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Based on interview, record review and document review, the facility failed to ensure an effective Governing Body was responsible for the conduct of the hospital when the hospital failed to:

1) Ensure the Chief Medical Officer was consulted by the Governing Body on matters related to the quality of medical care provided to patients periodically throughout the fiscal or calendar year (See Tag A 0053).

2) Ensure the hospital formulated a three-year capital budget (See Tag A 0073).

3) Meet the Condition of Participation of Patient Rights (See Tag A 0115).

4) Meet the Condition of Participation of Quality Assurance and Performance Improvement (See Tag A 0263).

The cumulative effect of these systemic practices resulted in the failure to ensure there was an effective governing body which was legally responsible for the conduct of the hospital.

Based on document review and interview, the facility failed to provide evidence the Governing Body consulted with its Chief Medical Officer on a regular basis.

Findings include:

On 02/09/2021 at 2:05 PM, the Chief Medical Officer identified self as responsible for all clinical and administrative oversight.

On 02/18/2021 at 10:00 AM, the Chief Executive Officer was unable to provide documented evidence the Governing Body regularly consulted with its Chief Medical Officer periodically throughout the fiscal or calendar year and included discussion of matters related to the quality of medical care provided to patients of the hospital.

Based on document review, interview and observation, the facility's Governing Body failed to ensure the Chief Executive Officer (CEO) was responsibly managing the facility.

Findings include:

On 02/18/2021 between 10:00 AM and 12:15 PM, the CEO verbalized representing the Governing Body and the responsibility for overseeing Patient Rights and Quality Assurance and Performance Improvement. The CEO indicated being responsible for the resources to ensure safe/quality care, treatment and services and for implementing policies and training.

Failures occurred under the conditions of participation for Governing Body, Patients Rights and Quality Assurance and Performance Improvement.

Bylaws Of The Board Of Trustees were provided and established as the facility's overall governing document.

Article 1 Bylaw establishing legal authority:
Member means the management company which is the sole member and owner of the company.

Article 2 Bylaw establishing legal authority:
2.2 Management Of The Hospital
The member (management company) has the authority to select and appoint the Chief Executive Officer to manage the day-to-day business affairs and administration of the hospital. The Chief Executive Officer reports to the member (management company), while maintaining continuing communication with the Board and Medical Staff.

Article 2 Bylaw not met:
2.2 Management Of The Hospital
The Board is the Governing Body of the hospital and retains ultimate responsibility for the hospital's compliance with all applicable federal, state and local laws and regulations (Cross-Reference Tags A 0053, A 0073, A 0122, A 0123, A 0131, A 0144, A 0145, A 0184, A 0273, A 0283, A 0297 and A 0309).

Article 3 Bylaw establishing legal authority:
3.2 Number and Qualifications
3.2.1(a) The Board shall consist of the Chief Executive Officer.

Article 7 Bylaws not met:
7.3 Management Of The Environment Of Care
7.3.1 The Board shall oversee oversee the planning and implementation of methods for providing for the safety, protection and care of hospital patients and others, and ensure allocation of appropriate resources to maintain a safe, secure environment (See Tag A 0144).

7.6 Performance Improvement
7.6.1 The Board shall oversee and recommend resources and support systems for an effective, hospital-wide performance improvement program (See Condition level Tag A 0263).

7.6.5 The Board shall establish and approve a process for prompt resolution of patient grievances (See Tags A 0122 and A 0123).

7.6.6 The Board shall oversee the performance improvement activities of the hospital to ensure that actions are taken appropriate to the findings, and that outcome of such actions is documented (See Tags A 0283, A 0297 and A 0309).

7.9 Departmental Policies And Procedures: The Board shall require that the hospital's leaders and other relevant personnel collaborate in the development of hospital-wide patient care programs, policies and procedures that describe how patients' care needs are assessed and met. (See Tags A 0131, and A 0145 ).

Article 8 Bylaw establishing legal authority:
8.2 Authority And Duties
8.2.1 The Board shall empower the Chief Executive Officer to be responsible for the hospital's management.

Article 8 Bylaws not met:
8.2 Authority And Duties
8.2.1(a) To establish effective operations (See Condition level Tags A 0043, A 0115 and A 0263).
8.2.1(e) To carry out all policies established by the Board and the Member (management company) (See Tags A 0122, A 0123, A 0131, A 0145, and A 0184).

Based on document review and interview, the facility failed to provide a capital expenditure budget for at least a 3-year period.

Findings include:

On 02/18/2021 at 8:10 AM, the Director of Performance Improvement presented a capital expenditure budget which covered only the current year 2021.

On 02/18/2021 at 10:00 AM, the Chief Executive Officer reiterated the facility only completed yearly budgets, as evidenced by capital expenditures outlined for 2021.

