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Based on observation, record review, and interview, the facility failed to protect the rights to receive care in a safe environment for 3 of 12 (Patients #1, #2, and #3) patients.

1. Patient #2 was able to obtain two syringes from the nurse's station from an unlocked cart on 12/06/2023. One syringe was accounted for after a contraband room search on 12/07/2023. Staff was unable to account for second syringe.

2. Female Patient #1 and male Patient #2 were able to congregate unsupervised in the male patient's room with the intent to be sexually active on 12/06/2023. Patient #1 reported that she injected methamphetamine in exchange for sex with Patient #2 on 12/06/023 while on staff close observational status.

3. Staff failed to ensure a safe, drug-free patient care environment and prevent that Patient #2 was able to hide an illegal substance on his body throughout the admission process and approximately 52 hours into his inpatient hospitalization.

4. Although on constant staff observation, Patient #3 was left staff unobserved in the bathroom on 12/15/2023 and attempted suicide by hanging.

5. After the installation of a new medication dispensing system on 12/14/2023, staff failed to follow hospital policy and ensure that all alerts for dispensing psychotropic medications were properly functioning. Within 24 hours, one patient (Patient #3) received a long-acting antipsychotic medication instead of the short-acting formula ordered to address the agitation following her suicide attempt.

Cross Refer Tag A0144

Based on observation, record review, and interview, the facility failed to ensure that a safe environment was provided for 3 of 12 (Patients #1, #2, and #3) patients.

1. Staff failed to ensure that medical supplies including sharps were secured from unauthorized patient use. While distracting the nursing staff, Patient #2 was able to take two syringes out of a medical cart on 12/07/2023 and used at least one of them for illegal substance use injection while inpatient hospitalized.

2. Staff failed to prevent two patients of the opposite sex (Patient #1 and Patient #2) to spend time in a patient room together where they reportedly used illegal drugs and had consensual intercourse.

3. Staff failed to prevent Patient #2 to bring an illegal substance into the hospital and on to the patient unit. Patient #2 was able to hide Methamphetamine undetected by staff through the admission process and approximately 52 hours into his hospitalization until 12/6/2023 when a Patient #1 reported having received and intravenously used the substance she received from Patient #2.

4. Although on constant staff observation, Patient #3 was left alone in the bathroom and attempted suicide by hanging on 12/15/2023.

5. Staff failed to ensure appropriate alarms systems to prevent medication errors were fully functioning during the transitional installation of medication dispensing systems [Pyxis System]. Patient #3 required psychotropic medication administration after an attempt to commit suicide in her inpatient bathroom; in addition to the short-acting antipsychotic medication ordered for the patient's mental health condition at that time, Patient #3 received its long-acting formula.

Findings Included:

1. Patient #2's Inpatient Comprehensive Psychiatric Evaluation completed on 12/05/2023 at 2:08 PM reflected the following, " ...Date of Admission: 12/04/2023 ...Chief Complaint ...4 days ago patient wanted to run into traffic has also been thinking about overdosing on pills ...Patient is 55-year-old with a prior diagnosis of paranoid schizophrenia who is presenting with worsening of mood and anxiety symptoms with increase in paranoia suicidal thoughts ...Patient also has been abusing stimulant methamphetamine ...over the last 6 months patient has been abusing amphetamines ...1 to 2 times a week ...cannabis smoking 1-2 or 3 times a week up ...Diagnoses: 1. Schizophrenia chronic paranoid type. 2. Methamphetamine use disorder severe. 3. Cannabis use disorder moderate to severe ..."

During an interview on 12/20/2023 at 11:30 AM, Personnel #4 stated that " ...We did a search of [Patient #2's] room and found a syringe that was unused. We traced back on the cameras to figure out how he got the syringes. He stole them from an emergency cart that was located behind the nurse's station. He distracted the nurse by asking her to get him some medication and she went to the medication room. He reached over the counter and was able to reach the syringes from an unlocked cart. The syringes have since been removed from that cart and are now locked up in the medication room. The cart has also been locked ..."

2. Patient #1's Inpatient Comprehensive Psychiatric Evaluation completed on 12/01/2023 at 2:17 PM reflected the following, " ...Date of Admission: 11/30/2023 ...patient is a 35-year-old female with history of bipolar disorder and polysubstance use disorder ...Patient reports history of hatred towards men due to history of abuse physically emotionally and sexually. Patient has a history of self-harm by scratching cutting trying to find a vein to inject methamphetamines in ...substances usage primarily methamphetamines ...cocaine ...benzodiazepines ...Patient had stated in intake 'I am bipolar I am meth addict' ...Diagnoses: 1. Bipolar disorder most recent episode mixed severe with psychosis. 2. Sedative hypnotic use disorder severe. 3. Methamphetamine disorder severe ..."

