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Based on interviews, review of the organizational chart, review of incident logs, and review of QAPI documentation it was determined that the hospital failed to ensure it complied with all State laws and rules that pertained to hospital licensure and organization. The hospital's leadership, incident reporting and management, and QAPI systems were combined with that of OSH-Salem, a separately licensed hospital, and that of non-hospital licensed SRTFs on each campus that are licensed by another agency. The co-mingling of those systems resulted in a lack of clear leadership, and a lack of clear and accurate information pertaining to the hospital's patient care safety operations and outcomes.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A22 under CFR 482.11(b) - Standard: Licensure of Hospital.

2. Refer to the findings cited at Tag A145 under CFR 482.13(c) - Standard: Privacy and Safety.

3. Refer to the findings cited at Tag A286 under CFR 482.21(a), (c)(2), (e)(3) - Standard: Patient Safety.

Based on interview and review of organizational and QAPI documentation it was determined that the 75-bed hospital at OSH-JC failed to ensure it complied with State hospital licensing requirements. Although the hospital at OSH-JC shared Federal Medicare certification with the hospital at OSH-Salem campus, the hospital at OSH-JC exceeded the distance requirements for a State licensed hospital satellite location and therefore was required to independently comply with State licensing rules. Hospital leadership and organizational systems were not independently maintained for this separately State licensed hospital.

Findings include:

1. The definition for a hospital "Satellite" at OAR 333-500-0010(46) "means a building or part of a building owned or leased by a hospital, and operated by a hospital in a geographically separate location from the hospital, with a separate physical address from the hospital but that is within 35 miles from the hospital ..."

The OSH-JC campus is approximately 65 miles, and one hour and 15 minutes drive time, from the OSH-Salem campus and was not approved as a hospital satellite location for State licensing purposes. The hospital at OSH-JC was separately licensed as a hospital on 03/10/2015 as it demonstrated provisions for independent compliance with the State licensing requirements for hospitals.

2. OAR 333-505-0010(1) and (3), "Administrator," requires that "Each hospital shall employ or contract with a chief executive officer (CEO) or administrator who is responsible for the operation of the hospital and hospital based services in a manner commensurate with the authority conferred by the governing body, supports the delivery of high quality hospital care and services and ensures compliance with all hospital policies and applicable state and federal laws and regulations. In determining the appropriate number of facilities for which a CEO or administrator is responsible, the governing body of the hospital or health system should consider distance between hospitals and the size and complexity of each facility ... The hospital shall notify the Division, in writing, of the voluntary or involuntary termination of the CEO or administrator as well as the appointment of a new CEO or administrator."

During interview with clinical and program leaders on 12/13/2021 @ 1530 they stated that the hospital at OSH-JC no longer had an onsite administrator and at the time of the survey entrance that the PD-JC was in charge. They indicated that OSH executive leadership staff offices were located at the OSH-Salem campus, approximately 65 miles from OSH-JC.

During interview with clinical and program leaders on 12/14/2021 @ 1445 staff stated that the most recent OSH-JC administrator, who had been onsite full-time, had "retired" in December of 2020 and the OSH-JC "administrator position had been eliminated." Staff described the current onsite leadership at OSH-JC as being "shared" by three clinical and program leaders.

Review of SA hospital licensing records for 2020 reflected that the OSH-JC "administrator" at that time had not been the individual identified by staff during the 12/13/2021 and 12/14/2021 interviews above and there was no indication in the records that he/she had been appointed or had retired. Rather, the licensing records submitted by OSH-JC reflected the OSH-JC administrator was the OSH-Salem administrator.

3. OAR 333-505-0030(2), "Organization, Hospital Policies," requires that "A hospital shall adopt and maintain clearly written definitions of its organization, authority, responsibility and relationships."

Beginning at the time of the survey entrance there were repeated requests for an organizational chart the delineated the OSH-JC leadership and reporting structure. None was provided until 01/13/2022.

An OSH internal email provided on 01/13/2022 was dated 11/18/2020 @ 1400 and included the following information:
* "The following email is for all staff on the OSH both the Junction City and Salem campuses from the [OSH Superintendent].
* The retirement of the [OSH-JC Deputy Superintendent] was "upcoming."
* "OSH Realignment Plan for Junction City Campus
Effective, Jan. 1, 2020 (sic): Instead of a deputy superintendent, Junction City Campus leaders will report to their respective OSH Executive Team members and department directors:
- The Junction City program director will report to the OSH deputy superintendent (one for both campuses).
- The Junction City deputy chief nursing officer will report to the OSH chief nursing officer.
- The Junction City associate chiefs (Psychiatry, Psychology, Social Work, and Treatment Services) will report to their associated OSH discipline chiefs.
- The Junction City treatment mall manager will report to the OSH treatment mall director.
- The Junction City security director will report to the OSH safety and security director.
- Junction City facilities, environmental and food and nutrition services managers will report to their OSH department directors within OSH Operations.
- Junction City's two safety specialists will report to the OSH safety and emergency preparedness manager."
* "Please see the new OSH organizational chart for more information ... We understand this will be a big shift for the Junction City Campus community ... A key component of this plan is also a stronger OSH leadership presence on the Junction City Campus, both virtually and in-person once the pandemic passes ...".

The undated, "Oregon State Hospital Superintendent Org Chart" attached to the email did not distinguish the leadership and reporting structure for the OSH-JC campus as separate from the OSH-Salem campus and further, did not distinguish the leadership and reporting structure for the licensed hospital on either campus from the non-hospital licensed SRTFs on both campuses. For example:
* Unspecified "Program Directors" for a number of "programs" were identified as direct reports to the "Deputy Superintendent," who was identified as a direct report to the OSH "Superintendent." The listed "programs" were not specified as hospital, SRTF or other types. Those included generically "Junction City."
* Generically, "Salem and Junction City Campuses ... Nursing Direct Care ... Medicine ... Pharmacy ... Psychiatry ... Psychology ... Social Work ... Treatment Services" were identified as direct reports to the "Chief of Nursing" and "Chief Medical Officer," who were identified as direct reports to the OSH "Superintendent."
* Generically, "Facilities and Support Operations" and "Safety & Security" for "Salem and Junction City Campuses," and "Quality Management," were identified as direct reports to the "CFO/COO," who was identified as a direct report to the OSH "Superintendent."

During interview on 01/13/2022 @ 1245 the OSH Superintendent confirmed that the OSH executive team that included the OSH DS, the OSH CNO, the OSH CMO and the OSH CFO/COO were located in offices at the OSH-Salem campus and that there was no administrator or "deputy superintendent" or other executive leadership staff located onsite at OSH-JC. He/she confirmed that there had been an onsite administrator at OSH-JC who had retired and that when that occurred there had been a "re-alignment" of the OSH-JC and OSH-Salem leadership structure. He/she also indicated that executive leadership staff had planned to conduct "routine rounds twice a month" at OSH-JC, however, those had not occurred consistently during the Covid-19 pandemic.

4. OAR 333-505-0060(1) and (2), "Quality Assessment and Performance Improvement" requires that "The governing body of a hospital must ensure that there is an effective, written, facility-wide quality assessment and performance improvement program to evaluate and monitor the quality and appropriateness of patient care ... All organized services related to patient care, including services furnished by a contractor, must be evaluated."

Refer to the findings cited at Tag A263 under CFR 482.21 - CoP: Quality Assessment and Performance Improvement that reflected the QAPI data and documentation for the hospital at OSH-JC was not clearly differentiated from the hospital at OSH-Salem campus.

Based on observations, interviews, review of incident and medical record documentation for 36 of 37 OSH-JC patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37), review of P&Ps, review of PERA documentation and review of other documentation it was determined that the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A22 under CFR 482.11(b) - Standard: Licensure of Hospital.

2. Refer to the findings cited at Tag A115 under CFR 482.13 - CoP: Patient's Rights.

3. Refer to the findings cited at Tag A263 under CFR 482.21 - CoP: Quality Assessment and Performance Improvement.

4. Refer to the findings cited at Tag A385 under CFR 482.23 - CoP: Nursing Services.

5. Refer to the findings cited at Tag A438 under CFR 482.24(b) - Standard: Form and Retention of Records.

6. Refer to the findings cited at Tag A700 under CFR 482.41 - CoP: Physical Environment.

7. Refer to the findings cited at Tag A750 under CFR 482.42(a) - Standard: Infection Control Program.

8. Refer to the findings cited at Tag A1640 under CFR 482.61(c)(1) - Standard: Treatment Plan.

Based on observations, interviews, review of incident and medical record documentation for 36 of 37 OSH-JC patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37), review of P&Ps, review of PERA documentation and review of other documentation it was determined that the hospital failed to fully develop and implement P&Ps that recognized and protected each patient's right to provision of care in a safe setting. Those failures resulted in actual and potential physical and psychological harm to patients.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tags A144 and A145 under CFR 482.13(c) - Standard: Privacy and Safety.