Based on observation, interview, record review and document review, the facility failed to:

1) Ensure the grievance policy included timeframes for the completion of the grievance process and notification of the results in writing (See Tag A 0122).

2) Ensure a patient was informed of the decision regarding a grievance (See Tag A 0123).

3) Ensure a guardian was informed prior to implementing a proposed change of treatment for a minor patient (See Tag A 0131).

4) Ensure patients were cared for in a safe environment (See Tag A 0144).

5) Ensure patients were free from assaultive and sexual familiarity incidents by identifying, investigating, analyzing, and implementing preventive actions regarding such incidents involving peers (See Tag A 0145).

6) Ensure nurses conducted/documented face to face seclusion/restraint assessments within an hour after releasing patients (See Tag A 0184).

The cumulative effect of these systematic practices resulted in the failure of the facility to protect and promote patients' rights in the delivery of care to patients.

Based on interview and document review, the hospital failed to ensure the grievance process specified a time frame for review of the grievance and the provision of a final response.

Findings include:

The hospital policy and procedure titled Complaint and Grievance Process, revised 09/11/2019, indicated a grievance was an oral or written complaint that was not immediately resolved within 24 hours of the time of the complaint.

The policy indicated all grievances received immediate priority and would be investigated within 24 hours of receipt. The hospital would attempt to provide a response within seven business days of receiving a grievance. If the grievance were not resolved, the investigation not completed, or the corrective action was still being evaluated within the seven-business day timeframe, the hospital would verbally inform the patient stating the hospital would continue to work to resolve the grievance and the hospital would follow-up with another response within seven business days. The policy indicated the patient would be provided with written notice of the steps taken to resolve the grievance, the results of the grievance process, and the date of completion of the grievance process. The policy lacked a timeframe for the provision of the results of the grievance process and the written response.

On 02/12/2021 at 2:15 PM, the Director of Risk Management verbalized the hospital policy lacked a timeframe for the provision of the results of the grievance process and the written response to the complainant. The Director of Risk Management expressed the policy should have a timeframe for completion of the results and written response.

Based on interview, record review, and document review, the hospital failed to provide a patient with a written notice of the results of a grievance decision for 1 out of 1 grievance reviewed (Patient 22).

Findings include:

Patient 22 was admitted on 09/22/2020 with diagnoses including major depressive disorder. The patient was discharged on 09/25/2020.

On 02/11/2021 in the morning, the Chief Executive Officer (CEO) revealed Patient 22
was an employee at a different psychiatric facility at the time of admission to the hospital. The patient had voiced a grievance the admission to the hospital was divulged to the employer. The CEO indicated for all grievances the hospital should reach out to the patient to share what had been discovered during the investigation.

On 02/11/2021 at 9:00 AM, the Privacy Officer (PO) recalled being notified by the Director of Risk Management that Patient 22 complained of an information breach and the PO was assigned to investigate the concern. The PO indicated shortly following admission to the hospital, Patient 22 complained co-workers from Patient 22's place of employment sent condolence messages to the patient's family member indicating they knew of the hospitalization. Patient 22 was concerned hospital staff had leaked this information. Patient 22 stated being upset that co-workers at the place of employment knew about the hospitalization. The PO recalled investigating the concern. The PO reported the investigation revealed there was no evidence hospital staff breached patient confidentiality. The PO reported documenting the investigation and the conclusion. The PO had not been trained it was necessary to inform patients of the results of the investigation in writing. The PO verbalized not sending a letter with the results of the investigation to the patient.

On 02/11/2021 in the morning the Director of Risk Management recalled receiving the grievance from Patient 22 on 09/23/2021 and had assigned the investigation of the grievance to the PO as it had to do with privacy. The Director of Risk Management indicated the patient should have been notified in writing of the outcome and conclusion of the grievance. The Director of Risk Management indicated Patient 22 called the hospital on 02/05/2021 and left a voice mail asking about the results of the grievance investigation. The Director of Risk Management indicated the patient had not been informed of the outcome of the grievance investigation but should have been.

The facility investigation report indicated on 09/23/2020 Patient 22 was in fear of losing employment at another hospital because co-workers at the other hospital were aware of the admission to the hospital. The section of the document titled Breach Investigation indicated interviews were conducted with Patient 22 and five hospital employees. The employees denied divulging Patient's 22's admission to the other hospital. The document concluded on 09/25/2020 there was no breach proven to have taken place by staff at the hospital. The investigation lacked documentation the patient was notified of the outcome of the investigation.

The hospital policy and procedure titled Complaint and Grievance Process, revised 09/11/2019, indicated the patient would be provided with written notice of the steps taken to resolve the grievance, the results of the complaint and grievance process, and the date of completion of the complaint and grievance process. The policy lacked information on who was to be responsible for ensuring the grievance was investigated and the results reported.

