HospitalInspections.org

Based on policy and procedure review, medical record review, observations, incident report review, meeting minutes review, assignment sheets review, quality monitoring data/committee meeting minutes, personnel files review and staff and physician interviews, the governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights for a safe environment; an organized and effective quality assessment and performance improvement program for patient safety; an organized nursing service for supervision of nursing care; and an effective emergency services to meet behavioral health patient care needs.

The findings included:

1. The hospital failed to provide care in a safe environment by failing to evaluate environmental barriers and coordinate resources to ensure an autistic IDD patient was safely discharged for 1 of 1 autistic patients (Pt #6) discharged from the ED, by failing to evaluate proper functioning of a specialty bed before returning it to patient use for 1 of 3 patients on specialty beds (Pt #21) and by failing to provide constant nursing supervision and adequate staffing at all times for patient safety on 2 of 2 locked adult behavioral health halls (Halls 400, 500).

~cross refer to 482.13 Patient Rights' Standard: Tag 0144

2. The hospital failed to ensure staff applying and monitoring enclosure posey bed restraints were trained and demonstrated competency in the application, monitoring and care of a patient for 3 of 3 personnel files reviewed of Emergency Department staff who cared for a patient in an enclosure posey bed restraint (Staff 2, Staff 11, Staff 12).

~cross refer to 482.13 Patient Rights' Standard: Tag 0196

3. The hospital failed to provide an effective quality assessment and performance improvement program by failing to
conduct an internal investigation and implement corrective actions for an adverse event that resulted in patient injury in 1 of 3 patients reviewed on a specialty bed (Patient #21); and failed to provide monitoring to evaluate changes in care location and staffing for effectiveness and safety for acutely ill psychiatric patients.

~cross refer to 482.21 Quality Assessment and Performance Improvement Standard: Tag 0286

4. The hospital's governing body failed to ensure an effective quality assessment and performance improvement program that involved all hospital departments and services by failing to have quality monitoring data for the food and nutritional services provided to patients.

~cross refer to 482.21 Quality Assessment and Performance Improvement Standard: Tag 0308

5. The hospital failed to provide an organized nursing service for supervision of nursing care by failing to provide constant licensed nursing supervision for acutely ill behavioral health patients on 2 of 2 locked adult behavioral health halls (Hall 400 and Hall 500).

~ cross refer to 482.23 Nursing Services Standard: Tag A0395

6. The facility emergency department staff and providers failed to organize Emergency Services to provide for a safe discharge plan by failing to evaluate environmental barriers and coordinate resources prior to discharge for 1 of 1 sampled Autistic, IDD patient that discharged from the emergency department (Patient #6).

~cross refer to 482.55 Emergency Services Standard: Tag 1103

Based on facility policy review, medical record review, observations, incident report review, meeting minutes review, staff assignment sheets review, personnel files review, and staff and physician interviews, the hospital failed to protect and promote patients' rights by failing to ensure care in a safe environment and to ensure staff were trained and demonstrated competence in caring for a patient in a enclosure posey bed restraint.

The findings included:

1. The hospital failed to provide care in a safe environment by failing to evaluate environmental barriers and coordinate resources to ensure an autistic, IDD patient was safely discharged for 1 of 1 autistic patients (Pt #6) discharged from the ED, by failing to evaluate proper functioning of a specialty bed before returning it to patient use for 1 of 3 patients on specialty beds (Pt #21), and by failing to provide constant nursing supervision and adequate staffing at all times for patient safety on 2 of 2 locked adult behavioral health halls (Halls 400, 500).

~cross refer to 482.13 Patient Rights' Standard: Tag 0144

2. The hospital staff failed to ensure staff applying and monitoring enclosure posey bed restraints were trained and demonstrated competency in the application, monitoring and care of a patient for 3 of 3 personnel files reviewed of Emergency Department staff who cared for a patient in an enclosure posey bed restraint (Staff 2, Staff 11, Staff 12).

~cross refer to 482.13 Patient Rights' Standard: Tag 0196

Based on facility policy review, medical record review, observations, incident report review, meeting minutes review, staff assignment sheets review, and staff and physician interviews, the facility staff failed to evaluate environmental barriers and coordinate resources for a safe discharge from the ED (Emergency Department) for 1 of 1 sampled autistic (related to autism-a developmental disability caused by differences in the brain) and IDD (intellectual and developmental disabilities) patient (Patient #6), failed to evaluate proper functioning of a specialty bed before returning it to patient use for 1 of 3 patients on specialty beds (Pt #21), and failed to provide constant levels of staffing and licensed nurse presence for safety on 2 of 2 locked adult behavioral health halls (Halls 400, 500).

The findings included:

Review on 09/01/2023 of the Hospital policy titled "Discharge to Alternative Level of Care" effective 05/07/2021 revealed "The Transitions of Care team member will assess and coordinate services for transitions based on the patient/family choice, clinical needs, and insurance benefit plan."

Review on 09/01/2023 of the Hospital policy titled "Involuntary Commitment" effective 11/09/2022 revealed " ... Renewal of Commitment: A custody order is valid for 7 days ... A new Affidavit and Petition for Involuntary Commitment (Form AOC-SP-300) and First Examination for Involuntary Commitment (Form DMH 5-72-19) must be completed prior to the expiration of the current order if the patient still meets involuntary commitment criteria. The two forms must be faxed to the Magistrate's Office and the new findings will be issued for the new petition by the Magistrate's Office ... Rescinding Involuntary Commitment: A patient under Involuntary Commitment can be released from the Involuntary Commitment by any certified commitment examiner during the first examination (First Examination for Involuntary Commitment [form DMH 5-72-19]) or any other time during the encounter based on collateral information obtain from Clinical Social Work (CSW), Behavioral Health counselor, or psychiatrist's recommendation using the Notice of Commitment Change (form DMH 579-01). A copy of this form must be faxed to the Clerk of Court, the original mail to the Clerk of Court, and a copy sent to Health Information Management. The Notice of Commitment Change Form can only be completed by an attending physician.

