HospitalInspections.org

Based on facility document review, policy review, video recording review, medical record reviews, observations and interview, the Governing Body failed to be effective in carrying out its responsibilities for the conduct of the hospital and ensure the hospital's ongoing compliance with all Conditions of Participation in order for quality of care to be provided to all patients. The failure of the Governing Body to carry out its responsibility for the oversight of the conduct of the hospital, failure to enforce, monitor and revise as needed their Plan of Correction; and failure to ensure all hospital policies and procedures to protect the safety and health of patients and prevent serious outcomes placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being.

The Governing Body's failure to manage the hospital functions, improve processes to ensure quality of care and ensure an environment and culture of safety resulted in 25 of 28 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25) sampled patients not receiving protective care, safety care and preventative care from the hospital.

The findings included:

1. Review of the hospital's "Amended and Restated Governing Board Bylaws" adopted July 21, 2021 revealed, "...The Facility is owned by the Corporation. The Corporation is managed by a Board of Directors that have been elected by the shareholders of the Corporation. The Governing Board serves as the governing body of the Facility to the extent that the Board of Directors has delegated authority to it...The Governing Board is ultimately accountable for the safety and quality of care, treatment, and services provided by the Facility. The primary function of the Governing Board is to assure that the Facility and its Medical Staff provide quality medical care that meets the needs of the community..."

2. Review of the facility's Plan of Correction accepted 9/6/2022 revealed, " ...a Governing Board member, was delegated the responsibility of ensuring provision of care in a safe setting and completion of all corrective actions with the Governing Board maintaining overall responsibility for compliance with all Conditions of Participation ..."

2. Review of the CEO Job Description" revealed, "...The Chief Executive Officer shall serve as the executive officer with day-to-day responsibility for the management and operation of the hospital. The CEO has primary responsibility for the development, implementation, and achievement of the hospital's strategic business plan in conjunction with routine operations to include: quality of care, staff development...Manages day-to-day operations and staff so that the hospital achieves its objectives in all of the following key performance areas...effective patient care outcomes..."

3. Review of the Chief Operating Officer (COO) Job Description revealed, "...Purpose Statement: Provide management oversight and direction for day-to-day operational activities of the facility. Essential Functions...Manage and implement programs to ensure all employees are committed to quality and service...Actively participate in strategic planning and corresponding development activities including regulatory preparedness and quality improvement..."

4. Review of the Chief Nursing Officer (CNO) Job Description revealed, "...Chief Nursing Officer is responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing and other departments and the delivery of behavioral health and nursing services. Collaborates with interdisciplinary treatment teams, other departments, and with administration to ensure that all residents physical, biopsychosocial, age, developmental and cultural needs are met. Provides leadership to assure compliance with local, state, federal regulations and nursing practice standards. Essential Functions...Manage the daily operations of nursing services...Integrate nursing functions with clinical and programs, assuring efficient and effective operations...Evaluate service needs and staffing requirements to assure needs of people supported are met. Provide effective staff management...that assures utilization of personnel to best meet the needs of the people receiving support and services. Develop and implements health care related training that assures the best possible delivery of health related supports and services. Reviews training at least annually and makes modifications as needed. Develop and maintains documentation systems for continuity of care...Monitor unit/floor functioning by making frequent rounds. Intervene in crisis situations and investigate incidents. Develop and implement tools to measure, assess and improve quality of nursing care, treatment and service...Oversee nursing services documentation to ensure it meets all standards..."

5. The Governing Body failed to ensure patients' rights to receive care in a safe setting were followed for 25 of 28 sampled patients.
Refer to A 115 and A 144.

6. The Governing Body failed to ensure Nursing Services adhered to facility policies to protect 25 of 28 vulnerable patients from actual and/or potential harm; failed to ensure the facility was staffed with an appropriate number of nursing staff to meet the needs of all patients on 25 of 26 days reviewed.
Refer to A 385 and A 392.

Based on facility document review, policy review, video recording review, medical record review, observation and interview, the facility failed to ensure care was provided in a safe setting for 25 of 28 (Patient #1, #2, #2, #4, #5, #6, #7, #8, #9. #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25) sampled patients; failed to ensure staff followed the facility's Plan of Correction for falls for 1 of 1 (Patient #1) patients reviewed with falls; and failed to follow their policy to ensure each unit was safely staffed with a staff to patient ratio of 1 staff for every 5 patients from 7:00 PM until 7:00 AM on 25 of 26 (10/1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 15, 2022) days reviewed.

The facility's failure to ensure care was provided in a safe setting, failure to ensure staff followed all policies to promote the safety of all patients, failure to follow the Plan of Correction for falls, and failure to ensure the facility was safely staffed placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being.

The findings included:

1. Review of the hospital's "Adult Patient Handbook, Patient Rights" section revealed, "...Patients have the right to be protected from neglect, physical, verbal, and emotional abuse..."

2. Review of the hospital's "Observations, Patient" policy revised 7/2021 revealed, "...In order to maintain patient safety,the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN...The psychiatric practitioner will order one of three levels of observation at time of admission and as the patient's condition warrants a change: a. 15 minute b. 5 minute c. One-to-one...All patients are monitored at minimum once in every 15-minute block of time...During rounds stafff are to...Make direct visual contact; look for signs of danger or distress...Observe sleeping patients to confirm they are breathing by watching for the rise and fall of the patient's chest at minimum three times...Remain vigilant for specific patients on Special Precautions..."

3. Review of the facility's "The Medical Record" policy revised on 10/2022 revealed, "Purpose: To provide documentation principles that apply to all documented entries made to the medical record...When authenticating an entry, the author will verify that the entry being authenticated is his entry or that he is responsible for the entry, and that the entry is accurate..."

4. Review of the facility's "Fall Precautions and Prevention" policy dated 4/2020 revealed, "...Patient safety is an ongoing responsibility of all staff...All patients admitted to the hospital will be assessed using the MORSE Falls Assessment as part of the Nursing Assessment. Based on this assessment, each patient will be placed in a risk category...Standard Falls Prevention Interventions - apply to all patients...Routine q [every] 15 minute observations..."

5. Review of the facility's Plan of Correction accepted on 9/6/2022 revealed, "...The CEO, a Governing Board member, was delegated the responsibility of ensuring provision of care in a safe setting and completion of all corrective actions with the Governing Board maintaining overall responsibility for compliance with all Conditions of Participation...The COO and DRM [Director of Risk Manager] developed an audit tool for post incident that included the requirements for the nurse to document...accurate completions of a Morse Fall assessment for all assessments post fall..."

6. Review of the Quality Council Meeting Minutes dated 8/25/2022 revealed, "...Leadership Rounds...Rounding observations sheets are also inspected during leadership rounds to determine if the staff are compliant with concurrent and timely documentation... survey on patient rights throughout the month of July. IJ [Immediate Jeopardy] was called and immediate plan implemented...Data required to be included in meeting have been included above including...environmental rounds..."

7. Review of the Camera Surveillance Weekly Random Monitoring Sheets completed 8/12/2022 through 10/17/2022 revealed the facility had ongoing issues regarding staff completing observation rounds and nursing rounds appropriately.

8. Review of the Governing Board ad-hoc Meeting Minutes October 24th, 2022 & October 25th, 2022 revealed, "... Rounding non-compliance identified through investigation at facility level during investigation..."

9. Review of the facility's "Admission" policy revealed "...Purpose: To establish guidelines for admissions to a Behavioral Health unit to assure that patients are appropriately admitted...Admission to a Behavioral Health unit [also known as the General Psychiatric Unit (GPU) is for adults suffering from an acute psychiatric condition(s) or from an acute exacerbation of a chronic conditions. Such patients will also require intensive psychiatric intervention with different levels of medical treatment...Dual Diagnosis Unit [DDU] "...provides inpatient care and treatment for adults dealing with Dual Diagnosis (both a psychiatric and substance abuse/dependence diagnosis). the following criteria will be met for all admissions. (A1 and A2 are required): A. The patient will have a Dual-Diagnosis with both a primary psychiatric as well as a substance abuse/dependence diagnosis...1. Behavior which is life-threatening, destructive or disabling to self or others, exhibited y one or more, of the following...Suicidal and /or homicidal ideations, threats, plan, or attempts and are considered to be a low or moderate risk for acting-out behaviors...2. Substance abuse/dependence (current history of), with one, or more of the following...Withdrawal symptoms including seizures, marked tremors, delirium tremors, hallucinations, marked confusion, memory impairment, and/or disorientation to time and/or place...Acute psychotic reaction secondary to alcohol and/or drug use...Mental Health Unit [also known as the Intensive Treatment Unit [ITU)] Admission Criteria Primary psychiatric diagnosis as...evidenced by one or more of the following...suicidal and/or homicidal ideations with a clearly devised plan with an intent to carry out, and/or considered a high risk for violent acting out behavior...Unmanageable behavior in the home and/or community...Severely dysfunctional in the family and/or home/community support system...Alternatives for less restrictive and less intensive treatment would not meet patient's clinical needs...Senior Care Unit [SCU]...Admission to the Senior Care Unit is indicated for patients who...meet one or more of the following criteria...Suicidal behavioral and/or ideation, with poor impulse control and/or little or no support from their environment...Combative or assaultive behavior or ideations, which poses a threat to others...An acute onset of or intensification of delirium or disorientation, bizarre or delusional behavior that results in the patient being incapable of performing activities of daily living..."

10. Review of the facility's "Staffing Plan for Nursing Services" approved on 7/2021 and revised on 9/2022 revealed, "...The Staffing Plan for Nursing Services reflects specific service needs to meet patient care and organizational needs...This staffing plan outlines requirements...The staffing for all units is a 1:5 staff to patient ratio...The goal of staffing each unit is to ensure patient safety in healthcare delivery..."

11. The facility failed to protect Patient #2, an acutely psychotic male, involuntarily admitted to the facility on 10/7/2022 with diagnosis of Schizoaffective Disorder Bipolar Type from Patient #3, an acutely psychotic HIV positive male on parole for sexual battery male admitted on 10/5/2022 with diagnosis of Schizophrenia.