2. Refer also to the findings cited at Tags A118, A122 and A123 under CFR 482.13(a)(2) - Standard: Patient Grievances

Based on review of grievance documentation for 1 of 1 patient reviewed for grievances (Patient 7) it was determined that the hospital failed to ensure patients' rights were recognized, protected, and promoted in regards to grievance response, investigation and documentation:
* Responses to and investigations of patient grievances were not clear, complete or timely.
* A written grievance notice that contained the required elements including the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion was not provided for each grievance submitted.

Findings include:

1. Refer to the grievance findings for Patient 7 cited at Tags A122 and A123 under CFR 482.13(a)(2) - Standard: Patient Grievances.

Based on review of grievance documentation for 1 of 1 patient reviewed for grievances (Patient 7) it was determined that the hospital failed to ensure patients' rights were recognized, protected, and promoted in regards to timeliness of grievance review and response.

Findings include:

1. Refer to the findings related to grievances submitted by Patient 7 on 07/04/2021, 09/25/2021, 11/12/2021 and 11/18/2021 that are cited at Tag A144 under CFR 482.13(c) - Standard: Privacy and Safety.

Based on review of grievance documentation for 1 of 1 patient reviewed for grievances (Patient 7) it was determined that the hospital failed to ensure patients' rights were recognized, protected, and promoted in regards to the written grievance notice to patients or their representatives.

Findings include:

1. Refer to the findings related to grievances submitted by Patient 7 on 07/04/2021, 09/25/2021, 11/12/2021 and 11/18/2021 that are cited at Tag A144 under CFR 482.13(c) - Standard: Privacy and Safety.

Based on observations, interviews, review of incident and medical record documentation for 36 of 37 OSH-JC patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37), review of P&Ps, review of PERA documentation and review of other documentation it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient's right to receive care in a safe setting. The hospital's failures to provide adequate observation, supervision and other preventive measures and precautions created an unsafe EOC that resulted in actual and potential physical, mental or emotional harm to patients and included:
* Failure to prevent elopement of patients during off-campus activities.
* Failure to maintain accountability for patients during on-campus activities off the secure unit.
* Failure to prevent patient entry into unauthorized areas.
* Failure to prevent patient to patient sexual contact and sexual assault.
* Failure to prevent patient to patient physical altercations.
* Failure to prevent patient suicide attempts and self-harm with contraband, unsafe and prohibited items.
* Failure to prevent other unsafe conditions in the physical environment.
* Staff responses to incidents failed to include investigations to identify causes and to plan and implement corrective actions to prevent recurrence for the affected patient and other patients.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

A. Following are findings related to an unsafe EOC as result of failures to prevent elopement of patients during off-campus activities, to maintain accountability for patients during on-campus activities off the secure unit, and to prevent patient entry into unauthorized areas:

1.a. P&Ps related to the prevention of elopement and unsupervised access to unauthorized areas included:

1.b. The P&P titled "Unauthorized Leave" dated as 03/22/2021 reflected that "In this policy, unauthorized leave means a patient leaves the confines of the assigned unit or secure perimeter without authorization, or leaves the supervision of staff while on the grounds of OSH or during authorized supervised travel in the community. A patient who walks away from their responsible party or who overstays an off-ground pass is also considered to be on unauthorized leave."

This P&P was specific to steps and processes following a successful patient elopement from the facility, a secure unit or during an off-grounds outing. The P&P did not address steps to prevent elopement or "unauthorized leave."

1.c. The P&P titled "On-grounds and Off-grounds Movement" dated as 03/22/2021 reflected that "All movement outside the secure perimeter, including on-grounds and off-grounds activities and discharges, requires a trip slip ... 'Trip slip' refers to the form completed any time a patient leaves the secure perimeter." All procedures and directions on the seven-page P&P were not clear. For example:

* "Escorting staff are responsible for the following on the day of the outing. 1. Before leaving, escorting staff must gather the patient, trip slip, and any necessary belongings for the outing. a. Escorting staff must print and distribute a copy of the trip slip to every staff member participating in the outing, to the appropriate treatment mall or unit, and to Security when exiting the secure perimeter. b. Before leaving, staff in charge of the outing must hold a meeting with the patient and other staff to discuss staff roles, patient needs, goals, rules, behavioral expectations, and commitments. c. Any changes or additions made before the outing to the itinerary or patient list must be revised by staff to reflect the change or addition. Copies of the revised trip slip must be printed and distributed as directed above ... Escorting staff must provide a copy of the trip slip to Security before exiting the secure perimeter."

* "While outside the secure perimeter, staff must follow security guidelines described in this policy. A peer or 'buddy' system' is not an acceptable substitution for staff security responsibilities ... 2. During an outing, patient badges must be kept with staff on the staff member's person ... 3. Staff must verify that patients remain within 'line of sight' and within speaking distance of staff members. This means staff must maintain consistent visual contact with patients and be able to communicate using a normal speaking voice. 4. When escorting, staff must vary spacing in the group and verify one staff member is at the rear of the group ... 6. After verifying the restroom does not contain potential risks or alternative exits, staff must continuously observe the restroom door the entire time patients are inside."

* "Attachment A ... B. Before the patient may go on the outing, the [TMM] must approve a mall-based outing ... 2. Before approving the trip slip, the appropriate manager must complete the form sections regarding unit or mall acuity, appropriate staff-to-patient ratios, destination appropriateness, and whether staff pairing with the patient is appropriate ... C. The [RN] must verify safety and security for the unit and patient on the day of the outing ... 3. The RN must perform the clinical screen to assess the patient's mental status and any concerns or safety issues that could affect the outing."

The P&P did not clearly define expectations about all aspects of recreational off-grounds outings. For example:
* It was not clear how far in advance of the outing clinical assessments and approvals for patient attendance must occur.
* It was not clear how far in advance changes in patient attendance were allowed once the Trip Slip had been approved.
* It did not specify what the "rules, behavioral expectations, and commitments" were that were to be discussed during a pre-outing meeting.
* It did not include provisions to assess patients for possession of cell phones that were prohibited on outings.
* It was not clear what aspects of pre-outing activities were to be documented and where.
* It was not clear whether the driver of the vehicle for the outing was also one of the staff responsible for supervising patients, and not clear how staff to patient ratios were to be maintained while one staff person was driving and was unable to respond to problems or behaviors if those occurred in the vehicle.
* It was not clear how staff to patient ratios would be met in public restroom facilities in all instances. For example: On an outing approved for a ratio of two staff to four patients, in the case where a staff person needed to use the restroom that would leave one staff person responsible for supervision of four patients. In the case where one patient used the restroom in a multi-stall facility that would leave three patients outside of the restroom to be supervised by the second staff person.
* It did not clearly specify how staff were to "vary spacing" during the outing.
* It included no provisions or criteria for discontinuing the outing in the presence of concerning patient behaviors or other problems that may arise.

1.d. The P&P titled "Transportation Ratios and Escorting Patients" dated as 05/14/2021 reflected that it "... establishes transportation ratios and staff escorting expectations during transports within OSH's secure perimeter to maintain a safe environment."
* "Transportation ratios are not considered to be to (sic) supervision ratios for activities in areas such as a plaza or quad, or during therapeutic groups off-unit, or for other similar reasons."
* "Minimum staff-to-patient transportation ratios inside the secure perimeter ... are ... [on inpatient units] ... one staff for groups of two to five patients (1:5), and two staff for groups of six to ten patients (2:10)."
* "Staff escorting patients ... are responsible to take appropriate precautions to maintain a safe environment, such as securing doors and observing patient activity during transport."
* "If a patient without appropriate privileges is found unescorted, the staff person who finds them becomes responsible for the patient and must immediately escort them to their unit."

1.e. The P&P titled "Continuous Rounds, Census, and Milieu (RCM) Management" dated as 11/01/2019 included the following:
* "Staff assigned to RCM duties must verify the presence and viability of each patient on the unit at least once per hour, at random intervals (within 10 minutes before or after the top of each hour)."
* "If at any time a patient's presence cannot be verified, the following must occur ..."
* "RCM staff must maintain awareness of the location and status of all patients assigned to the unit, including knowing if and when individual patients are off-unit."
* "Document patent movement on and off the unit which occurs outside of the hourly checks ... If only a single patient or a small group of patients leave or return to the unit ... If a large group of patients leave or return to the unit (for example in relation to Treatment Mall or a meal) ..."
* "Unit staff must complete hand-off communication with Treatment Mall staff whenever patients move from a unit to a Treatment Mall and whenever patients move from a Treatment Mall back to a unit."

2.a. The medical record for Patient 7 reflected that he/she was admitted to OSH-JC on 06/04/2020 and that he/she had eloped on 12/02/2021 during an off-grounds outing and had not been located as of the start date of this survey on 12/13/2021. The record included the following information:

2.a.i. A court document titled "Judgement upon Finding of Guilty Except for Insanity and Placement under PSRB" reflected that Patient 7 was "placed under the jurisdiction of the Psychiatric Security Review Board for care, custody and treatment for a maximum period of time not to exceed 5 years; and ... committed to the custody of the state mental hospital ..." The order was signed on 03/30/2020.

