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Based on observation, interview, record review and policy review, the Governing Body failed to ensure accountability and effective oversight of the hospital and hospital staff and compliance with the requirements under 42 CFR 482.12 Condition of Practice (CoP) Governing Body.

The hospital failed to:
- Ensure the CEO provided effective oversight and management of the entire hospital. (A-0057)
- Provide a safe patient care environment for one current patients (#23) and one discharged patient (#4) of 24 medical records reviewed. (A-0144)
- Ensure staff appropriately monitored and documented special precautions, every five minute and/or every 15-minute checks as ordered for five current patients (#3, #18, #19, #20 and #21) and three discharged patients (#5, #10, and #11) of 24 medical records reviewed. (A-0144)
- Ensure the provider renewed one to one (1:1, continuous visual contact with close physical proximity) orders every 24 hours per policy for one current patient (#3) and one discharged patient (#4) of two medical records with 1:1 observation orders reviewed. (A-0144)
- Ensure the provider renewed all special precaution (Suicide [SP, precautions taken to ensure patients are safe and free of self-injury or self-harm], Self Harm [behavior that is harmful or potentially harmful to oneself], Assault [AP, measures to alert staff of a patient's potential to become violent with others], and Sexually Acting Out [SAO, inappropriate, harmful, out of control sexual behaviors in children and adults]) orders every 24 hours per policy for two current patients (#20 and #21) and two discharged patients (#10 and #11) out of 24 medical records reviewed. (A-0144)
- Ensure that staff recognize sexual acting out behaviors and initiate appropriate precautions for one discharged patient (#11) with SAO precautions reviewed. (A-0144)
- Ensure nursing staff performed assessments and re-assessments of patients every shift for two current patients (#3 and #20) and one discharged patient (#10) of 24 patient medical records reviewed. (A-0144)
- Ensure safety incidents were properly reported, documented, and investigated per policy for two current patients (#3, and #8) and three discharged patients (#4, #10, and #11) of 24 medical records reviewed. (A-0145)
- Provide education to staff following a patient safety incident involving one discharged patient (#4). (A-0145)
- Ensure safety incidents were properly reported, documented, and investigated per policy for two current patients (#3, and #8) and three discharged (#4, #10, and #11) of 24 patient medical records reviewed. (A-0145)
- Ensure all restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) episodes were appropriately documented on the restraint log for one current (#3) and two discharged patients (#4 and #10) of six restraint patient records reviewed. (A-0175)
- Ensure all restraint documentation was completed for two current patients (#3 and #8) and two discharged (#4 and #10) patients of six restraint patient records with reviewed. (A-0175)
- Ensure Emergency Safety Intervention (ESI, the use of restraint or seclusion as an immediate response to and emergency safety situation) packets were completed for two current patients (#3 and #8) and two discharged patients (#4 and #10) of six restraint patient medical records reviewed. (A-0175)
- Ensure face to face evaluations were completed for two current patients (#3 and #8) and two discharged patients (#4 and #10) of six restraint patient medical records reviewed. (A-0178)

These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.12 CoP: Governing Body.

Please refer to A-0057, A-0115, A-0144, A-0145, A-0175 and A-0178.


39354

Based on interview, record review and policy review, the hospital's Governing Body failed to ensure the Chief Executive Officer (CEO) provided effective oversight and management of the hospital and hospital staff and complied with the requirements under 42 CFR 482.12 Condition of Participation (CoP): Governing Body. These failures had the potential to affect the safety and quality of care for all patients admitted to the hospital.

Findings included:

Review of the hospital's document titled, "Bylaws of the Medical Staff," dated 2025, showed the CEO was the person appointed by the board to act on its behalf in the overall administration of the hospital. While the governing body is ultimately responsible for the safety and quality of care provided at the hospital, medical staff and administration are expected to collaborate to ensure safe quality care.

Review of the hospital undated document titled, "CEO Position Description," showed the CEO should ensure the hospital staff is knowledgeable of regulatory standards applicable to their departments and that the standards of care are met. Quality patient care should be ensured through oversight of performance improvement programs and the set standards. The CEO is responsible for ensuring compliance of staff with the hospital's policies and procedures regarding patient safety.

