DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
524043 A. BUILDING __________
B. WING ______________ 		05/25/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
GRANITE HILLS HOSPITAL 1706 S 68TH ST, MILWAUKEE, WI, 53214
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A0115 Patient Rights
482.13
Corrected On: 07/25/2023
37419 Based on record review and interview, the facility failed to identify and communicate assaultive or aggressive behaviors in 3 of 10 patients admitted involuntarily with a history of aggressive behavior (Patient #4, #8 & #9), failed to properly train 3 of 8 direct patient care staff, (Mental Health Technicians A, O, & P), failed to report assaultive behavior to appropriate authorities in 2 of 2 assault cases (Patient #1 and Patient #3), senior management failed to ensure a safe environment for patients and staff by failing to appropriately investigate and analyze workplace hazards in 2 of 3 incidents reviewed (Patient #1 & #3), and failed to ensure communication of unacceptable performance in 1 of 4 Medical Health Technician personnel records reviewed (MHT A). Findings include: The facility failed to identify and communicate assaultive or aggressive behaviors in 3 of 10 patients admitted involuntarily with a history of aggressive behavior (Patient #4, #8 and #9). SEE TAG A-0144 Failed to ensure patients were free from abuse by failing to properly train 3 of 8 direct patient care staff, (Mental Health Technician (MHT) A, MHT O, and MHT P); failing to ensure a rapid response was immediately initiated per policy in 1 of 2 (Patient #1) assault incidents; failing to thoroughly investigate abuse incidents per policy in 2 of 2 incidents (patient #1 and patient #3) and failing to report assault incidents per policy to appropriate authorities in 1 of 2 assault cases (Patient #3). SEE TAG A-0145 Senior management failed to ensure a safe environment for patients and staff by failing to appropriately investigate and analyze abuse incidents in 2 of 3 incidents reviewed (Patient #1 & #3). SEE TAG A-286 The facility failed to ensure communication of unacceptable performance in 1 of 4 Medical Health Technician personnel records reviewed (MHT A). SEE TAG A-0386 The cumulative effect of these systemic problems reduces the ability to ensure a safe environment for patients and staff and affects all patients and staff in the facility.
A0144 Patient Rights: Care In Safe Setting
482.13(c)(2)
Corrected On: 07/25/2023
37419 Based on record review and interview, the facility failed to follow their policies and procedures to identify and communicate assaultive or aggressive behaviors in 3 of 10 patients admitted involuntarily with a history of aggressive behavior (Patient #4, #8 & #9) in a total of 10 medical records reviewed. Findings include: Record review of "Workplace Violence Prevention Program" #11023437, effective date 1/12/2022, under Hazard Identification and Control, c. Work Practice Controls, Patient Assessment and Intake 3. revealed "Admittance of non-voluntary or unwilling patients is communicated in advance... those with a history of aggression and assaultive precautions are assigned as possible aggressive." Under Hazard Identification and Control revealed "all unit staff is equipped with communication radios" to alert staff to patients that may be out of control, "aggressive/assaultive or summon code assistance." Responsibilities Program Authority revealed "The authority for implementation and enforcement of this Workplace Violence Prevention Program is vested with the senior management team of this facility." Record review of "Admission Process for the Voluntary and Involuntary Patient" #11023110, effective date 1/13/2022 under Arrival and Admission of Involuntary Patients "Upon reviewing and accepting a transfer of the Involuntary Patient, The Intake Department Staff notifies the Charge Nurse on the receiving unit, and the Nurse Manager/supervisor...reports that the patient is on a court commitment. Unit notification and name of RN (registered nurse) spoken to is documented on the intake communication form." Review of Patient #4's closed medical record revealed Patient #4 was a 22-year-old admitted involuntarily from an acute care hospital emergency department with a diagnosis of schizoaffective disorder, bipolar type, ADHD (Attention deficit hyperactivity disorder), and unspecified anxiety on 3/31/2023 at 3:20 PM. Psychiatric Sbar (Situation-Background-Assessment-Recommendation) Intake to Unit Patient Report Worksheet dated 3/31/2023 at 12:30 PM with row titled "Intake to Unit Communication" not completed. Bright green colored High Risk Visual Notification sheet under high risk areas, with "X" in box in front of "Assault." Handoff Communication box "Unit handoff received by" with no signature. Psychiatric Evaluation 4/01/2023 at 7:30 AM under brief admission history revealed "aggressive towards staff and patients. Patient was running in milieu (hallway) hitting other patients in the head." There was no documentation that the