HospitalInspections.org

Based on policy review, document review, video recording review, medical record reviews, observation, and interview, the Governing Body failed to ensure patients were provided safe care, used the training techniques learned to provide non-violent interventions and ensure adequate staffing on units to promote care in a safe setting for 7 of 12 (Patient #1, #7, #8, #9, #10, #11, and #12) sampled patients, 1 of 1 (Patient #6) bedbound patient, and 153 random patients; and failed to follow the hospital's policy to ensure each unit was safely staffed with sufficient staff to prevent abuse to patients and staff during multiple time periods which totaled 204 calendar days reviewed.

The failure to enforce, monitor and ensure adequate staffing to meet the needs of the patients in a safe environment; and failure to ensure all hospital policies and procedures to protect the safety and health of patients and prevent serious outcomes placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being.

The Governing Body's failure to manage the hospital functions, improve quality of care and ensure an environment and culture of safety resulted in 8 incidents with 3 patients suffering injuries when the patients did not receive protective care, safe care and preventative care from the hospital.

The findings included:

1. Review of the hospital's job description, "Chief Executive Officer [CEO]" revealed, "... The CEO has primary responsibility for the development, implementation, and achievement of the hospital's strategic business plan in conjunction with routine operations to include: quality of care, staff development, maintenance of licensure and accreditations, financial performance, and continuous quality improvement... Essential Functions... Manages day-to-day operations and staff so that the hospital achieves its objectives in all of the following key performance areas... effective patient care outcomes ...appropriate fiscal management... maintenance of licensure, accreditation and other regulatory criteria ... implementation of focused business development processes ...medical staff compliance with regulatory and accreditation guidelines... Serves as the final authority for resolution of staff performance concerns and performance improvement activities as appropriate... Guarantee prompt, thorough follow-up of any patient safety issues including system-issue corrections and proactive assessment of high-risk areas... Standard Expectations... Complies with organization policies, procedures, performance improvement initiatives and maintains organizational and industry policies regarding confidentiality... Education/Experience/Skill Requirements... Capable of working within established policies, procedures and practices prescribed by the organization... Supervisory Requirements... Full responsibility for [named hospital] ..."

Review of the hospital's "Chief Nursing Officer [CNO] Job Description" revealed, " ... Responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing, other departments and the delivery of behavioral health/nursing services in a positive, empathetic, and professional attitude toward customers at all times. Collaborates with interdisciplinary treatment teams, other departments and administration to ensure that all residents' physical, biopsychosocial, age, developmental and cultural needs are met and when they are not met, acknowledges and works to resolve customer complaints. Provide leadership to assure compliance with local, state, and federal regulations, as well as nursing practice standard. Recognizes that patient safety is a top priority...
Essential Functions... Anticipates and effectively manage changes in census and acuity and allocates nursing resources based on measurement of patient acuity/care needed ... Role models expectations related to customer service and demonstrates a sense of urgency related to the importance of patient safety ... Evaluate service needs and staffing requirements to ensure needs of patients are met ...Provide effective staff management (hiring, development, training, performance feedback, etc.) that ensures utilization of personnel to best meet the needs of the patients ... Develop and implement health care related training that assures the best possible delivery of health related supports and services. Review training at least annually and makes modifications as needed ... Intervene in crisis situations and investigate incidents ..."

Review of hospital's policy "Plan for the Provision of Care" effective: 03/2023, revealed, "... Mission, Vision, Values ... [named Hospital] mission is to provide quality, compassionate care for all of the individuals we serve ... Organization: The Governing Board of [named Hospital] has ultimate responsibility and authority for all patient care services provided ... The Board strives to assure that a comparable level of care is provided to patients in all units, areas or departments throughout [named hospital]... The senior management team consists of the Chief Executive Officer (CEO), Medical Director, Chief Nursing Officer (CNO), Director of Risk Management Director of Quality Improvement, Director of Human Resources, and the Chief Financial Officer (CFO) ... The management team functions as the organizational planning body for budget, staffing and programmatic direction and patient care ...Department Directors are accountable for the overall functioning of their departments, especially in the areas of competency, maintaining high standards of ethics, timely performance evaluation, providing appropriate inservice education, adherence to risk management/safety protocols and performance improvement activities ... Care is provided according to an established code of ethical conduct and strict adherence to patient rights..."

Review of the Hospital's Adult Patient Handbook, revealed, "Confidentiality/Patient Rights...If we become aware of any allegations or [of] abuse or neglect, we are required by law to report that information to the [named Department]. We will honor the law in the interest of protecting you and others. We are committed to honoring your rights as a patient during your stay at [named hospital] ...

2. The Governing Body failed to ensure patients' rights to receive care in a safe setting were promoted when 8 of 12 sampled patients were involved in abuse/neglect/assault situations. One of the 12 patients (Patient #8) was involved in an assault incident and received injuries that were evaluated and treated at an outside hospital. One of the patients (Patient #1) was taken into the courtyard and left in the courtyard without supervision. Patient #1 was away from the hospital and the police found Patient #1 and the patient was returned to the hospital. One patient (Patient #7) was left in the shower without supervision and fell from the wheelchair. The patient stated hit head.

The facility's Incident Log/Reports from from multiple periods of time reviewed from 1/1/2024 through 11/22/2024, representing 204 days, revealed incidents of patient to patient verbal and/or physical assaults; incidents of patient to staff verbal and/or physical assaults; incidents of potential staff to patient abuse; patient falls; and 6 medication variances involving 5 identified patients and 1 unidentified patient: and allegations of patient sexual assault.
Refer to A- 057, A-115 and A-144.

3. The Governing Body failed to ensure Nursing Services adhered to hospital policies to protect all current and future vulnerable patients from actual and/or potential harm; failed to ensure the hospital was staffed with an appropriate number of nursing staff to meet the needs of all patients on 204- days reviewed.
Refer to A-385 and A-392

Based on facility document review, policy review, video recording review, medical record review, observation and interview, the facility failed to ensure patients' rights to be free from verbal and physical abuse by staff were protected; the failure to ensure patients' received care and services provided in a safe setting for 7 of 12 (Patient #1, #7, #8, #9, #10, #11, and #12) sampled patients, 1 of 1 (Patient #6) bedbound patients, and 153 random patients; and failed to follow the hospital's policy to ensure each unit was safely staffed with sufficient staff to prevent abuse to patients and staff during multiple time periods which totaled 204 calendar days reviewed.

The hospital failure to ensure care was provided in a safe setting, failed to ensure staff followed all policies to promote the safety of all patients, and failed to ensure the facility was safely staffed placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being.

The findings included:

Review of the facility's "Chief Nursing Officer Job [CNO] Description" revealed, " ... Responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing, other departments and the delivery of behavioral health/nursing services in a positive, empathetic, and professional attitude toward customers at all times. Collaborates with interdisciplinary treatment teams, other departments and administration to ensure that all residents' physical, biopsychosocial, age, developmental and cultural needs are met and when they are not met, acknowledges and works to resolve customer complaints. Provide leadership to assure compliance with local, state, and federal regulations, as well as nursing practice standard. Recognizes that patient safety is a top priority ... Essential Functions ... Anticipates and effectively manage changes in census and acuity and allocates nursing resources based on measurement of patient acuity/care needed ... Role models expectations related to customer service and demonstrates a sense of urgency related to the importance of patient safety ... Evaluate service needs and staffing requirements to ensure needs of patients are met ...Provide effective staff management (hiring, development, training, performance feedback, etc.) that ensures utilization of personnel to best meet the needs of the patients ... Develop and implement health care related training that assures the best possible delivery of health related supports and services. Review training at least annually and makes modifications as needed ... Intervene in crisis situations and investigate incidents ...

Review of hospital's policy "Plan for the Provision of Care" effective: 03/2023, revealed, "... Mission, Vision, Values ... [named Hospital] mission is to provide quality, compassionate care for all of the individuals we serve ... Organization: The Governing Board of [named Hospital] has ultimate responsibility and authority for all patient care services provided ... The Board strives to assure that a comparable level of care is provided to patients in all units, areas or departments throughout the facility... The senior management team consists of the Chief Executive Officer (CEO), Medical Director, Chief Nursing Officer (CNO), Director of Risk Management Director of Quality Improvement, Director of Human Resources, and the Chief Financial Officer (CFO) ... The management team functions as the organizational planning body for budget, staffing and programmatic direction and patient care ...Department Directors are accountable for the overall functioning of their departments, especially in the areas of competency, maintaining high standards of ethics, timely performance evaluation, providing appropriate inservice education, adherence to risk management/safety protocols and performance improvement activities ... Care is provided according to an established code of ethical conduct and strict adherence to patient rights..."

The hospital failed to ensure all vulnerable patients received care and services in a safe setting and remained free of mental and physical abuse to promote quality of care for all patients entrusted in the care of the staff of the Hospital.
Refer to A 0144.

Based on policy review, facility document review, video recording review, medical record review, observation and interview, Nursing Services failed to provide adequate oversight and supervision of nursing staff to ensure patients' needs were met and care was provided in a safe setting for 7 of 12 (Patient #1, #7, #8, #9, #10, #11, and #12) sampled patients, 1 of 1 (Patient #6) bedbound patient, and 153 random patients; and failed to follow the hospital's policy to ensure each unit was safely staffed with sufficient staff to prevent abuse to patients and staff during multiple time periods which totaled 204 calendar days reviewed.

