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Based on document review, and interview, it was determined that the Hospital failed to ensure patients' rights were protected. This potentially affects an approximately 18 patients on the census. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to ensure psychotropic medications were explained and consents obtained with the patient prior to administration of the medications. See deficiency at A-131.

2. The Hospital failed to ensure patient was safe from harm. See deficiency at A-144 A.

3. The Hospital failed to ensure appropriate patient safety precautions were in place. See deficiency at A-144 B.

4. The hospital failed to ensure that all precautions ordered were included in the every 15 minute precautions monitoring. See deficiency at A-144 C.

Based on document review and interview, it was determined that for 1 of 5 (Pt. #3) records reviewed, the Hospital failed to ensure psychotropic medications were explained and consents obtained with the patient prior to administration of the medications.

Findings include:

1 The clinical record for Pt #3 was reviewed on 11/20 18. Pt. #1 was a 23 year old male, admitted on 11/17/18 with a diagnosis of schizoaffective disorder. The clinical record contained orders for Depakote (for mood stabilization) 500 mg (milligrams) PO (by mouth) every 12 hours; and Zyprexa (anti-depressant) 10 mg every 12 hours, PO. The clinical record indicated Depakote and Zyprexa were administered on 11/19/18 at 7:59 PM. The "Psychotropic Medication Notice and Consent Form" did not indicate the psychotropic medications ordered for Pt. #3.

2. The Hospital Policy titled, "Consent to Psychotropic Medication Treatment" (reviewed 3/2017), required, When an order for psychotropic medication is written, it will list the patient's name and medication(s) on a "Notification of Psychotropic Medication" form. If more than one psychotropic medication is ordered at the same time, it may be listed on one form.

3. The Director of Behavioral health (E #12), was interviewed on 11/21/18 at approximately 9:35 AM. E #12 indicated that the expectation is to mark the medication ordered on the form before discussing and obtaining the patient's consent.

A. Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) patients' reviewed for suicidal ideation, the Hospital failed to ensure that patient was safe from harm.

Findings include:

1. On 11/20/18 at approximately 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 53 year old Caucasian male admitted to the Hospital on 10/4/18 due to suicidal ideation.

- The clinical record included a physician's order for violence (assault) and suicide precautions dated 10/4/18 at 12:23 AM.

- The Progress Notes of E #6 (Registered Nurse) dated 10/8/18 at 6:21 PM included, " ... Patient roommate came out of the room yelling that his roommate jump off the window. Staff immediately responded, noted window screen opened. Blankets and bedsheets scattered on the floor near the window. Saw patient lying on the ground on his abdomen, both hands tucked in under his abdomen. Code gold (patient elopement) was activated... (MD #1) ... made aware."

- The Progress Notes of the Hospital's Emergency Department Registered Nurse, dated 10/8/18 at 4:46 PM included, " ... (Pt. #1) jumped from 3 RD floor (third floor) window landing on grassed area, on tailbone ... admits to pain of coccyx (tailbone) area only able to move all extremities ... (Pt. #1) ... pleasant affect is appropriate calm, denies SI (suicidal ideation), states I just wanted out ... (ambulance) here for transport, patient stable ... (Registered Nurse at Hospital 2) given report ..."

- The Hospital's ED Physician's History and Physical Report dated 10/8/18 at 4:32 PM included, " ... Reason for visit: Back pain/fall ... 53 year old man who jumped from second floor window found on the ground outside of hospital is brought to the emergency department with complaint of right sided and low back pain. He states he landed on his buttocks... Assessment and Plan: Trauma center transfer ... Diagnosis: Major trauma. Back pain ..."

2. On 11/21/18 at approximately 1:25 PM, the Hospital's policy titled, "Patient Rights and Responsibilities" (reviewed 1/17) was reviewed and included, "Purpose: To ensure that care, treatment, and services are provided... To comply with regulatory requirements... our goal is to make the Patient's visit as pleasant as possible..."

3. On 11/20/18 at approximately 1:24 PM and on 11/21/18 at approximately 12:30 PM, interviews were conducted with E #2 (Performance Improvement Director). E #2 said that the required every 15 minutes check was not appropriately done by the mental health specialist (E #10). E #2 said, "He (E #10) falsified the 15 minute check documentation. E #2 added that he (E #2) spoke to Pt. #1s mother and knew that Pt. #1 suffered a pelvis (base of spine) fracture and L5 (lumbar/back) fusion.

B. Based on document review and interview, it was determined that for 2 of 5 (Pt. #1 and Pt. #2) patients' clinical records reviewed at risk for elopement, the Hospital failed to ensure appropriate precautions were in place.

