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

Findings include:

1. The hospital failed to ensure that appropiate precautions were put in place for a patient with sexually acting out behaviors. (A-144 A)

2. The hospital failed to ensure completion of an incident report for an allegation of an incident of abuse. (A-144 B)

3. The hospital failed to ensure that seizure precautions were in place and completed as ordered. (A-144 C)

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A. Based on document and interview, it was determined that for 1 of 2 (Pt. #2) patients with history of sexually acting out, the Hospital failed to ensure patient was placed on proper precautions.

Findings include:

1. The Hospital's policy titled, "Precaution System (4/2023)" was reviewed on 3/202/2024 and included, "Sexual aggression: Patient has verbalized intent or has a history of sexual acting out that puts others at risk and is likely to act out if not closely observed. Patient will not be alone with other patients at any time."

2. The Hospital's policy titled, "Patient Rights and Responsibilities (1/2024)" was reviewed on 3/20/2024 and required, "Each patient shall be assured of individualized treatment which shall include: ... Each patient's treatment plan is developed to meet the assessed needs of the patient."

3. On 03/19/2024 at approximately 9:30 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the hospital on 02/04/2024 at 8:35 AM, with a diagnosis of disruptive mood dysregulation disorder. Pt. #2's clinical record included the following:

- The High-risk Notification Alert note dated 02/04/2024 at 8:35 AM, indicated - Pt. #2 on Suicidal Precautions, assault risk precautions, self-harm - hitting himself ...precautions.

- The initial psychiatric evaluation (MD #3) dated 02/04/2024 at 1:39 PM, included, "Patient [Pt. #1] was seen today ... becoming increasingly aggressive at home and has been very angry agitated at times delusional ...self-harming ... mother reports that patient [pt. #2] has not received a proper psychiatric evaluation in the past because she believes that he has cognitive problems ...increasingly violent and sometimes acting sexually inappropriate with his younger brother ...Precautions: Suicide, Assault -patient [pt. #2] remain on Q15s and does not require 1:1 observation due to non-access to preferred means."

- The psychiatrist progress note dated 02/05/2024 at 12:58 PM, included, "Patient [Pt. #2] remains unstable at this point, is hospitalized due to physical aggression ...spoke to mother ...apparently has been now sexually inappropriate with his younger brother and also cruel to animals ..."

- The psychiatrist progress note dated 02/06/2024 at 11:40 AM, included, "Patient [Pt. #2] insists that the ex-roommate [Pt. #1] is lying about this patient sexually abusing him ...and is compliant with medication at this time ...now in the hospital he [Pt. #2] tried to have sex with his roommate [Pt. #1] but also telling us that he did not do anything ...mom report that there is a family history of bipolar disorder runs on the mom side of the family ...current precautions: Suicide, Assault, Self-Injury, and Sexual Aggression ...patient [Pt. #2] is transferred to ATU [acute treatment unit] due to sexually assaulting his roommate [Pt. #1]."

- The nursing progress note by Registered Nurse (E #9) dated 02/05/2024 at 11:49 PM, included, "around 2130 [9:30 PM], a peer [Pt. #1] made a boundary allegation against the patient [Pt. #2], the patient [pt. #2] denied the allegation. Psychiatrist and medical notified, orders carried out, Supervisor aware, and guardian mother notified."

4. On 03/20/2024 at approximately 1:10 PM, the Associate Hospital Administrator (E #7) was interviewed. E #7 stated that she (E #7) was not sure why (Pt. #2) was not placed on precautions for sexually inappropriate behavior prior to the allegations.

5. On 03/21/2024 at approximately 9:30 AM, the Psychiatrist (MD #3) for Pt. #2 was interviewed. MD #3 stated that the patient (Pt. #2) was placed on suicidal and assault precautions. MD #3 stated that the primary and immediate precautions were for suicidal and self-harm and assault, later on during the patient (Pt. #2) stay based on behavior the other precautions as needed could be added to the safety precautions. MD #3 stated that he (MD #3) completed the initial psychiatric evaluation and was not aware of the sexual inappropriate behavior at that time. MD #3 stated that patient (Pt. #2) was brought in for suicidal, assault, and self-harm, so those precautions were the priority.


B. Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) patients with incidents involving abuse, the Hospital failed to file an incident report, in accordance with policy.

Findings include:

1. The Hospital's policy titled, "Patient Rights and Responsibilities (1/2024)" was reviewed on 3/20/2024 and required, "The patient has the right to be free from ... physical abuse. The hospital has trained facility staff to assess and immediately report signs or suspicions of patient abuse or neglect."

2. The Hospital's policy titled, "Prevention Abuse and Neglect & Reporting (9/2022)" was reviewed on 3/21/2024 and required, "Any staff member who receives an allegation by a patient ... that involves abuse, neglect, or harm to a patient must immediately report this information to a supervisor to ensure safety for the patient."

3. The Hospital's policy titled, "Completion of Healthcare Peer reports/Incident Reports (2/2021)" was reviewed on 3/20/2024 and required, "The incident report should be thoroughly completed once the situation is stabilizing during the same shift in which the incident occurred, or as soon as possible. ... manner in which the incident report should be completed: ... Incidents are considered occurrences that are not part of the patient's routine day/care ... Provide a summary of the incident ... Forward report to Risk Management as soon as possible and must be within 72 hours of the incident occurrence."

4. On 03/19/2024 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 02/02/2024 at 3:40 AM with a diagnosis of major depressive disorder. Pt. #1's clinical record included the following:

- The nursing progress note dated 02/02/2024 at 1:32 PM, included, " ...patient called mother and alleged that he was attacked by a peer, but staff said he wasn't hit by any patient. He [Pt. #1] also reported to his [Pt. #1] mother that ...was slammed to the ground by a staff. Per RN and staff that didn't happen ...risk informed ...when patient alleged that he was slammed on the ground by a staff writer cam to the floor assessed the patient and everything was within the normal limits. Writer called the mother and explained the situation, she was understanding, physician notified and patient [Pt. #1] put under staff buddy precaution ..."

-The nursing progress note dated 02/03/2024 at 5:17 PM, included, " ...patient [Pt. #1] mom called to speak to son ...told mom that he had three lumps o his head and did not get medical treatment yesterday ...when pt. [Pt. #1] too meds [medications] in the morning, the nurse asked how he was he told nurse he was okay ...pt's mom [Pt. #1's mom] called and was being disrespectful to staff ...was coming to sign a five-day ...mom called police and the ambulance to the hospital ...when pt. [Pt. #1] went to talk to the police, the patient [Pt. #1] fell out and a code blue was called ...pt. [Pt. #1] was A/OX4 [alert and oriented to person, place, time, and surrounding] and vitals were ok, it did not appear that patient had a seizure ...patient said head hurt and he was bleeding internally ...patient sent to [Name of Hospital B] for further observation ...physician notified ...pt. [Pt. #1] left around 11:40 AM and came back from ER around 2:45 PM ..."

-The physician order dated 02/03/2024 at 11:32 AM, included, " ...Send to ED [emergency department] to examine root perfusion and possible trauma ..."

-The hospital transfer form dated 02/03/2024 at 11:40 AM, included, " ...Time of Transfer 11:40 AM ...Receiving hospital [Hospital B] ...Emergency Room ...Presenting problem: Patient complaining of headache ...Vitals: Blood Pressure: 118/71; Pulse: 74; Respirations: 16; Temperature: 98.4; Mental Status: Alert; Communication Ability: Can speak, can write and understands ...Patient Condition upon Transfer: Stable ..."

