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Based on a review of facility documents, medical records (MR) and employee interviews (EMP), it was determined that the facility failed to maintain a safe environment for psychiatric patients while they were inpatients at the facility for two of ten medical records reviewed (MR1, MR2).


Findings Include:


A review on August 15, 2025, at 11:25, of the facility's policy, revealed, "Patient Privileges" (Last Revised: 2/19/2025) "Policy: It is the policy of Center for Mental Health and Well Being to uphold patient rights at all times. In the event a patient ' s behavior endangers themselves and others, a privilege may be restricted or revoked to ensure safety of all patients and staff. Procedure: 1. The physician may restrict patient privileges for a limited period of time if the privilege is causing dangerous or aggressive behavior. Ie Patients fighting over telephone, visitor sneaking in contraband, attempting to leave while outside courtyard, etc. 2. The RN may temporality restrict privileges based on risk level to patient or staff until MD is notified. 3. Visitors may be restricted if visitor has violated visitation policy or if visitor is increasing dangerous or aggressive patient behaviors. 4.No patient shall be subject to the withholding of privileges, nor to any system of rewrds, except as a part of the individualized treatment plan. 5. Treatment plans will identify the revoked privilege and the goals to recover access to restricted or revoked privileges and the goal as to recover access to restricted or revoked privileges."


"1:1 Constant Observation" (Last Revised: 9/6/2023): "Guidelines: ...3. The observation flow sheet is initiated by the RN. 4. An order is entered as a 1 to 1 observation. 5. A staff member must be within an arms length distance of the patient at all times if implemented for a suicidal patient ...7. Staff are to constantly observe the actions of the patient. 8. Staff must document every 15 minutes on the appropriate observation flow sheet. 9. The one to one observations for suicide prevention can only be discontinued by a physician."



Review of MR1 on August 15, 2025, revealed that the patient was a 46 year old male admitted to the hospital on August 6, 2025, as a 201, an involuntary commitment to the psychiatriatric unit. MR1 initally presented to the hospital with the staff of the Washington City Mission who were concerned for his safety stating that he was delusional and felt that the police were after him and he had to hide all the cars on the second floor of the building before they were stolen. MR1 was seen in the Emergency Department and admitted. The patient denied suicide or homocide but his actions were documented as acute and delusional. His past medical history was sexually abused as a child, PTSD, Anxiety, Cocaine, Opiates and multi substance abuse and grandiose ideas. He was described by the psychiatritrist as delusional, Bipolar, Manic dirty in appearance, bedraggled and on arrival a low risk for suicide. On August 9, 2025, the psychiatrist noted that MR1 remained delusional and wanted to leave. On August 10, 2025, the psychiatrist documented that MR1 was getting really aggressive, the delusional behavioral continued . On August 11, 2025, 12:42 PM, MR1 presented to his session with the psychiatrist and had been refusing all medications. On August 11, 2025, 15:24 PM, the chart revealed that the patient went outside during a RN group in the courtyard and jumped the fence and eloped.


During an interview on August 15, 2025, at 2:50 PM, EMP2 stated that despite documentation of aggressive, and delusional behavor on the psychiatric unit, MR1 still had the opportunity to utilize the patient priviledges policy.


A review of MR2 revealed a 28 year old female who was admitted to the hospital on May 17, 2025. MR2 arrived via EMS after a suicide attempt at home after being found as an attempted hanging with a sweatshirt. MR2 had a cervical collar applied by the EMS and was a 302, an involuntary admission to the psychiatric unit and considered a high risk for suicide. Her past medical history was Anxiety, Depression, PTSD, Personality Disorder, Previous Suicide Attempts. MR2 was admitted to the psychiatric unit and and order was placed for a 1:1 sitter to be present with her at all times. On May 18, 2025, MR2's record revealed that while whe had a 1:1 sitter that she was found alone in the bathroom attempting to strangle herself with her scrub pants. MR2 was alone in the bathroom and the sitter was outside of the room. A few minutes later on May 18, 2025, MR2 was found for the second time alone in the bathroom and this time was found to have socks wrapped around her neck and double knotted and she was once again attempting to strangle herself and the sitter was not present at her side and located was outside of the room.


During an interview on August 15, 2025, at 2:50 PM, EMP2 confirmed MR2 was ordered a 1:1 sitter and the sitter was not in the room with the patient on two occassions as per the sitter policy.

Based on a review of facility documents, medical records (MR) and staff interview (EMP), it was determined that the facility failed transition or remove a four point locked restraint once behaviorial criteria was achieved in one of two restraint records reviewed (MR8).

Findings include:
On August 15, 2025, a review of the "Restraint and Seclusion Policy" (Last Revised: 9/13/2024) was completed and revealed the following: DEFINITIONS: ... Violent, Self -Destructive Restraint and Seclusion- the application of restraint or seclusion used primarily to protect the patient against injury to self or others due to emergent, dangerous behaviors, unanticipated outburst of severe or destructive behavior that poses an imminent danger to the patient and others, aggressive/ assaultive behavior, behavior dangerous to self or the environment. PHYSICIAN ' S ORDERS- VIOLENT AND SELF-DESTRUCTIVE RESTRAINTS: ...C. Patients may be released from a restraint at any time when there has been a reduction in the behavior that led to being placed in the restraint. If the patient no longer needs the more restrictive order i.e. only two limbs as opposed to four, a new order is required. The transition to the lesser restrictive restraint is considered the same episode of restraint and a new face to face evaluation would not be needed for each modification. However if restraints are discontinued prior to the expiration of the original order, a new order must be obtained prior to reinitiating the restraint and the requirements restart. When the original order expires, a new order must be obtained from the physician. REASSESSMENT: A. Restraint and seclusion should be ended at the earliest possible time ...D. The continued need for the use of restraint and seclusion will be reassessed and documented at the following frequency:... for a violent and self-destructive restraint- every 15 minutes. DISCONTINUATION AND REMOVAL OF RESTRAINTS: A. Restraints and seclusion should be ended at the earliest possible time. B. When the patient in violent and self-destructive restraint or seclusion meets the behavioral criteria for removal as assessed by the registered nurse, then a trial of removal should be attempted. If the patient's behavior remains under control, then the restraint or seclusion is discontinued.

On August 15, 2025, a review of MR8 revealed that MR8 presented to the Emergency Department on August 14, 2025 at 9:30 AM. MR8 was accompanied by the police.
MR8's spouse was petitioning for an involuntary commitment (302). Upon arrival, MR8 was described as "agitated" and "aggressive toward others." At 9:30 AM, MR8 was ordered and placed in four point locked restraints for his safety and the safety of the staff. At 10:15 AM, 10:30 AM, and 10:45 AM, MR8 is described as "sleeping and calm." At 11:15 AM, the patient is described as, "calm." Restraints were discontinued at 11:30 AM; one hour and 15 minutes after MR8s behavior was noted as "calm." There was no attempt documented to transition to a less restrictive restraint nor was there an trial removal attempt documented per hospital policy.

On August 15, 2025, at 2:09 PM, EMP3 confirmed the above finding.