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Based on document review and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to ensure that staff conducting patient rounds were aware of each patient's safety precautions (A-144 A)

3. The hospital failed to ensure that safety precautions were put in place to protect other patients after an allegation of sexual abuse was made. (A-144 B)

4. The hospital failed to ensure that allegations of abuse were reported and escalated up to leadership in order for a thorough investigation to be completed. (A-145)

A. Based on observation, document review, and interview, it was determined that for 1 of 1 staff (Patient Care Technician/PCT E#17) and 4 of 26 patients (Pts. #12, #13, #14,#15) observed on the Adult Behavioral Health Unit (ABHU), the hospital failed to ensure that staff conducting patient rounds were aware of each patient's safety precautions.

Findings include:

1. During a tour of the ABHU on 03/03/2025, at approximately 10:40 AM, a PCT (E#17) was observed conducting patient observational rounds for the patients on census (26 total). The rounding sheet did not include the precautions for each patient.

2. The clinical records for Pts. #12, #13, #14, #15 were reviewed during the tour and indicated the following:

- Pt. #12 had active orders placed on 02/20/2025 for boundary violation precautions.
- Pt. #13 had active orders placed on 02/26/2025 for close watch precautions for elopement (asking for boots to leave).
- Pt. #14 had active orders placed on 02/19/2025 for boundary violation precautions due attempting to enter other patient's room.
- Pt. #15 had active orders placed on 03/03/2025 at 12:32 AM for close watch precautions due to walking to the double doors (main unit exit/entrance doors). Pt. #15 also had active orders for boundary violation precautions placed on 03/03/2025 at 8:05 AM due to trying to go into other patient's rooms.

3. The hospital's policy titled, "Psychiatric Precautions and Observation Levels - Psychiatric Inpatient Program" (revised 11/2023), was reviewed and required, "...The safety of patients is a priority during hospitalization. The inpatient psychiatric unit ensures patient safety through a level of monitoring and observation based on patient's need and assessed risk... The levels are designed to provided increasing intensity of monitoring and precautions..."

4. An interview was conducted with the PCT (E#17) on 03/03/2025, at approximately 10:45 AM. E#17 stated that patients can be on elopement, fall, and allergy precautions. E#17 was not aware that Pts. #12-#15 were on additional precautions such as close watch and boundary violations.

5. An interview was conducted with Psychiatrist (MD#5) on 03/05/2025, at approximately 11:30 AM. MD#5 stated that patients on placed on certain safety precautions depending on risk level and concerns. MD#5 stated that the staff working with the patients on the unit are expected to know what precautions each patient is on so that they can observe for certain risk behaviors for example wandering around exit doors (elopement risk).


B. Based on document review and interview, it was determined that for 2 of 2 patient (Pts. #3 and #6) records reviewed for patient-to-patient abuse allegations, the hospital failed to ensure that safety precautions were put in place to protect other patients after an allegation of sexual abuse was made.

Findings include:

1. The hospital's policy titled, "Psychiatric Precautions and Observation Levels - Psychiatric Inpatient Program" (revised 11/2023), was reviewed and required, "...Risk for Boundary Violations (BV) is indicative for patients demonstrating sexual provocativeness, making inappropriate sexual comments, intimidating sexual like behavior to others, touching peers, invading personal space of peers, and limited impulse control..."

2. The hospital's policy titled, "Reporting, Reviewing, and Responding to Allegations of Abuse" (revised 02/2024), was reviewed and required, "...If the person alleged to have caused the abuse is an [Hospital] patient, the Unit/Department Leader will promptly notify the attending physician of the patient alleged to have caused the abuse. The Unit/Department Leader, hospital or medical group administrator or service line leader, and the attending physician may transfer the alleged abuser, if an inpatient, to another unit or other appropriate location, and may adjust the patient's plan of care/services to include additional monitoring..."

