HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to provide care in a safe setting when the hospital failed to:
- Ensure that contraband (items that are illegal, forbidden, or that can be used to harm self or others) was not accessible to patients on four units (#4, #5, #6 and #7) of five units observed. (A-0144)
- Ensure that wheelchairs had protective coverings over openings to prevent contraband transport into the hospital for two units (#5 and #6) of five units observed. (A-0144)
- Remove ligature (anything which could be used for the purpose of hanging or strangulation) risks related to an ice machine with a three-foot long cord and a four foot, six inch-long shower hose, on one unit (#7) of five units observed. (A-0144)
- Secure and/or remove ligature and safety risks related to two-foot, six-inch cords attached to a cable boxes and video players on three units (#5, #6 and #7) of five units observed. (A-0144)
- Secure and/or remove ligature risk related to an unattended linen cart for one unit (#4) of five units observed. (A-0144)
- Secure and/or remove ligature and safety risks related to an unattended three-tiered linen cart and two shower chairs for one unit (#7) of five units observed. (A-0144)
- Ensure that psychiatric (relating to mental illness) safe chairs were used in two day rooms on one unit (#7) of five units observed. (A-0144)
- Ensure bathroom doors did not lock from the inside for two units (#5 and #6) of five units observed. (A-0144)
- Ensure that the day room door did not lock from the inside for one unit (#7) of five units observed. (A-0144)
- Ensure that there were psychiatric safe screws were used on construction plywood for two units (#4 and #5) of five units observed. (A-0144)
- Ensure that there were psychiatric safe screws used for door hinges, locks and latches for four units (#4, #5, #6 and #7) of five units observed. (A-0144)
- Ensure an immediate, thorough investigation was performed, along with education provided to staff related to fentanyl powder being found on one patient (# 25) of one patient investigation for contraband. (A-145)
- Ensure hospital staff reported an event when a shank (a handcrafted bladed-weapon resembling a knife or sharp object that can inflict injury to another person) being found in one patient's (#32) wheelchair. (A-145)
- Ensure staff education was provided for patient-to-patient sexual contact for two patients (#7 and #8) of two allegations were investigated. (A-0145)
- Ensure staff education was provided for an allegation of staff-to-patient sexual contact for one patient (#6) of one allegation investigated. (A-0145)
- Ensure staff education was provided after an investigation related to a self-inflicted injury for one suicidal (to cause one's own death) patient (#11) of one patient assigned an incorrect observation level. (A-0145)

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

Based on observation, interview, record review and policy review, the hospital failed to provide care in a safe setting when the hospital failed to:
- Ensure contraband (items that are illegal, forbidden, or that can be used to harm self or others) was not accessible to patients on four units (#4, #5, #6 and #7) of five units observed.
- Ensure wheelchair openings had protective coverings to prevent the transport of hidden contraband into the hospital for three units (#5 and #6) of five units observed.
- Remove the ligature (anything which could be used for the purpose of hanging or strangulation) risks related to an ice machine with a three-foot long cord on one unit (#7) of five units observed.
- Remove the ligature risk related to a four-foot-long shower hose on one unit (#7) of five units observed.
- Remove and/or secure ligature and safety risks related to a cable box and video players with two foot six-inch-long cords on three units (#5, #6 and #7) of five units observed.
- Remove and/or secure ligature risk of an unattended linen cart from one unit (#4) of five units observed.
- Remove and/or secure ligature and safety risks related to unattended three-tiered linen cart and two shower chairs on one unit (#7) of five units observed.
- Ensure that psychiatric (relating to mental illness) safe chairs were used in two dayrooms on one unit (#7) of five units observed.
- Ensure that bathroom doors did not lock from the inside for two units (#5 and #6) of five units observed.
- Ensure that the dayroom door did not lock from the inside for one unit (#7) of five units observed.
- Ensure that there were psychiatric safe screws used on construction plywood for two units (#4 and #5) of five units observed.
- Ensure that there were psychiatric safe screws used for door hinges, locks and latches for four units (#4, #5, #6 and #7) of five units observed.

Findings Included:

Review of the hospital's policy titled, "Contraband," dated 03/2023 showed:
- On admission a thorough search will be made of the patient, purses, pockets, luggage, and belongings.
- Staff would send contraband items with the family or secure in the designated locations.
- Contraband includes any item deemed unsafe by staff, any item with strings or any item with sharp edges.
- Additional contraband items listed were, belts, shoelaces, handkerchiefs, scarves, and clothing with ties, boots (includes steel toe), cans (aluminum, metal - such as aerosol cans), cameras, cell phones, chains, cigarette lighters, computers, cosmetic containers, mirrors, mouthwash/gel toothpaste containing alcohol, aerosols, drawstrings, earphones, electronic devices (all), glass or ceramic objects and picture frames, glass containers, guns, hats, headbands, knives, mace/pepper spray, matches, medications (including any type of medication or illegal substances), metal grooming equipment (including combs), mirrors (including make-up compacts with mirrors), nail polish or polish remover, needles, paperclips, pins (includes straight and safety pins), plastic bags of any size, purses, razors, scissors, sewing needles, hooks or scissors of any kind.
- Room checks are assigned to a MHT on the assignment sheet each shift during waking hours.
- Room searches should be conducted if/when there is reasonable cause that a patient possesses potentially dangerous items or if contraband is suspected on the patient unit.
- Examine all chairs, cushions, beds, dressers, stands, closets, furniture, light/lamp fixtures, wall grills and covers, heating and air conditioning units, electrical equipment (clocks and radios), bathroom fixtures and fittings as well as cabinets, sinks, paper towel dispensers, etc.
- Check under, behind, and on top of furniture, under the mattress, in bed linens, patient drawers, folded and dirty clothing, and shoes. Keep in mind that people intending to hide something can sometimes be very resourceful. Search any place that can be used to hide potentially dangerous articles.

Observation on 08/26/24 at 10:15 AM, in room 46 on Unit Four, showed a five-inch pile of paper towels and an extra roll of unopened toilet paper on the sink.

Observation with concurrent interview on 08/26/24 at 10:18 AM, in room 47 on Unit Four, showed a five-inch pile of paper towels and two extra rolls of unopened toilet paper on the sink and one small pencil on a shelf behind the patient's door. Staff F, Nurse Educator, stated patients were not to have pencils or extra toilet paper or paper towels in their room.

Observation with concurrent interview on 08/26/24 at 10:22 AM, in room 48 on Unit Four, showed a three-inch pile of paper towels and an extra roll of unopened toilet paper on the sink, half roll of toilet tissue on the shelf behind the patient's door and a single use hairbrush on the windowsill. Staff F stated hairbrushes were single use and were supposed to be thrown away and not left in the room.

Observation with concurrent interview on 08/26/24 at 10:29 AM, in room 42 on Unit Four, an extra roll of unopened toilet paper was on the sink, two disposable unopened toothbrushes, four small pencils, five packets of deodorant wipes and two packets of moisturizer were on the bedside table. Staff F stated no personal care items were to be left in patient rooms.

During an interview on 08/26/24 at 10:45 AM, Staff G, Behavioral Health Associate (BHA), stated BHAs were responsible for room checks. Room checks for contraband were performed daily but the policy states two times a day. Patients were not to have pencils in their rooms, but some patients want to write. Toothbrushes and hairbrushes were one time use items that were to be taken from the patient after use.

Observation on 08/26/24 at 1:35 PM, outside the shared seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) room door, on Unit Five and Unit Six, showed three wash tubs filled with loose papers, flash cards, and more than 60 crayons.

Observation on 08/27/24 at 9:25 AM, in room 75 on Unit Seven, showed a non-psychiatric safe hairbrush.

Observation on 08/27/24 at 9:35 AM, in patient room 72 on Unit Seven, showed a toothbrush and three rolls of unopened toilet paper in the bathroom.

Observation on 08/27/24 at 9:30 AM, in patient room 78 on Unit Seven, showed two three-inch stacks of paper towels.

Observation on 08/26/24 at 1:35 PM, on Unit Five and Unit Six, showed two patient wheelchairs that were missing the rubber protective pieces on the front wheels.

Observation on 08/27/24 at 9:25 AM, in dayroom 7B on Unit Seven, showed an ice machine with an unsecured three-foot power cord.

Observation on 08/26/24 at 1:50 PM, in the shower room on Unit Seven, showed an unsecured four-foot-long flexible metal shower hose.

During an interview on 08/26/24 at 2:20 PM, Staff D, Chief Nursing Officer (CNO), stated patients were not monitored or timed when they were in the shower room on Unit Seven.

Observation on 08/26/24 at 1:35 PM, in the shared "green" activity room on Unit Five and Unit Six, showed an unsecured two-foot six-inch cord hanging down from the TV.

Observation on 08/27/24 at 9:25 AM, in dayroom 7B on Unit Seven, showed an unsecured DVD player.

During an interview on 08/28/24, at 1:35 PM, Staff C, Clinical Director, stated staff were to be in the dayrooms at all times when patients were present.

Review of the hospital's undated policy titled, "Environmental Services (EVS) Management Program-Linen Management," showed EVS staff stocks the main linen closet and units. They will use the clean linen cart only to transport clean linen to the units.

Observation with concurrent interview on 08/26/24 at 10:28 AM, in the Day Room on Unit Four, the Acute Psychiatric Unit, showed a lightweight linen cart on wheels with three bath size towels and eight wash cloths. There was a five-inch stack of paper towels on the bathroom sink. Staff F, Staff Educator, stated she was unsure why linens on a cart were in the dayroom.

