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Based on review of 12 medical records, policies and procedures, and other pertinent documentation, interviews with staff and unit observations, the surveyors identified multiple standard level violations under the Condition of Participation of Patient Rights.

The findings include:

1. The hospital failed to provide a written response to the patients' grievances. See tag A-0123.
2. The hospital failed to uphold the right to confidentiality for patients on the Red Brick #4 unit. See tag A-0143.
3. The hospital failed to provide care in a safe setting to multiple patients on the following units: Red Brick #4, Noyes, and Dayhoff B. See tag A-0144.
4. The hospital failed to enter renewal orders for a seclusion episode for Patient #3 and failed to enter accurate restraint orders for Patients # 4, 7, and 12. See tag A-0168.
5. The hospital failed to monitor Patient #3 while in seclusion. See tag A-0175.
6. The hospital failed to complete a timely face-to-face evaluation following a restraint of Patient #3. See tag A-0178.

The cumulative effect of these failures created an unsafe environment of care that did not protect or promote the rights of patients in the hospital.

Based on review of five patient grievance files, staff email communication, hospital policies and procedures, and other pertinent documents, it was determined that the facility failed to ensure that a written notice was provided to individuals who filed a grievance at the conclusion of the grievance investigation process. This was evident in four of five grievances reviewed.

On July 8, 2021, the surveyors reviewed five patient grievance files. Four of the five grievance files reviewed did not have resolution notices/letters included in the documentation provided. The hospital provided an email communication from the Rights Advisor assigned to the reviewed grievances which stated that the 4 grievances had, "No resolution letter. Spoke with the patient via telephone. Please see the note within the case."

The surveyors did not locate any other written communication to the patients who submitted grievances which would satisfy the requirements of this regulation.

Based on unit observations and review of the hospital policies, procedures, and other pertinent documents, it was determined that the hospital failed to uphold the rights of patients to personal privacy, as evidenced by: 1) presence of a posted patient list in the main hall of Red Brick #4 which contained patient-specific dietary information, and 2) presence of a posted patient list in the dining room of Red Brick #4 which identified the patients who could eat in the dining room based on their completed COVID-19 vaccination.

The surveyors reviewed the policy titled "Patient Rights and Responsibilities". Section E. 1. of the policy stated, "All patients have the right to expect reasonable safety and privacy in the environment and in [hospital] practices while residing at the hospital." Section E. 2. stated, "All patients' records are confidential. Any information known about a patient should be kept confidential and should not be revealed without the patient's written consent, unless permitted by law."

1) On July 7, 2021 at approximately 10:00 am, the surveyors performed observations on Red Brick #4 unit. During this observation, the surveyors noted the presence of a posted patient list in the main hall of the unit which contained patient-specific dietary information. This list included various patient's first names and last initials, as well as their individual diets, dietary restrictions, or dietary concerns. The main hall of the unit was located on the first floor and was utilized by patients throughout the day.

2) During the same unit observations, the surveyors also noted the presence of a posted patient list in the dining room which identified first names of the patients who could eat in the dining room. The surveyors were later informed during an informal interview with the unit staff that the unit was piloting a new patient dining arrangement at the time of survey. Per the arrangement, patients who were fully vaccinated against COVID-19 infection would eat in the dining room, and the unvaccinated patients would eat in the Day Hall area. Based on this explanation, one could conclude that the list posted in the dining room contained the names of patients who were fully vaccinated against COVID-19.

Based on unit observations, review of 12 medical records, hospital policies, procedures, and other pertinent documents, it was determined that the hospital failed to provide care in a safe setting to multiple patients on various units, as evidenced by:

1) 2 separate direct observations of the medication room being unsecured and unattended on Red Brick #4 unit;

2) a direct observation of the medication room keys left unattended in an unsecured drawer on Red Brick #4 unit;

3) a direct observation of an unsecured bottle of laundry detergent stored in a nurses station without full security of the area of Red Brick #4;

4) a direct observation of 2 unlocked open doors to an unattended shower room with potential ligature points on the Noyes Unit;

5) staff failure to document complete contraband searches for Patient #12 (P12) on the Dayhoff B unit.

