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Based on observation, interview and record review, the hospital failed to ensure appropriate supervision to maintain safety for 5 of 5 sampled vulnerable patients (Patients # 1, 2, 5, 6, and 7), all of whom were patients on a medical unit; and to provide adequate supervision of 5 of 5 sampled patients (Patients # 1, 2, 5, 6, and 7) to prevent patient to patient abuse, of whom Patient #1 died from injuries sustained while alone with his roommate without required staff checks.

The cumulative effect of A144 and A145 resulted in the condition of participation not being met.

The findings included:

Based on observation, interview and record review, the hospital failed to ensure appropriate supervision to maintain safety for 5 of 5 sampled patients (Patients # 1, 2, 5, 6, and 7) who were patients on a medical unit within the psychiatric hospital. Refer to A144.

Based on observation, interview and record review, the hospital failed to provide adequate supervision of this vulnerable population for 5 of 5 sampled patients (Patients # 1, 2, 5, 6, and 7) to prevent patient to patient abuse, of whom Patient #1 died from injuries sustained while unsupervised with another patient for a prolonged period. Refer to A145.

Based on observation, interview and record review, the hospital failed to ensure appropriate supervision to maintain safety for 5 of 5 sampled patients (Patients # 1, 2, 5, 6, and 7).

The findings included:

This hospital is a mental health facility. The hospital's Patient Handbook documented "South Florida State Hospital is committed to providing a safe, secure and comfortable environment for everyone" and patient rights in Mental Health facilities include "The right to be safe and not be neglected nor abused."

The hospital's Policy and Procedure titled Supervision of Persons Served (patients), effective 12/14/20 and reviewed 10/03/22, documents "The purpose of this policy is to ensure the provision of a safe and secure environment, through the process of staff supervision and accountability" and "The primary purpose of the use of the Patient Activity Monitoring Management (PAMM) System for face checks is to ensure the presence and safety of the person served (patient)" and "The minimum level of supervision is 30-minute checks."

1) Review of Patient #1's record revealed he was admitted to the hospital on 07/18/22 and had diagnoses of schizophrenia and developmental intellectual disabilities. Review of the hospital event log revealed Patient #1 did not have episodes of aggression towards peers or staff since his admission on 07/18/22 until episodes occurred on 08/27/22, 09/09/22, and 09/11/22.

During interview on 10/04/22 at 12:02 PM, Risk Manager A and the Chief Nursing Officer reported Patients #1 and 2 became roommates on 08/24/22 but had no "incidents" with each other before 09/13/22.

The hospital event log documented on 08/27/22 at 6:05 PM, Patient #1 entered another patient's room resulting in an altercation when that patient attempted to push him out and Patient #1 started hitting him, resulting in contusion to that patient's left eye and an orbital "blow out" fracture. Patient #1's, Event Note dated 09/09/22 at 2:51 PM, documented at approximately 11:50 AM Patient #1 grabbed a wheelchair and threw it towards another patient for no apparent reason, was administered "as needed" medications and redirected to his room. Patient #1's Event Note dated 09/09/22 at 3:06 PM documented after medication, Patient #1 continued to be aggressive in the hallway, grabbed staff, entered a medical staff room with force and "knocked out" a computer monitor, leading to brief placement in seclusion. A Psychiatrist's "General Note" dated 09/09/22 at 3:19 PM documents Patient #1 "is becoming more unpredictable," described the above events, medications were adjusted, and "we are to monitor his response closely." An Event Note dated 09/11/22 at 4:39 PM documented Patient #1 was asking for food when he got angry and struck an MHT (Mental Health Technician) in the face.

Review of Patient #2's record revealed he has a history of schizophrenia and was admitted to the hospital on 03/16/22. Patient #2's Monthly Psychiatric Progress Note dated 09/12/22, addend 09/14/22, documented on 09/13/22 at about 7:30 AM Patient #2's roommate (Patient #1) was found lying on the floor in blood and unresponsive, in supine position face covered in blood, no vitals could be ascertained; Patient #2 was questioned by police and reportedly admitted to having a fight with his roommate. (Patient #2 was removed from the facility by law enforcement.)

Review of Patient #1's "Observation History Report" for 09/13/22 revealed that despite his recent escalation in aggressive events, Patient #1 continued to be on the lowest level of supervision with 30-minute "face checks." Review of camera footage outside the room of Patients #1 and 2 revealed staff did not perform 30- minute "face checks" as they were not looking into the room to check on Patients #1 and #2 on 09/12/22 between 10:55 PM and 11:51 PM and on 09/13/22 between 1:09 AM and 2:15 AM, between 2:17 AM and 3:51 AM; and between 4:41 AM and 7:09 AM. It was at 7:09 AM that Patient #1 was found on the floor unresponsive, as noted above.

Patient #1's General Note dated 09/13/22 at 2:07 PM documented the following information was obtained from the acute care hospital to which Patient #1 was transferred: he arrived to the Emergency Room after a reported assault in the facility, in cardiac arrest with prolonged CPR over 30 minutes prior to arrival; his exam was consistent with devastating irreversible brain injury; assessment findings of traumatic subarachnoid hemorrhage, status post assault with orbital fracture, zygomatic fracture, nasal bone fracture; and based on neurological exam there were no brain stem reflexes. An Event Note dated 09/14/22 at 3:00 PM documented Patient #1 died of "brain death" and had been pronounced dead by two physicians.

2) Review of Patient #5's "Observation History Report" for 10/03/22 at 7:00 AM until 10/04/22 at 12:10 PM revealed he was supposed to be observed every 30 minutes but there were gaps in observations involving 3 of 4 MHTs and all shifts: on 10/03/22 day shift of 1 hour and 47 minutes, 6 hours and 1 minute, and 1 hour and 53 minutes, on 10/03/22 night shift of 42 minutes, and of 1 hour and 7 minutes, and on 10/04/22 day shift of 1 hour and 42 minutes, and 2 hours and 30 minutes. (Refer to A398)

3) Review of Patient #6's "Observation History Report" for 10/03/22 at 7:00 AM until 10/04/22 at 12:10 PM revealed he was to be observed every 30 minutes and the following gaps in observations involving at least 3 of 5 MHTs and all shifts during that time: 1 hour and 47 minutes, 6 hours 2 minutes, 1 hour and 52 minutes, 48 minutes, 1 hour and 7 minutes, 1 hour and 46 minutes, and 2 hours and 28 minutes. (Refer to A398).

4) Review of Patient #7's "Observation History Report" for 10/03/22 at 7:00 AM until 10/04/22 at 12:10 PM revealed he was to be observed every 30 minutes and the following gaps in observations involving 3 of 5 MHTs and all shifts during that time: 1 hour and 49 minutes, 2 hours and 27 minutes, 3 hours and 38 minutes, 1 hour and 52 minutes, 1 hour and 7 minutes, 1 hour and 43 minutes, and 2 hours and 31 minutes. (Refer to A398)

During interview on 10/04/22 at 10:23 AM, the Chief Nursing Officer (CNO) reported they investigated Patient #1's event the morning of 09/13/22 and learned a MHT falsified checking on the patients and did not go to the room to check on Patients #1 and #2 for about 2 hours, which was addressed with the MHT. When asked about any corrective actions to minimize risks to other patients, the CNO reported this was viewed as an isolated incident and staffing had not changed on that unit. The CNO stated they are recruiting a person to review PAMM scanning (electronic face checks). When asked if they have done any audits to observe staff to ensure they are rounding to patient rooms, the CNO denied doing so and said they used the electronic times in the PAMM scans (as reviewed in the above "Observation History Reports"), but never thought to observe staff were physically rounding, although they could do so by camera. The CNO also reported MHTs are fully staffed but they are short on nurses, and it is difficult to get floor nurses to actively supervise the MHTs. The CNO did not report any efforts, planned or completed, to educate MHTs about the importance of observing patients at the required intervals or to check to ensure this was being done on the involved unit or throughout the hospital.