3. The clinical record of Pt. #3 was reviewed on 03/05/2025. Pt. #3 was admitted on 12/10/2024 with a diagnosis of schizoaffective disorder. A Nursing Progress note, dated 12/17/2024 at 8:40 PM, included "...[Pt.#3] started yelling in the hallway, 'Get this guy out of my f*cking room! [Pt.#6] masturbating in front of me!' When Pt.#3 was asked to calm down, Pt.#3 became more agitated and restless. Argumentative. Very paranoid. 'I need to call my lawyer. It's a violation of my rights.'... [Pt.#3] was hard to redirect at this time, continued to be verbally aggressive and disruptive in the dayroom, and became combative when redirected. PRN [as needed] medication was given..." An Advanced Nurse Practitioner/APN (E#21) note, dated 12/18/2024 at 3:08 PM included, "... [Pt.#3] states that [Pt.#3] was 'sexually assaulted' by [Pt.#3] roommate [identified as Pt. #6] last night and describes this as the masturbating in the room and 'threatening to exposed penis to [Pt. #3]'..." The record indicated that Pts. #3 and #6 were moved to different rooms following the event; however, no additional precautions (i.e. boundary violations) were put in place for Pt. #3.

4. Security Reports regarding Pt. #3's incident on 12/17/2024 indicated that security was called to assist with holding Pt. #3 for the PRN [as needed] medication administration. The report indicated that during the hold, Pt. #3 grabbed the genitals of one of the security officers.

5. The clinical record of Pt. #6 was reviewed on 03/05/2025. Pt. #6 was admitted on 12/16/2024 with a diagnosis of schizophrenia. The record did not include any documentation of the incident with Pt. #3 on 12/17/2024 and lacked any documentation/implementation of precautions (i.e. boundary violations) after the allegation was made on 12/17/2024, and prior to the completion of the investigation into Pt. #3's abuse allegation on 12/20/2024.

6. An interview was conducted with the Advance Nurse Practitioner (APN/E#21) on 03/05/2025, at approximately 10:00 AM. E#21 stated that they have different types of precautions they could place for sexual behaviors/risk including sexually acting out/boundary violations for the aggressor and sexual victimization for the patient at risk for abuse. Pt. #3 did not have a history of sexual abuse or trauma and they determined Pt. #3 did not need to be on any sexual victimization precautions since there was no physical contact reported between Pt. #3 and Pt. #6. E#21 stated that if the roommate was the accused perpetrator, they would have placed the roommate on sexually acting out precautions; however, E#21 stated that the roommate was not under their medical groups service.

Based on document review and interview, it was determined that for 1 of 3 (Pt. #3) abuse allegations reviewed, the hospital failed to follow their policy to promptly report and escalate an allegation of abuse, in order to prevent a delay in investigation and initiation of measures to protect patient(s) from abuse.

Findings include:

1. The hospital's policy titled, "Reporting, Reviewing, and Responding to Allegations of Abuse" (revised 02/2024), was reviewed and required, "...A. An [Hospital] employee, agent, volunteer, contracted staff or Medical Staff Member who observes or receives an allegation of misconduct, verbal abuse, physical abuse, sexual abuse, or otherwise has reasonable cause to believe that a patient has been abused, must promptly inform their Unit/Department Leader. B. The Unit/Department Leader will promptly notify: ... 2. Clinical Risk Management... C. If the allegation is against an employee (including, but not limited to, employed medical providers), the Clinical Risk Manager will also notify Human Resources... When there is reasonable cause to believe that a patient has been subjected to abuse by an [Hospital] Care Team Member, the Unit/Department Leader, hospital or medical group administrator, and service line leaders have the authority to make decisions concerning the role of the staff member alleged to have abused the patient. Decisions may include administrative leave/suspension pending investigation, removal from further patient contact during investigation, assignment of a chaperone, or other appropriate measures as needed to secure patient and team member safety..."

2. The clinical record of Pt. #3 was reviewed on 03/05/2025. Pt. #3 was admitted on 12/10/2024, with a diagnosis of schizoaffective disorder. The record indicated that on 12/17/2024 at 8:40 PM, Pt. #3 became combative and required security intervention to assist in holding Pt. #3 in order for nursing staff to administer PRN (as needed) medication for agitation. A psychiatry progress note, dated 12/19/2024 at 10:46 AM included, "...[Pt. #3] Charges that staff put a knee on [Pt. #3'] spine unnecessarily (likely an allusion to PRN medication given 2 days ago for agitation)..."

