HospitalInspections.org

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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation it was determined that the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all Conditions of Participation.

The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Condition Tag A-115 under CFR 482.13 - CoP: Patient's Rights that reflects that policies, procedures, and systems for the provision of safe care were not clear, complete, or implemented (Tag A-144); that identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur (Tag A-145); and that response to, investigation of, and follow-up to patient grievances related to safe care were not clear, complete or timely (Tag A-118).

2. Refer to the findings cited at Condition Tag A-263 under CFR 482.21 - CoP: Quality Assessment and Performance Improvement that reflects additionally that the hospital failed to ensure that incidents and adverse patient events were clearly identified, tracked, investigated and analyzed, and that corrective actions were planned and implemented to prevent recurrence of those, to promote learning throughout the hospital, and to establish clear expectations for patient safety. Further, there was no process for systematic identification and tracking of negative outcomes to patients that involved patient injuries, ED visits, and hospitalizations in relation to incidents (Tag A-286).

3. Refer to the findings cited at Condition Tag A-385 under CFR 482.23 - CoP: Nursing Services that reflects additionally that the RN failed to supervise the nursing care for each patient to ensure the provision of safe and appropriate care that included prevention of patient to patient altercations and injuries, and sexual contact. RN failures included, but were not limited to: failure to ensure nursing staff appropriately supervised and observed patients to prevent incidents, failure to ensure investigations of incidents were complete and corrective actions were taken that prevented recurrence, and failure to ensure that response to grievances regarding patient safety were timely and appropriate (Tag A-395).
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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation, it was determined that the hospital failed to ensure each patient's right to provision of care in a safe setting, the right to freedom from all forms of abuse and neglect, and the right to prompt and appropriate response to grievances. Those failures resulted in actual and potential physical and psychological harm to patients.

The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A-144 under CFR 482.13(c)(2) - Standard: Privacy and Safety that reflects that policies, procedures, and systems for the provision of safe care were not clear, complete, or implemented and resulted in the following:
* Failure to prevent patient to patient physical altercations and injuries.
* Failure to prevent patient to patient sexual contact and sexual assault.
* Failure to ensure staff carried out assigned duties related to all aspects of observation and supervision of patients.
* Failure to ensure TCPs and ES orders were followed.
* Failure to ensure door security and situational awareness practices that ensured patient safety.
* Failure to ensure all high risk patient care areas monitored by 24/7 security staff video monitoring were fully observable and did not include blind spots.
* Failure to ensure staff practices were in accordance with, and supported by, written and approved P&Ps for the following:
- Condom distribution to patients.
- Processing and tracking police reports filed on behalf of patients who had been assaulted by other patients.
- Security staff "access control" video monitoring
* Failure to ensure Code Blue responses were organized, appropriate, and documented.
* Failure to ensure staff training related to patient safety was current.

2. Refer to the findings cited at Tag A-145 under CFR 482.13(c)(3) - Standard: Privacy and Safety that reflects that identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur.

3. Refer to the findings cited at Tag A-118 under CFR 482.13(a)(2) - Standard: Patient Grievances that reflects that response to, investigation of, and follow-up to patient grievances related to safe care were not clear, complete or timely.
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Based on review of grievance documentation for 1 of 1 patient reviewed for grievances (Patient 11) it was determined that the hospital failed to ensure patients' rights were recognized, protected, and promoted in regards to patient grievances. Response to, investigation of, and follow-up to patient grievances were not clear, complete or timely.

Findings include:

1. Review of patient grievance documentation filed by Patient 11 revealed the following:

1.a. A "Patient Grievance" form was signed and dated by Patient 11 on 08/13/2023 at 1932. At the top of the form Patient 11 had written in large letters "*Emergent*." The grievance was described as "[Patient 10] is continuing to provoke and instigate myself and other patients. [MHT] witnessed [Patient 10] provoking me as I walked back onto the unit at approx. 6:02 pm. Just now [Patient 10] lunged at [another patient] with a raised fist attempting to intiate [sic] a violent interaction. Staff unwillingness to address this issue is putting staff and patient [sic] in harm's way ... emergency transfer [Patient 10] to another unit." The "For Staff use only" box reflected the "Date Received" was 08/14/2023.

The "Grievance Committee Response" reflected the "Date of Grievance Review" was 08/21/2023 and the response was "attached" to the form. The undated attachment contained one paragraph that reflected "IDT is aware of the issues that are happening between you and the described peer and have taken the necessary follow up. All follow up will be confidential to protect patient privacy. In the future please encourage peers who are having issues to reach out to staff or complete their own grievances so that we may follow up with them."

1.b. A second "Patient Grievance" form was signed and dated by Patient 11 on 08/13/2023 with no time. The grievance was described as "[Patient 10] has been increasing [their] aggressive behavior toward me and other patients. Flicking [another patient] and pushing through people. Just now in East TV Room I was grabbing a spoon after receiving my meal and [Patient 10] walked in from the air court and threw [their] shoulder into me ... Move [Patient 10] to another ward, My safety and the safety of the other patients is at risk." The "For Staff use only" box reflected the "Date Received" was 08/14/2023.

The "Grievance Committee Response" reflected the "Date of Grievance Review" was 08/21/2023 and the response was "attached" to the form. The undated attachment was identical to the one described in the grievance above.

