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A. Based on clinical record review, video review, document review and interviews it was revealed the Governing Body failed to ensure the day to day operations and grievance policies and procedures of the hospital are followed. This failure was revealed in one (1) (patient #4) out of thirty (30) patient cases reviewed. This failure has the potential for all patients, staff, visitors and acquaintances to be at risk for injury.

Findings include:

1. A review of the medical record for patient #4 revealed a Psychiatric Evaluation dated 12/29/20 at 11:37 a.m. by Physician Assistant #1 that states in part, "Her roommate filed for a protective order earlier this week." A Master Treatment Plan dated 01/04/21 at 4:08 p.m. states, "Per commitment paperwork, her roommates have taken a protective order against her. ... Called State Troopers four (4) - five (5) times in the past two (2) days. She told police she was going to buy a gun so if she is followed, she can feel protected. ... stated that she tried to escape the other day. ..." Physician orders dated 01/02/21 at 8:48 p.m. states in part: "Patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday" and on 01/03/21 at 2:59 p.m. states in part: "Change: patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday to patient is restricted from using phone due to repeated calls to police and community mental health center. Patient only to make calls to her attorney and the advocate. ALL calls must be made via nursing station. Must be renewed on Monday, Wednesday and Friday." This order was renewed again on 01/06/21 at 9:43 a.m. and again on 01/12/21 at 8:40 a.m.

2. A review of facility Grievance Logs for 12/2020 and 01/2021 revealed there were not any grievances reported by police or any individual reporting patient #4 has been calling them and breaking restraining/protective orders against her.

3. A review of facility policy, "Handling of Patient Complaint/Grievances," effective date 02/06/20, states in part: "A "patient grievance" is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by the staff present) by a patient, or the patient's representative, Legal Aid Patient Advocate, facility employee or other individual on behalf of any patient regarding the patient's care, treatment, housing, services, accommodations, etc., alleged abuse or neglect, issues related to the hospital's compliance with the Medicare conditions of Participation, or Medicare beneficiary billing complaint related to rights and limitations. ... If the complaint cannot be resolved, the staff member shall promptly assist the patient with initiating a "Patient Grievance," file it on their behalf or contact the Legal Aid Patient Advocated ... or the nursing supervisor ... to initiate a "Patient Grievance." ... Complaint or grievance resolution shall be given top priority by those receiving the complaint or grievance and by those involved in resolving the circumstances and implementing corrective actions, if indicated. Investigations will be resolved within seven (7) days. ..."

4. A review of Title 64, "Legislative Rule Department of Health and Human Resources, Series 59, Behavioral Health Client Rights," states in part: "12.4. Restrictions. Any deviation from the telephone and mail rights afforded by subsections 12.2 and 12.3 of this rule can only be authorized by the interdisciplinary team or the physician for a time specified by the team. A complete report relative to the restriction of telephone or mail rights and the reasons therefore shall be made a part of the client's medical record, signed and dated by the client's attending physician, and reflected in the client's nursing care plan. Restrictions of mail and telephone rights shall expire in three (3) days unless reviewed."

5. A telephone interview was conducted on 01/11/21 at 5:23 p.m. with Sheriff Officer #1. When asked if he had tried to file a complaint at the hospital and how he tried to file a complaint, he stated in part, "I've been trying since last Thursday (01/07/21) to get someone to call me back. I have warrants to serve to patient #4. I left a total of seven (7) messages with different departments and no one has called me back and I even told them I needed to complain because I must serve this woman before she gets discharged. She is breaking restraining orders from inside the hospital and they are allowing it to happen, something has to be done."

6. A telephone interview was conducted on 01/12/21 at approximately 1:15 p.m. with the Chief Executive Officer. When asked if he found out if he received a call from a Police Officer about patient #4 calling individuals who had restraining orders against her, he stated in part, "The Director of Health Information Management (HIM) had a voicemail that was left. The officer called the next day and spoke with HIM employee #1, who notified the Director of HIM. The Director notified the social worker who notified the medical provider. We never followed up and called the policeman back." When asked if a complaint was filed, he stated in part, "If someone calls and provides us information, it goes to the treatment team who would address it. The treatment team would take steps to limit the behavior. It is not a complaint. With regards to the patient, the law informant called and made it known patient is a nuisance and we take steps to limit and prevent it."

7. A telephone interview was conducted with physician #1 on 01/12/21 at approximately 1:55 p.m. When asked if the patient was on phone restrictions, he stated in part, "If it's signed by me, that is what happens. I have a responsibility to approve the orders." When asked if the nurses were not monitoring the patient who was calling people outside the facility who had restraining orders against her, he stated in part, "I don't think I can offer an excuse. It shouldn't happen. The order is there. Staff should redirect the patient. I expect staff to follow the orders and screen patient's calls. I assume the order would be followed as written. ... I feel like, now looking back, I should have done it from the beginning. ..." When asked about the treatment plan, he stated in part, "In the treatment plan we should discuss all things that have therapeutic relevance. We also put in the plan to restrict something. We didn't do it. We should be held responsible. ..."

8. A telephone interview was conducted with the Nurse Manager #1 on 1/12/21 at 4:49 p.m. When asked if he was notified of an individual calling to report they were receiving phone calls from patient #4 against restraining orders, he stated in part, "I was never told about a call from someone reporting they were being called by the patient and had a restraining order." When asked if it would be a complaint, he stated in part, "I would consider this report a complaint." He noted on the complaint process, they notify the physician, tell them the problem and put phone restrictions in place. He concurred it should have been reported and the physician notified. He stated, "If a patient had a rental car ordered previously, and a patient is verbalizing she is going to break out and she broke the door lock and got into the anteroom, I would have notified the doctor immediately." I feel this patient should have been put on a continual close observation (CCO).

9. A telephone interview was conducted with Registered Nurse (RN) #2 on 01/12/21 at 5:44 p.m. She stated in part, "That is true. She was calling people. I remember her being on the phone a lot and we were extremely busy and short on staff. We weren't always able to catch her doing it. ... Patients are supposed to come to the nurse's station to get calls made. She noted the patient's room was right across from a phone. There are four (4) phones in the hallway, three (3) in the day room and one (1) in the hallway across from her room. It was an easy phone to get to because of location." When asked if she received any calls from individuals reporting she was calling them against restraining orders, she stated in part, "I am the one who took the call from the person and I reported it to my supervisor. That person also called the authorities. I notified the lead nurse on the unit. I don't remember the day. Normally I write a note but don't recall I made a note. It may have been because I told her." When asked about the complaint process, she stated in part, "I don't know the process when an outside person calls, so I notified the lead nurse. When asked if there is a protocol, she stated in part, "I don't know if there is a protocol."

10. An interview was conducted with the Lead RN #1 on 1/12/21 at 6:32 p.m. When asked if the patient was on phone restrictions, she stated in part, "It depends on the orders and with nursing staff, it's harder to restrict calls. The patient doesn't have to be honest who she is calling. If the order says from the nursing desk, then staff dials the phone number and the patient can talk at the nurse's desk or staff transfer the call to the day phone." She noted there are four (4) phones on the unit and patients can access them at any time. She stated it is more difficult to monitor phone restrictions by nursing if the order doesn't state "at the nurse station." When asked if she was notified of a complaint by a RN about someone calling to report she had a restraining order against patient #4 and was receiving phone calls, she stated in part, "I never received any information or any information written. I don't remember being told about any calls coming in for a complaint of the patient calling someone outside the facility."

B. Based on clinical record review, video review, document review and interviews it was revealed the Governing Body failed to ensure facility staff follow policies and procedures to provide patient care in a safe setting. This failure was revealed in one (1) (patient #4) out of thirty (30) clinical records reviewed. This failure has the potential for all patients, staff, visitors and acquaintances to be at risk for injury.

Findings include:

1. A review of the medical record for patient #4 revealed an Elopement Assessment dated 12/28/20 at 7:40 p.m. documented, "The patient has not made any statements indicating intent to elope, exhibited behaviors indicating intent to elope" and states in part: "Elopement Risk is Low." A Mental Health Therapist (MHT) Elopement Risk Scale on 12/29/20 at 4:05 p.m. documented, "The patient has not persistently stated in a hostile or aggressive manner that she wants to leave the unit or find a way to leave and does not have risky behaviors such as trying to open doors." Behavioral Notes dated 12/31/20 at 5:32 p.m. noted the patient ordered a rental car the previous day that was delivered to the hospital. At 9:15 p.m. the patient was documented as stating, "I will give each of you two (2) million dollars if you will open the door and let me out." ... She became upset, ran and kicked the first security door. Patient #4 was able to break the lock on the door." At 10:37 p.m. documentation revealed, "Patient #4 ran down the hall and kicked the door again breaking the locking device. A staff member once again placed in front of the door until it could be repaired." On 01/1/21 at 8:02 a.m. a Behavior Note states in part: "Received phone call from 911 this morning stating that they received a call from patient #4. She informed 911 that she was going to break out of here last night ..." On 01/01/21 at 9:14 a.m. it was documented the Advanced Practice Registered Nurse was made aware of the patient's behavior. No documentation was noted in the medical record that the physician was immediately notified of a potential elopement risk.

2. A review of a video recording was conducted on 12/31/20. A video recording dated 12/31/20 at 9:42 p.m. revealed patient #4 approached the locked entry door to C2 Unit, broke into a run and then kicked the door, backed up and reattempted to kick the door open. One (1) staff member came from the nurse's station and interrupted the patient and redirected her away from the door. At 9:44 p.m. the patient approached the door again, ran and kicked the locked door breaking open the door and entered the ante room. She attempted to kick the locked ante room door. One (1) staff member entered the ante room, interrupted the patient and remained with her. At 9:45 p.m. additional staff arrived helping to redirect the patient from the area. At 9:46 p.m. the patient walked back into the C2 unit from the ante room and staff was posted at the C2 entrance door.

