HospitalInspections.org

Based on observation, record review, and interview, the psychiatric hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The psychiatric hospital failed to protect and promote each patient's rights as evidenced by:
1) Failure to increase Patient #1's observation level immediately following a violent incident involving Patient #1 per hospital policy (see Findings Tag A0144);
2) Failure to ensure patients did not have access to items that could cause harm to themselves (see Findings Tag A0144);
3) Failure to ensure each patient received an armband for accurate identification per hospital policy (see Findings Tag A0144);
4) Failure to obtain an order for physical hold on 1 (#2) of 3 (#1-#3) medical records reviewed (see Findings Tag A0154);
5) Having standing PRN orders for the administration of Benadryl, Haldol, and Ativan intramuscularly PRN (as needed) for severe physical aggression or threats of physical harm. Indication: aggressive behavior in 13 (#1-#3, #R1-#R10) of 17 (#1-#3, #R1-#R14) medication records reviewed (see Findings Tag A0160); and
6) Failure to maintain documentation of restraint use for 2 (#1, #3) of 3 (#1-#3) patients reviewed for use of chemical restraint (see Findings Tag A0175).

Based on record reviews and interview, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice is evidenced by:
1) Failure of the hospital to implement a performance improvement plan after a patient to staff physical assault (see Findings Tag A0283); and
2) Failing to accurately self-report an incident involving assault (see Findings Tag A0286).

Based on observation, record review, and interview, the psychiatric hospital failed to ensure patients received care in a safe setting as evidenced by:
1) failure to increase Patient #1's observation level immediately following a violent incident involving Patient #1 per hospital policy;
2) failure to ensure patients did not have access to items that could cause harm to themselves; and
3) failure to ensure each patient received an armband for accurate identification per hospital policy.
Findings:

A review of hospital policy titled, "Patient Rights," last revision 03/21/2018, revealed in part: "In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to: 17. Be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. 18. Be free from all forms of abuse and harassment. 19. Receive care in a safe setting."

1) Failure to increase Patient #1's observation level immediately following a violent incident involving Patient #1 per hospital policy.

A review of hospital policy titled, "Levels of Observation," last revised 06/13/2024, revealed in part: "Assessment and Determination of Needs: 1. The Charge RN may increase a patient's level of observation at any time if his/her assessment indicates such a need, but it is the nurse's responsibility to contact the authorized licensed prescriber on duty to issue a corresponding order. 2. If the patient is found to be "at risk" for self-harm, assaultive, or sexually acting-out behaviors, the registered nurse will initiate/maintain Line of Sight observation until the physician has been consulted. "At Risk" behaviors are evidenced by: a. Suicidal/homicidal ideation without immediate plan, ability to verbalize reasonable safety, and agreement to give staff a warning if their personal risk situation changes. b. Recent history of suicide and/or aggressive or sexually acting out behavior but can process issues and does not demonstrate severe agitation or require constant de-escalation or redirection. 3. If the patient is at "high risk" for self-harm, assaultive, elopement, or sexually acting out behaviors, the registered nurse will initiate 1:1 observation of the patient and will consult the physician as soon as possible who will determine the need for further observation. "High risk" behaviors are evidenced by: a. Constant suicidal/homicidal ideation with plan and the inability to ensure staff of immediate safety. b. Actively involved in property destruction and/or sexually acting out behaviors which require continuous redirection. c. Isolating/secretive behaviors, severe agitation, pacing, threatening others, and not able to process behaviors with staff. d. Any other unsafe behaviors which place self or others in immediate jeopardy."

Review of Patient #1's medical record revealed the patient was admitted 03/08/2025 on a PEC (Physician's Emergency Certificate) with Suicidal Ideation and had a diagnosis of MDD. Patient #1 was on Q15 minute observations and Suicide/Self-harm Precautions were initiated on 03/09/2025 at 4:06 AM. Further review of Patient #1's medical record revealed he was involved in an incident where Patient #1 was aggressive and threatening toward staff, which resulted in a physical altercation with an MHT.

Review of nursing assessment for Patient #1 on 03/09/2024 following the altercation revealed in part:
Patient #1 was placed in a therapeutic hold and escorted to room.
7:26 AM- Benadryl, Haldol, Ativan given.
7:40 AM- Patient in room crying an yelling out, when staff checked, Patient #1 had broken toilet seat and made several scratches and superficial lacerations to left anterior forearm, picture uploaded to chart. Forearm cleaned, bandage applied. Providers notified.
Orders received with observation status 1:1.

