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Based on document review, video surveillance review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13 Patient Rights.

Findings include:

1. The hospital failed to ensure an appropriate suicide assessment and reassessment as required; and failed to implement sufficient observation and supervision. See A-144.

2. The hospital failed to ensure that the alleged perpetrators/staff (E#7 and E#8) were suspended pending investigation of allegations of abuse. See A-145.

The IJ still remains at 42 CFR 482.13, Patient Rights, and was identified at 7/25/2023 due to the hospital's failure to ensure that patients were protected from staff suspected of abuse while investigations were in still progress; and the failure to properly evaluate and implement measures to address the patient's self-harming behaviors. Subsequently, the patient eloped from Hospital A. This failure is likely to cause serious harm, to the 27 patients on census at the hospital.

The IJ was announced on 7/25/2023 at 5:00 PM, during a meeting with the Chief Executive Officer, and the Chief Medical Officer. The IJ was not removed by survey exit date of 7/25/2023.

Based on document review, video surveillance review, and interview, it was determined that for 2 of 13 patient's (Pt. #s 1 and 2) clinical records reviewed who were at high risk for suicide, the hospital failed to ensure an appropriate suicide assessment and reassessment as required; and failed to implement sufficient observation and supervision. Subsequently, Pt. #1 eloped from the Hospital A.

Findings include:

1. The hospital's policy titled, "Suicide Risk Assessment" (6/2022) was reviewed and indicated, "... The facility ...conduct a suicide assessment of patients who have screened positive for suicidal ideation ... If (a) patient is screened and found to be at moderate or high risk, the suicide risk assessment, SAFE-T Protocol is completed by a Master prepared clinician or Registered Nurse to identify risk factors, protective factors, and to assess the patient for thoughts, plans and suicidal intent ... The Registered Nurse reassess risk of suicide on every patient ... suicide risk may be ... reassessed on an as needed/ongoing basis as indicated by the patient's clinical and/or behavioral presentation ...Treatment Team: The treatment team is advised of any relevant information gained from the suicide risk assessment ..."

2. The hospital's policy titled, "Observations, Patient" (6/2022) was reviewed and indicated, "Policy ... 3. The RN (registered nurse) may increase the level of observation if the patient's condition changes ... 6. All patients are monitored at minimum once in every 15-minute block of time ...8. 1:1 Observation. a. 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 ... b. Requires a precaution level, i.e., suicide, elopement ... f. Staff are to remain within visual range and close proximity (easy reach) of patient at all times ..."

3. On 7/20/2023, the clinical record of Pt. #1 was reviewed. On 7/18/2023, Pt. #1 was admitted to the Hospital A with a diagnosis of major depressive disorder. The clinical record included the following:

- A Crisis Assessment (assessment of an individual experiencing a crisis that threatens their safety) dated 7/18/2023 at 7:00 AM, completed at Hospital C, indicated that Pt. #1 had increasing suicidal ideation with cutting behaviors (self-harming behaviors). Pt. #1 required intensive or immediate action to address Pt. #1's risky behavior.

- Transfer form dated 7/18/2023 at 11:40 AM, from Hospital C indicated, that Pt #1's diagnosis was suicidal ideation.

- On 7/18/2023 at 1:49 PM, Hospital A's Registered Nurse/ RN (E #3) nursing admission/assessment indicated that Pt. #1 was referred for hospitalization due to suicidal ideation with a plan to cut her wrist. Prior to admission, Pt. #1 attempted to scratch forearm with a broken glass. E #3's suicide risk assessment for Pt. #1 was low risk for suicide.

- Pt. #1's Safety Observation Rounds (every 15 minutes monitoring) for 7/18/2023 from 1:50 PM through 6:32 PM, were reviewed. From 1:50 PM through 2:25 PM (total of 35 minutes), there was no documentation that every 15 minutes monitoring checks were completed.

- On 7/18/2023 at 6:25 PM, E #3's note indicated that Pt. #1 verbalized that she had swallowed a screw found inside the shower. (MD #1/Attending Psychiatrist and the medical physician) were contacted and ordered to send Pt. #1 to an outside hospital's Emergency Department (ED) for a medical evaluation. There was no suicide reassessment for Pt. #1 conducted after Pt. #1's incident.

4. On 7/18/2023, the video surveillance indicated that at 10:39 PM, a patient transport vehicle (Medicar) arrived and parked in front of the Hospitals A's main entrance. Pt. #1 was returning from Hospital B's ED , after being evaluated from the incident of swallowing a screw.

