HospitalInspections.org

This condition is not met as evidenced by;

Based on interview, medical record review, review of video surveillance footage, review of hospital records, and review of facility policies, it was determined the facility failed to follow physician orders for supervision levels, failed to document the implementation of supervision levels, failed to implement proper interventions to ensure patient safety from falls, staff, and other patients, and failed to implement safety precautions related to patient's unsafe behaviors (A144). The facility failed to ensure vulnerable patients were free from abuse from staff and other patients and failed to investigate allegations of abuse (A145). The cumulative effects of these systemic practices resulted in the agency's inability to ensure patient safety needs would be met.

Based on medical record review, staff interview, police interview, review of hospital records, review of video footage, and review of facility policies, it was determined the facility failed to follow physician orders for supervision levels, failed to document the implementation of supervision levels, failed to implement proper interventions to ensure patient safety from falls, staff, and other patients, and failed to implement safety precautions related to patient's unsafe behaviors. This affected eight (#1, #2, #3, #4, #6, #7, #8 and #9) of 10 patients reviewed. The census was 43.

Findings include:

1. Review of the medical record for Patient #1 revealed the patient was admitted to the facility from the hospital on 11/15/22 at 1:12 PM for psychosis. There was an order on 11/15/22 at 3:00 PM with no stop date for suicide.

Review of Patient #1's Medical Treatment Plan revealed on 11/15/22 hypertension was added and on 11/16/22 mild dehydration was added as actively treated medical conditions. Falls was never added to the Medical Treatment Plan. Further review of the plan of care revealed non-skid socks were listed as an intervention.

Review of Patient #1's Multidisciplinary Treatment Plan, initiated on 11/15/22, revealed falls was not indicated as a problem and the level of observation was indicated as every 15 minutes. In addition, the treatment plan did not list the patient's psychiatric diagnosis.

Review of the Psychiatric Evaluation, dated 11/16/22, revealed the patient was lying on the floor "for no reason." The patient was resisting being lifted from the ground. The doctor noted the patient had a lot of resistance and could not provide much of a history. The doctor noted the patient was posturing, had preservation, was guarded, withdrawn, fearful, and was responding to internal stimuli. The provider noted the patient was placed on fall risk precautions and every 15-minute checks. The doctor diagnosed the patient with catatonia secondary to psychosis.

Review of the History and Physical Examination completed on 11/16/22 revealed Patient #1 was diagnosed with hypertension, mild dehydration, bipolar and psychosis.

Review of the Level of Care assessment, dated 11/16/22, revealed the nurse failed to complete the initial fall risk assessment.

Review of the Nursing Shift Assessments/Fall Risk Assessments revealed the patient was a high risk for falls, as evidenced by a score of seven or higher, on 11/16/22 at 5:00 PM and on 11/19/22, 11/21/22,11/23/22, 11/25/22, and 11/26/22 during the 7:00 AM-PM shift. Further review of the fall risk assessment forms revealed on 11/20/22 during the 7:00 AM-PM shift the nurse noted the patient scored a three on the fall risk assessment. However, the nurse assessed the patient as confused but did not account for the two points on the fall risk assessment. In addition, the nurse failed to account for two points for the patient's fall on 11/18/22 which would have raised the fall risk to a nine, representing a high risk for falls. The patient was not assessed for falls on 11/22/22 and 11/24/22.

Review of the transfer summary, dated 11/18/22, revealed Patient #1 was being transferred to the hospital because he fell and hit his head. The nurse noted some swelling to the left side of the face. Review of the 11/18/22 7:00 AM -7:00 PM nursing shift progress note revealed the patient was in the shower, the call light came on and the nurse heard a "bang." The patient was assessed and sent to the emergency room for evaluation due to a busted left lower lip and report of hitting his head. The nurse noted interventions as line of sight (LOS) and use of a wheelchair.

Review of the physician orders revealed an order for LOS starting on 11/18/22 at 7:00 PM with no stop date. However, fall precautions were not ordered until 11/25/22 at 2:00 AM. In addition, there was no order noted for wheelchair usage.

Review of the Nursing Shift Assessments revealed the patient's level of observation was noted as every 15 minutes, instead of the ordered LOS listed at the top of the form, for the 11/20/22 PM-AM shift, 11/21/22 PM-AM shift, 11/22/22 AM-PM shift, 11/22/22 PM-AM shift, 11/24/22 AM-PM shift and the 11/25/22 PM-AM shift. Further review of the Nursing Shift Assessments revealed fall precautions were not checked on the 11/22/22 AM-PM shift and the 11/22/22 PM-AM shift.

Review of the Close Observation Sheets revealed the observation level was not indicated on 11/15/22 from 12 PM-12 AM, 11/16/22 from 12 PM-12 AM, 11/17/22 from 12 PM-12 AM, 11/18/22 from 12 PM-12 AM, 11/20/22 from 12 PM-12 AM, 11/21/22 from 12 PM-12 AM, 11/24/22 from 12 PM-12 AM, and on 11/26/22 from 12 pm-12 AM.

Further review of the Close Observation Sheets revealed the only shifts fall precautions were checked were 11/20/22, 11/21/22, 11/24/22, and 11/26/22 on the 12 AM-12 PM shift, and on 12 PM -12 AM shift on 11/22/22 and 11/23/22. In addition, review of the Close Observation Sheets revealed on 11/24/22 12:00 AM through 12:00 PM shift the level of observation was listed as every 15 minutes and line of sight. On 11/25/22 for the 12:00 AM through 12:00 PM shift the level of observation was listed as every 15 minutes instead of the ordered line of sight.

Review of the transfer summary dated 11/22/22 revealed Patient #1 was being transferred to the hospital because he was "pushed" inside the facility while he was walking which caused him to fall and hit his head. Review of the emergency room disposition for 11/22/22 revealed the patient was discharged back to the facility after being seen and diagnosed with a "fall." There was no further notation or investigation in the medical record in regards to the patient being pushed.

Review of a transfer summary dated 11/26/22 at 6:45 PM revealed Patient #1 was being transferred to the hospital because of a head injury after being "struck by another patient." The nurse noted the patient was alert. There was no notation the police were notified.

Review of an Interdisciplinary Progress Note dated 11/26/22 at 6:45 PM revealed per witness (Staff Q), Patient #1 was struck in the chin with the fist of a male peer (Patient #2). The patient fell to the floor striking his head. The patient was initially unresponsive but woke up within a minute. A verbal order was received to send Patient #1 to the emergency department for evaluation.

Review of the hospital medical record for the hospital visit on 11/26/22 revealed the patient arrived via emergency medical services (EMS) at 7:03 PM after being assaulted at the psychiatric hospital. On arrival Patient #1's Glasgow Coma Scale (GCS), used to describe the extent of impaired consciousness, was 13, but quickly decompensated to five, indicating severe traumatic brain injury. A head computerized tomography (CT) scan was performed revealing a "very large left-sided subdural hematoma" with 2.5 centimeters (cm) of midline shift and herniation. The patient was diagnosed with a subdural hematoma. An emergency left craniotomy for decompression of the left sided subdural hematoma was performed on 11/26/22. Patient #1 remained intubated and was admitted to the neurological intensive care unit (NICU).

Review on 12/05/22 at approximately 4:10 PM of a mute video recording with of the Maple Unit on 11/26/22 at 6:27 AM revealed Staff E and Staff Q seated behind the nurses station. Patient #1 was noted standing in front of and facing the nurses' station with a white blanket wrapped around his upper body. Patient #2 walked around and behind Patient #1 towards Staff Q, who handed him a pair of yellow non-skid socks. Staff E and Staff Q were conversing inside the nurses station, while Patient #2 was wrapping the socks around both of his fists. Patient #1 was speaking with another patient, who was all the way to the right of the nurses' station, with his head turned towards the patient he was speaking with and away from Patient #2. Patient #2 was walking to the left side of the nurses' station and the right side of Patient #1. Patient #2 stood there for a second, Patient #1 glanced at Patient #2 and turned his head back to the left. Then Patient #2 takes his right fist back and swings it at the right side of Patient #1's face, knocking him to the ground. Staff Q responds to Patient #1 and Staff E takes Patient #2 to another area. Interview at the time of the observation with Staff A and Staff B verified this footage was not reviewed prior to this review.

Interview on 11/30/22 at 12:20 PM with Staff A verified Patient #2 assaulted Patient #1 on the Maples Unit on 11/26/22.