2.a.ii. A Progress Note dated 12/02/2021 at 1412 by an MHT reflected that "During dayshift [Patient 7] pace (sic) the halls. [He/she] when (sic) on a on ground walk with Treatment mall as well as an outing. He attend (sic) lunch of (sic) the unit."

2.a.iii. A Progress Note dated 12/02/2021 at 1738 written by an MHT reflected that Patient 7 had approached the MHT at approximately 0910 to ask to go on the Urban Hike scheduled for that day at 1300. Patient 7 "was reminded that the group was full as it already had 4 peers assigned that had committed to attend the group for that day and [he/she] could be looked at as an alternate for the next time the group met. [Patient 7] then asked who else led the group and if this writer was a co-lead and not the lead ... at approximately 1030 this writer was informed that [Patient 7] had contacted the groups (sic) second Co-Lead and talked about the outing. [Patient 7] had been added and approved to the outing trip slip at around 1230 with IDT and Nursing staff approval as [he/she] was able to talk a peer into not attending the group, the group left the facility at 1305, [Patient 7] and a peer were asked by staff to use the restroom prior to leaving the facility as public restrooms are few in the community ... at approximately 1340 the group arrived at their destination ... [Patient 7] immediately asked to use the restroom as the vehicle pulled into the parking stall ... [Patient 7] begun (sic) to walk in front of the group and creating short gaps of 10 to 12 feet ... clients were once again reminded by staff to remain together. [Patient 7] would create gaps between [him/herself] and the group ... one staff led the group with three clients while one remained behind walking close to [Patient 7]. [Patient 7] begun (sic) to run ... [he/she] left the group at a fast run heading East bound from the 5th street market Provisions store parking lot and headed East bound direction til staff lost sight of him. Local police and OSH-JC facility were promptly notified."

2.a.iv. A Group Note dated 12/02/2021 at 2005 written by the AC reflected that "This morning [Patient 7] attended the Mindful Activity group that took place in the sensory quad at 09:05 ... [patient] approached me and walk (sic) along side and began making conversation ... [He/she] discussed being added to the Urban Hiking group. I replied to [patient] that I could possible add [him/her] to group as an alternate and seek approval. I also let [him/her know I did have a unit drive today with [his/her] unit if [he/she] wanted to check in with the unit staff for that. [Patient 7] said [he/she] didn't just want to do a drive, that [he/she] liked getting out and walking or hiking around like [he/she] done (sic) before with me. I ... let [him/her] know at this time I didn't have any space today that I was aware of. [He/she] asked more about if all the clients were going today ... [He/she] continued to ask about group and whether others attend regularly ... At 11:00 when I arrived on the unit preparing to leave for another outing, [Patient 7] approached me to say one of the clients declined to [go on Urban Hike] so [he/she] was hoping to go ... I then discussed the decline of today's group with [Patient 38 who had declined] and [he/she] replied [Patient 7] asked [him/her] if [he/she] could skip the outing today so [Patient 7] could go. I reported to RN on unit what [Patient 38] said. Unit RN approved the trip slip following manager approval. [TMM] was notified by email [his/her] approval was not showing up and other manager was requested for approval. [Patient 7] was approved for outing today by [his/her] unit RN just before leaving unit for outing and after unit peer declined to attend. [Patient 7], along with group peers and staff, entered vehicle and I collected name badges from all clients and placed them in backpack to be carried during duration of outing."

The note continued and described a stop at a coffee drive-through prior to arriving at the hike destination that reflected that "While waiting at drive through, [Patient 7] asked how long it was going to take, as we were 4th in line for the drive up window. I sensed [he/she] may be concerned about the time, and I reflected back asking [Patient 7] if [he/she] was concerned we would have enough time to do our walk. [Patient 7] said [he/she] just wanted to make sure we could walk around without running out of time ... when arriving [Patient 7] asked if a bathroom would be available while stating [he/she] needed to use the bathroom, and even though before leaving unit [he/she] stated [he/she] had used the restroom ... Other staff went into bathroom following [Patient 7] and other [patient] ... Group left bathroom and began walking ... I noticed [Patient 7] getting farther ahead of group about 8 or 10 feet, I said to all of the group, 'Just a reminder we all need to stay close together as a group' ... Group then began walking towards the market and [Patient 7] remained at back of group with other staff, as we arrived to the holiday tree area ... I began hearing other staff yelling my name ..." The note reflected that the AC did not see Patient 7 again but that the other staff person and the patients informed him/her that Patient 7 had "run" and the other staff person had "lost line of sight" and that Patient 7 remained on "unauthorized leave" at the time this note was written.

2.a.v. A Progress Note dated 12/02/2021 at 1531 written after the elopement by an RN reflected that "When I spoke with [Patient 7] today, [he/she] held a linear conversation, was calm and polite. [His/her] behavior appeared baseline. [He/she] follows staff's directions and follows the unit expectations ... medication complaint. [Patient 7] participated in an on grounds walk during the 1000 hour and there were no issues reported. [He/she] has participated in multiple walks and outings with no reported concerns ... I spoke with [LIP] about the possibility of adding [him/her] to the group which [he/she] approved. I emailed each group leads to see if this was a possibility. In the afternoon I was informed that [Patient 7] was added to the trip slip which I approved."

There was no documentation by the RN related to the report he/she had received prior to the outing, that Patient 7 had talked another patient out of going on the outing at last minute so that he/she could go on the outing instead.

Further, the RN's note contained inaccurate information about the patient's participation on an "on grounds walk during the 1000 hour" on 12/02/2021 as reflected in the following group note written on 12/07/2021 at 0823.

2.a.vi. A Group Note dated 12/07/2021 at 0823 was written by an MHT for "On Grounds Walk ... Date of Group Service ... 12/2/2021." The note reflected that "[Patient 7] was approved to attend the on grounds walk but was excused from the walk due to being on another pass on the mall."

That group note also contradicted the MHT note referenced earlier in this finding that was written on 12/02/2021 at 1412 and reflected that "During dayshift [Patient 7] ... when (sic) on a on ground walk ... as well as an outing."

2.a.vii. A "Personal Property - Non - Clothing Items Stored on Unit" form included the following entry: "Nokia 106 cell phone & [charger] 11/8/21" with a staff person's initials. A second similar form reflected a "Phone Sim Card" was added to the patient's personal property on "11/13," followed by another staff person's initials. There was no other documentation about the phone.

2.a.viii. An "OSH Cell Phone Agreement" form was signed and dated by Patient 7 on 11/10/2021, two days after the cell phone had been added to the patient's property. A space for "IDT approval" contained the following notation: "Verbal approval from [LIP] 11/12/21 1635 [RN's name]."

The form included the following stipulations for the patient:
* "1. Patients must obtain IDT authorization for the cell phone prior to obtaining the cell phone."
* "2. Cell phones must be purchased through OSH approved vendors only. Cell phones must only be capable of sending and receiving voice and text. No camera, internet access or other function will be allowed."
* "3. Cell phones must be minutes-style only through use of minutes cards. No calling plans, individual or otherwise are allowed for the phones."
* "4. Cell phones are not to be taken to the treatment mall. No cell phones on any staff supervised on- or off-grounds activities, unless there is prior approval, on a case-by-case basis."
* "10. All cell phones will be recorded on the patient's property sheets along with the corresponding phone identification, serial number and phone number."

Documentation in the record did not clearly reflect that the stipulations identified in the agreement under numbers 1, 2, 3, 4, and 10 had been met for Patient 7.

2.a.ix. Review of Patient 7's IDT treatment plan dated 11/15/2021 revealed it contained no documentation of goals and interventions related to off-campus outings and the patient's possession and use of a cell phone.

2.a.x. A "Risk Review - Forensic" form for Patient 7 reflected the "Date of Risk Review" was 06/29/2021. The form reflected that "Off-Grounds" privileges for staff to patient ratio of 2:1 had been requested and "approved 6/29/2021." The form also reflected that "Off-Grounds" privileges for staff to patient ratio of 2:4 had been requested and "approved 6/29/2021."

This discrepancy was confirmed during interview with leadership, clinical and program staff that included the DCNO-JC, the PD-JC, the TMM and a Psychiatrist on 12/14/2021 beginning @ 1000.

2.b. A "Trip Slip for Departure" form reflected that an "on grounds walk ..." was scheduled for 12/02/2021 at 1000. The form listed four patients that included Patient 7 and a notation next to each of the four names reflected "Approval" for the trip. The form had the word "Cancelled" printed over the top of the trip description in a red, large, bold font. A noted reflected "Cancelled Note all clients declined on grounds walk" and "Cancelled [Reason] Cancelled by Patient."

During interview with leadership, clinical and program staff on 12/14/2021 beginning @ 1430 the TMM confirmed that the 12/02/2021 on grounds walk had been cancelled.

2.c. A "Trip Slip for Departure" form reflected that an "Urban hike and community reintegration going to 5th street market ..." was scheduled for 12/02/2021 at 1300. It identified two "Escorting Staff" as an AC and an MHT. The form listed five patients that included Patient 7. A notation next to Patient 7 and three other patients' names reflected "Approval" for the trip. A notation next to the fifth name reflected "Declined" for the trip.
There was no indication on the form when those approvals occurred and there was no reason documented for the patient who declined.

