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Based on interview, record review, review of the facility's video, and review of the facility's Governing Board By-Laws - Appendix I, it was determined the facility failed to have a Governing Body which was effective in carrying out its responsibilities for the conduct of hospital staff for two (2) of ten (10) sampled patients (Patients #1 and #2). Patient #1 was found hanging from a bathroom door and subsequently died. Patient #2 experienced a spiral fracture to the left arm after being in a protective hold by staff.

The findings include:

Review of the facility's Rules and Regulations - Appendix I, revised 05/2017, revealed the Governing Body must approve the Rules and Regulations and Medical Staff Bylaws for the operation of the facility. The document also stated both the Rules and Regulations' and the Medical Staff Bylaws' function was to promote the delivery of quality healthcare within the hospital. In addition, it stated each appointed medical staff member must practice according to both.

Review of the facility's Patient and Family Handbook, not dated, revealed patients had the right to be treated with respect and dignity by all facility staff and the right to safe, clean, and accessible conditions and/or services in the facility.

Review of the Patient Services Handbook, dated 08/27/2017, revealed patients could expect reasonable safety related to the facility's practices and the environment. Continued review revealed patients would be free from the use of seclusion and restraints as a means of coercion, convenience, or retaliation by staff. Further review revealed restraints would only be used if clinically required and in accordance with the careplan. Restraints were to be used only as a last resort and in the least restrictive manner possible to protect the patient and others from harm.

1. Record review, interview, and review of the facility's video revealed there were no observation level checks conducted for Patient #1, on 07/17/2022 at 6:45 PM, 7:00 PM, and 7:15 PM. Patient #1 was found, on 07/17/2022 at 7:38 PM, hanging from his/her bathroom door. Despite resuscitative efforts, Patient #1 was declared deceased at 8:07 PM.

Review of the observation check book, dated 07/17/2022, revealed it was documented that Patient #1 was visually checked on at 6:45 PM and 7:00 PM. In the 7:15 PM block, it was documented that Patient #1 was checked on at 7:09 PM.

2. Record review, interview, and review of the facility's video revealed Patient #2 was escorted to seclusion after an aggressive outburst toward staff at the nurses' station. There was no video camera in the seclusion room. It was reported by staff that Patient #2 was pulling and twisting his/her arm in an effort to break free of the physical hold and subsequently sustained a spiral fracture to the left arm. The fracture required surgical fixation with plates and screws.

Interviews with the Director of Risk and Compliance (DRC), the Chief Nursing Officer (CNO), and the Administrator, on 08/04/2022, at 11:20 AM, 11:37 AM, and 11:48 AM, respectively, revealed they were all members of the Governing Body. Further interviews revealed the investigative process for Patient #1 revealed negligence in following the Behavioral Health Unit's process of completing the observational checks. Per the interviews, they all stated, Patient #2 was pulling and twisting his/her arm in an effort to break free of the hold. Therefore, the facility's investigation could not determine the physical hold was the sole causative factor for Patient #2's spiral fracture to the left arm. In addition, they all stated, as members of the Governing Body, it was their responsibility to ensure patients received care in a safe setting and that patients' rights were observed by staff. They stated it was their expectation that all staff followed the facility's policies, which was not done for Patients #1 and #2.

Refer to A-0144, A-0395

Based on interview, record review, review of the facility's video, and review of the facility's Patient Rights policy, it was determined the facility failed to protect and ensure patients' rights were provided for two (2) of ten (10) sampled patients (Patients #1 and #2). Patient #1 was not afforded consistent every fifteen (15) minute observational checks as ordered. Patient #1 was found hanging from the bathroom doorframe in his/her bathroom.

Patient #2 was escorted to seclusion for an aggressive outburst at the nurses' station and suffered a spiral fracture to the left arm during a safety hold which required surgery to repair the fracture.

Review of the facility's Patient and Family Handbook, not dated, revealed patients had the right to be treated with respect and dignity by all facility staff. In addition, the handbook stated patients had the right to safe, clean, and accessible conditions and/or services in the facility.

Review of the Patient Services Handbook, dated 08/27/2017, revealed patients could expect reasonable safety from the facility's practices and environment. Continued review revealed patients would be free from the use of seclusion and restraints as a means of coercion, convenience, or retaliation by staff. Further review revealed restraints would only be used if clinically required and in accordance with the careplan. Restraints were to be used only as a last resort and in the least restrictive manner possible to protect the patient and others from harm.

1. The facility's Behavioral Health Unit (BHU) admitted Patient #1, on 07/09/2022, with diagnoses that included Suicidal Ideation.

