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The Condition of Participation for Patient Rights has not been met.

Based on clinical record review, video review, review of hospital policy and staff interview for 2 of 2 sampled patients reviewed for inappropriate behaviors, the hospital failed to ensure patients were free from sexual contact and for 1 of 3 sampled patients, (Patient #3) who was reviewed for alleged abuse, the hospital staff failed to maintain boundaries with a patient.

Based on clinical record review, review of hospital policy and staff interview for 1 of 3 sampled patients reviewed for restraints (Patient #5), the hospital failed to ensure the patient was removed from restraints when the absence of behaviors was identified.

Based on clinical record review, review of hospital policy and staff interview for 2 of 3 sampled patients reviewed for restraints (Patient #5 and #6), the hospital failed to ensure a face to face was conducted within one hour of initiation of the restraint.

Please see A145, A174 & A178

Based on clinical record review, video review, review of hospital policy and staff interview for 2 of 2 sampled patients reviewed for inappropriate behaviors, the hospital failed to conduct fifteen minute checks to ensure patients were free from sexual contact and for 1 of 3 sampled patients, (Patient #3) who was reviewed for alleged abuse, the hospital staff failed to maintain professional boundaries with a patient by sharing social media contact with the patient. The findings include:

1. Patient #1 was admitted on 5/18/22 after having outbursts, aggressive behaviors and agitation at home. The History and Physical dated 5/18/22 noted Patient #1 was seen earlier in the Emergency Department (ED), cleared by psych, and returned home. The patient was readmitted to the ED on 5/18/22 for ongoing behavioral management issues and diagnoses included intellectual restriction, bipolar disorder, impulse control, and behavioral issues. The physical exam noted the patient as mildly anxious and upset. The note further identified the patient would be transitioned back to the behavioral health unit for assessment.

Review of physician orders dated 5/18/22 identified the Patient was on every fifteen minutes observations from 5/18/22 until 5/27/22, when the patient was placed on a continuous patient observation with a sitter.

Review of nursing progress notes dated 5/27/22 at 7:32 PM noted that around 6:00 PM Patient #1 referred to Patient # 2 as their boyfriend, and Patient #1 entered Patient #2's room. The note identified the registered nurse entered the patient's room and asked Patient #1 to leave the room and Patient #2 stated that they had a "quick kiss" and would have to wait to do anything else when they were out of the hospital. The note identified the supervisor, administrator on call and security were notified. The note identified Patient #1 became agitated and was unable to be verbally redirect. The note further identified the patient went back to their room and reported to the nurse with security present that they (Patient #1 and #2) engaged in sexual activities. The note identified Patient #1 and Patient #2 stated it happen on 5/26/22 and it occurred multiple times.

Review of progress notes dated 5/29/22 at 6:26 AM noted Patient #1 was observed to be upset, talking to self, and verbalized feeling upset. The note further identified that while the patient was walking back to their room, the patient had an emotional outburst, tearful regarding "boyfriend" and stated that they had engaged in sexual activities, one-to-one sitter remains at bedside.

Nursing progress notes dated 5/30/22 at 9:37 AM noted the one-to-one was discontinued and the patient was increased to a status 2, every fifteen-minute checks.

Behavioral health progress note dated 5/30/22 at 1:37 PM noted today the patient's behavior has shown some improvement, is less intrusive and able to follow directions and was placed on every fifteen-minute checks.

Nursing progress notes dated 5/30/22 at 9:52 PM noted at approximately 7:45 PM Patient #1 became upset, tearful, and yelling after observing Patient #2 talking to another patient. The note identified at approximately 8:55 PM Patient #2 was observed in the hall, outside of Patient #1's room attempting a verbal interaction with Patient #1. Patient #2 was redirected; the psychiatrist was called and Patient #1 was placed back on one-to-one observation to assist in maintaining appropriate behaviors and safe interactions.

Patient #2 presented to the ED on 5/23/22 for a psych evaluation. The ED provider notes dated 5/23/22 at 5:02 PM identified the patient diagnoses included Schizophrenia and the patient would be transferred to the behavioral health unit for a psychiatric evaluation.

Physician orders dated 5/23/22 directed the patient to be on every fifteen-minute observations.

Nursing progress notes dated 5/27/22 at 5:58 PM noted Patient #2 stated to staff that Patient #1 went to Patient #2's room for a "quick kiss" and reported that they (Patient #1 and #2) had some sexual contact. The note identified the supervisor and administrator on call were made aware of the incident. The note further identified Patient #2 reported that these activities have happened in his/her room on previous days.

Nursing progress notes dated 5/28/22 at 9:58 PM noted the patient was redirected for calling peers baby and telling peers of the opposite gender "I love you". Status 2 maintained with every fifteen minutes checks for safety. Further review of Patient #2's clinical record with the Nurse Manager of the Behavioral health unit identified the patient was maintained on every fifteen-minute safety checks until discharge on 6/1/22.

Although staff documented that fifteen minutes checks were conducted a review of video recording dated 5/26/22 from 2:45 PM through 7:58 PM identified Patient #1 and Patient #2 engaged in intimate sexual encounter several times during the times when it was documented that checks were completed.