Medical record review on 08/15/2023 for Patient #6 revealed a 26-year-old male arrived to Campus B's Emergency Department (ED) on 07/08/2023 at 0304 for "Aggressive Behavior". ED Triage Note at 0309 revealed "BIB (brought in by) ... EMS ([county initials] emergency medical services) & (and) PD (Police Department) with c/o (complaint of) aggressive behavior. Initially taken to Campus C, given Geodon (medication used to treat mental health conditions) and Ativan (sedative medication), told too aggressive for them and sent here. Hx (history) of autism." Patient #6 was assigned an acuity level of 2 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Vital Signs at 0311 were "BP (blood pressure): 99/84 Temp (temperature): 97.5 F (Fahrenheit) ... Pulse Rate: 84 Resp (respiratory rate): 20 SpO2 (oxygen saturation): 99%." Review of the ED Provider Note at 0515 revealed "attempted to call patient's Father but call went to voicemail. Will continue to observe in the ED, sedation as needed with CSW (clinical social work) assistance in the AM (morning) ... Clinical Course 0513 Patient becoming increasingly loud and agitated in the hallway. Had Geodon at Campus C just a few hours ago. Will give additional Ativan IM (intramuscular) for now. 0529 Patient becoming more physically aggressive with staff as Ativan given. Will attempt to de-escalate but if he continues to be dangerous, will need restraints. 0638 Spoke with the patient's Step-mother ... who reports he has attacked her and his father He was previously in and out of hospitals and group homes. They have only had him for the last month. They are no longer able to take care of him ... Final diagnoses: Aggressive behavior ... ED Discharge Orders: None." Review of the Nurse Note dated 07/08/2023 at 0805 revealed "This nurse called patients father at 0804, no answer. Called step mother (Name of step mother) at 0805 ... explained ... that patient is medically and psych cleared and patient must be picked up from ER (emergency room). (Name of step mother) states she is afraid of patient because patient is screaming. This nurse gave (Name of step mother) names of 3 (three) psychiatric hospitals in NC (North Carolina) per (Name of step mother) request. (Name of step mother) stated she will file IVC (involuntary commitment) on member. Writer educated (Name of step mother) is welcome to file IVC, however, patient is already psych cleared by providers. Educated member must be picked up from ED or parents could be held liable for abandonment. (Name of step mother) stated ED needs to let patient sign himself out. Writer advised patient will not be allowed to leave ED on his own due to ID/cognitive impairment and presence of legal guardianship. (Name of step mother) stated she is not picking patient up and hung up the phone." Nurse Note dated 07/08/2023 at 1325 revealed "Pt refusing to cooperated (sic), screaming and leaving room, pinch (sic) grabbing staff, placed in soft restraints for safety. Pt has been medicated and will be removed after med effect." Nurse Note dated 07/08/2023 at 1936 revealed "Patient is hitting himself in the head and biting the police. Patient walked up on sitter and security staff had to physically move patient back to his room." Nurse Note dated 07/08/2023 at 2000 revealed "Patient just smacked the police officer in the head." Nurse Note dated 07/09/2023 at 2036 revealed "Patient open handed hit me in the chest. Then charged at me. (County initial) PD (police department) and security took patient down. We restrained the patient. MD (Medical Doctor) notified." Nurse Note dated 07/10/2023 at 0055 revealed "Patient wake (sic) up and start to get agitated. Patient yelling and screaming in the bed 'I want to go home'. Restraints ordered and applied ..." Review of the ED Provider Note on 07/10/2023 at 0719 revealed "... Currently, the patient is currently restraint (sic) after aggressive behavior overnight ... Plan: Current plan is for placement ... is not under involuntary commitment." Nurse Note dated 07/10/2023 at 1350 revealed "Pt shouting out in his room ...Pt difficult to redirect ... After exiting the room pt charged towards me and made it approximately 15' (feet) before being accosted (approached/addressed) by (County initial) PD police officers and carried to bed. De-escalation techniques unsuccessful ... patient attacking (County initial) PD officers. Pt made two attempts at charging (County initial) PD officers and forcibly grabbed one's arm trying to scratch and claw at his skin. (MD #36) called to bedside and pt placed in soft restraints." The ED Provider Note dated 07/11/2023 at 0900 revealed "... Recent changes in the last 24 (twenty-four) hours include outburst of aggressive behavior, scratched staff members overnight and required to be restrained ... Plan: Current plan is for placement ... is under involuntary commitment." ED Provider Note dated 07/11/2023 at 1814 revealed "... evaluated the patient multiple times this afternoon, he continues to be aggressive, violent and requiring multiple people and physical restraint to keep him in bed. He has been medicated today with additional medicines ... without relief ... will give additional medication at this time ... anticipate he will require additional restraint and close observation. He is being followed closely by the TTS/psychiatry (Therapeutic Triage Specialist). Hopefully they will continue to monitor and offer medication and behavioral guidance. There is been (sic) a concern the patient has been self injuring himself by pounding his head. He does not show any signs of acute head injury at this time ... do not think it would be beneficial to get a head CT (computerized tomography - combination of x-ray images from different angles to form detailed images of a body part) at this time." Nurse Note dated 07/12/2023 at 0831 revealed "While giving medication, pt became extremely agitated and began screeching. Pt kicked this RN (Registered Nurse) in abdomen. Pt then took medication." ED Provider Note dated 07/12/2023 at 0906 revealed "... Currently, the patient is violent and aggressive requiring chemical and physical restraint ... Plan: Current plan is for psychiatric placement ... is under involuntary commitment." Nurse Note dated 07/12/2023 at 1203 revealed "Pt verbally and physically aggressive with staff. Pt charging sitting (sic) and making hand motions as if to hit her. Pt placed in violent restraints ..." Nurse Note dated 07/12/2023 at 1700 revealed "Pt screaming, comtinues (sic) to hit his head, and hit security officer." Nurse Note dated 07/12/2023 at 2207 revealed Pt aggressive. Pt attempted to grab staff by arm, but was unsuccessful. Pt ran out of room, trying to fight with security. Pt redirected to room. Pt attempted to hit and kick staff while redirecting to room ... Restraints administered. Pt attempted to hit and kick staff while putting on restraints." Nurse Note dated 07/13/2023 at 0525 revealed "Patient pushed (NT #11 Name) aggressively to the door. Screaming, uncooperative. (MD #37) notified for medication and violent restraints order." ED Provider Note dated 07/13/2023 at 0810 revealed "... Currently, the patient is restraint (sic) in the bed. Sleeping ... have reviewed the labs performed to date as well as medications administered while in observation. Recent changes in the last 24 hours include patient continues (sic) with severe aggression and agitation. He has required multiple. (sic) Some restraint as well as psychotropic medications. Plan: Current plan is for placement to (initials of hospital) hospital when bed becomes available ... is under involuntary commitment." Nurse Note dated 07/13/2023 at 2234 revealed "Message sent to (MD #38) regarding pt's behavior and restrain order to expire at 2245, feel unsafe for pt and medical staff for pt to be removed from restraints at this time as pt still have (sic) outburst of behavior and has not shown extensive periods of calm and cooperative behavior ..." ED Provider Note dated 07/14/2023 at 0517 revealed "Patient intermittently agitated, yelling and physically aggressive with staff. Had several hours of good control after Haldol (medication used to treat certain types of mental disorders) earlier in the shift. Has not had good control with other antipsychotics (medication used to treat mental disorders) and anxiolytics (medication to treat anxiety). Will give additional dose now. In soft restraints for patient and staff safety." Nurse Note dated 07/14/2023 at 0831 revealed "Pt remains in four point restraints. He is non-redirectable. Shouting constantly at staff ..." Nurse Note dated 07/14/2023 at 1422 revealed "Patient running out to desk trying to hit security guard then proceeds to fall on floor. Patient escorted back to bed and restrained." Nurse Note dated 07/15/2023 at 0951 revealed "Pt screeching, coming out of room charging at staff. Pt escorted back to room by security and (County initial) PD. Restraints placed on pt for staff and patient safety ..." Nurse Note on 07/15/2023 at 1335 revealed "MD notified of pressure injuries to bilateral wrists." Nurse Note dated 07/15/2023 at 1720 revealed "Pt talked on phone to dad, then became very upset, screeching, charging at security and (County initial) PD out of room. Pt swinging fists and grabbing this RN and NT sitter. Pt carried back to bed and physical hold performed to place patient in restraints. Pt continued to be aggressive and uncooperative while placing restraints. MD notified." Review of the ED Provider Note dated 07/16/2023 at 1019 revealed "... Recent changes in the last 24 hours include (sic) continues with periods of outburst requiring intermittent chemical as well as physical restraint. Patient has explosive behavior. Will benefit from not being in the unit where he is at. Plan: Current plan is for placement ... is under involuntary commitment." Nurse Note dated 07/16/2023 at 1300 revealed "Pt continues to charge out of room at staff despite redirection and security assist back to bed. Pt resisting and on floor. Kicking (County initial) PD. Placed in 4 point restraints, provider aware and order obtained. Pt aware of criteria for release." Nurse Note dated 07/16/2023 at 1854 revealed "Pt is increasingly agitated and rushed out of his room towards his sitter; put his hands on safety sitter's shoulders. Sitter and security staff were able to get pt to return to his room but he is highly agitated and difficult to redirect at this time. RN and sitter explained behavioral rules and told pt he would be placed back into restraints if he puts his hands on staff or continues acting aggressively." ED Provider Note dated 07/17/2023 at 0900 revealed "... Plan: Current plan is for placement. Family unable to care for patient at home ... is under involuntary commitment." Nurse Note dated 07/19/2023 at 0622 revealed "Patient attempting to push past sitter to exit room. Patient unable to be redirected. MHT (mental health technician) and (County initial) PD had to physically place patient back in bed." ED Provider Note dated 07/19/2023 at 0636 revealed "Patient became agitated and threatening to staff, required physical restraints for staff safety. I have ordered a dose of ziprasidone (medication used to treat mental health conditions) for staff safety." ED Provider Note dated 07/21/2023 at 0908 revealed "... Pt (patient) with hx (history of) autism and chronic behavioral issues, periods of agitated behavior. He was abandoned in ED by family who have refused to pick him up. Pt desires to return home. On exam, pt with mild swelling and erythema (redness) to left shoulder (?due to prior IM injections). No crepitus or abscess noted. ?mild cellulitis (bacterial skin infection). Staff to avoid using left shoulder for IM injections (and avoid any IM injections as much as possible). Warm compresses to area. Keflex (antibiotic) po (by mouth) ... Recent changes in the last 24 hours include ED obs (observation), reassessment, and TOC (transition of care) placement. Plan: TOC team working on placement ..." Nurse Note dated 07/21/2023 at 1333 revealed "Pt increasingly agitated, charged staff member and grabbed them. Pt given IM sedation, and then tried to get out of bed. Pt screaming, and placed into violent restraints. MD notified." Nurse Note dated 07/24/2023 at 2127 revealed Patient charged out of room screaming multiple times even after PRN (as needed) zyprexa (medication to treat mental disorders) (sic) and PRN ativan (sic). Notified (MD #38). New order for one-time dose IM Geodon ordered and given ..." Nurse Note dated 07/24/2023 at 2209 revealed "Patient not calming down after medications and constant calm de-escalation speaking with patient and holding his hand. He is screaming, yelling and charging at staff. He grabbed the security officer and almost broke the skin with his nails. New order for violent restraints and placed on patient ..." ED Provider Note dated 07/25/2023 at 1056 revealed "... Psych NP (Nurse Practitioner) saw the patient and they still recommend that patient be placed. Plan: Current plan is for inpatient psychiatry placement. Patient will be managed in the ED until placement ... is under involuntary commitment." Nurse Note dated 07/26/2023 at 1230 revealed "Pt attempted to push nurse tech through door. Pt redirected to sit in his bed and PRN meds were given." Nurse Note dated 07/26/2023 at 1514 revealed Pt came out of room, began hitting the windows on the door and screaming." Nurse Note dated 07/26/2023 at 1950 revealed "Pt. Became aggressive, grabbing staff and scratching back of neck. Pt. Became aggressive when informed he will go home when his daddy feels better. Pt. Jumped up and grabbed staff around neck, digging finger nails in back of staff's neck." Nurse Note dated 07/26/2023 at 2117 revealed "Patient very agitated and charging out of room multiple times. He scratched MHT (NT #11's name), on the back of the neck and broke the skin ... Violent restraints ordered and IM medication. Violent restraints applied with staff and security present. IM medication given ..." Nurse Note dated 07/27/2023 at 2007 revealed "Pt attempted to come at this writer d/t (due to) 'feeling anxious' about his father. Security redirected pt back to bed." Nurse Note dated 07/28/2023 at 0828 revealed "Patient continues to be agitated. Yelling, coming out of room, trying to attack security, grabbing, scratching staff, uncooperative with redirection. Provider notified." ED Provider Note dated 07/28/2023 at 0927 revealed "... patient got agitated and started trying to attack staff and running out of his room. Patient was placed in restraints and was given his daily medicines ... Recent changes in the last 24 hours include agitation and violence towards staff requiring restraint and getting his medications. Plan: Current plan is for inpatient placement ... is under involuntary commitment." Nurse Note dated 07/30/2023 at 0302 revealed "Pt very focused on discharge home and phone call to family members, pt came out of room attempting to grab staff and assault them. Verbal redirection ineffective, pt ran out of room and attempted to to (sic) grab staff after working himself into a rage. Several attempts to verbally de-escalate and well as bargain with pt with privileges." Nurse Note dated 07/30/2023 at 0415 revealed "Patient agitated walk (sic) from room to nursing statin (sic) grabbed the this (sic) tech wrist and hand hard." Review of the ED Provider Note dated 07/30/2023 at 1521 revealed "... Plan: Current plan is for social work helping to seek placement ... is under involuntary commitment." Review of the ED Provider Note dated 07/31/2023 at 1120 revealed "Recent changes in the last 24 hours include he continues to have behavioral problems requiring constant redirection. Plan: Current plan is for placement when bed is available ... redid his involuntary commitment paperwork today ... is under involuntary commitment." Nurse Note dated 07/30/2023 at 1625 revealed "Pt becoming agitated, came from room and grabbed tech by wrist and shirt. Pt assisted back to room by security ..." Nurse Note dated 07/30/2023 at 1812 revealed PT to door asking this RN to 'come here.' When RN states that she will not come now, he charges at desk, pt assisted back to room and bed by security. As soon as staff leaves the room, pt comes out of room again and charges at staff. Pt placed in 4 point restraints at this time." Nurse Note dated 07/31/2023 at 0225 revealed "Becoming aggressive and violent attempting grab at staff when he is met at the door." Nurse Note dated 07/31/2023 at 0442 revealed "Is able to bite his wrist restraints off." Nurse Note dated 07/31/2023 at 0450 revealed "Throughout the night security called to the bedside due to patients outbursts, aggressive posture and attempts to physically grab at staff and to assist in restraining patient." Review of the ED Provider Note dated 07/31/2023 at 2100 revealed " ... Patient acutely agitated, threatening staff, not redirectable. Patient presented danger to himself and other hospital staff. Will apply chemical restraints and physical restraints. Patient with improvement to his mental status and compliance following chemical restraints ..." Nurse Note dated 07/31/2023 at 2205 revealed "This is the worst I have ever seen this patient behave. He has tried to scratch, bite, squeeze the hands of security, and rip the clothing of security office. (sic) He has got out of his restraints three times and laid across the floor. He is constantly screaming the names of staff members repeatedly. The MD has been made aware of the volatile behavior." Nurse Note dated 08/01/2023 at 0249 revealed "Patient came running out of his room for the phone. Staff had to physically put the patient back in his room. Back in restraint for patient and staff safety." Nurse Note dated 08/02/2023 at 2210 revealed "Patient is banging fist against door and walls. Grabbing on staff and attempting to wrap his arm around staff member neck." Review of the Psychiatry Provider Note dated 08/03/2023 at 1214 revealed "Patient is not suicidal, homicidal, or psychotic and does not need inpatient psychiatric care. Crisis and safety planning done by NP prior to recommending discharge ..." Review of the Provider Note dated 08/03/2023 at 1245 revealed "Patient needs to have a repeat kidney function and lithium level in one week. For behavioral health needs you are advised to follow up with the resources listed below: For psychiatry in the (City Name) area contact ... at your earliest opportunity to schedule a new patient appointment ... As an alternative, contact (County Name) Behavioral Health ... They offer psychiatry/medication management and therapy. New patients are seen in their walk-in clinic ... Please note that to be eligible for services you must bring an ID (identification) or a piece of mail with your name and a (County Name) address ... If you are in need of residential treatment to stabilize a crisis contact (Name of Facility) ... SC (South Carolina) ... For your ongoing behavioral health needs and to explore other treatment options for which you are eligible, stay in communication with your (Name) Health care coordinator ... For other services and benefits stay in touch with (Name) with (Organization)." Review of the Counselor Note dated 08/03/2023 at 1245 revealed "Per NP#17, this pt does not require psychiatric hospitalization at this time. NP #17 has spoken to pt's mother/co-guardian, (Name), notifying her of disposition. Pt presents under IVC initiated by EDP (emergency department provider - Name) Pt is psychiatrically cleared. Discharge instructions include referrals for area outpatient providers as well as his NC. A TOC consult has been ordered to facilitate pt's return to the community." Nurse Note dated 08/04/2023 at 0648 revealed "When patient woke up, he was able to be redirected a couple of times. Now, he is very anxious and agitated and charged out of room a couple of times. One of the times he charged out of room and wrapped his arms around NT (nurse tech) and squeezed her really tight. He also charged out of room and security was able to get him back in his room. Notified (MD #37). New order for 2 mg (milligrams) IM ativan ordered and given ..." Nurse Note dated 08/04/2023 at 2213 "Patient is charging out of room, very anxious, and unable to calm down with verbal de-escalation. Security has been present along with (NT #11's name), MHT. Already given PRN PO (by mouth) ativan and PO zyprexa. Notified (MD #39). New order for 10 mg IM geodon ordered and given." Nurse Note dated 08/04/2023 at 2317 revealed "Patient increasingly aggressive and unable to redirect. Notified (MD #39) New order for 2 mg ativan ordered and given ..." Nurse Note dated 08/05/2023 at 2057 revealed "Patient is very anxious and agitated. He hit his head really hard multiple times against he (sic) metal part of the door. He also squeezed my hand really tight. Notified (MD #35 name). New order for restraints and geodon 10mg IM ordered and given. Restraints placed with security and staff present." Nurse Note dated 08/05/2023 at 2241 revealed "Patient continues to scream and move up and down in the bed in restraints. Notified (MD #35 name). New order for Ativan 2mg IM ordered and given ..." Review of the ED Provider Note dated 08/06/2023 at 0809 revealed " ... Currently, the patient is awake, standing in doorway, requesting to go home ...Recent changes in the last 24 hours include recurrence of agitation last night requiring Ativan and restraints. Plan: Current plan if for placement ... is under involuntary commitment." Nurse Note dated 08/06/2023 at 2049 revealed "Patient had been speaking with his sitter, repetitive questions per normal. Patient then suddenly started screaming and banging his hands on the room glass. Security and sitter at bedside and patient placed on bed. Sitter now sitting in room speaking quietly with patient. PRN given as ordered." Nurse Note date 08/06/2023 at 2054 revealed "Pt screaming and kicking staff at bedside. Pt agitated and continues to jerk at restraints." Nurse Note dated 08/07/2023 at 0331 revealed "Patient continuously pushing past sitter to exit room. Several security guards needed for redirection to place back in bed." Review of the ED Provider Note dated 08/07/2023 at 0902 revealed "... Recent changes in the last 24 hours include had some aggressive behavior last night. Plan: Current plan is for waiting for mom to pick patient up ... is under involuntary commitment." Review of the Nurse Note dated 08/07/2023 at 1131 revealed "I have spoke with Patient #6's mother this morning and am awaiting a call back. Attempted to call dad with the call going straight to voicemail. (County initial) PD has been contacted to go to the father's home to make him aware that Patient #6 is ready for discharge and that if he does not come get his son, he will be arrest (sic) for abandonment. If I have not received a return call from mother within the hour, I will contact the police department in her area as well since her and dad are equal guardian and both a (sic) refusing to come get him." Nurse Note dated 08/07/2023 at 1150 revealed (County initial) PD has make (sic) contact patient's dad (Dad's name). Dad is denying avoiding hospital phone calls even though he has been including (sic) calls from me. (County initial) PD asked that I give the dad a deadline so he can arrange for Patient #6 to be picked up. Dad and (County initial) PD made aware that he has until today at 1700 to pick patient up or we will proceed with abandonment charges. (County initial) PD agrees this is a reasonable request and plenty of time. Officer (Name of officer) had requested that I call him if dad does not arrive by 1700." Nurse Note dated 08/07/2023 at 1345 revealed "Mother has made me aware that she is not picking patient up today and she would like one more day. She believes that NC start (a statewide community crisis prevention and intervention program for individuals age six and above with intellectual/developmental disability and co-occurring complex behavioral and/or mental health needs) is going to have a spot for Patient #6 in a program they have tomorrow despite being told by (Corporates name) SW (social work) that Patient #6 does not qualify for this program. The mother is now saying due to the weather she cannot come now. (County initial) PD had been update that the mother now also has no intention of picking up the patient either." Nurse Note dated 08/07/2023 at 1454 revealed "(Name of County mom lives in) County Sheriff has been notified and is on the way to mother's home at this time." Psychiatry Provider Note dated 08/07/2023 at 1625 revealed "... -Patient continues to remain a danger to self and others, continues to meet criteria for involuntary commitment. Patient appears to be at psychiatric baseline, therefore does not meet inpatient psychiatric criteria. Will psychiatrically clear patient at this time ..." Nurse Note dated 08/07/2023 at 1724 revealed "Information has been provided to (County initial) PD Officer (Officer Name). Warrants are being take out against Mom and Dad at this time for abandonment of patient." Nurse Note dated 08/08/2023 at 0314 revealed "Pt starting asking (sic) why staff said his daddy was going to heaven. Pt became agitated and grabbed staff and attempted to hit. Security and nurse came in and redirected to bed." Nurse Note dated 08/08/2023 at 0409 revealed "Increasingly agitated over the last hour. Episodic high-pitched screaming and attempting to leave room, with these episodes increasing in frequency. Less redirectable than earlier. Struck (NT #11's name) and myself in the chest ... Obtained order for geodon 10mg IM. Pt is actually agreeable to this as we would all like to avoid physical restraints if possible. Pt lied (sic) in bed and pulled down pants for shot without any manual hold or restraint. Administered geodon IM ..." Nurse Note dated 08/08/2023 at 0949 revealed "(Name of County mom lives in) County has contacted me this morning stating that Patient #6's mother is coming to (City Name) this morning to turn herself into (County initial) PD for her warrant and then she is coming to pick Patient #6 up. It will be later today as it is a 3hr (three hour) drive. Nurse Note dated 08/08/2023 at 1017 "Patient yelling and running out of room. Pinched security officer until bruise. Escorted back to bed." Nurse Note dated 08/08/2023 at 1030 "Pt placed in restraints per charge nurse." Review of the ED Provider Note (MD #6) dated 08/08/2023 at 1326 revealed "... the patient is continuing with his ongoing behaviors consistent with his autism spectrum disorder. He has been cleared by psychiatry and is medically cleared ... Psych: Patient is intermittently aggressive and then is interactive and redirectable ... Plan: Current plan is for d/c (discharge) to home ... is under involuntary commitment ..." Nurse Note dated 08/08/2023 at 1650 revealed "Pt is speaking with confused speech. PT (sic) 'screeched' before making a statement about having to urinate in a urinal instead of the bathroom. Pt was redirect back to his room." Nurse Note dated 08/08/2023 at 1657 revealed "Pt stormed out of room aggressively asking about his phone call. Pt is now banging and screaming against window." Nurse Note dated 08/08/2023 at 1720 revealed "Pt lunged at security and was redirected back to bed." Nurse Note dated 08/08/2023 at 1810 revealed "... was able to verbally deescalate with (County initial) PD and security at bedside. PO PRN meds given to help." Review of the ED Timeline at 08/08/2023 at 1819 revealed "ED Disposition set to Discharge". Patient #6 was discharged on 08/08/2023 at 2235. Review of the Medical Record revealed no Provider note or assessment of Patient #6 by MD #16, who set the ED disposition to discharge. Review of the Provider Orders and Restraint Flowsheet revealed Patient #6 was in physical restraints 21 (twenty-one) of the 31 (thirty-one) days between July 8, 2023 through August 8, 2023 while Patient #6 was in Campus B's ED. Review revealed Patient #6 was under IVC that was initiated on 07/10/2023, renewed 07/17/2023, 07/24/2023 and 07/31/2023. There was no documented reason for allowing the IVC to expire on 08/07/2023 and no documentation of the IVC being rescinded. However, there were Provider notes dated 08/07/2023 and 08/08/2023 that continued to document Patient #6 was "under involuntary commitment."