Review of the facility's Final Expanded Investigative Report, dated 08/01/2022, revealed that on 07/17/2022, at 7:38 PM, staff observed Patient #1 hanging from his/her bathroom door. The Report revealed a Patient Care Assistant (PCA) discovered the incident and immediately called for assistance from floor staff. Continued review revealed a Code Blue (a hospital designation that means a Cardiac/Respiratory event or a medical emergency that could not be moved) was initiated. Respondents included the BHU House Supervisor, the medical center's Code Team and the Emergency Department (ED) Physician. Patient #1 was pronounced dead, on 07/17/2022 at 8:07 PM. Further review of the report revealed the Certified Nursing Assistant (CNA), who was responsible for providing the ordered observational checks of Patient #1, did not complete those checks as ordered on 07/17/2022 at 6:45 PM, 7:00 PM, and 7:15 PM, as per the video recording.

2. Review of Patient #2's medical record revealed the facility admitted Patient #2 on 07/17/2022, via a Judge's order for worsening suicidal ideation. Diagnoses included Major Depressive Disorder, Severe; Borderline Personality Disorder; and Aggressive Behavior.

Review of the facility's Final Expanded Investigative Report, not dated, revealed Patient #2 had been escorted to the seclusion area for an aggressive attack, aimed at staff, at the nurses station on 07/20/2022, at 4:36 AM. Continued review revealed Patient #2 alleged Security Guard #2 had his/her left arm in an improper physical restraint hold, and his/her arm broke. Patient #2 was sent to the emergency department (ED), where he/she was diagnosed with a spiral fracture to the left arm. The fracture required surgical fixation with plates and screws.

Review of the facility's video, dated 07/20/2022, revealed Patient #2 was standing at the nurses' station and became aggressively violent toward staff and his/her sitter. Patient #2 was escorted to the seclusion room, after being placed in a physical hold, by Patient Care Assistant (PCA) #1 and Security Guard #1. The video ended after the patient entered the seclusion room because there were no video cameras in the seclusion room.

Interview with Security Guard #1, on 07/26/2022 at 1:24 PM, revealed once Security Guard #1, PCA #1, and Patient #2 were through the seclusion door, Patient #2 became aggressive again. He stated, at the same time, Registered Nurse (RN) #2 was laying the mattress down on the floor, and PCA #1 was backing out of the room. He stated Security Guard #2 came in the room, and they re-initiated the approved two (2) man hold. At this time, Patient #2 stated his/her left arm was broken.

Interview with Patient #2, on 07/28/2022 at 2:11 PM, revealed he/she felt Security Guard #2 pulled his/her arm back further than he should have and that was why his/her arm broke.

Interview with the Administrator, on 08/04/2022 at 11:48 AM, revealed the investigative process for Patient #1 revealed negligence in following the Behavioral Health Unit's process of completing the observational checks, which was a violation of patient rights. The Administrator also stated the investigative process for Patient #2, revealed, even though the physical hold was not the only causative factor involved in Patient #2's spiral fracture to the left arm, it was a factor. It was also a violation of Patient #2's rights.

Based on interview, record review, review of the facility's video, and review of the facility's Patient Handbooks, it was determined the facility failed to protect and ensure patient rights were provided for two (2) of ten (10) sampled patients (Patients #1 and #2). Patient #1 was not afforded consistent every fifteen (15) minute rounding checks as ordered; was subsequently found hanging from the bathroom doorframe in his/her bathroom; and, was pronounced dead a few minutes later, after resuscitative efforts failed.

Patient #2 was escorted to seclusion for an aggressive outburst at the nurses' station and suffered a spiral fracture to the left arm during a safety hold, which required surgery to repair the fracture.

The findings include:

Review of the facility's Patient and Family Handbook, not dated, revealed patients had the right to be treated with respect and dignity by all facility staff and the right to safe, clean, and accessible conditions and/or services in the facility.

Review of the Patient Services Handbook, dated 08/27/2017, revealed patients could expect reasonable safety because of the facility's practices and environment. Continued review revealed patients would be free from the use of seclusion and restraints as a means of coercion, convenience, or retaliation by staff. Further review revealed restraints would only be used if clinically required and in accordance with the careplan. Restraints were to be used only as a last resort and in the least restrictive manner possible to protect the patient and others from harm.

1. Review of Patient #1's medical record revealed the facility's Behavioral Health Unit (BHU) admitted Patient #1, on 07/09/2022, with diagnoses that included Suicidal Ideation.

Review of the facility's Final Expanded Investigative Report, dated 08/01/2022, revealed, on 07/17/2022, at 7:38 PM, Patient #1 was observed to be hanging from his/her bathroom door. The report revealed Patient Care Assistant (PCA) #2 discovered the incident and immediately called for assistance from floor staff. A "Code Blue" (a hospital designation that meant a Cardiac/Respiratory event or a medical emergency where the patient could not be moved) was initiated. Respondents included the BHU House Supervisor, the Medical Center's Code Team, and the Emergency Department (ED) Physician.

