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Based on observation, record review, and interview, the hospital failed to ensure each patient's right to receive care in a safe setting. The deficient practice was evidenced by failure to maintain a safe outdoor recreation environment as evidenced by a two broken picnic tables with exposed screws displaying sharp ends posing a potential risk of injury.
Findings:

During a tour of the facility on 04/07/2025 between 11:15 AM to 12:00 PM tow broken picnic tables with exposed screws noted in the patient outside area.

In an interview on 11:25 AM, S1QAPID verified the two broken picnic tables with exposed screws displaying sharp ends posing a potential risk of injury.

Based on record review and interview, the hospital failed to ensure the QAPI program analyzed adverse patient events that impacted patient safety and quality of care. This deficient practice was evidenced by failure of the hospital to conduct a thorough investigation involving 2 patients identified on the LDH Self Report Log 2025.
Findings:

Review of LDH Self Report dated 03/06/2025 verified that on 03/05/2025 Patient #1 went into Patient #2's room and pulled Patient #2's undergarments down.

Review of video footage dated 03/05/2025 between 9:35 PM and 9:51 PM with S3POD and S1QAPID revealed the following:
03/05/2025 at 21:35.48 reveals Patient #1 exiting his room walking down the hallway in front of the nurses' station and getting water from the water fountain.
03/05/2025 at 21:36.24 Patient #1 is seen walking around the corner going down the female hallway into Patient #2's room
03/05/2025 at 21:51.00 Patient #1 is seen walking around the corner from the female hallway walking in front of the nurses' station returning to his room.

Review of Patient #1's Night Observational Checklist dated 03/05/2025 reveals at 9:15 PM, 9:30 PM, and 9:45 PM MHT documented Patient #1 was in his room cooperative/appropriate.

Review of Patient #2's Night Observational Checklist dated 03/05/2025 reveals at 9:15 PM and 9:30 PM Patient #2 was in bed cooperative/appropriate. Further review revealed at 9:45 PM Patient #2 was in the hallway nervous, jumpy, and shaky.

In an interview on 04/09/2025 at 1:15 PM S1QAPI confirmed that the investigation into the incident with Patient #1 and Patient #2 that all employees followed hospital policies/procedures eventhough Night Observational Checklists for Patient #1 and Patient #2 do not match the video footage reviewed.

Based on record review and interview, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice is evidenced by the failure to update the care plan of 1 (#3) of 3 (#1-#3) patient reviewed for completed and updated care plans.
Findings:

A review of the hospital policy number PC-018 last reviewed 11/11/2021 titled, "Multidisciplinary Treatment Plans," revealed in part: PURPOSE: To establish guidelines for the development of multidisciplinary treatment plans that provide direction for the patient's course of treatment, utilize input from all disciplines, establish ongoing individualized treatment, and promote progress during treatment. POLICY: It is the policy of the hospital to provide an individualized plan of care that is based on assessment of the patient's mental, physical, and psychosocial needs and that is reflective of a multidisciplinary approach to the patient care.

A review of the hospital policy number NUR 004 last reviewed 10/04/2023 titled, "Precautions", revealed in part: PURPOSE: the purpose of the policy is to provide staff with guidelines for monitoring patients that are placed on special precautions. PRECAUTIONS: 5. Seizure- A patient who has a history of a seizure disorder, on a Detox Protocol, or that has had a seizure during their hospitalization. PROCEDURE: 5. A. When a patient is placed on seizure precautions, all nursing staff are made aware and fall precautions orders will be initiated.

A review of Patient #3's medical record revealed Patient #3 was admitted on 03/26/2025 with ETOH Dependence and past medical history included seizures. Further review revealed Detox Protocol ordered on 03/28/2025. Review of Patient #3's Multidisciplinary Treatment Plan did not reveal seizure precautions or fall precautions as per hospital policy for a patient with diagnosis of seizures and/or detox protocol order.

In an interview on 04/09/2025 at 11:40 AM, S1QAPID verified above mentioned findings.

Based on observation and interview, the hospital failed to ensure supplies were maintained to an acceptable level of safety and quality. This deficient practice was evidence by expired patient care supplies available for patient use.
Findings:

Observations during a walk-through of the hospital on 04/07/2025 from 11:15 AM to 12:00 PM revealed expired patient care supplies available for patient use and included:
1) Transystem Sterile Transport Swab suitable for aerobes and anaerobes, quantity 50 swabs, with expiration date of 07/31/2023; and
2) Anaerobic Vacutainer Purple Top Vials 40ml, quantity 2 vials, with an expiration of 04/03/2025.

In an interview on 04/07/2025 and present on the hospital walk-through, S1QAPID confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure all patients treatments were within compliance of particular aspects of the patients' individualized treatment program as evidenced by failure to have signed master treatment plan by MD 1(#3) of 3(#1-#3) patients' treatment plans reviewed for the sample.
Findings:

A review of the hospital policy number PC-018 last reviewed 11/11/2021 titled, "Multidisciplinary Treatment Plans," revealed in part: PURPOSE: To establish guidelines for the development of multidisciplinary treatment plans that provide direction for the patient's course of treatment, utilize input from all disciplines, establish ongoing individualized treatment, and promote progress during treatment. PROCEDURE: 3. The mult-disciplinary treatment team is comprised of the physician, nurse, licensed therapist, and recreational therapist. Outside agencies/caregivers may also be included as appropriate. The plan shall be approved and signed by the physician to ensure continuity of care, coordination, and integration of services provided.

Review of Patient #3's medical record revealed Patient #3 was admitted on 03/26/2025 for ETOH abuse on a formal voluntary admission. Further review of Patient 3's Multidisciplinary Integrated Master Treatment Plan initiated on 03/26/2025 did not reveal a signature by a physician.

In an interview on 04/09/2025 at 11:35 AM, S1QAPID confirmed Patient #3's Multidisciplinary Integrated Master Treatment Plan was not signed by a MD.