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Based on review of video footage, staff interviews, medical record review, and review of facility documents, it was determined the facility failed to ensure that the patient's right to receive care in a safe setting, is maintained.

Findings include:

1. The facility failed to ensure that staff performing two-to-one (2:1) observation maintain continuous visual observation of the patient at all times.

2. The facility failed to ensure that staff report all instances of abuse or neglect.

3. The facility failed to ensure that staff do not use cell phones in patient care areas.

4. The facility failed to ensure that staff perform environmental rounds every 15 minutes.

5. The facility failed to ensure that patients on 2:1 observation receive assessments from a nurse every two hours, in accordance with facility policy.

(Cross refer to Tag A-144)

Based on staff interviews, review of video footage, review of one of ten medical records (#1), and review of facility documents, it was determined the facility failed to ensure that: 1) both staff members performing two-to-one (2:1) observation maintain continuous visual observation of the patient at all times; 2) staff report all instances of abuse or neglect; 3) staff do not use cell phones in patient care areas; 4) patients on 2:1 observation receive assessments from a nurse every two hours, in accordance with facility policy; 5) staff perform environmental rounds every 15 minutes.

Findings include:

1) Reference: Facility policy titled, "Levels of Observation/Precautions" last revised 10/2021 states, "[Name of facility] has a responsibility to provide a safe, therapeutic environment for patients. Patients identified as being at risk for behavior causing harm to self or others require specialized levels of observation and monitoring in order to minimize such occurrences or, when necessary, provide immediate intervention. ... Definitions: A. 1:1 (one-to-one)Observation: Orders require continuous visual observation at a distance of one arm's length or up to six feet, one patient to one assigned staff member. ... C. 2:1 (two-to-one) Observation: 2:1 precautions may be used only in exceptional circumstances and for a short time only. May only be ordered with Clinical Director's authorization. ... 1:1 Observation ... 1. The order for 1:1 Observation must be written for each patient by the psychiatrist or Advanced Practice Nurse (APN) and renewed daily after a face-to-face assessment of the patient by psychiatrist/APN. Each written order must specify the behaviors to be observed and the physical proximity of the assigned staff member to the patient. In no case should the distance between staff and patient be more than six (6) feet. ... The order shall also specify the hours/shifts for which the patient shall be on 1:1 observation. Orders must be renewed daily."

During the entrance conference on 03/21/23, Staff #4 (Chief Operating Officer) confirmed that on 03/16/23, Patient #1 (P1) reported to a facility staff member that another staff member (Staff #19) sexually assaulted him/her on 03/15/23, during the 3:00 PM - 11:00 PM shift. Staff #4 stated that at the time of the alleged assault, P1 was being housed on Drake East 1, also known as the "Recovery and Reintegration (R&R) Unit." Staff #4 stated that patients who are not responding to their treatment plans or are displaying increasingly aggressive behavior may be temporarily housed on Drake East 1. Staff #4 stated that P1 was transferred to Drake East 1 the day before the alleged incident occurred. Staff #4 stated that P1 was on 2:1 observation (two staff members observing one patient) for aggressive behavior, and Staff #19 was one of two staff members assigned to observe the patient. Staff #4 stated that the other staff member assigned to observe P1 (Staff #18) was possibly asleep at the time of the alleged assault. Staff #4 stated Drake East 1 consists of two wings, one of which is used to house COVID positive patients. Staff #4 confirmed that P1 was the only patient housed on this wing.

Staff #4 stated P1 initially reported the incident to Staff #8, Health Services Technician (HST), on 03/16/23. Staff #8 then reported the incident to Staff #30 (Charge RN), who then reported the incident to PSCU (Patient Services Compliance Unit) and the Health Services Police Department (HSPD). The patient was assessed by a physician at the facility then taken to the Emergency Department (ED) and examined by a SANE (Sexual Assault Nurse Examiner) nurse. Staff #4 stated that at approximately 9:30 PM on 03/16/23, the patient returned to the same unit in the facility and was again placed on 2:1 observation.

Review of the incident report dated 03/16/23 at 11:00 AM, revealed a physician's note written by Staff #31 (Psychiatrist) that stated, "03/16/23 1:00 PM - Psychiatry: RN called this writer on hospital phone around 12:30 PM to report allegation of sex between patient and staff on previous day (03/15/23) on 3pm to 11pm shift." Staff #31's physician note indicated P1 reported details of a sex act that occurred between him/her and Staff #19. P1 also reported being scared of Staff #19.