3. An incident report for Pt. #3's abuse allegation was filed on 12/19/2024 at 7:38 PM (nearly 9 hours after the allegation was initially received). The report included a security report attachment that indicated two security officers (E#19 and E#20) were involved in the incident on 12/17/2024. Emails provided by the Clinical Risk Manager (E#31) on 03/05/2025 indicated that the investigation and interviews began on 12/20/2024 at approximately 9:00 AM. The documents provided included interviews with the staff present during the incident on 12/17/2024, including nursing staff and Security Officers (E#19 and E#20). The emails indicated that a leadership meeting was held on 12/20/2024 at 4:00 PM to discuss the results of the investigation. The allegation was unsubstantiated.

4. Security Staff Schedules from 12/17/2024 to 12/23/2024 were reviewed and indicated that both Security Officers (E#19 and E#20) were scheduled to work an eight hour shift from 12/19/2024 at 4:00 PM to 12/20/2024 at 12:00 AM, after the allegation was received and prior to completion of the investigation. Timesheets for both E#19 and E#20 were reviewed and confirmed that both E#19 and E#20 worked their shifts on 12/19/2024 as scheduled.

5. An interview was conducted with the Clinical Risk Manager (E#31) on 03/05/2025 at approximately 2:00 PM. E#31 stated that the incident/abuse allegation for Pt. #3 was not filed until after hours (evening) on 12/19/2024. E#31 stated that E#31 was on PTO (paid time off at the time) that day; however, there was another clinical risk management team member on-call while E#31 was off. E#31 stated that they (Clinical Risk Management) were not notified of the allegation until E#31 came in the next morning (12/20/2024) and E#31 logged into the incident reporting system and saw the report. E#31 stated that the expectation when an allegation of abuse comes in after hours, is to call the Clinical Risk Manager on-call so that an investigation can be initiated right away and steps can be taken to protect the patient(s). E#31 stated that if the alleged staff is working at the time of the allegation, they will involve HR (human resources) and have the staff removed from patient care. E#31 stated that if the staff is not working at the time, they try to complete as much of the investigation prior to their next shift to determine whether or not they need to be put on administrative leave. E#31 stated that they try to complete the investigation within the first day. E#31 stated that the interviews were conducted by HR (human resources) and legal on 12/20/2024 after E#31 sent out a request for interviews that morning. E#31 stated that all interviews and video review were completed by 4:00 PM on 12/20/2024 and they could not substantiate the allegation, as staff interviews did not indicate anyone was pressing their knee on Pt. #3's back/spine. E#31 stated that the Security Supervisor reviewed the video, but it only showed when Pt. #3 came out into the hallway initially and was then escorted back into the room by security. E#31 stated that the medication administration and holding of the patient occurred inside the patient's room where there are no cameras.

Based on document review and interview, it was determined that the hospital failed to follow to ensure that a physical hold used to restrict a patient's movement against their will was considered as restraints for 1 of 3 restraint records (Pt. #3). This has the potential to affect any patients forcibly placed in a physical hold.

Finding includes:

1. The hospital's policy titled, "Restraint Usage" (revised 11/2023), was reviewed and required, "...Physical Hold - Holding a patient in a manner that restricts the patient's movement against the patient's will is considered restraint... Violent or Self-destructive Behavior Restraint Usage Description: Restraints for management of violent or self-destructive behavior can only be used in emergency situations... If restraint is initiated by the RN [registered nurse] due to an immediate patient need, the RN notifies the physician/LP [licensed practitioner] immediately (within a few minutes) of the initiation of restraint and a verbal or written order is obtained. A physician or LP performs one-hour face-to-face evaluation of the patient within one hour after the initiation of restraint..."

