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Based on record review and interview, the hospital failed to inform 1 (#3) of 3 (#1-#3) patients, or when appropriate, the patient's representative, of the patient's rights, in advance of furnishing patient care.
Findings:

Review of hospital policy "Title: Patient Rights, No: RR-07, Date of Last Revision: 6/2023" revealed, in part: "Policy: The Hospital protects and promotes patient's rights that are extended to all patients and prohibits discrimination. It is the policy of the Hospital to ensure that patient rights are communicated to all patients and their legal guardian and employees to avoid any misunderstanding of those rights, and to provide a list of patients' rights to all patients or their legal guardian upon admission. Procedure: 1. The following rights shall be afforded to all patients and are not subject to modification: a. Patients have the right to be fully informed before or upon admission about their rights and responsibilities and about any limitation on these rights imposed by rules of the hospital."

Review of Patient #3's medical record revealed an admission date of 08/28/2025. Further review failed to reveal evidence that Patient #3 or their representative was informed of their patient rights.

In an interview on 09/03/2025 at 1:38 PM, S3Patient Advocate confirmed Patient #3's medical record failed to reveal evidence they or their representative was notified of their patient rights.

Based on record review and interview, the hospital failed to ensure the patient right to make informed decisions regarding his or her care. This deficient practice was evidenced by failing to obtain informed consent for treatment form for 1 (#3) of 3 (#1-#3) sampled patients.
Findings:

Review of hospital policy "Title/Subject: Admission Procedure-Intake Office, Policy Number: IN-010, Revision Date: 1/23" revealed, in part: "II. Purpose. To ensure that the individual meeting criteria for hospitalization are informed, knowledgeable, and consent to Formal Voluntary Admission and treatment in a psychiatric setting, they also agree to abide by outlined rules and regulations and to follow the course of treatment prescribed by the attending physician. III. Procedure. The Intake Coordinator or intake designee will: H. Intake Coordinator or Designated unit staff will notify patient and family on the forms in the admission packet and obtain patient's consent on the following: Formal Voluntary or Non-contested Admission, Conditions of Admission, Acknowledgment of Notification of Rights, Notice of Advanced Directives, Addendum to consent for Admission and Conditions of Admission Form Regarding Advance Directives."

Review of Patient #3's medical record revealed an admission date of 08/28/2025. Further review failed to reveal evidence that Patient #3 or their representative signed an informed consent for treatment.

In an interview on 09/03/2025 at 1:41 PM, S3Patient Advocate confirmed Patient #3's medical record failed to reveal evidence they or their representative signed informed consent for treatment.

Based on record review and interview, the hospital failed to ensure the patient right to receive care in a safe setting. This deficient practice was evidenced by failing to ensure all patient care staff (S4LPN) completed mandatory training after an event where a patient (#1) experienced a medical emergency for 1 (#1) of 3 (#1-#3) sampled patients.
Findings:

Review of the hospital's LDH Self-Report dated 07/31/2025 revealed, in part, Patient #1 experienced altered mental status on 07/31/2025 at 12:18 PM that resulted in a Code Blue and Medical Send Out. Review of the hospital investigation revealed S4LPN was present during the event. The hospital substantiated the allegation and found that there was a delay of calling the code blue and getting additional assistance to the patient. Further review revealed, in part: "On August 12th and August 14th, the organization held a Town Hall Meeting that provided all 100% of staff training which covered the following: Mission and Vision of the Organization; Patient Safety; Shift-to-Shift Rounding; The ObservSMART Value; Zero Tolerance; Hospital Codes (Code Green, Blue, White Yellow, and etc.); Incident Reporting (Levels of Incident Reporting and Reductions); Compliance; Risk Management. The organization will complete additional staff training on utilizing the ROAR/Panic Button technology. 100% of staff will be trained. The organization will be also training the staff on the following policies and procedures: Code Blue; Early Response; Emergency Response."

Review of hospital 08/12/2025 and 08/14/2025 Town Hall Meeting and Educational Attendance Roster revealed no evidence S4LPN attended the training.

Review of hospital nursing staff revealed S4LPN currently employed by the hospital.

In an interview on 09/03/2025 at 8:33 AM, S2Interim CNO confirmed S4LPN still employed by hospital. S2Interim CNO confirmed that S4LPN did not complete the hospital staff training on 08/12/2025 or 08/14/2025.

Based on record review and interview, the hospital failed to ensure the Quality Assessment and Performance Improvement program measured, analyzed, and tracked quality indicators to monitor the safety and effectiveness of hospital services and operations. This deficient practice was evidenced by failing to ensure results of code blue evaluations were submitted to the performance improvement committee as stated in hospital code blue policy.
Findings:

Review of hospital policy "Title: Code Blue, No: POC-11, Date of Last Revision: 10/2023" revealed, in part: "Code Blue Drills. The CNO/designee will conduct Code Blue drills each shift, minimum quarterly. The Code Blue drill event will be documented on the Code Blue Record. The Code Blue drills will be evaluated through completion of the Code Blue Evaluation form by the Registered Nurse. The Code Blue Evaluation will be reviewed by the CNO to identify training needs, process issues, etc. Results of the evaluations will be submitted to the Performance Improvement Committee and Medical Executive Committee."

In an interview on 09/03/2025 at 10:50 AM, S2Interim CNO confirmed the hospital had no evidence results of code blue evaluations were submitted to the Performance Improvement Committee.

Based on record review and interview, the registered nurse failed to supervise the care provided to each patient. The deficient practice was evidenced by failure of the RN to conduct code blue drills each shift, minimum quarterly as stated in hospital code blue policy.
Findings:

Review of hospital policy "Title: Code Blue, No: POC-11, Date of Last Revision: 10/2023" revealed, in part: "Code Blue Drills. The CNO/designee will conduct Code Blue drills each shift, minimum quarterly. The Code Blue drill event will be documented on the Code Blue Record. The Code Blue drills will be evaluated through completion of the Code Blue Evaluation form by the Registered Nurse. The Code Blue Evaluation will be reviewed by the CNO to identify training needs, process issues, etc. Results of the evaluations will be submitted to the Performance Improvement Committee and Medical Executive Committee."

In an interview on 09/03/2025 at 8:33 AM, S2Interim CNO confirmed for year 2025, hospital had no evidence Code Blue drills conducted quarterly each shift as stated in hospital Code Blue policy.

Based on record review and interview, the hospital failed to ensure a complete neurological examination was recorded at the time of the admission physical examination. This deficient practice was evidenced by failing to have a complete neurological assessment with examination of Cranial Nerves I-XII for 1 (#3) of 3 (#1-#3) sampled patients.
Findings:

Review of hospital policy "Title/Subject: Assessment/Reassessment, Policy Number: NSG 03, Revision Date: 3/2024" revealed, in part: "Policy: All patients admitted to the hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the interdisciplinary team to prioritize identified problems within the Interdisciplinary Treatment Plan. Procedure: 3. History and Physical. a. Within the first twenty-four (24) hours of the patient's admission, a practitioner will complete a history and physical examination and shall include a neurological examination. The following shall be included in the History and Physical documentation: xi. Cranial Nerves Examination I-XII-in detail and how tested for each."

Review of Patient #3's medical record revealed an admission date of 08/28/2025. Further review of Patient #3's history and physical and medical record revealed no evidence of complete neurological assessment with examination of Cranial Nerves I-XII.

In an interview on 09/03/2025 at 11:54 AM, Interim CNO confirmed Patient #3's medical record failed to reveal evidence of complete neurological assessment with examination of Cranial Nerves I-XII.