Review of P1's medical record revealed the patient was admitted to the facility on 01/29/19. Throughout P1's admission, there were numerous documented incidents of the patient displaying self-injurious behaviors that included attempts to swallow objects, attempts to cut and scratch him/herself with sharp objects, and banging his/her head against the wall.

Review of physician orders revealed that an order for 2:1 observation was written by the Clinical Director on 03/09/23 at 8:51 AM. The order states, "Observation - Shift 1 (11PM-7AM) - 2:1 W/in (within) 6 feet and eye sight; Observation - Shift 2 (7am-3pm) - 2:1 W/in 6 feet and eye sight; Observation - Shift 3 (3pm-11pm) - 2:1 W/in 6 feet and eye sight ... Behavior: Self-injurious and Aggressive Behavior." Physician's orders for 2:1 observation were re-ordered by the Clinical Director from 03/10/23 to 03/21/23.

Upon interview on 03/21/23 at 10:35 AM, Staff #4 and Staff #6 (Risk Management) stated that video camera footage from 03/15/23 on Drake East 1 was reviewed. Staff #4 stated, "We reviewed camera footage on the unit. We could see some things on the camera. The cameras don't capture the whole unit, but you can see when the alleged perpetrator went into the patient's room with [him/her] and closed the door. It did appear as if the other staff member was sleeping."

Video camera footage from Drake East 1 on 03/15/23, from 2:45 PM to 11:30 PM, was reviewed on 03/21/23 at 1:30 PM, in the presence of Staff #3 (Assistant Director of Nursing), Staff #4, Staff #6, and Staff #15 (Director of QI), and on 03/22/23 at 10:43 AM, in the presence of Staff #1 (Quality Director), Staff #6, Staff #15, and Staff #17 (Chief Nursing Officer). The following was indicated:

(i) On numerous occasions from 2:52 PM to 11:30 PM, one of the two staff members assigned to perform 2:1 observation for P1 left the unit, leaving one staff member alone to observe P1. Physician's orders for P1 indicate the patient was on 2:1 observation, which requires two staff members to maintain continuous visual observation of P1 at a distance of no more than six feet.

(ii) On numerous occasions from 2:52 PM to 11:30 PM, one of the two staff members assigned to perform 2:1 observation for P1 entered P1's bedroom alone, instead of both staff members entering P1's bedroom to maintain visual observation of the patient.

(iii) From 3:08 PM to 3:09 PM, P1 was in the bedroom alone and unsupervised. There were no staff members visually observing the patient during this time. At 3:09 PM, Staff #8 went alone into P1's bedroom. At 3:10 PM, Staff #8 exited the patient's room and the unit, leaving P1 in the bedroom alone and unsupervised. At 3:11 PM, Staff #21 entered P1's bedroom alone to check on the patient.

(iv) From 3:18 PM to 3:19 PM, P1 was in the bedroom alone and unsupervised. There were no staff members visually observing the patient during this time.

(v) At 6:48 PM, Staff #18, Health Services Technician (HST) and Staff #19 (HST) were performing 2:1 observation for P1. Staff #18 appeared to be sitting in a chair asleep, with his/her head resting back against a wall and his/her legs outstretched in front of him/her. Staff #18 does not change from this position until 7:04 PM, when he/she sits up, places his/her head in his/her hands, then rests his/her elbows on his/her thighs.

(vi) At 7:17 PM, P1 walked into the bedroom. Staff #19 followed P1 into the bedroom, then closed the door. Staff #18 stood up, then moved to the chair closest to the bedroom door. Staff #18 then sat down and leaned his/her head back against the wall in a resting position. Staff #18 did not enter P1's bedroom with Staff #19.

(vii) At 7:23 PM, Staff #19 exits P1's bedroom, enters the Day Room and drops an item in the trash, then returns to P1's bedroom. At 7:24 PM, P1 exits the bedroom, enters the Day Room and throws an item in the trash, then returns to his/her bedroom. The bedroom door closes. Staff #18 was awake at this time, but remained seated and did not enter P1's bedroom with the patient and Staff #19. At 7:31 PM, P1 exits the bedroom and enters the Day Room. At 7:32 PM, Staff #19 exits P1's bedroom and enters the Day Room.

