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Based on observation, interview and record review, the hospital failed to meet the Condition of Participation (COP) for Patient Rights when:

1. The hospital failed to inform 32 of 32 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13, Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, and Patient 32) of the patient's rights to be free from all forms of abuse including financial, emotional and neglect. (Refer to A 116)

2. The hospital failed to provide Notification of Patient Rights for 3 of 32 sampled patients (Patient 18, Patient 32, and Patient 26). (Refer to A 116)

3. The hospital failed to obtain information about Advance Directives (a legal document that indicates a person's wishes for medical treatment) for one of 32 sampled patients (Patient 18). (Refer to A 132)

4. The hospital failed to provide care in a safe environment. (Refer to A 144)

5. The hospital failed to investigate four of four sampled patients' (Patient 1, Patient 2, Patient 3, and Patient 4) incidents in a timely manner. (Refer to A 145)

6. The hospital failed to protect one of 32 sampled patients (Patient 2) from sexual abuse. (Refer to A 145)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provisions of patient's right to be provided care in a safe environment.

Based on interview and record review:

1.The hospital failed to ensure 32 of 32 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13, Patient 14, Patient 15, Patient 16, Patient 17, Patient 18, Patient 19, Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, Patient 26, Patient 27, Patient 28, Patient 29, Patient 30, Patient 31, and Patient 32) of the patient's rights to be free from all forms of abuse including financial, emotional and neglect. This failure had the potential to result in financial, emotional abuse or neglect to go unnoticed by staff.

2. The hospital failed to provide 3 of 32 sampled patients (Patient 18, Patient 32, and Patient 26) Notification of Patient's Rights. This failure had the potential to result in Patient 18, Patient 32, and Patient 26 or guardians being unaware of their rights.

Findings:

1. During a concurrent interview and record review on 8/11/22, at 10 AM, with Health Information Management Director (HIMD), Patient 17's "Patient Rights Notification" (PRN), dated 6/3/22 was reviewed and the PRN, indicated, ". . . 12. Receive care in a safe setting, free from verbal or physical abuse or harassment. You have the right to access protective services including notifying government agencies of neglect and abuse." HIMD reviewed the hospital wide patient rights being provided to all patients and or guardians and confirmed it was incomplete. The form did not include emotional, financial or neglect. HIMD stated, "That's what we give to all patients on admission. I don't know why it only includes verbal and physical abuse and not including the other forms like sexual, financial, and others there's a lot of forms of abuse."

During a concurrent interview and record review on 8/11/22, at 11:30 AM, with Chief Nursing Officer (CNO), CNO reviewed the PRN. CNO stated, "Yes this [Patient Rights-Hospital Wide] is what we provide to all patients. I see it's not complete it should include the other forms of abuse [Financial, sexual, emotional]."

2a. During a concurrent interview and record review on 8/11/22, at 10:15 AM, with HIMD, Patient 18's Medical Record (MR) was reviewed. HIMD was unable to find documentation of PRN provided to Patient 18 or guardian. HIMD reviewed Patient 18's MR twice and stated, "It's not here."

2b. During a concurrent interview and record review, on 8/11/22, at 10:18 AM, with HIMD, Patient 32's MR was reviewed. HIMD was unable to find documentation PRN was provided to Patient 32 or guardian. HIMD stated, "I can't find it."



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2c. During a concurrent interview and record review on 8/12/22, at 2:51 PM, with CNO, Patient 26's MR, undated was reviewed. CNO stated, she was not able to find the PRN in Patient 26's MR, and stated it should have been in the MR.

Based on interview and record review, the hospital failed to obtain information regarding Advance Directives (AD-a legal document that indicates a person's wishes for medical treatment) for 1 of 32 sampled patients (Patient 18). This failure had the potential for staff to be unaware of the patient's and/or legal representative's wishes for treatment.

Findings:

During a concurrent interview and record review on 8/11/22, At 10:15 AM, with HIMD, Patient 18's medical record (MR) was reviewed. The MR indicated, Patient 18 was admitted on 6/7/22 and no documentation of AD. HIMD reviewed Patient 18's MR for the second time and was unable to find AD documentation.