3. A review of facility policy, "Incident Reporting and Review," effective date 05/04/20, states in part: "Employees who witness or are aware of an incident are responsible for completing and signing an Incident Report form at the time they become aware of the incident. Reporting must be completed and submitted prior to the end of current shift or within eight (8) hours of the incident, whichever is earlier. Incident reports must be completed when: There is a potential for injury (regardless of severity) to patients, employees or visitors. In the event of damage to or loss of hospital and/or patient property. ... Elopement or attempted elopements ..."

4. A review of facility incident reports from 12/28/20 through 01/12/21 revealed there were no incidents reported for patient #4 for renting a rental car two (2) times, verbalizing attempting to elope and for kicking open the locked entry door in C2 unit which broke the door lock and attempting to kick and break open the door from the ante room to the C2 unit.

5. A review of facility policy, "Levels of Observation," effective 07/15/19, states in part: "All patients are placed on an observation level based on clinical assessment of the patient's needs, risk conditions and behavior. ... To provide staff guidelines related to an increased level of observations. ... A nurse may initiate a Close Constant Observation (CCO), for any patient behavior that requires an increase in observation for safety, such as, but not limited to self-harm, aggression, suicidal or homicidal ideation, sexually inappropriate behavior, fall risk, elopement risk, etc., then consult with medical staff and obtain an order. ... A nurse may initiate a one (1) to one (1), for any patient behavior that requires an increase in observation for safety, such as, but not limited to; self-harm, aggression, suicidal or homicidal ideation, sexually inappropriate behavior, fall risk, elopement risk, etc., then consult with medical staff and obtain an order."

6. A review of facility policy, "Measuring Elopement Risk Behaviors," effective 06/15/20, states in part: "The hospital will ensure a safe and therapeutic environment through assessing and continuously measuring patient risk for elopement. ... All hospital staff will complete annual training on situational awareness, specifically on elopement risk behaviors that may indicate a patient is seeking opportunities to leave."

7. A telephone interview was conducted with Physician #1 on 01/12/21 at approximately 1:55 p.m. When asked if he was notified of the patient renting a car from a rental company, he stated in part, "I was off on 12/31/20 and 1/1/01. I was not here. ... They would have notified the on-call provider."

8. An interview was conducted with Nurse Manager #1 on 1/12/21 at approximately 4:49 p.m. When asked about the elopement process, he stated in part, "If a patient had a rental car ordered previously, and a patient is verbalizing she is going to break out and she broke the door lock and got into the anteroom, I would have notified the doctor immediately. I feel this patient should have been put on a continual CCO."

9. A telephone interview was conducted with RN #1 on 1/12/21 at 5:18 p.m. When asked about elopement she stated, "I would notify the provider on call immediately and follow doctor orders. If they feel it is necessary, may place them on one (1) to one (1) or CCO." She stated CCO means no obstacles in the way of the view of the patient and one (1) to one (1) is in arm's length.

10. A telephone call was conducted with RN #2 on 1/12/21 at 5:44 p.m. She stated, "I don't know if patient was place on increased elopement precautions. She tried to kick the door down and we had it repaired. ... She was calling people. I remember her being on the phone a lot and we were extremely busy and short on staff. We weren't always able to catch her doing it." She stated, "I don't think we knew she ordered the vehicle. She did it twice and they delivered it twice. It was on two (2) different days. I don't remember if the physician was notified."

11. An interview was conducted with Lead RN #1 on 1/12/21 at 6:32 p.m. She stated in part, "I was aware she had ordered a rental car. I know I was here one day when she did it. I don't remember when. I think she rented it twice. ... She at times was verbalizing wanting to leave. ...The elopement should have been changed. I don't know the policy off the top of my head, but the nurse should have called the on-call doctor to let them know and the doctor would write an order for the elopement risk." She concurred the nurse should have called the doctor as soon as the situation was controlled.

C. Based on clinical record review, document review and interviews it was revealed the Governing Body failed to ensure all nurses follow hospital incident reporting policies and procedures. This failure was revealed in one (1) out of thirty (30) clinical records reviewed. This failure has the potential for all patients, staff, visitors and acquaintances to be at at risk for injury.

Findings include:

1. A review of the medical record for patient #4 revealed an Elopement Assessment dated 12/28/20 at 7:40 p.m. documented, "The patient has not made any statements indicating intent to elope, exhibited behaviors indicating intent to elope" and states in part: "Elopement Risk is Low." A Psychiatric Evaluation dated 12/29/20 at 11:37 a.m. by Physician Assistant #1 states in part: "Her roommate filed for a protective order earlier this week." A Mental Health Therapist (MHT) Elopement Risk Scale on 12/29/20 at 4:05 p.m. documented, "The patient has not persistently stated in a hostile or aggressive manner that she wants to leave the unit or find a way to leave and does not have risky behaviors such as trying to open doors." Behavioral Notes dated 12/31/20 at 5:32 p.m. noted the patient ordered a rental car the previous day that was delivered to the hospital. At 9:15 p.m. the patient was documented as stating, "I will give each of you two (2) million dollars if you will open the door and let me out." ... She became upset, ran and kicked the first security door. Patient #4 was able to break the lock on the door." At 10:37 p.m. documentation revealed, "Patient #4 ran down the hall and kicked the door again breaking the locking device. A staff member once again placed in front of the door until it could be repaired." On 01/1/21 at 8:02 a.m. a Behavior Note states in part: "Received phone call from 911 this morning stating that they received a call from patient #4. She informed 911 that she was going to break out of here last night ..." On 01/01/21 at 9:14 a.m. it was documented the Advanced Practice Registered Nurse was made aware of the patient's behavior. No documentation was noted in the medical record the physician was immediately notified of a potential elopement risk. Physician orders dated 01/02/21 at 8:48 p.m. states in part: "Patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday" and on 01/03/21 at 2:59 p.m. states in part: "Change patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday. The patient is restricted from using phone due to repeated calls to police and community mental health center. Patient only to make calls to her attorney and the advocate. ALL calls must be made via nursing station. Must be renewed on Monday, Wednesday and Friday." This order was renewed again on 01/06/21 at 9:43 a.m. and again on 01/12/21 at 8:40 a.m. A Master Treatment Plan dated 01/04/21 at 4:08 p.m. states, "Per commitment paperwork, her roommates have taken a protective order against her. ... Called state troopers four (4) - five (5) times in the past two (2) days. She told police she was going to buy a gun so if she is followed, she can feel protected. ... stated that she tried to escape the other day. ..."

2. A review of a video recording was conducted on 12/31/20. A video recording dated 12/31/20 at 9:42 p.m. revealed patient #4 approached the locked entry door to C2 Unit, broke into a run and then kicked the door, backed up and reattempted to kick the door open. One (1) staff member came from the nurse's station and interrupted the patient and redirected her away from the door. At 9:44 p.m. the patient approached the door again, ran and kicked the locked door breaking open the door and entered the ante room. She attempted to kick the locked ante room door. One (1) staff member entered the ante room and interrupted the patient and remained with her. At 9:45 p.m. additional staff arrived helping to redirect the patient from the area. At 9:46 p.m. the patient walked back into the C2 unit from the ante room and staff was posted at the C2 entrance door.

3. A review of facility policy, "Incident Reporting and Review," effective date 05/04/20, states in part: "Employees who witness or are aware of an incident are responsible for completing and signing an Incident Report form at the time they become aware of the incident. Reporting must be completed and submitted prior to the end of current shift or within eight (8) hours of the incident, whichever is earlier. Incident reports must be completed when: There is a potential for injury (regardless of severity) to patients, employees or visitors. In the event of damage to or loss of hospital and/or patient property. ... Elopement or attempted elopements ..."

4. A review of facility incident reports from 12/28/20 through 01/12/21 revealed there were no incidents reported for patient #4 for renting a rental car two (2) times, verbalizing attempting to elope and for kicking open the locked entry door in C2 unit which broke the door lock and attempting to kick and break open the door from the ante room to the C2 unit.

5. A telephone interview was conducted with Registered Nurse (RN) #2 on 01/12/21 at 5:44 p.m. She stated in part, "That is true. She was calling people. I remember her being on the phone a lot and we were extremely busy and short on staff. We weren't always able to catch her doing it. ... Patients are supposed to come to the nurse's station to get calls made. She noted the patient's room was right across from a phone. There are four (4) phones in the hallway, three (3) in the day room and one (1) in the hallway across from her room. It was an easy phone to get to because of location." When asked if she received any calls from individuals reporting she was calling them against restraining orders, she stated in part, "I am the one who took the call from the person and I reported it to my supervisor. That person also called the authorities. I notified the lead nurse on the unit. I don't remember the day. Normally I write a note but don't recall I made a note. It may have been because I told her." When asked about the complaint process, she stated in part, "I don't know the process when an outside person calls, so I notified the lead nurse. When asked if there is a protocol, she stated in part, "I don't know if there is a protocol."

6. An interview was conducted with Lead Registered Nurse #1 on 1/12/21 at 6:32 p.m. She stated in part, "I was aware she had ordered a rental car. I know I was here one day when she did it. I don't remember when. I think she rented it twice. ... She at times was verbalizing wanting to leave. ...The elopement should have been changed. I don't know the policy off the top of my head, but the nurse should have called the on-call doctor to let them know and the doctor would write an order for the elopement risk." She concurred the nurse should have called the doctor as soon as the situation was controlled. When asked about complaints from an outside person she stated, "I never received any information or any information written. I don't remember being told about any calls coming in for a complaint of patient calling outside facility." When asked about the complaint policy she stated, "Usually you talk to the on-call doctor to prevent it from happening. Nurses should fill out an incident report. It goes to us (Nurse Manager, Nurse Care Coordinator, to compliance). I am notified by an incident report or verbal report. If I receive a verbal report, I will tell the nurse to do an incident report and then I would follow up with the treatment team."

D. Based on clinical record review, document review and interviews, it was revealed the Governing Body failed to ensure all nurses follow physician orders for phone restrictions for patient #4. This failure was revealed in one (1) out of thirty (30) clinical records reviewed. This failure has the potential for all patients, staff, visitors and acquaintances to be at at risk for injury.