Review of the Emergency Department (ED) Event Note and the Code Resuscitation Record, both dated 07/17/2022, revealed a "Code Blue" was called to the BHU at 7:45 PM. When the Code Team arrived, Patient #1 was connected to a heart monitor, which showed asystole (absence of a heartbeat rhythm); BHU staff provided Basic Life Support (BLS) which consisted of CPR (Cardiopulmonary Resuscitation); the Code Team then initiated Advanced Cardiac Life Support (ACLS). Per the record, Patient #1 was intubated (a breathing tube placed into the trachea to facilitate artificial air exchanges) at 7:52 PM. Continued review revealed pulse and rhythm checks were completed approximately every three (3) to five (5) minutes, with asystole continuing. The Code was discontinued at 8:07 PM by the ED Physician, and Patient #1 was pronounced dead.

Additional review of the facility's Final Expanded Investigative Report, dated 08/01/2022, revealed the incident was discovered at the start of the night shift (7:00 PM to 7:00 AM). The report stated all 7:00 AM to 7:00 PM staff were called back to the facility for interviews. Further review of the report, revealed the video from Patient #1's hallway was reviewed. It was determined Certified Nursing Assistant (CNA) #6, who was responsible for providing the ordered observational checks, did not complete those checks as ordered. Subsequently, CNA #6 was suspended and terminated.

Review of the facility's video, dated 07/17/2022, revealed CNA #6 did not perform observation level checks as ordered. At the time of his/her death, Patient #1 was ordered to be on every fifteen (15) minute observation checks. Video review revealed CNA #6 did not make an observation round at 6:45 PM, 7:00 PM, and 7:15 PM. It was observed that CNA #6 did make an observation round at 7:09 PM.

Review of the observation level rounding book for 07/17/2022, 7:00 AM to 7:00 PM timeframe, revealed all observation level times were documented as being completed, including the 6:45 PM and 7:00 PM times. It was observed that the 7:09 PM check from the video was documented in the 7:15 PM blank.

Due to regional catastrophic flooding and resultant loss of utilities in most areas, during the survey, Patient Care Assistant (PCA) #2 and Certified Nursing Assistant (CNA) #6 could not be contacted for interview.

Interview with Advanced Practice Registered Nurse-Psychiatric Mental Health Nurse Practitioner (APRN-PMHNP) #1, on 07/26/2022 at 9:30 AM, revealed observational levels were determined in a number of ways, and there was no concrete process to determine when an observation level needed to be changed, increased or decreased. She stated it was a combination of how the patient interacted in the milieu, such as positive/negative interactions with peers/staff; and, how the patient participated with the therapist alone or in a group setting, such as making positive/negative statements. Continued interview revealed in the case of Patient #1, he/she was making overall progress. She stated, although Patient #1 acknowledged suicidal ideation that was chronic, he/she always expressed positivity. APRN-PMHNP #1 stated there were no red flags to Patient #1's behaviors. She stated she felt Patient #1's observation level was appropriate at the time of his/her death.

Interview with Registered Nurse (RN) #1, on 07/26/2022 at 10:39 AM, revealed she was the 7:00 AM to 7:00 PM nurse on 07/17/2022, caring for Patient #1. She stated she observed Patient #1 during her shift making progress, evidenced by interactions and displays of appropriate affect/emotions. RN #1 stated she had observed Patient #1 being a jokester on the unit that day, even turning a cartwheel in the community area. She stated it was a genuine shock when Patient #1 was found at shift change that evening. RN #1 stated the incident happened during the change-of-shift report, so she was not able to observe the last day shift rounds being made. She stated Patient #1 had not expressed any obvious concerns during her shift. RN #1 stated, on 07/18/2022, staff had been re-educated on Patient Observations, Purposeful RN Rounding, Suicide Risk, and Ligature Risk. She stated, on 07/19/2022, the Ligature Risk training was presented again.

Interview with APRN-PMHNP #2, on 07/26/2022 at 10:57 AM, revealed Patient #1's death came as a shock. APRN-PMHNP #2 stated she had seen Patient #1 on 07/17/2022. She stated Patient #1 was interacting appropriately, denied suicidal ideation, and there were no verbalizations or actions that would have been an indicator of what would happen. She stated Patient #1 had complex post-traumatic stress disorder (PTSD).

Interview with RN #2, on 07/27/2022 at 1:10 PM, revealed Patient #1 had expressed the desire to move on by facing his/her legal troubles; was exhibiting positively on the Unit with peer and staff interactions and verbalizations. Further interview revealed, on 07/18/2022, Management had presented training that included Suicide Risk, Purposeful RN Rounding, Ligature Risk, and Patient Observation. RN #2 also stated that the Ligature Risk training was given again on 07/19/2022.

Interview with the ED Physician, on 08/03/2022 at 2:03 PM, revealed Patient #1 had expired (died) approximately thirty (30) minutes prior to the Code Team's arrival. (Comparison of the last documented observational round at 7:09 PM and the time of Patient #1's discovery at 7:38 PM was approximately thirty (30) minutes).

