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Based on observation of video footage of the Behavioral Health Unit Floor three (3) dated 07/03/2023 from 12:53 p.m. to 5:25 p.m., facility staff interviews, patient #1 medical record review, and facility policy and procedure review, the facility failed to ensure Patient #1's Patient Rights were protected on two (2) of two (2) days of survey.

Findings Include:

Observation of Video footage dated 07/03/2023 from 12:53 p.m. to 5:25 p.m. of the Behavioral Health Unit Floor Three (3) hallway at 11:45 a.m. to 1:10 p.m. on 07/27/2023 with the Director of Security, Director of Clinical services Outpatient, and Compliance/Risk Management Director revealed:

12:53:36 P.M. - Patient #1 enters his room.
01:14:08 P.M. - Registered Nurse (RN) #2 enters Patient #1's room.
01:46:07 P.M. - Patient #1 exits his room and stood in the hallway.
01:47:09 P.M. - Patient #1 enters his room.
01:49:51 P.M. - Patient #1 exits room and walks up and down the hallway.
01:52:00 P.M. - Patient #1 enters his room.
02:07:47 P.M. - Mental Health Technician (MHT) #1 entered patient #1's room .
02:45:02 P.M. - MHT #1 entered patient #1's room
03:20:33 P.M. - MHT #1 entered patient #1's room
04:03:51 P.M. - MHT #1 entered patient #1's room
05:04:36 P.M. - RN #1 entered patient #1's room
05:05:23 P.M. - RN #1 exits patient #1's room, sees MHT #1 re-enters patient room.
05:05:53 P.M. - MHT #1 enters patient #1's room.
05:06:19 P.M. - RN #2 enters patient #1's room.
05:06:30 P.M. - MHT #1 exits patient #1's room.
05:07:10 P.M. - Crash Cart arrives in patient #1's room.
05:08:01 P.M. - Code Team arrives to Patient #1's room.
05:25 P.M. - Patient #1 taken to the Emergency Department, Cardiopulmonary Resuscitation still in process.

Interview with MHT #1 on 07/27/2023 at 12:12 p.m. confirms no visual safety checks on Patient #1 between 4:03 p.m. and 5:04 p.m. when Patient #1 was found unconscious.

Interview with the Director of Clinical Services (DCS) at 12:45 p.m. on 07/27/2023, confirmed the safety checks on the patient #1 were not performed per the facility policy and procedures, every 15 minutes based on observation and review of video footage dated 07/03/2023 from 12:53 p.m. to 5:25 p.m. of the Behavioral Health Unit Floor Three (3) hallway.

Interview with the Compliance/Risk Management Director, at 12:50 p.m. on 07/27/2023, confirmed the safety checks were not performed on patient #1, every 15 minutes per the facility policy and procedures based on observation and review of the video footage dated 07/03/2023 from 12:53 p.m. to 5:25 p.m. of the Behavioral Health Unit Floor Three (3) hallway.

Review of Patient #1's Medical record titled "Precaution Flowsheet" dated 07/03/2023 reveals patient #1 was on standard observation level (safety checks every 15 minutes) for patient safety; Documentation on the flowsheet at 1615 (4:15 p.m.), 1630 (4:30 p.m.), 1645 (4:45 p.m.) and 1700 (5:00 p.m.) by MHT #1 states "2S" (patient in bed and asleep) has been marked through and documented as errors. There is no video footage of staff entering patient #1's room from 4:03 p.m. to 5:04 p.m. when patient was found unconscious.

Review of facility policy and procedure titled, "Suicide Risk assessment/reassessment, observing and interventions", Policy # PSY_585, effective 03/04/2009, reveals, " ...Policy: It is the policy of ...to create an environment of care ...successful management of patients who are at an increased risk for suicide or self-destructive behaviors ...Patients at risk for suicide require intensive support, close observation, frequent re-assessment and application of protective measures for emotional and physical well-being at all times ... C. Patient monitoring: 1. All patients will be monitored at least every 15 minutes ... E. 1. It is the responsibility of all staff to maintain a safe and therapeutic milieu for all patients at all times. 2. Safety and Environmental Rounds are to be conducted at regular intervals according to the program policy ...".

