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Based on review of medical records, review of facility policy and procedures, and staff interviews the facility failed to promote and protect patient rights for 3 (#1, #2 and #3) of 4 patients. Refer to A0144.

Based on review of medical records, review of facility policy and procedures, and staff interviews, the facility failed to ensure a safe setting for 3 (#1, #2, #3) of 4 patients.

Findings included:

Review of the facility policy "Protection from Abuse, Neglect and Exploitation" last reviewed 09/19/2022. Policy states no individual served by Centerstone will be subjected to physical or verbal abuse by any employee or patient/client.

Review of Patient #1's medical record revealed the patient was admitted on 06/29/2023 for schizoaffective disorder, bipolar type. Review of Physician documentation on 06/30/2023 showed Patient #1 was noted pacing and demanding to be let out early in the morning. He began banging on the double doors. The staff brought an ETO (Emergency Treatment Order- medications used in hospitals to calm patients who are endangering themselves or staff) and a restraint chair. The patient lunged at the staff resulting in the staff to perform a take- down (when a patient is forced down and immobilized for application of a restraint). Review of the nurse's notes revealed Patient #1 resisted verbal de-escalation and physically fought staff members. Patient #1 was taken to the floor where an ETO medication was administered. It was at that point the nurse noticed deformity to right forearm and an abrasion to the right side of the forehead from the carpet. The patient was then sent to an acute care hospital for evaluation.

Review of the video footage with no audio from 06/30/2023 with Staff A, Vice President of Quality (VPQ), Patient #1 was pacing the halls, Staff E, Behavioral Health Technician (BHT), noted to bring in a restraint chair. After bringing in restraint chair, Patient #1 walked past the chair and down the hall. Upon returning, Staff E, BHT wrapped his arms around Patient #1 and body slammed Patient #1 to the ground. Then Staff G, BHT laid on top of both Patient #1 and Staff E, BHT. Staff F, Registered Nurse (RN) was seen stepping on Patient #1's right arm as she leaned over him.

On 01/31/2024 at 10:35 AM, an interview was conducted with Staff D, Case Manager/BHT. During the interview, she stated Staff E told the patient to get into the restraint chair himself or the staff will put him in the chair. Soon after that was said, the take- down occurred.

On 01/31/2024 at 12:00 PM, an interview was conducted with Staff A, VPQ. During the interview, she stated the take down was unnecessary and Staff E BHT, Staff F RN and Staff G BHT were sent home and taken off the schedule during the timeframe of the investigation. After investigating and reviewing the video footage, Staff E, BHT, Staff F, RN and Staff G, BHT were terminated.

Review of Patient #2 medical record revealed the patient was admitted on 09/13/2023 for alcohol abuse and generalized anxiety. Review of nurse's notes on 09/13/2023 revealed patient #2 was admitted on a voluntary basis seeking help with alcohol detoxification. Patient #2 uses a cane for assistance with ambulation. Review of nurse's notes on 09/14/2023 revealed Patient #2 was observed on video falling to the ground because another patient had pushed him, and subsequently complained of neck pain. Patient #2 was taken to an acute care hospital for evaluation. Review of Physician notes on 09/18/2023 revealed Patient #2 had to be reminded he experienced a fall and that he was sent out to an acute care hospital for evaluation and was sent back to facility with no concerns. Patient #2 verbalized concerns that he may have early signs of dementia stating that he will not drive himself as he is afraid he will get lost. Patient #2 reports his sister has dementia.

On 01/31/2024, review of video footage with no audio from 09/14/2023 with Staff A VPQ was conducted. Video shows Patient #2 walking down the facility hallway with his cane for assistance. At the end of the hallway, Patient #2 is seen walking into another patient's room. He is then seen falling back to the ground and the other patient is standing over him with Patient #2's cane. Then staff is seen running down the hallway toward the patient.