Findings include:

1. A review of the medical record for patient #4 revealed a Psychiatric Evaluation dated 12/29/20 at 11:37 a.m. by Physician Assistant #1 that states in part, "Her roommate filed for a protective order earlier this week." A Master Treatment Plan dated 01/04/21 at 4:08 p.m. states, "Per commitment paperwork, her roommates have taken a protective order against her. ... Called State Troopers four (4) - five (5) times in the past two (2) days. She told police she was going to buy a gun so if she is followed, she can feel protected. ... stated that she tried to escape the other day. ..." Physician orders dated 01/02/21 at 8:48 p.m. states in part: "Patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday" and on 01/03/21 at 2:59 p.m. states in part: "Change: patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday to patient is restricted from using phone due to repeated calls to police and community mental health center. Patient only to make calls to her attorney and the advocate. ALL calls must be made via nursing station. Must be renewed on Monday, Wednesday and Friday." This order was renewed again on 01/06/21 at 9:43 a.m. and again on 01/12/21 at 8:40 a.m.

2. A review of Title 64, "Legislative Rule Department of Health and Human Resources, Series 59, Behavioral Health Client Rights," states in part: "12.4. Restrictions. Any deviation from the telephone and mail rights afforded by subsections 12.2 and 12.3 of this rule can only be authorized by the interdisciplinary team or the physician for a time specified by the team. A complete report relative to the restriction of telephone or mail rights and the reasons therefore shall be made a part of the client's medical record, signed and dated by the client's attending physician, and reflected in the client's nursing care plan. Restrictions of mail and telephone rights shall expire in three (3) days unless reviewed."

3. A telephone interview was conducted on 01/11/21 at 5:23 p.m. with Sheriff Officer #1. When asked if he had tried to file a complaint at the hospital and how he tried to file a complaint, he stated in part, "I've been trying since last Thursday (01/07/21) to get someone to call me back. I have warrants to serve to patient #4. I left a total of seven (7) messages with different departments and no one has called me back and I even told them I needed to complain because I must serve this woman before she gets discharged. She is breaking restraining orders from inside the hospital and they are allowing it to happen, something has to be done."

4. A telephone interview was conducted on 01/12/21 at approximately 1:15 p.m. with the Chief Executive Officer. When asked if he found out if he received a call from a Police Officer about patient #4 calling individuals who had restraining orders against her, he stated in part, "The Director of Health Information Management (HIM) had a voicemail that was left. The officer called the next day and spoke with HIM employee #1, who notified the Director of HIM. The Director notified the social worker who notified the medical provider. We never followed up and called the policeman back." When asked if a complaint was filed, he stated in part, "If someone calls and provides us information, it goes to the treatment team who would address it. The treatment team would take steps to limit the behavior. It is not a complaint. With regards to the patient, the law informant called and made it known patient is a nuisance and we take steps to limit and prevent it."

5. A telephone interview was conducted with physician #1 on 01/12/21 at approximately 1:55 p.m. When asked if the patient was on phone restrictions, he stated in part, "If it's signed by me, that is what happens. I have a responsibility to approve the orders." When asked if the nurses were not monitoring the patient who was calling people outside the facility who had restraining orders against her, he stated in part, "I don't think I can offer an excuse. It shouldn't happen. The order is there. Staff should redirect the patient. I expect staff to follow the orders and screen patient's calls. I assume the order would be followed as written. ... I feel like, now looking back, I should have done it from the beginning. ..." When asked about the treatment plan, he stated in part, "In the treatment plan we should discuss all things that have therapeutic relevance. We also put in the plan to restrict something. We didn't do it. We should be held responsible. ..."

6. A telephone interview was conducted with the Nurse Manager #1 on 1/12/21 at 4:49 p.m. When asked if he was notified of an individual calling to report they were receiving phone calls from patient #4 against restraining orders, he stated in part, "I was never told about a call from someone reporting they were being called by the patient and had a restraining order." When asked if staff was not monitoring patient's calls he stated in part, "I am not able to speculate how the patient was able to make the calls outside the facility. I couldn't say one way or another if staff was not monitoring patient's phone restrictions." He concurred if the patient was able to make calls then the staff was not monitoring for the phone restrictions.

7. A telephone interview was conducted with Registered Nurse (RN) #2 on 01/12/21 at 5:44 p.m. She stated in part, "That is true. She was calling people. I remember her being on the phone a lot and we were extremely busy and short on staff. We weren't always able to catch her doing it. ... Patients are supposed to come to the nurse's station to get calls made. She noted the patient's room was right across from a phone. There are four (4) phones in the hallway, three (3) in the day room and one (1) in the hallway across from her room. It was an easy phone to get to because of location."

8. An interview was conducted with the Lead RN #1 on 1/12/21 at 6:32 p.m. When asked if the patient was on phone restrictions, she stated in part, "It depends on the orders and with nursing staff, it's harder to restrict calls. The patient doesn't have to be honest who she is calling. If the order says from the nursing desk, then staff dials the phone number and the patient can talk at the nurse's desk or staff transfer the call to the day phone." She noted there are four (4) phones on the unit and patients can access them at any time. She stated it is more difficult to monitor phone restrictions by nursing if the order doesn't state "at the nurse station."

Based on clinical record review, document review and staff interviews it was determined the facility failed to protect patient's rights to provide care in a safe setting and follow their complaint policy. This failure was identified in one (1) out of thirty (30) patient records. These findings have the potential for all patients to be at risk for injury. (See tags A 118, A 119 and A 144).

A. Noncompliance: An IJ to Patient Rights (Care in a Safe Setting) and Nursing Services (Supervision and Evaluation of the Nursing Care of Each Patient) was called on 01/11/21 at 3:50 p.m. because the facility failed to ensure care was provided in a safe setting and failed to immediately notify the physician immediately of a potential elopement.

B. Harm or Potential: The potential for a likely serious adverse outcome due to the staff failing to supervise and evaluate changes in patient behavior and immediately notify the physician of the potential elopement risk.

C. Immediacy: The nursing staff failed to notify the physician immediately of a potential elopement risk.

D. An immediate plan of correction was received and sent to the State Agency Program Director. It was accepted and the facility abated the IJ on 01/12/21 at 9:14 p.m.

Based on clinical record review, document review and interviews it was revealed the facility failed to ensure hospital staff file a grievance related to patient #4 following the facility complaint policy and procedures. This failure was identified in one (1) out of thirty (30) patients. This failure has the potential for all patients and acquaintances to be a risk for injury.

Findings include:

1. A review of the medical record for patient #4 revealed a Psychiatric Evaluation dated 12/29/20 at 11:37 a.m. by Physician Assistant #1 that states in part, "Her roommate filed for a protective order earlier this week." A Master Treatment Plan dated 01/04/21 at 4:08 p.m. states, "Per commitment paperwork, her roommates have taken a protective order against her. ... Called State Troopers four (4) - five (5) times in the past two (2) days. She told police she was going to buy a gun so if she is followed, she can feel protected. ... stated that she tried to escape the other day. ..." Physician orders dated 01/02/21 at 8:48 p.m. states in part: "Patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday" and on 01/03/21 at 2:59 p.m. states in part: "Change: patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday to patient is restricted from using phone due to repeated calls to police and community mental health center. Patient only to make calls to her attorney and the advocate. ALL calls must be made via nursing station. Must be renewed on Monday, Wednesday and Friday." This order was renewed again on 01/06/21 at 9:43 a.m. and again on 01/12/21 at 8:40 a.m.

2. A review of facility Grievance Logs for 12/2020 and 01/2021 revealed there were not any grievances reported by police or any individual reporting patient #4 has been calling them and breaking restraining/protective orders against her.

3. A review of facility policy, "Handling of Patient Complaint/Grievances," effective date 02/06/20, states in part: "A "patient grievance" is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by the staff present) by a patient, or the patient's representative, Legal Aid Patient Advocate, facility employee or other individual on behalf of any patient regarding the patient's care, treatment, housing, services, accommodations, etc., alleged abuse or neglect, issues related to the hospital's compliance with the Medicare conditions of Participation, or Medicare beneficiary billing complaint related to rights and limitations. ... If the complaint cannot be resolved, the staff member shall promptly assist the patient with initiating a "Patient Grievance," file it on their behalf or contact the Legal Aid Patient Advocated ... or the nursing supervisor ... to initiate a "Patient Grievance." ... Complaint or grievance resolution shall be given top priority by those receiving the complaint or grievance and by those involved in resolving the circumstances and implementing corrective actions, if indicated. Investigations will be resolved within seven (7) days. ..."

4. A review of Title 64, "Legislative Rule Department of Health and Human Resources, Series 59, Behavioral Health Client Rights," states in part: "12.4. Restrictions. Any deviation from the telephone and mail rights afforded by subsections 12.2 and 12.3 of this rule can only be authorized by the interdisciplinary team or the physician for a time specified by the team. A complete report relative to the restriction of telephone or mail rights and the reasons therefore shall be made a part of the client's medical record, signed and dated by the client's attending physician, and reflected in the client's nursing care plan. Restrictions of mail and telephone rights shall expire in three (3) days unless reviewed."

5. A telephone interview was conducted on 01/11/21 at 5:23 p.m. with Sheriff Officer #1. When asked if he had tried to file a complaint at the hospital and how he tried to file a complaint, he stated in part, "I've been trying since last Thursday (01/07/21) to get someone to call me back. I have warrants to serve to patient #4. I left a total of seven (7) messages with different departments and no one has called me back and I even told them I needed to complain because I must serve this woman before she gets discharged. She is breaking restraining orders from inside the hospital and they are allowing it to happen, something has to be done."