Review of the Incident Report, Incident Report Investigation, facility video recording, medical record and interviews with staff revealed Patient #2 and #3 were left unattended along with 11 other patients on 10/9/2022 from 1:54 AM until at least 2:29 AM when the video recording ended. Patient #3 was observed on video entering Patient #2's room at 1:44 AM and did not exit Patient #2's room until 2:29 AM. There were no staff members observed completing patient observations or safety rounds during that time. Review of the Patient Observations for both Patient #2, #3, and the other 11 patients revealed staff documented the patients were observed by staff every 15 minutes during the time no staff were observed on video completing observations or safety checks.

12. Medical record review revealed Patient #1 was admitted to the facility on 10/1/2022 with diagnosis of Schizophrenia. Patient #1 was psychotic and had a history of multiple medical problems including Hypertension, Diabetes Mellitus and Atrial Fibrillation and was noted to be a high risk for falls. Patient #1 was housed on the same unit as Patient #2 and #3 when they were all left unsupervised by staff on 10/9/2022 from 1:44 AM until 2:29 AM.

The facility failed to ensure the Morse Fall Risk Assessments were accurate which was also previously cited and written as a corrective measure in the facility's Plan of Correction dated 9/24/2022.

Review of the nursing documentation dated 10/12/2022 revealed Patient #1 informed a staff member he had fallen on 10/10/2022. The patient was noted to have multiple bruises and a large hematoma on his abdomen as a result of the fall. Review of the 22 Morse Fall Risk Assessments completed after 10/10/2022 revealed no documentation the patient had fallen in the facility.

13. Review of a video recording dated 10/24/2022 at 9:18 PM through 10/25/2022 at 7:00 AM revealed Registered Nurse (RN) #3 was observed entering Patient #1's room with what appeared to be a medicine cup on 10/24/2022 at 9:27 PM and exited the patient's room at 9:28 PM. There were no other staff observed entering Patient #1's room until 7:14:51 AM when MHT #2, day shift staff, was observed entering the patient's room and exited just 6 seconds later. At 8:12:42 AM, MHT #2 entered Patient #1's room and discovered he was pulseless and not breathing. The video recording further revealed no staff members were observed making patient observations or safety rounds on the other 9 patients on the hallway from 9:00 PM on 10/24/2022 through 7:00 AM on 10/25/2022. Review of the Patient Observation forms for Patient #1 and the other 9 patients revealed staff documented the patients were observed every 15 minutes.

14. The facility failed to protect Patient #24, an acutely psychotic male, and Patient #25, an acutely psychotic female from Patient #23, an acutely psychotic male on Sexual Acting Out Precautions. Patient #23 had a sexual encounter with both Patient #24 and #25 on 6/1/2022.

15. Review of the Daily Staffing for 10/1/2022 through 10/25/2022 revealed the staff to patient ratio was greater than the 1 to 5 ratio required on the Staffing policy.

Refer to A 0144.

Based on facility document review, policy review, video recording review, medical record review, observation and interview, the facility failed to ensure care was provided in a safe setting for 25 of 28 (Patient #1, #2, #2, #4, #5, #6, #7, #8, #9. #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25) sampled patients; failed to ensure staff followed the ordered falls precaution for 1 of 1 (Patient #1) patients reviewed with falls which was also previously cited and written as a corrective measure in the facility's Plan of Correction dated 9/24/2022, and failed to follow their policy to ensure each unit was safely staffed with a staff to patient ratio of 1 staff for every 5 patients from 7:00 PM until 7:00 AM on 25 of 26 (10/1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25, 2022) days reviewed.

The facility's failure to provide care in a safe setting, promote safety by not following facility policies and procedures, failure to follow previous plans of correction for falls and failure to ensure the facility was staffed to meet patient's individual needs placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being.

The findings included:

1. Review of the hospital's "Adult Patient Handbook, Patient Rights" section revealed, "...Patients have the right to be protected from neglect, physical, verbal, and emotional abuse..."

2. Review of the hospital's "Observations, Patient" policy revised 7/2021 revealed, "...In order to maintain patient safety,the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN...The psychiatric practitioner will order one of three levels of observation at time of admission and as the patient's condition warrants a change: a. 15 minute b. 5 minute c. One-to-one 2. The psychiatric practitioner may also order a precaution level of observation for: a. Suicide b. Assault c. Elopement d. Seizure e. Fall f. Sexual Acting Out...Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following...Level of observation...Precaution...Location...Behavior...Activity...Time...Staff Initial and Signature...Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and or to back fill time frames that were not completed in a timely manner...All patients are monitored at minimum once in every 15-minute block of time...During rounds stafff are to...Make direct visual contact; look for signs of danger or distress...Observe sleeping patients to confirm they are breathing by watching for the rise and fall of the patient's chest at minimum three times...Remain vigilant for specific patients on Special Precautions..."

3. Review of the facility's "The Medical Record" policy revised on 10/2022 revealed, "Purpose: To provide documentation principles that apply to all documented entries made to the medical record, regardless of the media used to create or maintain the record. All medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided, consistent with hospital policies and procedures...The content of the medical record, which includes written and electronic documents, must be sufficiently detailed, legible and organized to enable: the practitioner responsible for the patient to identify the patient, provide continuing care, determine the patient's condition at a specific time...When authenticating an entry, the author will verify that the entry being authenticated is his entry or that he is responsible for the entry, and that the entry is accurate.

4. Review of the facility's "Fall Precautions and Prevention" policy dated 4/2020 revealed, "...Patient safety is an ongoing responsibility of all staff. In order to reduce the risk of patient injuries as a result of a fall, nursing staff will assess and re-assess the patient's level of risk for fall and implement appropriate interventions...All patients admitted to the hospital will be assessed using the MORSE Falls Assessment as part of the Nursing Assessment. Based on this assessment, each patient will be placed in a risk category...Nursing shall place the patient on fall precautions when indicated and ensure the practitioner is notified and orders the level of observation and precautions consistent with the assessed level of risk...Standard Falls Prevention Interventions - apply to all patients...Routine q [every] 15 minute observations..."

5. Review of the Quality Council Meeting Minutes dated 8/25/2022 revealed, "...Leadership Rounds...Rounding observations sheets are also inspected during leadership rounds to determine if the staff are compliant with concurrent and timely documentation. Review of leadership rounds suggest observations were up to date over 89 % [percent] of the time. The other 11% were reviewed with the employee and manager to discuss ways and importance of staying up to date...survey on patient rights throughout the month of July. IJ [Immediate Jeopardy] was called and immediate plan implemented...Data required to be included in meeting have been included above including...environmental rounds..."

6. Review of the facility's Plan of Correction accepted on 9/6/2022 revealed, "...The CEO, a Governing Board member, was delegated the responsibility of ensuring provision of care in a safe setting and completion of all corrective actions with the Governing Board maintaining overall responsibility for compliance with all Conditions of Participation...The COO and DRM [Hospital #1's Risk Manager] developed an audit tool for post incident that included the requirements for the nurse to document...accurate completions of a Morse Fall assessment for all assessments post fall..."

7. Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 8/12/2022 for 8/9/2022 for the time period of 1:21 AM - 3:21 AM on the Intensive Treatment Unit (ITU) revealed, "...Staff observed conducting 15 minute checks: Yes. They need to use clip board and do concurrent rounds. Staff observed
monitoring hallway: Yes....Other observations: Yes Nurse did not do hourly rounds...Follow-up needed: Yes,.........Reminder of concurrent rounds & RN rounds. Who was notified for follow-up? [CNO]..."

Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 8/15/2022 for 8/15/2022 for the time period of 1:00 AM - 3:00 AM on the ITU revealed, "...Staff observed conducting 15 minute checks: Yes. They need to use clip board and do concurrent rounds. Staff observed monitoring hallway: Yes....Other observations: Yes Nurse did not do hourly rounds...Follow-up needed: Yes. Reminder to staff. Who was notified for follow-up?" There was no documentation who was notified.

Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 8/25/2022 for 8/25/2022 for the time period of 1:00 AM - 3:00 AM on the ITU revealed, "...Staff observed conducting 15 minute checks: Yes. Not using clipboard. Staff observed monitoring hallway: Yes. But not stationed in zones...Other observations: Yes. RN did not round. Follow-up needed: Reminder of expectations...Who was notified for follow-up? [CNO]..."

Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 9/8/2022 for 9/6/2022 for the time period of 1:00 AM - 3:00 AM on the ITU revealed, "...Staff observed conducting 15 minute checks: Yes. Not using clipboard. Staff observed monitoring hallway: Yes...Other observations: Yes; nurse came out of nursing station. Follow-up needed: No..."

Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 9/16/2022 for 9/13/2022 for the time period of 1:00 AM - 3:00 AM on the ITU revealed, "...Staff observed conducting 15 minute checks: Yes. They need to use clipboard. Staff observed monitoring hallway: Yes. Please remind on zone locations...Other observations: Yes; Nurse did not round. Follow-up needed: Staff Reminder Who was notified for follow-up? [CNO]..."

Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 9/26/2022 for 9/26/2022 for the time period of 1:00 AM - 3:00 AM on the ITU revealed, "...Staff observed conducting 15 minute checks: Yes. [MHT #1] needs to go in the room [Named another MHT] needs to use clipboard. Staff observed monitoring hallway: Yes. They need to communicate 2 [to] ensure 1 is always in hall...Other observations: Yes; RN did not make rounds. Follow-up needed: Yes. Who was notified for follow-up? [CNO]..."

Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 10/3/20222 for 10/3/2022 for the time period of 1:00 AM - 3:00 AM on the ITU revealed, "...Staff observed conducting 15 minute checks: Yes & No They were not completed by going in room c [with] clipboard. [MHT #5] did walkbys. Staff observed monitoring hallway: Yes...Other observations: Yes nurse did not round. Follow-up needed: Yes; Education Who was notified for follow-up? [CNO]..."

Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CNO on 10/13/2022 for 10/13/2022 for the time period of 2:00 AM - 3:30 AM on the Senior Care Unit [SCU] revealed, "...Staff observed conducting 15 minute checks: No. No observation round was completed...Staff observed in zones at all times. No BHA [Behavioral Health Associate] on break. Area left unattended...Follow-up needed: Yes. Who was notified for follow-up? [named a nurse manager]..."

Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 10/17/2022 for 10/17/2022 for the time period of 1:02 AM - 3:02 AM on the ITU revealed, "...Staff observed conducting 15 minute checks: Yes. Not using clipboard. Staff observed monitoring hallway: Yes. But should have been stationed at each end...Other observations: Yes; HS [house supervisor] made rounds which is good..."

8. Review of the Governing Board ad-hoc Meeting Minutes October 24th, 2022 & October 25th, 2022 revealed, "...This ad-hoc meeting has spanned over two days for survey updates...Survey requested items and complaints were reviewed with members of the governing board. Daily updates as to findings and issues were discussed - Rounding non-compliance identified through investigation at facility level during investigation. Developed plan with governing board assistance to provide patient safety through observation rounding. Incident October 25th provided additional insight to rounding non-compliance. Plan developed to include leadership and leadership team. Governing Board reviewed plan with recommendations. Action plan was submitted to state survey agency..."

9. Review of the facility's "Admission" policy revealed "...Purpose: To establish guidelines for admissions to a Behavioral Health unit to assure that patients are appropriately admitted...Admission to a Behavioral Health unit [also known as the General Psychiatric Unit (GPU) is for adults suffering from an acute psychiatric condition(s) or from an acute exacerbation of a chronic conditions. Such patients will also require intensive psychiatric intervention with different levels of medical treatment...Dual Diagnosis Unit [DDU] "...provides inpatient care and treatment for adults dealing with Dual Diagnosis (both a psychiatric and substance abuse/dependence diagnosis). the following criteria will be met for all admissions. (A1 and A2 are required): A. The patient will have a Dual-Diagnosis with both a primary psychiatric as well as a substance abuse/dependence diagnosis...1. Behavior which is life-threatening, destructive or disabling to self or others, exhibited y one or more, of the following...Suicidal and /or homicidal ideations, threats, plan, or attempts and are considered to be a low or moderate risk for acting-out behaviors...2. Substance abuse/dependence (current history of), with one, or more of the following...Withdrawal symptoms including seizures, marked tremors, delirium tremors, hallucinations, marked confusion, memory impairment, and/or disorientation to time and/or place...Acute psychotic reaction secondary to alcohol and/or drug use...Mental Health Unit [also known as the Intensive Treatment Unit [ITU)] Admission Criteria Primary psychiatric diagnosis as...evidenced by one or more of the following...suicidal and/or homicidal ideations with a clearly devised plan with an intent to carry o out, and/or considered a high risk for violent acting out behavior...Unmanageable behavior in the home and/or community...Severely dysfunctional in the family and/or home/community support system...Alternatives for less restrictive and less intensive treatment would not meet patient's clinical needs...Senior Care Unit [SCU]...Admission to the Senior Care Unit is indicated for patients who...meet one or more of the following criteria...Suicidal behavioral and/or ideation, with poor impulse control and/or little or no support from their environment...Combative or assaultive behavior or ideations, which poses a threat to others...An acute onset of or intensification of delirium or disorientation, bizarre or delusional behavior that results in the patient being incapable of performing activities of daily living..."

10. Review of the facility's "Staffing Plan for Nursing Services" approved on 7/2021 and revised on 9/2022 revealed, "...The Staffing Plan for Nursing Services reflects specific service needs to meet patient care and organizational needs...This staffing plan outlines requirements as well as contingency plans for unexpected events that may temporarily disrupt staffing in order to sustain safe business operations...Nursing Department Staff is composed of both licensed and unlicensed personnel. RNs [Registered Nurses] and LPNs [Licensed Practical Nurses]...Behavioral Health Associates [also referred to as Mental Health Technicians (MHTs)]...General Nursing Staff to Patient Ratios by unit: The staffing for all units is a 1:5 staff to patient ratio...The minimum staffing needed for each skill level (RNs, LPNs, Behavioral Health Associates, others) is determined by the nurse-patient ratio guidelines and patient care needs of the populations...Core coverage includes ensuring there is 1 RN on each unit at all times and that there is at minimum 2 staff on each unit at all times...The goal of staffing each unit is to ensure patient safety in healthcare delivery...A Registered Nurse plans, assigns, supervises, and evaluates the nursing care of each patient daily...The unit will be staffed with an adequate number of RNs, LPNs, and BHAs to maintain a therapeutic milieu and a safe environment...Safe Staffing Guidelines To secure optimal patient care, these guidelines outline staffing expectations to be observed by all service lines...An RN must always be on the unit. Neither an RN House Supervisor nor and LPN can serve as the RN on the unit...Must always maintain one RN, LPN, or other licensed staff member on the unit...Minimum of two staff members are scheduled on each unit..."

11. Medical record review for Patient #1, a 69 year old male, revealed an admission date of 10/1/2022 with diagnosis of Schizophrenia.

Review of the Medical Screening Exam (MSE) dated 9/30/2022 at 11:58 PM revealed, "...Significant Medical History...Diabetes..." (Diabetes is a condition that affects the way the body processes blood sugar resulting in too much sugar in the blood). "Hypertension [HTN]..." (HTN, high blood pressure, is a condition in which the force of the blood against the artery walls is too high.) "GERD [Gastro-esophageal Reflux Disease]..." (GERD is a chronic disease that occurs when stomach acid or bile flows into the esophagus (food pipe) and irritates the lining.) "Arthritis...A fib [Atrial Fibrillation]" (A-Fib is an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart. A-fib increases the risk of stroke, heart failure and other heart-related complications.) "...Hx DVT [History of Deep Vein Thrombosis]..." (A DVT is blood clot in the deep vein, usually in the legs.) "Gout..." (Gout is a form of arthritis characterized by severe pain, redness, and tenderness in joints. Pain and inflammation occur when too much uric acid crystallizes and deposits in the joints.) "...Believes he can predict future..."

Review of the Intake Assessment dated 10/1/2022 at 12:40 AM revealed Patient #1 was transported to the facility via ambulance. The patient was manic and extremely psychotic. Patient #1 had gone "into a restaurant with only his underwear on and was found wandering the street by [local police department]...Misses meds [medications] sometimes...Past or present medical conditions...DM [Diabetes Mellitus], HTN, GERD, Arthritis, A-Fib, Gout, [symbol for increased] chol [cholesterol]...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...Potential danger to self or others..."

Review of the High Risk Notification Form dated 10/1/2022 at 1:56 AM revealed, "...Level of Observation Ordered by Practitioner: Q 15 min...Precautions ordered by Practitioner...Fall...Manic, Bizarre, flight of ideas...Known Medical Problems: DM, HTN, GERD, Arthritis, A-fib, Gout, DVT, [symbol for increased] chol..."

Review of the Nursing Admission Assessment dated 10/1/2022 revealed Patient #1 arrived on the unit at 2:00 AM. The patient was oriented to the unit and provided the patient handbook. The patient was noted to have Past Medical History which included Neuropathy, Pain in the left knee, HTN, elevated cholesterol, Gout, Deep Vein Thrombosis, Diabetes Mellitus, Seasonal Allergy and Atrial Fibrillation.

Review of the physician's orders dated 10/1/2022 at 2:32 AM, revealed "...15 Minute Checks...Fall Precautions...Admit to GPU [General Psychiatric Unit]..."

Review of the Care Plan created on 10/1/2022 at 2:47 AM, revealed, "...Fall risk procedures implemented...Verification of Q 15 minutes observation record by nurse done Q shift at 0700 [7:00 AM] and 1900 [7:00 PM]...Vital signs Q 12 hours...Q 15 min observation paper record completed & to nurse at end of shift..."

Review of the Initial Treatment Plan (Nursing) created on 10/1/2022 at 3:41 AM revealed Patient #1 had a total of 5 active medical problems which included Hypertension, History of A-Fib, History of DVT, Gout, and Knee Pain.

Review of the Psychiatric Evaluation dated 10/1/2022 at 7:53 AM revealed Patient #1 "...came out of his room this morning and began threatening others unprovoked...Admitting Diagnosis Schizoaffective Bipolar..."

Review of the History and Physical completed by the Medical Director on 10/1/2022 at 11:10 AM, revealed "...Psych management per [Psychiatrist #1]. Tylenol for aches and pains. Milk of Magnesia for indigestion. Risperidone and divalproex per psych. Cetirizine for allergies. Clonidine for high blood pressure. Supplement potassium. Sliding scale [insulin] for diabetes...Verapamil for cardiac arrhythmias and high blood pressure. Allopurinol for gout. Amiodarone for cardiac arrhythmias. Continue aspirin. Atorvastatin for dyslipidemia [high cholesterol]. Eliquis for anticoagulation [blood thinner to decrease risk of recurrent blood clots]. Folic acid, hydrochlorothiazide, and metoprolol for hypertension. Vitamin D supplementation..."

Patient #1 was present on the same hallway and unit here Patient #2 was housed and video footage revealed no staff members were observed conducting Q 15 minute checks on 10/9/2022 from 1:54 AM until 2:29 AM.

12. Review of the Morse Fall Assessment for Patient #1 dated 10/10/2022 at 7:13 PM revealed "...History of Falls - Immediate or within 3 months...Yes...Modify Date/Time: 10/13/2022 16:56...No..." The "No" had a line drawn through it indicating the answer was changed from "No" to "Yes" on 10/13/2022.

Review of a Nurse Progress note dated 10/12/2022 at 10:42 AM, revealed Patient #1 told the nurse "that he fell, or rather tried to get up from a chair in the dayroom, but his legs were a bit weak, and he lost his balance, So I fell or sat down the way, I'm used to, after which a man told me to get up, but I couldn't, so he pulled me over the floor to my room". He did not mention, if it was the chair right outside his room or in the opposite side of the room. I [nurse writing progress note] asked, if he [the patient] told someone, when it [fall] happened, he said that it happened Monday [10/10/2022], and that he did inform the nurse. [The nurse writing the note] Asked which nurse [the patient told of the fall and] he said that he couldn't tell them apart..."