Interview with the Director of Nursing (DON), on 08/04/2022 at 11:00 AM, revealed she had not observed any negative interactions by Patient #1 to peers or staff. She stated staff had not reported that Patient #1 continued to express self-harm ideation on the Unit.

Interview with the Executive Director (ED) of the BHU, on 08/04/2022 at 11:17 AM, revealed the Director had not observed any negative interactions by Patient #1 to peers or staff. The Director stated there had not been any reports from staff about Patient #1 expressing on-going self-harm ideation on the BHU.

2. Review of Patient #2's medical record revealed the facility admitted Patient #2 on 07/17/2022, via a Judge's petition for worsening suicidal ideation. Diagnoses included Major Depressive Disorder, Severe; Borderline Personality Disorder; and Aggressive Behavior.

Review of the facility's Final Expanded Investigative Report, not dated, revealed Patient #2 had been escorted to the seclusion area for an aggressive attack, aimed at staff, at the nurses' station on 07/20/2022 at 4:36 AM. Continued review revealed Patient #2 alleged Security Guard #2 had his/her left arm in an improper physical restraint hold, and his/her arm broke. Patient #2 was sent to the emergency department (ED) and an investigation was initiated. Security Guards #1 and #2 were suspended pending the outcome of the investigation.

Review of the facility's video, dated 07/20/2022, revealed Patient #2 was standing at the nurses' station, when he/she suddenly threw a brush at the nurse behind the plexiglas barrier, and attempted to reach through the barrier at the nurse, then whirled around and began attacking his/her one-to-one (1:1) sitter. Continued review revealed Patient #2 was then placed in a physical hold by Patient Care Assistant (PCA) #1 and Security Guard #1 and escorted toward the seclusion room. Additional video review revealed PCA #1 and Security Guard #1 escorted Patient #2 through the seclusion room door. This was the end of the video because there were no video cameras in the seclusion room.

Interview with Behavioral Health Unit (BHU) Physician #1, on 07/26/2022 at 9:15 AM, revealed Patient #2 was on constant one-to-one (1:1) observation related to an intermittent explosive disorder (IED, characterized by sudden episodes of unwarranted anger that explode into a rage despite a lack of apparent provocation or reason). She stated Patient #2 was appropriate when he/she was not de-escalating.

Interview with Security Guard #1, on 07/26/2022 at 1:24 PM, revealed he responded to the "Code Green" (an internal emergency situation). He further stated he observed Patient #2's behaviors and despite verbal attempts at de-escalation by himself and staff, Patient #2 continued to attack staff. He stated he and PCA #1 were able to institute an approved physical hold and escort Patient #2 to the seclusion room without continued aggression. He stated once they were through the seclusion door, as RN #2 was laying the mattress down on the floor and PCA #1 was backing out of the room, Patient #1 became aggressive again. He stated, by that time, Security Guard #2 was in the room, and they re-initiated the approved two (2) man hold to sit Patient #2 down on the mattress so everyone could back out of the room. He stated, at that time, Patient #2 stated his/her arm was broken. Per the interview, Security Guard #1 stated the purpose of attempting to have a patient sit on the mattress instead of just standing and staff attempting to back out of the room was for the safety of all involved. He stated, if a patient was sitting, it would take more time for them to get up off the mattress and come toward the seclusion room door; therefore, staff would have more time to safely back out the door.

Interview with Security Guard #2, on 07/26/2022 at 1:33 PM, revealed he responded to the "Code Green" on 07/20/2022. He stated, by the time he arrived, staff and Patient #2 were already in seclusion, and PCA #1 was backing out as RN #2 was laying the mattress on the floor. He stated he observed Patient #2 became aggressive, and he assisted Security Guard #1 place Patient #2 in an approved hold. He stated it was at this time, that Patient #2 verbalized his/her arm was broken. Security Guard #2 stated at no time was Patient #2 placed in an improper hold to cause a broken arm. Additional interview revealed while Patient #2 was in the hold with both security guards, he/she was forcefully trying to remove his/her left arm from Security Guard #2's hold.

Interview with PCA #1, on 07/28/2022 at 8:27 AM, revealed he was assigned to provide one-to-one (1:1) care for Patient #2 on the 07/20/2022 night shift. Further interview revealed that at approximately 4:30 AM, Patient #2 had finished a shower and was at the nurses' station to request a brush to brush his/her hair. PCA #1 stated Patient #2 became aggressive about the brush, threw the brush at the nurse behind the barrier, attempted to attack the nurse through the barrier, and then turned and began attacking PCA #1. PCA #1 stated a "Code Green" was called, and Security Guard #1 arrived. Further interview revealed attempts at verbal de-escalation were unsuccessful, and Patient #2 was placed in an approved hold and escorted back to seclusion. PCA #1 stated Patient #2 walked through the seclusion door willingly; however, as PCA #1 was backing out the door, Patient #2 became aggressive again. PCA #1 stated RN #2 was laying the mattress down, when Security Guard #2 arrived. PCA #1 stated Security Guard #2 implemented an approved hold, along with Security Guard #1; and, at no time was an inappropriate hold instituted on Patient #2.