Observation on 08/27/24 at 9:25 AM, in the shower room on Unit Seven, showed two non-psychiatric safe shower chairs and a three-shelf non-psychiatric safe rolling cart, unattended.

Observation on 08/27/24 at 9:25 AM, on Unit Seven, showed nine non-psychiatric safe chairs in dayroom 7A and six non-psychiatric safe chairs in dayroom 7B.

Observation on 08/26/24 at 1:35 PM, in all the patient bathrooms on Unit Five and Unit Six, showed the doors locked from the inside and required a key to enter.

Observation on 08/26/24 at 1:50 PM, on Unit Seven, showed:
- The dayroom doors had deadbolt locks on the inside that required a key to unlock them to enter.
- Dayroom 7A had four patients and no staff members present.
- Dayroom 7B had two patients and no staff members present.

During an interview on 08/28/24, at 1:35 PM, Staff C, Clinical Director, stated staff were to always in the dayrooms when patients were present.

Review of the hospital's policy titled, "Construction & Renovations", dated 05/2023 showed:
- The policy applied to all construction or renovation projects whether completed by outside contractors or hospital personnel.
- The director of plant operations, risk management, infection control, or the contractor will conduct a documented risk assessment to identify hazards that could potentially compromise patient care in occupied areas of the building.
- The risk assessment team will select and implement proper controls to reduce risk based on designated level of risk of the planned activity.

Observation on 08/26/24 at 1:35 PM, on Unit Five and Unit Six, across from the nurses' station, at the door access for Unit Four, showed three pieces of plywood that were attached with non-psychiatric safe screws.

Observation on 08/27/24 9:25 AM, in room 41 on Unit Four, showed the door latch was attached with non-psychiatric safe screws.

Observation on 08/27/24 at 9:25 AM, in room 42 on Unit Four, showed the door handle was attached with non-psychiatric safe screws.

Observation on 08/26/24 at 1:50 PM, in the shower room on Unit Seven, showed a deadbolt lock on the inside of the door, the door automatically locked when closed and a key was required to enter. The lock and the hinges were attached with non-psychiatric safe screws.

During an interview on 08/29/24, at 10:15 AM, Staff E, Chief Executive Officer (CEO), stated he expected all equipment and furniture to be psychiatric safe.



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Based on interview, record review, policy review and video review, the hospital failed to ensure the safety of all patients when patient safety events were not appropriately investigated, to provide adequate monitoring for the level of patient needs, and to provide education to all staff and when:
- One patient (#25) was found to have fentanyl (medication used to treat severe pain, and is a high-risk drug for theft or personal use) powder on a Behavioral Health Unit (BHU);
- One patient (#32) was found to have a metal shank (make-shift knife-like weapon) on a BHU;
- One patient (#6) allegedly had sexual contact with a Behavioral Health Associate (BHA);
- Two patients (#7 and #8) allegedly had sexual contact;
- One patient (#11) had a self-inflicted injury and incorrect observation status was assigned to prevent further injury of a suicidal (to cause one's own death) patient; and
- One patient (#10) was restrained (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) and placed in seclusion (the involuntary confinement of a person alone in a room or area from which the patient was physically prevented from leaving) by untrained staff.

Findings included:

Review of the hospital's policy titled, "Risk Management Incident Investigation," dated 01/2023, showed:
- The need for an investigation was based on the review and evaluation of Incident Reports.
- Investigations are a preventative tool to avoid reoccurrence of incidents, improve the quality of care and to cultivate education of all levels of staff.
- The hospital should control the incident scene, determine immediate actions to be taken, evaluate the environment, preserve evidence and gather data.
- An Incident Data Analysis and Investigation Report should be completed for each investigation.