Based on interview, record review, and document review the facility failed to notify the legal guardian prior to placing a male to female transgender patient in a room with a male patient for 1 of 30 sampled patients. (Patient 1).

Findings include:

Patient 1 (P1) was admitted to the facility on 01/29/2021 with a diagnosis of disruptive mood dysregulation disorder.

A psychological assessment dated 01/30/2021, documented P1 was an adolescent who identified as a male to female transgender.

A Physician's Order dated 01/29/2021, documented to place P1in a blocked room - transgender.

A Nurse's Note dated 01/31/2021, documented P1 was in a blocked room for transgender. When P1 became aware the room was blocked, P1 indicated "I'm not transgender. I like boy things I'm just sassy". An Advanced Practice Registered Nurse (APRN) ordered to unblock the room since P1 and the APRN discussed the matter.

On 02/05/2021 at 12:01 PM, a Charge Nurse indicated if a patient identified as transgender. The patient would be placed in a blocked room which meant the patient would not have a roommate.

On 02/05/2021 at 12:36 PM, a physician indicated P1 identified as a male to female transgender. The physician explained if a newly admitted patient identified as transgender the patient would have been placed in a blocked room. The physician indicated a transgender patient's room could have been unblocked if it were ordered by a physician. The physician verbalized an APRN did not have the authority to unblock a transgender patient's room without consulting with the patient's legal guardian, the physician, and the treatment team.

A Nurse's Note dated 02/01/2021 at 6:00 PM, documented P2 reported to have engaged in sexual activity with a peer, guardian made aware, patient gathered all belongings; paperwork given to guardian, no issues with discharge

On 02/05/2021 at 1:57 PM, the Charge Nurse who was working with P1 and P2 on 01/31/2021 indicated P1 explained P1 was not transgender and wanted to have a male roommate. The Charge Nurse verbalized the APRN verbally ordered P1's room to be unblocked and P1 and P2 were moved out of their originally assigned rooms and placed in a room with each other.

On 02/05/2021 at 2:49 PM, the APRN indicated P1 felt singled out and wanted to have a male roommate. The APRN verbalized P1's room was unblocked and assigned P1in a room with P2.

A facility report dated 02/01/2021, documented P2 pressured P1 into performing fellatio (oral sex). Initially P1 agreed but decided to no longer perform the sexual act. P1 and P2 had a disagreement and P1 verbalized wanting a room change.

On 02/05/2021 at 4:09 PM, a Charge Nurse indicated P1 reported to a mental health technician (MHT) P2 pressured P1 to perform oral sex on P2. The charge nurse indicated P1 had initially agreed to perform a sexual act on P2, but then told P2 they no longer wanted to perform the act and the two patients had a disagreement.

On 02/09/2021 at 10:45 AM, P1's legal guardian indicated based on P1's sexual orientation and diagnosis P1 should not have been assigned a room with a male roommate.

On 02/09/2021 at 2:04 PM, the medical director indicated a newly admitted patient who identified as transgender should have been placed in a blocked room. The medical director indicated if a transgender patient were to have a roommate, the patient's legal guardian should have been notified, and a treatment team meeting should have taken place to decide the room assignment.

P1's medical record lacked documented evidence a physician was notified prior to unblocking P1's room, and if P1's legal guardian was notified of the new room assignment.

On 02/09/2021 at 4:16 PM, both the Chief Nursing Officer (CNO) and the Director of Risk Management confirmed P1's room should not have been unblocked without notifying the patient's legal guardian and conduct a treatment team meeting to discuss the room assignment.

The facility's policy titled Transgender Patients dated 01/01/2020, documented room assignment would be made with consideration with preference, availability, clinical presentation, and risk. In the case of adolescents, guardians would be involved in the decision. The transgender patient would be given the choice to room in a private room if available. If requested or agreed upon, the transgender patient may be assigned to a room with another patient of the gender with which the transgender patient identifies.

Based on observation, interview and document review, the facility failed to provide a safe, ligature "resistant" or "free" environment for the residents in seven out of seven units.

Findings include:

Center for Clinical Standards and Quality/Survey & Certification Group Memo 18-06-Hospitals dated 12/08/2017: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation, and Center for Clinical Standards and Quality/Survey & Certification Group Memo 18-21-Hospitals dated 07/20/2018: State Agencies may use their judgment as to the identification of ligature and other safety risk deficiencies.

On 02/16/2021, the following ligature concerns throughout the facility were observed:

1) Older Building Section 100-400 observed in the 400 unit.
A) The following rooms revealed tri-hinged doors located on the outside of the doors facing the resident common areas:
i) Nurse Station Door.
ii) Nutrition Room Doors in the Day Rooms.
iii) Seclusion Room Doors.