Interview with RN #2, on 07/28/2022 at 8:37 AM, revealed the RN was laying down the mattress for Patient #2 to sit on. RN #2 stated at no time did she observe an inappropriate hold.

Interview with Patient #2 (one-to-one (1:1) sitter was present outside the door), on 07/28/2022 at 2:11 PM, revealed he/she did feel safe being in the facility and had no care concerns. Patient #2 stated that he/she felt Security Guard #2 did pull his/her arm back further than he should have and that was why his/her arm broke.

Interview with the BHU Executive Director, on 07/29/2022 at 1:45 PM, revealed he had reviewed restraint audit tools for 2021 and 2022 thus far. He stated there had not been any reported injuries during that time frame, and he believed staff members were performing the holds correctly, as they had been educated on this at hire and annually. Continued interview revealed he had reviewed BHU records, and there had never been a reported death on the Unit. Additional interview revealed corrective actions were taking place for both incidents.

Interview with the Administrator, on 08/04/2022 at 11:48 AM, revealed the investigative process for Patient #1 revealed negligence in following the Behavioral Health Unit process of completing the observational checks, which was a violation of patient rights by not providing a safe environment. The Administrator also stated the investigative process for Patient #2, revealed, even though the physical hold was not the only causative factor involved in Patient #2's spiral fracture to the left arm, it was a factor. It was also a violation of Patient #2's rights by not providing a safe environment.

Based on interview, record review, review of the facility's job descriptions, review of the facility's video, and review of the facility's policies and procedures, it was determined the facility failed to provide adequate nursing supervision in a safe environment for two (2) of ten (10) sampled patients (Patient #1 and Patient #2).

Review of the Supervision Policy, Reference Number IV-PC-039, approved 02/2019, revealed it was the policy of the Psychiatric Center to provide adequate patient monitoring consistent with patient safety. Continued review revealed every fifteen (15) minute checks meant there was to be direct visualization of the patient every fifteen (15) minutes. Also, a Physician's Order was required for a change in a patient's supervision level.

Review of the Nurse Aide (NA) job description (also applied to Certified Nursing Assistants (CNA)), dated 03/31/2005, revealed NA's were to maintain a safe/secure therapeutic environment and maintain every fifteen (15) minute physical environment checks.

Review of the Staff Nurse job description, dated 03/21/2005, revealed staff nurses provided clinical supervision to Licensed Practical Nurses (LPN) and NA's. Staff nurses were also responsible for providing a safe, secure patient environment. Additional review of the job description defined Supervision as the provision of guidance by a qualified nurse for the accomplishment of a nursing task with periodic observation and evaluation of the performance of the task including validation that the nursing task has been performed according to established standards of practice [201 KAR (Kentucky Administrative Regulation) 20:400 Section 1(7)].

Review of the facility's video for Patient #1, dated 07/17/2022, revealed every fifteen (15) minute observation checks were not performed at 6:45 PM and 7:00 PM for Patient #1. Review of the observation level documentation, dated 07/17/2022, revealed all spaces had a time and employee initials. Further review revealed there was a documented check at 7:09 PM in the 7:15 PM block.

Review of the facility's video for Patient #2, dated 07/20/2022, revealed Patient #2 became aggressive at the nurse's station; was not able to be verbally de-escalate; and, was escorted to seclusion by Security Guard #1 and Patient Care Assistant (PCA) #1. Video coverage ended as the three entered the seclusion room. Patient #2 stated he/she suffered a spiral fracture to the left arm as a result of an improper physical hold, initiated by Security Guards #1 and #2 in the seclusion room.

Refer to: A-0395 and A-0396

Based on interview, record review, review of the facility's job descriptions, review of the facility's videos, and review of the facility's policy, it was determined the facility failed to provide adequate nursing supervision in a safe environment for two (2) of ten (10) sampled patients (Patients #1 and #2).

Patient #1 was not afforded consistent every fifteen (15) minute rounding checks as ordered. Staff found Patient #1 hanging from the bathroom doorframe in his/her bathroom, and was pronounced dead a few minutes later, after resuscitative efforts failed.

Patient #2 was escorted to seclusion for an aggressive outburst at the nurses' station and suffered a spiral fracture to the left arm during a safety hold, which necessitated surgery to repair the fracture.

The findings include:

Review of the Supervision Policy, Reference Number IV-PC-039, approved 02/2019, revealed it was the policy of the Psychiatric Center to provide adequate patient monitoring consistent with patient safety. Continued review revealed every fifteen (15) minute checks meant there was to be direct visualization of the patient every fifteen (15) minutes. Also, a Physician's Order was required for a change in a patient's supervision level.

