HospitalInspections.org

Based on interview, record review, and observation, the facility failed to meet the Condition of Participation (CoP) for the patients right to be free from harm, neglect, and harassment by failing to comply with the requirements as evidenced by the following:

A. The facility failed to maintain a process that allows the patient or patient's guardian/representative (as allowed under State law) the right to make informed decisions about the care provided to patients admitted to [Name of Unit]. Refer to 0131.

B. The facility failed to provide information on, and the opportunity to complete an advance directive (a legal document that allows a person to outline their medical preferences and designate a healthcare agent to carry them out) to patients admitted to [Name of Unit]. Refer to 0132.

C. The facility failed to ensure the patients' right to receive care in a safe setting, and to be free from harm, harassment, and neglect, by not providing sufficient staff to meet therapy, support staff, and follow-up care to meet patient needs, and as acuity indicates. Refer to 0144.

D. The facility failed to protect the patients' rights to be free from abuse, harassment, and neglect by failing to prevent, report, and respond to sentinel events. Refer to 0145.

E. The facility failed to protect the patients' right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff leading to the inappropriate use of a medical restraint for purposes other than to prevent harm to self or others. Refer to 0154.

F. The Facility failed to provide the least restrictive dose of medication leading to oversedation and a violation of the patients' right to be free from unnecessary or unusually large amounts of medication. Refer to 0165.

G. The facility failed to understand and adhere to the definition of seclusion and to obtain Physician's Orders for apparent seclusions incidents. Refer to 0168.

Based on interview and record review the facility failed to maintain a process for patients to be informed of contact information for Department of Health (DOH) Complaints for all patients receiving treatment in the psychiatric unit of the facility. This failed practice can lead to patient's not being informed of the process for entering a complaint/grievance, can lead to repeat complaint issues and can lead to patient harm.

The findings are:


A. Record review of patient admission packet for Behavioral Health patients most recent update 01/2022, confirmed the form does not contain DOH complaints contact number or website information with instruction on how to file a compliant online.

B. Record review of NMAC 7.1.13.8 B. Notification: (1) Incident reporting: Any person may report an incident to the bureau by utilizing the DHI (Department of Health Improvement) toll free complaint hotline at 1-800-752-8649. Any consumer, employee, family member or legal guardian may also report an incident to the bureau directly or through the licensed health care facility by written correspondence or by utilizing the bureau's incident report form. The incident report form and instructions for the completion and filing are available at the division's website, at https://dhi.health.state.nm.us/elibrary/ironline/hflc_instructions.php or may be obtained from the department by calling the toll-free number at 1-800-752-8649.

C. On 08/09/22 at 10:30 am during interview with S(staff)6 (Director of Quality) who confirmed, "the facility received the flyer [Department of Health Complaints Contact] when it first came out but the information in the patient packet has not been updated. I am not sure why the flyer is not posted on the units; I will check on that."

Based on record review and interview the facility failed to maintain a process that allows the patient or his or her representative (as allowed under State law) to have the right to make informed decisions regarding his or her care in reference to obtaining medication consents for prescribed medications for 8 patients (P(patient) 1, P2, P3, P5, P6, P8, P9, P10) of 10 (P1-P10) patient records reviewed. This failed practice can lead to the patient or his or her representative not being able to make an informed decision about the medications being prescribed and can lead to patient harm.

The findings are:

A. Record review of facility policy titled "Consent for Administration of Psychotropic Medications policy" revision date 03/02/20 states:
1. Under section labeled "Purpose" to acknowledge the patient's right of "informed consent" for use of psychotropic medication, and to define situations when informed consent may be waived.
2. Under section labeled "Procedure" document states:
a. Written documentation of the patient's informed consent for each psychotropic medication prescribed should be obtained.
b. To give informed consent, the patient should be provided with sufficient information that includes the following:
- The nature of the patient's psychiatric condition.
- Reasons for taking the medication, including the likelihood of improving or not improving without such medication.
- Reasonable alternative treatments available, if any.
- The type, frequency (including PRN (as needed)), amount, method (oral or injection) and duration of the medication(s).
- The possible side effects of the medication(s). That the patient has the right to withdraw consent at any time.

B. Record review conducted for P1 date of admission 04/27/22 confirmed:
1. 05/02/22 Medication Consent for Haloperidol 5 mg po once, under Patient Signature states: Verbal Consent. No mention of who gave verbal consent or why it was a verbal consent given.
2. 05/05/22 Medication Consent for Ativan 2 mg IM NOW (immediately) Haldol 2 mg IM NOW, Benadryl 50 mg IM NOW, under Patient Signature states: Verbal Consent. No mention of who gave verbal consent or why it was a verbal consent given.
3. 05/05/22 Medication Consent to Discharge Abilify 10 mg po HS, Zydis ODT 5 mg po SL NOW one, under Patient Signature states: Verbal Consent. No mention of who gave verbal consent or why it was a verbal consent given.

C.Record review conducted for P2 date of admission 05/05/22 confirmed:
1. 05/05/22 Medication Consent to Discharge Risperdal 1 mg po BID, Discharge Gabapentin 300 mg po TID and Start 400 mg po TID, Discharge Prozac 10 mg po Daily, Discharge Trazadone 50 mg po bedtime, Start Trazadone 50 mg po HS PRN, Zyprexa 10 mg po bedtime, Zyprexa Zydis 5 mg SL TID PRN, Lithium 900 mg po NOW once, Lithium 900 mg po QAM, Zyprexa Zydis 5 mg SL once NOW, under Patient Signature states: Verbal Consent. No mention of who gave verbal consent or why it was a verbal consent given.

D. Record review conducted for P3 date of admission 04/27/22 confirmed:
1. 04/27/22 Medication Consent for Zoloft 50 mg (no mention of how often), Olanzapine 20mg (no mention of how often), under Patient Signature states: Verbal Consent. No mention of who gave verbal consent or why it was a verbal consent given.
2. 04/27/22 Medication Consent for Zoloft 50mg po daily, Zyprexa 5 mg BID, Gabapentin 300 mg po TID, Trazadone 50mg po QHS, under Patient Signature states: Verbal Consent. No mention of who gave verbal consent or why it was a verbal consent given.
3. 04/28/22 Medication Consent for Gabapentin 600mg po TID, Lithium 900 mg po NOW once, then 900 mg po QAM, under Patient Signature states: Verbal Consent. No mention of who gave verbal consent or why it was a verbal consent given.
4. 04/30/22 Medication Consent for Zyprexa 20 mg QHS, Trazadone 100 mg QHS PRN, "X" written in under patient signature indicating where to sign but no signature or why not signed by patient.
5. 05/01/22 Medication Consent for Lithium CR 900 mg Q Day, Zoloft 100 mg QHS, Zyprexa 10 mg with breakfast and dinner, "X" written in under patient signature indicating where to sign but no signature or why not signed by patient.

E. Record review conducted for P5 date of admission 04/26/22 confirmed:
1. 04/26/22 Consent to Treatment under Patient Signature states Unable to Sign, no indication of why.
2. 04/26/22 Medication Consent for Celexa 10 mg po Q Day (daily), Gabapentin 300 mg po TID, under Patient Signature states: Verbal Consent. No mention of who gave verbal consent or why it was a verbal consent given.
3. 04/27/22 Medication Consent for Hydroxyzine 25 mg po (no mention how often), under Patient Signature states: Verbal Consent. No mention of who gave verbal consent or why it was a verbal consent given.
4. 04/27/22 Medication Consent for Olanzapine 5 mg BID, under Patient Signature states: Verbal Consent. No mention of who gave verbal consent or why it was a verbal consent given.