1.c. A third "Patient Grievance" form was signed and dated by Patient 11 on 08/16/2023 at 0950. The grievance was described as "I filed 2 grievances within the last 72 hours about [Patent 10's] continual aggressive behavior and [on 08/15/2023] in the milieu of Tree 1 [Patient 10] violently assaulted me by close fist strike to the left temple of my head. When I returned from the E.R. at approx 7 pm [Patient 10] was already out of seclusion. This morning in East Plaza at approx 9:15 [Patient 10] came out and began to attempt an altercation from afar telling staff '[Patient 11] can't be within 10 feet of me.' This is systemic supported abuse and violence." The "For Staff use only" box reflected the "Date Received" was 08/17/2023.

The "Grievance Committee Response" reflected the "Date of Grievance Review" was 08/29/2023 and the response was "The treatment team has reviewed the issues and resolved it. The two patients currently do not reside on the same unit. The IDT may not discuss patient treatment with you."

1.d. The fourth related "Patient Grievance" form was signed and dated by Patient 11 on 08/22/2023 at 1555. The grievance was described as "On, or about, August 15th at approximately 3:30PM I was assaulted by [Patient 10]. I do not believe the report has been forwarded to law enforcement and/or the Marion County DA for prosecution. The the [sic] documentation and proper reporting of this crime needs to be done immediately. If this violent assault is not reported, investigated, and charges are not filed I will hold each, and every, member of the Treatment Team, P.E.T, and all other relevant parties accountable both personally and professionally to the harm inflicted by this neglect. This will include each, and every licensee, who is charged with my care and treatment as a public servant of Oregon ... I still have not spoken with a detective, OSH security, or even been approached by a therapist to talk about, decompress, or process this attack for which I am the victim." The "For Staff use only" box reflected the "Date Received" was 08/23/2023.

The "Grievance Committee Response" reflected the "Date of Grievance Review" was 08/29/2023 and the response was "On 8/29 management called security to inquire about the police report regarding the assault. The police report was submitted by the unit on 8/15/23. Security stated that it had not yet been sent out to OSP for review. The detective who usually picks them up missed a week due to other obligations. It was stated the [detective] should return this week and will receive it by end of week sometime. Management asked if security was planning to follow up and they stated they don't typically check in after each report unless a patient requests it specifically as there are too many to keep up with at times according to security. Management has reach out to the IDT and the therapist that you are currently working with on 8/29 and let them know you would appreciate meeting to help you process/decompress regarding the incident."

2. In response to surveyor request for tracking information related to the police report that was filed, an internal OSH email, with an attachment, sent from the DOS dated 03/13/2024 at 0807 was provided. It included the following information: "Like most of our stuff we don't have a written protocol but the process is described below ... This was closed out by [detective name] without being assigned a case number due to not meeting prosecutorial guidelines. At the time the case was received, the unofficial protocol we were using was ... Incident occurs prompting a report made to OSP ... [unit staff] fills out an OSP reporting form and submits it to the Security Management email box. Form is received by Security and printed ... Printed form is maintained by Security Investigator until OSP makes a visit to OSH to collect these forms ... When OSP detectives come to OSH, the printed forms are handed over to the detectives ..."

3.a. The document attached to the 03/13/2024 email from the DOS was titled "Oregon State Hospital - Security Department Reporting of a crime" was reviewed. It included the following information:
* "Date of Incident: 08/15/2023"
* "Reported by: [NM identified in the incident report]"
* "Date/Time: 08/15/2023 at 1530"
* "Victim of Crime: [Patient 11]"
* "Suspect of Crime: [Patient 10]"
* "Summary of Incident: [Patient 11] was speaking to the Unit Administrator ... [Patient 10] walked up ... swung around the staff and punched [Patient 11] in the left eye ... eye immediately began to swell, become bruised ..."
* "Signature of person completing this report" that was followed by a signature.

The lower part of the form had two sections, one of which was for "Security Use Only" which contained the following:
* "Date Submitted:"
* "Submitting Manager:"
* "Reporting Manager Signature:"
Those fields were blank and contained no entries.

The last section of the form for "Dispatch Use Only" contained the following:
* "Date Received:"
* "Case Number:"
Those fields were blank and contained no entries.

3.b. As of the date of the survey there was no documentation to reflect when that report had been received by the Security Department and whether or when it had been submitted to OSP. Nor was there evidence that Patient 11 had been updated as to the status of the report to OSP after the 08/29/2023 "Grievance Committee Response" for the 08/22/2023 grievance Patient 11 had filed.

4. Refer also to Finding 3 for Patient 11 cited at Tag A-144 under CFR 482.13(c)(2) - Standard: Privacy and Safety that reflects Patient 11 was assaulted and injured by Patient 10 on 08/15/2023 after submission of their grievances related to concerns about safety for themselves and others.
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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of P&Ps and review of other documentation it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient's right to receive care in a safe setting. The hospital's failures to provide adequate observation, supervision and other preventive measures and precautions created an unsafe EOC that resulted in actual and potential physical, mental or emotional harm to patients. Deficient practices included:
* Failure to prevent patient to patient physical altercations and injuries.
* Failure to prevent patient to patient sexual contact and sexual assault.
* Failure to ensure staff carried out assigned duties related to all aspects of observation and supervision of patients.
* Failure to ensure TCPs and ES orders were followed.
* Failure to ensure door security and situational awareness practices that ensured patient safety.
* Failure to ensure all high risk patient care areas monitored by 24/7 security staff video monitoring were fully observable and did not include blind spots.
* Failure to ensure staff practices were in accordance with, and supported by, written and approved P&Ps for the following:
- Condom distribution to patients.
- Processing and tracking police reports filed on behalf of patients who had been assaulted by other patients.
- Security staff "access control" video monitoring
* Failure to ensure Code Blue responses were organized, appropriate, and documented.
* Failure to ensure staff training related to patient safety was current.
* Failure to ensure incident investigations were clear and complete to identify causes and to plan and implement corrective actions to prevent recurrence for the affected patient and other patients.