Intake Department staff notified the Unit, on admission, that Patient #4 was admitted involuntarily with assaultive behavior. Review of Patient #8's closed medical record revealed Patient #8 was a 38-year-old admitted involuntarily from an acute care facility on 4/26/2023 for a suicide attempt and was discharged 5/04/2023. Psychiatric Sbar - Intake to Unit Patient Report Worksheet dated 4/26/2023 at 9:13 AM under box titled Assessment, revealed "Chief Complaint... attempted homicide." Row titled "Intake to Unit Communication" with no signatures. There was no documentation that the Intake Department staff notified the Unit, on admission,that Patient #8 was admitted involuntarily with a history of an attempted homicide. Patient #9's open medical record revealed Patient #9 is a 17-year-old inpatient with suicidal ideation admitted involuntarily on 5/04/2023 with a diagnosis of schizophrenia, bipolar disorder and depression. Psychiatric Sbar - Intake to Unit Patient Report Worksheet dated 5/04/2023 at 10:36 AM under Box labeled Situation, Other, revealed "history of serious agg. (aggression) towards others" written in. Row titled "Intake to Unit Communication" with no signatures. There was no documentation that the Intake Department staff notified the Unit, on admission, that Patient #9 was admitted involuntarily with a history of serious aggression towards others. On 5/09/2023 at 9:40 AM during interview with Nurse Manager E, Manager E stated notification of involuntary patients with special nursing care needs between the intake department and unit is confirmed with signatures from the intake specialist and the unit's registered nurse on "the Sbar tool" during admission . Manager E confirmed Patients #4, #8 and #9's Sbar tool did not include the Unit's RN signatures.
A0145 Patient Rights: Free From Abuse/Harassment
482.13(c)(3)
Corrected On: 07/25/2023
37419 Based on record review and interview the facility failed to ensure patients were free from abuse by failing to properly train 3 of 8 direct patient care staff, (Mental Health Technician (MHT) A, MHT O, and MHT P); failing to ensure a rapid response was immediately initiated per policy in 1 of 2 (Patient #1) assault incidents; failing to thoroughly investigate abuse incidents per policy in 2 of 2 incidents (patient #1 and patient #3) and failing to report assault incidents per policy to appropriate authorities in 1 of 2 assault cases (Patient #3). Findings include: Record review of policy "Caregiver Misconduct Management" #11023501, effective date 1/13/2022 under Procedure was provided by CNO B and under Training revealed "all new hires ... and staff having direct patient care access will be required to complete additional Caregiver Misconduct training as part of their new employee onboarding education. Administrative management staff will be expected to have a general understanding of this Caregiver Misconduct Management policy and will review the policy annually, or on an as needed bases, as a result of incidents occurring... All staff will complete the Therapeutic Boundaries training within HealthStream and complete all post-test and attestation documents upon hire and annually." Under Initial Assessment/Notification v. revealed "All staff... witnessing or having knowledge of injury will report it immediately. Under d. v. revealed "For children/adolescents, the supervisor or professional clinical staff must notify the Department of Children & Families, Division of Milwaukee Child Protective Services immediately at 414-220-SAFE. The Supervisor will assure... staff completes required documentation of the incident in the medical record... before the end of the employee's shift." Under Formal investigation Process revealed "The hospital Risk Manager/Compliance Officer or designee has oversight of the investigation. The Manager/House Supervisor on Duty will immediately initiate the investigation by... interviewing and obtaining statements... from All staff/patients who may have been present at the time of the incident and all staff/patients who may have information regarding the incident. Statements will include: date and time, specific location, where the witness was ... who was involved or in the area, and a description of the alleged incident... This must be done prior to staff leaving for the day." For children under 18 "the investigation of abuse shall be coordinated with the Division of Milwaukee Child Protective Services." Under Reporting Requirements revealed "Reports of alleged caregiver misconduct shall be reported to DQA (Division of Quality Assurance) within seven (7) calendar days of the incident." Record review of policy "Rapid Response" #11023330, effective date 1/13/2023 under Purpose "to bring critical care expertise to the patient's bedside." Record review of policy "Workplace Violence Prevention Program" #11023437, effective date 1/13/2022 under Milieu (environment) considerations revealed "all unit staff is equipped with communication radios that includes altering (sic) staff to