F. Record review conducted for P6 date of admission 05/09/22 confirmed:
1. 05/10/22 Physician obtained "Certification and Application for Emergency Psychotropic Medications" for Haldol 10 mg IM, Ativan 2 mg IM, Cogentin 1 mg IM, no other Medications provided. During patient's stay the medications provided include Zyprexa, Olanzapine, Fluoxetine, Haloperidol, Lorazepam, Diphenhydramine, Gabapentin, Trazadone, Benztropine, Carbamazepine. There were no medication consents obtained for the medications listed and no record of the medications being discussed with the patient/guardian.

G. Record review conducted for P8 date of admission 07/12/22 confirmed:
1. 07/13/22 Medication Consent for Olanzapine 5mg (no mention of how often), under Patient Signature, left blank.

H. Record review conducted for P9 date of admission 04/22/22 confirmed:
1. 04/22/22 Consent for Treatment under Patient Signature states Unable to Sign, no mention of why patient was unable to sign given.
2. 04/23/22 Medication Consent for Depakote ER 250 mg po BID, under Patient Signature states: Verbal Consent. No mention of who gave verbal consent or why it was a verbal consent given.

I. Record review conducted for P10 date of admission 07/11/22 confirmed:
1. 07/12/22 Medication Consent for Zoloft 25 mg QAM, Gabapentin 300 mg TID, Lamictal 25 mg QHS, Abilify 2.5 mg QHS, (1xIM Haldol5mg, Cogentin 1mg, Lorazepam 2 mg) patient verbally agreed to receive the shot to RN (Registered Nurse), Librium 25mg tapering down, No physician signature noted.
2. Medication Consent for Gabapentin 600 mg TID, Olanzapine 10 mg SL BID PRN, no physician signature noted.

J. On 08/08/22 at 4:15 pm during interview with S(staff)5 (Director of Behavioral Health) who confirmed, "[in reference to medication consents] the patient or guardian give consent to medications. If it is a guardian [giving consent] the consent is obtained over the phone. The physician puts the order for the medication in the system then the nurse gets the consent over the phone. The nurse will tell the guardian what the medication is used for (like depression) and will inform them of possible side effects (like EPS) that could require another medication like Cogentin to be added. The physician does not obtain the consent."

K. On 08/10/22 at 10:58 am during interview with S11(Registered Nurse) who confirmed in reference to medication consents: if they[patient] don't have a treatment guardian, I tell them about their medications, if at any time you don't want to take these medications, you can submit written notification or verbal. And then have them[patient] sign the paper. If the patient has a guardian, I call them and educate and get verbal consent and then pass to another RN and they gain verbal consent too. In reference to the roll of the doctor in obtaining medication consents: "I don't know, I know that we get medication consent, but I don't know."

L. On 08/10/22 at 11:35 am during interview with S12 (Charge Nurse) who confirmed: In reference to medication consent process: "Psychotropics, they have to give us consent. By signing the consent form, they agree to medication but can still refuse. If guardian then we (2 nurses) have to make contact and get consent from the guardian. MD [doctor] signs after we sign.

Based on record review and interview the facility failed to provide information on, and the opportunity to complete an Advance Directive (a legal document that lets a person outline their medical preferences and designate a healthcare agent to carry them out) for 10 (P1-P10) of 10 [P1-P10] patients reviewed. This failed practice can lead to the violation of patient's rights by not allowing patients to designate another individual and outline medical preferences as permitted by state law.

The findings are:

A. Record review of Facility's Policy titled, "Patient Admission Procedures [Name of Unit] Policy," effective 09/01/2004, Revised 04/26/2017, states page 2. para 3, "Patients will be provided information on, and the opportunity to complete an Advance Directive."

B. Record review of Facility's "Patient Information [Name of Unit] Behavioral Health and Wellness" (undated) shows no information regarding advance directives.

C. Record review of Facility's "Disclosing Patient Information to Family/Friends Directive," effective date 10/11, revision date 07/21, shows no information or opportunity to designate an advance directive.

D. Record review of Facility's "Patient Admission" documents, shows no information or opportunity to designate an advance directive.

E. Record review of P1-P10, Medical Record, dated 01/01/2022-08/08/2022, shows no documentation of an opportunity for patients to complete or decline an advance directive.

F. In an interview with S(staff)12 (Registered Nurse), on 08/10/2022 at 11:35 am, when asked about opportunities for patients to designate a treatment guardian (a person or agent designated by an individual to make healthcare decisions for the individual, should they become incapacitated or unable to make decisions for themselves) or complete an advance directive, S12 states, "Documentation should be in the Physician's note."

G. In an interview with S9 (Medical Doctor (MD)), on 08/10/2022 at 12:12 pm, S9 states, "I have not routinely asked if they want to appoint a guardian/agent in the event that they become incapacitated."

H. In an interview with S10 (MD), on 08/10/2022 at 2:03 pm, S10 states, "I don't really know if a patient appointed guardian/agent would be ok or if it would need to be legal."

I. Record review of New Mexico's "Mental Health Care Treatment Decisions Act" 24-7B-4, effective date 05/17/2006, states:
a. Item F., "A mental health treatment decision made by an agent (an individual designated in a power of attorney for mental health treatment to make a mental health treatment decision for the individual granting the power) for a principal (an adult ... who, while having capacity, has made a power of attorney for mental health treatment by which the adult ... delegates the right to make mental health treatment decisions ... to an agent) is effective without judicial approval."
b. Item G., "A written advance directive for mental health treatment may include the individual's nomination of a choice of guardian of the individual.
c. Item I., "A written advanced directive for mental health treatment is valid only if it is signed by the principal and a witness ..."
d. Item J., "For purposes of the advance directive for mental health treatment, the witness shall not be: ...The attending qualified health care professional; or an owner, operator or employee of a mental health treatment facility at which the principal is receiving care or of any parent organization of the mental health treatment facility.

Based on record review and interview the facility failed to ensure that the patient has the right to receive care in a safe setting in reference to providing sufficient staff to provide support services, therapy and aftercare for patients who are victims of trauma in the facility, for 2 patients (P(patient) 1 and P2) of 10 patient records reviewed (P1-P10). This failed practice is likely to result in patients not being free harm and not being able to process their trauma.

A. The facility failed by not ensuring the Patients Rights: Free from Abuse/Harassment: Refer to tag A0145

B. The facility failed by not ensuring the Recording of Progress Notes were completed: Refer to tag A1655.

Based on record review and interview the facility failed to protect the patients' rights to be free from abuse or harassment and failed to prevent, report and respond to the incidents for 2 (P1, P10) of 10 (P1-P10) patients reviewed. This failed practice led to a sexual assault and attempted assault on the 2 patients and may lead to further patient harm.

The findings are:

INCIDENT 1: Sexual Assault
A. Record review of P2, Patient Observation Form, dated 05/06/2022, shows the following boxes checked: "Line of Sight", "1:1", "Sexually Acting Out."

B. Record review of P(patient)2, Provider Order Summary, Admit Service date of 05/05/2022 and a discharge date of 05/06/2022, shows a patient observation order from S(staff)9, Psychiatrist, for "One to One, Arm's length" acknowledged by S12, Charge Nurse, on 05/06/2022 at 0138 (1:38 am).

C. Observation of video camera 27, dated 05/06/2022 shows P(patient)2 entering P1 room at 3:34 pm and no staff present until staff enters room at 3:41 pm and removes P2 from the room.

D. In an interview with S(staff)1, Behavioral Health Technician (BHT), on 08/10/2022 at 11:00 am, S1 states, "We heard something, some scuffling and opened the door. When we opened the door, he [P2] had his mouth on her [P1] breast and hand touching the other breast." When asked if the facility interviewed [S1] about the incident, S1 states, "One of the nurses asked what we saw but no one else from quality or further up asked. The Police got a statement."

E. Record review of [Name of City] Police Department, Reporting Officer Narrative states "[S7] stated two of her nurses found a male patient groping a female's breast in her room."