Findings include:

1.a. The P&P titled "Continuous Rounds, Census, and Milieu (RCM) Management" dated as 05/01/2023 was reviewed and included the following:
* "Nursing staff must perform continuous rounds focused on census and milieu management (RCM) at all times on each unit when patients are present."
* "RCM rounds and related verifications and observations are documented on the Unit Patient Census and Status Flowsheet, also known as the 'RCM Flowsheet.'"
* "The oncoming RN (or Lead LPN) must note each patient's status next to the patient's name on the RCM Flowsheet using the 'Daily Clinical Screening Status' codes found on the flowsheet."
* "For patients on Enhanced Supervision, both the type and level of supervision must be noted."
* The RN (or Lead LPN) must verify that RCM duties are being continuously and accurately performed and documented by observing the RCM's actions and reviewing the RCM Flowsheet at least twice per shift."
* "RCM staff must maintain a continuous presence in the milieu, walking each hall and varying their routes and times in order to prevent any identifiable patterns. This activity must occur on all shifts."
* "RCM staff must not station themselves in the Bubble, at the Hub, or other unit location and must only access these areas for short periods of time (less than 5 minutes) to complete specific RCM-related tasks."
* "When not actively completing RCM-related observation rounds, RCM staff must remain in the milieu, therapeutically interacting with patients, facilitating positive social interactions, providing assistance to patients and co-workers, and intervening early to defuse tense or potentially dangerous situations."
* "RCM staff must verify that patients are not engaging in unsafe or unlawful behavior and must intervene if such behavior is noted. This includes but is not limited to: monitoring for potentially aggressive behaviors to staff or peers and intervening ... monitoring for potential sexual contact between patients and intervening ..."
* "RCM staff must verify the presence and viability of each patient on the unit at least once per hour, at random intervals (within 10 minutes before or after the top of each hour)."
* "RCM staff must maintain continuous possession of the RCM clipboard, flowsheet(s), and a two-way radio ...

1.b. The P&P titled "Procedure B: Environment Checks" dated as 06/07/2023 was reviewed and included the following:
* "To protect the safety of patients and staff, OSH staff are responsible to maintain the cleanliness and sanitation of patient care areas, including patient rooms. Environment checks may be conducted as often as necessary, and frequency may change depending on patient, unit, or treatment mall need ... Staff are encouraged to involve patients in maintaining cleanliness and sanitation of their rooms whenever possible ..."
* "OSH staff designated in these procedures are authorized to: Enter a patient's room to remove food and fluids (excluding water) ... Enter a patient's room to remove and dispose of garbage; Check to ensure state-issued bedding is clean ... Ensure dirty clothing is in a covered laundry basket ... During rounding or other environmental monitoring, dispose of patient sundry items which are unlabeled or past the listed expiration date ..."
* "Designated staff include; Nurses, including contracted nurse staff; Mental Health Technicians (MHT); Interdisciplinary team members (IDT); Clinical support staff ... Environmental Services staff."

