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Based on the seriousness of the non-compliance, the facility failed to substantially comply with this condition.

Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility staff failed to substantially comply with this condition.

These following standards were cited and show a systemic nature of noncompliance with regards to patient rights as follows:

482.13(c)(2) Tag A- 0144 The information reviewed during the survey provided evidence the facility failed to provide adequate supervision thus resulting a sexual assault between two behavioral health inpatients and failed to ensure that visitors to the behavioral health unit and inpatients are properly searched for contraband thus resulting in a drug overdose of one patient.

482.13(c)(3) Tag A- 0145 The information reviewed during the survey provided evidence the facility failed to ensure that a behavioral health patient was protected from all forms of harassment for one patient.

Based on review of facility documents, medical records (MR) and interview with facility staff (EMP), it was determined that the facility failed to provide care in a safe setting by failing to provide adequate supervision thus resulting a sexual assault between two of two behavioral health inpatients (PT1/MR1 and PT2/MR2) and by failing to ensure that visitors to the behavioral health unit and inpatients are properly searched for contraband thus resulting in a drug overdose in one of one patient (PT3/MR3).

Findings Include:

Conemaugh Memorial Medical Center ... PolicyStat ID: 11405488 ... Policy Area: Organizational - Clinical policy and procedure dated March 2022, revealed, "Patient Rights Statement of Policy: It is the policy of Conemaugh health System (CHS) to respect the rights of patients during their hospitalization and to recognize that each patient is an individual with unique health care needs. Staff will provide considerate, respectful care, incorporating patient's personal values and belief systems and strive to protect each patient's dignity. ... 4. A policy to render care and treatment appropriate to the patient's condition. ... 12. Policies and processes to ensure a patient's right to management of symptoms related to their illness, including prompt and appropriate management of pain. ... 14. A policy that respects a patient's right to designate visitors. ... The hospital reserves the right to restrict visitation in medically appropriate circumstances. ... This policy is meant to provide a framework for the Conemaugh Health System philosophy, of patient care and is used in conjunction with other policies to assure that patients' rights are recognized and respected."

Review of "Conemaugh Health System A Statement of the Patient's Rights" revealed, "Conemaugh Health System is committed to providing quality care to all patients and to make their visit as pleasant as possible. Our concern and respect for you, is addressed in this Statement of Patient's Rights. 1. You have the right to respectful care given by skilled staff. ... 9. You have the right to quality care and high professional standards that are always kept and reviewed. ... 15. You have the right to be free from any form of restraints - both physical and drug - that is not medically necessary. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid any personal discomfort. ... 28. You have a right to be informed of your visitation rights, including any clinical restriction or limitations to this right. ... A Statement of the Patient's Responsibilities As a patient, you are responsible for the following: ... 3. You and your visitors should be thoughtful of other patients by following the rules and the Tobacco Addiction policy. ... 10. You should not take drugs that have not been prescribed by your doctor and given to you by hospital staff. 11. You should not consume alcoholic beverages or toxic substances during your stay."


Conemaugh Memorial Medical Center ... PolicyStat ID: 10690686 ... Policy Area: Behavioral Health ... Patient Rights Mental Health policy and procedure dated November, 2021. "Purpose To ensure that care, treatment and services are provided in a way that respects and fosters dignity, autonomy, positive self-regard, civil rights, and involvement of patient. Policy: No patient shall be deprived of any rights, benefits, or privileges guaranteed by law, while a patient is on the unit. ... ."


Conemaugh Memorial Medical Center ... Department of Behavioral Medicine Bill of Rights dated August 31, 2017. "You have a right to be treated with dignity and respect You shall retain all civil rights that have not been specifically curtailed by order of court 1. You have the right to unrestricted and private communication inside and outside this facility including the following: ... d. To receive visitors of your own choice at reasonable hours unless your treatment team has determined in advance that a visitor would seriously interfere with your or others treatment or welfare. e. To receive visitors and send unopened letters and to have outgoing letters stamped and mailed. Incoming mail may be examined for good reason in your presence for contraband. Contraband means specific property which entails a threat to your health and welfare or to the hospital community. ... 3. You have the right to keep and to use personal possessions, unless it has been determined that specific personal property is contraband. ... 6. You have the right to receive treatment in the least restrictive setting within the facility necessary to accomplish the treatment goals. ... 8. You have the right not to be subjected to any harsh or unusual treatment. ... ."