Review of the hospital's policy titled, "Incident Report (IR) Descriptions and Severity Guide," dated 01/2023, showed:
- Numerous criteria are considered when identifying incidents. They include: was it intended, or unexpected; was it a distinct event, episode, happening, or encounter; did it interrupt patient care or was it disruptive to the patient care environment; did it result in or cause a negative impact on patients/visitors or did it impact the safety and security of the unit; was the harm caused by the incident temporary, long-term, or permanent; the severity of the harm, ranging from no obvious injury, to significant injury, and/or death.
- The initial incident severity level assigned may not be the final severity level.
- Severity Level I incidents are considered to be major events. They include: patient injuries (unspecified, self-inflicted, recreational) that require admission to a medical/surgical (Med/Surg) unit; physical abuse by staff with major harm/injury; injury resulting from restraint use that requires transfer to Med/Surg unit for major injuries (fractures, chipped tooth, sutures); a suicide attempt that requires admission to a Med/Surg unit; seizures requiring admission to intensive care unit (ICU, a unit where critically ill patients are cared for); a sudden or unexpected change in medical condition (chest pain, shortness of breath, cardiac event, respiratory event, paralysis, high fever, severe pain) that requires admission to an ICU; patient death (accidental, suicide, homicide, medical, or unknown/to be determined); allegations of patient to patient non-consensual or coerced sexual/body exposure; allegations of staff involvement or deliberate action of sexual/body exposure where genitals were exposed or touched; sexual intercourse with staff involvement; patient to patient attacks where the aggressor is admitted to a Med/Surg unit for care.
- Severity Level II incidents are considered to be moderate events. They include: verbal or mental/psychological abuse by staff; physical abuse by staff (striking, pushing, or other use of physical force); patient self-injury that requires outside medical treatment (sutures, staples); neglect or exploitation by staff; restraint use that requires outside medical evaluation or treatment; seizures requiring admission to a Med/Surg unit; patient to patient allegation of oral sex or digital penetration involving minor patients, low-functioning patients or patients on involuntary status; staff involved boundary violations (failure of staff to divulge a pre-existing relationship with a patient, staff gives money/valuables to a patient, staff escorts patient to inappropriate location for patient to be in; staff leaves a mobile device available or unattended for use by patient); contraband found (items, substances, weapons, or any unauthorized property that were obtained or imported by a patient or visitor, found in his/her possession; drug paraphernalia found in a parking lot; a patient distributing or hoarding cheeked medication or meds administered but not ingested or makeshift weapons); if police are contacted related to the incident.
- Severity Level III incidents are considered to be minor events. They include: patient to patient exposed genitalia, kissing, or hugging; patient exposing genitalia to staff; patient to patient boundary violations (obscene or vulgar gestures towards a peer, divulges personal or private information of a peer, patient takes or uses a peer's belongings without permission); patient to patient attacks where the aggressor sustains minor injury (bruising, redness, laceration) that was limited to first aid;
- Severity Level IV incidents are considered to be inconsequential events. They include: patient to patient attacks where the aggressor is not injured; incorrect medication dispensing, incorrect medication labeling, delay in dispensing of medications, or lack of availability of medications as long as they did not impact the patient.

Review of the hospital's policy titled, "Sentinel Event (actual events that could or did cause patient harm)," dated 02/2023 showed:
- A sentinel event could include unexpected death, serious physical or psychological injuries, or any event with a chance of a serious adverse outcome.
- The hospital should immediately respond, investigate, analyze the information and response to assure improvement of the safety and quality of patient care.
- An Root Cause Analysis (RCA, a tool to help study events where a patient harm or undesired outcomes occurred in order to find the root cause) should be completed to determine the underlying cause of the event and potential process improvement to reduce the likelihood of reoccurrence.
- Based on the RCA, an action plan should be developed.
- Events identified as Sentinel events should be reported to the Risk Manager (RM).
- Once identified, an initial review would be conducted within one day to determine the need for a process change or staff education.
- The event would be investigated by a multidisciplinary team.
- The preliminary RCA completed within 30 days and the final RCA completed by day 45 from identification of the event.
- All documentation, reviews and findings, should be maintained as an investigation file
with the RM.

Review of the hospital's policy titled, "Contraband," dated 03/2023 showed:
- On admission a thorough search will be made of the patient, purses, pockets, luggage, and belongings.
- Staff would send contraband items with the family or secure in the designated locations.
- Contraband includes any item deemed unsafe by staff, any item with strings or any item with sharp edges.
- Additional contraband items listed were, belts, shoelaces, handkerchiefs, scarves, and clothing with ties, boots (includes steel toe), cans (aluminum, metal - such as aerosol cans), cameras, cell phones, chains, cigarette lighters, computers, cosmetic containers, mirrors, mouthwash/gel toothpaste containing alcohol, aerosols, drawstrings, earphones, electronic devices (all), glass or ceramic objects and picture frames, glass containers, guns, hats, headbands, knives, mace/pepper spray, matches, medications (including any type of medication or illegal substances), metal grooming equipment (including combs), mirrors (including make-up compacts with mirrors), nail polish or polish remover, needles, paperclips, pins (includes straight and safety pins), plastic bags of any size, purses, razors, scissors, sewing needles, hooks or scissors of any kind.
- Room checks are assigned to a MHT on the assignment sheet each shift during waking hours.
- Room searches should be conducted if/when there is reasonable cause that a patient possesses potentially dangerous items or if contraband is suspected on the patient unit.
- Examine all chairs, cushions, beds, dressers, stands, closets, furniture, light/lamp fixtures, wall grills and covers, heating and air conditioning units, electrical equipment (clocks and radios), bathroom fixtures and fittings as well as cabinets, sinks, paper towel dispensers, etc.
- Check under, behind, and on top of furniture, under the mattress, in bed linens, patient drawers, folded and dirty clothing, and shoes. Keep in mind that people intending to hide something can sometimes be very resourceful. Search any place that can be used to hide potentially dangerous articles.