1.c. The P&P titled "Enhanced Supervision" dated as 11/09/2017 was reviewed and included the following:
* "Oregon State Hospital (OSH) strives to promote and maintain the safety, health, and wellbeing of patients, in part by minimizing the occurrence of aggressive, suicidal, or self-destructive behavior. While persons who engage in such behavior often require a targeted increase in therapeutic interventions, which may include the increased presence of staff, this need must be weighed against the intrusion and isolation that such interventions may create. The least intrusive means of providing effective treatment must be used, with the goal of helping patients regain the ability to maintain safety toward self and others without the need for an increased staff presence."
* "The psychiatrist or psychiatric mental health nurse practitioner (PMHNP), using clinical input from other members of the interdisciplinary treatment team (IDT), must determine the type and level of enhanced supervision necessary to safeguard patients and staff. The IDT must collaboratively plan and implement
therapeutic interventions to address dangerous, self-destructive, and/or suicidal behavior, or needs associated with medical illness."
* "The type of enhanced supervision indicates the primary behavior or condition that warrants more careful monitoring and/or intervention ... 'Behavior supervision' may be ordered to provide enhanced monitoring and intervention for patients who are at risk of engaging in dangerous behaviors. These behaviors may include harming others, elopement, sexual contact with peers, etc."
* "The level of enhanced supervision describes the frequency with which staff make contact with the patient being supervised. 1. "Unobtrusive supervision" means a staff member must be assigned to be aware of a patient's location and activities at all times, and have visual and, if the patient is awake and able, verbal contact with the patient at least three (3) times per hour, at irregular intervals, never more than 30 minutes apart. 2. "Close supervision" means a staff member must be assigned to be aware of a patient ' s location and activities at all times, and to have visual and, if the patient is awake and able, verbal contact with the patient at least five (5) times per hour, at irregular intervals, never more than 15 minutes apart. 3. "1:1 supervision" means a staff member must be assigned to monitor a patient's location and activities at all times. The assigned staff member must maintain constant visual contact and consistent physical proximity, as well as verbal contact while the patient is awake, within parameters specified by the physician/PMHNP order and as described on the Intervention Card. The psychiatrist or PMHNP must specify additional parameters, as appropriate, in the order. Supervision at staff ratios greater than 1:1 (2:1, etc.) means the same as 1:1 except that more than one staff person is assigned to monitor the
patient.
* "'Intervention card' means the document which assists staff working with any patient on 1:1 supervision and some patients on lower-level supervision. The Intervention Card includes the supervision order, the behavior(s) of concern, the hypothesis about the underlying reason for the behavior(s), and recommended interventions."
* "Patient education handout means the document that is prepared for a patient who is placed on enhanced supervision. It provides information about the behavior of concern, any limitations on patient movement or property, and how often the patient can expect to interact with staff."
* "Initial Response to Acute Safety Concern, Any HCP who becomes aware of a patient's unsafe, unpredictable, or suicidal behavior or deterioration in medical condition must immediately take measures to verify the safety of patients and others, and notify the registered nurse or licensed practical nurse (nurse). The nurse must: 1. Immediately assess the patient and implement necessary safety and security measures. 2. If there is a need to assess for enhanced supervision, immediately contact the psychiatrist or PMHNP responsible for the patient's care, or the Psychiatrist On Duty (POD).
3. When necessary, authorize temporary supervision and implement required documentation until the psychiatrist or PMHNP is available. 4. Document in a progress note the assessment of the patient, the specific behavior(s) and/or medical condition(s) that prompted intervention, the method of intervention, the patient's response to the intervention, and the reason this specific intervention was used. 5. Determine if a search of the patient's person or property may be necessary ..."
* "Initiation of enhanced supervision ... Behavioral or suicide/self-harm supervision must be ordered only following face-to-face assessment by a psychiatrist or PMHNP. When a behavioral or suicide/self-harm supervision is needed, the psychiatrist or PMHNP must determine the primary type of supervision, the level of supervision, and any other relevant therapeutic interventions to be utilized. Findings must be documented in a progress note."
* "Reassessment of enhanced supervision a. If any patient is started on enhanced supervision by a covering psychiatrist or PMHNP, the patient must be reassessed by the attending psychiatrist or PMHNP the next business day, with the assessment documented in a progress note. b. If a patient remains on 1:1 or greater supervision for seven (7) consecutive days following the previous face-to-face assessment, the attending or covering psychiatrist or PMHNP or medical physician (in the case of medical supervision) must personally reassess the patient. This assessment must be documented in a progress note. If supervision
continues to be deemed appropriate, a rationale for ongoing supervision and interventions to help the patient become safe must be documented. c. If a patient is on 1:1 or greater supervision for 14 consecutive days, the attending or covering psychiatrist or PMHNP or medical physician (in the case of medical supervision) must inform the supervisor, Chief Medical Officer (CMO), or designee. This discussion must include review of the treatment provided to the patient, and the patient ' s progress toward safety. The practitioner must document this discussion (including rationale for ongoing supervision, alternatives considered, and any change in interventions provided based on supervisor review) in a progress note. This must be repeated at each consecutive 14 days the patient remains on 1:1 or greater supervision."
* "Discontinuation or change of enhanced supervision a. Only a psychiatrist or PMHNP may discontinue behavioral or suicide/selfharm supervision, and only following a face-to-face examination. This applies also to temporary supervision implemented by the nurse. b. Only a psychiatrist or PMHNP may change an order for behavioral or suicide/self-harm supervision. For significant changes (increase or decrease in level, change of type, or significant changes in parameters - for example, discontinuation of restriction to unit), a personal examination is required. For minor changes (for example, small modifications to allowed property), personal examination shall be at the discretion of the ordering practitioner."
* "Enhanced Supervision Orders 1. All orders for enhanced supervision must be entered into the electronic medical record, and must contain the following required elements:
a. Type of supervision
b. Level of supervision
c. Primary behavior(s) of concern
d. Time of day that supervision is required
e. Distance staff should remain from the patient while supervising
f. Allowed patient movement, particularly off unit
g. Allowed patient property"
* "The psychiatrist or PMHNP order may modify the default parameters for enhanced supervision.
a. Default parameters include:
i. Enhanced supervision level and type is around the clock (24 hours per day)
ii. Enhanced supervision is applicable in all areas, both on and off the unit
iii. A patient on enhanced supervision may attend and participate in most treatment mall classes and activities, cafeteria meals, quad time, visits, and religious services.
iv. Continuous visualization of the head, neck and hands of any patient on 1:1 or greater suicide/self-harm supervision is required, including during patient use of bathroom and shower.
v. For a patient on 1:1 or greater supervision, staff must remain approximately 2 arms' length from the patient (in the doorway, if the patient is in their bedroom)."

1.d. The P&P titled "Enhanced Supervision" dated as 02/28/2024 was reviewed and included the following:
* "This policy establishes guidelines for enhanced supervision at Oregon State Hospital (OSH). OSH strives to promote and maintain the safety, health, and wellbeing of patients by minimizing the occurrence of aggressive, suicidal, or self destructive behavior. This policy applies to all OSH staff."
* "The need for targeted increase in therapeutic intervention must be weighed against the intrusion and isolation that such interventions may create. The least intrusive means of providing effective treatment must be used, with the goal of helping patients regain the ability to maintain safety toward self and others without the need for an increased staff presence."
* "The psychiatrist or psychiatric mental health nurse practitioner (PMHNP), using clinical input from other members of the interdisciplinary treatment team (IDT), must determine the type and level of enhanced supervision necessary to safeguard patients and staff. The IDT must collaboratively plan and implement therapeutic interventions to address dangerous, self-destructive, and/or suicidal behavior, or needs associated with medical illness."
* "'Enhanced supervision' is careful monitoring and/or intervention characterized by types that indicate the primary behavior or condition and levels that describe the frequency with which staff contact the supervised patient ... 'Behavioral supervision' provides enhanced monitoring and intervention for patients who are at risk of engaging in dangerous behaviors including harming others, elopement, sexual contact with peers, etc. ... Level: 'Unobtrusive supervision' means a staff member must be assigned to be aware of a patient's location and activities at all times. Staff must have visual contact at least three (3) times per hour and, if the patient is awake and able, verbal contact with the patient at irregular intervals, never more than 30 minutes apart ... 'Close supervision' means a staff member must be assigned to be aware of a patient's location and activities at all times. Staff must have visual contact at least five (5) times per hour and, if the patient is awake able, verbal contact with the patient, at irregular intervals, never more than 15 minutes apart ... '1:1 supervision' means a staff member must be assigned to monitor a patient's location and activities at all times. The assigned staff member must maintain constant visual contact and consistent physical proximity, as well as verbal contact while the patient is awake, within parameters specified by the physician/PMHNP order and as described on the Intervention Card. The psychiatrist or PMHNP must specify additional parameters, as appropriate, in the order."
* "'Intervention card' is the document which assists staff working with any patient on supervision. The Intervention Card includes the supervision order, the behavior(s) of concern, the hypothesis about the underlying reason for the behavior(s), and recommended interventions."
* "'Patient education handout' is the document prepared for a patient who is placed on enhanced supervision, providing information about the behavior of concern, any limitations on patient movement or property, and how often the patient can expect to interact with staff."