2.d. Medical record documentation for Patient 38, the patient who declined the trip on 12/02/2021, was provided in form of a Group Note dated 12/02/2021 at 1206, written within an hour prior to the Urban Hike departure. There was no documentation related to the Urban Hike outing that the patient had "declined" and none to reflect that staff had talked to Patient 38 about the circumstances that led to his/her decision to decline the off grounds outing.

During interview on 12/14/2021 beginning @ 1430 staff confirmed that the Group Note was the only note written for Patient 38 on 12/02/2021 and there were no other group notes or nursing progress notes, including late entries, written for that day.

2.e. Incident documentation for Patient 7's elopement was reviewed. It contained similar documentation to the 12/02/2021 medical record progress notes written at 1738 and 2005 that were referred to earlier in these findings. In addition, a report written for the incident date and time of 12/02/2021 @ 1408 reflected that "At approximately 1406 [Patient 7] ran away from the group as the group was in an off grounds outing to the Eugene 5th Street market area parking lot. Client had been advised several times by staff that the group was to stay together and client continued to create gaps in the group by creating distance between himself and the group. The group had turned left to enter a covered area and client ran away from the group headed East at a fast run. Staff called out [his/her] name and maintained line of sight until [he/she] was not visible while notifying second staff of the incident. "

2.e.i. Additional incident documentation dated 12/02/2021 reflected that on 12/02/2021 @ 1530 staff were directed to "conduct a Room Search of [Patient 7's room] ... The purpose of the search was to locate the client's phone and any information about [Patient 7] absconding from [his/her] trip ... The search was able to find a blue book of resources with a page torn out of Portland area food kitchens and two envelopes addressed to Colorado. The phone was never located."

2.e.ii. An OQM form identified for this incident reflected "Leadership Directives: Level II Investigation: [OQM staff] 12/3/21 ... [Patient 7], GEI, was on an outing in the community in Eugene, Oregon. [Patient 7] was reported to have run from staff resulting in an unauthorized leave. Law enforcement was notified along with Comm Center. Patient was still at large at the time of this document (1115, 12/3/21)."

2.e.iii. A document titled "December 2, 2021 Timeline" reflected a number of notifications and communications and that on 12/02/2021 at 1450 an "incident report" was generated. However, there was no information on the timeline that reflected that an investigation into how this elopement was allowed to occur had been conducted or initiated as of the start date of this survey, 12/13/2021. There was additionally no information that reflected any changes to practices regarding off-site outings had been made to mitigate recurrence until an investigation was completed and long-term corrective actions planned and implemented.

2.f. A "Junction City outings" document reflected that 21 "off grounds" outings had occurred from 12/03/2021, the date of Patient 7's elopement, through the date of this survey on 12/14/2021.

2.f.i. Documents titled "Trip Slips for Departure" included 14 "Trip Slips" for off grounds outings to destinations other than medical or health related purposes. There were six of those outings on which there was more than one patient and those were:
* On 12/05/2021 @ 0945 w/ four patients
* On 12/06/2021 @ 1300 w/ four patients, for which the AC present during Patient 7's elopement was assigned.
* On 12/07/2021 @ 1400 w/ four patients
* On 12/08/2021 @ 1400 w/ three patients
* On 12/09/2021 @ 1305 w/ three patients, for which the MHT and AC who were present during Patient 7's elopement were assigned.
* On 12/09/2021 @ 1510 w/ four patients

2.g. During interview with staff that included the DCNO-JC, DON-JC, the PD-JC and the TMM on 12/14/2021 @ 1155 they provided the following information:
* Patient 7 had a cell phone on his/her personal property list.
* It could not be found after the elopement.
* Patients are not searched or asked about their phones before they leave the unit for the treatment mall or outings or other off-unit destinations.
* Regarding where Patient 7 obtained the phone, whether through an approved vendor, the response was "good question."

2.h. During interview with staff present during the outing on 12/15/2021 beginning @ 1035 the details and information contained in the medical record and incident documentation were reviewed and confirmed. Regarding Patient 7's cell phone, staff stated they had no knowledge that Patient 7 had a cell phone on the outing. It was also disclosed that staff didn't check the patient and didn't ask the patient about a cell phone prior to leaving the facility or during the outing, and that this interview was the first time the cell phone questions had come up since the elopement

2.i. During interview with staff that included the DCNO-JC and the PD-JC on 12/14/2021 @ 1525 regarding the hospital's follow-up and investigation of the elopement the following information was provided:
* OSH-JC staff stated that the investigation was managed by staff at OSH-Salem and the status of an investigation was not known.
* OSH-JC staff had not been directed by OSH Executive Team to make any changes to practices around outings.
* Off-grounds outings had continued without changes since the 12/02/2021 elopement.
* The MHT and AC responsible for the 12/02/2021 outing had continued to be assigned to off-grounds outings.

2.j. In an email from the DQM received on 01/17/2022 @ 2020, 46 days after Patient 7's elopement, information provided included the following:
* "Follow up activity" in response to Patient 7's elopement "occurred immediately" and "efforts are still underway."
* On 12/02/2021 @ 1823 the OSH Superintendent sent an email to all staff. That email reflected "To all OSH Staff, I am writing to notify you that a patient is currently on unauthorized leave. The person, [Patient 7], is a patient on the Junction City Campus. [Patient 7] was last seen at about 2:07 p.m. at the 5th Street Public Market in Eugene, where [he/she] was on a group outing. [He/she] ran away from the group and left the immediate area. The hospital has notified both state and local law enforcement, and they are now conducting a search for the missing patient. We have issued a news release to state media organizations, asking for anyone having information leading to whereabouts of [Patient 7] to call the Oregon State Police at [phone number]. I will keep you apprised as more information becomes available."
* On 12/03/2021 the DQM assigned an internal investigation.
* On 12/03/2021 applicable documents for Patient 7 were gathered and review and discussion begun with the OSH Superintendent and other leadership staff.
* As result of the review "... an opportunity for performance improvement ..." was identified related to the ways that Patient 7 went about securing him/herself a place on the outing. "... many of which were concerning. This was to be considered in any upcoming outings and would be formalized as an action item upon completion of the systems investigation and report."
* A medication review was requested "in order to identify any potential decompensation concerns that should be shared with law enforcement during the course of the ongoing search."
* A meeting was held "to review the notification and warrant process across parties and determine any immediate opportunity for improvements and/or consistency."
* On 12/13/2021 the DQM "verbally instructed the [OQM] investigator to pause the internal investigation due to [CMS SA Surveyor] arrival. The intent was to avoid a conflict or interference with [the CMS SA] investigation."
* On 12/22/2021 the DQM "instructed the investigator resume the investigation as there did not appear to be any conflict with [the CMS SA] investigation."

There was no other documentation provided of investigation, identified opportunities for improvement or actions taken or planned to prevent another elopement.

The 12/13/2021 action described in the email to discontinue the hospital's internal investigation had not been discussed with the surveyor during the survey and was contradictory to CMS survey practice. It is the expectation that providers maintain continuous compliance with all requirements regardless of parallel investigations by other agencies, including the CMS SA.

2.k. In an email received on 12/29/2021 @ 1212 from the PD-JC he/she reported that that Patient 7 had been found in a coastal Oregon town on 12/27/2021, 25 days after he/she had eloped, and had been returned to OSH-Salem.

2.l. Findings related to Patient 7's elopement during a supervised off-grounds outing reflected failures on the part of the hospital that included:
* Failure to maintain situational awareness and conduct assessment related to the patient's behaviors that allowed him/her to orchestrate the last minute off-grounds outing change.
* Failure to adhere to P&Ps regarding pre-outing meetings that were to include discussion of rules and behavioral expectations.
* Failure to maintain situational awareness and conduct assessment related to the patient's concerns about time, rest room use and his/her continued creation of gaps and distance from the group.
* Failure by nursing and MHT staff to document accurate progress notes.
* Failure to actively investigate the elopement and to take immediate actions to prevent recurrence during an investigation.

As of 01/17/2022 no changes to practices had been made to prevent recurrence and protect patients during the investigation such as the temporary suspension of recreational off-grounds outings, or not approving changes within a specified time prior to an outing to ensure time for complete and appropriate assessment.

3.a. Multiple other incidents, and grievances, that reflected an unsafe EOC and actual and potential physical, mental or emotional harm for Patient 7 prior to his/her elopement included the following:

3.b. A "Patient Grievance" form noted as received on 07/06/2021 was signed and dated by Patient 7 on 07/04/2021. It reflected "I don't feel safe with [Patient 5] on the unit as the situation currently stands. Something significant should be done like a security constant or move [Patient 5] to a higher security unit."

There was no documentation of investigation of the reason the patient felt unsafe and what "situation" that involved Patient 5 he/she was referring to.