6. A telephone interview was conducted on 01/12/21 at approximately 1:15 p.m. with the Chief Executive Officer. When asked if he found out if he received a call from a Police Officer about patient #4 calling individuals who had restraining orders against her, he stated in part, "The Director of Health Information Management (HIM) had a voicemail that was left. The officer called the next day and spoke with HIM employee #1, who notified the Director of HIM. The Director notified the social worker who notified the medical provider. We never followed up and called the policeman back." When asked if a complaint was filed, he stated in part, "If someone calls and provides us information, it goes to the treatment team who would address it. The treatment team would take steps to limit the behavior. It is not a complaint. With regards to the patient, the law informant called and made it known patient is a nuisance and we take steps to limit and prevent it."

7. A telephone interview was conducted with physician #1 on 01/12/21 at approximately 1:55 p.m. When asked if the patient was on phone restrictions, he stated in part, "If it's signed by me, that is what happens. I have a responsibility to approve the orders." When asked if the nurses were not monitoring the patient who was calling people outside the facility who had restraining orders against her, he stated in part, "I don't think I can offer an excuse. It shouldn't happen. The order is there. Staff should redirect the patient. I expect staff to follow the orders and screen patient's calls. I assume the order would be followed as written. ... I feel like, now looking back, I should have done it from the beginning. ..." When asked about the treatment plan, he stated in part, "In the treatment plan we should discuss all things that have therapeutic relevance. We also put in the plan to restrict something. We didn't do it. We should be held responsible. ..."

8. A telephone interview was conducted with the Nurse Manager #1 on 1/12/21 at 4:49 p.m. When asked if he was notified of an individual calling to report they were receiving phone calls from patient #4 against restraining orders, he stated in part, "I was never told about a call from someone reporting they were being called by the patient and had a restraining order." When asked if it would be a complaint, he stated in part, "I would consider this report a complaint." He noted on the complaint process, they notify the physician, tell them the problem and put phone restrictions in place. He concurred it should have been reported and the physician notified. He stated, "If a patient had a rental car ordered previously, and a patient is verbalizing she is going to break out and she broke the door lock and got into the anteroom, I would have notified the doctor immediately." I feel this patient should have been put on a continual close observation (CCO).

9. A telephone interview was conducted with Registered Nurse (RN) #2 on 01/12/21 at 5:44 p.m. She stated in part, "That is true. She was calling people. I remember her being on the phone a lot and we were extremely busy and short on staff. We weren't always able to catch her doing it. ... Patients are supposed to come to the nurse's station to get calls made. She noted the patient's room was right across from a phone. There are four (4) phones in the hallway, three (3) in the day room and one (1) in the hallway across from her room. It was an easy phone to get to because of location." When asked if she received any calls from individuals reporting she was calling them against restraining orders, she stated in part, "I am the one who took the call from the person and I reported it to my supervisor. That person also called the authorities. I notified the lead nurse on the unit. I don't remember the day. Normally I write a note but don't recall I made a note. It may have been because I told her." When asked about the complaint process, she stated in part, "I don't know the process when an outside person calls, so I notified the lead nurse. When asked if there is a protocol, she stated in part, "I don't know if there is a protocol."

10. An interview was conducted with the Lead RN #1 on 1/12/21 at 6:32 p.m. When asked if the patient was on phone restrictions, she stated in part, "It depends on the orders and with nursing staff, it's harder to restrict calls. The patient doesn't have to be honest who she is calling. If the order says from the nursing desk, then staff dials the phone number and the patient can talk at the nurse's desk or staff transfer the call to the day phone." She noted there are four (4) phones on the unit and patients can access them at any time. She stated it is more difficult to monitor phone restrictions by nursing if the order doesn't state "at the nurse station." When asked if she was notified of a complaint by a RN about someone calling to report she had a restraining order against patient #4 and was receiving phone calls, she stated in part, "I never received any information or any information written. I don't remember being told about any calls coming in for a complaint of the patient calling someone outside the facility."

Based on clinical record review, document review and interviews it was revealed the facility failed to follow their grievance policy and procedure by failing to file a grievance and ensure a prompt resolution was completed. This failure was identified in one (1) out of thirty (30) patients. This failure has the potential for all patients and acquaintances to be at risk for injury.

Findings include:

1. A review of the medical record for patient #4 revealed a Psychiatric Evaluation dated 12/29/20 at 11:37 a.m. by Physician Assistant #1 that states in part, "Her roommate filed for a protective order earlier this week." A Master Treatment Plan dated 01/04/21 at 4:08 p.m. states, "Per commitment paperwork, her roommates have taken a protective order against her. ... Called State Troopers four (4) - five (5) times in the past two (2) days. She told police she was going to buy a gun so if she is followed, she can feel protected. ... stated that she tried to escape the other day. ..." Physician orders dated 01/02/21 at 8:48 p.m. states in part: "Patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday" and on 01/03/21 at 2:59 p.m. states in part: "Change: patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday to patient is restricted from using phone due to repeated calls to police and community mental health center. Patient only to make calls to her attorney and the advocate. ALL calls must be made via nursing station. Must be renewed on Monday, Wednesday and Friday." This order was renewed again on 01/06/21 at 9:43 a.m. and again on 01/12/21 at 8:40 a.m.

2. A review of facility Grievance Logs for 12/2020 and 01/2021 revealed there were not any grievances reported by police or any individual reporting patient #4 has been calling them and breaking restraining/protective orders against her.

3. A review of facility policy, "Handling of Patient Complaint/Grievances," effective date 02/06/20, states in part: "A "patient grievance" is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by the staff present) by a patient, or the patient's representative, Legal Aid Patient Advocate, facility employee or other individual on behalf of any patient regarding the patient's care, treatment, housing, services, accommodations, etc., alleged abuse or neglect, issues related to the hospital's compliance with the Medicare conditions of Participation, or Medicare beneficiary billing complaint related to rights and limitations. ... If the complaint cannot be resolved, the staff member shall promptly assist the patient with initiating a "Patient Grievance," file it on their behalf or contact the Legal Aid Patient Advocated ... or the nursing supervisor ... to initiate a "Patient Grievance." ... Complaint or grievance resolution shall be given top priority by those receiving the complaint or grievance and by those involved in resolving the circumstances and implementing corrective actions, if indicated. Investigations will be resolved within seven (7) days. ..."

4. A review of Title 64, "Legislative Rule Department of Health and Human Resources, Series 59, Behavioral Health Client Rights," states in part: "12.4. Restrictions. Any deviation from the telephone and mail rights afforded by subsections 12.2 and 12.3 of this rule can only be authorized by the interdisciplinary team or the physician for a time specified by the team. A complete report relative to the restriction of telephone or mail rights and the reasons therefore shall be made a part of the client's medical record, signed and dated by the client's attending physician, and reflected in the client's nursing care plan. Restrictions of mail and telephone rights shall expire in three (3) days unless reviewed."

5. A telephone interview was conducted on 01/11/21 at 5:23 p.m. with Sheriff Officer #1. When asked if he had tried to file a complaint at the hospital and how he tried to file a complaint, he stated in part, "I've been trying since last Thursday (01/07/21) to get someone to call me back. I have warrants to serve to patient #4. I left a total of seven (7) messages with different departments and no one has called me back and I even told them I needed to complain because I must serve this woman before she gets discharged. She is breaking restraining orders from inside the hospital and they are allowing it to happen, something has to be done."

6. A telephone interview was conducted on 01/12/21 at approximately 1:15 p.m. with the Chief Executive Officer. When asked if he found out if he received a call from a Police Officer about patient #4 calling individuals who had restraining orders against her, he stated in part, "The Director of Health Information Management (HIM) had a voicemail that was left. The officer called the next day and spoke with HIM employee #1, who notified the Director of HIM. The Director notified the social worker who notified the medical provider. We never followed up and called the policeman back." When asked if a complaint was filed, he stated in part, "If someone calls and provides us information, it goes to the treatment team who would address it. The treatment team would take steps to limit the behavior. It is not a complaint. With regards to the patient, the law informant called and made it known patient is a nuisance and we take steps to limit and prevent it."

7. A telephone interview was conducted with physician #1 on 01/12/21 at approximately 1:55 p.m. When asked if the patient was on phone restrictions, he stated in part, "If it's signed by me, that is what happens. I have a responsibility to approve the orders." When asked if the nurses were not monitoring the patient who was calling people outside the facility who had restraining orders against her, he stated in part, "I don't think I can offer an excuse. It shouldn't happen. The order is there. Staff should redirect the patient. I expect staff to follow the orders and screen patient's calls. I assume the order would be followed as written. ... I feel like, now looking back, I should have done it from the beginning. ..." When asked about the treatment plan, he stated in part, "In the treatment plan we should discuss all things that have therapeutic relevance. We also put in the plan to restrict something. We didn't do it. We should be held responsible. ..."

8. A telephone interview was conducted with the Nurse Manager #1 on 1/12/21 at 4:49 p.m. When asked if he was notified of an individual calling to report they were receiving phone calls from patient #4 against restraining orders, he stated in part, "I was never told about a call from someone reporting they were being called by the patient and had a restraining order." When asked if it would be a complaint, he stated in part, "I would consider this report a complaint." He noted on the complaint process, they notify the physician, tell them the problem and put phone restrictions in place. He concurred it should have been reported and the physician notified. He stated, "If a patient had a rental car ordered previously, and a patient is verbalizing she is going to break out and she broke the door lock and got into the anteroom, I would have notified the doctor immediately." I feel this patient should have been put on a continual close observation (CCO).

9. A telephone interview was conducted with Registered Nurse (RN) #2 on 01/12/21 at 5:44 p.m. She stated in part, "That is true. She was calling people. I remember her being on the phone a lot and we were extremely busy and short on staff. We weren't always able to catch her doing it. ... Patients are supposed to come to the nurse's station to get calls made. She noted the patient's room was right across from a phone. There are four (4) phones in the hallway, three (3) in the day room and one (1) in the hallway across from her room. It was an easy phone to get to because of location." When asked if she received any calls from individuals reporting she was calling them against restraining orders, she stated in part, "I am the one who took the call from the person and I reported it to my supervisor. That person also called the authorities. I notified the lead nurse on the unit. I don't remember the day. Normally I write a note but don't recall I made a note. It may have been because I told her." When asked about the complaint process, she stated in part, "I don't know the process when an outside person calls, so I notified the lead nurse. When asked if there is a protocol, she stated in part, "I don't know if there is a protocol."

