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Based on observation, interview and document review, it was determined that the facility failed to provide Patient care in a safe setting by not following the facility policy to search Patient belongings before allowing Patient access to belongings to protect the patient for one (1) of two (2) Patients (Patient # 1),
failed to protect patients from abuse for one (1) of two (2) Patients (Patient # 2), and
failed to report witness abuse at the time of the occurrence for one (1) of two (2) Patients (Patient # 2).

See Tags # 144 and # 145 for details.

Based on observation, interview and document review, it was determined that the facility failed to provide Patient care in a safe setting by not following the facility policy to search Patient belongings before allowing pateint access for one (1) of two (2) Patients (Patient # 1).

The findings include:

On May 5, 2023 at 11:00 a.m., a tour of the facility Emergency Department (ED) and Mental Health (MH) Pavilion was conducted.

On May 8, 2023 at 12:25 p.m., observation of security camera footage for April 26 and 27, 2023 revealed the following:
On April 26, 2023 at 4:36 p.m., Patient # 1 enters the ED. Patient # 1 was observed wearing "leggings and a hoodie" ambulating thru the walk thru security scanner after removing what appears to be a cell phone from front pocket of hoodie. No alarm was noted by the scanner.
At 6:36 p.m., Patient # 1 was observed in room in the ED. Patient # 1 changed into hospital scrubs and clothes were placed in a paper bag.

Security video on April 27, 2023 at 12:02 a.m. showed hospital staff has clothes. [Family Member] was with Patient # 1.
At 2:48 a.m., after shown to [Family Member], Patient # 1's clothes in a paper bag are placed in a locker.
At 8:57 a.m., Patient # 1 travels to the inpatient Mental Health (MH) building. Patient # 1 walks in from safe care with staff and security. No clothes/paper bag was with Patient or Staff. During interview Staff Member # 6 stated "unable to open locker when the Patient was transferred."
At 4:27 p.m., [Family Members] of Patient # 1 are seen entering MH building. [Family Member] places bag of belongings on counter with a Staff Member. Staff Member does not take anything out of the bag. [Family Member] walks thru the security scanner without alarm. Belongings bag was then passed thru security scanner by a Staff Member. No alarm.
At 4:28 p.m., [Family Members] arrived on 11th floor. Belongings are placed on counter with a Staff Member.
At 4:50 p.m. Staff Member was observed taking some of the belongings out of the bag and writing on a piece of paper. Items could be seen in the bag that were not taken out of the bag.

On May 8, 2023 at 3:45 p.m., Staff Member # 2 provided two documents titled "Personal belongings inventory checklist". The first checklist is dated April 27, 2023 at 4:52 p.m. and does not include a "hoodie". The second checklist is dated April 28, 2023 at 8:21 a.m. and includes "hoodie - blue SOI" (brand of clothing).

At 3:55 p.m., a clinical record review for Patient # 1 revealed Mental Health note dated May 1, 2023 at 2:23 p.m. "During EOC (environment of care) two razor blades were discovered in patient room on desks. Providers were notified. Patient was placed in hospital scrubs per provider. Pt stated "I cut my leg". Patient told "RN" (Registered Nurse) that "I had the razors in my hoodie in the emergency department." Patient showed this RN superficial cuts to upper right thigh. [Family Member] was notified of incident by "RN". Patient is currently calm and cooperative attending group. Peds provider assessed patient."

Psychiatry Progress Note dated May 1, 2023 at 3:21 p.m. reads in part "A: Pair of superficial, minor, fresh, deliberate self inflicted cuts.
P: Keep clean monitor for infection, applying Bacitracin as needed. Unit to perform an RCA (root cause analysis) to determine source of the razor and to prevent future occurrences.
S: Called to assess patient. Last evening was found to have a razor in possession and used it to self inflict a pair of cuts on right thigh. Reportly the razor was in a "hoodie" brought in from home, though the origin of the hoodie remains uncertain. It was supposedly clear by security and nursing. How the razor got in is under investigation. The cuts are small, not bleeding and non-tender.
O: awake, alert cooperative."

On May 8, 2023 at 1:45 p.m., an interview with Staff Member # 7 revealed "the security officer did not wand or hand check belongings. Items were placed in the the walk through."