2. A Security Incident Report filed by Security Officer (E#20) on 12/17/2024, included, "On December 17th 2024 at 8:25 PM a call was dispatched to [Behavioral Health Unit] for [Pt. #3]... to redirect [Pt. #3] back to room for safety reasons... After a final warning to cooperate, additional anger was show by [Pt. #3] and the decision was made to reposition [Pt. #3] to a safer angle where [Pt. #3] was no longer a face to face threat to myself or Nursing staff in vicinity. While escorting [Pt. #3] down the hallway [Pt. #3] began to flail [Pt. #3's] arms aggressively while attempting to escape from the safety maneuver that was applied to prevent [Pt. #3] from striking anyone. When we arrived inside [Pt. #3's] assigned room, [Pt. #3] was placed on bed in a position where it would be safe to administer a PRN [as needed medication] by Nursing staff but [Pt. #3] began to attempt to bite us, spit on us and used [Pt. #3's] left hand to successfully grab my genitals and gripped for a short time until I was able to break him free and hold his arm away from my body. I finally noticed [other Security Officer E#19] was behind me holding [Pt. #3's] legs for additional support which caused [Pt. #3] to finally stop tensing up and potentially harming staff further. [Pt. #3] was released from [Pt. #3] holds and agreed to not attempt anymore violence towards staff."

3. The clinical record of Pt. #3 was reviewed on 03/04/2025. Pt. #3 was admitted on 12/10/2024 to the Behavioral Health Unit with a diagnosis of schizoaffective disorder, bipolar type. The record indicated that on 12/17/2024 at 8:40 PM, Pt. #3 became combative and required an emergency administration of medication for agitation. The record lacked documentation of a restraint order for the physical hold.

4. An interview was conducted with Security E#19 on 03/04/2025 at 1:15 PM. E#19 stated that the officers were called for Pt.#3. E #19 stated that E #19 was told that Pt.#3 grabbed E#20 (officer) by the genital area, but was not in the room when this happened. E #19 stated that E#20 was there to hold Pt.#3 by the shoulder or leg for safety during the injection administration.

5. An interview was conducted with Psychiatrist (MD#5) on 03/05/2025, at approximately 11:30 AM. MD#5 stated that a physical hold used to administer a medication to a combative patient does not require an order. MD#5 stated that these things happen quickly and the patient is not held for a long time (less than a minute) to administer the medication. MD#5 stated that if the patient needs to be placed in mechanical restraints, then they would place an order.

Based on document review and interview, it was determined that for 1 of 3 restraint records (Pt. #3) reviewed, the hospital failed to ensure that a face-to-face evaluation was completed within one hour of violent restraint initiation as required.

Findings include:

1. The hospital's policy titled, "Restraint Usage" (revised 11/2023), was reviewed and required, "...Physical Hold - Holding a patient in a manner that restricts the patient's movement against the patient's will is considered restraint... Violent or Self-destructive Behavior Restraint Usage Description: Restraints for management of violent or self-destructive behavior can only be used in emergency situations... If restraint is initiated by the RN [registered nurse] due to an immediate patient need, the RN notifies the physician/LP [licensed practitioner] immediately (within a few minutes) of the initiation of restraint and a verbal or written order is obtained. A physician or LP performs one-hour face-to-face evaluation of the patient within one hour after the initiation of restraint..."

2. The clinical record of Pt. #3 was reviewed on 03/04/2025. Pt. #3 presented to the Hospital's emergency department on 12/09/2024 and was admitted on 12/10/2024 to the Behavioral Health Unit with a diagnosis of schizoaffective disorder, bipolar type. The record indicated that on 12/09/2024 from 1:16 PM to 2:00 PM, Pt. #3 was placed in violent restraints due to aggressive/combative behavior. The record lacked documentation of a face-to-face evaluation completed after the restraint episode on 12/09/2024, within 12 hours of restraint initiation. The record also indicated that on 12/17/2024 at 8:40 PM, Pt. #3 became combative and required an emergency administration of medication for agitation. Security reports associated with the emergency medication administration on 12/17/2024, indicated that Pt. #3 was placed in a physical hold by security staff; however, the record lacked documentation that the physician was notified of the physical hold and no face-to-face evaluation was completed.

