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Based on review of two (2) of ten (10) medical records (#2, #4), staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure that documentation regarding contraband searches, is included in the medical record.

Findings include:

Reference #1: Facility Policy, "Search of Patients" states, "Policy... if at any other time there is reasonable cause to assume the hiding of dangerous objects on the patient's person, then the Charge Nurse/Nursing Supervisor will contact the attending physician or designee to obtain an order to conduct the search. ... Purpose: All searches are conducted to maintain a safe, controlled environment for patient and staff to remove objects, including medications, which a patient might use to harm self or others. Procedures: 1. Two staff members are assigned to conduct the search; one staff member must be a Registered Nurse and the other staff member the same sex of the patient. ... Staff conducting the search will make documentation in the clinical record to include: a. Search done and reasons for the same. b. Contraband found and disposition of the same. c. Patient's reaction... ."

Reference #2: Facility policy, "Contraband" states, " ... It is the policy of [Name of facility] to preserve the privacy, safety, and security of patients, employees, and visitors. Privacy includes freedom form unreasonable search of personal belongings or the premises and furniture being used by patients. ... Conducting a Contraband Search... 2. If the patient refuses the search, an order must be obtained from the attending physician or designee. ... b. Room Searches... (1) In order to assure privacy and protection, searches of rooms or belongings must be conducted with the patient present. ... Documentation... All searches must be clearly documented in the patient's medical record and should include... b. Include information demonstrating that the search was conducted in the most effective and least restrictive means possible to meet both medical and security needs. ... c. Include who conducted the search and who was present during the search. ... d. Include patient's response to being initially questioned about the contraband, as well as his/her response to being advised that the items must be submitted to staff. ... e. Indicate what, if any, contraband was found, as well as where the contraband is being stored. ... ."

1. Review of Medical Record #2 on 4/15/21 revealed the following:

a. The patient was voluntarily admitted to the facility on 2/11/21 with an admitting diagnosis of Psychiatric-Depressive Disorder and Anxiety Disorder.

b. A Mental Health Associate progress note dated 2/23/21 at 1:00 PM states, "[Name of patient] was placed on 1:1 (one to one) protocol. ... . Patient had a room and body check with a doctor order due to him/her cheeking and snorting Vistaril. ... . Patient denies any involvement in cheeking and inhaling Vistaril. ... ."

c. There was no evidence in the medical record of a physician's order for a body search.

(i) There was no evidence in the medical record that the patient consented to the room search or evidence of a physician's order for the room search.

(ii) There was no documentation in the medical record indicating who conducted the body search and room search, and who was present during both searches.

(iii) There was no documentation in the medical record indicating whether the patient was present during the room search.

(iv) There was no documentation in the medical record that included information demonstrating that the search was conducted in the most effective and least restrictive means possible.

(v) There was no documentation in the medical record that included the patient's response to being questioned about the contraband, as well as his/her response to being advised that the items must be submitted to staff.

(vi) There was no documentation in the medical record that indicated what, if any, contraband was found during the searches, as well as where the contraband was being stored.

2. Upon interview on 4/14/21 at 11:40 AM, Staff #9 confirmed that a physician order is required to conduct a patient body search for suspected contraband.

3. Staff #3 confirmed the above findings on 4/15/21 at 12:45 PM.



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4. Review of Medical Record #4 on 4/15/21 revealed the following:

a. The patient was involuntarily admitted to the facility on 3/24/21. The physician's history and physical indicated that the patient was psychotic, not taking his/her meds, delusional, and reporting that he/she was Jesus Christ and part of the CIA. The patient has a history of schizophrenia and substance abuse. An order to involuntarily commit the patient was ordered on 3/24/21 at 10:10 PM.

b. Nurse's notes dated 3/25/21 state, " ... Pt (patient) was able to calm down after being in QR x 30 min (quiet room for 30 minutes). Pt walked out at 8 AM began threatening staff in room saying 'You're next' and pt whipped out a crack pipe towards this writer and continue to yell 'You're next.' Pt was made to do a body search/room search after paraphernalia was found. ... ."

c. A verbal order for a body search was written on 3/25/21 at 8:43 AM.

d. There was no evidence in the medical record that the patient consented to the room search or evidence of a physician's order for the room search.

