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Based on review of medical records (MR), staff interviews, review of video surveillance, and review of facility documents, it was determined that the facility failed to ensure: 1). Q15 (Every 15 minutes) patient monitoring on the involuntary psychiatric unit was conducted to ensure patient safety (A0144); and 2). an incident report and investigation were completed concerning an allegation of assault (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients.

On January 14, 2025, at 4:11 PM, an Immediate Jeopardy (IJ) was identified for the facility's failure to ensure that staff conduct Q15 patient monitoring on the behavioral health involuntary unit (A-0144). On January 14, 2025, at 4:33 PM, the IJ template was presented to the administration and a removal plan was requested. On January 15, 2025, at 10:41 AM, a second IJ was identified for the facility's failure to ensure that staff complete an incident report upon a patient's allegation of assault and the the facility completes an investigation of the alleged event (A-0144). On January 15, 2025, at 12:11 PM, the IJ template was presented to the administration and a removal plan was requested. On January 15, 2025, at 2:24 PM, an acceptable removal plan was received. The facility implemented the following to address the IJs: education was provided to Behavioral Health Unit nurses, mental health aides, and mental health counselors about compliance to the safety rounding policy and impact on patient safety by the Chief Nursing Officer, Director of Quality, and Clinical Manager. The education included: Review of the policy titled, "Safety Rounds," which indicated that rounds are to be completed every 15 minutes; Importance of accurate documentation, integrity, and data validity; Licensing requirements and impact of noncompliance to safety rounds; and Reinforced teamwork for coverage to complete safety rounds. Policies for Incident Reporting, Patient Abuse Reporting, and Reportable Police Cases were updated. All Behavioral Health Unit staff including nursing, mental health aides, mental health counselors, therapists, discharge planners, psychiatric providers (MD [Medical Doctor], APN [Advanced Practice Nurse], PA [Physician Assistant]), and security officers were provided this education. The IJ was removed on January 15, 2025, at 3:07 PM, after the State Survey Agency verified the full implementation of the removal plan, and Condition Level non-compliance remains (A0144).

Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting

Based on the review of medical records (MR), staff interviews, review of video surveillance, and review of facility documents, it was determined the facility failed to ensure: 1). Q15 (Every 15 minutes) patient monitoring was conducted on the behavioral health involuntary unit to maintain patient safety; and 2). staff complete an incident report upon a patient's allegation of assault and that the facility conducts an investigation of the alleged event.

Findings include:

1. Facility policy titled, "Safety Rounds" (Reviewed January 2022) stated, " ... I. Policy: ...A. The Charge Nurse is responsible for assigning nursing staff to make unit rounds in order to account for all patients' whereabouts and ensure a safe environment. B. Rounds are made a minimum of every fifteen (15) minutes. ... D. Rounds are completed by assigned staff. ... III. Procedures: ... C The assigned staff member(s) personally locates each patient listed (unless on pass or out on hospital outing), and documents the patient's location on the Rounds Sheet under the appropriate time column. The staff member places his/her initials at the top of the column above the time. ... G. The staff member must enter the room to observe the condition of the patient."

On 01/14/25 at 1:45 PM, a video surveillance footage review of "Unit 4-Main, Hall-East" was conducted with Staff (S)9 (Safety Manager) and S2 (Director of Risk, Compliance and Privacy). The following was revealed:

On 12/27/24 from 03:00 AM until 04:00 AM, there were no staff members observed in the hallway conducting Q15 patient monitoring rounds. At 4:11 AM, S18 (Registered Nurse [RN]) was observed opening the doors to patient rooms and entering the patient rooms.

A review of Patient (P)1's medical record revealed that on 12/27/24, S19 (Mental Health Aide [MHA]) documented the following Q15 safety rounds:

12/27/24 at 03:03 AM, "BH (Behavioral Health) Patient Location: Patient Room; BH Patient Activity: Appears sleeping." A review of the video surveillance revealed that there were no staff observed conducting Q15 safety rounds on the unit at the time this was documented.

12/27/24 at 03:29 AM, "BH (Behavioral Health) Patient Location: Patient Room; BH Patient Activity: Appears sleeping." A review of the video surveillance revealed that there were no staff observed conducting Q15 safety rounds on the unit at the time this was documented.

12/27/24 at 03:44 AM, "BH (Behavioral Health) Patient Location: Patient Room; BH Patient Activity: Appears sleeping." A review of the video surveillance revealed that there were no staff observed conducting Q15 safety rounds on the unit at the time this was documented.

12/27/24 at 03:59 AM, "BH (Behavioral Health) Patient Location: Patient Room; BH Patient Activity: Appears sleeping." A review of the video surveillance revealed that there were no staff observed conducting Q15 safety rounds on the unit at the time this was documented.