Based on observation, interview and record review, the hospital failed to provide adequate supervision of this vulnerable population for 5 of 5 sampled mental health patients (Patients # 1, 2, 5, 6, and 7) to prevent patient to patient abuse, of whom Patient #1 died from injuries sustained while alone in his room with his roommate for a prolonged period without staff observing them at least every 30 minutes as required.

The findings included:

This hospital is a public mental health facility. The hospital's Patient Handbook documents "South Florida State Hospital is committed to providing a safe, secure and comfortable environment for everyone" and patient rights in Mental Health facilities include "The right to be safe and not be neglected nor abused."

1) Review of Patient #1's record revealed he was admitted to the hospital on 07/18/22 and had diagnoses of schizophrenia and developmental intellectual disabilities. Review of the hospital event log revealed Patient #1 did not have episodes of aggression towards peers or staff since his admission on 07/18/22 until episodes occurred on 08/27/22, 09/09/22, and 09/11/22.

During interview on 10/04/22 at 12:02 PM, Risk Manager A and the Chief Nursing Officer reported Patients# 1 and 2 became roommates on 08/24/22 but had no "incidents" with each other prior to 09/13/22.

The hospital event log documents on 08/27/22 at 6:05 PM, Patient #1 entered another patient's room resulting in an altercation when the patient attempted to push him out and Patient #1 started hitting him, resulting in contusion to that patient's left eye and an orbital "blow out" fracture. Patient #1's Event Note dated 09/09/22 at 2:51 PM documented at approximately 11:50 AM Patient #1 grabbed a wheelchair and threw it towards a peer (another patient) for no apparent reason, was administered "as needed" medications and redirected to his room. Patient #1's Event Note dated 09/09/22 at 3:06 PM documented after medication, Patient #1 continued to be aggressive in the hallway, grabbed staff, entered a medical staff room with force and "knocked out" a computer monitor, leading to brief placement in seclusion. A Psychiatrist's "General Note" dated 09/09/22 at 3:19 PM documented Patient #1 "is becoming more unpredictable," described the above events, that medications were adjusted, and "we are to monitor his response closely." An Event Note dated 09/11/22 at 4:39 PM documented Patient #1 was asking for food and struck an MHT (Mental Health Technician) in the face, and that he had been medicated.

Review of Patient #2's record revealed he has a history of schizophrenia and was admitted to the hospital on 03/16/22. Patient #2's Monthly Psychiatric Progress Note dated 09/12/22, addend 09/14/22, documented on 09/13/22 at about 7:30 AM Patient #2's roommate (Patient #1) was found lying on the floor in blood and unresponsive, in supine position face covered in blood, no vital signs could be ascertained; Patient #2 was questioned by police and reportedly admitted to having a fight with his roommate; and "He is not known to be disruptive, threatening, or assaultive spontaneously. However we know that if he feels threatened he will retaliate forcefully as he had done it in the past in a different unit."

During interview on 10/04/22 at 12:12 PM, Psychiatrist F explained Patient #2 was involved in a serious incident on another unit during a previous admission, in which Patient #2's other roommate at that time had beaten up 2 patients, and when that roommate came in the room Patient #2 "beat him up pretty bad"; Psychiatrist F believed Patient #2 had expected the previous roommate "was going to beat him up too" and that it was a preemptive attack. During this interview, Psychiatrist F reported Patient #2 never spontaneously assaults anybody and stated something had to happen to get Patient #2 to react, "he did not hit anybody for nothing," Patient #2 would even tolerate someone hitting him, but if he thinks someone is really going to beat him up, he would act. Psychiatrist F denied staff consulting him before placing Patients # 1 and 2 together and believed they had only been roommates for 2 days but said this is a nursing decision.

The hospital's Policy and Procedure titled Supervision of Persons Served "patients", effective 12/14/20 and reviewed 10/03/22, documented, "The primary purpose of the use of the Patient Activity Monitoring Management (PAMM) System for face checks is to ensure the presence and safety of the person served" and "The minimum level of supervision is 30-minute checks."

Review of Patient #1's "Observation History Report" for 09/13/22 revealed despite the recent escalation in aggressive events, Patient #1 continued to be on the lowest level of supervision with 30 minute "face checks." Review of camera footage outside the room of Patients #1 and #2 revealed staff did not perform 30 minute "face checks" as they did not look into the room to check on Patients #1 and #2 between face checks performed on 09/12/22 at 10:55 PM and 11:51 PM; on 09/13/22 between a face check at 1:09 AM and 2:15 to 2:17 AM (when one of these patients left the room, was seen with staff, and returned to the room); on 09/13/22 between 2:17 AM and 3:51 AM; and on 09/13/22 between 4:41 AM and 7:09 AM. It was at 7:09 AM that Patient #1 was found on the floor unresponsive.

Patient #1's General Note dated 09/13/22 at 2:07 PM documented the following information was obtained from the acute care hospital to which Patient #1 was transferred: he arrived to the Emergency Room after a reported assault in the facility, in cardiac arrest with prolonged CPR over 30 minutes prior to arrival; his exam was consistent with devastating irreversible brain injury; assessment findings of traumatic subarachnoid hemorrhage, status post assault with orbital fracture, zygomatic fracture, nasal bone fracture; and based on neurological exam there were no brain stem reflexes. An Event Note dated 09/14/22 at 3:00 PM documented Patient #1 died of "brain death" and was pronounced dead by two physicians.

2) Review of Patient #5's "Observation History Report" for 10/03/22 at 7:00 AM until 10/04/22 at 12:10 PM revealed he was supposed to be observed every 30 minutes but that there were gaps in observations involving 3 of 4 MHTs and all shifts: on 10/03/22 day shift of 1 hour and 47 minutes, 6 hours and 1 minute, and 1 hour and 53 minutes, on 10/03/22 night shift of 42 minutes, and of 1 hour and 7 minutes, and on 10/04/22 day shift of 1 hour and 42 minutes, and 2 hours and 30 minutes. (Refer to A398)

3) Review of Patient #6's "Observation History Report" for 10/03/22 at 7:00 AM until 10/04/22 at 12:10 PM revealed he was supposed to be observed every 30 minutes and the following gaps in observations involving at least 3 of 5 MHTs and all shifts during that time: 1 hour and 47 minutes, then 6 hours 2 minutes, 1 hour and 52 minutes, 48 minutes, 1 hour and 7 minutes, 1 hour and 46 minutes, and 2 hours and 28 minutes. (Refer to A398)

4) Review of Patient #7's "Observation History Report" for 10/03/22 at 7:00 AM until 10/04/22 at 12:10 PM revealed he was supposed to be observed every 30 minutes and the following gaps in observations involving 3 of 5 MHTs and all shifts during that time: 1 hour and 49 minutes, 2 hours and 27 minutes, 3 hours and 38 minutes, 1 hour and 52 minutes, 1 hour and 7 minutes, 1 hour and 43 minutes, and 2 hours and 31 minutes. (Refer to A398)

During interview on 10/04/22 at 10:23 AM, the Chief Nursing Officer (CNO) reported they investigated Patient #1's event the morning of 09/13/22 and review of camera footage did not show what happened but did reveal that an MHT did not go to the room to check on Patients# 1 and 2 for about 2 hours. When asked about corrective actions to minimize risks to other patients, the CNO reported this was viewed as an isolated incident and staffing has not changed on that unit. The CNO stated they are recruiting a person to review PAMM scanning (electronic face checks). When asked if they have done any audits to observe staff to ensure they are rounding to patient rooms, the CNO denied doing so and said they used the electronic times in the PAMM scans (as reviewed in the above "Observation History Reports"), and never thought to observe staff were physically rounding, although they could do so by camera. The CNO also reported MHTs are fully staffed but they are short on nurses, and that it is difficult to get floor nurses to actively supervise the MHTs.