The failure of Nursing Services to ensure care was provided in a safe setting, failure to ensure staff followed policies to promote the safety of all patients, and failure to ensure the hospital was safely staffed with nursing personnel placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being.

The findings included:

1. Review of the hospital's policy "Staffing Plan for Nursing Services" revealed, "Status: Pending ... The Staffing Plan for Nursing Services reflects specific service needs to meet patient care and organizational needs... The staffing plan outlines requirements as well as contingency plans for unexpected events that may temporarily disrupt staffing in order to sustain safe business operations... Guidelines: The Staffing Plan has been developed to identify staffing needs based on the following criteria: [named Hospital] safe staffing guidelines... patient population... average daily census... length of stay... Specialty needs of patient population served/acuity... physical environment and available technology ... Type of patient care delivered system utilized ... skill mix ...Competencies required ... measurable outcomes of clinical care ... Cross training of personnel and "floating staff" augments staffing and optimizes resources. Utilization of outside agency staff is limited to episodes when other means of staffing have been exhausted. Evaluation is performed within each unit to ensure the skill mix reflects the patient care needs availability of staff, vacancy and budget standards ... In general, the units are staffed 1:5 overall with minimum of 1:14 for Nurses ... The minimum staffing needed for each skill level (RNs, [Registered Nurses] LPNs [Licensed Practical Nurses], Behavioral Health Associates [BHAs], others) is determined by the nurse-patient ratio guidelines and patient care needs of the population ... coverage includes ensuring there is 1 RN on each unit at all times and that there is at minimum 2 staff on each unit at all times.."

Review of hospital's policy "Plan for the Provision of Care," effective: 03/2023, revealed, "... Mission, Vision, Values ... [named Hospital] mission is to provide quality, compassionate care for all of the individuals we serve ... Nursing Services - Nursing care services are organized under the direction of the CNO [Chief Nursing Officer]...Staffing patterns are determined by a combination of employees per occupied bed ratio (inpatient) and a patient acuity system, with consideration given to individual patient needs in each program..."

2. Review of the hospital's "Nurse Manager RN Job Description" revealed, " ...Assist the DON [Director of Nursing]/CNO with directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing for assigned unity. Oversees the delivery of behavioral health/nursing services in a positive, empathetic, and professional attitude toward customers at all times. Recognize that patient safety is a top priority..."

3. The hospital failed to provide sufficient staff and adequate oversight and supervision of nursing staff to ensure Patient #1, #7, #8, #9, #10, #11, and #12's needs were met and a safe, protective environment was provided.

The hospital failed to provide sufficient oversight and supervision of nursing staff to ensure Patient #6's needs were met within a safe, protective environment.

The hospital failed to provide sufficient staff and adequate oversight and supervision of nursing staff to ensure 153 Random Patients needs were met in a safe, protective environment.

The hospital failed to maintain sufficient staffing on 1 incident days reviewed and 3 observation days of units during the onsite survey.

Refer to A-395

Based on facility document review, policy review, video recording review, medical record review, observation, and interview, the Chief Executive Officer (CEO) failed to be effective in carrying out the responsibilities for the management of the hospital to ensure ongoing compliance with the Conditions of Participation in order for quality of care to be provided to all patients. The failure of the Chief Executive Officer to carry out the responsibility for the oversight of the conduct of the hospital failure to enforce and monitor the provision of care in a safe setting and the failure to protect the safety and health of the patients and prevent serious outcomes placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well being.

The CEO's failure to manage the hospital's functions, improve the quality of care and ensure an environment and culture of safety resulted in 7 of 12 (Patient #1, #7, #8, #9, #10, #11, and #12) sampled patients,1 of 1 (Patient #6) bedbound patient, and 153 random patients not receiving protective care, safe care and preventative care from the hospital.

The findings included:

1. Review of the hospital's job description, "Chief Executive Officer" revealed, "... The CEO has primary responsibility for the development, implementation, and achievement of the hospital's strategic business plan in conjunction with routine operations to include: quality of care, staff development, maintenance of licensure and accreditations, financial performance, and continuous quality improvement... Essential Functions... Manages day-to-day operations and staff so that the hospital achieves its objectives in all of the following key performance areas... effective patient care outcomes ...appropriate fiscal management... maintenance of licensure, accreditation and other regulatory criteria ... implementation of focused business development processes ...medical staff compliance with regulatory and accreditation guidelines... Serves as the final authority for resolution of staff performance concerns and performance improvement activities as appropriate... Guarantee prompt, thorough follow-up of any patient safety issues including system-issue corrections and proactive assessment of high-risk areas... Standard Expectations... Complies with organization policies, procedures, performance improvement initiatives and maintains organizational and industry policies regarding confidentiality... Education/Experience/Skill Requirements... Capable of working within established policies, procedures and practices prescribed by the organization... Supervisory Requirements... Full responsibility for [named hospital]..."

2. Review of hospital's policy "Plan for the Provision of Care" effective: 03/2023, revealed, "... Mission, Vision, Values ... [named Hospital] mission is to provide quality, compassionate care for all of the individuals we serve ... Organization: The Governing Board of [named Hospital] has ultimate responsibility and authority for all patient care services provided ... The Board strives to assure that a comparable level of care is provided to patients in all units, areas or departments throughout the named hospital]... The senior management team consists of the Chief Executive Officer, Medical Director, Chief Nursing Officer (CNO), Director of Risk Management, Director of Quality Improvement, Director of Human Resources, and the Chief Financial Officer (CFO) ... The management team functions as the organizational planning body for budget, staffing and programmatic direction and patient care ...Department Directors are accountable for the overall functioning of their departments, especially in the areas of competency, maintaining high standards of ethics, timely performance evaluation, providing appropriate inservice education, adherence to risk management/safety protocols and performance improvement activities ... Care is provided according to an established code of ethical conduct and strict adherence to patient rights..."

Review of hospital's policy "Patient Rights and Responsibilities" revised: 04/2018, revealed, The approval signature by the Governing Board remains pending. The approver is identified as: Chief Executive Officer. The Chief Executive Officer (CEO) for the hospital is identified as the Administrator. "... Patients have the right to be treated with consideration, respect, and full recognition of their dignity and individuality... Patients have the right to be protected by the licensee from neglect; from physical, verbal, and emotional abuse (including corporal punishment); and from all forms of misappropriation and/or exploitation..."

3. The CEO failed to ensure quality care was provided to the patients who received care from Hospital; failed to ensure the patients received care and services in a safe environment; and failed to carry out the responsibility for the oversight of the conduct of the hospital failure to enforce and monitor the provision of care in a safe setting.

a. On 8/31/2024, Patient #12 was involved in an altercation with 5 (unidentified) staff members who grabbed the patient's arm but the patient snatched it away from the staff. BHA #13 got Patient #12 pinned into a corner near the entrance door and Patient #12 elbowed BHA #13 which caused BHA #13 to lose his footing. Both the patient and the BHA fell to the ground.

b. On 9/12/2024, Patient #11 was involved in a verbal altercation with BHA #12 that led to a physical altercation.

c. On 10/29/2024, Patient #8 spat on Behavioral Health Associate (BHA) #4. BHA #4 then retaliated and began hitting Patient #8 multiple times in the face resulting in injuries that Patient #8 was transferred to an outside hospital for evaluation and treatment. There was no documentation provided of the name of the hospital Patient #8 was transferred for treatment and evaluation.

During an interview on 11/25/2024 at 1:08 PM, the Administrator/CEO stated that the morning after the incident involving BHA #4 and Patient #8 occurred on 10/29/2024, she reviewed the incident report and video footage of the incident. The Administrator confirmed that the unit staff physically abused Patient #8. The Administrator stated she interviewed the unit staff who were present during the incident; and all the unit staff present during the incident were initially suspended during the hospital investigation. The Administrator stated that none of the unit staff present during the incident admitted that any patient abuse by staff occurred. The Administrator stated that BHA #4 denied abusing Patient #8 on 10/29/2024. The Administrator stated that she contacted law enforcement, and police officers from the Police Department #1 came to the hospital and took a report.

d. On 11/17/2024, Patients #9 spat on BHA #3. BHA #3 then attacked Patient #9. BHA #3 tried to restrain Patient #9. Patient #10 attacked BHA #3.

e. Patient #1 was a patient was on 1:1 (1 qualified staff to 1 high risk patient) precautions due to being on homicide precautions. Patient #1 had threatened to kill local police officers and the local District. On 2/6/2025, Patient #10 was taken out to the courtyard to smoke by BHA #38. There was no other staff or patients present in the courtyard at the time BHA took Patient #1 to the courtyard. BHA #38 left Patient #1 in the courtyard without supervision. Patient #1 climbed the fence and eloped from the facility.

f. Patient #7 was a patient who suffered from Postural Orthostatic Tachycardia Syndrome (POTS - a syndrome that affects blood flow and heart rate when you stand up) and Suicide Attempts and Seizures. Patient #7 was 1:1 precautions due to suicidal tendency.
On 2/19/2025, Patient #7 was taken to a shower room off the East Unit, placed in a wheelchair accessible chair and left in the shower without supervision. Patient #10 was found about an hour after being left without supervision in the shower and lying on the floor. Patient #10 had an abrasion to her forehead and elbow.