Review of facility policy and procedure titled, "Safety Observations", numbered #PSY_586, last review date 09/01/2020, reveals, " ...Policy: It is the policy of the Program that staff monitoring is instituted to prevent patients from harming themselves or others ... I. Standard Observation: Consists of fifteen (15) minute checks by a staff member. 1. The staff member records location and behavior on all patients at random intervals not to exceed 15 minutes. 2. Assigned staff will make direct contact with patients and confirm they are in no danger or distress. 3. Observations should be completed standing in a doorway or at a distance particularly for patients who are sleeping if respirations are visible. If the staff member cannot see the patient breathing, he/she should enter the room, approach the patient, and ensure they are not in any distress. 4. All patients at a minimum are on Standard Observation."

During the exit conference on 07/27/2023 at 5:15 p.m. with the Chief Nursing Officer, the Infection Prevention Director, the Executive Director of Nursing, the Compliance/Risk Management Director, and the Administrator survey findings related to alleged complaint were discussed. No further documentation was provided for review during exit conference.

Based on observation of video footage of the Behavioral Health Unit Floor three (3) dated 07/03/2023 from 12:53 p.m. to 5:25 p.m., facility staff interviews, patient #1 medical record review, and facility policy and procedure review, the facility failed to provide a safe environment to prevent patient #1's self-harm on two (2) of two (2) days of survey.

Findings Include:

Cross reference to 0115/482.13 for the facility's failure to provide a safe environment.

During the exit conference on 07/27/2023 at 5:15 p.m. with the Chief Nursing Officer, the Infection Prevention Director, the Executive Director of Nursing, the Compliance/Risk Management Director, and the Administrator survey findings related to alleged complaint were discussed. No further documentation was provided for review during exit conference.

Based on observation of video footage of the Behavioral Health Unit Floor three (3) dated 07/03/2023 from 12:53 p.m. to 5:25 p.m., facility staff interviews, Patient #1's medical record review, and facility policy and procedure review, the facility's nursing staff failed to provide nursing services to ensure a safe environment of care and management of patients who are at an increased risk for suicide or self-destructive behaviors on two (2) of two (2) days of survey.

Findings Include:

Observation of Video footage dated 07/03/2023 from 12:53 p.m. to 5:25 p.m. of the Behavioral Health Unit Floor Three (3) hallway at 11:45 a.m. to 1:10 p.m. on 07/27/2023 with the Director of Security, Director of Clinical services Outpatient, and Compliance/Risk Management Director revealed:

12:53:36 P.M. - Patient #1 enters his room.
01:14:08 P.M. - Registered Nurse (RN) #2 enters Patient #1's room.
01:46:07 P.M. - Patient #1 exits his room and stood in the hallway.
01:47:09 P.M. - Patient #1 enters his room.
01:49:51 P.M. - Patient #1 exits room and walks up and down the hallway.
01:52:00 P.M. - Patient #1 enters his room.
02:07:47 P.M. - Mental Health Technician (MHT) #1 entered patient #1's room .
02:45:02 P.M. - MHT #1 entered patient #1's room
03:20:33 P.M. - MHT #1 entered patient #1's room
04:03:51 P.M. - MHT #1 entered patient #1's room
05:04:36 P.M. - RN #1 entered patient #1's room
05:05:23 P.M. - RN #1 exits patient #1's room, sees MHT #1 re-enters patient room.
05:05:53 P.M. - MHT #1 enters patient #1's room.
05:06:19 P.M. - RN #2 enters patient #1's room.
05:06:30 P.M. - MHT #1 exits patient #1's room.
05:07:10 P.M. - Crash Cart arrives in patient #1's room.
05:08:01 P.M. - Code Team arrives to Patient #1's room.
05:25 P.M. - Patient #1 taken to the Emergency Department, Cardiopulmonary Resuscitation still in process.

Interview with MHT #1 on 07/27/2023 at 12:12 p.m. confirms no visual safety checks on Patient #1 between 4:03 p.m. and 5:04 p.m. when found unconscious.

Interview with the Director of Clinical Services (DCS) at 12:45 p.m. on 07/27/2023, confirmed safety checks on the patient #1 were not made on Patient #1 every 15 minutes per the facility policies and procedures based on observation and review of video footage dated 07/03/2023 from 12:53 p.m. to 5:25 p.m. of the Behavioral Health Unit Floor Three (3) hallway.