Interview on 12/01/22 at 11:40 AM with Staff A verified Patient #1's 11/21/22 incident nor the 11/26/22 incident was on the Complaint/Grievance Log. Staff A verified the missing observations from 11/18/22 at 8:45 PM through 11/19/22 at 1:00 AM on Patient #1's Close Observations Sheets. In addition, she verified the Close Observation Sheets did not list the level of observation for the patient on 11/15/22 12:00 PM through 12:00 AM, 11/16/22 12:00 PM through 12:00 AM, 11/17/22 12:00 PM through 12:00 AM, 11/18/22 12:00 PM through 12:00 AM, 11/20/22 12:00 PM through 12:00 AM, 11/21/22 12:00 PM through 12:00 AM, 11/24/22 12:00 PM through 12:00 AM and 11/26/22 12:00 PM through 12:00 AM. In addition, Staff A verified the Close Observation Sheets on 11/24/22 for the 12:00 AM through 12:00 PM shift had the level of observation listed as every 15 minutes and LOS and on 11/25/22 at 12:00 AM through 12:00 PM the level of observation was listed as every 15 minutes instead of the ordered LOS. Staff A also verified that Patient #1's treatment plan did not list falls.

Review on 12/07/22 of the facility policy titled "Levels of Observation and Precautions," effective 11/22, revealed the nursing staff and medical providers will assess patients for risk level and make level of observation and precaution recommendations based on the risk level assessment findings and patient behavior throughout their stay. It is critical that patient observation levels and precautions are documented on the Patient Observation Record and communicated with team members. The different levels of observation are every 15 minutes (least restrictive), line of sight (continuous visual monitoring) and 1 to 1 (most restrictive). A physician's order is required to decrease or discontinue a level of observation or precaution. Prior to the patients discharge, the physician substantiates in the medical record that he potential for high-risk behavior no longer exists or exists at a level that can be safely managed in a less restrictive level of care. Medical record entries consistently reflect behavioral observations and patient mental status indicating the necessity for the level of observation or precaution noted. For suicide precautions the patient will be moved to a room closer to the nursing station if a room is available. The patient will be on increased observation level if identified as moderate or high suicide risk as evidenced by a clinical evaluation and an assessment of risk. Nursing staff will complete a suicide assessment shiftly. Any patient who scores three or higher on the Broset Violence Checklist or if nursing identifies to be at a high risk for aggression/violence must be placed on Aggression Precautions. Staff is to monitor behavioral signs of aggression closely so there is a lower threshold to offer medication or intervene.

Review on 12/12/22 of the facility policy titled "Assessment- Fall," effective 10/22, revealed patients on the inpatient units will be assessed for potential risk for falls during the admission process and daily thereafter. A score of zero to six means the patient has a low risk for falls. A score of seven or above indicates the patient is a high risk for falls. When a patient is a high fall risk staff shall evaluate the patient for implementation of one or more interventions. The interventions include but are not limited to the following: move the patient to a room closer to the nursing station, provide an assistive device such as walker or wheelchair, encourage the use of non-slip footwear, orient and re-orient confused patient to the environment and assessing the need for an increased level of observations to prevent falls. If a patient refuses to use a clinically indicated assistive device for ambulation, the nurse will assess the appropriateness of the patient safety leaving the unit unassisted. The patients fall risk and interventions will be added to the treatment plan. If a patient falls, an incident report will be completed and a re-assessment of fall risk and post-fall documentation will be completed and in the chart. If an assistive device is clinically indicated an order will be obtained.

2. Review of Patient #2's medical record revealed an admission date of 11/23/22. The patient was "pink slipped" from jail for psychosis. Consents were signed by the patient on 11/23/22 at 4:08 PM.

Review of the Screening Assessment dated 11/23/22 at 2:46 PM, completed by the Licensed Social Worker (Staff L) revealed the interview was completed with the patient and other, as the patient was an involuntary hold. Staff L noted the patient reported depression at 10/10, anxiety at 0/10, manic behavior, paranoia and delusions. Staff L noted Patient #2 scored a high risk on the Columbia-Suicide Severity Rating Scale indicating suicidal intent with a plan and recent acts. Staff L noted the patient had a history of physical aggression. Staff L noted the patient reported history of aggressive behaviors while he was at another treatment facility. Staff L noted the patient had poor impulse control.

Review of Patient #2's Nursing Admission Assessment. dated 11/23/22. revealed the patient was a high risk for suicide and should be placed on 1:1 observation. The nurse noted the patient stated he liked to fight and has shot a dog in the head. The nurse listed the patient's psychosocial problems as suicidal ideations, unstable mood, potential for violence, altered thought process and potential boundary violation. Further review of the medical record revealed Patient #2 was never placed on 1:1 observations.

Review of the Safety Assessment form, dated 11/23/22, revealed the patient reported thoughts of harming himself and others.

Review of Patient #2's Inpatient Comprehensive Psychiatric evaluation, dated 11/24/22, revealed the patient was agitated, yelling, cursing, and threatening another patient. The physician noted the patient had a history of multiple hospitalizations and a history of aggression while receiving inpatient treatment. The patient was noted to have a history of schizophrenia and bipolar disorder with medication noncompliance. The physician noted this is the patient's sixth admission to the facility stating his behavior was resistant, threatening, and impulsive. The physician also noted Patient #2 was suicidal with a plan to overdose on medications. The physician placed the patient on every 15-minute observations related to the aggression. The plan was to admit the patient to the Laurel Unit, obtain routine labs, restart home medications, provide standard as needed medications, encourage group and milieu treatment, work with social workers for appropriate placement and follow up care as symptoms begin to stabilize. The patient was diagnosed with schizoaffective bipolar type with an estimated length of stay of five to seven days.

Review of Patient #2's orders revealed on 11/24/22 the patient was moved from the Laurels Unit to the Maple Unit.

Review of Pt #2's Level of Care Assessment, dated 11/24/22, revealed the patient was "displaced" and the social worker (Staff M) noted she was unable to meet with the patient due to the patient's level of agitation and aggression.

Review of Patient #2's Multidisciplinary Treatment Plan, dated 11/24/22, revealed the patient was pink slipped due to suicidal ideations with a plan. Aggression was not listed on the plan until 11/26/22, however the patient was aggressive upon admission.

Review of a transfer form dated 11/24/22 at 12:47 AM revealed the patient was sent to the emergency room because his right hand was swollen after he punched a wall.

Review of the nursing note dated 11/24/22 for the 7:00 AM through 7:00 PM shift revealed Patient #2 was transferred from the Laurels Unit to Maple Unit for aggression. On 11/24/22 at 7:45 AM the patient received the antihistamine medication Vistaril for anxiety.

Review of the nursing note dated 11/24/22 for the 7:00 PM through 7:00 AM shift revealed the patient's observation level was increased to LOS for safety through the 11/25/22 7 AM-7 PM shift.

Review of Patient #2's orders revealed on 11/25/22 at 4:00 AM through 10:56 AM the level of observation was changed to line of sight.

Review of the Nursing Assessment dated 11/25/22 for 7:00 PM through 7:00 AM revealed Patient #2 was very agitated all night. He refused his Depakote (medication for acute treatment of manic episodes associated with bipolar disorder) and became very agitated. The patient was given Ativan (anti-anxiety medication) and Benadryl (antihistamine) intramuscularly (IM) but continued to escalate. The patient was throwing objects, destroying computers, physically and verbally threatening staff, and he spat in a nurse's face. The physician was notified and ordered Zyprexa (antipsychotic). The nurse noted the patient continued to escalate, throwing objects and ripping paperwork. The note seemed to abruptly end.

Review of Daily Inpatient Progress Notes revealed on 11/25/22 the physician (Staff G) noted the patient was angry, threatening and getting into arguments with "everybody including peers and staff." He has poor impulse control, no insight and his judgement is impaired. Staff G noted the patient's mood as hostile. The patient reported thoughts of hurting other people. For the assessment of progress in treatment and achieving goals, the physician noted the patient's behaviors were poorly controlled. Under the rationale for continued inpatient stay, the physician noted the patient demonstrated a risk of harm to others and/or extreme aggression requiring inpatient monitoring. In addition, he noted the patient was unable to care for himself or perform activities of daily living and the acute treatments pose a reasonable risk of complications that would further cause dangerous deterioration of the individual's mental and/or physical health. The diagnosis was listed as bipolar disorder.

Review of the 11/26/22 7:00 AM through 7:00 PM Nursing Assessment revealed the patient was extremely agitated, disruptive, impulsive, destroyed computers, threatened staff and tried to enter the nursing station. The nurse noted the patient was very labile, unpredictable, and created a situation that greatly increased anxiety in peers. The patient's level of observation remained every 15-minute checks from 11/25/22 at 7:00 PM-7:00 AM through discharge.

Review of a Psychiatric Progress Note dated 11/26/22 revealed the patient's behavior was aggressive, he tore papers on the nursing station, beat on the providers door, spat at the provider, and picked up computers and threw them on the floor breaking them. The provider noted the as needed IM injections were not helping him.