During an interview on 2/25/2025 at 2:20 PM, the CNO stated that all hospital units had walk-in showers. The CNO was asked about BHA #102 leaving Patient #7 alone in the shower and Patient #7 falling and hitting her head. The CNO confirmed that BHA #102 left Patient #7 alone in a shower "last Wednesday [2/19/2025] at 8:36 AM" and Patient #7 fell and hit her head. The CNO reported that BHA #102 did not let the other BHAs on the unit know that Patient #7 was left in the shower. The CNO stated that Patient #7 had small abrasions on her forehead and elbow from the fall.
Refer to A-144 and A-392

3. The hospital's Administrator/Chief Executive Officer failed to be responsible and provide the oversight needed to ensure the care and services provided by the hospital's staff to its vulnerable patient population was done so in a safe environment and ensure the promotion of patients' rights when multiple incidents of patient-to-patient assault/attacks, patient-to-staff assault/attacks, staff-to-patient abuse, falls, medication variances, and sexual assaults were allowed to occur for the 204 days of incident log/reports reviewed.

The facility's Incident Log/Reports from from multiple periods of time beginning 1/1/2024 and ending 11/22/2024 revealed incidents of verbal and/or physical assaults involving 96 identified patients and an undetermined number of unidentified patients.

Review of the facility's Incident Log/Reports from from multiple periods of time beginning 1/1/2024 and ending 11/22/2024, for a total of 204 days of incident logs/reports reviewed, revealed 49 incidents of verbal and/or physical assaults from 36 patients to an undetermined number of staff.

Review of the facility's Incident Log/Reports from multiple periods of time beginning 1/1/2024 and ending 11/22/2024, for a total of 204 days of incident logs/reports reviewed, revealed 10 incidents of potential staff to patient abuse involving 8 patients and an undetermined number of staff members.

Review of the facility's Incident Log/Reports from multiple periods of time beginning 1/1/2024 and ending 11/22/2024, for a total of 204 days of incident logs/reports reviewed, for a total of 204 days of incident logs/reports reviewed, revealed 31 falls involving 25 patients.

Review of the facility's Incident Log/Reports from multiple periods of time beginning 1/1/2024 and ending 11/22/2024, revealed 6 medication variances involving 5 identified patients and 1 unidentified patient.

Review of the facility's Incident Log/Reports from 1/1/2024 - 3/31/2024 and 8/1/2024 -11/22/2024 (204 calendar days) revealed 9 allegations of sexual assault involving 13 identified patients.

Refer to A- 057, A-115 A-144, A-385 and A-392

Based on policy review, document review, video recording review, medical record review, observation and interview, the hospital failed to ensure care was provided in a safe setting for seven (7) of 12 (Patient #1, #7, #8, #9, #10, #11, and #12) sampled patients reviewed, and one (1) of one (1) (Patient #6) bedbound patient, and 153 random patients; failed to ensure staff maintained 1:1 (1 qualified staff member is assigned to 1 high-risk patient) for two (2) of two (2) (Patient #1 and #7) sampled patient; The hospital failed to ensure the hospital was safely staffed with a staff to patient ratio of one (1) staff for every five (5) patients to ensure sufficient staff was available to meet the patient's needs.

The Hospital's failure to provide care in a safe setting, promote safety by not following order levels of observation and the failure to ensure the hospital was staffed to meet the patient's individual needs placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well-being.

The findings included:

1. Review of the hospital's policy, "Patient Rights and Responsibilities" revised: 04/2018 with the approval signature by the Governing Board pending and the approver identified as the Chief Executive Officer (CEO), revealed, "...Patients have the right to be treated with consideration, respect, and full recognition of their dignity and individuality...Patients have the right to be protected by the licensee from neglect; from physical, verbal, and emotional abuse (including corporal punishment); and from all forms of misappropriation and/or exploitation...Patients have the right to privacy while receiving services..."

Review of the hospital's policy, "Patient Abuse and Neglect" revised 07/2018, with the approval signature by the Governing Board pending and the approver identified as the Chief Executive Officer (CEO), revealed, "... [named Hospital] expects every employee to establish and maintain an appropriate professional, therapeutic relationship with each patient... [named hospital] is committed to the safety and well-being of every patient and there shall be no tolerance for the expression or demonstration by a staff member of inappropriate social and/or sexual behavior toward any patient ... Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. [named Hospital] shall protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members...other patients...All cases of suspected abuse/neglect/exploitation as defined in this policy, whether or not an actual injury has occurred, will be reported and investigated promptly in compliance with state law and regulation...Mental/Psychological Abuse...Acts that inflict emotional harm, invoke fear and/or humiliate, intimidate, degrade, demean or otherwise negatively impact the mental health. Examples include derogatory, threatening, belittling, humiliating, or profane or obscene language toward a patient, physical intimidation...Physical abuse is defined as acts of assault/battery...Examples include assault behavior physically, putting a patient in a seclusion or restraint (lack of freedom) without justification of imminent danger to self or others, pushing, hitting, slapping, or striking a patient...Verbal Abuse...The use of offensive and/or intimidating language that can provoke or upset an individual. Examples include cursing/verbally threatening a patient, cursing/verbally threatening in front of a patient...verbally criticizing a patient... Neglect...Any circumstances which result from leaving unfinished or unattended one's duties and responsibilities for patient care which endangers a patient's life or development or impairs the patient's functioning...Prevention and Training...Orientation and ongoing training of employees on issues related to abuse prohibition practices including definitions of abuse, neglect, exploitation, signs of burnout, reporting allegations, and appropriate interventions to deal with difficult behaviors...Nonviolent Crisis Intervention (CPI) training bi-annually [twice a year typically once every 6 months] to assist staff in understanding and identifying patient abuse, neglect or exploitation...Identifying, correcting and intervening in situations in which abuse, neglect, mistreatment...is more likely to occur... Identification...Identify possible incidents or allegation that need investigation...Any alleged, suspected or witnessed abuse, neglect, exploitation or abandonment by an employee...or caregiver shall be reported to the immediate supervisor as soon as it is known...Notify patient's physician immediately of any alleged, suspected or witnessed abuse or neglect and suggest physician examines the patient and documents assessment as soon as possible..."

Review of the hospital's policy, "Observations, Patient" with effective date of 11/2022 with the next review date of 11/2023 with approval signature by the Governing Board, revealed, "...In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner...The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change...15 minute...Q [every] 5 minute...one-to-one...The physician may also order a precaution level of observation for... suicide... assault... elopement... seizure...fall... sexual acting out..."

Review of the hospital's "Risk Management Incident Reporting Policy" revised 07/2018 with the approval signature by the Governing Board pending and the approver identified as the Chief Executive Officer (CEO), revealed, " ...The Incident Report is a Risk Management tool that raises awareness of actual or potential exposures to harm... enables the hospital to manage risk, increase safety, and improve the quality of health care provided in the hospital through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan... will help... in identifying and analyzing potential areas of risk and implementing measures to improve the overall quality of care and promote a culture of safety throughout the hospital... Any hospital staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report before the end of the shift/work day... An "incident" is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety..."

2. Review of the hospital's Adult Patient Handbook, revealed, Confidentiality/Patient Rights... " If we become aware of any allegations or [of] abuse or neglect, we are required by law to report that information to the [named Department]. We will honor the law in the interest of protecting you and others. We are committed to honoring your rights as a patient during your stay at [named Hospital] ... Patient Responsibilities ... Speak up if you have any concerns related to safety or feel your rights have been violated in any way ... No violence will be tolerated at [named Hospital]. Violence is any behavior that can be interpreted as dangerous to self, staff, patients, or others. This includes verbal or physical abuse or threats. Staff may encourage you to take a quiet time or a time out if your behavior is becoming unsafe or disruptive to the milieu (the environment in which a patient receives care). Staff may physically hold you to help you regain control if your behavior becomes harmful to yourself or others and you may be escorted to a less stimulating environment so that you may attempt to regain control of yourself ... Safe staffing guidelines ... An RN [Registered Nurse] must always be on the unit. Neither an RN House Supervisor nor an LPN can serve as the RN on that unit ... One staff person cannot be left alone on an inpatient unit ... Minimum of two staff members are scheduled on each unit/area/campus regardless of census ..."

Review of the hospital's "Chief Nursing Officer Job Description [CNO]" revealed, " ... Responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing, other departments and the delivery of behavioral health/nursing services in a positive, empathetic, and professional attitude toward customers at all times. Collaborates with interdisciplinary treatment teams, other departments and administration to ensure that all residents' physical, biopsychosocial, age, developmental and cultural needs are met and when they are not met, acknowledges and works to resolve customer complaints. Provide leadership to assure compliance with local, state, and federal regulations, as well as nursing practice standard. Recognizes that patient safety is a top priority...Essential
Functions... Anticipates and effectively manage changes in census and acuity and allocates nursing resources based on measurement of patient acuity/care needed ... Role models expectations related to customer service and demonstrates a sense of urgency related to the importance of patient safety ... Evaluate service needs and staffing requirements to ensure needs of patients are met ...Provide effective staff management (hiring, development, training, performance feedback, etc.) that ensures utilization of personnel to best meet the needs of the patients ... Develop and implement health care related training that assures the best possible delivery of health related supports and services. Review training at least annually and makes modifications as needed ... Intervene in crisis situations and investigate incidents ...

3. Medical record review for Patient #12 revealed an admission date of 8/27/2024 with diagnoses that included Schizoaffective Disorder, Bipolar Type, Suicidal Ideations and hearing voices saying to kill yourself. Patient #12 was admitted voluntarily and assigned to the East Unit.