Review of Patient #1 and Patient #2's every fifteen-minute checks for 5/26/22 noted checks were completed every fifteen minutes from the top of the hour as ordered. Review of the video monitoring dated 5/26/22 at 6:31 PM and 6 seconds noted Mental Health Worker (MHW) #3 was observed to walk down the hallway away from the common area where Patient #1 and Patient# 2 were located. At 6:44 PM and 28 seconds MHW #3 was observed to be near the day room window and was seen stretching her head to the right looking at the day room and then walked back to the middle of the hall to the chair and sat down.

Interview with the Nurse Manager for behavioral health on 6/13/22 at 11:30 AM stated that she was made aware that Patient #1 reported to the nurse on 5/27/22 that there was intimacy between Patient #1 and Patient #2. The Nurse Manager stated that Patient #1 was placed on a one-to-one and although every fifteen-minute checks on Patient #2 continued, no new interventions were implemented to ensure that all patients were free from sexual activity. The Nurse Manager stated that when she returned to work on 5/31/22 the investigation was started and she along with risk management reviewed the video of the unit and noted Patient #1 and Patient #2 engaged in sexual activity on several occasions. The Nurse Manager stated that while reviewing the video it was identified that MHW #3 failed to do every fifteen minutes checks on the patients as ordered. The Nurse Manager stated that after the incident all staff were re-educated on every fifteen-minute checks and the nurses will assist with the checks one time during the hour.

Interview with MHW #3 on 6/13/22 at 1:29 PM stated that on 5/27/22 she was the only MHW on the unit and had asked the nurse to help with the checks around dinner time. MHW #3 stated that it was a busy night, and she couldn't remember if she saw the patients every fifteen minutes as ordered. MHW #3 stated that if she had seen the patients together, she would have separated them and report it to the nurse.

Interview with RN #1 on 6/13/22 at 3:30 PM stated that Patient #1 entered Patient #2 room and she redirected Patient #1 out of the room. RN #1 stated that Patient #2 told her that Patient #1 and Patient #2 had a quick kiss. RN #1 stated that she notified the Supervisor and Administrator on duty. RN #1 stated that the patient during that time was agitated and not able to be redirected. RN #1 stated when the patient calmed down Patient #1 told her that they engaged in sexual activities. RN #1 stated that she reported the incident to the nurse manager and placed Patient #1 on a one-to-one observation. RN #1 stated that Patient #2 was continued on every fifteen-minute checks.

Interview with RN #2 on 6/23/22 at 3:00 PM stated that she spoke to Patient #2 who told her that they had been sexually active with each other. RN #2 stated that although Patient #1 was placed on a one-to-one, Patient #2 remained on every fifteen-minute checks.

Interview with RN #3 on 6/23/22 at 3:30 PM stated that she was present when Patient #2 was interviewed by security and reported that he/she was involved sexually with Patient #2. RN #3 stated that they maintained Patient #2 on every fifteen-minute checks and did not feel it was relevant to increase Patient # 2's monitoring status.




2. Patient #3's diagnoses included mood disorder and made suicidal statements.
Review of the facility's documentation dated 6/13/22 alleged that MHW #1 gave Patient #3 a gift with their initials on it and shared her contact information for their social media account with the patient. The documentation noted a DCF-136 form was completed. Further review of the hospital documentation noted video surveillance was reviewed, and on the evening of 6/9/22 and a rehab staff observed MHW #1 and Patient #3 sitting in close proximity of one another. On 6/10/22 at approximately 11:00 AM MHW #2 observed MHW #1 and Patient #3 walking down the hall together and MHW #1 handed the patient something and was heard saying "put this in your room." The documentation noted that MHW #1 was interviewed by hospital staff and identified she had given the patient a black bracelet with her initial on the day of the patients discharge because they had a relationship. MHW #1 identified she had provided the patient with her social network contact information to provide support to the patient after discharge if the patient needed it, and that she did have contact with the patient after discharge. Additionally, the hospital documentation noted that MHW #1 recalls signing the professional boundaries contract but could not recall specific details.

Interview with the Director of Nurses for Behavioral Health on 8/2/22 at 11:30 AM stated that MHW #1 was placed on administrative leave and terminated for not following hospital policy. Interview with MHW #2 on 8/3/22 at 10:40 AM stated that she was providing a one-to-one with another patient when she saw MHW #1 come from another unit and handed Patient #3 something and said, "put this in your room." MHW #2 stated that MHW #1 had her hand on the patient's back while they were walking down the hall. Review of MHW #1 personal file identified MHW #1 signed the Professional Boundaries for Clinical Staff on 11/1/21.

Review of the Professional Boundaries for Clinical Staff policy noted professional boundaries are a basic competency for all mental health professionals, they protect the patient and the staff, communication should be centered on the patient and not the staff, under no circumstances is it ever acceptable to violate professional boundaries with a patient. Indications of boundary violations are spending extra time with a patient, giving or receiving gifts from a patient, exchanging contact information for post-hospitalization (emails, text, websites, social networking sites and phone numbers), sharing personal information, and physical contact beyond what is normally necessary such as for vital signs. The policy further identified post discharge contact between staff members and patient outside the hospital is prohibited and grounds for immediate dismissal.

