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Based on medical record review, staff interviews, review of facility documents, and review of video surveillance it was determined that the facility failed to provide care in safe setting by 1.) failing to conduct levels of observation per facility policy (A0144); 2.) failing to mitigate risks identified on the Environment Risk Assessment (ERA) according to facility's plan (A0144); 3.) failing to implement safety measures for patients on the unit (A0144); and 4.) failing to conduct a body, clothing, and belongings search for two of two patients (P1 and P3) upon return to the facility (A0144).

Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting

Based on medical record review, staff interviews, review of facility documents, and review of video surveillance, it was determined that the facility failed to provide care in safe setting by 1) failing to conduct levels of observation per facility policy; 2) failing to mitigate risks identified on the Environment Risk Assessment (ERA) according to facility's plan; 3) failing to implement safety measures for patients on the unit; and 4) failing to conduct a body, clothing, and belongings search for two (2) of two (2) patients (P1 and P3) upon return to the facility.

Findings Include:

1.) Facility policy titled, "Constant Observations and Levels of Observation Including Safety Watch" reviewed 8/22, states, " ...Policy: It is the policy of [facility name] to provide protection when a patient's behavior represents a danger to self or safety of others. ...Levels of Observation: 1. Constant Observation (CO, 1:1) is used for ...destructive behavior. CO is constant visual contact whereas the staff member remains in close proximity of the patient at all times so that the staff may immediately respond to a change in the patient's status. A ratio of a minimum of one staff member to one patient shall always be maintained ...Process/Procedure: Initiation of CO 1. [facility name] Staff identifies that a patient is verbalizing suicidal or homicidal, or destructive acts and notifies the Charge Nurse immediately. The Charge Nurse will notify the Assistant Director of Nursing (ADN)/Nurse Manager. 2. Institutes CO precautions, 1:1 staff to patient ratio, and notifies the LIP [Licensed Independent Practitioner] for the necessity to evaluate within one hour. ...5. The CO orders must be written as one of the following: ...b. 1:1 staff to patient ratio: "Close visual contact" (within eight feet) for patients deemed more at risk for agitated/destructive behavior. ...d. 2:1 staff to patient ratio: For highly agitated/destructive/impulsive behavior. ...Q15, Q30 and Patient Safety/Risk of Fall (Safety Watch) Procedure 1. Q15 checks are appropriate for patients who do not display demonstrated overt ...destructive behavior ...c. Q30-Minute Checks is the standard level of observation on ...12A ... This level would be for patients assessed to be clinically and behaviorally stable, not presenting as an imminent risk to self, others, or property. ...".

On 5/6/24 at 1:58 PM, medical record review was conducted with S8 (Unit Manager). P1 was admitted to 12A on 6/14/23 at 3:08 PM, with a diagnosis of Schizophrenia and Intellectual Disability. P1 had Physicians Orders dated 6/14/23 at 4:53 PM, for "Level of Observation: Q30 MIN". The RN Progress Note on 4/28/24 at 7:26 PM, stated, "Patient was found missing during 1830 [6:30 PM] headcount. The glass window in [his/her] room was found shattered with pieces on the floor. The window screen was also missing ...". The RN Progress Note on 4/28/24 at 9:39 PM, stated, "At approximately 8:45 PM, patient returned from [facility name] ER via stretcher accompanied by [facility name] nursing supervisor and RN. ... Patient right hand (palm) with laceration measuring 5 x 3 cm and abrasion to left thumb. Affected area cleansed and covered with dry dressing. Seen by [doctors name] ROC. Will continue to monitor. ...". The RN Progress Note on 4/29/24 at 12:33 AM, stated, "Patient was AAOx3 (awake, alert, and oriented), received at 11pm start of shift, comfortable sitting in recliner, denies any discomfort or distress, denies any pain. Nursing CO (constant observation) was implemented due to patient safety and risk of another elopement. Patient was seen by [doctors name] to assess laceration wound on [his/her] hand but was unable to suture ...will defer to surgery team to do it later today."

4/29/24 at 8:34 PM, P1 was admitted to unit A1 (Acute Care) and had Physician's order for "Level of Observation: Q15 MIN".

On 5/6/24 at 1:58 PM, S8 stated, "Nursing CO, is nursing close observation, there is no order for this, no documentation form and it is not in any policy, but it is done when a nurse thinks a patient needs to be observed more closely." S8 confirmed Nursing CO is not the same as Constant Observation.

On 5/6/24 at 2:00 PM, S2 (Chief Nursing Officer) and S3 (Director of Nursing) reviewed the facility policy, titled, "Constant Observation and Levels of Observation Including Safety Watch" and confirmed that P1 demonstrated destructive and impulsive behavior by breaking a window, and a 1:1 or Constant Observation should have been ordered. S3 confirmed P1 did not have an order for 1:1 observation or Constant Observation once he/she returned to 12A after eloping.