Based on record review and staff interview, the hospital failed to use analysis of an adverse patient event to implement appropriate corrective preventative actions to address risks to other patients.

The findings included:

The hospital's Policy and Procedure titled Supervision of Persons Served (patients), effective 12/14/20 and reviewed 10/03/22, documented, "The purpose of this policy is to ensure the provision of a safe and secure environment, through the process of staff supervision and accountability" and "The primary purpose of the use of the Patient Activity Monitoring Management (PAMM) System for face checks is to ensure the presence and safety of the person served (patient)" and "The minimum level of supervision is 30-minute checks."

1) Review of Patient #1's record revealed he was admitted to the hospital on 07/18/22 and had diagnoses of schizophrenia and developmental intellectual disabilities. Review of the hospital event log revealed Patient #1 did not have episodes of aggression towards peers or staff since his admission on 07/18/22 until episodes occurred on 08/27/22, 09/09/22, and 09/11/22.

During interview on 10/04/22 at 12:02 PM, Risk Manager A and the Chief Nursing Officer reported Patients# 1 and #2 became roommates on 08/24/22 but had no "incidents" with each other prior to 09/13/22.

The hospital event log documented on 08/27/22 at 6:05 PM, Patient #1 entered another patient's room resulting in an altercation when that patient attempted to push him out and Patient #1 started hitting him, resulting in contusion to that patient's left eye and an orbital "blow out" fracture. Patient #1's Event Note dated 09/09/22 at 2:51 PM documented, at approximately 11:50 AM, Patient #1 grabbed a wheelchair and threw it towards a peer (another patient) for no apparent reason, was administered "as needed" medications and redirected to his room. Patient #1's Event Note dated 09/09/22 at 3:06 PM documented after medication, Patient #1 continued to be aggressive in the hallway, grabbed staff, entered a medical staff room with force and "knocked out" a computer monitor, leading to brief placement in seclusion. A Psychiatrist's "General Note" dated 09/09/22 at 3:19 PM documented Patient #1 "is becoming more unpredictable," described the above events, medications were adjusted, and "we are to monitor his response closely." An Event Note dated 09/11/22 at 4:39 PM documented Patient #1 was asking for food and struck an MHT (Mental Health Tech) in the face, and he had been medicated.

Review of Patient #2's record revealed he had a history of schizophrenia and was admitted to the hospital on 03/16/22. Patient #2's Monthly Psychiatric Progress Note dated 09/12/22, signed on 09/14/22, documented on 09/13/22 at about 7:30 AM Patient #2's roommate (Patient #1) was found lying on the floor in blood and unresponsive, in supine position face covered in blood, no vital signs could be ascertained; Patient #2 was questioned by police and reportedly admitted to having a fight with his roommate; and "He is not known to be disruptive, threatening, or assaultive spontaneously. However we know if he feels threatened he will retaliate forcefully as he had done it in the past in a different unit."

During interview on 10/04/22 at 12:12 PM, Psychiatrist F explained Patient #2 was involved in a serious incident on another unit during a previous admission, in which Patient #2's roommate at that time had beaten up 2 patients, and when that roommate came in the room Patient #2 "beat him up pretty bad"; that Psychiatrist F believed Patient #2 had expected the previous roommate "was going to beat him up too" and that it was a preemptive attack. During this interview, Psychiatrist F reported Patient #2 never spontaneously assaults anybody and stated something had to happen to get Patient #2 to react, "he did not hit anybody for nothing," Patient #2 would even tolerate someone hitting him, but if he thinks someone is really going to beat him up, he would act. Psychiatrist F denied staff consulting him before placing Patients # 1 and #2 together and believed they had only been roommates for 2 days but said this is a nursing decision.

Review of Patient #1's "Observation History Report" for 09/13/22 revealed despite his recent escalation in aggressive events, Patient #1 continued to be on the lowest level of supervision with 30 minute "face checks." Review of camera footage outside the room of Patients #1 and #2 revealed staff did not perform 30 minute "face checks" they did not look into the room to check on Patients #1 and #2 on 09/12/22 between 10:55 PM and 11:51 PM; on 09/13/22 between 1:09 AM and 2:15 AM (when one of these patients left the room, was seen with staff, and returned to the room); on 09/13/22 between 2:17 AM and 3:51 AM; and on 09/13/22 between 4:41 AM and 7:09 AM. It was at 7:09 AM that Patient #1 was found on the floor unresponsive, as noted above.

Patient #1's General Note dated 09/13/22 at 2:07 PM documented the following information was obtained from the acute care hospital to which Patient #1 was transferred: that he arrived to the Emergency Room after a reported assault in the facility, in cardiac arrest with prolonged CPR over 30 minutes prior to arrival; his exam was consistent with devastating irreversible brain injury; assessment findings of traumatic subarachnoid hemorrhage, status post assault with orbital fracture, zygomatic fracture, nasal bone fracture; based on neurological exam there were no brain stem reflexes. An Event Note dated 09/14/22 at 3:00 PM documented Patient #1 died of "brain death" and was pronounced dead by two physicians.

2) Review of Patient #5's "Observation History Report" for 10/03/22 at 7:00 AM until 10/04/22 at 12:10 PM revealed he was supposed to be observed every 30 minutes but that there were gaps in observations involving 3 of 4 MHTs and all shifts: on 10/03/22 day shift of 1 hour and 47 minutes, 6 hours and 1 minute, and 1 hour and 53 minutes, on 10/03/22 night shift of 42 minutes, and of 1 hour and 7 minutes, and on 10/04/22 day shift of 1 hour and 42 minutes, and 2 hours and 30 minutes. (Refer to A398)

3) Review of Patient #6's "Observation History Report" for 10/03/22 at 7:00 AM until 10/04/22 at 12:10 PM revealed he was supposed to be observed every 30 minutes and the following gaps in observations involving at least 3 of 5 MHTs and all shifts during that time: 1 hour and 47 minutes, then 6 hours 2 minutes, 1 hour and 52 minutes, 48 minutes, 1 hour and 7 minutes, 1 hour and 46 minutes, and 2 hours and 28 minutes. (Refer to A398)

4) Review of Patient #7's "Observation History Report" for 10/03/22 at 7:00 AM until 10/04/22 at 12:10 PM revealed he was to be observed every 30 minutes and the following gaps in observations involving 3 of 5 MHTs and all shifts during that time: 1 hour and 49 minutes, 2 hours and 27 minutes, 3 hours and 38 minutes, 1 hour and 52 minutes, 1 hour and 7 minutes, 1 hour and 43 minutes, and 2 hours and 31 minutes.(Refer to A398)

During interview on 10/04/22 at 10:23 AM, the Chief Nursing Officer (CNO) reported they investigated Patient #1's event the morning of 09/13/22 and review of camera footage did not show what happened but did reveal that an MHT did not go to the room to check on Patients #1 and #2 for about 2 hours. When asked about any corrective actions to minimize risks to other patients, the CNO reported this was viewed as an isolated incident and staffing has not changed on that unit. The CNO stated they are recruiting a person to review PAMM scanning (electronic face checks). When asked if they have done any audits to observe staff to ensure they are rounding to patient rooms, the CNO denied doing so and said they used the electronic times in the PAMM scans (as reviewed in the above "Observation History Reports"), and never thought to observe the staff were actually physically rounding, although they could do so by camera. The CNO also reported MHTs are fully staffed but they are short on nurses, and it is difficult to get floor nurses to actively supervise the MHTs. The CNO did not report any efforts, planned, or completed, to reeducate MHTs about the importance of checking on patients at the required intervals or to check this was being done on the involved unit or throughout the hospital, nor any measures to address reassessments of patients and their supervision level for escalation in adverse behaviors.

