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Based on medical record review, observations made during tour, facility policy review, and staff interview, the facility failed to ensure the safety of patients related to ligature risks (Patient #1 and Patient #2), levels of observation (Patient #3), and evidence of a thorough investigation after a report of sexual abuse. The cumulative effect of these practices resulted in the facility's inability to ensure a safe setting for patients.

Based on observation. record review, interview and policy review, the facility failed to ensure patients were cared for in a safe setting related to ligature risk, levels of observation, and completion of thorough investigation. This affected three (Patients #1, #2 and #3) of ten records reviewed. The facility's census was 39.

Findings include:

1. The facility's 23-bed Adult Inpatient Psychiatric unit and 21-bed Geriatric Inpatient Psychiatric unit were toured on 09/07/21 at approximately 2:00 PM. The census at the time of the tour of the 21-bed Geriatric unit was 20. Ten residents were seated around a large rectangular-shaped table in the center of the milieu playing a game led by one staff member. Patient #1 was laying in bed A in room 103. He/She appeared to be sleeping. Both upper bed railings were in the up position. A blue plastic cover was on one of the bed rails to prevent the patient from putting his/her arms through the railings. The second railing, however, did not have the protective covering on it. This was confirmed with Staff A, present during the tour. Room 106 was also toured. Two beds were in this room, bed A and bed B. Patient #2 was sleeping in one of the two beds. The two upper bed railings on bed A were in the upward position. Neither of the two bed railings were covered with the protective plastic to protect the patient.

During interview on 09/07/21 at 3:50 PM, Staff A stated the bed rail slip covers should be placed on all hospital beds to prevent strangling, suffocating, or bodily injury when residents or part of their body are caught between rails or between the bed rails and mattress.

Review of the facility policy titled "Fall Prevention Protocol", effective 06/15/18, stated staff members are instructed to maintain beds in low position with side rails up x two. Staff members are further instructed to ensure all bed rails are covered with ligature resistant slips.


2. A. Review of the medical record of Resident #3 revealed he/she was transferred from a skilled nursing facility on 08/17/21 at 7:55 PM with delusions. According to the Intake Screening form, the patient had a medical history of asthma, osteoporosis, epilepsy, hearing loss, congestive heart failure, restless leg syndrome, hypertension, and an unsteady gait. The patient required a wheelchair as an assistive device. The Skin Assessment on admission noted the patient had scattered bruising. Diagrams representing the front and the back body revealed the patient had bruising to bilateral arms and the right leg. The front diagram also noted an arrow to the resident's genital area. The wording next to the arrow stated "bruising." The multidisciplinary treatment plan noted the patient was admitted with the active problems of an alteration in reality and a fall risk. The patient's treatment goal was "for someone to believe me."

The initial psych evaluation revealed the patient was admitted related to an increase in delusions and hallucinations. According to the physician, the patient reported being attacked during a recent stay at the Emergency Department. The patient believed she had been tied down to the bed while the physician was in the room and impregnated by aliens. The physician ordered staff to perform every 15 minute checks on the patient.

The Safety Round Monitoring Log was reviewed. The patient was laying down in bed with every 15 minute check from 10:00 PM on 08/17/21 to 11:45 PM and sleeping in bed from 12:00 AM on 08/18/21 to 06:45 AM. The space for the 15 minute check at 07:00 AM was blank. From 02:15 PM to 07:00 PM on 08/19/21, the 15 minute checks revealed the patient was quiet in the hall. The space at 07:15 PM was again blank.

During interview on 09/08/21 at 2:30 PM, Staff A confirmed that the medical record lacked documentation staff performed 15 minute checks as required by facility policy and ordered by the psychiatric physician.

Review of the facility policy titled "Levels of Observation", effective 06/15/16, stated it is the policy of the facility to provide a safe environment and utilize levels of monitoring and observation matched to the patient's individualized needs and based on assessed risk. The three levels of observation used at the facility are:

a. Routine observations: minimum patient observation of at least every 15 minutes. All patients will be monitored every 15 minutes unless a higher level of observation is ordered.

b. One to one (1:1) observation: constant visual observation of a patient within arm's length, unless a different distance is specified by physician's order.

c. Line of sight (LOS) observation:: keeping the patient under direct supervision within eye sight of staff at all times.

Regardless of routine, 1:1, or LOS observations, all patients will have documentation of their location and behavior every 15 minutes. Documentation will occur on the 15 Minute Observation log.

2 B. A nurse's note on 08/18/21 at 05:30 PM stated the patient had signs of aggression. The note stated the patient was singing loudly, yelling, and exit-seeking. The nurse administered medications to reduce the patient's aggression. The nurse also noted he/she obtained a urine sample for a culture using a straight catheter (a soft, thin tube gently inserted into the urethra opening into the bladder).

The patient was transported to an Emergency Department on 08/22/21 at 10:00 PM after he/she became extremely lethargic and his/her blood pressure dropped to 77/42.

A nurse's note composed by Staff B, the Director of Nursing, on 08/23/21 at 5:58 AM stated he/she received a phone call from the nursing supervisor at the facility where the patient had been transferred informing him/her that bruising on the patient's inner thighs and a labial tear were reported by an Emergency Department nurse. The note also stated that the patient had been straight catheterized for a urine culture on 08/18/21. Although bruising was noted in the vaginal area on admission, a labial tear was not identified. A second note on 08/23/21 at 3:00 PM stated that Staff B spoke with a case manager at the facility where the patient was transferred who revealed that a gynecological exam was performed and police took a report of the bruising and tear.

Staff A was interviewed on 09/10/21 at 11:45 AM and asked to provide the documentation of an investigation. Staff A provided written documentation of a manager follow-up which indicated that administrative staff members viewed video footage of the Geriatric Psychiatric unit and there was no suspicious activity involving the patient. The written follow-up also noted that "collateral information and statements from the patient indicated abuse occurred at the nursing home." There was no indication that the nurse that performed the straight catheterization was interviewed. Staff A was asked if an attempt was made to obtain a copy of the SANE nurse's examination report and he/she replied an attempt was made on 09/09/21, however, the facility reported being unable to provide this documentation without the patient's consent. Staff A was also asked if an attempt was made to obtain a copy of the police report and he/she stated an attempt was not made. It was confirmed that documentation of manager follow-up lacked evidence of a thorough investigation.