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Based on policy review, medical record review, hospital document review, video footage review and interview, the hospital failed to thoroughly investigate an allegation of neglect for 1 of 3 (Patient #1) sampled patients.

The finding included:

1. Review of the hospital's "Alleged or Suspected Abuse (Child and/or Adult)" policy revealed, "...Types of Abuse...Neglect includes both physical and emotional types of omissions. Neglect includes...failure to provide supervision...`

2. Medical record review for Patient #1 revealed an admission date of 10/4/18 with diagnoses which included Schizophrenia, Alcohol Use Disorder, Cannabis Use Disorder, Homicidal Ideation and Suicidal Ideation.

A Clinical Note dated 10/5/18 revealed, "...I [Physician #1] responded to a code blue overhead. on arrival, active compressions being perform ACLS [advanced cardiac life support] per protocol initiated...initial rhythm was asystole...there was no ROSC [return of spontaneous circulation] achieved. i pronounced patient expired at 0808 [8:08 AM]..."

The Discharge Summary dated 10/17/18 revealed, "...Patient was admitted to [Psychiatric Unit] due to worsening of mood and polysubstance abuse. Patient has a history of benzodiazepine abuse and was placed on the CNS [central nervous system] protocol by the tele psych on the morning of October 4th. He received 4 doses of phenobarbital after which the CNS protocol was discontinued due to sedation as per protocol. Patient was seen by attending physician on noon of October 4th and it was observed that patient was sedated due to phenobarbital load at which time the CNS protocol was officially discontinued. Later that evening the patient was observed on the unit interacting with peers and staff appropriately...The following morning nursing staff discovered the patient unresponsive at 7:50 AM. Rapid response team was called and code blue protocol was observed...Patient was pronounced dead by [Physician #1] at 8:08 a.m. Afterwards multiple peers on the same unit came forward informing staff that the deceased had offered them Xanax the previous night. Staff search[ed] the patient's room [after Patient #1 pronounced dead] and found two Xanax [benzodiazepine] tabs [tablets] as well as two Subutex [narcotic] tabs in the patient's belongings. It is unclear when and how the patient gained access to the contraban[d] medications. It was observed after the fact that the patient's issues [shoes] contained hidden compartments ..."

3. Review of the "Executive Summary" (summary of debriefing meeting held by the hospital after Patient #1's death, not dated) revealed, "...10/4/18 ...06:32 [6:32 AM]...Belonging assessment reviewed on tape and noted to be thorough...10/5/18...8:10 [AM]...During clean up loose pills were found in the room. (2 X [times] 2gm [gram, pills identified by pharmacy as 2 milligrams rather than 2 grams] Xanax, 1 subutex) In addition, he had a hole in the inside of his shoe under the insole that he could have concealed drugs on admission..."

Review of the video footage of the belonging assessment for Patient #1 revealed the footage was partially blocked by two video screens, and the camera was approximately 30 feet away from the actual belonging assessment. The video footage revealed Mental Health Associate (MHA) #2 wrote down the personal items on a piece of paper, but there was no documentation of personal belongings in Patient #1's medical record. The personal belongings search was conducted by one staff member (hospital policy required either staff and patient or two staff members). The hidden compartment in Patient #1's shoe was not found during the personal belongings search.

The hospital concluded the belonging assessment was thorough, but the assessment was not performed according to hospital policy and failed to identify the hidden compartment in Patient #1's shoes.

4. Review of the "Executive Summary" revealed the hospital reviewed the video footage and determined the nurse/technician (tech) did not actually go into the room on several occasions after 5:00 AM on 10/5/18.

The video footage was not kept, and there was no documentation when staff entered the room after 5:00 AM.