Review of Patient #2's orders revealed on 11/26/22 orders for aggression precautions were initiated.

Review of Pt #2's Broset Violence Checklist assessment, to assess short term violence risk, revealed on 11/26/22 at 9:04 AM the patient scored seven on the Broset assessment as the patient destroyed two computer monitors and was verbally threatening staff. A score greater than two indicates the risk for violence is very high.

Review of Inpatient Therapy Note dated 11/26/22 at 12:30 PM revealed the patient was hostile, angry, aggressive, argumentative, and defensive. The therapist noted the patient arrived late, was disruptive and threatening to hurt people in the group.

Review of Patient #2's Seclusion/Restraint Treatment Plan revealed it was initiated on 11/26/22 as the patient was at risk for being restrained and/or placed in seclusion due to increased aggression and agitation. However, the patient had received emergency medications on 11/24/22, 11/25/22 and 11/26/22 without the plan in place.

Review of an Interdisciplinary Progress Note dated 11/26/22 at 6:45 PM revealed the Patient Care Associate (PCA), Staff D, witnessed Patient #2 attacking a male peer (Patient #1) by striking him in the chin with his fist, sending the peer to the floor where he hit his head and became unresponsive initially. The peer had bleeding from the scalp. Patient #2 was removed from the area and the peer was sent to the emergency room via EMS.

Review of Patient #2's Seclusion and Restraint Initiation of Intervention Order, dated 11/26/22 at 8:15 PM, revealed the patient was placed in physical restraints for verbal and physical abuse towards staff from 8:23 PM through 8:25 PM. The patient was also given emergency medications of Ativan, the antipsychotic Haldol and Benadryl. The nurse noted the patient was very agitated and aggressive towards staff. The patient was spitting and throwing objects on the Maple Unit.

Review of an Interdisciplinary Progress Note dated 11/26/22 at 10:30 PM revealed Patient #2 became "very agitated" while standing by the nurses station. The patient threw things and spat at staff. The patient refused medications by mouth and IM medications were given to the patient as ordered by the provider.

Review of the Seclusion and Restraint Initiation of Intervention/Order dated 11/26/22 at 8:23 PM revealed the patient was restrained from 10:55 PM through 10:58 PM and in seclusion from 10:58 PM through 11:10 PM because the patient jumped into the nursing station looking for items to harm staff.

Review of Patient #2's Close Observation Sheets from admission through discharge revealed the level of observation was always documented as either every 15-minutes or not documented at all. On 11/24/22 for the 12:00 PM through 12:00 AM timeframe there was no time, initials or level of observation documented. On 11/25/22 for the 12:00 AM through 12:00 PM shift the patient was noted to be on every 15-minute checks., however, review of the order dated 11/24/22 revealed the patient was to be on the LOS observation level. On 11/26/22 for the 12:00 PM through 12:00 AM shift there was no time, date, initials or observation level noted. Further review of the Close Observation Sheets revealed on 11/26/22 the patient was noted to have behaviors of agitation at 1:15 AM-2:45 AM, 8:00 AM-8:15 AM, 11:15 AM-12:00 PM, 6:45 PM-8:00 AM, 7:15 PM-7:30 PM and from 8:00 PM-2:00 AM.

Review of Patient #2's Observations Log from admission through discharge revealed the patient reported an anxiety level of 10/10 on 11/24/22, 11/25/22 and 11/26/22. On 11/26/22 the patient reported a 10/10 anxiety level at 12:02 PM and at 11:24 PM. At 12:02 PM the patient was given IM Benadryl, Ativan, and Zyprexa. The nurse noted at 1:55 PM the patient's anxiety improved. On 11/26/22 8:26 PM the patient was given IM Benadryl, Ativan, and Zyprexa with the nurse noting on 11/27/22 at 12:18 AM that the patient's symptoms were relieved.

Review of Patient #2's Discharge Summary, dated 11/27/22 revealed the patient was discharged due to his behaviors towards staff and peers.

Interview on 12/05/22 at 2:26 PM, Staff B verified the Patient Care Associates (PCA) use the Close Observation Sheets to know what level of observation a patient is on. Staff B verified Patient #2's 11/25/22 line of sight order was not documented on the 11/25/22 AM-PM Close Observation Sheet.

Interview on 12/06/22 at 4:20 PM with Staff G, the physician for the Maple Unit to revealed Patient #2 was admitted to the facility on other occasions. Patient #2 was discharged from another psychiatric hospital, then to jail and then pink slipped to this facility. Staff G stated the patient was admitted to the Laurels Unit but because he was punching people, walls and breaking computers he was transferred to the Maple Unit. Staff G stated he assessed Patient #2 on 11/25/22 and the patient stated he was okay, but he did not want the Thorazine, only the Depakote. Staff G stated on 11/25/22 at around 5:00 PM the behaviors started, but the patient did not seem to be responding to internal stimuli. Staff G stated "It was more like an act. He suddenly grabs someone and hits them." Staff G stated Friday 11/25/22 and Saturday 11/26/22 Patient #2 broke computers and hit staff and patients unprovoked. Staff G stated Patient #2 hit a patient and a nurse and when the police arrived he said he was sexually assaulted. Patient #2 was taken to the hospital and arrived back to the facility on 11/27/22. Staff G said the police saw the patient but sent him back to the facility.

Interview on 12/08/22 at 3:40 PM with Staff M, revealed she did complete Patient #2's Initial Treatment Plan/Screening on admission. Staff M stated when she arrived to complete the assessment, the patient was unavailable as he was getting transferred from the Laurels Unit to the Maple Unit for aggression. Staff had informed her that the patient was aggressive, and they did not feel it was safe for her to meet with the patient at that time. Staff M stated she completed his treatment plan using previous assessments. Staff M verified aggression was not on the treatment plan and stated "I should have added aggression in hindsight."

Interview on 12/08/22 with the officer who responded to the 11/26/22 incident where Patient #2 hit a nurse revealed the nurse contacted the police after being punched in her face. The nurse stated Patient #2 was "out of control" and she was trying to get him under control when he punched her so hard that she fell. The officer stated other staff were around verifying what the nurse was reporting, but she did not get the names. The officer stated, "The employees lightly told her that Patient #2 had also hit a patient and was hard to be controlled." The officer did not interview Patient #2 as he was told by staff the patient was sedated. Staff also reported to the officer that the patient was on a "pink slip" and the officer stated officers do not have the authority to remove a "pink slipped" patient from a medical facility. The officer stated she referred the nurse to the prosecutors. The officer stated she heard that officers had to go back out on 11/26/22 on night shift because the family of Patient #1 called police about the assault.

Review on 12/01/22 of the facility policy titled "Patient Bill of Rights," effective 08/2022, revealed each person who accesses mental health services was informed of their rights. The rights include but are not limited to the right to be treated in a safe environment, the right to reasonable protection from physical, sexual or emotional abuse, the right to a current individualized treatment plan that addresses the needs and responsibilities of an individual that specifies the provision of appropriate and adequate services, to be free from seclusion or restraint and the right to refuse or consent to services.

Review on 12/07/22 of the facility policy titled "Seclusion and Restraint," last revised on 09/2021, revealed patients are assessed upon admission and on a continual basis throughout their course of treatment for behaviors that are potentially dangerous to self or others. Patients are given a copy of the facility's Seclusion and Restraint policy on admission. The nurse is to assess the patient's behavior on a regular basis to determine any imminent risk of the patient physically harming self, staff, or others. Further review of the policy revealed when a patient is presenting behaviors that are such that they present an imminent danger to the patient or others, staff should separate the patient from the group, redirect the patient, engage in 1:1, take the patient to their room with staff present and/or administer ordered medication. Staff is to document the interventions attempted or the rationale for not using the interventions.

Review on 12/12/22 of the hospital policy titled "Treatment Planning," last revised 07/22, revealed the master treatment plan must be completed within 24 hours of admission for inpatients. Every patient admitted will have an individualized plan specific to his/her assessed needs and the patient's physician will direct and participate in all phases of the treatment planning process. Staff is to document the plan was mutually agreed upon and copy was provided to the patient. An assessment will be completed prior to the delivery of services. The patients' needs are identified from the information contained on the initial assessments to include the comprehensive psychiatric evaluation, history and physical, screening assessment, level of care/psychosocial assessment, initial nursing assessment and/or the activity therapy assessment. Nursing will initiate the treatment plan within eight hours of admission, with at least one goal identified by the individual. Care and treatment decisions are made on a collaborative basis, with input from all disciplines providing care and services to the patient. The plan of care, treatment and services includes but not limited to an overview, diagnoses, estimated length of stay and authentication signatures, date, and time for the comprehensive treatment plan that consists of this sheet and applicable problem sheets individualized to the needs of the patient.