On 5/7/24 at 2:26 PM, an interview was conducted with S7 (Chair of Psychiatry). S7 stated, " ... [the elopement] was a single event but not baseline for this patient. [P1] is intellectually disabled and impulsive."

The facility failed to implement Constant Observation (CO, 1:1) as per facility policy for P1 who was identified as impulsive and/or destructive after breaking a window with a nightstand and eloping.

2) Facility policy titled, "Constant Observations and Levels of Observation Including Safety Watch" reviewed 8/22, states, " ...15-minute Checks (Q15) are used for all BHS [Behavioral Health Service] inpatient units as the admission level of precaution, with the exception of non-acute units (see Q30 Procedure). Thereafter, level of precaution is based on the acuity and clinical status of the patient. 3. 30-Minute Checks (Q30) are used for BH [Behavioral Health] patients on non-acute units as the standard level of precaution. ...5. Hourly Rounding by Registered Nurses (RN/LPN) (Behavioral Health Division only): The RN/LPN must perform hourly rounding on all patients and document on the Head Count/Evacuation Form ..."

On 5/6/24, a review of the "Environmental Risk Assessment (ERA): Ligature, Suicide and Self-Harm Unit 12A" reviewed 3/30/24, revealed the following: " ...Item Windows/Glass; Risk Interior and exterior should not yield sharp shards of glass when broken that can be used as a weapon; Location Most exterior walls and interior doors; Mitigation Plan Nursing performs Q [every]15/Q30 minutes rounding throughout the unit on a regular basis based on the patient Aquity [sic] ...Item Night Stand; Risk Should be sturdy and heavy as possible to minimize likelihood of patients throwing or using as a weapon; Location Bedrooms; Mitigation Plan Nursing performs Q [every]15/Q30 minutes rounding throughout the unit on a regular basis based on the patient Aquity [sic] ..."

On 5/8/24, a review of facility documents and work orders from the 12/2023 until 5/2024 detailed the following windows were broken on the Behavior Health Units:

On 12/8/23, Unit 12B, Room 33, the facility report stated, " ...Summary on 12/8/23 housekeeper reported broken window in room 33. Patient [initials] who stayed in this room denied any involvement in this incident, stated: "the bird flew into this window." No injury noted on patient, patient removed from the room and room was locked for safety until window will be replaced. ROC [resident on call] examined pt [patient], found to be agitated, STAT meds [medications] were given PO [by mouth]."

On 1/8/24, Unit 12B, Room 32, the Work Order M-360565, stated, " ...Problem: Window ...Reason: 12b-32 window is broken and needs to be fixed ASAP as it is an elopement risk and safety issue. ..." S1 confirmed there was no incident filed for this window, and indicated the broken window was not patient related.

On 4/28/24, Unit 12A, Room 23, the facility report stated, " ...Summary Patient was found missing during 1830 [6:30 PM] headcount. The glass window in [his/her] room was found shattered with pieces on the floor. The window screen was also missing. ..."

On 5/6/24 at 10:40 AM, a tour was conducted on unit 12A. During the tour, Room 23 was observed to have six windows intact. S5 confirmed the broken window was replaced with shatter resistant glass. S5 (Director of Facilities) indicated the window that broke was not shatter resistant. S5 stated, "we replace the glass windows as they break with shatter resistant windows." S5 stated, the window in Room 23 was repaired with "cardboard and had staff observing the room at all times." S5 confirmed three patients were in Room 23, while the window was temporarily repaired with cardboard. Four nightstands were observed to be unsecured and movable in Room 23. All patient rooms within Unit 12A contained nightstands that were unsecured and movable.

On 5/7/24 at 10:44 AM, time stamped video surveillance review of "Bldg 12A East" for P1 was conducted. The video did not contain any audio. S15 (Director of Security) confirmed room 23's doorway was visible in the surveillance video and had a view of the hallway directed towards the nurse's station. Review of the video surveillance dated 4/28/24 revealed the following:

5:27 PM- Staff was observed conducting patient rounding.

6:16 PM- P1's roommate, P4, was observed walking in the hallway and enter Room 23.

6:26 PM- P4 was observed to exit Room 23 and interact with S9 (Registered Nurse-RN) who appeared to be conducting patient rounding, both S9 and P4 walked into Room 23. Upon interview, S8 confirmed S9 was performing patient rounding and, the glass in the window was identified to be broken at this time.

From 6:26 PM- 6:50 PM- multiple staff members entered and exited Room 23, P2 and P4 were observed to enter and exit the room during this time as well.

6:50 PM- Two maintenance workers were observed in the hallway walking into Room 23, carrying what appeared to be a large piece of cardboard and other equipment.

Review of the video surveillance dated 4/29/24 revealed the following:

7:31 AM- S8 and S9 were observed in the hallway and entering Room 23. S8 was present during video surveillance review and confirmed the window had been repaired with cardboard and three patients remained in Room 23 at that time. S8 stated, "I was doing bedside nurse report with [S9]". When questioned if there was a staff member monitoring Room 23 when he/she was at the bedside, S8 stated, "no."