During a review of the hospital's policy and procedure (P&P) titled, "PATIENT RIGHTS-HOSPITAL WIDE" (undated), the P&P indicated, "8. Formulate advance directives . . . All patient's rights apply to the person who has legal responsibility to make decisions regarding medical care on your behalf."

Based on observation, interview, and record review, the hospital failed to provide care in a safe environment for four of 32 sampled patients (Patient 1, Patient 2, Patient 20, and Patient 21) when:

1a. Patient 2 was not consistently observed every 5 minutes according to Physician (MD) order.

1b. Patient 1, a registered sex offender, recently released from jail and with Suicide/Self Harm, Assault (A threat or attempt to inflict offensive physical contact of bodily harm on a person)/Homicide (When one human being causes the death of another), and Sexual Acting Out (SAO) precautions was placed in a room with Patient 2 who was identified as vulnerable (A person in need of special care, support, or protection because of age, disability, or risk of abuse or neglect) and gravely disabled (Because of mental illness, the person cannot take care of his/her basic, personal needs.).

These failure resulted in an alleged sexual abuse of Patient 2 by Patient 1 and caused emotional distress to Patient 2.

2. Patient 20, (identified as a danger to others DTO), was a placed in a room with Patient 21, (identified as vulnerable).

This failure placed Patient 21 to be at risk for repeated incidents of abuse by Patient 20 and had the potential to cause Patient 21 emotional distress.

Findings:

1a. During a concurrent observation and interview on 8/15/22, at 11:45 AM, with Risk Manager (RM), in the conference room, of the hospital's video survellance recording, the video date stamped 7/19/22 between 6:10.27 PM and 6:34:18 PM was observed and noted the following:

At 6:11 PM, Patient 2 went into room 607 wearing a green gown.
At 6:12.34 PM, Patient 1 went into room 607, Patient 2 was in the room.
At 6:13.01 PM, Patient 2 came out of room 607 not wearing the green gown and went back in. Patient 1 still in the room
At 6:13.04 PM, Patient 2 came out of room 607. Patient 1 in the room
At 6:15.18, Patient 2 went back to room 607, Patient 1 in the room
At 6:16 PM, Patient 1 came out of the room wearing a blue shirt and a short gray pants.
At 6:17 PM, Patient 1 went back to room 607, Patient 2 in the room
At 6:18.59 PM, Patient 1 came out of the room, tying his pants. Patient 2 still in the room 607
6:19.28, Patient 1 went back to room 607. Patient 2 in the room. Entry door closed
6:20 PM, Mental Health Worker (MHW) 3 arrived and stayed in the hallway by the day room holding a clip board but did not observe Patient 1.
6:25.3 PM, Patient 1 peeked out by the door of room 607 not wearing a shirt, Patient 2 in the room. Door closed.
6:32.37 Patient 2 came out of room 607 wearing light blue shirt and dark colored short pants. Patient 1 still in room 607
6:34.18 PM, Patient 1 came out of room 607 and went to dayroom.

RM confirmed Patient 1 and Patient 2 were in room 607 from 6:19.28 PM through 6:32.38 PM approximately 13 minute. MHW 3 did not observe Patient 1 every 5 minutes as ordered by the Physician on 7/19/22, at 6:20 PM, 6:25 PM, and 6:30 PM.

During an interview on 9/12/22, at 9 AM, with MHW 3, MHW 3 stated, "I was on my second day off of orientation. I was assigned to observe [Patient 1] every five minutes and [Patient 2] every 15 minutes. The other nine patients are every 15 minutes observation. It gets difficult . . . I was distracted and missed every five minutes observation of [Patient 1] but I documented it as done."

During a review of Patient 1's "Adult Admitting Physician Orders [AAPO]" completed by MD 1 dated 7/15/22, at 11 PM, the AAPO was reviewed and indicated, "OBSERVATION LEVELS: Q [Every] 5 Minutes Interval . . . TYPE OF PRECAUTIONS: Suicide/Self Harm Assault/Homicide SAO. . ."

