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Based on document reviews and interviews, it was determined that the Condition of Participation ("CoP") for Governing Body was not met as evidenced by the Governing Body's failure to provide oversight of the hospital as evidenced by the failure to implement all possible strategies to ensure one (1) of ten (10) sampled patient's right to receive care in a safe setting.

Findings:

The Governing Body has failed to provide oversight of the hospital as evidenced by the following:

1. Condition: §482.13 CoP: Patient Rights also known as A-0115 - Based on document review and interviews, it was determined that the Condition of Participation for Patient Rights was not met as evidenced by the hospital's failure to ensure a patient's right to receive care in a safe setting for one (1) of ten (10) sampled patients, who was on safety checks (Patient #6). This patient was sent to an acute care hospital and was discovered to have sustained multiple fractures. See A-0115 for details.

2. Standard: §482.13(c)(2) Patient Rights also known as A-0144 - Based on document review and interviews, the hospital failed to ensure a patient's right to receive care in a safe setting for one (1) of ten (10) sampled patients, who was on safety checks (Patient #6). This patient was sent to an acute care hospital and was discovered to have sustained multiple fractures. See A-0144 for details.

The cumulative effect of these deficient practices resulted in noncompliance with this CoP.

Based on document review and interviews, it was determined that the Condition of Participation for Patient Rights was not met as evidenced by the hospital's failure to ensure a patient's right to receive care in a safe setting for one (1) of ten (10) sampled patients, who was on safety checks (Patient #6). This patient was sent to an acute care hospital and was discovered to have sustained multiple fractures.

Finding:

Standard: §482.13(c)(2) Patients Rights: Care in a Safe Setting also known as A-0144 - Based on document review and interviews, the hospital failed to ensure a patient's right to receive care in a safe setting for one (1) of ten (10) sampled patients, who was on safety checks (Patient #6). This patient was sent to an acute care hospital and was discovered to have sustained multiple fractures. See A-0144 for details.

The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.

Based on document review and interviews, the hospital failed to ensure a patients right to receive care in a safe setting for one (1) of ten (10) sampled patients, who was on safety checks (Patient #6). This patient was sent to an acute care hospital and was discovered to have sustained multiple fractures.

Findings:

Spring Harbor Hospital Policy and procedure statement, titled "Levels of Observation/Freedom of Movement (FOM)", last revised 4/18, indicates: "Patients are assigned a level of observation and freedom of movement based on their clinical presentation. Patients are monitored for safety according to their prescribed level of observation. "Further, "5 minute checks: When prescribed the staff member will conduct checks every 5 minutes and document the patient's location on the designated observation form.
Five-minute checks may be used if the level of acuity requires a more frequent and intensive level of observation than 15 minute checks".

On 2/18/2021, patient #6 was admitted to Spring Harbor Hospital, positive for suicidality and diagnosed with Bipolar Disorder, Post Traumatic Stress Disorder (PTSD), Borderline Personality Disorder, alcohol use disorder, and fibromyalgia. The patient s "Admission History and Physical", dated 2/19/2021, stated the patient had no history of seizures or falls.

On 2/22/2021, the patient had been placed in a hold, due to self-harm, with no apparent injury. The patient completed a orazepam taper alcohol detox protocol on 2/24/2021.

A nursing note, dated 2/27/2021 at 2:04 PM , was written by Nurse #1 who worked the day shift. The noted stated, "... reported to guide [himself/herself] to the floor and start convulsing for approximately 10 seconds ... Provider notified... PT [patient] was non-compliant with requests to keep [his/her] arms still while getting BP [Blood pressure] ...".

A nursing note, dated 2/27/2021 at 11:00 PM , was written by Nurse #2, who had worked the evening shift. The note stated " He/She reported pain in [his/her] neck and both shoulders. TC [telephone call] to PA[physician assistant] on call ... patient reported that [he/she] had a "seizure" and that [he/she] was incontinent of urine ... It was noted that [his/her] speech was thick. Writer asked patient to show [his/her] tongue and it was noted as black and blue with swelling. PA notified again and she came to see patient. She wrote the order to transport patient to MMC [Maine Medical Center] ED [Emergency Department] for evaluation ... [ He/She] left the unit via ambulance at 19:10 [7 :10 PM]".