Interview with the Compliance/Risk Management Director, at 12:50 p.m. on 07/27/2023, confirmed the safety checks were not made on patient #1, every 15 minutes per the facility policy based on observation and review of the video footage dated 07/03/2023 from 12:53 p.m. to 5:25 p.m. of the Behavioral Health Unit Floor Three (3) hallway.

Review of Patient #1's Medical record titled "Precaution Flowsheet" dated 07/03/2023 reveals standard observation level for patient safety every 15 minutes with comparison to video footage dated 07/03/2023 from 12:53 p.m. to 5:25 p.m. of the Behavioral Health Unit Floor Three (3) hallway reveal:

- 1:30 p.m. documentation "2A"- (patient in bed/calm) No observation of staff entering patient #1 room from 1:14:08 p.m.-2:07:47 p.m.
- 1:45 p.m. - documentation "2R" - (patient in bed/relaxed) - Video Observation reveals 1:46:07 p.m. patient #1 came out of rooom stood in hallway; 1:47:09 p.m. went back in room, 1:49:51 p.m. patient back in the hallway, 1:52:00 p.m. returned to room, No observation of staff entering room from 1:14:08 p.m. to 2:07:47 p.m.
- 2:00 p.m. - documentation "2R"- (patient in bed/relaxed); Video observation 2:07:47 p.m. staff entered patient room.
- 2:15 p.m. - documentation "2R"- (patient in bed/relaxed); No video observation of staff entering room from 2:07:47 to 2:45:02 p.m.
- 2:30 p.m. documentation "2A" - (patient in bed/calm); No video observation of staff entering room from 2:07:47 p.m. to 2:45:02 p.m.
- 2:45 p.m. documentation "2R"- (patient in bed/relaxed); Video observation of staff entering room at 2:45:02 p.m.-? 3:00 p.m. documentation "2R"- (patient in bed/relaxed); No video observation of staff entering room from 2:45:02 p.m. to 3:20:33 p.m.
- 3:15 p.m. documentation "2R"- (patient in bed/relaxed); Video observation of staff entering room at 3:20:33 p.m.
- 3:30 p.m. documentation "2S"- (patient in bed/asleep); No video observation of staff entering room from 3:20:33 p.m. to 4:03:51 p.m.
- 3:45 p.m. documentation "2S"- (patient in bed/asleep); No video observation of staff entering room from 3:20:33 p.m. to 4:03:51 p.m.
- 4:00 documentation "2S"- (patient in bed/asleep); Video observation of staff entering room at 4:03:51 p.m.
- 4:15 p.m., 4:30 p.m., 4:45 p.m. and 5:00 p.m. documentation of patient in bed and asleep has been marked through and documented as errors. No video observation of staff entering patient room from 4:03:51 p.m. to 5:04:36 p.m. when patient was found unconscious.

Review of facility policy and procedure titled, "Suicide Risk assessment/reassessment, observing and interventions", Policy # PSY_585, effective 03/04/2009, reveals, " ...Policy: It is the policy of ...to create an environment of care ...successful management of patients who are at an increased risk for suicide or self-destructive behaviors ...Patients at risk for suicide require intensive support, close observation, frequent re-assessment and application of protective measures for emotional and physical well-being at all times ... C. Patient monitoring: 1. All patients will be monitored at least every 15 minutes ... E. 1. It is the responsibility of all staff to maintain a safe and therapeutic milieu for all patients at all times. 2. Safety and Environmental Rounds are to be conducted at regular intervals according to the program policy ...".

Review of facility policy and procedure titled, "Safety Observations", numbered #PSY_586, last review date 09/01/2020, reveals, " ...Policy: It is the policy of the Program that staff monitoring is instituted to prevent patients from harming themselves or others ... I. Standard Observation: Consists of fifteen (15) minute checks by a staff member. 1. The staff member records location and behavior on all patients at random intervals not to exceed 15 minutes. 2. Assigned staff will make direct contact with patients and confirm they are in no danger or distress. 3. Observations should be completed standing in a doorway or at a distance particularly for patients who are sleeping if respirations are visible. If the staff member cannot see the patient breathing, he/she should enter the room, approach the patient, and ensure they are not in any distress. 4. All patients at a minimum are on Standard Observation."

During the exit conference on 07/27/2023 at 5:15 p.m. with the Chief Nursing Officer, the Infection Prevention Director, the Executive Director of Nursing, the Compliance/Risk Management Director, and the Administrator survey findings related to alleged complaint were discussed. No further documentation was provided for review during exit conference.