During a concurrent interview and record review on 8/11/22, at 10 AM, with HIMD, Patient 1's "OBSERVATION ROUNDS/PRECAUTION [ORP]" dated 7/19/22 was reviewed. The ORP indicated, there was no documentation Patient 1 was observed every five minutes according to MD order on 7/19/22, at 12:15 PM, 12:20 PM, 12:25 PM, 12:30 PM, and 12:35 PM. HIMD stated, "Nobody documented."

During a concurrent interview and record review on 8/11/22, at 10:18 AM, with CNO. Patient 1's ORP dated 7/19/22 was reviewed. The ORP indicated, there was no documentation Patient 1 was observed at 12:15 PM, 12:20 PM, 12:25 PM, 12:30 PM, and 12:35 PM. At 6:20 PM, 6:25 PM, and 6:30 PM, MHW 3 documented Patient 1 was observed but did not show on the recorded video observed. CNO stated, "Yes I see that."

During a review of Patient 2's "Physician Progress Note [PPN]" (undated,) the PPN indicated, "Subjective Report: Sexually Inappropriate w/ [with] peer in the unit . . ."

During a review of hospital's policy and procedure (P&P) titled "Rounds of Patient Observation" dated 3/12/21, the P&P indicated, "POLICY: All patients will be routinely observed in compliance with physician orders and prescribed protocol . . . 8. Every 5 Minute Observations b. Staff will observe patient and document on the Patient Observation Record every 5 minutes. c. Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress. . . "

1b. During an interview on 8/9/22, at 2 PM, with Director of Quality and Risk Department (DQRD), DQRD stated, "House supervisor completes the intake, gets the report and makes the decision where to put the patient. [Patient 2], a 19-year-old male was admitted to Unit 600 Adult Unit on 7/12/22. [Patient 2] is vulnerable. [Patient 1] a 30-year-old male, registered sex offender, was just released from jail was admitted on 7/15/22 and was placed to Unit 600 as [Patient 2's] roommate." DQRD confirmed Patient 1 should have been placed in a room without a roommate because of all Patient 1's precautions.

During an interview on 8/9/22, at 2:48 PM, with Patient 2, Patient 2 stated, "I was in a room [Bathroom] and somebody came in [Patient 1], he pinned me down and told me about a lot of bad things and gang activities. It was in the rest room. He was trying to rape me and let me do things I was uncomfortable. He pinned me, I was standing, and he pushed me to the wall, grabbed my leg tight and did sexual (sic) to my penile area. I was very scared. [Patient 1] was from prison and I was very scared. I told [case manager]. I am just 19 years old and in a group of older people."

During an interview on 8/9/22, at 3:15 PM, with Case Manager (CM) 1, CM 1 stated, "[Patient 2 was being discharged the next day, so it was on 7/19/22 after 5 PM, around 6:45 PM in Unit 600 where [Patient 2] was. [Patient 2] reported to me he did not want to be roommate with [Patient 1] because [Patient 1] was sexually abusing [Patient 2]. [Patient 2] gave [Patient 1] oral sex and [Patient 1] was suggesting different sexual acts and it happened few minutes ago. I reported it to the night nurse, then I spoke to House Supervisor (HS).

During an interview 8/10/22, at 10:46 AM, with Intake Registered Nurse (IRN) 3, IRN 3 stated, on 7/15/22, early morning, IRN 3 received Patient 1's referral from Psychiatric Evaluation Center (PEC) regarding (Patient 1's) pending placement to a state hospital, just released from jail, a registered sex offender, sex molestation, indecent exposure, and gravely disabled. IRN 3 was not comfortable accepting Patient 1. IRN 3 brought the case to the 10 AM meeting and presented to Chief Executive Officer (CEO). Before 3:30 PM, Director of Intake Department (DID), and Social Services Director (SSD) instructed IRN 3 to accept Patient 1. Hand off report was given to night house supervisor (HS 1). IRN 3 stated Patient 1 should have not been placed in a room with another patient specially with a vulnerable patient like Patient 2. IRN 3 also stated the hospital does not have a process to identify precautions of other patients like Patient 2.