A "Patient Grievance Response" form dated 07/13/2021 reflected under "Response/Information," only: "The concerns expressed in this grievance have naturally resolved due to administration changes on the unit. The hospital staff continue to prioritize safety and encourage [Patient 7] to immediately let staff know when [he/she] feels unsafe - at any time." In response to the question on the form "Are you satisfied with the response?" the box next to "No" was checked and Patient 7 signed and dated the form on 07/13/2021.

It was not clear what "administration changes" referred to or why that would "naturally resolve" the concerns in the grievance. There were no other signatures on the form and although two staff members' names were on the form it was not clear if either of them was the author of the form or what their position/title/roles were at the hospital.

3.c. Incident documentation for Patient 7 reflected that on 08/14/2021 @ 1235 staff "found a pill on the floor against the wall in the west hall about 3 feet to the left of room M3534. [Staff] believe the pill belongs

Based on observations, interviews, review of incident and medical record documentation for 36 of 37 OSH-JC patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37), review of P&Ps, review of PERA documentation and review of other documentation it was determined that the hospital failed to fully develop and implement clear P&Ps that ensured each patient's right to be free from all forms of abuse and neglect.

Identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur.

The CMS Interpretive Guidelines for this requirement at CFR 482.13(c)(3) reflects "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Further, the CMS Interpretive Guidelines reflect those components necessary for effective abuse protection include, but are not limited to:
o Prevent.
o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1.a. The P&P titled "Patient Abuse or Mistreatment Allegation Reporting" dated as 05/05/2021 included the following:
* "'Abuse or mistreatment' means any act or absence of action toward a patient by staff inconsistent with prescribed treatment and care and falls within the definitions of abuse ..."
* "'Neglect, such as failure to provide the care, supervision or services necessary to maintain the physical and mental health of a patient that may result in physical harm or significant emotional harm to the patient ... the failure of staff to make a reasonable effort to protect a patient from abuse; or withholding of services necessary to maintain the health and well-being of a patient which leads to physical harm of the patient."
* "'Physical abuse ... Any physical injury by other than accidental means or that appears to be at variance with the explanation given for the injury ... Willful infliction of physical pain or injury ..."
* "'Sexual abuse or mistreatment' such as sexual harassment; sexual exploitation or inappropriate exposure to sexually explicit language or material; any sexual contact between staff and a patient; failure to discourage sexual advances by a patient; or any sexual contact that is achieved through force, trickery, threat or coercion ..."
* "'Verbal abuse or mistreatment' such as threat of significant physical or emotional harm to the patient through use of yelling, ridicule, harassment, coercion, threats, mental cruelty, inappropriate sexual comments, intimidation, cursing, foul language or other forms of communication which are derogatory or disrespectful of the patient; remarks intended to provoke a negative response by the patient ..."
* "...abuse or mistreatment conduct is prohibited at OSH and includes, but not limited to: abandonment ... physical harm to a patient caused by other than accidental means ... willful infliction of physical pain or injury ... neglect ... verbal abuse or mistreatment ... condoning abuse or mistreatment ..."
* "Abuse and mistreatment allegations will be investigated by the Office of Training, Investigation, and Safety (OTIS) (sic) All categories of prohibited conduct allegations will be examined as part of the OTIS investigation."
* "After a report of alleged abuse has been made, the following steps must be completed to enhance the investigation and protect patients: The Superintendent or their designee will implement protective measures as appropriate ...

1.b. The P&P titled "Incident Reporting" dated 03/27/2017 included the following:
* "[OSH HCP] must accurately report incidents in accordance with this policy. In response OSH must conduct thorough investigations, prepare reports showing the tracking and trending of data, and implement and monitor corrective or preventive actions."
* "Every HCP who witnesses a reportable incident as defined in this policy must promptly report the incident in the OSH incident reporting system when possible."
* "A reported incident which falls within established criteria will be investigated by the Critical Incident Review Panel as indicated in the committee charter."
* "Reportable incident" was defined as "any occurrence involving:
1. physical aggression on members or visitors, regardless of injury;
2. bodily injury to patients whether the injury is considered minor, moderate, or severe;
3. patient self-harm, including suicide attempt, with or without injury;
4. patient falls ...
5. sexual contact between patients or with a patient;
6. patient choking when attempting to swallow;
7. unanticipated patient death;
8. security problems and crime or suspicious events including, but not limited to: property loss or intentional damage, contraband or patient possession of prohibited items, substance abuse by a patient, and unauthorized leave or significant attempt of unauthorized leave;
9. environment of care issues including, but not limited to the presence of hazardous material, utility or systems failure, medical equipment failures, emergency preparedness issues and safety issues;
10. laboratory issues ...
11. medication errors not associated with a patient, including narcotic count variances or medication found outside the medication administration process."

Although the P&P included "Policy" and "Definitions" components, there were no procedure components in the document, including steps for staff to take in response to the incident beyond reporting in the incident reporting system. Further, there were no procedures for how investigations of incidents to prevent recurrence were to occur for those that did not fall "within established criteria" for "Critical Incident Review Panel" investigation and who was to conduct those.

1.c. In relation to response to contraband the P&P titled "Staff Response to Alleged Criminal Acts and Contraband" dated as 05/01/2015 reflected the following:
* "All [OSH] employees are responsible for protecting patient and staff by reporting and responding to alleged criminal acts and observations of contraband being introduced into the organization as directed in this policy."
* "Contraband" was defined as "any controlled substance, drug paraphernalia, unauthorized currency, or any other article which by statute, rule, order, or the state institution's policies, is prohibited from being in a patient's possession, and the use of which could endanger the safety or security of the institution."
* "The following must occur for the confiscation, control and disposition of contraband: All contraband which may be part of an illegal act must be retained in is existing condition and turned over to OSP or other investigating authority ... If immediate police response is expected, a weapon should be left alone in the secured crime scene ... All other items considered contraband must be turned over to the Security Department."
* A memo on OSH letterhead dated 11/17/2021 was attached to the P&P and referenced the P&P by title and number. It included P&P clarification that indicated that "Contraband is considered a criminal act when a person purposefully supplies contraband to a patient or when a patient knowingly makes, obtains, or possesses contraband as defined in OSH policy."

The P&P lacked information related to investigations that included, for example: How patients in the secure facility would have come to be in possession of such contraband items, what systems to prevent contraband items in the secure facility had failed and what actions would be taken to prevent recurrence.

A secure, psychiatric hospital or unit must be responsible to have systems in place that do not allow patients access to contraband, and unsafe and prohibited items for the protection of themselves and others. Allowing patients access to those items creates an unsafe EOC and is neglect.

1.d. In relation to response to sexual assault the P&P titled "Staff Response to Alleged Criminal Acts and Contraband" dated as 05/01/2015 included the following:
* "All [OSH] employees are responsible for protecting patient and staff by reporting and responding to alleged criminal acts and observations of contraband being introduced into the organization as directed in this policy."
* "Criminal acts or crimes" are as defined in the [ORS] and [OARs]."
* "Sexual assault" was defined as "any unwanted sexual contact."
* "If the report or allegation includes any information that patient abuse as occurred at OSH, an immediate report to the Superintendent and to the Office of Adult Abuse Prevention and Investigations is required ..."
* "An incident report must also be completed ..."
* "If the alleged victim, patient or staff prefers to file a police report independently and requests staff assistance, staff must provide the victim with the [OSP] phone number."
* "In the event an alleged criminal act is determined to have occurred, the following steps must be taken: Staff must contact the Security Department ... The Security Department must in turn report the incident to the appropriate law enforcement agency, fire department, or medical response personnel ... Staff must ensure that scenes related to alleged criminal acts are secured, and evidence is preserved and not destroyed ... The scene of the alleged criminal act must remain secured and undisturbed until released by OSP or the Superintendent ... Whenever practical, involved staff or patient should not be interviewed by anyone except a police agency representative ... Staff must make every reasonable effort to provide emotional support to the victim."

The P&P was not clear or complete. For example:
* It did not include provisions for protection of the patient who was assaulted and separation from the patient who was alleged to have committed the assault.
* It was not clear what was a "criminal act," how staff were to know that, and who would decide that.
* It did not include provisions related to the hospital's responsibility to immediately protect the patient, mitigate further incidents, conduct an investigation separate from any criminal investigation, identify whether hospital failures contributed to the incident, and develop and implement corrective actions to prevent recurrence.

1.e. The P&P titled "Sexual Activity Between Patients" dated as 03/27/2017 reflected the following:
* "Oregon State Hospital (OSH) has the responsibility to take reasonable steps to discourage sexual contact between patients and to direct appropriate follow-up actions if sexual contact or sexual assault occurs."
* "When a patient or [HCP] alleges that sexual contact between patients occurred, HCP must: 1. notify the patient's [psychiatric LIP] or the Physician Officer of the Day ... 2. submit an incident report for each suspected or confirmed sexual contact incident ... 3. notify the Infection Prevention and Employee Health Department ... 4. report the incident to the Security Department."
* "The interdisciplinary treatment team must review and address the sexual contact Incident ..."
* "HCP must follow OSH Policy and Procedure 8.019, "Staff Response to Alleged Criminal Acts and Contraband," when responding to an allegation of sexual assault.
* "HCP must provide education to patients and family members or legal representatives about this policy."
* "'Sexual assault' means an incident of sexual contact between patients where criminal activity is alleged to have occurred as defined by Oregon Criminal Code, including, but not limited to, non-consensual sexual intercourse or penetration, and those acts involving an alleged victim who lacks capacity to consent to a sexual act."
* "'Sexual contact' means any touching of the sexual or other intimate parts of a person or causing such person to touch the sexual or other intimate parts of the actor for the purpose of arousing or gratifying the sexual desire of either party."