Telephone interview on 08/17/2023 at 1132 with RN #1 revealed she was the Assistant Director of Campus B's ED and remembered Patient #6. Patient #6 was a 26-year-old male who came in from his dad and step-mom's, he was IDD and Autistic and aggressive at times. RN #1 did not have a lot of direct interaction with Patient #6 however he was in Campus B's ED for 31 (thirty-one) days. There is a behavioral health meeting every Monday through Friday via Webex with the team to go through all the patients that have not been cleared by psychiatry and Patient #6 was discussed during the meetings. When a patient has no where to go or someone refuses to pick the patient up, as is what happened with Patient #6, the patient is considered a boarder patient and the barriers to placement are discussed in the SW (social work)/CM (case manager) meetings that take place on Tuesday and Thursdays. Interview revealed on 08/03/2023, Patient #6 was Psych cleared. Staff notified Patient #6's family, he was ready to be picked up. Patient #6's dad refused to pick him up since being brought in and said we should call mom. SW reached out to mom about the patient being ready to be picked up however mom kept delaying, saying she had to find someone to sit with her elderly mother, then it was the weather. RN #1 reached out to mom from a telephone number she did not recognize and explained it was time to come get Patient #6. Explained to mom "in NC there is something if not picked up considered child abandonment." Interview revealed RN #1 spoke with the hospital legal team who agreed about pursuing abandonment since mom and dad did not/would not come get Patient #6. RN #1 contacted (County) PD who went to dad's and had him call the hospital. Dad was given a deadline

Based on review of medical records, personnel file reviews and staff interviews, the hospital failed to ensure staff applying and monitoring enclosure posey bed restraints were trained and demonstrated competency in the application, monitoring and care of a patient for 3 of 3 personnel files reviewed of hospital Emergency Department staff who cared for a patient in an enclosure posey bed restraint (Staff 2, Staff 11, Staff 12).

The findings included:

Closed record review on 08/15/2023 of Patient #15 revealed a 25-year-old male who presented to the hospital's Emergency Department (ED) on 04/12/2022 at 1812 ambulatory with local police department for a chief complaint of involuntary commitment (IVC) for psychiatric evaluation and autism spectrum disorder. Review of the ED Provider Note documented on 04/12/2022 at 1822 revealed Patient #15 was sent to the ED for worsening behavioral issues and reportedly destroying things in the group home where he resided. The Provider notes revealed that Patient #15 was autistic and had trouble communicating. Labs and medications ordered. The Patient was brought in with increased agitation and was easily distracted. Patient #15 was redirected multiple times during the Provider's exam. The Patient was medically cleared and admitting/observation was discussed with the admitting physician, patient and/or family and they were comfortable with the plan. Patient #15 was placed in observation in the ED on 04/12/2022 at 1901. Review of the record revealed provider orders for non-violent restraints (enclosure bed) documented on Saturday, 04/30/2022 at 2028 (bed not available till Monday 05/02/2022). Review of ED nurse's note dated 05/02/2022 at 1201 revealed "Pt (patient) placed in 'Posie Bed'." Review of psychiatry provider note dated 05/03/2022 at 1138 revealed Patient #15 remained in the Posey enclosure bed. Review of restraint monitoring documentation by nursing staff revealed bed enclosure restraint was started on 05/02/2022 at 1200 through 05/03/2022 at 1400 when documentation indicated Patient #15 was sitting up in a chair. Nursing restraint documentation revealed the enclosure bed was discontinued on 05/03/2022 at 1600 and re-started at 1615. Documentation revealed the enclosure restraint bed was discontinued on 05/03/2022 at 2230. Patient #15 was admitted to the Intensive Care/Stepdown unit on 05/03/2022 at 2057, transferred to med-surg-tele unit on 05/09/2022 at 1027 and discharged to group home on 06/21/2022 at 1501.

Review of an email sent to ED staff from the Assistant Nurse Manager on 05/09/2022 at 1514 (7 days after the enclosure restraint bed was initiated) revealed "Enclosure beds are a form of nonviolent restraint and can only be used in very special circumstances. Please read the education and watch the 3 min video from the Posey which linked in the education. Once you review the education, please sign the education roster located at the Charge desk."

Review on 09/01/2023 of the personnel file for Staff #2 the hospital ED Registered Nurse who initiated the enclosure posey bed for Patient #15 on 05/02/2022, revealed the RN's date of hire to be 10/08/2018. Review failed to reveal any Enclosure Posey Bed restraint training during orientation or since hire and prior to use on a patient.

Interview on 08/22/2023 at 1030 with Staff #2, revealed he along with the nurse technician and security placed Patient #15 in the enclosure bed. Staff #2 stated the bed was delivered by the central distribution staff. The central distribution staff provided education on how to set up the bed and it's functionality. Interview revealed Staff #2 did not recall any specific training about the enclosure being a restraint. Interview revealed Staff #2 cared for Patient #15 from initiation of the enclosure bed (05/02/2022 at 1200) to the end of his shift (1900) on 05/02/2022.

Review on 09/01/2023 of the personnel file for Staff #11, a hospital ED Registered Nurse who cared for Patient #15 while restrained in the enclosure posey bed from 05/02/2022 to 05/03/2022, revealed the RN's date of hire to be 07/12/2021. Review failed to reveal any Enclosure Posey Bed restraint training during orientation or since hire and prior to use on a patient.