Review of a Patient Care Note dated 10/12/2022 at 10:02 AM revealed Patient #1 had "new bruises on his lt [left] side that he reports occurred yesterday morning [10/11/2022] but seems unsure of time frame. Reports he was having trouble standing up when in the day room and lost his balance. States peers were trying to help him to his room and onto the bed, states he was on his knees in the floor beside his bed and when someone was pulling him onto the bed his side was rubbed on the wooden box bed. Large bruise just prox [proximate] to lat [lateral] hip that extends from lower abdominal fold to it post [posterior] lat back with probable hematoma in central portion, some lighter bruising proximal at lt lat lower rib cage. Pt [patient] states that the bruise noted on his rt [right] lat prox lower leg/post hip and some smaller ones just distal occurred 3 days ago. He has superficial abrasion on his rt elbow. Pt has had bruising on his knees since admission, slightly darker areas now. Nurse from unit present for assessment as well..."

An Incident Report Form dated 10/12/2022 at 10:00 AM was reviewed in the presence of the Risk Manager. The surveyor was not provided a copy of the report as it was "Privileged and Confidential." The report revealed Patient #1 had an unwitnessed fall in the dayroom on 10/10/2022. The report further indicated the patient had multiple bruises. The patient reported to the nurse that he had fallen and no staff would help him so he asked patients to help him and they "pulled him across the bedframe." The patient had "multiple bruises."

Review of the 22 Morse Fall Risk Assessments completed from 10/12/2022 at 9:56 PM through 10/24/2022 at 1:10 AM revealed the fall assessments failed to reflect the patient falling on 10/10/2022.

In an interview on 10/31/2022 at 12:40 PM, RM stated she had "watched the video and did not see a fall." The RM then verified the fall must have occurred in the patient's room since he was "pulled across the bedframe."

In an interview on 10/31/2022 at 1:15 PM, the CNO was asked if the facility was still auditing the Fall Risk Assessments as stated in the Plan of Correction accepted on 9/6/2022. The CNO stated, "Yes." This surveyor asked to see documentation of the audit completed for Patient #1.

Review of the Audit for Patient #1's fall reported on 10/12/2022 revealed, the Fall Risk assessment was dated 10/10/2022 and indicated the assessment had been modified to indicate the patient had fallen.

In an interview on 10/31/2022 at 12:41 PM, the RM was asked why the Fall Risk Assessment that indicated the patient had fallen was dated 10/10/2022, but the facility did not know about the fall until 10/12/2022 when it was reported. The RM stated, "I'm not sure if they went in and back dated it and tried to update it..."

In an interview on 10/31/2022 at 1:28 PM, the CNO was asked if the facility was still auditing and monitoring the Fall Risk Assessments to ensure they were accurate. The CNO stated, "We are only doing it on the ones who had the falls." The CNO was asked if they were monitoring all the Fall Risk Assessments for the patients who had fallen. The CNO stated, "Just the one [Fall Risk Assessment] they do right after they fall." The CNO verified they were not monitoring or auditing any of the other Fall Risk Assessments to ensure they were accurate.

13. Continued review of Patient #1's medical record revealed he was active on the unit and participated in group therapy sessions throughout the day on 10/24/2022.

Review of the Medication Administration Record for 10/24/2022 at 9:21 PM revealed Patient #1 was given his night-time medications which included 2 mg of Risperdal, 5 mg of Eliquis, 10 mg of Zyrtec, 25 mg of Metoprolol, 120 mg of Verapamil, 200 mg of Pacerone, and 250 mg of Depakote.

Review of the Patient Observations sheet completed by MHT #1 dated 10/24/2022 beginning at 8:15 PM through 10:00 PM revealed Patient #1 was observed every 15 minutes in the Activity Room, his behavior was calm, and he was sitting or lying.

Review of the Patient Observation sheets completed by MHT #1 dated 10/24/2022 beginning at 10:15 PM through 11:45 PM, revealed Patient #1 was observed every 15 minutes in his room, his mood was calm, and he was sitting/lying.

Review of the Patient Observation sheet completed by MHT #1 dated 10/25/2022 beginning at 12:00 AM through 5:45 AM revealed Patient #1 was observed every 15 minutes in his room, his mood was calm, and he appeared to be asleep with his chest rising and falling.

Review of the Patient Observation sheet completed by MHT #1 dated 10/25/2022 beginning at 6:00 through 7:30 AM, revealed Patient #1 was observed every 15 minutes in his room, his mood was calm, and he was sitting/lying.

Review of the Patient Assessment Report completed by RN #3, the House Supervisor, on 10/25/2022 at 1:11 AM revealed the RN completed a full skin assessment and fall risk assessment on Patient #1.

Review of the RN/Staff Hourly Intentional Rounding Form dated 10/24/2022 beginning at 9:00 PM revealed RN #3 made hourly rounds at 9:00 PM and 10:00 PM. The report further revealed RN #2 made rounds at 11:00 PM and on 10/25/2022 at 12:00 AM, 2:00 AM, 4:00 AM, and 6:00 AM.

Observations in the facility's lobby on 10/25/2022 beginning at 8:22 AM revealed "Code Blue" was paged overhead twice. The "Code Blue" page was repeated at 8:23 AM. At 8:24 AM, Emergency Medical Services (EMS) personnel arrived and were escorted from the lobby toward the patient areas.

Review of a Nurse Progress Note written by RN # 4 on 10/25/2022 at 8:15 AM revealed, "Informed by BHT that patient [Patient #1] may not be breathing. This RN immediately entered patient's room to find [Patient #1] lying on bed with eyes closed. No respirations noted. Carotid artery located with no palpable pulse. Skin cool to touch. Instructed staff to call 911. Exited patient room to call for assistance. Nurse [RN #5] instructed to call for MRT [Medical Response Team] and to bring crash cart to patient's room right away. MRT response team paged overhead. Returned to patient's room, CPR [cardiopulmonary resuscitation] initiated. Began chest compressions until crash cart arrived moments later. AED [automated external defibrillator, a device used to hellp get the heart to start beating] probes applied to chest, prompts followed with "no shock advisable" each time. Medical response team arrived, staff alternated in continuing chest compressions and administering O2 [oxygen] via Ambu bag per CPR protocol until EMS [Emergency Medical Services] arrival. Pt remained with no pulse and no respirations. EMS arrived in patient's room at 0826 [8:26 AM] and declared patient deceased. CPR not continued by EMS. MD notified..."

Review of the Progress Quick Note written by the Family Nurse Practitioner (FNP) on 10/25/2022 at 9:18 AM revealed Patient #1 "was found in his room unresponsive apneic pulseless around 8:15. CPR was initiated. 911 was called. EMS arrived. Pt was pronounced deceased at 08:30 [8:30 AM]...notified his daughter (next of kin) about his death, autopsy was offered. she will let us know about the autopsy and funeral home...transplant notified of death..."

Review of the Progress Quick Note written by the FNP on 10/15/2022 at 10:19 AM revealed Patient #1's "Daughter declined autopsy..."

Review of the Discharge Summary dated 10/25/2022 revealed "...Per report, patient was found by staff unresponsive at 08:15 this morning. Staff began CPR. AED applied with "No shock advised" as the prompt. Staff continued CPR until EMS arrived at 08:26 and pronounced the patient deceased..."

Review of the EMS Prehospital Patient Record dated 10/25/2022 revealed EMS personnel were dispatched to the facility for a reported "Cardiac Arrest/Death" at 8:19 AM. The EMS unit arrived at 8:22 AM, and were at Patient #1's bedside at 8:25 AM. The record revealed, "...In summary...Crew arrived on scene and found pt laying supine [on his back] on bed with stiff board under his upper back. At this time hospital staff was performing cpr. They had him [Patient #1] hooked up to an aed and were attempting to gain iv access...They were performing CPR with manual compressions and assisting ventilations with a bvm [bag/valve/mask] and high flow o2 [oxygen]. At this time...monitor showing the pt in asystole. [Asystole is a dire form of cardiac arrest in which the heart stops beating and there is no electrical activity in the heart.] They [facility staff] reported that someone went in there around 730 [7:30 AM] and the pt was naked laying in bed and told the pt to get dresses [dressed] but didn't check to see if he was breathing at this time. The did not know the last time he was breathing. At this time pt was apnic [apneic, not breathing] and did not have a pulse. Pt's pupils were fixed and dilated and not reactive, his jaw was stiff and had signs of lividity on his upper torso. [Lividity is the bluish-purple discoloration of skin after death. It is a sign of livor mortis and occurs when blood pools at the lowest point of the body due to gravity and loss of circulation. Livor mortis starts to develop 2 - 4 hours after death.] At this time crew determined to discontinue resuscitation attempts due to signs of Obvious death including pt being cold to the touch in a warm room, signs of lividity, and rigor mortis. [Rigor mortis is the stiffening of the body after death. It begins throughout the body at the same time but the body's smaller muscles such as those in the face, neck arms and shoulders are affected first. Rigor normally appears within the body around 2 hours after death.]...Pt announced without vitals at 0827 [8:27 AM]...Disposition DOA [Dead on Arrival]..."

Review of the Certificate of Death signed by the Medical Director on 10/27/2022 revealed Patient #1's cause of death was "Hypertension Cardiovascular Disease."

In an interview on 10/24/2022 at 3:48 PM, the CNO was asked what was expected of staff when completing Q 15 minute observations on the patients. The CNO stated, "During the day, go to where the patient is and visually lay eyes on them...At night because they [patients] are in the patients' rooms they are to go in the room, visualize and verify a rise and fall of the patient's chest to make sure they are breathing." The CNO was asked how the observations should be documented. The CNO stated, "Q 15 minute rounds; location, behavior, and their [staff] initials..."

In an interview on 10/25/2022 at 10:54 AM, the Medical Director stated he was not in the facility when Patient #1 was found pulseless. The physician continued and stated Patient #1 had cardiac arrhythmias and coronary artery disease. The Medical Director stated, "Today he [Patient #1] was found passed away in his sleep..."