3. An interview was conducted with the Director of Nursing (E#1) on 03/06/2025, at approximately 10:35 AM. E#1 confirmed that no face-to-face evaluations had been completed/documented for either the mechanical restraint episode on 12/09/2024 or the physical hold on 12/17/2024. E#1 stated that the provider should complete a face-to-face evaluation within 1 hour of each restraint episode. E#1 stated that a physical hold is considered a restraint if used to restrict the patient's movement.

Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The hospital failed to post EMTALA signage regarding treating patients regardless of insurance. Refer to to A-2402.

2. The hospital failed to ensure that a medical screening examination was completed to determine if a medical emergency existed. Refer to A-2406.

Based on document review, observation, and interview, it was determined that for 1 of 1 Emergency Department, the hospital failed to post signage related to the rights of the individual with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA).

Findings include:

1. On 3/3/2025, the hospital lacked documentation of a policy regarding EMTALA signage.

2. A tour of the Emergency Department and Patient Entrance Areas were conducted on 3/3/2025, between approximately 10:00 AM and 10:40 AM with the Emergency Department (ED) Specialist (E#9). The EMTALA signage posted throughout the Emergency Department did not include that patients will be treating regardless of insurance.

3. An interview was conducted on 3/3/2025, at approximately 10:30 AM, with the ED #9. E#9 stated that EMTALA signage should include patients have a right to be seen regardless of insurance.

Based on document review and interview, it was determined that for 1 of 20 (Pt #1) ED (Emergency Department) clinical record reviewed for Medical Screening Examinations (MSE), the hospital failed to conduct a MSE for a minor patient, to see if a medical emergency exists.

Findings include:

1. On 3/3/2025, the hospital's policy titled, "Emergency Medical Treatment" (dated 10/2023) was reviewed and indicated, "The purpose of this policy is to provide quality, nondiscriminatory care and to comply with the Federal Emergency Medical Treatment and Active Labor Act (EMTALA) ...Any person who comes to the Emergency Department receives an appropriate Medical Screening Examination (MSE) to determine whether an emergency medical condition exists ...The screening is not delayed based on the patient's ability to pay or method of payment.

2. On 3/3/2025, the hospital's policy titled, "Emergency Authorization for Treatment of a Minor" (dated 12/2023) was reviewed and indicated, "When providing emergent or non-emergent care to a minor: Provide care and treatment to the minor without delay necessary to stabilize the minor's condition and perform the appropriate medical screening exam..."

3. On 3/3/2025, Pt. #1's "Ambulance Call Report" (dated 10/4/2024 at 2:55 AM) was reviewed and indicated, "Chief complaint - glass in foot. Presenting problem trauma - laceration. Upon arrival, Pt. #1 (minor) found well kept no distress sitting on chair. Initial assessments - mental status alert; person; place; time. GCS (glascow coma scale - a neurological assessment tool used to evaluate a person's level of consciousness). Verbal response: oriented; GCS motor response: obeys command; Neuro unremarkable; airway patent, breathing respiration rate: respiration 16; sP02 99; breathing quality: regular; right lung inspiration and expiration: clear; left lung inspiration and expiration: clear; skin color; normal; skin temperature: normal; skin condition: normal; left foot - 1st digit penetration; vital signs at 3:00 AM - blood pressure 130/90, pulse 100 and respirations 16; alert and oriented x3. Additional notes: Upon arrival found Pt. #1 sitting alert and oriented x3. Bleeding was controlled. Guardian stated Pt. #1 stepped on glass while horsing around with friends in dormitory. Upon assessment, Pt. #1 history and vitals as above and a piece of glass observed in foot. Pt. #1 denies any nausea, dizziness or vomiting. Crew irrigated, wrapped, and transported to ED (emergency department) where charge nurse stated that they cannot treat Pt. #1 due to no guardian present. EMS (emergency medical service) provided nurse with Pt. #1's parents phone number who live out of state. Crew advocated for Pt. #1 to get treated including explaining to ED that first off, Pt. #1 has guardian in the dorm counselor who was there and was an adult and furthermore Pt. #1 is alert and oriented and can make decisions. Charge nurse (E #12) then stated since this is not emergent she will not treat, as policy of hospital is not to treat without guardian or parental consent. Crew continued to try and negotiate treatment for Pt. #1 at which point nurse (E #12) stated that she would have no other choice but to call the police and let them sort it out and then potentially treat Pt. #1. Six police officers arrived and were befuddled by the request as they had never dealt with this before. They then called Pt. #1's parents who did not respond as expected since it was high holidays and Pt. #1 explained this to hospital and police multiple times. Eventually, police stated they can not do anything further and that hospital will not treat Pt. #1. EMS then drove Pt. #1 and guardian back to dormitory and Pt. #1 stated they will uber it to emergency room another hospital (Hospital B) and try and get treated there. Upon follow up with Pt. #1, went to medical doctor and got treated a couple of hours later."

