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Based on interview, record review, and policy review, the hospital failed to follow their policy to respect the right to privacy for Patient #6 when a staff member used a personal cell phone to record a patient interview. This failure had the potential to affect all patients admitted to the behavioral health hospital with their respect for the right of privacy.

Findings included:

Review of the hospital's policy titled, "Patient Rights," dated 05/16/22, showed patients have the right to privacy while receiving services. Patients have the right to have their personal information kept confidential in accordance with state and federal confidentiality laws.

Even though requested, the hospital failed to provide a policy on personal cell phone use.

During an interview on 01/11/24 at 4:30 PM, Patient #6, stated that she asked a staff member for a pregnancy test on 01/05/24 and that she had consensual sex with another patient. Staff T, Behavioral Health Associate (BHA), took out her personal cell phone and recorded her statement regarding the incident.

During a phone interview on 01/16/24 at 5:20 PM, Staff V, Registered Nurse (RN), stated that he "heard through the grapevine that Patient #6 had alleged having consensual sex with another patient." He attempted to talk to Patient #6, but she refused to talk to him. He then asked Staff T, BHA, to obtain a statement of the events. He stated that he did not ask her to record the conversation using her personal cell phone and that she did it on her own. He did not listen to the conversation and instructed Staff T to give the statement to Staff M, RN Supervisor.

During a phone interview on 01/17/24 at 10:00 AM, Staff T, BHA, stated that:
- She was instructed by Staff V, RN, to record the statement made by Patient #6, regarding the alleged incident of her having consensual sex with another patient, using her personal cell phone.
- She went to Staff HH, Milieu (a person's social environment) Coordinator, who told her that Staff V wanted her to use her personal cell phone to record the incident of consensual sex with another patient.
- She recorded the statement made by Patient #6 using her personal cell phone on 01/05/24.
- Staff V told her to give the recording to the RN Supervisor and he did not listen to the conversation.
- Staff M, RN Supervisor, did not listen to the recorded statement and instructed her to delete the conversation.
- She deleted the conversation from her personal cell phone.
- Staff M had a coaching session with her regarding the incident.

Even though requested, the hospital failed to identify and arrange an interview with Staff HH, Milieu Coordinator.

During a phone interview on 1/17/24 at 11:10 AM, Staff M, RN Supervisor, stated that:
- She was informed that Patient #6 made a statement alleging that she had consensual sexual contact with another resident.
- She was aware that Staff T, BHA, had recorded the statement by Patient #6 regarding the incident using her personal cell phone.
- She told Staff T to delete the conversation and that she never listened to the conversation recorded on the cell phone.
- She counseled all staff involved.

Even though requested, the hospital failed to provide the counseling and disciplinary actions to the staff that were involved in using personal cell phones to record patient statements.

During a phone interview on 01/17/24 at 9:15 AM, Staff Z, Therapist, stated that she was told that Staff V, RN, told Staff T, BHA, to record the statement of Patient #6 regarding the consensual sex between her and another patient. She stated that she did not listen to that conversation and that it was deleted.

During an interview on 01/11/24 at 3:15 PM, Staff A, Chief Nursing Officer (CNO), stated that he was not aware of anyone using their personal cell phone to record a patient statement. He stated that it should have never occurred and that staff were not to record anything using their personal cell phones.

During an interview on 01/10/24 at 2:30 PM, Staff P, Medical Director, stated that he was aware of staff using their personal phones while on duty. He had brought up personal cell phone use previously with administration, but nothing had been done.

Based on observation, interview, record review, policy review and video review, the hospital failed to:
- Recognize an incident of sexual maladaptive behavior (SMB, sexual behaviors that are age-inappropriate or potentially harmful) between one current minor patient (#6) and one discharged minor patient (#7) that warranted a self-report to the Bureau of Hospital Standards (BHS);
- Recognize an incident of SMB between one current minor patient (#6) and one discharged minor patient (#7) that warranted the necessity for a prompt investigation and staff education to prevent reoccurrence; and
- Promptly investigate a suicide (to cause one's own death) attempt by one discharged patient (#9).