Review of the hospital's undated document titled, "Organizational Structure," showed the CEO was on the Board of Directors and all administrative staff reported to her.

During an interview on 09/23/25 at 11:00 AM, Staff B, CEO, stated that she was responsible for all patients admitted to the hospital; ensuring all staff follow hospital policies and procedures; and for providing a safe patient care environment.



39354

Based on interview, record review and policy review, the hospital failed to:
- Ensure restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) episodes were appropriately documented on the restraint log for one current patient (#3) and two discharged patients (#4 and #10) of six restraint patient records reviewed.
- Ensure the required restraint documentation was completed for two current patients (#3 and #8) and two discharged (#4 and #10) patients of six restraint patient records with reviewed.
- Ensure Emergency Safety Intervention (ESI, the use of restraint or seclusion as an immediate response to and emergency safety situation) packets were completed for two current patients (#3 and #8) and two discharged patients (#4 and #10) of six restraint patient medical records reviewed.

Review of the hospital's policy titled, "Emergency Behavioral Interventions: Use of Restraint and Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving)," revised 09/2025, showed the Chief Nursing Officer (CNO) shall maintain the restraint and seclusion log.

Review of the hospital's policy titled, "Emergency Behavioral Interventions: Use of Restraint and Seclusion," revised 09/2025, showed staff must document the assessment, monitoring and evaluation of any patient in restraint or seclusion.

Review of the hospital's undated document titled, "Emergency Safety Intervention (ESI) Justification Packet," showed the Nursing Director was to sign and date the packet, and the physician was to be notified within 30 minutes of the results of the safety intervention.

Review of Patient #3's medical record showed:
- She was 14-year-old admitted on 08/20/25 for disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger, and frequent, intense temper outbursts).
- Physician orders included suicide (to cause one's own death) precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm [SH, behavior that is harmful or potentially harmful to oneself]).
- On 09/07/25 at 5:45 PM, a chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) was ordered for self-harm behaviors.
- No nursing documentation or ESI Justification Packet were completed.

Review of Patient #4's medical record, dated 08/28/25 through 09/16/25, showed:
- She was a 15-year-old female who was admitted on 08/28/25 for DMDD and Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy).
- Physician orders included SI, self-harm and assaultive precautions assault precautions (AP, measures to alert staff of a patient's potential to become violent with others).
- On 09/03/25 at 2:26 PM, a chemical restraint was ordered for self-harm and property destruction.
- No nursing documentation or ESI Justification Packet were completed.

Review of Patient #8's medical record dated 08/21/25 through 09/16/25 showed:
- She was a 13-year-old female who was admitted on 08/21/25 with MDD.
- Physician orders included SP, self-harm, and purge precautions (monitoring patient behaviors and emotions particularly around mealtimes).
- On 09/08/25 there was an order for physical restraints.
- On 09/11/25 there was an order for physical restraints and chemical restraints.
- On 09/13/25 there was an order for physical restraints and chemical restraints.
- No nursing documentation or ESI Justification Packet were completed.

Review of Patient #10's medical record showed:
- He was a 17-year-old admitted on 07/10/25 for MDD.
- Physician orders included SI and SH special precautions.
- On 09/06/25 at 3:00 PM, a chemical restraint was ordered for uncontrolled anxiety and hitting his head. No nursing documentation or ESI Justification Packet were completed.
- On 09/07/25 at 4:05 PM, a chemical restraint was ordered for self-harm behaviors. The Nursing Director did not sign off on the ESI Justification Packet.

Review of the hospital's document titled, "September 2025 Restraint Reporting Log" dated 09/2025 showed:
- On 09/07/25, there was no documentation for Patient #3's chemical restraint on the restraint reporting log.
- On 09/03/25, there was no documentation for Patient #4's chemical restraint on the restraint reporting log.
- On 09/08/25, there was no documentation for Patient #8's physical restraints on the restraint reporting log.
- On 09/11/25, there was no documentation for Patient #8's physical restraints and chemical restraints on the restraint reporting log.
- On 09/13/25, there was no documentation for Patient #8's physical restraints and chemical restraints on the restraint reporting log.
- On 09/06/25, there was no documentation for Patient # 10's chemical restraint on the restraint reporting log.
- On 09/07/25, there was no documentation for Patient # 10's chemical restraint on the restraint reporting log.