1.e. The P&P titled "Use of Personal Portable Electronic Devices" dated as 09/30/2022 was reviewed and included the following:
* "The purpose of this protocol is to define expectations relative to the use of personal portable electronic devices by nursing staff, as well as by other staff when working in the capacity of nursing staff or under the supervision of unit nursing management, while on duty at Oregon State Hospital (OSH). The goal of this protocol is patient and staff safety."
* "Personal portable electronic devices (PPED)" means any personal, self-contained, easily carried by an individual electronic device that has the capacity to receive, record, collect, store, or transmit data or images. Types of devices include, but are not limited to: cellular phones, hand-held computers, book viewers, music players, games, watches, fitness trackers, headphones (including earbuds), and speakers."
* "Primary patient care area" means all on-ground areas in which patients may normally be expected to be present. Primary patient care areas, such as clinic and treatment mall rooms and dining halls, become secondary patient care areas outside of normal hours of operation."
* "Staff may not access or interact with PPED while on assignment in a patient care role or while working on a patient living unit. (Questions regarding the applicability of this protocol to a specific person or role must be directed to unit nursing management.)
1. All non-hospital issued PPED must be turned off or set on silent mode and safely stored, preferably in the employee's locker, during the work shift. Watches and fitness trackers may be worn but must be silenced.
2. Employees are encouraged to utilize the central staff phone in their assigned work area for emergency contacts.
3. If the employee chooses to carry their PPED on their person, the following rules apply.
a. The device (exclusive of fitness trackers and watches), must not be visible to a patient, regardless of the actual or anticipated position or posture of the staff. For example, a phone that extends above a pants' pocket, even if covered by a shirt or other garment, is not allowed.
b. The staff member must not answer, or otherwise interact with, the device in a primary patient care area or in the presence of patients.
c. The staff member must not leave a patient care assignment to answer, or otherwise interact with, the device without insuring adequate coverage during the staff 's absence.
* "Except as noted above, staff may only access and interact with PPED while on rest and meal breaks. This access and use must not occur in primary patient care areas (even when no patients are visible) or where it could cause disruption or distraction to other staff (such as unit chart rooms, medication rooms, etc.)."

1.f. A document titled "Attachment C Staff Prohibited Items" dated 07/06/2022 was reviewed and included the following:
* "The following items may be transported through patient care areas under secure possession of health care personnel (HCP), and must be stored in a secure, non-patient-care area (such as a break room or staff locker) as indicated in OSH Policy and Procedure 8.044, "Contraband and Prohibited Items".
These items may not be used in patient-care areas, even under the secure possession of HCP: glass, mirror or ceramic items; plastic bags or plastic wrap; personal toiletries (e.g., hair brushes, soaps, perfumes, deodorant, toothpaste, toothbrush, Aerosolized products); personal electronic devices not issued by OSH (e.g., cellphones, radios, MP3 players, cameras, or recording devices of any kind)."

1.g. The P&P titled "Sexual Activity Involving Patients" dated as 12/08/2022 was reviewed and included the following:
* "Oregon State Hospital (OSH) has the responsibility to take reasonable steps to discourage sexual contact between patients and to direct appropriate follow-up actions if sexual contact or sexual assault occurs. This policy establishes definitions of appropriate touch and inappropriate sexual behaviors for patients
and expectations for staff response in the event of such behaviors."
* "Staff and patients are authorized to use appropriate touch; however, staff and patients must receive permission before touching another person. Even if permission is received, the other party may change their mind at any time, and the appropriate touch must stop immediately ... Staff must follow Procedures A if staff witness or receive reported allegations of a patient engaging in inappropriate sexual behaviors (other than sexual contact) with another person ... Staff must follow Procedures B if staff witness or receive reported allegations of a patient engaging in sexual contact with another person. Patient sexual contact is considered a reportable incident ..."
* "'Appropriate touch' includes, but is not limited to: Handshakes, Fist bumps, Touching a person's shoulder, Side hugs, and Any behavior normally associated with friendship or emotional support. 'Inappropriate sexual behaviors' include: Sexual contact, Intimate/inappropriate touching, Kissing, Extended hand holding, Full body hugs, Hugs from behind, Sexual conversations/statements, Going off alone with another patient to be more intimate, Other behaviors normally associated with sexual interactions or relationships, and/or Any sexual or dating behavior the interdisciplinary treatment team deems as contraindicated for recovery."
* "'Sexual assault' means an incident of sexual contact between patients where criminal activity is alleged to have occurred as defined by Oregon Criminal Code, including, but not limited to, non-consensual sexual intercourse or penetration, and those acts involving an alleged victim who lacks capacity to consent to
sexual contact."