Findings included:

Review of the hospital's policy titled, "Patient Rights and Ethics," dated 05/16/22, showed patients have the right to be protected from neglect, physical, verbal and emotional abuse.

Review of the hospital's policy titled, "SMB: Early Identification, Observation, Intervention, Response and Notification, dated 04/30/21, showed:
- The hospital should provide a safe, therapeutic environment of care including the prevention of patient-to-patient incidents;
- This should be accomplished by monitoring the patient with a suspected potential for sexual aggression and implementing intervention steps to minimize the risk of sexual behavior;
- They should implement a response and notification plan in the event of a sexual allegation and/or incident;
- Boundary violations between patient-to-patient contact should include attempts to sneak into the other patient's rooms and eluding staff observations;
- Sexual allegations include what the patient reports and alleges;
- Sexual Intercourse includes oral, vaginal, or anal penetration or fondling of the patient's sex organs by another individual's hand, sex organ, or object;
- Discovery of a sexual allegation can occur as reported by the patient allegedly involved;
- Upon report of an allegation of patient-to-patient sexual behavior; the charge nurse and facility leadership should initiate the investigation, obtain statements including interviews of the patients involved, any witnesses, and staff directly responsible for the observation rounds at the time of the event and clarification of the type of sexual contact.
- The following should be offered to patient: An evaluation, sexual transmitted disease (STD) testing to include human immunodeficiency virus (HIV, virus that attacks the cells that help the body fight infection), Chlamydia (a sexually transmitted infection caused by a bacteria), Gonorrhea (an infection caused by a bacterium), Hepatitis (inflammation of the liver. The various forms of viral hepatitis are named after different letters of the alphabet) B and C, and pregnancy testing;
- Implementation of SMB Precautions;
- Implementation of increased level of monitoring;
- Inform patients of their rights;
- Complete an incident report during the shift the incident occurred and forward to Risk Management for review;
- The person discovering the incident/event should notify the Charge Nurse or Nurse Supervisor immediately during the shift in which the incident/allegation occurs;
- The charge nurse will contact the Director of Risk Management, Chief Executive Officer (CEO), and the attending provider immediately after the incident occurs or is discovered to discuss the incident.
- The attending provider will review all relevant findings with the patients involved and documents the discussion and patient responses in the medical record and assess the need for additional interventions and orders.
- The clinical team should update the patients' treatment plan;
- Parents or guardians shall be notified by the charge nurse of the allegation if the incident involves minors;
- The Director of Risk Management should notify the assigned corporate risk manager within 24 hours and notify local/state agencies;
- The Director of Risk Management should initiate and oversee sexual allegations to provide protection of patient rights, and to prevent similar occurrences; and
- The Director of Risk Management should oversee the documentation in the medical record involving the alleged incident, notifications, staff interventions, and patient response.

Review of the hospital's policy titled, "Alleged Abuse Neglect," dated 05/16/22, showed:
- Staff members who have reasonable cause to suspect that a patient has been subjected to abuse or neglect within the facility must immediately report such an event.
- Sexual abuse is any touching, directly or through clothing of any individual for a sexual manner.
- When patient-to-patient abuse is identified, the registered nurse (RN) will place the patient committing the offense on every five-minute safety observation (5-minute visualization and documentation of the safety of each patient) or one-to-one (1:1, continuous visual contact with close physical proximity) observation and notify the attending/on-call physician.
- The RN will complete a nursing assessment of the patient who was abused to evaluate the patient's physical and mental condition.
- Reports of abuse or neglect which occur while the patient is hospitalized will be thoroughly investigated by the Risk Manager or other staff as assigned by the CEO.

Review of the incident report log showed on 01/04/24 Patient #6 reported to staff that she missed her menstrual period (when blood and tissue from the uterus come out the vagina) and alleged that she had consensual sexual intercourse with Patient #7 on 12/20/23; when she went to his room, went into his bathroom and had sexual contact. A self-report was not made to BHS.