3. Review of the medical record for Patient #3 revealed an admission on 11/20/22 to the inpatient psychiatric facility following an incident that occurred in the partial hospitalization program in which the patient was suspected of taking another patients suboxone and was intoxicated on the unit. A random drug screen was completed and the patient tested positive for suboxone without having a prescription. The patient was told she would be administratively discharged from the program and then reported she was going to take all of her medications and kill herself. She then began punching herself.

The medical record revealed Patient #3 had self injurious behaviors which included punching self and hitting her head on the wall. There were no interventions and/or precautions in place to address these behaviors.

Interview on 12/14/22 at 3:38 PM, Staff N verified the findings.

4. Review of the medical record for Patient #4 revealed an admit date of 12/04/22 to the inpatient psychiatric facility.

Review of the comprehensive psychiatric evaluation completed on 12/05/22 noted the patient with a history of depression and polysubstance abuse seeking alcohol detox. The patient reported having a period of sobriety for nineteen months, however had experienced some psychosocial stressors that worsened his mood and increased his drinking of 80% whiskey daily.

Review of the 7:00 AM to 7:00 PM Nursing Assessment dated 12/06/22 noted Patient #4 to be calm at the beginning of the shift, but became increasingly irritable throughout the day. He later started yelling, lifting up the computer, and kicking chairs, requiring emergency antianxiety medications be administered at 5:15 PM.

Review of the Broset Violence Checklist, used to determine the initiation of aggression precautions, on 12/06/22 at 9:21 AM and 6:06 PM, noted the patient was not attacking objects, had no boisterous behaviors, no confused behaviors, no irritable behaviors, no physical threat behaviors, and no verbal threat behaviors, therefore scoring the patient low risk for violence.

Review of the ancillary non medication orders noted the patient was not placed on aggression precautions until 12/07/22 at 10:00 AM.

Review of the Discharge Summary noted on 12/06/22 the patient was disruptive, violent, requiring the administration of emergency medications. Per the provider documentation the patient was planning to transition to a partial hospitalization program. On 12/07/22 the patient was notified his referral had been declined due to the behavioral disturbance the prior day and therefore the patient no longer met criteria for admission. The provider noted the patient became irritated, hostile, and knocked over a housekeeper's cleaning cart on his way to breakfast, remained agitated and very hard to redirect.

Interview on 12/14/22 at 3:54 PM verified the finding.

5. Review of the medical record for Patient #6 revealed an admit date of 11/18/22 to the inpatient psychiatric facility after endorsing suicidal ideation with a plan and intent to overdose on medications.

Review of the ancillary orders noted the patient was placed on suicide precautions on 11/18/22 at 5:00 AM.

Based on record review, staff interview, police interview, review of hospital records, review of video surveillance footage,and review of the facility policies, the facility failed to ensure vulnerable patients were free from abuse from staff and other patients and failed to investigate allegations of abuse. This affected one (Patient #1) of 10 patients reviewed but had the potential to affect all patients. The census was 43.

Findings include:

1. Review of the medical record for Patient #1's revealed the patient was admitted to the facility from the hospital on 11/15/22 at 1:12 PM for psychosis. There was an order on 11/15/22 at 3:00 PM with no stop date for suicide.

Review of the Psychiatric Evaluation, dated 11/16/22, revealed the patient was lying on the floor "for no reason." The patient was resisting being lifted from the ground. The doctor noted the patient had a lot of resistance and could not provide much of a history. The doctor noted the patient was posturing, had preservation, was guarded, withdrawn, fearful, and was responding to internal stimuli. The doctor diagnosed the patient with catatonia secondary to psychosis.

Review of the History and Physical Examination completed on 11/16/22 revealed Patient #1 was diagnosed with hypertension, mild dehydration, bipolar and psychosis.

Review of the transfer summary dated 11/22/22 revealed Patient #1 was being transferred to the hospital because he was "pushed" inside the facility while he was walking which caused him to fall and hit his head. Review of the emergency room disposition for 11/22/22 revealed the patient was discharged back to the facility after being seen and diagnosed with a "fall." There was no further notation or investigation in the medical record in regards to the patient being pushed.

Review of a transfer summary dated 11/26/22 at 6:45 PM revealed Patient #1 was being transferred to the hospital because of a head injury after being "struck by another patient." The nurse noted the patient was alert. There was no notation the police were notified.

Review of an Interdisciplinary Progress Note dated 11/26/22 at 6:45 PM revealed per witness (Staff Q), Patient #1 was struck in the chin with the fist of a male peer (Patient #2). The patient fell to the floor striking his head. The patient was initially unresponsive but woke up within a minute. A verbal order was received to send Patient #1 to the emergency department for evaluation.

Review of the hospital medical record for the hospital visit on 11/26/22 revealed the patient arrived via emergency medical services (EMS) at 7:03 PM after being assaulted at the psychiatric hospital. On arrival Patient #1's Glasgow Coma Scale (GCS), used to describe the extent of impaired consciousness, was 13, but quickly decompensated to five, indicating severe traumatic brain injury. A head computerized tomography (CT) scan was performed revealing a "very large left-sided subdural hematoma" with 2.5 centimeters (cm) of midline shift and herniation. The patient was diagnosed with a subdural hematoma. An emergency left craniotomy for decompression of the left sided subdural hematoma was performed on 11/26/22. The surgeon noted the patient was intubated, had a left blown pupil, and extensive posturing in the upper extremities with a positive cough and corneal response. The patient tolerated the surgery without any complications. He remained intubated and was admitted to the neurological intensive care unit (NICU).

Review on 12/05/22 at approximately 4:00 PM of the facility's mute video recording of the Maple Unit for 11/21/22 at 8:53 AM revealed a staff member was seated at the nursing station. Other staff and patients were moving throughout the unit. A tall unknown male was walking towards the door to go outside but he paused and stepped to the side when he got near enough to the door as he noticed someone was coming in the other door from outside. The door to the inside opened to the nursing station. Patient #1 is seen at the door with a gown and a blanket wrapped around his left shoulder. Suddenly, you see Patient #1's right shoulder jerk forward and the patient falls down on his bottom, then his back. Patient Care Associate (PCA) Staff D was observed on the video to be at the door but never enters the building and goes back out to the courtyard.

Review of a mute video recording of the courtyard outside of the Maple Unit on 11/21/22 at approximately 8:52 AM revealed Patient #1 was outside with other patients and Staff D. Patient #1 looks confused and attempts to reach out to grab something from Staff D three times. At first Staff D puts his hand up as if to direct Patient #1 to stop. The second and third time Staff D grabs the patient by the wrist and pushes it away. Patient #1 then grabs something off of the table and Staff D grabs the patient's hand to get the item but Patient #1 resists. Staff D then snatches the item roughly from the patient. Next, Staff D guides Patient #1 back towards the facility door to go inside with his left hand in the middle of Patient #1's back. Once they get to the door, Staff D opens it and attempts to guide the patient through the door with his hand placed in the middle of patient's back. Patient #1 attempts to resists with his legs and by leaning back. Staff D forces the patient in the door and the door closes behind them for a small amount of time. Next, the door opens to the courtyard and Staff D comes back out through the door, but his head is turned towards the inside of the facility. The tall male then comes out behind Staff D. At the time of the video footage observation Staff A and Staff B verified this footage was not reviewed prior to this review.

Interview on 12/01/22 at 3:10 PM with Staff E revealed she was a nurse on Maple Unit on 11/21/2. Staff E stated Patient #1 was confused and needed a lot of re-direction throughout his stay. Staff E stated they were encouraging the patient to use a wheelchair due to confusion, but he continued to get up. Staff E stated at the time of Patient #1's fall on 11/21/22 her back was turned to the door, so she did not witness the fall. When she turned around, she noticed Assistant Director of Nursing (Staff C) and the nurse practitioner (Staff O) responding to the patient. She went to get a wheelchair and Staff C instructed her to call 911 to send the patient to the emergency room. Staff E stated Staff O reported the patient was pushed at the time of the incident.

Interview on 12/01/22 at 3:36 PM with Staff C revealed on 11/21/22 she was walking out of the office and saw Patient #1 falling on the floor. Staff C stated she went to get a machine to obtain vital signs and called for nurses to respond. Staff O was there and gave orders to transfer the patient to the emergency room. Staff O stated to Staff C the patient had been shoved and hit his head. Staff C stated at the time she did not think the patient had been intentionally pushed by staff but that he was bumped into, resulting in the fall. Therefore she did not think an investigation was needed. Staff C stated she could not tell who was behind the patient coming in from outside but verified that staff are the only ones who can open the doors. Staff C verified a staff member had to open the door for Patient #1. Staff C verified whoever was behind the patient did not come in behind the patient to assist. Staff C verified it was Staff D who walked Patient #1 in from outside on 11/21/22. Staff C stated Staff D continued his shift and worked three additional shifts at the facility after the incident. Staff C stated she had never witnessed Staff D abuse patients but stated he was a "little aggressive" during incidents.