B) The following rooms revealed no anti-ligature handles located on the outside of the doors facing the main area common hallways:
i) Exam Room Doors.
ii) Soiled Room Doors.

2) New Building Section 500-700 observed in the 600 unit.
A) The following rooms revealed overhead mechanical door closers located on the outside of the doors facing the patient common areas:
i) Dayroom Patio Exit Doors.
ii) Laundry Room Doors.

3) New Building Section 500-700 observed in the 600 unit.
A) The following rooms revealed overhead mechanical door closers located on the inside of the doors where patients voluntarily spent time.
i) Quiet Room Doors.

On 02/16/2021 in the late afternoon, observation of the 600 Adult Dayroom revealed an unsupervised patient watching television. The Director of Plant Operations present indicated facility staff could observe the patient without necessarily being present in the Dayroom. The patient was observed for a few minutes without staff present or in the line of sight from the nursing station.

On 02/16/2021 at 2:00 PM, the Director of Plant Operations revealed an environmental risk assessment had been completed by the facility in January 2021 and was provided for review. The environmental risk assessment identified the use of exposed door hinges of Nutrition Room Doors as a ligature risk for each unit; however, the other items noted were not identified. The Director of Plant Operations indicated corporate felt it was not necessary to replace the exposed tri-hinged doors and non-ligature handles in non-patient rooms or supervised areas. The overhead mechanical door closers identified were acknowledged as a ligature risk, but again were dismissed from being high risk because they were in supervised areas (Dayroom Patio Doors) or required an employee with a key to gain access (Laundry Room Doors and Quiet Room Doors).

On 02/16/2021 at 2:20 PM, the Director of Risk Management indicated employees would probably not be required to continuously observe patients who requested to use the quiet room.

On 02/16/2021 at 2:40 PM, a Unit Manager indicated overstimulated patients used the Quiet Rooms upon request to nurses. The stay inside might last 15 minutes or so. There was usually someone nearby when a patient was inside.

On 02/18/2021 at 11:14 AM with the Chief Executive Officer (via phone) and Director of Risk Management present, revealed the overhead mechanical door closer identified were acknowledged as a potential risk. A patient could be alone in the quiet room if the door were closed with the overhead mechanical door closer inside as well. The facility's only response to addressing the risk was continuous observation, which was not verbalized as a requirement in previous interviews. The facility lacked documented evidence of a policy or guideline governing supervision in the event a patient requested to use the quiet room.

On 02/18/2021 at 11:30 AM, the Chief Executive Officer acknowledged door hardware replacement was identified as an essential priority in the capital budget plan for 2021. The rationale for the budget request was a requirement supported by the facility's accrediting organization. The Chief Executive Officer acknowledged the door hardware replacement was synonymous with door issues previously discussed, but the facility was unsure when the item would be addressed.

Based on interview, record review, and document review the facility failed to ensure the process regarding an incident of alleged sexual acting out between two adolescent patients (Patient (P) 1 and P2) was followed and failed to identify, investigate, analyze, and implement preventive actions involving peer to peer incidents involving assault and sexual familiarity allegations for 8 of 30 sampled patients (Patient 1, 2, 10, 11, 12)

Findings include:

The facility policy titled Sexually Acting Out (SAO)with an effective date of 05/31/2019, documented the following:
1.2 No patient shall participate in any sexual acts while undergoing treatment, regardless of age or perceived consent. Allegations, including reports of any sexual intimidation or abuse, will be promptly investigated and treatment will be adjusted, as necessary.
4.6 If any incident involving a report or evidence of sexual activity occurs, the hospital must investigate and determine if the occurrence involved patient-perceived consensual activity (adult patients only), coerced, or abusive behavior.
4.7 For alleged incident involving sexual behavior, the following procedure must be utilized:
(a) The staff person who received any information regarding alleged inappropriate sexual behavior will report the incident immediately to the Charge Nurse. The Charge Nurse will immediately notify the Nursing Supervisor.
(b) The Charge Nurse and / or Nursing Supervisor will interview the patients involved in the alleged sexual behavior. This must be done individually. If clinically appropriate, a follow-up interview can be conducted with all involved parties. Specific questions must be asked to help determine the exact behavior involved whether or not it was voluntary or coerced.
(c) The Charge Nurse or Nursing Supervisor will notify the Director of Risk Management / Performance Improvement, the Chief Nursing Officer, the Director of Clinical Services and / or assigned therapist, the Attending Psychiatrist (of each patient involved, if indicated), the Medical Director, and the Chief Executive Officer.
(d) The Attending Physician, or designee, will notify the family or guardian, if known.
(e) The incident will be documented in the patient's medical record, referring only to the incident as "alleged sexual behavior."
(f) An occurrence or incident report is completed.
(g) In the case of sexual behavior involving a minor, Child Protective Services (CPS) must be notified. Document your action in a progress note. Notify the parent (or guardian / case worker, as applicable) and document this communication.
(j) The identified Nursing Supervisor and / or therapist will follow-up with treatment planning accordingly.