(viii) At 9:22 PM, P1 got up and went into the bedroom. Staff #18 and Staff #19 remained seated outside of the bedroom conversing. P1 was in the bedroom alone and unsupervised from 9:22 PM until 9:29 PM. At 9:29 PM, Staff #19 went into P1's bedroom alone to check on him/her.

(ix) At 9:35 PM, Staff #18 left the unit and was relieved by Staff #21. Staff #19 and Staff #21 were assigned to perform 2:1 observation for P1 at this time. At 9:36 PM, Staff #19 and Staff #21 turned the lights down on the unit and entered P1's bedroom. At 9:39 PM, Staff #21 exited P1's bedroom and left the unit, leaving P1 in the bedroom alone with Staff #19. Staff #21 returned to the unit at 9:44 PM.

Upon interview on 03/21/23 at 1:45 PM, Staff #3 and Staff #6 confirmed that when patients are on 2:1 observation, both observers should continuously monitor the patient. Staff #6 stated, "When a patient is on 2:1, both staff members should move together. They should have both gone in the room with the patient. No one should be leaving the unit."

Upon interview on 03/22/23 at 10:10 AM, Staff #6 confirmed that video camera footage from Drake East 1 on 03/15/23 was reviewed by Risk Management staff on 03/16/23, the day the alleged assault was reported by the patient. Staff #3, Staff #4, and Staff #17 confirmed that there was no additional re-education or training provided to staff on or after 03/16/23 regarding maintaining continuous visual observation of patients during 1:1 and 2:1 observation.

2) Reference: Facility policy titled, "Code of Conduct Behaviors That Undermine a Culture of Safety in the Workplace" last revised 04/2019 states, " ... To assure quality and to promote a culture of safety, [name of facility] must establish an atmosphere that promotes appropriate behaviors and reinforces zero tolerance for Behaviors that undermine a culture of safety for patients, employees, and visitors. ... B. Examples of Behaviors that Undermine a Culture of Safety and are Prohibited ... Failure to report any behaviors that undermine a culture of safety. ... Sexual contact with patients. ... C. Reporting Requirements ... a. Any staff person who has direct or indirect knowledge, including a strong suspicion, of any of the above activities taking place must report such activity in writing. ... ."

During the entrance conference on 03/21/23, Staff #4 confirmed that on 03/16/23, P1 reported to a facility staff member that Staff #19 sexually assaulted him/her on 03/15/23, during the 3:00 PM - 11:00 PM shift. Staff #4 stated that P1 was on 2:1 observation for aggressive behavior and Staff #19 was one of two staff members assigned to observe the patient. Staff #4 stated that the other staff member assigned to observe P1, Staff #18, was possibly asleep at the time of the alleged assault.

Video camera footage from Drake East 1 on 03/15/23, from 2:45 PM to 11:30 PM, was reviewed on 03/21/23 at 1:30 PM, in the presence of Staff #3, Staff #4, Staff #6, and Staff #15. The following was indicated:

At 7:17 PM, P1 walked into the bedroom with Staff #19 following him/her into the bedroom, then closing the door. Staff #18 stood up, then moved to the chair closest to the bedroom door. Staff #18 then sat down and leaned his/her head back against the wall in a resting position. Staff #18 did not enter P1's bedroom with Staff #19.

At 7:23 PM, Staff #19 exits P1's bedroom, enters the Day Room and drops an item in the trash, then returns to P1's bedroom. At 7:24 PM, P1 exits the bedroom, enters the Day Room and throws an item in the trash, then returns to the bedroom. The bedroom door closes. Staff #18 was awake at this time but remained seated and did not enter P1's bedroom with the patient and Staff #19.

At 7:28 PM, Staff #20 (HST) enters the unit. Staff #18 stands and walks towards Staff #20, who walked halfway onto the unit. Staff #18 conversed with Staff #20 for a few seconds, then Staff #20 turned and left the unit. Staff #18 returned to his/her seat in the Day Room. There was no indication that Staff #18 told Staff #20 that Staff #19 and P1 were in the patient's bedroom alone with the door closed.

Upon interview on 03/21/23 at 2:46 PM, Staff #6 confirmed that Staff #18 did not report Staff #19's inappropriate behavior with P1. Staff #6 stated, "We are still waiting for a statement from [Staff #18] about that night. [He/She] was put off duty before we could get a statement." Staff 4 and Staff #6 confirmed that employees are required to report situations that violate the facility's Code of Conduct policy.