In an interview on 10/25/2022 at 1:40 PM, RN #4 stated, "I walked in the door with my purse still on my should and the tech [MHT #2] came up and said 'I don't think [Patient #1] is breathing.' I went in there [Patient #1's room] and he was not breathing. No pulse. I told staff to call 911 and went to the nurses station to tell staff to get the crash cart and went back to the patient and started compressions. I hooked up the AED and followed the prompts...AED said 'shock not advised.' I was on the unit at 8:15 AM..." The RN was asked when she assessed the patient, was Patient #1 warm or cold. RN #4 stated, "He was cold."

In an interview on 10/25/2022 at 1:46 PM, the FNP stated, "I came in on the end of it. When I got there EMS was already on the scene. he had already been pronounced dead." The FNP was asked if she assessed the patient. The FNP stated "No."

In an interview on 10/25/2022 at 1:55 PM, MHT #2, day shift staff

Based on facility document review, policy review, video recording review, medical record review, observation and interview, Nursing Services failed to provide adequate oversight and supervision of nursing staff to ensure patients' needs were met and care was provided in a safe setting for 25 of 28 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25) sampled patients; failed to ensure staff followed the facility's Plan of Correction for falls for 1 of 1 (Patient #1) patients reviewed with falls; failed to ensure staff followed the facility's Vital Signs policy for 6 of 28 (Patient #1, #2, #3, #23, #24, and #25) sampled patients; and failed to follow their policy to ensure each unit had a staff to patient ratio of 1 staff for every 5 patients from 7:00 PM until 7:00 AM on 25 of 26 (10/1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25/2022) days reviewed.

The failure of Nursing Services to ensure care was provided in a safe setting, failure to ensure staff followed all policies to promote the safety of all patients, failure to follow falls precaution process as per facility policy, §482.23(b) Standard: Staffing and Delivery of Care, failure to ensure all staff followed policies for vital signs, and failure to ensure the facility was safely staffed with nursing personnel placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being.

The findings included:

1. Review of the Chief Nursing Officer (CNO) Job Description revealed, "...Chief Nursing Officer is responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing and other departments and the delivery of behavioral health and nursing services...Provide effective staff management...that assures utilization of personnel to best meet the needs of the people receiving support and services...Monitor unit/floor functioning by making frequent rounds. Intervene in crisis situations and investigate incidents...Oversee nursing services documentation to ensure it meets all standards..."

2. Review of the RN Job Description revealed, "...Responsible for professional nursing care to patients...to foster a supportive and therapeutic environment. Recognize that patient safety is top priority...Provide and coordinate care by assessing physical and behavioral health needs of patient, develop and implement nursing care plans, maintain medical records..."

3. Review of the Behavioral Health Associate (BHA or Mental Health Technician (MHT) Job Description revealed "...Responsible for providing personal care services to patients at the facility under the direction of clinical or nursing leadership...Recognize that patient safety is a top priority...Ensure the well-being of patients and provide a positive, supportive and structured environment....Responsible for conducting safety checks and ensuring that supervision is conducted at 15 minute intervals, as noted in special precautions, or in accordance with individualized supervision guidelines as needed...document timely, accurate and appropriate clinical information in patient's medical record...Assist in providing a safe, secure and comfortable environment for patients..."

4. Review of the hospital's "Adult Patient Handbook, Patient Rights" section revealed, "...Patients have the right to be protected from neglect, physical, verbal, and emotional abuse..."

5. Review of the hospital's "Observations, Patient" policy revised 7/2021 revealed, "...In order to maintain patient safety,the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN...The psychiatric practitioner will order one of three levels of observation at time of admission and as the patient's condition warrants a change: a. 15 minute b. 5 minute c. One-to-one...All patients are monitored at minimum once in every 15-minute block of time...During rounds stafff are to...Make direct visual contact; look for signs of danger or distress...Observe sleeping patients to confirm they are breathing by watching for the rise and fall of the patient's chest at minimum three times...Remain vigilant for specific patients on Special Precautions..."

6. Review of the facility's "The Medical Record" policy revised on 10/2022 revealed, "Purpose: To provide documentation principles that apply to all documented entries made to the medical record...When authenticating an entry, the author will verify that the entry being authenticated is his entry or that he is responsible for the entry, and that the entry is accurate.

7. Review of the facility's "Fall Precautions and Prevention" policy dated 4/2020 revealed, "...Patient safety is an ongoing responsibility of all staff...All patients admitted to the hospital will be assessed using the MORSE Falls Assessment as part of the Nursing Assessment. Based on this assessment, each patient will be placed in a risk category...Standard Falls Prevention Interventions - apply to all patients...Routine q [every] 15 minute observations..."

8. Review of the facility's Plan of Correction accepted on 9/6/2022 revealed, "...The CEO, a Governing Board member, was delegated the responsibility of ensuring provision of care in a safe setting and completion of all corrective actions with the Governing Board maintaining overall responsibility for compliance with all Conditions of Participation...The COO and DRM [Director of Risk Manager] developed an audit tool for post incident that included the requirements for the nurse to document...accurate completions of a Morse Fall assessment for all assessments post fall..."

9. Review of the Camera Surveillance Weekly Random Monitoring Sheets completed 8/12/2022 through 10/17/2022 revealed the facility had ongoing issues regarding staff completing observation rounds and nursing rounds appropriately.

10. Review of the Quality Council Meeting Minutes dated 8/25/2022 revealed, "...Leadership Rounds...Rounding observations sheets are also inspected during leadership rounds to determine if the staff are compliant with concurrent and timely documentation...survey on patient rights throughout the month of July. IJ [Immediate Jeopardy] was called and immediate plan implemented...Data required to be included in meeting have been included above including...environmental rounds..."

11. Review of the Governing Board ad-hoc Meeting Minutes October 24th, 2022 & October 25th, 2022 revealed, "... Rounding non-compliance identified through investigation at facility level during investigation..."

12. Review of the facility's "Vital Signs" policy dated 10/2021 revealed, "...Vital signs will be taken at the time of admission, as ordered by the practitioner and no less frequently than twice a day..."

13. Review of the facility's "Admission" policy revealed "...Purpose: To establish guidelines for admissions to a Behavioral Health unit to assure that patients are appropriately admitted...Admission to a Behavioral Health unit [also known as the General Psychiatric Unit (GPU) is for adults suffering from an acute psychiatric condition(s) or from an acute exacerbation of a chronic conditions. Such patients will also require intensive psychiatric intervention with different levels of medical treatment...Dual Diagnosis Unit [DDU] "...provides inpatient care and treatment for adults dealing with Dual Diagnosis (both a psychiatric and substance abuse/dependence diagnosis). the following criteria will be met for all admissions. (A1 and A2 are required): A. The patient will have a Dual-Diagnosis with both a primary psychiatric as well ass a substance abuse/dependence diagnosis...1. Behavior which is life-threatening, destructive or disabling to self or others, exhibited y one or more, of the following...Suicidal and /or homicidal ideations, threats, plan, or attempts and are considered to be a low or moderate risk for acting-out behaviors...2. Substance abuse/dependence (current history of), with one, or more of the following...Withdrawal symptoms including seizures, marked tremors, delirium tremors, hallucinations, marked confusion, memory impairment, and/or disorientation to time and/or place...Acute psychotic reaction secondary to alcohol and/or drug use...Mental Health Unit [also known as the Intensive Treatment Unit [ITU)] Admission Criteria Primary psychiatric diagnosis as...evidenced by one or more of the following...suicidal and/or homicidal ideations with a clearly devised plan with an intent to carry o out, and/or considered a high risk for violent acting out behavior...Unmanageable behavior in the home and/or community...Severely dysfunctional in the family and/or home/community support system...Alternatives for less restrictive and less intensive treatment would not meet patient's clinical needs...Senior Care Unit [SCU]...Admission to the Senior Care Unit is indicated for patients who...meet one or more of the following criteria...Suicidal behavioral and/or ideation, with poor impulse control and/or little or no support from their environment...Combative or assaultive behavior or ideations, which poses a threat to others...An acute onset of or intensification of delirium or disorientation, bizarre or delusional behavior that results in the patient being incapable of performing activities of daily living..."

13. Review of the facility's "Staffing Plan for Nursing Services" approved on 7/2021 and revised on 9/2022 revealed, "...The Staffing Plan for Nursing Services reflects specific service needs to meet patient care and organizational needs...This staffing plan outlines requirements...The staffing for all units is a 1:5 staff to patient ratio...The goal of staffing each unit is to ensure patient safety in healthcare delivery..."

14. The facility failed to protect Patient #2, an acutely psychotic male, involuntarily admitted to the facility on 10/7/2022 with diagnosis of Schizoaffective Disorder Bipolar Type from Patient #3, an acutely psychotic HIV positive male on parole for sexual battery male admitted on 10/5/2022 with diagnosis of Schizophrenia.

Review of the Incident Report, Incident Report Investigation, facility video recording, medical record and interviews with staff revealed Patient #2 and #3 were left unattended along with 11 other patients on 10/9/2022 from 1:54 AM until at least 2:29 AM when the video recording ended. Patient #3 was observed on video entering Patient #2's room at 1:44 AM and did not exit Patient #2's room until 2:29 AM. There were no staff members observed completing patient observations or safety rounds during that time. Review of the Patient Observations for both Patient #2, #3, and the other 11 patients revealed staff documented the patients were observed by staff every 15 minutes during the time no staff were observed on video completing observations or safety checks.

15. Review of the Patient Vital Signs for Patient #2 dated 10/8/2022 through 10/25/2022 revealed Patient #2's vital signs were not assessed every 12 hours per the facility's Vital Signs policy.

16. Review of the Patient Vital Signs for Patient #3 dated 10/6/2022 through 10/11/2022 revealed Patient #3's vital signs were not assessed every 12 hours per the facility's Vital Signs policy.

17. Medical record review revealed Patient #1 was admitted to the facility on 10/1/2022 with diagnosis of Schizophrenia. Patient #1 was psychotic and had a history of multiple medical problems including Hypertension, Diabetes Mellitus and Atrial Fibrillation and was noted be at a high risk for falls. Patient #1 was housed on the same unit as Patient #2 and #3 when they were all left unsupervised by staff on 10/9/2022 from 1:44 AM until 2:29 AM.