- At 10:39:20 PM (hours/minutes/seconds), E #4 (Behavioral Health Technician) came out of the vehicle and went to the Hospital A's main entrance door. While E #4 was checking the Hospital A's main entrance, E #4 did not have a view of Pt. #1.

-At 10:39:43 PM, Pt. #1 exit the vehicle. Pt. #1, then proceeded to leave the Hospital A premises.

5. On 7/24/2023 at approximately 9:33 AM, an interview was conducted with MD #1 (Pt. #1's Attending Psychiatrist). MD #1 stated that Pt. #1 should have been assessed as moderate risk for suicide. MD #1 stated patients that are at moderate risk for suicide, the hospital can implement heightened level of observation and monitoring to keep safe and protect from harm.

6. On 7/24/2023 at approximately 10:02 AM, a telephone interview was conducted with E #3 (Registered Nurse). E #3 stated that she conducted Pt. #1's admission assessment and was assessed at low risk for suicide. E #3 stated that when she checked Pt. #1's room for the shower screw, one of the four shower screws was missing. E #3 stated that she did not complete a suicide risk reassessment.

7. On 7/24/2023 at approximately 10:18 AM, a telephone interview was conducted with E #4 (Behavioral Health Technician). E #4 stated that Pt. #1 was sitting at the back of the vehicle while she (E #4) sat in the front. After Pt. #1's incident, E #4 stated that there was no other training that the hospital has provided after the incident of Pt. #1 elopement.

8. On 7/24/2023 at approximately 12:15 PM, an interview with E #5 (Chief Nursing Officer) was conducted. E #5 stated that when Pt. #1 said that she swallowed a screw, a suicide risk reassessment should have been conducted and Pt. #1 should have been placed on one to one observation.



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9. The clinical record of Pt. #2 was reviewed on 7/25/2023. Pt. #2 was a 17-year old admitted to the 5th Floor Adolescent Boys Behavioral Health Unit (BHU) on 7/14/2023, with a diagnosis of major depressive disorder, recurrent and severe with psychiatric symptoms. The Psychosocial Assessment, dated 7/17/2023, indicated that Pt. #2 had a history of trauma which included, "Pt reports that [Pt. #2] was raped by someone that [Pt. #2] does not know."

- Pt. #2 was placed on suicide, assault, and elopement precautions on 7/14/2023 at 11:41 PM. Orders for SAO precautions were placed on 7/18/2023 at 7:56 AM due to being "inappropriate towards female staff." Pt. #2 was on every 15 minutes (Q15) monitoring initially on 7/14/2023. On 7/18/2023 at 7:58 AM, Pt. #2's observation status was changed to every 5 minutes (Q5) per physician's orders.

- Observational Rounds from 7/18/2023-7/24/2023 were reviewed and indicated that Pt. #2 was not monitored for SAO precautions until 7/24/2023 (6 plus days after orders for SAO were placed). In addition, Pt. #1 was only monitored every 15 minutes (despite active orders for Q5 during the following times) from 7/18/2023 8:00 AM to 7/19/2023 12:15 AM; and 7/19/2023 3:55 PM to 7/21/2023 12:40 AM.

Based on document review, video surveillance review, and interview, it was determined that for 2 of 2 patients (Pts. #2 and #3) reviewed for allegations of abuse, the hospital failed to ensure that 2 of 2 alleged perpetrators/staff (E#7 and E#8) were suspended pending investigation of allegations of abuse, in order to protect any other patients from abuse.

Findings include:

1. The hospital's policy titled, "Abuse and Neglect" (dated 6/2022) was reviewed and required, "It is the policy of the Hospital that any staff who witness or suspect a patient has been abused either physically or verbally will report such abuse to the appropriate authority IMMEDIATELY ... This suspicion may be based upon verbal report, visual observation, physical evidence or upon behaviors which provides reasonable belief that a patient may have been or may become a victim ... Staff who witness or suspect the patient has been abused ... will report such abuse to the Administrator on Call (AOC) IMMEDIATELY and complete an incident report... Staff-to-Patient Abuse or Neglect: The staff member shall be notified of the allegation and suspended from duty, pending results of the investigation. If the staff member is working at the time of the allegation of abuse, the department head will assign replacement staff as necessary to complete the shift. Under no circumstances will the alleged perpetrator remain on any patient care unit. The CEO [Chief Executive Officer] and the Director of Risk Management will be notified immediately ... Investigation: Reports of Abuse or Neglect which occur while the patient is hospitalized will be thoroughly investigated by the Risk Manager or other staff, qualified to detect abuse and not involved in the alleged victim's treatment, as assigned by the Chief Executive Officer within 24 hours of the initial report. All internal review findings shall be documented and filed according to the hospital procedures and made available to the Department of Health upon request. Interviews related to the investigation will be completed by the Risk Manager, Human Resources Director or the Patient Advocate, as assigned by the Chief Executive Officer ... At no time will the manager of the accused staff participate in the investigation other than to respond to questions if interviewed ... "