Review of the Nurse Aide (NA, also applied to Certified Nursing Assistants) job description, dated 03/31/2005, revealed NA's were to maintain a safe/secure therapeutic environment and maintain every fifteen (15) minute physical environment checks.

Review of the Staff Nurse job description, dated 03/21/2005, revealed staff nurses provided clinical supervision to Licensed Practical Nurses (LPN) and NA's. Staff nurses were also responsible for providing a safe, secure patient environment. Additional review of the job description defined Supervision as the provision of guidance by a qualified nurse for the accomplishment of a nursing task with periodic observation and evaluation of the performance of the task including validation that the nursing task has been performed according to established standards of practice [201 KAR (Kentucky Administrative Regulation) 20:400 Section 1(7)].

Review of the Patient Services Handbook, dated 08/27/2017, revealed restraints were to be used only as a last resort and in the least restrictive manner possible to protect the patient and others from harm.

1. Review of the facility's video for Patient #1, dated 07/17/2022, revealed every fifteen (15) minute observation checks were not performed at 6:45 PM and 7:00 PM for Patient #1 by the Certified Nursing Assistant (CNA) assigned that duty, CNA #6. The video did show that CNA #6 did make an observation round at 7:09 PM.

Review of the observation level rounding book for 07/17/2022, 7:00 AM to 7:00 PM timeframe, revealed all observation level times were documented as being completed with employee initials, including the 6:45 PM and 7:00 PM times. It was observed that the 7:09 PM check from the video was documented in the 7:15 PM blank.

Due to regional catastrophic flooding and resultant loss of utilities in most areas, CNA #6 could not be contacted for interview.

Interview with Behavioral Health Unit (BHU) Physician #1, on 07/26/2022 at 9:15 AM, revealed she was aware of the incident with Patient #1 but was unable to recall specifics, as she had only treated Patient #1 once or twice. She stated the Advanced Practice Registered Nurses (APRN) were the Qualified Medical Provider (QMP) that had the most contact with patients on the Units. She stated, on 07/13/2022, she had written the order for Patient #1's observation level to be upgraded from every eight (8) minutes to every fifteen (15) minutes. She stated the observation level was changed because of Patient #1's progress since admission. Physician #1 stated observation level changes were a collaborative effort between the treatment team that included a Physician, therapies, and nursing staff. She also stated the treatment team observed a patient's interactions with peers and staff in the milieu (social environment) to determine observation levels.

Interview with APRN/Psychiatric Mental Health Nurse Practitioner (APRN/PMHNP) #1, on 07/26/2022 at 9:30 AM, revealed she was shocked by Patient #1's demise. She stated the patient had been exhibiting positive attitudes on the Unit and interacting positively with staff/peers. She stated Patient #1 would acknowledge Suicidal Ideations, but that was chronic. She further stated observation levels were determined by collaborative efforts that included the treatment team considering staff observations/interactions. APRN/PMHNP #1 also stated observation levels could change from day-to-day and hour-to-hour. She stated she felt Patient #1's observation level was appropriate at the time of his/her death.

Interview with Registered Nurse (RN) #1, on 07/26/2022 at 10:39 AM, revealed she had been assigned as Patient #1's day shift nurse on the day he/she expired. She stated that Patient #1 was making progress, displaying positive interactions, appropriate affect, and emotions. She stated Patient #1 voiced no concerns and was being a jokester on the day of his/her death; so it came as a real shock. RN #1 stated the incident happened during the change-of-shift report, so she was not able to observe the last day shift rounds being made. She stated staff were re-educated after the event on a lot of things, including ligature hyper-awareness, the new process for change of shift (walking rounds), supervision of patients, and CNA's doing observation level rounds (to make sure they were being done and not just documenting they were done), and RN's making every two-hour rounds.

Interview with APRN-PMHNP #2, on 07/26/2022 at 10:57 AM, revealed she had interacted with Patient #1 just a few hours before he/she was discovered. She stated it was a great shock, but felt the observation level was appropriate on the day of his/her death. She stated Patient #1 did not exhibit any verbalizations or actions that would have indicated he/she was thinking about self-harm; and, the patient did not verbalize any suicidal ideation. She stated Patient #1 was very upbeat and positive. She stated Patient #1 had Complex Post-Traumatic Stress Disorder because of the abuse suffered at a very young age and which continued for years.

Interview with RN #2, on 07/27/2022 at 1:10 PM, revealed Patient #1 was doing much better, by interacting positively with staff/peers and by being ready to move on and face legal troubles. She stated Patient #1 had been brought to the facility from jail, where he/she had tried to hang himself/herself on 07/09/2022, the morning of admission. However, RN #2 stated there had been no indication Patient #1 was thinking about hurting himself/herself. She stated, after the event, nursing staff was educated on the new process for shift change of making walking rounds, purposeful rounding, ligature hyper-awareness, and ensuring observation level checks were actually being completed and not just documented.