12/27/24 at 04:04 AM, "BH (Behavioral Health) Patient Location: Patient Room; BH Patient Activity: Appears sleeping." A review of the video surveillance revealed that there was no staff observed conducting Q15 safety rounds on the unit at the time this was documented.

On 01/14/25 at 2:05 PM, S9 confirmed that Q15 Safety Rounds were not conducted on 12/27/24 from 03:00 AM until 04:11 AM. S2 confirmed that S19 documented Q15 Safety Rounds in the patient's medical record as indicated above, but did not conduct the Q15 Safety Rounds as per facility policy. Upon request, S9 failed to provide the "11-7" Nursing Assignment sheet for 12/26/24 (11:00 PM on 12/26/24 until 07:00 AM on 12/27/24).

A review of the "12/28/24, 11-7" Nursing Assignment sheet (11:00 PM on 12/28/24 until 07:00 AM on 12/29/24) documented the nursing shift assignments as follows: S17 (Registered Nurse [RN]) was assigned "Q Hourly Rounds" (every hour); S18 (RN) was assigned "Q Hourly Rounds" and "Q15 mins (minutes)" 2am-3am (02:00 AM until 03:00 AM) and 5am-6am (05:00 AM until 06:00 AM); S16 (MHA) was assigned "all patients." The Nursing Assignment sheet lacked documentation of the staff member responsible for conducting the Q15 safety rounds from 11:00 PM until 02:00 AM, 03:00 AM until 05:00 AM, and 06:00 AM until 07:00 AM.

A review of the video surveillance footage from 12/29/24 (02:00 AM until 04:00 AM) revealed that there was no staff observed conducting Q15 patient monitoring rounds from 02:00 AM until 02:40 AM, when S17 (RN) appeared on video and was observed opening the doors and entering the patient rooms at 02:40 AM. There was no staff observed conducting Q15 patient monitoring rounds, again, until S16 appeared to conduct Q15 patient monitoring rounds at 04:29 AM.

Review of Patient (P)1's medical record revealed that on 12/29/24, S17 documented the following Q15 safety rounds for P1:

12/29/24 at 02:02 AM, "BH (Behavioral Health) Patient Location: Patient Room; BH Patient Activity: Appears sleeping." A review of the video surveillance revealed that there was no staff observed conducting Q15 safety rounds on the unit at the time this was documented.

12/29/24 at 02:29 AM, "BH (Behavioral Health) Patient Location: Patient Room; BH Patient Activity: Appears sleeping." A review of the video surveillance revealed that there was no staff observed conducting Q15 safety rounds on the unit at the time this was documented.

12/29/24 at 02:31 AM, "BH (Behavioral Health) Patient Location: Hallway." P1 was observed to be in the hallway at the nursing station at that time.

12/29/24 at 02:53 AM, "BH (Behavioral Health) Patient Location: Patient Room; BH Patient Activity: Awake." Video surveillance review showed S17 opening the doors and entering the patient rooms at 02:40 AM.

On 12/29/24, S16 (MHA) documented the following Q15 safety rounds for P1:

12/29/24 at 03:14 AM, "BH (Behavioral Health) Patient Location: Patient Room; BH Patient Activity: Appears sleeping." A review of the video surveillance revealed that there was no staff observed conducting Q15 safety rounds on the unit at the time this was documented.

12/29/24 at 03:35 AM, "BH (Behavioral Health) Patient Location: Patient Room; BH Patient Activity: Appears sleeping." A review of the video surveillance revealed that there was no staff observed conducting Q15 safety rounds on the unit at the time this was documented.

12/29/24 at 03:59 AM, "BH (Behavioral Health) Patient Location: Seclusion-1; BH Patient Activity: [Blank]." During the review of the video surveillance, P1 was observed speaking with S16 and S20 (Security Officer) in the hallway outside of the Seclusion Room. There were no staff observed conducting Q15 safety rounds on the unit at the time this was documented.

12/29/24 at 04:12 AM, "BH (Behavioral Health) Patient Location: Seclusion-1; BH Patient Activity: [Blank]." During the video surveillance review, P1 was observed entering the Seclusion Room at 04:01 AM without any staff member and the door to the seclusion room remained open. There were no staff observed conducting Q15 safety rounds on the unit at the time this was documented.

On 01/14/25 at 2:33 PM, S9 confirmed that no staff were observed in the patient hallway conducting safety rounds, and that Q15 Safety Rounds were completed only once from 02:00 AM until 04:29 AM (at 02:40 AM). S2 confirmed that S16 and S17 documented the Q15 Safety Rounds in the patient's medical record, but did not conduct the Q15 Safety Rounds as per facility policy.