During an interview on 8/10/22, at 11:35 AM, with Social Services Director (SSD), SSD stated, "I'm not involved in assigning beds or accepting patients. I was consulted prior to admission of [Patient 1] as far as his current presentation: not exhibiting sexual behaviors. CEO and DID are the ones who accept or not accept patients."

During an interview on 8/11/22, at 10:18 AM, with CNO, CNO stated Patient 1 should have been placed with no roommate.

During an interview on 8/15/22 at 9:38 AM, with DID, DID stated, "When patient comes in, the Intake staff gets the patient's information. Intake staff is responsible for assigning patient's room. Every morning meeting, we talk about acuities of each Unit's patients, we consider age, precautions, and patients for discharge. The Intake staff calls the unit to give basic information about the patient being admitted. A couple of weeks ago this was changed to calling the house supervisor instead of the unit nurse. House Supervisor (HS) has an input. MHW in the unit enter the patient's information to the computer. . . For any Intake department staff's concerns re: medical problems they are supposed to call the psychiatrist and get approval to accept." DID added, "Regarding [Patient 1], the packet was received from PEC early of the day on 7/15/22. [Patient 1] has some legal issues like a registered sex offender. The CEO was called and referred us to SSD to let us know. [SSD] brought back the paperwork and said we can take [Patient 1] on "SAO" precaution and "No Roommate". [SSD] and I talked to [IRN 3] to call PEC. Before I left, I added on the bed board "NO ROOMMATE" and I emailed everyone working that weekend and the house supervisor. There was definitely a room for 'NO ROOMMATE' for [Patient 1]. I don't know why [Patient 1] was placed with a roommate. I don't know if there's a process for identifying the roommate's precautions."

During a review of Patient 1's medical record (MR), the "Intake Assessment" dated 7/15/22 was reviewed and indicated "SEXUAL ACTING OUT RISK [SAO] SCREEN Behavior Observations 5 points Manic state, 5 points Sexually explicit speech, comments. Hx [History] of sex offender. SEXUAL RISK SCORE: 10. 6-14 Moderate Risk: RN to consult MD [Physician] for SAO precaution and discuss any additional necessary orders or practices of the following: blocked room/"no roommate" status, "distance rule" from peers. . ."

During a review of the hospital's policy and procedure (P&P) titled, "Room Assignments and Responsibilities" dated, 1/23/19, the P&P indicated, "PURPOSE: To provide a safe environment for patients. To ensure nursing observation and care are provided. To take into consideration patient's compatibility with others. POLICY: Patients will be assigned rooms according to their level of acuity, needs and compatibility. . . PROCEDURE . . . The Charge Nurse will review the initial assessment/admission request packet and determine a room assignment. Patients who are assessed and identified to be eminent threat to self or others will be placed on 1:1 [One nurse to one patient] . . . to assure patient safety."



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2. During a review of the hospital's "Bed Board Report" (BBR), dated 6/3/22, the BBR indicated, "Patient 20 and 21" were roommates.

During a review of Patients 20's "Intake Assessement" (IA), dated 6/3/22, the IA indicated, "Danger to Others - Score of 20 - Do not room with vulnerability patient."

During a review of Patient's 21's "IA" dated 6/3/22, the IA indicated, "Vulnerability Risk Screen - Score of 15 - Do not room with a patient on DTO (Danger or SAO precautions."

During a concurrent interview and record review, on 8/12/22, at 11:45 AM, with CNO, Patient 20 and Patient 21 IA's dated 6/3/22 were reviewed. CNO stated, Patient 20 and Patient 21 should not have been roommates according to their high risk precautions. CNO stated, we have an opportunity for improvement and the process for assigning roomates based on high risk precautions will be changed. CNO stated, intake staff had been assigning roomates and did not look at each patients high risk precautions prior to placing patients in rooms.