-The [Hospital B] ED physician history and physical dated 02/03/2024 at 1:48 PM, included, " ...Chief Complaint: EMS [emergency medical services] reports pt. [Pt. #1] was in altercation last night at [Name of Hospital A] ...reports getting hit in the head and is complaining of foot pain ...acting appropriately on arrival ...denies reports of LOC [loss of consciousness] ...last night he [Pt. #1] was assaulted by other patients, according to the patient was punched on his head, he [Pt. 31] fell and hit his [Pt. #1] back of head ... no loss of consciousness ...pain in his left foot and was limping ...x-ray of foot was negative for fracture ...told patient and the staff that he [Pt. #1] has foot sprain along with head injury, Ace wrap was applied and he was transferred ...needs symptomatic management with icing, ibuprofen ..."

5. On 03/21/2024 at approximately 12:00 PM, the BHU Registered Nurse (E #1) was interviewed regarding (Pt. #1) sent to (Hospital B) via ambulance on 02/03/2024. E #1 stated that that day the mom had called the ambulance and police to the hospital. E #1 stated that she (E #1) always asks patient (Pt. #1) how he was doing, and patient (Pt. #1) had responded that he (Pt. #1) was doing fine. E #1 stated that later after few hours around noon she (E #1) saw the ambulance and the police on the unit to pick up patient to take him (Pt. #1) to the emergency room (Hospital B). E #1 stated that the patient (Pt. #1) then complained about three (3) lumps in his head. E #1 stated that (E #1) assessed the patients (Pt. #1's) head and found nothing no lumps or bruises on head. E #1 stated that as the police was on the unit on 02/03/2024, patient (Pt. #1) had seizures and a code blue was called and the psychiatrist was notified, and patient (Pt. #1) was sent to the (Hospital B) for evaluation. E #1 stated the RN-RN report was obtained from the (Hospital B) and the nurse stated that everything was within normal limits. E #1 stated that she (E #1) was not aware that patient (Pt. #1) had a closed head injury and sprain of the foot. E #1 stated that she (E #1) does not recall Pt. #1 have ace bandage to his (Pt. #1) left foot. E #1 stated that usually when any patient is sent out by ambulance an incident report is completed, but she (E #1) does not recall completing an incident report for that day on 02/03/2024.

6. On 03/21/2024 at approximately 12:15 PM, an additional interview was conducted with (E #7) Associate Hospital Administrator. E #7 stated that the video footage did not show (Pt. #1) having any altercation with other patients on the unit. E #7 stated that there no incident report was completed by nursing staff for this incident.

C. Based on document review and interview, it was determined that for 1 of 2 (Pt #1), clinical records reviewed for patients with seizures, the Hospital failed to ensure that documentation of seizure precautions were in place and updated following a reported seizure episode.

Findings include:

1. The Hospital's policy titled, "Seizure Precautions" (dated 8/2023), was reviewed, and required, " ...Procedure ...Staff will protect patients experiencing seizure activity from injury and/or cessation of breathing ...The Nurse will document all observations and interventions if a seizure occurs in the patient's medical record. The Treatment Team will hold a case conference of the patient has frequent seizures while in the facility. The conference will determine what special precautions are required to protect the patient from injury, i.e., wearing of a helmet, bed rails, escorting patient to activities, etc."

2. The clinical record of Pt #13 was reviewed on 4/2/2024. Pt #13 was voluntarily admitted on 3/15/2024 at 11:48 AM, to 3 West (Adult Behavioral Unit), with a diagnosis of major depressive disorder.

- Pt #13's (Initial) "Integrated Nursing Assessment", dated 3/15/2024, included " ...Risk assessment ...Medical condition ...seizures ...Patient has a vagal nerve simulator implanted in upper left chest ...Patient will be monitored for safety q 15 [every 15 minutes] ..."

- Pt #13's orders included an order for seizure precautions (dated 3/15/2024) to be in place.

- A psychiatric note (dated 3/17/2024 at 10:02 PM) documented by a Psychiatrist (MD #7), included, " ...Patient reported [Pt #13] had a seizure episode last night [3/16/2024] and [Pt #13's] roommate is a witness. [Pt #13] kept saying that [Pt #13] needed to transfer to another facility due to multiple medical issues ..."