Review of the hospital's undated document titled, "Program Orientation Booklet," showed the 3 South (3S) unit was an 18 bed co-ed (used by both males and females) adolescent step-down unit. Patients were to avoid inappropriate physical contact and that it was a "no touch" facility.

Even though requested, the hospital failed to provide a Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to fine the root cause) Investigation Policy.

Even though requested, the hospital failed to provide video surveillance of the alleged sexual misconduct incident that occurred on 12/19/23 or 12/20/23 between Patient #6 and Patient #7.

Review of Patient #6's medical record showed:
- She was a 14-year-old, admitted on 11/01/23 for Disruptive Mood Disorder (a condition of extreme irritability, anger, and frequent, intense temper outbursts) and to rule out oppositional defiant disorder dysregulation (a disorder marked by defiant and disobedient behavior to authority figures).
- Her past psychiatry history included seven suicide attempts by overdose and one event of banging head until she lost consciousness. She was admitted for the safety of the patient and others.
- On 11/08/23, she wrote a note to staff stating that a male patient had just broken up with her and that they had kissed on two occasions.
- On 01/04/24 at 9:04 PM, she requested a pregnancy test and that was reported to the nurse.
- On 01/04/24 at 11:00 PM, she reported to staff that she may be pregnant. A note was placed in the physician communication book for an evaluation and the incident was reported to the nursing supervisor.
- On 01/05/24 at 3:25 PM, Patient #6 alleged she had consensual sexual intercourse with another patient on 12/19/23 and/or 12/20/23. The nurse then talked to patient to discuss the incident.
- On 01/05/24 at 3:40 PM, she had somatic (multiple, persistent physical) complaints due to previous accusations of consensual sex and it was under investigation.
- On 01/06/24 at 12:04 PM, Patient #6 had reported a few days ago that she had sexual relations with another patient and that she had not had a pregnancy test. An order was obtained from the physician for a pregnancy test and patient's guardian was contacted.
- On 01/06/24, a urine pregnancy test was completed and results were negative.
- On 01/10/24 at 12:51 PM, orders were written by Staff II, Nurse Practitioner (NP), to draw labs on 01/11/24 for STD testing.
- On 01/10/24 at 13:35 PM, orders were written by Staff II, to add SMB precautions, SMB evaluation, and block room.

Review of the behavioral health patient observation sheet showed that SMB precautions were initiated on 01/10/24 at 3:05 PM; six days following Patient #6 making a statement of SMB on 01/04/24.

During an interview on 01/11/24 at 4:30 PM, Patient #6, stated that on the evening of 12/20/23 she waited for the staff to do 15-minute safety checks and then ran down the hall to Patient #7's room. They went into the bathroom and had consensual sexual intercourse. She did not tell anyone about the incident until 01/05/24 when she requested a pregnancy test because she had missed her menstrual cycle. She stated that she was instructed to call her parents and tell them about the incident and she called them and told them about the incident. No one from administration had talked to her and there was no change in her precautions. She stated she thought she would be put on SMB precautions but never was.

During an interview on 01/10/24 at 3:00 PM, Staff C, Director of Risk Management, stated that he "had been busy with the other two self-reports and had not investigated this SMB allegation/incident." He was not aware that Patient #6 had not been placed on SMB precautions. He was not aware that STD testing had not been ordered. He stated that there was always a nurse supervisor present 24 hours per day and the expectation was for the nurse supervisor to ensure that the patient was safe, had the appropriate precautions ordered and ensured all physicians were notified. He did not make a self-report to BHS.

During a phone interview on 1/17/24 at 11:10 AM, Staff M, RN Supervisor, stated that she was informed that Patient #6 had made a statement alleging that she had consensual sexual contact with another patient. She stated she obtained and reviewed the statements from staff and sent those to the Risk Management team to complete the investigation. She could not recall when she did this and stated that Staff GG, SMB Coordinator, always took care of the precautions. She was to notify the provider of the incident and obtain an order from the provider for a SMB evaluation and SMB precautions. She stated she also did this but could not recall when she did this and what provider was notified. She was not aware that there was no documentation that showed the psychiatric provider had been notified. The medical provider was notified and ordered a pregnancy test, but he does not order safety precautions. She was not aware that STD testing had not been ordered until 01/12/24. She was not aware that Patient #6 had not been on SMB precautions until a state surveyor was present and inquired about the incident. No education had been provided to staff on the policy for SMB.