4. On 3/3/2025, Pt. #1's ED clinical record (dated 10/4/2024) from Hospital A was reviewed and included: Pt. #1's timeline - 3:21 AM - Pt. #1 arrived via ambulance. At 3:40 AM - ED notes written by ED Charge Nurse (E #12). E #12 wrote "Pt. #1 to ED via ambulance from a boarding school for glass in foot. Pt. #1 and ambulance staff both stated unable to provide parental permission. Ambulance staff overheard discussing with Pt. #1 in front of desk that ambulance staff member would step out to receive parental consent call as "parent." Expressed to EMT (emergency medical technician) and Pt. #1 that all party members would have to be present at time of phone call to parents to obtain consent to treat. When explained that we needed parental information no matter what the circumstance, ambulance staff member suggested treating Pt. #1 before police could arrive for report. At 4:07:02 AM - CPD (local police) contacted, ambulance left ED. At 4:07:08 AM - written by ED Nurse (E #13) - CPD was called and notified by charge RN of Pt. #1 and Pt. #1's unaccompanied minor status, as requested by ambulance EMTs. Police en route. EMTs informed police en route at their request. EMTs stated that they didn't ask the police to be called. EMTs left the ED at 4:04 AM. Pt. #1 and Pt. #1's "dormitory counselor" remain in the waiting room at this time. Pt. #1 is pacing back and forth in front of the desk. Asked Pt. #1 to sit and relax while we wait, Pt. #1 still pacing. At 4:15:17 AM, police in ED. Ambulance staff members also back in ED. Police speaking with Pt. #1 now. At 4:34 AM, police on scene, talking with Pt. #1. Police states they are alright with Pt. #1 leaving in Pt. #1 chooses. At 4:46:48 AM, Pt. #1 left ED."

5. On 3/4/2025 at 930 AM, an interview was conducted with E #13 - Triage ED nurse. E #13 stated E #13 was the triage nurse on 10/4/2024 when Pt. #1 was in the ED. E #13 stated that the ED should treat minor patients and do a MSE without consent. E #13 stated that lack of consent should not be a reason that a patient does not receive a MSE.

6. On 3/4/2025 at 10:00 AM, an interview was conducted with E #12 - ED Charge Nurse. E #12 stated that E #12 cared for Pt. #1 on 10/4/2024. E #12 stated that E #12 was trying to obtain consent to treat from Pt. #1's parent but was unsuccessful. E #12 stated that a patient should receive a MSE even if the patient is a minor. E #12 stated that consent is not necessary for a minor patient to receive a MSE and treatment in the ED. E #12 stated that Pt #1 did not receive a MSE. E #12 stated that the police were called because Pt. #1 was an unaccompanied minor. E #12 stated that Pt. #1 left the ED because Pt. #1 was not receiving treatment.

7. On 3/4/2025 at 11:00 AM, an interview was conducted with the ED Manager (E #21). E #21 stated that a minor patient who arrives in the ED should receive a MSE and treatment. E #21 stated that consent is not necessary when treating a minor patient in the ED. E #21 stated that the ED staff try to obtain consent prior to a minor patient being discharged from the ED.

8. On 3/4/2025 at 3:00 PM, an interview was conducted the ED Physician (MD #6). MD #6 stated that MD #6 does not remember Pt. #1. MD #6 stated that all patients should receive a MSE. MD #6 stated that a minor patient should receive a MSE. MD #6 stated that consent is not required to do a MSE and treat a minor patient.