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Based on interviews and records reviewed, the Hospital 1) failed to ensure that one Patient (#4) out of a sample of 10 patients was supervised per Hospital policy; Patient #4 was not being supervised per ordered 1:1 constant observation (1 staff member assigned to watch 1 patient) and was able to elope from the Hospital on 1/25/24 and 2) the Hospital failed to protect 1 Patient (Patient #1) out of a sample of 10 patients from abuse and retaliation by 2 staff members on 2 separate occasions.

Cross Reference:

482.13 (c)(2) Patient ' s Rights: Privacy and Safety (0144) (0145)

Based on interviews and records reviewed, the Hospital failed to ensure that a patient was supervised per Hospital policy for one patient (Patient # 4) of 10 sampled patients; Patient #4 was not being supervised per ordered 1:1 constant observation and was able to elope from the Hospital on 1/25/24.

Findings include:

Review of the Hospital 's Suicide Risk Screening, Assessment, and Mitigation Policy, dated 5/19/23, indicated one to one observation: One observer to one patient. The provision of a member of the hospital ' s staff (employed or contracted) to be in close proximity, with the patient in full view in the same room, except for patients that are violent or on precautions due to infectious disease risk. Those patients will be monitored by a staff member, who must have an unobstructed view of the patient (including the patient ' s face, neck, and hands). Patients at moderate and high-risk for suicide: Observation is maintained during bathroom use and when patients are transported to tests or other areas of the facility.

Review of the medical records indicated Patient #4 presented to the Emergency Department (ED) on 1/20/24 with an overdose of Klonopin (a benzodiazepine drug used to treat seizures, panic attacks, and anxiety). Patient #4 has a history of depression, anxiety and substance use disorder. The medical record further indicated that Patient #4 met criteria for a section 12 (Emergency restraint and temporary involuntary hospitalization of a person posing risk of serious harm by reason of mental illness), was on suicide ideation (SI) precautions and was placed on 1:1 constant observation. Patient #4 was admitted medically awaiting psychiatric placement and was being followed by Psychiatry.

Review of Patient #4 ' s medical record indicated that there was a physician order for Suicide risk level moderate placed at 9:26 P.M on 1/20/24, further indicating that staff are in close proximity and in full view during bathroom use.

Review of Patient #4's medical record indicated that there was a physician order for 1:1 Constant Observation placed at 9:24 P.M on 1/21/24.

Review of the Psychiatry Consult Progress Note cosigned by the Attending Physician, dated 1/25/24 at 2:11 P.M., indicated that Patient #4 has a history of alcohol and opiate use disorder in remission, on methadone (a narcotic used to treat moderate to severe pain as well as narcotic drug addiction), depression, and anxiety, who presented to the ED on a section 12 after an overdose of Klonopin. The note further indicated that Patient #4 continued to meet Section 12 criteria due to concern for his/her safety outside of the Hospital.

Review of the Nurses Note documented by Registered Nurse # 3, dated 1/25/24 at 5:13 P.M., indicated that Patient #4 was on 1:1 observation for SI and Section 12. The Nurses Note indicated that she was alerted by staff that Patient #4 went missing. The Nurses Note further indicated that Patient Observer # 2 was unable to tell her when Patient #4 went missing, and that Patient #4 had IV access when he/she eloped.

During an interview on 7/31/24 at 1:30 P.M., the Risk Manager #1 said the Hospital did not perform a full Root Cause Analysis (RCA) on the event involving Patient #4. She indicated that Patient #4 was a high-risk patient due to SI, was on a section 12, had eloped with IV access. She said Campus Police as well as the local Police Department were notified, but Patient #4 was never located. She said this was investigated by Human Resources (HR) and tasked to the Nurse Manager of 7 East for review of the event and staff education.

During an interview on 7/31/24 at 2:30 P.M., the Nurse Manager of 7 East said she rounds daily on all patients requiring a 1:1 observation. She said on 1/25/24 Patient #4 expressed wanting to leave the Hospital at which time she went over his/her plan of care. She said she was on the unit when Patient #4 eloped, and she was alerted by staff at this time. She said she spoke to Patient Observer # 2 who said she turned her back for one second while Patient #4 went to the bathroom to assist the other patient in the next bed as he was calling for help. She said HR was involved in the investigation and Patient Observer # 2 was put on probation for six months with a remedial education plan. She said opportunities were identified for education on the expectations while conducting 1:1 constant observation as well as implementing bedside shift report. She said she has been educating staff through huddles twice a day on the unit. The Nurse Manager of 7 East was unable to provide documentation to support education was implemented.