Interview on 08/23/2023 at 0850 with Staff #11, revealed she received an email from the ED assistant director referencing the Enclosure Posey Bed during the time the Patient was in the ED. Interview revealed Staff #11 stated she had not received any education on the Enclosure Posey bed prior to use on the named Patient. Interview revealed the nurse did not recall if she documented the enclosure bed as a restraint. Interview revealed Staff #11 cared for Patient #15 while in the enclosure posey bed on 05/02/2022 and 05/03/2022.

Review on 09/01/2023 of the personnel file for Staff #12, a hospital ED Registered Nurse who cared for Patient #15 while restrained in the enclosure posey bed on 05/03/2022, revealed the RN's date of hire to be 03/23/2020. Review failed to reveal any Enclosure Posey Bed restraint training during orientation or since hire and prior to use on a patient.

Interview on 08/22/2023 at 1350 with Staff #12, revealed she received an email referencing the Enclosure Posey Bed during the time the Patient was in the ED. Interview revealed Staff #12 stated she had not received any education on the Enclosure Posey bed prior to use on the named Patient. Interview revealed Staff #12 cared for Patient #15 while in the enclosure posey bed on 05/03/2022.

Interview on 08/21/2023 at 1140 with RN #22 revealed the RN did receive annual restraint education but had not received education on the Enclosure Posey bed.

Interview on 08/21/2023 at 1215 with RN #23, a hospital clinical nurse specialist, revealed that when staff in the ED or on the inpatient units need an Enclosure Posey restraint bed, they contact central distribution to deliver the bed and then contact the inpatient rehab staff or RN #23 for training. RN #23 stated she provided the staff with a "Just in-time" flyer that contained a link to a 3-minute video the staff should watch prior to using the enclosure bed on a patient. The staff were expected to sign an education roster to indicate attendance/completion. The attendance sheet should be collected and the staff education completion should be entered into the health learning system by the Unit Director, Unit Secretary or Staff Education Department staff. Interview revealed the beds were mostly used by the inpatient rehab unit and that the inpatient rehab staff received annual competency training on the Enclosure Posey beds.

Interview on 08/23/2023 at 1115 with the RN #24 revealed the enclosure bed was considered a restraint. The bed was often determined to be the least-restrictive measure because the patients have full mobility of all extremities and were able to move around in the bed without being able to climb out of the bed. The staff should have received training on the enclosure bed and why the bed was considered a non-violent restraint prior to patient use.

Request from administration, during the survey, for documentation of staff training/education on the Posey Enclosure bed revealed no documented evidence of staff training/education.

Based on policy review, quality monitoring data, quality committee meeting minutes, medical record reviews, incident report reviews and staff interviews the hospital failed to implement and maintain an effective, hospital-wide, data-driven quality assessment and performance improvement program for patient safety and improved clinical performance.

The findings included:

1. The hospital staff failed to conduct an internal investigation and implement corrective actions for an adverse event that resulted in patient injury in 1 of 3 patients reviewed on a specialty bed (Patient #21); and failed to provide monitoring to evaluate changes in care location and staffing for effectiveness and safety for acutely ill psychiatric patients.

~cross refer to 482.21 Quality Assessment and Performance Improvement Standard: Tag 0286

2. The hospital's governing body failed to ensure an effective quality assessment and performance improvement program that involved all hospital departments and services by failing to have quality monitoring data for the food and nutritional services provided to patients..

~cross refer to 482.21 Quality Assessment and Performance Improvement Standard: Tag 0308

Based on review of hospital policy, incident report review, medical record review and interviews with staff, the hospital staff failed to conduct an internal investigation and implement corrective actions for an adverse event that resulted in patient injury in 1 of 3 patients reviewed on a specialty bed (Patient #21) and failed to provide monitoring to evaluate changes in care location and staffing for effectiveness and safety for acutely ill psychiatric patients.

The findings included:

1. Review of policy titled "Management Plan: Medical Equipment Management Plan" with effective date of May 2022, revealed "Mission: The Medical Equipment Management Plan of (Named Facility) provides for safe, appropriate, and properly functioning medical equipment for diagnosis, monitoring, treatment, and patient care. It also serves to prevent equipment-related injury. SCOPE: This Medical Equipment Management Plan covers the activities of all (Named Hospital) accredited sites. The scope includes equipment leased, loaned, or owned and operated by vendors contracted to provide a clinical service...Safe Medical Devices Act: Any incident in which a patient or staff member is injured by a medical equipment problem, failure, or malfunction will be immediately reported to the Safety Zone Portal. Department director/manager will quarantine the medical equipment in question until returned to service or permanently removed from service. Risk Management may request that Clinical Engineering investigate the incident and the equipment in question and report their findings. The Risk Management Department reports the incident to the manufacturer and submits a report to the Food and Drug Administration (FDA) as directed in the Safe Medical Devices Act of 1990. A copy of the report will also be forwarded to the Environment of Care Committee/Medical Equipment Subcommittee."

Review of policy titled "Incident Reporting" with effective date of 07/19/2022 revealed "POLICY: The (named facility) Incident Reporting Program provides an effective method for reporting, investigation, follow -up, analysis, and trending of incidents involving patients and visitors. This should result in improved risk identification, risk evaluation, and claims management. This in turn should minimize loss and improve the quality of medical services and safety. Incident reports are for the review of the quality of care provided at (named facility). DEFINITION: An incident is an event that is inconsistent with a (named facility) policy or procedure, or that is not part of the routine care of a patient. Such incidents may or may not result in actual injury. There are two types of incidents: serious and non-serious. Serious incidents should be reported to the department director immediately and they include, but are not limited to, the following: ...10. A medical device failure that results in death or serious injury/illness.... Investigation and Follow-Up: The department director, in conjunction with Risk Management as mutually determined appropriate, is responsible for communication as needed with the patient or visitor and for resolving the causative risk if possible. This would include getting other management staff in the organization involved as needed to resolve the issue and future risk. The systemwide director of Risk Management has accountability for managing the incident reporting and analysis program."

Closed medical record review of Patient #21 revealed a 65 year old male who was admitted on 10/10/2022 and diagnosed with C-6 quadriplegia (Cervical 6 level of spinal cord paralysis. Patient is unable to have sensation or function of everything in the body from the top of the ribcage on down, including all four extremities). Patient #21 was transferred to the rehab unit on 10/20/2022 at 1537. Review revealed Patient #21 was placed on specialty bed (Agility/SizeWise Model number for blower AALT and mattress ALT 35) on 10/25/2022. Review of LPN (Licensed Practical Nurse) #21's note dated 10/29/2022 at 1456 revealed "This nurse notified of very warm air bed by NT (nurse technician) and vital signs significant for temp (temperature) of 100.1 F (Fahrenheit). This nurse uncovered patient (Patient #21) and call (sic) MD (Medical Doctor). Instructed to uncover patient and monitor.... Pt (Patient) relocated to power chair and new airbed ordered from portable equipment." Review of the discharge summary dated 11/14/2022 at 0516 written by PA (Physician Assistant) #20 revealed "Hospital Course: ...Patient with small blister on backside from burn/stage II coccyx secondary to burn from mattress not pressure continue local skin care."

Review of the incident report completed on 10/29/2022 at 1606 by LPN #21 revealed "This nurse notified of very warm air bed by NT and vital signs significant for temp of 100.1 F. This nurse uncovered patient and call (sic) MD. Instructed to uncover patient and monitor.... Pt relocated to power chair and new airbed ordered from Portable Equipment. Please select any appropriate integrity issues involved: Blister. C) Minimal harm- minimal symptoms or loss of function or injury limited to additional treatment, monitoring and/or increased length of stay."

Review on 08/21/2023 of the incident report revealed Risk Management (RM #27) was notified of the incident report on 10/31/2022 at 2203, 2 days after the incident. Review of the comments on 11/3/2022 at 1701 from Supervisor #32 revealed "How preventable was the incident? Almost certainly could have been prevented. Equipment/Device: Function. Human Factors: Health Issues. Investigation Details: Patient was noted to have a blister to the right mid sacrum that was thought to be from the low air loss mattress being too hot. Mattress was replaced when noted."

Review revealed the facility failed to provide documentation of a FDA report completed regarding the bed incident.

Interview on 08/31/2023 at 1355 with Contract Manager #25 revealed "our department was not notified of the potential injury to the patient." Interview acknowledged a previous e-mail response which indicated there was no pickup call logged to the company, so the equipment got pushed downstairs and that was it. The customer service team had no email or phone call on 10/29/2022 or 10/30/2022 requesting services, notification of malfunction, or of an incident but because they visit the hospital daily, the tech on 10/30/2022 would know to check the soiled room in Portable Equipment. The tech would have cleaned the bed, gotten it patient ready to go back out to a location or placed on standby. Interview revealed the bed was reissued to another patient on 11/02/2022 at 1414 and the bed was not evaluated for proper functioning prior to being issued.

Interview on 09/01/2023 at 0930 with Risk Manager #27 (RM #27) revealed the incident report was reviewed a few days after the incident. Interview revealed RM #27 was not aware the bed was reissued to another patient on 11/02/2022, 3 days after the incident. The interview revealed there was not a full investigation into the incident. Interview revealed the policy was not followed.



36956

2. Review of the "Quality and Performance Improvement Plan" approved and effective 12/01/2022 revealed, "PURPOSE: The Quality and Performance Improvement Plan is a coordinated, comprehensive, and continuous effort to improve performance of care and services throughout the (name of facility system). Its goal and purpose shall be to promote the health and safety of patients throughout the organization and to strive to provide optimal outcomes with continuous improvement. (Facility name) leaders ensure that important processes and activities are measured, assessed, and improved systematically throughout the organization. ..."

Observation on 08/17/2023 at 1007 during tour of the Campus D Behavioral Health Hospital (BHH) Adult unit revealed an opened area and the unit nurse's station. The unit had two locked badge accessible halls (400 and 500) and an unlocked hall (300). The 400 and 500 halls were located to the left of the nurse's station and the 300 hall was located to the right of the nurse's station. There was no visibility between the 400 and 500 locked halls.

Observation on 08/23/2023 at 0849 during tour of the admission area for Campus D BHH revealed the patient admission and skin assessment area was located away from the Campus D BHH Adult locked unit and not visible to that area.

Review on 08/30/2023 of hospital documentation titled "Scope of Services...BHH Adult Unit ...Reviewed 8/7/2023 revealed, "1 ....Department Description - The Adult Unit is a 50 bed Acute Care Unit providing 7 days a week 24 hours a day inpatient psychiatric treatment....A patient classification is utilized to determine the acuity level and/or number of nursing personnel needed....For the high acuity hall the ratios are 1 nurse to 8/9 patients and 2 MHT (Mental Health Technicians) to 8/9 patients 24 hours a day 7 days a week ..."

Review of BHH staff minutes dated 07/27/2023 and 08/02/2023 revealed on 08/07/2023 the BHH Adult unit would change the one acute, locked 500 hall from a seventeen bed into a nine bed hall. The unlocked 400 hall would transition into a locked eight bed hall. The BHH staff voiced concerns about RN (Registered Nurse) and MHT (Mental Health Technician) staff leaving the locked halls and staff being left alone on a hall with acute patients. The staff was concerned regarding safety for staff and patients when the RN and MHT left the locked hall to admit patients and when the MHT left to accompany patients to the ED (Emergency Department) without any coverage.

Interview on 08/18/2023 at 1451 with RN #51 revealed on 08/08/2023 the unlocked 400 hall became a locked hall and matched the 500 hall. The 500 hall had acute thought disorder patients that could exhibit violent behaviors. Interview revealed the unit Charge Nurses had assignments on the locked units. RN #51 expressed the Charge Nurses should never include assignments on the 400 and 500 halls because acutely ill psychiatric patients are left without licensed nursing supervision when the Charge Nurse had to leave a hall. RN #51 stated the CN covered all halls, sometimes had assignments on the locked halls, and often times performed admissions off the unit. Interview revealed there was an increased risk of harm for patients and staff when a locked hall was left without supervision of a nurse.

Interview on 08/29/2023 at 1034 with RN #48 revealed staffing before 08/07/2023 was 2 RNs and 2 Techs on the 500 hall and 2 RNs and 2 Techs on the 400 hall. After 08/07/2023 staffing changed to 1 RN and 2 Techs on each locked hall. RN #48 stated the unit did not always have enough staff. The assigned CN often split patients with the 300 hall staff and had a full assignment on one of the locked halls. If the CN was assigned to the locked hall and received an admission, the nurse had to leave the hall to admit the patient. RN #48 stated one hall would be unsupervised thirty minutes to one hour. RN #48 stated, "I have been Charge Nurse, had an assignment on the 500 hall, and had to perform admissions off the hall. I have done admissions off the hall 30 minutes depending on the patient to an hour."