During an interview on 09/23/25 at 10:53 AM, Staff B, Chief Executive Officer (CEO), stated that she expected staff to follow all policies and procedures. All patients who were put in restraints, including chemical restraints, were to be placed on the restraint log.

During an interview on 09/23/25 at 11:30 AM, Staff C, CNO, stated that she reviews all incident reports and forwards them to the Quality Director, who maintains the restraint log.

During an interview on 09/23/25 at 10:27 AM, Staff H, Quality-Risk-Infection Control Director, stated the lack of restraint documentation for patients was a direct result of failure of staff to complete the required incident reports and documentation.


39354

Based on interview, record review and policy review, the hospital failed to ensure restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) episodes were appropriately documented on the restraint log and the required restraint documentation was completed, along with Emergency Safety Intervention (ESI, the use of restraint or seclusion as an immediate response to and emergency safety situation) packets for three current (#3, #4 and #8) and one discharged (#10) restraint patients of six restraint patient medical records reviewed.

Review of the hospital's policy titled, "Emergency Behavioral Interventions: Use of Restraint and Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving)," revised 09/2025, showed the Chief Nursing Officer (CNO) shall maintain the restraint and seclusion log.

Review of the hospital's policy titled, "Emergency Behavioral Interventions: Use of Restraint and Seclusion," revised 09/2025, showed staff must document the assessment, monitoring and evaluation of any patient in restraint or seclusion.

Review of the hospital's undated document titled, "Emergency Safety Intervention (ESI) Justification Packet," showed the Nursing Director was to sign and date the packet, and the physician was to be notified within 30 minutes of the completion of the face-to-face evaluation.

Review of Patient #3's medical record showed:
- She was 14-year-old admitted on 08/20/25 for disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger, and frequent, intense temper outbursts).
- Physician orders included suicide (to cause one's own death) precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm [SH, behavior that is harmful or potentially harmful to oneself]).
- On 09/07/25 at 5:45 PM, a chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) was ordered for self-harm behaviors.

Review of Patient #4's medical record, dated 08/28/25 through 09/16/25, showed:
- She was a 15-year-old female who was admitted on 08/28/25 for DMDD and Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy).
- Physician orders included SI, self-harm and assaultive precautions assault precautions (AP, measures to alert staff of a patient's potential to become violent with others).
- On 09/03/25 at 2:26 PM, a chemical restraint was ordered for self-harm and property destruction.

Review of Patient #8's medical record dated 08/21/25 through 09/16/25 showed:
- She was a 13-year-old female who was admitted on 08/21/25 with MDD.
- Physician orders included SP, self-harm, and purge precautions (monitoring patient behaviors and emotions particularly around mealtimes).
- On 09/08/25 there was an order for physical restraints.
- On 09/11/25 there was an order for physical restraints and chemical restraints.
- On 09/13/25 there was an order for physical restraints and chemical restraints.

Review of Patient #10's medical record showed:
- He was a 17-year-old admitted on 07/10/25 for MDD.
- Physician orders included SI and SH special precautions.
- On 09/06/25 at 3:00 PM, a chemical restraint was ordered for uncontrolled anxiety and hitting his head.
- On 09/07/25 at 4:05 PM, a chemical restraint was ordered for self-harm behaviors.

Review of the hospital's document titled, "September 2025 Restraint Reporting Log" dated 09/2025 showed:
- On 09/07/25, there was no documentation for Patient #3's chemical restraint on the restraint reporting log.
- On 09/03/25, there was no documentation for Patient #4's chemical restraint on the restraint reporting log.
- On 09/08/25, there was no documentation for Patient #8's physical restraints on the restraint reporting log.
- On 09/11/25, there was no documentation for Patient #8's physical restraints and chemical restraints on the restraint reporting log.
- On 09/13/25, there was no documentation for Patient #8's physical restraints and chemical restraints on the restraint reporting log.
- On 09/06/25, there was no documentation for Patient # 10's chemical restraint on the restraint reporting log.
- On 09/07/25, there was no documentation for Patient # 10's chemical restraint on the restraint reporting log.