patients that may be out of control, aggressive/assaultive or summon code assistance." TRAINING Record review of policy "CPI (crisis prevention institute) Staff Training" #11023228 effective 1/13/2022 under Procedures revealed "newly hired patient care staff will be required to attend the CPI training... must be competently assessed and deemed competent by a certified CPI Trainer before working in one of the identified patient care areas... Ongoing training will be provided on a hospital wide annual basis." Record review of Mental Health Technician (MHT) A's personnel file revealed MHT A was hired 1/03/2023 and terminated 5/03/2023. There was no evidence that Therapeutic Boundary training or caregiver misconduct training was completed during onboarding. Record review of MHT O's personnel file revealed MHT O started 3/01/2022, her CPI training expired 3/31/2023, and renewal of her CPI certificate was dated 5/09/2023 (39 days after expiration). Record review of MHT P's personnel file revealed MHT P started 2/23/2023, her CPI training was completed on 5/08/2023 (76 days after her hire date). On 5/10/2023 at 10:25 AM during interview with Human Resource Director L, Director L confirmed "I can't find any" proof of completion of onboarding education for MHT A. Director L confirmed "that's what he (CPI instructor) gave me" when questioned about the dates on MHT P and O's CPI training. Patient #1 Patient #1's medical record review revealed Patient #1 was admitted from another healthcare system, involuntarily on 4/10/2023 at 6:02 AM for threatening to kill his father and case worker with a diagnosis of unspecified mood disorder with psychotic features. In an online self-reported incident submitted by Chief Nursing Officer (CNO) B on 05/01/2023, CNO B reported, "Patient #1 was sitting in a chair by the phones. Mental Health Technician (MHT A) was in the hallway interacting with the patients. Interactions between this patient and staff were not going well and continued to escalate. The patient asked (MHT A) if she was threatening him. Witnesses state (MHT A) told the patient yes and he slapped her. At this point (MHT A) struck Pt #1 a few times and Patient #1 was pushed back against the bathroom door. They were separated by other staff, but (MHT A) was able to get away from them and went back at Pt. #1 striking him again." At this point the other staff members moved (MHT A) to the Treatment planning room where (MHT A) continued to yell at patient #1 thru the window and he slammed his fists against the door ...As (MHT A) was being escorted out of the unit (MHT A) went back into the seclusion area to yell at Patient #1 thru the glass again ..." On 5/09/2023 at 1:23 PM during telephone interview with Agency Registered Nurse (RN) I, RN I stated as she witnessed the event, it was noted no one had a phone or radio and did not immediately have the ability to call a rapid response stating, "that can't happen" and "we need to be more aware." A Phone or Radio was not immediately available to call for a rapid response as per facility policies. During review of Patient #1's medical record with Manager E on 5/09/2023 at 12:47 PM, it was noted Patient #1 was put into seclusion 4/26/2023 at 7:43 PM and taken out at 8:30 PM. Seclusion/Restraint Order under Reason for Intervention with boxes checked in front of imminent danger to self and to others with "Pt (patient) punched staff 2+ times already ... not following cues/directions pt ramping up" hand-written in. The Post Intervention Face to Face Evaluation page 2 was blank. The Termination/Post Intervention Nursing Summary and Notifications page under Notifications was blank. There were no physician or registered nursing signatures. The Seclusion/Restraint Patient Debriefing was not complete, there was no time, date, or registered nurse signature. Manager E confirmed these portions should be completed post seclusion. Psychiatric progress note dated 4/27/2023 at 10:47 AM revealed "Patient claims the reason he hit female staff multiple times last night was "because she threatened me." Informed patient that if she verbally threatened him that physically assaulting her would not be the responsible choice...Patient continues to show no remorse." Discharge summary revealed Patient #1 "continued to have episodes of anger outbursts, aggression, and not taking responsibility for his actions." On 4/27/2023, Patient #1 was court ordered to be transferred to maximum security mental health facility and was transferred 4/28/2023 at 2:25 PM. On 5/09/2023 at 12:25 PM during interview with CNO B while reviewing follow-up surrounding the self-reported incident report regarding Patient #1, "notes" were provided. CNO B provided a copy of an e-mail dated 5/08/2023 at 3:39 PM from MHT M to CNO E with her write-up of the incident (13 days after the incident occurred). CNO B stated MHT A "was terminated." CNO B stated she was not aware staff did not have access to their radios and confirmed interviews and witness statements from all staff/patients who may