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Based on record review and staff interview, the facility failed to ensure patients had the right to make informed decisions regarding their care (A0131). The facility failed to ensure patients received care in a safe setting (A0144).

Based on record review and staff interview, the facility failed to ensure patients had the right to make informed decisions regarding their care for ten of ten patient medical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10). The active census was 49.

Findings include:

1. Review of the medical record for Patient #1 revealed psychotropic medications were prescribed/administered and no informed consent for psychotropic medications was obtained prior to administration.

2. Review of the medical record for Patient #2 revealed psychotropic medication were prescribed/administered and no informed consent for psychotropic medications was obtained prior to administration.

3. Review of the medical record for Patient #3 revealed psychotropic medications were prescribed/administered and no informed consent for psychotropic medications was obtained prior to administration.

4. Review of the medical record for Patient #4 revealed psychotropic medications were prescribed/administered and no informed consent for psychotropic medications was obtained prior to administration.

5. Review of the medical record for Patient #5 revealed psychotropic medications were prescribed/administered and no informed consent for psychotropic medications was obtained prior to administration.

6. Review of the medical record for Patient #6 revealed psychotropic medications were prescribed/administered and informed consent for psychotropic medications was signed by the Registered Nurse.

7. Review of the medical record for Patient #7 revealed psychotropic medications were prescribed/administered and no informed consent for psychotropic medications was obtained prior to administration.

8. Review of the medical record for Patient #8 revealed psychotropic medications were prescribed/administered and informed consent for psychotropic medications was signed by the Registered Nurse.

9. Review of the medical record for Patient #9 revealed psychotropic medications were prescribed/administered and informed consent for psychotropic medications was signed by the Registered Nurse.

10. Review of the medical record for Patient #10 revealed psychotropic medications were prescribed/administered and informed consent for psychotropic medications was signed by the Registered Nurse.

These findings were confirmed with Staff Q on 12/15/2020 at 8:44 AM.

Based on record review and staff interview, the facility failed to ensure patients received care in a safe setting for two of 10 patients reviewed (Patient #1 and #3). This had the potential to affect all patients admitted to the inpatient psychiatric facility. The active census was 49.

Findings include:

1. Review of the medical record for Patient #1 revealed the patient was admitted to the inpatient psychiatric unit on 11/16/2020 with a diagnosis of schizoaffective disorder. The patient was placed on assault precautions and a fifteen minute observation level. Review of incident reports noted the patient eloped from the facility on 11/18/2020.

Review of the incident report dated 11/18/2020 at 4:45 PM revealed the patient eloped from the Renew psychiatric unit. The nurse was notified by the mental health technician that he/she could not locate the patient on the unit. A code green was called and all doors were found to be locked at this time. The facility notified local law enforcement at 5:15 PM in which it was reported the patient may have been seen on the I-70 freeway. The patient was brought back to the facility by local law enforcement on 11/18/2020 at 6:10 PM.

An interview was conducted with Staff D and Staff H on 12/07/2020 at 12:34 PM who reported this was not a common occurrence for the facility. There was a system glitch from a power surge and/or a power outage with observed flickering of lights. This resulted in the door magnets releasing for a short period of time. They did not know why this occurred and a generator test was not being performed at that time. The facility developed mitigation strategies to ensure patient safety following the incident. Although the door was currently functioning properly they took additional measures and contacted a local vendor on 11/30/2020 for a proposal to install a magnalock to ensure higher security.

Staff H provided an email from the vendor dated 12/07/2020 for the estimated cost to remove the existing maglock and install a new increased holding strength magnalock. The proposal included adjusting and aligning the entire opening of the door for proper closing and latching. In addition, the facility was currently working with special project manager and a city agency for a price quote for installing fencing from the egress areas.

The facility provided the surveyor the mitigation strategies following the elopement. A request was made for any monitoring logs of exit doors leading to the exterior of the building. Staff H advised he/she had no monitoring logs, however nursing may have monitoring logs.

An interview was conducted with Staff E on 12/07/2020 at 12:46 PM who reported he/she rounded on the units daily to ensure doors were locked. A request was made for monitoring of the doors following the elopement incident. Staff E was unable to provide any documented evidence of monitoring of the exit doors upon request.

A phone interview was conducted with Staff Q on 12/09/2020 at 9:13 AM who confirmed the facility had no documented monitoring for exterior doors in egress areas. Effective 12/09/2020 the facility implemented increased daily environmental rounds to include an audit tool for monitoring all doors. This process was not implemented until 12/09/2020 at 12:30 PM during the survey process.

