HospitalInspections.org

Based on observation, interview, closed record review, and review of the facility's policy, it was determined the facility failed to have a Governing Body which was effective in carrying out its responsibilities for the conduct of the hospital.

Interview with the facility's Chief Executive Officer (CEO), on 10/07/2021 at 8:27 AM, revealed the Governing Body failed to ensure: Patient #4's private and personal information was protected from other patients' line of sight; Patient #2 and Patient #3 received care in a safe setting. Patient #2 cut his/her self twice with contraband brought into the facility, consumed an indeterminate amount of unsecured chemicals, tied leggings around his/her neck while unattended by staff in his/her room, obtained a plastic spoon from the nursing station, broke it, and injured self, and Patient #3 suffered a broken arm during an absence without leave (AWOL) event and the facility failed to ensure five (5) additional patients were protected from physical, and verbal abuse (Patients #1, Patient #18, Patient #6, Patient #16 and Patient #15):

1. Observation of video footage on, 10/15/2020, revealed Patient #1, was struck in the face by Registered Nurse (RN) Supervisor #2 during a physical restraint. Continued observation of the video footage revealed Mental Health Technician #14 inappropriately drop the patient onto the concrete floor and the patient landed on his/her right side. Continued observation of the video camera footage revealed MHT #14 inappropriately hyperextend the patient's neck, and place his hand around the patient's jaw, and neck area. Once the patient went into a supine position, staff placed a regular pillow under his/her head, rather than a restraint pillow.

2. Observation of video footage, on 09/18/2021, revealed Patient #18 was pulled down onto his/her bed mattress, by his/her ankles, by Lead Mental Health Technician #1, while the patient sat on his/her bed. Patient #18 had been placed in seclusion, in his/her room, by Lead Mental Health Technician #1, without a physician order. The witness to the incident, Mental Health Technician (MHT) #16, did not report her allegation to a supervisor until hours after the incident occurred, and the Director of Nursing (DON) had not been notified by Nurse Supervisor #3 until around 8:00 AM on 09/19/2021. Staff failed to perform an assessment on Patient #18, after the allegation of abuse had been made by Mental Health Technician #16, until hours after the alleged incident had occurred.

3. Record review and interview revealed, on 06/23/2020, Patient #6 was hit in his/her face by an unknown peer, however, the incident was not reported or investigated for either patient.

4. Record review and interview revealed, Patient #16 was physically assaulted by Patient #15, on two (2) different occasions.

5. Record review and interview revealed Patient #15 alleged he/she had been verbally assaulted and harassed by Patient #16; however, staff failed to investigate and provide an effective intervention to protect the patient from further verbal abuse/harassment.

The findings include:

Review of the facility's document titled, "Medical Staff Bylaws" dated 01/2021, defined the Governing Board (Governing Board) as the local advisory board for the facility. Per the document, the facility's purpose was to serve as a multi-purpose mental health facility which provided patient care. Further review revealed the cooperative effort of the Medical Staff, the Administration, and the Governing Board were necessary to provide quality of care for all patients.

Review of the Quality Assurance and Performance Improvement Plan (QAPI), dated 01/2020, and 01/2021 revealed, the Governing Body of the facility "has the ultimate responsibility and authority to establish, maintain and support an effective Quality Assessment Performance Improvement (QAPI) program. The Governing Body assures that the necessary structures are established, and the processes are implemented to assess and continually improve the overall quality and efficiency of patient care. The Governing Body receives and acts upon recommendations regarding quality assessment and improvement activities".

Review of the PI Meeting Agenda's dated, 06/25/2020 - 02/25/2021, revealed National Patient Safety Goals had been discussed at each meeting.

Interview with the Director of Nurses (DON), on 09/24/2021 at 9:00 AM, revealed she was a Governing Board (Governing Board) member and had attended one (1) Governing Board Meeting in May/June 2021. Per interview, the Governing Board developed and approved the rules and regulations of the hospital, in accordance with the Center for Medicare and Medicaid Services (CMS) regulatory guidance.

Telephonic interview with the Interim Medical Director, on 09/27/2021 at 8:00 AM, revealed the function of the Governing Board was to govern the hospital, and the Governing Board was the "base of the pyramid" which held the facility together. He revealed he had not been made aware of any of the above-mentioned incidents, except for the incident with Patient #1. Continued interview revealed none of the above-mentioned incidents involving the other patients had been discussed in the Governing Board Meetings. Per interview, he had just "gone with the flow"; however, should have looked more into what needed to be discussed in the Governing Board Meetings. The Interim Medical Director revealed the facility's goal was to make the facility's patients' lives better.

Interview with the CEO, on 10/07/2021 at 8:27 AM, revealed the Governing Board met quarterly, and the purpose of the Governing Board was to ensure the rules and regulations of the facility were being followed, and the facility met compliance issues. Per interview, the Governing Board reviewed all issues that pertained to the safe operation of the facility. The CEO stated the Governing Board also reviewed reports from the facility's various committees, such as, the Medical Executive Committee (MEC), and the Performance Improvement (PI) Committee, to ensure the facility had met Quality of Care, and Compliance Standards. He stated he utilized a "dashboard" to access various reports on Restraints, Patient Satisfaction, Safety, and all the Core Measures. Continued interview revealed the Governing Board had not been as functional as it could be, and there were areas of improvement which the Governing Board needed to address, from a system's standpoint. The CEO revealed the Governing Board had "dialogue" regarding old issues, and although discussion of past issues was required, he could not say it had ever been very effective. He further revealed the Governing Board, generally, did not solve facility issues, and problems, but rather discussed the status of the facility. In addition, the CEO stated, to ensure, the facility provided the Quality-of-Care patients deserved, the facility first had to provide it.

Refer to A-0143, A-0144, A-0145 and A-0167

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to protect and promote patient rights and failed to provide care in a safe setting for eight (8) of nineteen (19) sampled patients (Patient #1, Patient #2, Patient #3, Patient #4, Patient #6, Patient #15, Patient #16 and Patient #18).

Record review and interview revealed the facility failed to ensure Patient #2 did not carry contraband into the facility and onto the patient unit (razor, leggings) resulting in self-harm, failed to ensure chemicals had been properly stored or supervised resulting in Patient #2 accessing chemicals and drank an indeterminate amount.

Record review and interview revealed the facility failed to implement appropriate interventions for elopement. Patient #3 eloped from the facility multiple times through an exit door. Patient #3 fell and broke his/her arm during an elopement.

Observation of video footage, record review and interview revealed the facility failed to protect Patient #1 and Patient #18 from staff physical abuse. Review of video footage revealed staff striking Patient #1 across the face during a restraint and staff grabbing the legs of Patient #18 to force the patient from a seated to lying position.

Record review and interview revealed the facility failed to protect Patient #6, Patient #15 and Patient #16 from abuse.

Record review and interview revealed the facility failed to protect Patient #4's private information from other residents.

Refer to A-0143, A-0144, A-0145, A-0167.

Based on interview, closed record review and review of the facility's policy, it was determined the facility failed to protect and promote each patient's rights to personal privacy for one (1) of nineteen (19) sampled patients, Patient # 4.

The findings include:

Review of the facility's policy and procedure titled, "Patient Rights Under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule," dated 06/2021, revealed the facility had a comprehensive system of policies and procedures which was to assist in ensuring patients' privacy rights were protected.

Review of the facility's policy and procedure titled, "Patient Rights," dated 01/2021, revealed "the patient has the right to, within the limits of the law, to personal privacy and confidentiality of their information". Per review, "the patient has the right to the confidentiality of his/her clinical records." Continued review revealed the facility respected and recognized each patient's dignity and desired to prevent any measure which might lead to prohibition of his/her rights, including privacy.

Review of Patient #4's closed clinical record revealed the facility admitted the patient, on 08/17/2021, with diagnoses which included Bipolar Disorder, Unspecified; and Major Depressive Disorder, recurrent, severe, without Psychotic features. Review revealed Patient #4 had voluntarily admitted him/herself to the facility.

Review of the Complaint Intake Information, dated 08/24/2021, revealed Patient #4 alleged another patient, Patient #19, had looked at a telephone (phone) message from his/her sister. Per review, Patient #19 had contacted Patient #4's family member and told the family member he/she would like to "marry" Patient #4, or his/her family member. the facility's Phone Call Log had been lying on the nurse's station desk and had been left open by a staff member. Per review, Patient #19 had been able to view Patient #4's personal phone message information and obtained the patient's family member's phone number and called Patient #4's family member. Further review revealed the facility's Risk Manager (RM) had attempted to call the complainant; however, the complainant had not called the RM back.

Review of the facility's " HIPAA Violation and Breech", undated with no time or signature, revealed the investigation was ongoing. Continued review revealed, Patient #19 had retrieved a written phone message intended for Patient #4, and Patient #19 was able to call Patient #4's family member and conduct a conversation of concern regarding Patient #4. Continued review revealed telephone messages were to be hand delivered to the patient, and not left unattended. Per review, the Phone Message Tracker Book was to be kept in a locked drawer away from wandering patients due to patient confidentiality. Patient #19 had been able to review the message by leaning over the nurse's station. The facility had a duty to protect all patient information in regard to both patients.

Review of the documentation provided by the facility's Risk Manager (RM), on 09/01/2021 at 9:00 AM, revealed it was a "guideline" to determine if a HIPAA violation had occurred and documentation of findings. Continued review revealed a patient should not have access to another patient's phone messages. Per the guideline, the facility had a duty to protect all the patient's information regarding both patients. Further review revealed the facility had identified a change in the facility's process needed to occur to prevent further events, such as occurred with Patient #19 having obtained Patient #4's family member's phone number.

Interview with Licensed Practical Nurse (LPN) #1, on 08/31/2021 at 12:10 PM, revealed she had received mandatory annual training on HIPAA every year, and staff needed to make sure all patients' personal information was kept private.

Interview with the Assistant Director of Nurses (ADON), on 08/31/2021 at 3:29 PM, revealed she remembered the incident, and she believed the family member had called the facility to report another patient had called the family member at home. Continued interview revealed the incident when Patient #19 had obtained Patient #4's family member's phone number, should never have happened. Per interview, a patient's information should always be kept confidential as required.

Interview with the Risk Manager (RM), on 09/01/2021 at 9:00 AM, revealed the facility's Phone Call Record Log had been left open by an unknown staff member at the Nurse's Station and another patient viewed the Log and obtained Patient #4's personal telephone message information. She stated the Phone Call Record Log should not have been left lying open for patients to view, read, and obtain other patients' private information. Further interview revealed another patient, Patient #19 had read Patient #4's private message in the open Phone Call Record Log and had proceeded to call the patient's family member.

Interview with Mental Health Technician (MHT) #8, on 09/03/2021 at 2:10 PM, revealed staff received mandatory training at least once a year on HIPAA, and the importance of maintaining all patients' privacy.

Interview with Physician #1, on 09/24/2021 at 8:00 AM, revealed the facility had to enforce and uphold HIPAA practice and patient confidentiality as required. Per interview, any personal patient information should never have been out in full view of other patients.

Interview with the Director of Nursing (DON), on 09/24/2021 at 9:00 AM, revealed the incident where Patient #19 had viewed and used Patient #4's private personal information should never have happened. She stated the facility needed to correct what had occurred because patient privacy was the law. Per interview, other patients should never have been able to access to another patient's personal information.

Interview with the Chief Executive Officer (CEO), on 10/07/2021 at 8:23 AM, revealed it was his expectation that staff followed the HIPAA laws and patient confidentiality, as per the facility's policies and procedures.

Based on observation, interview, closed record review, and review of the facility's policy, it was determined the facility failed to ensure patients received care in a safe setting for two (2) of nineteen (19) sampled patients, Patient #2 and Patient #3.

1. The facility failed to ensure Patient #2's safety, for a patient with a known history of suicidal ideation and self-inflicted wounds, as evidenced by the following:
A) Facility staff conducting the admission process allowed Patient #2 to go to the unit with contraband (a razor), which the patient was able to access and cut him/herself on 03/01/2021 requiring an Emergency Department (ED) visit.
B) Facility staff allowed Patient #2 to access contraband (razor), which the patient was able to access and cut him/herself on 03/10/2021 requiring an Emergency Department (ED) visit.
C) Facility staff allowed Patient #2 to access and consume an indeterminate amount of an unsecured chemical product, Clorox Bleach Germicidal Cleaner, which the patient obtained from an unsupervised housekeeping cart.
D) Facility staff allowed Patient #2 access to leggings and allowed the patient to be unattended in his/her room, where he/she tied the leggings around his/her neck.
E) In addition, facility staff allowed Patient #2 to gain access to a plastic spoon located at the nurse's station, which he/she broke in half and attempted to injure self.

2. The facility failed to ensure Patient #3's safety, for a patient with a known history of elopements, as evidenced by, facility staff allowed Patient #3 to elope from the facility on several occasions. On, 09/09/2021, staff allowed Patient #3 to elope once again, and when the police arrived, a struggle occurred, during which the patient and Police Officer fell to the ground. As a result of the fall, Patient #3 experienced a broken arm which required surgical repair.

The findings include:

Review of the facility's policy and procedure titled, "Patient Safety Council," dated 01/2021, revealed "the Patient Safety Council was designed to improve patient safety, reduce risk and respect the dignity of those we service by assuring a safe environment." Review revealed the policy related specifically to minimize physical injury, undue psychological stress, and accidents during a patient's hospitalization. "The organization-wide safety program will include all activities contributing to the improvement and maintenance of patient safety." Per the policy, "leadership is responsible for establishing a culture of safety that minimizes hazards and potential patient harm by focusing on processes of care. The leadership will foster a safe environment through their personal example; emphasizing patient safety as an organization priority; providing education to all staff regarding the commitment to reduction of adverse outcomes; supporting proactive reduction in adverse outcomes; and integrating patient safety priorities into the new design and redesign of all relevant organization processes, functions and service. Per the policy, the Patient Safety Measures also included an emphasis on the provision of care, treatment and services, and the function of the environment of care. Further review revealed the facility's Chief Executive Officer (CEO) was to chair the Patient Safety Council, and the Patient Safety Officer would be the Director of Performance Improvement/Risk Management.

Review of the facility's policy and procedure titled, "Patient Rights," dated 01/2021, revealed the facility "recognizes and respects the dignity of each person admitted and desires to prevent any measures which might lead to prohibition of rights. It is the policy of the hospital to ensure protection and support of fundamental human, civil, constitutional, and statutory rights of each person served by the hospital insofar as is within the reasonable capabilities and limitations of the hospital and consistent with treatment". Continued review revealed "the patient has the right to receive care in a safe setting".

Review of the facility's policy and procedure titled, "Environment of Care Committee," dated, 01/2021, revealed "the administration and senior leadership of the facility are responsible for safety and security."

Review of the facility's policy and procedure titled "Contraband," with no date, and which was in effect when Patient #2 was admitted to the facility, revealed tights, leggings, jeggings, sharp objects, weapons, or anything which could be used as a weapon, found upon a patient's admission, was to be stored in the patient's effects until discharge or sent home with the patient's family on admission.

Review of the facility's revised policy and procedure titled "Contraband", dated, 03/03/2021, revealed the facility had revised the policy to include Crocs, and metal items, as well as, the previous policy's noted leggings, jeggings, tights, sharp objects, weapons, or anything which could be used as a weapon, which were to be sent home with family or stored until the patient's discharge.

Review of the facility's policy and procedure titled "Metal Detector," dated 01/2021, revealed the facility "recognizes the patients' right to privacy, dignity, to be free from unnecessary searches; and to keep and use their personal property. Patients, staff, and visitors also have the right to a safe and therapeutic environment, which necessitates the hospital safeguard against items that may present a hazard to personal safety or the therapeutic environment." Per the policy "the patient is scanned with a metal detector wand prior to the admission assessment. The patient is instructed to empty their pockets and take off their shoes prior to using the metal detector wand. Any contraband or unsafe items are removed during the search and given to a family member if present, if nobody present, staff will take measures to secure their belongings. Any illegal drugs or weapons found on a patient during the admission search will be confiscated and turned over to local law enforcement for proper disposal".

Review of the facility's Safety Data Sheet (SDS) for the "Super Sani-Cloth® Germicidal Disposable Wipe," product, dated 06/20/2021, revealed, if inhaled, the product could potentially be harmful and might cause irritation of the respiratory tract. If the product came into contact with the eyes it caused serious eye irritation, pain, redness, and itching. Continued review revealed if the product maintained prolonged contact with the skin it potentially caused irritation, drying and dermatitis. If ingested, the product might be harmful if swallowed, and could potentially cause nausea, vomiting, diarrhea, dizziness, or drowsiness.

Observation, on 09/01/2021 at 8:00 AM, with the Assistant Director of Nursing (ADON) revealed a container of Super Sani-Cloth® Germicidal Disposable Wipes sitting on the nurse's station desk and accessible to the patients.

Observation, on 09/03/2021 at 10:00 AM, of the facility's Front Lobby Receptionist performing a metal detector screening demonstration, revealed the Receptionist failed to scan the Surveyor's hands with the metal detector wand or ask the Surveyor to open her hands during the scanning process.

Observation, on 09/08/2021 at 8:00 AM, with the ADON of Classroom #5, revealed an instructor sitting behind a desk, with a container of Sani-Wipes with a purple lid directly behind the instructor. Continued observation revealed the Sani-Wipes were unsecured and accessible to the patients in the classroom.

1. Closed clinical record review revealed Patient #2 was admitted to the facility on 02/27/2021, with diagnoses which included Severe Alcohol Disorder, Borderline Personality Disorder, and Schizoaffective Disorder, Depressive Type. Continued review revealed, on admission, Patient #2 had been scanned with the metal detector wand and cleared for admission to the facility.

