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Based on interview and record review, the hospital failed to ensure one of seven sampled patients (Patient 2) grievance was promptly processed according to the hospital's P&P. This failure created the risk of unresolved safety and quality concerns and substandard patient care for patients.

Findings:

During a review of the hospital's P&P titled, "Grievances and Complaints" dated 1/20/25, the P&P showed:

* Grievance is defined as the written or verbal report of issues that cannot be addressed immediately, may concern an alleged violation of patient rights, hospital compliance with regulatory agencies, or if the patient requests a formal written response to their concern.

* All internal complaints and grievances are to be submitted verbally or in writing to the hospital staff, either by the patient, the patient's representative, or a staff member if a patient is unable to execute a written complaint.

* Follow-up will begin with the Court Liaison Quality Department Coordinator/Designee upon receipt of the complaint. The Court Liaison Quality Department Coordinator/Designee will interview all individuals with knowledge of events surrounding the complaint.

* Based on the results of the investigation, the Court Liaison Quality Department Coordinator/Designee will take immediate steps to resolve or rectify the situation or refer the issue to the appropriate department head for further analysis and appropriate action. The Court Liaison Quality Department Coordinator/Designee will respond, verbally and in writing to the person about the action being taken on his/her complaint within seven days of receipt of the complaint for significant issues. The written response must include hospital name, name of contact person, steps taken to investigate the complaint, results of complaint process, and date of completion.

During a review of the Grievance Log for August 2025, the Grievance Log showed no grievance was filed.

During a review of Patients 2 and Patient 3's closed medical records on 9/29/25 starting at 1100 hours, Patients 2 and 3's medical records showed the following:

* Patient 2's medical record showed Patient 2 was admitted to the hospital on 8/3/25 and discharged on 8/19/25.

* Patient 3's medical record showed Patient 3 was admitted to the hospital on 8/4/25 and discharged on 9/11/25.

- During a review of Patient 3's Progress Note dated 8/9/25 at 1638 hours, the Progress Notes showed Patient 3 was sexually acting out with peers.

- During a review of Patient 3's Psychiatric Progress Note dated 8/9/25 at 1928 hours, the Psychiatric Note showed Patient 3 was sexually acting out by touching another patient's private part and was not on 1:1 observation.

During an interview with RN 1 in the presence of the CNO on 9/29/25 at 1408 hours, RN 1 stated Patient 3 touched Patient 2's private part during group therapy on 8/9/25 and RN 1 reported the incident to the house supervisor.

During an interview with the Director of Quality on 9/30/25 at 0852 hours, the Director of Quality stated Patient 2 reported the incident on 8/12/25. The Director of Quality did not consider it a grievance and verified the grievance process was not followed.

Based on interview and observation, the hospital failed to ensure the master treatment plans (MTP) were updated as per the hospital's P&P for one of seven sampled patients (Patient 3). These failures created the risk of substandard healthcare outcomes to the patients in the hospital.

Findings:

Review of the hospital's P&P titled, "Master Treatment Plan," dated October 2024 showed within 72 hours of admission, members of the treatment team shall further develop the MTP that is based on a comprehensive assessment of the patient's presenting problems, physical health, and emotional and behavioral status. The Team will consist of the provider, nursing staff, social services staff, adjunctive therapy staff, and other clinical disciplines, as appropriate. The master treatment plan review shall be reviewed within seven days of completion, with the exception of significant events which should be updated within 24 hours. The treatment plan review shall include new issues, updates to problems/goals as identified in the master treatment plan form.

During a review of Patient 3's closed medical record on 9/29/25 starting at 1100 hours, the medical record showed Patient 3 was admitted to the hospital on 8/4/25 and discharged on 9/11/25.

Review of the Master Treatment Plan dated 8/5/25, showed "sexual acting out" was identified as initial problem #1.

The Psychiatric Problem Sheet for problem #1 dated 8/5/25, documented interventions for attending psychiatrist, nursing, social services, and activity therapy.

During a review of the Progress Note for Patient 3 dated 8/9/25 at 1638 hours, the Progress Note showed Patient 3 was sexually acting out with peers. After the incident, Patient 3 was directed to their room and educated about appropriate behavior. The NP was notified, and one-to-one supervision was ordered.

During a review of the Psychiatric Progress Note for Patient 3 dated 8/9/25 at 1928 hours, the Psychiatric Progress Note showed Patient 3 was sexually acting out by touching another patient's private part and was now on 1:1 observation.

During an interview with RN 1 in the presence of the CNO on 9/29/25 at 1408 hours, RN 1 stated Patient 3 touched Patient 2's private part during the group therapy on 8/9/25.

During an interview and concurrent medical record review with the CNO on 9/30/25 at 0920 hours, the CNO stated the MTP review was to be done every seven days after the initial MTP or after any event. The CNO further stated there was no updated MTP review after the event and no regular MTP review every seven days. The CNO verified the findings.

Based on interview and record review, the hospital failed to ensure one of seven sampled patients (Patient 2) sexual assault was reported to the CDPH within 24 hours after the detection. This failure had a risk of delaying the investigation of the event and of violating the patient's rights.

Findings:

During a review of the hospital's P&P titled, "Incident Reports: Classification System," revised 3/12/25, the P&P showed the following:

VI. Reporting:

Pursuant to Health and Safety Code sections 1279.1 and 1279.3, adverse events shall be reported by the hospital through a secure internet website maintained by the Department pursuant to the following timelines:

* Adverse events that are ongoing, urgent or emergent, threatening the welfare, health, or safety of patients, personnel, or visitors, shall be reported within 24 hours after the adverse event is detected.