Review on 12/05/22 at approximately 4:10 PM of a mute video recording with of the Maple Unit on 11/26/22 at 6:27 AM revealed Staff E and Staff Q seated behind the nurses station. Patient #1 was noted standing in front of and facing the nurses' station with a white blanket wrapped around his upper body. Patient #2 walked around and behind Patient #1 towards Staff Q, who handed him a pair of yellow non-skid socks. Staff E and Staff Q were conversing inside the nurses station while Patient #2 was wrapping the socks around both of his fists. Patient #1 was speaking with another patient, who was all the way to the right of the nurses' station, with his head turned towards the patient he was speaking with and away from Patient #2. Patient #2 was walking to the left side of the nurses' station and the right side of Patient #1. Patient #2 stood there for a second, Patient #1 glanced at Patient #2 and turned his head back to the left. Then Patient #2 takes his right fist back and swings it at the right side of Patient #1's face, knocking him to the ground. Staff Q responds to Patient #1 and Staff E takes Patient #2 to another area. Interview at the time of the observation with Staff A and Staff B verified this footage was not reviewed prior to this review.

Interview on 11/30/22 at 11:11 AM with Staff A, revealed there had been no investigations for abuse since 11/15/22.

Interview on 11/30/22 at 12:20 PM with Staff A verified Patient #2 assaulted Patient #1 on the Maples Unit on 11/26/22. Staff A verified the incident on 11/21/22 had not been investigated prior to the surveyor's arrival.

Interview on 12/01/22 at 11:40 AM with Staff A, revealed Patient #1's 11/21/22 fall was now an open investigation as they are still not sure if the patient fell. She stated leadership has just reviewed the cameras but they cannot tell if the patient was pushed.

Interview on 12/01/22 at 11:40 AM with Staff A verified neither Patient #1's 11/21/22 incident or the 11/26/22 incident was on the Complaint/Grievance Log.

Interview on 12/01/22 at 12:00 PM with Staff B revealed the facility now has an open investigation for the 11/21/22 incident of Patient #1. Staff B stated videos of the fall/shove were available but it is hard to make out if the patient was pushed.

Interview on 12/08/22 at 12:00 PM with Staff A and Staff B revealed Staff D was not terminated after this incident. They verified that he worked three more shifts after the 11/21/22 incident with Patient #1. His access to the building has been revoked as of 12/01/22. Staff D has since called and resigned

2. Review of Patient #2's medical record revealed an admission date of 11/23/22. The patient was "pink slipped" from jail for psychosis. Consents were signed by the patient on 11/23/22 at 4:08 PM. The patient was accompanied by police upon arrival. Consents were signed by the patient on 11/23/22 at 4:08 PM.

Review of the Screening Assessment dated 11/23/22 at 2:46 PM, completed by the Licensed Social Worker (Staff L) revealed the interview was completed with the patient and other, as the patient was an involuntary hold. Staff L noted the patient reported depression at 10/10, anxiety at 0/10, manic behavior, paranoia and delusions. Staff L noted Patient #2 scored a high risk on the Columbia-Suicide Severity Rating Scale indicating suicidal intent with a plan and recent acts. Staff L noted the patient had a history of physical aggression. Staff L noted the patient reported history of aggressive behaviors while he was at another treatment facility. Staff L noted the patient had poor impulse control.

Review of Patient #2's Nursing Admission Assessment. dated 11/23/22. revealed the patient was a high risk for suicide and should be placed on 1:1 observation. The nurse noted the patient stated he liked to fight and has shot a dog in the head. The nurse listed the patient's psychosocial problems as suicidal ideations, unstable mood, potential for violence, altered thought process and potential boundary violation. Further review of the medical record revealed Patient #2 was never placed on 1:1 observations.

Review of the Safety Assessment form, dated 11/23/22, revealed the patient reported thoughts of harming himself and others.

Review of Patient #2's Inpatient Comprehensive Psychiatric evaluation, dated 11/24/22, revealed the patient was agitated, yelling, cursing, and threatening another patient. The physician noted the patient had a history of multiple hospitalizations and a history of aggression while receiving inpatient treatment. The patient was noted to have a history of schizophrenia and bipolar disorder with medication noncompliance. The physician noted this is the patient's sixth admission to the facility stating his behavior was resistant, threatening, and impulsive. The physician also noted Patient #2 was suicidal with a plan to overdose on medications. The physician placed the patient on every 15-minute observations related to the aggression. The plan was to admit the patient to the Laurel Unit, obtain routine laboratory test, restart home medications, provide standard as needed medications, encourage group and milieu treatment, work with social workers for appropriate placement and follow up care as symptoms begin to stabilize. The patient was diagnosed with schizoaffective bipolar type with an estimated length of stay of five to seven days.

Review of Patient #2's orders revealed on 11/24/22 the patient was moved from the Laurels Unit to the Maple Unit.

Review of Pt #2's Level of Care Assessment, dated 11/24/22, revealed the patient was "displaced" and the social worker (Staff M) noted she was unable to meet with the patient due to the patient's level of agitation and aggression.

Review of a transfer form dated 11/24/22 at 12:47 AM which revealed the patient was sent to the emergency room because his right hand was swollen after he punched a wall.

Review of Patient #2's Multidisciplinary Treatment Plan, dated 11/24/22, revealed the patient was pink slipped due to suicidal ideations with a plan. Aggression was not listed on the plan until 11/26/22, however the patient was aggressive upon admission.

Review of the nursing note dated 11/24/22 for the 7:00 AM through 7:00 PM shift revealed Patient #2 was transferred from the Laurels Unit to Maple Unit for aggression. On 11/24/22 at 7:45 AM the patient received the antihistamine medication Vistaril for anxiety.

Review of the nursing note dated 11/24/22 for the 7:00 PM through 7:00 AM shift revealed the patient's observation level was increased to line of sight (LOS) for safety through the 11/25/22 7 AM-7 PM shift.

Review of Patient #2's orders revealed on 11/25/22 at 4:00 AM through 10:56 AM the level of observation was changed to LOS.

Review of SP #2's Seclusion/Restraint Treatment Plan revealed it was initiated on 11/26/22 as the patient was at risk for being restrained and/or placed in seclusion due to increased aggression and agitation.

Review of the Nursing Assessment dated 11/25/22 for 7:00 PM through 7:00 AM, revealed Patient #2 was very agitated all night. He refused his Depakote (medication for acute treatment of manic episodes associated with bipolar disorder) and became very agitated. The patient was given Ativan (anti-anxiety medication) and Benadryl (antihistamine) intramuscularly (IM) but continued to escalate. The patient was throwing objects, destroying computers, physically and verbally threatening staff, and he spat in a nurse's face. The physician was notified and ordered Zyprexa (antipsychotic). The nurse noted the patient continued to escalate, throwing objects and ripping paperwork.

Review of Daily Inpatient Progress Notes revealed on 11/25/22 the physician (Staff G) noted the patient was angry, threatening and getting into arguments with "everybody including peers and staff." He has poor impulse control, no insight and his judgement is impaired. Staff G noted the patient's mood as hostile. The patient reported thoughts of hurting other people. For the assessment of progress in treatment and achieving goals, the physician noted the patient's behaviors were poorly controlled. Under the rationale for continued inpatient stay, the physician noted the patient demonstrated a risk of harm to others and/or extreme aggression requiring inpatient monitoring. In addition, he noted the patient was unable to care for himself or perform activities of daily living and the acute treatments pose a reasonable risk of complications that would further cause dangerous deterioration of the individual's mental and/or physical health. The diagnosis was listed as bipolar disorder.

Review of the 11/26/22 7:00 AM through 7:00 PM Nursing Assessment revealed the patient was extremely agitated, disruptive, impulsive, destroyed computers, threatened staff and tried to enter the nursing station. The nurse noted the patient was very labile, unpredictable, and created a situation that greatly increased anxiety in peers. The patient's level of observation remained every 15-minute checks from 11/25/22 at 7:00 PM-7:00 AM through discharge.

Review of a Psychiatric Progress Note dated 11/26/22 revealed the patient's behavior was aggressive, he tore papers on the nursing station, beat on the providers door, spat at the provider, and picked up computers and threw them on the floor breaking them. The provider noted the as needed IM injections were not helping him.

