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Based on staff interviews, record reviews, observations, review of the facility policies and procedures, facility security videos and a review of incidents and internal investigations that occurred on the Behavioral Health Unit (BHU); the facility failed to: 1) maintain a safe environment for patients identified as being at risk for hypersexual activity; 2) ensure nursing staff were following the policy to keep contraband off the floor; and 3) provide nursing supervision of patient care for 3 of 11 sampled patients (Patients 1, 3 and 11). These failures resulted in 1 patient (Patient 1) with identified hypersexual activity to engage in oral sex with another peer (Patient 3); and to allow 1 patient (Patient 11) that was preparing for discharge to have 3 knives in their possession on the BHU. The failure to provide supervision and maintain a safe environment had the potential to affect other patients on the Behavioral Health Unit which could have led serious injury or death. These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that the Condition of Participation for Patient Rights was not met, and that Immediate Jeopardy (IJ) conditions existed and had been ongoing at this facility since 1/10/19, posing a threat of potential serious injury, harm, impairment or death of patients admitted with psychiatric diagnosis and risk factors. The administrator was informed of the IJ determination by the State Agency [SA] on 1/29/19 at 1:25 PM. The total sample size was 11. The facility census was 25 in medical care and 8 on the BHU.

The failure to implement immediate effective action plans had the potential to affect the care of all patients in the facility. The administrative staff implemented measures to remove the immediacy on 1/29/19 at 1:30 PM by implementing the following:

- Provided education to all staff working on the BHU prior to their shift regarding 15 minute observation rounds and the implementation of a updated Observation Form.
- Following staff education and prior to starting their shift on the BHU, required staff to complete a quiz.
- Initiated compliance audits (managed by the Director of Clinical Effectiveness) to be completed daily for 90 days to ensure staff are observing patients in their rooms and in the day room every 15 minutes.
- Initiated random video audits to ensure compliance with 15 minute observation rounds.
- Provided staff with the January 2019 revision of the Rounds For Patient Observation Policy.
- Provided staff with the January 2019 revision of the Personal Search of Patient Property Policy.
- Reinforced the policy that the BHU patients will not be taken down to security/communications office to pick up their inventoried items until the time of discharge.

Refer to A 144.

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Based on staff interviews, record reviews, observations, review of the facility policies and procedures, facility security videos and a review of incidents and internal investigations that occurred on the Behavioral Health Unit (BHU); the facility failed to: 1) maintain a safe environment for patients identified as being at risk for hypersexual activity; 2) ensure nursing staff were following the policy to keep contraband off the floor; and 3) provide nursing supervision of patient care for 3 of 11 sampled patients (Patients 1, 3 and 11). These failures resulted in 1 patient (Patient 1) with identified hypersexual activity to engage in oral sex with another peer (Patient 3); and to allow 1 patient (Patient 11) that was preparing for discharge to have 3 knives in their possession on the BHU. The failure to provide supervision and maintain a safe environment had the potential to affect other patients on the Behavioral Health Unit which could have led serious injury or death. The total sample size was 11. The facility census was 25 in medical care and 8 on the BHU.

These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that the Condition of Participation for Patient Rights was not met, and that Immediate Jeopardy (IJ) conditions existed and had been ongoing at this facility since 1/10/19, posing a threat of potential serious injury, harm, impairment or death of patients admitted with psychiatric diagnosis and risk factors. The administrator was informed of the IJ determination by the State Agency [SA] on 1/29/19 at 1:25 PM. The administrative staff implemented measures to remove the immediacy on 1/29/19 at 1:30 PM.

Findings are:

A. A review of Patient 1's current medical record revealed that the patient is a 29 year old admitted to the BHU on 1/4/19 from an outside hospital under a Board of Mental Health petition (a petition that requires a patient identified as being dangerous to self or others and has a mental illness to be held in the facility) after the patient was found outside, naked making snow angels in freezing weather. The patient remains a current patient on the BHU on 1/29/19 receiving mental health treatment. A review of the Psychiatric Admission Assessment by MD L dated 1/5/19 revealed the patient had a history of psychiatric hospitalizations and being non-compliant with medications. During the intake assessment the doctor noted that the patient had peppered speech (to utilize a lot of examples during the conversation), flight of ideas (rapid shifting of content of speech and rambling) and was naked. The patients diagnoses include Schizoaffective disorder, bipolar type (a chronic mental health condition characterized by episodes of hallucinations, delusions, mania and depression) and a Methamphetamine use disorder (Methamphetamine is an addictive stimulant that that has harmful effects on the central nervous system.) The patient meets the criteria due to hospitalization due to psychosis and inability to take care of self/grave disability. Review of physician progress note and nurses notes revealed:
-RN C (1/5/19 18:56 (6:56 PM) Progress notes) documented "Sexually inappropriate, hypersexual, patient takes off clothes and walks in hallway naked. Is able to be redirected."
-MD L noted (1/6/19 12:23 PM Progress note) that, "(gender) is noted to be sexually inappropriate at times..."
-RN D noted (on the 7am-7pm shift change progress notes), "Patient stripped down this a.m. (0917) in the group room 5052. Patient was standing in front of another male patient. The male patient stood there and looked."
-MD L noted (1/11/19 10:39 AM), "Took off clothes yesterday. (Gender) has ben hyper-sexual and impulsive."
-RN E noted (1/13/19 9:52 AM) "Patient was found undressed in the group room".
-RN F noted (1/23/19 at 12:26 AM)" Delusions grandiose and sexually preoccupied."

A review of the information provided by the transport team on 1/4/19 from hospital A to this admission to the BHU indicated, The patient was picked up at Hospital A at 1940 (7:40 PM) and the transport team delivered the patient at 2050 (8:50 PM). "Hypersexual- comments frequently."

A review of Patient 1's physician orders revealed:
-1/4/19 at 23:26 (11:26 PM) 15 minute checks for Level of Observation due to Falls, Elopement, Self Harm and Psychosis.
-1/10/19 at 17:35 (5:35 PM) Line of Sight Level of Observation.

A review of the incident report dated 1/11/19 revealed:
-On 1/10/19 at 15:55 (3:55 PM) the RN (Registered Nurse) was notified by security to check on two patients (Patients 1 & 3) in the group room 5052 due to inappropriate behavior. RN A and BHT (behavioral health technician) Z went to the group room and found Patient 1 performing oral sex on Patient 3.
- The Interim Nurse Manager for BHU was immediately notified of the event. As a result of this incident, the facility immediately began to segregate patients by gender into different hallways on the unit. The cross doors were closed to both sides of the unit and the group room door was closed. The Medical Director (MD L) was notified by staff. An order was placed for a LOS (line of sight level of observation - an order to ensure staff can see a patient at all times) for Patient 1. Security was requested to make more frequent rounding. Staff was instructed to speak to each patient separately about the event and education was attempted with both patients about appropriate boundaries and behavior. Both patients have documented altered thought processes prior to and after the event. On 1/11/19 the LOS was lifted. The Security Director reviewed and discovered a missed opportunity for consistent rounding occurred leading up to this event. It was noted by reviewing the video that staff had not met the 15 minute rounding requirements. It was discovered the team member who was assigned to rounds at the time of tihs event had been employed on the BHU for less than 1 month. Education and coaching/counseling took place with this associate. Segregation by gender will continue until such time it is deemed safe to intermingle the patients on the milieu. When the staff was informed by Security that the patients had been seen on camera and staff came into the room, it had been over 30 minutes since staff had last looked into this room.