Review of the hospital's policy titled, "Visitation," dated 08/30/22, showed patients were not permitted to receive any belongings from visitors during visitation hours.

Review of the hospital's policy titled, "Abuse and Neglect," dated 03/2023, showed:
- It is the policy of the hospital that any staff who witness or suspect a patient has been abused either physically or verbally while in the hospital or prior to admission will report such abuse to the appropriate authority immediately.
- This includes patient to patient, staff to patient, or suspicion that a patient may have been at risk for abuse.
- If the abuse allegation is made against staff, the Administrator on call will notify police.

Review of the hospital's policy titled, "Observations, Patient," dated 03/2023, showed:
- A psychiatric (related to mental illness) practitioner will order one of three levels of visual observation at the time of admission and when the patient's condition warrants a change: 15-minute, five-minute, or one to one (1:1, continuous visual contact with close physical proximity).
- All patients are monitored at a minimum once every 15 minutes.
- Patients are placed on 5-minute observation if their behavior is unpredictable and there is potential for harm to self.
- 1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others. The interdisciplinary treatment plan will include or be revised to include the 1:1 observation.

Review of the hospital's policy titled, "Suicide Precautions," dated 11/2022, showed:
- The psychiatric practitioner shall order observation and precautions consistent with the assessed level of risk. Suicide risk, level of observations and/or placement on suicide precautions (SP, precautions taken to unsure patients are safe a free for self-injury or self-harm) will be communicated to staff.
- RNs shall implement SP as indicated based on results and/or observations including pre-admission history of recent suicide attempt or ideation, self-harmful behavior (behavior that is harmful or potentially harmful to one's self), suicidal ideation (SI, thoughts of causing one's own death), talk of self-harm, and the results of ongoing assessments.
- The attending/covering physician will be contacted immediately to obtain an order for SP and level of observation if there is a decision to change from an existing order.
- Suicide risk will be addressed in the interdisciplinary treatment plan and updated as needed.
- Continued risk for suicide will be assessed on an ongoing basis and documented by medical and clinical staff.

Review of the hospital's document titled, "Handle With Care (HWC) Behavior Management System (the hospital's training for verbal de-escalation and physical intervention methods)," copyright 2012, showed:
- Handle With Care is dedicated to the reduction of institutional violence through tension reduction, use of preventative actions that result in a decrease in the need for the use of physical restraint, use of prompt, skillful and appropriate intervention when physical restraint is necessary, and creating a universal perception of physical and psychological safety.
- Instruction was given for verbal de-escalation techniques, limit setting, patient communication, and care-giver behavior. Role play exercises were included.
- Instruction was given for physical interventions, including their appropriate use, techniques, and patient safety factors.

Review of the hospital's policy titled, "Restraint," revised 05/01/23, showed:
- Restraint means the use of manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his arms, legs, body, or head freely.
- Physical restraint includes measures approved by the hospital's HWC training to limit or restrict body movement. Holding a patient who is not cooperative with receiving a medication through injection and/or approved HWC holds is considered a physical restraint.
- Staff training requirements include use of nonphysical intervention skills and safe application and use of all types of restraint used in the hospital.

Review of the hospital's policy titled, "Seclusion," dated 03/2023 showed:
- Seclusion may only be ordered by a psychiatrist (physician who specializes in mental health disorders) and only for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others after less restrictive interventions are ineffective or ruled out.
- Seclusion must be discontinued at the earliest possible time regardless of the scheduled expiration of the order.
- A RN will document the behaviors which led to the need for the use of seclusion.

Review of the hospital's document titled, "Incident Report Form (Patient #25)," dated 08/14/24 at 6:00 PM, showed:
- Staff S, Nursing Supervisor, reported contraband was found on Unit Five-Six.
- At 12:30 PM, Staff X, LPN, called and notified her that while walking Patient #25 to the lobby for discharge, he gave Staff X a paper towel with an unknown substance in it. Patient #25 stated another male patient gave it to him after a visit. Staff X took the contraband to the pharmacy where it was destroyed.
- Staff X, and Staff O, RN Manager were listed as witnesses.
- The Physician, CNO and administration were notified.
- The severity was classified as a level three.

Review of the undated hospital's document titled, "Prescription Destroyer Pharmaceutical Disposal," showed on 08/14/24, Staff EE, Pharmacist, disposed of one unknown crushed pill and was witnessed by Staff S, Nursing Supervisor.

Review of the hospital's document titled, "Belongings Inventory List (Patient #25)," dated 08/05/24, showed:
- Staff were to inventory patient belongings before they were taken to the unit.
- All other belongings will be placed in a bin and locked in the secure belongings room.
- Patient #25's items secured in the belongings room were: a navy drawstring bag, a belt, a cellular phone charger, a cellular phone and identification.