Review of Patient #2's "Psychiatric Evaluation," dated 02/27/2021 at 6:19 PM, and signed by Physician #3 on 03/29/2021, revealed the facility's justification for Patient #2's admission included his/her agitation, delusions, anxiety, depression, hallucinations, and the patient being a danger to self and others or property. Per the review, Patient #2 had behavioral or emotional conditions and complications which required twenty-four (24) hour nursing and medical care. Continued review revealed the evaluation noted Patient's #2's chief complaint, in the patient's own words, was his/her suicidal ideation (SI), depression, and alcohol (ETOH) abuse. The review revealed, on admission, Patient #2 had reported SI, severe anxiety, and self-harm, with increased issues with command type hallucinations to harm and hurt him/herself. Further review revealed Patient #2, on admission, had also reported self-harming behaviors of cutting self on his/her stomach, arms, and legs.

Review of Registered Nurse (RN) #9's "Intake Assessment," dated 02/27/2021 at 6:30 PM, for Patient #2 revealed the patient had a plan to hang him/herself and to cut his/her wrists. Review revealed Patient #2 denied a history of violence, or threats against others. Per review, the Suicide Risk Assessment noted Patient #2 scored as a high risk for suicide. Review of RN #9's, RN Narrative Summary for Patient #2, dated 02/27/2021 at 9:20 PM, revealed the patient had talked freely of suicide and having no reason to live.

Review of the "Final Ancillary Orders," dated 02/27/2021 at 8:00 PM, for Patient #2 revealed Advanced Practice Registered Nurse (APRN) #1 had ordered Patient #2's to be on every fifteen (15) minute checks as his/her Level of Observation, and for the patient to be on suicide precautions.

Review of the "High Risk Notification Alert," signed and dated, on 02/27/2021 at 9:00 PM, by RN #10 and RN #11, revealed Patient #2 had a history of and currently had a high risk for self-harm and suicide.

Review of Milieu Coordinator (MC) #1's, "Personal Belongings Inventory," dated 02/27/2021 at 9:10 PM, for Patient #2 revealed on admission the patient had presented to the facility with one (1) pair of leggings which had been stored in the facility's patient effects (PE) area.

Review of the "Temporary Treatment Plan," dated, on 02/27/2021 at 9:30 PM, for Patient #2, signed by RN# 9, revealed the patient was a danger to self with interventions which included to encourage him/her to seek out staff if thinking of harming him/herself, and for staff to question the patient directly to determine if he/she was having such thoughts. Per review, other interventions included ensuring Patient #2's room was clear of sharp objects, observing the patient for self-injurious thoughts/behaviors, and prompting him/her to utilize positive coping skills. Further review revealed however, the "List of Coping Skills" contained no documented evidence of coping skills identified by staff for Patient #2, in order for staff to prompt the patient to use.

A) Review of the facility's, "Interdisciplinary Master Treatment Plan," for Patient #2, dated 03/01/2021, revealed a Depression with Suicidal Ideation Individual Treatment Plan (ITP) had been developed, which included the following information under "Problem #1": the patient reported having suicidal ideation with no plan; however, had endorsed increased depression for four (4) days and anxiety which he/she had cut him/herself in order to relieve the anxiety. Continued review of the "Interdisciplinary Master Treatment Plan" revealed Problem #3 addressed Patient #2's Assaultive/Aggressive/Self Harm ITP for having been found with a razor blade hidden in his/her clothing which had not been removed by staff during the admission process. Per review of Problem #3, Patient #2 had subsequently used the razor blade to cut his/her arms deep enough to require stitches.

Review of the, "Nursing Progress Note," signed by RN #7 which was dated 03/01/2021 and timed as 8:30 AM, and prior to Patient #2's self-harm with a razor blade, revealed Patient #2 continued to report auditory and visual hallucinations, and was positive for SI with a plan to cut his/her wrist. Continued review revealed Patient #2 had started to work out the details of how he/she would kill him/herself. Review further revealed Patient #2's last suicide attempt had been on 12/28/2020, when the patient had cut his/her wrists. However, there was no documented evidence the facility implemented interventions or increased monitoring.

Review of the facility's "Psychosocial Assessment," for Patient #2, dated 03/01/2021 at 3:01 PM, and signed by Clinical Social Worker #1, revealed, prior to Patient #2's self-harm with a razor blade, the patient reported a plan to cut his/her wrists and to hang him/herself. Per review, Patient #2 also reported having hallucinations to harm and hurt him/herself. However, there was no documented evidence the facility implemented immediate interventions or increased monitoring.

Review of the incident report regarding the contraband event for Patient #2 revealed, on 03/01/2021, the patient had a razor blade hidden in his/her shoe. Per review, Patient #2 obtained the razor blade from his/her shoe and began slicing his/her arms. Review revealed staff found Patient #2 bloody with something metal in his/her hand, and when staff tried to get the patient to hand over the metal item, he/she refused to do so. Continued review revealed staff then grabbed at Patient #2's arms and had to force the razor blade out of his/her hand. Further review revealed Patient #2 had blood everywhere, and his/her wounds were cleaned by a nurse. In addition, review revealed Patient #2 was sent to the local hospital's Emergency Department (ED), and returned to the facility, on 03/02/2021 at 12:30 AM.

Review of the "Outside Consultation Form, dated 03/01/2021, no time, revealed Patient #2 had been evaluated at a local hospital's ED for self-inflicted lacerations that required suture repair. Per review, the ED Physician recommended keeping the patient's wounds clean and dry, and for follow-up to return to the acute care hospital for suture removal in ten (10) to twelve (12) days.

Review of Physician #3's Observations/Precautions, dated 03/01/2021, revealed the following orders for Patient #2's therapy/treatment: unit restrictions; body to be visualized for hidden weapons; and no shoes for the patient related to two (2) previous elopements and the patient having hidden a razor in his/her "Croc" shoe.

Review of the "Nursing Progress Note," signed and dated by RN #8, on 03/01/2021 at 7:55 PM, revealed Patient #2 had been uncooperative with staff. Per review, Patient #2 had been found with contraband and had used the contraband to self-inflict wounds. Further review revealed Patient #2 had Suicidal Ideation (SI) with a plan to cut self, however, the facility did not provide increased monitoring.

Review of the "Additional Nursing Progress Notes," dated 03/01/2021 and signed by RN #15, revealed Patient #2 was calm, and cooperative when he/she arrived back at the facility from the hospital ED. Review revealed Patient #2's forearms to his/her upper shoulder area had over forty (40) lacerations which were open and moist, from the incident where the patient used contraband to cut him/herself.

B) Continued review of the facility's, "Interdisciplinary Master Treatment Plan" for Patient #2, dated 03/10/2021, revealed Problem #4 was a Problem Sheet for a Significant Treatment Event, that addressed Patient #2's behavior of cutting both his/her forearms with a second razor blade which the patient had hidden for self-harming.

Review of the "Nursing Progress Note", for Patient #2, dated and signed, on 03/10/2021 at 6:46 AM, by RN #12, revealed the patient had been thinking about harming or killing him/herself, and had a plan for doing so. However, there was no documented evidence the facility implemented interventions or increased monitoring.

Review of the "Nursing Progress Note" dated and signed, on 03/10/2021 at 8:00 PM, by RN # 13, revealed Patient #2 had become upset when he/she was not allowed to go into his/her room. Per review, Patient #2 told staff, "you will be sorry", and the patient eventually walked down to the end of the hallway. Review revealed staff kept checking on Patient #2; however, the patient had been able to cut him/herself at 7:00 PM. Further review revealed Patient #2 told staff the patient needed to "stop the voices" as the reason for the cutting. In addition, review further revealed Patient #2 reported pain where he/she had cut him/herself with another piece of the razor the patient said he/she had brought into the facility.

Review of the "Every Fifteen (15) Minute Check Report," for Patient #2, dated 03/10/2021 at 8:18 PM, signed by Milieu Coordinator (MC) #2 revealed around 7:00 PM that evening, staff had observed the patient sitting alone at the end of the hallway. Per the report, the Milieu Coordinator walked down the hallway to check on Patient #2 and discovered the patient cutting his/her arms with something metal. Review revealed MC #2 stopped Patient #2 from further cutting, and the patient was observed to have several cuts on his/her arms. Per review, the supervisor came to the unit, and staff searched Patient #2's room thoroughly; however, nothing had been found.

Review of the facility's incident report for Patient #2 revealed the patient had been observed on, 03/10/2021, by a MC to be cutting him/herself with something metal. Further review revealed the patient had been sitting at the end of the hall on his/her unit. The MC had walked down to check Patient #2, and found the patient cutting his/her arms with something metal. Review revealed staff stopped Patient #2 from cutting him/herself further, and the patient had several cuts on his/her arms. Further review revealed the piece of metal Patient #2 had used for cutting him/herself was confiscated, and the patient was thoroughly searched by staff with nothing new found. In addition, review revealed Patient #2 had reported to staff he/she had the metal since admission to the facility.

Review of the "Additional Nursing Progress Notes", dated 03/10/2021 at 10:00 PM, by RN #13, revealed around 6:50 PM on 03/10/2021, Patient #2 had been informed he/she could not go into his/her room until the medications had been administered, and could not go outside to smoke due to non-participation in his/her "groups". Review revealed Patient #2 became upset and asked to be left alone. Per review, at 7:05 PM, staff checked on Patient #2 at the end of the hall, and discovered the patient was bleeding from cuts on his/her arms. Continued review revealed an MHT held Patient #2 and the nurse grabbed the patient's left arm and noticed a razor blade between his/her fingers. Review revealed the Program Director was able to remove the blade from between Patient #2's fingers, and orders obtained to transport the patient to the ED for evaluation of the extensive lacerations to his/her right forearm. In addition, Patient #2 was placed on 1:1 observation until he/she left the facility at 9:20 PM via ambulance for transport to the ED.

Review of the local hospital's ED documentation revealed Patient #2 had arrived on 03/10/2021 at 9:42 PM for treatment of lacerations. Per review, the History and Physical (H&P) section revealed Patient #2 recently been seen at the ED with similar symptoms, and the patient had a "long" history of self-inflicted lacerations to the arms over the years. Review revealed Patient #2 complained of three (3) self-inflicted lacerations to his/her right forearm on this admission. Review of the Physical Examination revealed Patient #2 had two (2) gapping lacerations to his/her right forearm, which measured four (4) centimeters (cm) each. Continued review of the Physical Examination revealed the two lacerations required six sutures to each laceration for repair. Further review of the ED documentation revealed Patient #2 left the ED for return to the facility on 03/10/2021.

Review of the facility's "Final Ancillary Orders" for Patient #2 revealed Physician #3 had given an order, on 03/10/2021 at 9:00 PM, for the patient to be placed on 1:1 observation, with a stop date for the 1:1 observation of 03/13/2021 at 8:00 AM.

C) Review of the facility's incident reports, for Patient #2, revealed, on 03/17/2021, the patient accessed Clorox Bleach Germicidal Cleaner and ingested an undetermined amount of the product. Per review, staff contacted the Poison Control Center, and the facility was advised to monitor Patient #2, with no urgent concerns related to staff. Further review revealed the Provider (Physician and/or APRN) had been notified, and an order received to place Patient #2 on one-to-one (1:1) observation.

Review of the facility's "Safety Data Sheet" (SDS) dated 01/15/2019, revealed possible side effects of the "Clorox Bleach Germicidal Cleaner" product included: possible irritation of the respiratory tract; slight irritation of the eye if contact was made; and slight skin irritation if skin contact occurred. Further review other possible side effects noted were if the product was ingested it might cause irritation to the mucous membranes, might cause gastrointestinal irritation, nausea, vomiting and diarrhea.

D) Review of an additional incident report for Patient #2 revealed, on 03/23/2021, the patient had been found in his/her bathroom which was located in his/her room, with leggings around his/her neck. Per review, Patient #2 was conscious and breathing the entire time after being discovered and had not resisted staff when they removed the leggings. Review further revealed Patient #2 stated he/she had tied the leggings around his/her neck because of "the voices". In addition, review revealed staff removed Patient #2's clothes and linens from his/her room, and the one-to-one (1:1) observation continued as ordered at hour of sleep with no additional interventions implemented.

E) Review of the "Nursing Progress Notes," dated 03/26/2021 at 4:20 PM, by RN #16 revealed Patient #2 had reached across and behind the nursing station desk where the plastic forks were stored by staff. Per review, Patient #2 obtained a fork and broke it, and then began slicing at the previously self-inflicted wounds on his/her left forearm before an MHT could intervene. Further review revealed Patient #2 refused to release the fork fragment when the MHT attempted to remove it from his/her hand. Review further revealed Patient #2 fought the MHT and attempted to harm the MHT. In addition, review revealed Patient #2 was placed in a restraint for his/her safety, and for safety of staff. However, there was no documented evidence the facility implemented interventions or increased monitoring.

Review of the "Fifteen (15) Minute Check" log, dated 03/26/2021 at 5:22 PM, noted by MHT #11, revealed Patient #2 became agitated after a remark made by a male peer during a clinical group. Per review, the therapist was able to process the event with Patient #2, and the peer apologized to the patient; however, Patient #2 later became angry about the clinical group event and reached over the nursing station to grab a fork from the corner of the station. Continued review revealed staff immediately intervened, but the patient had the fork and had broken it in half before staff could remove the broken fork from Patient #2's hand. Review revealed the staff person "struggled" to get the fork from Patient #2, and during the struggle the patient scratched his/her left forearm and almost scratched staff. Further review revealed the staff person restrained Patient #2 due to the patient being an imminent risk to self and others.

Review of the incident report for Patient #2 for the incident involving the plastic fork revealed on 03/26/2021, the patient was able to obtain a plastic fork off the nursing station desk which he/she broke. Patient #2 used the broken plastic fork to begin slicing at the existing self-inflicted wounds on his/her left forearm before the MHT could intervene. Further review revealed Patient #2 refused to release the fork fragment and fought the MHT in attempts to harm the MHT.

Interview with MHT #4, on 09/01/2021 at 3:15 PM, revealed Patient #2 had gotten upset because he/she was not allowed to go into his/her room on 03/01/2021, and had stayed at the end of the hallway, sitting in the corner. Per interview, right at shift change that evening around 6:45 PM, MHT #4 had given report to the on-coming MHT and had glanced down the hallway at Patient #2. MHT #4 stated as she glanced at Patient #2, something did not look right, and so the MHT had gone done to the end of the hallway and found the patient "slashing" both of his/her arms. Interview revealed MHT #4 "pleaded" with Patient #2 to stop; however, the patient would not stop, and the MHT asked him/her to give her the blade. Continued interview revealed Patient #2 refused to give her the blade, so MHT #4 grabbed his/her arms from behind to stop the patient from further cutting. Per the MHT, the razor blade Patient #2 had used to cut him/herself with had been about one-half inch long, and about two (2) to three (3) inches long. Interview revealed MHT #4 ended up getting cut through her gloves, across her hands, and had to go to the ED to get a tetanus shot. MHT #4 stated she had also been the one who had performed Patient #2's admission search, and remembered the patient had a wadded-up tissue he/she carried onto the unit. Further interview revealed Patient #2 kept wiping his/her eye with the wadded-up tissue, and the tissue had been the one thing she had not checked. Per MHT #4, Patient #2 later told her he/she had carried the razor onto the unit in the wadded-up tissue. Interview further revealed "normally", staff did not ask patients to throw away their tissues, and staff did not usually check inside a wadded-up tissue. Additionally, MHT #4 revealed the way she saw it, the razor should have been detected when Patient #2 went through the facility's metal detector wand process.

Interview with the Assistant Director of Nursing (ADON), on 09/01/2021 at 3:40 PM, revealed Patient #2 had been scanned (wanded) by the facility's metal detector wand in the facility's front lobby prior to being admitted to the facility. Per interview, Patient #2 was also required to empty his/her pockets, and any phones given to staff, and then the patient was taken into the intake process room. She stated newly admitted patients were then escorted to their assigned unit by staff, where they were asked to undress from the waist down and don a paper gown. Review revealed all the patient's belongings were searched including their shoes. The ADON revealed Patient #2 had apparently hidden a very small razor in his/her Croc shoe on admission, and the razor blade had not been detected by the metal detector upon Patient #2's admission despite the admission process being followed. Continued interview revealed on 03/01/2021, Patient #2 had gotten upset because staff would not allow him/her access to his/her bedroom. The ADON stated Patient #2's door was locked during the day, in order to prevent the patient from isolating self, and to be visible so he/she could be monitored at least every fifteen (15) minutes by staff. Interview revealed when staff observed Patient #2, after the incident where the patient became upset, they found Patient #2 with blood on him/her, and something metal in his/her hand. Per the ADON, apparently Patient #2 taken the razor blade hidden inside of his/her Croc shoe and sliced his/her arms. According to the ADON, staff attempted to encourage Patient #2 to give them the blade; however, the patient refused to do so. She revealed staff then grabbed Patient #2's arms and forced the blade out of the patient's hand. The ADON stated due to Patient #2's injuries, he/she was transferred to the local ED for evaluation, and eventually returned to the facility and was placed on a 1:1 observation.

Continued interview with the ADON, on 09/01/2021 at 3:40 PM, revealed Patient #2 had gotten upset again, on 03/10/2021, and staff found the patient with another piece of razor cutting him/herself again. Per interview, Patient #2 took a bottle of Clorox Bleach Germicidal Cleaner on 03/17/2021 around lunch time, off an unattended housekeeping cart. The ADON revealed the Housekeeper responsible for that cart had been terminated because she had left the chemicals unattended and unsecured despite the training and education provided by the facility. She stated this incident should never have happened. Interview revealed Patient #2 tied a pair of leggings around his/her neck while alone in his/her bathroom on 03/23/2021, even though the patient had an order for 1:1 observation at hours of sleep, when the incident occurred. Per the ADON, an MHT had "mistakenly" unlocked Patient #2's bedroom door that evening, and the patient had gone inside the room unattended by staff. Further interview revealed leggings were not allowed on the patient units because they could be used for strangulation by a patient. The ADON stated on 03/26/2021, Patient #2 found a plastic fork at the Nursing Station, broke the plastic fork, and began to slice at the existing self-inflicted wounds on his/her arms, before the MHT could intervene. In addition, interview revealed Patient#2 refused to release the fork, and fought with the MHT, attempting to harm the MHT. Per interview Patient #2 had to be put in a restraint, in order for staff to retrieve the fork and ensure the patient's and staff's safety.