Review of Patient #2's orders revealed on 11/26/22 orders for aggression precautions were initiated.

Review of Pt #2's Broset Violence Checklist assessment, to assess short term violence risk, revealed on 11/26/22 at 9:04 AM the patient scored seven on the Broset assessment as the patient destroyed two computer monitors and was verbally threatening staff.

Review of Inpatient Therapy Note dated 11/26/22 at 12:30 PM revealed the patient was hostile, angry, aggressive, argumentative, and defensive. The therapist noted the patient arrived late, was disruptive and threatening to hurt people in the group.

Review of Patient #2's Seclusion/Restraint Treatment Plan revealed it was initiated on 11/26/22 as the patient was at risk for being restrained and/or placed in seclusion due to increased aggression and agitation. However, the patient had received emergency medications on 11/24/22, 11/25/22 and 11/26/22 without the plan in place.

Review of an Interdisciplinary Progress Note dated 11/26/22 at 6:45 PM revealed Staff D witnessed Patient #2 attacking a male peer (Patient #1) by striking him in the chin with his fist, sending the peer to the floor where he hit his head and became unresponsive initially. The peer had bleeding from the scalp. Patient #2 was removed from the area and the peer was sent to the emergency room via EMS.

Review of Patient #2's Seclusion and Restraint Initiation of Intervention Order, dated 11/26/22 at 8:15 PM, revealed the patient was placed in physical restraints for verbal and physical abuse towards staff from 8:23 PM through 8:25 PM. The patient was also given emergency medications of Ativan, the antipsychotic Haldol and Benadryl. The nurse noted the patient was very agitated and aggressive towards staff. The patient was spitting and throwing objects on the Maple Unit.

Review of an Interdisciplinary Progress Note dated 11/26/22 at 10:30 PM revealed Patient #2 became "very agitated" while standing by the nurses station. The patient threw things and spat at staff. The patient refused medications by mouth and IM medications were given to the patient as ordered by the provider.

Review of the Seclusion and Restraint Initiation of Intervention/Order dated 11/26/22 at 8:23 PM revealed the patient was restrained from 10:55 PM through 10:58 PM and in seclusion from 10:58 PM through 11:10 PM because the patient jumped into the nursing station looking for items to harm staff.

Review of the Discharge Summary dated 11/27/22 completed by Staff F revealed Patient #2 had an unplanned discharge on this date. The patient had struck another patient on the unit then claimed he was sexually assaulted by the patient he struck. Patient #2 was then taken to the hospital by the police to complete a rape kit. Staff F noted the patient returned the morning of 11/27/22.

Interview on 12/01/22 at 3:10 PM with Staff E revealed she was a nurse on Maple Unit on 11/26/22. She was in the medication room and did not witness Patient #2 punch Patient #1. She assessed Patient #1 who had hit his head directly on the floor after being punched and called the supervisor to send the patient to the emergency room. Staff E stated Patient #2 was very aggressive, he gets really angry, and was completely unpredictable. Staff E stated she had already given Patient #2 emergency medications for smashing all of the computer equipment earlier, so there was no emergency medication to administer at the time. She stated the patient took the medications willingly but did not respond to the emergency medications.

Interview on 12/06/22 at 9:05 AM with Staff A and Staff B revealed after striking Patient #1, Patient #2 punched a nurse manager in the face on 11/26/22 causing her to be sent to the hospital and off work.

Interview on 12/05/22 at 2:26 PM, Staff B verified Patient #2's 11/26/22 rape allegation was not listed on the compliant log.

Interview on 12/06/22 at 2:42 PM with Staff A and Staff B verified staff did not contact police when Patient #2 hit Patient #1. Staff B stated the nurse called the police after she was hit and for Patient #2's allegation of sexual assault.

Interview on 12/06/22 at 3:15 PM with Nurse Practitioner, Staff F, revealed she was a provider at the facility on 11/26/22 and 11/27/22. She stated Patient #2 was saying he wanted to go home on 11/26/22. She stated "His behaviors were not against people, he would only harm things and objects." Staff F verified Patient #2 had been exhibiting aggressive behaviors previously. Staff F verified she was aware Patient #2 had hit another patient on 11/26/22. She stated Patient #2 punched another patient because he said the patient sexually assaulted him. Staff F verified Patient #2 also punched a nurse in the face on 11/26/22 for trying to administer emergency medications. Staff F stated the patient refused medications on the last day of his stay, had an anti-social personality disorder and was manipulative. Staff F stated they were with Patient #2 on 11/26/22 and he was aggressive, throwing things and acting out. Staff F stated she was not sure why he hurt Patient #1 as Patient #1 physically could not have raped Patient #2. She stated Patient #2 acts out to get what he wants. She stated she was operating off the history provided by the doctor and her personal assessment skills. Staff F stated she is not involved in the treatment plan and doesn't know what it is. She stated with all of the patients she has to see she doesn't have time to review treatment plans.

Interview on 12/06/22 at 4:20 PM with Staff G, the physician for the Maple Unit to revealed Patient #2 was admitted to the facility on other occasions. Patient #2 was discharged from another psychiatric hospital, then to jail and then pink slipped to this facility. Staff G stated the patient was admitted to the Laurels Unit but because he was punching people, walls and breaking computers he was transferred to the Maple Unit. Staff G stated he assessed Patient #2 on 11/25/22 and the patient stated he was okay, but he did not want the Thorazine, only the Depakote. Staff G stated on 11/25/22 at around 5:00 PM the behaviors started, but the patient did not seem to be responding to internal stimuli. Staff G stated "It was more like an act. He suddenly grabs someone and hits them." Staff G stated Friday 11/25/22 and Saturday 11/26/22 Patient #2 broke computers and hit staff and patients unprovoked. Staff G stated Patient #2 hit a patient and a nurse and when the police arrived he said he was sexually assaulted. Patient #2 was taken to the hospital and arrived back to the facility on 11/27/22. Staff G said the police saw the patient but sent him back to the facility.

Interview on 12/08/22 at 2:00 PM with Intake Assessment Lead (Staff L) revealed they never received a referral for Patient #2, he just showed up with the police. The patient was then admitted to the Laurels Unit. Staff L stated she was aware of the patient's aggression upon admission and noted the patient had previously broken someone's bones and had stomped on someone. Staff L stated she did report this information to the nursing supervisor and a unit nurse, but she could not remember who they were.

Interview on 12/08/22 at 3:40 PM with Staff M, revealed she did complete Patient #2's Initial Treatment Plan/Screening on admission. Staff M stated when she arrived to complete the assessment, the patient was unavailable as he was getting transferred from the Laurels Unit to the Maple Unit for aggression. Staff had informed her that the patient was aggressive, and they did not feel it was safe for her to meet with the patient at that time. Staff M stated she completed his treatment plan using previous assessments. Staff M verified aggression was not on the treatment plan and stated "I should have added aggression in hindsight."

Interview on 12/08/22 with the officer who responded to the facility on 11/26/22 when Patient #2 hit a nurse revealed the nurse contacted the police after being punched in her face. The nurse had reported Patient #2 was "out of control" and she was trying to get him under control when he punched her so hard that she fell. The officer stated other staff was verified what the nurse was reporting, however she did not get their names. The officer stated, "The employees lightly told her that Patient #2 had also hit a patient and was hard to be controlled." The officer did not interview Patient #2 as he was told by staff the patient was sedated. Staff also reported to the officer the patient was in the facility on a "pink slip" and officers do not have the authority to remove a "pink slipped" patient from a medical facility. The officer stated she referred the nurse to the prosecutors. The officer stated she heard officers had to go back to the facility on 11/26/22 during the night shift because the family of Patient #1 had called police about the assault.

Interview on 12/08/22 with Staff A and Staff B verified the above findings.

Review on 11/30/22 of the facility policy titled "Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation," dated 07/19, revealed patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation. Employees shall protect patients from harm, abuse, neglect and exploitation. Employees shall not subject a patient to any sort of abuse or neglect. Employees shall use only the degree of force necessary to repel or secure a violent and aggressive patient and which is permitted by the governing body. Violation of this policy by an employee shall be grounds for dismissal. All allegations, observations or suspected cases of abuse, neglect or exploitation that occur in the facility will be investigated. All suspected and/or observed cases of abuse must be reported immediately to the Director of Quality and Risk, or their designee. The Director of Quality and Risk will assist employees to file the report and report to the appropriate authorities. Staff will safeguard against the offending individual. The offending individual will be restricted of access to the patient. In instances of investigations concerning a staff member's behavior it is preferable to assign the involved staff member to non-patient care activities. All allegations shall be immediately and thoroughly investigated until conclusion.