Review of Patient #25's medical record, dated 08/05/24, showed:
- He was a 59-year-old homeless male who was admitted to the hospital seeking treatment for alcohol and opioid detoxification (the process of removing drugs or alcohol from the body).
- On 08/14/24 at 2:00 PM, Staff S, RN Supervisor noted a "powder substance was tested and preliminary findings showed it was positive for fentanyl. It was taken to the pharmacy to be destroyed."
- At 3:46 PM, Staff X, LPN, noted the fentanyl was found wrapped in a paper towel in Patient #25's possession. The patient stated he had received it from another patient who threatened to harm him if he did not take the drugs offered to him. The supervisor was immediately notified and the paper towel was given to the nurse supervisor for further testing.

Although requested, there was not a documented investigation or staff education related to fentanyl contraband being found in the patient's possession on the BHU.

During a telephone interview on 09/01/24 at 11:35 AM, Staff E, CEO, stated there was no room for error when contraband was found on the units. Staff were expected to immediately report any found contraband to the RN Supervisor who would notify the administrator on call. An incident report and an investigation would be started for anything outside of normal, such as finding a shank or fentanyl on the unit. He expected the investigation to have been documented. He stated it was "incredibly concerning" that fentanyl was rated as a level three severity level by RM on the Incident Report form and that it should have been a level one and reported to the corporate RM.

During a telephone interview on 09/01/24 at 12:10 PM, Staff D, CNO, stated the lack of an investigation after fentanyl was found on the unit did not meet her expectations. An investigation should have been documented. Depending on the findings, house wide education concerning what to do if a suspicious medication or substances were found, the processes and reporting to the state should have been started.

During an interview on 08/28/24 at 8:45AM, Staff B, RM, stated she was notified after the patient's discharge on 08/14/24 that fentanyl was found on Patient #25. An investigation was not started because it was identified that another patient gave it to him. The other patient was interviewed but never admitted the fentanyl belonged to him and it was still unknown where it came from. The fentanyl did not cause any known harm but had the potential to cause harm to the entire hospital, the staff and the patients. She did not know if the environment was cleaned and sanitized, but room and body checks were completed. Nothing would have been done differently because no harm was done. The drugs were found and a room search was conducted. There was no staff education after the contraband was found, but the staff would have benefited from some. It there had been a different outcome, a self-report would have been completed. There was no police involvement with this incident.

During an interview on 08/28/24 at 11:04 AM, Staff W, Medical Director, stated the fentanyl was found when Patient #25 was leaving. She spoke with the other patient involved and he denied giving the fentanyl contraband to Patient #25. He was not a reliable source of information.

During an interview on 08/26/24 at 1:40 PM, Staff S, RN Supervisor, stated powdered fentanyl was found in a balled-up paper towel by staff on Patient #25 two weeks ago as he was being discharged from Unit Five-Six. The patient was given the contraband by another patient while on the unit. Patient #25 indicated that the other patient received the contraband from a visitor. The other patient was allowed to go to the residential unit since they could not prove that he had given the contraband to Patient #25. The RN Supervisor swabbed the white powdered substance and confirmed it was fentanyl. They were not sure where the contraband came from. No education was provided to house wide staff about this incident, the finding of this type of contraband or how to respond when it was found. On the spot and in the moment education concerning the finding of the fentanyl contraband was provided to the RN and BHA involved in this incident. The RN Supervisor questioned the thoroughness of the body assessments because she knew the intake staff were short staffed.

During an interview on 08/27/24 at 2:05 PM, Staff O, RN Manager, stated fentanyl was found on the unit on 08/14/24. A patient on Unit Five-Six had a napkin with a white powdery substance. She was notified that day of the findings.

During a telephone interview on 08/29/24 at 11:56 AM, Staff X, LPN, stated Patient #25 handed her the fentanyl in a paper towel on Unit Five-Six. When he handed it to her, she had ungloved hands and he stated, "I do not know what this is." The LPN contacted her supervisor who then had the unknown substance tested. She was told it tested positive for fentanyl. She documented a note in the patient's record and the nursing supervisor completed the incident report.

During a telephone interview on 08/29/24 at 12:10 PM, Staff Y, RN, stated she was present when fentanyl was found on Unit Five-Six. Staff X, LPN, found it when Patient #25 unpacked his belongings from his wheelchair. Staff X took the substance to the nursing station. She was not wearing gloves and neither her, nor Staff X, were wearing masks. She immediately notified the supervisor and manager. A search of every room and every patient was initiated. She did not fill out an incident report. The supervisor tested the substance and confirmed that it was positive for fentanyl.

During an interview on 08/28/24 at 1:48 PM, Staff EE, Pharmacist, stated she disposed of an unknown powder that was thought to be fentanyl. Staff S, Nursing Supervisor, brought the substance the pharmacy in a sealed plastic baggie, wearing gloves and a mask. The substance was placed into the drug disposal bottle which contains a liquid that deactivates the medication. She did not test the substance and did not know if it was tested beforehand. She not aware of any staff education related to what to do if fentanyl was found on the unit or the reporting process. Everyone should have been educated after this event.