Interview with the Chief Executive Officer (CEO), on 09/02/2021 at 10:57 AM, and on 10/07/2021 at 8:27 AM, revealed his expectation was that all of the patients were kept safe, and no contraband entered the facility. He stated chemicals should all be safely secured and were monitored through observation of staff, and through review of video. He revealed any Housekeeper who left chemicals out, and in reach of the patients, did not belong in a psychiatric facility. He said the facility should not have eating utensils out, and within reach of the patients and forks should have been secured somewhere in the nurse's station. He revealed he was not certain if the facility metal detector would have identified the type of metal the razor blade contained.

Interview with the front lobby receptionist on, 09/03/2021 at 10:50 AM, revealed she had received training on how to use the metal detector wand upon hire. She stated the purpose of wanding all patients, before they go back to their units, was to ensure no contraband was brought into the facility. She revealed normally, she would ask a patient to open their hands, and she would also wand the hands as well. She stated if the battery in the wand was low, or drained, the wand would not beep. She stated she did not ask the surveyor to open her hands, because she was nervous.

Interview with the Housekeeping Supervisor, on 09/03/2021 at 10:57 AM, revealed the Housekeeping Carts always needed to be close to the housekeeper as they worked, and should be locked, and kept with the housekeeper. This will help prevent the patients from getting into the chemicals.

Interview with Housekeeper #1, on 09/03/2021 at 11:19 AM, revealed the housekeeping carts should be kept locked, and taken with the housekeeper at all times and chemicals should not be open or around the patients.

Interview with Housekeeper #2, on 09/03/2021 at 11:27 AM, revealed the housekeeping carts should be locked at all times to prevent the patients getting into it.

Interview with Registered Nurse (RN) #17, on 09/03/2021 at 1:40 PM, revealed she was an Admissions Coordinator. She stated no tissues should be wadded up, and taken to the unit, as the tissue could contain sharp items, and other contraband. She continued to state the patients were not allowed to have leggings on the unit because they could be used for strangulation. RN #17 revealed there should be no chemicals, or sharp items available to the patients, and these types of items needed to be locked up.

Interview with RN # 12, on 09/03/2021 at 2:00 PM, revealed there should not be any items, such as hand sanitizer, on a nursing station desk and accessible to the patients. She stated all eating utensils should be accounted for, or staff would search the entire unit. RN #12 went onto state utensils could be used by the patients as a weapon.

Interview with Mental Health Technician (MHT) #8, on 09/03/2021 at 2:10 PM, revealed leggings were not allowed on the units because it was a ligature

Based on policy review, observation, closed record review, and interview it was determined the facility failed to ensure patients were free from all forms of abuse or harassment for five (5) of nineteen (19) sampled patients (Patient #1, #18, #6, #15 and #16).

Review of facility video footage revealed, on 10/15/2020, Registered Nurse Supervisor #2 struck Patient #1 on the left side his/her face while Patient #1 was restrained.

Review of facility video footage revealed, on 09/18/2021, Lead Mental Health Technician (MHT) #1 grabbed Patient #18 by his/her ankles, and forced Patient #18 from a sitting position to a supine position.

Record review revealed Patient #6 was hit in his/her face by an unknown peer, on 06/23/2020; however, the incident was not reported or investigated.

Record review revealed Patient #16 was physically assaulted by Patient #15 twice on 05/21/2020.

Record review revealed Patient #15 was verbally assaulted/harassed by Patient #16 on 05/21/2020.

The findings include:

Review of the facility's policy and procedure, titled "Patient Abuse, Neglect, and/or Harassment", dated 01/2021, revealed the facility "does not tolerate abuse, neglect, or harassment of patients whether from staff, other patients, or visitors". The facility "has a system whereby all suspected incidents or patient complaints of abuse, neglect, or harassment were investigated and acted upon". The facility employees were trained in the prevention, identification, and reporting procedure for suspected patient abuse, neglect, or harassment. The facility defined abuse as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. this includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect is considered a form of abuse and was the failure to provide goods and services necessary to avoid harm, mental anguish, or mental illness. Harassment is threatening, or tormenting behavior". Per the facility's policy, "reporting suspected incidents of patient abuse, neglect or harassment are reported (either verbally or in writing,) to the Charge Nurse or Nurse Manager and will receive immediate attention and response. The Charge Nurse or Nurse Supervisor assesses the situation, takes appropriate action to secure patient safety, and called the Director of Risk Management and the CEO, or the Administrator on-call for further instruction". Continued review revealed if a facility "employee is accused of patient abuse, neglect, or harassment, he/she is immediately removed from all patient care areas and placed on Administrative Leave until the allegation is substantiated or unsubstantiated through investigation". Per the policy, "if a patient is accused of abusing, neglecting, or harassing another patient, the patient suspected of abuse is separated from the general patient milieu and is placed on close supervision until it is determined that the patient no longer poses a threat to the suspected victim. Patients having a 'substantiated' incident of patient abuse, neglect or harassment may be reported to the police department and/or other authorities as specified in the Abuse/Neglect Reporting policy." The charge nurse would complete an Incident Report, and the Incident Report would be sent to Risk Manager (RM). The facility patients were protected from abuse during the investigation of allegations of abuse, neglect, or harassment from the direct care areas of the building. "If another patient was accused of abuse, neglect, or harassment, the patient suspected in the incident is removed from the general patient milieu and is kept on a 1:1 observation until it can be determined that the patient is no longer a threat to the patient making the allegation". Incidents of abuse, neglect, or harassment would be discussed, and therapeutic interventions identified by the Treatment Team as part of the treatment planning for the patient making the accusations, and for any patients who were accused. The Director of Risk Management would begin an investigation as soon as he/she was in receipt of an incident of patient abuse, neglect, or harassment, usually this was the following business day, following the incident. However, the CEO or AOC may initiate an investigation as soon as they were notified of an incident of patient abuse, neglect, or harassment.

Review of the facility's policy and procedure, titled, "Incident Reporting", dated 01/2021, revealed the purpose of the policy was to provide a systematic process for documentation, tracking and trending all incidents to ensure proper management and timely implementation of risk management/quality of care strategies. Any incident which was not consistent with the routine delivery of care or operation of the hospital or expected outcomes of patients shall be promptly, accurately, and factually reported by the witnessing or having knowledge of the incident.

1. Review of Patient #1's closed record revealed the facility admitted Patient #1, on 08/22/2020, with diagnoses to include Suicidal and Homicidal Ideation, Disruptive Mood Dysregulation Disorder, Major Depressive Disorder recurrent, severe and without psychosis. Patient #1 also had a history of mild Cerebral Palsy that resulted in spasms in his/her legs.

Observation of video camera footage with the Chief Executive Officer (CEO), and the Assistant Director of Nursing (ADON), on 09/08/2021 at 2:45 PM, revealed, on 10/15/2020, at approximately 3:45 PM, Patient #1 had been placed into a physical restraint, and was escorted into the Seclusion Room by Mental Health Technician (MHT) #14. Upon entrance to the Seclusion Room, MHT #14 was observed to throw the patient onto the concrete floor and the patient landed on his/her right side. At approximately 3:48 PM, Registered Nurse (RN) Supervisor #2 entered the Seclusion Room. At approximately 3:49 PM, RN Supervisor #2 leaned over Patient #2, and spoke with him/her. At this point, the RN Supervisor #2 left the Seclusion Room, and as he left, he was observed to remove his glasses. Upon return to the Seclusion Room at 3:49 PM, the nurse was observed to bend down by the patients left side and tap the patient under his/her chin with his right hand. Seconds later, the RN Supervisor #2 was observed to strike the patient on the left side of the patient's face, using his right hand. The nurse's actions appeared to further escalate Patient #1.

Review of RN Supervisor #2's time sheet revealed RN Supervisor #2 continued to work at the facility, on 10/16/2020, 10/18/2020, 10/19/2020, and 10/20/2020, despite allegations of abuse towards Patient #1.

Review of a documented interview, conducted by the former Risk Manager with Patient #1, on 10/20/2020 at 1:35 PM, revealed the patient reported while he/she had been placed in seclusion, and in a full restraint, RN Supervisor #2 had come into the seclusion room, and yelled at the patient to stop. Patient #1 reported he/she would have calmed down if RN Supervisor #2 had not come into the room, yelling and cussing. Per the documented interview, RN Supervisor #2 had heard him/her screaming and he barged in the Seclusion Room. Patient #1 reported he/she had asked the RN Supervisor why he had come into the Seclusion Room. Patient #1 reported RN Supervisor #2 took off his glasses, and wristwatch, he/she had told the RN Supervisor that he had better not touch him/her. The patient reported RN Supervisor #2 had told him/her to get the fuck up, shut the fuck up, and calm down. The patient also reported that RN Supervisor #2 had slapped him/her really hard and left a mark on his/her face.

Review of RN Supervisor #2's written statement, undated with no time, revealed, on 10/15/2020, staff had to place Patient #1 into a restraint. RN Supervisor #2 had gone into the Seclusion Room, and Patient #1 was head thrashing, and attempting to bite staff. Further review of his written statement revealed he asked the patient to calm down; however, the patient screamed out profanities, and stated to RN Supervisor #2, that he would be fired, and that the RN Supervisor was not in charge. Continued review of RN Supervisor #2's written statement revealed Patient #1 continued to bite, and RN Supervisor #2 asked the patient to stop biting him and the staff. RN Supervisor #2 reported in his statement that he had tried to ask the patient about what had happened that led to the restraint; however, the patient would not respond to him, except to call him names, and try to bite the staff.

Review of the facility's, "Universal Health Services (UHS) BH Intensive Analysis document, undated, revealed camera footage of this incident had been reviewed, on 10/21/2020 and the video corroborated Patient #1 and the MHT's reports that RN Manager #2 (RN Supervisor #2) had slapped Patient#1 during a restraint. Continued review of the Analysis revealed the video showed the patient escalated while in a restraint in response to verbal interactions with RN Manager #2, and in response to being slapped. Continued review of the incident documentation revealed, on 10/20/2020, a nurse reported to the former Risk Manager concerns which surrounded an accusation that Patient #1 had been slapped by RN Manager #2. Review of the Analysis revealed a nurse had stated concerns about the facility not following policy and procedure on abuse, as RN Manager #2 had continued to work, and had not been placed on Administrative Leave. The Human Resources (HR) Director advised the former Risk Manager, on 10/20/2020, that Patient #1 had not been interviewed yet. The former Risk Manager had notified the patient's parent via telephone, on 10/22/2020 at 2:50 PM, and informed them about the incident which involved their child and apologized for the delayed notification.

Review of RN Supervisor #2's Human Resource file (HR) revealed RN Supervisor #2 had been employed by the facility, on 06/06/2017, and had been terminated by the facility on 12/14/2020. Continued review of the HR file revealed he had completed abuse training upon hire, on 11/2019 and on 11/2020. RN Supervisor #2 had also received training on "Verbal De-escalation Competency" on 09/23/2020.

Interview with the Chief Executive Officer (CEO), on 09/08/2021 at 2:20 PM, revealed he had viewed the video camera footage from the incident, on 10/15/2020, and he observed RN Supervisor #2 strike Patient #1 in the face while the patient had been restrained and placed in a Seclusion Room. He stated the patient must have said something to RN Supervisor #2 for him to act this way. The CEO stated RN Supervisor #2 also got down to the patient's level and appeared to have spoken to the patient. He revealed he had also observed RN Supervisor #2 put his hands on the patient's face. He went onto state RN Supervisor #2 should not have spoken with the patient, and the patient should have been the one doing all the talking. Continued interview revealed he had received a telephone call, on or about Thursday night, after the incident had occurred, from the former Risk Manager. He stated she informed him that a staff person had called her to let her know RN Supervisor #2 had slapped Patient #1 in the face. Therapist #1 had also spoken, and validated the incident with Patient #1, on 10/16/2020. Further interview revealed RN Supervisor #2 continued to work, he believed one half (1/2) a day on 10/16/2021; however, the CEO stated that he should have suspended RN Supervisor #2 as soon as he was made aware of the abuse allegation, per the facility's abuse policies and protocol.

Interview with Mental Health Technician (MHT) #2, on 09/08/2021 at 2:18 PM, and again, on 09/22/2021 at 3:00 PM revealed, on 10/15/2020, she had participated in the restraint process of Patient #1. She revealed the patient was de-escalating when RN Supervisor #2 entered the Seclusion Room and the patient told him to leave. Per MHT #2, RN Supervisor #2 responded to the patient and told him/her that he runs the unit. MHT #2 stated RN Supervisor #2 then left the Seclusion Room and took his glasses off. When he came back into the Seclusion Room, he insinuated to Patient #1 that the patient and he could go one to one. At this point, Patient #1 became agitated and his/her behaviors escalated again. She stated she observed RN Supervisor #2 bend down and pop the patient right in the face. Per interview, she had tried not to freak out because RN Supervisor #2 was her boss. She revealed she did not report the incident to anyone until the next day, 10/16/2021. The MHT #2 stated she felt intimidated by RN Supervisor #2, and she had a family to take care of, and did not want to lose her job. Further interview revealed, on 10/16/2021, Patient #1 spoke with former Therapist #7, and told her that RN Supervisor #2 had slapped him/her in the face. She went onto state she thought allegations of abuse had to be reported within twenty-four (24) hours. She revealed she did not informed Patient #1's nurse, but she should have reported what she had observed to the nurse immediately. Per interview she reported the allegation of abuse, on 10/16/2020 around 9:00 AM, to the Director of the Human Resources (HR) Department. She revealed the Human Resources Director informed her not to tell the CEO, or the Risk Manager about the incident MHT #2 had observed. MHT #2 stated she remembered thinking to herself, why would the HR Director not want the CEO, or the RM informed about her observation. MHT #2 said the HR Director did not tell her why she should not tell them because she would usually report something like this to the former RM. She stated the next day, RN Supervisor #2 showed up for work. Per interview, RN Supervisor #2 had been rude to her the following day, after she had reported the incident to HR. She stated Patient #1 told anyone who would listen about his/her experience with RN Supervisor #2 in the Seclusion Room.

Telephonic interview with the former Risk Manager (RM), on 09/08/2021 at 3:03 PM, revealed she had been employed at the facility as the RM, as well as the Compliance Officer. She stated, on the morning of 10/16/2020, she had been made aware of the allegation by MHT #2. She stated MHT #2 informed her that, on 10/15/2020, during a restraint hold with Patient #1, RN Supervisor #2 came into the Seclusion Room, and incited the patient, made threats to the patient, and told the patient if he instructed the staff to let him/her up, then he would go after the patient. RN Supervisor #2 took off his glasses, leaned down to Patient #1, and slapped the patient in the face. Continued interview revealed she immediately texted the CEO, and the Director of HR, and informed them of the allegation of abuse to Patient #1, from RN Supervisor #2. The former RM stated both the CEO and the Director of HR reported that they had not been made aware of the allegation. She stated the RN on the unit, or someone in authority, should have been notified immediately after the incident occurred. The former RM stated Patient #1 did have a bruise on his/her face, and the facility had delayed in reporting the incident to the authorities, and RN Supervisor #2 should have been placed on leave pending the outcome of the abuse investigation. She stated she had interviewed Patient #1, on 10/20/2020, and after the interview, she instructed the nurse to immediately contact the Advanced Registered Nurse Practitioner (APRN). She stated after the ARNP had assessed the patient, a medical consult was ordered, and completed by Physician #3. She stated, the physician ordered an x-ray of Patient #1's face, and the X-ray was negative for abnormal findings.

Interview with the HR Director, on 09/08/2021 at 2:00 PM, and 3:30 PM, revealed she had been made aware of the incident regarding a child being slapped by staff by the former RM. She stated anytime an employee had to be suspended, generally the employee would be asked to come into the CEO's Office, and she would sit in on the suspension. She revealed RN Supervisor #2 had been suspended without pay pending the investigation. She revealed she believed the former RM had received a document from the Department of Community Based Services (DCBS) which stated their investigation had been completed, and substantiated. At that point, the facility terminated RN Supervisor #2. Continued interview revealed staff involved in an investigation were instructed not to talk about the incident to others because the facility needed to complete the investigation. She stated the CEO completed most of the investigation and RN Supervisor #2 had been suspended on 10/21/2020, pending the outcome of the investigation. Per interview, she could not state why RN Supervisor #2 had not been immediately suspended after the allegation.

Telephonic interview with former Therapist #1, on 09/09/2021 at 10:52 AM, revealed she was no longer employed at the facility. She stated MHT #2 had approached her, on 10/15/2020, and asked her to step off the unit but she could not. The next day, on 10/16/2020, Patient #1 proceeded to tell her that while he/she had been placed in a restraint, on 10/15/2020, RN Supervisor #2 had slapped him/her in the face. Therapist #1 immediately called her clinical director and informed her about what had been reported to her by the patient. She went onto state that after that, she approached MHT #2 and asked her what had happened, and MHT #2 told her the exact same story Patient #1 had told her. She revealed RN Supervisor #2 was a strong mentor on the unit, and had informed her that he was not mad at her for having reported the alleged abuse to HR. She stated the facility had provided education on abuse, and any allegations of abuse should be reported to a supervisor, immediately.