Review on 12/01/22 of the facility policy titled "Patient Bill of Rights," effective 08/2022, revealed each person who accesses mental health services is informed of their rights. The rights include the right to reasonable protection from physical, sexual or emotional abuse, and the right to a current individualized treatment plan that addresses the needs and responsibilities of an individual that specifies the provision of appropriate and adequate services.

Review on 12/07/22 of the facility policy titled "Seclusion and Restraint," last revised on 09/2021, revealed patients are assessed upon admission and on a continual basis throughout their course of treatment for behaviors that are potentially dangerous to self or others. The nurse is to assess the patient's behavior on a regular basis to determine any imminent risk of the patient physically harming self, staff, or others. When a patient is presenting behaviors that are such that they present an imminent danger to the patient or others, staff should separate the patient from the group, redirect the patient, engage in 1:1, take the patient to their room with staff present and/or administer ordered medication. Staff is to document the interventions attempted or the rationale for not using the interventions.

Review on 12/12/22 of the hospital policy titled "Patient Violence Mitigation Program," last revised 03/22, revealed to ensure a thorough assessment of risk for violence and aggression, patients will be screened upon admission and throughout the course of treatment utilizing the Broset Violence Checklist (BVC). The Broset Violence Checklist is an evidenced based tool that evaluates six categories (confusion, irritability, boisterousness, verbal threats, physical threats, and attacking objects) that helps to predict imminent violent behavior in patients. Presence of a behavior gives a score of 1, absence gives a score of 0, with a total possible score of 6. A score of 0= low risk of aggression/violence, a score of 1-2 indicates a moderate risk for aggression/violence, and a score of three or higher indicates a high risk for aggression/violence. Throughout treatment the patient's BVC assessment, levels of observation and precautions are reassessed based on the patient's current needs and updated as clinically indicated. The treatment plan will reflect any interventions and treatment. All patient precautions must be transcribed on the patient close observation rounding sheet. Positive behavioral plans use interventions that avoid the use of punishment and use positive behavioral strategies to manage dangerous and serious interpersonal problems. The plans are developed by the clinical services department to include the multidisciplinary treatment team to support the safety of the patient with a patient specific plan.

This condition is not met as evidenced by:

Based on interview, medical record review and review of the facility policies, it was determined the facility failed to safely discharge a patient (A802). The cumulative effect of this practice resulted in Patient #2 being discharged without properly completing the treatment plan in regard to aggression and anxiety and without proper outpatient mental health linkage.

Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure patients were safely discharged. This affected one (Patient #2) of ten patients reviewed. The census was 43.

Findings include:

Review of Patient #2's medical record revealed an admission date of 11/23/22. The patient was "pink slipped" from jail for psychosis. Consents were signed by the patient on 11/23/22 at 4:08 PM.

Review of the Screening Assessment dated 11/23/22 at 2:46 PM, completed by the Licensed Social Worker (Staff L) revealed the interview was completed with the patient and other, as the patient was an involuntary hold. Staff L noted the patient reported depression at 10/10, anxiety at 0/10, manic behavior, paranoia and delusions. Staff L noted Patient #2 scored a high risk on the Columbia-Suicide Severity Rating Scale indicating suicidal intent with a plan and recent acts. Staff L noted the patient had a history of physical aggression. Staff L noted the patient reported history of aggressive behaviors while he was at another treatment facility. Staff L noted the patient had poor impulse control.

Review of Patient #2's Inpatient Comprehensive Psychiatric evaluation, dated 11/24/22, revealed the patient was agitated, yelling, cursing, and threatening another patient. The physician noted the patient had a history of multiple hospitalizations and a history of aggression while receiving inpatient treatment. The patient was noted to have a history of schizophrenia and bipolar disorder with medication noncompliance. The physician noted this is the patient's sixth admission to the facility stating his behavior was resistant, threatening, and impulsive. The physician also noted Patient #2 was suicidal with a plan to overdose on medications. The physician placed the patient on every 15-minute observations related to the aggression. The plan was to admit the patient to the Laurel Unit, obtain routine labs, restart home medications, provide standard as needed medications, encourage group and milieu treatment, work with social workers for appropriate placement and follow up care as symptoms begin to stabilize. The patient was diagnosed with schizoaffective bipolar type with an estimated length of stay of five to seven days.

Review of the Safety Assessment form dated 11/23/22 revealed the patient reported thoughts of harming himself and others.

Review of Patient #2's Multidisciplinary Treatment Plan, dated 11/24/22, revealed the patient was pink slipped due to suicidal ideations with a plan. Aggression was not listed on the plan until 11/26/22, however the patient was aggressive upon admission.

Review of Pt #2's Level of Care Assessment, dated 11/24/22, revealed the patient was "displaced" and the social worker (Staff M) noted she was unable to meet with the patient due to the patient's level of agitation and aggression.

Review of Daily Inpatient Progress Notes revealed on 11/25/22 the physician noted the patient was angry, threatening and getting into arguments with "everybody including peers and staff." He has poor impulse control, no insight and his judgement is impaired. Staff G noted the patient's mood as hostile. The patient denied suicidal ideations but reported thoughts of hurting other people. For the assessment of progress in treatment and achieving goals, the physician noted the patient's behaviors were poorly controlled. Under the rationale for continued inpatient stay, the physician noted the patient demonstrated a risk of harm to others and/or extreme aggression requiring inpatient monitoring. In addition, he noted the patient was unable to care for himself or perform activities of daily living and the acute treatments pose a reasonable risk of complications that would further cause dangerous deterioration of the individuals mental and/or physical health. The diagnosis was listed as bipolar disorder.

Review of the 11/26/22 7:00 AM through 7:00 PM Nursing Assessment revealed the patient was extremely agitated, disruptive, impulsive, destroyed computers, threatened staff and tried to enter the nursing station. The nurse noted the patient was very labile, unpredictable, and created a situation that greatly increased anxiety in peers.

Review of an Interdisciplinary Progress Note dated 11/26/22 at 6:45 PM revealed the Patient Care Associate (PCA), Staff D, witnessed Patient #2 attacking a male peer (Patient #1) by striking him in the chin with his fist, sending the peer to the floor where he hit his head and became unresponsive initially. The peer had bleeding from the scalp. Patient #2 was removed from the area and the peer was sent to the emergency room via EMS.

Review of the Discharge Summary, dated 11/27/22, completed by the Nurse Practitioner (Staff F) revealed Patient #2 was having an unplanned discharge. The patient arrived to the facility with the police and was admitted for extreme agitation, suicidal and homicidal ideations. The provider noted the patient has a history of schizophrenia, bipolar disorder, noncompliance with medication and reported suicidal ideations with a plan to overdose on medication. The provider noted the patient was experiencing depression at a 10/10 with isolation, helplessness, hopelessness, worthlessness, and low appetite. The patient presented to intake with rapid speech, agitation, poor impulse control and an increased activity level. The provider noted the patient was agitated upon arrival. He reported paranoia, The patient was initially placed on the Laurels Unit and was transferred to the Maple Unit related to him yelling, threatening and cursing at another patient. During his stay the patient was non-adherent to pharmacological treatment and required numerous emergency medications. Staff F noted the patient was very aggressive and abusive to staff and other patients. Staff F noted "This provider witnessed him pulling out both computers and the monitors from the nurses station, throwing them and breaking them." Staff F noted the patient has jumped over the nursing station and threatened staff several times. He has attempted to throw a chair over the nursing station to hurt staff. Staff F stated nursing staff reported the patient was angry, irritable and has argumentative social interactions. Staff F noted "The day before he was discharged nursing staff noted he was angry, labile, disruptive, impulsive and agitated." The patient was refusing to take Depakote (treats seizures and bipolar disorder). Staff F noted the patient was making sexually inappropriate comments to other patients and staff. Staff F also noted the patient assaulted other staff and patients by spitting on them. Staff F noted the patient ultimately assaulted another patient (Patient #2) causing the patient to be sent to the hospital with severe injuries. Staff F noted the patient was given Thorazine (treats mental illness and behavioral disorders) intramuscular (IM), which did not reduce his agitation. The patient claimed he was sexually assaulted by the patient he physically assaulted, Patient #1. Patient #2 was then taken to the hospital by the police to complete a rape kit. Staff F noted the patient returned the morning of 11/27/22. Staff F documented "After speaking to the administrative team and the physician, a decision was made that due to his aggressive behavior and his physical assault on another patient, he was discharged upon his arrival back." Staff F noted the patient arrived back to the facility on 11/27/22 with emergency medical services. Staff F noted she asked the patient, "Are you ready to go home?" The patient replied "Yes, am I able to do that?" Staff F replied, "Yes. I have your paperwork here if you want to sign it." Staff F noted she asked the patient was he having any plans of suicide or homicidal ideations, mania or audiovisual hallucinations and he denied it. Staff F noted Patient #2 called a homeless shelter on his own cell phone and made arrangements to go there after discharge from the facility. The facility called an Uber and sent his medication scripts to a pharmacy to be filled. Staff F stated she walked the patient to the Uber and the patient stated "Thank you man," and was discharged. Staff F noted the patient's mood as irritable with rapid speech. The prognosis was noted as poor to fair depending on the patient's adherence to the treatment plan, community referral and arranged services.