have information regarding the incident, was not documented as required by facility policy. Patient #3 Review of policy "Sexual Aggression and Victimization Prevention and Precautions" under Definitions, Sexual Allegations, Sexual Intercourse revealed "fondling of the patient's sex organ(s) by another individual's hand." Under Response revealed Discovery of a Sexual Allegation can occur either as witnessed by staff, and/or as reported to staff by a third party witness." Upon report of discovery of an allegation... facility leadership... initiate investigation including interviews of the patients involved... any witness(es), and staff directly responsible for the observation rounds at the time of the event." Under Risk Manager/designee revealed "Notify the police in all sexual assault, intercourse cases that involve a minor... Notify State Agencies and call in a Childline/Adult Protective Services Report... Sexual Allegations are investigated for reasons including... protection of patient rights, to find causes, and to prevent similar occurrences." Patient #3's medical record review revealed Patient #3 was a 16-year-old involuntarily admitted 4/10/2023 for self-harm by cutting herself and suicidal ideation with a past psychiatric history of major depressive disorder. Nursing note 4/13/2023 at 7:47 PM revealed "a peer reported having sexual contact with patient." Psychiatric evaluation dated 4/11/2023 at 12:45 PM under Justification for Hospitalization revealed box checked in front of "Dangerous to self, others or property with need for controlled environment." Under History revealed "reports being sexually abused by her father... Has multiple felonies pending for hitting others." Nursing progress note dated 4/12/2023 at 7:47 PM revealed "Pt admitted that her peer did digitally penetrate her vagina... Patient also admitted that she "snuck" into her peers room in order to "make out" after the digital penetration...Supervisor and risk management updated. MD on call [Interim Medical Director S] updated." Record review of incident report log with detailed review of safety reports for 3 patients was completed. Safety report received 4/13/2023 was reviewed and revealed "Patient's peer reported to AT (activities therapist) that she digitally penetrated patient's vagina and that they made out in the peer's room. Patient did verify that this took place... Per patient and peer incident took place approximately 4/11/2023." On 5/09/2023 at 11:30 AM during interview with Interim CEO C, when questioned about the investigation and follow-up of incident regarding Patient #3, CEO C stated they separated Patient #3 and the peer immediately, and would have communicated to the staff, the need to keep Patient #3 in eye site at all times and keep Patient #3 separated from the peer. CEO C stated it would be passed on at all handoffs and shared in the daily huddles. CEO C stated since his arrival, he has initiated a daily huddle at 8 AM with administration and nursing leaders to improve their communication. When asked for documentation of the investigation, CEO C stated he was having difficulty getting into information collected by the previous risk manager (he had taken a new position outside this facility). On 5/09/2023 at 3:04 PM AM during interview with Interim CEO C, when asked for the follow-up investigation of the incident reports, CEO C stated there is no documentation of the investigations. CEO C stated he confirmed with UHS Risk Management R "that's all we have" and "to my knowledge" Child Protective Services (CPS) was not notified. REPORTING Review of policy "Incident Report-IR/Incident Reporting Process" #11023704, effective date 1/20/2022 under Purpose revealed "A. Support timely and accurate reporting of serious injuries, unexpected outcomes, suspected violations of law or Federal/State regulations or other mandatory reporting situations." Under Procedure revealed "The facility Risk Manager assumes overall responsibility for the IR/Incident Reporting process." Record review of incident report #23-85205 regarding Patient #3, date of incident 4/13/2023 at 8:51 PM, date received 4/13/2023 (not timed), under Comments revealed "patient's peer reported she digitally penetrated patients' vagina and that they made out in the peer's room. Patient did verify that this took place... Patient and peer immediately separated after report of incident. Per patient and peer incident took place approximately 4/11/2023." Under J. Notification of Physician revealed [physician S]. Under L "Notification Name Time:" revealed Interim Medical Director S, prior Risk Management Director T, and House Supervisor U. Notification of state authorities was not documented. On 5/09/2023 at 3:04 PM during interview with Interim CEO C, when asked for the follow-up investigation on incidents #23-85205, CEO C stated there is no documentation of the investigations. CEO C stated "that's all we have" and confirmed "to my knowledge" Child Protective Services (CPS) was not notified of incident #23-85205."