The findings include:

1) The surveyors reviewed the hospital policy titled "Medication-Control Substances." Section A of the policy stated, "All medications will be kept under lock and key." Section H of the policy stated, "Medication keys will be handled only by licensed staff. Medication keys are not to be left unattended on counter tops, desk drawers." Section L. stated, "The licensed staff person assigned to medication will be responsible for the keys and will keep them on their person at all times."

On July 7, 2021 at approximately 10:00 AM, two nurse surveyors and one environmental health surveyor performed observations on Red Brick #4 Unit.

Upon arrival to the first floor of the unit, the nurse surveyors noted an unlocked, unsecured access window in the medication room door. This door led directly from the main unit hallway to the medication room. The nurse was not physically present in the room at the time of the observation. When the surveyors posed a question about the unsecured access window, the Chief Nursing Officer (CNO) and Chief Compliance Officer (CCO) called for the medication nurse. Upon arrival to the area, the medication nurse, Licensed Practical Nurse #1 (LPN1), stated he/she was upstairs. In response to the question if the access window was supposed to be secured, LPN1 stated, "I suppose it should be."

Approximately 1 hour after the nurse surveyors observed the unlocked, unsecured access window to the medication room, the environmental health surveyor observed the second door to the medication room that was unlocked and unsecured. This second door was located between the medication room and the main nurses' station office area on the first floor of the unit. At the time of this observation, the medication room was unattended by LPN1 or any other staff. The horizontally divided door leading from the hallway into the nurses' station had the top portion open and unsecured, and could have served as a point of access by patients.

2) Immediately following the first encounter with the nurse surveyors at approximately 10:00 AM on July 7, 2021, LPN1 was observed entering the medication room and opening an unsecured desk drawer to retrieve a set of keys. The nurse surveyors asked LPN1 what the keys were to, and LPN1 stated, "They're the medication keys." The keys were not attended by LPN1 prior to the retrieval from the desk drawer.

3) During unit observations on Red Brick #4 Unit at approximately 11:00 AM on July 7, 2021, the nurse surveyors asked the unit staff about the location and patient access to the laundry room. The staff stated that the laundry room was located on the second floor of the unit, was always secured when not in use by patients, and was always under supervision when in use. The surveyors then inquired about the storage location of the laundry detergent. The staff stated, "In the nurses station." Upon further observations at this location, the surveyors determined that the laundry detergent was located in the upstairs nurses' station, under a countertop. The area did have a locked door and a wall/counter which was approximately 4 foot tall. The area above this wall/counter could have served as a point of access by patients.

4) At approximately 11:30 am on July 7, 2021, the nurse surveyors performed observations on Noyes Unit. On the second floor of the unit, the surveyors observed a shower room with two unlocked and physically opened doors without staff presence in the immediate area. The shower room contained potential ligature points: air/heat radiator-type ventilation system. The surveyors asked the staff present if the room was commonly left unsecured. The staff responded "No", and informed the surveyors that the housekeeper had just finished cleaning the area. The surveyors did not see the housekeeping staff in the immediate area, but observed patients present throughout the hallway adjacent to the bathroom.

5) On August 6, 2021, the surveyors reviewed the policy titled "Contraband and Contraband Searches. " Section V of the policy stated, " General Guidelines for all type Searched: Regardless of the type and reason for the search, the search shall always be conducted in a dignified and professional manner and the following considerations are to be followed: ... " Subsection 5 of Section V further stated, " Documentation Requirements: The Charge Nurse or designee is responsible for documenting on a progress note the following: date, time, and the justification for any physical search of the patient or the patient ' s room; the findings and disposition of any contraband items; any subsequent actions take with the patient; and names of staff members involved. The Charge Nurse or designee shall document observations of the patient ' s condition and the rationale for implementation of this procedure in a progress note before the end of the shift .... "

Patient #12 (P12) was a minor who was admitted to this hospital for treatment of a mental illness. P12 had a history of medication non-compliance, elopements, aggression towards others, homicidal ideations, and suicidal ideations.

Approximately 2 months following the admission, P12 assaulted another patient, Patient #11 (P11). Review of P12's medical record determined that P12 was on Close Observations (CO, 15 minute checks with hourly log documentation of the patient ' s whereabouts and activities) at the time of the incident. Review of P11 's medical record determined that P11 was on one-to-one observation (continuous observation by a staff present within an arm's length of a patient) at the time of the incident.