Telephonic interview with RN Supervisor #2, on 09/09/2021 at 2:06 PM, was unsuccessful. Message left on his voicemail; however, he did not return the call.

Interview on 09/10/2021 at 9:17 AM, with the Risk Manager Coordinator (RMC), revealed she was a Patient Advocate, and instructed staff on "Handle with Care", which was the facility's crisis management. She revealed each staff member received a participant manual, and there was also an eight (8) hour class that had to be completed. She stated the facility educated staff on when it was okay to put their hands on a patient, and how to properly put hands on a patient. She stated staff must first use less restrictive measures. The RMC stated verbally throwing out "stop it" by staff to a patient(s) was not appropriate. A patient threat was not considered a reason for staff to put their hands on a patient. Even if a patient had lunged at other peer (s), the staff could stand between them, and try to de-escalate the situation. Per interview, Patient #1 should have had a "Behavioral Crisis Intervention" in place prior to 10/23/2020. If a patient was receptive to de-escalate, staff should initiate dialogue with whoever had the best rapport with the patient. The Risk Management Coordinator stated the facility had to keep the patients safe, and it was not okay, at any time, for staff to just drop a patient to the floor, and this type of staff behavior was not what staff were taught to do when they received training on "Handle with Care" procedures. Further interview revealed the former Risk Manager used to evaluate and observe restraint/seclusion videos for staff technique, but she did not know who was doing it now.

Interview with the Assistant Director of Nurses (ADON), on 09/10/2021 at 10:33 AM, after viewing the video camera footage of the incident with the Surveyor, the ADON identified staff errors during the restraint. She stated staff did not provide Patient #1 with a proper transition to the Seclusion Room floor and revealed observation of the footage confirmed RN Supervisor # 2 had slapped the patient on the face. Per interview, it made the ADON want to vomit.

Telephonic interview with RN #26, on 09/15/2021 at 9:30 AM, revealed since she had been employed with the facility, she had not physically put her hands on any patient. She revealed if a patient tried to spit, hit, or bite staff, staff were trained on how to handle this type of situation. She stated first, staff should keep their limbs away from the patient's body as much as possible. RN #26 stated there was absolutely no way for staff to justify pulling a patient's hair or slapping a patient, and these actions were not the type of behavior portrayed by professionals. She reported the facility gave a very thorough "Handle with Care" class and educated the staff on how to handle certain situations with the patients.

Interview with the Risk Manager (RM), on 09/15/2021 at 10:00 AM, revealed abuse was when a patient had experienced neglect, or wrong doing. She stated any suspicion of abuse should be reported immediately through the chain of command, and laterally reported to the Risk Manager, the CEO, and the Director of Nursing via the Nurse Supervisor. She stated if she received notification of any type of alleged physical or sexual abuse she would immediately report to the facility. She stated the facility's first responsibility was to keep all the patients safe. The allegation should be reported to the Department of Community Based Services (DCBS) immediately. The RM stated she had reviewed the video footage of the incident with Patient #1, and it looked like RN Supervisor #2 had slapped Patient #1. She went on to state she did not like the manner in which the patient had been initially placed on the floor of the Seclusion Room by the MHT, and staff had hyperextended the patient's neck more than they should have during the restraint. She stated staff received training on how to handle patients who spit and bite, and it was not by slapping the patient in the face

Interview with RN Supervisor #1, on 09/16/2021 at 9:00 AM, revealed staff had received training on the restraint and seclusion process, and it was not appropriate to throw a patient onto the floor. RN Supervisor #1 stated staff were trained in "Handle with Care" education, which directed the staff to step back a little from the patient and set the patient down on their buttocks. She revealed staff should never lay a hand on a patient, with the exception of the restraint process. She stated during a restraint situation, if the patient spit or attempted to bite staff, the staff have been trained to place towels, or pillows over their face.

Interview with the Director of Nursing (DON), on 09/24/2021 at 9:00 AM, revealed all employees were instructed on abuse at least yearly. She stated the facility wanted to be proactive, and try to utilize huddles, in order to make staff more aware of possible issues with abuse, and also to identify problems with the current policies. She stated she had seen the video from 10/15/2020 and wanted to cry. The DON stated several of the employees did not adhere to our "Handle with Care" process, and many actions by staff were not done appropriately. She revealed Patient #1 had been likely harmed when the RN Supervisor #2 slapped him/her. She stated she expected staff to immediately report abuse to a supervisor, even if they were not sure abuse had actually occurred. She stated staff should not leave the facility and think about an allegation of abuse before they report it. She went onto state the facility's goal was to ensure all patients were safe, and to follow the processes the facility had in place to ensure patient safety.

Telephonic interview with the Interim Medical Director, on 09/27/2021 at 8:00 AM, revealed he had heard about the incident between Patient #1 and a staff member, and was horrified. He stated no patient should ever be harmed while in the facility and the facility's policy revealed after an allegation of abuse had been made, the alleged person, should be sent home right away. He stated it was his expectation that the Administration and the Attending Physician be notified right away. He revealed he was just aghast by this situation, and he had not been made aware by anyone that the accused employee had not been suspended right away.

Interview with the Chief Executive Officer (CEO), on 10/07/2021 at 8:27 AM, revealed he thought this incident between Patient #1, and RN Supervisor #2 was horrible. The CEO stated it was his expectation that staff to put patient safety first. He revealed in the past, RN Supervisor #2, had actually helped the facility with the de-escalation of our patients. The CEO stated it was possible that RN Supervisor #2's grandiosity and frustrations made him strike Patient #1. He stated staff should treat the patients right, and the facility's biggest failure, in the past, was that staff had not been held accountable.

2. Review of the closed medical record revealed the facility admitted Patient #18, on 09/10/2021, with the diagnosis of Disruptive Mood Dysregulation Disorder.

Observation of the facility's video camera footage, dated 09/18/2021 at 9:10 PM, revealed Patient #18 sitting at the head of his/her bed with his/her legs crossed. Continued observation revealed Lead Mental Health Technician #1 had walked around to the left side of the patient's bed and was observed to use both of her arms/hands to grasp both of the patient's lower legs/feet, and pulled the patient from a sitting position, to a supine position and then she threw a linen sheet over the patient and exited the patient's room.

Review of MHT Lead Technician #1's timecard revealed, on 09/18/2021, she had continued to work on the unit until 10:54 PM, approximately one (1) hour and forty-five minutes after the incident with Patient #18 had been observed by MHT #16.

Review of the "Summary of Events" report revealed, on 09/18/2021 at 9:17 PM, Patient #18 had not followed staff directions at bedtime, and had acted out on the unit by slamming doors to rooms. He/she had also walked into other patient rooms. The report stated MHT #16 went to help MHT Lead Technician #1 because of the tension between the MHT Lead Technician #1 and Patient #18 had escalated. The MHT Lead Technician #1 would not allow MHT #16 to intervene, and stated, "She had this." MHT #16 stated she then observed MHT Lead Technician #1 grab the patient under the left shoulder, on the inner left arm biceps area. MHT Lead Technician #1 then picked up the patient enough that the patient's left foot came off the ground. Continued review of the report revealed MHT #16 described the maneuver as snatching the patient. MHT #16 heard MHT Lead Technician #1 yell at the patient to go to bed and observed the Lead Technician #1 throw the patient on the bed. Patient#18 complained of pain in his/her arm and wrist to MHT #16. Per the report, the video footage review of this event was skipped by a delay and did not display from 9:08 PM until 9:09 PM. The video footage only showed the patient already on the bed, sitting in an Indian style position at 9:09 PM. MHT Lead Technician #1 was seen yelling on video at the patient with unfriendly facial expressions. The video revealed MHT Lead Technician #1 proceeded to jerk the patient abruptly, grab the patient's ankle forcefully pulling the patient down into a lying position. The action had been made for no apparent cause. MHT Lead Technician#1 proceeded to walk away and looked at the patient in an un-friendly way. MHT Lead Technician#1 then proceeded to sit in the patient's doorway for the next hour. Per the clinical record, there were no seclusion orders. Per the report, Patient #18 displayed fear by his/her facial expressions, and the body language of MHT Lead Technician#1 in the footage review. Patient #18 complained of pain in arm/wrist to MHT #16, and review revealed RN #27 did not assess the patient, as it was not her patient for the shift, and the patient was asleep at the time it had been reported to her, on 09/19/20021 at 1:00 AM, by MHT #16. The report revealed the "Patient Injury Assessment", or an "Event Summary" had not been found in the clinical record at this time. The incident had then been reported to RN Supervisor #4 by RN Supervisor #3, on 09/19/2021 at 8:00 AM. On 09/19/2021 at 8:00 AM, the Director of Nurses (DON) completed notifications. The DON notified the patient's Guardian and Physician #3. The Guardian became upset and expressed the patient was not safe in the facility and wanted him/her discharged.

Telephonic interview with MHT #16, on 09/30/2021 at 12:45 PM, revealed, on 09/18/2021, between 8:00 PM and 9:00 PM, she had worked on the Rainbow Unit. MHT #16 revealed that later in the evening, MHT Lead Technician#1 had been in an argument with Patient #18 because it was the patient's bedtime. The patient had slammed doors, and she had been concerned because she did not want the patient to slam their fingers in the door. She stated the patient agreed to stop, and to calm down, and she did get him/her to calm down and encouraged the patient to sit on his/her bed. She stated MHT Lead Technician #1 must have observed the patient in his/room and still not in bed, so MHT Lead Technician #1 entered the patient's room, and literally pushed MHT #16 aside. She stated she observed MHT Lead Technician #1 grab the patient on his/her left side, on top of his/her arm, and right before the shoulder, and lifted the patient off the floor, and threw him/her into the bed. She stated Patient #18 was a very small person. She revealed at that point, MHT Lead Technician #1 handed her book to MHT #16 and told her to assume care of all of her patients, as she proceeded to get a chair, and sit right outside of Patient #18's room. MHT#16 revealed she later reported her observation to RN # 27. MHT #16 revealed she could not recall if RN #27 went to Patient #18's room or not, because RN#27 had informed her that she was not Patient #18's nurse. MHT #16 stated, she had also gone directly to HR the following morning and provided a statement, which was sent directly to Risk Management. The MHT stated staff had all received recent training on abuse, and what had to be done if you witness abuse. She revealed she had immediately reported what she had observed to RN #27, as well as Nurse Supervisor #3.

Telephonic interview with MHT Lead Technician #1, on 09/30/2021 at 2:20 PM, revealed she worked at the facility from 2:30 PM until 11:30 PM. She stated an allegation of abuse had been made against her on a night that one (1) of the patients on the Rainbow Unit had become defiant and refused to go to bed. MHT Lead Technician #1 revealed the allegation was that she had picked Patient #18 up and threw him/her on the bed. She revealed when she had gone to re-direct the patient, she had held the patient lightly on the left side of his/her armpit, but she had not lifted the patient off the ground. She went onto state Patient #18 had climbed up on the bed on his/her own and seemed to be fine. She stated once she told the patient to lay down, he/she had laid down. She revealed she had completed her entire shift, and she had sat in a chair, outside of the patient's room because whenever a patient became defiant, she would usually sit outside of the patient's door, to provide reassurance to the patient. She revealed no one at the facility had spoken with her about the allegation until the next morning. She went onto state she had to be stern with Patient #18 on that night, and by stern, she meant she told the patient, no and to get in the bed. Per interview it was never appropriate for staff to put their hands on a patient, unless there was danger involved. MHT Lead Technician #1 stated the facility had provided recent training on abuse.

Telephonic interview with RN #27, on 09/30/2021 at 2:29 PM, revealed she did not see or witness the alleged event between Patient #18, and MHT Lead Technician #1. She stated MHT #16, who had witnessed the event, had approached, and informed her about the incident between Patient #18 and MHT Lead Technician #1. RN #27 stated she had instructed MHT 16 to notify the Nursing Supervisor because the allegation was serious, and it needed to be reported. She revealed together, she, and the MHT informed the Nurse Supervisor, and Nurse Supervisor #3 informed both the MHT and the RN, that she would inform Administration, and the Director of Nurses (DON) about the incident. RN #27 stated the next thing she knew was MHT Lead Technician #1 had been put on leave. She revealed Patient #18 had not been her patient, and she had made the patient's nurse (RN #28) aware of the allegation

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the safe, and appropriate use of restraints and seclusion had been implemented for two (2) of nineteen (19) sampled patients, Patient #1, and Patient # 18.

1. Patient #1 was observed, on the facility's video camera footage, escorted by former Mental Health Technician (MHT) #14, with the use of a physical restraint. However, the use of MHT #14's physical restraint techniques used on Patient #1 were not per facility protocol.

2. Patient #18 was placed in seclusion in his/her room, by MHT Lead Technician #1, without a Physician's Order.

The findings include:

Review of the facility's policy and procedure titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion", dated 01/2021, revealed the policy's purpose was "to assure compliance with all laws, rules, and regulations related to federal and state health care programs". Per review, the facility "supported each patient's right to be free from restraint or seclusion and therefore limited the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff. Restraint/seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or a substitute for adequate staffing. The patient's rights, dignity, privacy, safety, and well-being will be supported and maintained. Restraint or seclusion will be discontinued as soon as possible." Review revealed the policy defined a physical escort as "using a light grasp to escort a patient to a desired location. If the patient can easily remove or escape the grasp, it is not a physical restraint. If the patient cannot easily remove or escape the grasp this would be a physical restraint." Per the policy, a physical restraint was defined as the application of any manual method that immobilized or reduced the ability of a patient to move his/her arms, legs, body, or head freely. Review revealed physical restraint was also called a therapeutic hold, protective hold, or manual restraint. Review revealed if a patient was involuntarily restricted to a room alone, and/or staff were physically intervening to prevent the patient from leaving the room or giving the perception that threatened the patient with physical intervention if the patient attempted to leave the room it was seclusion. Further review revealed if a restraint or seclusion was used, in emergency situations only, it required an order from the Physician. Seclusion episode for a patient under age eighteen (18) shall require notification of a family member, parent, guardian, or conservator. Debriefing following the use of seclusion was important to reduce the use of recurrent seclusion. When a patient had presented behavior that was dangerous to self, or others, so that seclusion was necessary, a review and modification to the treatment plan was indicated within eight (8) hours to reflect the problem associated with the seclusion/restraint, goals related to prevention of further restraint/seclusion, interventions which define alternative approaches to address the identified problem, and review of the plan with the patient. The use of seclusion would be thoroughly documented in the patient's medical record. Training requirements for all direct patient staff would receive on-going training and demonstrate an understanding of staff behaviors impact on the behaviors of patients and recognizing signs of any incorrect application of a restraint.

Review of the facility's "Handle with Care Behavior Management System" Participant Manual, dated 2006, revealed guidance for a Primary Restraint Technique (PRT) - Solo Takedown" as follows: Initiate the Takedown- take a long step back lowers staff center of gravity, drawing the patient off balance. Staff palm were against the patient's back to support his/her weight, then staff take a deep step back, lowers their knee to the floor slowly staging the patient's descent to a sitting position, and then staff drop one knee. Then, staff should drop their other knee, and bring the client to a sitting position.

1. Closed record review revealed the facility admitted Patient #1, on 08/22/2020, with the following diagnoses: Suicidal and Homicidal Ideation, Disruptive Mood Dysregulation Disorder, Major Depressive Disorder recurrent, severe and without Psychosis. Patient #1 also had a history of mild Cerebral Palsy that resulted in spasms in his/her legs.

Observation of video camera footage with the Chief Executive Officer (CEO), and the Assistant Director of Nursing (ADON), on 09/08/2021 at 2:45 PM, revealed, on 10/15/2020, at approximately 3:45 PM, Patient #1 had been placed into a physical restraint, and taken into the Seclusion Room by Mental Health Technician (MHT) #14. Upon entrance to the Seclusion Room, former MHT #14 was observed to drop the patient onto the concrete floor and the patient landed on his/her right side. Continued observation of the video camera footage revealed former MHT #14 was observed to hyperextend the patient's neck, and place his hand around the patient's jaw, and neck area. Once the patient went into a supine position, staff placed a regular pillow under his/her head.

Interview with former MHT #14, on 09/09/2021 at 9:48 AM, did not occur, however, a message was left for a callback, he did not return the call during the course of the survey.

Interview, on 09/10/2021 at 9:17 AM, with the Risk Manager (RM) Coordinator revealed she was a patient advocate and used to work at the facility as a MHT and she also instructed staff with the facility's eight (8) hour Crisis Management class called, "Handle with Care." She revealed, this was a hands on and in person training, where employees were provided with a participant manual. Continued interview revealed it was okay for staff to put their hands on a patient, but staff have to appropriately and properly put hands on a patient. She revealed staff were instructed how to appropriately and safely sit patients down on the ground during the restraint process, but it was not okay to drop or throw a patient onto the floor. The RM Coordinator stated the former Risk Manager previously evaluated and observed restraint/seclusion videos for proper, or improper techniques, but she did not know if anyone was doing that now. She stated the facility could not correct improper techniques, unless the facility was aware, and the facility should re-train staff. She revealed, she tried to go to all restraint and seclusion events (Code Blue) to observe staff, and what was going on during the event.

Interview, on 09/10/2021 at 10:33 AM, with the Assistant Director of Nursing (ADON) revealed while watching the video from 10/15/2020, she had observed errors staff had made. Per interview staff should not have grabbed Patient #1 by his/her neck during the restraint, and the patient had not been transitioned to the floor properly. She revealed an impact cushion was thicker than a regular pillow and were available for staff to use under a patient's head during a restraint.

Interview with the Risk Manager (RM), on 09/15/2021 at 10:00 AM, revealed she had reviewed the camera footage from 10/15/2020. She stated she did not like the way Patient #1 had been taken to the floor upon entry into the Seclusion Room. She stated, it appeared to her that staff also hyperextended the patient's neck.