There was no other information or direction in the P&P related to response and investigation by staff.

1.f. A document titled "Critical Incident Investigation Operating Procedure ... Incident Screening" dated as 05/18/2021 reflected:
* "Objective ... Establish a standardized process for incident screening by Critical
Incident Investigators for CIR leadership."

* The following were defined:
- "Abuse of Illegal Substance ...
- Atypical Seclusion or Restraint Event ...
- Choking with Injury or Medical Intervention ...
- Illegal Item Possession ... Items in this category include any item that possession alone is prosecutable under Oregon Statute and which pose a risk to the safety and security of the OSH facilities, patients, and staff. This category does not include nuisance contraband, small amounts of tobacco or items that have been deemed by the report writer as having a potential of creating risk without an established intent by the possessor.
- Medication Diversion: The intentional and/or planned concealing, smuggling, transferring or sale of prescribed medications for inappropriate use by the prescribed user or others.
- Missed Code Blue ...
- Patient to Patient or Patient to Staff Assault with Serious Injury to Patient or Staff: Any assault by a patient toward another patient or an OSH staff member where an injury is sustained as a direct result of the assault and that injury is serious enough in nature to require specialized medical procedures above and beyond basic first aid ...
- Reasonable Suspicion ...
- Serious Crime: Any crime that would be classified as a felony under Oregon Statute or any person-to-person crime classified under Oregon Statue as a Class A Misdemeanor. This category does not include alleged criminal acts from a non-patient toward a non-patient.
- Serious Patient Injury ...
- Serious Self-Harm ...
- Serious Suicide Attempt ...
- Serious System Failure ....
- Sexual Contact ... The touching of the sexual or other intimate parts of a person or causing such person to touch the sexual or other intimate parts of the actor for the purpose of arousing or gratifying the sexual desire of either party.
- Unattended/ Wandering Patient: An event of a patient within the secured perimeter of OSH, which requires the patient to be under supervision and no supervision was present.
- Unauthorized Leave (UL) or Significant Attempt: An event of a patient making a significant and intentional attempt toward, or successful attempt of, leaving the custody of OSH prior to discharge ... on grounds ... off grounds ...
- Unexpected Patient Death ..."

The following was reflected in the P&P:
* "OSH Critical Incident Investigators are tasked with the screening of critical incidents listed in the Critical Incident Review (CIR) Critical Incident Grid for Level 2 Incidents (See attachment A). In addition to the Level 2 Incidents on attachment A of this procedure, OSH Critical Incident Investigators are tasked with the screening of incidents involving; unexpected patient deaths, unattended/wandering patients, sexual contact, missed code blue events, and medication diversion. Investigators will present screenings to OSH CIR Leadership for decision making purposes and investigation assignments. CIR leadership will determine follow-up assignments to include, but not limited to critical incident investigations, referral to hospital disciplines, the tracking and trending of data, or additional investigator assignments such a document reviews, video pulls, or video reviews. CIR leadership may also decline to accept the screening on the grounds the screened incident does not rise to the level of a critical incident or close the event without further assignments if satisfied with the information already known."

* "For screening purposes sexual contact incidents are screened based on physical sexual contact without the need to identify intent during the screening phase. In the event of reported sexual contact occurs involving patients only; the investigator will use available documentation to determine if the act was consensual. Any alleged sexual contact by staff toward patients qualifies as a sexual contact event. In the event of consensual sexual contact between patients, critical incident investigators are to verify the ability of the patient to give consent. If a patient has a guardian over him/her, the patient is not able to legally provide consent. If consent is able to be determined, and it is clear system failures did not contribute to the sexual contact and that direct care clinical staff are aware of the sexual contact, the incident may be closed by the critical incident investigator with documentation of the above on the critical incident screening document. In the event of a reported sexual contact by brief, potentially accidental contact by a patient toward a staff member where there is no complaint the contact was intentional, the investigator may screen the incident out."

* "OSH Critical Incident Investigators will screen Incident Reports, Communication Log Entries, Nursing Reports and Medical reports to identify potential reportable events. Patient records, unit management staff, and OSH security video (when authorized) may be used to help the investigator in determining if there is reasonable suspicion an event falls within reporting criteria for CIR Leadership referral. The purpose of the screening process is to identify if there is reasonable suspicion an event meets the definition of one or more of the categories listed as a Level II incident on the attached CIR Critical Incident Grid."

1.g. "Attachment A", a one-page document titled "CIRP Critical Incident Grid" that was referenced in the P&P in 1.f. above was dated 05/18/2021 and reflected the following:

* For "Minor/Significant or 'Near Miss'" incidents the "Level of Review" was "Leadership review and follow-up as necessary" and the "Turnaround" time was "2 Business Days." Those incidents were listed as:
"Non-injury patient altercations
Choking without injury
Property loss/theft or intentional damage
Contraband
Minor patient injury
Substance abuse by patient"

* For "Serious/Critical" incidents the "Level of Review" was "OSH Investigations conduct full Critical Incident Review" and the "Turnaround" time was "10 Business Days." Those incidents were listed as:
"Illegal item possession
Abuse of illegal substance
Atypical seclusion or restraint event
Choking with Medical Intervention
Patient-patient or patient-staff assault with serious injury to patient or staff
Serious self-harm
Serious suicide attempt
Serious patient injury
UL or significant attempt
Serious crime
Serious system failure"

* For "Sentinel" incidents the "Level of Review" was "Superintendent or Designee initiates full interdisciplinary review" and the "Turnaround" time was "As Directed." Those incidents were listed as:
"The Joint Commission Sentinel Event"

On the grid it was unclear how "Minor/Significant" and "Serious/Critical" were defined and there was no information that described the "Leadership review and follow-up as necessary" and "full Critical Incident Review." Further the types of incidents listed on the "Grid" did not clearly align with those identified in other P&Ps described in this finding.

In addition, for the "Minor/Significant or 'Near Miss'" incidents the response was reflected as "Leadership review and follow-up as necessary." It was not clear what the leadership review and follow-up consisted of and did not provide assurance that those incidents that also reflected potential patient neglect would be investigated to identify corrective actions to prevent recurrence.

1.h. A document titled "Critical Incident Investigation Operating Procedure ... Scope of Investigations" dated as 05/18/2021 reflected:
* "Critical Incident Investigations are limited in scope to the identification of system failures."
* "Critical Incident Review (CIR)" was defined as "a formal process in the review of suspected and identified critical incidents directly impacting the operations of the Oregon State Hospital and/or the clients it serves to identify any necessary improvements in an attempt to prevent similar events in the future."
* "Personnel Issues" was defined as "those events where policy or procedures are in place but not adhered to by an individual."
* "During the course of a system investigation the Investigator may use, but is not limited to, available patient records, hospital documentation, written policies and procedures, video ... witness and subject interviews, and outside investigation documentation to aid in the identification of system failures."
* "OSH Investigators are not charged with investigating personnel issues that may have contributed to a critical incident. In the event a critical incident was the result of personnel issues the Investigator is to provide notification to the Director of Quality Management about describing how the critical incident did not result from a system failure and recommend the closure of the investigation. The request for case closure, and authorization to close the case, will be placed in the electronic case file."
* "It is the charge of Critical Incident Investigator to contact the responsible program director during an investigation and notify them of critical system failures when the failure has a direct impact on life or safety of any person and immediate attention could prevent future failures. The investigator will document the communication of such reports in the investigation report along with any action that have been taken to prevent future failures."

1.i. The P&P titled "Sentinel Events and Root Cause Analyses" dated 05/11/2016 included the following:
* "OSH will review each adverse patient event which involves a patient committed to OSH and which meets criteria for a Sentinel Event ...
* "Any time a Sentinel Event occurs, or when otherwise directed by the Superintendent for serious incidents that do not meet the definition of a Sentinel Event, OSH must complete a thorough and credible [RCA], implement improvements to reduce risk, and monitor the effectiveness of the improvements as part of its ongoing performance improvement efforts."
* "'Adverse patient event' for the purposes of this policy means an event where a patient may be injured including, but not limited to:
1. an unanticipated death ...
2. a suicide of any patient ...
3. an elopement (unauthorized leave) resulting in a related death (suicide or homicide), or major loss of function or severe temporary harm to the patient;
4. a fall resulting in death or major permanent loss of function as result of the injuries sustained in the fall;
5. an abduction;
6. a rape, assault, or homicide that occurs while a patient is committed to OSH; or
7. an identified case of unanticipated death or major permanent loss of function associated with a health care-associated infection, assault, homicide, or other crime."
* "'Sentinel Event' means an unexpected occurrence involving death, permanent harm, severe temporary harm, or serious risk thereof. The phrase 'or the risk thereof' includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome."
* "The Superintendent must determine the action to be taken in response to an adverse patient event, including whether a RCA is required ... A RCA assigned by the Superintendent must be completed within 45 calendar days ... At the completion of a RCA, an action plan must be generated that identifies strategies to reduce the risk of similar events occurring in the future ..."