1. Review of MR1 nursing documentation dated October 7, 2022, at 7:51 PM revealed that PT1/MR1 is sexually preoccupied and reached for staff member genitals multiple times.

Continued review of MR1 nursing documentation dated October 22, 2022, at 11:50 AM revealed that the RN was notified by the Mental Health Technician (MHT) that PT1/MR1 stated PT2/MR2 walked into PT1/MR1 room and placed genitals on PT1/MR1 lips, causing PT1/MR1 to have an emesis.

Further review of MR1 nursing documentation MR1 dated October 23, 2022, 3:33 AM revealed a decline in physical condition as PT1/MR1 had an emesis, was medicated as ordered for symptoms and at 7:40 AM was found lying on bathroom floor in right lateral recumbent position. MR1 revealed, that the patient was noted to have abrasions on right side of face, knuckles of right hand, and bilateral knees.



2. Review of MR2 nursing notes revealed that on October 16, 2022, at 6:55 PM, revealed that PT2/MR2 was advised against being sexually inappropriate with other patients and documentation on October 22, 2022, at 8:24 PM, revealed PT2/MR2 admitted to sexually assaulting a resident.

Continued review of MR2 psychiatric physician progress notes dated October 23, 2022, revealed that PT2/MR2 admitted to incident of inappropriate behavior yesterday.


3. Review of facility documentation dated October 22, 2022, revealed documented evidence of the sexual assault PT1/MR1 by PT2/MR2. The documentation also revealed that inpatient census on the BHU at the time of the assault was 22, that there were two RNs and one MHT, one RN was at the nurse's station, the other RN was in the dining room monitoring patients eating lunch and the MHT was completing 15 minute check patient observations at the time of the assault.


4. Review of security documentation dated October 22, 2022, revealed that at first PT1/MR1 denied the allegations of sexual assault, but then admitted to it after further discussion with the RN. The documentation also revealed that PT1/MR1 stated that PT2/MR2 had been harassing PT1/MR1 for several days and today PT2/MR2 entered the room of PT1/MR1 and preceded to place genitalia in the mouth of PT1/MR1. Continued review of the documentation revealed PT1/MR1 stated that this act was non-consensual.


5. Review of progress note dated October 10, 2022, revealed on October 6, 2022, nursing staff noticed PT3/MR3 seemed confused, hallucinating and was tremulous with progressive change in level of confusion and worsening mental status. PT3/MR3 was transferred to the medical ICU. Per review MR3, while in the ICU, PT3/MR3 admitted to having received opioids from a visitor and had been treated for acute metabolic encephalopathy related to opioid withdrawal. PT3/MR3 was medically stabilized and readmitted to inpatient psychiatry on October 7, 2022.

6. Interview with EMP7 on October 26, 2022, at approximately 11:30 AM revealed that the events/incidents have increased on the BHU, including the most recent sexual assault and fentanyl overdose. EMP7 stated that there is nothing in place to search visitors for contraband, outside the unit, there is no ability to search or wand them, there is nothing in our current policy. EMP7 stated that they have to trust that the visitors are honest in emptying their pockets before entering the BHU. EMP7 stated that a patient's visitor who brought the fentanyl in was inappropriately "touchy." during their visits. EMP7 stated it was that patient who gave the fentanyl to PT3/MR3. EMP7 stated that PT1/MR1 could be sexually preoccupied and has made sexual gestures, doesn't have boundaries and at times, is not redirectable. EMP7 stated that PT2/MR2 mentions sexual acts verbally, but had never acted on them.