18. The facility failed to follow the Plan of Correction to ensure the Morse Fall Risk Assessments were accurate.

Review of the nursing documentation dated 10/12/2022 revealed Patient #1 informed a staff member he had fallen on 10/10/2022. The patient was noted to have multiple bruises and a large hematoma on his abdomen as a result of the fall. Review of the 22 Morse Fall Risk Assessments completed after 10/10/2022 when the patient fell revealed no documentation the patient had fallen in the facility.

19. Review of a video recording dated 10/24/2022 at 9:18 PM through 10/25/2022 at 7:00 AM revealed Registered Nurse (RN) #3 was observed entering Patient #1's room with what appeared to be a medicine cup on 10/24/2022 at 9:27 PM and left exited the patient's room at 9:28 PM. There were no other staff observed entering Patient #1's room until 7:14:51 AM when MHT #2, day shift staff, was observed entering the patient's and exited just 6 seconds later. At 8:12:42 AM, MHT #2 entered Patient #1's room and discovered he was pulseless and not breathing. The video recording further revealed no staff members were observed making patient observations or safety rounds on the other 9 patients of the hallway from 9:00 PM on 10/24/2022 through 7:00 AM on 10/25/2022. Review of the Patient Observation forms for Patient #1 and the other 9 patients revealed staff documented the patients were observed every 15 minutes.

20. Review of the Patient Vital Signs for Patient #1 dated 10/1/2022 through 10/25/2022 revealed Patient #1's vital signs were not assessed every 12 hours per the facility's Vital Signs policy.

19. The facility failed to protect Patient #24, an acutely psychotic male, and Patient #25, an acutely psychotic female from Patient #23, an acutely psychotic male on Sexual Acting Out Precautions. Patient #23 had a sexual encounter with both Patient #24 and #25 on 6/1/2022.

21. Review of the Patient Vital Signs for Patient #23 dated 5/30/2022 through 6/10/2022 revealed Patient #23's vital signs were not assessed every 12 hours per the facility's Vital Signs policy.

22. Review of the Patient Vital Signs for Patient #24 dated 5/25/2022 through 6/14/2022 revealed Patient #24's vital signs were not assessed every 12 hours per the facility's Vital Signs policy.

23. Review of the Patient Vital Signs for Patient #25 dated 6/1/2022 through 6/17/2022 revealed Patient #25's vital signs were not assessed every 12 hours per the facility's Vital Signs policy.

24. Review of the Daily Staffing for 10/1/2022 through 10/25/2022 revealed the staff to patient ratio was greater than the 1 to 5 ratio required on the Staffing policy.

Refer to A 0144.

Based on facility document review, policy review, video recording review, medical record review, observation and interview, the facility failed to ensure Nursing Services provided adequate oversight and supervision of nursing staff to ensure patients' needs were met and care was provided in a safe setting for 25 of 28 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25) sampled patients; failed to ensure staff followed the facility's Plan of Correction for falls for 1 of 1 (Patient #1) patients reviewed with falls; and failed to ensure staff following the facility's Vital Signs policy for 6 of 28 (Patient #1, #2, #3, #23, #24, and #25) sampled patients; and failed to follow their policy to ensure each unit had a staff to patient ratio of 1 staff for every 5 patients from 7:00 PM until 7:00 AM on 25 of 26 (10/1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25/2022) days reviewed.

The findings included:

1. Review of the Chief Nursing Officer (CNO) Job Description revealed, "...Chief Nursing Officer is responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing and other departments and the delivery of behavioral health and nursing services. Collaborates with interdisciplinary treatment teams, other departments, and with administration to ensure that all residents physical, biopsychosocial, age, developmental and cultural needs are met. Provides leadership to assure compliance with local, state, federal regulations and nursing practice standards. Essential Functions...Manage the daily operations of nursing services...Integrate nursing functions with clinical a nd programs, assuring efficient and effective operations...Evaluate service needs and staffing requirements to assure needs of people supported are met. Provide effective staff management...that assures utilization of personnel to best meet the needs of the people receiving support and services. Develop and implements health care related training that assures the best possible delivery of health related supports and services. Reviews training at least annually and makes modifications as needed. Develop and maintains documentation systems for continuity of care...Monitor unit/floor functioning by making frequent rounds. Intervene in crisis situations and investigate incidents. Develop and implement tools to measure, assess and improve quality of nursing care, treatment and service...Oversee nursing services documentation to ensure it meets all standards..."

2. Review of the RN Job Description revealed, "...Responsible for professional nursing care to patients...to foster a supportive and therapeutic environment. Recognize that patient safety is top priority...Provide and coordinate care by assessing physical and behavioral health needs of patient, develop and implement nursing care plans, maintain medical records...Provide nursing care and services within the standards and scope of nursing practice as defined within the...policies, procedures and protocols...Ensure patient's status is assessed on an ongoing basis and pertinent information gathered is documented...Collaborate with others to ensure that all patients' physician biopsychosocial, age, developmental and cultural needs are met and when they are not met, acknowledges and works to resolve customer complaints...Provide direction or coordinate thee activities of the unit as directed..."

3. Review of the Behavioral Health Associate (BHA or Mental Health Technician (MHT) Job Description revealed "...Responsible for providing personal care services to patients at the facility under the direction of clinical or nursing leadership...Recognize that patient safety is a top priority...Demonstrate a sense of urgency related to the importance of patient safety and provide excellent customer services...Ensure the well-being of patients and provide a positive, supportive and structured environment....Responsible for conducting safety checks and ensuring that supervision is conducted at 15 minute intervals, as noted in special precautions, or in accordance with individualized supervision guidelines as needed...document timely, accurate and appropriate clinical information in patient's medical record...Assist in providing a safe, secure and comfortable environment for patients...

4. Review of the hospital's "Adult Patient Handbook, Patient Rights" section revealed, "...Patients have the right to be protected from neglect, physical, verbal, and emotional abuse..."

5. Review of the hospital's "Observations, Patient" policy revised 7/2021 revealed, "...In order to maintain patient safety,the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN...The psychiatric practitioner will order one of three levels of observation at time of admission and as the patient's condition warrants a change: a. 15 minute b. 5 minute c. One-to-one 2. The psychiatric practitioner may also order a precaution level of observation for: a. Suicide b. Assault c. Elopement d. Seizure e. Fall f. Sexual Acting Out...Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following...Level of observation...Precaution...Location...Behavior...Activity...Time...Staff Initial and Signature...Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and or to back fill time frames that were not completed in a timely manner...All patients are monitored at minimum once in every 15-minute block of time...During rounds stafff are to...Make direct visual contact; look for signs of danger or distress...Observe sleeping patients to confirm they are breathing by watching for the rise and fall of the patient's chest at minimum three times...Remain vigilant for specific patients on Special Precautions..."

6. Review of the facility's "Fall Precautions and Prevention" policy dated 4/2020 revealed, "...Patient safety is an ongoing responsibility of all staff. In order to reduce the risk of patient injuries as a result of a fall, nursing staff will assess and re-assess the patient's level of risk for fall and implement appropriate interventions...All patients admitted to the hospital will be assessed using the MORSE Falls Assessment as part of the Nursing Assessment. Based on this assessment, each patient will be placed in a risk category...Nursing shall place the patient on fall precautions when indicated and ensure the practitioner is notified and orders the level of observation and precautions consistent with the assessed level of risk...Standard Falls Prevention Interventions - apply to all patients...Routine q [every] 15 minute observations..."

7. Review of the facility's Plan of Correction accepted on 9/6/2022 revealed, "... The COO [Chief Operating Officer and DRM [Hospital #1's Risk Manager] developed an audit tool for post incident that included the requirements for the nurse to document...accurate completions of a Morse Fall assessment for all assessments post fall..."

8. Review of the facility's "The Medical Record" policy revised on 10/2022 revealed, "Purpose: To provide documentation principles that apply to all documented entries made to the medical record, regardless of the media used to create or maintain the record. All medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided, consistent with hospital policies and procedures...The content of the medical record, which includes written and electronic documents, must be sufficiently detailed, legible and organized to enable: the practitioner responsible for the patient to identify the patient, provide continuing care, determine the patient's condition at a specific time...When authenticating an entry, the author will verify that the entry being authenticated is his entry or that he is responsible for the entry, and that the entry is accurate.

9. Review of the facility's "Admission" policy revealed "...Purpose: To establish guidelines for admissions to a Behavioral Health unit to assure that patients are appropriately admitted...Admission to a Behavioral Health unit [also known as the General Psychiatric Unit (GPU) is for adults suffering from an acute psychiatric condition(s) or from an acute exacerbation of a chronic conditions. Such patients will also require intensive psychiatric intervention with different levels of medical treatment...Dual Diagnosis Unit [DDU] "...provides inpatient care and treatment for adults dealing with Dual Diagnosis (both a psychiatric and substance abuse/dependence diagnosis). the following criteria will be met for all admissions. (A1 and A2 are required): A. The patient will have a Dual-Diagnosis with both a primary psychiatric as well ass a substance abuse/dependence diagnosis...1. Behavior which is life-threatening, destructive or disabling to self or others, exhibited y one or more, of the following...Suicidal and /or homicidal ideations, threats, plan, or attempts and are considered to be a low or moderate risk for acting-out behaviors...2. Substance abuse/dependence (current history of), with one, or more of the following...Withdrawal symptoms including seizures, marked tremors, delirium tremors, hallucinations, marked confusion, memory impairment, and/or disorientation to time and/or place...Acute psychotic reaction secondary to alcohol and/or drug use...Mental Health Unit [also known as the Intensive Treatment Unit [ITU)] Admission Criteria Primary psychiatric diagnosis as...evidenced by one or more of the following...suicidal and/or homicidal ideations with a clearly devised plan with an intent to carry o out, and/or considered a high risk for violent acting out behavior...Unmanageable behavior in the home and/or community...Severely dysfunctional in the family and/or home/community support system...Alternatives for less restrictive and less intensive treatment would not meet patient's clinical needs...Senior Care Unit [SCU]...Admission to the Senior Care Unit is indicated for patients who...meet one or more of the following criteria...Suicidal behavioral and/or ideation, with poor impulse control and/or little or no support from their environment...Combative or assaultive behavior or ideations, which poses a threat to others...An acute onset of or intensification of delirium or disorientation, bizarre or delusional behavior that results in the patient being incapable of performing activities of daily living..."