2. Review of Patient #2's medical record revealed the facility admitted Patient #2 on 07/17/2022, via a Judge's Petition for worsening suicidal ideation. Diagnoses included Major Depressive Disorder, Severe; Borderline Personality Disorder; and Aggressive Behavior. Review of the Operative Report, dated 07/22/2022, revealed the patient sustained a spiral fracture to the left arm. The fracture required surgical fixation with plates and screws.

Review of the facility's Final Expanded Investigative Report, not dated, revealed Patient #2 was escorted to the seclusion area for an aggressive attack, aimed at staff, at the nurses' station on 07/20/2022 at 4:36 AM. Continued review revealed Patient #2 alleged Security Guard #2 had his/her left arm in an improper physical restraint hold, and broke his/her arm. The facility sent Patient #2 to the emergency department (ED) and an investigation was initiated. Security Guards #1 and #2 were suspended pending the outcome of the investigation.

Review of the facility's video, dated 07/20/2022, revealed Patient #2 was standing at the nurses' station, when he/she suddenly threw a brush at the nurse behind the Plexiglas barrier, attempted to reach through the barrier at the nurse, and then whirled around and began attacking his/her one-to-one (1:1) sitter. It was at this time that Patient #2 was placed in a physical hold by Patient Care Assistant (PCA) #1 and Security Guard #1 and escorted toward the seclusion room. Additional video review revealed PCA #1 and Security Guard #1 escorted Patient #2 through the seclusion room door and the video ended at that point. There were no video cameras in the seclusion room.

Interview with Behavioral Health Unit (BHU) Physician #1, on 07/26/2022 at 9:15 AM, revealed Patient #2 was on constant one-to-one (1:1) observation related to an intermittent explosive disorder (IED, characterized by sudden episodes of unwarranted anger that explode into a rage despite a lack of apparent provocation or reason). She stated Patient #2 was appropriate when he/she was not de-escalating.

Interview with Security Guard #1, on 07/26/2022 at 1:24 PM, revealed he responded to the "Code Green" (an internal emergency). He further stated he observed Patient #2's behaviors and despite verbal attempts at de-escalation by himself and staff, Patient #2 continued to attack staff. Additional interview revealed he and PCA #1 were able to institute an approved physical hold and escort Patient #2 to seclusion without continued aggression. However, he stated once they were through the seclusion door, and as RN #2 was laying the mattress down on the floor and PCA #1 was backing out of the room, Patient #2 became aggressive again. He stated by that time Security Guard #2 was in the room. He stated he and Security Guard #2 re-initiated the approved two (2) man hold to sit Patient #2 down on the mattress so everyone could back out of the room. He stated, at that time, Patient #2 stated his/her arm was broken. Further interview revealed the purpose of attempting to have a patient sit on the mattress instead of just standing and staff attempting to back out of the room was for the safety of all involved. He stated, if a patient was sitting, it would take more time for the patient to get off the mattress and come toward the seclusion room door, and staff would have more time to safely back out the door.

Interview with Security Guard #2, on 07/26/2022 at 1:33 PM, revealed he responded to the "Code Green" on 07/20/2022. He stated, by the time he arrived, staff and Patient #2 were already in seclusion and PCA #1 was backing out the door as RN #2 was laying the mattress on the floor. He stated he observed that Patient #2 became aggressive, and he assisted Security Guard #1 place Patient #2 in an approved hold. He stated it was at this time Patient #2 verbalized his/her arm was broken. Further interview revealed that at no time was Patient #2 placed in an improper hold to cause a broken arm. He stated while Patient #2 was in the hold with both security guards, the patient was forcefully trying to remove his/her left arm from Security Guard #2's hold.

Interview with PCA #1, on 07/28/2022 at 8:27 AM, revealed the PCA was assigned to provide one-to-one (1:1) care for Patient #2 on the 07/20 2022 night shift. Further interview revealed at approximate 4:30 AM, Patient #2 had finished a shower and was at the nurses' station to request a brush to brush his/her hair. Continued interview with PCA #1 revealed Patient #2 became aggressive about the brush, threw the brush at the nurse behind the barrier, attempted to attack the nurse through the barrier, and then turned and began attacking PCA #1. PCA #1 stated a "Code Green" was called, and Security Guard #1 arrived. PCA #1 stated attempts at verbal de-escalation were unsuccessful, and Patient #2 was placed in an approved hold and escorted back to seclusion by PCA #1 and Security Guard #1. PCA #1 stated Patient #2 walked through the seclusion door willingly. However, as PCA #1 was backing out the door, Patient #2 became aggressive again. PCA #1 stated RN #2 was laying the mattress down, and Security Guard #2 arrived in the seclusion room. PCA #1 stated Security Guard #2 implemented an approved hold, along with Security Guard #1. In addition, PCA #1 stated at no time was an inappropriate hold instituted on Patient #2.