On 04/07/2025 at 1:03 PM, review of video footage navigated by S1DON of the incident involving Patient #1 on 03/09/2025 from 6:21:16 AM - 6:21:46 AM revealed in part:
S4MHT facing camera with back to nurse station. S4MHT exchanging words with Patient #1.
Patient #1 standing with back to camera outside medication room.
S6MHT walks up with vital sign machine and stands behind S4MHT.
Patient #1 runs at S4MHT, knocking the observation tablet out of S4MHT.
S4MHT swings right arm with closed fist and hits Patient #1 and both fall back into nurse station.
During this time, S6MHT backs up with vital sign machine. S8RN comes out nurse station, S5MHT comes into camera view, both attempting to separate Patient #1 and S4MHT.
Patient #1 ends up on the ground when S5MHT attempts to separate S4MHT from Patient #1.
Video clip ends 6:21:46 AM.

On 04/07/2025 at 2:30 PM, review of video footage navigated by S3MHTC of the incident involving Patient #1 on 03/09/2025 starting at 6:22 AM revealed in part:
6:22 AM- Patient #1 carried by S4MHT using Patient #1's shirt, while S5MHT is carrying Patient #1's lower extremities.
6:22:41 AM- Patient #1 carried inside room a by S4MHT and S5MHT. S6MHT and S7MHT in room, door to room closed.
6:23 AM- S9RN enters room a and then exits with S6MHT. S4MHT, S5MHT and S7MHT remain in room a with Patient #1, door cracked open.
6:23:58 AM- S7MHT exits room a and closes door.
6:24:15 AM- S5MHT enters room a and closes door.
6:24:55 AM- S5MHT exits room a. S4MHT and S6MHT remain in room a with Patient #1.
6:27 AM- S9RN and S10LPN enter room and close door. (Per S3MHTC this is when the Patient #1 was given Haldol, Benadryl, and Ativan.)
6:28:10 AM- S9RN and S10LPN exit room a.
6:28:40 AM- S6MHT exits room.
6:28:44 AM- S4MHT exits room a and closes door. Patient #1 alone in room.
6:34:56 AM- An unidentified patient walks to room a and cracks open door and runs toward nurse station. (Patient #1 was left alone in room with door closed for 6 minutes.)
6:35:38 AM- S5MHT, S7MHT, S8RN, and S9RN go to room a.
6:36:23 AM- S5MHT walks out room a carrying a toilet seat followed by S8RN.
6:37:36 AM- Patient #1 placed in chair in hallway outside his room a.
6:38 AM- S8RN talking to Patient #1 in hallway.
6:42 AM- S8RN applies dressing to Patient #1 left forearm.
6:45 AM- S8RN walks away from Patient #1.

In an interview on 04/07/2025 at 3:10 PM, S1DON confirmed that the video review revealed Patient #1 had aggressive and assaultive behavior in the above mentioned incident. S1DON confirmed that the RN can increase the level of observation on a patient. S1DON confirmed that Patient #1's displayed behavior made him "high risk" per policy due to his aggression and assaultive behavior towards staff. S1DON further confirmed that the observation level was not increased immediately after the violent altercation with S4MHT until after Patient #1 was found by another patient harming himself.

2) Failure to ensure patients did not have access to items that could cause harm to themselves.

Observations during a walk-through of the hospital on 04/07/2025 from 9:51 AM to 10:30 AM revealed a toothbrush and a tube of toothpaste on the windowsill of the bathroom in room b.

In an interview on 04/07/2025 at 10:27 AM, S3MHTC confirmed that patient hygiene products are locked in a closet after use. S3MHTC further confirmed that patients should not have access to the above mentioned items.

3) Failure to ensure each patient received an armband for accurate identification per hospital policy.

Review of hospital policy titled, "Medication and Treatment Administration," approved 01/25/2024, revealed in part: "Procedure-Inpatient: 4. As each patient approaches the medication nurse, the nurse will identify the patient by the following methods: c. Check the patient's wristband."

Observations during a walk-through of the hospital on 04/07/2025 from 9:51 AM to 10:30 AM revealed an armband for Patient #R1 on the windowsill of the bathroom in room b.

In an interview on 04/07/2025 at 10:27 AM, S3MHTC confirmed Patient #R1 was missing her armband and that Patient #R1 should have one on per policy.