Patient #2's Inpatient Comprehensive Psychiatric Evaluation completed on 12/05/2023 at 2:08 PM reflected the following, " ...Patient is 55-year-old with a prior diagnosis of paranoid schizophrenia ...Patient also has been abusing stimulant methamphetamine ...over the last 6 months patient has been abusing amphetamines ...1 to 2 times a week ...cannabis smoking 1-2 or 3 times a week up ...Diagnoses: 1. Schizophrenia chronic paranoid type. 2. Methamphetamine use disorder severe. 3. Cannabis use disorder moderate to severe ..."

During an interview on 12/20/2023 at 3:49 PM, Personnel #7 stated that "I remember [Patient #1] and [Patient #2]. On 12/6, I had conversations with them regarding boundaries. I walked in on them in [Patient #2]'s room together. When I entered the room, [Patient #2] had [Patient #1] by the hand and was leading her into the bathroom. I came in at the right time and I stopped them. I let her know that her behavior was not acceptable, and she couldn't be in another patient's rooms..."

Record review of the facility policy titled "Patient Bill of Rights" dated 01/2021 reflected the following, "Basic Rights for All Patients ...You have the right to a clean and humane environment in which you are protected from harm ..."

3. Patient #2's Inpatient Comprehensive Psychiatric Evaluation completed on 12/05/2023 at 2:08 PM reflected the following, " ...Patient is 55-year-old with a prior diagnosis of paranoid schizophrenia ...Patient also has been abusing stimulant methamphetamine ...over the last 6 months patient has been abusing amphetamines ...1 to 2 times a week ...cannabis smoking 1-2 or 3 times a week up ...Diagnoses: 1. Schizophrenia chronic paranoid type. 2. Methamphetamine use disorder severe. 3. Cannabis use disorder moderate to severe ..."

Facility staff provided a screenshot of treatment team note completed on 12/07/2023 at 4:02 PM by Personnel #8 reflected the following, "[Patient #1]-During the completion of the Safety Plan, pt [patient] reported to therapist that she had used meth [methamphetamine] yesterday while on the unit ...Pt then stated that she received Meth from [Patient #2]. Pt stated that between 2 and 3 pm on 12/6/23 [Patient #2] grabbed two needles from the Nurses station and that the cameras would have seen it. Pt then stated it was at 5 pm yesterday when her and the other pt used the Meth IV consensual. This is when pt provided two versions of the next allegations. Pt first made the allegations that she was offered meth in return for sexual favors. Pt then stated she was forced to take Meth IV and then Raped in the shower ..."

Witness Statement written on 12/08/2023, untimed, by Personnel #18 reflected the following, "On Wednesday December 6th PT [Patient #1] stated to me that she traded sex with another male pt for drugs (ICE) [methamphetamine]. PT [Patient #1] also stated she and the male PT had been planning it for a few days and she could have stuck herself instead of him doing it."

4. Patient #3's Inpatient Comprehensive Psychiatric Evaluation completed on 12/12/2023 at 11:29 AM reflected the following, " ...Date of Admission: 12/11/2023 ...Chief Complaint: I bought a gun 5 days ago ...patient is a 27-year-old single, adult, Indian American female ...She reported buying a gun 5 days ago with an intent to use it on herself. This has triggered her admission. Patient reports that her 1st mental health contact was at the age of 13. Since then she has been hospitalized over 15 times in inpatient psychiatric setting. She also reports 5 suicide attempts in the past in terms of attempting to strangle herself/hang herself or even overdose ...Diagnoses: major depressive disorder recurrent severe without psychosis, rule out bipolar disorder mixed, PTSD (post-traumatic stress disorder), generalized anxiety disorder, rule out borderline personality disorder, panic disorder, history of sedative hypnotic dependence and alcohol use disorder binge type in remission, victim of trauma, single, inability to advance herself in life due to significant mental health issues, severe impairment in functionality ..."

Patient #3's 7:00PM-7:00AM Shift Nursing Assessment completed on 12/15/2023 at 7:00 AM reflected that Patient #3 was on line of site observation for previous suicide attempts in the hospital, but denied any homicidal or suicidal ideation. Patient refused suicide assessment and would not contract for safety. Patient's mood and affect were described to be flat, angry, and irritable with high levels of anxiety (8 out of 10) and depression (10 out of 10).

Patient #3's Interdisciplinary Progress Note completed on 12/15/2023 at 12:45 PM reflected the following, "[Patient #3] was found in restroom with makeshift noose (made of bra/pants) around her neck this afternoon. Patient was responsive and showed no s/s of injury ...Patient was transported from bathroom to seclusion room in order to de-escalate situation and administer emergency medication safely and privately ..."

Patient #3's 7:00PM-7:00AM Shift Nursing Assessment completed on 12/16/2023 at 5:00 AM reflected that Patient #3 refused nursing and suicide assessment reporting that she could not think. Patient was withdrawn from peers and isolative to her bedroom.

