.

During a concurrent interview and record review on 7/25/2025 at 12:17 p.m. with RN 1, Patient 24's group progress notes titled, "[unit] Adult Group Note Friday (group note)," dated 1/10/2025, was reviewed. The group note indicated, "Patient (Patient 24) stated she is not happy with tall male nurses coming into her (Patient 24's) room at night, makes her anxious." RN 1 stated this could be avoided by providing proper interventions such as avoiding male staff assignment rounding for Patient 24 at night and alert male staff to stay from a distance with Patient 24 in order to avoid triggering her stress and making her (Patient 24) anxious.

During a concurrent interview and record review on 7/25/2025 at 2:47 p.m. with the Director of Clinical Services (DCS), Patient 24's "Psychosocial Assessment (assessment completed by social service staff)," dated 1/6/2025, was reviewed. The "Psychosocial Assessment" indicated, Patient 24 had history of trauma as a sexual abuse victim. The "Psychosocial Assessment" also indicated, "severe and chronic depression, and history of trauma" as the high-risk psychosocial issues requiring early treatment planning and interventions. DCS stated there should be a treatment plan developed to address Patient 24's past sexual abuse trauma to provide proper intervention to aid Patient 24's mental health healing process. DCS further stated Patient 24's treatment plan did not address Patient 24's past trauma.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Patient-Centered Care Planning," dated 5/2025, the P&P indicated, "It is the policy of [the facility] to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions ... Each discipline completing their individual assessments will begin to identify the patient's problems to be treated and the focus of their treatment interventions which will be included in the MTP (master treatment plan)."

During a review of the facility's policy and procedure (P&P) titled, " Active and Individualized Treatment," dated 5/2024, the P&P indicated, "Active treatment is substantive engagement with the patient in their care through the course of a day which occurs in the therapeutic milieu where our patients are surrounded by a safe, structured community through which their activities of daily living are a means of encouraging healthier ways of thinking and behaving ... It is the policy of [the facility] to provide care and a model of active treatment for all patients hospitalized at the facility. Active treatment services provided must be ... provided under an individualized treatment plan."