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Based on a review of facility documents, security video footage, tour of the facility, medical records (MR), and employee interviews (EMP), it was determined that the facility failed to maintain a safe environment for psychiatric patients by permitting patient to use an unsecured courtyard, not securing access to remote control batteries, and not adhering to the policy for courtyard privileges for six of six medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6).


Findings include:


Review on November 21, 2025, of facility policy "Rights and Responsibilities of Patients", last revised October 2024, revealed "You have the right to: ... Receive care in a safe setting free from any form of abuse, harassment, and neglect. ...".


Review on November 21, 2025, of facility policy "Behavioral Health Courtyard (Patient Recreation Area)", established May 24, 2024, revealed, "Objective: To define the appropriate standards of which patients must meet to gain access and the privilege of attending the courtyard, describe authorized activities, and ensure safety of staff and patients in the courtyard. ... To provide an outdoor recreation area for patient activities. These activities may include individual and group discussion, group recreational activities, and activities designed to improve physical well-being. ... All policies applicable to patient care areas within the behavioral health service apply to the courtyard. ... Patients with a positive Broset assessment/score above 0 on most recent assessment must be reassessed prior to attending courtyard, unless otherwise authorized by attending psychiatrist. ... Patients with active, violent charges will not be permitted in the courtyard. ... Patients on a 1:1/sitter observation status for self-harm, suicide precautions, or any other behavioral health safety rationale are permitted in the courtyard, as long as the 1:1 remains with the patient at all times. ... Patients who are on self-harm precautions will only be permitted in the courtyard if they have a 1:1 staff with them in the courtyard. ... Patients with a history of becoming aggressive/violent or eloping in the courtyard must have approval to attend courtyard privileges by the attending psychiatrist before courtyard time. ...".


Review on November 21, 2025, of surveillance video from the behavioral health courtyard, dated November 13, 2025, revealed the footage of the courtyard elopement event. In the video, MR1 is seen sitting on a bench alone, drinking a beverage. MR1 walks away quickly from the bench and leaps over the vinyl fence, elopes from the patient courtyard, and sprints away through the parking lot. The elopement occurred on November 13, 2025 at 1:42 PM.



Tour of the facility conducted on November 21, 2025, at 11:00 AM, revealed a fenced-in outdoor space, approximately 20 x 30 yards in size, used by behavioral health patients and staff. Observations include: There are three entry points to the courtyard, two gates at either side which provide access to a parking lot, and a sidewalk parallel to a two-way road. The third access point is through the behavioral health building, requiring interior badge clearance. To re-enter the building, one must use a key. Initial view of the space revealed several areas of patient safety concern. Within the perimeter of the courtyard is a volleyball net with hanging strings, a basketball hoop, several seating areas (benches and tables), a metal framed awning with torn/loose fabric, and approximately seven trees. Five of these trees are located within arm's reach of the perimeter fence. There are portions of vinyl fencing which have gaps beneath, measuring eight to eleven inches from the ground. The height of vinyl fencing next to the storage shed is below the height of the surveyor (approximately 5 feet 9 inches with shoes on). EMP7 confirmed this section of fencing as the site of MR1's elopement.


During interview on November 21, 2025, at 11:15 AM, EMP7 confirmed the close proximity of trees and the height of the vinyl perimeter fence to be high elopement risks.


Review on November 21, 2025, at 12:00 PM, of correspondence between the Facilities Director, Chief Nursing Officer, and Patient Safety Officers, included a courtyard perimeter assessment, conducted by EMP9 and EMP14. This document revealed the following environmental concerns related to patient safety: "The courtyard currently has three types of barriers to prevent elopement: a vinyl fence ... some aluminum fencing ... and a few spans of brick wall ... I have found numerous concerns with each type of barrier. The brick walls can be scaled with not much more than a running jump. There are also numerous trees near different parts of the wall as well as other grab-points that can assist with scaling. The aluminum fencing that has been added to the tops of some of the brick walls ... can possibly be used as an aid to scaling the wall. The vinyl fencing not only can be scaled with a running jump, but also has large gaps at the bottom of the fence that could allow for a smaller patient to crawl under with minimal effort. The vinyl fence is also the weakest of all fences and could possibly be broken through by a strong and determined patient. ... There are also numerous picnic tables and benches in the area that could aid with scaling any of the barriers. Additionally, the trees, the aluminum fencing, and the awning over the one picnic table ... present numerous ligature risks in the space. ...".


During an interview on November 21, 2025, at 1:30 PM, EMP14 confirmed the above to be safety hazards in this patient setting.


On November 21, 2025, at 11:25 AM, a tour of two patient lounges on the behavioral health unit was conducted. The lounges included seating, reading material, and a television. At 11:25 AM, the second-floor lounge revealed a television remote with removable back plate, and two AA batteries inside. At 11:30 AM, the third-floor lounge revealed two television remotes, with removable back plates, each with two AAA batteries inside.