Review of the documentation related to the incident determined that P12 entered the bathroom and walked past P11's one-to-one observer who unsuccessfully attempted to redirect P12 from entering the bathroom where P11 was at the time. P12 proceeded to assault and stab P11 in the thigh with a metal object. Staff called for assistance and a behavioral code was initiated. P12 was placed in restraints and given PRN (as needed) psychiatric medications. P12 remained in restraints for approximately 4 hours.

According to the restraint documentation by the Registered Nurse (RN) in P12's chart, P12, "attacked, stabbed peer, attempted to stab another peer, not following staff redirection. " The RN also documented that P12 had, " a piece of metal (about 7 inches long) that is used in filling papers."

No documentation leading up to the assault indicated that P12 had contraband in his/her possession. The incident report from the date of the incident documented that the patient stated he/she had found the metal piece, " ...outside of the nurses station office on the floor." Further review of P12's record determined that P12 told a physician 4 days after the assault, " [he/she] found the piece of metal in the shower in the days prior to the incident and then hid it under [his/her] pillow. "

The surveyors determined through the chart review that, approximately 1 month prior to the assault, P12 had been ordered contraband checks every shift. The surveyors reviewed nursing progress notes in P12's chart for 22 days leading up to the incident for information related to the contraband search findings. Out of 66 shift progress notes, only 10 notes contained any information regarding the status of the contraband check for that respective shift, as required by the hospital policy. The last complete documentation for the contraband search was entered 3 days before the incident.

Without proper documentation of date/time/findings of the contraband searches in the shift progress notes, as required by the hospital policy, the surveyors could not confirm that the contraband searches that were conducted, as ordered. Failure of the staff to perform/document contraband searches, as ordered and required, placed all patients and staff of the unit at risk of an injury.

Based on review of 5 restraint/seclusion records, hospital policy and procedures, and interviews with staff, it was determined that hospital failed to enter appropriate orders for restraint/seclusion events for 4 of 5 restraint/seclusion records reviewed. The hospital failed to ensure that: 1) providers entered required renewal orders for a seclusion event for Patient #3 which lasted 19.5 hours; 2) providers timely entered a written seclusion order for Patient #3; 3) providers entered complete and/or accurate restraint orders for Patients #3, #4, #7, and #12.

The findings include:

1) The surveyors reviewed the hospital policy titled "Seclusion and Restraint". Under the section "IV. Seclusion/Restraint Orders", the policy stated: "A. All seclusions/restraints must be authorized by an order from a physician ...F. The initial telephone order is only valid until a physician makes an in-person evaluation. No seclusion/restraint shall extend beyond one hour without a written order by a physician ...G. The physician's order for seclusion/restraint may not exceed four hours for adults and two hours for adolescents... H. Seclusion/restraints may only be continued upon renewal of the order."

P3 was a 60+ year old patient admitted to the hospital for the treatment of mental health conditions. P3 exhibited behaviors requiring the use of restraint/seclusion on multiple occasions throughout P3's admission.

P3 had one seclusion event which occurred on day 15 and extended into day 16 of P3's admission. Review of the restraint log and the seclusion/restraint monthly log determined that the seclusion event lasted for a total of 19 hours and 30 minutes. Per hospital policy, P3's seclusion order should have been renewed four times prior to the discontinuation of seclusion. The surveyors were able to locate the initial seclusion order and the first renewal order, which covered the first 8 hours of the seclusion. The surveyors were not able to locate the remaining 3 renewal orders which would cover the remaining 11 hours and 30 minutes that P3 had spent in seclusion. Based on the lack of provider renewal orders for the last 11.5 hours of the seclusion event, the surveyors were unable to determine if the provider had the oversight of the event during that time frame and was assessing the patient for the continued need for seclusion.

2) Review of P3's medical record for a separate seclusion event on day 16 of P3's admission showed a telephone order obtained by the nurse at 3:30 pm. The provider signed the telephone order at 5:00 pm. This was outside of the hospital's allotted time of one hour for a provider written order.

3) The surveyor reviewed the hospital policy titled "Seclusion and Restraint." Section IV. E. stated, "The physician must: 2. Enter a complete order in the patient's medical record on the 'Seclusion and Restraint Physician's Orders' form."