11. Review of the facility's "Vital Signs" policy dated 10/2021 revealed, "...Vital signs will be taken at the time of admission, as ordered by the practitioner and no less frequently than twice a day..."

12. Review of the facility's "Staffing Plan for Nursing Services" approved on 7/2021 and revised on 9/2022 revealed, "...The Staffing Plan for Nursing Services reflects specific service needs to meet patient care and organizational needs...This staffing plan outlines requirements as well as contingency plans for unexpected events that may temporarily disrupt staffing in order to sustain safe business operations...Nursing Department Staff is composed of both licensed and unlicensed personnel. RNs [Registered Nurses] and LPNs [Licensed Practical Nurses]...Behavioral Health Associates [also referred to as Mental Health Technicians (MHTs]...General Nursing Staff to Patient Ratios by unit: The staffing for all units is a 1:5 staff to patient ratio...The minimum staffing needed for each skill level (RNs, LPNs, Behavioral Health Associates, others) is determined by the nurse-patient ratio guidelines and patient care needs of the populations...Core coverage includes ensuring there is 1 RN on each unit at all times and that there is at minimum 2 staff on each unit at all times...The goal of staffing each unit is to ensure patient safety in healthcare delivery...A Registered Nurse plans, assigns, supervises, and evaluates the nursing care of each patient daily...The unit will be staffed with an adequate number of RNs, LPNs, and BHAs to maintain a therapeutic milieu and a safe environment...Safe Staffing Guidelines To secure optimal patient care, these guidelines outline staffing expectations to be observed by all service lines...An RN must always be on the unit. Neither an RN House Supervisor nor and LPN can serve as the RN on the unit...Must always maintain one RN, LPN, or other licensed staff member on the unit...Minimum of two staff members are scheduled on each unit..."

13. Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 8/12/2022 for 8/9/2022 for the time period of 1:21 AM - 3:21 AM on the Intensive Treatment Unit (ITU) revealed, "...Nurse did not do hourly rounds...Follow-up needed...Reminder of concurrent rounds & RN rounds..."

14. Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 8/15/2022 for 8/15/2022 for the time period of 1:00 AM - 3:00 AM on the ITU revealed, "...Remind staff that someone should always be on the hall monitoring...Follow-up needed..."

15. Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 8/25/2022 for 8/25/2022 for the time period of 1:00 AM - 3:00 AM on the ITU revealed, "...Staff observed monitoring hallway...But not stationed in zones...RN did not round. Follow-up needed Reminder of expectations..."

16. Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 9/16/2022 for 9/13/2022 for the time period of 1:00 AM - 3:00 AM on the ITU revealed, "...Please remind on zone locations...Nurse did not round. Follow-up needed..."

17. Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 9/26/2022 for 9/26/2022 for the time period of 1:00 AM - 3:00 AM on the ITU revealed, "...[MHT #1] needs to go in the room... They need to communicate 2 [to] ensure 1 is always in hall.. RN did not make rounds. Follow-up needed..."

18. Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 10/3/20222 for 10/3/2022 for the time period of 1:00 AM - 3:00 AM on the ITU revealed, "...Staff observed conducting 15 minute checks. Yes & No They were not completed by going in room c [with] clipboard. [MHT #5] did walkbys...nurse did not round. Follow-up needed..."

19. Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the Chief Nursing Officer (CNO) on 10/13/2022 for 10/13/2022 for the time period of 2:00 AM - 3:30 AM on the Senior Care Unit [SCU] revealed, "...No observation round was completed...Staff observed in zones at all times. No BHA [Behavioral Health Associate] on break Area left unattended...Follow-up needed..."

20. Review of a Camera Surveillance Weekly Random Monitoring Sheet completed by the CEO on 10/17/2022 for 10/17/2022 for the time period of 1:02 AM - 3:02 AM on the ITU revealed, "...Staff observed conducting 15 minute checks. Yes. Not using clipboard. Staff observed monitoring hallway. Yes. But should have been stationed at each end..."

21. Review of the Quality Council Meeting Minutes dated 8/25/2022 revealed, "...Leadership Rounds...Rounding observations sheets are also inspected during leadership rounds to determine if the staff are compliant with concurrent and timely documentation. Review of leadership rounds suggest observations were up to date over 89 % [percent] of the time. The other 11% were reviewed with the employee and manager to discuss ways and importance of stating up to date...survey on patient rights throughout the month of July. IJ [Immediate Jeopardy] was called and immediate plan implemented...Data required to be included in meeting have been included above including...environmental rounds..."

22. Review of the Governing Board ad-hoc Meeting Minutes October 24th, 2022 & October 25th, 2022 revealed, "...This ad-hoc meeting has spanned over two days for survey updates...Survey requested items and complaints were reviewed with members of the governing board...Rounding non-compliance identified through investigation at facility level during investigation. Developed plan with governing board assistance to provide patient safety through observation rounding. Incident October 25th provided additional insight to rounding non-compliance. Plan developed to include leadership and leadership team. Governing Board reviewed plan with recommendations. Action plan was submitted to state survey agency..."

23. Medical record review for Patient #2, a 20 year old male, revealed the patient was involuntarily admitted on 10/7/2022 with diagnosis of Schizoaffective Disorder, Bipolar type. (People with this condition experience psychotic symptoms such as hallucinations or delusions, as well as symptoms of a mood disorder.) Patient #2 was taken to Hospital #2 by police after his mother informed police the patient had been screaming and experiencing auditory hallucinations. Patient #2 was noted to be at risk for harming himself or others.

Review of the Intake Assessment dated 10/7/2022 at 10:00 PM revealed Patient #2 had an "...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...Potential danger to self or others..."

Review of the High Risk Notification Form signed by an Intake nurse and unit nurse dated 10/7/2022 at 11:45 PM revealed, "...Level of Observation Ordered by Practitioner: Q 15 min [every 15 minutes]...Precautions ordered by Practitioner...Assault...Psychotic/Confused: Visual Hallucinations..."

Review of the physician's orders dated 10/7/2022 at 11:31 PM, revealed "...15 Minute Checks...Assault Precautions...Admit to GPU [General Psychiatric Unit]..."

Review of the Nurse Progress Note dated 10/8/2022 at 12:03 AM revealed, Patient #2 arrived on the GPU on 10/7/2022 at 11:45 PM. The patient was alert and oriented. "...Per report, pt has been experiencing visual hallucinations and undressing at home around mother/grandmother..."

Review of the Care Plan created on 10/8/2022 at 12:20 AM revealed, "...Q 15 min Observation..."

Review of the Behavioral Health (BH) Initial Treatment Plan (Nursing) created on 10/8/2022 at 12:28 AM revealed, "...Problem...Pt undressing randomly at home..."

Review of the Discharge Planning note dated 10/8/2022 at 7:17 AM revealed, "...This therapist attempted to complete the psychosocial assessment...He [Patient #2] walked past this therapist and took his clothes off at the unit door...Patient is experiencing psychosis and was non responsive to this therapist..."

Review of the History and Physical dated 10/8/2022 at 10:59 AM revealed Patient #2 was "...Admitted to the hospital...diagnosis of schizoaffective disorder. He appears to be responding to internal stimuli, somewhat delusional..."

Review of the Psychiatric Evaluation dated 10/11/2022 at 4:24 PM, revealed Patient #2 was "...Dangerous to self, others or property with need for controlled environment, Emotional or behavioral conditions and complications requiring 24 hour medical and nursing care..."

Review of the physician's orders dated 10/12/2022 at 1:15 PM revealed Patient #2 was to be tested for Gonorrhea, Chlamydia, Rapid Plasma Reagin (Syphilis), and Human Immunodeficiency Virus (HIV).

Review of a Quick Note written by the Advanced Practice Nurse (APN) on 10/12/2022 at 1:34 PM revealed Patient #2 had complaints of rectal pain after he had sexual intercourse with another patient on the unit. The APN assessed the patient and there were "...no signs of trauma, bleeding, or bruising noted to rectal area, pt denies any pain currently, HIV, RPR, HSV, gonorrhea and chlamydia ordered..."

Review of a Nurse Progress Note dated 10/13/2022 at 8:46 AM revealed Patient #2 told RN #7 "...that he had been having sex with men on the unit and...it was not consensual..." The note further revealed the incident was reported to the Supervisor, then Patient #2 changed his story and told the nurse that the sex was only with Patient #3 and the sex was consensual, but his rectum was sore and he wanted to be tested for Sexually Transmitted Infections (STI).

Review of a physician's order dated 10/14/2022 at 6:00 PM revealed "...Sexual Acting Out Precautions..." was ordered.

Review of a Progress Quick Note dated 10/25/2022 at 1:00 PM revealed "...hiv [HIV] negative, rpr [RPR] non-reactive, all other test still pending...10/13 - antiretrovirals ordered for prophylaxis, pt refusing...pt needs to fu [follow-up] with the health department..."

Review of the lab results revealed both the Rapid Plasma Reagin and HIV tests were negative. There was no documentation the Gonorrhea/Chlamydia screening was ever collected; therefore there were no results available.