2. The hospital's policy titled, "Unit Response to a Sexual Abuse Allegation" (revised 12/8/2022), was reviewed and required, "RN / Administrator on call RESPONSIBILITY: If Staff on Patient [abuse] is reported or suspected: Immediately pull staff aside, take keys/badge and send staff home pending investigation. Contact Nurse Manager or DON [Director of Nursing] that is on call, the Administrator on Call, Risk Manager (or designee) ..."

3. On 7/24/2023, an Incident Report, dated 7/20/2023 at 4:50 PM, included, "On the fifth floor west side of the building client [Pt. #2] made allegations that [Pt. #2] was raped by two Behavioral Health Associates [BHAs]. The Client [Pt. #2] said that this took place yesterday (July 19th, 2023) around 11:00 PM. The client [Pt. #2] said that one of the alleged perpetrator is [BHA E#7]." The incident report did not include who was the second perpetrator; however per interview with the CEO (E#1), BHA E#8 was the other named perpetrator.

4. The Investigation Report, dated 7/21/2023, included, "7/20/2023 Approximately 4pm, therapist came to my office stating a patient on the 5th floor, who is actively psychotic, pulled him [therapist] aside and stated he had been sexually assaulted by two staff the prior night in his room ... He [therapist] was instructed to complete an incident report ... I [Chief Executive Officer/CEO/E#1] notified Milieu Manager [E#9], stating that the two individuals would have to be suspended pending investigation ... I then contacted his psychiatrist [MD#1] requesting for him to block the patient's room and ensure SAO (sexually acting out) precautions are in place..." The report indicated that E#9 was notified of the abuse allegation on 7/20/2023; however, lacked documentation of the exact time E#9 was notified. The report did not include when E #7 or E #8 were suspended, pending the investigation of abuse or when Pt. #2 was blocked.

5. The clinical record of Pt. #2 was reviewed on 7/25/2023. Pt. #2 was a 17-year old admitted to the 5th Floor Adolescent Boys Behavioral Health Unit (BHU) on 7/14/2023, with a diagnosis of major depressive disorder, recurrent and severe with psychiatric symptoms. The Psychosocial Assessment, dated 7/17/2023, indicated that Pt. #2 had a history of trauma which included, "Pt reports that [Pt. #2] was raped by someone that [Pt. #2] does not know."

- The Observational Rounds for Pt. #2, dated 7/20/2023, indicated that E#7 was completing every 15-minute rounds on patients between approximately 7:00 PM to 11:00 PM (after the Hospital was made aware of the allegation of abuse from Pt. #2 against E#7).

6. On 7/24/2033, a Grievance Communication Form, dated 7/20/2023 (date grievance received by hospital), was reviewed and included, "[Pt. #3] reports that 2 male staff [identified as BHAs E#7 and E#8] held [Pt. #3] down 'extra hard' [on 7/19/2023]. [Pt. #3] reports 'getting manhandled and was tired of getting hurt by them [E#7 and E#8]' [Pt. #3] reports that one grabbed [Pt. #3's] neck and [Pt. #3] fell on the floor, hit [Pt. #3's] head. [Pt. #3] said [Pt. #3's] arm was twisted and they [E#7 and E#8] held [Pt. #3's] legs. [Pt. #3] reports they [E#7 and E#8] put their [E#7 and E#8] knees on [Pt. #3] neck and [Pt. #3] woke up feeling sore this morning. [Pt. #3] has dark spot on [the] neck and reports that [Pt. #3's] legs were hitting the bed hard." This grievance was filed under the category Physical Abuse; however, an incident report related to the allegation of abuse was not filed as required by policy. The only incident report filed for Pt. #3 on 7/19/2023 was related to Pt. #3's aggressive behavior (attacking staff) and that she required four holds (physical restraints) that evening from approximately 8:13 PM - 9:08 PM.