1.h. The P&P titled "Sexual Activity Involving Patients" dated as 02/16/2024 was reviewed and included the following:
* "'Appropriate touch' includes, but is not limited to:
1. Handshakes,
2. Fist bumps,
3. Touching a person's shoulder,
4. Side hugs, and
5. Any behavior normally associated with friendship or emotional support.
B. 'Inappropriate sexual behaviors' include:
1. Sexual contact,
2. Intimate/inappropriate touching,
3. Kissing,
4. Extended hand holding,
5. Full body hugs,
6. Hugs from behind,
7. Sexual conversations/statements,
8. Going off alone with another patient to be more intimate,
9. Other behaviors normally associated with sexual interactions or relationships,
and/or
10. Any sexual or dating behavior the interdisciplinary treatment team deems as
contraindicated for recovery

1.i. The "Procedure B: Staff Response to Sexual Contact Involving Patients" dated as 02/16/2024 was reviewed and included the following:
* "For witnessed sexual contact or upon receiving a report of alleged sexual contact: 1. Staff must notify the lead RN ... and a manager on site ... The lead RN or PNM must notify: a. The patient's psychiatrist/psychiatric mental health nurse practitioner (PMHNP) or Psychiatrist on Duty ... The unit Nurse Manager or program nurse manager (PNM) if after hours, OSH Security department, The Infection Prevention and Employee Health Department. Psychiatry staff must meet with all involved patients individually to assess immediate medical and psychological needs ... Psychiatry and nursing staff must collaborate to determine what environmental interventions are needed to limit contact between involved patients. This may include transfer ... Staff must report the incident ... Staff must document the incident and intervention in every involved patient's electronic medical record ..."

1.j. The "Procedure A: Staff Response to Inappropriate Sexual Behaviors Involving Patients" dated as 12/08/2022 was reviewed and included the following:
* "For witnessed inappropriate sexual behaviors, staff must intervene to stop the inappropriate sexual behaviors. Appropriate interventions include, but are not limited to: 1. Instructing the individuals to stop and separate, 2. Call for additional staff for assistance ..."
* "For witnessed inappropriate sexual behaviors or alleged inappropriate sexual behaviors: 1. Staff must notify the lead RN of the incident (PNM if the incident occurs on an SRTF unit). 2. The lead RN may consult with the interdisciplinary team (IDT) and/or PNM to determine if room changes or other environmental interventions are needed to limit contact between the involved patients. 3. Staff must document the incident and intervention in every involved patient's electronic medical record ... 4. The IDT must meet to determine if further assessment of any involved patient to identify additional treatment needs is appropriate, or if treatment care plan updates are necessary ... Inappropriate sexual behaviors between a patient and staff must be reported."

1.k. The Procedure B: Staff Response to Inappropriate Sexual Behaviors Involving Patients" dated as 12/08/2022 was reviewed and included the following:
* "Following an incident of patient sexual contact, the IDT must: 1. Meet no later than the next business day, excluding weekends and holidays, to review and address the incident. Treatment care plan updates that may result from the IDT meeting must be made per OSH policy 6.011, "Treatment Care Planning."
2. Meet with all involved patients to assess any further psychological or medical needs and coordinate any recommended follow-up services ... If sexual contact occurs between patients that all involved patients describe as consensual, Psychology or Psychiatry staff will assess each involved patient for capacity to give consent and document the assessment in the electronic medical record ... If one or more involved patient does not describe the sexual contact as consensual, no assessment will occur. Instead, staff must follow OSH policy 8.019, 'Staff Response to Alleged Criminal Acts' ... Staff must follow OSH policy 8.019 if it is determined that a patient does not have capacity to consent, or a suspected sexual assault has occurred."

1.l. During interview with staff that included the DSC, the QMD and others on 02/28/2024 beginning at 1615 they stated that the policy definitions of sexual contact had been changed on 02/05/2024 to include what had been previously categorized as "intimate touching." Those "intimate touching" encounters between patients had not previously required that an incident report and an investigation be completed. As of the 02/05/2024 policy change those behaviors were considered to be "sexual contact" and would require an incident report and investigatory next steps.

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2. The following is regarding an incident involving Patient 22 and Patient 23.

2.a. During interview with staff that included the Superintendent, CNO, QMD, DSC, COM, CMO, DNS, and PD on 02/28/2024 beginning at ~ 1630 staff stated that on 02/10/2024 at ~ 1030 Patient 22 physically attacked Patient 23. They stated that the unwitnessed assault occurred without provocation in the AN1 air court and resulted in physical harm to Patient 23 that included LOC and a head laceration. When Patient 23 was found a Code Blue was called, 911 was called, and the patient was transported to the local acute care hospital for ED services. The following information was provided during the interview:
* Upon return from the ED later the day of the incident, Patient 23 was transferred to the OSH medical unit for care and monitoring.
* Security staff initiated video review immediately after the incident to determine what happened and who had assaulted Patient 23.
* When it was shown on video that Patient 22 was the aggressor, orders for 1:1 observation and for placement in seclusion were initiated for Patient 22 until they could be transferred to another unit.
* An Everbridge email notification was sent to hospital leadership staff on the day of the incident at 1117 to inform them that Patient 23 had been transported to the acute care hospital secondary to LOC and "contusion" over the left eye.
* On 02/12/2024 hospital leadership met to continue follow-up actions and initiate the formal investigation that was underway at the time of this survey.
* Video recordings of unit, patient, and staff activities prior to the event had been reviewed.
* Staff adherence to unit shift assignments had been evaluated.
* Medical records for Patient 22 and Patient 23 had been reviewed.
* Initial investigation findings included that RN and MHT staff assigned to be continually present in the milieu were not in the milieu at the time of the incident, that observation orders in place for Patient 23 had not been followed, and there was a lack of staff supervision to ensure assignments were followed.
* Initial actions taken included communications to all staff regarding their responsibilities to comply with unit assignments and to maintain continual presence on the milieu.
* Staff changes were made that included placement of employee staff on AL during the investigation, and termination of some agency staff contracts.