10. An interview was conducted with the Lead RN #1 on 1/12/21 at 6:32 p.m. When asked if the patient was on phone restrictions, she stated in part, "It depends on the orders and with nursing staff, it's harder to restrict calls. The patient doesn't have to be honest who she is calling. If the order says from the nursing desk, then staff dials the phone number and the patient can talk at the nurse's desk or staff transfer the call to the day phone." She noted there are four (4) phones on the unit and patients can access them at any time. She stated it is more difficult to monitor phone restrictions by nursing if the order doesn't state "at the nurse station." When asked if she was notified of a complaint by a RN about someone calling to report she had a restraining order against patient #4 and was receiving phone calls, she stated in part, "I never received any information or any information written. I don't remember being told about any calls coming in for a complaint of the patient calling someone outside the facility."

Based on clinical record review, video review, document review and interviews it was revealed the Registered Nurse (RN) failed to ensure patient #4 received care in a safe setting. This failure was revealed in one (1) (patient #4) out of thirty (30) clinical records reviewed. This failure has the potential for all patients, staff, visitors and acquaintances to be at risk for injury.

Findings include:

1. A review of the medical record for patient #4 revealed an Elopement Assessment dated 12/28/20 at 7:40 p.m. documented, "The patient has not made any statements indicating intent to elope, exhibited behaviors indicating intent to elope" and states in part: "Elopement Risk is Low." A Mental Health Therapist (MHT) Elopement Risk Scale on 12/29/20 at 4:05 p.m. documented, "The patient has not persistently stated in a hostile or aggressive manner that she wants to leave the unit or find a way to leave and does not have risky behaviors such as trying to open doors." Behavioral Notes dated 12/31/20 at 5:32 p.m. noted the patient ordered a rental car the previous day that was delivered to the hospital. At 9:15 p.m. the patient was documented as stating, "I will give each of you two (2) million dollars if you will open the door and let me out." ... She became upset, ran and kicked the first security door. Patient #4 was able to break the lock on the door." At 10:37 p.m. documentation revealed, "Patient #4 ran down the hall and kicked the door again breaking the locking device. A staff member once again placed in front of the door until it could be repaired." On 01/1/21 at 8:02 a.m. a Behavior Note states in part: "Received phone call from 911 this morning stating that they received a call from patient #4. She informed 911 that she was going to break out of here last night ..." On 01/01/21 at 9:14 a.m. it was documented the Advanced Practice Registered Nurse was made aware of the patient's behavior. No documentation was noted in the medical record that the physician was immediately notified of a potential elopement risk.

2. A review of a video recording was conducted on 12/31/20. A video recording dated 12/31/20 at 9:42 p.m. revealed patient #4 approached the locked entry door to C2 Unit, broke into a run and then kicked the door, backed up and reattempted to kick the door open. One (1) staff member came from the nurse's station and interrupted the patient and redirected her away from the door. At 9:44 p.m. the patient approached the door again, ran and kicked the locked door breaking open the door and entered the ante room. She attempted to kick the locked ante room door. One (1) staff member entered the ante room, interrupted the patient and remained with her. At 9:45 p.m. additional staff arrived helping to redirect the patient from the area. At 9:46 p.m. the patient walked back into the C2 unit from the ante room and staff was posted at the C2 entrance door.

3. A review of facility policy, "Incident Reporting and Review," effective date 05/04/20, states in part: "Employees who witness or are aware of an incident are responsible for completing and signing an Incident Report form at the time they become aware of the incident. Reporting must be completed and submitted prior to the end of current shift or within eight (8) hours of the incident, whichever is earlier. Incident reports must be completed when: There is a potential for injury (regardless of severity) to patients, employees or visitors. In the event of damage to or loss of hospital and/or patient property. ... Elopement or attempted elopements ..."

4. A review of facility incident reports from 12/28/20 through 01/12/21 revealed there were no incidents reported for patient #4 for renting a rental car two (2) times, verbalizing attempting to elope and for kicking open the locked entry door in C2 unit which broke the door lock and attempting to kick and break open the door from the ante room to the C2 unit.

5. A review of facility policy, "Levels of Observation," effective 07/15/19, states in part: "All patients are placed on an observation level based on clinical assessment of the patient's needs, risk conditions and behavior. ... To provide staff guidelines related to an increased level of observations. ... A nurse may initiate a Close Constant Observation (CCO), for any patient behavior that requires an increase in observation for safety, such as, but not limited to self-harm, aggression, suicidal or homicidal ideation, sexually inappropriate behavior, fall risk, elopement risk, etc., then consult with medical staff and obtain an order. ... A nurse may initiate a one (1) to one (1), for any patient behavior that requires an increase in observation for safety, such as, but not limited to; self-harm, aggression, suicidal or homicidal ideation, sexually inappropriate behavior, fall risk, elopement risk, etc., then consult with medical staff and obtain an order."

6. A review of facility policy, "Measuring Elopement Risk Behaviors," effective 06/15/20, states in part: "The hospital will ensure a safe and therapeutic environment through assessing and continuously measuring patient risk for elopement. ... All hospital staff will complete annual training on situational awareness, specifically on elopement risk behaviors that may indicate a patient is seeking opportunities to leave."

7. A telephone interview was conducted with Physician #1 on 01/12/21 at approximately 1:55 p.m. When asked if he was notified of the patient renting a car from a rental company, he stated in part, "I was off on 12/31/20 and 1/1/01. I was not here. ... They would have notified the on-call provider."

8. An interview was conducted with Nurse Manager #1 on 1/12/21 at approximately 4:49 p.m. When asked about the elopement process, he stated in part, "If a patient had a rental car ordered previously, and a patient is verbalizing she is going to break out and she broke the door lock and got into the anteroom, I would have notified the doctor immediately. I feel this patient should have been put on a continual CCO."

9. A telephone interview was conducted with RN #1 on 1/12/21 at 5:18 p.m. When asked about elopement she stated, "I would notify the provider on call immediately and follow doctor orders. If they feel it is necessary, may place them on one (1) to one (1) or CCO." She stated CCO means no obstacles in the way of the view of the patient and one (1) to one (1) is in arm's length.

10. A telephone call was conducted with RN #2 on 1/12/21 at 5:44 p.m. She stated, "I don't know if patient was place on increased elopement precautions. She tried to kick the door down and we had it repaired. ... She was calling people. I remember her being on the phone a lot and we were extremely busy and short on staff. We weren't always able to catch her doing it." She stated, "I don't think we knew she ordered the vehicle. She did it twice and they delivered it twice. It was on two (2) different days. I don't remember if the physician was notified."

11. An interview was conducted with Lead RN #1 on 1/12/21 at 6:32 p.m. She stated in part, "I was aware she had ordered a rental car. I know I was here one day when she did it. I don't remember when. I think she rented it twice. ... She at times was verbalizing wanting to leave. ...The elopement should have been changed. I don't know the policy off the top of my head, but the nurse should have called the on-call doctor to let them know and the doctor would write an order for the elopement risk." She concurred the nurse should have called the doctor as soon as the situation was controlled.

Based on clinical record review, video review, document review and interviews it was revealed the Registered Nurse failed to supervise and evaluate patient care and follow facility policies and procedures for patient #4. This failure was identified in one (1) out of thirty (30) patient records. These findings have the potential for all patients to be at risk for injury. (See tags A 395 and A 398).

A. Noncompliance: An IJ to Patient Rights (Care in a Safe Setting) and Nursing Services (Supervision and Evaluation of the Nursing Care of Each Patient) was called on 01/11/21 at 3:50 p.m. because the facility failed to ensure care was provided in a safe setting and failed to immediately notify the physician immediately of a potential elopement.

B. Harm or Potential: The potential for a likely serious adverse outcome due to the staff failing to supervise and evaluate changes in patient behavior and immediately notify the physician of the potential elopement risk.

C. Immediacy: The nursing staff failed to notify the physician immediately of a potential elopement risk.

D. An immediate plan of correction was received and sent to the State Agency Program Director. It was accepted and the facility abated the IJ on 01/12/21 at 9:14 p.m.

Based on clinical record review, video review, document review and interviews it was revealed the Registered Nurse (RN) failed to supervise and evaluate nursing care for patient #4 in a safe setting. This failure was revealed in one (1) out of thirty (30) clinical records reviewed. This failure has the potential for all patients, staff, visitors and acquaintances to be at risk for injury.

Findings include:

1. A review of the medical record for patient #4 revealed an Elopement Assessment dated 12/28/20 at 7:40 p.m. documented, "the patient has not made any statements indicating intent to elope, exhibited behaviors indicating intent to elope" and states in part: "Elopement Risk is Low." A Mental Health Therapist (MHT) Elopement Risk Scale on 12/29/20 at 4:05 p.m. documented, "the patient has not persistently stated in a hostile or aggressive manner that she wants to leave the unit or find a way to leave and does not have risky behaviors such as trying to open doors." Behavioral Notes dated 12/31/20 at 5:32 p.m. noted the patient ordered a rental car the previous day that was delivered to the hospital. At 9:15 p.m. the patient was documented as stating, "I will give each of you two (2) million dollars if you will open the door and let me out." ... She became upset, ran and kicked the first security door. Patient #4 was able to break the lock on the door." At 10:37 p.m. documentation revealed, "Patient #4 ran down the hall and kicked the door again breaking the locking device. A staff member once again placed in front of the door until it could be repaired." On 01/1/21 at 8:02 a.m. a Behavior Note states in part: "Received phone call from 911 this morning stating that they received a call from patient #4. She informed 911 that she was going to break out of here last night ..." On 01/01/21 at 9:14 a.m. it was documented the Advanced Practice Registered Nurse was made aware of the patient's behavior. No documentation was noted in the medical record that the physician was immediately notified of a potential elopement risk.