On May 8, 2023 at 2:00 p.m., an interview with Staff Member # 11 revealed "these are the only two (2) belongings lists for [Patient # 1]. Staff should check each item before it is placed in inventory."

On May 8, 2023 at 1:55 p.m. a review of the facility policy titled "Metal detection process" revealed "The security officer will request all hand carried items, such as backpacks and purses, be placed upon the inspection table so items can be visually inspected, searching for weapons as defined below. If an individual refuse to permit inspection of any hand carried items, the individual will not be permitted to bring those items to the Behavioral Health units.
Any items that will be transferred directly to a patient, shall be fully divested in the private screening room. Remove all items from the bag or suitcase and conduct a thorough visual and hand search of each item to ensure contraband items are not transferred to the patient. Once initial search has been conducted, utilize the hand magnetometer to illicit a response for any detected metals."

On May 8, 2023, the findings were discussed with Staff Member # 1 during the exit interview.

Based on observation, interview and document review, it was determined that the facility failed to protect patients from abuse and facility staff failed to report witness abuse at the time of the occurrence for one (1) of two (2) Patients (Patient # 2).

The findings include:

On May 8, 2023 at 2:00 p.m., observation of security camera footage for May 4, 2023 revealed the following:
At 10:16 p.m., Patient # 2 was observed sitting on the floor in the hallway of the Emergency Department (ED) of the main hospital. Staff Members # 12, # 13, # 14, # 15 and # 17 are seen in the hallway near Patient # 2. Staff Member # 12 grabs Patient # 2 by the arm and drags Patient # 2 down the hallway into a room. Staff Member # 12 can be seen in the room with Patient # 2 from the hallway. There are no cameras in Patient rooms.

On May 8, 2023 at 2:15 p.m., an interview with Staff Member # 6 revealed "received an email on morning of May 5, 2023 concerning the incident. Then there was verbal communication of the incident by [Staff Member # 17]. It was reported that [Staff Member # 12] was cursing [Patient # 2] and possibly hit and/or pinched [Patient # 2] in the room after dragging [Patient # 2] by the arm into the room. There was no injury to [Patient # 2]"
The (staff) recruiter was called and [Staff Member # 12] was terminated and badge access was deactivated. [Staff Member # 12] continued to work until 7:00 a.m. on May 5."

On May 8, 2023 at 2:30 p.m., an interview with Staff Member # 16 revealed "All staff have been re-educated on the hands off approach. [Staff Members # 13, # 14, # 15 and # 17] were interviewed and stated "incident was no ok". [Staff Members # 13, # 14, # 15 and # 17] are been suspended pending investigation and have no badge access to the facility. The incident was reported by [Staff Member # 17] to [Staff Member # 6] by text on May 5, 2023 in the morning."

On May 8, 2023 at 4:00 p.m., a clinical record review for Patient # 2 revealed an ED PowerNote dated May 4, 2023: "At 10:15 p.m. patient became agitated and staff gave PRN (as Needed) meds of PO atarax and IM olanzaine and considered restraints but were able to successfully de-escalate - on exam at 10:45, patient is calm again and resting in room, responsive to verbal stimuli and asking for quiet for the rest of the night."
Patient care documentation for May 4, 2023 reads in part: "10:19 p.m. disruptive, hostile, increased energy.
10:22 p.m. pt came out of room, refused to return to room, becomes loud in the hall. Pt is unable to be managed by a single staff member. 2.5 mg IM zyprexa is given to pt's rt deltoid. Pt continues to scream, pound head and hand on window.
10:24 p.m. agitated. disruptive. impulsive. increased energy.
10:32 p.m. pt remains non compliant, beats on window. provider called, visits, orders restraints, pt goes to bed and remains quiet. no restraints applied at this time."

The facility policy titled "Escalation Protocol for Patient Care, Safety Concerns or Off Policy Requests" reads in part "[Name of Facility] requires that all team members demonstrate the moral courage and moral responsibility to deliver safe, quality care. All providers and staff are responsible for: bringing family or patient concerns or other safety concerns to their clinical supervisor(s) and care team in a timely manner."

On May 8, 2023, the findings were discussed with Staff Member # 1 during the exit interview.