2.b. Review of Patient 23's medical record reflected that they sustained injuries and had subsequent hospitalizations that included:

* A "Patient Progress Note" written by an OSH MD on 02/10/2024 at 1250 included the following: "Writer got called about the code blue in AN-1 at around I 0:50 AM this morning. When I went to the unit, [Patient 23] was lying down in the air court area, with [their] face towards ground bleeding profusely from a laceration on the forehead. Pt was conscious and able to talk with staff but could not recollect what happened. Staff were able to reposition [the patient] with [their] face facing side ways and apply pressure on the lacerated wound to prevent further bleeding. Pt later stated that someone choked [them] from behind and [they were] unconscious for a moment. I've noticed a deep lacerated wound on the right side of [their] forehead approximately 8 cm x 4 cm. EMS arrived and applied pressure dressing on [the patient's] head ... sent to Salem Hospital ER for further evaluation and treatment."

* A local hospital ED encounter note for 02/10/2024 included the following: "The patient ... presents to the Salem Health Emergency Department with head, face and neck pain after being assaulted. Patient states that [they were] assaulted ... at the Oregon State Hospital states that [they were] choked and then thrown to the ground and [they] landed on the edge of concrete brick. [They state] that [they were] getting choked and then [they] felt like [they were] going to pass out and was thrown to the ground and does not remember what happened after that. Staff at the bedside were able to get video of this and did state that it was caught on camera and [Patient 21] was choked and thrown to the ground and [they] did have a loss of consciousness ... Patient has a large gaping X shaped laceration across [their] forehead extending over the bridge of the nose and down towards the right eye but does not involve the globe or the lid ... does have some swelling of the eyelid on the left that progressed throughout [their] stay here. Neck: ... does have tenderness over the anterior neck ... evaluated for facial laceration, head injury, choking episode with neck pain. Ddx includes, but is not limited to: I have concerns for intracranial hemorrhage, skull fracture, facial bone fr

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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation it was determined that the hospital failed to fully develop and implement clear P&Ps that ensured each patient's right to be free from all forms of abuse and neglect. Identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur.

The CMS Interpretive Guidelines for this requirement at CFR 482.13(c)(3) reflects "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Further, the CMS Interpretive Guidelines reflect those components necessary for effective abuse protection include, but are not limited to:
o Prevent.
o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

Findings include:


40575

1.a. The P&P titled "Incident Reporting" dated as revised 02/05/2024 was reviewed and included the following:
* "OSH staff must accurately report incidents in accordance with this policy. In response, OSH must conduct thorough investigations, prepare reports showing the tracking and trending of data, and implement and monitor corrective or preventative actions."
* "Any of the following reportable incidents must be reported ... Code Blue ... ER visit or admission of a patient ... Physical aggression toward patients, staff, or visitors resulting in any degree of injury ... Sexual contact and inappropriate sexual behaviors between patients or with a patient ... Sexual crimes or an inappropriate sexual behavior ..."

1.b. The P&P titled "Procedure A: Reporting an Incident" dated as 02/05/2024 was reviewed and included the following:
* "Unless otherwise noted in this policy, every staff who witnesses a reportable incident must complete a separate incident report for each person involved in the reportable incident within one business day of the reportable event. For example, in a patient-to-patient aggression incident where a staff member is
injured, three incident reports would be required to be submitted by each person that witnessed the reportable incident - one for each patient involved and one for the injured staff."
* "For reportable incidents involving patients (i.e. incident reports with patients listed as "subject") an RN must assess the involved patient(s), when it is safe to do so, and document in the Progress Note. This assessment should consider elements appropriate to the nature of the incident, such as physical and psychological safety, access to prohibited items, and risk for recurrence."
* "Each incident report must identify the reporting staff ' s location at the time of the incident."
* "If the incident report includes information from another source, the reporting staff must provide the name of the outside source and indicate if they were a witness or an involved party."

1.c. The P&P titled "Procedure B: Incident Report Response" dated as 02/05/2024 was reviewed and included the following:
* "The Incident Review Form must include: a. A brief summary of the incident (reference all incident reports describing the incident); b. A description of factors which contributed to the incident; and c. Actions taken or planned to respond to the incident, including but not limited to patient assessment and documentation in the patient medical record. d. Description of how OSH will prevent the event from reoccurring."

2. Refer to the incident investigation findings cited at Tag A-144 under CFR 482.13(c)(2), Standard: Privacy and Safety. Those findings reflect the hospital's failure to ensure investigations of incidents/events that reflected potential neglect were clear, complete, and accurate to prevent recurrence for those patients who experienced actual and potential harm, and for other patients.
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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation it was determined that the hospital failed to ensure that the QAPI program was effective to ensure the provision of safe and appropriate care to patients in the hospital.

The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Condition Tag A-115 under CFR 482.13 - CoP: Patient's Rights that reflects that policies, procedures, and systems for the provision of safe care were not clear, complete, or implemented (Tag A-144); that identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur (Tag A-145); and that response to, investigation of, and follow-up to patient grievances related to safe care were not clear, complete or timely (Tag A-118).