Based on observation of video footage of the Behavioral Health Unit Floor three (3) dated 07/03/2023 from 12:53 p.m. to 5:25 p.m., facility staff interviews, Patient #1's medical record review, and facility policy and procedure review, the facility's nursing staff failed to provide safety checks based on the facility's standard to monitor patient #1 every 15 minutes on two (2) of two (2) days of survey.

Findings Include:

Cross reference to A - 0385/482.23 for failure to ensure patient #1 was monitored every 15 minutes per policy and procedure.

During the exit conference on 07/27/2023 at 5:15 p.m. with the Chief Nursing Officer, the Infection Prevention Director, the Executive Director of Nursing, the Compliance/Risk Management Director, and the Administrator survey findings related to alleged complaint were discussed. No further documentation was provided for review during exit conference.

Based on observation of video footage of the Behavioral Health Unit Floor three (3) dated 07/03/2023 from 12:53 p.m. to 5:25 p.m., facility staff interviews, Patient #1's medical record review, and facility policy and procedure review, the facility's nursing staff failed to adhere to facility patient safety policies and procedures to prevent patient self-harm and suicide event on two (2) of two (2) days of survey.

Findings Include:

Cross Refer to A-0385/482.23 for the facility's failure to ensure nursing staff followed policies and procedures.

During the exit conference on 07/27/2023 at 5:15 p.m. with the Chief Nursing Officer, the Infection Prevention Director, the Executive Director of Nursing, the Compliance/Risk Management Director, and the Administrator survey findings related to alleged complaint were discussed. No further documentation was provided for review during exit conference.

Based on observation of video footage of the Behavioral Health Unit Floor three (3) dated 07/03/2023 from 12:53 p.m. to 5:25 p.m., facility staff interviews, and medical record review of Patient #1's "Precaution Flowsheet," the facility failed to provide accurate documentation of required 15-minute patient checks to ensure patient safety and prevent self-harm on two (2) of two (2) days of survey.

Findings Include:

Observation of Video footage dated 07/03/2023 from 12:53 p.m. to 5:25 p.m. of the Behavioral Health Unit Floor Three (3) hallway at 11:45 a.m. to 1:10 p.m. on 07/27/2023 with the Director of Security, Director of Clinical services Outpatient, and Compliance/Risk Management Director revealed:

12:53:36 P.M. - Patient #1 enters his room.
01:14:08 P.M. - Registered Nurse (RN) #2 enters Patient #1's room.
01:46:07 P.M. - Patient #1 exits his room and stood in the hallway.
01:47:09 P.M. - Patient #1 enters his room.
01:49:51 P.M. - Patient #1 exits room and walks up and down the hallway.
01:52:00 P.M. - Patient #1 enters his room.
02:07:47 P.M. - Mental Health Technician (MHT) #1 entered patient #1's room .
02:45:02 P.M. - MHT #1 entered patient #1's room
03:20:33 P.M. - MHT #1 entered patient #1's room
04:03:51 P.M. - MHT #1 entered patient #1's room
05:04:36 P.M. - RN #1 entered patient #1's room
05:05:23 P.M. - RN #1 exits patient #1's room, sees MHT #1 re-enters patient room.
05:05:53 P.M. - MHT #1 enters patient #1's room.
05:06:19 P.M. - RN #2 enters patient #1's room.
05:06:30 P.M. - MHT #1 exits patient #1's room.
05:07:10 P.M. - Crash Cart arrives in patient #1's room.
05:08:01 P.M. - Code Team arrives to Patient #1's room.
05:25 P.M. - Patient #1 taken to the Emergency Department, Cardiopulmonary Resuscitation still in process.

Interview with MHT #1 on 07/27/2023 at 12:12 p.m. confirms no visual safety checks on Patient #1 between 4:03 p.m. and 5:04 p.m. when found unconscious.

Interview with the Director of Clinical Services (DCS) at 12:45 p.m. on 07/27/2023, confirmed the safety checks on the patient #1 were not made per the facility policy and procedures, every 15 minutes based on observation and review of video footage dated 07/03/2023 from 12:53 p.m. to 5:25 p.m. of the Behavioral Health Unit Floor Three (3) hallway.

Interview with the Compliance/Risk Management Director, at 12:50 p.m. on 07/27/2023, confirmed the safety checks were not made on patient #1, every 15 minutes per the facility policy and procedures based on observation and review of the video footage dated 07/03/2023 from 12:53 p.m. to 5:25 p.m. of the Behavioral Health Unit Floor Three (3) hallway.