During an interview in the Ethics and Compliance Office on 12/10/18 at 2:00 PM, the Director of Nursing for Senior Services was asked when did a staff member last enter Patient #1's room before he was found unresponsive and pulseless by another patient on 10/5/18 at 7:40 AM, she stated the tech entered the room on 10/5/18 at 7:15 AM. The Director of Nursing for Senior Services stated she determined this when she and the Nurse Manager of the Adult Treatment Program interviewed Contract MHA #1. The Director of Nursing for Senior Services confirmed there was no documentation of the interview, no documentation of the time when Contract MHA #1 last entered the room, and the video footage had not been kept.

During a phone interview on 11/27/18 at 1:18 PM, Contract MHA #1 stated she could not remember the time she last went into Patient #1's room on 10/5/18.

5. The "Executive Summary" revealed, " ...Patient was found on stomach, pulseless and was cold, rigid, mottled extremities and red faced ..." There was no documentation by the hospital how this information was provided or where it came from.

During an interview in the Ethics and Compliance Office on 11/28/18 at 9:00 AM, the Vice President of Quality stated she did not know who made this statement or where the information came from.

During an interview in the Ethics and Compliance Office on 11/27/18 at 10:00 AM, Registered Nurse (RN) #5 (first staff to witness unresponsive patient), stated he could not recall the condition of the body when he entered the room on 10/5/18.

During an interview in the Ethics and Compliance Office on 11/28/18 at 10:56 AM, Physician #2 stated the staff had already begun chest compressions when he entered Patient #1's room on the morning of 10/5/18. Physician #2 stated he was "sort of QBing (quarterbacking) and making sure the team had all the necessary equipment." When asked if he ever touched the body, Physician #2 stated he checked for a pulse and a blood pressure. Physician #2 stated he was not struck that the body was cold, but the body became cold as the code went on. The documentation of the code revealed the code lasted 11 minutes (from 7:55 AM to 8:06 AM).

During an interview in the Ethics and Compliance Office on 12/10/18 at 11:00 AM, when asked about the statement that the body was found cold, rigid, mottled extremities and red faced, the Vice President of Quality stated the statement was inaccurate. When asked when did they (hospital staff) determine the statement to be false, the Vice President of Quality stated after this surveyor's interviews with the staff. The hospital was unable to provide any documentation or evidence about the condition of the body when it was found. The hospital dismissed its own findings after the surveyor conducted an investigation into the condition of the body.

6. The "Executive Summary" revealed Contract MHA #1, who documented she rounded on Patient #1 on 10/5/18 from 5:00 AM to 7:00 AM, was terminated after review of the video footage during that timeframe and interview with Contract MHA #1. According to the summary, the video footage revealed the tech did not round each time she documented but was at the front desk. The hospital was unable to provide documentation of the interview with Contract MHA #1 or the video footage.

During an interview in the Ethics and Compliance Office on 12/10/18 at 2:00 PM, the Director of Nursing for Senior Services stated she and the Nurse Manager of the Adult Treatment Program interviewed Contract MHA #1 and reviewed the video footage. The Director of Nursing for Senior Services confirmed there was no documentation of the interview, and the video footage was not available. When asked what time was the last time Contract MHA #1 was in Patient #1's room on 10/5/18, the Director of Nursing for Senior Services stated 7:15 AM. There was no documentation provided by the hospital that indicated when Contract MHA #1 did or did not enter Patient #1's room on 10/5/18 from 5:00 AM to 7:00 AM. The hospital added to the intake information on 1/11/19 that Contract MHA #1 did not enter the room during this time on 4 separate occasions. This information was not provided to the surveyor during the investigation, and there was no documentation provided which indicated Contract MHA #1 did not enter Patient #1's room 4 times.

7. During an interview in the Ethics and Compliance Office on 11/28/18 at 9:00 AM, the Vice President of Quality presented a document entitled "Executive Summary." The Vice President of Quality stated this was the hospital's investigation for the incident of Patient #1's death and was a summary of the debriefing meeting which the hospital used to conduct the Serious Event Analysis. The Vice President of Quality confirmed there were no documented interviews or documented personnel in the summary presented to the state surveyor.