A0286 Patient Safety
482.21(a), (c)(2), (e)(3)
Corrected On: 07/25/2023
37419 Based on record review and interview senior management failed to ensure a safe environment for patients and staff by failing to appropriately investigate and analyze workplace hazards in 2 of 3 incidents reviewed in a total of 3 incident reports reviewed (Patient #1 and #3). Findings include: Record review of policy "Caregiver Misconduct Management" #11023501, effective date 1/13/2022 Under Formal investigation Process revealed "The hospital Risk Manager/Compliance Officer or designee has oversight of the investigation. The Manager/House Supervisor on Duty will immediately initiate the investigation by... interviewing and obtaining statements... from All staff/patients who may have been present at the time of the incident and all staff/patients who may have information regarding the incident. Statements will include: date and time, specific location, where the witness was... who was involved or in the area, and a description of the alleged incident... This must be done prior to staff leaving for the day." Record review of "Incident Report-IR/Incident Reporting Process" #11023704, effective date 1/20/2022 under Purpose revealed "for trending analysis of reporting incidents to improve patient safety." Under procedure revealed "Conduct follow up and investigation to ensure that appropriate actions are taken to prevent further incident/injury and or re-occurrence." Patient #1's closed medical record revealed Patient #1 was a 16-year-old admitted from another healthcare system, involuntarily on 4/10/2023 at 6:02 AM for threatening to kill his father and case worker with a diagnosis of unspecified mood disorder with psychotic features. Progress note 4/26/2022 at 7:40 PM revealed patient (pt) "punched staff [Mental Health Technician A] 2+ times already, full force in the face - pt not following cues/directions. pt ramping up." Discharge summary revealed Patient #1 "continued to have episodes of anger outbursts, aggression, and not taking responsibility for his actions." On 4/27/2023, Patient #1 was court ordered to be transferred to maximum security mental health facility and was transferred 4/28/2023 at 2:25 PM. Record review of incident 23-97523 dated 4/26/2023 at 7:35 PM, received 4/26/203 (not timed) regarding Patient #1, under Comments revealed Administrator on Call was notified approximately 7:54 PM and "was debriefed about the incident that had occurred." There was no further documentation of the investigations, analysis, or follow-up of the incident On 5/09/2023 at 1:23 PM during telephone interview with Agency Registered Nurse (RN) I, RN I stated she witnessed the caregiver misconduct event between Patient #1 and Mental Health Technician (MHT) A. RN I stated no one had a phone or radio on them when the incident happened and they did not have the ability to call a rapid response, had to yell for help, and stated, "that can't happen." Patient #3's medical record revealed Patient #3 was a 16-year-old admitted involuntarily on 4/10/2023 for self harm with a diagnosis of major depressive disorder and a history of "multiple felonies pending for hitting others". Nursing progress note dated 4/12/2023 at 7:47 PM revealed "Pt admitted that her peer did digitally penetrate her vagina... Patient also admitted that she "snuck" into her peers room in order to "make out" after the digital penetration...Supervisor and risk management updated. MD (physician) on call [Interim Medical Director S] updated." Record review of incident 23-85205 dated 4/13/2023 at 8:51 PM, received 4/13/2023 (not timed) regarding Patient #3, under Comments revealed "Patient and peer immediately seperated (sig) after report of incident...Per patient and peer incident took place approximately 4/11/2023." There was no further documentation of the investigations, analysis, or follow-up of the incident. On 5/09/2023 at 12:25 PM during interview with Chief Nursing Officer (CNO) B, when asked what the expectation was for an investigation of caregiver misconduct, CNO B stated "I took notes" and asked staff to "get me" a write-up of what happened. When asked for the investigation of Incidents 23-85205, 23-97523 and policies on caregiver misconduct and investigation of a patient assault, CNO B stated "I will look again." On 5/10/2023 at 7:45 AM during interview with Interim Chief Executive Officer C, CEO C confirmed there was no further documentation of the investigations, analysis, or follow-up of the incidents that took place with Patient #1 and Patient #3.