Based on review of facility documents and medical records (MR) and interview with facility staff (EMP), it was determined that the facility failed to ensure that a behavioral health patient was protected from all forms of harassment in one of one patient (PT4/MR4).

Findings Include:

Conemaugh Memorial Medical Center ... PolicyStat ID: 11405488 ... Policy Area: Organizational - Clinical policy and procedure dated March 2022, revealed, "Patient Rights Statement of Policy: It is the policy of Conemaugh health System (CHS) to respect the rights of patients during their hospitalization and to recognize that each patient is an individual with unique health care needs. Staff will provide considerate, respectful care, incorporating patient's personal values and belief systems and strive to protect each patient's dignity. CHS acknowledges that the patient has the right to make decisions regarding medical care; this includes discontinuation of therapy to the extent permitted by law. ... The Statement of Patient's Rights and Responsibilities is attached as Appendix A of this policy. Requirements: CHS assures patient rights are supported by the following: ... 2. A policy on informed decision making which requires patient, parent/guardian, or surrogate involvement. ... 3. A policy on personal privacy and confidentiality of information. 4. A policy to render care and treatment appropriate to the patient's condition. ... 7. Addressing the psychosocial needs of the patient which are identified during the hospital stay and initiating appropriate referrals as necessary. ... This policy is meant to provide a framework for the Conemaugh Health System philosophy, of patient care and is used in conjunction with other policies to assure that patients' rights are recognized and respected. ... ."
Review of "Conemaugh Health System A Statement of the Patient's Rights" revealed, "Conemaugh Health System is committed to providing quality care to all patients and to make their visit as pleasant as possible. Our concern and respect for you, is addressed in this Statement of Patient's Rights. 1. You have the right to respectful care given by skilled staff. ... 5. You have the right to expect privacy and confidentiality with regard to your care. ... You have the right to quality care and high professional standards that are always kept and reviewed. ... You have the right to refuse any drugs, treatment, or procedures. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid any personal discomfort. ... ."

Conemaugh Memorial Medical Center ... PolicyStat ID: 10690686 ... Policy Area: Behavioral Health ... Patient Rights Mental Health policy and procedure dated November, 2021. "Purpose To ensure that care, treatment and services are provided in a way that respects and fosters dignity, autonomy, positive self-regard, civil rights, and involvement of patient. Policy: No patient shall be deprived of any rights, benefits, or privileges guaranteed by law, while a patient is on the unit. ... ."

Conemaugh Memorial Medical Center ... Department of Behavioral Medicine Bill of Rights dated August 31, 2017. "You have a right to be treated with dignity and respect You shall retain all civil rights that have not been specifically curtailed by order of court 1. You have the right to unrestricted and private communication inside and outside this facility including the following: ... 5. You have the right to participate in the development and review of your treatment plan. 6. You have the right to receive treatment in the least restrictive setting within the facility necessary to accomplish the treatment goals. 7. You have the right to be discharged from the facility as soon as you no longer need care and treatment. 8. You have the right not to be subjected to any harsh or unusual treatment. ... ."