2. A review of a video recording was conducted on 12/31/20. A video recording dated 12/31/20 at 9:42 p.m. revealed patient #4 approached the locked entry door to C2 Unit, broke into a run and then kicked the door, backed up and reattempted to kick the door open. One (1) staff member came from the nurse's station and interrupted the patient and redirected her away from the door. At 9:44 p.m. the patient approached the door again, ran and kicked the locked door breaking open the door and entered the ante room. She attempted to kick the locked ante room door. One (1) staff member entered the ante room, interrupted the patient and remained with her. At 9:45 p.m. additional staff arrived helping to redirect the patient from the area. At 9:46 p.m. the patient walked back into the C2 unit from the ante room and staff was posted at the C2 entrance door.

3. A review of facility policy, "Incident Reporting and Review," effective date 05/04/20, states in part: "Employees who witness or are aware of an incident are responsible for completing and signing an Incident Report form at the time they become aware of the incident. Reporting must be completed and submitted prior to the end of current shift or within eight (8) hours of the incident, whichever is earlier. Incident reports must be completed when: There is a potential for injury (regardless of severity) to patients, employees or visitors. In the event of damage to or loss of hospital and/or patient property. ... Elopement or attempted elopements ..."

4. A review of facility incident reports from 12/28/20 through 01/12/21 revealed there were no incidents reported for patient #4 for renting a rental car two (2) times, verbalizing attempting to elope and for kicking open the locked entry door in C2 unit which broke the door lock and attempting to kick and break open the door from the ante room to the C2 unit.

5. A review of facility policy, "Levels of Observation," effective 07/15/19, states in part: "All patients are placed on an observation level based on clinical assessment of the patient's needs, risk conditions and behavior. ... To provide staff guidelines related to an increased level of observations. ... A nurse may initiate a Close Constant Observation (CCO), for any patient behavior that requires an increase in observation for safety, such as, but not limited to self-harm, aggression, suicidal or homicidal ideation, sexually inappropriate behavior, fall risk, elopement risk, etc., then consult with medical staff and obtain an order. ... A nurse may initiate a one (1) to one (1), for any patient behavior that requires an increase in observation for safety, such as, but not limited to; self-harm, aggression, suicidal or homicidal ideation, sexually inappropriate behavior, fall risk, elopement risk, etc., then consult with medical staff and obtain an order."

6. A review of facility policy, "Measuring Elopement Risk Behaviors," effective 06/15/20, states in part: "The hospital will ensure a safe and therapeutic environment through assessing and continuously measuring patient risk for elopement. ... All hospital staff will complete annual training on situational awareness, specifically on elopement risk behaviors that may indicate a patient is seeking opportunities to leave."

7. A telephone interview was conducted with Physician #1 on 01/12/21 at approximately 1:55 p.m. When asked if he was notified of the patient renting a car from a rental company, he stated in part, "I was off on 12/31/20 and 1/1/01. I was not here. ... They would have notified the on-call provider."

8. An interview was conducted with Nurse Manager #1 on 1/12/21 at approximately 4:49 p.m. When asked about the elopement process, he stated in part, "If a patient had a rental car ordered previously, and a patient is verbalizing she is going to break out and she broke the door lock and got into the anteroom, I would have notified the doctor immediately. I feel this patient should have been put on a continual CCO."

9. A telephone interview was conducted with RN #1 on 1/12/21 at 5:18 p.m. When asked about elopement she stated, "I would notify the provider on call immediately and follow doctor orders. If they feel it is necessary, may place them on one (1) to one (1) or CCO." She stated CCO means no obstacles in the way of the view of the patient and one (1) to one (1) is in arm's length.

10. A telephone call was conducted with RN #2 on 1/12/21 at 5:44 p.m. She stated, "I don't know if patient was place on increased elopement precautions. She tried to kick the door down and we had it repaired. ... She was calling people. I remember her being on the phone a lot and we were extremely busy and short on staff. We weren't always able to catch her doing it." She stated, "I don't think we knew she ordered the vehicle. She did it twice and they delivered it twice. It was on two (2) different days. I don't remember if the physician was notified."

11. An interview was conducted with Lead RN #1 on 1/12/21 at 6:32 p.m. She stated in part, "I was aware she had ordered a rental car. I know I was here one day when she did it. I don't remember when. I think she rented it twice. ... She at times was verbalizing wanting to leave. ...The elopement should have been changed. I don't know the policy off the top of my head, but the nurse should have called the on-call doctor to let them know and the doctor would write an order for the elopement risk." She concurred the nurse should have called the doctor as soon as the situation was controlled.

A. Based on clinical record review, document review and interviews it was revealed the facility failed to ensure all nurses follow their grievance policy and procedures. This failure was identified in one (1) out of thirty (30) patients. This failure has the potential for all patients and acquaintances to be at risk for injury.

Findings include:

1. A review of the medical record for patient #4 revealed a Psychiatric Evaluation dated 12/29/20 at 11:37 a.m. by Physician Assistant #1 that states in part, "Her roommate filed for a protective order earlier this week." A Master Treatment Plan dated 01/04/21 at 4:08 p.m. states, "Per commitment paperwork, her roommates have taken a protective order against her. ... Called State Troopers four (4) - five (5) times in the past two (2) days. She told police she was going to buy a gun so if she is followed, she can feel protected. ... stated that she tried to escape the other day. ..." Physician orders dated 01/02/21 at 8:48 p.m. states in part: "Patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday" and on 01/03/21 at 2:59 p.m. states in part: "Change: patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday to patient is restricted from using phone due to repeated calls to police and community mental health center. Patient only to make calls to her attorney and the advocate. ALL calls must be made via nursing station. Must be renewed on Monday, Wednesday and Friday." This order was renewed again on 01/06/21 at 9:43 a.m. and again on 01/12/21 at 8:40 a.m.

2. A review of facility Grievance Logs for 12/2020 and 01/2021 revealed there were not any grievances reported by police or any individual reporting patient #4 has been calling them and breaking restraining/protective orders against her.

3. A review of facility policy, "Handling of Patient Complaint/Grievances," effective date 02/06/20, states in part: "A "patient grievance" is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by the staff present) by a patient, or the patient's representative, Legal Aid Patient Advocate, facility employee or other individual on behalf of any patient regarding the patient's care, treatment, housing, services, accommodations, etc., alleged abuse or neglect, issues related to the hospital's compliance with the Medicare conditions of Participation, or Medicare beneficiary billing complaint related to rights and limitations. ... If the complaint cannot be resolved, the staff member shall promptly assist the patient with initiating a "Patient Grievance," file it on their behalf or contact the Legal Aid Patient Advocated ... or the nursing supervisor ... to initiate a "Patient Grievance." ... Complaint or grievance resolution shall be given top priority by those receiving the complaint or grievance and by those involved in resolving the circumstances and implementing corrective actions, if indicated. Investigations will be resolved within seven (7) days. ..."

4. A review of Title 64, "Legislative Rule Department of Health and Human Resources, Series 59, Behavioral Health Client Rights," states in part: "12.4. Restrictions. Any deviation from the telephone and mail rights afforded by subsections 12.2 and 12.3 of this rule can only be authorized by the interdisciplinary team or the physician for a time specified by the team. A complete report relative to the restriction of telephone or mail rights and the reasons therefore shall be made a part of the client's medical record, signed and dated by the client's attending physician, and reflected in the client's nursing care plan. Restrictions of mail and telephone rights shall expire in three (3) days unless reviewed."

5. A telephone interview was conducted on 01/11/21 at 5:23 p.m. with Sheriff Officer #1. When asked if he had tried to file a complaint at the hospital and how he tried to file a complaint, he stated in part, "I've been trying since last Thursday (01/07/21) to get someone to call me back. I have warrants to serve to patient #4. I left a total of seven (7) messages with different departments and no one has called me back and I even told them I needed to complain because I must serve this woman before she gets discharged. She is breaking restraining orders from inside the hospital and they are allowing it to happen, something has to be done."

6. A telephone interview was conducted on 01/12/21 at approximately 1:15 p.m. with the Chief Executive Officer. When asked if he found out if he received a call from a Police Officer about patient #4 calling individuals who had restraining orders against her, he stated in part, "The Director of Health Information Management (HIM) had a voicemail that was left. The officer called the next day and spoke with HIM employee #1, who notified the Director of HIM. The Director notified the social worker who notified the medical provider. We never followed up and called the policeman back." When asked if a complaint was filed, he stated in part, "If someone calls and provides us information, it goes to the treatment team who would address it. The treatment team would take steps to limit the behavior. It is not a complaint. With regards to the patient, the law informant called and made it known patient is a nuisance and we take steps to limit and prevent it."

7. A telephone interview was conducted with physician #1 on 01/12/21 at approximately 1:55 p.m. When asked if the patient was on phone restrictions, he stated in part, "If it's signed by me, that is what happens. I have a responsibility to approve the orders." When asked if the nurses were not monitoring the patient who was calling people outside the facility who had restraining orders against her, he stated in part, "I don't think I can offer an excuse. It shouldn't happen. The order is there. Staff should redirect the patient. I expect staff to follow the orders and screen patient's calls. I assume the order would be followed as written. ... I feel like, now looking back, I should have done it from the beginning. ..." When asked about the treatment plan, he stated in part, "In the treatment plan we should discuss all things that have therapeutic relevance. We also put in the plan to restrict something. We didn't do it. We should be held responsible. ..."

8. A telephone interview was conducted with the Nurse Manager #1 on 1/12/21 at 4:49 p.m. When asked if he was notified of an individual calling to report they were receiving phone calls from patient #4 against restraining orders, he stated in part, "I was never told about a call from someone reporting they were being called by the patient and had a restraining order." When asked if it would be a complaint, he stated in part, "I would consider this report a complaint." He noted on the complaint process, they notify the physician, tell them the problem and put phone restrictions in place. He concurred it should have been reported and the physician notified. He stated, "If a patient had a rental car ordered previously, and a patient is verbalizing she is going to break out and she broke the door lock and got into the anteroom, I would have notified the doctor immediately." I feel this patient should have been put on a continual close observation (CCO).