The P&P contained no information related to immediate mitigation strategies to prevent recurrence and protect patients during the duration of the RCA process and the implementation of corrective actions which could take up to 45 days.

2.a. During interview on 12/13/2021 at 1710 leadership, clinical and program staff provided the following information:
* Incidents were generally entered into a hospital-wide, electronic incident reporting system.
* Incidents involving alleged staff to patient abuse were entered into a separate electronic system and were not included in the incident reporting system.
* All incident reporting activity was managed by staff at the OSH - Salem campus and any investigations determined to be needed were conducted by OQMIs, whose offices were located at the Salem campus.

2.b. During interview with leadership, quality, clinical and program staff on 12/14/2021 at 1550 the DQM provided the following information:
* Every day OQMIs review the incident reports submitted electronically, they review other electronic communication systems, and "If they see something that meets criteria" they bring to a weekly OQM meeting for review to determine what follow-up would be indicated.
* OQM investigations were conducted for sentinel events, and for critical incidents that met criteria.

2.c. In response to requests for a log of hospital patient incident/events at the OSH-JC campus from which a sample could be selected for review of incident/event investigations and follow-up, on 12/14/2021 and 12/15/2021 OSH staff provided multiple log iterations that upon review were determined not to be complete or accurate. For example: The log included the non-hospital, separately licensed SRTF facility incidents; The log erroneously identified dates and types of incidents for the wrong patients; The log did not specify the type or nature of incident for many entries.

2.d. During interview with leadership, quality, clinical and program staff on 12/15/2021 beginning @ 1530, the DQM and OQMI provided the following information about incident logs and investigations:
* The incident logs provided to the surveyor in response to the request on the survey needs list did not include all incidents at OSH-JC campus. There were entries on the log for which the campus/location had not been identified and those were not included in the log provided.
* "Any incident report that doesn't have a location will not be on the [incident log]. This is a fault of the database."
* If the surveyor wanted a log of all incidents at OSH-JC, staff would need to run a log of all incidents on both the OSH-Salem and OSH-JC campus.
* The incident reporting "database was built before OSH-JC was built" and therefore didn't allow for entries of accurate patient locations, including that it still referenced an OSH-Portland campus that was closed in March of 2015.
* All incident reports for OSH-JC and OSH-Salem were electronically reviewed daily by OQM staff who work on the OSH-Salem campus and that "critical incidents" of sexual contact, wandering, and injuries that require more than first aid are "pulled" for investigation by the OQM staff who work on the OSH-Salem campus.
*OQM staff did not investigate or follow-up on incidents that did not meet the criteria to be pulled for investigation.

2.e. During further interview with leadership, quality, clinical and program staff on 12/16/20201 beginning @ approximately 1000 the DQM and MD&A provided the following information:
* They confirmed that the organization maintained an incident log for OSH-JC that was combined with the incident log for OSH-Salem.
* The log was also combined with the non-hospital, separately licensed SRTF facility that was on the same campus and in the same building as the hospital.
* The log "doesn't capture every incident."
* It was known that the "data system doesn't meet the needs."
* In relation to the inaccurate logs provided to the surveyor earlier as requested on the survey needs list, they decided to filter out what they thought was wanted and did not confirm with the surveyor.
* They confirmed that the incident log did not ensure an accurate accounting of the incidents/events that occurred at OSH-JC.
* They electronically demonstrated the complete electronic version of the full log that was observed to consist of approximately 166 columns that aligned with the rows for each incident entered. When a sample was printed, the log consisted of 14 letter sized pieces of paper in landscape orientation taped together.

3. Review of the complete electronic version of the final incident logs provided on 12/16/2021 revealed the following:
* The log for the month of June 2021 reflected there were 83 incidents entered after staff "filtered" out OSH-Salem campus and non-hospital SRTF incidents. Of those 83 incidents there were 37 incident entries identified for hospital patients at OSH-JC and 44 entries where the location/campus of the incident was blank and not specified for either OSH-JC or OSH-Salem.
* Similarly, on the log for July 2021 there were 70 incidents of which 35 were for hospital patients at OSH-JC and 35 entries did not specify the incident location/campus.
* On the log for August 2021 there were 65 incidents of which 32 were for hospital patients at OSH-JC and 33 entries did not specify the incident location/campus.
* On the log for September 2021 there were 54 incidents of which 28 were for hospital patients at OSH-JC and 24 entries did not specify the incident location/campus.
* On the log for October 2021 there were 89 incidents of which 50 were for hospital patients at OSH-JC and 37 entries did not specify the incident location/campus.
* On the log for November 2021 there were 105 incidents of which 46 were for hospital patients at OSH-JC and 56 entries did not specify the incident location/campus.

There was a lack of assurance that the last version of the logs provided as described in this finding completely and accurately identified all incidents/events for tracking and investigation.

4. Refer to the incident/event findings cited under Tag A144, CFR 482.13(c)(2), CoP Patient's Rights - Standard: Right to safe care. Those findings reflect the hospital's failure to ensure investigations of incidents/events that reflected potential neglect were clear, complete, and accurate to prevent recurrence for those patients who experienced actual and potential harm, and for other patients.

Based on observations, interviews, review of incident and medical record documentation for 36 of 37 OSH-JC patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37), review of P&Ps, review of PERA documentation and review of other documentation it was determined that the hospital failed to ensure that the QAPI program was effective to ensure the provision of safe and appropriate care to patients in the hospital.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A286 under CFR 482.21(a), (c)(2), (e)(3) - Standard: Patient Safety.

2. Refer to the findings cited at Tag A115 under CFR 482.13 - CoP: Patient's Rights.

Based on observations, interviews, review of incident and medical record documentation for 36 of 37 OSH-JC patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37), review of P&Ps, review of PERA documentation and review of other documentation it was determined that the hospital failed to ensure that incidents and adverse patient events were clearly identified, tracked, investigated and analyzed. Further, the hospital failed to plan and implement corrective actions to prevent recurrence of those, to promote learning throughout the hospital, and to establish clear expectations for patient safety.

Findings include:

1. Refer to the findings cited at Tags A144 and A145 under CFR 482.13(c) - Standard: Privacy and Safety.

2.a. Review of QAPI documentation titled "OSH Performance System Quarterly Performance Review" dated 11/02/2021 revealed that data for 12 measures were documented for the period of the second quarter of 2020 through the third quarter of 2021 for "Junction City" and were related to the following:
* "Manual Restraints"
* "Mechanical Restraints"
* "Seclusion"
* "Patient to Patient Aggression"
* "Falls"
* "Patient Treatment Participation"

Graph data for those measures was described as for "Junction City" and did not differentiate between the 75-bed hospital on the OSH-JC campus and the separately licensed non-hospital SRTF facility on the same campus and in the same building as the hospital.

2.b. Data for other measures included on the "Quarterly Performance Review" that were documented for the period of the second quarter of 2020 through the third quarter of 2021 for "Oregon State Hospital" included the following:
* "Staff Training"
* "Informed Consent Duration"
* "Fire Drills"
* "Monthly Safety Checklist"
* "Admission Package Completion"
* "Med variance"

Data for those measures was described as for "Oregon State Hospital" and did not differentiate between the seperately licensed 75-bed hospital on the OSH-JC campus and the OSH-Salem campus.

3. Other QAPI data and documentation reviewed was not clear or accurate. For example:

* Data on a "Medication Variance Trends Report" for the numbers of types of errors and the percentages of those types of errors for the period of November 2020 through October 2021 did not differentiate between the hospital on the OSH-JC campus and the hospital on the OSH-Salem campus.

* A "Fall Trends Report ... High Risk Patient Fall Events ... Non-High Risk Patient Fall Events ..." for October 2021 reflected that there were "0.00" falls on each of the three OSH-JC hospital units. However, review of the October incident/event log reflected that there were at least three patient falls on those units that occurred on 10/12/2021, 10/25/2021 and 10/31/2021.

* Data for "Percent of All Fall Events with Reported Moderate or Severe Injury by Month" for the period of November 2019 through October 2021 did not differentiate between the hospital on the OSH-JC campus and the hospital on the OSH-Salem campus.

* Data on the "Utilization Trends Report" for the period of November 2019 through October 2021 did not differentiate between the hospital on the OSH-JC campus and the hospital on the OSH-Salem campus.

4. Review of the "Oregon State Hospital Performance Management" plan for 2021 revealed no provisions to distinguish QAPI activity and data between the two separately licensed hospital at OSH-Salem campus and OSH-JC campus.