A review of the facility security video on 1/24/19 for the incident between Patient 1 and 3 on 1/10/19 revealed:
-At 3:17 PM Patient 1 entered the group/multipurpose room and sat on loveseat and made a phone call.
-At 3:25 PM BHT Y gave Patient 1 a snack in multipurpose room.
-At 3:34 PM Patient 3 entered the group/multipurpose room and sat beside Patient 1 who was talking on the phone.
-At 3:39-3:42 PM Patient 1 left the room and returned.
-At 3:44 PM Patient 1 and Patient 3 are standing in the multipurpose room and Patient 1 removed shoes and was seen touching Patient 3's genitals.
-At 3:45 PM Patient 1 shuts the door and removes all clothing.
-At 3:46 PM Patient 3 removes shirt and pulls down pants. Patient 1 puts clothes back on and Patient 3 pulls up pants. Pt 1 then "peeks" into Pt 3 pants.
-At 3:48 PM Patient 1 goes to loveseat and gets on telephone, Pt 3 puts on shirt and stands in front of Patient 1 with a blanket draped around shoulders.
-At 3:49 PM Patient 3 pulls down pants.
-At 3:50 PM Patient 1 is observed with lips on Patient 3's genitals, Patient 3's hips are gyrating.
-At 3:51 PM Patient 1 stands, and Patient 3 kisses Patient 1,then returns to providing Patient 3 oral sex.
-At 3:53 PM Patient 3 removes pants and is sitting in a chair and Patient 1 continues to provide Patient 3 oral sex.
-At 3:55 PM SECURITY NOTIFIED NURSING THAT THEY NEEDED TO GO CHECK 2 PATIENTS IN THE MULTIPURPOSE ROOM.
-At 3:58 PM RN A and BHT Z along with Security enter the room. Patient 1 is escorted out, Patient 3 dresses and leaves room and doors to room are closed.

B. A review of Patient 3's closed medical record revealed that the patient is a 20 year old admitted to the BHU on 1/10/19 at 2:19 AM from the emergency room initially as a voluntary admission, then became a Board of Mental Health petition after requesting to leave AMA (against medical advice) due to delusional, paranoid and loose association behaviors. A review of the Psychiatric Admission Assessment by MD M dated 1/10/19 at 8:13 AM revealed the patient had a history of psychiatric diagnoses of ADHD (Attention-deficit hyperactivity disorder), ODD (Oppositional Defiance Disorder), and Bipolar Disorder along with a history of 3 previous suicide attempts. The patient meets the criteria due to hospitalization due to danger to self. Review of physician progress note and nurses notes revealed:
-RN G (on the 1/10/19 7am-7pm shift change progress notes) documented "Patient is alert and oriented to name only. Is paranoid and grandiose delusions, stated having visual and auditory hallucinations. Patient has poor insight and judgement.
-RN A (on the 1/10/19 1738 (5:38 PM) Progress notes) that, at 1558 (3:58 PM) found the patient receiving oral sex from a (gender) peer. The patients were educated on appropriate behavior and boundaries and have been separated. Will continue to monitor for safety every 15 minutes and monitor the cameras.

A review of Patient 3's Discharge Summary (dated 1/24/19 at 16:21 (4:21 PM) revealed that the patient's mental status improved on current medications. No suicidal ideation, no homicidal ideation, no delusional statements. No auditory or visual hallucinations reported. The discharge diagnosis was schizoaffective disorder, bipolar type and cannabis abuse.

C. A review of Patient 11's closed medical record revealed that the patient is a 54 year old who was admitted to the BHU on 1/5/19 and discharged 1/10/19. The patient was an Emergency Protection Custody admission (police determined a danger to self). Diagnoses at the time of discharge were Bipolar disorder (a mental illness that results in unusual shifts in activity making the ability to carry out day to day tasks almost impossible at times) , Post-traumatic stress disorder (a mental health condition that is triggered by a terrifying event), alcohol use disorder-severe-dependence, and methamphetamine use disorder-severe.

When the patient was admitted a contraband search was completed. The patient had 3 knives upon admission. The patients valuables including a credit card, debit card, cash and 3 knives were turned into the security/communications area to keep until discharge. A review of the facility security video revealed on 1/10/19 at 4:05 PM BHT Y escorted the patient to the property window in the basement of the hospital. This property was returned to Patient 11 including the 3 knives, the patient signed the inventory sheet and BHT Y escorted Patient 11 back up to the BHU to await final discharge. At 4:10 PM in the BHU hallway in front of the nurses station BHT Y asked the patient for the knives and Patient 11 gave them to BHT Y. BHT Y then took them into the med room and gave them to RN D. The patient was then discharged at 5:01 PM and walked to the vehicle and the knives were returned to the patient.

D. A review of the Patient Bill of Rights booklet revised in 2018 is provided to each patient on admission. The states, you have the right to "Receive care in a safe environment, free from all forms of abuse."

