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Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure that patients are cared for in a safe setting as evidenced by: failing to ensure that patients do not have access to contraband and failing to ensure that the patient environment is safe by ensuring that all ligature risks are mitigated. (A-144)












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Based on medical record review, staff interviews, and review of facility documents it was determined that the facility failed to ensure 1) patients in the locked Drake West-2 Unit did not have access to contraband 2) beds in the Drake West-2 Unit are properly secured to the floor for patient safety.

1) Reference: Facility policy titled "Search and Removal of Contraband in the Environment of Care (effective 12/5/23)", stated, "I. Scope of Policy A. ...all administrative, support, and clinical staff will assure that contraband and potentially dangerous objects will be identified and removed from the hospital environment in an expeditious manner. ... B ...potentially dangerous items that threaten or jeopardize the health, security, safety of the patients, staff, or visitors must be prohibited and/or eliminated from the environment when found. These items are identified as contraband; therefore, the hospital limits possession of such items by patients...II. Definitions A. Contraband: Contraband is defined as any item/object that may threaten the health, safety and/or security of patients or others in the hospital. For all patients in locked units' contraband includes the following: ...7. Pieces of wire ..."

On 1/30/24 at 11:30 AM, a tour was conducted on the Drake West-2 Behavioral Health unit. During the tour multiple patients were observed standing in the common area of the hallway in close proximity to one another socializing. There was a combination of patients observed to be wearing surgical masks and others without. An interview was conducted with S11 (Registered Nurse [RN]) at 11:35 AM, who confirmed there were patients who tested positive for COVID on the unit. S11 stated "we try to encourage patients to wear masks, distance themselves from other patients and stay in rooms". At 11:46 AM, an interview was conducted with S12 (RN) who stated, "I try to encourage the patients to wear a mask, and during medication pass not line up near each other, especially if they are COVID positive.". The surgical mask given to the patients on the Drake West-2 Unit was provided. Upon inspection of the surgical masks, the nose bridge of the mask was identified to have two metal wire strips. This finding was revealed to S1 (Quality Assurance Coordinator), S8 (Chief of Medicine) and S10 (Assistant Director of Nursing).

On 1/30/24 at 1:11 PM, S5 (Deputy Chief Executive Officer) observed the metal found within the mask given to patients. S5 confirmed the policy related to Contraband identifies "pieces of metal" as items patients should not have for their safety.

2) A tour was conducted on the Drake West-2 Behavioral Health unit on 1/30/24 at 11:30 AM. S10 (Assistant Director of Nursing) stated the unit had a capacity of 27 beds and census of 29 patients. S10 indicated that the two additional patients were accommodated by putting additional beds on the unit. During the tour S10 confirmed the two beds brought to the Drake West-2 unit were in rooms W-215 and W-219. During a tour of Room W-215, there were three beds observed to be bolted to the ground and one bed that was observed unbolted. During a tour of Room W-219, there were three beds observed to be bolted to the ground and one bed that was observed unbolted.

On 1/30/24 at 1:11 PM, upon interview with S5, he/she indicated the unbolted beds were a patient safety concern due to the possibility of a patient barricading themselves in their room or using the bed to wrap a sheet around as a ligature point. S5 confirmed the additional beds placed in W-215 and W-219 were unbolted. S5 indicated the facility is in the process of bolting every bed within the facility. S5 had the two unbolted beds removed from the Drake West-2 Unit and rearranged room assignments so that all patients were in bolted beds.

On 1/30/24 medical record review was conducted. Patient (P) 9 was admitted to the Drake West- 2 Unit on 12/1/23 with a diagnosis of Major Depressive Disorder and Psychoactive Substance use. On 12/1/23 at 1:58 PM a Physician's Order was placed for "Periodic Visual Observation [PVO]" due to Self-Injurious/Aggressive Behavior. On 12/18/23 at 3:35 PM, a Physician Order was placed to discontinue "Periodic Visual Observation". A Physician's Order was placed on 1/26/24 at 5:00 PM, for "Periodic Visual Observation" due to Self-Injurious/Aggressive Behavior. An interdisciplinary note from 1/26/24 at 8:00 PM, stated, "RN Note ...Pt on PVO for SIB [Self-injurious behavior] after punching mirror in [his/her] room, saying [he/she] was agitated and felt sad. No visible injury and pt is able to move fingers, denies pain. ...".

On 1/30/24 the facility document titled, "(Drake) Internal Environment Suicide Risk Assessment Audit" was reviewed and patient beds were not identified as a risk.

On 1/30/24 at 3:30 PM, S5 confirmed that P9, who was on PVO for SIB, was in room W-219 in an unbolted bed.

On 1/31/24 at 10:30 AM, a tour of the Drake West-2 Unit was conducted with S5. Rooms W-215 and W-219 were observed, and all beds were confirmed to be bolted to the floor, there were no unbolted beds identified on the unit.

Based on staff interviews, medical record review and review of facility documents, it was determined that the facility failed to ensure implementation of the policy and procedure addressing Quarantine for COVID-19 patients.

Findings Include:

Facility Policy titled "Implementing Unit Quarantine for COVID-19 (Exposure Protocol) (effective 4/18/23)", stated, "I. POLICY ...Patients who test positive are transferred to the COVID 19 Unit and those patients who have tested negative are monitored every shift for COVID 19 symptoms, throughout the expected incubation period of the virus. ...Procedure A. Precautions ... 2. Monitor Patients for COVID-19 Symptoms for 7 days: ...c. Patients and staff are to be tested twice weekly (Binax and PCR) d. Patients are the be tested on day 1 (Binax) and repeat testing on day 3 (PCR) and day 5 (Binax) of the quarantine period, and if all results return negative, the unit will be medically cleared on the 7th day and the quarantine is lifted. ..."

On 1/30/24 medical record review revealed that Patient (P) 2 was admitted to the behavioral health unit Drake West-2 on 1/4/24 at 10:10 AM. A Nursing Note from the sending facility stated, "Date 01/02/24 0835 [8:35 AM] ....Note: COVID Antigen test (Flowflex) performed on [P2]. Result - negative. [P2] has no s/s [signs or symptoms] of Covid." P2 tested positive for COVID on 1/20/24 at 1:00 PM. An Interdisciplinary Progress Note on 1/20/24 at 2:00 PM, stated, " ...At about 1:00 PM pt [patient] c/o [complaining of] sore throat, running nose and headache. Binax done, + for Covid-19, ....New order to also isolate pt ...". A Nursing Note on 1/21/24 at 9:00 PM, stated, "Positive Covid 19. ... Pt is not compliance [sic] with staying in [his/her] room. Pt encouraged to stay in [his/her] room as much as possible. ..."

On 1/31/24 at 10:03 AM, an interview was conducted with S9, who confirmed the facility did not follow the current policy related to Covid-19 positive patients and staff. On 1/20/24 at 1:00 PM, P2 tested positive for COVID, he/she was not transferred to an isolation unit as per policy. S9 was unable to provide evidence that the facility was testing COVID exposed patients or staff as per policy. S9 confirmed the facility made the Drake West-2 Unit into an "isolation" unit once two patients tested positive for COVID, rather than transferring the two patients to an isolation unit as per facility policy.