Interview on, 09/16/2021 at 9:00 AM, with Registered Nurse (RN) Supervisor #1, revealed staff received training on restraints (Handle with Care) as well as other in-services. She stated, it was not appropriate to throw a patient down on the floor during a restraint. She revealed staff should step back from the patient and set them down on their buttocks. She revealed if a patient was in a hold, it was not appropriate for the patient to be in the Seclusion Room.

2. Closed record review revealed the facility admitted Patient #18, on 09/10/2021, with the diagnosis of Disruptive Mood Dysregulation Disorder. Continued review revealed there was no documented evidence of a physician's order for seclusion event on 09/18/2021.

Observation of the facility's video camera footage revealed, on 09/18/2021 at 9:10 PM, Patient #18 was sitting at the head of his/her bed with his/her legs crossed. Continued observation revealed Lead Mental Health Technician #1 walking around to the left side of Patient #18's bed. Lead Mental Health Technician #1 was observed to use both of her arms/hands to grasp both of the patient's lower legs/feet, and pull the patient from a sitting position, to a supine position. Per observation, she then threw a linen sheet over the patient, and exited the patient's room.

Telephonic interview with MHT #16, on 09/30/2021 at 12:45 PM, revealed, on 09/18/2021, between 8:00 PM and 9:00 PM, MHT Lead Technician #1 had been in an argument with Patient #18 because the patient did not want to go to bed. MHT #16 stated the patient had slammed doors, and she had been concerned because she did not want the patient to slam their fingers in the door. She stated the patient agreed to stop, and to calm down. She stated she did get the patient to calm down and had encouraged the patient to sit on his/her bed. MHT #16 went on to reveal MHT Lead Technician #1 had observed the patient in his/her room and the patient was still not in the bed. She stated the MHT Lead Technician #1 entered Patient #18's room, and literally pushed her (MHT #16) aside, grabbed the patient on his/her left side, on top of his/her arm, and right before the shoulder, and lifted the patient off the floor, and threw him/her onto the bed. She stated Patient #18 was a very small person. Continued interview revealed MHT Lead Technician #1 then handed her a book and instructed MHT #16 to assume care of MHT Lead Technician #1's patients. MHT #16 stated MHT Lead Technician #1 then proceeded to get a chair and sat right outside of Patient #18's room.

Telephonic interview with MHT Lead Technician #1, on 09/30/2021 at 2:20 PM, revealed an allegation of abuse had been made against her on a night that one (1) of the patients on the Rainbow Unit had become defiant, and refused to go to bed. MHT Lead Technician #1 stated the allegation was that she had picked Patient #18 up and threw him/her on the bed. Continued interview revealed when she had gone to re-direct the patient, she had held the patient lightly on the left side of his/her armpit, but she had not lifted the patient off the ground. Patient #18 had climbed up on the bed on his/her own and seemed to be fine. She stated once she told the patient to lay down, he/she had laid down. She revealed she had completed her entire shift, and she had sat in a chair, outside of the patient's room because whenever a patient became defiant, she would usually sit outside of the patient's door, to provide reassurance to the patient. She revealed no one at the facility had spoken with her about the allegation until the next morning. Per interview she stated she had to be stern with Patient #18 on that night, and by stern, she meant she told him/her no, and to get in the bed. She went on to state it was never appropriate for staff to put their hands on a patient, unless there was danger involved. MHT Lead Technician #1 stated the facility had provided recent training's on abuse.

Telephonic interview, on 09/30/2021 at 2:29 PM, with RN #27, revealed she had gone outside to smoke, and when she returned to the unit, MHT Lead Technician #1 was sitting outside of Patient #18's door.

Interview with the Director of Nursing, on 09/24/2021 at 9:00 AM, revealed patient safety was the facility's number one (#1) goal. She stated all staff have to follow the processes the facility had put into place to ensure the patients were kept safe.

Interview with the Risk Manager (RM), on 09/30/2021 at 3:30 PM, revealed Patient #18's family was upset with the incident that occurred between the patient, and the MHT Lead Technician #1, and had already filed a complaint with the Compliance Hotline, and she had relayed this information to the CEO. She stated MHT #16 had not reported what she had witnessed right away because she was scared and intimidated by MHT Lead Technician #1. She stated MHT #16 waited until 1:00 AM, the following morning (09/19/2021) to report the incident to RN #27. The RM revealed no staff went to Patient #18's room to check on him/her, but someone should have.

Interview with the CEO, on 10/07/2021 at 8:27 AM, revealed two (2) years ago, the facility had a high number of restraints, which has now been reduced. He stated his goal was to eliminate seclusion, and to drastically reduce restraints on the Child Unit. He stated staff should treat the patients right.

Based on observation, interview, record review, and review of the facility's policy, it was determined the governing body failed to have an effective system in place to ensure the Quality Assurance Performance Improvement program performed appropriate monitoring and audits to ensure patient's rights were protected and promoted. The facility failed to ensure patients had the right to care in a safe setting for two (2) of nineteen (19) sampled patients (Patient #2, and Patient #3), failed to ensure patients had the right to be free from abuse and harassment for five (5) of nineteen (19) sampled patients (Patient #1, Patient #6, Patient #15, Patient #16, and Patient #18), failed to ensure patients had the right to safe, and appropriate restraint and seclusion techniques for two (2) of nineteen (19) sampled patients (Patient #1, and Patient #18) and failed to ensure patients had the right to personal privacy for one (1) of nineteen (19) sampled patients (Patient #4).

Record review and interview revealed the facility failed to ensure Patient #2 did not carry contraband into the facility and onto the patient unit (razor, leggings) resulting in self-harm on 03/01/2021 and 03/10/2021, failed to ensure chemicals had been properly stored or supervised resulting in Patient #2 accessing chemicals and drank an indeterminate amount and failed to ensure plastic eating utensils were properly stored or supervised resulting in Patient #2 obtaining a plastic fork, breaking the fork and injuring his/herself with the broken fork.

Record review and interview revealed the facility failed to implement appropriate interventions for elopement. Patient #3 eloped from the facility multiple times through an unsecured exit door. On 09/09/2021, staff allowed Patient #3 to elope once again, and when the police arrived, a struggle occurred, during which the patient and Police Officer fell to the ground. As a result of the fall, Patient #3 experienced a broken arm which required surgical repair.

Observation of video footage, record review and interview revealed the facility failed to protect Patient #1 and Patient #18 from staff physical abuse. Review of video footage revealed staff striking Patient #1 across the face during a restraint and staff grabbing the legs of Patient #18 to force the patient from a seated to lying position.

Record review and interview revealed the facility failed to protect Patient #6, Patient #15, and Patient #16 from abuse.

Record review and interview revealed the facility failed to protect Patient #4's private information from other residents.

The findings include:

Review of the Quality Assurance and Performance Improvement Plan (QAPI), dated 01/2021 revealed, the Governing Body of the facility "has the ultimate responsibility and authority to establish, maintain and support an effective Quality Assessment Performance Improvement (QAPI) program. The Governing Body assures that the necessary structures are established, and the processes are implemented to assess and continually improve the overall quality and efficiency of patient care. The Governing Body receives and acts upon recommendations regarding quality assessment and improvement activities".

Review of the PI Meeting Agendas, dated 06/25/2020 through 02/25/2021, revealed National Patient Safety Goals had been discussed at each meeting.

Review of the Facility's Environment of Care (EOC)/Life Safety Committee minutes, dated 01/26/2021, revealed Risk Management reported the facility's cameras continued to be reviewed and checked regularly. Per review, Risk Management had continued to review the cameras for holds, and restraints that had occurred during patient incidents, and a Reduction Performance Improvement (PI) plan had been developed, and implemented.

Review of the Environment of Care (EOC)/Life Life Safety Committee minutes, dated 02/23/2021, revealed data on restraints and seclusions was being tracked, analyzed, and reported monthly, and the facility had met their goals.

Review of the EOC/Life Safety Committee minutes, dated 03/30/2021, revealed Risk Management reported the cameras continued to be reviewed and checked regularly. Per review, PI reported the goals for the Performance Plan had been met.

Review of the Medical Executive Committee (MEC) Fourth Quarter 2020 Annual Meeting Minutes, dated 01/29/2021, revealed the former Risk Manager reported Performance Improvement (PI) activities to include; patient satisfaction goals, reduction of seclusions/restraints, discharge planning, and a decrease in medication errors. Per review, PI had reported the Restraint Reduction report for the first quarter of 2021.

Review of the MEC/Governing Body Minutes, dated 07/21/2021, revealed PI provided a thorough overview of the facility's current situation in regard to declines in restraints, patient aggression, elopements, and falls.

Interview with the Risk Manager (RM), on 09/15/2021 at 10:00 AM, revealed she was a member of the Quality Assurance and Performance Improvement Plan committee. She stated the first responsibility of the facility was to keep all the patients safe and ensure all employees had received training on abuse, and in the proper use of restraint and seclusion. Per interview the members included Health Information Management (HIM), Admissions, Nursing, Infection Preventionist, Human Resources, and the Medical Director. She stated the Performance Improvement Committee had met during the time of this survey, and all the data from reports, and investigations of any allegations of abuse were aggregated, and incorporated into PI for discussion.

Interview with the Chief Executive Officer (CEO), on 10/07/2021 at 8:27 AM, revealed he was a member of the Quality Assurance and Performance Improvement Plan (PI) committee. The committee members included Nursing, Infection Preventionist, the Medical Director, Health Information Management, Risk Management and Admissions. Per interview, information and data discussed in the Quality Assurance and Performance Improvement Plan (PI) committee was presented to the governing body. Continued interview revealed the governing body reviewed all issues that pertained to the safe operation of the facility.

Refer to A-0286.

Based on observation, interview, record review, and policy review, it was determined the facility failed to implement an effective Quality Assurance Performance Improvement Program (QAPI) to ensure the patient's right to receive care in a safe setting for seven (7) of nineteen (19) sampled patients (Patients #1, #2, #3, #6, #15, #16 and #18).

The findings include:

Observation of the facility's Military Unit 2 and accompanied by Assistant Director of Nursing (ADON), on 09/01/2021 at 8:00 AM, revealed a container of Super Sani-Cloth® Germicidal Disposable Wipes sitting on the Nurse's Station Desk readily accessible to the patients on the unit. Further observation revealed several patients in the area around the Nurse's Station Desk.

Observation of the facility's Front Lobby Receptionist performing a metal detector screening demonstration, on 09/03/2021 at 10:00 AM, revealed the employee did not scan the Surveyor's hands with the metal detector wand or ask the Surveyor to open her hands.

Observation with the ADON of Classroom #5, on 09/08/2021 at 8:00 AM, revealed an instructor sitting behind a desk. Continued observation revealed directly behind the instructor was a container of Sani-Wipes with a purple lid, unsecured and accessible to the patients.

Review of the facility's policy and procedure titled, "Patient Safety Council," dated 01/2021, revealed "the Patient Safety Council was designed to improve patient safety, reduce risk and respect the dignity of those we service by assuring a safe environment." Review revealed the policy related specifically to minimize physical injury, undue psychological stress, and accidents during a patient's hospitalization. "The organization-wide safety program will include all activities contributing to the improvement and maintenance of patient safety." Per the policy, "leadership is responsible for establishing a culture of safety that minimizes hazards and potential patient harm by focusing on processes of care. The leadership will foster a safe environment through their personal example; emphasizing patient safety as an organization priority; providing education to all staff regarding the commitment to reduction of adverse outcomes; supporting proactive reduction in adverse outcomes; and integrating patient safety priorities into the new design and redesign of all relevant organization processes, functions and service. Per the policy, the Patient Safety Measures also included an emphasis on the provision of care, treatment and services, and the function of the environment of care. Further review revealed the facility's Chief Executive Officer (CEO) was to chair the Patient Safety Council, and the Patient Safety Officer would be the Director of Performance Improvement/Risk Management.

Review of the facility's policy and procedure titled, "Patient Rights," dated 01/2021, revealed the facility "recognizes and respects the dignity of each person admitted and desires to prevent any measures which might lead to prohibition of rights. It is the policy of the hospital to ensure protection and support of fundamental human, civil, constitutional, and statutory rights of each person served by the hospital insofar as is within the reasonable capabilities and limitations of the hospital and consistent with treatment". Continued review revealed "the patient has the right to receive care in a safe setting".

Review of the facility's policy and procedure titled, "Restriction of Patient Rights," dated 01/2021, revealed "cause for denying a patient the exercise of a right exists when the person authorized to deny patient's rights has good reason to believe: that the exercise of the specific right would be injurious to the patient; or that there is evidence that the specific right, if exercised, would 1) seriously infringe on the rights of others; or 2) the facility would suffer serious damage if the specific right is not restricted; and that there is 3) no less restrictive way of protecting the interests specified in 1), 2), or 3)."

Review of the facility's policy and procedure, titled "Patient Abuse, Neglect, and/or Harassment", dated 01/2021, revealed the facility "does not tolerate abuse, neglect, or harassment of patients whether from staff, other patients, or visitors". The facility "has a system whereby all suspected incidents or patient complaints of abuse, neglect, or harassment were investigated and acted upon". The facility employees were trained in the prevention, identification, and reporting procedure for suspected patient abuse, neglect, or harassment. The facility defined abuse as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. this includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect is considered a form of abuse and was the failure to provide goods and services necessary to avoid harm, mental anguish, or mental illness. Harassment is threatening, or tormenting behavior". Per the facility's policy, "reporting suspected incidents of patient abuse, neglect or harassment are reported (either verbally or in writing,) to the Charge Nurse or Nurse Manager and will receive immediate attention and response. The Charge Nurse or Nurse Supervisor assesses the situation, takes appropriate action to secure patient safety, and called the Director of Risk Management and the CEO, or the Administrator on-call for further instruction". Continued review revealed if a facility "employee is accused of patient abuse, neglect, or harassment, he/she is immediately removed from all patient care areas and placed on Administrative Leave until the allegation is substantiated or unsubstantiated through investigation". Per the policy, "if a patient is accused of abusing, neglecting, or harassing another patient, the patient suspected of abuse is separated from the general patient milieu and is placed on close supervision until it is determined that the patient no longer poses a threat to the suspected victim. Patients having a 'substantiated' incident of patient abuse, neglect or harassment may be reported to the police department and/or other authorities as specified in the Abuse/Neglect Reporting policy." The charge nurse would complete an Incident Report, and the Incident Report would be sent to Risk Manager (RM). The facility patients were protected from abuse during the investigation of allegations of abuse, neglect, or harassment from the direct care areas of the building. "If another patient was accused of abuse, neglect, or harassment, the patient suspected in the incident is removed from the general patient milieu and is kept on a 1:1 observation until it can be determined that the patient is no longer a threat to the patient making the allegation". Incidents of abuse, neglect, or harassment would be discussed, and therapeutic interventions identified by the Treatment Team as part of the treatment planning for the patient making the accusations, and for any patients who were accused. The Director of Risk Management would begin an investigation as soon as he/she was in receipt of an incident of patient abuse, neglect, or harassment, usually this was the following business day, following the incident. However, the CEO or AOC may initiate an investigation as soon as they were notified of an incident of patient abuse, neglect, or harassment.

Review of the facility's policy and procedure titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion", dated 01/2021, revealed the policy's purpose was "to assure compliance with all laws, rules, and regulations related to federal and state health care programs". Per review, the facility "supported each patient's right to be free from restraint or seclusion and therefore limited the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff. Restraint/seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or a substitute for adequate staffing. The patient's rights, dignity, privacy, safety, and well-being will be supported and maintained. Restraint or seclusion will be discontinued as soon as possible." Review revealed the policy defined a physical escort as "using a light grasp to escort a patient to a desired location. If the patient can easily remove or escape the grasp, it is not a physical restraint. If the patient cannot easily remove or escape the grasp this would be a physical restraint." Per the policy, a physical restraint was defined as the application of any manual method that immobilized or reduced the ability of a patient to move his/her arms, legs, body, or head freely. Review revealed physical restraint was also called a therapeutic hold, protective hold, or manual restraint. Review revealed if a patient was involuntarily restricted to a room alone, and/or staff were physically intervening to prevent the patient from leaving the room or giving the perception that threatened the patient with physical intervention if the patient attempted to leave the room it was seclusion. Further review revealed if a restraint or seclusion was used, in emergency situations only, it required an order from the Physician. Seclusion episode for a patient under age eighteen (18) shall require notification of a family member, parent, guardian, or conservator. Debriefing following the use of seclusion was important to reduce the use of recurrent seclusion. When a patient had presented behavior that was dangerous to self, or others, so that seclusion was necessary, a review and modification to the treatment plan was indicated within eight (8) hours to reflect the problem associated with the seclusion/restraint, goals related to prevention of further restraint/seclusion, interventions which define alternative approaches to address the identified problem, and review of the plan with the patient. The use of seclusion would be thoroughly documented in the patient's medical record. Training requirements for all direct patient staff would receive on-going training and demonstrate an understanding of staff behaviors impact on the behaviors of patients and recognizing signs of any incorrect application of a restraint.

Review of the facility's policy and procedure, titled, "Incident Reporting", dated 01/2021, revealed the purpose of the policy was to provide a systematic process for documentation, tracking and trending all incidents to ensure proper management and timely implementation of risk management /quality of care strategies. Any incident which was not consistent with the routine delivery of care or operation of the hospital or expected outcomes of patients shall be promptly, accurately, and factually reported by the witnessing or having knowledge of the incident.