During an interview on 09/23/25 at 10:53 AM, Staff B, Chief Executive Officer (CEO), stated that she expected staff to follow all policies and procedures.

During an interview on 09/23/25 at 10:27 AM, Staff H, Quality-Risk-Infection Control Director, lack of restraint documentation for patients was a direct result of failure of staff to complete the required incident reports.

Based on interview, policy review and record review the hospital failed to ensure face-to-face evaluations were completed for two current patients (#3 and #8) and two discharged patients (#4 and #10) of six restraint patient medical records reviewed.

Review of the hospital's policy titled, "Emergency Behavioral Interventions: Use of Restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) and Seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving)," revised 09/2025, showed:
- A face-to-face evaluation was an assessment by a physician or qualified designee of the individual within one hour following the initiation of restraint or seclusion to verify the need for restraint or seclusion and to approve its continuation.
- The evaluation must include an assessment of the individual's immediate situation, reaction to the restraint or seclusion, medical and behavioral condition and the need to continue or terminate the restraint or seclusion.
- The physician who delegated the face-to-face evaluation must ensure that a physician performs a follow up evaluation of the patient face-to-face not later than 24 hours following the initiation of the restraint or seclusion.
- Documentation of the one-hour face-to-face evaluation will be a permanent part of the patient's medical record.

Review of the hospital's undated document titled, "Emergency Safety Intervention (ESI, the use of restraint or seclusion as an immediate response to and emergency safety situation) Justification Packet," showed the Nursing Director was to sign and date the packet, and the physician was to be notified within 30 minutes of the completion of the face-to-face evaluation.

Review of Patient #3's medical record showed:
- She was a 14-year-old admitted on 08/20/25 for DMDD.
- Physician orders included suicide (to cause one's own death) precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm [SH, behavior that is harmful or potentially harmful to oneself]).
- On 09/07/25 at 5:45 PM, a chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) was ordered for self-harm behaviors. No face-to-face evaluation was completed.

Review of Patient #4's medical record dated, 08/28/25 through 09/16/25, showed:
- She was a 15-year-old female who was admitted on 08/28/25 with disruptive mood dysregulation disorder (DMDD, condition of extreme irritability, anger, and frequent, intense temper outbursts), Major Depressive Disorder (MDD, a mental health condition that causes persistently low mood and loss of interest in activities that once brought joy), generalized anxiety disorder (GAD, ongoing anxiety that interferes with daily activities) and suicidal/suicidal ideation (SI, thoughts of causing one's own death).
- Physician orders included suicidal/suicidal ideation (SI, thoughts of causing one's own death), self-harm and assaultive precautions (AP, measures to alert staff of a patient's potential to become violent with others).
-On 09/03/25 at 2:26 PM, a chemical restraint was ordered for self-harm and property destruction. No face-to-face evaluation was completed

Review of Patient #8's medical record dated 08/21/25 through 09/16/25 showed:
- She was a 13-year-old female who was admitted on 08/21/25 with MDD.
- Physician orders included SP, self-harm, and purge precautions (monitoring patient behaviors and emotions particularly around mealtimes).
- On 09/08/25 there was an order for physical restraints.
- On 09/11/25 there was an order for physical restraints and chemical restraints.
- On 09/13/25 there was an order for physical restraints and chemical restraints.
- There was no face-to-face evaluation was completed.

Review of Patient #10's medical record showed:
- On 07/10/25, he was a 17-year-old admitted for schizo-affective disorder (mental health disorder where speech and thought are disorganized, and a person may find it hard to function socially and at work, and may experience hearing voices that are not real), anxiety, and oppositional defiant disorder (ODD, a disorder marked by defiant and disobedient behavior to authority figures).
- He was placed on SI and SH special precautions
- On 09/06/25 at 3:00 PM, a chemical restraint was ordered for uncontrolled anxiety and hitting his head. No face-to-face evaluation was completed.
- On 09/07/25 at 4:05 PM, a chemical restraint was ordered for self-harm behaviors. A face-to-face evaluation was completed by a registered nurse (RN); however, the results were not shared with the physician.

During an interview on 09/23/25 at 10:53 AM, Staff B, Chief Executive Officer (CEO), stated that she expected staff to follow all policies and procedures.