Upon interview on 03/21/23 at 10:50 AM, Staff #4 stated that after the facility was made aware of the incident, a hospital-wide email was sent to staff regarding the facility's Code of Conduct policy. Staff #4 was asked if he/she could verify that all staff received and reviewed the email. Staff #4 stated, "We know that all staff do not have email, so nursing was planning on doing an in-service with staff regarding compliance with the Code of Conduct policy. We haven't done the inservice yet."

3) Reference: Facility policy titled, "Levels of Observation/Precautions" last revised 10/2021 states, " ... 7. The Nursing staff assuming a 1:1 Observation may under no circumstances utilize any personal electronic devices including cell phones, iPods, earbuds, etc., during the observation. If nursing staff has a cell phone on their person, they must put the cell phone on the off position prior to assuming the responsibility of the 1:1 assignment and the cell phone must never be visible during the observation time."

Video camera footage from Drake East 1 on 03/15/23, from 2:45 PM to 11:30 PM, was reviewed on 03/21/23 at 1:30 PM, in the presence of Staff #3, Staff #4, Staff #6, and Staff #15, and on 03/22/23 at 10:43 AM, in the presence of Staff #1, Staff #6, Staff #15, and Staff #17. The following was indicated:

(i) At 6:54 PM, Staff #19 takes out his/her cellphone and begins looking at it. At 6:55 PM, P1 leans towards Staff #19 and he/she begins showing P1 something on his/her cellphone. The "PSCU Complaint Call Team Response Form" dated 03/16/23 at 12:36 PM states, "Brief Description of Complaint: ... 03/16/23 ... Caller left a message stating [P1] alleged [he/she] had sex with staff [Staff #19] and that it happened on 3-11 shift yesterday. [P1] is 2:1. ... Summary of Team Meeting: ... According to [P1], at the time of the alleged incident, one of [his/her] 2:1 staff was sleeping. [He/She] stated that the accused staff [Staff #19] showed [him/her] something on [his/her] phone including a pornographic video. ... ."

(ii) At 7:28 PM, Staff #18 was seated in the Day Room on his/her phone while Staff #19 and P1 were in the patient's bedroom with the door closed.

(iii) At 7:43 PM, Staff #18 was on his/her cell phone while seated in the Day Room.

Upon interview on 03/21/23 at 1:35 PM, Staff #3 stated that staff are not permitted to be on cell phones in patient care areas.

Upon interview on 03/22/23 at 10:10 AM, Staff #6 confirmed that video camera footage from Drake East 1 on 03/15/23 was reviewed by Risk Management staff on 03/16/23, the day the alleged assault was reported by the patient. Staff #3, Staff #4, and Staff #17 confirmed that there was no additional re-education or training provided to staff on or after 03/16/23 regarding the restriction of cell phone use by staff in patient care areas.

4) Reference: Facility policy titled, "Levels of Observation/Precautions" last revised 10/2021 states, " ... A. 1:1 Observation ... 8. A registered nurse will assess the patient every two hours (15 minutes either before or after two hours is acceptable), collaborate with the assigned staff, monitor the completeness of the 15-minute observation, and sign off on the Level of Observations/Precaution Record to ensure that the procedure has been followed. ... ."

Upon interview on 03/21/23 at 11:00 AM, Staff #3 stated that nurses are required to assess patients who are on 1:1 or 2:1 observation every two hours. Staff #3 stated that there is a form for each patient where nurses document their assessments. A request was made to Staff #3 for the nurse's documentation of P1 on 03/15/23 from 3:00 PM to 10:45 PM. Review of the "Level of Observation/Precaution Record Entry Form" dated 03/15/23 and review of video footage from Drake East 1 on 03/15/23 from 2:45 PM to 11:00 PM revealed the following:

The video footage on Drake East 1 from 2:45 PM to 11:00 PM revealed that Staff #22 (RN assigned to Drake East 1) entered the unit and assessed P1 at the following times: 3:46 PM, 3:57 PM, 3:59 PM, 4:46 PM, 7:11 PM, and 10:15 PM. On the "Level of Observation/Precaution Record Entry Form" dated 03/15/23, Staff #22 documented that he/she assessed P1 at the following times: 3:00 PM, 4:45 PM, 6:45 PM, 8:30 PM, and 10:00 PM. Based on review of the video footage, Staff #22 falsely documented that he/she assessed P1 at 3:00 PM, 6:45 PM, and 8:30 PM. There was no evidence that Staff #22 assessed P1 every two hours, as indicated in facility policy.