Review of the hospital's document titled, "Incident Report Form (Patient #32)," dated 08/28/24, showed:
- On 08/28/24, Staff LL, RN, reported contraband in the form of a sharp metal shank was found and located in the Assessment and Referral (A&R) office.
- Staff S, Nursing Supervisor, was listed as a witness.
- An attached note indicated "a few weeks prior," Staff LL, A&R RN, was contacted by a staff member from Unit Five-Six and asked to search for a shank hidden in the patient #32's personal wheelchair. The wheelchair was stored in the A&R office overnight when the patient was transported to a local hospital. Staff LL found a shank hidden in the wheelchair.
- The nursing supervisor responded to A&R and was able to observe the shank.
- No other administrative members were notified of the incident.
- There was no severity level classification documented.

Review of Patient #32's medical record, dated 08/10/24, showed:
- He was a 46-year-old male admitted to the acute inpatient behavioral health program for fentanyl and alcohol detoxification.
- He admitted to using fentanyl and consuming one pint of vodka daily. He did not want to live and had suicidal ideation (SI, thoughts of causing one's own death).
- On 08/13/24 at 1:48 PM, he was transferred to a local hospital for a compression fracture (a type of broken bone that can cause your spine to collapse).
- A progress note indicated a shank was found concealed in his personal wheelchair.

During an interview on 09/01/24 at 12:10 PM, Staff D, CNO, stated she was not notified by the A&R staff about the issues concerning the contraband in the wheelchair. She expected the staff who were aware of, or who found the contraband, to file an incident report by the end of their shift.

During an interview on 08/28/24 at 8:45AM, Staff B, RM, stated she was notified about the event regarding the shank concealed in the wheelchair, the morning of 08/28/24 by the A&R Director. The RN that found the shank in the wheelchair on 08/14/24 had not filed an incident report.

During an interview on 08/26/24 at 1:40 PM, Staff S, RN Supervisor, stated a metal shank was found by an A&R staff member. The shank was concealed in Patient #32's personal wheelchair that located in the belongings room. The wheelchair was not on the unit when the shank was found.

During an interview on 08/27/24 at 2:05 PM, Staff O, RN Manager, stated there was a shank found in a wheelchair and was unsure of who it belonged to. An incident report should have been completed after the shank was found.

During an interview on 08/29/24 at 12:10 PM, Staff Y, RN, stated a shank found in Patient #32's wheelchair on nursing Unit Five-Six. Patient #32 was transferred to another hospital and his wheelchair was placed in the A&R office. When she took the wheelchair to the A&R office, the staff informed her "the wheelchair was not ours."

During a telephone interview on 09/01/24 at 10:35 AM, Staff LL, Admissions RN, stated she checked the wheelchair and found a shank inside of it. She was not sure if the wheelchair had ever been on the unit. She was not present the night Patient #32 was sent to the hospital.

During a telephone interview on 09/01/24 at 10:35 AM, Staff PP, Intake Assessment Counselor, stated he performed the admission assessment on Patient #32. He remembered that the patient brought in his own wheelchair and cane. The wheelchair did not appear to have been altered and he allowed the patient's wheelchair to go on to the unit with the patient. He was new to the role, had two days training, did not have anyone to confer with and used his best judgement when he performed the wheelchair assessment.

During an interview on 08/29/24 at 11:09 AM, Staff O, RN Manager, stated she would have expected all frontline nursing staff to have received education regarding contraband, how to report findings and what to do if contraband was found on the inpatient units.

Review of the hospital's document titled, "Incident Report Form (Patient #6)," dated 06/10/24, showed:
- At 10:00 PM, Patient #6 made allegations that Staff Z, BHA, sexually abused her on or around 05/30/24. She was unsure of the time of day.
- Patient #6 indicated Staff Z entered the bathroom while she was changing clothes. She did not have a shirt on when he grabbed her by the shoulders, pressed his body against hers, and stated, "you know I've had a lot of wet dreams lately and if you calm down, I'll let you play with it." Staff Z never removed his pants, but he pushed his hips forward against her. Patient #6 pushed him away and he stated, "You're ridiculous, you're here for a suicide attempt and I wish it would have been successful."
- Her guardian was notified along with the administrator on call.
- At 10:08 PM, Staff Z was informed of the allegation, relieved of his hospital badge and keys, and suspended pending investigation.
- The severity level was classified as a level one.

Review of Patient #6's medical record, dated 05/27/24, showed:
- She was a 25-year-old female admitted for a suicide attempt. She attempted to overdose by taking melatonin and hydroxyzine, along with open wounds to her wrists.
- She resides on a locked BHU, but had been home for a weekend visit.
- Her suicide risk level was high; her initial observation level was every five minute checks, but on 05/27/24 at 12:56 PM, her observation level was increased to 1:1 due to her picking on her wrist wounds.