F. Record review of [Name of City] Police Department, Case Supplemental Report, states " [P2] advised when he saw the female [P1] laying there, his demons got the better of him ... he picked up her shirt, exposing her breast, and began to massage her breast ... Due to [P2] unlawfully and intentionally applying force to the unclothed breast of [P1], ... [P2] was charged with Criminal Sexual Contact."

G. Record review of the Facility's Event Report, with Event ID: [Number], states under Investigation Findings: "Male Patient [P2] was removed from female patient [P1] room by staff. Physician, Risk management and AOD [Administrator On Duty] were all notified. Staff contacted local law enforcement to file a report. Male patient reported to law enforcement to have touched the female patients' breast without her consent. Male patient was arrested and taken into custody." There is no mention of the facility analyzing the event to prevent it from happening in the future not reporting event to NMDOH (New Mexico Department of Health).

H. In an interview on 08/10/2022 at 2:30 pm with S8, Director of Risk Management, when asked about guidelines for reporting sentinel events (a patient safety event that results in death, permanent physical or psychological harm, or severe temporary harm) stated "That was not a sentinel event [P2 and P1]. We weren't' sure that really happened. We report to the state if it's abuse, neglect, and/or exploitation. I don't consider what happened to be part of any of those categories."

I. Record review of Event Reporting Policy, Original publish date: 02/02/2014; Published Date: 06/23/2020, states "Sexual abuse/assault as a sentinel event is defined as nonconsensual sexual contact involving a patient and another patient, staff member, or other perpetrator while being treated or on premises of the hospital, including oral, vaginal, or anal penetration or fondling of the individual's sex organ(s) by another individual's hand, sex organ, or object. One or more of the following must be present to determine that the incident is a sentinel event:
a. "Any staff-witnessed sexual contact as described above.
b. "Admission by the perpetrator that sexual contact, as described above, occurred on the organization's premises.
c. "Sufficient clinical evidence obtained by the health care organization to support allegations of unconsented sexual contact"

J. Record review of P1, Medical Record, duration of admission beginning 04/27/2022, shows no documentation of notification to P1 that event occurred (as patient was medically restrained at time of event; refer to A-0154). There is no documentation of follow up assessment, counseling or further services provided by staff/facility to P1 regarding sentinel event.

K. Record review of P1, Medical Record, duration of admission beginning 04/27/2022, shows no documentation of notification to Guardian or designated patient representative of sentinel event.

INCIDENT 2: Attempted sexual assault
L. Observation of video camera 11, dated 07/14/2022:
a. Starting at 6:33 pm shows P3 pacing in front of P10's room. P3 stops, stares and stands in the doorway of P10's room multiple times throughout the video. There are 3 different staff that walk by P3 while he is pacing in front of the doorway. Staff do not intervene.
b. At 6:47 pm, P3 attempts to enter P10's room and forcefully shuts the door, another patient tries to stop the door from closing. Four staff located in the Nurses' Station across from P10's room, come out and open the door. P3 then leaves P10 room.

M. Record review of P3, Nursing Assessment, dated 07/13/2022 at 6:01 pm, states "Patients goals/hopes for admission ... have sex for the first time."

N. Record review of P3, Nursing Notes on 07/14/2022 at 7:00 pm, states "I wanted to rape her [P10]."

O. Record review of P3, Nursing Care Plan, created on 07/15/2022 at 2:44 am, states "History of Violence ... Attempted to rape peer ... thinks its ok to rape people if you really want to."

P. Record review of P3, Nursing Notes, dated 07/15/2022 at 3:45 pm, addendum 07/15/2022 at 5:24 pm, stated, "At 1700 [5pm] pt [patient] made a comment in front of group of pts stating 'I was sent by the FBI (Federal Bureau of Investigations) to rape [P10].' Pt sent to secluded room due to safety of other patients at this time."

Q. In an interview on 08/10/2022 at 9:15 am with S6, Director of Quality, when asked why the above incident was not listed as an adverse event stated, "This was not considered an adverse event because nothing actually happened. It was found during an observation and prevented."

R. In an interview with S2, BHT, on 08/10/2022 at 11:00 am, S2 states, "[P3] thought it was in [P3's] best interest to sexually assault a female patient. So, [P3] barricaded himself into the female patient's room right across from the nurse's station. [P3] closed the door, held it closed and then he another patient saw and was trying to get in... [P3] told [P10] 'take your clothes off.' [P10] claimed [P3] touched her."

S. Record review of P10, Medical Record, duration of admission beginning 07/11/2022, shows now record of follow up assessment, counseling or services provided by staff to P10 regarding traumatic event. No record of preventative measures taken to restrict continued psychosocial harm to P10 by exposing P10 to P3 in group setting after P3's attempt to rape P10.

T. In an interview with S7, Director of Behavioral Health (DBH), on 08/11/2022 at 4:16 pm, when asked about documentation of follow-up care, counseling, and services that were provided by the staff/facility to P10 in regard to the traumatic event occurring on 07/14/2022, S7 states, "I couldn't find a note from social work or RN directly referencing follow-up with the patient."

Based on record review and interview the facility failed to protect the patients' right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff. This failed practice led to the inappropriate use of a medical restraint for purposes other than to ensure the immediate physical safety of the patient, or others for 1 (P1) of 10 (P1-P10) patients reviewed.

The findings are:
A. Record review of Facility's Policy titled, "Restraint and Seclusion Policy," dated 02/02/2015, revision date 06/04/2020, defines, "Restraint: A restraint can be a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is NOT a standard treatment or dosage for the patient's condition."

B. Record review of Facility's Policy titled, "Restraint and Seclusion Policy," dated 02/02/2015, revision date 06/04/2020, states, Item B: "Assessment of Risk Factors: Restraint or seclusion use is limited to situations in which there is imminent risk of a patient physically harming himself or herself, staff, or others, and nonphysical interventions would not be effective."

C. Record review of P1, [Name of Unit] Group, dated 05/05/2022 at 5:09 pm, states, "Patient was an active participant and was polite while peers and group leader spoke and demonstrated activity .... Patient chose to attend group. She sat quietly during the group."

D. Record review of P1, Nursing Assessment, dated 05/05/2022 at 5:17 pm, documented, "Thoughts of harm to self: None; Denies SI (Suicidal Ideation) on assessment; Thoughts of harm to others: None; Denies HI (Homicidal Ideation) on assessment."

E. Record review of P1, Nursing Notes, dated 05/05/2022 at 5:54 pm, states, "Observed in hallway evasive and withdrawn from others ... Denies SI and HI on assessment."

F. Record review of Federal Drug Administration Guidelines (FDA), Haldol (a medication under the class of antipsychotics) Brand of Haloperidol Injection (For Immediate Release), Revised 2005, revealed on page 11 para.4, "Parenteral (administered or occurring elsewhere in the body than the mouth or intestinal tract) medication, administered intramuscularly (administered directly into muscle tissue, e.g. by injection) in doses of 2 to 5 mg, is utilized for prompt control of acutely agitated schizophrenic patient with moderately severe to very severe symptoms."

G. Record review of P1, Medication administration Record (MAR), dated 05/05/2022 at 6:06 pm, documented, "Haldol 10 mg IM Once; Ativan 2 mg IM Once; Benadryl 50 mg IM Once .... Left Buttock given by RN," as ordered by S(staff)10, MD.

H. Record review of P1, Medical Record, dated 04/27/2022-06/10/2022 shows no documentation that patient was a threat to harm self or others at time of, or prior to administration of medical restraint (refer to finding G) on 05/05/2022 at 6:06 pm.

I. Record review of P1, Patient Observation Form, dated 05/05/2022-5/06/2022, shows the following patient activity on 15-minute rounding (level of observation used to document patient location and activity as implemented by trained personnel):
a. 05/05/2022: 1930 (7:30 pm) - 05/06/2022 at 1545 (3:45 pm) patient room sleeping.
b. 05/06/2022: 1600 (4:00 pm) patient room with staff.