During an interview on 8/15/22, at 9:38 AM, with DID, DID stated the Intake staff had been responsible for assigning rooms, and that process will be changed.

During a review of the hospital's policy and procedure (P&P) titled, "Room Assignments and Responsibilities," dated 1/23/2019, the P&P indicated, "Purpose: To provide a safe environment for patients . . . Procedure: High-risk patients will be assigned a designated high-risk unit for evaluation, observation and supervision."

Based on interview and record review, the hospital failed to follow it's policy and procedure on abuse to ensure:

1. One of 32 sampled Patients (Patient 2) was protected from abuse when Patient 2 reported Patient 1 had forced him to perform sexual acts. This failure resulted in violating Patient 2's rights to be free from any form of abuse.

2. Investigations for allegations of abuse were completed in five business days for four of 32 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 4). This failure resulted in incomplete investigations and had the potential for future occurrences of abuse.

Findings:

1. During an interview on 8/9/22, at 2:48 PM, with Patient 2, Patient 2 stated, "I was in a room [Bathroom] and somebody came in [Patient 1], he pinned me down and told me about a lot of bad things and gang activities. It was in the rest room. He was trying to rape me and let me do things I was uncomfortable. He pinned me, I was standing, and he pushed me to the wall, grabbed my leg tight and did sexual (sic) to my penile area. I was very scared. [Patient 1] was from prison and I was very scared. I told [case manager]. I am just 19 years old and in a group of older people."

During a review of Patient 2's "Nursing Progress Notes" (NPN) dated, 7/19/22 at 8 PM, the NPN indicated, " per pt (Patient 2), sometime before start of PM shift, pt's [Patient 1] roommate (after shower) made him do lewd [offensive in a sexual way] acts on one another. Pt (Patient 2) reported this to Social Worker around 7 pm . . . "

During a review of Patient 2's "Social Service Progress Notes" (SSPN) dated, 7/19/22 at 6:45 PM, the SSPN indicated, ". . . Case Manager (CM 1) met with patient to go over discharge plan and forms. At this time, (Patient 2) reported his peer and roommate performed oral sex on him, felt manipulated and threatened to continue to engage in sexual acts. Writer asked him to stay in common room areas unitl nurses speak with him and change [sic] him rooms."

During an interview on 8/9/22, at 3:15 PM, with CM 1, CM 1 stated, "[Patient 2] was being discharged the next day, so it was on 7/19/22 after 5 PM, around 6:45 PM in Unit 600 where [Patient 2] was. [Patient 2] reported to me he did not want to be roommate with [Patient 1] because [Patient 1] was sexually abusing [Patient 2]. [Patient 2] gave [Patient 1] oral sex and [Patient 1] was suggesting different sexual acts and it happened few minutes ago. I reported it to the night nurse, then I spoke to HS. I went back to my desk and reported to Administrative on call (AOC).

During an interview on 8/12/22, at 3:53 PM, with House Supervisor (HS) 1, HS 1 stated, she recalled the night Patient 1 was admitted. HS 1 stated, the intake nurses were busy with admissions and [HS 1] completed Patient 1's assessment. HS 1, reviewed Patient 1's history and knew [Patient 1] had a history of being a sexual predator. HS 1 stated, we had no rooms at that time for him to have his own room. HS 1 stated, "I did not call the administrator because I was running the floor and had to help the intake nurses." HS 1, stated, "I didn't check the roommates precautions."

During a review of the hospital's policy and procedure (P&P) titled, "Abuse, Identifying, Reporting, and Facility Initiated Investigations" dated 4/4/22, the P&P indicated, "Policy All patients have the right to be free from physical or mental abuse of any form . . . 1. Prevention: [Hospital] is fully committed to preventing abuse and neglect and to review specific incidents for "lessons learned" which form a feedback loop for necessary process and policy change. . . iv. the assessment, care planning, and monitoring of patients with special needs or behaviors that may require additional resources to safetly manage, without neglecting the care needs of any other patient on the unit."