Conemaugh Memorial Medical Center Medical Staff Bylaws ... Appendix C-Policy Regarding Behavior That Undermines a Culture of Safety dated July 2, 2021. "1.1 Purpose and Objective It is the policy of the hospital for all individuals working in the Hospital to treat others with respect, courtesy, and dignity, and to conduct ourselves in a professional, cooperative manner, and in compliance with the Code of Conduct of LifePoint Hospitals. This policy, which replaces the Disruptive Practitioner Policy, sets for the requirement that all physicians and allied health professionals who work in the Hospital will act in a professional and respectful manner at all times. Further, this policy defines behavior or behaviors that undermine a culture of safety, and outlines how to report and address it. The objectives of this policy are to ensure quality patient care by promoting a safe, cooperative, and professional health care environment and to provide Hospital employees with a work environment based on respect and one that encourages personal and professional growth. ... Any employee who engages in behavior or behaviors that undermine a culture of safety, including employed Practitioners, may be dealt with in accordance with the Hospital's human resource policies. ... 2.1 Behavior that Undermines a Culture of Safety For purposes of this policy, behavior that undermines a culture of safety (herein referred to as 'Undermining Behavior') is any behavior that substantially intimidates others, affects morale or staff turnover, disrupts the smooth operation of the Hospital, adversely affects the ability of others to perform their jobs appropriately, poses a threat or potential threat to safe quality patient care, or exposes the Hospital or Medical Staff to potential liability. Behavior that does not substantially impact a culture of safety is behavior that is outside the scope of this policy. Behavior which may arise to the level of Undermining Behavior may include but is not limited to, behavior such as: 2.1(a) Rude, abusive or intimidating behavior or comments to Hospital personnel, other Practitioners, Hospital visitors, patients, or their families, or other behavior that negatively affects the ability of others to do their jobs. ... ."


1. Review of MR4 revealed, "... MH 781 Consent for Voluntary Inpatient Treatment ... I understand that in order to leave before I am discharged, I must give 72 hours advance notice in writing to those in charge of my treatment; and confirm that my rights and responsibilities while a patient in the hospital have been explained to me. ... Explanation of Voluntary Admission Rights For adult patients, patients 14 years of age or over but less than 18 years of age, and for the parents or guardians of children under 14 years of age. Before your ... voluntary admission to this hospital, you ... have the right to: 1. An explaination of the type of treatment which may be involved. 2. An explaination of any restraints or restrictions which may be used. Upon your ... admission, you ... will have the following rights: 1. Within 72 hours after admission, an [sic] plan of treatment will be developed. You may participate in the development of this plan. 2. You may withdraw ... from treatment at any time by giving written notice in advance to the Director of the facility; however, 3. You may be asked to remain in the facility for a specified period of time up to 72 hours after you request discharge. If, when you request discharge, you are asked to remain ... for this period of time, someone will immediately explain why to you. The facility may institute involuntary commitment proceedings during this period. 4. You ... may not be transferred from this facility to another facility without your consent. In addition to the above rights, the Bill of Rights attached applies to you ... upon admission. You will receive a longer, more detailed version of these rights within 72 hours of admission. ... Request to Withdraw from Treament I hereby give notice of intent to withdraw myself within the next 72 hours from treatment. I understand that a member of the treatment staff may discuss this matter with me and make a decision during this time period. ... ." Request to Withdraw from Treament documentation was dated August 26, 2022, and signed by the patient and a witness.

Continued review of MR4 revealed a progress note by CF1 which stated, "... 08/26/22 0940 ... Psychiatric Progress Note ... Hospital Day 4 ... Chief Complaint: 'I have been feeling dizzy' ... Interval History: The patient has mood and anxiety symptoms. ... episodes of dizziness and elevated blood pressure. Vital Signs in last 24 hours: ... BP: ... 115/55 ... Mental Status Exam: ... Behavior: alert and cooperative. Eye contact is fair. ... Mood/Affect: Depressed/anxious Thought Process/association: Concrete without loose associations/flight of ideas. Thought content: Denies SI/HI ... Denies Delusions, Paranoia. Mental Grasp/Cognition-Appear to understand Sensorium/Memory-Oriented x 4/Generally intact immediate & remote recall. Intelligence/fund of knowledge-Estimated as functioning within an average range Attention Span/concentration: fair Insight/Judgement-Both fair ... Time spent: 25 minutes, including patient seen on unit and assessed, including > 50% time spent in counseling with the patient about medication compliance and follow up to reduce risk of relapse, educating about current acute condition, discharge goals, and care coordination. Supportive psychotherapy provided and problem solving with patient. I discussed/counseled about recovery ... ."