Based on record review, observation, and interview the hospital failed to maintain adequate nurse staffing on numerous occasions by having only one nurse and/or failing to have a Registered Nurse (RN) present and immediately available on each locked housing unit for 7 of 7 units with approximate patient censuses of 35 to 58 patients each, within a consistent hospital census of 351 patients (see A392); failed to ensure a Registered Nurse is immediately available for bedside care on each individual housing unit and to supervise care by Licensed Practical Nurses for 7 of 7 units (see A393); and failed to supervise Mental Health Techs to ensure they checked on 5 of 5 patients (Patients# 1, 2, 5, 6, and 7) at least every 30 minutes as required by hospital policy and to ensure an RN Supervisor is on duty after hours and on weekends for 8 of 30 12-hour shifts (see A398).

The cumulative effect of A392, A393 and A398 resulted in the condition of participation as not being met.

The findings included:

Based on hospital record review and staff interview the hospital failed to maintain adequate nurse staffing on numerous occasions by having only one nurse on a unit and/or failing to have a Registered Nurse present and available on each unit for 7 of 7 locked housing units (Vizcaya, Las Olas, Sanibel, Tequesta, Okeechobee, Everglades, and Royal Palms), which each had a patient census of 35 to 58 mental health patients, affecting all 351 patients in the hospital (refer to A392).

Based on record review and staff interview the hospital failed to ensure a Registered Nurse is immediately available on each locked unit for bedside care and/or to supervise care by Licensed Practical Nurses for 7 of 7 units (refer to A393)

Based on record review, observation, and staff interview the hospital failed to supervise Mental Health Techs to ensure they checked on 5 of 5 sampled mental health patients reviewed for "face checks" (Patients #'s 1, 2, 5, 6, and 7) at least every 30 minutes as required by hospital policy and to ensure an RN Supervisor is on duty at all times after-hours and on weekends, affecting 8 of 30 12-hour shifts (refer to A398)

Based on hospital record review and staff interview, the hospital failed to maintain adequate nurse staffing on numerous occasions by having only one nurse on a unit and failing to have a Registered Nurse present and immediately available on each unit. This affected 7 of 7 locked housing units (Vizcaya, Las Olas, Sanibel, Tequesta, Okeechobee, Everglades, and Royal Palms) which each had an approximate patient census of 35 to 58 patients on each unit, for a total and consistent census of 351 mental health patients.

The findings included:

Finalized schedules that included staff call-offs and staffing adjustments were provided by the hospital for the dates of 09/19/22 through 10/03/22. These schedules documented the daily census was stable at 351 mental health patients for each of these dates. The hospital license documented capacity for 368 beds. Each unit is housed in a separate free-standing building within the hospital grounds. Review of these finalized schedules and patient census revealed the following:

On the Vizcaya unit, which is a medical unit for mental health patients who are medically fragile and need closer monitoring for their medical conditions, 1 LPN (Licensed Practical Nurse) was the only nurse on duty the night of 09/19/22 from 11:00 PM to 7:30 AM. One Registered Nurse (RN) was the only nurse on duty for the Vizcaya unit on the morning of 09/21/22 after an LPN was scheduled to leave at 5:00 AM until 7:00 AM when the next shift started. On 09/26/22 there was 1 RN for the Vizcaya unit from 7:00 AM until 7:00 PM. One LPN was the only nurse on duty again on the night of 10/03/22 from 11:00 PM to 7:30 AM. The patient census for the Vizcaya unit as of 10/03/22 was 49 patients.

On the Las Olas unit on 09/19/22, 1 RN worked 7:00 AM to 7:00 PM and a second RN worked 7:30 AM to 10:00 AM for "med pass," leaving one nurse from 10:00 AM to 7:00 PM. That same night (9/19/22), 1 RN worked 7:00 PM to 7:00 AM and an LPN worked 7:00 PM to 11:30 PM, leaving one nurse from 11:30 PM until 7:00 AM the following morning. One LPN was the only nurse on duty for Las Olas the night of 09/23/22 for 11:00 PM to 7:30 AM. Upon further review of the schedule, there was no RN/Nurse Supervisor the night of 09/23/22 from 12:30 AM to 7:00 AM and one "Nursing Office RN" during this time for the entire hospital (average census of 351 forensic and mental health patients). On 09/25/22, 1 RN worked 7:00 PM to 7:00 AM and a second nurse worked 7:00 PM to 11:00 PM, leaving one nurse for Las Olas from 11:00 PM until 7:00 AM the following morning. The night of 09/26/22, 1 RN worked 7:00 PM until 7:00 AM as the only nurse on Las Olas. Again on 09/28/22, 1 RN was the only nurse on Las Olas from 7:00 PM until 7:00 AM. On Sunday, 10/02/22, one LPN worked on Las Olas from 7:00 AM to 7:00 PM and a second LPN worked 7:00 AM to 10:30 AM for "med (medication) pass", leaving no second nurse after 10:30 AM until 7:00 PM and no RN coverage for the entire 12-hour shift. The Las Olas unit had a census of 35 patients as of 10/03/22.

On the Sanibel Unit one RN was the only nurse on 09/19/22 from 7:00 AM until 7:00 PM. On 09/21/22, 1 RN worked 7:00 AM to 7:00 PM, 1 LPN worked 7:00 AM to 3:30 PM, and 1 LPN worked 7:00 AM to 9:35 AM. This left one nurse on Sanibel from 3:30 PM until 7:00 PM. That night (09/21/22) there was 1 LPN, and no second nurse, from 7:00 PM to 7:00 AM. The night of 09/22/22, 1 LPN worked 7:00 PM to 11:30 PM and 1 RN worked 7:00 PM to 6:00 AM, not only leaving 1 nurse from 11:30 PM to 6:00 AM, but also leaving patients and Mental Health Techs with no evidence of nurse coverage between 6:00 AM and 7:00 AM the morning of 09/23/22. Upon closer review of the schedule, there was no Nurse Supervisor for the hospital on the night of 09/22/22 from 7:00 PM to 7:00 AM and one "Nursing Office RN" for the hospital. Furthermore, since an RN on the Okeechobee unit also went home at 6 AM on 09/23/22 (see below), leaving one LPN on that unit until 7:00 AM, it was not possible for the Nursing Office RN to have covered the Sanibel and Okeechobee units simultaneously and the documentation provided does not indicate the Nursing Office RN went to either of these 2 units. On Sunday, 09/25/22, an LPN worked 7:00 AM to 7:30 PM and an RN worked 7:00 AM to 11:30 AM, leaving the LPN as the only nurse on the Sanibel unit from 11:30 AM until 7:00 PM. On Sanibel on 09/26/22 an LPN worked 7:00 AM to 7:30 PM whereas an RN worked 7:00 AM to 11:00 AM for "meds only", leaving the LPN as the only nurse from 11:00 AM until 7:00 PM. On 10/03/22 one LPN was the only nurse assigned to patient care on the Sanibel unit from 7:00 AM to 7:00 PM. The Sanibel unit had a census of 58 patients as of 10/03/22.

On the Tequesta Unit one LPN was the only nurse assigned to patient care on 09/19/22 from 7:00 AM to 7:30 PM. On 09/20/22 1 RN worked 7:00 PM to 7:30 PM and an LPN came in 11:00 PM to 7:30 AM, which left the RN as the only nurse until 11:00 PM. On 09/21/22 1 RN worked 7:00 AM to 7:30 AM and 1 LPN worked 7:00 PM to 11:30 PM, leaving 1 nurse on Tequesta from 11:30 PM to 7:00 AM. On Sunday, 09/25/22, 1 RN was the only nurse on Tequesta from 7:00 AM to 7:30 PM. On 09/27/22, 1 RN worked 7:00 PM to 7:00 AM and an LPN worked 7:00 PM to 11:00 PM, leaving the RN as the only nurse on Tequesta from 11:00 PM to 7:30 AM the following morning. Again on 09/28/22, 1 RN worked 7:00 PM to 7:30 AM and an LPN worked 7:00 PM to 11:00 PM, leaving the RN as the only nurse on Tequesta from 11:00 PM to 7:00 AM the following morning. On 10/02/22, 1 LPN worked 7:00 PM to 7:30 AM and 1 LPN worked 7:00 PM to 11:30 PM, leaving 1 LPN as the only nurse on Tequesta from 11:30 PM until 7:00 AM the following morning. On 10/03/22 one RN worked as the only nurse from 7:00 AM to 7:00 PM. The Tequesta unit had a census of 56 patients as of 10/03/22.