A Physician Assistant's Progress Note, dated 2/28/2021 (late entry) for service on 2/27/2021 at 2:00 PM, stated "He/She declined serious injury at that time ... [he/she] asked for help, and that [he/she] reiterated that [he/she] wanted to take [his/her] pain away". The Pysician Assistant ordered Seroquel, a medication, and additional Gabapentin, a medication, for fibromyalgia pain.

On 3/10/2021 at 2:51 PM, Psychiatric Technician ("Psych Tech") #1, who worked on the day shift and completed five (5) minute safety checks on 2 West Unit A side corridor was interviewed. She stated the Patient #6.s "bedroom was down at the very end of the corridor, furthest from the nurse's station"; she had not witnessed the patient have a fall or a seizure, but another patient had claimed to witness a fall and seizure, and had informed staff.

On 3/10/2021 at 3:15 PM, Psych Tech #2, who had completed safety checks on the A and B side corridors of 2 West Unit on day shift, was interviewed. She stated she did not see Patient #6 fall or have a seizure.

On 3/11/2021 at 10:19 AM, the PA was intervewed. She confirmed seeing Patient #6 at 11:00 AM as part of patient rounds, again at 2:00 PM, after Nurse #1 contacted her, and again at 6:30 PM after Nurse #2 contacted her. During her assessments at 11:00 AM and 2:00 PM, there did not appear to be any physical injury. In relation to the 2:00 PM assessment, she stated, "I felt like this was likely behavioral and not medical, not a seizure"; she attributed the pain to be "emotional pain" and generalized fibromyalgia pain; and she stated, "I'm absolutely confident [he/she] was not injured at 2:00 PM...[he/she] was lucid and
moving [his/her] arms freely". In relation to the 6:00 PM assessment, she stated, " at 6:00 PM , [he/she] was cradling right arm with left hand and stated [he/she] fell "; she confirmed the patient was on five (5) minute checks on 2/27/2021, due to "regressed" behaviors; and stated, "five (5) minute checks is something Psych Techs do, or a nurse can do them, too... they document where the patient is, if visualized and resting, to ensure patient safety".

On 3/11/2021 at 2:50 PM, in an phone interview with two (2) former patients, both on the phone at once, they recall talking with Patient #6 at the end of 2 West A side corridor on 2/27/2021, when the patient appeared to have a seizure and fell to the ground from a standing position. They recall
Patient # 6"... hit his head and back of shoulders on the floor". One of the patients informed staff "around meal time" and staff went to Patient #6's room "around 5:30 PM".

On 3/12/2021 at 9:11 AM, Nurse #1, who worked the day shift on 2/27/2021 was interviewed and he was specifically asked about the note he wrote in Patient # 6's record on 2/27/2021 at 2:04 PM . He stated, he understood the PA's determination to be a "pseudo-seizure", the patient was coherent, and able to use his/her arms; staff placed their hands under [his/her] arms without any resistance to assist him/her to bed and did not observe swelling of the back or shoulders; and he confirmed the patient was on five (5) minute safety checks, since 9:15 AM on 2/27 /2021, due to regressive behaviors and to ensure patient safety.

On 3/15/2021 at 3:10 PM, Psych Tech #3 who worked the evening shift on 2/27/2021 was interviewed. She confirmed Patient #6 was on five (5) minute checks; it was "hectic due to Epic [new charting system] starting"; there can be up to twenty-four (24) patients on 2 West Unit at full capacity with twelve (12) patients on each corridor; "Some staff do patient checks on one side and record after they finish checks on patients"; she does checks and records in real-time; and safety checks "can get a bit overwhelming and meeting the needs of all patients". She recalls peering into Patient #6's room on 2/27/2021 through an ajar door and stated, "not once did [he/she] say [he/she] was injured or there was a fracture". She did not witness a fall or a seizure. She informed Nurse #2 of Patient #6 stating "help" and a desire to go to the hospital. Nurse #2 assessed Patient #6, notified the PA, who re-assessed the patient, and sent him/her to an acute care hospital for further evaluation.

At the acute care hospital it was discovered Patient #6 had fractured his/her left humerus, right scapula, and had two spine compressions (T-5 and T-6).

Patient #6 was on five (5) minutes checks. It was reported by other patients that the patient had a fall and seizure around the evening meal time. No staff were aware of this ie: witness or heard anything until the other patients reported to them. The client sustained several fractures.