5. During review and interview with leadership, quality, clinical and program staff on 01/13/2022 beginning @ 0950 staff confirmed that data identified in the findings for this Tag was reflective of both hospitals on the OSH-Salem campus and the OSH-JC campus combined, or of both the licensed hospital units and the non-hospital licensed SRTF units combined.

Based on observations, interviews, review of incident and medical record documentation for 36 of 37 OSH-JC patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37), review of P&Ps, review of PERA documentation and review of other documentation it was determined that the hospital failed to ensure that nursing services were organized and managed to ensure the provision of safe and appropriate care to each patient in the hospital.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A395 under CFR 482.23(b)(3) - Standard: RN Supervision of Nursing Care.

2. Refer to the findings cited at Tag A115 under CFR 482.13 - CoP: Patient's Rights.

Based on observations, interviews, review of incident and medical record documentation for 36 of 37 OSH-JC patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37), review of P&Ps, review of PERA documentation and review of other documentation it was determined that the RNs failed to supervise the nursing care for each patient to ensure the provision of safe and appropriate care.

Findings include:

1. Refer to the findings cited at Tags A144 and A145 under CFR 482.13(c) - Standard: Privacy and Safety

Based on review of medical records for 1 of 1 patient (Patient 7) it was determined that the hospital failed to ensure that medical record entries were promptly written and filed in patients' record to ensure they were accessible to other care providers when needed for patient assessment, decision-making and planning the patient's care.

Findings include:

1. The closed medical record for Patient 7 was reviewed. The patient's record was closed as result of having successfully eloped from the facility on 12/02/2021. The medical record included the following documents and entries written between two days to 33 days after the care and services had been provided. None of the documents and entries below were identified as late entries.

* A Group Note with service date of 11/04/2021 at 0900 was written and signed on 12/07/2021 at 1151, 33 days after the group encounter.
* A Group Note with service date of 11/21/2021 at an unspecified time was written and signed on 12/04/2021 at 1315.
* A Group Note with service date of 11/23/2021 at an unspecified time was written and signed on 12/02/2021 at 1330.
* A Group Note with service date of 11/24/2021 at an unspecified time was written and signed on 12/02/2021 at 1241.
* A Group Note with service date of 11/28/2021 at an unspecified time was written and signed on 12/04/2021 at 1712.
* A Group Note with service date of 11/28/2021 at an unspecified time was written and signed on 12/05/2021 at 1309.
* A Group Note with service date of 11/29/2021 at 1400 was written and signed on 12/02/2021 at 1106.
* A Group Note with service date of 11/30/2021 at 1300 was written and signed on 12/02/2021 at 0850.
* A Group Note with service date of 11/30/2021 at 1400 was written and signed on 12/06/2021 at 1103.
* A Group Note with service date of 11/30/2021 at an unspecified time was written and signed on 12/02/2021 at 1332.
* A Group Note with service date of 11/30/2021 at an unspecified time was written and signed on 12/06/2021 at 1035.
* A General Note for "November 2021" was written and signed on 12/10/2021 at 1156.
* A Group Note with service date of 12/01/2021 at 1300 was written and signed on 12/03/2021 at 1513.
* A Group Note with service date of 12/02/2021 at an unspecified time was written and signed on 12/07/2021 at 0823.

Based on observations, interviews, review of incident and medical record documentation for 36 of 37 OSH-JC patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37), review of P&Ps, review of PERA documentation and review of other documentation it was determined that the hospital failed to develop and maintain the EOC in a manner that ensured the provision of safe and appropriate care to patients in the hospital.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A701 under CFR 482.41(a) - Standard: Maintenance of Physical Plant.

2. Refer to the findings cited at Tag A115 under CFR 482.13 - CoP: Patient's Rights.

Based on observations, interviews, review of incident and medical record documentation for 36 of 37 OSH-JC patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37), review of P&Ps, review of PERA documentation and review of other documentation it was determined that the hospital failed to maintain the EOC, and to identify and mitigate hazards and risks, to ensure the safety and well-being of patients in the hospital.

Findings include:

1. Refer to the findings cited at Tags A144 and A145 under CFR 482.13(c) - Standard: Privacy and Safety.

2.a. The "Annual Environmental & Suicide Risk Assessment (ESRA) - 2020-21" dated 02/19/2021 was reviewed. It reflected that "The following areas and units were assessed, and the established Room Risk Levels were verified based on the accessibility of the room by patients and the items present in the room ... Treatment Malls ... [OSH-JC Mountain] ... [OSH-JC Mountain Units 1-3] ... Outdoor Quads/Areas ... [OSH-JC Mountain] ... Patient areas listed above were assessed for physical safety and ligature risks for patients. While this assessment is accomplished annually, OSH currently has several processes in place for continued assessment of physical safety and ligature risks to patients ... During this assessment each room was assessed for current use and if appropriate room risk level currently identified matches the current use, and if any actions to mitigate risk to patients were required ... Dining ... [OSH-JC] ..."

Although the assessment stated that "items present in the room" were included in the assessment, there was no indication that all items in patient rooms and in the EOC, including, but not limited to, patients' personal belongings, food items, linens, room signs, art hanging on patient room doors, utensils in the dining room, unsafe items that patients were allowed to check-out and use without supervision, and other items identified in the findings in this report had been included in the assessment to ensure the safety of all patients.

2.b. An untitled spreadsheet table provided with the risk assessment listed EOC and safety related requests made by staff beginning 04/27/2021 and through 12/06/2021. There were no entries related to assessment of items in the EOC including, but not limited to, personal belongings in patient rooms, food, linens, room signs, paper and art covering patient room doors, utensils in the dining room and other items in the EOC identified in the findings in this Tag.

3. Twenty-six "Safety Monthly Inspection Checklist" forms completed for distinct units and treatment areas beginning July 2021 and through November 2021 were reviewed.

Eighteen of the 26 forms had a "Revision" date of 03/01/2019 printed at the bottom of the form while eight of the forms had a "Revision" date of 04/01/2021. It was unclear whether revisions to the form on 04/01/2021 had impact on the checklist items.

Verbiage on the two-page forms reflected "Monthly safety inspections of patient care units ... are required to ensure a safe environment for staff, patients and visitors ..." The forms did not include spaces or sections related to items in the EOC identified in the findings in this Tag.

Further, documentation did not reflect timely follow-up of all items noted as "Non-Compliant." For example: Checklists for OSH-JC Mountain 1 patient unit reflected that the "Fire Drill Coordinator Kit accessible & complete" was "Non-Compliant" for the monthly inspections conducted on 07/03/2021, 08/01/2021, 09/04/2021 and 11/07/2021.

4. During tour of the hospital with the PD-JC on 12/15/2021 beginning @ 1440 observations on the Mountain 2 unit and in common areas included the following:
* Hallway ceiling tiles on Mountain 2 were observed to be warped and did not lay flush to the ceiling tile frame.
* Ceiling tiles in the hallway outside of the patient dining room were observed to have water stains.

Based on observations, interviews, review of incident and medical record documentation for 36 of 37 OSH-JC patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 and 37), review of P&Ps and review of other documentation it was determined that the hospital failed to ensure the infection prevention and control program included surveillance, prevention and control to ensure the safety and well-being of patients.

Findings include:

1. Refer to the applicable findings cited at Tags A144 and A145 under CFR 482.13(c) - Standard: Privacy and Safety.

2.a. During tour of the hospital with the PD-JC on 12/13/2021 beginning @ approximately 1800 observations on the Mountain 1 unit included the following:
* Multiple patient rooms were observed from the hallway to have an inordinate and excessive number of items strewn on beds, floors and surfaces in a cluttered and disorganized manner that rendered the floor and surfaces in those rooms not readily cleanable.
* A household type plastic laundry basket with large openings on all four sides and with no cover was placed on the floor underneath a sink in the hallway. The basket contained unfolded and crumpled towels and linens as if they had been used.

2.b. During tour of the hospital with the PD-JC on 12/15/2021 beginning @ 1440 observations on the Mountain 2 and Mountain 3 units, and in common areas included the following:
* Multiple patient rooms were observed from the hallway to have an inordinate and excessive number of items strewn on beds, floors and surfaces in a cluttered and disorganized manner that rendered the floor and surfaces in those rooms not readily cleanable.
* A brown paper bag was placed on the floor in the hallway under the Mountain 2 medication room window and overflowed with garbage. Items observed on the top of the contents of the bag included multiple used face masks, used drinking cups and an empty Kleenex box.
* Purell Hand Sanitizer dispenser affixed to hallway wall, with "M3-39" handwritten on it, did not contain any hand sanitizer.
* Purell Hand Sanitizer dispenser affixed to hallway wall, with "LC-86" handwritten on it, did not contain any hand sanitizer.

Based on interviews and review of incident and medical record documentation for 5 of 5 patients whose treatment plan was reviewed (Patients 7, 12, 16, 17 and 20) it was determined that the hospital failed to ensure that an individualized and comprehensive treatment plan was developed and followed for each patient.

Findings include:

1. Refer to the treatment plan findings for Patients 7, 12, 16, 17, 20 cited at Tag A144 under CFR 482.13(c) - Standard: Privacy and Safety.