During an interview on 01/11/24 at 2:30 PM, Staff T, Behavioral Health Associate (BHA), stated that Staff V, RN, asked her to record Patient #6's alleged incident. She stated that she provided a written statement for the incident involving Patient #6. She stated that Patient #6 was not placed on SMB precautions. She stated that "no one believed her and did not really investigate the incident." She stated that Patient #6 had previously been seen kissing another patient but that nothing had been reported. No one from administration had spoken to her about the incident. No education had been provided to staff regarding SMB.

During an interview on 01/10/24 at 11:00 AM, Staff H, RN, stated that Patient #6 had not been placed on SMB precautions. She stated "All sexual misconducts should be immediately placed on SMB precautions. I am not sure what happened and why she is not." An initial pregnancy test had been completed but no tests had been done for STDs. She stated that should have been completed after the reported incident but there was no order and it had not been done. No education had been provided about SMB.

During an interview on 01/10/24 at 10:50 AM, Staff F, BHA, stated that Patient #6, was not on SMB precautions since the sexual misconduct incident was reported to staff. No education had been provided to staff about SMB.

During an interview on 01/10/24 at 10:55 AM, Staff G, BHA, stated that Patient # 6 was not on SMB precautions. She stated that they had not changed anything since the incident of sexual misconduct was reported. No education had been provided about SMB.

During a phone interview on 01/19/24 at 12:30 PM, Staff GG, Clinical Psychologist, Coordinator of SMB, stated that she received an order on 01/10/24 for a SMB assessment of Patient #6. She did the assessment on 01/12/24 and recommended SMB precautions for Patient #6. During her assessment Patient #6 stated she was looking for opportunities to engage in sexual activities. She felt she was a high risk for continued behaviors. She stated that patients should be placed on SMB precautions immediately to keep the patient safe. Staff should notify the psychiatric provider immediately and then the provider would order a SMB assessment. Her assessment was to determine if patients needed SMB precautions continued or if they could be discontinued. No in-house investigation of this alleged event occurred prior to a state surveyor inquiring about the incident. No education was provided to staff regarding SMB. Patient #6 did not have SMB precautions until 01/12/24; seven days after staff was made aware of the incident.

During a phone interview on 01/19/24 at 11:30 AM, Staff X, Milieu (a person's social environment) Coordinator, stated that on 01/05/24, Patient #6 stated that she thought she was pregnant and reported a consensual sexual contact had occurred with Patient #7 on 12/20/23. She notified Staff W, RN, of the alleged incident. She stated that Patient #6 was not on SMB precautions until 01/12/24. No one from administration had contacted her regarding an investigation. No education had been provided to staff regarding SMB.

During a phone interview on 01/16/23 at 5:20 PM, Staff V, RN, stated that he "heard through the grapevine that Patient #6 had requested a pregnancy test." He stated that Patient #6 would not talk to anyone but Staff T, BHA, regarding the incident. Staff T recorded a statement made by Patient #6. He stated that Staff GG, SMB Coordinator, wrote all the orders for SMB precautions. Staff GG would do an assessment and then "push everything up the chain of command." Staff M, RN Manager 3S, was aware of the situation. He did not recall if he had written an incident report. He did not notify any physician or place Patient #6 on SMB precautions. Patient #6 was not placed on SMB precautions and no one investigated the incident until after a state surveyor was present and inquired about the incident. No education had been done for SMB.

During a phone interview on 01/24/24, at 12:30 PM, Staff II, NP, stated there was no documentation of notification to the psychiatric provider and that he was not aware of Patient #6's incident until 01/08/24. The medical provider was contacted for an order for the urine pregnancy test on 01/06/24. The medical provider only addressed the medical needs and that the psychiatric provider ordered all safety precautions. All incidents should be reported to the psychiatric provider and medical provider immediately and the SMB policy clearly stated the steps staff should follow. He stated the incident was not investigated until a state surveyor inquired about the incident. No education had been provided to staff regarding the SMB policy.