Review of the facility policy titled, "Elopement," dated 02/2019, revealed if the patient is located and returned, staff shall place the patient on Line of Sight observation status and Elopement precautions. The Registered Nurse shall obtain a physician order for the level of observation and precaution.

Further review of the patient's record revealed no evidence any new orders were obtained or that the patient was placed on elopement precautions upon return to the facility as per policy.

This was confirmed in a phone interview with Staff Q on 12/09/2020 at 9:13 AM.

2. Review of the Allegation of Sexual Assault Policy, dated 02/2019, revealed staff will report any assault allegation and maintain a safe and supportive environment for the victim.

Review of the medical record for Patient #3 revealed the patient was involuntarily admitted on 11/21/2020 at 5:30 AM following an emergency room evaluation. The patient had no past history of psychosis and was noted to have received a steroid injection for hip pain on 11/18/2020. Several days later the patient presented to the emergency department due to auditory/visual hallucinations. The patient reportedly was hearing helicopter noises, seeing people outside of his/her home, and exhibiting bizarre behaviors. The physician suspected steroid induced psychosis and found the patient to be a substantial risk to himself/herself and/or others and would benefit from hospitalization for treatment/stabilization.

Review of the nursing intake assessment dated 11/21/2020 at 5:38 AM noted the patient reported her chief complaint upon admission was "I am here to find my future husband." The patient was placed on fifteen minute safety checks with elopement and suicide precautions. The patient was admitted to the inpatient psychiatric facility due to unspecified psychosis.

Review of an incident report for Patient #3 dated 11/21/20 at 8:15 AM revealed an occurrence of patient/patient sexual intercourse. The nurse noted he/she was notified the patient's door her room was closed and moaning could be heard. It was noted the patient was unclothed and lying with her legs open engaged in sexual intercourse with a another patient (Patient #1). Further, the incident report dated 11/22/2020 noted a medical transfer and/or change in patient condition. Patient #3 reported the sexual encounter the prior day was nonconsensual. The patient was to be transferred to a local emergency room to be evaluated by a Sexual Assault Nurse Examiner (SANE) and to be provided Plan B emergency contraception.

Review of the medical record lacked evidence the Registered Nurse completed a nursing assessment until 1:00 PM on 11/21/2020 to evaluate the patient's physical and mental condition. The patient was not moved to another unit until the following day upon return from the emergency room to ensure the patient's safety. In addition, review of the patient observation record failed to include monitoring for sexually inappropriate behaviors.

Review of an 11/19/2020 interdisciplinary plan revealed Patient #1 was exhibiting sexually inappropriate behaviors. Review of Patient #1's observation record revealed the patient was not being monitored for sexually acting out behaviors. The patient was not placed on 1:1 until 11/23/2020 at 11:52 AM for sexually violent behaviors.

This was confirmed in a phone interview with Staff Q on 12/09/2020 at 9:13 AM.

This substantiates Substantial Allegation OH00117550.

Based on medical record review, review of incident reports, and policy review, the facility failed to ensure a registered nurse evaluated the nursing care for one of ten patients reviewed (Patient #2). The active census was 49.

Findings include:

Review of the Medication Administration Policy, revised 08/2020, revealed the effect of the P.R.N. (as needed) medication must be documented after one hour of giving medication.

Review of the medical record for Patient #2 revealed the patient was admitted to the facility on 11/09/2020 following an emergency room evaluation. It was noted the patient required emergency psychotropic medications and restraints while in the emergency department due to aggression.

During the course of the hospitalization the patient displayed very aggressive behaviors toward staff and other patients. He/she was noted as intrusive, with a disorganized thought process, unable to follow commands and/or redirection, and observed pacing the hallway at times. He/She required emergency psychotropic medications to be administered multiple times due to his aggressive-combative behavior. The patient was placed on suicide and elopement precautions with fifteen minute checks for safety.

Review of the prescribed medications included the following; Ativan 1 milligram (mg) intramuscularly (IM) every four hours prn (anxiety), Trazodone 50 mg orally every four hours prn (insomnia), Haldol 5 mg IM every four hours prn (severe agitation), Diphenhydramine 50 mg by mouth every six hours prn (mild-moderate extrapyramidal symptoms (EPS)), Diphenhydramine 50 IM every six hours prn (severe EPS), Hydroxyzine 50 mg by mouth every four hours prn (mild anxiety), Depakote 500 mg by mouth twice a day, Thorazine 50 mg IM now, Cogentin 2 mg by mouth now, Thorazine 100 mg by mouth now, Zyprexa 5 mg by mouth now.