(i) There was no documentation in the medical record indicating who conducted the body search and room search, and who was present during both searches.

(ii) There was no documentation in the medical record indicating whether the patient was present during the room search.

(iii) There was no documentation in the medical record that included information demonstrating that the search was conducted in the most effective and least restrictive means possible.

(iv) There was no documentation in the medical record that included the patient's response to being questioned about the contraband, as well as his/her response to being advised that the items must be submitted to staff.

(v) There was no documentation in the medical record that indicated what, if any, contraband was found during the searches, as well as where the contraband was being stored.

5. Staff #1 and Staff #2 confirmed the above findings on 3/25/21 at 3:30 PM.

A. Based on random observations, staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure that contraband items are not stored in patient rooms.

Findings include:

Reference: Facility policy, "Contraband" states, " ... It is the policy of [Name of Facility] to preserve the privacy, safety, and security of patients, employees, and visitors. ... Prohibited items include... sharp objects... PROCEDURE... 3. ... aerosol cans with alcohol content will be removed and stored in the sharps closet. ... The following items are considered sharps and should be secured according to policy... pens/pencils... ."

1. During a tour of Unit 1 (Young Adult Unit) on 4/14/21 at 11:00 AM, a Glade air freshener aerosol can was found in the Seclusion Room bathroom.

a. Upon interview at 11:01 AM, Staff #3 and Staff #4 confirmed that the aerosol can should not be stored in the Seclusion Room bathroom.

2. During a tour of Unit 3 (General Adult Unit) on 4/14/21 at 11:20 AM, a half-filled eight (8) ounce bottle of hand sanitizer was observed on the bathroom sink in Patient Room #305.

a. Upon interview at 11:22 AM, Staff #4 confirmed that the hand sanitizer, or any alcohol containing product, should not be stored in a patient's room.

3. During a tour of Unit 6 (Older Adult Unit) on 4/14/2021 at 1:14 PM, the following was observed:

a. A pencil was lying on the bedside table between the two beds in Patient Room #601.

b. A marker pen was lying on the bedside table in Patient Room #604.

4. Upon interview at 1:32 PM, Staff #21 confirmed that pencils and marker pens are prohibited in patient rooms.

5. Staff #1 and Staff #2 confirmed the above findings on 4/14/21 at 4:00 PM.

B. Based on one (1) of three (3) observations of oral medication administration, staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure that safety checks are performed when oral medications are administered to patients.

Findings include:

Reference: Facility policy, "Administration of Medication" states, " ... D. Administration ... 3. The nurse will observe closely while the patient is taking medications. Special attention should be given to patients who might be suicidal or not swallowing ('cheeking') medications. ... ."

1. During a tour of Unit 4 (Dual Diagnosis Unit) on 4/14/21 at 11:45 AM, the following was observed:

a. Staff #15 handed Patient #14 a clear plastic cup with oral medication in it through the window of the medication room. Staff #14 then turned around, walked to a door located in the back of the room, and began talking to another staff member. While Staff #15 was talking with the staff member, Patient #14 swallowed the medication, drank a small amount of water, and disposed of the medication cup. Staff #15 then approached the medication window and spoke with Patient #14. Patient #14 then walked away.

(i) Patient #14 did not open his/her mouth and stick his/her tongue out to allow Staff #15 to complete a mouth check, as required by facility policy.

2. Upon interview at 11:48 AM, Staff #15 stated that after oral medication is administered, he/she should ask the patient to open his/her mouth and stick his/her tongue out so that staff can check to ensure the patient swallowed the medication.

3. Staff #1 and Staff #2 confirmed the above finding on 4/15/21 at 3:30 PM.