During a phone interview on 01/23/24, at 12:30 PM, Staff A, Chief Nursing Officer (CNO), stated that his expectation of staff was to report all alleged incidents to the on-call physician as soon as staff was made aware of an incident. Nurses should implement safety precautions immediately following an incident and then obtain the order from the physician. He expected all alleged incidents to be reported and investigated immediately.

Review of the hospital's policy titled, "Alleged Abuse Neglect," dated 05/16/22, showed neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. This includes, but is not limited to, failure to provide adequate supervision during an event in which one individual cause serious injury to another.

Review of the hospital's policy titled, "Observation and Patient Monitoring - Acute Services," dated 05/17/21, showed:
- Observation levels were initiated by a provider order.
- During rounds, staff are to make direct visual contact and look for signs of danger or distress.
- Staff were to remain vigilant for specific risks to patients on Special Precautions.
- Staff were to observe the patient's environment for potential hazards that could be corrected.
- A patient would be placed on five-minute checks (5-minute visualization and documentation of the safety of each patient) if their behavior was unpredictable and potential risk for harm to self/or others, yet behavior is not at the point of requiring 1:1 observation.
- 1:1 was the highest level of precautions and was reserved for patients who were so unpredictable that without a dedicated staff member there was a risk of the patient harming self or others.
- Patients who actively harm self or others require increased monitoring and appropriate interventions.

Review of the untimed video recording dated 01/04/24 showed Patient #9's activities as follows:
- She returned from shower and was given socks.
- She laid the socks on the bed while she was eating.
- She laid down on the bed under the suicide blanket.
- The BHA was present in the room using an ObservSmart IPAD (a device used to document safety checks) to document the activities of Patient #9.
- The BHA continuously looked at a cell phone while Patient #9 was under a suicide blanket moving about in bed.
- BHA walked to the doorway with her back to Patient #9 but remained standing in the doorway. It appeared Patient #9 was completely under the suicide blanket.
- BHA briefly sat back down and then got back up and walked to the doorway.
- BHA returned to bedside, sat down and immediately returned to looking at the cell phone. She picked up the Observesmart IPAD and appeared to document the 1:1 observations but immediately returned to looking at the cell phone.
- A nurse walked into the room and stood over Patient #9.
- The nurse pulled back the blanket and the BHA jumped up and ran to the bedside.
- The BHA ran out of the room and returned with a pair of scissors.
- The nurse was standing over Patient #9, rolled her over and no movement from Patient #9 was observed. Visualization of Patient #9 on video was hindered while the nurse was standing over her.
- Additional staff responded to Patient #9's room.
- Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) arrived.

Even though requested, the hospital failed to provide additional video from 01/04/24.