During an interview on 12/20/2023 at 9:20 AM, Personnel #1 stated " ...Last Friday, [Patient #3] had tied paper scrubs around her neck while she was in the bathroom. She was originally on a 1:1, but the doctor downgraded her to a line of sight. The PCA allowed the patient to shut the door. The PCA stood right outside the bathroom door, but she wasn't watching her ...the patient was taking too long and then [Personnel #15] immediately called a code ...used shears to remove the paper scrubs from her neck ..."

During an interview via telephone on 12/20/2023 at 8:05 PM, Personnel #15 stated the following, "I remember [Patient #3] and the incident that happened with her. She was on 'line of sight' observation, so I wasn't supposed to let her out of my sight. She asked to go to the restroom, so I went into the room with her. She asked for scrubs, so I got her some paper scrubs. She then said she was going to shower. I realized she was in the shower for too long and when I opened the curtain, she had made a noose with the paper scrubs. I called a code ..."

Record review of the facility policy titled "Levels of Observation and Precautions" dated 02/2023 reflected the following, " ...Line of sight observation: This level of observation is very restrictive and involves continuous visual monitoring at all times ...Staff must be within visual contact of the patient at all times ...When using the 'Special Bathing' area of the Hospital, staff will be required to monitor the patient inside the 'Special Bathing' area at all times ..."

5. During an interview on 12/20/2023 at 1:20 PM, Personnel #5 stated "I was not aware of a medication error that occurred on 12/15 with [Patient #3]...We just had our Pyxis swap out on 12/14; we finished the process Thursday of last week. We have a pop-up warning in the Pyxis system that comes up to remind the nurse that there are two kinds of Haldol-short acting and long acting. Those pop-up warnings have not been installed in the new Pyxis machines. I haven't had a chance to get them installed. There normally would have been a pop-up verifying that she wanted a long-acting Haldol. I still need to add all the medication warnings in the Pyxis system ...I will get those pop-ups installed and get all my labels in place for the look alike, sound alike medications. We are working on it, but I will get that moved to the top."

During a phone interview on 12/20/2023 at 7:12 PM, Personnel #16 stated " ...I had never administered emergency medications ...I pulled the medications and I only got one vial of the Haldol 5 mg. [Personnel #19] told me that I needed two vials because the order was for 10 mg. When I got back in the Pyxis I typed in "Hal" and then I picked the first Haldol that showed up on the screen. It was not the regular Haldol, it was Haldol Decanoate. I just grabbed that one and we tried to draw it up. We couldn't draw up the entire vial. The patient ended up getting Haldol 5 mg [short acting] from the first vial and only a small amount from the second vial with Haldol Decanoate 50 mg [long acting]. When we were doing our paperwork afterwards, [Personnel #19] realized what had happened. We told the doctor, and he ordered Cogentin. She slept for most of the shift after the emergency medication, but I didn't notice any adverse reactions."

During an interview on 12/21/2023 at 9:34 AM, Personnel #5 stated "I put in all the high alert medication alerts, but I still need to test it to see if I did everything right. The new Pyxis and the old Pyxis machines were supposed to be cloned. That is why I thought all the safety mechanisms were in place. I didn't know until yesterday that they had not been installed ... I have stickers that say long-acting and short-acting, but we are switching units, so I haven't placed those stickers yet. If I place those on the cubies [cubicles] and then we move units then I will have to throw those cubies away so I'm waiting to place stickers until we move units..."

During a tour of the Cedar Unit with Personnel #5 and Personnel #1 on 12/21/2023 at 9:30 AM, the medication removal was simulated for Haldol Decanoate, Invega, and Depakote ER from the Pyxis The high alert stickers were not found on the cubies or on the vials for those psychotropic medications.

During an interview on 12/21/2023 at 12:24 PM, Personnel #1 stated "we are moving units next week, but the stickers should have been placed for the high alert medications regardless of having to throw away the cubies."

The facility policy titled "Pyxis MedStation-Policy and Procedure" dated 06/2022 reflected the following, " ...Procedures are designed to provide safe and accurate provision of medication, secure storage, accurate accountability for controlled substances and other drugs, accurate patient billing, and compliance with State and Federal regulations ...High alert medications will require a phone call to the on-call pharmacist for verification that the dosage form/strength is correct. A prompt will appear on the screen if verification is necessary ..."

The facility policy titled "High Risk Medication, Look Alike/Sound Alike Medications and Overrides" dated 05/2023 reflected the following, " ...High Alert Medications-drug/s which are involved in a higher percentage of medication incidences and/or sentinel and significant events, or that carry an increased risk for error, abuse, injury, or other adverse outcome ...Medication storage bins in the Pharmacy may also be labeled with such cautionary statements as, 'Caution: Sounds like ...' or 'Look Alike/Sound Alike' or other cautionary labels as deemed appropriate by the Director of Pharmacy ..."