Interview on 08/29/2023 at 1015 with MHT #53 revealed, on the locked 500 hall, the staffing grid (assignment) did not account for the MHT when the MHT left Campus D to accompany patients for scans or medical assessments on Campus A or Campus B. The grid did not tell the story as to what happened throughout the day. MHT #53 felt unsafe when left alone on the locked hall with aggressive patients.

Interview per telephone on 08/29/2023 at 1558 with CNO #41 revealed since 08/07/2023 she was not able to provide monitoring of licensed nursing staff and staffing coverage when staff left the hall. Interview revealed CNO #41 was aware of the staff concerns about inadequate staffing and safety that had been voiced in meetings. The CNO stated that she felt the concerns were not valid and that staff were complaining due to the change in the hall set-up. Interview revealed there was no quality monitoring or data to evaluate the number or duration of times that staffing was reduced from planned staffing ratios. No data was available to evaluate if the new high acuity halls (400 and 500 halls) staffing plan was effective since the change was put in place on 08/07/2023.

In summary, on 08/07/2023 a change was made to convert the 400 hall to a locked patient area, resulting in two locked halls and one unlocked hall to house acute psychiatric patients. One licensed nurse was assigned to each locked hall, with two MHT's for eight patients on the 400 hall and 9 patients on the 500 hall. There was no visibility between the halls. Interviews and staffing sheets indicated licensed nursing staff may be assigned patients on two halls, which would cause them to be off their main hall intermittently. Licensed and unlicensed staff also left the hall to perform skin assessments for new admissions. MHTs had to leave the halls to go off campus with patients for emergency department visits or scheduled diagnostic tests, leaving the hall with reduced staff. These off-hall activities resulted in a lack of constant licensed nursing presence on all halls and a decrease in total staff on a hall. Leadership interviews revealed these issues occurred but only for short periods of time. Requests for monitoring related to the changes did not yield any monitoring data. Without quality monitoring of staffing for a constant licensed nursing presence and adequate staff on each locked hall at all times there was increased risk of serious harm for patients and others.

Based on review of hospital policy, quality monitoring data, quality committee meeting minutes, and staff interviews, the hospital's governing body failed to ensure an effective quality assessment and performance improvement program that involved all hospital departments and services by failing to have quality monitoring data for the food and nutritional services provided to patients.

The findings included:

Review of the "Quality and Performance Improvement Plan" approved and effective 12/01/2022 revealed, "PURPOSE: The Quality and Performance Improvement Plan is a coordinated, comprehensive, and continuous effort to improve performance of care and services throughout the (name of facility system). Its goal and purpose shall be to promote the health and safety of patients throughout the organization and to strive to provide optimal outcomes with continuous improvement. (Facility name) leaders ensure that important processes and activities are measured, assessed, and improved systematically throughout the organization. ... ROLES AND RESPONSIBILITIES FOR QUALITY AND PERFORMANCE IMPROVEMENT: Executive Leadership: Provides oversight for systemwide and hospital quality and patient safety initiatives. ... DEPARTMENTAL AND STAFF RESPONSIBILITIES FOR QUALITY IMPROVEMENT: ... Senior leaders hold regular meetings to review performance data ... Staff participate on teams, in data collection, and in reporting of department specific and organizational improvement activities. ... Leadership maintains monitoring, regulatory requirements and quality and patient safety initiatives in nursing and ancillary departments (inpatient and outpatient reporting). ... METHODOLOGY: ... All projects will focus on achieving, through ongoing measurement and intervention, demonstrable and sustained improvement in significant aspects of clinical care and non-clinical services to have a beneficial impact on health outcomes and patient satisfaction. ... STRUCTURE FOR REPORTING AND REVIEW OF ACTIVITIES: The administration of the hospital and medical staff has established committees that relate to quality improvement activities. The hospital and medical staff committees provide information to the Quality Management Council/Patient Safety Committee relating to identification of opportunities for improvement, analysis of data, recommendations for improvement, actions taken, and analysis of the impact of the recommended interventions(s). ..."

Review of QAPI monitoring from October 2022 through June 2023 revealed no data was collected, aggregated and reported for food and nutritional services, or included in the quality and safety dashboard. There were no quality indicators regarding dietary services included in the hospital tracking.

Review of quality committee meeting minutes from August 2022 through June 2023 (most recent available minutes) revealed no aggregated data was reported regarding food and nutritional services.

Interview on 09/01/2023 at 1630 with QA #40 (quality assurance staff member) reported dietary and nutritional services were provided at multiple campuses throughout the hospitals. Interview revealed there was no quality data for food and nutritional services available. Interview revealed no data for food and nutritional services was reported to the governing body or leadership team.

Based on observations, hospital policy review, meeting minutes review, staff assignment sheets review, medical record review, and staff and physician interviews, the hospital's nursing staff failed to supervise and provide oversight to ensure a safe environment of care to behavioral health patients.

The findings included:

The hospital's nursing staff failed to provide constant licensed nursing supervision for acutely ill behavioral health patients on 2 of 2 locked adult behavioral health halls (Hall 400 and Hall 500).

~ cross refer to 482.23 Nursing Services Standard: Tag A0395

Based on observations, hospital policy review, meeting minutes review, staff, assignment sheets review, medical record review, and staff and physician interviews, the hospital's nursing staff failed to provide constant licensed nursing supervision for acutely ill behavioral health patients on 2 of 2 locked adult behavioral health halls (Hall 400 and Hall 500).

The findings included:

On 08/17/2023 at 1007 tour of the Campus D Behavioral Health Hospital (BHH) Adult unit revealed an opened area and the unit nurse's station. The unit had two locked badge accessible halls (500 and 400) and an unlocked hall (300). The 500 and 400 halls were located to the left of the nurse's station and the 300 hall was located to the right of the nurse's station.

On 08/23/2023 at 0849 tour of the admission area for Campus D BHH revealed the patient admission and skin assessment area was located away from the Campus D BHH Adult locked unit and not visible to that area.

Review on 08/30/2023 of hospital documentation titled "Scope of Services ...BHH Adult Unit ...Reviewed 8/7/2023 revealed "1 ....Department Description - The Adult Unit is a 50 bed Acute Care Unit providing 7 days a week 24 hours a day inpatient psychiatric treatment. The treatment Program is to help Adults with psychiatric problems remain safe, ...3. Services Provided - Services provided include the provision of a safe and therapeutic environment 24 hours a day, 7 days a week by RN (Registered Nurse) Staff that are supported by an ancillary staff of LPN's (Licensed Practical Nurse), Mental Health Technicians and a Unit Secretary. Physician supervision and intervention daily ....4. Admission Criteria ...The following are criteria to be used in deciding whether or not to admit an Adult for inpatient psychiatric care: ...Patients with mood disorders, including depression, impulse disorders and mania, who have demonstrated suicidal or homicidal thoughts, intent, or attempt to harm themselves or others ....Patients with acute thought disorders including hallucinations, delusions, and/or paranoia that interferes with his/her daily functioning and poses a threat to the health and safety of the patient and/or others ...5. Staffing Plan/Ratios ...The Adult Unit works on the team model of nursing care delivery. While the master staffing plan must be flexible, there are some standards set based on the specified level of care required by most patients admitted to each unit ....A patient classification is utilized to determine the acuity level and/or number of nursing personnel needed ....For the high acuity hall the ratios are 1 nurse to 8/9 patients and 2 MHT (Mental Health Technicians) to 8/9 patients 24 hours a day 7 days a week ..."

Review on 08/31/2023 of "BHH Staff Meeting" minutes dated 07/27/2023 revealed " ... 9) Transition of 400 Hall to a locked Unit ... Minutes/Summary, Assignments and Decisions ... 400 hall to locked Unit: Plan to transition the 400 hall into locked unit to mirror 500 hall. Current state only 500 hall is locked and able to provide space for more acute/thought disordered pts (patients) ... Proposed staffing: feedback has been received that if given a choice 1 RN and 2 MHT's would be preferred on the 500 Hall to better manage milieu. 1 RN and 2 MHT's will be piloted on the 400 Hall as well. We will try the staffing suggestion to see how that works, not set in stone and subject to change ... Questions continue about the staffing and safety. What happens with (sic) when you have admissions, 1 MHT goes out for Scans or now you're down a staff member. Now you have no one to watch the hall ...or if there is a 1:1 (aggressive, disruptive or suicidal patients require a staff within eyesight of patient for safety)." Review revealed the plan to transition the 400 hall into a locked unit will "Go live pilot" on 8/7/23 and the CNO #41 will continue to address concerns. Continued review of BHH Nursing Meeting minutes dated 08/02/2023 revealed the agenda included the transition to the BHH 400 hall. The minutes noted a nursing staff member voiced concerns to the 400 hall transition from an unlocked unit to a locked unit. The staff member voiced concerns because " ...there may be only 4 nurses with 30 patients and an increased acuity. Need two nurses to review STARR (Safe Training and Responsible Restraints) packet, cant (sic) leave the unit to draw meds. AC (Administrative Coordinator) may be able to help, but not if there are walk-ins." The staff stated "... asked about walk-ins and what resources can help because if we are going to mass overhaul this needs to be revisited. The AC cant (sic) be on the 400 500 halls and in the lobby at the same time ..."

Review on 08/31/2023 of meeting minutes from a BHH TOWN HALL MEETING dated 08/09/2023 revealed "Updates from PowerPoint....BHH is now a programmatic shift to where we are bringing in additional thought disorder patients for the 400 hallway to make this unit more secure. There is a lot that goes into this including process change, staffing change, and physical changes to accommodate this need ...."

Review on 09/01/2023 of the "BHH Census and Nursing Report Sheet Adult Unit" (Assignment sheets) dated 08/08/2023 7:00am - 7:00pm shift revealed four RNs were assigned to the unit and three of the four RNs were assigned to split the halls (the RN provided patient care on more than one hall including locked halls). RN #56 was assigned to the unlocked double occupancy 300 hall (room numbers 300/02, 301/01, 301/02, 302/01, 302/02, 303/01, 304/01, 304/02, 305/01, and 305/02). RN #44 was assigned as the Charge Nurse (CN) for the entire Adult Unit, was assigned patients on the unlocked double occupancy 300 hall (room numbers 306/01,307/01,307/02) and assigned patients on the locked 400 hall (room numbers 400, 401, 402, 403, and 404). Review revealed RN #45 was assigned patients on the locked 400 hall (room numbers 405,406, 407) and assigned patients on the locked 500 hall (rooms numbers 500, 501, 502, and 503). Review revealed RN #49 was assigned patients on the locked 500 hall (room numbers 504, 505, 506, 507 and 508). Review revealed RN #44, RN #45 and RN #56 were assigned as the admitting nurses. Review of the BHH Admissions on 08/08/2023 at 1551 revealed RN #44 admitted a patient and performed the skin assessment. This required the admitting RN and the skin assessment staff (MHT) to be off the hall. Review revealed on 08/08/2023 during the 7:00am - 7:00pm shift potential existed for at least one locked hall to be left unsupervised by a licensed nurse and staffing during this time was reduced to 1 MHT for eight patients.

Review of the "BHH Census and Nursing Report Sheet Adult Unit" (Assignment sheets) dated 08/08/2023 for the 7:00pm - 7:00am shift revealed three RNs were assigned to the BHH Adult unit. RN# 50 was assigned to the unlocked double occupancy 300 hall (rooms 300/02, 301/01, 302/01, 302/02, 303/01, 303/02, 304/01, 304/02, 305/01 and 305/02). RN #47 was assigned to the unlocked double occupancy 300 hall (rooms 306/01, 307/01, 307/02) and the entire locked 400 hall (rooms 400, 401, 402, 403, 404, 405, 406, and 407). Review revealed RN #47 left the locked 400 hall to assess, evaluate and provide care for assigned patients on the unlocked 300 hall. RN #46 was assigned to the locked 500 hall (room numbers 500, 501, 502, 503, 504, 505, 506, 507 and 508). The CN for the Adult unit with a census of 30 patients was RN #46. Review of the BHH Admissions on 08/08/2023 revealed RN #46 admitted two patients and performed skin assessments at 0057 and 0209. When RN #46 left the unit to perform the two patient admissions, the adult unit with the census of 30 patients was left with 2 RNs for the 300 hall, locked 400 hall, and locked 500 hall. Review revealed on 08/08/2023 during the 7:00pm- 7:00am shift at least one locked hall was left unsupervised by a licensed nurse and staff was reduced.