Further review of MR4 revealed, "... Progress Notes ... 08/27/22 1229 ... Psychiatric Progress Note ... Hospital Day 5 ... Chief Complaint: 'anxiety' Interval History: ... patient is doing very well ... reports ... is no longer feeling suicidal. ... Patient apparently was wanting to leave but the covering doctor yesterday told [patient] that [patient] will have to request a 302 commitment if [patient ] left and therefore patient chose to stay back. ... ."

Review of MR4 also revealed a nurse's note dated August 26, 2022, 7:00 PM -7:00 AM shift note that stated the supervisor and charge nurse spoke to the patient's mother about the "issues" on daylight shift.


2. Review of facility documentation dated August 26, 2022, revealed CF1 had treatment plan discussion with a voluntary (201) patient (PT4/MR4) in the hallway around other peers which made the patient feel uncomfortable and CF1 also told the patient that if PT4/MR4 refused to stay, PT4/MR4 would be placed on a 90 day hold, if PT4/MR4 refused to stay voluntarily. The documentation also stated that CF1 would not have seen PT4/MR4 if the 201 wasn't signed yet. The documentation also revealed that following this patient/psychiatrist interaction, PT4/MR4 was observed to be crying on the phone with parent and expressed to the staff fear of any further participation in treatment plan.


3. Review of a follow-up letter dated September 23, 2022, from EMP5 to CF1 that acknowledged CF1 discussion with PT4/MR4 regarding the patient's treatment plan while in the presence of other patients, that the patient felt intimidated, threatened, was later observed to be crying while the phone to parent and expressed fear to further participate in treatment plan. The documentation also suggested that concerns and conduct need to be handled professionally and a copy of the "Behavior Undermining a Culture of Safety" (BUCS) was attached for CF1 review.


4. Interview with EMP4 on October 26, 2022, at 11:15 AM revelaed that it was heard that there was a physician bullying patients with a 302, but EMP4 did not witness this directly.

5. Interview with EMP7 on October 26, 2022, at approximately 11:30 AM revealed that there was one incident where CF1 was very threatening to a patient.

Based on review of facility documents and interview with facility staff (EMP), the facility failed to provide an adequate number of registered nurses to ensure that all patient care and safety needs were met by failing to adhere to adopted staffing matrix on the inpatient behavioral health unit.

Findings Include:


Conemaugh Memorial Medical Center ... PolicyStat ID: 11165377 ... Policy Area: Behavioral Health ... Scope of Service-Adult Psychiatric Unit (GS7) policy and procedure dated March, 2022. "Standards of Patient Care The American Nurses Association Scope and Standards of Nursing Practice, as well as the Psychiatric-Mental Health Nursing: Scope & Standards of Practice guide patient care. The standards outline the fundamental elements for effective delivery of patient care in psychiatric nursing and guide nursing practice. Patient Care Goals Patient care goals at Memorial Medical Center are outlined in the 'Plan for the Provision of Patient Care' and include: ... C. The patient is provided with a safe, therapeutic environment. D. The patient's physical needs are met through appropriate patient care interventions. E. The patient's psychological stress is minimized and coping abilities enhanced. F. The patient and/or support system is provided with information and/or resources to provide ongoing support/care to the best of their ability. G. The patient's rights are respected and assured. H. The patient and/or support system will be satisfied with the care provided. ... SCOPE: A. The adult psychiatric inpatient unit located on the 7th floor of the Good Samaritan building (GS7) serves the community as part of a continuous, comprehensive mental health delivery system. ... E. Safety practices include 15 minute safety checks, staff monitoring of all community areas and staff presence during meals and visiting hours. ... F. Nursing care, daily psychiatric assessments, therapy and medication management are provided to meet the emotional, behavioral, physical, cultural, educational and spiritual needs of the adult patient population. ... ."


Review of facility documentation dated October 22, 2022, revealed documented evidence of the sexual assault PT1/MR1 by PT2/MR2. The documentation also revealed that inpatient census on the BHU at the time of the assault was 22, that there were two RNs and one MHT, one RN was at the nurse's station, the other RN was in the dining room monitoring patients eating lunch and the MHT was completing 15 minute check patient observations at the time of the assault.