Upon interview on 03/22/23 at 10:43 AM, Staff #6 stated, "I am going to be transparent. I reviewed the video tape and saw that the nurse did not go in to check on the patient when [he/she] said [he/she] did." Staff #6 confirmed that the nurse did not assess the patient every two hours.

Upon interview on 03/22/23 at 10:10 AM, Staff #3 and Staff #17 confirmed that there was no re-education provided to nursing staff after the video footage was reviewed regarding performing nursing assessments of patients on 1:1 or 2:1 observation every two hours.

5) During a tour of Drake East 1 on 03/21/23 at 11:53 AM, an interview was conducted with Staff #8 (HST). Staff #8 indicated that he/she was assigned to do "safety checks" for the day. Upon further inquiry, Staff #4 stated that environmental safety checks are conducted on each unit by an HST every 15 minutes. Staff #4 stated that the HST assigned to perform environmental safety checks is required to check the unit for any safety or security concerns and document the rounds on a "Patient Safety and Security Check Form." Staff #4 stated that there is always an HST assigned to conduct environmental safety checks on each unit.

Upon interview on 03/21/23 at 1:53 PM, Staff #4 and Staff #6 identified Staff #20 as the HST assigned to perform environmental safety checks on Drake East 1 on 03/15/23. Review of video footage from Drake East 1 on 03/15/23 from 2:45 PM to 11:00 PM revealed the following:

(i) At 3:59 PM, Staff #20 entered the unit, walked to the middle of the unit near the Day Room, then exited the unit. Upon interview, Staff #6 confirmed that Staff #20 did not perform environmental safety checks on the unit.

(ii) At 5:09 PM, Staff #20 entered the unit, walked to the middle of the unit near the Day Room, then exited the unit. Upon interview, Staff #6 confirmed that Staff #20 did not perform environmental safety checks on the unit.

(iii) At 7:28 PM, Staff #20 entered the unit and was met near the door by Staff #18. Staff #20 conversed with Staff #18, walked towards the Day Room, then turned back and exited the unit. Upon interview, Staff #6 confirmed that Staff #20 did not perform environmental safety checks on the unit.

(iv) At 9:57 PM, Staff #20 entered the unit and performed an environmental safety check of the unit.

(v) At 11:04 PM, Staff #20 entered the unit with another HST and performed an environmental safety check of the unit.

On the "Patient Safety and Security Check Form" for Drake East 1 dated 03/15/23, under the section labeled "Every 15 minutes Staff Initials," Staff #20 documented his/her initials every 15 minutes from 3:15 PM to 11:00 PM. By documenting his/her initials, Staff #20 falsely indicated that he/she performed environmental safety checks on Drake East 1 every 15 minutes from 3:15 PM to 11:00 PM.

On the "Patient Safety and Security Check Form" for Drake East 1 dated 03/15/23, Staff #22 (RN) initialed at 3:15 PM, 4:45 PM, 7:00 PM, 9:15 PM, and 10:15 PM that Staff #20 performed environmental safety checks every 15 minutes.

Upon interview on 03/22/23 at 10:10 AM, Staff #3 and Staff #17 confirmed that there was no re-education provided to nursing staff or HSTs after the video footage was reviewed regarding performing environmental safety checks every 15 minutes.

The SA verified implementation of the IJ removal plan on 03/27/2023. Verification of the implementation of the IJ removal plan included review of staff education and sign-in sheets regarding the following: Reporting allegations of abuse or neglect, maintaining continuous visual observation when performing 2:1 or 1:1 observation, no cellphones permitted in clinical areas, conducting environmental checks every 15 minutes, RN rounding every two hours, and falsifying documentation. A facility tour and staff interviews were conducted to verify all staff received re-education. The facility implemented its IJ removal plan and the IJ was lifted on 03/27/23 at 1:45 PM.

Based on observation of video camera footage, staff interviews, and review of facility documents, it was determined the facility failed to ensure that nursing services adhere to acceptable standards of practice and the facility's policies and procedures.

Findings include:

1. The facility failed to ensure that registered nurses assess patients at least every two hours, in accordance with facility policy. (Cross refer to Tag A-395)

2. The facility failed to ensure that nurses are present during patient mealtimes, in accordance with facility policy. (Cross refer to Tag A-395).

3. The facility failed to ensure that nurses monitor HSTs to verify that environmental safety checks are conducted every 15 minutes. (Cross refer to Tag A-398).