- A psychiatric note (dated 3/18/2024 at 11:58 AM), documented by Pt #13's Attending Psychiatrist (MD #1), included, "Chief complaint (in patient's own words) 'I had a seizure on Saturday [3/16/2024-1 day after admission]'. I [MD #1] talked to the patient ...Patient states this past weekend, had a seizure, does not feel comfortable here because of health issues ...Precautions: Suicide ...Treatment plan ...Has a general medical condition (other than mental disorder) requiring hospital care and due to psychological aspects, patient cannot be managed as well on non-psychiatric unit ..." The note did not include any updated seizure precautions.

- A subsequent note by MD #1 (dated - 3/19/2024 at 11:25 AM), included, "Chief Complaint (in patient's own words); 'I was sent to the emergency room'. [2nd seizure] ...Patient became agitated, irritable, stated that brought a seizure. [Pt #`13] was sent to the emergency room ...and was sent back at 11:30 PM. Patient states that [Pt #13] was upset yesterday, states 'staff brought aggression [to] me and that brought a seizure' ...Patient also talked about [Pt #13's] medical issues including seizure that also impacts [Pt #13's] emotional health...watch for seizure ...has been placed one-to-one at night and also has been closely watched by staff during the day. [Pt #13] is on seizure precautions ..."

- On 3/18/2024 at 4:00 PM, a new observation order was entered for "1:1 observation overnight". A 2nd order for "1:1 observation" was placed on 3/19/2024, to modify the timing of the 1:1 to 11pm-7am.

- Pt #13's Patient Observation Record (rounding sheets) from 3/15/2024-3/20/2024, were reviewed. The sheets include an area that staff marks for special precautions. The rounding sheets included only 2 days that seizure precautions were marked (3/15/2024 and 3/16/2024).

- Pt #13's Interdisciplinary Master Treatment plan included the identified problem of seizures (dated 3/15/2024). Pt #13 reported a seizure on 3/16/2024. However, the treatment plan was not updated/revised following the reported 1st seizure episode or after the 2nd seizure when the patient was sent out to the ED (emergency department).

- RN daily Progress notes (pre-printed form), dated 3/15/2024-3/19/2024, included suicide precautions. However, there were no seizure precautions documented on the daily progress notes.

3. On 4/4/2024 at 9:33 AM, an interview was conducted with Psychiatrist (MD #7). MD #7 stated that MD #7 was on-call on the weekend and saw Pt #13. MD #7 stated that Pt #13 told MD #7 that Pt #13 had a seizure on Sunday and that the roommate witnessed it. MD #7 stated that MD #7 told the nursing staff about Pt #13's reported seizure on 3/16/2024 and that they should let the medical team know so that they could consult. MD #7 stated that seizure precautions on a patient would include maintaining close proximity to the patient; putting the patient's room close to the nursing station; and keeping the patient in the dayroom for close monitoring.

4. On 4/4/2024 at approximately 11:45 AM, an interview was conducted with a Unit Manager (E #35). E #35 stated that the treatment plan should be updated after a seizure event. E #35 stated that Pt #13's treatment plan was more than likely not updated since the 1st seizure was not witnessed by staff. E #35 reviewed and acknowledged that Pt #13's treatment plan was not updated after the 2nd seizure (3/18/2024). E #35 stated that there is a box for the staff to mark seizure precautions on the rounding sheets. E #35 stated that if there is an order for seizure precautions, then it should be marked on the patient's rounding sheets.

Based on document review and interview, it was determined that for 1 of 1 (Pt #13) clinical record reviewed, the hospital failed to ensure that nursing reviewed a patient's medical record prior to admission, in order to ensure the patient's medical needs were met.