On the Okeechobee Unit on 09/19/22, 1 RN worked 7:00 AM to 7:00 PM and 1 RN worked 7:00 AM to 9:30 AM for "med pass", leaving 1 RN as the sole nurse from 9:30 AM to 7:00 PM. On 09/20/22, 1 LPN was scheduled 7:00 AM to 7:30 PM and 1 RN was scheduled 7:00 AM to 6:00 PM with a note "must leave PM TO" (OT = overtime), leaving no RN coverage and 1 LPN as the only nurse from 6:00 PM to 7:00 PM. That night (09/20/22 to 09/21/22), 1 LPN was the only nurse assigned to Okeechobee from 7:00 PM to 7:00 AM. On the morning of 09/23/22, an RN was scheduled to leave at 6:00 AM, leaving an LPN as the only nurse until 7:00 AM. On 09/24/22, 1 RN worked 7:00 AM to 7:30 PM and 1 RN worked 7:00 AM to 11:00 AM, leaving 1 nurse between 11:00 AM and 7:00 PM. On Sunday, 09/25/22, 1 RN was the only nurse on Okeechobee from 7:00 PM to 7:00 AM. On the Okeechobee unit two LPNs worked without RN coverage 3 nights in a row: on 09/24/22, 09/25/22, and 09/26/22 from 7:00 PM to 7:00 AM each night. On the next night, 09/27/22, one LPN was the only nurse on the Okeechobee unit from 7:00 PM to 7:00 AM. On 09/28/22, 1 RN was the only nurse assigned to patient care on Okeechobee from 7:00 PM to 7:00 AM. On 10/03/22, 1 RN worked 7:00 AM to 7:30 PM and 1 RN worked 7:00 AM to 10:00 AM for "med pass," leaving 1 nurse assigned to patient care from 10:00 AM to 7:00 PM. That night (10/03/22) 1 RN was the only nurse from 7:00 PM to 7:00 AM. The Okeechobee unit had a census of 57 patients as of 10/03/22.

On the Everglades Unit on 09/19/22, 1 RN was the only nurse assigned to patient care from 7:00 AM to 7:00 PM. That night, 09/19/22, 1 RN was the only nurse from 7:00 PM to 7:00 AM. On Saturday, 09/24/22, one LPN was the only nurse assigned to patient care after an RN left at 12:00 PM until 07:00 PM, after which 1 LPN was the only night nurse on Everglades, from 7:00 PM to 7:00 AM. There was also no Nurse Supervisor that night (09/24/22) from 12:30 PM to 7:00 AM but one "Nursing Office" RN for the hospital. This was the third night in a row with no Nursing Supervisor at night and 1 or 2 "Nursing Office" RNs. The following shift, on the day of 09/25/22, was covered by 2 LPNs from 7:00 AM until 10:30 AM, one of whom had been pulled from the nursing office for "med pass," after which one LPN stayed on duty without RN coverage until 7:00 PM. This was the only evidence of administrative or managerial nurses assuming direct patient care for the 15 days reviewed. On the night of 09/26/22 one LPN was the only nurse on duty for the Everglades unit from 7:00 PM to 07:00 AM. On the night of 09/28/22, 1 RN worked 7:00 PM to 7:00 AM and an LPN worked 7:00 PM to 11:00 PM, leaving one nurse on the unit from 11:00 PM to 7:00 AM. On 09/30/22, 1 RN was the only nurse assigned to patient care from 7:00 AM to 7:00 PM. On 10/03/22, 1 RN worked 7:00 AM to 7:00 PM and 1 RN worked 7:00 AM to 12:00 PM, leaving the Everglades with 1 nurse from 12:00 PM to 7:00 PM. The Everglades unit had a census of 47 patients as of 10/03/22.

On the Royal Palms Unit on 09/20/22, 1 RN worked 7:00 PM to 7:00 AM and 1 RN worked 7:00 PM to 11:45 PM for "med pass only", which left one nurse on the unit from 11:45 PM to 7:00 AM. On 09/21/22, 1 RN was the only nurse from 7:30 PM to 7:00 AM. On 09/24/22, 1 RN worked 7:00 PM to 7:30 AM and 1 LPN worked 7:00 PM to 11:00 PM, leaving 1 nurse on Royal Palms from 11:00 PM to 7:00 AM. On 09/25/22, 1 RN was assigned 7:00 PM to 7:30 AM and 1 LPN was assigned 7:00 PM to 11:30 PM, leaving one nurse on the unit from 11:30 PM to 7:00 AM. On 09/26/22, 1 RN was the only nurse assigned to patient care from 7:00 AM to 7:00 PM. On 09/30/22, 1 LPN was the only nurse assigned to patient care from 7:00 AM to 7:00 PM. On 10/01/22, 1 RN was the only nurse assigned to Royal Palms from 7:00 PM to 7:00 AM. On Sunday, 10/02/22, 1 RN was assigned 7:00 AM to 7:00 PM and 1 RN from 7:00 AM to 10:30 AM for "med pass", leaving 1 nurse from 10:30 AM to 7:00 PM. The night of 10/02/22, 1 RN was assigned 7:00 PM to 7:30 AM and 1 LPN from 7:00 PM to 11:00 PM for "C-wing med pass only", leaving 1 nurse on Royal Palms from 11:00 PM to 7:00 AM. On 10/03/22, there was 1 RN as the only nurse from 7:00 PM to 7:00 AM. The Royal Palms Unit had a census of 50 patients as of 10/03/22.

During interview on 10/05/22 at 12:51 PM, Risk Manager A reported administrative and managerial nurses have helped on the units when there are nursing shortages. Upon further inquiry whether this is actually done or if there might be only one nurse to a whole unit, Risk Manager A stated, "If there is one nurse and they ask for help, they can get an administrative nurse who could help."

During interview on 10/05/22 at 2:50 PM, the Assistant Director of Nursing (ADON) reported nurse staffing is low, recruitment efforts at job fairs have not been very successful, and they considered using agency nurses but have not contacted any agencies. During this interview, the ADON stated all the nurses in the facility pick up extra shifts or, when asked, stay over a few hours to help administer medications. The ADON also reported the Vizcaya Unit has a dedicated Nurse Manager whereas all other Nurse Managers have 2 units each (day shift only). The ADON also reported Nursing Supervisors work from 4:00 PM to 12:30 AM and from 12:00 AM to 8:30 AM but these supervisors cover the whole facility.

During interview on 10/03/22 at 1:25 PM, Registered Nurse, Staff B stated their unit is usually scheduled to have 2 RNs or 1 RN with 1 LPN, whereas it used to have 3 nurses, and when a nurse calls out, management tries but may not get a replacement. Staff B explained sometimes there is only one nurse on the units and a couple weeks ago worked as the only nurse with over 50 patients. Staff B stated when this happens the Unit Manager is supportive and says to call them if there is a problem, and that they will come help for 10 to 15 minutes at a time, but they do not take an assignment or help pass medications and cannot do routine documentation. (Refer to Conditions at A115 and A385)

Based on record review and interview the hospital failed to ensure a Registered Nurse is immediately available for bedside care on each unit and/or to supervise care by Licensed Practical Nurses. This affected 7 of 7 locked individual housing units (Vizcaya, Las Olas, Sanibel, Tequesta, Okeechobee, Everglades, and Royal Palms).