On 8/31/2024, Patient #12 began beating on the nursing station window. BHA #13, BHA #8, BHA #9, Licensed Practical Nurse (LPN) #2, and nurse from Agency #1 were unsuccessful in de-escalating Patient #12.

The medical record documented an incident on 8/31/2024. The hospital's summary of the video footage revealed the following:
Five (5) staff members surrounded Patient #12, and the staff members attempted to grab Patient #12's arm, but he snatched his arm away. BHA #13 cornered Patient #12 near the entrance door, and Patient #12 elbowed BHA #13 causing BHA #13 to lose his footing. BHA #13 and Patient #12 then fell to the ground. While attempting to get up from the ground, BHA #13 pulled Patient #12 up by his shirt, and BHA #13 placed his forearm on Patient #12's neck to pin him to the entrance door of the unit. Patient #12 swung his fist toward BHA #13's face. BHA #13 placed Patient #12 in a chokehold. LPN #2 administered as needed medication to Patient #12 to calm the patient.

4. Medical record review for Patient #11 revealed an admission date of 9/4/2024 with diagnoses which included Schizoaffective Disorder - Bipolar Type, Auditory Hallucinations and Responding to Internal Stimuli. Patient #11 had an extensive history of mental health treatment and delusional thought processes with anxiety throughout his admission.

Review of an Incident Investigation Report dated 10/01/2024 follows:
On 9/12/2024, Patient #11 was involved in a verbal altercation with BHA #12 that led to a physical altercation. Patient #11 reported he was "jacked up by staff and pushed to the floor." On 9/12/2024, Patient #11 was asked by BHA #12 to use hand sanitizer after Patient #11 was observed "playing with his nose". Patient #11 became aggressive toward BHA #12 and "got in his face, stating, 'I don't know who he is' and that "he had a bad day'." BHA #12 asked Patient #11 to back up, and when the patient refused, BHA #12 pushed Patient #11 and attempted to escort him back to the unit. Staff Nurse #1 reported walking into the cafeteria and witnessing BHA #12 pushing Patient #11 out of the cafeteria. Patient #11 fell to the ground, and BHA #12 continued to hit Patient #11 several times before staff was able to redirect BHA #12 to walk away. Patient #11 began making threats to other staff. BHA #12 attempted use of verbal de-escalation with Patient #11, but it was not successful. Patient #11 began to yell, "[expletive] you. I will kill you." BHA #12 immediately attempted the use of handle with care restraints, but Patient #11 was out of control and BHA #12 had no choice but to push Patient #11 out the door. The HRD stated the video footage showed Patient #11 being pushed out of the serving area multiple times into the cafeteria. Patient #11 fell to the ground causing BHA #12 to fall, and they began to scuffle on the floor.

5. Medical record review for Patient #8 revealed an admission date of 10/17/2024 with diagnoses that included Hallucinations and Manic Mood with Psychosis. Patient #8 was placed on 15-minute safety checks. The Patient had a history including physical aggression, medication non-compliance, delusions, auditory and visual hallucinations, labile mood, impulsive behavior, disorganized thought, irritable mood, oppositional/defiant behavior, manic behavior, and sexually inappropriate behavior. Patient #8 was a high risk for suicide and was on Elopement Precautions. The Patient was involuntarily admitted to the Hospital.

The Nursing Progress Note dated 10/29/2024, electronically signed by Nurse #5, revealed, "Unprovoked, [Patient #8] entered the day room and hit another patient on the unit. Patient #8 continued to grow more angry, agitated and aggressive towards all patients and staff with no specific target. [Patient #8] began to verbally provoke and physically attack multiple patients on the unit which resulted in physical altercations between multiple patients. The Patient was secluded in the quiet activity room. [named Nurse Practitioner (NP)] #6 was notified. [named NP] #6 advised that the Patient would be discharged the next day (10/30/2024) and gave orders to place the Patient in seclusion". Patient calmed down after being in seclusion and was later admitted to an acute care hospital after assaulted by a staff member. The patient was discharged due to an acute care hospital.

Review of the hospital's video recording of the assault on 10/29/2024 of Patient #8 revealed the following:
At 7:24:50, Behavioral Health Associate (BHA) #4 was seen standing in the doorway. Patient #8 was seen standing in the hallway. Patient #8 and BHA #4 appeared to be talking to each other.
At 7:25:27, BHA #4 walked into the hallway toward Patient #8.
At 7:26:08, Patient #8 moved toward BHA #4 and attempted to hit at BHA #4.
At 7:26:10, BHA #4 walked after Patient #8 and wrestled him to the floor.
At 7:26:15, BHA #4 began hitting Patient #8 while the patient was on the floor.
At 7:26:20, BHA #5 grabbed Patient #8 and took him to another hallway and held Patient #8 down to the floor.
At 7:26:21, BHA #4 went to the hallway where Patient #8 was being held down. BHA #4 began to hit Patient #8 while he was on the floor. An unidentified staff member hit Patient #8.
At 7:26:43, Patient #8 ran away and entered a doorway. BHA #4 and other staff followed Patient #8.
At 7:27:00, Patient #8 ran out of the doorway into another doorway.
At 7:27:07, BHA #4 followed Patient #8 through the doorway and wrestled with Patient #8 while the patient is on the floor. Multiple staff and patients entered the room where BHA #4 and Patient #8 are wrestling. A patient hit Patient #8.
At 7:27:29, Multiple staff leave the room while BHA #4 hovers over Patient #8 who was still seen lying on the floor.
At 7:27:48, BHA #4 hit Patient #8 in the face multiple times while Patient #8 was lying on the floor.
At 7:28:11, BHA #4 exited the room while Patient #8 continues to lay on the floor. BHA #4 exited the room, paces back and forth in the hall before exiting through another door.
At 7:28:31, Patient #8 was viewed walking out of the room, until he was out of view of the camera.

Review of Nurse #5's summary of the video footage for the incident that occurred on 10/29/2024 at 7:25 PM revealed: The camera video footage of the alleged physical abuse incident involving Patient #8, BHA #4, BHA #5, BHA #6, BHA #7, Nurse #1, and Nurse #2 was reviewed. The video footage had no audio component. Patient #8 was viewed "swinging at" BHA #4 in front of the nurses station on the East Unit. BHA #4 was then seen actively "going after" Patient #8 and tackling him onto the floor. BHA #5 got Patient #8 up from the floor and took him down the hallway away from BHA #4. BHA #5 held Patient #8 down in the unit hallway. While BHA #5 had Patient #8 held down in the hallway on the East Unit, BHA #4 went to where Patient #8 was being held down by BHA #5 and began attacking and kicking Patient #8. Multiple East Unit patients were seen fighting in a "free for all" situation on the East Unit. Patient #8 was able to get off the floor in the hallway and ran away from BHA #4. Patient #8 was viewed running to the day room and then to the phone room in what appeared to be an attempt to escape from BHA #4. BHA #4 actively pursued Patient #8 into the phone room, and BHA #4 shut the phone room door behind him. Patient #8, BHA #4, and BHA #5 were observed on the camera footage to be shut in the phone room together. BHA #5 was standing beside BHA #4. BHA #4 got on top of Patient #8 and repeatedly hit Patient #8 in the face. BHA #6 was seen on the video footage standing in front of the closed phone room door. No other staff entered the phone room while BHA #6 was standing in front of the closed door. BHA #6 watched BHA #4 repeatedly hit Patient #8 and failed to intervene. BHA #7 was present on the unit when the incident occurred. BHA #7 was viewed leaving the unit. The House Supervisor arrived on the East Unit, BHA #4 got off of Patient #8 and ceased hitting him.
The House Supervisor contacted the Chief Nursing Officer and was advised by the Chief Nursing Officer to place Patient #8 in Seclusion for his own safety. Patient #8 was sent to an outside hospital for treatment and evaluation the following morning for surgical treatment of facial/eye injuries. Patient #8 was reported to have significant facial/eye injuries requiring emergency surgical repair.

The police report of the assault of Patient #8 from Police Department (PD) #1 dated 10/30/2024 was reviewed. A summary of the police report from PD #1 follows: Police Officer #1 was dispatched to the hospital on 10/30/2024 in response to an alleged assault. The report documented the Chief Executive Officer (CEO) reported that on 10/29/2024 at approximately 7:25 PM, (named BHA #4) was seen to repeatedly punch (named Patient #8). (named Patient #8) sustained injuries and was transported to an outside hospital for emergency surgery. The report documented the CEO stated the injury Patient #8 sustained was an orbital fracture. The report documented Police Officer #1 reviewed the camera footage. The Police Officer documented Patient #8, and BHA #4 had what looked like a "heated conversation" based on their body language. The conversation then led to the patient swinging his right hand in a punching motion at BHA #4's head. BHA #4 evaded the punch and took Patient #8 to the ground. Patient #8 had several staff members pile on top of him before escaping and running away. BHA #4 pursued Patient #8 down a hallway which was out of view from the camera. Moments later Patient #8 ran back into camera view and into a room with glass windows. BHA #4 was seen entering the room, took Patient #8 to the ground, and repeatedly punched Patient #8 in the face.