J. In an interview with S7 on 08/09/2022 at 2:00 pm, when asked about the use of medical restraints, S7 states, "We give emergency medications when they're having a behavior (aggressive, violent, suicidal), that we give IM usually."

K. Record review of P1, MAR, dated 05/06/2022 shows no additional one-time dose of emergency medications given to P1 prior to sentinel event on 05/06/2022 at 3:34 pm, (refer to Tag 0145) to account for ongoing inappropriate medical restraint.

L. In an interview with S(staff)10, Medical Doctor (MD), on 08/10/2022 at 2:03 pm, S10 states, "To keep everyone safe we assess them, assure that they are stable enough to enter into the population. Some of them we have to medicate them again. Sometimes we have to call a 'Code Strong,' in other words an armed-strong (it's the hospitals security). Sometimes we'll get a patient on the unit that is a danger to others, and sometimes to themselves. And with a violent patient you want to have a show of force, to prevent them from being violent."

M. Record review of P1, Medical Record, duration of admission beginning 04/27/2022, shows no documentation of notification to guardian or patient representative of medical restraint applied to P1.

N. Record review of Facility's [Name of Unit] "Restraint & Seclusion Log, dated 01/01/2022-08/08/2022, Shows no record of restraint or seclusion for P1 for duration of admission beginning 04/27/2022.

O. Record review of [Name of City] Police Department, Reporting Officer Narrative, on 05/06/2022 at 4:44 pm, states, "[S7, Director of Behavioral Health] stated ... [P1] was heavily sedated and was not awake during the incident (refer to Tag A-0145)... I [Officer] spoke with [P1] and asked her if she wanted to talk to me. [P1] kept her eyes close [sic] and didn't speak."

P. Record review of [Name of City] Police Department, Reporting Detective Narrative, on 05/06/2022 at approximately 6:30 pm, states, "[S1, Behavioral Health Technician (BHT)] advised [P1] is heavily sedated and unresponsive and she was in this state at the time of the incident. I attempted to speak with [P1] but she was unresponsive."

Based on record review and interview the Facility failed to provide the least restrictive dose of medication for 1 (P10) of 10 (P1-P10) patients reviewed. This failed practice led to oversedation and a violation of the patients' right to be free from unnecessary or unusually large amounts of medication.

The findings are:

A. Record review of facility's handbook titled, "Legal Rights of an Adult Recipient of Mental Health Services in New Mexico," dated June 2001, states "you have the right to be free from unnecessary or unusually large amounts of medication; to be free from the use of medication as punishment, for the convenience of the staff; or in amounts that interfere with achieving the goals in your treatment plan."

B. Record review of Federal Drug Administration (FDA) Guidelines, Haldol Brand of Haloperidol Injection (For Immediate Release), Revised 2005, revealed on page 10 para.11, "OVERDOSAGE Manifestations ... The most prominent of which would be: ... 3) sedation."

C. Record review of P10, Medication Administration Record (MAR), on 07/11/2022 at 10:00 pm, documented, "Haldol 5 mg + Cogentin 1 mg IM NOW; Ativan 2 mg IM NOW ... Unable to scan but did give ... Left Buttock," as ordered by S9, MD.

D. Record review of P10, Nursing Assessment, on 07/12/2022 at 2:06 am, states, "Patient did not answer many questions, as she was continuing self-harmful [sic] behavior and was sedated after admission."

E. Record review of P10, Nursing Assessment, on 07/12/2022 at 2:22 am, states, "Effects of first dose/New medication evaluated? Y (yes); Evidence of positive clinical response to medications: Decreased Agitation."

F. Record review of P10, Nursing Note, on 07/12/2022 at 2:35 am, states, "Orders were received for an injection, which was given at 2200 (10:00 pm) ... Staff stayed with pt (patient) until 2300 (11:00 pm) when it was determined [P10] was asleep. [P10] was in the seclusion room, so we could still observe on camera. Pt continues to sleep at time of this writing."

G. Record review of P10, Medical Record, dated 07/12/2022 shows one time dose of Haldol 5 mg to be an effective dose in managing P10 behavior, per finding F.

H. Record review of P10, Provider Notes, on 07/12/2022 at 10:55 am, states, "On my face-to-face encounter with the patient she was in bed... Apparently she just received shots. She was not able to answer to my request to interview her ... recent sedation."

I. Record review of P10, Psychosocial Assessment [Name of Unit], dated 07/12/2022 at 4:22 pm, documented, "Patient was given an injection, therefore pt wasn't able to complete this assessment due to being sedated."

J. Record review of P10, Patient Observation Form: 15 Minute Rounding (level of observation used to document patient location and activity as implemented by trained personnel), dated 07/11/2022-07/13/2022. Documents:
a. "07/11/2022 at 2220-2300 (10:20 pm-11:00 pm): seclusion room with staff."
b. "07/11/2022 at 2315(11:15 pm) -07/12/2022 at 1015(10:15 am): Seclusion room sleeping."
c. "07/12/2022 at 1045(10:45 am -07/13/2022 at 0630(6:30 am): Patient room sleeping."
d. "07/13/2022 at 0900-1030(9:00 am-10:30 am): seclusion room sleeping."

K. Record review of Federal Drug Administration Guidelines (FDA), Haldol (a medication under the class of antipsychotics) Brand of Haloperidol Injection (For Immediate Release), Revised 2005, revealed on page 11 para.4, "Parenteral (administered or occurring elsewhere in the body than the mouth or intestinal tract) medication, administered intramuscularly (IM)(administered directly into muscle tissue by injection) in doses of 2 to 5 mg, is utilized for prompt control of acutely agitated schizophrenic patient with moderately severe to very severe symptoms."

L. Record review of P10, MAR, on 07/13/2022 at 12:19 pm, documented, "Haldol 10 mg IM Once; Ativan (a medication under the class of antianxiety agents, Benzodiazepine, Sedative-Hypnotic) 2 mg IM Once; Benadryl (a medication under the class of antihistamine, Sedative-Hypnotic) 50mg IM Once ... Right Buttock GAVE," as ordered by S10, MD.

M. Record review of P10, Medical Record, dated 07/13/2022, shows one time dose of Haldol 10 mg to be an inappropriate dose per findings A-K.

N. In an interview with S10, MD on 08/10/2022 at 2:03 pm, when asked about sedation as a sign of overdose for some medications S10 prescribes to his patients, S10 states, "It's not about sedation, it's about stabilization."

O. In an interview with S9, MD, on 08/10/2022 at 12:12 pm, S9 states, "Sedation automatically makes a patient more of a fall risk ... I don't think you have to sedate them to being obtunded and I'm not sure that's any better than a manic episode either.

P. Record review of P10, Nursing Notes, on 07/13/2022 at 12:25 pm, states, "12:05(pm) ... [S10, MD] give [sic] IM order. Order was received and administered. Pt was put in seclusion room for closely [sic] monitoring ... 12:20 (pm) pt noted insupine [sic] position sleeping."

Q. Record review of P10, Nursing Notes, dated 07/14/2022 at 12:15 am, states, "Patient was sleep [sic] in timeout room after being medicated during the day shift for adverse (harmful) behavior."

R. Record review of P10, Patient Observation Form: 15-Minute Rounding (level of observation used to document patient location and activity as implemented by trained personnel), dated 07/13/2022-07/14/2022 documented,
a. "07/13/2022 at 1230-2200(12:30 pm-10:00 pm): seclusion room sleeping."
b. "07/13/2022 at 2330(11:30 pm) -07/14/2022 at 0615 (6:15 am): Patient room sleeping."

Based on record review, observation and interview, the facility failed to understand and adhere to the definition of seclusion and to obtain Physician's Orders for seclusions for 4 (P2, P3, P6 and P10) of 10 (P1-10) patients reviewed. This failed practice led to a violation of patient rights.