Based on policy review, record review, and interview, the hospital failed to ensure the use of restraints was in compliance with accepted standards of care. This deficient practice was evidenced by failure to obtain an order for physical hold on 1 (#2) of 3 (#1-#3) medical records reviewed.
Findings:

A review of hospital policy titled, "Patient Rights," last revision 03/21/2018, revealed in part: "In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to: 17. Be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. 18. Be free from all forms of abuse and harassment. 19. Receive care in a safe setting. Additionally, in accordance with La R.S. 28:171 patients at behavioral health hospitals have the right to: 4. Not be placed in restraints or in seclusion except in an emergency to protect you or others from physical injury. 12. Receive medication with a physician's order and it cannot be used as a punishment or for the convenience of staff. 14. Receive medically appropriate treatment for your condition."

A review of hospital policy titled, "Restraint or Seclusion," last revision 10/17/2024, revealed in part: "Policy: The use of manual restraints (i.e. physical holds), mechanical restraints, and seclusion are permitted for use only: To ensure the safety and security of individuals due to imminent danger. When less restrictive measures have been considered and are deemed ineffective. NEVER as a punitive measure, for behavior modification, or for the convenience of staff. In accordance with all state and federal regulations and laws and Beacon policy.
The use of Restraint or Seclusion requires the following documentation in the patient's record: A detailed description of the behaviors considered a threat to the patient and/or others and the clinical justification for use. A description of the less restrictive intervention techniques attempted and inadequacy of those techniques. Contact with a licensed prescriber to describe behaviors, interventions, and obtain an order for the use of Restraint or Seclusion.
In an emergency, a registered nurse, trained in aggressive behavior management, may direct staff members to implement manual restraints, mechanical restraints, and/or seclusion order by a prescriber. In a case such as this, the registered nurse must contact an authorized licensed prescriber for an order immediately after implementation. Restraint or Seclusion may never be ordered on a PRN (or "as needed") basis.
Procedure: 2. The registered nurse ensures that an order has been obtained from an authorized licensed prescriber and that all documentation is accurately initiated, including an incident report.
Definitions:
Manual or Mechanical Restraint - Any manual, physical method, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, that cannot be easily and intentionally removed by the patient (considering the patient's physical condition and ability to accomplish the objective).
Chemical Restraint - A drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
Physical Holding for Medication Administration - If the patient is being held so that the medication can be administered against the patient's will (that is, during "a forced psychotropic medication procedure") and/or the patient is held in such a manner that movement is restricted and the patient cannot easily remove or escape the grasp, the hold IS considered a Restraint."

Review of Patient #2's medical record revealed the Patient #2 was a FVA (formal voluntary admit) on 03/20/2025 with SI (suicidal ideation) and a diagnosis of Schizoaffective Disorder and Bipolar. Seclusion documentation by the nurse for 03/22/2025 revealed in part: 9:35 PM Administered Haldol, Benadryl, and Ativan IM (intramuscular). During administration patient is kicking staff, fighting against the staff for IM injection. Unable to be redirected verbally. Further review of Patient #2's medical record failed to reveal an order for a physical hold.

In an interview on 04/08/2025 at 1:06 PM, S11CE confirmed there was no order for a physical hold to administer PRN medications for aggressive behavior to Patient #2. S11CE confirmed that per policy there should be an order for a physical hold.

Based on policy review, record review, and interview, the hospital failed to ensure the use of PRN (as needed)medication was standard treatment for the patient's medical or psychiatric condition and in compliance with accepted standards of care. This deficient practice is evidenced by having standing PRN orders for the administration of Benadryl, Haldol, and Ativan intramuscularly PRN (as needed) for severe physical aggression or threats of physical harm. Indication: aggressive behavior in 13 (#1-#3, #R1-#R10) of 17 (#1-#3, #R1-#R14) medication records reviewed.
Findings:

A review of hospital policy titled, "Patient Rights," last revision 03/21/2018, revealed in part: "In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to: 17. Be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. 18. Be free from all forms of abuse and harassment. 19. Receive care in a safe setting. Additionally, in accordance with La R.S. 28:171 patients at behavioral health hospitals have the right to: 4. Not be placed in restraints or in seclusion except in an emergency to protect you or others from physical injury. 12. Receive medication with a physician's order and it cannot be used as a punishment or for the convenience of staff. 14. Receive medically appropriate treatment for your condition."