Review of the facility's policy and procedure titled "Metal Detector," dated 01/2021, revealed the facility "recognizes the patients' right to privacy, dignity, to be free from unnecessary searches; and to keep and use their personal property. Patients, staff, and visitors also have the right to a safe and therapeutic environment, which necessitates the hospital safeguard against items that may present a hazard to personal safety or the therapeutic environment." Per the policy "the patient is scanned with a metal detector wand prior to the admission assessment. The patient is instructed to empty their pockets and take off their shoes prior to using the metal detector wand. Any contraband or unsafe items are removed during the search and given to a family member if present, if nobody present, staff will take measures to secure their belongings. Any illegal drugs or weapons found on a patient during the admission search will be confiscated and turned over to local law enforcement for proper disposal".

Review of the facility's policy and procedure titled "Contraband," undated, and was the policy in effect when Patient #2 was admitted by the facility. Continued review revealed leggings, jeggings, tights, sharp objects, weapons, or anything which could be used as a weapon, was to be sent home with the patient's family on admission or stored in the patient's personal effects until discharge.

Review of the facility's revised policy and procedure titled "Contraband, "dated, 03/03/2021, revealed Leggings, Crocs, sharp objects, metal items, weapons, or anything which could be used as a weapon was to be sent home with the patient's family upon admission or stored in the patient's effects until he/she was discharged.

Review of the facility's policy and procedure titled, "Environment of Care Committee," dated, 01/2021, revealed "the administration and senior leadership of the facility are responsible for safety and security."

Review of the facility's Safety Data Sheet (SDS) for the product "Super Sani-Cloth® Germicidal Disposable Wipe," dated 06/20/2021, revealed the product might cause irritation of the respiratory tract and might be harmful if inhaled. Per review, the product caused serious eye irritation, and redness, itching, and pain to the skin. Review revealed prolonged contact with the skin might cause irritation, with drying and dermatitis. Further review revealed if the product was ingested it might cause gastrointestinal irritation, nausea, vomiting and diarrhea. In addition, the SDS revealed the product might be harmful if swallowed and might cause drowsiness or dizziness.

1. Closed medical record review revealed the facility admitted Patient #2 (voluntarily), on 02/27/2021, with diagnoses to include Schizoaffective Disorder, Depressive Type, Borderline Personality Disorder and Severe Alcohol Disorder. Continue review revealed Patient #2 had been scanned with the metal detector wand, on 02/27/2021, on admission and had been cleared to enter the facility.

Review of Patient #2's "Psychiatric Evaluation," dated 02/27/2021 at 6:19 PM and signed by Physician #3, on 03/29/2021, revealed the justification for hospitalization included hallucinations, delusions, agitation, anxiety, depression resulting in significant loss of functioning, and he/she was a danger to self and or others or property. Continued review revealed the Patient #2 required a controlled environment and had emotional or behavioral conditions and complications requiring twenty-four (24) hour medical and nursing care. Review revealed Patient #2's justification for hospitalization by Physician #3 also included his/her failure of social or occupational functioning, and failure of treatment at a lower level. The evaluation revealed Patient's #2's chief complaint, in his/her own words was depression, alcohol (ETOH) abuse, and suicidal ideation (SI). Further review revealed Patient #2 reported severe anxiety, self-harm, and SI on admission. In addition, Patient #2 had reported increased issues with command type hallucinations to harm, and hurt self, and reported self-harming with cuts on arms, stomach, legs, and upper arms.

Review of the "Intake Assessment," dated 02/27/2021 at 6:30 PM, and signed by Registered Nurse (RN) #9 at 9:00 PM, revealed Patient #2 reported he/she had a plan to cut his/her wrists, and to hang his/herself. Per review, Patient #2 denied a history of violence, or threats against others. Continued review revealed the Suicide Risk Assessment noted Patient #2 scored a twenty-three (23) on the assessment and was a high risk for suicide. Review of the RN Narrative Summary, dated and signed by RN #9 on 02/27/2021 at 9:20 PM, revealed Patient #2 had been admitted to the facility's Acute Inpatient Services, and the patient talked freely about suicide and having no reason to live.

Review of Patient #2's "Final Ancillary Orders," dated 02/27/2021 at 8:00 PM, revealed Advanced Registered Nurse Practitioner (ARNP) #1 had given an order for Patient #2's Level of Observation to be completed every fifteen (15) minutes by staff. In addition, the orders included placing the patient on suicide precautions.

Review of the "High Risk Notification Alert," signed and dated, on 02/27/2021 at 9:00 PM by RN# 10 and RN #11, revealed Patient #2 historically had, and currently had suicide risk and self-harm risk.

Review of the "Personal Belongings Inventory," dated and signed on 02/27/2021 at 9:10 PM by Milieu Coordinator (MC) #1, revealed Patient #2 had presented to the facility with one (1) pair of leggings, and the leggings were stored in the patient effects (PE) area.

Review of Patient #2's "Temporary Treatment Plan," signed and dated on 02/27/2021 at 9:30 PM by RN# 9, revealed the danger to self-specific intervention focus included: encouraging the patient to seek out staff if having thoughts of harming self, questioning Patient #2 directly to determine whether the patient had any thoughts to harm self and ensuring his/her room was cleared of sharp objects. Further review revealed the self-injurious-specific intervention focus included for staff to observe the patient for self-injurious thoughts/behaviors and to prompt the patient to utilize positive coping skills; however, there was no documented evidence of coping skills identified by staff.

A) Review of Patient #2's "Interdisciplinary Master Treatment Plan", dated 03/01/2021, revealed the facility had developed a Depression with Suicidal Ideation Individual Treatment Plan (ITP) that addressed Patient #2's reported suicidal ideation with no plan. Review of Problem #1, the patient endorsed increased depression for four (4) days after his/her last discharge and reported cutting self to relieve anxiety, with cuts to his/her arms, stomach, and legs. Continued review of the "Interdisciplinary Master Treatment Plan" revealed Problem #3 was the Assaultive/Aggressive/Self Harm ITP for Patient #2 which addressed being found with a razor blade hidden in his/her clothing which had not been removed during the admission process. Per review of Problem #3, Patient #2 had subsequently cut his/her arms deep enough to require stitches, and a staff member had also been cut by the patient.

Review of the incident report for Patient #2 revealed, on 03/01/2021, the patient had a razor blade hidden in his/her shoe. He/she took the razor blade out of his/her shoe and was slicing his/her arms. The staff found blood and something metal in his/her hand. Staff tried to get the patient to hand it over and he/she refused. Staff grabbed the patient's arms and had to force the blade out of his/her hand. The patient had blood everywhere. Wounds were cleaned by a nurse, and the patient was sent to the local Emergency Department. The patient returned to the facility, on 03/02/2021 at 12:30 AM.

Review of the "Outside Consultation Form, dated 03/01/2021, no time, revealed Patient #2 had been evaluated at a local hospital Emergency Department (ED) for a self-inflicted laceration. Per review, the ED Physician recommended keeping the patient's wounds clean and dry, and to follow-up with the acute care hospital for suture removal in ten (10) to twelve (12) days.

Review of the, "Nursing Progress Note," signed and dated 03/01/2021 at 8:30 AM by Registered Nurse (RN) #7 and prior to Patient #2's self-harm of cutting on 03/01/2021, revealed Patient #2 continued to report auditory and visual hallucinations, and was positive for Suicidal Ideation with a plan to cut his/her wrist. The patient reported he/she had started to work out the details of how to kill his/herself. Continued review of the assessment revealed the patients last suicide attempt had been on 12/28/2020, when he/she had cut his/her wrists; however, there was no documented evidence the facility implemented interventions.

Review of the "Psychosocial Assessment," dated 03/01/2021 at 3:01 PM, and signed by Clinical Social Worker #1 (prior to Patient #2's self-harm of cutting on 03/01/2021), revealed Patient #2 reported a plan to cut his/her wrists and to hang his/herself. The patient reported hallucinations to harm and hurt self; however, there was no documented evidence the facility implemented additional interventions.

Review of Physician #3's Observations/Precautions, dated 03/01/2021, revealed Therapy/Treatment for Patient #2 included unit restrictions, visualized body exam for hidden weapons and no shoes related to two (2) previous elopements and a razor hidden in his/her "Croc" shoe.

Continued review of the "Nursing Progress Note," signed and dated by RN #8, on 03/01/2021 at 7:55 PM, revealed Patient #2 had been uncooperative with staff and the patient was found with contraband and had caused self-inflicted wounds. Per the Nursing Progress Note, Patient #2 had Suicidal Ideations with plan to cut self.

Review of the "Additional Nursing Progress Notes," dated 03/01/2021 and signed by RN #15, revealed Patient #2 was calm, and cooperative when he/she arrived back at the facility. Continued review revealed Patient #2 had over forty lacerations to his/her forearms to upper shoulders that were open and moist.

B) Review of the "Nursing Progress Note", dated, and signed on 03/10/2021 at 6:46 AM, by RN #12 revealed Patient #2 was thinking about harming/killing his/herself, and the patient had a plan; however, there was no documented evidence the facility implemented additional interventions.

Review of the "Every Fifteen (15) Minute Check Report," dated and signed on 03/10/2021 at 8:18 PM, by Milieu Coordinator (MC) #2 revealed around 7:00 PM, Patient #2 was observed sitting at the end of the hallway alone. Per the report, the Milieu Coordinator walked down to check on the patient and discovered the patient was cutting his/her arms with something metal. The MC stopped the patient, and the supervisor came to the unit. The patient has several cuts on his/her arms. The patient's room was searched thoroughly, and nothing was found.

Record review of the facility's incident report revealed, on 03/10/2021, the patient had been sitting on the unit, at the end of the hall. A Mental Health Technician (MHT) walked down to check on the patient, and the patient was cutting his/her arms with something metal. The MHT stopped the patient, and the supervisor came to the unit. There were several cuts on his/her arms. The piece of metal used to cut his/herself was confiscated. Patient #2 reported having this metal since admission. Patient #2 was searched thoroughly, and nothing new found.

Continued review of the "Nursing Progress Note", dated and signed, on 03/10/2021 at 8:00 PM, by RN # 13, revealed Patient #2 became upset when he/she was not allowed to go into his/her room. The patient stated, "you will be sorry". The patient eventually went to the end of the hall, and staff kept check on him/her, but he/she was able to cut his/herself at 7:00 PM. The patient stated the staff needed to "stop the voices". The Nurse Practitioner was notified. The patient reported pain after cutting his/herself with a piece of razor he/she had brought into the facility.

Review of the "Additional Nursing Progress Notes", dated and signed, on 03/10/2021 at 10:00 PM, stated around 6:50 PM Patient #2 had been informed he/she could not go into his/her room until medications had been given, and he/she could not go outside to smoke due to (D/T) non-participation in groups. The patient became upset and asked to be left alone. At 7:05 PM, staff had checked on the patient in the hall, and found Patient #2 was bleeding from the arms. The patient was being held already by a Mental Health Technician (MHT), and a nurse grabbed the patient's left arm and noticed a razor blade between his/her fingers. The Program Director was able to remove the blade. The patient was then placed on 1:1 observation, and orders were obtained for transport to the emergency department (ED) for evaluation of the lacerations to the right forearm, which were too extensive for basic first aid. The patient was sent out at 9:20 PM with staff escort via ambulance.

Review of the local hospital documentation revealed Patient #2 had arrived at the hospital, on 03/10/2021 at 9:42 PM, and was admitted to the emergency department (ED). Review of the History and Physical (H&P) revealed the patient complained of self-inflicted lacerations to the right forearm. Patient #2 had been seen recently with similar symptoms and had a long history of self-inflicted lacerations to bilateral arms over the years. Review of the physical examination revealed Patient #2 had two (2), four (4) centimeters (cm) gapping lacerations to the right forearm. Continued review revealed each of the lacerations required six (6) sutures to repair the wound. The patient left the ED, on 03/10/2021, and returned to the facility.

Record review of the "Final Ancillary Orders" revealed Physician #3 had given orders to place Patient #2 on 1:1 observation, on 03/10/2021 at 9:00 PM, with a stop date of 03/13/2021 at 8:00 AM.

Further review of the "Interdisciplinary Master Treatment Plan" revealed Problem #4 was a Significant Treatment Event, dated 03/10/2021, addressing Patient #2's second self-harm of cutting both forearms with a razor he/she had hidden.

C) Review of Patient #2's incident report revealed, on 03/17/2021, the patient took Clorox Bleach Germicidal Cleaner and ingested an undetermined amount. The Poison Control Center was contacted, and the facility was advised to monitor the patient with no urgent concerns. The Provider was notified, and the patient was placed on 1:1 observation.

Record review of the "Safety Data Sheet" (SDS), dated 01/15/2019, revealed "Clorox Bleach Germicidal Cleaner" may cause irritation of respiratory tract. If contact with the eye, may cause slight irritation. Skin contact may cause slight skin irritation. Ingestion may cause irritation to mucous membranes, gastrointestinal irritation, nausea, vomiting and diarrhea.

D) Review of Patient #2's incident report revealed, on 03/23/2021, the patient tied leggings around his/her neck while in the bathroom in his/her room. The patient was conscious and breathing the entire time and did not resist staff when they took the pants. Continued review of the report revealed Patient #2 stated he/she did it because of the voices. Clothes and linens were removed from the room with one-to-one observation to continue as ordered at night.

E) Review of the "Nursing Progress Notes," dated and signed by RN #16, on 03/26/2021 at 4:20 PM, stated Patient #2 had reached across, and behind the nursing station desk to where the plastic forks were stored. He/she obtained a fork and broke it. With the broken fork, he/she then began slicing at his/her previously self-inflicted wounds on his/her left forearm before a MHT could intervene. The patient refused to release the fork fragment, and fought the MHT, reportedly attempting to harm the MHT. The patient was placed in a restraint for the safety, and staff.

Review of the "Fifteen (15) Minute Check" log, dated 03/26/2021 at 5:22 PM by MHT #11, stated Patient #2 became agitated due to a remark that was made by a male peer during a clinical group. The therapist was able to process with the patient, and the peer apologized to him/her but later, the patient became angry about it again, and reached over the nursing station and grabbed a fork that was stored in that area. Staff immediately intervened but the patient was able to grab one (a fork) and break it in half. Staff struggled to get the fork from the patient and the patient almost scratched staff and did manage to scratch his/her left (L) forearm before the staff was able to restrain the patient due to an imminent risk to self and others.

Review of the incident report revealed, on 03/26/2021, Patient #2 broke a plastic fork that he/she took off the nurse's desk and began slicing at existing self-inflicted wounds on his/her left forearm before the MHT could intervene. The patient refused to release fork fragment and fought the MHT in attempts to harm the MHT.

Interview with MHT #4, on 09/01/2021 at 3:15 PM, revealed Patient #2 had gotten upset because he/she had not been allowed to go into his/her room, so the patient stayed at the end of the hallway, and sat in the corner. Per interview with MHT #4, right at shift change, around 6:45 PM, MHT #4 gave report to the on-coming MHT and glanced down the hallway at the patient. She stated something did not look right, and there he/she was, slashing both of his/her arms. The MHT revealed she pleaded with the patient to stop and the patient did stop, and the MHT asked the patient to give her the blade but the patient would not. Continued interview with MHT #4 revealed she had to grab the patient's arms from behind to stop him/her. The MHT stated that she ended up getting cut through her gloves, and across her hands, and she had to go to the ED to get a tetanus shot. She revealed the razor blade was about one-half an inch tall, and about two (2) to three (3) inches long. The MHT went on to state that she was the one who did Patient #2's admission search. She revealed she remembered the patient had a waded-up tissue that he/she carried onto the unit and Patient #2 had kept wiping his/her eye with the tissue. However, the MHT stated she had not checked the tissue, or asked the patient to throw the tissue away. MHT #4 revealed the patient told her later, that he/she had carried the razor onto the unit in this tissue. MHT #4 stated that normally, staff do not ask patients to throw away their tissues, nor do they check inside of the tissue. Further interview revealed she did not know why the metal detector wand did not detect the razor. She revealed she did believe this patient may have cut someone else if he/she had gotten mad enough. MHT #4 went onto state she had observed and stopped Patient #2 many times because he/she chased after other patients.

Interview with the Assistant Director of Nurses (ADON), on 09/01/2021, at 3:40 PM, revealed, prior to Patient#2's admission to the facility, the patient had been scanned (wanded) by the metal detector wand in the front lobby of the facility. The patient had also been required to empty his/her pockets, along with any phones, and then the patient was taken into the intake process room. She stated newly admitted patients were then escorted to their assigned unit by staff, where they were asked to un-dress from the waist down and don a paper gown. She stated, then, all the patient's belongings were searched to include their shoes. She went onto state Patient #2 had apparently hidden a very small razor in his/her Croc shoe, and the razor blade had not been discovered by the metal detector upon admission despite the process being followed. Continued interview with the ADON revealed that, on 03/01/2021, the patient had gotten upset because staff would not allow him/her access to his/her bedroom. The ADON stated the patient's door was locked during the day, to prevent the patient from isolating self and to be visible on the unit where he/she could be monitored at least every fifteen (15) minutes by the staff. She revealed when staff observed the patient, they also observed blood, and something metal in the patient's hand. Continued interview revealed apparently the patient had a razor blade hidden inside of his/her Croc shoe, took the razor blade out of his/her shoe and sliced his/her arms. The ADON stated, staff attempted to encourage the patient to hand over the blade; however, Patient #2 refused. Staff had to grab his/her arms and force the blade out of his/her hand. During this attempt to retrieve the razor, MHT #4, received a hand laceration. The patient was then transferred to the local ED for evaluation and was eventually returned to the facility and placed on a 1:1 observation. She revealed, on 03/10/2021, Patient #2 had gotten upset, and had been found by staff with another piece of razor, and cutting his/herself, again. The ADON stated, on 03/17/2021, around lunch time, Patient #2 had taken a bottle of Clorox Bleach Germicidal Cleaner off an un-attended housekeeping cart on the Adult Unit. She stated this incident should not have happened; however, on 09/01/2021 and 09/08/2021 revealed cleaning wipes were observed to be unsecured and accessible to patients. She went

Based on interview, record review, and review of the facility's video, policies and documents, it was determined the facility failed to provide adequate nursing supervision and a safe environment free from abuse for six (6) of nineteen (19) patients (Patient #1, Patient #2, Patient #6, Patient #15, Patient #16 and Patient #18).