The facility's policy titled Incident Reporting last revised on 12/02/2013, documented the following:
- In accordance with its risk management program, (the hospital) will provide an effective process to guide reporting of incidents, including identification of the type of incident such as critical or sentinel events.
- The Director of Quality and Risk Management and the Chief Nursing Officer were responsible for the investigation of incidents which occur in the hospital.
- The incident repot must be completed immediately following an event.
- The following categories not limited to, are reported on the incident report form: assaultive behavior to peer, boundary violation with peer, and sexual familiarity with peer.
- The purpose of the report is to collect information and document facts concerning the incident, provide a means of evaluating why the incident occurred to avoid similar, future occurrences. Accuracy, legibility, and confidentiality are integral to the incident reporting process as it is essential to maintaining the integrity of the Risk Management Program.
- The incident report form is to be completed as soon as possible after an adverse event and turned in to the department director/supervisor before the end of shift in which the incident occurred.
- The individual completing the form should describe what was seen or statement heard, being careful to state as fact only those things of which they have first-hand knowledge. A list of all witnesses to the incident should be included whether they are an employee or some other person with first-hand knowledge.
- Once the report has been completed, it will then be sent to the appropriate department manager or supervisor for review and initial investigation of the incident. The department manager or supervisor will then sign the report and forward it to the Risk Manager who collects and maintains tis data within 24 hours of the incident.

1) An incident report dated 02/01/2021, documented Patient 1's (an adolescent patient) legal guardian arrived at the facility in the evening on 02/01/2020 very emotional and crying. The report documented the legal guardian was contacted by a staff member to inform the guardian Patient 1 (P1) had performed oral sex on P2, and P1 should have not had a roommate.

The report dated 02/01/2021, documented P1 was pressured by P2, to perform fellatio (oral sex). Initially P1 had agreed but decided to no longer perform the sexual act. P1 and P2 then had a disagreement and P1 verbalized wanting a room change. The report lacked documented evidence the appropriate agencies, including Child Protective Services was notified of the incident.

On 02/05/2021 at 4:09 PM, a charge nurse indicated P1 reported to a mental health technician (MHT) P1 was pressured to perform oral sex on P2. The charge nurse indicated P1 reported P1 initially agreed to perform oral sex on P2, but then told P2 they no longer wanted to perform the act and they got into a verbal argument. The charge nurse indicated the incident was reported to the house supervisor and an incident report was completed. The charge nurse revealed all incidents were reported to the house supervisor who was responsible for completing the incident report and submitting the report to the Director of Risk Management.

On 02/10/2021 at 2:55 PM, the Director of Risk Management indicated receiving a report on 02/02/2021 involving P1's legal guardian. The Director of Risk Management indicated the report involved a legal guardian and not a patient which led to the report being over-looked. The Director of Risk Management indicated not learning of the incident until 02/03/2021. The Director of Risk Management verbalized the house supervisor did not submit the report within 24 hours per the facility's policy.

On 02/11/2021 at 11:39 AM, the house supervisor acknowledged receiving the report from the charge nurse. The house supervisor confirmed the report was not turned in to the Director of Risk Management within 24 hours. The house supervisor indicated incident reports should have been completed and submitted to the Director of Risk Management within 24 hours.

On 02/11/2021 at 2:05 PM, the Chief Nursing Officer (CNO) acknowledged the incident was not thoroughly investigated. The CNO indicated this was because report was not submitted to the Director of Risk Management within 24 hours of the incident for review.

On 02/16/2021 at 2:28 PM, the Director of Risk Management indicated following an incident involving alleged sexual abuse the appropriate agencies including law enforcement and Child Protective Services (CPS) should be notified. The Director of Risk Management confirmed CPS and law enforcement agencies were not notified following the incident between P1 and P2.


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2) Patient 10 was admitted on 01/23/2021 with a diagnosis of disruptive mood dysregulation disorder.

On 01/31/2021 at 6:30 PM, an incident report documented the patient was involved in a sexual familiarity (sexual acting out) incident with another patient. There was no corresponding incident report identifying the other patient. The Director of Risk Management signed off the incident as no further action needed.

On 02/10/2021 at 4:00 PM, the Director of Risk Management was unable to identify the other patient involved in the incident.

On 02/11/2021 at 2:15 PM, the Director of Risk Management indicated Patient 10 denied the incident on 02/01/2021. The update was not included on the original incident report.

3) Patient 11 was admitted on 01/09/2021 with a diagnosis of major depressive disorder with recurrent severe psychotic symptoms.