A review of hospital policy titled, "Restraint or Seclusion," last revision 10/17/2024, revealed in part: "Policy: The use of manual restraints (i.e. physical holds), mechanical restraints, and seclusion are permitted for use only: To ensure the safety and security of individuals due to imminent danger. When less restrictive measures have been considered and are deemed ineffective. NEVER as a punitive measure, for behavior modification, or for the convenience of staff. In accordance with all state and federal regulations and laws and Beacon policy.
Restraint or Seclusion may never be ordered on a PRN (or "as needed") basis.
Definitions:
Chemical Restraint - A drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
Physical Holding for Medication Administration - If the patient is being held so that the medication can be administered against the patient's will (that is, during "a forced psychotropic medication procedure") and/or the patient is held in such a manner that movement is restricted and the patient cannot easily remove or escape the grasp, the hold IS considered a Restraint."

A review of the medication records for Patient's #1-#3 and Patient's #R1-#R10 revealed standing PRN orders for the following medications:
Benadryl 50mg/ml, 50mg (1ml) IM Q6H PRN to be given with Haldol and Ativan. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior.
Haldol 5mg/ml, 5mg (1ml) IM Q6H PRN to be given with Benadryl and Ativan. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior.
Ativan 2mg/ml, 2mg (1ml) IM Q6H PRN to be given with Benadryl and Haldol. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior.

In an interview on 04/07/2025 at 3:12 PM while reviewing the medical record of Patient #1, S1DON confirmed the medication listed above was administered to Patient #1 was a chemical restraint. When asked where the order was for the chemical restraint, S1DON confirmed that the above mentioned PRN orders for Haldol, Benadryl, and Ativan as the orders for the restraint . S1DON further confirmed that having the above mentioned standing PRN orders does not follow their Restraint or Seclusion hospital policy.

Based on record review and interview, the hospital failed to ensure patients were monitored according to accepted standards of care. This deficient practice was evidenced by failure to maintain documentation of restraint use for 2 (#1, #3) of 3 (#1-#3) patients reviewed for use of chemical restraint.
Findings:

A review of hospital policy titled, "Restraint or Seclusion," last revision 10/17/2024, revealed in part: "Policy: The use of manual restraints (i.e. physical holds), mechanical restraints, and seclusion are permitted for use only: To ensure the safety and security of individuals due to imminent danger. When less restrictive measures have been considered and are deemed ineffective. NEVER as a punitive measure, for behavior modification, or for the convenience of staff. In accordance with all state and federal regulations and laws and Beacon policy.
The use of Restraint or Seclusion requires the following documentation in the patient's record: A detailed description of the behaviors considered a threat to the patient and/or others and the clinical justification for use. A description of the less restrictive intervention techniques attempted and inadequacy of those techniques. Contact with a licensed prescriber to describe behaviors, interventions, and obtain an order for the use of Restraint or Seclusion.
In an emergency, a registered nurse, trained in aggressive behavior management, may direct staff members to implement manual restraints, mechanical restraints, and/or seclusion order by a prescriber. In a case such as this, the registered nurse must contact an authorized licensed prescriber for an order immediately after implementation. Restraint or Seclusion may never be ordered on a PRN (or "as needed") basis.
Procedure: 2. The registered nurse ensures that an order has been obtained from an authorized licensed prescriber and that all documentation is accurately initiated, including an incident report. 3. The nursing documentation in the EMR serves as the Restraint of Seclusion log. 4. A qualified staff member is assigned to provide continuous monitoring at a 1:1 level of observation.
Restraint and Seclusion Log: Data elements from the log are analyzed for patterns/trends related to excessive use of all types of restraints, use of physical restraints or drugs to substitute for adequate staffing, monitoring, assessment, unmet patient care needs, prolonged restraint use, effectiveness of actions taken to reduce prolonged restraint use and opportunities for improving compliance with standards. The log contains the following elements: A. Date and time of order B. Shift C. Staff who initiated the process D. The length of each episode E. Day of the week each episode was initiated F. Type of restraint or seclusion used (including physical restraint or drug used as restraint) G. Compliance with requirements defined in the standards H. Injuries sustained by the patient or staff I. Age of the patient.
Definitions:
Manual or Mechanical Restraint - Any manual, physical method, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, that cannot be easily and intentionally removed by the patient (considering the patient's physical condition and ability to accomplish the objective).
Chemical Restraint - A drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
Physical Holding for Medication Administration - If the patient is being held so that the medication can be administered against the patient's will (that is, during "a forced psychotropic medication procedure") and/or the patient is held in such a manner that movement is restricted and the patient cannot easily remove or escape the grasp, the hold IS considered a Restraint."