4. The facility failed to ensure that Supervisors of Nurses (SONs) conduct unit rounds to evaluate patient care, in accordance with facility policy. (Cross refer to Tag A-398).

Based on observation of video footage, staff interviews, and review of facility documents, it was determined the facility failed to ensure that: 1) registered nurses assess patients at least every two hours, in accordance with facility policy; 2) nurses are present during patient mealtimes, in accordance with facility policy.

Findings include:

1) Reference: Facility policy titled, "Levels of Observation/Precautions" last revised 10/2021 states, " ... A. 1:1 Observation ... 8. A registered nurse will assess the patient every two hours (15 minutes either before or after two hours is acceptable), collaborate with the assigned staff, monitor the completeness of the 15-minute observation, and sign off on the Level of Observations/Precaution Record to ensure that the procedure has been followed. ... ."

Upon interview on 03/21/23 at 11:00 AM, Staff #3 stated that nurses are required to assess patients who are on 1:1 or 2:1 observation every two hours. Staff #3 stated that there is a form for each patient where nurses document their assessments. A request was made to Staff #3 for the nurse's documentation of P1 on 03/15/23 from 3:00 PM to 10:45 PM. Review of the "Level of Observation/Precaution Record Entry Form" dated 03/15/23 and review of video footage from Drake East 1 on 03/15/23 from 2:45 PM to 11:00 PM revealed the following:

The video footage on Drake East 1 from 2:45 PM to 11:00 PM revealed that Staff #22 (RN assigned to Drake East 1) entered the unit and assessed P1 at the following times: 3:46 PM, 3:57 PM, 3:59 PM, 4:46 PM, 7:11 PM, and 10:15 PM. On the "Level of Observation/Precaution Record Entry Form" dated 03/15/23, Staff #22 documented that he/she assessed P1 at the following times: 3:00 PM, 4:45 PM, 6:45 PM, 8:30 PM, and 10:00 PM. Based on review of the video footage, Staff #22 falsely documented that he/she assessed P1 at 3:00 PM, 6:45 PM, and 8:30 PM. There was no evidence that Staff #22 assessed P1 every two hours, as indicated in facility policy.

Upon interview on 03/22/23 at 10:43 AM, Staff #6 stated, "I am going to be transparent. I reviewed the video tape and saw that the nurse did not go in to check on the patient when [he/she] said [he/she] did." Staff #6 confirmed that the nurse did not assess the patient every two hours.

Upon interview on 03/22/23 at 10:10 AM, Staff #3 and Staff #17 confirmed that there was no re-education provided to nursing staff after the video footage was reviewed regarding performing nursing assessments of patients on 1:1 or 2:1 observation every two hours.

2) Reference: Facility policy titled "Monitoring Patients at Mealtime (Patient Safety) last revised 09/14/22 states, " ... The following guidelines pertain to all areas where food is served to patients (i.e. ... units ...) ... B. Nursing/Complex Staff Responsibilities ... 3. A Licensed Nurse and another nursing staff member will be circulating throughout the cafeteria dining room at mealtime to monitor patients for safe eating practices while providing patient assistance, identification, and provision of prescribed meal plan. ... 4. No meals are served until a nurse is present to supervise the meal. ... ."

Video camera footage from Drake East 1 on 03/15/23, from 2:45 PM to 11:30 PM, was reviewed on 03/21/23 at 1:30 PM, in the presence of Staff #3, Staff #4, Staff #6, and Staff #15, and on 03/22/23 at 10:43 AM, in the presence of Staff #1, Staff #6, Staff #15, and Staff #17. The following was indicated:

(i) At 4:17 PM, Staff #21 brought in a food tray for P1 and the patient began eating at a table in the Day Room. There was no nurse present while the patient was eating. Upon interview, Staff #6 stated that a nurse should have been present while P1 was eating.

(ii) At 7:10 PM, Staff #21 brought in a food tray for P1, followed by Staff #22 (RN). P1 sat at a table in the Day Room and began eating. Staff #22 stood near the table observing P1. At 7:11 PM, Staff #22 left the unit while P1 was still eating. P1 finished his/her meal at 7:15 PM. There was no nurse present while the patient was eating from 7:11 PM to 7:15 PM. Upon interview, Staff #6 stated that Staff #22 should have stayed on the unit until P1 finished his/her meal.