Review of Pt #2's Broset Violence Checklist, to assess short term violence predictability, revealed on 11/26/22 at 9:04 AM Patient #1 scored a seven on the Broset assessment as the patient destroyed two computer monitors and was verbally threatening staff. A score of greater than three indicates a high risk for violence.

Interview on 11/30/22 at 12:20 PM with Staff A revealed Patient #2 assaulted Patient #1 on the Maples Unit on 11/26/22.

Interview on 12/06/22 at 3:15 PM with Staff F revealed she was a provider at the facility on 11/26/22 and 11/27/22. She stated Pt #2 was saying he wanted to go home on 11/26/22. She stated his behaviors were not against people, he would only harm things and objects. Staff F verified the patient had been exhibiting aggressive behaviors previously. Staff F verified she was aware Patient #2 had hit another patient on 11/26/22. She stated Patient #2 punched another Patient #1 because he said the patient sexually assaulted him. Staff F stated Patient #2 also punched a nurse in the face on 11/26/22 for trying to administer emergency medications. Staff F stated the patient refused medications on the last day of his stay, had an anti-social personality disorder and was manipulative. Staff F then stated "I was with him on 11/26/22 and he was aggressive, throwing things and acting out." She stated Patient #2 acts out to get what he wants. Staff F stated she is not involved in the treatment plan and doesn't know what it is. She stated with all of the patients she has to see, she doesn't have time to review treatment plans.

Interview on 12/06/22 at 4:20 PM with Staff G, the provider for the Maple Unit, revealed Patient #2 was admitted to the facility "quite a few times." Patient #2 was discharged from another psychiatric hospital, then to jail and then pink slipped to this facility. Staff G stated he assessed Patient #2 on 11/25/22 and the patient stated he was okay, but he did not want the Thorazine, only the Depakote. Staff G stated on 11/25/22 at around 5:00 PM the behaviors started but the patient did not seem to be responding to internal stimuli. Staff G stated, "It's more like an act. He suddenly grabs someone and hits them." Staff G stated Friday 11/25/22 and Saturday 11/26/22 Patient #2 broke computers and hit staff and patients unprovoked. Staff G stated Patient #2 is upset related to his lack of support, homelessness, and loneliness. Staff G stated the patient can't follow safety rules and may have a personality disorder that is "not exactly bipolar disorder."

Interview on 12/07/22 at 8:20 AM with Director of Clinical Services (Staff H) revealed a patient who is homeless and noncompliant with medications would be considered "high risk." Staff H stated his staff would need to ensure an appointment for outpatient mental health was set and they would write a bridge prescription for the patient to have medications until they see the outpatient mental health provider

Interview on 12/08/22 at 2:32 PM with Staff G stated if the aggressive behavior is out of the blue or the patient is not responding to internal stimuli, there is no higher level of care to transfer them to. Staff G stated "The only other place he could have gone is prison." Staff G stated Staff F was considering the safety of the other patients when considering the discharge to the community without supervision.

Interview with Staff A and B verified Patient #2 was discharged to homeless shelter via an Uber ride with his prescriptions sent to a pharmacy. They verified the patient was told to go to an outpatient psychiatric treatment center as a walk-in and no follow up appointments were made. They verified the patient had physically assaulted a patient and a nurse, threw and destroying two facility computers and stated he was raped on 11/26/22. Staff A and Staff B verified the patient was sent to the emergency room after the incident on 11/26/22 an upon his arrival back he was immediately discharged. They verified the treatment plan goals were not met as the patient was reporting anxiety at a 10/1 and displaying aggressive behaviors throughout his stay.

Review on 12/07/22 of the facility policy titled "Discharge and Transition Planning," effective 12/21, revealed the facility engages in ongoing transition planning at the start of services, throughout the course of treatment and at the time of discharge using the Discharge Planning Progress Note. The Discharge Planning Progress Note will be completed by the treating therapist and will be initiated at admission. Discharge documentation will minimally include the initial discharge conversation with the patient, weekly discharge discussions, discharge conversation within 24 hours of discharge, information on living arrangements, safety concerns addressed prior to discharge and aftercare plans to include provider and therapy appointments. The patients discharge plan will include referrals and aftercare. Patients discharging from inpatient services should have a provider appointment set within seven days of discharge. If this is not possible, it should be documented thoroughly. Staff will discuss the discharge plan and provide the patient with a copy. The discharge plan should include the following information; the date of admission and discharge, reason for hospitalization, post discharge contact number, the next provider of care (include name, address, phone and appointment time), continued treatment medication, attempts to obtain release of information if needed, medical appointment information as needed, type of place patient was discharged to and information on options and resources if symptoms recur or additional services are needed. Patients will have a completed treatment plan that is updated based on regulatory guidelines and internal policy standards. Each plan will be individualized to the patient and include a preliminary discharge plan that is developed with the resident. Further review of the policy revealed that a successful discharge occurs when the treatment team determines that a patient is ready for discharge from the level of care being provided. If a patient has met and maintained clinical goals, the patient will be discharged with an appropriate discharge plan. Staff is to complete the discharge checklist, notify the referral source if authorized to release information and notify family and/or support system 24 hours prior to discharge and/or the day of discharge. If a patient needs a higher level of care due to increased risks such as actively suicidal, homicidal, or increased aggression and cannot be maintained at the current level of care, the patient should be stepped up to a higher level of care. The program provider and appropriate staff should make that determination. Further review of the policy revealed if a patient was assessed as high to moderate suicide risk intervention will occur. The interventions may include developing a plan to mitigate the risk of suicide at the facility, developing a safety plan focused on post discharge safety, counseling and follow-up care, increased levels of observation, updating goals and interventions on the treatment plan, accessing different supportive services, and providing referrals for appropriate levels of care upon discharge.

Review on 12/12/22 at 9:30 AM of the facility policy titled "Voluntary and Involuntary Admission Process," last approved on 06/22, revealed applications of voluntary admission may be initiated by any person who is 18 yrs of age or older and who is, appears to be, or believes to be mentally ill. A patient is determined to meet criteria for hospitalization per ORC 5122 following the completion of a Level of Care/Psychosocial Assessment. The patient is provided with an Application of Voluntary Admission to initiate hospitalization and the patient is willing to sign it. Through the level of care/psychosocial assessment, a patient is determined to meet criteria for hospitalization per ORC 5122, but the patient is not willing to sign an Application of Voluntary Admission. The hospital can initiate an Application of Emergency Admission (Pink Slip). The hospitals assessment specialist will notify the physician that a patient meeting criteria per ORC 5122 is not willing to sign an Application of Voluntary Admission and the physician will determine whether the process for involuntary commitment should be initiated. A person admitted to a psychiatric hospital pursuant to ORC 5122 may be involuntary committed for up to 3 court days. Ohio Revised Code 5122.01 (B) states a mentally ill person subject to court order, means a mentally ill person who, because of the person's illness: (1) represents a substantial risk of harm to self as manifested by evidence of threats of, or attempts at, suicide or serious self-inflicted bodily harm; (2) represents a substantial risk of physical harm to others as manifested by evidence of recent homicidal or other violent behavior, evidence of recent threats that place another in reasonable fear of violent behavior and serious physical harm, or other evidence of present dangerousness; (3) or represents a substantial and immediate risk of serious physical impairment or injury to self as manifested by evidence that the person is unable to provide for and is not providing for the person's basic physical needs because of that person's mental illness and that appropriate provision for those needs cannot be made immediately available in the community; or (4) Would benefit from treatment for the person's mental illness and is in need of such treatment as manifested by evidence of behavior that creates a grave and imminent risk to substantial rights of others or the person. Further review of the policy revealed that an application of voluntary admission may be denied by the Medical Director should hospitalization be inappropriate. The Medical Director of the hospital may discharge any patient who has recovered or whose hospitalization is no longer advisable. A voluntary committed patient may request in writing their release from the hospital. A patient admitted to the facility must be seen by a physician within 24 hours of admission. Per ORC 5122, only a physician can release a patient from a "pink slip." If after three court days, the physician concludes that continued stay is required and the patient is not willing to sign an application of voluntary admission, the hospital can initiate the probate process.