HospitalInspections.org

Based on observation, interview, the facility failed to:

1. Ensure one of two sampled contracted security guards (CSG 1) wore a hospital issued identification badge.

2. Provide documented evidence that one of two sampled CSG (CSG 1) had a license and a background check.

This deficient practice had for the impersonation of security guards and compromise patient safety.

Findings:

1. During an interview and observation, on 1/3/22 at 12:35 p.m., CSG 1 stated he is working an eight hour shift and is responsible for monitoring the unit's hallways for possible patient elopement (leaving without permission). No identification (ID) badge was observed and when asked, CSG 1 stated, "I'm new. It's my first day."

A review of a section of the Employee Handbook titled, "Dress Code," undated indicated dress code guidelines include name badges:
1. Employees must wear the Facility's issued identification card at all times while on duty.
2. The picture and name shall be visible at all times.








28045

2. During an interview and record review, on 1/4/22 at 2:45 p.m., the Director of Human Resources (DHR) and Human Resource Manager (HRM), stated that the Human Resource Department does not have an employee file for Contracted Security Guard (CSG 1) or for other employees that are contracted to perform security duties for the Behavioral Health Unit (BHU). DHR and HRM also stated they "were not aware that any contracted security staff were employed" by the hospital.

During an interview, on 1/5/22 at 11:30 a.m., the Public Safety Manager (PSM), was unable to provide a list of staff and scheduled assignments for all contracted security guards assigned to work in the BHU. PSM also stated that the scheduling of CSG 1 is "handled" between the hospital corporation and the contracted security guard company. PSM further stated the Public Safety Department does not know the name of security guards in advance arriving to work in the BHU from the contracted security company.

During an interview, on 1/5/22 at 11:40 a.m., the Director of Public Safety (DPS) and PSM stated that they do not have an employee file for CSG 1 or for any other security guards assigned to BHU from the contracted security company. DPS and PSM was unable to provide any documented evidence for CSG 1 security background check, professional security guard license or qualifications to perform the duties and responsibilities of security guard working in the BHU.

During an interview, on 1/5/22 at 2:40 p.m., with Performance Improvement Manager (PIM), was unable to provide an employee file or any documented evidence of CSG 1 security background check and clearance, a professional security guard license or qualifications to perform the duties and responsibilities of security guard working in the BHU.

A record review titled "Public Safety Department Monthly Personal Assignment" dated for the months for July 2021 to January 2022 indicated no security guard names were identified on the assignment roster that were assigned to BHU from the contracted security company.

Based on observations, interview, and record reviews, the facility did not meet the Conditions of Participation with regards to Nursing Services by failing to:

1. Prevent the elopement for one of thirty sampled patients (Patient1) in the Behavioral Health Unit (BHU), who was placed on an involuntary 72-hour hold. This deficient practice resulted in Patient 1's elopement and was never found. (Refer to A 395).

2. Ensure two of two sampled staff, Licensed Vocational Nurse (LVN 1) and Mental Health Worker (MHW 1), wore identification badges in the BHU. This deficient practice had the potential for patients to be confused for staff member, therefore, increasing the potential for a patient elopement to go unnoticed. (Refer to A 395)

3. Monitor two of thirty sampled patients (Patient 7 and Patient 19) every 15 minutes in accordance with the facility's policies and procedures. This deficient practice had the potential for patients to go unmonitored and possibly hurt themselves or others. (Refer to A 395)

4. Monitor one of thirty sampled patients (Patient 7) every 15 minutes in accordance with the patients' plan of care. (Refer to A 396)

5. Ensure that policies and procedures were followed for two of nine sampled patients (Patient 8 and Patient 10). This deficient practice had the potential to result in:

5.a. Physical harm or injury when Patient 8 was transferred to a lower acuity (level of complexity) unit with unsecured areas, despite not meeting the unit's admission criteria (Refer to A398)

5.b. Physical harm or injury when Patient 10's condition was not assessed prior to his transfer to a lower acuity and less secured unit. (Refer to A 398)

The Cumulative effect of these deficiencies resulted in the hospital's inability to ensure the Condition of Participation for Nursing Services was met.

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

1. Prevent the elopement (leaving facility without notice) for one of thirty sampled patients (Patient 1) in the Behavioral Health Unit (BHU). This deficient practice resulted in Patient 1's elopement and was never found.

