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Based on observation, staff interview, medical record review, policy review, and incident report review, the facility failed take appropriate and immediate action to protect all patients patients from abuse (A145), patient medical record information confidentiality was maintained (A147), and patients were free of restraints (A154). The systemic effect of these practices resulted in the facility's inability to ensure the safety of the patients. The facility had a census of 62 patients.

Based on medical record review, staff interview, incident report review and policy review, the facility failed to ensure that all patients were free from actual or potential abuse and/or injury while admitted to the facility. This affected four (Patients #3, #4, #5 and #10) of 11 records reviewed. The active census was 62.

Findings include:

1. Review of the medical record for Patient #3 revealed an admission date of 02/11/21 with a diagnosis of schizoaffective disorder. The patient was admitted for suicidal and homicidal ideation with poor insight and judgement. The patient had multiple episodes of aggressive behaviors requiring emergency psychotropic medications and restraint. The patient was sexually inappropriate and was masturbating and required a private room.

Review of the medical record for Patient #4 revealed an admission date of 02/12/21 after police were dispatched as the patient had suicidal ideation and was standing in the middle of an intersection.

Review of the unusual occurrence log and incident reports noted a patient/patient physical altercation occurred on the Balance unit on 02/13/21. The incident report noted Patient #3 punched Patient #4 on the right cheek while the patient waiting for the Registered Nurse to check a blood sugar level. Patient #3 was administered emergency psychotropic medications for aggression and Patient #4 was moved to another unit to prevent further altercation. Review of the unusual occurrence log noted on 02/19/21 Patient #3 then punched a male patient on the left side of the head behind his ear. The patient apologized to the patient following the incident stating he mistook the peer for another peer on the unit who was annoying him.

During interview on 03/31/21 at 11:12 AM. Staff A stated Patient #3 did not have an increased level of observation until after the second incident. The patient was then placed on line of sight observation instead of the standard fifteen minute check. Review of the flow sheets failed to include sexual acting out precautions and/or the potential for physical assault.

2. Review of the medical record for Patient #10 revealed the patient was admitted on 03/27/21 with a diagnosis of suicidal ideation and was attending to internal stimuli.

Review of the incident report dated 03/27/21 revealed the patient physically assaulted another patient without provocation. The facility staff attempted non-physical interventions without success and the patient was administered emergency psychotropic medications. The patient was moved to another unit following the incident.

During tour of Balance unit on 03/29/21 at 11:07 AM the patient was observed physically assaulting another patient on the unit by smacking him in the face.

Review of the medical record indicated the patients level of observation was not increased following both incidents and remained on the standard fifteen minute checks.

The patient was discharged from the facility on 03/30/21 without further incident.


3. Review of the medical record for Patient #5 revealed the patient was admitted to the facility on 02/07/21 for psychosis. During the hospitalization the patient exhibited sexually inappropriate behaviors by masturbating in both private and public areas. Per the psychiatrist documentation the patient exhibited poor impulse control and would easily become agitated and rage without provocation.

Review of the nursing documentation dated 02/09/21 at 6:30 AM revealed the patient became angry after a phone conversation with the mother. The patient began to threaten everyone on the unit claiming he had a gun. The patient began making moves to fight other patients and refused all redirection. When the aggression could not be controlled the physician was notified and emergency psychotropic medications were administered.

On 02/09/21 the Social Worker documented the patient was sexually preoccupied and was making female patients uncomfortable on the unit and the patient needed moved to another unit. On 02/10/21 at 5:30 AM the patient was aggressive towards staff and patients and began going into other patients rooms and touching them without permission. Redirection failed and the patient became aggressive kicking doors. When the unit became disrupted the physician was notified in order to protect everyone on the unit.

Review of the flow sheets indicated no increased level of observation and the patient remained on the standard fifteen minute checks. Review of the flow sheets lacked precautions for sexual acting out behaviors and/or the potential for physical assault.

During interview on 03/31/21 at 3:03 PM, Staff E stated increased observation levels are on a case by case basis. If a patient is identified as sexually acting out and/or physically aggressive the expectation is that monitoring is to be documented on the flow sheet with the appropriate precautions.

Review of the hospital policy titled "Patient Rights and Responsibilities", effective 05/14/2018), stated the hospital fully supports, endorses, and enforces the rights of patients. The purpose of the policy is to assure that the dignity and rights of all patients are respected and protected, and that patient's and/or their representative have the information necessary to exercise these rights. The patient has the right to reasonable protection from physical, sexual, or emotional abuse or harassment.

The three primary levels of observation used at the facility are:

a. Routine observations: minimum patient observation of at least every fifteen (15) minutes. All patients will be monitored every 15 minutes unless a higher level of observation is ordered.

b. One to one (1:1) observation: constant visual observation of a patient within arm's length.

c. Line of sight (LOS) observation: keeping the patient under direct supervision within eye sight of staff at all times.

Based on observation, record review and interview, the facility failed to ensure confidential patient information was not visible to other patients on the units. This affected four (Patients #12, #13, #14 and #15) in the facility. This had the potential to affect all patients in the facility. The facility census was 62.

Findings include:

1. During tour of the "Sage" unit on 03/29/21 at 10:28 AM, patient documentation for Patients #12, #13 and #14 was observed at the nursing station desk. The documentation included patient's first and last names, and date of birth and could be seen by other patients standing at the nurses station without staff present.

During interview on 03/29/21 at 10:28 AM, Staff B verified the information was in plain view.

2. During the tour of the "Grace" unit on 03/29/21 at 10:42 AM patient documentation for Patient #15 was observed at the nursing station desk. The documentation included the patient's first and last name and date of birth and could be seen by other patients standing at the nurses station without staff present.

During interview on 03/29/21 at 10:40 AM, Staff B verified the information was in plain view.

Review of the hospital policy titled "Patient Rights" revealed patients have a right for confidentiality of his or her clinical records.

Based on observation, record review and staff interview, the facility failed to ensure patients were free of restraints. This affected one (Patient #11) of eleven patient medical records reviewed. This had the potential to affect all patients in the facility. The facility census was 62.

Findings include:

Medical record review revealed Patient #11 was admitted from a nursing home related to increased behaviors. The patient was ambulatory on admission. The Fall Risk Assessment, dated 03/23/21, rated the patient with a score of six, moderate risk. The medical record contained on documentation related to the use of a geriatric recliner.

During an observation on the "Grace" unit on 03/31/21 at 12:01 PM., Patient #11 was in a geriatric recliner, leaning back with her legs elevated. At the time of the observation, Staff G was asked to demonstrate how the geriatric recliner operated. A handle was on the back and bottom of the chair. The bar could be lifted to release the chair so it could be tilted forward. From Patient #11's position in the chair, she could not reach the handle. Staff G verified that the patient could not release the chair.

During an observation on 03/31/21 at 1:00 PM, Patient #11 was in the geriatric recliner, wiggling around and trying to lift her bottom off the seat.

During interview on 03/31/21 at 1:00 PM, Staff A stated residents should be assessed on admission and throughout their stay for fall risk. Based on the fall assessment findings, the doctor would then order a geriatric recliner. Staff A verified there was no physician order or assessment for the use of a geriatric recliner for Patient #11.