The undated Behavioral Health Inpatient Handbook states:
-We must restrict any hazardous items that could jeopardize your safety or the safety of other patients. The following is a list of restricted items. Some of these items may be used in certain instances under direct supervision and require prior approval from the treatment team.
-Sharp items of any kind
-Weapons of any kind

E. An interview with the Interim Nurse Manager of the BHU, Director of Nurses and the New Nurse Manager of BHU on 1/28/19 at 10:55 AM revealed:
-We reviewed the facility security video for that day on 1/10/19 and found that the BHT (Y) did not complete the assigned 15 minute observation rounds. Did meet with the employee and explain the expectation and importance of the 15 minute observation rounds.
-We usually have no issue with 15 minute observation rounds being completed. I do a "secret shopper" type of quality on the day shift to see that the staff are doing the rounds. (BHT Y) had only been here less than 1 month.
-We looked at the process, currently it is documented on the computer system since 2015. We are looking at possibly changing the observations to paper. We called a meeting.
-During my assessment, there was an individual failure and not a systemic failure and I identified a failure in our documentation. No changes to the 15 minute checks (such as initiating the paper sheets) has started.
- I did send all the BHU staff an email on 1/11/19 and talked about the 15 minute checks in a staff meeting on 1/16/19.
-I suggested a meeting to review the 15 minute rounding, and asked to arrange a meeting for 1/21/19, and had a meeting on 1/23/19.

F. On 1/28/19 at 10:20 AM an interview with BHT Y was completed. BHT Y was assigned on 1/10/19 day shift to do 15 minute checks and to take Patient 11 down to security/communications office to get the belongings secured there before discharge. The BHT Y identified the following related to 1/10/19 during the interview:
-Was new on staff here, starting less than 1 month ago and had been a nursing assistant, but not worked on a Mental Health floor before. In orientation was told that for 15 minute checks needed to go and see where they are, and for contraband it is removed on the initially entrance to the unit and taken to security.
- When asked about the incident on 1/10/19 with Patient 1 and Patient 3, BTH Y stated recalling that day. "I was on that side. In report I was told that (Patient 1) was sexually promiscuous and had been taking off (gender) clothes. (Patient 3) was new and came in the night. They said (Pt 3) could be dangerous, but (gender) slept all morning. (Pt 1) was active up and about asking for coffee, med's, stuff. I was assigned to do the 15 minute checks and we still do all the other things for everyone. I was sent down to security for a discharging patient. On admission they inventory their valuables. I was putting away supplies, taking patients to the dining room, assisting with activity of daily living as need. I walked downstairs to security with a discharging patient. I was preoccupied about that, as it was my 1st discharge alone and security gave the patient (Patient 11) their belongings including the 3 knives. When we got up on the unit I asked the (Pt 11) for them and gave them to the nurse. I was in the desk area when security called up about the incident between Pt 1 and Pt 3, and everyone flew out. I did not go in because there was a nurse and nurse aid already going and I needed to chart the checks. Charting the 15 minute checks still takes me 5-10 minutes." They separated the two of them and shut the doors to the multipurpose room. The next day when I arrived at work the (Interim Nurse Manager of BHU) talked to me about the importance of every 15 minute rounds; I have insight; told about being off the floor; and told the manager I will try to be careful and more observant. So far there have been no changes, I still see where patients are and document it. I sometimes use a piece of paper so I can keep track and be sure and see and document it. I think better communication on the unit would be helpful.

G. Review of the security video for a random audit to verify that the 15 minute observation checks were being done by other staff on other shifts was completed by the survey team, with the Interim Nurse Manager of BHU and the New Nurse Manager of BHU on 1/28/19 at 3 PM. Video footage was reviewed of rounding on the BHU during the night shift on 1/28/19 from 4:00 AM until 4:30 AM. The Nurse Manager of BHU stated that there were 7 patients on the A hall. Each patient have their own bedroom. At 4:14 AM a BHT come out of nursing station went to 1 room and checked the patient and returned to the nursing station only looking in 1 of the 7 rooms for the 30 minutes from 4:00 AM - 4:30 AM. At 4:35 AM the BHT went down the hallway and looked in 4 of 7 rooms, the multipurpose room was locked and the doors were closed.

At 3 :15 PM on 1/28/19 the Interim Nurse Manager of BHU verified that on 1/28/19 from 4:00 AM-4:30 AM the 15 minute observation checks were not completed.