Closed medical record review revealed Patient #51 was admitted to BHH on 08/18/2023 at 1553 (admission area) with a diagnosis of Schizoaffective Disorder (mental health disorder with signs and symptoms of hallucinations, delusion, mood disorders of depression or mania). Patient #51's location at 1712 upon arrival to the Adult 500 hall in the dayroom. (1 hour and 19 minutes after the patient was located in the admissions area). Review of the "BHH Census and Nursing Report Sheet Adult Unit" (Assignment sheets) dated 08/18/2023 for the 7:00am - 7:00pm shift revealed the admitting RN was RN #45. Review revealed potential existed for at least one locked hall left unsupervised by a licensed nurse with a reduction in staff.

Closed medical record review for Patient #54 revealed on 08/22/2023 a 56 year old male was admitted to BHH at 1645 with a diagnosis of Schizoaffective disorder. Patient #54's location at 1723 was on the Adult 400 hallway (1 hour and 38 minutes after the patient was located in the admissions area). Review of the "BHH Census and Nursing Report Sheet Adult Unit" (Assignment sheet) dated 08/22/2023 for the 7:00am- 7:00pm shift revealed RN #48 was the CN and was assigned to the locked 400 hall with a patient census of eight. RN #50 was assigned to the locked 500 hall with a census of nine. Review of the the BHH Admissions revealed the admitting RN was RN #48. Review revealed potential existed for at least one locked hall left unsupervised by a licensed nurse with a reduction in staff during the 7:00am - 7:00pm shift.

Interview on 08/18/2023 at 0830 with the BHH CNO #41, AC #42 and Accreditation and Patient Safety (APS #43) revealed in February 2023 there was a regulatory agency review with recommendations that the 500 hall staffing needed to be reviewed because of the high patient acuity. The 500 hall was the only locked hall on the unit. The 400 and 300 halls were unlocked with less acute patients. After the recommendations the staffing changed to 2 RNS and 1 MHT. Due to the need to care for more psychotic patients from the Emergency Department (ED) and the community the 400 hall was converted from an unlocked hall to a locked hall to mirror the locked 500 hall. On 08/07/2023 the 400 hall became a locked hall and provided care for Thought Disorder patients. On 08/07/2023 the 400 hall staffing was 1 RN and 2 MHTs to 8 patients and the 500 hall staffing was 1 RN and 2 MHTs to 9 patients. Interview on 08/29/2023 at 1558 with CNO #41 revealed she was not able to provide a monitoring of licensed nursing staff and staffing coverage when staff had to leave the hall. CNO #41 stated a licensed nurse and a MHT left the hall to perform admission and skin assessments on newly admitted patients. The licensed nurse had to remain with the patient until the patient could be moved to the assigned hall.

Interview on 08/18/2023 at 1451 with RN #51 revealed on 08/08/2023 the unlocked 400 hall became a locked hall and matched the 500 hall. The 500 hall had acute thought disorder patients and could exhibit violent behaviors. Interview revealed the unit Charge Nurses had assignments on the locked units. RN# 51 expressed the Charge Nurses should never include assignments on the 400 and 500 halls because acutely ill psychiatric patients are left without licensed nursing supervision when the Charge Nurse leaves a hall. RN #51 stated the CN covered all halls, sometimes had assignments on the locked halls, and often times performed admissions off the unit. Interview revealed there was an increased risk of harm for patients and staff when a locked hall was left without supervision of a nurse.

Interview on 08/29/2023 at 1034 with RN #48 revealed staffing before 08/07/2023 was 2 RNs and 2 Techs on the 500 hall and 2 RNs and 2 Techs on the 400 hall. After 08/07/2023 staffing changed to 1 RN and 2 Techs on each locked hall. RN #48 stated the unit did not always have enough staff. The assigned CN often split patients with the 300 hall staff and had a full assignment on one of the locked halls. If the CN was assigned to the locked hall and received an admission, the nurse had to leave the hall to admit the patient. RN #48 stated one hall would be unsupervised thirty minutes to one hour. RN #48 stated, "I have been Charge Nurse, had an assignment on the 500 hall, and had to perform admissions off the hall. I have done admissions off the hall 30 minutes depending on the patient to an hour."

Interview on 08/18/2023 at 1653 with MHT #52 on the locked 500 hall revealed often 1 MHT was left to cover the entire hall because the RN went off the hall to admit patients. Sometimes the RN assigned to the 500 hall was assigned as CN and covered the entire unit. Often there was 1 MHT left on the hall for eight to nine patients. Interview revealed the MHT had to go off the hall with the licensed nurse to admit patients and assist with skin assessments leaving one MHT on the hall. MHT #52 stated "we have talked about this for a long time and was told we worry too much about acuity. I don't think asking about acuity coverage is too much for our safety."

Interview on 08/29/2023 at 1015 with MHT #53 revealed, on the locked 500 hall, the staffing grid (assignment) did not account for the MHT when the MHT left Campus D to accompany patients for scans or medical assessments on Campus A or Campus B. The grid did not tell the story as to what happened throughout the day. MHT #53 felt unsafe when left alone on the locked hall with aggressive patients.

Interview on 08/29/2023 at 1101 on the unlocked 300 hall with RN #44 and MHT#54 revealed all behavioral health staff were trained to work on all behavioral health halls including the locked halls. RN #44 revealed the CN would split the halls with 1 RN assigned to the 300 hall and the 400 hall. The problem "is" the RN on the 400 hall would leave the 400 hall to provide care for the assigned patients on the 300 hall. Interview revealed the locked hall often would not have RN supervision.

Interview on 08/29/2023 at 0930 with AC #55 revealed the RN or CN from the Adult unit/hall performed patient admissions off the unit in the admissions area. The admission process and the skin assessment took at least 30 minutes or more depending on the patient's behavior. The admission staff remained with the patient until the patient was transferred to the assigned unit. The admission staff consisted of two staff members, one of which is a licensed nurse.

Interview on 08/29/2023 at 1558 with CNO #41 revealed CNO #41 acknowledged the staffing would reduce to 1 staff but "never purposely or planned."CNO #41 revealed staff left the hall but not for an extended time "no more than 10 to 15 minutes not for hours or a shift by any means."

In summary, on 08/07/2023 a change was made to convert the 400 hall to a locked patient area, resulting in two locked halls and one unlocked hall to house acute psychiatric patients. One licensed nurse was assigned to each locked hall, with two MHT's for eight patients on the 400 hall and 9 patients on the 500 hall. There was no visibility between the halls. Interviews and staffing sheets indicated licensed nursing staff may be assigned patients on two halls, which would cause them to be off their main hall intermittently. Licensed and unlicensed staff also left the hall to perform skin assessments for new admissions. MHTs had to leave the halls to go off campus with patients for emergency department visits or scheduled diagnostic tests, leaving the hall with reduced staff. These off-hall activities resulted in a lack of constant licensed nursing presence for nursing supervision of care.

Based on facility policy review, medical record review, and staff and physician interviews, the facility staff failed to have effective emergency services to meet the needs of patients that presented to the Emergency Department.

The findings included:

The facility emergency department staff and providers failed to organize Emergency Services to provide for a safe discharge plan by failing to evaluate environmental barriers and coordinate resources prior to discharge for 1 of 1 sampled Autistic, IDD patient that discharged from the emergency department (Patient #6).

~cross refer to 482.55 Emergency Services Standard: Tag 1103

Based on facility policy review, medical record review, and staff and physician interviews, the facility staff failed to organize Emergency Services to provide for a safe discharge plan by failing to evaluate environmental barriers and coordinate resources prior to discharge for 1 of 1 sampled Autistic, IDD patient that discharged from the emergency department (Patient #6).

The findings included:

Review on 09/01/2023 of the Hospital policy titled "Discharge to Alternative Level of Care" effective 05/07/2021 revealed "The Transitions of Care team member will assess and coordinate services for transitions based on the patient/family choice, clinical needs, and insurance benefit plan."

Review on 09/01/2023 of the Hospital policy titled "Involuntary Commitment" effective 11/09/2022 revealed " ... Renewal of Commitment: A custody order is valid for 7 days ... A new Affidavit and Petition for Involuntary Commitment (Form AOC-SP-300) and First Examination for Involuntary Commitment (Form DMH 5-72-19) must be completed prior to the expiration of the current order if the patient still meets involuntary commitment criteria. The two forms must be faxed to the Magistrate's Office and the new findings will be issued for the new petition by the Magistrate's Office ... Rescinding Involuntary Commitment: A patient under Involuntary Commitment can be released from the Involuntary Commitment by any certified commitment examiner during the first examination (First Examination for Involuntary Commitment [form DMH 5-72-19]) or any other time during the encounter based on collateral information obtain from Clinical Social Work (CSW), Behavioral Health counselor, or psychiatrist's recommendation using the Notice of Commitment Change (form DMH 579-01). A copy of this form must be faxed to the Clerk of Court, the original mail to the Clerk of Court, and a copy sent to Health Information Management. The Notice of Commitment Change Form can only be completed by an attending physician.