On 01/31/2024 at 11:00 AM, an interview was conducted with Staff A, VPQ. During the interview, Staff A, VPQ stated when we investigated the incident, the staff said Patient #2 was known to pace the hallways and sometimes even wander into other patients' rooms. The staff also said they knew the other patient at the end of the hallway was in his room and was agitated. When Patient #2 walked down the hallway, he wandered into the agitated patient's room and that patient got up and pushed Patient #2 down for coming into his room. The staff was not watching Patient #2 carefully when he walked down towards the agitated patient's room.

Review of patient #3 medical record revealed patient was a 15-year-old patient admitted on 11/10/2023 for Bipolar Disorder, severe depression and suicidal ideation. Patient #3 ordered visual observation, 1:1 (For patients identified as high risk for suicide who have access to ligature or other safety risks, constant 1 to 1 visual observation must be implemented.) at all times. Review of physician's notes from 11/11/2023 showed Patient #3 stated "I wanted to kill myself". Patient #3 admits to swallowing a loose piece of metal that was lying around her bathroom and experienced abdominal pain. Patient #3 then states prior to swallowing the metal, she also swallowed glass. Patient #3 was transferred to this facility after being medically cleared at an acute care hospital. Review of nurse's notes revealed on 11/17/2023 Patient #3 came to staff at the medication window and stated, "I've done something bad, but not to anyone else, just myself." When asked what Patient #3 did, she stuck her tongue out and revealed 8-10 staples. Patient #3 was advised multiple times to spit the staples out, but she stated she did not want to and wanted to hurt herself. Patient #3 then walked away from the medication window and went to sit near a window. When approached by another staff member to spit the staples out, Patient #3 stated "I will not. I want to kill myself, and by any means necessary, I will, and you cannot stop me." Patient #3 then swallowed the staples. The Physician was notified, and Patient #3 was transferred to an acute care hospital for evaluation. Review of physician notes on 11/18/2023 reveals, Patient #3 was sent out last night after showing numerous staples in her mouth to staff and then proceeded to swallow them before staff could intervene. Patient #3 was transferred to an acute care facility for evaluation and was medically cleared. Upon return, Patient #3 states she found the staples in coloring books on the unit.

On 01/31/2024, review of video footage with no audio from 11/17/2023 with Staff A, VPQ and Staff C, OM (Operations Manager) was performed. Based on video surveillance, Patient #3 is seen sitting at a table with 2 other patients placing multiple things in her mouth and not spitting them back out. Staff C, OM verifies a behavioral health technician is sitting in the corner of the room watching Patient #3 and not stopping her from eating items.

On 01/31/2024 at 11:00 AM, an interview was conducted with Staff A, VPQ. Staff A stated when we investigated the incident, we discovered the therapy intern brought in magazines/pamphlets that were held together by the staples and left them in the day room. Her reasoning for bringing them in is for an art project. The therapy intern did not think about the staples being a safety issue for the patients.

On 01/31/2024 at 01:45 PM, a follow up interview was conducted with Staff C, OM. Staff C, OM stated Staff A, VPQ asked me to review the video. The video shows Patient #3 sitting at a table with 2 other patients. They seem to be talking, laughing, coloring with markers and dancing in their seats; there is no audio unfortunately. Throughout the video, you can see Patient #3 putting things in her mouth and not spitting anything back out. The behavioral health technician is not in the view, but I was told she is sitting in the corner of the room watching them. She did not stop the patient from putting things in her mouth.

Based on facility record review and interviews conducted, the facility failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program for 1 of 1 QAPI program. Refer to A0286.

Based on video review, interview conducted, and record review, the facility failed to analyze events involving patient harm without prompt intervention in order to seek effective preventive measures to protect the patients in 1 of 1 QAPI program. The lack of sufficient safety measures places all patients at risk for harm.