2. Ensure two of two sampled staff, Licensed Vocational Nurse (LVN 1) and Mental Health Worker (MHW 1), wore identification (ID) badges in the BHU. This deficient practice had the potential for patients to be confused for staff members, therefore, increasing the potential for a patients' elopement to go unnoticed.

3. Monitor two of thirty sampled patients (Patient 7 and Patient19) every 15 minutes in accordance with the facility's policies and procedures. This deficient practice had the potential for patients to go unmonitored and possibly hurt themselves or others.

Findings:

1. During a tour of the BHU with the BHU Director (BHUD) and the BHU Clinical Supervisor (CSUP), on 1/3/2021 at 11:14 a.m., the front door to the Main Entrance was locked from the outside and unlocked from the inside. Two elevators were observed in the lobby on the first floor. The BHU consisted of two units. One (1) South unit was located on the first floor. The other unit, two (2) East was located on the second floor.

During an observation, on 1/3/2022 at 12:22 p.m., on the 2 East unit, two elevators (# 10 and #11) were observed. A red line was observed on the floor a few feet away from both elevators. No Cameras were observed in the 2 East unit. A security guard was observed across the hallway from the elevators. Another security was observed at an exit, at the end of a patient hallway, leading to the main hospital. Two unlocked double doors, lead to the old skilled nursing facility (SNF), which was not in use. The SNF unit had stairwells that lead downstairs to the first floor and basement exits. The exits were unlocked and only had local alarms that did not make audible sound at the nurse's station.

During an interview, on 1/3/2022 at 12:35 p.m., the BHUD stated a badge was not required to access the elevators. The BHUD stated the elevators lead to the first floor, second floor, and basement. The BHUD stated that on 8/16/2021, Patient 1 eloped from the 2 East Unit, located on the second floor. The BHUD stated no one saw Patient 1 elope, and she assumed that Patient 1 took the elevator down to the basement or the first floor and exited the facility. The BHUD stated it was the nurses' responsibility to monitor the patients and since the incident with Patient 1 on 8/16/2021, they added an extra security guard to monitor the hallway leading up to main hospital and placed a red line on the floor, meant to be a reminder for patients not to cross the red line. The BHUD stated that the admission criteria for the 2 East unit had been modified, to include stable patients, who were not actively acting up. The BHUD stated that no changes had been made to the elevator or exits leading to the outside of the building.

During an observation and interview, on 1/3/2022 at 1:19 p.m., four computers were observed in the nurses' station, two on the left side of the elevators, and two facing away from the elevators. Registered Nurse (RN 1) was observed sitting at the nurses' station, facing away from the elevators and adjacent door, leading to the former SNF. RN 1 stated he did not have a clear view of the elevators from where he was seated. RN 1 stated that mental health workers (MHW) conduct rounds on patients every fifteen minutes. RN 1 stated anyone can go up and down the elevators, no badge was needed.

During an interview, on 1/5/2022 at 10:33 a.m., the BHUD stated Patient 1 eloped on 8/16/2021, and stated the staff caring for Patient 1 no longer worked at the facility and was unavailable for interview. The BHUD stated she investigated the incident. The BHUD stated that on 8/16/2021 at 8:15 p.m., Patient 1 was not found in the bedroom, restroom, or basement. The BHUD stated staff should have been monitoring Patient 1. The BHUD stated she assumed Patient 1 eloped by taking the elevator and exiting the building through exit doors in the lobby or in the basement. The BHUD stated Patient 1 could have used any one of the four exits (SNF, main hospital, fire exit, or the elevator) on the second floor to elope. The BHUD stated security and police were called and Patient 1 was never found.

During an interview, on 1/5/2022 at 11:04 a.m., the Charge Nurse (CN 1) stated visitors needed to be escorted up and down the elevators. CN 1 stated a badge was not required to use the elevators, and there was a potential for visitors or patients to take the elevators to the first floor or basement, then exit the building. CN 1 stated Patient 1 eloped on 8/16/21, unwitnessed. CN 1 stated exits should be monitored at all times.

During a phone interview, on 1/5/2022 at 12:00 p.m., Contracted Security Guard (CSG 1), stated his security guard duties and responsibilities for the day of 8/16/2021 at the BHU Second floor, 2 East Unit was to " basically watch no one exits the stairwell, watching the two hallways, and stairwells only." CSG 1 stated that nursing is in charge of monitoring the elevators. CSG 1 also stated he can only see the patient rooms, stairwell exit doors, two hallways and had no view of the elevator where he was sitting. CSG 1 further stated that, " I would have to turn my body to see the elevators." CSG 1 stated that he was the only security guard on duty for that shift.