During an interview in the Ethics and Compliance Office on 11/29/18 at 7:45 AM, the Manager of Quality Improvement stated the hospital conducted a Serious Event Analysis to determine what happened during the incident with Patient #1. The Manager of Quality Improvement stated the hospital staff who conducted the meeting did not write down what anyone said or who said what. The Manager of Quality Improvement stated several people might have been talking at one time during the debriefing, and no one documented who was there or what each person said. The Manager of Quality Improvement stated they did not interview anyone separately to investigate the incident.

Based on personnel file review and interview, the hospital failed to ensure staff was adequately educated and trained for 5 of 5 (Registered Nurse (RN) #1, 2, 3, 4 and 5) sampled registered nurses and 4 of 4 (Mental Health Associate (MHA) #1, 2, 3 and 4) sampled mental health associates.

The findings included:

1. Review of the facility's "Competency Assessment" policy revealed, "...SCOPE...Applies to all employees...PURPOSE...To define mechanisms used to assess and maintain competency of employees as required for the position and by regulatory agencies...DEFINITIONS...Competency: A competency refers to the knowledge, skills, abilities, and behaviors required to perform assigned duties and responsibilities safely and aptly...Competency Assessment: Competency assessment is conducted initially as a part of orientation. Ongoing competency assessment occurs at a minimum annually...RESPONSIBILITIES...Management is responsible for ensuring a mechanism exists to identify area-specific competency requirements; creating an environment that promotes timely competency assessment and ongoing growth and development; providing education to employees on the competency process; monitoring employee progress; and participating in evaluation of the competency process...The initial competency assessment will include, at a minimum, the validation of core competencies specific to the role and responsibility of each position or position type...Ongoing competency assessment is an essential process for verifying an individual's ability to perform their assigned job role by evaluating the ability to apply knowledge, perform skills and demonstrate critical thinking..."

2. Review of the personnel file for RN #1 revealed a date of hire of 10/5/15. There was no documentation of education, training or competencies provided by the hospital.

Review of the personnel file for RN #2 revealed a date of hire of May 2017. There was no documentation of education, training or competencies provided by the hospital.

Review of the personnel file for RN #3 revealed a date of hire of 9/1/95. There was no documentation of education, training or competencies provided by the hospital.

Review of the personnel file for RN #4 revealed a date of hire of 7/19/10. There was no documentation of education, training or competencies provided by the hospital since her orientation in 2010.

Review of the personnel file for RN #5 revealed there was no documentation of education, training or competencies provided by the hospital.

3. Review of the personnel file for MHA #1 revealed there was no documentation of education, training or competencies provided by the hospital.

Review of the personnel file for MHA #2 revealed a date of hire of 11/16/15. There was no documentation of education, training or competencies provided by the hospital.

Review of the personnel file for MHA #3 revealed a date of hire of 2/27/04. There was no documentation of education, training or competencies provided by the hospital.

Review of the personnel file for MHA #4 revealed there was no documentation of education, training or competencies provided by the hospital.

4. During an interview in the Ethics and Compliance Office on 11/27/18 at 12:44 PM, when asked about annual training for the staff of the mental health units, the Director of Nursing for Senior Services stated, "...we don't do annual competencies..." The Director of Nursing stated there was no documentation for the training the mental health associates received for the belongings search and rounding.

During an interview in the Ethics and Compliance Office on 11/28/18 at 12:41 PM, the Clinical Educator for (Psychiatric Facility in hospital) stated she covered the suicide prevention class with new employees during orientation but did not provide any formal annual training to staff.

Based on policy review, medical record review, video footage review, hospital documents and interview, the hospital failed to assess a patient at risk for suicide and violent behavior for 3 of 3 (Patient #1, 2 and 3) sampled patients.

The findings included:

1. Review of the hospital's "Assessment and Management of Violent Patients" policy revealed, "...POLICY...All patients admitted to the (Psychiatric Unit) will be assessed at the time of admission for current risk of violence as well as history of violent behavior...All patients admitted to the (Psychiatric Unit) will be continuously reassessed using the Broset Violence Checklist...PROCEDURE...Initial Broset scores will be obtained during the intake assessment or on the unit if patient is a direct admit. Afterwards, the staff will obtain Broset scores every four while awake for the first twenty-four..."