1) Record review and interview revealed the facility allowed Patient #2 to have possession of contraband (razor blade) on two (2) separate occasions, 03/01/2021 and 03/10/2021, during which time the patient inflicted harm to self, and staff. The facility failed to ensure Clorox Bleach Germicidal Cleaner was secured and on 03/17/2021, Patient #2 ingested an unknown quantity of the product. In addition, on 03/23/2021, Patient #2 tied leggings around his/her neck while unattended in his/her room; and on 03/26/2021, the patient was allowed access to a plastic fork which he/she broke and inflicted injury to self, and attempted to injure staff.

2) Observation of the facility's video footage, dated 10/15/2020, revealed Patient #1 being taken by staff to the seclusion room during a physical restraint. Continued observation of the footage revealed a Mental Health Technician (MHT) entered the seclusion room with Patient #1 throwing the patient to the floor after entrance to the room. During the restraint and seclusion process of Patient #1, it was observed a Registered Nurse (RN) entered the seclusion room, touched the patient's chin, and proceeded to strike the patient across the face with his hand. As the restraint/seclusion process continued, the RN was not immediately suspended as required, nor was the abuse inflicted on Patient #1 reported until the following day 10/16/2020 per the facility's policies and procedures.

3) Observation of the facility's video camera footage, dated 09/18/2021 at 9:10 PM, revealed Patient #18 sitting at the head of his/her bed with his/her legs crossed. Continued observation revealed Lead Mental Health Technician #1 had walked around to the left side of the patient's bed and was observed to use both of her arms/hands to grasp both of the patient's lower legs/feet, and pulled the patient from a sitting position, to a supine position and then she threw a linen sheet over the patient and exited the patient's room.

4) Review of the facility's "Every Fifteen (q15) Minute Check" document, signed and dated, on 06/23/2020 at 10:08 PM, by MHT #1, revealed a narrative which stated, Patient #6 was hit in the face by a peer. Patient #6 was separated from the peer; however, there was no documented evidence the facility implemented their abuse protocol.

5) Review of the, "Nursing Progress Note", dated 05/21/2020 at 7:38 PM, and signed by RN #29 revealed Patient #16 was pushed by another patient twice during the medication pass; however, there was no documented evidence the facility implemented their abuse policy and protocol.

6) Review of the "BH Division Healthcare Peer Review Report" revealed the first altercation Patient #16 had with Patient #15 occurred, on 05/21/2020 at 7:21 PM. After the incident, Patient #15 had been placed on peer restriction; however, facility staff allowed Patient #15 to physically attacked Patient #16 again, on 05/21/2020 at 7:26 PM. This incident resulted in a restraint for Patient #15; however, there was no documented evidence the facility implemented their abuse policy and protocol for either of the two events on 05/21/2020.

Refer to A-0395

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. The facility failed to
adequately supervise nursing personnel so patient care would be provided in a non-abusive environment for five (5) of nineteen (19) patients (Patient #1, Patient #6, Patient #15, Patient #16 and Patient #18). The facility failed to ensure nursing services were provided in a safe environment for one (1) of nineteen (19) patients (Patient #2).

The findings include:

Review of the facility's policy and procedure, titled "Patient Abuse, Neglect, and/or Harassment", dated 01/2021, revealed the facility "does not tolerate abuse, neglect, or harassment of patients whether from staff, other patients, or visitors". The facility "has a system whereby all suspected incidents or patient complaints of abuse, neglect, or harassment were investigated and acted upon". The facility employees were trained in the prevention, identification, and reporting procedure for suspected patient abuse, neglect, or harassment. The facility defined abuse as "the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. this includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect is considered a form of abuse and was the failure to provide goods and services necessary to avoid harm, mental anguish, or mental illness. Harassment is threatening, or tormenting behavior". Per the facility's policy, "reporting suspected incidents of patient abuse, neglect or harassment are reported (either verbally or in writing,) to the Charge Nurse or Nurse Manager and will receive immediate attention and response. The Charge Nurse or Nurse Supervisor assesses the situation, takes appropriate action to secure patient safety, and called the Director of Risk Management and the CEO, or the Administrator on-call for further instruction". Continued review revealed if a facility "employee is accused of patient abuse, neglect, or harassment, he/she is immediately removed from all patient care areas and placed on Administrative Leave until the allegation is substantiated or unsubstantiated through investigation". Per the policy, "if a patient is accused of abusing, neglecting, or harassing another patient, the patient suspected of abuse is separated from the general patient milieu and is placed on close supervision until it is determined that the patient no longer poses a threat to the suspected victim. Patients having a 'substantiated' incident of patient abuse, neglect or harassment may be reported to the police department and/or other authorities as specified in the Abuse/Neglect Reporting policy." The charge nurse would complete an Incident Report, and the Incident Report would be sent to Risk Manager (RM). The facility patients were protected from abuse during the investigation of allegations of abuse, neglect, or harassment from the direct care areas of the building. "If another patient was accused of abuse, neglect, or harassment, the patient suspected in the incident is removed from the general patient milieu and is kept on a 1:1 observation until it can be determined that the patient is no longer a threat to the patient making the allegation". Incidents of abuse, neglect, or harassment would be discussed, and therapeutic interventions identified by the Treatment Team as part of the treatment planning for the patient making the accusations, and for any patients who were accused. The Director of Risk Management would begin an investigation as soon as he/she was in receipt of an incident of patient abuse, neglect, or harassment, usually this was the following business day, following the incident. However, the CEO or AOC may initiate an investigation as soon as they were notified of an incident of patient abuse, neglect, or harassment.

Review of the facility's policy and procedure titled, "Patient Rights," dated 01/2021, revealed the facility "recognizes and respects the dignity of each person admitted and desires to prevent any measures which might lead to prohibition of rights. It is the policy of the hospital to ensure protection and support of fundamental human, civil, constitutional, and statutory rights of each person served by the hospital insofar as is within the reasonable capabilities and limitations of the hospital and consistent with treatment". Continued review revealed "the patient has the right to receive care in a safe setting".

Review of the facility's policy and procedure titled "Metal Detector," dated 01/2021, revealed the facility "recognizes the patients' right to privacy, dignity, to be free from unnecessary searches; and to keep and use their personal property. Patients, staff, and visitors also have the right to a safe and therapeutic environment, which necessitates the hospital safeguard against items that may present a hazard to personal safety or the therapeutic environment." Per the policy "the patient is scanned with a metal detector wand prior to the admission assessment. The patient is instructed to empty their pockets and take off their shoes prior to using the metal detector wand. Any contraband or unsafe items are removed during the search and given to a family member if present, if nobody present, staff will take measures to secure their belongings. Any illegal drugs or weapons found on a patient during the admission search will be confiscated and turned over to local law enforcement for proper disposal".

Review of the facility's policy and procedure titled, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion", dated 01/2021, revealed the policy's purpose was "to assure compliance with all laws, rules, and regulations related to federal and state health care programs". Per review, the facility "supported each patient's right to be free from restraint or seclusion and therefore limited the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. The patient has a right to be free from restraint/seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff. Restraint/seclusion use will not be based on history of past use or dangerous behavior, as a convenience for staff, or a substitute for adequate staffing. The patient's rights, dignity, privacy, safety, and well-being will be supported and maintained. Restraint or seclusion will be discontinued as soon as possible." Review revealed the policy defined a physical escort as "using a light grasp to escort a patient to a desired location. If the patient can easily remove or escape the grasp, it is not a physical restraint. If the patient cannot easily remove or escape the grasp this would be a physical restraint." Per the policy, a physical restraint was defined as the application of any manual method that immobilized or reduced the ability of a patient to move his/her arms, legs, body, or head freely. Review revealed physical restraint was also called a therapeutic hold, protective hold, or manual restraint. Review revealed if a patient was involuntarily restricted to a room alone, and/or staff were physically intervening to prevent the patient from leaving the room or giving the perception that threatened the patient with physical intervention if the patient attempted to leave the room it was seclusion. Further review revealed if a restraint or seclusion was used, in emergency situations only, it required an order from the Physician. Seclusion episode for a patient under age eighteen (18) shall require notification of a family member, parent, guardian, or conservator. Debriefing following the use of seclusion was important to reduce the use of recurrent seclusion. When a patient had presented behavior that was dangerous to self, or others, so that seclusion was necessary, a review and modification to the treatment plan was indicated within eight (8) hours to reflect the problem associated with the seclusion/restraint, goals related to prevention of further restraint/seclusion, interventions which define alternative approaches to address the identified problem, and review of the plan with the patient. The use of seclusion would be thoroughly documented in the patient's medical record. Training requirements for all direct patient staff would receive on-going training and demonstrate an understanding of staff behaviors impact on the behaviors of patients and recognizing signs of any incorrect application of a restraint.

1. Review of the closed medical record revealed the facility admitted Patient #2 (voluntarily), on 02/27/2021, with diagnoses to include Schizoaffective Disorder, Depressive Type, Borderline Personality Disorder and Severe Alcohol Disorder. Continue review revealed Patient #2 had been scanned with the metal detector wand, on 02/27/2021, on admission and had been cleared to enter the facility.

Review of the facility's "Psychiatric Evaluation," for Patient #2, dated 02/27/2021 at 6:19 PM and signed by Physician #3, on 03/29/2021, revealed the justification for Patient #2's hospitalization included hallucinations, delusions, agitation, anxiety, depression resulting in significant loss of functioning, and he/she was a danger to self and or others or property. Continued review revealed the Patient #2 required a controlled environment and had emotional or behavioral conditions and complications requiring twenty-four (24) hour medical and nursing care. Review revealed Patient #2's justification for hospitalization by Physician #3 also included his/her failure of social or occupational functioning, and failure of treatment at a lower level. The evaluation revealed Patient's #2's chief complaint, in his/her own words was depression, alcohol (ETOH) abuse, and suicidal ideation (SI). Further review revealed Patient #2 reported severe anxiety, self-harm, and SI on admission. In addition, Patient #2 had reported increased issues with command type hallucinations to harm, and hurt self, and reported self-harming with cuts on arms, stomach, legs, and upper arms.

Review of the "Intake Assessment," dated 02/27/2021 at 6:30 PM, and signed by Registered Nurse (RN) #9 at 9:00 PM, revealed Patient #2 reported he/she had a plan to cut his/her wrists, and to hang his/herself. Per review, Patient #2 denied a history of violence, or threats against others. Continued review revealed the Suicide Risk Assessment noted Patient #2 scored a twenty-three (23) on the assessment and was a high risk for suicide. Review of the RN Narrative Summary, dated and signed by RN #9 on 02/27/2021 at 9:20 PM, revealed Patient #2 had been admitted to the facility's Acute Inpatient Services, and the patient talked freely about suicide and having no reason to live.

Review of Patient #2's "Final Ancillary Orders," dated 02/27/2021 at 8:00 PM, revealed Advanced Registered Nurse Practitioner (ARNP) #1 had given an order for Patient #2's Level of Observation to be completed every fifteen (15) minutes by staff. In addition, the orders included placing the patient on suicide precautions.

Review of the "High Risk Notification Alert," signed and dated, on 02/27/2021 at 9:00 PM by RN# 10 and RN #11, revealed Patient #2 historically had, and currently had suicide risk and self-harm risk.

Review of the "Personal Belongings Inventory," dated and signed on 02/27/2021 at 9:10 PM by Milieu Coordinator (MC) #1, revealed Patient #2 had presented to the facility with one (1) pair of leggings, and the leggings were stored in the patient effects (PE) area.

Review of Patient #2's "Temporary Treatment Plan," signed and dated on 02/27/2021 at 9:30 PM by RN# 9, revealed the danger to self-specific intervention focus included: encouraging the patient to seek out staff if having thoughts of harming self, questioning Patient #2 directly to determine whether the patient had any thoughts to harm self and ensuring his/her room was cleared of sharp objects. Further review revealed the self-injurious-specific intervention focus included for staff to observe the patient for self-injurious thoughts/behaviors and to prompt the patient to utilize positive coping skills; however, there was no documented evidence of coping skills identified by staff.

A) Review of Patient #2's "Interdisciplinary Master Treatment Plan", dated 03/01/2021, revealed the facility had developed a Depression with Suicidal Ideation Individual Treatment Plan (ITP) that addressed Patient #2's reported suicidal ideation with no plan. Review of Problem #1, the patient endorsed increased depression for four (4) days after his/her last discharge and reported cutting self to relieve anxiety, with cuts to his/her arms, stomach, and legs. Continued review of the "Interdisciplinary Master Treatment Plan" revealed Problem #3 was the Assaultive/Aggressive/Self Harm ITP for Patient #2 which addressed being found with a razor blade hidden in his/her clothing which had not been removed during the admission process. Per review of Problem #3, Patient #2 had subsequently cut his/her arms deep enough to require stitches, and a staff member had also been cut by the patient.

Review of the incident report for Patient #2 revealed, on 03/01/2021, the patient had a razor blade hidden in his/her shoe. He/she took the razor blade out of his/her shoe and was slicing his/her arms. The staff found blood and something metal in his/her hand. Staff tried to get the patient to hand it over and he/she refused. Staff grabbed the patient's arms and had to force the blade out of his/her hand. The patient had blood everywhere. Wounds were cleaned by a nurse, and the patient was sent to the local Emergency Department. The patient returned to the facility, on 03/02/2021 at 12:30 AM.

Review of the "Outside Consultation Form, dated 03/01/2021, no time, revealed Patient #2 had been evaluated at a local hospital Emergency Department (ED) for a self-inflicted laceration. Per review, the ED Physician recommended keeping the patient's wounds clean and dry, and to follow-up with the acute care hospital for suture removal in ten (10) to twelve (12) days.

Review of the, "Nursing Progress Note," signed and dated 03/01/2021 at 8:30 AM by Registered Nurse (RN) #7 and prior to Patient #2's self-harm of cutting on 03/01/2021, revealed Patient #2 continued to report auditory and visual hallucinations, and was positive for Suicidal Ideation with a plan to cut his/her wrist. The patient reported he/she had started to work out the details of how to kill his/herself. Continued review of the assessment revealed the patients last suicide attempt had been on 12/28/2020, when he/she had cut his/her wrists; however, there was no documented evidence the facility implemented interventions.

Review of the "Psychosocial Assessment," dated 03/01/2021 at 3:01 PM, and signed by Clinical Social Worker #1 (prior to Patient #2's self-harm of cutting on 03/01/2021), revealed Patient #2 reported a plan to cut his/her wrists and to hang his/herself. The patient reported hallucinations to harm and hurt self; however, there was no documented evidence the facility implemented additional interventions.

Review of Physician #3's Observations/Precautions, dated 03/01/2021, revealed Therapy/Treatment for Patient #2 included unit restrictions, visualized body exam for hidden weapons and no shoes related to two (2) previous elopements and a razor hidden in his/her "Croc" shoe.

Continued review of the "Nursing Progress Note," signed and dated by RN #8, on 03/01/2021 at 7:55 PM, revealed Patient #2 had been uncooperative with staff and the patient was found with contraband and had caused self-inflicted wounds. Suicidal Ideation with plan to cut.

Review of the "Additional Nursing Progress Notes," dated 03/01/2021 and signed by RN #15, revealed Patient #2 was calm, and cooperative when he/she arrived back at the facility. Continued review revealed Patient #2 had over forty lacerations to his/her forearms to upper shoulders that were open and moist.

B) Review of the "Nursing Progress Note", dated, and signed on 03/10/2021 at 6:46 AM, by RN #12 revealed Patient #2 was thinking about harming/killing his/herself, and the patient had a plan; however, there was no documented evidence the facility implemented additional interventions.

Review of the "Every Fifteen (15) Minute Check Report," dated and signed on 03/10/2021 at 8:18 PM, by Milieu Coordinator (MC) #2 revealed around 7:00 PM, Patient #2 was observed sitting at the end of the hallway alone. Per the report, the Milieu Coordinator walked down to check on the patient and discovered the patient was cutting his/her arms with something metal. The MC stopped the patient, and the supervisor came to the unit. The patient has several cuts on his/her arms. The patient's room was searched thoroughly, and nothing was found.

Record review of the facility's incident report revealed, on 03/10/2021, the patient had been sitting on the unit, at the end of the hall. A Mental Health Technician (MHT) walked down to check on the patient, and the patient was cutting his/her arms with something metal. The MHT stopped the patient, and the supervisor came to the unit. There were several cuts on his/her arms. The piece of metal used to cut his/herself was confiscated. Patient #2 reported having this metal since admission. Patient #2 was searched thoroughly, and nothing new found.

Continued review of the "Nursing Progress Note", dated and signed, on 03/10/2021 at 8:00 PM, by RN # 13, revealed Patient #2 became upset when he/she was not allowed to go into his/her room. The patient stated, "you will be sorry". The patient eventually went to the end of the hall, and staff kept check on him/her, but he/she was able to cut his/herself at 7:00 PM. The patient stated the staff needed to "stop the voices". The Nurse Practitioner was notified. The patient reported pain after cutting his/herself with a piece of razor he/she had brought into the facility.