During an interview on 8/1/24 at 10:50 A.M., Patient Observer # 2 indicated that on 1/25/24, she was assigned to provide 1:1 observation of Patient #4 due to SI. Patient Observer # 2 acknowledged that as the 1:1 observer, it was required to provide constant visual observation, including while using the bathroom, for the assigned patient. Patient Observer #2 said while Patient #4 was in the bathroom she helped the patient in the next bed losing visual sight of Patient #4 for an unknown period of time. She said when she went back to the bathroom Patient #4 was no longer there. She said she alerted the Nurse Manager of 7 East and RN #3 that Patient #4 was missing. Patient Observer # 2 said she received education as a result of Patient #4 ' s elopement.

During an interview on 8/1/24 at 11:15 A.M., Registered Nurse (RN) # 3 indicated that Patient #4 was on a 1:1 constant observation due to elopement risk and Section 12. She said she gave Patient Observer # 2 bedside report. RN #3 said that Patient Observer # 2 acknowledged receiving hand off from the previous PCA. RN # 3 said approximately 40 minutes later she was alerted by Patient Observer # 2 that Patient #4 was missing.

The Hospital failed to provide care in a safe setting for Patient #4, when the Patient eloped from the Hospital while ordered for 1:1 constant observation and failed to implement system wide corrective actions to prevent a like occurrence.

Based on records reviewed, policy review, and interviews, the Hospital failed to protect 1 Patient (Patient #1) out of a sample of 10 patients from abuse and retaliation by 2 staff members on 2 separate occasions.

Findings included:

Review of Hospital Policy ' Patient Rights and Responsibilities ' , effective 12/17/21, indicated that patients have a fundamental right to medical care that safeguards their personal dignity and respects their cultural, psychosocial and spiritual values.

Patient #1 presented to the Hospital ' s Pediatric Emergency Department (ED) from a group home on 11/17/23 after increased aggression toward staff, hitting staff and self-harm behaviors. Patient #1 was placed on a Section 12 (Emergency restraint and temporary involuntary hospitalization of a person posing risk of serious harm by reason of mental illness) due to Suicidal Ideation (SI) and ordered for Constant Observation (CO) with a 1:1 (1 staff member assigned to watch 1 patient).

1) Review of Social Work Plan of Care note dated 12/14/23 indicated the Director of Social Work was notified about an event on 12/4/23 in which a staff member had spit on Patient #1.

During an interview on 7/30/24 at 1:24 P.M., Registered Nurse (RN) #1 said she was working the night of the incident involving Patient #1 and a staff member. RN #1 said Patient #1 was very unpredictable with behaviors and therefore said the Patient was always a 1:1. RN #1 said that another day prior to this event, Patient Observer #1 was assigned to Patient #1 and was observed by RN #1 to be making facial expressions in response to his/her behavior, agitating Patient #1. RN #1 provided education to Patient Observer # 1 regarding not making faces at Patient #1 and how to avoid agitating patients. RN #1 said on the night of this event, Patient #1 was not on her assignment, but during start of shift report, it was reported the Patient was escalating his/her behaviors, so RN #1 went to go check in with the Patient and was able to de-escalate the Patient. RN #1 said later that night, she was told by another staff member that Patient Observer #1 had spit on Patient #1. RN #1 said at some point in the evening, she believed Patient #1 also had to be restrained but was unsure if this was after the spitting incident. RN #1 said after the event, the Pediatric ED had panic alarm buttons installed in the patient rooms and that staff were reminded to ask for help if they felt they needed a break from an assignment, but she was unsure of any other actions or education done with staff after this event. RN #1 said Patient Observer #1 was the same Observer that she had spoken to about not making faces at Patient #1 prior to this incident.

During an interview on 7/31/24 at 3:00 P.M., the ED Nurse Manager said she assisted another nurse manager with the investigation into Patient Observer #1 spitting on Patient #1. The Nurse Manager said that observers are trained and oriented prior to working with patients on how to escalate concerns and when to report to nurses. The Nurse Manager said her understanding was that Patient #1 had spit at Patient Observer #1 and that the Patient Observer had spit back on the Patient. She said after the event, the Observer was moved out of the Pediatric area, panic buttons were installed in the rooms in the Pediatric ED and said staff was reminded to ask for help when needed.

During an interview on 8/1/24 at 1:19 P.M., Patient Observer #1 said that Patient #1 needed a 1:1 at all times due to behaviors. Patient Observer #1 said she received a brief training at the time she was hired by the Hospital and shadowed another observer the first few weeks. Patient Observer #1 said on the day of this event, the Patient needed to be restrained on two separate occasions. Patient Observer #1 said during the time of the two restraints being applied she told the nurse assigned to Patient #1 and other staff that she was tired and asked for help but was told that she had to stay with Patient #1. Patient Observer #1 said that after the 2nd restraint was removed, Patient #1 began spitting at her and she told Patient #1 words to the effect of ' if you want to spit, I can spit too ' and then spit on Patient #1. Patient Observer #1 said she knew that she wasn ' t supposed to touch the Patient but said she didn ' t know that spitting wasn ' t something that should be done to a patient. Patient Observer #1 said after this, she went out on leave, was informed that she should not spit on patients and was transferred out of the Pediatric ED to another unit. Patient Observer #1 said the only training that she completed after this was the Annual Training required by the Hospital but was unsure of any additional trainings or education completed as a result of this.