Patient #1
Review of Patient #1's medical record revealed the patient was admitted 03/08/2025 on a PEC (Physician's Emergency certificate) with Suicidal Ideation and had a diagnosis of MDD (major depressive disorder).

Review of Patient #1's Medication Administration Record revealed the following medications were administered on 03/09/2025 at 8:21 AM:
Benadryl 50mg/ml, 50mg (1ml) IM Q6H PRN (intramuscular every 6 hours as needed) to be given with Haldol and Ativan. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior.
Haldol 5mg/ml, 5mg (1ml) IM Q6H PRN to be given with Benadryl and Ativan. PRN (as needed) for severe physical aggression or threats of physical harm. Indication: aggressive behavior.
Ativan 2mg/ml, 2mg (1ml) IM Q6H PRN to be given with Benadryl and Haldol. PRN (as needed) for severe physical aggression or threats of physical harm. Indication: aggressive behavior.

Further review of Patient #1's medical record failed to reveal restraint documentation by the nurse.

In an interview on 04/07/2025 at 3:12 PM, S1DON confirmed that the Haldol, Benadryl, and Ativan PRN orders were the order for the chemical restraint. S1DON confirmed there was no documentation of restraint use in Patient #1's medical record.

Patient #3
Review of Patient #3's medical record revealed the patient was admitted on 02/26/2025 with Suicidal Ideation and had a diagnosis of Schizoaffective Disorder, Methamphetamine/Cocaine/Cannabis Use Disorder.

Review of Patient #3's Medication Administration Record revealed the following medications were administered on 02/28/2025 at 10:08 AM and at 9:36 PM:
Benadryl 50mg/ml, 50mg (1ml) IM Q6H PRN to be given with Haldol and Ativan. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior.
Haldol 5mg/ml, 5mg (1ml) IM Q6H PRN to be given with Benadryl and Ativan. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior.
Ativan 2mg/ml, 2mg (1ml) IM Q6H PRN to be given with Benadryl and Haldol. PRN for severe physical aggression or threats of physical harm. Indication: aggressive behavior.

Further review of Patient #3's medical record failed to reveal restraint documentation by the nurse.

In an interview on 04/08/2025 at 1:45 PM, S11CE confirmed that the Haldol, Benadryl, and Ativan PRN orders is a chemical restraint. S11CE confirmed there was no documentation of restraint use in Patient #3's medical record.

Based on record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. This deficient practice was evidenced by failure of the hospital to implement a performance improvement plan after a patient to staff physical assault.
Findings:

A review of hospital policy titled, "Patient Rights," last revision 03/21/2018, revealed in part: "In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to: 17. Be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. 18. Be free from all forms of abuse and harassment. 19. Receive care in a safe setting. Additionally, in accordance with La R.S. 28:171 patients at behavioral health hospitals have the right to: 4. Not be placed in restraints or in seclusion except in an emergency to protect you or others from physical injury. 12. Receive medication with a physician's order and it cannot be used as a punishment or for the convenience of staff. 14. Receive medically appropriate treatment for your condition."

A review of hospital policy titled, "Restraint or Seclusion," last revision 10/17/2024, revealed in part: "Policy: The use of manual restraints (i.e. physical holds), mechanical restraints, and seclusion are permitted for use only: To ensure the safety and security of individuals due to imminent danger. When less restrictive measures have been considered and are deemed ineffective. NEVER as a punitive measure, for behavior modification, or for the convenience of staff. In accordance with all state and federal regulations and laws and Beacon policy.
Definitions:
Manual or Mechanical Restraint - Any manual, physical method, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, that cannot be easily and intentionally removed by the patient (considering the patient's physical condition and ability to accomplish the objective).
Chemical Restraint - A drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.
Seclusion - The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.
Escort - Escorting a patient to a location IS considered a Restraint if the patient cannot easily remove or escape the grasp of a staff member.
Physical Holding for Medication Administration - If the patient is being held so that the medication can be administered against the patient's will (that is, during "a forced psychotropic medication procedure") and/or the patient is held in such a manner that movement is restricted and the patient cannot easily remove or escape the grasp, the hold IS considered a Restraint."