Review of the hospital's self-report documentation, dated 06/01/24, showed the hospital completed thorough investigation but no staff education was provided for staff-to-patient sexual abuse.

Review of the hospital's document titled, "Incident Report Form (Patient #7 and #8)," dated 05/24/24, showed:
- On 05/23/24 at 10:30 PM, Unit Three Adolescents, a fellow patient reported that Patient #7 and Patient #8 allegedly had sexual interaction.
- Patient #8 entered Patient #7's bathroom, pulled down his pants and sucked his penis. They then had sex, he put his penis inside Patient #8 and "came".
- Interviews indicated that staff members were unaware of incident until it was reported by another patient.
- The severity level was classified as a level one.

Review of Patient #7's medical record, dated 05/20/24, showed:
- He was a 15 year-old male admitted for a suicide attempt, attempted hanging.
- His precautions included suicide and assault, with an observation level of every 15 minutes.
- His trauma assessment indicated that he had not experienced sexual abuse.

Review of Patient #8's medical record, dated 05/15/24, showed:
- She was a 16 year-old female admitted after eloping from a residential facility.
- When police located her, she was placed in the back of their vehicle where she found a sharp item and proceeded to cut her forearms.
- She reported SI with a plan to hang herself.
- Her precautions included SP and elopement, with an observation level of every 15 minutes.
- Her trauma assessment indicated that she had not experienced sexual abuse.

Review of the hospital's self-report documentation, dated 06/01/24, showed the hospital completed thorough investigation but no staff education was provided for patient-to-patient sexual misconduct.

During an interview on 08/28/24 Staff B, Risk Manager, stated there was no staff education provided related to staff-to-patient sexual abuse after the alleged incident with patient #6 or related to patient-to-patient sexual interaction after the alleged incident with patients #7 and #8. She did not know why education was not provided.

Review of hospital's undated incident log showed self-inflicted injuries reported for patient #11 on 05/25/24, 06/06/24, 06/11/24, 06/12/24, 07/02/24, 07/30/24, and 08/14/24.

Review of the hospital's document titled, "Incident Report Form (Patient #11)," dated 05/29/24, showed:
- On 05/25/24 at 8:25 PM, on Adult Acute Unit Four, Patient #11 became agitated due to a code green (a response from all available staff to respond to an escalating patient in an attempt to de-escalate the situation without using force and using the least restrictive intervention) related to another patient on the unit.
- She started banging her head, tore pieces of the floor out, using them to cut her forehead.
- The physcian was notified and Patient #11 was tranferred to an acute care hospital for treatment.
- The severity level was classified as a level two.

Review of the hospital's undated document titled, "Incident Investgation (Patient #11)," showed:
- On 05/26/24, upon admission, her suicide risk level was high. Suicide precautions (SP, precautions taken to ensure patients are free of self-harm or self-injury) were ordered and her level of observation was every five minutes.
- SP were implemented, but her suicide risk level was incorrectly entered as moderate.
- At 2:20 PM she arrived on the adult acute unit.
- At 3:20 PM, she reported SI with thoughts of banging her head and requested her helmet to protect her head. The nurse notified the nursing supervisor of the request and spoke with the patient. The patient asked to go to the quiet room due to being overstimulated. She remained in the quiet room for 30 minutes.
- Two hours later, she requested her helmet again. The nurse notified the physician and reported that an order for the helmet was placed. The nurse also notified the nursing supervisor a second time, requesting the helmet. No helmet order was entered.
- At 8:20 PM, the patient started banging her head against the wall, broke pieces of the floor and cut her forehead. The physician was notified, and she was transported to another hospital for treatment. Her forehead laceration (a deep cut or tear in skin) was treated with staples, and she returned to the hospital.
- At 3:40 AM, she returned to the hospital and as needed medication was ordered but there were no orders to change the patient's level of observation or precautions.
- On 05/26/24 in the afternoon, her observation level was increased to 1:1 after she picked at her wound causing it to bleed.
- There was no documented education on suicide precautions.

Review of the hospital's document titled, "Incident Report Form (Patient #11)," dated 07/04/24, showed:
- At 8:35 PM, Patient #11 complained that the as needed medication provided for headaches related to banging her head was not working.
- She repeatedly banged her head, causing a previous laceration to re-open and bleed.
- She was transported to another hospital for evaluation and treatment.
- The physician was notified.
- The severity level was classified as a level three.

Review of the hospital's undated document titled, "Incident Investigation (Patient #11)," showed:
- On 07/04/24, following a phone conversation with her mother, the patient became upset and banged her head on the wall, sustaining a laceration that required treatment with staples at a hospital. She was under observation every 15 minutes at the time.
- Upon return she was placed on 1:1 observation.
- On 07/05/24, her observation level was changed to every five minutes.
- The hospital identified