Based on record review and interview, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 3 patients (Patient #1). Patient #1 did not receive an assessment following reports on 12/06/2023 of sexually inappropriate behavior and intravenous [IV] drug use while inpatient at the facility.

Findings Included:

Record review of Patient #1's medical record did not evidence any progress notes, nursing notes, or therapy notes related to the patient's report of sexually inappropriate behavior or IV methamphetamine use during her inpatient admission.

Facility staff provided a screenshot of a treatment team note completed on 12/07/2023 at 4:02 PM by Personnel #8 that reflected the following, "[Patient #1]-During the completion of the Safety Plan, pt [patient] reported to therapist that she had used meth [methamphetamine] yesterday while on the unit ...Pt then stated that she received Meth from [Patient #2]. Pt stated that between 2 and 3 pm on 12/6/23 [Patient #2] grabbed two needles from the Nurses station and that the cameras would have seen it. Pt then stated it was at 5 pm yesterday when her and the other pt used the Meth IV consensual. This is when pt provided two versions of the next allegations. Pt first made the allegations that she was offered meth in return for sexual favors. Pt then stated she was forced to take Meth IV and then Raped in the shower ..."

Review of male Patient #2's medical record reflected an Interdisciplinary Progress Note completed on 12/07/2023 at 5:00 PM that "A female pt report to staff that she had done meth with pt during afternoon on 12/6/23. The female pt stated that [Patient #2] had obtained two syringes from the nurses station and used them to take meth intravenously on the unit. The female pt reported that the meth was supplied by [Patient #2] ..."

Patient #2's Inpatient Progress Note completed on 12/08/2023 at 1:46 PM reflected the following, " ...I discussed with patient concerns regarding another female peer making allegations that patient had boundary violations and had also given patient drugs while on the unit ... Patient was very non chalant when discussed about concerns of these boundaries ..."

During an interview on 12/20/2023 at 11:30 AM, Personnel #4 stated that Patient #1 "reported to a PCA [patient care associate] that another patient ran into her room with a syringe and stabbed her twice in the AC [antecubital] and then ran out of her room ...We found out that she had obtained drugs and a syringe from another patient and shot up. The patient she received the drugs from had brought the drugs into the facility in his rectum ...We did a search of his room and found a syringe that was unused. We traced back on the cameras to figure out how he got the syringes. He stole them from an emergency cart that was located behind the nurse's station. He distracted the nurse by asking her to get him some medication and she went to the medication room. He reached over the counter and was able to reach the syringes from an unlocked cart. The syringes have since been removed from that cart and are now locked up in the medication room. The cart has also been locked. The story was that the two patients met up a couple days prior to the incident and he asked her if she wanted some of his drugs. We saw on the video that she looked out for him while he passed her the drugs. We saw him drop the drugs on the floor when he walked past her, and she picked them up. There was a report that she had sex with the patient in exchange for the drugs. She said it was consensual, but we never saw any evidence of it. We did see them go away together, but it was less than five minutes. She went into his room, and we figure that is when they were shooting up. A PCA walked in on them, and they were fully clothed. The PCA immediately separated them. On her way out she apologized for planning everything. She spoke with a PCA during a smoke break on the day of her discharge and told her that the sex was consensual. The incident happened late on 12/6 and [Patient #1] was discharged early on 12/7..."

During an interview on 12/20/2023 at 12:00 PM, Personnel #3 stated that Patient #1 "does not have any documentation in her medical record regarding the meth incident or the inappropriate sexual behavior. There are no progress notes, nursing notes, or therapy notes that speak to the events. The therapist did not document the family session or the safety plan in the medical record."

During an interview on 12/20/2023 at 3:49 PM, Personnel #7 stated that "I remember [Patient #1] and [Patient #2]. On 12/6, I had conversations with them regarding boundaries. I walked in on them in [Patient #2]'s room together. When I entered the room, [Patient #2] had [Patient #1] by the hand and was leading her into the bathroom. I came in at the right time and I stopped them. I let her know that her behavior was not acceptable, and she couldn't be in another patient's rooms...They both apologized, and she went to her room and didn't come back out for the rest of the night. I did not see them doing drugs or having sex. She wasn't fighting him when he was holding her hand. They were both fully clothed. I reported it to my nurse and [Patient #1] was moved to another unit later in the day."

Witness Statement written on 12/08/2023, untimed, by Personnel #18 reflected the following, "On Wednesday December 6th PT [Patient #1] stated to me that she traded sex with another male pt for drugs (ICE) [methamphetamine]. PT [Patient #1] also stated she and the male PT had been planning it for a few days ..."