On 04/07/2025 at 1:03 PM, review of video footage navigated by S1DON of the incident involving Patient #1 on 03/09/2025 from 6:21:16 AM - 6:21:46 AM revealed in part:
S4MHT facing camera with back to nurse station. S4MHT exchanging words with Patient #1.
Patient #1 standing with back to camera outside medication room.
S6MHT walks up with vital Sign machine and stands behind S4MHT.
Patient #1 runs at S4MHT, knocking the observation tablet out of S4MHT.
S4MHT swings right arm with closed fist and hits Patient #1 and both fall back into nurse station.
During this time, S6MHT backs up with vital sign machine. S8RN comes out nurse station, S5MHT comes into camera view, both attempting to separate Patient #1 and S4MHT.
Patient #1 ends up on the ground when S5MHT attempts to separate S4MHT from Patient #1.
Video clip ends 6:21:46 AM.

On 04/07/2025 at 2:30 PM, review of video footage navigated by S3MHTC of the incident involving Patient #1 on 03/09/2025 starting at 6:22 AM revealed in part:
6:22 AM- Patient #1 carried by S4MHT using Patient #1's shirt, while S5MHT is carrying Patient #1's lower extremities.
6:22:41 AM- Patient #1 carried inside room a by S4MHT and S5MHT. S6MHT and S7MHT in room, door to room closed.

In an interview on 04/07/2025 at 1:10 PM, S1DON confirmed that staff did not respond using proper CPI technique.

In an interview on 04/07/2025 at 2:43 PM, S3MHTC confirmed that the video footage revealed Patient #1 was inappropriately brought to his room.

In an interview on 04/07/2025 at 2:55 PM, S1DON confirmed that staff on duty did not intervene when Patient #1 was being carried by his shirt and feet to his room by S4MHT and S5MHT. S1DON confirmed that S4MHT was terminated following this incident. S1DON commented that the staff know proper de-escalation, but they were just caught up in the moment because Patient #1 was fighting them. S1DON confirmed that all the staff she interviewed did not receive education on what is considered a restraint or proper de-escalation following the above mentioned incident. S1DON further confirmed that staff have not been educated on intervening to ensure the safety of each patient.

Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failing to accurately self-report an incident involving assault.
Findings:

Review of Patient #1's medical record revealed the patient was admitted 03/08/2025 on a PEC with Suicidal Ideation and had a diagnosis of MDD. Patient #1 was on Q15 minute observations and Suicide/Self-harm Precautions were initiated on 03/09/2025 at 4:06 AM.
Review of Patient #1's History and Physical Examination on 03/09/2025 revealed Patient #1 was evaluated at 9:05 AM by S12APRN. S12APRN documented the ROS, Patient #1 complained of jaw pain.

Review of the Hospital/Licensed Provider Abuse/Neglect Initial Report finalized on 03/10/2025 revealed the following documentation:
Incident Type documented as: Alleged Physical Abuse and Self-Injurious Behaviors
Date/Time Incident: 03/10/2025 at 7:30 AM

Patient Information documented on report included:
Patient #1 documented as Victim

Video Surveillance information documented on report included:
Video surveillance at incident site: yes
What was revealed on video? Answer: 03/09/2025 at 6:21 AM Patient #1 and S4MHT is observed in the hall in conversation with inappropriate nonverbal gestures (no audio). Patient #1 leans against the wall and seems to be removing his socks. S4MHT steps back as Patient #1 ambushes S4MHT by assaulting him. S4MHT responds in a defensive manner also swings with a closed fist hitting Patient #1 to left side of his face. Altercation continues as multiple staff members immediately respond attempting to separate both S4MHT and Patient #1. Immediately after separation, S7MHT enters patient room where he is brought into his room by S4MHT and S5MHT. S9RN and S10LPN enter the room and shortly exits. S6MHT returns and enters Patient #1's room. 6:27 AM S9RN and S10LPN return to the room. 6:28 AM all employees exit the room. 6:36 AM S5MHT enters Patient #1's room and S8RN follows. Patient #1 was removed from his room to sit into a chair outside with his left sleeve pulled up. S8RN returns to his chairside, completes an assessment, and provided wound care.