The findings included:

Finalized schedules that included staff call-offs and staffing adjustments were provided by the hospital for the dates of 09/19/22 through 10/03/22. These schedules documented the daily midnight census was stable at 351 patients for each of these dates. The hospital census on 10/03/22 documented 352 mental health patients and the hospital license documented capacity for 368 beds. Review of these finalized schedules revealed the following:


On the Vizcaya Unit, which is a medical unit for patients who are medically fragile behavioral health patients and need closer monitoring for their medical conditions, 1 Licensed Practical Nurse (LPN) and no Registered Nurse (RN) was on duty on the night of 09/19/22 for 11:00 PM to 7:30 AM and 1 LPN and no Registered Nurse was on duty the night of 10/03/22 for 11:30 PM to 7:30 AM. and staffing adjustments were provided by the hospital for the dates of 09/19/22 through 10/03/22. The patient census for the Vizcaya Unit on 10/03/22 was 49 patients.

On the Las Olas unit one LPN was the only nurse on duty the night of 09/23/22 for 11:00 PM to 7:30 AM. Upon further review of the schedule, there was no RN/Nurse Supervisor the night of 09/23/22 from 12:30 AM to 7:00 AM and one "Nursing Office RN" during this time for the hospital. On Sunday, 10/02/22, one LPN worked on Las Olas from 7:00 AM to 7:00 PM and a second LPN worked 7:00 AM to 10:30 AM for "med (medication) pass", leaving no second nurse after 10:30 AM until 7:00 PM and no RN coverage for the 12-hour shift. The Las Olas Unit had a census of 35 patients as of 10/03/22.

On the Sanibel Unit one LPN was the only nurse on duty the night of 09/21/22 from 7:00 PM to 7:00 AM. On 09/22/22 on the Sanibel Unit, 1 LPN worked 7:00 PM to 11:30 PM and 1 RN worked 7:00 PM to 6:00 AM, leaving patients and Mental Health Techs with no evidence of nurse coverage between 6:00 AM and 7:00 AM the morning of 09/23/22. Upon closer review of the schedule, there was no RN/Nurse Supervisor the night of 09/22/22 from 7:00 PM to 7:00 AM and one "Nursing Office RN" for the hospital. Furthermore, since the RN on the Okeechobee Unit also went home at 6 AM on 09/23/22 (see below), leaving one LPN on that unit until 7:00 AM, the Nursing Office RN could not have covered both units simultaneously, and the documentation provided does not indicate the Nursing Office RN went to either of these 2 units. On Sunday, 09/25/22, an RN worked until 11:30 AM for "meds only," leaving an LPN as the only nurse on the Sanibel Unit until 7:00 PM. On 09/26/22 an LPN worked 7:00 AM to 7:30 PM whereas an RN worked until 11:00 AM, leaving the LPN the only nurse until 7:00 PM. On 10/03/22 one LPN was the only nurse assigned to patient care on the Sanibel Unit from 7:00 AM to 7:00 PM. The Sanibel unit had a census of 58 patients as of 10/03/22.

On the Tequesta Unit one LPN was the only nurse assigned to patient care on 09/19/22 from 7:00 AM to 7:00 PM. The Tequesta Unit had a census of 56 patients as of 10/03/22.

On the Okeechobee Unit one LPN was the only nurse assigned to patient care on 09/20/22 from 7:00 PM to 7:00 AM and on the morning of 09/23/33 the RN was scheduled until 6:00 AM, leaving an LPN as the only nurse until 7:00 AM. On the Okeechobee unit two LPNs worked without RN coverage 3 nights in a row from 7:00 PM to 7:00 AM on 09/24/22, 09/25/22, and 09/26/22. On the next night, 09/27/22, one LPN was the only nurse on the Okeechobee Unit from 7:00 PM to 7:00 AM. The Okeechobee unit had a census of 57 patients as of 10/03/22.

On the Everglades Unit on Saturday, 09/24/22, one LPN was the only nurse assigned to patient care after an RN left at 12:00 PM until 07:00 PM, after which one LPN was the only nurse on that unit from 7:00 PM to 7:00 AM. There was also no Nurse Supervisor that night from 12:30 PM to 7:00 AM but one "Nursing Office" RN for the hospital. The following shift (the day of 09/25/22) was covered by 2 LPNs from 7:00 AM until 10:30 AM, one of whom had been pulled from the nursing office for "med pass," after which one LPN stayed on duty without RN coverage until 7:00 PM. On the night of 09/26/22 one LPN was the only nurse on duty for the Everglades Unit from 7:00 PM to 07:00 AM. The Everglades unit had a census of 47 patients as of 10/03/22.

On the Royal Palms Unit on 09/30/22, one LPN was the only nurse assigned to patient care from 7:00 AM to 7:00 PM. The Royal Palms Unit had a census of 50 patients as of 10/03/22.

During interview on 10/05/22 at 2:50 PM, the Assistant Director of Nursing (ADON) reported nurse staffing is low, recruitment efforts have not been successful, and that they considered using agency nurses but have not contacted any agencies. During this interview, the ADON stated all the nurses in the facility pick up extra shifts or, when asked, stay over a few hours to help administer medications. The ADON also reported the Vizcaya Unit had a dedicated Nurse Manager whereas all other Nurse Managers have 2 units each (day shift only), and Nursing Supervisors work from 4:00 PM to 12:30 AM and from 12:00 AM to 8:30 AM but these supervisors cover the whole facility.

During interview on 10/03/22 at 1:25 PM, Registered Nurse, Staff B stated their unit is usually scheduled to have 2 RNs or 1 RN with 1 LPN, whereas it used to have 3 nurses, and when a nurse calls out,management tries but may not get a replacement. Staff B explained sometimes there is only one nurse on the units, and they have worked as the only nurse with over 50 patients. Staff B stated when this happens the Unit Manager is supportive and says to call them if there is a problem, and that they will come help for 10 to 15 minutes at a time, but they do not take an assignment or help pass medications and cannot do routine documentation.

Based on record review, observation, and interview, the hospital failed to supervise Mental Health Technicians to ensure they checked on 5 of 5 patients reviewed for "face checks" (Patients #'s 1, 2, 5, 6, and 7) at least every 30 minutes as required by hospital policy and to ensure an RN Supervisor is on duty after hours and on weekends, affecting 8 of 30 12-hour shifts.

The findings included:

The hospital's Policy and Procedure titled Supervision of Persons Served (patients), effective 12/14/20 and reviewed 10/03/22, documented under Procedure and Levels of Supervision, "The minimum level of supervision is 30-minute checks." This Policy also documented under Procedure, "The primary purpose of the use of the Patient Activity Monitoring Management (PAMM) System for face checks is to ensure the presence and safety of the person served" and "Persons served activity/location/behavior will be logged by the staff into the PAMM tablets at the frequency ordered by the physician/APRN (Advanced Practice Registered Nurse). A picture of the Person Served, or their barcode at night, between 10pm and 6am will be taken and logged. At night, the person served will always be checked for signs of life (movement, rise and fall of the chest, or other signs)" and "The minimum expectation is that PAMM activity logging will be done at all times an observation status is assigned" and "During times when the PAMM tablets may not be functioning properly, the staff will continue with the paper face checks, to ensure continuous monitoring of the persons served. Unit RNs are directly accountable for the unlicensed staff on their units, and are expected to routinely check the Face Check Sheets and PAMM tablet monitors on the unit for compliance" and, "If the person served is in the shower, bathroom, or engaged in other activities where photo capture is not appropriate; or it is dark and a photo inside the room is not appropriate, staff will take a photo of the barcode posted outside of their room. Signs of life should be observed prior to any photo."