Review of the Patient Observations forms dated 10/7/2022 beginning at 11:45 PM through 10/23/2022 at 11:45 PM revealed Patient #2 was observed by staff every 15 minutes as follows:
10/7/2022 - Patient #2 was under Assault Precautions
10/8/2022 - Patient #2 was under Assault Precaution
10/9/2022 - Patient #2 was under Assault and Elopement Precautions
10/10/2022 - Patient #2 was under Assault and Elopement Precautions
10/11/2022 - Patient #2 was under Assault Precaution
10/12/2022 - Patient #2 was under Assault Precaution
10/13/2022 - Patient #2 was under Assault and Elopement Precautions
10/14/2022 - Patient #2 was under Assault and Elopement Precautions
10/15/2022- Patient #2 was under Assault and Elopement Precautions
10/16/2022 - Patient #2 was under Assault and Elopement Precautions
10/17/2022 - No precautions were noted
10/18/2022 - Patient #2 was under Assault, Elopement and Sexual Acting Out Precautions
10/19/2022 - Patient #2 was under Assault, Elopement and Sexual Acting Out Precautions
10/20/2022- Patient #2 was under Assault, Elopement and Sexual Acting Out Precautions
10/21/2022 - Patient #2 was under Assault, Elopement and Sexual Acting Out Precautions
10/22/2022- Patient #2 was under Assault, Elopement and Sexual Acting Out Precautions
10/23/2022 - Patient #2 was under Assault, Elopement and Sexual Acting Out Precautions
The Sexual Acting Out Precautions that were ordered on 10/14/2022 were not reflected on the Patient Observation forms until 10/18/2022. There were no lapses in documentation of the Q 15 minute checks noted.

Review of the Patient Vital Signs dated 10/8/2022 through 10/25/2022 revealed Patient #2's vital signs were not assessed every 12 hours per the facility's Vital Signs policy on the following dates:

10/8/2022 - vital signs were only assessed at 3:39 PM
10/9/2022 - vital signs were only assessed at 9:12 AM; Patient #2 refused to have his vital signs assessed at 9:33 PM.
10/12/2022 - vital signs were only assessed at 8:07 AM
10/16/2022 - vital signs were not assessed
10/24/2022 - vital signs were only assessed at 9:12 AM

The facility did not provide any vital sign assessments for Patient #2 for 10/5/2022 through 10/7/2022.

In an interview on 11/2/2022 at 12:45 PM, the CNO was asked how often patient vital signs should be assessed. The CNO stated "They are taken once a shift unless there's an order that says to take them differently."

24. Medical record review for Patient #3, a 40 year old male, revealed the patient was involuntarily admitted to the facility on 10/5/2022 with diagnosis of Schizophrenia after being found "...unresponsive in the road..." Patient #3 was initially taken to Hospital #3 by police. The patient was treated with Narcan with positive response. Patient #3 told the police "...he wanted to die...Pt has HIV...pt is on parole for life...sexual battery charge..."

Review of the Clinical Risk Assessment For Mask Use tool dated 10/5/2022 at 10:57 AM revealed Patient #3 was noted to have Medical Risk Factors of HIV.

Review of the Intake Assessment dated 10/5/2022 at 12:45 PM revealed Patient #3 had "...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...Potential danger to self or others..."

Review of the the High Risk Notification Form dated 10/5/2022 at 3:45 AM revealed "...Level of Observation Ordered by Practitioner: Q 15 min...Precautions Ordered by Practitioner...Suicide...Known Medical Problems: HIV +..." The patient was not placed on Sexual Acting Out Precautions even though he was on parole for life for sexual battery.

Review of the Psychiatric Evaluation dated 10/5/2022 at 3:11 PM revealed Patient #3 was "...On parole for life due to aggravated sexual battery. Spent time in prison...Admitting Diagnosis Paranoid Schizophrenia...Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning, Dangerous to self, others or property with need for controlled environment, Emotional or behavioral conditions and complications requiring 24 hour medical and nursing care...Legally mandated admission..."

Review of the physicians' orders dated 10/5/2022 at 5:29 PM revealed "...15 Minute Checks...Suicide Precautions..." The patient was not placed on Sexual Acting Out Precautions even though he was on parole for life for sexual battery.

Review of the History and Physical dated 10/6/2022 at 11:17 AM revealed Patient #3 was "...admitted with increased psychosis...Past Medical History: Schizophrenia, noncompliance, and drug abuse..." There was no documentation regarding Patient #3's HIV status.

Review of the Patient Observations forms dated 10/5/2022 beginning at 3:45 PM through 10/11/2022 at 10:00 AM revealed Patient #3 was observed by staff every 15 minutes. All observation forms except for 10/5/2022 and 10/11/2022 indicated Patient #3 was under Suicide Precautions. There were no lapses in documentation of the Q 15 minute checks noted.

Review of the Patient Vital Signs dated 10/6/2022 through 10/11/2022 revealed Patient #3's vital signs were not assessed every 12 hours per the facility's Vital Signs policy on the following dates:

10/6/2022 - vital signs were only assessed at 8:11 AM
10/7/2022 - vital signs were only assessed at 9:04 AM
10/8/2022 - vital signs were only assessed at 4:08 PM

In an interview on 11/2/2022 at 12:45 PM, the CNO was asked how often patient vital signs should be assessed. The CNO stated "They are taken once a shift unless there's an order that says to take them differently."

Patient #3 was discharged from the facility on 10/11/2022, the day before Patient #2 made the allegation of the sexual encounter.

25. Review of the Incident Report dated 10/12/2022 revealed there was an incident of "Misconduct/Sexual/Boundary Allegation between two patients that occurred on an unknown date and time.

Review of the Incident Investigation Report signed by the Risk Manager on 10/21/2022 revealed Patient #2 reported to the nurses that he had been having nonconsensual sex with other men on the unit. Patient #2 later changed his story to indicate he had a one-time sexual encounter with Patient #3, a patient that was known to be HIV positive, that was consensual and that he wanted to be tested. The facility's investigation further revealed Patient #2 informed the Patient Advocate that he did consent to having sex with Patient #3 but only because he felt coerced and pressured because Patient #3 informed him "he could go home sooner" if he had sex with him. The report further revealed Patient #2 was evaluated and there were no obvious signs of sexual trauma noted. Patient #2 was offered prophylactic treatment, but he refused. The "...RM reviewed extensive camera footage to ascertain when this incident could have occurred. On October 9, 2022, RM observed [Patient #3] enter the room of [Patient #2] at 1:44 am [AM] and he remains until 2:29 am [AM]...This investigation has been deemed inconclusive. RM only had the verbalizations of [Patient #2] regarding encounter which were inconsistent at times. RM was not able to speak with [Patient #3] despite attempts and no witnesses observed this incident...RM did assess that rounding was an issue due to staffing issues...Corrective Action as a Result of the Investigation: Many of the open BHT [Behavioral Health Tech] positions have been filled with HR [Human Resources] working diligently to fill the other vacancies..."

Review of the facility's video recording of the dayroom and hallway where Patient #2 was housed was completed with the facility's Risk Manager on 10/24/2022 beginning at 2:30 PM. The video started on 10/9/2022 at 1:42 AM. The video showed the entire dayroom and the hallway where Patient #2's room was located. MHT #5 was in view walking down the hallway opening doors to patient's rooms. Patient #14 was also visible in the day room.
At 1:43:05 AM, both MHT #5 and Patient #14 were no longer visible on camera.
At 1:44:02 AM, Patient #3 is seen walking entering Patient #2's room.
At 1:44:41 AM, MHT #5 re-entered the day room with Patient #14.
At 1:44:54 AM Patient #14 remained in the day room while MHT #5 walked out of view of the camera down the opposite hallway.
At 1:47:07 AM, MHT #5 reappeared in the day room and walked out the exit door out of view of the camera.
At 1:53:15 AM, MHT #5 re-entered the day room and walked down the opposite hallway out of view of the camera.
At 1:54:06 AM, MHT #5 re-appeared in the dayroom, them immediately exited through the doorway out of view of the camera. The video time then skipped to 2:29:14 AM, at which time, Patient #3 is seen exiting Patient #'2 room. Patient #3 walked up the hallway, through the day room, then out of view of the camera down the opposite hallway.

In an interview on 10/24/2022 at 2:38 AM, the Risk Manager was asked why there was a period of time the video did not record anything. The RM stated, "The camera skips time when there is no activity noted." The RM was then asked if that meant there was no one visible in the hallways making observations of the patients from 1:54:11 until 2:29:14. The RM stated "Yes." The RM verified the Patient Observation forms dated 10/9/2022 for both Patient #2 and #3 noted the patients were each observed in their own rooms at 1:45 AM, 2:00 AM, 2:15 AM, and 2:30 AM, even though MHT #5 was not observed making patient rounds at those times.

In an interview on 10/24/2022 at 2:52 PM, MHT #5 was asked if Patient #2 ever reported any allegations of sexual assault. MHT #5 stated, "No ma'am. This is the first time I'm hearing anything bout this." The MHT was asked how he made safety rounds on the patients. The MHT stated "I open the door and make sure they are asleep. I do open the room and make sure they are still there and still asleep or whatever." The MHT was asked how often he made patient observations. The MHT stated, "Every 15 minutes or every 30 minutes if I'm doing something else. If we don't have 2 techs, there's no one else in there to do the checks." The MHT was asked if he documented every 30 minutes or every 15 minutes. The MHT stated, "I document every time I went in the room..."

In an interview on 10/24/2022 at 2:57 PM, the RM stated she was informed of the incident by Registered Nurse (RN) #7 who told her the patient reported he had had sex with Patient #3 and it wasn't consensual. The RM then stated, Patient #2 later changed his story and said it was consensual, he just wanted to be tested. The RM was asked if she noted any concerns when she viewed the video footage. The RM stated, "Staffing was an issues. We only had 2 techs [MHTs], 1 was on female side and 1 on male side; he [MHT #5] was doing a great job. It was staffed appropriately but we had 2 call ins. We had 1 nurse..."

In an interview on 10/24/2022 at 3:30 PM, the Patient Advocate was asked what he could recall regarding the allegations made by Patient #2 toward Patient #3. The Patient Advocate stated, "It was brought to my attention to go speak with him [Patient #2]. I asked him what happened. He told me a different story from what he told other people. He said he felt pressured by the other person [Patient #3] to have sex with him because he promised him early discharge...The other person [Patient #3] supposedly told him the only way to get discharged was to have sex with him. He said I did it, but mostly because I was promised a discharge by the other patient." The Patient Advocate was asked if Patient #2 consented to the sex or not. The Patient Advocate stated, "He did because he told me he di