Findings include:

1. On 11/21/18 at approximately 9:30 AM, the Hospital's policy titled, "Elopement Precautions" (reviewed 9/18/18) was reviewed and included, "Policy: It is the policy of (the Hospital) to follow a sequence of actions in an attempt to minimize potential risks associated with a patient who is expressing the intention to elope... 2. When a patient makes a verbal threat to elope... the patient will be placed on Elopement Precaution including observation and documentation every 15 minutes on the Behavioral High Risk Precautions flow sheet.

2. On 11/20/18 at approximately 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 53 year old Caucasian male admitted to the Hospital on 10/4/18 due to suicidal ideation.

- The Progress Notes of E #6 (Registered Nurse) dated 10/8/18 at 6:21 PM included, " ... Patient roommate came out of the room yelling that his roommate jump off the window. Staff immediately responded, noted window screen opened. Blankets and bedsheets scattered on the floor near the window. Saw patient lying on the ground on his abdomen, both hands tucked in under his abdomen. Code gold (patient elopement) was activated... (MD #1) ... made aware."

- The Progress Notes of the Hospital's Emergency Department Registered Nurse dated 10/8/18 at 4:46 PM included, " ... (Pt. #1) jumped from 3 RD floor (third floor) window landing on grassed area, on tailbone ... admits to pain of coccyx (tailbone) area only able to move all extremities ... (Pt. #1) ... pleasant affect is appropriate calm, denies SI (suicidal ideation), states I just wanted out ... (ambulance) here for transport, patient stable ... (Registered Nurse at Hospital 2) given report ..."

- The clinical record did not indicate that Pt. #1 was placed on elopement precautions on 10/8/18.

3. On 11/20/18 at approximately 1:25 PM, an interview was conducted with E #2 (Performance Improvement Director). E #2 stated that based on the investigation, Pt. #1's roommate (Pt. #2) stated that they (Pt #1 and Pt. # 2) were trying to escape. E #2 said, I talked to both of them (Pt. #1 and Pt. #2) on the day of the incident.

4. On 11/21/18 at approximately 11:45 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 35 year old male admitted on 10/8/18 with a diagnosis of schizoaffective disorder. The Nurses' Progress Notes dated 10/9/18 was reviewed and included, " ... Per supervisor (E #8), patient is also possibly an accomplice to his roommate (Pt. #1) jumping out of the window ..." However, Pt. #2's safety precautions check from 10/8/18 through 10/11/18 did not indicate that Pt. #2 was placed on elopement precautions.

5. On 11/21/18 at approximately 9:18 AM and at 1:30 PM, interviews were conducted with E #12 (Director of Behavioral Health). E #12 stated, "I was at home when they called me about a patient (Pt. #1) jumping out of the window ... Came to work the next day ... Spoke with staff ( E #6/Registered Nurse) ... (E #6) stated that Pt. #1 wanted to leave... the Hospital ..." E #12 stated that patients are placed on elopement precautions if verbalizing of leaving the Hospital.


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C. Based on observation, document review and interview, it was determined that for 2 of 5 (Pt. #3 & 4) records reviewed, the hospital failed to ensure that all safety precautions ordered were recorded in the every 15 minute precautions monitoring sheet.

Findings include:

1. The clinical record for Pt #3 was reviewed on 11/20/18. Pt. #3 was a 23 year old male, admitted on 11/17/18 with a diagnosis of schizoaffective disorder. The physician's order, dated 11/17/18, included violence precaution (assault precaution-AP), fall, seizure and sexually acting out (SAO) precautions. The precautions monitoring sheets dated 11/17/18, 11/18/18 and 11/19/18 did not include the SAO precautions.

2. The clinical record for Pt #4 was reviewed on 11/20/18. Pt. #4 was a 28 year old male, admitted on 11/16/18 with a diagnosis of schizoaffective disorder. The physician's order, dated 11/16/18, included assault precaution (AP) and sexually acting out (SAO) precautions. The precautions monitoring sheets dated 11/16/18, 11/18/18 and 11/9/18 did not include SAO precautions.

3. The Hospital policy titled, "Patient Safety Rounds" (rev 10/17/18) was reviewed on 11/20/18. The policy required, "...all patients on the unit are placed on Close Observation precautions unless otherwise specified by an order from the Psychiatrist. Mandatory patient safety rounds are conducted every 15 minutes by a team member... The patient safety rounding tool allows the team member to document the location and the behavior of the patient. ...Purpose: to ensure the safety of all patients... To recognize any potential exposure risk or sudden change in behavior..."

4. The above findings were discussed with the Director of Behavioral Health during an interview on 11/21/18 at approximately 9:35 AM, who indicated that the type of precaution should be marked on the rounding tool, if it is ordered.