2.) Facility policy titled, "Patient Abuse Reporting" (Reviewed February 2022) stated, " ... All personnel who provide direct or indirect care to patients either on an occasional or regular basis will attend an educational program on an annual basis regarding the identification and reporting of diagnosed and/or suspected cases of elderly or disabled adult abuse and/ or neglect."

Facility policy titled, "Incident Reporting" (Reviewed February 2023) stated, " I. POLICY: ...All (Name of facility) employees are required to complete an incident report, documenting events that either result in, or have the potential to result in, injury or property damage or loss to patients ... III. SCOPE: All (Name of facility) employees are required to enter an incident in the electronic incident reporting system report at the time it occurred or as soon as possible. ... IV. QUALIFICATIONS/RESPONSIBLE PARTIES: ... The (Name of facility) Director, Risk Management reviews all electronic incident reporting system reports and will determine need for further investigation and when appropriate, report to external regulatory agencies ...VI. PROCEDURE: ... Employees must enter the incident in the electronic incident reporting system at the time it occurred or as soon as possible. Next steps: i. If the incident is having a direct patient impact, the incident must be documented in the patient record.; ii. Notify the immediate supervisor, Administration of the incident; iii. When appropriate, an investigation will be conducted. ...VII. DOCUMENTATION: Patient related incidences are documented within the patient's medical record. All incidences are captured and documented in the electronic incident reporting system reporting platform."

A review of P1's medical record revealed the following:

P1 was admitted to the Behavioral Health Unit (BHU) involuntary unit on 12/17/24 with a diagnosis of schizoaffective disorder.

In a Behavioral Health Note by S5 (Psychiatrist, BHU Medical Director) on 12/29/24 at 11:53 AM, it stated, "... History of Present Illness: Patient was seen this morning and continues to be delusional and paranoid. Patient states that [he/she] was possibly assaulted last night, despite not seeing anyone in [his/her] room. Patient states [he/she] had 'lines on my back', suggestive of an assault, that [he/she] refused to show writer and states 'it is not there anymore.' ... MSE (Mental Status Exam): ... Description of abnormal or psychotic thoughts including: AH (Auditory Hallucinations), VH (Visual Hallucinations), delusions: Delusional and paranoid ... Mood/affect: Upset affect: blunted ...Plan: 1. Mood/psychosis: Continue with current treatment regimen ..." There was no evidence in the medical record that the patient was examined for injury.

In a Behavioral Health Form - Interdisciplinary Team Meeting BH (Behavioral Health) entry on 12/30/24 it stated, "... Patient stated [he/she] thinks someone probably rape (sic) him last night. However [he/she] is not to (sic) sure if anything happened. Psychiatrist told patient if anyone should touch [him/her], [he/she] should reported (sic) so the proper procedures will take place."

A review of the BH IP (Inpatient) Provider Progress Note, written on 12/30/24 at 13:46 EST (1:46 PM), revealed, " ...History of Present Illness: ...Patient reports during treatment team [he/she] woke up during Saturday night around 4AM and felt like someone was putting pressure on [his/her] back but [he/she] did not see anyone. Reports [he/she] woke up in cold sweats and told the staff members. Patient reports a similar experience on the outside and reported [he/she] was raped at at (sic) that time, but no reports were made to the police."

Upon interview with S5 on 1/14/25 at 11:50 AM, when asked to describe the procedure if a patient reports a sexual assault, S5 stated, "First, the patient would be placed on 1:1 for safety, the medical team will conduct a physical exam, then submit an incident report if it is a confirmed event." When questioned if an incident report is submitted only if it was confirmed that an assault occurred, S5 stated, "No, an incident report should be generated if it is a confirmed or reported event." S5 confirmed that an alleged sexual assault would be discussed during the interdisciplinary treatment team meetings, which occur three times per week. When questioned if S5 recalls P1 reporting sexual assault to [him/her] on 12/29/24, S5 stated, "I asked the patient if [he/she] wanted to be examined, and the patient refused." When asked if S5 filed an incident report for the patient's allegation, S5 said "No."

A review of the facility's incident report log (November 2024-January 2025) lacked documentation that an incident report was filed on 12/29/24 when P1 reported the alleged sexual assault to BHU staff and the medical provider.

Upon interview with S2 (Director of Risk, Compliance, and Privacy) on 1/13/25 at 10:00 AM, he/she explained that according to the facility's policy, all staff are expected to file an incident report if a patient reports an alleged sexual assault, and an investigation would be conducted.

On 1/15/25 at 10:15 AM, S2 confirmed that staff did not complete an incident report on 12/29/24 when P1 reported a possible sexual assault. S2 confirmed the facility did not conduct an investigation concerning the patient's allegation.