Review of Patient #9's medical record showed:
- She was a 15-year-old female admitted on 12/31/23 and diagnosed with Major Depressive Disorder (a long period of feeling worried or empty with a loss of interest in activities once enjoyed).
- On 12/31/23 at 5:30 AM, the Intake Assessment showed that she was a high suicide risk as she was admitted for a suicide attempt at a residential facility by strangulation using socks and underwear the night prior to her admission on 12/31/23. She had multiple previous suicide attempts.
- On 12/31/23 safety interventions included five-minute safety checks, suicide smock and suicide blanket.
- On 01/01/24 at 2:35 PM, safety interventions included writing restrictions and it was noted that Patient #9 discussed possible elopement.
- On 01/02/24 at 8:40 AM, there was an order to discontinue the suicide smock and suicide blanket and to continue five-minute safety checks.
- On 01/03/24 at 5:00 PM, Patient #9 was found on the floor in the shower of her bathroom, face down with a white cloth tied around her neck. Scissors were used to remove the white cloth from around her neck. A medical emergency was called, EMS arrived and transported her to the Emergency Department (ED) for an evaluation.
- On 01/03/24 at 9:51 PM, she returned to the hospital from the ED. She was admitted to 3 North unit with physician orders of 1:1 continuous observation, suicide smock and suicide blanket.
- On 01/04/24 at 3:07 PM, Staff BB, BHA, found a pair of socks tied together by her bed. Socks were removed and nurse was notified.
- On 01/04/24 at 8:00 PM, Staff CC, RN, documented that patient had taken a shower and asked if she could have a pair of socks that her feet were cold. She called Staff EE, RN Supervisor, who told her that Patient #9 could have a pair of small white footies. She asked patient if she would contract for safety with the socks and Patient #9 stated yes.
- On 01/04/24 at 8:07 PM, documentation showed that the patient was asleep.
- On 01/04/24 at 10:00 PM, documentation showed that the patient remained asleep with chest rising and falling.
- On 01/04/24 at 10:30 PM, Staff FF, RN documented that Patient #9 requested a PRN medication and that she did not want to get up out of bed to get the medications. Staff FF, went into her room to administer the prn medication, called her name with no response from patient. She found a pair of socks tied around her neck and used a pair of scissors to cut them off.
- On 01/04/24 at 10:50 PM, Staff FF, RN documented that Patient #9 was transported to the ED via EMS transport.

During an interview on 01/09/24 at 1:00 PM, Staff C, Director of Quality, stated that he had not completed the investigation as he had been busy with another self-report. He had not watched the video until the state agency (SA) called and spoke to administration about the incident.

During an interview on 01/10/24 at 2:30 PM, Staff J, Medical Director, stated that staff were always on a cell phone when assigned to do patient safety checks. He had discussed with the administration team several times prior to this incident that staff assigned to do a 1:1 observation could miss what was going on with the patient because they were looking at a cell phone and not paying attention to the patient.

During a phone interview on 01/23/24, at 12:30 PM, Staff A, CNO, stated that his expectation of staff who were assigned to do safety checks and 1:1's should not be on cell phones. Cell phones had been allowed for emergencies only. He had not watched the video until the SA called and spoke to administration about the incident. No education had been provided to staff immediately following the incident.

During a phone interview on 01/16/24 at 3:00 PM, Staff AA, BHA, stated that:
- She was rotated as the BHA to Patient #9 for 1:1 observation on 01/04/24.
- Patient #9 asked for a pair of socks and stated her feet were cold. Staff AA, talked to the nurse and she stated that she could have a pair of socks.
- Staff AA was rotated out of 1:1 observation for Patient #9 and later was rotated back.
- Patient #9 was resting in her bed.
- Patient #9 requested a prn medication. She told the nurse that the patient would like her prn medication.
- The nurse came in to administer the medication and Patient #9 was unresponsive. The nurse found a pair of socks tied around the patient's neck.
- Staff AA went to get scissors to cut the socks off and called a code blue.
- Staff responded to the code blue. She was in panic mode and only remembers EMS taking the patient to the hospital.
- She was not aware that a pair of socks tied together had been found by the patient's bed earlier in the day.
- She talked to the nursing supervisor at the time of the incident and provided a written statement. She was not contacted by administration for any investigation of the incident.
- No education had been provided following the incident.

During a phone interview on 01/17/23 at 10:55 AM, Staff FF, RN, stated that:
- At approximately 10:20 PM, Patient #9 asked Staff AA, BHA, for a prn (as needed) medication.
- She went into Patient #9's room to administer her medication.
- Patient #9 did not respond verbally. She lifted the suicide safe blanket and saw a pair of socks tied around her neck. She told Staff AA to get scissors and the socks were cut away from the patient's neck.
- Staff arrived to help with the incident.
- EMS arrived and transported Patient #9 to the hospital.
- She was not aware of the incident of staff finding a pair of socks tied together by her bed earlier that day.
- She provided a written statement but no one from administration had talked to her.
- No education was provided following the incident.