7. The clinical record of Pt. #3 was reviewed on 7/25/2023. Pt. #3 was a 13-year old, admitted on 7/8/2023 to the 4th Floor Adolescent Girls BHU, with a diagnosis of intermittent explosive disorder. The Psychosocial Assessment, dated 7/10/2023, indicated that Pt. #3 had a history of physical abuse by a guardian's relative at the age of 12.

8. Staffing Timesheets from 7/18/2023-7/24/2023 were reviewed and indicated that E#7 worked the following days:
- 7/20/2023 1:30 PM to 11:00 PM
- 7/21/2023 3:00 PM to 11:00 PM
- 7/24/2023 2:00 PM to 9:45 PM

9. Video footage of the 5th Floor Unit on 7/20/2023, between 7:00 PM-12:00 PM was reviewed and confirmed that E#7 was observed working on the unit during this time and did not leave the unit until approximately 10:55 PM (nearly 7 hours after the allegation had been made).

10. An interview was conducted on 7/24/2023, at approximately 11:14 AM, with the Chief Executive Officer (E#1) who completed the investigation report for Pt. #2. E#1 stated that when they receive an allegation of abuse, the alleged staff members will be suspended immediately pending the results of the investigation. E#1 stated if the alleged staff are working at the time of the allegation, they will be sent home right away. E#1 stated that he notified E#9 on 7/20/2023 around 4 PM), that the two staff (E#7 and E#8) needed to be placed on suspension pending investigation; however, E#1 was not made aware that E#7 was actively working at that time (the evening of 7/20/2023 after the allegation from Pt. #2 was made). E#1 stated that the investigation was concluded on 7/21/2023, between approximately 2:30 PM - 3:00 PM and they were not able to substantiate the allegation. E#1 stated that the two staff were removed from suspension and were allowed to work the evening of 7/21/2023 (if scheduled). E#1 was not made aware of Pt. #3's allegation of abuse and stated, "I wasn't involved in that investigation."

11. An interview with the Patient Advocate (E#10) was conducted on 7/25/2023, at approximately 10:21 AM. E#10 stated they [Hospital A] received the complaint from Pt. #3, on the morning of 7/20/2023 around shift change (at approximately 7 AM). E#10 stated she immediately started an investigation. E#10 stated that the E #1 and Chief Nursing Officer (CNO) were notified when the allegation was received and should have been aware that the investigation had been started. Video of the 4th floor on 7/19/2023 (date/time of alleged incident) was reviewed; however, the patient (Pt. #3) reported that it occurred in the patient's room where no cameras are present. E#10 stated that Pt. #3 reported Pt. #3 was injured during a hold. E#10 stated that per the records, Pt. #3 was put in a hold about 4 times that evening due to aggressive behavior. E#10 stated that the employees may have been scheduled to work that evening but should have been placed immediately on suspension pending investigation. E#10 stated that the CNO is responsible for ensuring the alleged staff are taken off the schedule, sent home (out of the building), and do not report to work until the investigation is completed. E#10 stated that the investigation is still open at this time as they are waiting for two more interviews with witnesses. E#10 stated that she just received statements from the two alleged staff (E#7 and E#8) this morning (7/25/2023). E#10 stated that the two staff members should still be on suspension. E#10 stated that E#10 will update the CEO when the investigation is closed and what are the results of the investigation.

12. An interview was conducted with the Milieu Manager (E#9) on 7/25/2023, at approximately 11:08 AM. E#9 stated that E#9 was not made aware of Pt. #2's allegation until the morning of 7/21/2023 and that's when E#9 placed E#7 and E#8 on suspension pending the investigation. E#9 was instructed by the CEO (E#1) to conduct a video review as part of the investigation, despite the Hospital's policy stating that managers of the accused staff should not participate in the investigation (aside from responding to interview questions). E#9 stated that the video review did not show that E#7 or E#8 were even near Pt. #2 during the alleged time period. E#9 stated that E#7 and E#8 were taken of suspension status following the results of the investigation that afternoon on 7/21/2023. E#9 stated that in regard to Pt. #3's allegation of abuse, E#9 stated that staff should remain on suspension if the investigation is still in progress. E#9 was not involved with the investigation of Pt. #3's abuse allegation but was a witness to the first hold that occurred that evening of 7/19/2023, to which E#9 already provided a written statement. E#9 was not aware that Pt. #3's investigation was not yet completed. E#9 stated that both E#7 and E#8 were taken off suspension following his investigation of Pt. #2's allegation as of 7/21/2023. E#9 stated that both E#7 and E#8 are currently off suspension and that E#7 even worked last night (7/24/2023). E#9 stated that E#8 is not a regular staff and only works PRN (as needed).