A review of Patient 1's medical record indicated Patient 1 was admitted to the BHU on 8/15/2021 for suicidal ideations (thoughts of killing self).

A review of Patient 1's form titled, "Involuntary Patient Advisement," dated 8/15/2021, indicated Patient 1 was placed on an involuntary 72-hour hold because Patient 1 was likely to harm him or herself because Patient 1 complained of suicidal ideations to overdose on medications.

A review of a Patient 1's form titled, "Notice of Certification for Intensive Treatment Pursuant to Section 5250 (14 days intensive treatment) or 5270.15 (Additional 30 days intensive treatment) of The Welfare and Institutions Code," dated 8/17/2021 indicated Patient 1 was placed on a 14 day hold for being a danger to others, a danger to himself or herself, and gravely disabled (unable to care for self). Patient 1 was psychotic (loss of contact with reality), labile (emotionally unstable), unpredictable, and concerning for safety.

A review of Patient 1's "Every (Q)15 Minutes Observation Record," dated 8/16/2021 and 8/17/2021, indicated Patient 1 was absence without leave or missing (AWOL) beginning at 8:15 pm on 8/16/2021 and continued to be AWOL until 8/17/2021 at 7 pm. There was no further documentation on the record.

A review of Patient 1's, Nurse's Note, dated 8/16/2021 at 11:28 p.m., indicated Patient 1 was withdrawn and isolative. Approximately at 7:40 p.m., Patient 1 was visible on unit walking to restroom on unit and walking back to room. Patient 1 was seen in room by a MHW at approximately 8 p.m., resting and not in distress. Patient 1 was pacing until 8:15 pm. At approximately 8:15 p.m., MHW was gathering Patient 1 for medication and rounds. Patient 1 was not in the room. Staff began looking for Patient 1 on the unit. Staff checked all rooms, restrooms on unit, shower rooms and basement. Patient 1 was not found. A Nurse found a green hospital gown on the floor in the restroom. Hospital security, sheriffs, and physician were notified.

A review of Patient 1's, Nurse's Note, dated 8/17/2021 at 9:09 a.m., indicated Patient 1 remains AWOL status at this time. Nurse Practitioner (NP) was notified of AWOL status. Received orders to discharge Patient 1.

2. During an observation and interview on the BHU, on 1/3/2022 at 11:38 a.m., Licensed Vocational Nurse (LVN 1) was observed in the common area interacting with patients. LVN 1 wore a red shirt and was not wearing a hospital issued ID badge. LVN 1 stated she should be wearing an ID badge. CN 1 stated patients were identified by their wristbands and staff were identified by their ID badge.

During an observation and interview on the BHU, on 1/4/2022 at 4:13 p.m., MHW 1 was walking in the hallway wearing a black sweater. A hospital issued ID badge was not visible. MHW 1 stated her badge was under her sweater and took it out and placed it above her sweater. MHW 1 stated the badge should be visible at all times. CSG 2 stated some staff, and some patients wear street clothes on the unit. CSG 2 stated he identified staff by their ID badges.

A review of a section of the Employee Handbook titled, "Dress Code," indicated dress code guidelines are as include, Name Badges:
1. Employees must wear the Facility's issued identification card at all times while on duty.
2. The picture and name shall be visible at all times.
3. The badge shall be worn above the waistline on the upper torso.
4. Badges are not to be altered or defaced.

3.a. During a concurrent interview and record review, with the Clinical Supervisor (CSUP) for the BHU, on 1/4/2022 at 2:52 p.m., the CSUP reviewed Patient 7's rounding sheets and verified that Patient 7 was not monitored on 12/16/2021 from 3:30 p.m. to 4 p.m., and on 12/29/2021 from 11:45 p.m. to 12 a.m. The CSUP stated patients should be monitoring every fifteen (Q 15) minutes to ensure their safety and document their location, and behaviors.

A review of Patient 7's medical record indicated Patient 7 was admitted to the facility from an outside hospital for an attempted suicide by overdose with Tylenol (a medication that reduces pain and fever).

A review of Patient 7's"Q 15 Minutes Observation Record," dated 12/16/2021, indicated Patient 7's location and behavior was not monitored at 3:30 p.m., 3:45 p.m., and 4 p.m.

A review of Patient 7's "Q 15 Minutes Observation Record," dated 12/29/21, indicated Patient 7's location and behavior was not monitored at 11:45 p.m., and at 12 a.m.