Incident Details revealed in part:
2. How was incident discovered? Answer: Patient reported.
Patient #1 became verbally aggressive and threatening S9RN. S4MHT approached and attempted to verbally de-escalate Patient #1. Patient #1 was redirected to his room. Patient #1 returned to hall area where Patient #1 took his socks off and charged at S4MHT assaulting him in his face area. Patient #1 required to be brought to his room where he received an IM Benadryl, Haldol, and Ativan. Patient #1 alleged S4MHT left his room and entered again with a nurse who kicked him in the face saying, "Welcome to Beacon."
Patient #1 continued to scream and yell. Upon reassessment, Patient #1 had broken the toilet seat and used the broken piece cutting his left forearm. He was removed from his room for assessment, placed on increased observation, and room reassigned.
10. Did the Patient(s) sustain injury(ies) or adverse effects in relation to the incident? Answer: No
11. Describe injury(ies) and/or adverse effects and Treatment Provided: Answer: Multiple self-inflicted lacerations to left forearm. Area was cleaned with saline and wrapped with gauze. 03/10/2025 Patient #1 woke up with a blood vessel in his left eye, tenderness and swelling to his left jaw. Patient 1 was transferred to the hospital for evaluation and diagnosed with Subconjunctival Hemorrhage. Patient #1 returned to facility at 9:15 PM.

Initial Actions Taken:
Patient #1 was placed on 1:1 observation. Patient #1 received Benadryl, Haldol, Ativan IM following self-injurious behaviors. Patient #1 received wound care.

Comments documented on report revealed in part:
S1DON conducted individual interviews with both Patient #1 and the staff members that were on duty during the event.
In interview S4MHT denied kicking Patient #1 in face at all. After reviewing video footage, S4MHT stated, he didn't realize that he responded defensively as he remembered taking Patient #1 down.
In interviews with S5MHT, S6MHT, and S7MHT, they stated they responded to the impact and did not witness the entire incident.
In review of the camera, S4MHT did not respond with proper CPI disengagements. S4MHT proceeded with an unauthorized defensive response to Patient #1. Camera footage did not show S4MHT entering his room following event at any time while Patient #1 was in the room.
S4MHT was removed from the schedule and terminated.

On 04/07/2025 at 1:03 PM, review of video footage navigated by S1DON of the incident involving Patient #1 on 03/09/2025 from 6:21:16 AM - 6:21:46 AM revealed in part:
S4MHT facing camera with back to nurse station. S4MHT exchanging words with Patient #1.
Patient #1 standing with back to camera outside medication room.
S6MHT walks up with vital Sign machine and stands behind S4MHT.
Patient #1 runs at S4MHT, knocking the observation tablet out of S4MHT.
S4MHT swings right arm with closed fist and hits Patient #1 and both fall back into nurse station.
During this time, S6MHT backs up with vital sign machine. S8RN comes out nurse station, S5MHT comes into camera view, both attempting to separate Patient #1 and S4MHT.
Patient #1 ends up on the ground when S5MHT attempts to separate S4MHT from Patient #1.
Video clip ends 6:21:46 AM.

On 04/07/2025 at 2:30 PM, review of video footage navigated by S3MHTC of the incident involving Patient #1 on 03/09/2025 starting at 6:22 AM revealed in part:
6:22 AM- Patient #1 carried by S4MHT using Patient #1's shirt, while S5MHT is carrying Patient #1's lower extremities.
6:22:41 AM- Patient #1 carried inside room a by S4MHT and S5MHT. S6MHT and S7MHT in room, door to room closed.
6:23 AM- S9RN enters room a and then exits with S6MHT. S4MHT, S5MHT and S7MHT remain in room a with Patient #1, door cracked open.
6:23:58 AM- S7MHT exits room a and closes door.
6:24:15 AM- S5MHT enters room a and closes door.
6:24:55 AM- S5MHT exits room a. S4MHT and S6MHT remain in room a with Patient #1.
6:27 AM- S9RN and S10LPN enter room and close door. (Per S3MHTC this is when the Patient #1 was given Haldol, Benadryl, and Ativan.)
6:28:10 AM- S9RN and S10LPN exit room a.
6:28:40 AM- S6MHT exits room.
6:28:44 AM- S4MHT exits room a and closes door. Patient #1 alone in room.
6:34:56 AM- An unidentified patient walks to room a and cracks open door and runs toward nurse station. (Patient #1 was left alone in room with door closed for 6 minutes.)
6:35:38 AM- S5MHT, S7MHT, S8RN, and S9RN go to room a.
6:36:23 AM- S5MHT walks out room a carrying a toilet seat followed by S8RN.
6:37:36 AM- Patient #1 placed in chair in hallway outside his room a.
6:38 AM- S8RN talking to Patient #1 in hallway.
6:42 AM- S8RN applies dressing to Patient #1 left forearm.
6:45 AM- S8RN walks away from Patient #1.