Based on clinical record review, review of hospital policy and staff interview for 1 of 3 sampled patients reviewed for restraints (Patient #5), the hospital failed to ensure the patient was removed from restraints when the absence of behaviors was identified. The findings include:

Patient #5's diagnoses included schizoaffective disorder.

Nurse's notes dated 6/4/22 at 3:21 PM identified the patient was exposing themselves, threatening to hurt staff, shadow boxing, and banging the nurse's station. The note identified Security was called and the patient was medicated. The note further identified the patient attempted to swing at staff and was placed in a restraint chair at 3:14 PM.

Review of the physician orders dated 6/4/22 at 3:14 PM directed to utilize a restraint chair for violent or destructive behaviors. The order directed to discontinue the use of the restraint when there is an absence of behavior that required the restraint. Further review of the order identified the restraint chair was discontinued at 5:00 PM.

Nurse's notes dated 6/4/22 at 3:21 PM indicated patient exposing self, poor boundaries, threatening to hurt staff, shadow boxing, banging the nurse's station and attempting to swing at staff, security was called and the patient was placed in the restraint chair.

Review of the flow sheets for continuous observation dated 6/4/22 noted the patient was in the restraint chair from 3:15 PM through 5:00 PM. Further review of the flow sheets noted that although the flow sheets indicated the paient was in a restraint chair every fifteen minutes there was no documentation of the patient's behaviors at 3:45 PM, 4:16 PM, 4:46 PM and 5:00 PM.

Interview and review of Patient #5's clinical record with the Nurse Manager on 8/3/22 at 9:50 AM stated that behaviors are to be documented on in the flow sheets when under continuous observation every fifteen minutes while the patient is in the restraint. The Nurse Manager stated that the behaviors documented assist staff in determining when a restraint can be discontinued. Further review of the clinical record with the Nurse Manager failed to identify indication that staff had difficulty controlling the patient.

Review of the hospital policy for Restraint and Seclusion for emergency and inpatient departments noted that while a patient is in violent/self-destructive restraints, the patient must be on a one-to-one observation at all times and documented every 15 minutes on paper or electronically. The documentation must include the patients physical and emotional wellbeing, maintenance of patient's dignity and safety, signs of injury and free and easy breathing.

Based on clinical record review, review of hospital policy and staff interview for 2 of 3 sampled patients reviewed for restraints (Patient #5 and #6), the hospital failed to ensure the patient was seen face to face within one hour of initiation of the restraint. The findings include:

1. Patient #5's diagnoses included schizoaffective disorder. Nurse's notes dated 6/4/22 at 3:21 PM identified the patient was exposing themselves, threatening to hurt staff, shadow boxing and banging the nurse's station. The note identified Security was called and the patient was medicated. The note further identified the patient attempted to swing at staff and was placed in a restraint chair at 3:14 PM.

Review of physician orders dated 6/4/22 at 3:14 PM directed to utilize a restraint chair for violent or destructive behaviors. The order directed to discontinue the use of the restraint when the there is an absence of behavior that required the restraint. Further review of the order identified the restraint chair was discontinued at 5:00 PM.

Review of the clinical record with the nurse manager on 8/3/22 at 9:45 AM noted that the face-to-face requirement by the physician was documented at 4:59 PM, a total of an hour and 45 minutes after the start of the restraint.

2. Patient #6's diagnoses included substance abuse and psychosis.
Physician orders dated 5/29/22 at 9:42 AM directed to place the patient in a restraint chair due to a danger to self and others. The order further identified the restraint chair was discontinued at 10:43 AM.

Nurse's notes dated 5/29/22 at 10:00 AM noted the patient was banding on the nursing station window and trying to enter other patient rooms, security was called, and the patient was placed in a restraint chair and given intramuscular (IM) Thorazine/Ativan/Benadryl.

Nurse's notes dated 5/29/22 at 11:10 AM noted the patient was calm, cooperative, and apologetic and was removed from the restraint chair at 10:43 AM.

Review of the clinical record with the Nurse Manager on 8/3/22 at 9:55 AM noted that although the patient was seen by psychiatry on 5/29/22 at 12:02 PM and the note addressed continue with restraint and emergency medications to treat psychosis resulting in dangerous behaviors associated with detox, the note was documented an hour and 17 minutes after the restraint was discontinued. The Nurse Manager stated that there was no face-to-face completed within one hour of the initiation of the restraint chair.

Review of the hospital policy for restraints and seclusion for emergency and inpatient departments identified when a restraint is applied for violent/self-destructive seclusion, the provider or trained RN must see the patient face-to-face within one hour after the initiation of the intervention to evaluate and document the patient's immediate situation, reaction to the intervention, medical and behavioral condition as well as the need to continue or terminate the restraint.