3.b. During a concurrent interview and record review, on 1/4/2022 at 3:02 p.m., CSUP reviewed Patient 19's rounding sheets and verified Patient 19 was not monitored every 15 minutes as indicated in the facility's policy.

A review of Patient 19's medical record indicated Patient 19 was admitted to the facility on 8/5/2021. Patient 19 was brought by law enforcement and placed on a 72 hold for being a danger to himself and to others and being unable to care for himself.

A review of Patient 19's "Q 15 Minutes Observation Record," dated 8/19/2021, indicated Patient 19's location and behavior was not monitored at 11:15 p.m., and at 11:30 p.m.

A review of the facility's policy and procedure titled, "Nursing Rounds," dated 3/2021, indicated rounds are to be a minimum of every fifteen (15) minutes. Staff members are to personally locate each patient listed and document the patient's location and the behavior on the Rounds Sheet under the appropriate time column. The staff member places his/her initials at the top of the column above the time. While making rounds, the member should observe the environment for unsafe conditions.

Based on observation, interview, and record review, the facility failed to monitor one of thirty sampled patients (Patient 7) every 15 minutes in accordance with the patients' plan of care.

This deficient practice had the potential for patients to go unmonitored and possibly hurt themselves or others.

Findings:

A review of Patient 7's medical record indicated Patient 7 was admitted to the facility from an outside hospital for an attempted suicide by overdose with Tylenol (a medication that reduces pain and fever).

During an interview and record review, with the Clinical Supervisor (CSUP) for the Behavioral Health Unit (BHU), on 1/4/2022 at 2:52 p.m., the CSUP reviewed Patient 7's rounding sheets and verified that Patient 7 was not monitoring on 12/16/2021 from 3:30 p.m. to 4 p.m., and on 12/29/2021 from 11:45 p.m or at 12 a.m. The CSUP stated patients should be monitoring every fifteen (Q 15) minutes to ensure their safety and document their location, and behaviors.

A review of Patient 7's "Q 15 Minutes Observation Record," dated 12/16/2021, indicated Patient 7's location and behavior was not monitored at 3:30 p.m., 3:45 p.m., and 4 p.m.

A review of Patient 7's "Q 15 Minutes Observation Record," dated 12/24/2021, indicated Patient 7's location and behavior was not monitored at 11:45 p.m., or at 12 a.m.

A review of Patient 7's plan of care titled, "Psychiatric Multidisciplinary Treatment Plan," dated 12/4/2021, indicated patient 7's reason for admission was danger to self. Active Problems included risk for self-harm, DTS (danger to self). Interventions included for nursing staff to monitor Patient 7 for safety every fifteen (15) minutes.

Based on interview and record review, the facility failed to ensure that policies and procedures were followed for two of nine sample selected patients (Patient 8 and Patient 10).

1. Patient 8 was transferred to the Behavioral Health Unit (BHU) despite not meeting the unit's admission criteria.

2. Patient 10's condition was not assessed prior to his transfer to 1 South, higher acuity (needing greater degree of observation), to 2 East, which is a lower acuity and less secured unit.

This deficient practice had the potential to result in physical harm or injury.

Findings:

1. During an interview, on 1/4/2022 at 11:00 a.m., the BHU Clinical Supervisor (CSUP) stated the 2 East unit is less secured than the 1 South unit and that patient criteria for admission includes no active suicidal ideation (SI, thought of harming/killing themselves).

During a record review of Patient 8's "History & Physical" (H&P), dated 12/27/2021, indicated "Patient presented to emergency room (ER) complaining of suicidal ideation with plan to hang himself. He endorsed auditory hallucination, command type, telling him to hang himself." and "He reported he started hearing voices, and having suicidal thoughts to kill himself by hanging." Patient 8 was admitted in the 2 East unit, room 282, bed B on 12/28/2021 per record review with Registered Nurse (RN 2).

During a record review of Patient 8's "Nursing Progress Notes", dated 12/28/2021 indicated, "Admitted this 41 year old Hispanic male patient from the Emergency Department on a Voluntary commitment for Danger to Self.", "Complains of feeling depressed over present living situation saying, 'I need help I can not be safe outside'., and "Pt. complains of hearing voices in his head telling him to 'do bad things' wanted them to leave him alone."

During a record review of Patient 8's "Nursing Note", dated 12/28/2021, indicated, "The auditory hallucinations combined with homelessness causes him to have suicidal ideation with plan to hang himself but denies intent."