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2. During a review of the hospital's "Self-Report Boundary Violation Allegation" dated 7/20/22 (25 days ago), the Self-Report Boundary Violation Allegation, indicated, "An alleged event involving (2) patients [Patient 1 and Patient 2] was reported on Tuesday, 7/19/22. [Patient 2], an adult patient reported to staff a boundary violation involving peer [Patient 1].

During a review of the hospital's "Self-Report Boundary Violation Allegation" dated 7/22/22 (23 days ago), the Self-Report Boundary Violation Allegation, indicated, "An event involving (2) patients [Patient 3 and Patient 4] was reported Friday, 7/22/22. A possible boundary violation between two adolescents. [Patient 3 and Patient 4] while in the unit."

During an interview on 8/15/22 (25 and 23 days later), at 11:26 AM, with Chief Nursing Officer (CNO), CNO stated the investigations of the incidents (abuse allegations) were not completed. CNO stated, "We will complete the investigations today [25 and 23 days later]."

During a review of the hospital's policy and procedure (P&P) titled, "Abuse: Identifying, Reporting, and Family Initiated Investigations" dated 4/4/22, the P&P indicated, "Results of investigations will be reported within 5 working days of the occurrence and if the alleged violation is substantiated, appropriate corrective action is taken."

Based on observation, interview, and record review, the hospital did not meet the Condition of Participation (COP) for the Nursing Services as evidenced by:

1. The hospital failed to develop an individualized plan of care for one of 32 sampled patients (Patient 6) with autism (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave). (Refer to A 396)

2a. Ensure a neuro check (assess a patient's neurological functions, motor and sensory response, and level of consciousness) was initiated timely for one of 32 sampled patients (Patient 6) who had a head injury. (Refer to A 395)

2b. Ensure a continuous monitoring and assessment for one of 32 sampled patients (Patient 6) who was in seclusion. (Refer to A 395)

2c. Ensure an assessment was initiated immediately for one of 32 sampled patients (Patient 5) who eloped (ran away). Patient 5 was carried back to the facility and was showing signs and symptoms of a possible seizure (uncontrolled electrical disturbance in the brain). (Refer to A 395)

3. The hospital failed to ensure the Chief Nursing Officer (CNO) met the requirements of the job. (Refer to A 1702)

These failures resulted in delayed care and potential for adverse health outcomes for all patients.

The cumulative effect of this systemic failure resulted in negatively impacting the safety and quality of care, treatment, and services to all patients.

Based on observation, interview, and record review, the hospital failed to:

1. Ensure a neuro checks (assess a patient's neurological functions, motor and sensory response, and level of consciousness) were initiated timely for one of 32 sampled patients (Patient 6) with a head injury.

2. Ensure continuous monitoring and assessment for one of 32 sampled patients (Patient 6) who was in seclusion (involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving).

3. Ensure an assessment was initiated immediately for one of 32 sampled patients (Patient 5) who eloped (ran away) when Patient 5 was carried back to the facility and was showing signs and symptoms of a possible seizure (uncontrolled electrical disturbance in the brain).

These failures resulted in delayed care for Patient 5 and Patient 6 and had the potential for adverse health outcomes.

Findings:

1. During a review of Patient 6's "Nursing Progress Notes" (NPN) dated 7/16/22, at 5:10 PM, the NPN indicated, "Once seclusion [door] closes, patient [6] bang on door with head, result in cut in forehead [sic]."

During a review of Patient 's "Neurological Assessment and Flowsheet", dated 7/16/22, the Neurological Assessment and Flowsheet indicated, the assessment was initiated at 6:20 PM (one hour later from the head injury was sustained).

During an interview and record review on 8/12/22, at 2:44 PM, with Registered Nurse (RN) 1, RN 1 stated he was the nurse on duty during the placement of Patient 6 in the seclusion room. RN 1 reviewed Patient 6's Neurological Assessment and Flowsheet and stated, "The neuro checks was started at 6:20 PM [one hour later], should have been started immediately for a patient with head injury."