9. A telephone interview was conducted with Registered Nurse (RN) #2 on 01/12/21 at 5:44 p.m. She stated in part, "That is true. She was calling people. I remember her being on the phone a lot and we were extremely busy and short on staff. We weren't always able to catch her doing it. ... Patients are supposed to come to the nurse's station to get calls made. She noted the patient's room was right across from a phone. There are four (4) phones in the hallway, three (3) in the day room and one (1) in the hallway across from her room. It was an easy phone to get to because of location." When asked if she received any calls from individuals reporting she was calling them against restraining orders, she stated in part, "I am the one who took the call from the person and I reported it to my supervisor. That person also called the authorities. I notified the lead nurse on the unit. I don't remember the day. Normally I write a note but don't recall I made a note. It may have been because I told her." When asked about the complaint process, she stated in part, "I don't know the process when an outside person calls, so I notified the lead nurse. When asked if there is a protocol, she stated in part, "I don't know if there is a protocol."

10. An interview was conducted with the Lead RN #1 on 1/12/21 at 6:32 p.m. When asked if the patient was on phone restrictions, she stated in part, "It depends on the orders and with nursing staff, it's harder to restrict calls. The patient doesn't have to be honest who she is calling. If the order says from the nursing desk, then staff dials the phone number and the patient can talk at the nurse's desk or staff transfer the call to the day phone." She noted there are four (4) phones on the unit and patients can access them at any time. She stated it is more difficult to monitor phone restrictions by nursing if the order doesn't state "at the nurse station." When asked if she was notified of a complaint by a RN about someone calling to report she had a restraining order against patient #4 and was receiving phone calls, she stated in part, "I never received any information or any information written. I don't remember being told about any calls coming in for a complaint of the patient calling someone outside the facility."

B. Based on clinical record review, video review, document review and interviews it was revealed the facility failed to ensure all nurses follow policies and procedures for safe patient care for patient #4. This failure was revealed in one (1) out of thirty (30) clinical records reviewed. This failure has the potential for all patients, staff, visitors and acquaintances to be at risk for injury.

Findings include:

1. A review of the medical record for patient #4 revealed an Elopement Assessment dated 12/28/20 at 7:40 p.m. documented, "The patient has not made any statements indicating intent to elope, exhibited behaviors indicating intent to elope" and states in part: "Elopement Risk is Low." A Mental Health Therapist (MHT) Elopement Risk Scale on 12/29/20 at 4:05 p.m. documented, "the patient has not persistently stated in a hostile or aggressive manner that she wants to leave the unit or find a way to leave and does not have risky behaviors such as trying to open doors." Behavioral Notes dated 12/31/20 at 5:32 p.m. noted the patient ordered a rental car the previous day that was delivered to the hospital. At 9:15 p.m. the patient was documented as stating, "I will give each of you two (2) million dollars if you will open the door and let me out." ... She became upset, ran and kicked the first security door. Patient #4 was able to break the lock on the door." At 10:37 p.m. documentation revealed, "Patient #4 ran down the hall and kicked the door again breaking the locking device. A staff member once again placed in front of the door until it could be repaired." On 01/1/21 at 8:02 a.m. a Behavior Note states in part: "Received phone call from 911 this morning stating that they received a call from patient #4. She informed 911 that she was going to break out of here last night ..." On 01/01/21 at 9:14 a.m. it was documented the Advanced Practice Registered Nurse was made aware of the patient's behavior. No documentation was noted in the medical record that the physician was immediately notified of a potential elopement risk.

2. A review of a video recording was conducted on 12/31/20. A video recording dated 12/31/20 at 9:42 p.m. revealed patient #4 approached the locked entry door to C2 Unit, broke into a run and then kicked the door, backed up and reattempted to kick the door open. One (1) staff member came from the nurse's station and interrupted the patient and redirected her away from the door. At 9:44 p.m. the patient approached the door again, ran and kicked the locked door breaking open the door and entered the ante room. She attempted to kick the locked ante room door. One (1) staff member entered the ante room, interrupted the patient and remained with her. At 9:45 p.m. additional staff arrived helping to redirect the patient from the area. At 9:46 p.m. the patient walked back into the C2 unit from the ante room and staff was posted at the C2 entrance door.

3. A review of facility policy, "Incident Reporting and Review," effective date 05/04/20, states in part: "Employees who witness or are aware of an incident are responsible for completing and signing an Incident Report form at the time they become aware of the incident. Reporting must be completed and submitted prior to the end of current shift or within eight (8) hours of the incident, whichever is earlier. Incident reports must be completed when: There is a potential for injury (regardless of severity) to patients, employees or visitors. In the event of damage to or loss of hospital and/or patient property. ... Elopement or attempted elopements ..."

4. A review of facility incident reports from 12/28/20 through 01/12/21 revealed there were not any incidents reported for patient #4 for renting a rental car two (2) times, verbalizing attempting to elope and for kicking open the locked entry door in C2 unit which broke the door lock and attempting to kick and break open the door from the ante room to the C2 unit.

5. A review of facility policy, "Levels of Observation," effective 07/15/19, states in part: "All patients are placed on an observation level based on clinical assessment of the patient's needs, risk conditions and behavior. ... To provide staff guidelines related to an increased level of observations. ... A nurse may initiate a Close Constant Observation (CCO), for any patient behavior that requires an increase in observation for safety, such as, but not limited to self-harm, aggression, suicidal or homicidal ideation, sexually inappropriate behavior, fall risk, elopement risk, etc., then consult with medical staff and obtain an order. ... A nurse may initiate a one (1) to one (1), for any patient behavior that requires an increase in observation for safety, such as, but not limited to; self-harm, aggression, suicidal or homicidal ideation, sexually inappropriate behavior, fall risk, elopement risk, etc., then consult with medical staff and obtain an order."

6. A review of facility policy, "Measuring Elopement Risk Behaviors," effective 06/15/20, states in part: "The hospital will ensure a safe and therapeutic environment through assessing and continuously measuring patient risk for elopement. ... All hospital staff will complete annual training on situational awareness, specifically on elopement risk behaviors that may indicate a patient is seeking opportunities to leave."

7. A telephone interview was conducted with Physician #1 on 01/12/21 at approximately 1:55 p.m. When asked if he was notified of the patient renting a car from a rental company, he stated in part, "I was off on 12/31/20 and 1/1/01. I was not here. ... They would have notified the on-call provider."

8. An interview was conducted with Nurse Manager #1 on 1/12/21 at approximately 4:49 p.m. When asked about the elopement process, he stated in part, "If a patient had a rental car ordered previously, and a patient is verbalizing she is going to break out and she broke the door lock and got into the anteroom, I would have notified the doctor immediately. I feel this patient should have been put on a continual CCO."

9. A telephone interview was conducted with RN #1 on 1/12/21 at 5:18 p.m. When asked about elopement she stated, "I would notify the provider on call immediately and follow doctor orders. If they feel it is necessary, may place them on one (1) to one (1) or CCO." She stated CCO means no obstacles in the way of the view of the patient and one (1) to one (1) is in arm's length.

10. A telephone call was conducted with RN #2 on 1/12/21 at 5:44 p.m. She stated, "I don't know if patient was place on increased elopement precautions. She tried to kick the door down and we had it repaired. ... She was calling people. I remember her being on the phone a lot and we were extremely busy and short on staff. We weren't always able to catch her doing it." She stated, "I don't think we knew she ordered the vehicle. She did it twice and they delivered it twice. It was on two (2) different days. I don't remember if the physician was notified."

11. An interview was conducted with Lead RN #1 on 1/12/21 at 6:32 p.m. She stated in part, "I was aware she had ordered a rental car. I know I was here one day when she did it. I don't remember when. I think she rented it twice. ... She at times was verbalizing wanting to leave. ...The elopement should have been changed. I don't know the policy off the top of my head, but the nurse should have called the on-call doctor to let them know and the doctor would write an order for the elopement risk." She concurred the nurse should have called the doctor as soon as the situation was controlled.

C. Based on clinical record review, document review and interviews it was revealed the facility failed to ensure all nurses follow hospital incident reporting policies and procedures. This failure was revealed in one (1) out of thirty (30) clinical records reviewed. This failure has the potential for all patients, staff, visitors and acquaintances to be at at risk for injury.

Findings include:

1. A review of the medical record for patient #4 revealed an Elopement Assessment dated 12/28/20 at 7:40 p.m. documented, "The patient has not made any statements indicating intent to elope, exhibited behaviors indicating intent to elope" and states in part: "Elopement Risk is Low." A Psychiatric Evaluation dated 12/29/20 at 11:37 a.m. by Physician Assistant #1 states in part: "Her roommate filed for a protective order earlier this week." A Mental Health Therapist (MHT) Elopement Risk Scale on 12/29/20 at 4:05 p.m. documented, "The patient has not persistently stated in a hostile or aggressive manner that she wants to leave the unit or find a way to leave and does not have risky behaviors such as trying to open doors." Behavioral Notes dated 12/31/20 at 5:32 p.m. noted the patient ordered a rental car the previous day that was delivered to the hospital. At 9:15 p.m. the patient was documented as stating, "I will give each of you two (2) million dollars if you will open the door and let me out." ... She became upset, ran and kicked the first security door. Patient #4 was able to break the lock on the door." At 10:37 p.m. documentation revealed, "Patient #4 ran down the hall and kicked the door again breaking the locking device. A staff member once again placed in front of the door until it could be repaired." On 01/1/21 at 8:02 a.m. a Behavior Note states in part: "Received phone call from 911 this morning stating that they received a call from patient #4. She informed 911 that she was going to break out of here last night ..." On 01/01/21 at 9:14 a.m. it was documented the Advanced Practice Registered Nurse was made aware of the patient's behavior. No documentation was noted in the medical record the physician was immediately notified of a potential elopement risk. Physician orders dated 01/02/21 at 8:48 p.m. states in part: "Patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday" and on 01/03/21 at 2:59 p.m. states in part: "Change patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday. The patient is restricted from using phone due to repeated calls to police and community mental health center. Patient only to make calls to her attorney and the advocate. ALL calls must be made via nursing station. Must be renewed on Monday, Wednesday and Friday." This order was renewed again on 01/06/21 at 9:43 a.m. and again on 01/12/21 at 8:40 a.m. A Master Treatment Plan dated 01/04/21 at 4:08 p.m. states, "Per commitment paperwork, her roommates have taken a protective order against her. ... Called state troopers four (4) - five (5) times in the past two (2) days. She told police she was going to buy a gun so if she is followed, she can feel protected. ... stated that she tried to escape the other day. ..."