Review of the hospital's "Admission and Post-Admission Search of Patient Belongings" policy revealed, "...PURPOSE: To provide guidelines for admission searches which ensure the safety of all patients while promoting dignity and personal responsibility... PROCEDURE...Upon arrival to the unit, nursing staff will take the patient and the patient's possessions into a conference or treatment room for the search...staff will search belongings in patient's presence and not leave patient alone with their personal possessions. Possessions will not be left unattended until the search is completed. If the patient is unable to participate in the belongings inventory, two staff members will inventory together and sign...Nursing personnel will...Thoroughly search luggage, shoes, wallets, purses, cosmetic bags, etc. All items carried on the person or brought into the hospital must be checked and logged in on admission search sheet..."

2. Medical record review for Patient #1 revealed an admission date of 10/4/18 with diagnoses which included Schizophrenia, Alcohol Use Disorder, Cannabis Use Disorder, Homicidal Ideation and Suicidal Ideation. The "NURSING ADMISSION CHECKLIST" dated 10/4/18 revealed, "...Complete Safety/Risk/Regulatory Checklist: Broset...1st hour - Golden hour...Every four hours for the first 24 hours - Bronze hours..."

The initial Broset score was assessed upon arrival to the unit from the emergency department on 10/4/18 at 6:22 AM. The Broset score was assessed on 10/4/18 at 10:31 AM and 7:30 PM. There were no other assessments of Broset scores documented during Patient #1's first 24 hours.

During a phone interview on 11/27/18 at 12:01 PM, when asked how often should the nurse assess the Broset score after a patient was admitted, Registered Nurse (RN) #1 stated, "...we do it once a shift (shift is either 7:00 AM-7:00 PM or 7:00 PM to 7:00 AM which is 12 hours long)..."

During a phone interview on 11/28/18 at 8:03 AM, when asked how often should the nurse assess the Broset score after a patient was admitted, RN #4 stated, "...once per shift..."

There was no documentation of a personal belongings search maintained in Patient #1's medical record.

The Discharge Summary dated 10/17/18 revealed, "...Staff search[ed] the patient's room [after Patient #1 pronounced dead] and found two Xanax [benzodiazepine] tabs [tablets] as well as two Subutex [narcotic] tabs in the patient's belongings. It is unclear when and how the patient gained access to the contraban[d] medications. It was observed after the fact that the patient's issues contained hidden compartments..."

Review of the "Executive Summary" (summary of debriefing meeting held by the hospital after Patient #1's death, not dated) revealed, "...10/5/18...8:10 [AM]...During clean up loose pills were found in the room. (2 X [times] 2gm [gram, pills identified by pharmacy as 2 milligrams rather than 2 grams] Xanax, 1 subutex) In addition, he had a hole in the inside of his shoe under the insole that he could have concealed drugs on admission..."

Review of the video footage of the belongings search for Patient #1 revealed the footage was partially blocked by two video screens, and the camera was approximately 30 feet away from the actual belonging assessment. The video footage revealed Mental Health Associate (MHA) #2 wrote down the personal items on a piece of paper, but there was no documentation of personal belongings in Patient #1's medical record. The personal belongings search was conducted by one staff member (hospital policy required either staff and patient or two staff members). The hidden compartment in Patient #1's shoe was not found during the personal belongings search.

During a phone interview on 11/27/18 at 12:09 PM, when asked how she would check a patient's shoes during the personal belongings search, MHA #1 stated, "...put my hand down inside the shoe..."

During an interview in the Ethics and Compliance Office on 11/27/18 at 1:25 PM, when asked if it was appropriate for a staff member to put their hand down inside a patient's shoe during the belongings search, the Director of Nursing for Senior Services stated, " ...no ..." The Director of Nursing for Senior Services confirmed there was no documentation for the personal belongings search for Patient #1.