During a review of the hospital's "Neurological Assessment and Flowsheet", no date, the Neurological Assessment and Flowsheet indicated, "Instruction: Vital signs and neurological assessment should be done on the following schedule: Every 15 minutes for 1 hour, Every 30 minutes for 1 hour, Every hour for 4 hours, Every 4 hours for 24 hours."

2. During an observation of the video surveillance on 8/12/22, at 11 AM, in medical records office, the video surveillance date stamped 7/16/22, at 5:21 PM, Patient 6 was in the seclusion room, he hit his head on the door. Patient 6's forehead started to bleed, no staff attended. Patient 6 removed his shirt and held his shirt to his forehead. Patient 6 was pacing and sitting on the floor with his hand on his forehead. Staff entered the seclusion room at 6:01 PM (40 minutes later).

During an interview on 8/12/22, at 2 PM, with Mental Health Worker (MHW) 1, MHW 1 stated, he was sitting on the chair outside the seclusion room, documenting. MHW 1 stated, he should have not seated on the chair and should have continuously visually monitored Patient 6.

During an observation on 8/12/22, at 2:10 PM, outside the seclusion room, the seclusion door had a small glass window, and the chair was two feet away from the seclusion door window. The chair (where MHW 1 was sitting) had no visual access to monitor Patient 6 inside the seclusion room.

During an interview on 8/12/22, at 2:12 PM, with Director of Quality and Risk Department (DQRD), DQRD stated, MHW 1 should be constantly watching Patient 6. Patients in seclusion room require constant visual monitoring.

During a review of hospital's policy and procedure (P&P) titled, "Use of Seclusion and Restraint" dated 7/27/22, the P&P indicated, "The patient is continually monitored face-to-face by an assigned staff member."









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3. During a review of Patient 5's "Face Sheet" (FS) dated 8/2/22, the "FS" indicated, Patient 5 was admitted on 8/2/22 at 1:18 PM.

During a review of Patient 5's "Intake Assessment" (IA) dated 8/2/22, at 3 PM, the "IA" indicated, Patient 5 had a history of acute medical problems, and seizures. "IA" also indicated the patient stated, "I guess I had a seizure."

During a review of Patient 5's "Nursing Admission Assessment" (NAA), dated 8/2/22, at 11:35 PM, "NAA" indicated, "Received Pt [Patient 5] from ER [Emergency Room], awake, alert and verbally responsive, Pt admitted earlier but had to be sent out to ER for medical clearance after Pt upon getting out of car ran away and staff found Pt in park with a guy, Pt per documentation (Nursing) was shaking and rolling eyes."

During a concurrent interview and record review on 8/2/22, at 11:27 AM, with Certified Nursing Officer (CNO), Patient 5's "Medical Record" (MR), undated, the MR indicated, Patient 5 was admitted on 8/2/22, at 1:18 PM, patient had eloped prior to entering the facility. Patient was found in the park and was carried back to the facility. Per documentation Patient 5 was shaking and eyes rolling when Patient 5 was put into the seclusion room, but door was kept open. At 5 PM Registered Nurse (RN) 2 assessed the patient and patient was still unresponsive. RN 2 notified the Physician and obtained an order to send Patient to the ER for further evaluation. CNO stated, there should have been a nursing assessment done as soon as possible, but CNO was unable to find documentation where the patient had been assessed from the time of admission.

During an interview on 8/11/22, at 2:52 PM, with Intake Counselor (IC), IC stated, she had received Patient 5 in front of the hospital. IC stated, when she opened the door to the hospital, the patient ran across the street to the park. IC stated, she and other staff members followed her to the park. She stated Patient 5 went into the men's bathroom and was hiding behind the toilet. IC stated, Patient 5 complained of a stomach ache and witnessed Patient 5 vomiting and clutching both hands and noted her eyes rolling back. IC stated, one of the staff carried Patient 5 to the car and was carried out of the car back to the hospital. IC stated they put Patient 5 into unit 200 on the first floor in the seclusion room. IC stated, she then initiated Patient 5's intake assessment at 3 PM.