9:37 AM- S9 was observed to set up a chair outside of Room 23. S8 confirmed this was the first time he/she observed a staff member monitoring Room 23.

During the review of the video surveillance, there were no staff member observed monitoring Room 23, on 4/28/24 from 11:00 PM until 4/29/24 at 9:37 AM. This observation was confirmed by S3 and S8. S8 confirmed there was no staff member on the Staffing Assignment Sheets assigned to monitor Room 23, on 4/28-29/24 (11 PM-7 AM) or 4/29/24 (7 AM-3 PM).

Through video surveillance review, there were no staff observed to conduct patient rounds on the 12A hallway during the following times: 4/28/24 from 5:30 PM until 6:27 PM; 4/29/24 from 3:15 AM until 4:00 AM, and 4/29/24 from 6:00 AM until 7:00 AM.

The hallway observed on video surveillance included patient room numbers 17,19, 20, 21, 22, and 23. The rooms had a total of 19 patients assigned, three had a Level of Observation of Q15 minute rounding, 17 had a Level of Observation of Q30 minute rounding. All patients on 12A were ordered RN hourly rounding. The "RN Hourly Safety Round" and "MHA Safety Rounds" documentation indicated the patient rounding was performed, however, review of the video surveillance lacked evidence that rounding was completed per facility policy. On 5/7/24 at 12:25 PM, these findings were confirmed with S3 and S8. The lack of patient rounding by staff on the above-mentioned rooms and including Room 23A with a window that was temporarily repaired with cardboard, lead the facility to fail in mitigating the plan for risks identified on the ERA related to the nightstands and windows.

3) On 5/6/24 at 10:00 AM, S1 indicated on unit 12A, Room 23, P1 broke a window and eloped on 4/28/24. S1 indicated the broken window was temporarily repaired with cardboard on 4/28/24. S1 confirmed three patients remained in Room 23, with one staff member assigned to sit at the room at all times for safety until the window was repaired.

On 5/7/24 at 10:44 AM, time stamped video surveillance review of "Bldg 12A East" was conducted. The video did not contain any audio. Video surveillance review revealed no staff member was observed to be monitoring room 23 on unit 12A, on 4/28/24 from 11:00 PM until 4/29/24 at 9:37 AM, this observation was confirmed S3 and S8. S8 confirmed there was no staff member on the Staffing Assignment Sheets for 4/28-29/24 (11 PM-7 AM) or 4/29/24 (7 AM-3 PM).

4) Facility policy titled, "Safety Searches and Contraband" reviewed 8/22, states, "It is policy ...that the necessary precautions are taken to ensure the safety of all patients and staff. As a means of accomplishing this, searches shall be made of patients, patients' belongings at the time of admission, upon return from pass, ...B. Documentation of the search ...will be completed in a progress note in the patient's medical record. ...Process/ Procedure: Behavioral Health Division A. All patients admitted to a Behavioral Health Division inpatient unit or returning from a pass from Behavioral Health Division unit are required to have a body, clothing, and belongings search. ... Documentation 1. Nursing Progress Notes include: A. Reason for conducting search ..."

Facility policy titled, "Elopements (Unauthorized Discharge)" reviewed 8/22, states, " ...Policy It is the policy of [facility name] that in the event that a patient/resident [facility name] without authorization for discharge efforts will be made to locate the patient and assure that they are in a safe environment. In the event that any patient leaves the Behavioral Health Division without authorization, the following procedure will be initiated. ... Documentation on Medical Record ...d. conduction of search of patient and belongings for; drugs, alcohol, dangerous items ..."

On 5/6/24 at 1:58 PM, medical record review was conducted with S8 (Unit Manager). P1 was admitted to 12A on 6/14/23 at 3:08 PM, with a diagnosis of Schizophrenia and Intellectual Disability. The RN Progress Note on 4/28/24 at 7:26 PM, stated, "Patient was found missing during 1830 [6:30 PM] headcount. ..." The RN Progress Note on 4/28/24 at 9:39 PM, stated, "At approximately 8:45 PM, patient returned from [facility name] ER via stretcher accompanied by [facility name] nursing supervisor and RN. ..."

On 5/6/24 at 2:04 PM, S3 confirmed there was no documentation of a body search completed for P1 once he/she returned to the facility after eloping. S3 stated, "a body search should have been conducted and documented."

At 2:10 PM, review of P3's medical record revealed he/she was admitted on 1/21/22 and diagnosed with major depressive disorder. The RN Progress Note on 2/2/24 at 11:10 PM, stated, "Patient returned from out on pass in a stable condition." The RN Progress Note on 3/1/24 at 4:53 PM, stated, "Returned from pass with sister at 1625 [4:25 PM] in good spirits." S8 confirmed the medical record lacked documentation that body/clothing and belongings search was conducted upon P3's return to the facility.