A0395 Rn Supervision Of Nursing Care
482.23(b)(3)
Corrected On: 07/25/2023
37419 Based on record review and interview, the facility failed to follow policy and procedures to ensure communication of unacceptable performance in 1 of 4 Medical Health Technician personnel records reviewed (MHT A) in a total of 8 front line staff personnel records reviewed. Findings include: Record review of policy "Corrective Action Process" #11023200 effective date 1/13/2022 under Corrective Action Process 2 "revealed "Whenever a corrective action is required, the supervisor should record such infraction and document the action in writing as soon as practical using the Employee Corrective Action Report... a. Preventative Counseling... should be counseled initially and a summary of the preventative counseling should be written on the Report and placed in the employee's HR file." Record review of "Employee Corrective Action Report" with MHT A name, Final written warning, termination, and counseling event boxes checked and "Coaching related to arguing at the desk" typed in, not dated. MHT A and Chief Nursing Officer (CNO) B signatures were on the bottom with the date of 5/03/2023 written in. The line above Director, Human Resources Signature and Date were blank. . Record review of Mental Health Technician (MHT) A's personnel file revealed MHT A was hired 1/03/2023 and terminated 5/03/2023. There was no additional information regarding a previous counseling event in MHT A's HR file. On 5/09/2023 at 12:25 PM during interview with CNO B, CNO B stated she had only been there a few months, she was not involved in counseling with MHT A, and "was not sure" of any previous coaching referred to on the Employee Corrective Action Report. On 5/09/2023 at 12:47 PM during interview with Nurse Manager E, Manager E stated she was not involved with MHT A's termination and shook her head when asked what the counseling referred to in the Employee Corrective Action Report. On 5/10/2023 at 10:25 AM during interview with Human Resource (HR) Director L, HR L stated she had only been there "about 2 months" and was not aware of other counseling with MHT A. Director L confirmed it was not in MHT A's personnel file like "it should be."
A0450 Medical Record Services
482.24(c)(1)
Corrected On: 07/25/2023
37419 Based on record review and interview, the nursing staff failed to sign, date, time and complete the nursing evaluation in 5 of 10 inpatient admissions (Patient #3, #4, #5, #7 and #10) in a total of 10 medical records reviewed. Findings include: Record review of policy "Initial Nursing Admission Assessment" #11023315, effective 1/13/2022 revealed "each patient will be assessed by a registered nurse within eight (8) hours of admission." Review of Patient #3's closed medical record revealed Patient #3 was a 16-year-old admitted involuntarily with attempted suicide on 4/10/2023 with the diagnosis of major depressive disorder, recurrent, severe, and was discharged 4/17/2023. Patient #3's nursing assessment was not signed, dated or timed. Review of Patient #4 's closed medical record revealed Patient #4 was a 22-year-old admitted involuntarily with schizoaffective disorder, bipolar type, ADHD, and unspecified anxiety on 3/31/2023 and discharged 4/27/2023. Patient #4's nursing assessment was blank, there was no signature, time or date. Review of Patient #5's closed medical record revealed Patient #5 was a 35-year-old admitted involuntarily with hallucinations 3/03/2023 and a diagnosis of bipolar manic disorder. Pages 13 and 14 of the nursing assessment were blank and there was no signature, time or date. Review of Patient #7's closed medical record revealed Patient #7 was a 57-year-old admitted voluntarily on 4/27/2023 feeling suicidal with the diagnosis of bipolar affective disorder. Nursing assessment was signed with their credential, not dated or timed. Patient #10's open medical record was reviewed and revealed Patient #10 was a 58- year-old who was involuntarily admitted for a suicide attempt on 4/28/23 with a diagnosis of severe chronic schizophrenia. The nursing assessment was signed, dated 4/28/2023, but not timed. On 5/09/2023 at 9:40 AM during interview with Nurse Manager E, Manager E when asked if it is the expectation that the nursing assessments are signed with their credential, dated, and timed, Manager E stated "yes, when it is complete" that is the expectation.