2. Refer to the findings cited at Tag A-286 under CFR 482.21(a), (c)(2), (e)(3) - Standard: Patient Safety that reflects the hospital failed to ensure that incidents and adverse patient events were clearly identified, tracked, investigated and analyzed, and that corrective actions were planned and implemented to prevent recurrence of those, to promote learning throughout the hospital, and to establish clear expectations for patient safety. Further, there was no process for systematic identification and tracking of negative outcomes to patients that involved patient injuries, ED visits, and hospitalizations in relation to incidents.
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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation it was determined that the hospital failed to ensure that incidents and adverse patient events were clearly identified, tracked, investigated and analyzed. Further, the hospital failed to plan and implement corrective actions to prevent recurrence of those, to promote learning throughout the hospital, and to establish clear expectations for patient safety.

Findings include:

1. Refer to the findings cited at Tag A-144 under CFR 482.13(c)(2) - Standard: Privacy and Safety that reflects that policies, procedures, and systems for the provision of safe care were not clear, complete, or implemented and resulted in the following:
* Failure to prevent patient to patient physical altercations and injuries.
* Failure to prevent patient to patient sexual contact and sexual assault.
* Failure to ensure staff carried out assigned duties related to all aspects of observation and supervision of patients.
* Failure to ensure TCPs and ES orders were followed.
* Failure to ensure door security and situational awareness practices that ensured patient safety.
* Failure to ensure all high risk patient care areas monitored by 24/7 security staff video monitoring were fully observable and did not include blind spots.
* Failure to ensure staff practices were in accordance with, and supported by, written and approved P&Ps for the following:
- Condom distribution to patients.
- Processing and tracking police reports filed on behalf of patients who had been assaulted by other patients.
- Security staff "access control" video monitoring
* Failure to ensure Code Blue responses were organized, appropriate, and documented.
* Failure to ensure staff training related to patient safety was current.

2. Refer to the findings cited at Tag A-145 under CFR 482.13(c)(3) - Standard: Privacy and Safety that reflects that identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur.

3. Refer to the findings cited at Tag A-118 under CFR 482.13(a)(2) - Standard: Patient Grievances that reflects that response to, investigation of, and follow-up to patient grievances related to safe care were not clear, complete or timely.

4. During interviews with staff that included the DSC, QMD, and CMO about the patient incident log on 02/28/2024 and 03/04/2024 they indicated that the hospital had no process for systematic identification and tracking of outcomes to patients that involved patient injuries, ED visits, and hospitalizations in relation to incidents. They stated that information about patient injuries sustained and ED/hospital visits was only identifiable in individual patient incident reports or individual patient medical records.
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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation it was determined that the hospital failed to ensure that nursing services were organized and managed to ensure the provision of safe and appropriate care to each patient in the hospital.

The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Condition Tag A-115 under CFR 482.13 - CoP: Patient's Rights that reflects that policies, procedures, and systems for the provision of safe care were not clear, complete, or implemented (Tag A-144); that identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur (Tag A-145); and that response to, investigation of, and follow-up to patient grievances related to safe care were not clear, complete or timely (Tag A-118).

2. Refer to the findings cited at Tag A-395 under CFR 482.23(b)(3) - Standard: RN Supervision of Nursing Care that reflects an RN failed to supervise the nursing care for each patient to ensure the provision of safe and appropriate care that included prevention of patient to patient altercations and injuries, and sexual contact. RN failures included, but were not limited to: failure to ensure nursing staff appropriately supervised and observed patients to prevent incidents, failure to ensure investigations of incidents were complete and corrective actions were taken that prevented recurrence, and failure to ensure that response to grievances regarding patient safety were timely and appropriate.
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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation it was determined that the RN failed to supervise the nursing care for each patient to ensure the provision of safe and appropriate care.

Findings include:

1. Refer to the findings cited at Tag A-144 under CFR 482.13(c)(2) - Standard: Privacy and Safety that reflects that policies, procedures, and systems for the provision of safe care were not clear, complete, or implemented and resulted in the following:
* Failure to prevent patient to patient physical altercations and injuries.
* Failure to prevent patient to patient sexual contact and sexual assault.
* Failure to ensure staff carried out assigned duties related to all aspects of observation and supervision of patients.
* Failure to ensure TCPs and ES orders were followed.
* Failure to ensure door security and situational awareness practices that ensured patient safety.
* Failure to ensure all high risk patient care areas monitored by 24/7 security staff video monitoring were fully observable and did not include blind spots.
* Failure to ensure staff practices were in accordance with, and supported by, written and approved P&Ps for the following:
- Condom distribution to patients.
- Processing and tracking police reports filed on behalf of patients who had been assaulted by other patients.
- Security staff "access control" video monitoring
* Failure to ensure Code Blue responses were organized, appropriate, and documented.
* Failure to ensure staff training related to patient safety was current.

2. Refer to the findings cited at Tag A-145 under CFR 482.13(c)(3) - Standard: Privacy and Safety that reflects that identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur. Investigations of the majority of incidents were conducted primarily by hospital nursing and other clinical staff. Exceptions included investigations of incidents that resulted in significant or serious harm.

3. Refer to the findings cited at Tag A-118 under CFR 482.13(a)(2) - Standard: Patient Grievances that reflects that response to, investigation of, and follow-up to patient grievances related to safe care were not clear, complete or timely. Patient grievance response and follow-up was conducted primarily by hospital nursing and other clinical staff.
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