Upon interview on 03/22/23 at 10:10 AM, Staff #3 and Staff #17 confirmed that there was no re-education provided to nurses after the video footage was reviewed regarding ensuring that nurses are present during patient mealtimes.

Based on observation of video camera footage, staff interviews, and review of facility documents, it was determined the facility failed to ensure that: 1) nurses monitor Health Services Technician (HSTs) to verify that environmental safety checks are conducted every 15 minutes; 2) Supervisors of Nurses (SONs) conduct unit rounds to evaluate patient care, in accordance with facility policy.

Findings include:

1) During a tour of Drake East 1 on 03/21/23 at 11:53 AM, an interview was conducted with Staff #8 (HST). Staff #8 indicated that he/she was assigned to do "safety checks" for the day. Upon further inquiry, Staff #4 stated that environmental safety rounds are conducted on each unit by an HST every 15 minutes. Staff #4 stated that the HST assigned to perform environmental safety rounds is required to check the unit for any safety or security concerns and document the rounds on a "Patient Safety and Security Check Form." Staff #4 stated that there is always an HST assigned to conduct environmental safety rounds on each unit.

Upon interview on 03/21/23 at 1:53 PM, Staff #4 and Staff #6 identified Staff #20 as the HST assigned to perform environmental safety checks on Drake East 1 on 03/15/23. Review of video footage from Drake East 1 on 03/15/23 from 2:45 PM to 11:00 PM revealed the following:

(i) At 3:59 PM, Staff #20 entered the unit, walked to the middle of the unit near the Day Room, then exited the unit. Upon interview, Staff #6 confirmed that Staff #20 did not perform environmental safety checks on the unit.

(ii) At 5:09 PM, Staff #20 entered the unit, walked to the middle of the unit near the Day Room, then exited the unit. Upon interview, Staff #6 confirmed that Staff #20 did not perform environmental safety checks on the unit.

(iii) At 7:28 PM, Staff #20 entered the unit and was met near the door by Staff #18. Staff #20 conversed with Staff #18, walked towards the Day Room, then turns back and exits the unit. Upon interview, Staff #6 confirmed that Staff #20 did not perform environmental safety checks on the unit.

(iv) At 9:57 PM, Staff #20 entered the unit and performed an environmental safety check of the unit.

(v) At 11:04 PM, Staff #20 entered the unit with another HST and performed an environmental safety check of the unit.

On the "Patient Safety and Security Check Form" for Drake East 1 dated 03/15/23, under the section labeled "Every 15 minutes Staff Initials," Staff #20 documented his/her initials every 15 minutes from 3:15 PM to 11:00 PM. By documenting his/her initials, Staff #20 falsely indicated that he/she performed environmental safety checks on Drake East 1 every 15 minutes from 3:15 PM to 11:00 PM.

On the "Patient Safety and Security Check Form" for Drake East 1 dated 03/15/23, Staff #22 (RN) initialed at 3:15 PM, 4:45 PM, 7:00 PM, 9:15 PM, and 10:15 PM that Staff #20 performed environmental safety checks every 15 minutes.

Upon interview on 03/22/23 at 10:10 AM, Staff #3 and Staff #17 confirmed that there was no re-education provided to nursing staff or HSTs after the video footage was reviewed regarding performing environmental safety checks every 15 minutes.

2) Reference: Facility policy titled "Levels of Observation/Precautions" last revised 10/2021 states, " ... A. 1:1 Observation ... 9. The Supervisor of Nursing (SON) shall make frequent rounds, review Level of Observation/Precaution Record ... and provide consultation/supervision."

Video camera footage from Drake East 1 on 03/15/23, from 2:45 PM to 11:30 PM, was reviewed on 03/21/23 at 1:30 PM, in the presence of Staff #3, Staff #4, Staff #6, and Staff #15, and on 03/22/23 at 10:43 AM, in the presence of Staff #1, Staff #6, Staff #15, and Staff #17. There was no evidence on the video footage that Staff #26, identified as the Supervisor of Nursing (SON) on 03/15/23, conducted rounds on Drake East 1 from 2:45 PM to 11:30 PM. Upon interview on 03/22/23 at 10:10 PM, Staff #6 stated, "[Staff #26] was put off duty. [He/she] did not round on the unit like [he/she] should have."

Upon interview on 03/22/23 at 10:10 AM, Staff #3 and Staff #17 confirmed that there was no re-education provided to SONs after the video footage was reviewed regarding conducting rounds on each unit each shift.