The findings included:

Review of the Facility Quality Management Plan for Fiscal year 2023-2024 revealed Quality Management Plan (QPM) Purpose . . . to identify opportunities to improve care through intentional and proactive collection and analysis and interpretation of data, to evaluate performance trends . . . To monitor the implementation and evaluation of performance improvement activities.

Review of Patient #1's medical record revealed the patient was admitted on 06/29/2023 for schizoaffective disorder, bipolar type. Review of Physician documentation on 06/30/2023 showed Patient #1 was noted pacing and demanding to be let out early in the morning. He began banging on the double doors. The staff brought an ETO (Emergency Treatment Order- medications used in hospitals to calm patients who are endangering themselves or staff) and a restraint chair. The patient lunged at the staff resulting in the staff to perform a take-down (when a patient is forced down and immobilized for application of a restraint). Review of the nurse's notes revealed Patient #1 resisted verbal de-escalation and physically fought staff members. Patient #1 was taken to the floor where an ETO medication was administered. It was at that point the nurse noticed deformity to right forearm and an abrasion to the right side of the forehead from the carpet. The patient was sent to an acute care hospital for evaluation.

Review of the video footage with no audio from 06/30/2023 with Staff A, Vice President of Quality (VPQ), showed Patient #1 was pacing the halls. Staff E, Behavioral Health Technician (BHT), noted to bring in a restraint chair. After bringing in restraint chair, Patient #1 walked past the chair and down the hall. Upon returning, Staff E, BHT wrapped his arms around Patient #1 and body slammed Patient #1 to the ground. Then Staff G, BHT laid on top of both Patient #1 and Staff E, BHT. Staff F, Registered Nurse (RN) was seen stepping on Patient #1's right arm as she leaned over him.

On 01/31/2024 at 12:00 PM, an interview was conducted with Staff A, VPQ. During the interview, she stated the take down was unnecessary and Staff E BHT, Staff F RN and Staff G BHT were sent home and taken off the schedule during the timeframe of the investigation. After investigating and reviewing the video footage, Staff E, BHT, Staff F, RN and Staff G, BHT were terminated.

Review of Patient #2 medical record revealed the patient was admitted on 09/13/2023 for alcohol abuse and generalized anxiety. Review of nurse's notes on 09/13/2023 revealed Patient #2 was admitted on a voluntary basis seeking help with alcohol detoxification. Patient #2 uses a cane for assistance with ambulation. Review of nurse's notes on 09/14/2023 revealed Patient #2 was observed on video falling to the ground because another patient had pushed him, and subsequently complained of neck pain. Patient #2 was taken to an acute care hospital for evaluation. Review of Physician notes on 09/18/2023 revealed Patient #2 had to be reminded he experienced a fall and that he was sent out to an acute care hospital for evaluation and was sent back to facility with no concerns. Patient #2 verbalized concerns that he may have early signs of dementia stating that he will not drive himself as he is afraid he will get lost. Patient #2 reports his sister has dementia.

On 01/31/2024, review of video footage with no audio from 09/14/2023 with Staff A VPQ was conducted. Video shows Patient #2 walking down the facility hallway with his cane for assistance. At the end of the hallway, Patient #2 is seen walking into another patient's room. He is then seen falling back to the ground and the other patient is standing over him with Patient #2's cane. Then staff is seen running down the hallway toward the patient.

On 01/31/2024 at 11:00 AM, an interview was conducted with Staff A, VPQ. During the interview, Staff A, VPQ stated when we investigated the incident, the staff said Patient #2 was known to pace the hallways and sometimes even wander into other patients' rooms. The staff also said they knew the other patient at the end of the hallway was in his room and was agitated. When Patient #2 walked down the hallway, he wandered into the agitated patient's room and that patient got up and pushed Patient #2 down for coming into his room. The staff was not watching Patient #2 carefully when he walked down towards the agitated patient's room.