During unit observations on July 7 and July 9, 2021, various hospital staff reported to the surveyors that the only mechanical restraint used throughout the entire hospital was a restraint chair.

Continued review of P3's medical record identified a restraint order on day 53 of P3's admission which stated that P3 would be placed in 5-point leather restraints. This documentation contradicted the type of mechanical restraint available at the hospital at the time of the survey.

Patient #4 (P4) was a 30+ year old patient admitted to the hospital for the treatment of mental health conditions.

Approximately 5 months into P4's admission, P4 had 3 restraint episodes due to displaying physically threatening behavior. Review of the orders for 2 of P4's restraint episodes determined that P4 was placed in 4-point soft and 4-point leather restraints. This documentation contradicted the type of mechanical restraints available at the hospital.

Patient #7 (P7) was a 30 + year old patient who had been committed to the hospital as Incompetent to Stand Trial (IST).

Approximately 1.5 months after arrival to the hospital, P7 engaged in an altercation with a peer and refused redirection. The patient was placed in restraints for safety of others. The restraint episode lasted less than 1 hour. Review of the documentation related to the restraint determined that the corresponding physician's written order in the patent's chart was incomplete. " Restraint " was marked on the order sheet; however, the order lacked the type of restraint. Other restraint documentation, including the Registered Nurse (RN) progress note and RN initiation note, stated "chair restraint."

Patient #12 (P12) was a minor who was admitted to this hospital for treatment of a mental illness. P12 had a history of medication non-compliance, elopements, aggression towards others, homicidal ideations, and suicidal ideations.

Approximately 2 months following the admission, P12 assaulted another patient, Patient #11 (P11). Review of P12's medical record determined that P12 was on Close Observations (CO, 15 minute checks with hourly log documentation of the patient ' s whereabouts and activities) at the time of the incident. Review of P11 's medical record determined that P11 was on one-to-one observation (continuous observation by a staff present within an arm's length of a patient) at the time of the incident.

Review of the documentation related to the incident determined that P12 entered the bathroom and walked past P11's one-to-one observer who unsuccessfully attempted to redirect P12 from entering the bathroom where P11 was at the time. P12 proceeded to assault and stab P11 in the thigh with a metal object. Staff called for assistance and a behavioral code was initiated. P12 was placed in restraints and given PRN (as needed) psychiatric medications. P12 remained in restraints for approximately 4 hours.

Further review of P12's restraint documentation showed that two out of two physician's written orders for this restraint episode were incomplete. " Restraint " was marked on the order sheet; however, the order lacked the type of restraint, as well as the appropriate/approved length of time of use. The RN initiation note was marked, " Restraint, specify: 4 points. " A physician face-to-face form stated, " ...when [he/she] was release from chair ... " In several progress notes, the use of chair restraint was documented.

The surveyor was unable to determine the exact type of restraints that were used on P12 at the time of the intervention due to the lack of complete orders and varying documentation.

Based on review of 12 medical records, including 5 restraint/seclusion records, hospital policy and procedures, and interviews with staff, it was determined that hospital failed to monitor 1 of 5 patients while in seclusion/restraints.

The surveyors reviewed the hospital policy titled "Seclusion and Restraint". Under the section "VIII. Monitoring", the policy stated: "A. Patients in seclusion/restraints will be monitored in-person continuously by an assigned nursing staff who have been trained in the monitoring and assessment requirements. The patient must be in full view of the staff at all times for their protection."

P3 was a 60+ year old patient admitted to the hospital for the treatment of mental health conditions.

On days 15 and 16 of P3's admission, P3 was placed in seclusion due to behaviors which posed a danger to self and others. Review of the restraint log and the seclusion/restraint monthly log determined that the seclusion event lasted for a total of 19 hours and 30 minutes.

The surveyors reviewed P3's record and determined that the seclusion was initiated at 2:30 PM on day 15 of P3's admission. The hospital staff documented monitoring of P3 while in seclusion from 2:30 PM until 9:45 PM at 15 minute intervals. The last monitoring entry was entered at 9:45 PM. The medical record did not contain monitoring documentation for P3 while he/she was in seclusion for 12 hours from 10:00 pm through 10:00 am the following day. The seclusion was discontinued at 10:00 AM on day 16 of P3's admission.