On 01/10/2021 at 10:00 AM, a Registered Nurse documented Patient 11 was hit by another patient.

On 01/10/2021 at 8:50 PM, a Registered Nurse documented incident report and police contact for an assault. There was no documented evidence of the type of assault or the identified peer. There was no corresponding incident report identifying the other patient involved. The Director of Risk Management signed off the incident as no further action needed.

On 02/11/2021 at 2:15 PM, the Director of Risk Management indicated there was no corresponding incident report identifying the other patient involved in the incident, and the facility was unable to identify the patient who hit Patient 11.

4) Patient 12 was admitted on 01/11/2021 with a diagnosis of major depressive disorder.

On 01/17/2021 at 5:00 PM, an incident report documented the patient flashed peers.
There was no documented evidence identifying the peers. There was no corresponding incident report identifying the other patients involved in the incident. The Director of Risk Management signed off the incident as no further action needed.

On 02/11/2021 at 2:15 PM, the Director of Risk Management indicated there was no corresponding incident report identifying the other patients involved in the incident, and the facility was unable to identify the other patients.

5) The facility provided an incident report dated 01/20/2021, which documented a patient had pseudo seizures. There was no documented evidence identifying the patient. The Director of Risk Management signed off the incident as no further action needed.

6) The facility provided an incident report dated 01/31/2021, which documented a peer-to-peer physical altercation. There was no documented evidence identifying either patient. The Director of Risk Management signed off the incident as no further action needed.

On 02/11/2021 at 2:15 PM, the Director of Risk Management was unable to identify unknown Patient #35 and Patient #36.

On 02/18/2021 at 10:00 AM, the Chief Executive Officer and the Director of Risk Management were interviewed regarding the facility's Sexual Acting Out policy, last reviewed 07/2020) failing to identify and establish a peer-to-peer sexual familiarity incidents for minor's protocol.

The facility failed to follow its Incident Reporting policy (last revised 05/31/2019) by:
1. failing to report occurrences by the end of the shift in which the event occurred (Patient 11).
2. failing to have the employee who witnessed the event or discovered the event complete the incident report (Patient 11).
3. failing to document basic facts concerning incidents.
4. failing to complete and turn in incident reports to the department director/supervisor before the end of a shift in which the event occurred (Patient 1 and 2).

Based on record review, interview and policy review, the facility failed to conduct/document a one-hour face to face assessment for 2 of 30 patients (Patient 7 and 16).

Findings include:

1) Patient 7 was admitted on 11/27/2020 with a diagnosis of unspecified psychosis.

On 11/27/2020 at 8:25 PM, a physician ordered physical intervention (no specific intervention documented) and locked seclusion.

At 8:20 PM, a physician ordered emergency medication of 2 milligrams Ativan, 50 milligrams Benadryl and 5 milligrams Haldol, which a nurse administered intramuscularly at 8:30 PM.

The medical record documented the patient was physically restrained and then placed in locked seclusion for a total of 25 minutes, ending at 8:35 PM.

On the One Hour Face to Face Assessment for seclusion and restraint, the medical record documented the patient mumbled during sleep. The unknown assessor created a separate box showing the patient was in bed sleeping during the "assessment".

The assessment form lacked documented evidence sections 13-17 were completed, which include the Registered Nurse and Physician signoffs. There was no documented evidence who the assessor was or when that individual attempted to do the assessment.

On 02/10/2021 at 3:10 PM, the Chief Nursing Officer and a Unit Manager indicated Face to Face Assessments had to be completed after seclusion/restraint episodes.

On 02/18/2021 in the afternoon, the Chief Executive Officer acknowledged the facility would want to know who the face-to-face assessor was, and it was probably not acceptable for an assessor to document patient sleeping for a one-hour face to face assessment after receiving emergency medication.

2) Patient 16 was admitted on 12/17/2020 with a diagnosis of bipolar disorder.

On 12/17/2020 at 8:36 PM, a physician ordered physical intervention.

At 8:36 PM, a physician ordered emergency medication of 10 milligrams Zyprexa, which a nurse administered intramuscularly at 8:45 PM.

The medical record documented the patient was physically restrained and then administered emergency medication between 8:45-46 PM.

On the One Hour Face to Face Assessment for seclusion and restraint, the Registered Nurse documented the time of the assessment in 2 different areas on the form: 10:45 PM, which was 2 hours after the physical restraint and emergency medication administration.

On 02/10/2021 at 3:10 PM, the Chief Nursing Officer and a Unit Manager indicated Face to Face Assessments had to be completed after seclusion/restraint episodes.

On 02/18/2021 in the afternoon, the Chief Executive Officer acknowledged the facility would expect nurses to conduct/document the assessments an hour post seclusion/restraint/medication administration.