The Findings are:

A. Record review of the Facility's Policy titled, "Restraint and Seclusion Policy," effective 02/02/2015, revised 06/04/2020, documented, "Seclusion is ... involuntarily confining a patient alone in a room or an area where the patient is prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether the room is locked or not. In this situation the patient is being secluded."

B. In an interview with S7, Director of Behavioral Health (DBH), on 08/11/2022 at 3:03 pm, S7 states, "Locked seclusion is actually locking the seclusion room door and patient is locked in there."

Patient 2:
C. Record review of P2, Physician Orders, shows no order for seclusion for duration of admission dated 05/05/2022-05/06/2022.

D. Record review, Seclusion Log, dated 01/01/2022-08/08/2022, shows no documentation for seclusion for duration of admission for P2.

E. In an interview with S1, Behavioral Health Technician (BHT), on 08/10/2022 at 11:00 am, S1 states, "[P2] had his mouth on her breast and hand touching the other breast. I was with [S2, BHT] so we both ran in there ... [P(patient)2] admitted to it right away. At that point we put [P2] in the seclusion room."

F. Record review of P2, Physician Orders, shows no order for seclusion for duration of admission dated 05/05/2022-05/06/2022.

Patient 3:
G. Record review of P3, Physician Orders, shows no order for seclusion for duration of admission dated 07/13/2022-08/10/2022.

H. Record review, Seclusion Log, dated 01/01/2022-08/08/2022, shows no documentation for seclusion for duration of admission for P3.

I. Record review of P3, Nursing Notes, dated 07/14/22 at 7:00 pm, states "Pt (patient) removed from female pt room and sent to seclusion room."

J. Record review of P3, Nursing Notes, dated 07/15/2022 at 3:45 pm, addendum 07/15/2022 at 5:24 pm, stated, "Pt sent to secluded room due to safety of other patients at this time ... Pt currently in seclusion room on 1:1 evaluation."

K. In an interview with S7, DBH, on 08/09/2022 at 3:35 pm, S7 stated, "[P3] was taken to seclusion room as annotated in RN note, but the patient was not secluded in the room. Seclusion is when the door is locked."

Patient 6:
L. Record review for P6, Physician Orders, dated 05/10/2022 at 5:00 pm, shows no order for seclusion.

M. Record review, Seclusion Log, dated 01/01/2022-08/08/2022, shows no documentation for seclusion for duration of admission for P6.

N. Record review of P6, Patient Observation Form: 15-Minute Rounding (Rounding (level of observation used to document patient location and activity as implemented by trained personnel), 05/10/2022 at 9:15 am through 11:00 am documented, "Seclusion Room."

O. Record review of P6, Facility's "Alternatives Attempted Form," dated 05/10/2022 at 5:00 pm, under "Physicians Orders," box for Seclusion is NOT checked.


Patient 10:
P. Record review of P10, Physician Orders, shows no order for seclusion for duration of admission dated 07/11/2022-07/17/2022.

Q. Record review, Seclusion Log, dated 01/01/2022-08/08/2022, shows no documentation for seclusion for duration of admission for P10.

R. Record review of P10, Psychosocial [Name of Unit] Assessment, dated 07/12/2022 at 4:22 pm, documented, "Staff stayed with pt until 2300 (11:00 pm) when it was determined she was asleep. She was in the seclusion room."

S. Record review of P10, Nursing Notes, dated 07/13/2022 at 5:49 am, documented "(pt) taken to seclusion room."

T. Record review of P10, Nursing Notes, dated 07/13/2022 at 12:25 pm, documented, "Pt was put in seclusion room for closely monitoring. 12:20 pm ... Pt. noted in supine position sleeping."

U. In an interview with S(staff)7, DBH, on 08/09/2022 at 2:00 pm, when asked about the definition of seclusion S7 stated, "We give emergency medications when they're having a behavior ... If we give an injection, if the patient isn't in locked seclusion, they'll be in unlocked time-out."

V. In an interview with S7, DBH, on 08/11/2022 at 2:58 pm, when asked about reasons to put a patient in seclusion S7 stated, "We take them to the seclusion room because we don't know if we have to put them in 4 point (a form of physical restraint used to immobilize all four extremities of the patient and is indicated for violent/harmful behavior to self or others and less restrictive methods have not been effective in de-escalation) or seclusion."

W. During Observation on 08/08/2022 at 3:31 pm, it was observed that a patient was sleeping in seclusion room with seclusion room and ante-room (a small outer room that leads to another room) doors open. Upon inquiry, S7, DBH states, "Patients use the seclusion room for time-out or quiet time when they are feeling groggy."

X. Record review, Seclusion Log, dated 08/08/2022, shows no documentation for seclusion for all patients.

Based on interview, record review, and observation, the facility failed to meet the Condition of Participation (CoP) for nursing services by failing to comply with the requirements as evidenced by the following:

A. The facility failed to staff an appropriate number of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. The facility also failed to ensure, when needed, the immediate availability of registered nurse for care of any patient. Refer to 0392

B. The facility failed to develop a care plan that meets the patients' needs and to assign the nursing care of each patient in accordance with the patients' needs. Refer to 0396.

C. The facility failed to ensure adequate supervision over personnel to ensure they were adhering to the facilities policies and procedures. Refer to 0398.

Based on record review and interview the facility failed to provide adequate numbers of licensed Registered Nurses, Supervisory Personnel, Social Workers, and Behavioral Health Technicians for increased patient census, and/or acuity for 4 [P(patient) 1, P2, P3, P10] of 10 (P1-P10) patients reviewed. This failed practice can lead to patient harm, inappropriate use of medical restraints, continued psychosocial harm and a violation of patient's right to be free from abuse, neglect, and harassment by not meeting the needs of all patients in the facility.

The findings are:
A. In an interview with S(Staff)12, Charge RN, on 08/10/2022 at 11:35 am, when asked if [S12] feels if the [Name of Unit] has enough staff (to meet unit needs), S12 states, "Honestly, no. Because that's (1:1 observation orders) an entire person that is taken away from everything else that's going on. We could use more staff when that happens."

B. In an interview with S7, Director of Behavioral Health (DBH), on 08/12/2022 at 9:20 am, S7 states, "I think we could use more staff than we have ... I don't feel that we have enough nurses.... I think 3 RNs with 25 patients isn't safe. That's giving a charge (RN) a full load and the other nurses a full load. I have 3 Techs (BHTs) during the day I feel it's important to have 3 at night as well ... we need help ... When the acuity is high, I voice my concerns ... we have so many safety risks."

C. Record review of Facility's [Name of Unit] "Staffing Matrix,' Dated 07/10/2021, documents the number of Registered Nurses (RN) required to be scheduled each shift for patient census greater than 19, to be 2 RN's and 1 Charge (supervisory personnel) RN.

D. Record review for Facility's [Name of Unit] "Staff Schedule," dated 03/27/2022-07/21/2022, documents that either one floor RN and one Charge (supervisory) RN or 2 floor RN's and no charge RN was scheduled for shifts when the patient census was 19 or greater on the following dates:
a. Dayshift: 04/27, 05/12, 05/13, 05/18, 06/01, 06/02, 06/08, 06/22, 06/23, 06/24, 06/25, 06/26, 06/27, 06/28, 07/04, 07/05, 07/06, 07/07, 07/09, 07/10, 07/11, 07/17/2022.
b. Nightshift 04/27, 05/12, 05/13, 05/14, 05/15, 05/16, 05/18, 06/01, 06/02, 06/07, 06/08, 06/22, 06/23, 06/24, 06/26, 06/27, 06/28, 06/29, 06/30, 07/03, 07/05, 07/09, 07/10, 07/11, 07/18, 07/19, 07/20/2022.

E. Record review of Facility's [Name of Unit] "Staff Schedule," dated 03/27/2022-07/21/2022 reveals one charge RN and no floor RN(s) scheduled for patient census of 24 on day of 05/14/2022.