Review of patient #3 medical record revealed patient was a 15-year-old patient admitted on 11/10/2023 for Bipolar Disorder, severe depression and suicidal ideation. Patient #3 ordered visual observation, 1:1 (For patients identified as high risk for suicide who have access to ligature or other safety risks, constant 1 to 1 visual observation must be implemented.) at all times. Review of physician's notes from 11/11/2023 showed Patient #3 stated "I wanted to kill myself". Patient #3 admits to swallowing a loose piece of metal that was lying around her bathroom and experienced abdominal pain. Patient #3 then states prior to swallowing the metal, she also swallowed glass. Patient #3 was transferred to this facility after being medically cleared at an acute care hospital. Review of nurse's notes revealed on 11/17/2023 Patient #3 came to staff at the medication window and stated, "I've done something bad, but not to anyone else, just myself." When asked what Patient #3 did, she stuck her tongue out and revealed 8-10 staples. Patient #3 was advised multiple times to spit the staples out, but she stated she did not want to and wanted to hurt herself. Patient #3 then walked away from the medication window and went to sit near a window. When approached by another staff member to spit the staples out, Patient #3 stated "I will not. I want to kill myself, and by any means necessary, I will, and you cannot stop me." Patient #3 then swallowed the staples. The Physician was notified, and Patient #3 was transferred to an acute care hospital for evaluation. Review of physician notes on 11/18/2023 reveals, Patient #3 was sent out last night after showing numerous staples in her mouth to staff and then proceeded to swallow them before staff could intervene. Patient #3 was transferred to an acute care facility for evaluation and was medically cleared. Upon return, Patient #3 states she found the staples in coloring books on the unit.

On 01/31/2024, review of video footage with no audio from 11/17/2023 with Staff A, VPQ and Staff C, OM (Operations Manager) was performed. Based on video surveillance, Patient #3 is seen sitting at a table with 2 other patients placing multiple things in her mouth and not spitting them back out. Staff C, OM verifies a behavioral health technician is sitting in the corner of the room watching Patient #3 and not stopping her.

On 01/31/2024 at 11:00 AM, an interview was conducted with Staff A, VPQ. Staff A stated when we investigated the incident, we discovered the therapy intern brought in magazines/pamphlets that were held together by the staples and left them in the day room. Her reasoning for bringing them in is for an art project. The therapy intern did not think about the staples being a safety issue for the patients.

On 01/31/2024 at 01:45 PM, a follow up interview was conducted with Staff C, OM. Staff C, OM stated Staff A, VPQ asked me to review the video. The video shows Patient #3 sitting at a table with 2 other patients. They seem to be talking, laughing, coloring with markers and dancing in their seats; there is no audio unfortunately. Throughout the video, you can see Patient #3 putting things in her mouth and not spitting anything back out. The behavioral health technician is not in the view, but I was told she is sitting in the corner of the room watching them. She did not stop the patient from putting things in her mouth.

On 01/31/2024 at 02:00 PM, an interview was conducted with Staff A VPQ. Staff A stated after reviewing the incident plans for Patient #1, #2 and #3, I am now seeing there was no plan put into place to prevent any of the incidents from occurring in the future. During that time, there was no Risk Manager, so I was acting as the VP Quality and the Risk Manager. There were people helping me with the risk manager role, but I know was ultimately responsible as the risk manager. The people helping with the role were the ones that completed the incident plans, and I did approve them. I did the best I could covering both roles.

On 02/01/2023 at 12:47 PM, an interview was conducted with Staff H Director of Nursing (DON). Staff H states based on the review of the incidents that occurred, I've been brainstorming and have come up with some ideas that we could utilize in the future Some of these ideas include better management of patients that are on 1 to 1 observation, immediate notification and discussion for events with safety concerns, reminders to staff to remove items brought in to the patient day room when they leave, and reviewing safety competencies quarterly instead of annually.

Review of Inpatient Quality and Safety Agenda meetings from June 2023 to January 2024 revealed no mention of patient safety events or action plans.