* Sexual assault of a patient, including allegations of sexual assault of a patient, provided for under Health and Safety Code section 1279.1 (b)(6)(C), shall be reported within 24 hours after the detection.

During a review of Patients 2 and Patient 3's closed medical records on 9/29/25 starting at 1100 hours, Patients 2 and 3s medical records showed the following:

* Patient 2's medical record showed Patient 2 was admitted to the hospital on 8/3/25 and discharged on 8/19/25.

* Patient 3's medical record showed Patient 3 was admitted to the hospital on 8/4/25 and discharged on 9/11/25.

- During a review of the Progress Note for Patient 3 dated 8/9/25 at 1638 hours, Patient 3 was documented as sexually acting out with peers.

- During a review of the Psychiatric Progress Note for Patient 3 dated 8/9/25 at 1928 hours, Patient 3 was documented as sexually acting out by touching another patient's private part.

During an interview with RN 1 in the presence of the CNO on 9/29/25 at 1408 hours, RN 1 stated Patient 3 touched Patient 2's private part during the group therapy on 8/9/25. RN 1 further stated after the incident, he reported to the house supervisor.

During an interview with the Director of Quality on 9/30/25 at 0852 hours, the Director of Quality stated Patient 2 reported the incident on 8/12/25, and the incident was reported to the CDPH on the same day. When asked about the reporting system, the Director of Quality stated front line staff reported to the supervisors, the supervisors reported to Quality Department, then the Quality Department reported to the CDPH. The Director of Quality verified the house supervisor did not report the incident.

Based on interview and record review, the hospital failed to ensure one of seven sampled patients (Patient 6) was monitored while in seclusion as per the hospital's P&P. This failure posed a risk to patient safety due to the lack of timely monitoring and clinical evaluation during seclusion.

Findings:

During a review of the hospital's P&P titled Seclusion/Restraint revised 2/25, the P&P showed the RN will assign a trained staff person to monitor the patient face-to-face and document the patient's condition and response at least every fifteen minutes on the restraint/seclusion record. The patient in restraint/seclusion will be monitored continuously after being placed in physical restraints/seclusion by a team of staff members. The RN will continually assess the patient for release from restraints/seclusion. Assess the Patient's need for food and fluids: Offer patient food/fluid at mealtimes, offer supplemental fluids every fifteen minutes...Assess the patient's toileting needs: Offer the patient opportunities to use the toilet facilities at least every fifteen minutes and on patient's request. Observation Record includes: continue to document every fifteen minutes, or as ordered by provider noted; and all nursing care and interventions, i.e. fluids, toileting, skin and circulation checks, ROM, meals and vital signs.

During a review of Patient 6's closed medical record on 9/29/25, Patient 6's medical record showed Patient 6 was admitted to the hospital on 8/16/25 and discharged on 9/3/25.

During the review of the document titled "(Standardized) Seclusion/Restraint," the document showed Patient 6 was ordered to place in seclusion for four hours due to being an imminent danger to others on 9/1/25 at 1205 hours. The document showed Patient 6 was placed in seclusion from 9/1/25 at 1200 hours to 9/1/25 at 1305 hours (1 hour and 5 minutes).

During an interview and on 9/30/25 at 0945 hours with the CNO, a request was made for Patient 6's Seclusion/Restraint Flowsheet from the time Patient 6 was in seclusion on 9/1/25 from 1200 to 1305 hours (1 hour and 5 minutes). The CNO was unable to provide the document and was unable to show Patient 6 was monitored while in seclusion as per the hospital's P&P.

On 9/30/25 at 1025 hours, the CNO was notified and acknowledged the above findings.

Based on interview and record review, the hospital failed to ensure an adequate number of licensed nurses was maintained for Unit A on 9/2/25 PM shift as per the hospital's Staffing Matrix. This failure had the potential for poor patient outcomes.

Findings:

Review of the hospital's P&P titled Staffing Patterns and Patient Acuity revised March 2025 showed all shifts on each unit, are to be staffed using the staffing matrix, in accordance with title IX guidelines.

Review of the hospital's document titled Staffing Matrix revised August 2025 showed PM Staffing Guidelines as follows:

* 1-10 patients = 2 RNs per unit
* 11-15 patients = 3 RNs per unit
* 16-20 patients = 4 RNs per unit
* 21-25 patients = 5 RNs per unit
* 26-28 patients = 6 RNs per unit

During a record review on 9/29/25 at 1100 hours, the Nursing Department Daily Assignment dated 9/2/25 was reviewed. The Nursing Department Daily Assignment showed the census for Unit A at the start of the PM shift was 19. The census of Unit A at the end of the PM shift was 20. The document showed four RNs were on duty on the AM and PM shifts; RN 9 was on duty in Unit A from the start of the AM shift and worked into the PM shift.

Review of Patient 5's Progress Note dated 9/2/25 at 2153 hours, showed RN 9 transferred care of Patient 5 to remaining unit staff on 9/2/25 at 2153 hours.

During an interview on 9/23/25 at 1330 hours, with the CNO, the CNO stated the PM shift for Unit A on 9/2/25 was short and RN 9 had stayed over from dayshift to help pass medications. The CNO stated that the administration was made aware by the house supervisor and came in early at around 0400-0500 on the morning of 9/3/25 to help. The CNO acknowledged Unit A did not have four RNs to be on duty as per the hospital's P&P, from approximately 2153 hours on 9/2/25 to 0400 hours on 9/3/25.

On 9/30/25 at 1025 hours, the CNO was notified and acknowledged the above findings.