Review of Patient #1's Medical record titled "Precaution Flowsheet" dated 07/03/2023 reveals standard observation level for patient safety every 15 minutes and comparison to video footage dated 07/03/2023 from 12:53 p.m. to 5:25 p.m. of the Behavioral Health Unit Floor Three (3) hallway reveal:

- 1:30 p.m. - documentation "2A"- (patient in bed/calm) - No observation of staff entering patient #1 room from 1:14:08 p.m. - 2:07:47 p.m.
- 1:45 p.m. - documentation "2R" - (patient in bed/relaxed) - Video Observation reveals 1:46:07 p.m. patient #1 came out of room and stood in hallway; 1:47:09 p.m. went back in room, 1:49:51 p.m. patient back in the hallway, 1:52:00 p.m. returned to room, No observation of staff entering room from 1:14:08 p.m. to 2:07:47 p.m.
- 2:00 p.m. - documentation "2R"- (patient in bed/relaxed); Video observation 2:07:47 p.m. staff entered patient room.
- 2:15 p.m. - documentation "2R"- (patient in bed/relaxed); No video observation of staff entering room from 2:07:47 to 2:45:02 p.m.
- 2:30 p.m. documentation "2A" - (patient in bed/calm); No video observation of staff entering room from 2:07:47 p.m. to 2:45:02 p.m.
- 2:45 p.m. documentation "2R"- (patient in bed/relaxed); Video observation of staff entering room at 2:45:02 p.m.
- 3:00 p.m. documentation "2R"- (patient in bed/relaxed); No video observation of staff entering room from 2:45:02 p.m. to 3:20:33 p.m.
- 3:15 p.m. documentation "2R"- (patient in bed/relaxed); Video observation of staff entering room at 3:20:33 p.m.
- 3:30 p.m. documentation "2S"- (patient in bed/asleep); No video observation of staff entering room from 3:20:33 p.m. to 4:03:51 p.m.
- 3:45 p.m. documentation "2S"- (patient in bed/asleep); No video observation of staff entering room from 3:20:33 p.m. to 4:03:51 p.m.
- 4:00 documentation "2S"- (patient in bed/asleep); Video observation of staff entering room at 4:03:51 p.m.
- 4:15 p.m., 4:30 p.m., 4:45 p.m. and 5:00 p.m. documentation of patient in bed and asleep has been marked through and documented as errors. No video observation of staff entering patient room from 4:03:51 p.m. to 5:04:36 p.m. when patient was found unconscious.

Review of facility policy and procedure titled, "Suicide Risk assessment/reassessment, observing and interventions", Policy # PSY_585, effective 03/04/2009, reveals, " ...Policy: It is the policy of ...to create an environment of care ...successful management of patients who are at an increased risk for suicide or self-destructive behaviors ...Patients at risk for suicide require intensive support, close observation, frequent re-assessment and application of protective measures for emotional and physical well-being at all times ... C. Patient monitoring: 1. All patients will be monitored at least every 15 minutes ... E. 1. It is the responsibility of all staff to maintain a safe and therapeutic milieu for all patients at all times. 2. Safety and Environmental Rounds are to be conducted at regular intervals according to the program policy ...".

Review of facility policy and procedure titled, "Safety Observations", numbered #PSY_586, last review date 09/01/2020, reveals, " ...Policy: It is the policy of the Program that staff monitoring is instituted to prevent patients from harming themselves or others ... I. Standard Observation: Consists of fifteen (15) minute checks by a staff member. 1. The staff member records location and behavior on all patients at random intervals not to exceed 15 minutes. 2. Assigned staff will make direct contact with patients and confirm they are in no danger or distress. 3. Observations should be completed standing in a doorway or at a distance particularly for patients who are sleeping if respirations are visible. If the staff member cannot see the patient breathing, he/she should enter the room, approach the patient, and ensure they are not in any distress. 4. All patients at a minimum are on Standard Observation."

During the exit conference on 07/27/2023 at 5:15 p.m. with the Chief Nursing Officer, the Infection Prevention Director, the Executive Director of Nursing, the Compliance/Risk Management Director, and the Administrator survey findings related to alleged complaint were discussed. No further documentation was provided for review during exit conference.