Medical record review on 08/15/2023 for Patient #6 revealed a 26-year-old male arrived to Campus B's Emergency Department (ED) on 07/08/2023 at 0304 for "Aggressive Behavior". ED Triage Note at 0309 revealed "BIB (brought in by) ... EMS ([county initials] emergency medical services) & (and) PD (Police Department) with c/o (complaint of) aggressive behavior. Initially taken to Campus C, given Geodon (medication used to treat mental health conditions) and Ativan (sedative medication), told too aggressive for them and sent here. Hx (history) of autism." Patient #6 was assigned an acuity level of 2 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Vital Signs at 0311 were "BP (blood pressure): 99/84 Temp (temperature): 97.5 F (Fahrenheit) ... Pulse Rate: 84 Resp (respiratory rate): 20 SpO2 (oxygen saturation): 99%." Review of the ED Provider Note at 0515 revealed "attempted to call patient's Father but call went to voicemail. Will continue to observe in the ED, sedation as needed with CSW (clinical social work) assistance in the AM (morning) ... Clinical Course 0513 Patient becoming increasingly loud and agitated in the hallway. Had Geodon at Campus C just a few hours ago. Will give additional Ativan IM (intramuscular) for now. 0529 Patient becoming more physically aggressive with staff as Ativan given. Will attempt to de-escalate but if he continues to be dangerous, will need restraints. 0638 Spoke with the patient's Step-mother ... who reports he has attacked her and his father He was previously in and out of hospitals and group homes. They have only had him for the last month. They are no longer able to take care of him ... Final diagnoses: Aggressive behavior ... ED Discharge Orders: None." Review of the Nurse Note dated 07/08/2023 at 0805 revealed "This nurse called patients father at 0804, no answer. Called step mother (Name of step mother) at 0805 ... explained ... that patient is medically and psych cleared and patient must be picked up from ER (emergency room). (Name of step mother) states she is afraid of patient because patient is screaming. This nurse gave (Name of step mother) names of 3 (three) psychiatric hospitals in NC (North Carolina) per (Name of step mother) request. (Name of step mother) stated she will file IVC (involuntary commitment) on member. Writer educated (Name of step mother) is welcome to file IVC, however, patient is already psych cleared by providers. Educated member must be picked up from ED or parents could be held liable for abandonment. (Name of step mother) stated ED needs to let patient sign himself out. Writer advised patient will not be allowed to leave ED on his own due to ID/cognitive impairment and presence of legal guardianship. (Name of step mother) stated she is not picking patient up and hung up the phone." Nurse Note dated 07/08/2023 at 1325 revealed "Pt refusing to cooperated (sic), screaming and leaving room, pinch (sic) grabbing staff, placed in soft restraints for safety. Pt has been medicated and will be removed after med effect." Nurse Note dated 07/08/2023 at 1936 revealed "Patient is hitting himself in the head and biting the police. Patient walked up on sitter and security staff had to physically move patient back to his room." Nurse Note dated 07/08/2023 at 2000 revealed "Patient just smacked the police officer in the head." Nurse Note dated 07/09/2023 at 2036 revealed "Patient open handed hit me in the chest. Then charged at me. (County initial) PD (police department) and security took patient down. We restrained the patient. MD (Medical Doctor) notified." Nurse Note dated 07/10/2023 at 0055 revealed "Patient wake (sic) up and start to get agitated. Patient yelling and screaming in the bed 'I want to go home'. Restraints ordered and applied ..." Review of the ED Provider Note on 07/10/2023 at 0719 revealed "... Currently, the patient is currently restraint (sic) after aggressive behavior overnight ... Plan: Current plan is for placement ... is not under involuntary commitment." Nurse Note dated 07/10/2023 at 1350 revealed "Pt shouting out in his room ...Pt difficult to redirect ... After exiting the room pt charged towards me and made it approximately 15' (feet) before being accosted (approached/addressed) by (County initial) PD police officers and carried to bed. De-escalation techniques unsuccessful ... patient attacking (County initial) PD officers. Pt made two attempts at charging (County initial) PD officers and forcibly grabbed one's arm trying to scratch and claw at his skin. (MD #36) called to bedside and pt placed in soft restraints." The ED Provider Note dated 07/11/2023 at 0900 revealed "... Recent changes in the last 24 (twenty-four) hours include outburst of aggressive behavior, scratched staff members overnight and required to be restrained ... Plan: Current plan is for placement ... is under involuntary commitment." ED Provider Note dated 07/11/2023 at 1814 revealed "... evaluated the patient multiple times this afternoon, he continues to be aggressive, violent and requiring multiple people and physical restraint to keep him in bed. He has been medicated today with additional medicines ... without relief ... will give additional medication at this time ... anticipate he will require additional restraint and close observation. He is being followed closely by the TTS/psychiatry (Therapeutic Triage Specialist). Hopefully they will continue to monitor and offer medication and behavioral guidance. There is been (sic) a concern the patient has been self injuring himself by pounding his head. He does not show any signs of acute head injury at this time ... do not think it would be beneficial to get a head CT (computerized tomography - combination of x-ray images from different angles to form detailed images of a body part) at this time." Nurse Note dated 07/12/2023 at 0831 revealed "While giving medication, pt became extremely agitated and began screeching. Pt kicked this RN (Registered Nurse) in abdomen. Pt then took medication." ED Provider Note dated 07/12/2023 at 0906 revealed "... Currently, the patient is violent and aggressive requiring chemical and physical restraint ... Plan: Current plan is for psychiatric placement ... is under involuntary commitment." Nurse Note dated 07/12/2023 at 1203 revealed "Pt verbally and physically aggressive with staff. Pt charging sitting (sic) and making hand motions as if to hit her. Pt placed in violent restraints ..." Nurse Note dated 07/12/2023 at 1700 revealed "Pt screaming, comtinues (sic) to hit his head, and hit security officer." Nurse Note dated 07/12/2023 at 2207 revealed Pt aggressive. Pt attempted to grab staff by arm, but was unsuccessful. Pt ran out of room, trying to fight with security. Pt redirected to room. Pt attempted to hit and kick staff while redirecting to room ... Restraints administered. Pt attempted to hit and kick staff while putting on restraints." Nurse Note dated 07/13/2023 at 0525 revealed "Patient pushed (NT #11 Name) aggressively to the door. Screaming, uncooperative. (MD #37) notified for medication and violent restraints order." ED Provider Note dated 07/13/2023 at 0810 revealed "... Currently, the patient is restraint (sic) in the bed. Sleeping ... have reviewed the labs performed to date as well as medications administered while in observation. Recent changes in the last 24 hours include patient continues (sic) with severe aggression and agitation. He has required multiple. (sic) Some restraint as well as psychotropic medications. Plan: Current plan is for placement to (initials of hospital) hospital when bed becomes available ... is under involuntary commitment." Nurse Note dated 07/13/2023 at 2234 revealed "Message sent to (MD #38) regarding pt's behavior and restrain order to expire at 2245, feel unsafe for pt and medical staff for pt to be removed from restraints at this time as pt still have (sic) outburst of behavior and has not shown extensive periods of calm and cooperative behavior ..." ED Provider Note dated 07/14/2023 at 0517 revealed "Patient intermittently agitated, yelling and physically aggressive with staff. Had several hours of good control after Haldol (medication used to treat certain types of mental disorders) earlier in the shift. Has not had good control with other antipsychotics (medication used to treat mental disorders) and anxiolytics (medication to treat anxiety). Will give additional dose now. In soft restraints for patient and staff safety." Nurse Note dated 07/14/2023 at 0831 revealed "Pt remains in four point restraints. He is non-redirectable. Shouting constantly at staff ..." Nurse Note dated 07/14/2023 at 1422 revealed "Patient running out to desk trying to hit security guard then proceeds to fall on floor. Patient escorted back to bed and restrained." Nurse Note dated 07/15/2023 at 0951 revealed "Pt screeching, coming out of room charging at staff. Pt escorted back to room by security and (County initial) PD. Restraints placed on pt for staff and patient safety ..." Nurse Note on 07/15/2023 at 1335 revealed "MD notified of pressure injuries to bilateral wrists." Nurse Note dated 07/15/2023 at 1720 revealed "Pt talked on phone to dad, then became very upset, screeching, charging at security and (County initial) PD out of room. Pt swinging fists and grabbing this RN and NT sitter. Pt carried back to bed and physical hold performed to place patient in restraints. Pt continued to be aggressive and uncooperative while placing restraints. MD notified." Review of the ED Provider Note dated 07/16/2023 at 1019 revealed "... Recent changes in the last 24 hours include (sic) continues with periods of outburst requiring intermittent chemical as well as physical restraint. Patient has explosive behavior. Will benefit from not being in the unit where he is at. Plan: Current plan is for placement ... is under involuntary commitment." Nurse Note dated 07/16/2023 at 1300 revealed "Pt continues to charge out of room at staff despite redirection and security assist back to bed. Pt resisting and on floor. Kicking (County initial) PD. Placed in 4 point restraints, provider aware and order obtained. Pt aware of criteria for release." Nurse Note dated 07/16/2023 at 1854 revealed "Pt is increasingly agitated and rushed out of his room towards his sitter; put his hands on safety sitter's shoulders. Sitter and security staff were able to get pt to return to his room but he is highly agitated and difficult to redirect at this time. RN and sitter explained behavioral rules and told pt he would be placed back into restraints if he puts his hands on staff or continues acting aggressively." ED Provider Note dated 07/17/2023 at 0900 revealed "... Plan: Current plan is for placement. Family unable to care for patient at home ... is under involuntary commitment." Nurse Note dated 07/19/2023 at 0622 revealed "Patient attempting to push past sitter to exit room. Patient unable to be redirected. MHT (mental health technician) and (County initial) PD had to physically place patient back in bed." ED Provider Note dated 07/19/2023 at 0636 revealed "Patient became agitated and threatening to staff, required physical restraints for staff safety. I have ordered a dose of ziprasidone (medication used to treat mental health conditions) for staff safety." ED Provider Note dated 07/21/2023 at 0908 revealed "... Pt (patient) with hx (history of) autism and chronic behavioral issues, periods of agitated behavior. He was abandoned in ED by family who have refused to pick him up. Pt desires to return home. On exam, pt with mild swelling and erythema (redness) to left shoulder (?due to prior IM injections). No crepitus or abscess noted. ?mild cellulitis (bacterial skin infection). Staff to avoid using left shoulder for IM injections (and avoid any IM injections as much as possible). Warm compresses to area. Keflex (antibiotic) po (by mouth) ... Recent changes in the last 24 hours include ED obs (observation), reassessment, and TOC (transition of care) placement. Plan: TOC team working on placement ..." Nurse Note dated 07/21/2023 at 1333 revealed "Pt increasingly agitated, charged staff member and grabbed them. Pt given IM sedation, and then tried to get out of bed. Pt screaming, and placed into violent restraints. MD notified." Nurse Note dated 07/24/2023 at 2127 revealed Patient charged out of room screaming multiple times even after PRN (as needed) zyprexa (medication to treat mental disorders) (sic) and PRN ativan (sic). Notified (MD #38). New order for one-time dose IM Geodon ordered and given ..." Nurse Note dated 07/24/2023 at 2209 revealed "Patient not calming down after medications and constant calm de-escalation speaking with patient and holding his hand. He is screaming, yelling and charging at staff. He grabbed the security officer and almost broke the skin with his nails. New order for violent restraints and placed on patient ..." ED Provider Note dated 07/25/2023 at 1056 revealed "... Psych NP (Nurse Practitioner) saw the patient and they still recommend that patient be placed. Plan: Current plan is for inpatient psychiatry placement. Patient will be managed in the ED until placement ... is under involuntary commitment." Nurse Note dated 07/26/2023 at 1230 revealed "Pt attempted to push nurse tech through door. Pt redirected to sit in his bed and PRN meds were given." Nurse Note dated 07/26/2023 at 1514 revealed Pt came out of room, began hitting the windows on the door and screaming." Nurse Note dated 07/26/2023 at 1950 revealed "Pt. Became aggressive, grabbing staff and scratching back of neck. Pt. Became aggressive when informed he will go home when his daddy feels better. Pt. Jumped up and grabbed staff around neck, digging finger nails in back of staff's neck." Nurse Note dated 07/26/2023 at 2117 revealed "Patient very agitated and charging out of room multiple times. He scratched MHT (NT #11's name), on the back of the neck and broke the skin ... Violent restraints ordered and IM medication. Violent restraints applied with staff and security present. IM medication given ..." Nurse Note dated 07/27/2023 at 2007 revealed "Pt attempted to come at this writer d/t (due to) 'feeling anxious' about his father. Security redirected pt back to bed." Nurse Note dated 07/28/2023 at 0828 revealed "Patient continues to be agitated. Yelling, coming out of room, trying to attack security, grabbing, scratching staff, uncooperative with redirection. Provider notified." ED Provider Note dated 07/28/2023 at 0927 revealed "... patient got agitated and started trying to attack staff and running out of his room. Patient was placed in restraints and was given his daily medicines ... Recent changes in the last 24 hours include agitation and violence towards staff requiring restraint and getting his medications. Plan: Current plan is for inpatient placement ... is under involuntary commitment." Nurse Note dated 07/30/2023 at 0302 revealed "Pt very focused on discharge home and phone call to family members, pt came out of room attempting to grab staff and assault them. Verbal redirection ineffective, pt ran out of room and attempted to to (sic) grab staff after working himself into a rage. Several attempts to verbally de-escalate and well as bargain with pt with privileges." Nurse Note dated 07/30/2023 at 0415 revealed "Patient agitated walk (sic) from room to nursing statin (sic) grabbed the this (sic) tech wrist and hand hard." Review of the ED Provider Note dated 07/30/2023 at 1521 revealed "... Plan: Current plan is for social work helping to seek placement ... is under involuntary commitment." Review of the ED Provider Note dated 07/31/2023 at 1120 revealed "Recent changes in the last 24 hours include he continues to have behavioral problems requiring constant redirection. Plan: Current plan is for placement when bed is available ... redid his involuntary commitment paperwork today ... is under involuntary commitment." Nurse Note dated 07/30/2023 at 1625 revealed "Pt becoming agitated, came from room and grabbed tech by wrist and shirt. Pt assisted back to room by security ..." Nurse Note dated 07/30/2023 at 1812 revealed PT to door asking this RN to 'come here.' When RN states that she will not come now, he charges at desk, pt assisted back to room and bed by security. As soon as staff leaves the room, pt comes out of room again and charges at staff. Pt placed in 4 point restraints at this time." Nurse Note dated 07/31/2023 at 0225 revealed "Becoming aggressive and violent attempting grab at staff when he is met at the door." Nurse Note dated 07/31/2023 at 0442 revealed "Is able to bite his wrist restraints off." Nurse Note dated 07/31/2023 at 0450 revealed "Throughout the night security called to the bedside due to patients outbursts, aggressive posture and attempts to physically grab at staff and to assist in restraining patient." Review of the ED Provider Note dated 07/31/2023 at 2100 revealed " ... Patient acutely agitated, threatening staff, not redirectable. Patient presented danger to himself and other hospital staff. Will apply chemical restraints and physical restraints. Patient with improvement to his mental status and compliance following chemical restraints ..." Nurse Note dated 07/31/2023 at 2205 revealed "This is the worst I have ever seen this patient behave. He has tried to scratch, bite, squeeze the hands of security, and rip the clothing of security office. (sic) He has got out of his restraints three times and laid across the floor. He is constantly screaming the names of staff members repeatedly. The MD has been made aware of the volatile behavior." Nurse Note dated 08/01/2023 at 0249 revealed "Patient came running out of his room for the phone. Staff had to physically put the patient back in his room. Back in restraint for patient and staff safety." Nurse Note dated 08/02/2023 at 2210 revealed "Patient is banging fist against door and walls. Grabbing on staff and attempting to wrap his arm around staff member neck." Review of the Psychiatry Provider Note dated 08/03/2023 at 1214 revealed "Patient is not suicidal, homicidal, or psychotic and does not need inpatient psychiatric care. Crisis and safety planning done by NP prior to recommending discharge ..." Review of the Provider Note dated 08/03/2023 at 1245 revealed "Patient needs to have a repeat kidney function and lithium level in one week. For behavioral health needs you are advised to follow up with the resources listed below: For psychiatry in the (City Name) area contact ... at your earliest opportunity to schedule a new patient appointment ... As an alternative, contact (County Name) Behavioral Health ... They offer psychiatry/medication management and therapy. New patients are seen in their walk-in clinic ... Please note that to be eligible for services you must bring an ID (identification) or a piece of mail with your name and a (County Name) address ... If you are in need of residential treatment to stabilize a crisis contact (Name of Facility) ... SC (South Carolina) ... For your ongoing behavioral health needs and to explore other treatment options for which you are eligible, stay in communication with your (Name) Health care coordinator ... For other services and benefits stay in touch with (Name) with (Organization)." Review of the Counselor Note dated 08/03/2023 at 1245 revealed "Per NP#17, this pt does not require psychiatric hospitalization at this time. NP #17 has spoken to pt's mother/co-guardian, (Name), notifying her of disposition. Pt presents under IVC initiated by EDP (emergency department provider - Name) Pt is psychiatrically cleared. Discharge instructions include referrals for area outpatient providers as well as his NC. A TOC consult has been ordered to facilitate pt's return to the community." Nurse Note dated 08/04/2023 at 0648 revealed "When patient woke up, he was able to be redirected a couple of times. Now, he is very anxious and agitated and charged out of room a couple of times. One of the times he charged out of room and wrapped his arms around NT (nurse tech) and squeezed her really tight. He also charged out of room and security was able to get him back in his room. Notified (MD #37). New order for 2 mg (milligrams) IM ativan ordered and given ..." Nurse Note dated 08/04/2023 at 2213 "Patient is charging out of room, very anxious, and unable to calm down with verbal de-escalation. Security has been present along with (NT #11's name), MHT. Already given PRN PO (by mouth) ativan and PO zyprexa. Notified (MD #39). New order for 10 mg IM geodon ordered and given." Nurse Note dated 08/04/2023 at 2317 revealed "Patient increasingly aggressive and unable to redirect. Notified (MD #39) New order for 2 mg ativan ordered and given ..." Nurse Note dated 08/05/2023 at 2057 revealed "Patient is very anxious and agitated. He hit his head really hard multiple times against he (sic) metal part of the door. He also squeezed my hand really tight. Notified (MD #35 name). New order for restraints and geodon 10mg IM ordered and given. Restraints placed with security and staff present." Nurse Note dated 08/05/2023 at 2241 revealed "Patient continues to scream and move up and down in the bed in restraints. Notified (MD #35 name). New order for Ativan 2mg IM ordered and given ..." Review of the ED Provider Note dated 08/06/2023 at 0809 revealed " ... Currently, the patient is awake, standing in doorway, requesting to go home ...Recent changes in the last 24 hours include recurrence of agitation last night requiring Ativan and restraints. Plan: Current plan if for placement ... is under involuntary commitment." Nurse Note dated 08/06/2023 at 2049 revealed "Patient had been speaking with his sitter, repetitive questions per normal. Patient then suddenly started screaming and banging his hands on the room glass. Security and sitter at bedside and patient placed on bed. Sitter now sitting in room speaking quietly with patient. PRN given as ordered." Nurse Note date 08/06/2023 at 2054 revealed "Pt screaming and kicking staff at bedside. Pt agitated and continues to jerk at restraints." Nurse Note dated 08/07/2023 at 0331 revealed "Patient continuously pushing past sitter to exit room. Several security guards needed for redirection to place back in bed." Review of the ED Provider Note dated 08/07/2023 at 0902 revealed "... Recent changes in the last 24 hours include had some aggressive behavior last night. Plan: Current plan is for waiting for mom to pick patient up ... is under involuntary commitment." Review of the Nurse Note dated 08/07/2023 at 1131 revealed "I have spoke with Patient #6's mother this morning and am awaiting a call back. Attempted to call dad with the call going straight to voicemail. (County initial) PD has been contacted to go to the father's home to make him aware that Patient #6 is ready for discharge and that if he does not come get his son, he will be arrest (sic) for abandonment. If I have not received a return call from mother within the hour, I will contact the police department in her area as well since her and dad are equal guardian and both a (sic) refusing to come get him." Nurse Note dated 08/07/2023 at 1150 revealed (County initial) PD has make (sic) contact patient's dad (Dad's name). Dad is denying avoiding hospital phone calls even though he has been including (sic) calls from me. (County initial) PD asked that I give the dad a deadline so he can arrange for Patient #6 to be picked up. Dad and (County initial) PD made aware that he has until today at 1700 to pick patient up or we will proceed with abandonment charges. (County initial) PD agrees this is a reasonable request and plenty of time. Officer (Name of officer) had requested that I call him if dad does not arrive by 1700." Nurse Note dated 08/07/2023 at 1345 revealed "Mother has made me aware that she is not picking patient up today and she would like one more day. She believes that NC start (a statewide community crisis prevention and intervention program for individuals age six and above with intellectual/developmental disability and co-occurring complex behavioral and/or mental health needs) is going to have a spot for Patient #6 in a program they have tomorrow despite being told by (Corporates name) SW (social work) that Patient #6 does not qualify for this program. The mother is now saying due to the weather she cannot come now. (County initial) PD had been update that the mother now also has no intention of picking up the patient either." Nurse Note dated 08/07/2023 at 1454 revealed "(Name of County mom lives in) County Sheriff has been notified and is on the way to mother's home at this time." Psychiatry Provider Note dated 08/07/2023 at 1625 revealed "... -Patient continues to remain a danger to self and others, continues to meet criteria for involuntary commitment. Patient appears to be at psychiatric baseline, therefore does not meet inpatient psychiatric criteria. Will psychiatrically clear patient at this time ..." Nurse Note dated 08/07/2023 at 1724 revealed "Information has been provided to (County initial) PD Officer (Officer Name). Warrants are being take out against Mom and Dad at this time for abandonment of patient." Nurse Note dated 08/08/2023 at 0314 revealed "Pt starting asking (sic) why staff said his daddy was going to heaven. Pt became agitated and grabbed staff and attempted to hit. Security and nurse came in and redirected to bed." Nurse Note dated 08/08/2023 at 0409 revealed "Increasingly agitated over the last hour. Episodic high-pitched screaming and attempting to leave room, with these episodes increasing in frequency. Less redirectable than earlier. Struck (NT #11's name) and myself in the chest ... Obtained order for geodon 10mg IM. Pt is actually agreeable to this as we would all like to avoid physical restraints if possible. Pt lied (sic) in bed and pulled down pants for shot without any manual hold or restraint. Administered geodon IM ..." Nurse Note dated 08/08/2023 at 0949 revealed "(Name of County mom lives in) County has contacted me this morning stating that Patient #6's mother is coming to (City Name) this morning to turn herself into (County initial) PD for her warrant and then she is coming to pick Patient #6 up. It will be later today as it is a 3hr (three hour) drive. Nurse Note dated 08/08/2023 at 1017 "Patient yelling and running out of room. Pinched security officer until bruise. Escorted back to bed." Nurse Note dated 08/08/2023 at 1030 "Pt placed in restraints per charge nurse." Review of the ED Provider Note (MD #6) dated 08/08/2023 at 1326 revealed "... the patient is continuing with his ongoing behaviors consistent with his autism spectrum disorder. He has been cleared by psychiatry and is medically cleared ... Psych: Patient is intermittently aggressive and then is interactive and redirectable ... Plan: Current plan is for d/c (discharge) to home ... is under involuntary commitment ..." Nurse Note dated 08/08/2023 at 1650 revealed "Pt is speaking with confused speech. PT (sic) 'screeched' before making a statement about having to urinate in a urinal instead of the bathroom. Pt was redirect back to his room." Nurse Note dated 08/08/2023 at 1657 revealed "Pt stormed out of room aggressively asking about his phone call. Pt is now banging and screaming against window." Nurse Note dated 08/08/2023 at 1720 revealed "Pt lunged at security and was redirected back to bed." Nurse Note dated 08/08/2023 at 1810 revealed "... was able to verbally deescalate with (County initial) PD and security at bedside. PO PRN meds given to help." Review of the ED Timeline at 08/08/2023 at 1819 revealed "ED Disposition set to Discharge". Patient #6 was discharged on 08/08/2023 at 2235. Review of the Medical Record revealed no Provider note or assessment of Patient #6 by MD #16, who set the ED disposition to discharge. Review of the Provider Orders and Restraint Flowsheet revealed Patient #6 was in physical restraints 21 (twenty-one) of the 31 (thirty-one) days between July 8, 2023 through August 8, 2023 while Patient #6 was in Campus B's ED. Review revealed Patient #6 was under IVC that was initiated on 07/10/2023, renewed 07/17/2023, 07/24/2023 and 07/31/2023. There was no documented reason for allowing the IVC to expire on 08/07/2023 and no documentation of the IVC being rescinded. However, there were Provider notes dated 08/07/2023 and 08/08/2023 that continued to document Patient #6 was "under involuntary commitment."