3. Medical record review for Patient #2 revealed an admission date of 10/4/18 with diagnoses which included Major Depressive Disorder, Borderline Personality Features, Chronic Obstructive Pulmonary Disease and Diabetes Mellitus.

The "Non Hazard Items" and "Hazard Items" dated 10/4/18 revealed an inventory of Patient #2's belongings with each form signed by the patient and a staff member. A plain sheet of paper dated 10/4/18 contained a separate handwritten list of personal items not signed by anyone. The handwriting on the plain sheet of paper was different than the other two lists.

During an interview in the Ethics and Compliance Office on 11/27/18 at 1:25 PM, when asked about the unsigned list of personal items, the Director of Nursing for Senior Services stated she could not tell what happened with the belongings search for Patient #2 and confirmed the search was not done appropriately.

4. Medical record review for Patient #3 revealed an admission date of 10/10/18 with diagnoses which included Bipolar Depression, History of Posttraumatic Stress Disorder, and Diabetes Mellitus.

The "Non Hazard Items" and "Hazard Items" forms for documented the personal belongings search were blank. There was a plain sheet of paper dated 10/10/18 with a list of personal items. The list was not signed by anyone.

During an interview in the Ethics and Compliance Office on 11/27/18 at 1:25 PM, when asked about the unsigned list of personal items, the Director of Nursing for Senior Services confirmed the personal belongings search was not done appropriately for Patient #3.

Based on policy review, personnel file review and interview, the hospital failed to ensure adequate supervision and evaluation of the clinical activities of non-employee nursing personnel for 1 of 1 (Contract Mental Health Associate (MHA) #1) sampled contract nursing personnel.

The findings included:

1. Review of the hospital's "Competency Assessment" policy revealed, "...SCOPE...Contract staff will be held to the same standards as employees and the records must be maintained by the business entity...PURPOSE...To define mechanisms used to assess and maintain competency of employees as required for the position and by regulatory agencies...DEFINITIONS...Competency: A competency refers to the knowledge, skills, abilities, and behaviors required to perform assigned duties and responsibilities safely and aptly...Competency Assessment: Competency assessment is conducted initially as a part of orientation. Ongoing competency assessment occurs at a minimum annually...RESPONSIBILITIES...Management is responsible for ensuring a mechanism exists to identify area-specific competency requirements; creating an environment that promotes timely competency assessment and ongoing growth and development; providing education to employees on the competency process; monitoring employee progress; and participating in evaluation of the competency process...The initial competency assessment will include, at a minimum, the validation of core competencies specific to the role and responsibility of each position or position type...Ongoing competency assessment is an essential process for verifying an individual's ability to perform their assigned job role by evaluating the ability to apply knowledge, perform skills and demonstrate critical thinking..."

2. Review of the personnel file for Contract MHA #1 revealed 1 completed online course dated 8/21/17 and 2 completed online courses dated 8/22/17. The course subjects included code of conduct, orientation for clinical staff and regulatory compliance. There was no documentation of education, training or competencies which specifically addressed providing care for behavioral health patients.

3. During an interview in the Ethics and Compliance Office on 11/27/18 at 12:44 PM, when asked about annual training for the staff of the mental health units, the Director of Nursing for Senior Services stated, "...we don't do annual competencies..." The Director of Nursing stated there was no documentation for the training the mental health associates received for the belongings search and rounding.

During a phone interview on 11/27/18 at 1:18 PM, Contract MHA #1 stated she started working in the psychiatric unit of the hospital in August of 2017. Contract MHA #1 stated she left in November 2017 on maternity leave and re-signed to work in the psychiatric unit of the hospital in August 2018. Contract MHA #1 stated she was supposed to receive training when she re-signed but never received training.

During an interview in the Ethics and Compliance Office on 11/28/18 at 12:41 PM, the Clinical Educator for (Psychiatric Facility in hospital) stated the hospital did not provide orientation to contract staff. The Clinical Educator stated the contract staff does not go through the hospital for education and training.