Findings include:

1. The hospital's policy titled, "Procedures Regarding Inquiry Calls and the Scheduling of Assessments" dated 7/2022, was reviewed, and required, " ...Anyone calling for information about services will be offered an assessment ...and the information regarding the call will be documented on an Inquiry Call Form ...An inquiry Call Form is completed with the documentation regarding the assessment status ..."

2. The clinical record of Pt #13 was reviewed on 4/2/2024. Pt #13 was voluntarily admitted on 3/15/2024 at 11:48 AM, to the 3 West (Adult Behavioral Unit), with a diagnosis of major depressive disorder.

- Pt #13's "Inquiry Call Information" sheet (dated 3/15/2024), documented by the Intake Specialist (E #40), that includes the assessment and referral (A&R) information prior to admission, was reviewed. The sheet included: the patient's presenting problems/precipitating crisis; risk factors; if the assessment was completed; and if nursing and doctor were notified of referral. Pt #13's sheet indicated that Pt #13 had a history of seizures 1 month ago and has a seizure magnet. The section that indicates if the doctor or nurse were notified, was left blank. According to the Hospital's exclusionary criteria list (utilized prior to admission), Pt #13's seizure disorder falls under the "yellow" zone which requires approval from the nursing supervisor or doctor prior to admission. The clinical record and assessment and referral lacked nursing notes, prior to admission indicating if Pt #13 was medically cleared for admission.

- Pt #13's (Initial) "Integrated Nursing Assessment", dated 3/15/2024 on admission, included "...Medical condition ...seizures ...Patient has a vagal nerve simulator implanted in upper left chest ...Patient will be monitored for safety q 15 [every 15 minutes] ..."

3. On 4/2/2024 at 1:25 PM, an interview was conducted with the Director of A &R (Assessment and Referral/E #43). E#43 stated that prior to a patient being admitted, the A&R staff receives a call from either the ED or the community. E #43 stated that then A &R staff fill out the "Inquiry Call Sheet", gather all the information, and then look at the Exception Criteria list. E #43 stated that the Exception list has either green, yellow, or red areas. E #43 stated that if the patient falls within the green category, then the patient could be accepted into the facility. E #43 stated that if the patient has conditions that fall into yellow category, then the A & R staff should consult with the nursing staff or nursing supervisor to see if the facility can manage and accept the patient. E #43 stated that Pt #13 had a seizure disorder that falls under the yellow category. E #43 stated that the A &R staff should document on the inquiry sheet if the nursing supervisor was notified and aware of the patient that is either in the yellow or red (not allowed to be admitted at all) category on the exception list. E #43 acknowledged that Pt #13's "Inquiry Call Sheet" lacked documentation of a nursing supervisor being notified of Pt #13's admission.

4. On 4/3/2024 at 9:27 AM, an interview was conducted with the Intake Clinician (E #40). E #40 stated that E #40 did the intake for Pt #13. E #40 stated that Pt #13 had a magnet for an implant that was in the patient's chest. E#40 stated that if a patient has medical concerns, their department has to "run" the patient's medical information by the nursing supervisor to review. E #40 stated that since Pt #13 was in the "yellow zone" due to the seizure disorder, the chart should have reviewed by the nursing supervisor prior to admission. E #40 acknowledged that there should have been documentation on Pt #13's "Inquiry Call Information" sheet that indicated that the nursing supervisor was contacted.

5. On 4/3/2024 at 9:55 AM, an interview was conducted with a RN (E #11/Pt #13's Admitting RN). E #11 stated that E #11 did Pt #13's admission as the patient came here for suicidal ideation. E #11 stated that Pt #13 had a lot of medical issues and a vagal stimulator for seizure management. E #11 stated that when a patient is admitted, there is a verbal report from the A & R department. E #11 stated that when the patient is admitted, the nurse calls the MD (medical doctor) to get orders and let them know what medications that patient is currently taking. E #11 stated that E #11 is not sure what the process is on medically clearing a patient. E #11 stated that from what E #11 knows, Pt #13 was medically cleared by the sending hospital's ED (emergency department) prior to coming here (to this hospital).