Based on review of 10 medical records, including 4 restraint/seclusion records, hospital policy and procedures, and interviews with staff, it was determined that hospital failed to document a face-to face assessment conducted within 1 hour for 1 of 4 patients during several seclusion events.

Per hospital policy titled, Seclusion and Restraint, "V. Face-to-Face Evaluation and Immediate Plan of Care Review, A. The physician must perform an in-person evaluation of the patient within one hour of the initiation or continuation of seclusion/restraints, whether or not the patient remains in seclusion/restraints at the end of the hour. If the patient remains secluded or restrained, the physician should determine whether to continue the initial order or release the patient from seclusion/restraint and document the same ...B. The purpose of the in-person evaluation is to justify continuance or discontinuance of the seclusion/restraint; to assess the patient's clinical needs and current treatment plan and to determine an immediate plan of care following termination of the seclusion/restraint."

P3 was a 60+ year old patient admitted to the hospital for the treatment of mental health conditions. P3 exhibited behavior requiring the use of restraint/seclusion on multiple occasions throughout P3's admission.

On day 15 of P3's admission, P3 was placed in seclusion due to behaviors posing a danger to others. Review of the restraint log provided onsite and the seclusion/restraint monthly log, both documented that the seclusion episode lasted 19 hours and 30 minutes and extended into day 16 of the patient's admission. On day 16, P3's medical record lacks documentation of face-to-face assessment being conducted for what should have been documented as the 2:00 AM and 6:00 AM seclusion renewal event. The last face-to-face documented for P3 was at 10:50 PM on day 15.

Also on day 16, P3 had a telephone order for a separate episode of seclusion and a physical hold placed at 3:30 PM. The seclusion/restraint nursing initiation progress note was also timed at 3:30 PM, in addition to seclusion monitoring documentation that began at 3:30 PM. The provider's face-to-face assessment was documented at 5:20 PM, nearly 2 hours after P3 was placed in seclusion.

Based on unit observations in the Red Brick building #4 and informal staff interviews, it was determined that the hospital failed to maintain facilities in a manner that promoted patient safety and well-being.

The findings include:

On July 7, 2021 at approximately at 10:30 AM, the environmental heath surveyor performed observations on the first and second floors of Red Brick #4. The surveyor noted the following direct observations:

1) The closet light in Room 123 was not working.

2) Room 118 had a chipped, jagged floor below the window. The Facilities Director, who was present during observations, informed the surveyor that there used to be a standing radiator that had been removed from the floor in the area of the disrepair.

3) The Women's Bathroom had red, black, and rust colored stains on shower heads, walls, and shower curtains. The toilet stall furthest to the left had a wet, soiled white towel lying on the floor.

4) The Men ' s Bathroom had multiple cracks in the flooring. A wet towel was observed pressed against one of the cracks. The furthest right bathroom stall was observed with chipped flooring measuring approximately 2 feet x 4.5 feet.

5) Room 130 had cobwebs and debris along the walls.

6) Dead, upturned cockroaches were observed in the stairwell.

7) Bathroom 005 ' s sink had caulking in disrepair around the joint where the sink meets the wall which could allow water infiltration. The Facilities Director stated that the area was hardly ever dry to re-caulk and residents frequently picked at caulking.

8) The Sick Room had 2 living spiders in a web at the head of the bed.

9) A Nurses Station/Treatment Room Bathroom had water damage on the walls leading to bubbled paint and exposed drywall.

Based on unit observations and review of hospital policies, procedures, and other pertinent documents, it was determined that the hospital failed to ensure all employees were in compliance with the finger nail portion of the dress code policy, which created an increased risk of infection transmission.

The surveyor reviewed the policy titled "Dress Code." Section A. stated, "ALL employees, regardless of work setting, must adhere to the following standards: 4. Fingernails should be neat, clean and maintained. They may extend no more than ¼ in from fingertip. Nail polish may be worn if well-manicured. Any chipped polish shall be removed. Artificial nails or artificial nail products (i.e. tips, wraps, overlays, jewelry, etc) may not be worn."

During the observation of the Tawes A unit, the surveyors observed a non-clinical staff person with long, painted fingernails that appeared to be artificial. The surveyor brought this observation to the attention to the Assistant Director of Nursing #1 (ADON1) and asked if this staff was allowed to have them, the reply was, "No."