Telephone interview on 08/17/2023 at 1132 with RN #1 revealed she was the Assistant Director of Campus B's ED and remembered Patient #6. Patient #6 was a 26-year-old male who came in from his dad and step-mom's, he was IDD and Autistic and aggressive at times. RN #1 did not have a lot of direct interaction with Patient #6 however he was in Campus B's ED for 31 (thirty-one) days. There is a behavioral health meeting every Monday through Friday via Webex with the team to go through all the patients that have not been cleared by psychiatry and Patient #6 was discussed during the meetings. When a patient has no where to go or someone refuses to pick the patient up, as is what happened with Patient #6, the patient is considered a boarder patient and the barriers to placement are discussed in the SW (social work)/CM (case manager) meetings that take place on Tuesday and Thursdays. Interview revealed on 08/03/2023, Patient #6 was Psych cleared. Staff notified Patient #6's family, he was ready to be picked up. Patient #6's dad refused to pick him up since being brought in and said we should call mom. SW reached out to mom about the patient being ready to be picked up however mom kept delaying, saying she had to find someone to sit with her elderly mother, then it was the weather. RN #1 reached out to mom from a telephone number she did not recognize and explained it was time to come get Patient #6. Explained to mom "in NC there is something if not picked up considered child abandonment." Interview revealed RN #1 spoke with the hospital legal team who agreed about pursuing abandonment since mom and dad did not/would not come get Patient #6. RN #1 contacted (County) PD who went to dad's and had him call the hospital. Dad was given a deadline of 1700 to pick up Patient #6. The (County) PD Officer felt it was an appropriate time frame that dad was given to come get Patient #6. Interview revealed Patient #6 was at his baseline and he (Patient #6) got restrained at home. RN #1 stated she had read that in a note somewhere, however she was unable to locate that note at the time of the interview. RN #1 stated she had a responsibility to keep staff safe and to do so Patien