The Discharge Summary dated 11/5/2024 revealed during hospitalization at the Behavioral Health Hospital, Patient #8 was started on a combination of Risperdal (antipsychotic medication used to treat schizophrenia and bipolar disorder) and Trazadone (medication used to treat depression). The Patient remained psychotic-paranoid and responded to internal stimuli. Patient #8 was sent to an acute care hospital for treatment and evaluation of facial/eye injuries that occurred from an assault on 10/29/2024 as a medical emergency and was admitted to the acute care hospital. The Patient had limited participation in his therapies and remained psychotic at the time of discharge from the Behavioral Health Hospital.

Review of the Framework for Root Cause Analysis (RCA) and Corrective Actions of the incident of assault on 10/29/2024 involving Patient #8 was provided by the Risk Manager/Performance Improvement Director. A summary of the RCA follows:
On 10/29/2024 at 7:40 PM, Patient #8 was taken to seclusion for safety after initiating a fight with several other patients on East Unit. Patient #8's diagnosis was Schizophrenia, unspecified. Patient #8's medications included Risperdal 0.5 milligrams (mg) two times daily (treats Schizophrenia); Trazadone 50 mg at bedtime (treats depression). Patient #8's Past Medical/Psychiatric History was Schizophrenia, and medication noncompliance.

Analysis findings of the Root Cause Analysis (RCA) documented upon video review, it was found the staff did not follow proper Handle With Care ((HWC)- specialized training in verbal, de-escalation, safe, physical management, passive holding methods for aggressive, assaultive challenging behaviors) techniques, including assaulting the patient/aggressor during the altercation on the unit. Staff members who observed the event did not report the event to the supervisor, even when some reported they "heard that a staff member might have hit a patient". After investigation, it was determined that staff did not follow proper process of HWC techniques, calling a code for more assistance, reporting mishandling of HWC with patients, nurses not assisting staff during altercation, and not immediately assessing the patients after the altercation was resolved. Staff related human performance factors that contributed to the event were listed as: failure to follow established policies/procedures; "intentional" blindness/confirmation bias, possible inappropriate relationships allowing staff to cover for others even if policy is not followed, burnout, unable to control initial emotional response. Nurse on another unit reported difficulty using new phone to call code. Staffing ratios were deemed appropriate at time of incident.
The Causal Factors/Root Cause Details were:
Many staff that were interviewed did not feel that HWC was done incorrectly at any point during the event. Some staff even reporting that staff member who assaulted patient used "correct" technique without being prompted to describe the technique. All the staff involved in the physical altercation were up to date on the HWC training and Zero Tolerance training. The training methods the staff were up to date on were not implemented by the staff during the 10/29/2024 assault.

During an interview on 11/25/2024 at 12:30 PM, the Human Resources Director (HRD) stated she viewed the video footage of that incident. The summary of that review by the HRD follows:
Patient #8 and BHA #4 were fighting. The HRD stated that BHA #5, BHA #6, and BHA #7 were present during the fight, and once BHA #4 and named Patient #8 started to fight, a large group of patients (who were not named by the HRD) "jumped in". BHA #5 picked up the patient to separate him from BHA #4 and took Patient #8 down the hall and restrained him on the floor. BHA #4 went down the hall to where BHA #5 held the patient and kicked and assaulted Patient #8. Patient #8 and BHA #4 started fighting each other again, and the other patients (not named by the HRD) on the unit "jumped in" again and started fighting.
Patient #8 ran to the phone room and BHA #4 ran after the patient and closed the door. BHA #7 was at the nurses station and had full view of the incident between BHA #4 and Patient #8. BHA #7 made no attempt to help. Patient #8 was injured during the fight with BHA #4 and suffered an orbital fracture. Patient #8 was sent out to a trauma center for evaluation and treatment. The HRD stated BHA #4 was also injured with a swollen eye and an abrasion on the side of his face. The HRD stated Nurse #5 filled out an incident report that was not accurate and did not match the video footage. The HRD stated that none of the unit technicians tried to stop the assault on (named Patient #8) by BHA #4. Two nurses (unidentified by the HRD) from another unit were present at the time of the incident. A patient (unidentified) told (named Nurse #3) about the incident. The HRD stated (named Nurse #3) did nothing about the incident and didn't report it.

During an interview on 11/25/2024 at 1:08 PM, the Administrator/CEO stated that the morning after the incident involving BHA #4 and Patient #8 occurred on 10/29/2024, she reviewed the incident report and video footage of the incident. The Administrator confirmed that the unit staff physically abused Patient #8. The Administrator stated that she interviewed the unit staff who were present during the incident. The Administrator stated that none of the unit staff present during the incident admitted that any patient abuse by staff occurred. The Administrator stated that BHA #4 denied abusing Patient #8 on 10/29/2024.

6. The following involves the review of Patient #9 and Patient #10 who were involved in a physical altercation with staff:

(a) Medical record review for Patient #9 revealed an admission date of 11/6/2024 with diagnoses that included Schizoaffective Disorder, Bipolar Type. Patient #9's history and physical revealed he had been suicidal for a week, prior to admission, and wanted to jump in front of a car. The Patient had been noncompliant with psychiatric medication for the past month. Patient #9 was referred to the hospital for worsening Psychosis, Visual Hallucinations, Medication Non-Compliance, Paranoia, Depression, Hopelessness, and Suicidal Ideations. The Patient's medical record documented "multiple recent episodes of aggression towards staff". Patient #9 was housed on the East Unit of the hospital.

(b) Medical record review for Patient #10 was admitted to the Hospital on 10/3/2024 with diagnoses that included Schizoaffective Disorder with Hallucinations, Delusions, Agitation, Anxiety, and Depression, Depression and Suicidal Ideations. Patient #10 was documented to be a danger to himself, others, and/or property, with the need for a controlled environment. Patient #10 reported suicidal thoughts. Patient #10 was housed on the East Unit.

(c) Review of video footage of an alleged physical abuse incident that occurred on 11/17/2024 revealed Patient #9 spit on BHA #3 outside the nurses' station on the East Unit on 11/17/2024. BHA #3 then attempted to physically attack Patient #9. Unit staff restrained BHA #3 from hitting Patient #9 and moved him away from Patient #9. Patient #10 then attempted to hit BHA #3. BHA #3 and Patient #10 began physically fighting. Numerous other patients began fighting and hitting BHA #3. Multiple patients grabbed BHA #3's hair and were holding him by his hair as the physical altercation continued. Staff who arrived from other units and the two (2) nurses assigned to the East Unit were able to stop the fight and remove the patients' hands from BHA #3's hair.

(d) Review of the Hospital's video recording of the assault of Patient #9 revealed the following:
At 7:04:00, Patient #9 was viewed pacing on the unit and appeared agitated.
At 7:06:25, Patient #9 was viewed to spat on BHA #3.
At 7:06:28, BHA #3 attempted to attack Patient #9. BHA #3 was viewed to be restrained by other unit staff and moved away from Patient #9.
At 7:06:41, Patient #10 attempted to hit BHA #3. BHA #3 and Patient #10 began to physically fight. The camera footage revealed numerous patients (unidentified) on the unit join in the fight and struck BHA #3 and pulled his hair. Other unit staff (unidentified) tried to stop the fight.
At 7:08:19, The fight stopped. BHA #3 was released from the patients who held him by hair.

During an interview on 11/25/2024 at 12:30 PM, HRD stated she had viewed the video footage of the incident that occurred on 11/17/2024 between BHA #3, Patient #9, and Patient #10 and a summary follows:
The HRD stated Patient #9 was agitated, and BHA #3 approached him and tried to calm him. Patient #9 then spat on BHA #3. The unit nurse (unidentified) immediately intervened and tried to de-escalate the situation, but BHA #3 stepped around the unit nurse and attempted to hit Patient #9. Patient #10 then hit BHA #3, and BHA #3 hit Patient #10 back. Other unit patients (unidentified) began fighting with BHA #3. Another nurse (unidentified) stepped in and tried to control the patients. Several of the patients grabbed BHA #3's hair. The staff finally got the patients' hands out of BHA #3's hair. The House Supervisor was on the unit and tried to calm patients down. It was a very chaotic situation. Once BHA #3 and Patient #10 started fighting, other patients jumped in. The HRD stated she did not know if the patients or BHA #3 were injured. The HRD stated she did not know if anyone reported BHA #3 to the Abuse Registry.

7. Medical record review for Patient #1 revealed an admission date of 2/5/2025 with diagnoses that included Bipolar Disorder, current episode manic severe with psychotic features. Patient #1 remained manic with pressured speech, irritable mood, grandiose delusions and paranoia during his hospital stay. The patient had made several threats to the local police and the District Attorney. The patient was on 1:1 (1 qualified staff to 1 high-risk patient) precautions.

While surveyors were onsite on 2/11/2025 at approximately 11:00 AM, unidentified staff reported an incident where a patient (unidentified at the time) was taken out in the courtyard to smoke by (unidentified at the time) Behavioral Health Associate who left the patient outside without any supervision. While the patient was in the courtyard, the patient eloped over the fence and left the hospital property. When the staff returned to get the patient from the courtyard to bring back to the unit, they discovered the patient had eloped. The patient was identified as Patient #1 and the BHA was identified as BHA #38 as the staff who left Patient #1 in the courtyard without supervision.

When the surveyors were able to identify the patient that eloped as Patient #1. The surveyors requested to review Patient #1's medical record. There was no documentation Patient #1 eloped from the hospital on 2/6/2025.