The facility Seclusion, Restraint, Physical Hold policy (last reviewed 07/2020) page 4, part L:

The physician or qualified Registered Nurse shall perform a face-to-face evaluation within one (1) hour of the initiation of the episode/intervention regardless of the duration of the seclusion and/or restraint.

The facility Seclusion, Restraint, Physical Hold policy (last reviewed 07/2020) page 4, part G:

If physical restraint is indicated, two (2) staff must participate in the physical hold application. 1. If the physical restraint/hold is on a child patient, one staff may implement the hold while a second staff serves as a witness to monitor patient and staff safety for the duration of the hold.

Patient 7's Seclusion/Restraint Report lacked documented evidence 2 staff members participated in physical restraint intervention between 8:10-13 PM as noted in the report.

Patient 16's Seclusion/Restraint Report contained a narrative highlighting a Mental Health and Registered Nurse intervened, but the space in the report for indicating the number of staff involved in restraining the patient was left blank.

Based on document review and interview, the facility failed to implement and maintain an effective ongoing, hospital wide, data driven quality assessment and performance improvement plan (QAPI), that reflected the complexity of the hospital's organization and services involving all hospital departments and contracted services. Specifically, the hospital failed to:

1) Specify the frequency and detail of data collection (See Tag A 0273).

2) Identify actions aimed at performance improvement, to demonstrate at what intervals actions were implemented, to measure the success after actions were implemented and to track performance to ensure improvements were sustained (See Tag A 0283).

3) Consistently maintain a program to identify, investigate, analyze and implement preventive actions regarding incidents affecting patient safety and quality of care, and ensure information was documented completely and accurately reported to identify trends (See Tag A 0286).

4) Identify actions aimed at performance improvement, to demonstrate at what intervals actions were implemented, to measure the success after actions were implemented and to track performance to ensure improvements were sustained and choose and conduct annual performance improvement projects (See Tag A 0297).

5) Ensure quality assessment and performance improvement efforts addressed a previously identified priority for improved quality of care and patient safety (See Tag A 0309).

The cumulative effect of these systemic practices resulted in the failure to ensure an effective ongoing, hospital wide, data driven quality assessment and performance improvement plan implementation in the delivery of care to patients.

Based on document review and interview, the Governing Body failed to specify the frequency and detail of data collection.

Findings include:

On 02/18/2021 from 10:00 AM to Noon, facility documents provided were reviewed, including Bylaws of The Board of Trustees (undated), Organizational Performance Improvement Plan: Performance Improvement (last reviewed 04/2020), PI/Risk Annual Review 2020, Medical Staff Bylaws (October 4, 2019) and Medical Staff Rules and Regulations (09/11/2019).

On 02/18/2021 at 10:00 AM, the Chief Executive Officer and the Director of Performance Improvement were unable to locate (within the governing documents provided) and articulate the Governing Body's stance on frequency and detail of data collection in reference to the Quality Assurance Performance Improvement Program.

Based on clinical record review, document review and interview, the facility failed to identify actions aimed at performance improvement, to demonstrate at what intervals actions were implemented, to measure the success after actions were implemented and to track performance to ensure improvements were sustained.

Findings include:

On 02/18/2021 at 11:30 AM, the Director of Performance Improvement provided a document entitled Strategic Plan 2021 and Review 2020. The document highlighted incident prevention and enhanced investigation and sexual acting out precautions as opportunities for 2021 improved performance. To date, the Chief Executive Officer indicated a plan including those opportunities was a work in progress.

On 02/18/2021 in the morning, the Director of Performance Improvement provided several various documents displaying data collection, including Governing Body Meeting Minutes, Quality Meeting Minutes, Assaultive Behaviors per unit per shift, Quality Metric Report, Reducing Physical Restraint/Holds, Restraint/Seclusion, Sexual Acting Out Incidents per patients with precautions and Total Adverse Drug Reactions.

Except for the official performance improvement project: Reducing Physical Restraint/Holds, none of the aforementioned documents showed what actions were recommended and taken and at what intervals to improve the facility's performance. The Director of Performance Improvement initiated the performance improvement project on 09/20/2019, and verbalized an 18-month time frame, which would bring the project to an end 03/20/2021. There was no documentation showing the facility acted, modified its action, or evaluated actions taken or modified at any interval to explain its data trends, evaluate progress, and ensure sustained improvements.

On 02/18/2021 at 11:14 AM, the Director of Performance Improvement acknowledged the facility needed to improve its quality documentation to demonstrate the correlation between the data collected, the trends demonstrated, the actions taken, and improvements made and sustained or recommendations for modifications of actions if improvements were not made and sustained.

Based on document review and interview, the facility failed to identify actions aimed at performance improvement, to demonstrate at what intervals actions were implemented, to measure the success after actions were implemented and to track performance to ensure improvements were sustained.