Interview with RN #2, on 07/28/2022 at 8:37 AM, revealed he/she was laying down the mattress for Patient #2 to sit on and at no time did she observe an inappropriate hold.

Interview with Patient #2 (one-to-one (1:1) sitter was present outside the door), on 07/28/2022 at 2:11 PM, revealed he/she did feel safe being in the facility and had no care concerns. However, Patient #2 stated that he/she felt Security Guard #2 did pull his/her arm back further than he should have and that was why his/her arm broke.

Interview with the BHU Executive Director, on 07/29/2022 at 1:45 PM, revealed he had reviewed restraint audit tools for 2021 and 2022 thus far. He stated there had not been any reported injuries during that time frame and believed that staff members were performing the holds correctly as they had been educated on this, at hire and annually. Continued interview revealed he had reviewed BHU records, and there had never been a reported death on the Unit. Additional interview revealed corrective actions were taking place for both incidents because processes were identified that could be improved.

Based on interview, record review, review of the facility's job description, review of the facility's policy, and review of the facility's video, it was determined the facility failed to follow written care plans for one (1) of ten (10) sampled patients (Patient #1).

Review of Patient #1's Physician's orders, dated 07/13/2022, revealed an order to increase his/her level of observation from every eight (8) minutes to every fifteen minutes. Review of Patient #1's plan of care, dated 07/13/2022, revealed the plan of care was updated on 07/13/2022 to reflect the change. However, review of the facility's video revealed every (15) minute checks were not completed as ordered and care planned for Patient #1.

The findings include:

Review of the facility's policy titled, "Treatment Planning", Reference Number IV-PC-046, reviewed 06/20/2019, revealed the treatment team should review the patient's status on each goal and objective and revise them, adding or deleting problems/goals as needed with target dates throughout the course of treatment. Continued review of the policy revealed each discipline should develop goals, objectives, and interventions as clinically indicated and identify responsible staff. Goals and objectives must be observable and measurable.

Review of the Staff Nurse job description, dated 03/21/2005, revealed the staff nurse was responsible for assessment/reassessment of patients and documentation of nursing interventions. Continued review revealed the staff nurse was also responsible for implementing the plan of care. Further review revealed staff nurses provided clinical supervision to Licensed Practical Nurses (LPN) and Certified Nursing Assistants.

Review of Patient #1's medical record revealed the facility's Behavioral Health Unit (BHU) admitted Patient #1, on 07/09/2022, with diagnoses that included Suicidal Ideation. Further review revealed Patient #1's Physician's orders, dated 07/13/2022, revealed an order to decrease his/her level of observation from every eight (8) minutes to every fifteen (15) minutes.

Review of Patient #1's Treatment Plan (care plan), initiated on 07/09/2022, revealed the Treatment Plan was updated as the observation level changed. On 07/13/2022, Patient #1 had an observation frequency changed on his/her treatment plan from every eight (8) minutes to every fifteen (15) minutes, per the Physician's order.

Review of the facility's video related to Patient #1, dated 07/17/2022, revealed Certified Nursing Assistant (CNA) #6 did not perform observation level checks per the treatment plan. At the time of his/her death, Patient #1 was ordered to be on every fifteen (15) minute observation checks, which was reflected in the care plan. However, video review revealed CNA #6 did not make an observation round at 6:45 PM, 7:00 PM, or 7:15 PM. The video revealed CNA #6 did make an observation round at 7:09 PM.

Review of the observation level rounding book for 07/17/2022, from 7:00 AM to 7:00 PM, revealed all observation times for Patient #1 were documented as being completed, including the 6:45 PM and 7:00 PM times. The rounding book revealed that the 7:09 PM observation was documented in the 7:15 PM spot on the form.

Due to regional catastrophic flooding and resultant loss of utilities in most areas, CNA #6 could not be contacted for interview.

Interview with Registered Nurse (RN) #1, on 07/26/2022 at 10:39 AM, revealed nurses could update the care plan as needed. She stated she observed the Certified Nursing Assistants (CNA) as they made the observation checks to ensure they were being completed in a timely manner. However, she stated the incident with Patient #1 happened during the change-of-shift report, so she was not able to observe the last day shift rounds being made and whether the care plan was being followed.

Interview with RN #2, on 07/27/2022, at 1:10 PM, revealed typically the therapists were responsible to update a patient's care plan. Further interview revealed she was not sure if nurses could update the care plan. She stated she would review the observation check book to ensure the CNA's were making the rounds in a timely manner.

Interview with the Behavioral Health Unit (BHU) Director of Nursing (DON), on 08/04/2022 at 11:00 AM, revealed staff nurses were also responsible to update patient care plans, in addition to ensuring the interventions were being followed.