The Behavioral hospital's summary of the camera footage reviewed for 2/6/2025 incident of elopement revealed Patient #1 was taken outside the building into the courtyard by BHA #38. There were no other patients or staff outside in the courtyard at that time. BHA #38 was observed in the camera footage to leave the courtyard and re-entered the building. Patient #1 was left alone in the courtyard. Patient #1 was observed in the camera footage to climb over the courtyard fence and eloped from the hospital.

During an interview on 2/25/2025 at 2:20 PM, the Chief Nursing Officer (CNO) stated Patient #1 was very paranoid about the police being out to get him. Incident Report The CNO stated she put Patient #1 on 1:1 precautions before he eloped. When questioned why there was no documentation in Patient #1's medical record related to him eloping, the CNO stated that nurses get complacent and she was the only one auditing patient medical records. When asked if a Behavioral Health Associate could be assigned a 1:1 observation while also being assigned routine 15 minute checks on other patients, the CNO stated no. The CNO reported that there were no good communication chains at the hospital.

8. Medical record review revealed that Patient #7 was admitted to the hospital with a diagnosis of Major Depressive Disorder, recurrent without Psychotic Features. Patient #7 had a history of Postural Orthostatic Tachycardia Syndrome ((POTS) - a syndrome that affects blood flow and heart rate when you stand up) and Suicide Attempts and Seizures. Patient #7 was 1:1 due to suicidal tendency.

Review of the hospital's investigation review revealed that on 2/19/2025, at 8:50 PM, BHA #102 took Patient #7 via wheelchair to Unit #1, placed her in a shower, and left the shower and Unit #1, leaving Patient #7 unattended. When Patient #7 was found lying in the floor with part of her body still in the shower, Patient #7 stated she had hit her head. There was no documentation neurochecks were p

Based on hospital's policy review, document review, medical record review, video recording review, medical record review, observation and interview, the hospital failed to ensure nursing staff was adequate to provide care to meet patients' needs and nursing provided adequate oversight and supervision to ensure the patients' needs were met and care was provided in a safe setting for 7 of 12 (Patient #1, #7, #8, #9, #10, #11, and #12) sampled patients, 1 of 1 (Patient #6) bedbound patient, and 153 random patients; and the hospital failed to maintain sufficient staffing on 1 incident days reviewed and 3 observation days of units during the onsite survey.

The findings included:

1. Review of the hospital's policy "Staffing Plan for Nursing Services" revealed, "Status: Pending ... The Staffing Plan for Nursing Services reflects specific service needs to meet patient care and organizational needs... The staffing plan outlines requirements as well as contingency plans for unexpected events that may temporarily disrupt staffing in order to sustain safe business operations... Guidelines: The Staffing Plan has been developed to identify staffing needs based on the following criteria: [named Hospital] safe staffing guidelines... patient population... average daily census... length of stay... Specialty needs of patient population served/acuity... physical environment and available technology ... Type of patient care delivered system utilized ... skill mix ...Competencies required ... measurable outcomes of clinical care ... Cross training of personnel and "floating staff" augments staffing and optimizes resources. Utilization of outside agency staff is limited to episodes when other means of staffing have been exhausted. Evaluation is performed within each unit to ensure the skill mix reflects the patient care needs availability of staff, vacancy and budget standards ... In general, the units are staffed 1:5 overall with minimum of 1:14 for Nurses ... The minimum staffing needed for each skill level (RNs, [Registered Nurses] LPNs [Licensed Practical Nurses], Behavioral Health Associates [BHAs], others) is determined by the nurse-patient ratio guidelines and patient care needs of the population ... coverage includes ensuring there is 1 RN on each unit at all times and that there is at minimum 2 staff on each unit at all times ... When assigning the patient/staff ratio, the nursing leader (i.e. CNO [Chief Nursing Officer], Nurse Manager, House Supervisor) or designee will consider the abilities and competencies of all nursing staff personnel. The nursing leader or designee will modify the patient/staff ratio as deemed necessary according to the current patient acuity and/or patient volume ... The minimum staffing levels may be adjusted up or down based on workload assessment include patient acuity, staff skill level, and patient care activities including patient education, procedures, volume of admissions, discharges, and transfers ... The goal of staffing each unit is to ensure patient safety in healthcare delivery. Nursing staff are scheduled to provide quality/safe care ... Patient care workload and activities can fluctuate and therefore, requires ongoing assessment and planning to assure that adequate and qualified staff is available to meet patient care needs ... Staffing levels are assessed continuously, and adjustments are made for staff assignments based on the needs of the patient ... The CNO/Nurse Manager/House Supervisor or designee considers the following factors in determining staffing needs ... Patient census and core staffing hours are used to determine staffing needs ... Patient acuity, unit special needs, number of admissions and discharges are factored on a daily basis to ensure all patient needs are met ... A Registered Nurse is always available in the hospital to step in and assume charge duties when needed ... A Registered Nurse plans, assigns, supervises, and evaluates the nursing care of each patient daily ...The unit will be staffed with an adequate number of RNs, LPNs and BHAs to maintain a therapeutic milieu and a safe environment ... When core staffing to census and acuity results in 2 staff on a unit, a plan is in place to provide for meal breaks for personnel to maintain the safe staffing level of an RN and a BHA at all times ... Included in the assessment of staffing is identification of staff that are to respond to emergencies. At all times a minimum of 3 people are to be available to respond to emergencies and/or relieve unit staff on a temporary basis to allow them to respond to the emergency ... Staffing Alternatives to ensure Safe Staffing Guidelines are met ... Identify employees outside of the nursing department that have worked as a nurse or BHA prior to current assignment that are trained to provide direct patient care ... As part of the emergency operations plan, non-nursing staff are to be cross trained upon hire to perform patient care functions i.e. ... observation rounds, vital signs, staff escort, cleaning of environment and may be called upon to assist with providing patient care coverage until addition nursing care staff are available ... If these alternatives are unable to address the staffing needs, the Chief Nursing Officer or designee should be contacted to assist in determining other strategies in coordination with the CEO ... The Nurse Manager should regularly review the clinical sensitive indicators (i.e., patient falls, medication variances and/or patient satisfaction surveys) to evaluate the relationship, if any, to its staffing plan and identify yearly the specific indicators they will be measuring ... Selected performance indicators that fall below threshold shall cur department leaders to evaluate the data, reviewing factors that may have contributed to the occurrences, including staffing patterns, FTE [full time equivalent] allocation, skill mix, etc. If the analysis indicates that a staffing problem exists, Chief Nursing Officer [CNO]
in collaboration with CEO [Chief Executive Officer], CFO [Chief Financial Officer], PI [Performance Improvement]/Risk will evaluate the need to adjust staffing levels to meet patient care needs and monitor ..." There was no documentation the "Staffing Plan for Nursing Services" policy of the date the policy was approved.

Review of hospital's policy "Plan for the Provision of Care," effective: 03/2023, revealed, "... Mission, Vision, Values ... [named Hospital] mission is to provide quality, compassionate care for all of the individuals we serve ... Nursing Services - Nursing care services are organized under the direction of the CNO...Staffing patterns are determined by a combination of employees per occupied bed ratio (inpatient) and a patient acuity system, with consideration given to individual patient needs in each program. A core staff level is determined for each inpatient unit consisting of a charge nurses, mental health technicians, social workers and activity therapist...Adjustments to the core staffing levels are made on the basis of acuity. Such adjustments for planned staffing are made daily by the CNO or designee based on the individual needs of patients ..."

Review of the hospital's "Risk Management Incident Reporting Policy," revised 07/2018 revealed, " ... The Incident Report is a Risk Management tool that raises awareness of actual or potential exposures to harm ... enables the hospital to manage risk, increase safety, and improve the quality of health care provided in the hospital through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan ... will help ... in identifying and analyzing potential areas of risk and implementing measures to improve the overall quality of care and promote a culture of safety throughout the hospital..."

2. Review of the hospital's "Chief Nursing Officer Job Description" revealed, " ... Responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing, other departments and the delivery of behavioral health/nursing services in a positive, empathetic, and professional attitude toward customers at all times. Collaborates with interdisciplinary treatment teams, other departments and administration to ensure that all patients' physical, biopsychosocial, age, developmental and cultural needs are met and when they are not met, acknowledges and works to resolve customer complaints. Provide leadership to assure compliance with local, state, and federal regulations, as well as nursing practice standard. Recognizes that patient safety is a top priority ... Essential Functions ... Anticipates and effectively manage changes in census and acuity and allocates nursing resources based on measurement of patient acuity/care needed ... Role models expectations related to customer service and demonstrates a sense of urgency related to the importance of patient safety ... Evaluate service needs and staffing requirements to ensure needs of patients are met ...Provide effective staff management (hiring, development, training, performance feedback, etc.) that ensures utilization of personnel to best meet the needs of the patients ... Develop and implement health care related training that assures the best possible delivery of health related supports and services. Review training at least annually and makes modifications as needed ... Intervene in crisis situations and investigate incidents..."

Review of the hospital's "Nurse Manager RN Job Description" revealed, " ...Assist the DON [Director of Nursing]/CNO with directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing for assigned unity. Oversees the delivery of behavioral health/nursing services in a positive, empathetic, and professional attitude toward customers at all times. Recognize that patient safety is a top priority ...Anticipate and effectively manage changes in census and acuity and allocates nursing resources based on measurement of patient acuity/care needed... Manage the activities of staff, coordinating safe and appropriate care between departments and disciplines... Manage and evaluate work activities of nursing, technical... Identify the educational needs of others and develop educational or training programs... "

3. Medical record review for Patient #12 revealed an admission date of 8/27/2024 with diagnoses that included Schizoaffective Disorder, Bipolar Type, Suicidal Ideations and hearing voices saying to kill yourself. Patient #12 was admitted voluntarily and assigned to the East Unit.
On 8/31/2024, Patient #12 began beating on the nursing station window. BHA #13, BHA #8, BHA #9, Licensed Practical Nurse (LPN) #2, and nurse from Agency #1 were unsuccessful in de-escalating Patient #12.

