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Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient's rights as evidenced by:

Cross reference A0117: Failure to ensure a patient or patient's representative received a written copy of their patient rights.

Cross reference A-0144: Failure to ensure a patient bathroom, bedroom and seclusion room was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk.

The egregious nature of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.

Based on review of policies and procedures, medical records, and staff interview, the Department determined the administrator failed to ensure consents were completed for two patients in advance of furnishing or discontinuing patient care. This deficient practice poses the potential risk of patients receiving services they did not consent to.

Findings include:

Review of policy #RI 01, titled "Patient Rights and Responsibilities" last revised December 2023, revealed "...2. The Patient Rights and Responsibilities acknowledgment form shall be signed and placed in the patient ' s medical record...Each patient has the right to...18. To give general consent and, if applicable, informed consent to treatment...."

Review of Patient #1's medical record revealed Patient #1 was admitted to the licensed facility involuntarily on August 6, 2024. Further review revealed Patient #1 was granted a voluntary status at the licensed facility on August 8, 2024 at 9:46am. A request was made for evidence of Patient #1's Patient Rights and General Consent upon Patient #1's voluntary status. None was provided.

Review of policy #RI 23b, titled "Overflow Patients" last reviewed December 2023, revealed "...1. Patient may be placed in overflow space in the event of...clinical emergency. This will also require patient of (sic) guardian consent...."

Review of Patient #3's medical record on September 10, 2024 and September 11, 2024 revealed a "Progress Note" dated August 12, 2024, that states "...Patient was punched in the face and then slammed into the wall...A sleepout order was placed to prevent any further incidences...." Employee #1 confirmed the term "sleepout order" does not indicate an order is needed by a physician. A request was made for evidence that Patient #3 gave consent for the sleepout, per policies and procedures. None was provided.

Employee #1 confirmed an interview conducted on September 10, 2024 and September 11, 2024, that Patient #1's medical record did not contain evidence of signed Patient Rights or General Consent. Employee #1 also confirmed that Patient #3's medical record did not contain evidence of consent for the sleepout that occurred on August 12, 2024.

Based on observation, review of documents and staff interviews, it was determined the Hospital failed to ensure a patient bedroom and bathroom was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk and health and safety concerns. This deficient practice provides opportunities for patients to utilize these as tie off points, thus presenting a health and safety risk for patients that could result in self asphyxiation and death as well as ingesting potentially hazardous materials or using items to inflict self harm.

Findings include:

Observation on September 10, 2024, revealed the facility's non-compliance with State licensing requirements for environmental standards and physical plant standards to protect the health and safety of patients receiving treatment at the facility. Ligature risks and/or health and safety conditions were identified during the facility tour that included;

1. Patient bathroom sinks (Approximately 40) not flush with the wall creating a tie-off point.

2. Seclusion bathroom sinks (6) not flush with the wall creating a tie-off point.

3. Patient bedroom wall racks and door frames with non tamper resistant screws creating a self harm hazard.

4. Patient bathroom caulking not flush with the wall and shower wall panel and easily able to be removed creating a ligature and opportunity for patients to ingest potentially hazardous substances.

Document titled "Environmental rounds" for June, July and August 2024, did not identify the issues with bathrooms ligatures and the form does not address ligatures.

Interview with Employee #1, Employee #3 and Employee #26 confirmed in an interview on September 10, 2024, that the above identified ligatures and health and safety conditions were not addressed.

Based on facility policy, medical record review and staff interview, the Department determined that the Director of Nursing failed to ensure nursing services were provided as ordered for observation status for sexually acting out. This deficient practice can result in a patient not being properly observed and can result in patient harm, sexual assault or death.

Findings include:

Sexually acting out precautions:

Facility policy #PC 30, titled "Precautions," last reviewed and approved December 2023, states " ...when a patient is placed on precautions, the Observations Rounds Forms ...will be revised to reflect the precautions ordered ...."

Patient # 13 was placed on Sexually Acting Out (SAO) precautions on August 2, 2024. Observations Rounds Form indicated that SAO precautions were not implemented until August 4, 2024.

Patient # 14 was placed on SAO precautions on August 2, 2024. Observations Rounds Form did not reflect that SAO precautions were implemented at any time until the time of survey exit on August 12, 2024.

Patient # 15 was placed on SAO precautions on August 7, 2024. Observations Rounds Form indicated that SAO precautions were not implemented until August 8, 2024.

Patient # 16 was placed on SAO precautions on August 7, 2024. Observations Rounds Form indicated that SAO precautions were not implemented until August 8, 2024.

Employee # 8 confirmed in an interview on September 10, 2024, that Sexually Acting Out precautions were ordered for patient # 13, patient # 14, patient # 15, and patient # 16 by a physician and were not implemented as ordered timely.

Based on review of facility policies and procedures, medical records, and employee interview the Department determined the Administrator failed to ensure that patient care plans were updated with any changes to the patient's care plan and accurately reflected the patient's status and current goals. This deficient practice poses a potential risk to the health and safety of the patient when the patient's treatment plan is not re-evaluated and updated accurately after a qualifying event to determine whether the current treatment plan is effective or needs to be modified per facility policy.

Findings include:

Policy titled "Treatment planning" policy #PC 01, reviewed January 2024, states "...Modifications or additions made to goals and interventions, as appropriate, and whenever a significant event or change in condition arises...at a minimum every 7 calendar days...Significant change in medical, cognitive or behavioral status that requires changes in the interventions...."

Patient #13's Care Plan dated August 5, 2024 was updated after the patient was placed on Sexually Acting Out (SAO) precautions. However, the care plan was not marked as "Yes" for SAO precautions.

Patient #14's Care Plan dated August 2, 2024 was not updated after the patient was placed on Sexually Acting Out (SAO) precautions on August 2, 2024. A care plan update was completed on August 7, 2024 while Patient #14 remained on SAO precautions however, the care plan was marked as "No" for SAO precautions.

Patient #16's Care Plan dated August 7, 2024 was not updated after the patient was placed on Sexually Acting Out (SAO) precautions on August 7, 2024. A care plan update was completed on August 12, 2024 while Patient #16 remained on SAO precautions however, the care plan was marked as "No" for SAO precautions.

Interview with Employee #8 on September 11, 2024, confirmed that the care plan for Patient #13 did not reflect an accurate update of the SAO precautions, and the care plan for Patient #14 & #15 were not updated when the patient was placed on SAO precautions and when an update was completed they did not accurately reflect the SAO precautions.