During interview on November 21, 2025, at 11:31 AM, EMP7 confirmed the above to be safety hazards in this patient setting.



Review on November 21, 2025, of MR1 revealed a 23-year-old male patient admitted to the hospital on November 3, 2025, as a 201 voluntary commitment to the psychiatric unit. MR1 was admitted to the hospital with a diagnosis of Schizophrenia and the initial Broset score on admission was 1. On November 3, 2025, an order was placed by the physician in the medical record for the active self-harm protocol. MR1 chose not to participate in group therapy and was expressing an interest in leaving the hospital for several days. The medical care team documentation revealed that MR1 became a 302 involuntary commitment to promote safety on November 7, 2025. MR1 was in the patient courtyard on November 13, 2025, and the medical record does not reveal documentation of 1:1 staff-to-patient ratio during this time.


During an interview on November 21, 2025, at 1:15 PM, EMP3 confirmed the above.



Review on November 24, 2025, of MR2 revealed that the patient was a 78-year-old male admitted to the hospital on October 17, 2025, as a 302 involuntary commitment to the psychiatric unit. MR2 was admitted to the hospital with a diagnosis of Psychosis, and PTSD. The initial Broset score on admission was 0. On October 31, 2025, the Broset score was a 3. On November 1, 2025, the Broset score was a 2. On November 2, 2025, the Broset score was a 3 and on November 3, 2025, the Broset score was a 3. An order was placed by the physician in the medical record for the active self-harm protocol. MR2 also had an order for Courtyard/Smoking Privileges. Documentation in the medical record reveals that MR2 had a history of elopements but privileges were present in the medical record as evidenced by the admission orders on October 17, 2025.



Review on November 24, 2025, of MR3 revealed that the patient was a 55-year-old female admitted to the hospital on July 26, 2025, as a 302 involuntary commitment to the psychiatric unit. MR3 was admitted to the hospital with a diagnosis of Alcoholism. The initial Broset score on admission was 0. On July 26, 2025, the Broset score was a 0. On July 27, 2025, the Broset score was a 0. On July 28, 2025, the Broset score was a 0 and on July 29, 2025, the Broset score was not completed. An order was placed by the physician in the medical record for the active self-harm protocol. MR3 also had an order for Courtyard/Smoking Privileges. Documentation in the medical record reveals that MR3 had privileges were present in the medical record as evidenced by the admission orders on July 26, 2025, and documentation revealed lack of Broset scale for July 29, 2025.



Review on November 24, 2025, of MR4 revealed that the patient was a 43-year-old male admitted to the hospital on October 21, 2025, as a 302 involuntary commitment to the psychiatric unit. MR4 was admitted to the hospital with a diagnosis of Bipolar and Substance Abuse. The initial Broset score on admission was 0. On October 22, 2025, the Broset score was a 5. On October 23, 2025, the Broset score was a 0. On October 24, 2025, the Broset score was a 3 and on October , 2025, the Broset score was a 1. An order was placed by the physician in the medical record for the active self-harm protocol. MR4 also had an order for Courtyard/Smoking Privileges. Documentation in the medical record reveals that MR4 had privileges were present in the medical record as evidenced by the admission orders.



Review on November 24, 2025, of MR5 revealed that the patient was a 47-year-old male admitted to the hospital on September 3, 2025, as a 302 involuntary commitment to the psychiatric unit. MR5 was admitted to the hospital with a diagnosis of Alcohol withdrawal. The initial Broset score on admission was 1. Documentation does not reveal another Broset score. An order was placed by the physician in the medical record for the active self-harm protocol. MR5 also had an order for Courtyard/Smoking Privileges. Documentation in the medical record reveals that MR5 had privileges were present in the medical record as evidenced by the admission orders.


Review on November 24, 2025, of MR6 revealed that the patient was a 49-year-old female admitted to the hospital on May 15, 2025, as a 302, as an involuntary commitment to the psychiatric unit. MR6 was admitted to the hospital with a diagnosis of Intentional Overdose, Bipolar, and Anxiety. The initial Broset score on admission was 0. An order was placed by the physician in the medical record for the active self-harm protocol. MR6 also had an order for Courtyard/Smoking Privileges. Documentation in the medical record reveals that MR6 had privileges were present in the medical record as evidenced by the admission orders on May 15, 2025.


During medical record review on November 24, 2025, at approximately 12:00 PM, EMP22 confirmed the above medical record findings.

Based on a review of facility documents, medical records (MR) and employee interview (EMP), it was determined that the facility failed to obtain an order to continue seclusion in one of four restraint medical records reviewed (MR7).