Review of the medication administration record revealed the following medications were administered during the course of the hospitalization:

11/09/2020 at 6:55 PM patient medicated with Ativan, Haldol & Diphehydramine
11/09/2020 at 8:39 PM patient medicated with Trazadone, Hydroxyzine
11/09/2020 at 10:20 PM patient medicated with Ativan, Haldol & Diphehydramine
11/10/2020 at 7:00 AM patient medicated with Ativan, Haldol & Diphehydramine
11/10/2020 at 6:00 PM patient medicated with Ativan, Haldol & Diphehydramine
11/11/2020 at 5:45 AM patient medicated with Ativan, Haldol & Diphehydramine
11/11/2020 at 9:15 AM patient medicated with Ativan, Haldol & Diphehydramine
11/11/2020 at 1:20 PM patient medicated with Ativan, Haldol & Diphehydramine
11/11/2020 at 3:58 PM a telephone order for Thorazine 50 mg IM now (aggression), Zyprexa 5 mg by mouth three times daily (psychosis).
11/11/2020 at 4:45 PM physican order for Cogentin 2 mg by mouth now (EPS), Thorazine 100 mg by mouth now (psychosis), Zyprexa 5 mg by mouth now (psychosis).
11/11/2020 at 9:10 PM Nurse Re-assessment combative physically & verbally this evening. Disorganized thoughts. Medicated with Depakote 500 mg by mouth now.

The medical record lacked evidence the nurse assessed the patient one hour after administering the as needed medications as per policy.

Based on observation, staff interview, and record review, facility failed to ensure policies and procedures were implemented for preventing and controlling the spread of COVID-19. This could affect all patients receiving services from the facility. The active census was 49.

Findings include:

Review of the Policy and Procedure for Emergency Management Plan Annex for Pandemic Pathogen- COVID-19, approved 06/2020, revealed a pandemic disease has the potential to overwhelm the healthcare system and its resources. Effective pandemic planning and preparation requires collaboration between the individual organizations, public health authorities and entire healthcare community to meet the increased demand for services. A pandemic is a global infectious disease outbreak.

A pandemic occurs when an infectious pathogen emerges for which people have little or no immunity, and for which there is no vaccine. The disease spreads easily from person-to-person, causes serious illness, and can sweep across the country and around the world in a very short time. Resources will also be expected to continue to meet non-pandemic associated healthcare needs. Education and training requirements include transmission based precautions and donning and doffing of personal protective equipment.

Review of staff training dated 05/28/2020 titled, "Infection Control: Hand Hygiene, Proper Use of PPE, COVID-19 protocols" revealed participants will learn what is personal protective equipment (PPE), when to wear, and how to properly put on and remove (PPE). Universal precautions is treating everyone as infectious, and the best defense in prevention spread of infections include (PPE) that includes; gloves, masks, face shields, eye protectors, and gowns. In addition, screen all visitors upon entrance to the building. Anyone with an elevated temperature, signs or symptoms must not be allowed to work or stay in the building.

Upon entrance to the building on 12/07/2020 at 8:45 AM the surveyor was not screened for signs and/or symptoms of COVID-19 including a temperature check. This finding was confirmed with Staff D during the entrance conference who stated, "we need to get you screened." The screening did not occur and as a visitor the surveyor was able to move throughout the building.

A tour was conducted on an inpatient psychiatric unit on 12/07/2020 at 2:39 PM. A request was made to identify where personal protective equipment was maintained and/or available to staff. Staff looked throughout the nurses' station and was unable to locate any (PPE) available at that time. Although the (PPE) was maintained in an inventory stock, the unit had not been supplied adequate (PPE) to meet staff needs. Interviews were then conducted with staff and the following was identified:

Staff I was interviewed by phone on 12/09/2020 at 1:44 PM who reported gloves were not available in the correct sizes.

Staff K was interviewed by phone on 12/09/2020 at 3:02 PM who reported staff not being provided gloves. Some days staff did not have enough face masks for the patients and they had to call the nursing supervisor for a facemask which was then provided upon request. PPE was not stocked on the unit and staff had to call to ask when it was needed. Initially they were told not to ask for a facemask and to bring their own. The PPE was locked in the supply room on the unit; however, nursing staff did not have access to the supply room. When the supervisor was unavailable they do not have access to personal protective equipment.

Staff P was interviewed by phone on 12/14/2020 at 1:10 PM. He/She reported facemask's were not readily available on the unit and the facility did not provide adequate personal protective equipment. He/she had never seen gowns or eye protection on the unit available for staff.

These findings were discussed with Staff B on 12/10/2020 at 4:47 PM who stated PPE was maintained in the inventory stock. Staff B was unaware staff did not have available and/or an adequate supply of personal protective equipment on the units.