Review of the "Additional Nursing Progress Notes", dated and signed, on 03/10/2021 at 10:00 PM, stated around 6:50 PM Patient #2 had been informed he/she could not go into his/her room until medications had been given, and he/she could not go outside to smoke due to (D/T) non-participation in groups. The patient became upset and asked to be left alone. At 7:05 PM, staff had checked on the patient in the hall, and found Patient #2 was bleeding from the arms. The patient was being held already by a Mental Health Technician (MHT), and a nurse grabbed the patient's left arm and noticed a razor blade between his/her fingers. The Program Director was able to remove the blade. The patient was then placed on 1:1 observation, and orders were obtained for transport to the emergency department (ED) for evaluation of the lacerations to the right forearm, which were too extensive for basic first aid. The patient was sent out at 9:20 PM with staff escort via ambulance.

Review of the local hospital documentation revealed Patient #2 had arrived at the hospital, on 03/10/2021 at 9:42 PM, and was admitted to the emergency department (ED). Review of the History and Physical (H&P) revealed the patient complained of self-inflicted lacerations to the right forearm. Patient #2 had been seen recently with similar symptoms and had a long history of self-inflicted lacerations to bilateral arms over the years. Review of the physical examination revealed Patient #2 had two (2), four (4) centimeters (cm) gapping lacerations to the right forearm. Continued review revealed each of the lacerations required six (6) sutures to repair the wound. The patient left the ED, on 03/10/2021, and returned to the facility.

Record review of the "Final Ancillary Orders" revealed Physician #3 had given orders to place Patient #2 on 1:1 observation, on 03/10/2021 at 9:00 PM, with a stop date of 03/13/2021 at 8:00 AM.

Further review of the "Interdisciplinary Master Treatment Plan" revealed Problem #4 was a Significant Treatment Event, dated 03/10/2021, addressing Patient #2's second self-harm of cutting both forearms with a razor he/she had hidden.

C) Review of Patient #2's incident report revealed, on 03/17/2021, the patient took Clorox Bleach Germicidal Cleaner and ingested an undetermined amount. The Poison Control Center was contacted, and the facility was advised to monitor the patient with no urgent concerns. The Provider was notified, and the patient was placed on 1:1 observation.

Record review of the "Safety Data Sheet" (SDS), dated 01/15/2019, revealed "Clorox Bleach Germicidal Cleaner" may cause irritation of respiratory tract. If contact with the eye, may cause slight irritation. Skin contact may cause slight skin irritation. Ingestion may cause irritation to mucous membranes, gastrointestinal irritation, nausea, vomiting and diarrhea.

D) Review of Patient #2's incident report revealed, on 03/23/2021, the patient tied leggings around his/her neck while in the bathroom in his/her room. The patient was conscious and breathing the entire time and did not resist staff when they took the pants. Continued review of the report revealed Patient #2 stated he/she did it because of the voices. Clothes and linens were removed from the room with one-to-one observation to continue as ordered at night.

E) Review of the "Nursing Progress Notes," dated and signed by RN #16, on 03/26/2021 at 4:20 PM, stated Patient #2 had reached across, and behind the nursing station desk to where the plastic forks were stored. He/she obtained a fork and broke it. With the broken fork, he/she then began slicing at his/her previously self-inflicted wounds on his/her left forearm before a MHT could intervene. The patient refused to release the fork fragment, and fought the MHT, reportedly attempting to harm the MHT. The patient was placed in a restraint for the safety, and staff.

Review of the "Fifteen (15) Minute Check" log, dated 03/26/2021 at 5:22 PM by MHT #11, stated Patient #2 became agitated due to a remark that was made by a male peer during a clinical group. The therapist was able to process with the patient, and the peer apologized to him/her but later, the patient became angry about it again, and reached over the nursing station and grabbed a fork that was stored in that area. Staff immediately intervened but the patient was able to grab one (a fork) and break it in half. Staff struggled to get the fork from the patient and the patient almost scratched staff and did manage to scratch his/her left (L) forearm before the staff was able to restrain the patient due to an imminent risk to self and others.

Review of the incident report revealed, on 03/26/2021, Patient #2 broke a plastic fork that he/she took off the nurse's desk and began slicing at existing self-inflicted wounds on his/her left forearm before the MHT could intervene. The patient refused to release fork fragment and fought the MHT in attempts to harm the MHT.

Interview with MHT #4, on 09/01/2021 at 3:15 PM, revealed Patient #2 had gotten upset because he/she had not been allowed to go into his/her room, so the patient stayed at the end of the hallway, and sat in the corner. Per interview with MHT #4, right at shift change, around 6:45 PM, MHT #4 gave report to the on-coming MHT and glanced down the hallway at the patient. She stated something did not look right, and there he/she was, slashing both of his/her arms. The MHT revealed she pleaded with the patient to stop and the patient did stop, and the MHT asked the patient to give her the blade but the patient would not. Continued interview with MHT #4 revealed she had to grab the patient's arms from behind to stop him/her. The MHT stated that she ended up getting cut through her gloves, and across her hands, and she had to go to the ED to get a tetanus shot. She revealed the razor blade was about one-half an inch tall, and about two (2) to three (3) inches long. The MHT went on to state that she was the one who did Patient #2's admission search. She revealed she remembered the patient had a waded-up tissue that he/she carried onto the unit and Patient #2 had kept wiping his/her eye with the tissue. However, the MHT stated she had not checked the tissue, or asked the patient to throw the tissue away. MHT #4 revealed the patient told her later, that he/she had carried the razor onto the unit in this tissue. MHT #4 stated that normally, staff do not ask patients to throw away their tissues, nor do they check inside of the tissue. Further interview revealed she did not know why the metal detector wand did not detect the razor. She revealed she did believe this patient may have cut someone else if he/she had gotten mad enough. MHT #4 went onto state she had observed and stopped Patient #2 many times because he/she chased after other patients.

Interview with the Assistant Director of Nurses (ADON), on 09/01/2021, at 3:40 PM, revealed, prior to Patient#2's admission to the facility, the patient had been scanned (wanded) by the metal detector wand in the front lobby of the facility. The patient had also been required to empty his/her pockets, along with any phones, and then the patient was taken into the intake process room. She stated newly admitted patients were then escorted to their assigned unit by staff, where they were asked to un-dress from the waist down and don a paper gown. She stated, then, all the patient's belongings were searched to include their shoes. She went onto state Patient #2 had apparently hidden a very small razor in his/her Croc shoe, and the razor blade had not been discovered by the metal detector upon admission despite the process being followed. Continued interview with the ADON revealed that, on 03/01/2021, the patient had gotten upset because staff would not allow him/her access to his/her bedroom. The ADON stated the patient's door was locked during the day, to prevent the patient from isolating self and to be visible on the unit where he/she could be monitored at least every fifteen (15) minutes by the staff. She revealed when staff observed the patient, they also observed blood, and something metal in the patient's hand. Continued interview revealed apparently the patient had a razor blade hidden inside of his/her Croc shoe, took the razor blade out of his/her shoe and sliced his/her arms. The ADON stated, staff attempted to encourage the patient to hand over the blade; however, Patient #2 refused. Staff had to grab his/her arms and force the blade out of his/her hand. During this attempt to retrieve the razor, MHT #4, received a hand laceration. The patient was then transferred to the local ED for evaluation and was eventually returned to the facility and placed on a 1:1 observation. She revealed, on 03/10/2021, Patient #2 had gotten upset, and had been found by staff with another piece of razor, and cutting his/herself, again. The ADON stated, on 03/17/2021, around lunch time, Patient #2 had taken a bottle of Clorox Bleach Germicidal Cleaner off an un-attended housekeeping cart on the Adult Unit. She stated this incident should not have happened; however, on 09/01/2021 and 09/08/2021 revealed cleaning wipes were observed to be unsecured and accessible to patients. She went on to state, on 03/23/2021, Patient #2 had been found in his/her bathroom by staff with a pair of leggings tied around his/her neck. She revealed the patient had orders for 1:1 observation at hour of sleep; however, a MHT had mistakenly unlocked his/her bedroom door, and the patient had gone inside of his/her room, unattended by staff. She also stated leggings were not supposed to be on the unit because they could be used for strangulation. The ADON stated, on 03/26/2021, the patient had found a plastic fork at the Nursing Station and broke the plastic fork and began to slice at existing self- inflicted wounds on his/her arms, before the MHT could intervene. Patient#2 refused to release the fork, and fought the MHT, in an attempt to harm the MHT. The patient had to be put in a restraint, for staff to retrieve the fork.

Interview with the Chief Executive Officer (CEO), on 09/02/2021 at 10:57 AM, and on 10/07/2021 at 8:27 AM, revealed his expectation was that all the patients were kept safe, and no contraband entered the facility. He stated chemicals should all be safely secured and were monitored through observation of staff, and through review of video. He revealed any Housekeeper who left chemical out, and in reach of the patients, did not belong in a psychiatric facility. He revealed the facility should not have eating utensils out, and within reach of the patients and forks should have been secured somewhere in the nurse's station. Per interview, he was not certain if the facility's metal detector would have identified the type of metal the razor blade contained.

Interview with the ADON, on 09/08/2021, at 8:05 AM, revealed all chemicals in the facility were supposed to be secured so the patients did not have access, and possibly abuse the chemical, and cause harm.

Interview telephonically, on 09/08/2021 at 8:30 AM, with Patient #2 was unsuccessful. The patient did not answer the phone, and the voicemail had not been set up.

Interview with Physician #1, on 09/24/2021 at 8:00 AM, revealed his expectation was that safety was of high priority in the facility. He stated all patients being admitted to the facility should be thoroughly searched, and ensure all contraband was removed. He stated there was a breach in the standard of care when Patient #2 had been in possession of a razor blade, and this event should not have occurred because it posed a safety threat for all patients, and staff. He went on to state he had been informed that leggings were not permitted on the patient units as they could be used for a ligature. Physician #1 revealed he was not aware Patient #2 had consumed bleach nor that the patient had cut his/herself with a fork. He stated all chemicals and sharps should be secured so the patients could not obtain them, and cause harm.

Interview with the Director of Nursing, on 09/24/2021 at 9:00 AM, revealed her expectation was that all contraband was found during the admission process, and before a patient went into their unit. She stated anything, including waded up tissues, should be inspected by staff for contraband as well. She revealed all chemicals have to be kept out of the patients reach, and chemicals should be kept on the cleaning carts, and the cart should remain in the possession of the housekeeper at all times. She stated if a patient consumed chemicals the worst-case scenario would be localized irritation, upset stomach, or death. She revealed, at this time, leggings were not allowed on the units because they have the possibility of being used as a ligature. Lastly, the DON stated that in no way should there be un-secured cutlery on the patient units because of the risk that a patient might harm themselves, and other patients or staff.

Interview with the Interim Medical Director, on 09/27/2021 at 8:00 AM, revealed he was familiar with Patient #2 and the patient was on his service. He stated the facility had discussed whether or not they could meet the patient's needs; however, the facility would provide care and services to any person that was in danger. He described Patient #2 as adamant, and he/she would not accept the help the facility offered to him/her, and the patient also had a negative effect on the other patients. He stated, he was one hundred percent (100%) sure when patients were admitted to the facility, the facility should maintain their safety.

Immediate Jeopardy (IJ) was identified, on 09/02/2021, and the facility was notified on 09/02/2021. The facility submitted an acceptable Immediate Jeopardy (IJ) Removal Plan, on 09/03/2021, alleging the IJ was corrected on 09/03/2021. Review of the Removal Plan and an on-site validation determined the IJ was removed, on 09/08/2021.

The corrective actions the facility undertook to remove the IJ were as follows:

A. The facility contraband list was updated, on 03/03/2021, to include Croc shoes. All staff received training, on 03/12/2021, after the incident occurred, in regard to proper contraband searches.

Re

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure an effective infection prevention and control program was implemented for controlling transmission of infections within the facility between the facility and other facilities, regarding staff donning and appropriately wearing Personal Protective Equipment (PPE), in relation to facial masks.

Observations of multiple staff revealed the staff were not donning and wearing facial masks appropriately.

The findings include:

Review of the facility's policy and procedure titled, "Infection Control-Personal Protective Equipment (PPE)," dated 01/2021, revealed a mask should be worn in any situation to prevent the spread of micro-organisms from the nasopharynx of staff to patients and/or others who were susceptible. Continued review revealed when donning PPE, staff were to ensure their masks were secured with ties above and below the ears, and the mask was to fit snugly to a person's face and below their chin.

Review of the facility's guidance document, "Universal Masking of Staff, Patients, and Visitors in the Health Care Settings," dated 04/27/2021, revealed a Joint Commission Recommendation, dated 04/23/2021. Per review, the Joint Commission had issued a recommendation consistent with the Centers for Disease Control and Prevention's (CDC's) guidance that addressed the universal use of mask in the healthcare setting.

Review of the facility's Infectious Outbreak policy, dated 01/2021, revealed "a pandemic is a global infectious outbreak of a known or a new emerging virus. A pandemic can occur when a virus emerges for which humans have little or no immunity and transmits person to person. The viruses can cause serious illness or death." Continued review of the policy revealed the facility "follows the Infection Control Program to interrupt any healthcare associated outbreaks or pandemics as designated by the Centers for Disease Control and Preventions (CDC) for the protection of patients, medical staff, employees and visitors."

Review of the CDC's recommendation titled, "COVID-19 Interim Infection Prevention and Control Recommendations with Suspected or Confirmed COVID-19 in Healthcare Settings," dated 02/10/2021, revealed healthcare personnel were to wear a facemask at all times while in a healthcare facility as part of its source control efforts.

Review of the facility's "Infection Control Plan, 2021" revealed part of the Coronavirus-19 Management Plan was that all facility staff were mandated to wear a protective mask while in the facility.

Observation of Mental Health Technicians (MHT) #2, and MHT #3 in the dining room, on 08/31/2021 at 8:45 AM, revealed both MHT's were assisting patients with their meal. Continued observation revealed both MHT's masks were pulled down below their noses.

Observation of Registered Nurse (RN) #2, on 08/31/2021 at 12:55 PM, revealed the nurse was sitting at the Nurse's Station on the Adolescent Male Unit with her mask pulled down below her nose. Continued observation revealed a bottle of water, with the cap on the bottle, sitting on the desk several inches away from her.

Observation of Maintenance Staff #1 at the Administrative Receptionist Desk, on 09/01/2021 at 8:00 AM, revealed he had his mask pulled down below his nose and mouth while speaking with Administrative Receptionist #1. Further observation revealed Administrative Receptionist #1 also had her mask pulled down below her nose while speaking with Maintenance Staff #1.

Observation of MHT #9, on 09/01/2021 at 8:05 AM, revealed she was standing in the hallway of the Adult Unit with her mask pulled down below her nose.

Observation of Nurse Supervisor #1, on 09/08/2021, revealed the nurse was exiting an adjacent work area behind the front receptionist desk and her mask was pulled down below her nose and mouth.

Observation of Teacher #1, on 09/21/2021 at 1:17 PM, revealed he was sitting behind a desk in a classroom with several patients in the classroom. Continued observation revealed he was not wearing a mask as required.

Observation of RN #6, on 10/06/2021 at 11:00 AM, revealed she was escorting a discharged patient through the front lobby, with her mask pulled down below her nose.

Interview with MHT #2, on 08/31/2021 at 9:00 AM, revealed she was a Lead Mental Health Technician, and she provided guidance for other MHT's. She stated when observed with her mask down, it only very briefly to speak with a patient. Per interview, she became frustrated when she had to keep repeating herself because the patient could not hear her, so she had pulled her mask down to talk. Continued interview revealed she had received training on how to properly wear a mask, and masks were to be pulled up at all times. She further stated, staff should wash or sanitize their hands after touching or readjusting their mask.

Interview with MHT #3, on 08/31/2021 at 9:15 AM, revealed her mask had fallen down while she was putting utensils into a cup. The MHT stated a properly fitting mask should not have fallen down. Per interview, she had failed to fit her mask properly against her nose prior to the beginning of her shift. Continued interview revealed staff needed to wear a mask properly to protect the patients, and other staff members from Covid-19. She further stated she had received education and training on the proper use of PPE, and how to don the mask.

Interview with RN #2, on 08/31/2021 at 12:55 PM, revealed she did not have her mask pulled up over her nose because she had been drinking water at the time she was sitting at the Nursing Station.

Interview with the facility's Infection Preventionist Nurse, on 09/08/2021 at 9:45 AM, revealed staff had been educated and trained on how to properly don a face mask and the importance of wearing the masks properly. Continued interview revealed part of the facility's Infection Control surveillance plan included for all staff to wear masks while they were in the facility in order to decrease spread of disease.

Interview with Nurse Supervisor #1, on 09/08/2021 at 12:43 PM, revealed she had received training and education on when to wear a face mask and how to appropriately wear a mask. She stated she believed in wearing a mask in order to protect others from disease, could not recall having her mask pulled down below her nose.

Interview with Teacher #1, on 09/21/2021 at 1:17 PM, revealed he had forgotten to put his mask back on after taking his lunch. He stated it was standard procedure in a hospital to wear a mask in order to guard against the passing of Covid-19 to others.

Interview with the Director of Nursing (DON), on 09/24/2021 at 9:00 AM, revealed it was mandatory for staff to wear their facial masks appropriately while in the facility. She stated the facility was trying to prevent the spread of disease to patients, employees, community, and families.

Interview with the Interim Medical Director, on 09/27/2021 at 8:00 AM, revealed staff not wearing their face masks appropriately was just "wrong". He stated not wearing a face mask correctly was "horrible and ridiculous". Continued interview revealed the face mask was utilized to help prevent the transmission of disease from one (1) person to another person.

Interview with RN #6, on 10/06/2021 at 12:07 PM, revealed she had not been aware her facial mask had fallen down below her nose. She revealed she had received training on the proper use of PPE, and masks were worn to protect staff and patients from the spread of Covid-19.

Interview with the CEO, on 10/07/2021 at 8:27 AM, revealed it was his expectation that all staff wear their mask correctly to help prevent the spread of disease.