1) Review of Patient #1's record revealed he had a diagnosis of schizophrenia and developmental intellectual disabilities and episodes of unprovoked aggression towards peers and/or staff on 08/27/22, 09/09/22, and 09/11/22. Review of Patient #1's "Observation History Report" for midnight on 09/11/22 until 09/13/22 at 7:34 AM revealed he was to be observed "Q30" (every 30 minutes) and there were the following gaps in observations via the PAMM system: on 09/11/22 from 3:40 AM to 4:55 AM (1 hour 15 minutes), 4:55 AM to 5:50 AM (55 minutes), 5:50 AM to 6:43 AM (53 minutes), 7:58 AM to 9:31 AM (1 hour 33 minutes), 9:31 AM to 12:04 PM (2 hours 33 minutes), 12:04 PM to 1:40 PM (1 hour 36 minutes), 1:40 PM to 2:51 PM (1 hour 11 minutes), 3:46 PM to 5:31 PM (1 hour 45 minutes), 5:31 PM to 7:22 PM (1 hour 51 minutes), 7:43 PM to 9:51 PM (2 hours 8 minutes), 10:07 PM on 09/11/22 to 00:02 AM on 09/12/22 (1 hour 55 minutes); on 09/12/22 from 4:29 AM to 5:16 AM (47 minutes), 8:03 AM to 9:19 AM (1 hour 16 minutes), 9:45 AM to 10:39 AM (54 minutes), 10:48 AM to 1:48 PM (3 hours), 2:21 PM to 3:20 PM (59 minutes), 4:03 PM to 4:55 PM (52 minutes), 4:55 PM to 7:05 PM (2 hours 10 minutes), 7:05 PM to 8:08 PM (1 hour 3 minutes), 8:08 PM to 9:51 PM (1 hour 43 minutes), 9:51 PM to 10:10 PM; and on 9:13/22 from 4:41 AM to 5:29 AM (48 minutes).

Further review of Patient #1's "Observation History Report" for midnight on 09/11/22 until 09/13/22 at 7:34 AM also revealed multiple entries without photos of Patient #1 or scans of Patient #1's barcode, as required per hospital policy. During review of camera footage from 7:00 PM on 09/12/22 until at least 7:34 AM to 09/13/22, Mental Health Tech (MHT), Staff C was observed to approach Patient #1 and #2's room and scan the bar code on top of the door frame without looking into the window or opening the door to check on the patients at 10:14 PM (which corresponds to a 10:10 PM entry on the PAMM system). During further review of this rounding by Staff C, she was observed to scan 4 additional rooms in this hall without looking in the rooms and to bypass 3 rooms without scanning them before leaving that hall. Another MHT looked in rooms on this hall without the PAMM device on 09/12/22 at 10:55 PM (per camera time) and is observed to do face checks with the PAMM device from 11:51 PM to 1:09 AM on 09/13/22. Camera review revealed Staff C does not return to check on Patients # 1 and #2 after 10:14 PM on 09/12/22 until she is seen walking with Patient #1 (who left his room at 2:08 AM) on 09/13/22 between 2:15 AM and 2:17 AM during which he walks in the hall before returning to his room. However, Staff C created entries for Patient #1 on the PAMM scanner with blank (solid black) pictures on 09/12/22 timed as 10:33 PM, 10:56 PM, and 11:20 PM; and on 09/13/22 at 1:38 AM, and 2:03 AM and described him as "in room asleep" for each of these entries. Staff C created further entries on the PAMM scanner for Patient #1, without scans or photos but with black screens, on 09/13/22 timed as 2:29 AM "in shower" and 3:23 AM "in room asleep" without checking the room, where patient #1 remained, at those times. Another MHT did face checks with the PAMM scanner and looking in rooms from 3:51 AM (1 hour 34 minutes since he was last physically seen by any staff) until 4:41 AM (PAMM times). On 09/13/22 at 5:33 AM, the camera time (corresponding to 5:29 on the PAMM system), Staff C is seen to scan the top of Patient #1's door frame without looking in the room and does not return to this section of hallway until 7:08 AM (camera time). However, Staff C created further PAMM entries for Patient #1 with solid black screens for 09/13/22 at 5:54 AM, 6:23 AM, and 6:43 AM. Patient #1 did not leave his room during this time. On 09/13/22 at 7:08 AM (camera time, which is 7:04 AM PAMM time), Staff C scanned the top of Patient #1's doorway without looking in to check on the patient describing him as "in room asleep." One minute later, at 7:09 AM (camera time), 2 other MHTs went to Patient #1's doorway, one (Staff D) opened the door and entered before she ran out of the room in apparent alarm, after which multiple staff entered the room and Patient #1 was ultimately taken out of the hospital by fire rescue.

During interview on 10/4/22 at 5:07 PM, Staff D reported when she checked on Patient #1, she found him on the floor with blood around his head and went for help.

An event note by a nurse who responded to Patient #1's room that morning, dated 09/13/22 at 7:43 AM documented,while making rounds,2 MHTs found Patient #1 "on the floor lying in blood. Upon arrival to his room, he was on the floor in supine position face covered with blood and unresponsive. Medical STAT called CPR initiated. Assessment: Unresponsive, unable to ascertain vital signs CPR continued until Paramedics and Police arrived. Plan: Transported 911 to (name of acute care hospital) for further evaluation and treatment."


2) Patient #2 was the roommate of Patient #1. Review of Patient #2's record revealed he had a history of schizophrenia, cardiac arrhythmia, and hypertension. Review of Patient #2's "Observation History Report" for midnight on 09/11/22 until 09/13/22 at 10:47 PM revealed he was to be observed every 30 minutes and there were the following gaps in observations via the PAMM system: on 09/11/22 from 3:40 AM to 4:55 AM (1 hour 15 minutes), 4:55 AM to 5:50 AM (55 minutes), 5:50 AM to 6:42 AM (52 minutes), 7:51 AM to 9:30 AM (1 hour 39 minutes), 9:30 AM to 11:57 AM (2 hours 27 minutes), 11:57 AM to 1:33 PM (1 hour 36 minutes), 1:33 PM to 4:38 PM (3 hours 5 minutes), 4:38 PM to 6:31 PM (1 hour 53 minutes), 7:40 PM to 9:51 PM (2 hours 11 minutes), 10:06 PM on 09/11/22 to 00:02 AM on 09/12/22 (1 hour 56 minutes); on 09/12/22 from 4:29 AM to 5:15 AM (46 minutes), 8:01 AM to 9:15 AM (1 hour 14 minutes), 9:15 AM to 11:58 AM (2 hours 43 minutes), 11:58 AM to 1:42 PM (1 hours 44 minutes), 1:42 PM to 4:59 PM (3 hours 17 minutes), 4:59 PM to 7:05 PM (2 hours 6 minutes), 7:05 PM to 8:07 PM (1 hour 2 minutes); on 09/13/22 from 8:00 AM to 10:14 AM (2 hours 14 minutes), 11:19 AM to 12:03 PM (44 minutes), 12:06 PM to 2:01 PM (1 hour 55 minutes), 2:34 PM to 3:14 PM (40 minutes), and 6:58 PM to 7:55 PM (57 minutes).