F. Record review of Facility's [Name of Unit] "Staff Schedule," dated 03/27/2022-07/21/2022 reveals one floor RN and no charge RN scheduled for patient census of 22 on night of 06/29/2022.

G. Record review of Facility's [Name of Unit] "Staff Schedule," dated 03/27/2022-07/21/2022 reveals one floor RN and no charge RN scheduled for patient census of 23 on night of 06/30/2022.

H. Record review of Facility's [Name of Unit] "Staff Schedule," dated 03/27/2022-07/21/2022 reveals one floor RN and no charge RN is scheduled for patient census of 23 on night of 07/01/2022.

I. Record review of Facility's [Name of Unit] "Staff Schedule," dated 03/27/2022-07/21/2022 reveals one floor RN and no charge RN is scheduled for patient census of 20 on night of 07/02/2022.

J. Record review of Facility's [Name of Unit] "Staff Schedule," dated 03/27/2022-07/21/2022 reveals one Charge RN and no floor RN is scheduled for patient census of 18 on night of 07/08/2022.

K. Record review of Facility's [Name of Unit] "Staffing Matrix," dated 07/10/2021, documents the number of social workers required to be scheduled each shift for patient census 1-8 to be 1 Social Worker, and 9-25 to be 2 social workers.

L. Record review of Facility's [Name of Unit] "Patient Census," dated 04/27/2022-07/21/2022, reveals a patient census of 9 or greater for all dates.

M. Record review of Facility's [Name of Unit] "Staff Schedule," dated 04/27/2022-07/21/2022, reveals:
a. One social worker scheduled for dates 05/11/2022-05/14/2022; 05/16/2022-05/18/2022, 05/21/2022-0522/2022; 05/24/2022-05/27/2022; 05/30/2022-06/04/2022; 06/06/2022-06/09/2022 06/18/2022-06/25/2022; 06/27/2022-07/02/2022; 07/04/2022- 07/08/2022; 07/11/2022-07/16/2022; 07/18/2022-07/21/2022.
b. And no social worker scheduled for dates 05/15, 05/28, 05/29, 06/05, 06/19, 06/26, 07/03, 07/09, 07/10, and 07/17/2022.

N. Record review of Facility's [Name of Unit] "Staffing Matrix," dated 07/10/2021, documents the numbers of Behavioral Health Technicians (BHT) required to be scheduled for each shift for a patient census 15 or greater on dayshift, and 19 or greater on nightshift to be 2 BHT's.

O. Record review of Facility's [Name of Unit] "Staff Schedule," dated 03/27/2022-07/21/2022, reveals:
a. One BHT is scheduled for patient census of 15 or greater for days of: 06/19, 06/22, 06/23, 07/09/2022.
b. And one BHT is scheduled for patient census of 19 or greater for nights of: 05/13, 05/14, 05/15, 05/16, 05/18, 06/02, 06/07, 06/08, 06/22, 06/27, 06/29, 07/15, 07/16, 07/17, 07/20/2022.

P. Record review of Facility's [Name of Unit] "Staff Schedule," dated 03/27/2022-07/21/2022 reveals no BHT is scheduled for patient census of 19 for night of 06/01/2022.

Q. Record review of Facility's [Name of Unit] "Staff Schedule," dated 03/27/2022-07/21/2022 reveals no BHT is scheduled for patient census of 22 on night of 07/13/2022.

R. Record review of Facility's [Name of Unit] "Staff Schedule," dated 03/27/2022-07/21/2022 reveals no BHT is scheduled for patient census of 25 for night of 07/14/2022.

S. Record review of P2, Patient Observation, dated 05/06/2022 documents One-on-One direct patient observation requiring 1 additional trained personnel for unit staffing. The need for One-on-One direct patient care reveals that on this date, there was no additional staff assigned to the unit by the facility to meet the needs of all patients.

T. Record review of P3, Patient Observation, dated 07/14/2022-07/21/2022 documents One-on-One direct patient observation requiring 1 additional trained personnel for unit staffing. The need for One-on-One direct patient care reveals that on this date, there was no additional staff assigned to the unit by the facility to meet the needs of all patients.

U. Refer to tags 0145 and 0165 for sentinel event and inappropriate use of medical restraint to P1.

V. Refer to tag 0145 for sentinel event to P10.

Based on record review and interview the facility failed to develop a care plan that meets the patients' needs and to assign the nursing care of each patient in accordance with the patients' needs for 3 (P2, P3, P10) of 10 (P1-P10) patients reviewed. This failed practice led to patient harm by allowing a patient to be sexually assaulted by another patient, psychosocial harm, and potential suicide lethality (the capacity to cause death or serious harm).

The findings are:

Findings for Patient 2:
A. Record review of Facility Policy Titled, "Observation Levels Policy," effective date 01/14/2016, revision date 07/19/2022, states Item III.3. "One to One ... The staff member should never be farther away than staff can intervene to ensure safety. The patient remains within the ability of staff to intervene at all times."

B. Record review of P(patient)2, Provider Order Summary, Admit Service date of 05/05/2022 at 11:50 pm and a discharge date of 05/06/2022 at 6:27 pm, shows a patient observation order from S(staff)9, Psychiatrist, for "One to One, Arm's length" acknowledged by S12, Charge Nurse, on 05/06/2022 at 0138 (1:38 am).

C. In an interview with S7, Director of Behavioral Health (DBH), on 08/11/2022 at 2:54 pm, S7 states, "It looks like he [P2] was ordered as that (one to one observation: arm's length) at 0138 (1:38 am) in the morning (of 05/06/2022)." S7 confirmed 1:1 (One-on-One) observation order was active until discharge as indicated in medical record.

D. Record review of P2, Patient Observation Form (15-minute rounding), dated 05/06/2022, shows the following boxes checked: "Line of Sight," "1:1," "Sexually Acting Out." At time of incident 15:45 (3:45 pm) documentation of patient location and activity completed by staff is illegible.

E. Record review of P2, Medical Record, shows no Nursing Care Plan to address One-on-One patient observation for duration of P2's admission beginning 05/05/2022 at 11:50 pm.

F. Observation of video camera 27, dated 05/06/2022 shows P2 entering another patient's [P1] room at 3:34 pm and no staff present until staff enters room at 3:41 pm and removes P2 from the room.

G. In an interview with S(staff)1, Behavioral Health Technician (BHT), on 08/10/2022 at 11:00 am, S1 stated "We heard something, some scuffling and opened the door. When we opened the door, he [P2] had his mouth on her [P1] breast and hand touching the other breast."

Findings for Patient 3:
H. Record review of facility's Policy titled, "Observation Levels Policy" effective date 01/14/2016, revision date 07/19/2020, documented page 1.III.para2. "The Registered Nurse may not decrease an observation level. The attending physician/designee should be contacted to provide the level of observation order. Any discontinuation of monitoring or lessening of the level of monitoring should be by physician/designee order."

I. Record review of P3, Patient Observation Orders, date of admission 07/13/2022 at 11:45 am, documented, "Psychiatric Observation Observe Every 15 Min(utes)," created by RN at 12:36 pm.

J. Record review of P3, Patient Observation Orders, dated 07/14/2022 at 10:13 pm, documented, "Psychiatric Observation One-on-One, Line of sight, Created by [RN]."

K. Record review of P3, Patient's Plan of Care, with an initiation date 07/14/2022 through 07/21/2022, shows no Nursing Care Plan to address One-on-One patient observation.

L. Record review of P3, Patient Observation Orders, dated 07/21/2022 at 11:14 am, reveals, "Psychiatric Observation Every 15 min(minutes) ... D/C (discontinue) 1:1. Created by RN."

M. In an interview with S7, DBH, on 08/09/2022 at 3:35 pm, S7 states, "The physician is the one who is assessing [P3] and based off his observations and the nurse's reports, (physician) decides that the patient is safe to come off (One-on-One observation)."