During a review of Patient 5's "NPN", dated 8/2/22, at 5 PM, the "NPN" indicated, "[Patient 5] was still quite unresponsive, but breathing. MD notified, ordered to send to hospital ER for further evaluation."

During concurrent interview and record review, 8/15/22, at 10:10 AM, with RN 2, Patient 5's "NPN," dated 8/2/22, was reviewed. The NPN indicated, on 8/2/22, at 5 PM RN 2 documented, "Patient was still quite unresponsive, but breathing. MD notified, ordered to send to hospital ER for further evaluation." RN 2 stated she had been informed that the patient had been shaking and her eyes were rolling back. RN 2 stated, when she assessed the patient, the patient was looking down and still seemed unresponsive but breathing. RN 2 stated, she notified the physician and obtained an order for the patient to be sent out to ER to be evaluated.

During a review of Patient 5's "New Admit Vital Signs" (NAVS), dated 8/2/22, the NAVS indicated, Patient 5's vital signs were recorded on 8/2/22 at 11:50 PM (Approximately 10 hours after admission).

During a review of the hospital's policy and procedure (P&P) titled, "Emergencies-Medical", dated 7/27/22, the P&P indicated, "The nurse will immediately provide an assessment of the patient's physical status."

Based on interview and record review, the facility failed to develop an individualized plan of care for one of 32 sampled patients (Patient 6) with autism (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave). This failure had the potential for patients with autism to not receive the appropriate care.

Findings:

During a review of Patient 6's "Staff Restraint and Seclusion Debriefing", dated 7/16/22, the Staff Restraint and Seclusion Debriefing indicated, "Abrasion, cut to forehead due to head banging on seclusion door. Increased agitation wants to be alone in room. [sic]."

During an interview on 8/12/22, at 9:25 AM, with Registered Nurse (RN) 1, RN 1 stated, Patient 6 was becoming hostile, aggressive and more physical, so he was placed on seclusion and was restrained for few minutes. RN 1 stated, Patient 6 had a diagnosis of autism and so, the intervention is to place in seclusion, no other intervention, and was not given anything because he is autistic. RN 1 stated, "It's [seclusion intervention] a judgement call not to give anything."

During a concurrent interview and record review on 8/12/22, at 3:02 PM, with Chief Nursing Officer (CNO), CNO reviewed Patient 6's clinical record and stated, "I can't find a care plan for the diagnosis of autism." CNO stated, there should be a plan of care or a physician's order not to give anything and how to manage Patient 6's behaviors.

During a review of hospital's policy and procedure (P&P) titled, "Multidisciplinary Treatment Planning" dated 8/20/21, the P&P indicated, "Each patient shall have a written ,individual, comprehensive treatment plan within 72 hours of admission. This must be based on an inventory of the patient's strengths and disabilities, and must include: A substantiated diagnosis; Problem sheets for psychiatric conditions and medical conditions as diagnosed."

Based on interview and record review, the hospital failed to ensure the Chief Nursing Officer (CNO) met all the requirements of the job. This failure had the potential to result in CNO's inability to manage the nursing staff and negatively impact all patients' mental health and safety.

Findings:

During a concurrent interview and record review on 8/11/22, at 11:45 AM, with Human Resources Director (HRD), CNO's personnel file was reviewed and indicated CNO was hired on 6/16/22 with a Bachelor of Science in Nursing (BSN) and a Master of Science in Nursing (MSN). HRD stated, "[CNO] is a new hire."

During an interview on 8/15/22, at 11:26 AM, with CNO, CNO stated, "I went to Bakersfield College for nursing, to California State University of Bakersfield for my BSN and MSN. When I was a new grad (graduate), I worked in telemetry (Unit where patients are under constant monitoring), ICU (ICU-Intensive Care Unit, unit in a hospital providing care for critically ill or injured patients), Medical Surgical, and Emergency Room (ER- department of a hospital that provides immediate treatment for acute illnesses and trauma.) I don't have education on Psychiatric nursing. I don't have a psyche (Psychiatric- specially trained nurses who care for the psychological and physical well-being of people with mental health conditions or behavioral problems) background."