The medical record documented an incident on 8/31/2024. The hospital's summary of the video footage revealed the following: 5 staff members (unidentified) surrounded Patient #12, and the staff members attempted to grab Patient #12's arm, but he snatched his arm away. BHA #13 cornered Patient #12 near the entrance door, and Patient #12 elbowed BHA #13 causing BHA #13 to lose his footing. BHA #13 and Patient #12 then fell to the ground. While attempting to get up from the ground, BHA #13 pulled Patient #12 up by his shirt, and BHA #13 placed his forearm on Patient #12's neck to pin him to the entrance door of the unit. Patient #12 swung his fist toward BHA #13's face. BHA #13 placed Patient #12 in a chokehold. LPN #2 administered as needed medication to Patient #12 to calm the patient.

4. Medical record review for Patient #11 revealed an admission date of 9/4/2024 with diagnoses which included Schizoaffective Disorder - Bipolar Type, Auditory Hallucinations and Responding to Internal Stimuli. Patient #11 had an extensive history of mental health treatment and delusional thought processes with anxiety throughout his admission.

Review of an Incident Investigation Report dated 10/01/2024 follows:
On 9/12/2024, Patient #11 was involved in a verbal altercation with BHA #12 that led to a physical altercation. Patient #11 reported he was "jacked up by staff and pushed to the floor." On 9/12/2024, Patient #11 was asked by BHA #12 to use hand sanitizer after Patient #11 was observed "playing with his nose". Patient #11 became aggressive toward BHA #12 and "got in his face, stating, 'I don't know who he is' and that "he had a bad day'." BHA #12 asked Patient #11 to back up, and when the patient refused, BHA #12 pushed Patient #11 and attempted to escort him back to the unit. Staff Nurse #1 reported walking into the cafeteria and witnessing BHA #12 pushing Patient #11 out of the cafeteria. Patient #11 fell to the ground, and BHA #12 continued to hit Patient #11 several times before staff was able to redirect BHA #12 to walk away. Patient #11 began making threats to other staff. BHA #12 attempted use of verbal de-escalation with Patient #11, but it was not successful. Patient #11 began to yell, "[expletive] you. I will kill you."

5. Medical record review for Patient #8 revealed an admission date of 10/17/2024 with diagnoses that included: Hallucinations, Manic Mood with Psychosis, He was an involuntary admission. He was placed on 15-minute safety checks. The patient had a history including physical aggression, medication non-compliance, delusions, auditory and visual hallucinations, labile mood, impulsive behavior, disorganized thought, irritable mood, oppositional/defiant behavior, manic behavior, and sexually inappropriate behavior. Patient #8 was a high risk for suicide and was on Elopement Precautions.

Review of the hospital's video recording of the assault on 10/29/2024 of Patient #8 revealed the following:
At 7:24:50, Behavioral Health Associate (BHA) #4 was seen standing in the doorway. Patient #8 was seen standing in the hallway. Patient #8 and BHA #4 appeared to be talking to each other.
At 7:25:27, BHA #4 walked into the hallway toward Patient #8.
At 7:26:08, Patient #8 moved toward BHA #4 and attempted to hit at BHA #4.
At 7:26:10, BHA #4 walked after Patient #8 and wrestled him to the floor.
At 7:26:15, BHA #4 began hitting Patient #8 while the patient was on the floor.
At 7:26:20, BHA #5 grabbed Patient #8 and took him to another hallway and held Patient #8 down to the floor.
At 7:26:21, BHA #4 went to the hallway where Patient #8 was being held down. BHA #4 began to hit Patient #8 while he was on the floor. An unidentified staff member hit Patient #8.
At 7:26:43, Patient #8 ran away and entered a doorway. BHA #4 and other staff followed Patient #8.
At 7:27:00, Patient #8 ran out of the doorway into another doorway.
At 7:27:07, BHA #4 followed Patient #8 through the doorway and wrestled with Patient #8 while the patient is on the floor. Multiple staff and patients entered the room where BHA #4 and Patient #8 are wrestling. A patient hit Patient #8.
At 7:27:29, Multiple staff leave the room while BHA #4 hovers over Patient #8 who was still seen lying on the floor.
At 7:27:48, BHA #4 hit Patient #8 in the face multiple times while Patient #8 was lying on the floor.
At 7:28:11, BHA #4 exited the room while Patient #8 continues to lay on the floor. BHA #4 exited the room, paces back and forth in the hall before exiting through another door.
At 7:28:31, Patient #8 was viewed walking out of the room, until he was out of view of the camera.

6. Medical record review for Patient #9 revealed an admission date of 11/6/2024 with diagnoses that included Schizoaffective Disorder, Bipolar Type. Patient #9's history and physical revealed he had been suicidal for a week, prior to admission, and wanted to jump in front of a car. He had been noncompliant with psychiatric medication for the past month. Patient #9 was referred to the hospital for worsening Psychosis, Visual Hallucinations, Medication Non-Compliance, Paranoia, Depression, Hopelessness, and Suicidal Ideations. The patient's medical record documented "multiple recent episodes of aggression towards staff". Patient #9 was housed on the East Unit of the hospital.

Medical record review for Patient #10 was admitted to the Hospital on 10/3/2024 with diagnoses that included Schizoaffective Disorder with Hallucinations, Delusions, Agitation, Anxiety, and Depression, Depression and Suicidal Ideations. Patient #10 was documented to be a danger to himself, others, and/or property, with the need for a controlled environment. Patient #10 reported suicidal thoughts. Patient #10 was housed on the East Unit.

Review of the Hospital's video recording of the assault of Patient #9 revealed the following:
At 7:04:00, Patient #9 was viewed pacing on the unit and appeared agitated.
At 7:06:25, Patient #9 was viewed to spat on BHA #3.
At 7:06:28, BHA #3 attempted to attack Patient #9. BHA #3 was viewed to be restrained by other unit staff and moved away from Patient #9.
At 7:06:41, Patient #10 attempted to hit BHA #3. BHA #3 and Patient #10 began to physically fight. The camera footage revealed numerous patients (unidentified) on the unit join in the fight and struck BHA #3 and pulled his hair. Other unit staff (unidentified) tried to stop the fight.
At 7:08:19, The fight stopped. BHA #3 was released from the patients who held him by hair.

7. Medical record review for Patient #1 revealed an admission date of 2/5/2025 with diagnoses that included Bipolar Disorder, current episode manic severe with psychotic features. Patient #1 remained manic with pressured speech, irritable mood, grandiose delusions and paranoia during his hospital stay. The patient had made several threats to the local police and the District Attorney. The patient was on 1:1 [1 qualified staff to 1 high-risk patient] precautions.

The hospital's summary of the camera footage reviewed for 2/6/2025 incident of elopement revealed Patient #1 was taken outside the building into the courtyard by BHA #38. There were no other patients or staff outside in the courtyard at that time. BHA #38 was observed in the camera footage to leave the courtyard and re-entered the building. Patient #1 was left alone in the courtyard. Patient #1 was observed in the camera footage to climb over the courtyard fence and eloped from the hospital.

8. Medical record review revealed that Patient #7 was admitted to the hospital with a diagnosis of Major Depressive Disorder, recurrent without Psychotic Features. Patient #7 had a history of Postural Orthostatic Tachycardia Syndrome (POTS - a syndrome that affects blood flow and heart rate when you stand up) and Suicide Attempts and Seizures. Patient #7 was 1:1 due to suicidal tendency.

Review of the hospital's investigation review revealed that on 2/19/2025, at 8:50 PM, BHA #102 took Patient #7 via wheelchair to Unit #1, placed her in a shower, and left the shower and Unit #1, leaving Patient #7 unattended. When Patient #7 was found lying in the floor with part of her body still in the shower, Patient #7 stated she had hit her head. There was no documentation neurochecks were performed on the patient to determine any changes that indicated a possible head injury.

The hospital failed to provide sufficient staff and adequate oversight and supervision of nursing staff to ensure Patient #1, #7, #8, #9, #10, #11, and #12's needs were met and a safe, protective environment was provided.

9. Medical record review for Patient #6 revealed an admission date of 12/17/2024 with diagnoses that included Anxiety Disorder, Mood Disorder, and Depression Disorder. The patient has a past history of alcohol abuse, anxiety, and depression. Patient #6 was admitted to the hospital from a skilled nursing facility for evaluation and treatment of behaviors. The Patient acted out sexually inappropriate with insulting, vulgar, and crude language towards patients, staff, and other patient's family members while at the skilled nursing facility. He was unable to attend meals due to his ambulation issues. The Patient was irritable and depressed, and his speech was somewhat mumbled and rambled. The Patient did not participate in group since he was bedbound.

During an interview on 2/12/2025 at 12:30 PM, Nurse #10 stated, "We usually don't take bedbound patients. This one was a mystery. He was a placement issue and was here about 2 months." Nurse #10 staff had to provide maximum care for the patient, including feeding, dressing, grooming, toileting, turning and repositioning to prevent skin breakdown and other complications of decreased mobility.