N. Record review of P3, Patient Observation Orders, dated 07/21/2022 at 11:14am, shows no physician order or signature for discontinuation of One-on-One patient observation.

Findings for Patient 10:
O. Record review of Facility's Policy titled, "Observation Levels Policy," dated 01/14/2016, revision date 07/19/2020, reveals on page 3.11.2 "One to One: ...Criteria for this level of observation may include: Patient is highly volatile, impulsive (score greater than 20 on the checklist for aggression, sexually acting out) and/or suicidal requiring constant observation within immediate reach."

P. Record review of P10, Patient Observation, dated 07/11/2022-07/17/2022 shows no order for One-on-One observation per Suicide Precautions and Facility's Policy.

Q. Record review of P10, Patient Plan of Care, dated 07/11/2022-07/17/2022, shows no Nursing Care Plan to address One-on-One patient observation.

R. Record review of P10, Nursing Assessment, date of admission: 07/11/2022 at 9:12 pm, shows no Suicide Lethality Score documented.

S. Record review of P10, Patient Observation Orders, on 07/11/2022 at 9:50 pm, documented, "Psychiatric Patient Observation Observe Every 15 min (minutes) ... created by RN (Registered Nurse).

T. Record review of P10, Suicide Precautions, on 07/11/2022 at 9:52 pm, documented, "Suicide Precautions: assign appropriate level of safety check/observation ... created by RN."

U. Record review of P10. Nursing Assessment, dated 07/12/2022 at 1:57 am, states, "Patient safety issues: Suicide Risk High."

V. Record review of P10, Nursing Assessment, dated 07/12/2022 at 8:00 am, documented, "Total score for Suicide Lethality Scale: 106."

W. Record review of P10, Suicide Precautions, on 07/12/2022 at 8:00 am, documented, "Suicide Precautions: Assign appropriate level of safety check/observation ... created by RN"

X. Record review of P10, Provider Notes, dated 07/12/2022 at 10:55 am, States, "[P10] is currently on one-to-one observation because of her active suicidal ideation and recent sedation," Signed by Nurse Practitioner (NP).

Y. Record review of P10, Nursing Notes, on 07/12/2022 at 1:17 pm, documented, "Patient was extremely agitated and trying to gag herself ... Patient remains 1 to 1 at this time."

Z. Record review of P10, Nursing Assessment, dated 07/13/2022 at 12:02 am, documented, "Total score for Suicide Lethality Scale: 129."

AA. Record review of P10, Suicide Precautions, on 07/13/2022 at 11:51 pm, documented, "Suicide Precautions: Assign appropriate level of safety check/observation ... created by RN."

Based on record reviews and interview, the facility failed to ensure that assigned personnel was competent and qualified to monitor and/or care for 10 (P1 - P10) of 10 (P1-P10) patients reviewed. This deficient practice to ensure staff had proper qualifications can likely cause injury, serious harm, or death to all patients.

The findings are:

A. Record review of facility policy titled; "Observation Levels Policy" dated 07/19/2020 under "II. Responsibility: Inpatient Behavioral Health Staff. III. Policy, Three levels of patient monitoring are provided to ensure each patient receives the optimal level of safety in the lease restrictive manner. 1. Standard Observation (document at approximately 15-minute intervals); 2. Line of Sight (may use a sitter) (document at approximate 15-minute intervals, at a minimum); and 3. One to One which cannot be assigned a sitter. It should be a staff member with documented training and competencies related to observation and de-escalation of behavioral health patients. The staff member should never be farther away than staff can intervene and ensure safety. The patient remains within the ability of staff to intervene at all times (staff member constantly with the patient documents at approximate 15-minute intervals at a minimum). Definitions: Standard Observation: Minimal level of observation for all patients (approximately every 15 minutes). Line of Sight: A level of observation wherein the patient remains in staff view at all times. A specific staff member (can be a sitter) is assigned, and the line of sight observation is maintained by staff in person and not through video monitoring (NOTE: One staff can be assigned more than one patient, when appropriate). One to One (1:1): Consists of one to one staff observation of a patient by the assigned staff member who should never be farther away than staff can intervene and ensure safety. The patient remains within the ability of staff to intervene at all times. NOTE: Reference is made to documentation of rounds approximately every 15 minutes. Rounds are completed within 3 minutes of either side of each quarter hour. IV. Procedure; 5. During waking hour, observations should include "checking in" with patient verbally to ensure their safety and well-being, and identity needs for assessment or intervention. 9. Standard Observation; 9.2 Observations may not be completed standing in a doorway or at a distance, particularly for patients who are sleeping. It is expected that staff should enter the room, approach the patient, and check their identity, respirations, and ensure they are not in any distress. 11. One to One: 11.6 When a patient is sleeping in their bedroom, the staff member may be at the doorway with direct visual observation of the patient and should physically walk over to the patient at least every 15 minutes to check for respirations and any signs of distress.

Findings for P2:

B. Record review of Staff (S1) BH (Behavioral Health) Patient Observation form for Patient (P) 2 dated May 6, 2022, shows Observations: Check every 15 minutes, Line of Sight, and 1:1 monitoring. Precautions: Sexual Acting Out. No 15-minute patient check completed between 3:30 am and 4:00 am. 1 15-minute check completed outside of the window stated in the facility policy (rounds are completed within 3 minutes of either side of each quarter hour). 20 out of 41 patient location/activity codes entered by staff are not clear enough to read, indecipherable, 2 of 3 staff signatures showing checks have been completed are not clear enough to read who the staff member was that completed the check. 28 of 41 staff initials do not match signature/initials box of staff. 1 of 41 entries are not initialed by staff showing who completed the check on the patient.


C. Interview with Staff 1 (S1) on 08/10/22 at 11 am; when asked what kind of training was received, staff answered "I spent 1 week downstairs going through policies and procedures. I then went up to floor and shadowed another person for a week."

D. Record review of P2 video recording from 05/06/22 3:34 pm to 3:42 pm.
a) 3:34 pm, P2 is seen in hallway in proximity of P1's room.
b) 3:34 pm, P2 is seen standing at doorway of P1's room.
c) 3:34 pm, P2 is seen pushing opened door of P1's room and standing inside. P1 can be seen lying in bed.
d) 3:35 pm, P2 is seen stepping behind opened door of P1's room as another patient walks by doorway.
e) 3:35 pm - 3:41 pm, P1's door is closed with P2 inside room.
f) 3:41 pm, shows two behavioral health techs (BHT) S1 and S2 opening door to P1's room.
g) 3:41 pm, door to P1's room is open and one BHT can be seen on video.
h) 3:41 pm, BHT is removing P2 from P1's room.


Findings for P3:
E. Record review of 30 BH Patient Observation forms for P3 dated July 13, 2022, to August 11, 2022, shows 3 of 30 records show missed 15 minute patient checks, 8 of 30 records have illegible location/activity codes, 5 of 30 records are missing location/activity codes, 2 of 30 records are missing staff initials on 15 minute checks, 27 of 30 records have staff initials that do not match signature/initial box for staff, 2 of 30 records are missing staffing initials on 15 minute checks, 8 of 30 records have illegible times written in for 15 minute checks, and 2 of 30 records were completed outside of the window stated in the facility policy.

F. Record review of P3 video recording from 07/14/22 6:33:16 pm to 6:49:59 pm.
a) 6:33 pm, BHT is unlocking P10's door and letting patient into room.
b) 6:33 pm, patient P10 in room, door is left open and P3 is standing outside
c) 6:34 pm to 6:36 pm, P3 is seen in front of P10's room staring inside and pacing, walks away, walks back into room and again walks away when RN exits nursing station across the hall from room.
d) 6:39 pm - 6:44 pm, P3 is pacing in front of P10's room while tech and RN are walking up and down hallway.
e) 6:44 pm, P3 begins to walk in P10's room, is stopped by unknown patient and they stay in front of P10's door.
f) 6:45 pm - 6:47 pm, P3 begins to walk into P10's room, is again stopped by unknown patient, then are seen talking inside of patients room. Both P3 and unknown patient exit the room and are seen talking in front of P10's room again.
g) 6:47 pm, P3 steps inside P10's room and begins to close the door. Unknown patient is on other side of door trying to keep it from closing.
h) 6:47 pm, RN and 2 BHT's are seen rushing out of nursing station across to P10's room and getting P3 out of room.