The incident report failed to reveal that Patient #1 was left in his room alone, with the door closed, after receiving a chemical restraint and was not on 1:1 observation. The incident report failed to reveal that Patient #1 was found harming himself by another patient and not by the staff. The incident report also failed to reveal that S4MHT did enter Patient #1's room during the event.

In an interview on 04/07/2025 at 2:43 PM, S3MHTC confirmed that the video footage revealed Patient #1 was alone in his room after receiving medication. S3MHTC confirmed that video footage revealed that Patient #1 was found harming himself by another footage. S3MHTC further confirmed during video footage review that S4MHT inappropriately carried Patient #1 to his room at 6:22:41 AM and did not exit Patient #1's room until 6:28:44 AM.

In an interview on 04/07/2025 at 2:55 PM, S1DON confirmed that Patient #1 was not placed on 1:1 observation until after he was found harming himself.

Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by:
1) failure of the Registered Nurse to document patient observations every 2 hours for 1 (#3) of 3 (#1-#3) medical records reviewed; and
2) failure of the Registered Nurse to supervise staff to ensure timely observation rounds performed by the MHT for 1 (#1) 3 (#1-#3) Patient observation sheets reviewed.
Findings:

A review of hospital policy titled, "Levels of Observation," last revised 06/13/2024, revealed in part: "Routine Observation is the routine Level of Observation applied to patients that are not considered at risk and/or in need of increased supervision. At least every 15 minutes, a staff member directly visually observes the patient to determine: 1. Signs of life (breathing while asleep-rise and chest fall, no obvious distress) 2. Location 3. Behavior. While observing the patient, the staff member documents, the patient's location and behavior. Any change in behavior or demonstration of increased risk should be brought to the attention of the Charge Nurse immediately. Line of Sight observation is define as always maintaining visual observation of a patient. Although visualization is continuous, the staff member documents the patient's location and behavior at least every 15 minutes. One-to-One (1:1) Observation is maintained when a patient is considered at high risk and requires observation by a staff member dedicated only to that patient. Although visualization is continuous, the staff member documents the patient's location and behavior at least every 15 minutes."

1) Failure of the Registered Nurse to document patient observations every 2 hours for 1 (#3) of 3 (#1-#3) medical records reviewed.
Review of Patient #3's medical record revealed the patient was admitted on 02/26/2025 with Suicidal Ideation and had a diagnosis of Schizoaffective Disorder, Methamphetamine/Cocaine/Cannabis Use Disorder. Patient #3's medical record failed to reveal documentation by the Registered Nurse that observations were completed every 2 hours on 02/28/2025 from 7:00 AM - 7:00 PM. Further review of the Patient Observation Sheet failed to reveal documentation by the Registered Nurse that observations were performed every 2 hours on 02/28/2025 from 7:00 AM - 7:00 PM.

In an interview on 04/08/2025 at 1:52 PM, S11CE confirmed that the Registered Nurse should round every 2 hours on patients. S11CE also confirmed that there was no documentation that the RN performed rounds every 2 hours on 02/28/2025 from 7:00 AM - 7:00 PM.

2) Failure of the Registered Nurse to supervise staff to ensure timely observation rounds performed by the MHT for 1 (#1) 3 (#1-#3) Patient observation sheets reviewed.
Review of Patient #1's medical record revealed the patient was admitted on 03/08/2025 with Suicidal Ideation and had a diagnosis of MDD. Review of Patient #1's Patient Observation Sheet failed to reveal documentation by the MHT that Q15 minute observations were performed on 03/09/2025 between 1:53 AM - 3:17 AM.

In an interview on 04/08/2025 at 11:39 AM, S11CE confirmed that the MHT did not document that Q15 minute observations were performed on 03/09/2025 between 1:53 AM - 3:17 AM on Patient #1.

Based on observation and interview, the hospital failed to ensure supplies were maintained to an acceptable level of safety and quality. This deficient practice was evidenced by expired patient care supplies available for patient use.
Findings:

Observations during a walk-through of the hospital on 04/07/2025 from 9:51 AM to 10:30 AM revealed expired patient care supplies available for patient use and included:
1) BD Vacutainer Purple Top 4ml Vials, quantity 100 vials, with an expiration of 01/31/2025;
2) BD Vacutainer Red Top 10ml Vials, quantity 200 vials, with an expiration of 01/31/2025; and
3) BD Vacutainer Red Top 10ml Vials, quantity 100 vials, with an expiration of 02/28/2025.

In an interview on 04/07/2025 at 10:15 AM, S3MHTC confirmed the above mentioned findings.