2) Review of Registered Nurse Progress Note dated 12/27/23 indicated: writer informed on 12/26 that Patient #1 was inappropriately pushed by staff. Unit surveillance was pulled to investigate. Writer did observe Patient #1 run towards staff at 21:04 to which staff responded by pushing Patient #1 and resulted in Patient #1 falling on the floor.

Review of Hospital surveillance video from 12/25/23 on 7/31/24 at 10:45 A.M. indicated that at 21:03, Patient #1 was observed running into the pediatric common room in the pediatric section of the Emergency Mental Health (EMH) unit wrapped in a blanket. In the footage, 2 unidentified staff members were observed in the room. Patient #1 began running in the room and briefly went out of view in the opposite area of the room. Patient #1 was then observed back in frame at 21:04 and was noted to be falling backwards towards the ground with force and a 3rd staff member (Mental Health Associate #1) was then observed in the frame. Patient #1 remained lying on the ground while the initial 2 unidentified staff members approached him/her. One unidentified staff member made motions to Mental Health Associate (MHA) #1 to leave the room and then made gestures indicating shoving motions with two hands. MHA #1 then left the room.

During an interview on 8/1/24 at 2:11 P.M., MHA #1 said that he usually works at the Psychiatric Treatment and Recovery Center (PTRC) unit affiliated with the Hospital. MHA #1 said on 12/25/23, he was assigned to the EMH and rotated to cover the pediatric common room and arrived there around 7:00 P.M and Patient #1 was in the room. MHA #1 said later in the evening Patient #1 was laying on the ground and staff began trying to get the Patient to get up off the floor and take his/her night-time medications, but the Patient wasn ' t cooperating. MHA#1 said Patient #1 began spitting on the floor and throwing items around the room. MHA #1 said he and other staff were cleaning up the mess in the room and he was disposing of the trash in a trash can outside of the common room. MHA #1 said during the cleanup, Patient #1 had wrapped themself up in a blanket and walked around the room acting like he/she was going to hit staff. MHA #1 said he left the room again briefly to dispose of more trash and when he came back in, Patient #1 began running towards the MHA like he/she was about to hit the MHA. The MHA said he had a reflex and tried to deflect it, and the Patient fell to the ground. MHA #1 said the Patient laid on the floor after this and the nurse assigned to the Patient told the MHA he was unprofessional and asked him to step out of the room. MHA #1 said after the incident he received a letter from the Hospital indicating he could no longer work with pediatric patients or work in the EMH and that he received a written warning. MHA #1 said he retrained on the annual training, which included modules about how employees can protect themselves. MHA #1 said he was unsure if any additional training or education was done with staff.

During an interview on 7/31/24 at 10:27 A.M., the Director of Quality, Safety and Regulatory said she believes the direct staff involved in these events (Patient Observer #1 and MHA #1) were counseled after the events but was unable to say if any further actions or follow up was implemented by the Hospital.

During an interview on 7/31/24 at 11:37 A.M., Human Resources (HR) Representative #1 said she is responsible for investigating allegations against Hospital employees. HR Rep #1 said she was involved in investigating Patient Observer #1 after he/she spit on Patient #1 and MHA #1 after he pushed Patient #1. HR Rep #1 said on the surface these events were horrendous and egregious but there were extenuating circumstances for Patient #1. HR Rep #1 said that Patient #1 was aggressive, assaultive and behavioral. HR Rep #1 said she felt the staff involved in these incidents were untrained and clarified that she felt the staff were not trained to deal with this Patient. HR Rep #1 said she did not report back to the Hospital ' s Quality and Safety Department her thoughts and that she would expect the clinical managers investigating would share the concerns she raised.

During a follow up interview on 8/1/24 at 8:30 A.M., the Director of Quality, Safety and Regulatory acknowledged Patient #1 was spit on by a staff member assigned to care for them and then a few weeks later Patient #1 was pushed to the ground by a different staff member. The Director was unable to say if anyone had followed up with Patient #1 after these incidents. The Director said that after these incidents, the Hospital implemented panic buttons in the rooms in the Pediatric ED, offered training to help support staff against workplace violence, and tried to increase staff ratios in the Pediatric ED.

The Hospital implemented actions to support staff after it was substantiated that one staff member spit on Patient #1 and another staff member pushed Patient #1. However, the Hospital failed to implement corrective actions aimed at preventing a like occurrence from happening.