Findings for P1:
G. Record review of 45 BH Patient Observation forms for P1 dated April 27, 2022 to June 10, 2022, shows 10 of 45 records showing missed 15 minute patient checks, 23 of 45 records show illegible location/activity codes, 4 of 45 records are missing staff initials on 15 minute checks, 36 of 45 records have staff initials that do not match signature/initial box for staff, 14 of 45 records have illegible times written in for 15 minute checks, 4 of 45 records have incorrect, illegible or are missing date on form, and 9 of 45 records are missing observations/precautions marked on form.

Findings for P4:
H. Record review of 5 BH Patient Observation forms for P4 dated April 25, 2022, to April 29, 2022, show 1 of 5 missing date on form, 1 of 5 missing observations/precautions marked on form, 5 of 5 records have staff initials that do not match signature/initial box for staff, 2 of 5 records show illegible location/activity codes, 2 of 5 have illegible times written in for 15-minute checks.

Findings for P7:
J. Record review of 6 BH Patient Observation forms dated July 19, 2022, to July 24, 2022, show 6 of 6 records have staff initials that do not match signature/initial box for staff, 4 of 6 records show missing observations/precautions marked on form, 4 of 6 records show illegible location/activity codes and 1out of 6 records were completed outside the window stated in the policy.

Findings for P5:
K. Record review of 7 BH Patient Observation forms for P4 dated April 26, 2022 to May 2, 2022 show 1 of 7 forms are missing the date, 1 of 7 records were completed outside of the window stated in the facility policy, 7 of 7 records have staff initials that do not match signature/initial box for staff, 2 of 7 records missing observations/precautions marked on from, 5 of 7 records show illegible times written in for 15 minute checks and 7 of 7 records show illegible location/activity codes.

Findings for P6:
L. Record review of 5 BH Patient Observation forms dated May 09, 2022 to May 13, 2022 show 3 of 5 records were completed outside of the window stated in the facility policy, 5 of 5 records have staff initials that do not match signature/initial box for staff, 3 of 5 records are missing observations/precautions marked on form, 2 of 5 records show illegible times written in for 15 minute checks, 4 of 5 records show illegible patient location/activity codes, and 2 of 5 records show missed 15 minute patient checks completed.

Findings for P8:
M. Record review of 30 BH Patient Observation forms dated July 13, 2022, to August 11, 2022 show 28 of 30 records have staff initials that do not match signature/initial box for staff, 22 of 30 records show illegible/missing times written in for 15 minute checks, 27 of 30 show illegible location/activity codes, 3 out of 30 records show missed 15 minute patient checks completed, 1 of 30 records show missing staff initials for 15 minute check, 3 of 30 records were completed outside the window stated in the policy, 2 of 30 records show signature/initial box was not filled out by any staff members, 7 of 30 records show missing observations/precautions marked on form, and 5 of 30 records are missing date on form.

Findings for P9:
N. Record review of 3 BH Patient Observation forms dated April 27, 2022, to April 29, 2022, show 3 of 3 records have staff initials that do not match signature/initial box for staff, 1 of 3 records show illegible times written in for 15-minute checks, and 3 of 3 records show illegible location/activity codes.

Findings for P10:
O. Record review of 8 BH Patient Observation forms dated July 11, 2022, to July 17, 2022, show 7 of 8 records have staff initials that do not match signature/initial box for staff, 6 of 8 records show illegible times written in for 15-minute checks, 1 of 8 forms are missing observations/precautions marked on form, and 8 of 8 records show illegible location/activity codes.



46901

Based on record review and interview the facility failed to ensure adequate supervision over personnel to ensure they were adhering to the facilities policies and procedures for 1 (P3) of 10 (P1-P10) patients reviewed by permitting patients to congregate in a hallway in front of patient rooms. This failed practice led to patient breaking rules which caused psychosocial harm to P10.

The findings are:

A. Record review of a policy titled, "Patient Admission Procedures [Name of Unit] Policy," effective date 09/01/2004, revision date 04/26/2017, states Item C.2. "Patient will be given the patient handbook which includes an outline of program, rules and expectations, visiting hours, telephone usage, snack break policies, and other facilities and services."

B. Record review of an undated document titled, "Patient Information [Name of Unit] Behavioral Health & Wellness," which is included in the patient handbook, states, "Patients are not permitted in each other's rooms or in the doorway of other patients."

C. Observation of video camera 11, dated 07/14/2022 starting at 6:33 pm shows P3 pacing in front of P10's room. P3 stops, stares and stands in the doorway of P10's room multiple times throughout the video. There are 3 different staff that walk by P3 while he is pacing or standing in front of the doorway. Staff do not intervene. At 6:47 pm, P3 attempts to enter P10's room and forcefully shuts the door, another patient tries to stop the door from closing. Four staff located in the Nurses' Station across from P10's room, come out and open the door. P3 then leaves P10's room.

D. Record review of P3, Nursing Assessment, dated 07/13/2022 at 6:01 pm, states "Patients goals/hopes for admission ... have sex for the first time."

E. Record review of P3, Patient Medical Record, shows no interventions or precautions implemented to prevent sexual acting-out at time of admission.

F. Record review of P3, Nursing Notes on 07/14/2022 at 7:00 pm, states "I wanted to rape her [P10]."

G. Record review of P3, Nursing Care Plan, created on 07/15/2022 at 2:44 am, states "History of Violence ... Attempted to rape peer ... thinks its ok to rape people if you really want to."

H. Record review of P3, Nursing Notes, dated 07/15/2022 at 3:45 pm, addendum 07/15/2022 at 5:24 pm, stated, "at 1700 (5 pm) pt(patient) made a comment in front of group of pts stating 'I was sent by the FBI to rape [P10].' Pt sent to secluded room due to safety of other patients at this time."

I. Record review of P10, [Name of Unit] Group, dated 07/15/2022 at 3:30-4:45 pm, signed at 6:51 pm, states, "Patient chose to attend the group. Patient was an active participant and was polite while peers and group leader spoke and demonstrated activity."

J. In an interview on 08/10/2022 at 10:58 am with Staff (S11), Registered Nurse, States: "No patient is allowed in a room that is not their own, even if it is 2 girls or 2 guys"

Based on record review and observation the facility failed to maintain an infection prevention and control program that includes surveillance, prevention, and control of HAIs (Hospital Acquired Infections), for 2 staff (S) members (S3 and S10) of all staff observed during survey. This failed practice can lead to transmission of infections and can lead to harm for all patients.

The findings are:

A. Record review of facility's "Infection Prevention Program Plan" dated 05/18/22 states, under section titled, "Mission" The mission of the Infection Prevention Program is to reduce the risk of healthcare-associated infections (HCAI) for all patients, employees, licensed independent practitioners, volunteers, visitors, students and any other who enter the facility, and to minimize the morbidity, mortality and economic burden associated with HCAI through surveillance prevention and control measures.

B. On 08/10/22 at 2:30 pm during observation of an interview with Staff (S10) Psychiatrist who walked into the conference room, not wearing a mask, sat down at the table, S6 (Director Risk Manager) came into the room and handed S10 a mask and he put it on. Half-way into the interview he moved the mask under his nose and then took off the mask to finish the interview. He left the conference room with the mask in his hand.

C. On 08/11/22 at 12:35 pm during observation of the cafeteria, S3 (Chief Executive Officer) was not wearing a mask while standing at a table and providing cake and punch to all staff entering the cafeteria.