Findings include:


On November 25, 2025, a review of "Policy and Procedure for Patient Restraint and Seclusion" (Last Revised: 02/2024) was completed and revealed the following: "Section IV. Guidelines for Restraint and Seclusion Use: D. Restraints for violent, self-destructive behavior: These standards apply to Emergency or crisis management situations, where a patient's behavior becomes self-destructive or violent, presenting an immediate serious danger to his/her safety or that of others regardless of clinical setting. Restraints may be physical, chemical and/or seclusion ...Orders for Physical/Chemical Restraint for the Violent Self-destructive Patient: ...2. The physician order must be obtained as soon as possible ...8. Orders for restraint/seclusion must include: Date and Time of application/Clinical Application/Type of restraints .../Time limited order ... Callout Box: Up to 4 hours for individuals 18 years and older."


On November 25, 2025, a review of MR7 revealed that the patient was placed in seclusion for violent, self-destructive behavior on September 10, 2025, at 2:25 AM. MR7 remained in seclusion until 4:38 PM on September 10, 2025. The second order for continuing restraint was due, per policy, at 6:25 AM and not obtained until 10:18 AM, 7 hours and 53 minutes after the first order at 2:25 AM. Thus, exceeding the 4 hour time limit for violent, self-destructive restraints.


On November 24, 2025, at 11:14 AM, EMP6 confirmed that the order due at 6:25 AM was not completed per policy.

Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined that the facility failed to document a face to face evaluation/assessment completed by a licensed practitioner, certified nurse practitioner, or physician assistant, for seclusion of the violent, self-destructive patient in four of four seclusion records reviewed (MR7, MR8, MR9, and MR10).


Findings include:


On November 24, 2025, a review of "Policy and Procedure for Patient Restraint and Seclusion" (Last Revised: 02/2024) was completed and revealed the following: "Section IV. Guidelines for Restraint and Seclusion Use: D. Restraints for violent, self-destructive behavior: ...9. Face to Face Evaluation- One Hour and Eight Hour Assessments: The in person evaluation, conducted by a licensed practitioner, a certified nurse practitioner, or a physician assistant must be completed within one hour of the initiation of restraint or seclusion for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff, or others ... ".


On November 24, 2025, a review of MR7 revealed that the patient was placed in seclusion on September 10, 2025, at 02:25 AM. The face to face assessment was completed at 2:30 AM by EMP17, a registered nurse.


A second, time limited order was obtained on September 10, 2025, at 10:18 AM, with the face to face assessment occurring at 11:15 AM by EMP18, a registered nurse.


On November 24, 2025, a review of MR8 revealed that the patient was placed in seclusion on September 11, 2025, at 2:30 PM. The face to face assessment was completed at 2:50 PM by EMP19, a registered nurse.


On November 24, 2025, a review of MR9 revealed that MR9 was placed in seclusion on October 29, 2025, at 01:36 PM. The face to face assessment was completed at 2:00 PM by EMP9, a registered nurse.


On November 24, 2025, a review of MR10 revealed that MR10 was placed in seclusion on September 2, 2025, at 01:13 PM. The face to face assessment was completed at 1:15 PM by EMP18, a registered nurse.


The above findings were confirmed on November 24, 2025, at 12:00 PM by EMP6. At approximately 1:00 PM, EMP5 confirmed that the facility policy stated that only licensed practitioners, certified registered nurse practitioners, or physician assistants were permitted, by policy, to perform the face to face evaluation.

Based on a review of facility documents, personnel files (PF), and employee interviews (EMP), it was determined that the facility failed to provide evidence of training regarding the use of restraints and seclusion for violent and/or self-destructive patients for two of two agency registered nurses reviewed and assigned to the behavioral health unit (PF13 and PF14).


Findings Include:


On November 24, 2025, a review of "Policy and Procedure for Patient Restraint and Seclusion" (Last Revised: 02/2024) was completed and revealed the following: " Section VI. Education and Training: ...Staff Education and Training: 1. Orientation to this policy will be provided to all newly hired staff and agency personnel that have direct patient care responsibilities, responsibilities for the application of restraint or the monitoring or assessment of patients in restraint. At the end of orientation, the staff should be able to demonstrate competency in the application of restraint, implementation of seclusion if applicable, monitoring, assessment and providing care for a patient in restraint or seclusion."


On November 24, 2025, a review of the "Behavioral Health Nursing Learning Objectives " (competency checklist) (Last Updated: 5/24/2023) was completed and revealed, "In the Competency section, where this is an option, to choose either V, O, or D in the key: Circle O if the orientee observed the preceptor doing the procedure; Circle D if the nurse demonstrated the skill associated with that specific competency. If only D is available in the key section, the nurse must demonstrate the skill in order to be deemed competent ..." The Restraint and Seclusion section, on page 2, of the "Behavioral Health Nursing Learning Objectives" requires demonstrated skills.


On November 24, 2025, a review of PF13, agency registered nurse, revealed no documentation of completed restraint/or seclusion training/competency.


On November 24, 2025, a review of PF14, agency registered nurse, revealed no documentation of completed restraint/or seclusion training/competency.


On November 24, 2025, at approximately 1:15PM, EMP5 confirmed that PF13 and PF14 had no documentation of completed restraint/or seclusion training/competency.