During a review of the facility's "Admission Criteria for 2 East", dated 8/22/2021, the "Admission Criteria for 2 East" indicated, "No active suicidal or homicidal thought".

2. During a record review of Patient 10's "History & Physical" dated 12/28/21, indicated, "He said that he is hearing multiple voices telling him to kill himself."

During a record review of Patient 10's "Nursing Note", dated 12/28/2021, indicated, "Patient endorses SI with plan to run into traffic. Patient presents as depressed, sad, hopeless, helpless, impulsive, anxious, restless, labile, malodorous, disheveled in a hospital gown with sporadic eye contact."

During a record review of Patient 10's "MD Progress Note", dated 12/31/2021, indicated, "he stated 'I feel the same way as when I came in'."

During a record review of Patient 10's "Nursing Note", dated 12/31/2021 at 3:43 p.m., indicated, "Patient is paranoid, isolated, guarded, suspicious and withdrawn."

During a record review of Patient 10's "Event Management" (undated), the "Event Management" indicated, Patient 10 was transferred from Inpatient Psych, room 143, bed A (1 South unit) to room 285, bed A (2 East unit) on 12/31/2021 at 5:33 p.m.

During a record review of Patient 10's "Nursing Note", dated 1/1/2022 at 4:04 a.m., indicated, "Patient endorses details of hold, states he was experiencing intermittent auditory hallucinations that were making him want to do bad things." RN 2 verified there was no nursing documentation of transfer from 1 South to 2 East.

During an interview, on 1/5/2202 at 10:30 a.m., RN 2 stated he would have documented a narrative note indicating the time of transfer and describing Patient 10 and his criteria for transfer to 2 East.

During a review of the facility's policy and procedure (P&P) titled, "Assessment & Reassessment-Patient", dated 09/2021, indicated, "The goal is to identify patient specific problems for the development and implementation of a plan of care, incorporating assessment and continuing reassessment findings in order to adjust the plan of care accordingly to the needs of the patient."

43400

Based on observation and interview, the facility failed to ensure:

1. One of nine patients (Patient 11) and staff were aware of the significance of the red line in front of the Behavioral Health Unit (BHU) elevators,

2. Nine patients had no access to multiple unsecured doors leading to unsecured exits to public areas.

These deficient practices had the potential to result in patients' elopement causing physical harm or injury, even death.

Findings:

1. During a concurrent observation and interview, on 1/3/22 at 12:00 p.m., with the Behavioral Health Unit Director (BHUD), in BHU 2 East, a red line/tape was observed on the floor, in front of two elevators, across from the nurses' station next to the male patient restroom. The BHUD stated the line serves as a visual cue for patients to avoid access to the elevators, minimizing the risk for elopement. The BHUD stated patients and staff are aware of the purpose of the red line.

During an interview, on 1/4/22 at 4:15 p.m., with Patient 11, who was alert and oriented x4 (aware of self, location, time, and situation) was asked about the red line, Patient 11 stated he did not notice and was unaware of its purpose. Patient 11 stated he crossed the red line twice that day to use the alcohol-based hand rub (ABHR) that was wall-mounted next to one of two elevators. Patient 11 stated no staff approached him about crossing the red line to use the ABHR. Patient 11 stated he did not want to break the rules and will comply.


2. During a tour of the BHU, on 1/3/2022 at 11:00 a.m., in the presence of the Director of Public Safety (DPS), Public Safety Manager (PSM), BHUD, Behavioral Health Unit Clinical Supervisor (BHUCS), Performance Improvement Director (PID), and Performance Improvement Manager (PIM), the following was observed in the Behavioral Health Unit (BHU):


There were two total exit doors in the North area in the basement level - the first exit door in the north corridor that was unlocked with no door alarm device that entered a stairwell area. The second exit door in stairwell area was unlocked and with no alarm device exiting out to the hospital campus.
There was an exit door in the West area in the basement level that was unlocked with no alarm device exiting out to the hospital campus.

There were two total exit doors in the East area in the basement level - the first exit door in the East corridor that was unlocked with no door alarm device entering a stairwell area. The second exit door was unlocked with no alarm device exiting out to the hospital campus.

There was an exit door in the Radiation Therapy corridor in the basement level that was unlocked with a red alarm box exiting up to stairs onto the hospital campus.