1. Review of BHU inpatient census, staffing matrix and staffing schedules dated October 1, 2022, through October 26, 2022, (7-3 shift), was conducted with EMP7 at an onsite visit November 3, 2022, at 1:00 PM. There were a total of 76, eight hour shifts (7-3, 3-11 and 11-7). The BHU inpatient census ranged from 18-24 patients from October 1, 2022, through October 26, 2022 (7-3 shift). The Adult Behavioral Health unit has already been capped at 24 patients for a period of time due to previously cited staffing issues. The staffing matrix called for three Registered Nurses on all three shifts with a census of 18 and up to 24 patients. There were a total of 15 shifts that were able to accomodate this matrix, leaving 51 shifts that were covered by only two Registered Nurses. This at times, was often accomplished by staff volunteering overtime, or mandation when there were call offs or holes in the schedule. EMP7 confirmed the findings.



2. Review of facility documentation, undated, revealed, "3. Staffing Escalation Process: Staffing levels deemed 'critical' < 70% of employees are available for duty. ... Staffing level deemed 'crisis' * All contingency strategies have been exhausted. ... 5. Schedules reviewed by nursing leaders continuously to proactively fill gaps. ... ."

Interview with EMP9 on November 3, 2022, at approximatley 1:50 PM revealed, we have not updated our crisis staffing policy since the middle of the pandemic, we are still following the same one. EMP9 confirmed that the facility's staffing level was not deemed "crisis" for the month of October.


3. Interview with EMP7 on October 26, 2022, at approximately 11:30 AM revealed that the main concern the facility has is decompressing the ER, behavioral medicine is last on the list especially where staffing concerns are. EMP7 was told by CNO that they are still staffing at their critical staffing model. EMP7 stated that on 7-3 and 3-11 it has been one RN to 12 patients for a while and 11-7 has always had two RNs, but that 11-7 is more manageable for this. EMP7 stated that it is very difficult to provide quality, safe care with the current staffing model. EMP7 stated that most of her staff is agency, that employed staff has decreased. EMP7 stated that there is currently 3 MHTs, however, just received another resignation this morning, and five agency nurses, a lot of whom are bad performers, who are not permitted to be let go. EMP7 stated that there is a need for good, solid nurses on the BHU, some of those hired can't even do an accu check on a patient. EMP7 stated that the events/incidents have increased on the BHU, including the most recent sexual assault and fentanyl overdose. EMP7 stated that recently there was a patient on a 1:1 on the medical unit, who was blind and used a walking stick, that they wanted to admit to BHU, however, EMP7 told them that they did not have the staff, but they didn't want to hear that. EMP7 stated that she would have needed a 1:1 and that the walking stick could have been used as a weapon, the patient would not have been able to protect self as they would not be able to see if another patient would approach them. ... EMP7 stated that staff are being mandated, they're upset, only getting the regular bonus, all the others have gone away.

Interview with EMP2 on October 26, 2022, at 11:25 AM revealed that they feel the unit is short staffed. EMP2 stated that today there is one RN with eleven patients each, that they try to assign one RN with eight patients, but there is never enough RNs for that to happen.
Interview with EMP4 on October 26, 2022, at 11:15 AM. EMP4 stated that today there are eleven patients for each nurse, yesterday, they had twelve each. EMP4 stated that the job is very dynamic and RN's are doing clerical duties too. EMP4 stated that med administration takes a long time. EMP4 stated they have to do assessments, meds, attend treatment teams, admission/discharges, it is not safe.

Interview with EMP6 on October 26, 2022, at approximately 11:25 AM revealed that EMP6 was working the Saturday that the sexual assault occurred. EMP6 stated that there were 24 patients on the unit that day with only two RNs and one mental health tech, who was passing lunch trays when the event occurred. EMP6 stated that eight patients for one RN could be manageable but 12 is too many.