Findings include:

On 02/18/2021 at 11:30 AM, the Director of Performance Improvement provided a document entitled Strategic Plan 2021 and Review 2020. The document highlighted incident prevention and enhanced investigation and sexual acting out precautions as opportunities for 2021 improved performance. To date, the Chief Executive Officer indicated a plan including those opportunities was a work in progress.

On 02/18/2021 in the morning, the Director of Performance Improvement provided several various documents displaying data collection, including Governing Body Meeting Minutes, Quality Meeting Minutes, Assaultive Behaviors per unit per shift, Quality Metric Report, Reducing Physical Restraint/Holds, Restraint/Seclusion, Sexual Acting Out Incidents per patients with precautions and Total Adverse Drug Reactions.

Except for the official performance improvement project: Reducing Physical Restraint/Holds, none of the aforementioned documents showed what actions were recommended and taken and at what intervals to improve the facility's performance. The Director of Performance Improvement initiated the performance improvement project on 09/20/2019, and verbalized an 18-month time frame, which would bring the project to an end 03/20/2021. There was no documentation showing the facility acted, modified its action, or evaluated actions taken or modified at any interval to explain its data trends, evaluate progress, and ensure sustained improvements.

On 02/18/2021 at 11:14 AM, the Director of Performance Improvement acknowledged the facility needed to improve its quality documentation to demonstrate the correlation between its data collected, the trends demonstrated, the actions taken, and improvements made and sustained or recommendations for modifications of actions if improvements were not made and sustained. The facility did not conduct annual performance improvement projects.

A document entitled Performance Improvement Priority Criteria Grid was provided without any correlating performance improvement example.

Based on document review and interview, the facility failed to ensure all improvement actions were evaluated and failed to demonstrate the determination of the number of distinct improvement projects was conducted annually.

Findings include:

A review of the facility's Quality Assurance and Performance Improvement Plan revealed the facility collected data from various sources, including Governing Body Meeting Minutes, Quality Meeting Minutes, Assaultive Behaviors per unit per shift, Quality Metric Report, Reducing Physical Restraint/Holds, Restraint/Seclusion, Sexual Acting Out Incidents per patients with precautions and Total Adverse Drug Reactions.

There was no documentation showing the facility acted, modified its action, or evaluated actions taken or modified at any interval to explain its data trends, evaluate progress, and ensure sustained improvements.

On 02/18/2021 at 11:14 AM, the Director of Performance Improvement acknowledged the facility needed to improve its quality documentation to demonstrate the correlation between its data collected, the trends demonstrated, the actions taken, and improvements made and sustained or recommendations for modifications of actions if improvements were not made and sustained.

The facility failed to identify actions aimed at performance improvement, to demonstrate at what intervals actions were implemented, to measure the success after actions were implemented and to track performance to ensure improvements were sustained.

The facility did not conduct annual performance improvement projects aside from monitoring and reviewing its quality monitors.

On 02/18/2021 at 11:14 AM, the Chief Executive Officer and the Director of Performance Improvement acknowledged the facility failed to conduct annual improvement projects.

Based on record review and interview, the facility failed to document therapeutic follow-up after sexual acting out incident for 2 out of 30 sampled residents (Patient 3 and Patient 4).

Findings include:

Patient 3 was admitted on 01/30/2021 with a diagnosis of major depressive disorder without psychotic features.

Patient 4 was admitted on 01/28/2021 with a diagnosis of disruptive mood dysregulation disorder.

On 01/31/2021 at 9:35 PM, a Registered Nurse became aware of a sexual familiarity (sexual acting out) incident between Patient 3 and Patient 4. The patients were roommates.

On 01/31/2021, an incident report was completed for each patient by the Registered Nurse who was the first nurse informed.

On 02/02/2021, a Social Work Intern notified Child Protective Services of the incident and an adverse parental reaction upon notification. The Social Work Intern documented the patient was saddened by the parental reaction.

On 02/04/2021 at 10:45 AM, a Registered Nurse documented the patient self-harmed and tried to elope and was placed on 1:1 observation.

On 02/10/2021 at 4:00 PM, the Director of Risk Management was interviewed about therapeutic follow-up after the incident. The Director of Risk Management signed off the incident as no further action needed. Both patients had an updated treatment plan for sexual acting out, but both patients lacked documented evidence of therapeutic follow-up. The Director of Risk Management acknowledged there was no documented investigation beyond the incident reports. There was no evidence video cameras were reviewed to ensure supervision took place.

On 02/11/2021 at 8:24 AM, a Social Worker documented multiple interventions of therapeutic follow-up with a late entry for 02/01/2021.

On 02/11/2021 at 2:15 PM, a Registered Nurse and the Director of Risk Management acknowledged there was no documented evidence of any therapeutic follow-up for Patient 4 who was discharged on 02/03/2021.