Further review of Patient #2's "Observation History Report" for midnight on 09/11/22 until 09/13/22 at 7:34 AM also revealed multiple entries without photos of Patient #2 or scans of Patient #2's barcode, as required per hospital policy. During review of camera footage on the patients at 10:14 PM (which corresponds to a 10:10 PM entry on the PAMM system). During further review of this rounding by Staff C, she is observed to scan 4 additional rooms in this hall without looking in the rooms and to bypass 3 rooms without scanning them before leaving that hall. Another MHT looked in rooms on this hall without the PAMM device on 09/12/22 at 10:55 PM (per camera time) and is observed to do face checks with the PAMM device from 11:51 PM to 1:09 AM on 09/13/22. Camera review reveals Staff C does not return to check on Patient #2 after 10:14 PM on 09/12/22 until 2:15 AM and 2:17 AM during which she enters that room with Patient #1. However, Staff C created entries for Patient #2 on the PAMM scanner with blank (solid black) pictures on 09/12/22 timed as 10:32 PM, 10:56 PM, and 11:19 PM; and on 09/13/22 at 1:37 AM, and 2:03 AM and described him as "in room asleep" for each of these entries. Staff C created further entries on the PAMM scanner for Patient #2, without scans or photos but with black screens, on 09/13/22 timed as 2:03 AM, 2:29 AM, 2:56 AM, and 3:23 AM with each of these documented as "in room asleep" without checking the room, where Patient #2 remained at those times. Another MHT did face checks with the PAMM scanner and looking in rooms from 3:49 AM (2 hours 40 minutes since he was last physically seen by any staff) until 4:41 AM (PAMM times). On 09/13/22 at 5:33 AM camera time (corresponding to 5:29 on the PAMM system), Staff C was seen to scan the top from 7:00 PM on 09/12/22 until at least 7:34 AM to 09/13/22, on 09/12/22 Mental Health Tech (MHT), Staff C is observed to approach Patient# 1 and 2's room and scan the bar code on top of the door frame without looking into the window or opening the door to check of Patient #2's further PAMM entries for Patient #2 with solid black screens for 09/13/22 at 5:54 AM, 6:23 AM, and 6:43 AM. Patient #2 door frame without looking in the room and does not return to this section of hallway until 7:08 AM (camera time). However, Staff C created id not leave his room during this time. On 09/13/22 at 7:08 AM (camera time, which is 7:04 AM PAMM time), Staff C scanned the top of Patient #2's doorway without looking in to check on the patient describing him as "in room asleep."

During an interview with the Chief Nursing Officer (CNO) on 10/04/22 at 10::23 AM, he reported police questioned Patient #2 on 09/13/22 and ended up arresting him later that day for attempted murder of Patient #1.

3) Review of Patient #5's "Observation History Report" for 10/03/22 at 7:00 AM until 10/04/22 at 12:10 PM reveals he was to be observed every 30 minutes and the following gaps in observations: on 10/03/22 from 7:55 AM to 9:42 AM (1 hour 47 minutes), 9:42 AM to 3:43 PM (6 hours 1 minute), 5:25 PM to 7:18 PM (1 hour 53 minutes), 7:18 PM to 8:00 PM (42 minutes); and on 10/04/22 from 1:44 AM to 2:51 AM (1 hour 7 minutes), 7:58 AM to 9:40 AM (1 hour 42 minutes), and 9:40 AM to 12:10 PM (2 hours 30 minutes).

4) Review of Patient #6's "Observation History Report" for 10/03/22 at 7:00 AM until 10/04/22 at 12:10 PM revealed he was to be observed every 30 minutes and the following gaps in observation on 10/03/22 from 7:54 AM to 9:41 AM (1 hour and 47 minutes), 9:41 AM to 3:43 PM (6 hours and 2 minutes), 5:25 PM to 7:17 PM (1 hour and 52 minutes), 7:17 PM to 8:05 PM (48 minutes), and on 10/04/22 1:46 AM to 2:53 AM (1 hour and 7 minutes), 7:56 AM to 9:42 AM (1 hour and 46 minutes), and 9:42 AM to 12:10 PM (2 hours and 28 minutes).


5) Review of Patient #7's "Observation History Report" for 10/03/22 at 7:00 AM until 10/04/22 at 12:10 PM reveals he was to be observed every 30 minutes and the following gaps in observations: on 10/03/22 from 7:51 AM to 9:40 AM (1 hour 49 minutes), 9:40 AM to 12:07 PM (2 hours 27 minutes), 12:07 PM to 3:45 PM (3 hours 38 minutes), 5:23 PM to 7:15 PM (1 hour 52 minutes): and on 10/04/22 from 1:42 AM to 2:49 AM (1 hour 7 minutes), 7:54 AM to 9:37 AM (1 hour and 43 minutes), and 9:37 AM to 12:08 PM (2 hours and 31 minutes.


During a tour on 10/03/22 beginning at 1:25 PM of the Vizcaya unit, which is a " behavioral health and medical" unit for patients requiring care or monitoring for medical conditions, in addition to psychiatric care, and is the unit on which Patients #'s 1, 2, 5, 6, and 7 received care, staff identified MHT, Staff E as the person conducting face checks. Staff E was observed without a PAMM tablet or visible papers by which to keep track of patient face checks on the unit and was not rounding to patients.

Upon interview with Staff E on 10/03/22 at 2:37 PM, she confirmed she is assigned to face checks but said the PAMM scanner is "down." When asked how she is keeping track of face checks, she said she is "doing them." When asked the last time she did face checks, she answered "now." When asked how she knows who was where and when since she has no papers or PAMM tablet, she started naming and pointing at people in front of her, then naming people who she said were in rooms, but named several more people as lying in their rooms on the C-wing than were observed on tour.

During interview on 10/03/22 at 4:25 PM, the Chief Nursing Officer (CNO) stated the PAMM system was not "down" and that MHTs know to use paper in case it was down. During further interview on 10/04/22 at 12:02 PM, the CNO reported the PAMM system was not down the prior day, but one PAMM device did not synchronize properly so staff used the A-wing scanner and that there are back up PAMM devices on the unit. He confirmed all scans performed would be in the system and reflected on the "Observation History Reports" provided.

Review of "Observation History Reports" for Patients# 5, 6, and 7 for the day shift on 10/03/22 and the morning of 10/04/22 revealed the following: Patient #5 had a face check by another MHT at 9:42 AM, then a 6 hour and 1 minute gap until Staff E did the next face check at 3:43 PM, and that the following morning Staff E did 2 sequential face checks 1 hour and 42 minutes apart, and no face check after 9:40 AM until another MHT performed one at 12:10 PM; Patient #6 also had a gap of 6 hours 2 minutes between Staff E's face checks on 10/03/22, 2 sequential face checks by Staff E 1 hour and 46 minutes apart the following morning and no face check after 9:42 AM (also 10/04/22) until another MHT performed one at 12:10 PM; and Patient #7 did not have a face check after 12:07 PM until Staff E conducted it at 3:45 PM on 10/03/22, then a 1 hour 43 minute gap in sequential face checks the following day, these also by Staff E.

During interview on 10/04/22 at 10:23 AM, the Chief Nursing Officer (CNO) reported they investigated Patient #1's event the morning of 09/13/22 and review of camera footage did not show what happened but did reveal that an MHT did not go to the room to check on Patients# 1 and 2 for about 2 hours, which was addressed with that MHT. When asked about any corrective actions, the CNO reported this was viewed as an isolated incident and staffing has not changed on that unit. The CNO stated they are recruiting a person to review PAMM scanning, that this can be reviewed on a "dashboard" for compliance, and that Nursing Supervisors can also do this after hours. When asked if they have done any audits to observe staff and see if they are actually rounding to patient rooms, the CNO denied doing so and said they used the electronic times in the PAMM scans, and never thought to watch that they were physically rounding, which they could do by camera. The CNO also reported MHTs are fully staffed but they are short on nurses, and that it is difficult to get floor nurses to actively supervise the MHTs.

6) Review of adjusted staffing schedules (reflecting changes for callouts and call-ins) from 09/19/22 to 10/03/22 revealed no Nursing Supervisor on duty for the following shifts: on 09/22/22 at 4:00 PM to 09/23/22 at 7:30 AM, on 09/23/22 at 4:00 PM to 09/24/22 at 7:30 AM, on 09/24/22 at 12:30 PM to 09/25/22 at 8:00 AM (Saturday morning), and on 10/01/22 12:30 PM to 10/02/22 at 8:00 AM (Sunday morning).