The hospital failed to provide sufficient oversight and supervision of nursing staff to ensure Patient #6's needs were met within a safe, protective environment.

10. Review of the facility's Incident Log/Reports from 1/1/2024 - 3/31/2024 and 8/1/2024 -11/22/2024 (a total of 204 calendar days) revealed:
a. 76 incidents of verbal and/or physical assaults involving 96 identified patients and an undetermined number of unidentified patients.
b. 49 incidents of verbal and/or physical assaults from 36 patients to an undetermined number of staff.
c. 10 incidents of potential staff to patient abuse involving 8 patients and an undetermined number of staff members.
d. 31 falls involving 25 patients.
e. 6 medication variances involving 5 identified patients and 1 unidentified patient.
f. allegations of sexual assault involving 13 identified patients.

11. Observations during a tour of the patient units accompanied by House Supervisor #1 on 12/10/2024 at 7:30 PM, revealed the following:
a. Unit 1 had a current census of 12 patients. It was staffed with 1 nurse and 1 BHA. The nurse on the unit was unable to tell the Surveyor how many patients were currently on any type of ordered precautions. A second nurse on the unit was identified as being in orientation. House Supervisor #1 stated that staff in orientation were not counted in the staffing ratio. All patients on the unit were on 15-minute checks by staff.

b. Unit 2 had a current census of 15 patients. The unit was staffed with 1 RN, 1 LPN, and 2 BHAs. All patients were on 15-minute observations. Unit staff was unable to identify to the Surveyor if any of the patients were on any type of ordered precautions.

c. Unit 3 had a current census of 19 patients. The unit was staffed with 1 RN, 1 LPN, and 2 BHA. A third nurse, identified as in orientation, was present on the unit. Nurse #6 identified the following observations/precautions in addition to the 15-minute checks required for all patients.
1 patient was on Continuous Positive Airway Pressure (CPAP - a machine worn by a person who has sleep apnea or other sleep related breathing issues; it delivers constant air pressure to keep the airway open during sleep); 8 patients on suicide precautions;
2 patients on elopement precautions;
1 patient on Sexual Acting Out precautions;
1 patient on fall precautions.

During an interview on 12/10/2024 at 7:55 PM, Nurse #6 stated, "Generally every patient on that unit [Unit 3] is on some type of precautions."

d. Unit 4 had a current census of 18. There were 2 nurses present on the unit and 2 BHAs were assigned to that unit, but 1 of those BHAs was in orientation and could not be counted in the staffing ratio. That resulted in 2 nurses and 1 BHA as unit staff. In addition to the routine monitoring of all patients every 15 minutes, the following precautions were identified on the unit:
1 patient on fall precautions;
5 patients on suicide precautions;
1 patient on elopement precautions;
1 patient on homicide precautions;
3 patients on the unit were under the age of 21.

12. Observations during a tour of the patient units on 2/12/2024 at 12:30 PM, revealed the revealed the unit census at that time was 19. The unit was staffed with 2 RNs and 2 BHAs.
The patients were on the following precautions:
2 patients on elopement precautions;
8 patients were on suicide precautions,
6 patients were on fall precautions,
1 patient was on assault precautions,
1 patient was on seizure precautions.

During an interview on 2/12/2025 at 12:40 PM, Nurse #11 stated there are times when they don't have enough staff. Nurses and techs assigned to the unit sometimes get pulled to other units, leaving West Unit short of staff.

13. Observations during a tour of the patient units on 2/25/202 at 12:30 PM, revealed the following:
a. West/Geropsychiatric Unit on 2/25/2025 at 12:00 PM revealed the census was 19. RN #7 was the Charge Nurse for the West Unit on 2/25/2025. House Supervisor #1 was the Medication Nurse on 2/25/2025. There were 3 BHAs working on the unit that day. 1 patient was a 1:1 observation for high fall risk and was also very combative. There were 3 patients who require assistance with Activities of Daily Living (ADLs) on the unit, and 3 patients, ambulatory by wheelchair, require assistance of staff for toileting needs.

During an interview on 2/25/2025 at 12:10 PM, RN #7 stated the unit was not adequately staffed and more BHAs were needed on the unit. She stated she made unit rounds every hour. The BHAs make unit rounds every 15 minutes.

b. South Unit on 2/25/2025 at 12:20 PM revealed the unit census was currently 20. RN #8 worked as the medication nurse that shift. There were initially 2 BHAs assigned to the unit but 1 of those BHAs left at 11:30 AM (scheduled leave). There was currently only 1 BHA on the unit. RN #9 was currently doing the charting and RN #10 had to go with the patients to group.

During an interview on 2/25/2025 at 12:30 PM, when RN #8 was asked if she has ever been instructed by hospital leadership staff not to document an incident, RN #8 did not directly answer that question. She stated, "Things come up missing from Incident Reports." Last week, Corporate Office was here, a BHA dragged a patient by her ankles from behind the Nurses Station, the Chief Nursing Officer took up for the BHA, and the paperwork related to that incident was 'lost'. The Incident Report "came up missing." RN #8 stated during that interview that the new Chief Nursing Officer is "terrible, awful." RN #8 stated that staff bring complaints to Management but those complaints are overlooked. RN #8 described staff morale as "down the drain". RN #8 stated that leadership staff are hard to reach and don't answer calls.

c. Observations on the Aspen Unit on 2/25/2025 at 12:40 PM revealed the patient census was 17. One patient was on detoxification (detox - withdrawal from alcohol) precautions. The unit was staffed with 2 RN's, and 1 BHA.

14. During a telephone interview on 12/5/2024 at 11:00 AM, the CNO stated that in general the staffing on the units was not sufficient. The CNO stated actual staff working on specific days/shifts does not match with what is shown on the staffing schedule. The CNO stated there were multiple problems with unit staffing including 3 people had access to change the staffing schedule, staff might not go to the unit they were assigned, and there had been no staff accountability for problems such as call-ins and tardiness. The CNO stated, "There has been zero accountability and staff gets by with anything they want to... the lack of accountability by staff is absolutely ridiculous..." The CNO stated Administration knows there needed to be change in the structure at the hospital.

During a telephone interview on 12/6/2024 at 1:10 PM, the Assistant Director of Nursing stated the Staffing Coordinator (who was a Certified Nursing Assistant) made the staffing schedule. The Staffing Coordinator and the CNO go over the staffing schedule. When there was a different number of staff working on the unit as opposed to the number of staff the staffing schedule showed as working on the unit, the unit nurse was supposed to notify the scheduler. Attempts are then made to get additional staff utilizing (named Agency #1) and also by direct calls made to staff to see if they are willing to come in to work.

During an interview on 2/12/2025 at 3:00 PM, the CNO reported Nursing leadership steps in to be sure staffing was not short. The hospital was now considering 1:1 observations/precautions when they do the unit staffing. There "probably" had been times when all the unit staff were all agency staff. The CNO stated the staffing schedule should match the staff who were working the unit, and unit staffing was checked every shift.

During an interview on 2/25/2025 at 2:30 PM, Nurse Manager #2 stated the staff assignment sheets did not match actual unit staff; and the staffing schedule was padded to appear as if there are more staff working the units that the actual staff working the units.
Last weekend was Nurse Manager #2's weekend to work (2/22/2025 and 2/23/2025). The Nurse Manager #2 stated, "It was a ghost town There was not enough staff. No one would answer the telephone but me." The Nurse Manager #2 stated the hospital is not a safe environment, and there is a lack of staff on the units to support the patient acuity. The Nurse Manager stated the units did not get enough assigned staff. The Nurse Manager #2 stated that Expectations are unrealistic with what they have to work with at the hospital. The Nurse Manager stated the Staff feels patient acuity is too high.

16. An unsigned electronic mail was received on 2/23/2025 at 9:15 PM that documented the following: The Sender reported observations of staffing schedules that appeared to be padded; he/she came in to find staff names on the schedule, yet the staffing was frequently out of ratio. Names of staff who had called in remained on the schedule, creating a misleading representation of available staff. Despite having a staffing coordinator in place, the hospital continued to experience significant gaps in staffing which raised serious concerns regarding the safety and well-being of the patients.

An unsigned electronic mail was received on 2/26/2025 at 8:01 AM that documented staffing is way out of ratio. Copies of SuperView (time system utilized by (named hospital)) were attached to that e-mail.

An unsigned electronic mail was received on 2/25/2025 at 6:39 AM that documented an encounter of 1 BHA to 20+ patients. The e-mail also reported a patient who tried to elope from his assigned unit via the ceiling/roof on the Aspen Unit was not placed on 1:1 precautions and unit restrictions. That patient was brought to another unit by the nurse manager and the unit BHA was instructed to "take out for a smoke". That BHA was the only working staff on the floor. The BHA did as he was instructed and returned into the building to complete assigned task of checks on other patients. At no time was alternate/on clock BHA/nurses directed to assist or relieve that BHA. At the point of going back out (to where the patient was left to smoke) BHA noted the patient climbing the fence. That BHA attempted to push the panic button but the system did not work, The BHA yelled for assistance and proceeded after the patient.

The hospital failed to ensure oversight and supervision to monitor for changes in the patient population based on the changing patient needs to ensure adequate staffing to promote patients' safety and health and provide the care and services required by the patient to promote health and safety.

Refer to A-144