There were three total exits in the South area in the basement level - the first exit door in the South corridor was unlocked with a door alarm device entering a stairwell area. The stairwell had (2) exits doors, one exit door was unlocked with no alarm device exiting onto a public street and the second exit door was unlocked with no alarm device exiting to the hospital campus.

There was an exit door at the West Skilled Nursing Facility corridor on the Second Floor that was unlocked with a door alarm device entering a stairwell with an unlocked exit door exiting to the hospital campus.

There was an exit door by the Employee Health Wellness Room on the Second Floor that was unlocked with a door alarm device entering a stairwell area with an exit door exiting to the hospital campus.

There was an exit door in the East area corridor on the Second Floor that was unlocked with a door alarm device entering a stairwell leading down to stairwell with two exits doors, one exit door was unlocked with no alarm device exiting onto a public street and the second exit door was unlocked with no alarm device exiting to the hospital campus.

There were two sets of elevators on the Second Floor that were accessible to enter freely by staff and patients that travel to the first floor for an exit door exiting to the hospital campus or to the basement with five exit doors available to exit to the hospital campus or public street.

There was a set of exit doors on the Second Floor East corridor that was unlocked with no door alarm device that entered main hospital.

There was an exit door in the West corridor on the First Floor that was locked with an alarm device that could release the exit door upon activation of Fire Alarm System exiting to the hospital campus.

There was an exit door in the East corridor on the First Floor that was locked with an alarm device that could release the exit door upon activation of Fire Alarm System exiting to the hospital campus.

There was an exit door in the main lobby on the First Floor that is unlocked exiting to the hospital campus.

There were no cameras on the Second Floor sleeping level and Basement level at BHU.

There were 10 cameras on the First Floor sleeping level at BHU, but these cameras do not record.

During an observation from 1/3/2022 to 1/5/2022, from the times between 11:00 a.m., and 3:00 p.m., the surveyor observed Registered Nurse (RN 1) seated at the Nursing Station with his back towards the two sets of elevators on the Second Floor sleeping level because the Nursing Station charting desk surface is facing a wall. RN 1 was also observed facing a wall when seated and would have to turn 180 degrees around to have a view of the elevators to monitor for patients using the elevators.

During an interview, on 1/3/2022 at 11:30 am., the DPS stated the Second Floor sleeping level and Basement Level in the BHU do not have cameras. DPS also stated that the First Floor sleeping level do have cameras, but the cameras do not record images and are visually monitored at the Nursing Station. DPS further stated that all the exit doors on the Second Floor sleeping level and the Basement Level are unlocked and some of the exit doors have a door alarm device that is audible.

During an interview, on 1/3/2022 at 12 p.m., the DPS stated that the exit door alarm devices in the Basement Level and Second Floor sleeping level are only audible locally and the exit door alarm devices are not connected to any monitoring system that would alert the nursing staff or security guard staff that the exit doors have been opened. The DPS further stated nursing staff and security guard staff on the Second Floor sleeping level and First Floor sleeping level would not be able to hear the audible exit door alarms if the alarms were activated by opening the exit doors in Basement Level. DPS further stated the security guards that are called "rovers" to conduct routine patrols of the main hospital and other campus buildings only and to respond to other priority calls for security checks. DPS also stated that if the "rovers have time or if opportunity presents itself", the rovers will then conduct security rounds at the BHU. The DPS also stated that the Public Safety Department does not have a designated security guard to conduct security rounds for all the exit routes to ensure that the exit doors were not opened, and the door alarms were not activated on the Second Floor sleeping level and basement level of the BHU.

During a phone interview, on 1/5/2022 at 12:00 p.m., CSG 1 stated his security guard duties and responsibilities for the day of 8/16/2021 at the BHU Second Floor sleeping level was to basically watch if anyone exits the stairwell, watching the two hallways, and stairwells only. CSG 1 also stated that he could "only see the two hallways where I am sitting, and I can't see the elevators." CSG 1 further stated that "nursing is in charge of monitoring the elevators." CSG 1 also stated "the only view I have is the patient rooms, stairwell exit doors, and no view of the elevator where I was sitting." CSG 1 further stated that, " I would have to turn my body to see the elevators." CSG 1 stated that he was the only security guard on duty for that shift.

During an interview, on 1/5/2022 at 10:55 a.m., the BHUD stated he had no clue if the security guards make rounds in the basement or in the unit. The BHUD also stated patients have the potential to press the button on the elevator for the second floor to the first floor or to the basement to exit completely.