2. A review of a video recording was conducted on 12/31/20. A video recording dated 12/31/20 at 9:42 p.m. revealed patient #4 approached the locked entry door to C2 Unit, broke into a run and then kicked the door, backed up and reattempted to kick the door open. One (1) staff member came from the nurse's station and interrupted the patient and redirected her away from the door. At 9:44 p.m. the patient approached the door again, ran and kicked the locked door breaking open the door and entered the ante room. She attempted to kick the locked ante room door. One (1) staff member entered the ante room and interrupted the patient and remained with her. At 9:45 p.m. additional staff arrived helping to redirect the patient from the area. At 9:46 p.m. the patient walked back into the C2 unit from the ante room and staff was posted at the C2 entrance door.

3. A review of facility policy, "Incident Reporting and Review," effective date 05/04/20, states in part: "Employees who witness or are aware of an incident are responsible for completing and signing an Incident Report form at the time they become aware of the incident. Reporting must be completed and submitted prior to the end of current shift or within eight (8) hours of the incident, whichever is earlier. Incident reports must be completed when: There is a potential for injury (regardless of severity) to patients, employees or visitors. In the event of damage to or loss of hospital and/or patient property. ... Elopement or attempted elopements ..."

4. A review of facility incident reports from 12/28/20 through 01/12/21 revealed there were no incidents reported for patient #4 for renting a rental car two (2) times, verbalizing attempting to elope and for kicking open the locked entry door in C2 unit which broke the door lock and attempting to kick and break open the door from the ante room to the C2 unit.

5. A telephone interview was conducted with Registered Nurse (RN) #2 on 01/12/21 at 5:44 p.m. She stated in part, "That is true. She was calling people. I remember her being on the phone a lot and we were extremely busy and short on staff. We weren't always able to catch her doing it. ... Patients are supposed to come to the nurse's station to get calls made. She noted the patient's room was right across from a phone. There are four (4) phones in the hallway, three (3) in the day room and one (1) in the hallway across from her room. It was an easy phone to get to because of location." When asked if she received any calls from individuals reporting she was calling them against restraining orders, she stated in part, "I am the one who took the call from the person and I reported it to my supervisor. That person also called the authorities. I notified the lead nurse on the unit. I don't remember the day. Normally I write a note but don't recall I made a note. It may have been because I told her." When asked about the complaint process, she stated in part, "I don't know the process when an outside person calls, so I notified the lead nurse. When asked if there is a protocol, she stated in part, "I don't know if there is a protocol."

6. An interview was conducted with Lead Registered Nurse #1 on 1/12/21 at 6:32 p.m. She stated in part, "I was aware she had ordered a rental car. I know I was here one day when she did it. I don't remember when. I think she rented it twice. ... She at times was verbalizing wanting to leave. ...The elopement should have been changed. I don't know the policy off the top of my head, but the nurse should have called the on-call doctor to let them know and the doctor would write an order for the elopement risk." She concurred the nurse should have called the doctor as soon as the situation was controlled. When asked about complaints from an outside person she stated, "I never received any information or any information written. I don't remember being told about any calls coming in for a complaint of patient calling outside facility." When asked about the complaint policy she stated, "Usually you talk to the on-call doctor to prevent it from happening. Nurses should fill out an incident report. It goes to us (Nurse Manager, Nurse Care Coordinator, to compliance). I am notified by an incident report or verbal report. If I receive a verbal report, I will tell the nurse to do an incident report and then I would follow up with the treatment team."

D. Based on clinical record review, document review and interviews it was revealed the facility failed to ensure all nurses follow physician orders for phone restrictions for patient #4. This failure was revealed in one (1) out of thirty (30) clinical records reviewed. This failure has the potential for all patients, staff, visitors and acquaintances to be at at risk for injury.

Findings include:

1. A review of the medical record for patient #4 revealed a Psychiatric Evaluation dated 12/29/20 at 11:37 a.m. by Physician Assistant #1 that states in part, "Her roommate filed for a protective order earlier this week." A Master Treatment Plan dated 01/04/21 at 4:08 p.m. states, "Per commitment paperwork, her roommates have taken a protective order against her. ... Called State Troopers four (4) - five (5) times in the past two (2) days. She told police she was going to buy a gun so if she is followed, she can feel protected. ... stated that she tried to escape the other day. ..." Physician orders dated 01/02/21 at 8:48 p.m. states in part: "Patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday" and on 01/03/21 at 2:59 p.m. states in part: "Change: patient is restricted from using phone due to repeated calls to police. Must be renewed on Monday, Wednesday and Friday to patient is restricted from using phone due to repeated calls to police and community mental health center. Patient only to make calls to her attorney and the advocate. ALL calls must be made via nursing station. Must be renewed on Monday, Wednesday and Friday." This order was renewed again on 01/06/21 at 9:43 a.m. and again on 01/12/21 at 8:40 a.m.

2. A review of Title 64, "Legislative Rule Department of Health and Human Resources, Series 59, Behavioral Health Client Rights," states in part: "12.4. Restrictions. Any deviation from the telephone and mail rights afforded by subsections 12.2 and 12.3 of this rule can only be authorized by the interdisciplinary team or the physician for a time specified by the team. A complete report relative to the restriction of telephone or mail rights and the reasons therefore shall be made a part of the client's medical record, signed and dated by the client's attending physician, and reflected in the client's nursing care plan. Restrictions of mail and telephone rights shall expire in three (3) days unless reviewed."

3. A telephone interview was conducted on 01/11/21 at 5:23 p.m. with Sheriff Officer #1. When asked if he had tried to file a complaint at the hospital and how he tried to file a complaint, he stated in part, "I've been trying since last Thursday (01/07/21) to get someone to call me back. I have warrants to serve to patient #4. I left a total of seven (7) messages with different departments and no one has called me back and I even told them I needed to complain because I must serve this woman before she gets discharged. She is breaking restraining orders from inside the hospital and they are allowing it to happen, something has to be done."

4. A telephone interview was conducted on 01/12/21 at approximately 1:15 p.m. with the Chief Executive Officer. When asked if he found out if he received a call from a Police Officer about patient #4 calling individuals who had restraining orders against her, he stated in part, "The Director of Health Information Management (HIM) had a voicemail that was left. The officer called the next day and spoke with HIM employee #1, who notified the Director of HIM. The Director notified the social worker who notified the medical provider. We never followed up and called the policeman back." When asked if a complaint was filed, he stated in part, "If someone calls and provides us information, it goes to the treatment team who would address it. The treatment team would take steps to limit the behavior. It is not a complaint. With regards to the patient, the law informant called and made it known patient is a nuisance and we take steps to limit and prevent it."

5. A telephone interview was conducted with physician #1 on 01/12/21 at approximately 1:55 p.m. When asked if the patient was on phone restrictions, he stated in part, "If it's signed by me, that is what happens. I have a responsibility to approve the orders." When asked if the nurses were not monitoring the patient who was calling people outside the facility who had restraining orders against her, he stated in part, "I don't think I can offer an excuse. It shouldn't happen. The order is there. Staff should redirect the patient. I expect staff to follow the orders and screen patient's calls. I assume the order would be followed as written. ... I feel like, now looking back, I should have done it from the beginning. ..." When asked about the treatment plan, he stated in part, "In the treatment plan we should discuss all things that have therapeutic relevance. We also put in the plan to restrict something. We didn't do it. We should be held responsible. ..."

6. A telephone interview was conducted with the Nurse Manager #1 on 1/12/21 at 4:49 p.m. When asked if he was notified of an individual calling to report they were receiving phone calls from patient #4 against restraining orders, he stated in part, "I was never told about a call from someone reporting they were being called by the patient and had a restraining order." When asked if it would be a complaint, he stated in part, "I would consider this report a complaint." He noted on the complaint process, they notify the physician, tell them the problem and put phone restrictions in place. He concurred it should have been reported and the physician notified. He stated, "If a patient had a rental car ordered previously, and a patient is verbalizing she is going to break out and she broke the door lock and got into the anteroom, I would have notified the doctor immediately." I feel this patient should have been put on a continual close observation (CCO).

7. A telephone interview was conducted with Registered Nurse (RN) #2 on 01/12/21 at 5:44 p.m. She stated in part, "That is true. She was calling people. I remember her being on the phone a lot and we were extremely busy and short on staff. We weren't always able to catch her doing it. ... Patients are supposed to come to the nurse's station to get calls made. She noted the patient's room was right across from a phone. There are four (4) phones in the hallway, three (3) in the day room and one (1) in the hallway across from her room. It was an easy phone to get to because of location."

8. An interview was conducted with the Lead RN #1 on 1/12/21 at 6:32 p.m. When asked if the patient was on phone restrictions, she stated in part, "It depends on the orders and with nursing staff, it's harder to restrict calls. The patient doesn't have to be honest who she is calling. If the order says from the nursing desk, then staff dials the phone number and the patient can talk at the nurse's desk or staff transfer the call to the day phone." She noted there are four (4) phones on the unit and patients can access them at any time. She stated it is more difficult to monitor phone restrictions by nursing if the order doesn't state "at the nurse station."