During a phone interview on 01/16/24 at 11:30 AM, Staff BB, BHA, stated that:
- She was assigned as the BHA for Patient #9 on 01/04/24.
- She found a pair of socks that were tied together laying in the floor by Patient #9's bed.
- She removed the socks.
- She was re-assigned and told the BHA replacement that she had found a pair of socks tied together by Patient #9's bed.
- She did not recall if she notified the nurse but passed the information on to the oncoming BHA
- No one from administration had spoke with her regarding the incident.
- No education had been provided following the incident.

During a phone interview on 01/17/24 at 12:25 PM, Staff CC, Charge Nurse (CN), stated that:
- On 01/04/24 she received a call from a nurse who had requested approval for Patient #9 to have a pair of socks. She was unsure of time.
- She called Staff EE, Nurse Supervisor, and got approval to give Patient #9 a pair of small booties provided she was on 1:1 observation.
- At approximately 8:00 PM, she took Patient #9 her evening medications. The patient was cooperative and resting in bed.
- At 10:05 PM, she returned to the unit from a scheduled break and a code blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore heartbeat or breathing) had been called for Patient #9. She assisted at the nurses' station and got transfer paperwork ready.
- Patient #9 was transported by EMS to the hospital.
- She was not aware of a pair of socks found tied together by a BHA.
- She provided a written statement but no one from administration talked to her.
- No education was provided following the incident.

During a phone interview on 01/17/24 at 5:30 PM, Staff EE, Nurse Supervisor, stated that:
- He responded to the code blue that was called on 01/04/24 for Patient #9.
- Patient #9 was unresponsive. A pair of socks had been cut off from around her neck.
- Patient #9 was transported by EMS to the hospital.
- He was not aware was that a pair of socks tied together had been found by the patient's bed earlier in the day.
- No one from administration had talked to him regarding the incident.
- No education had been provided following the incident.

During a phone interview on 01/17/24 at 4:30 PM, Staff DD, BHA, stated she accompanied Patient #9 to the hospital and there were red marks on her neck. She had not been contacted by administration for a review of the incident and no education had been provided following the incident.

Based on interview, record review, and policy review, the hospital failed to ensure that the practioner responsible for the care of the patient authenticated, dated, and signed the restraint (any manual method, physical, or mechanical device that limits the ability of free movement of arms, legs, body, or head) and seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) orders within 24 hours for two patients (#11 and #12) of seven patients reviewed. This failure had the potential to cause poor nursing care outcomes for all patients placed in restraints.

Findings included:

Review of the hospital's policy titled, "Seclusion/Restraint: Acute and Residential Services," dated 11/30/23, showed the provider will sign the telephone/verbal order within 24 hours.

Review of Patient #12's medical record, showed:
- Patient #12 was placed in a physical restraint on 01/09/24 from 2:59 PM through 3:06 PM for banging their head against the wall and became aggressive to staff by swinging at them.
- A telephone order was obtained on 01/09/24 at 2:59 PM for the physical restraint.
- Review of Patient #12's restraint orders on 01/11/24 at 3:30 PM, showed the physician had not signed the order for the physical restraint on 01/09/24.

Review of Patient #11's medical record, showed:
- Patient #11 was placed in a physical restraint on 01/06/24 from 9:30 AM through 9:31 AM for an attempt to hit staff in the face and would not follow directions.
- A telephone order was obtained on 01/06/23 at 12:50 PM.
- Patient #11 was placed in a physical restraint on 01/08/24 at 5:20 PM through 5:23 PM for physical aggression towards staff.
- Patient #11 was placed in seclusion on 01/08/24 at 5:23 PM through 6:50 PM for physical aggression towards staff.
- A telephone order was obtained for seclusion and a physical restraint on 01/08/24 at 5:45 PM.
- Review of Patient #11's restraint and seclusion orders on 01/11/24 at 3:30 PM, showed the physician had not signed the orders for the physical restraint and seclusion on 01/06/24 or 01/08/24.

During an interview on 01/11/24 at 3:15 PM, Staff A, Chief Nursing Officer (CNO), stated that all verbal and telephone orders for restraints and seclusion must be signed by the physician within 24 hours.