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Based on observations that included live and recorded video footage, interviews, review of incident and medical record documentation for 33 of 33 patients reviewed for incidents in the last three months (Patients 1 through 33) and review of policies and procedures it was determined that the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital that complied with the Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

This is a repeat deficiency cited previously in surveys completed on 12/13/2018 and 02/28/2019.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13 - CoP Patient's Rights.

2. Refer to the findings cited under Tag A263, CFR 482.21 - CoP Quality Assessment and Performance Improvement.

3. Refer to the findings cited under Tag A385, CFR 482.23 - CoP Nursing Services.

Based on observations that included live and recorded video footage, interviews, review of incident and medical record documentation for 33 of 33 patients reviewed for incidents in the last three months (Patients 1 through 33) and review of policies and procedures it was determined that the hospital failed to fully develop and implement policies and procedures that ensured patients' rights to safe care were recognized, protected and promoted as follows:
* Patients were allowed access to contraband and unsafe items and timely and complete investigations of those incidents were not conducted to ensure those incidents did not recur.
* "Door security" measures were not followed and supervision was not provided to prevent patients from inappropriate departure, or elopement, from the secured facility and from secured units and timely and complete investigations of those incidents were not conducted to ensure those did not recur.
* Medications were not administered in a safe manner.
* The visitor policy was not followed.
* Smoking policies were not enforced.

Staff failures to prevent patient access to unsafe items, failures to comply with "door security" measures and lack of staff awareness and supervision resulted in harm to Patient 1 and Patient 2 and created an imminent risk of the likelihood of further harm to those patients and harm to other patients. The hospital was informed in writing on 09/26/2019 that two Immediate Jeopardy (IJ) situations existed. Refer to the detailed IJ findings documented under Tag A144, CFR 482.13(c)(2) - Standard: Right to receive care in a safe setting.

The hospital failed to submit an acceptable IJ Removal Plan prior to the conclusion of the survey and the IJ continued. An IJ Removal Plan was received on 10/23/2019 and approved. The implementation of the IJ Removal Plan was verified during a revisit on 10/24/2019 and the IJ was removed.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

This is a repeat deficiency cited previously in surveys completed on 12/13/2018 and 02/28/2019.

Findings include:

1. Refer to the findings cited under Tags A144 and A145, CFR 482.13(c) - Standard: Privacy and Safety.

Based on observations that included live and recorded video footage, interviews, review of incident and medical record documentation for 33 of 33 patients reviewed for incidents in the last three months (Patients 1 through 33) and review of policies and procedures it was determined that the hospital failed to fully develop and implement policies and procedures that ensured patients' rights to safe care were recognized, protected and promoted as follows:
* Patients were allowed access to contraband and unsafe items and timely and complete investigations of those incidents were not conducted to ensure those did not recur.
* "Door security" measures were not followed and supervision was not provided to prevent patients from inappropriate departure, or elopement, from the secured facility and from secured units and timely and complete investigations of those incidents were not conducted to ensure those did not recur.
* Medications were not administered in a safe manner.
* The visitor policy was not followed.
* Smoking policies were not enforced.

Staff failures to prevent patient access to unsafe items, failures to comply with "door security" measures and lack of staff awareness and supervision resulted in harm to Patient 1 and Patient 2 and created an imminent risk of the likelihood of further harm to those patients and harm to other patients. The hospital was informed in writing on 09/26/2019 that two Immediate Jeopardy (IJ) situations existed. Refer to the detailed IJ findings documented under Finding 2 below in this report.

The hospital failed to submit an acceptable IJ Removal Plan prior to the conclusion of the survey and the IJ continued. An IJ Removal Plan was received on 10/23/2019 and approved. The implementation of the IJ Removal Plan was verified during a revisit on 10/24/2019 and the IJ was removed.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

This is a repeat Standard-level deficiency cited previously in surveys completed on 12/13/2018, 02/28/2019, and 05/16/2019.

Findings include:

1. Policies and procedures reviewed included:

a. The policy and procedure titled "Facility Access, Door Security and Key Control" dated as last reviewed 03/14/2019 reflected that "This policy applies to all Cedar Hills Hospital...workforce members (employees and non-employees), contractors and visitors...Workforce members will...b. Exercise door awareness and conduct a 360 degree observation before walking in or out of a locked door in a patient care area. Staff must ensure a patient is not in the immediate vicinity of the door on either side of the door prior to opening it. They will not open a door if patients are in the immediate area. c. Maintain physical contact with their hand on the door until it is shut and locked behind them...Pay particular attention when opening the main entrance door or other exit while letting guest (sic) in or out. They shall conduct a 360 survey prior to opening the door. They will maintain physical door contact with their hand until the door is closed and locked after they have let their guest out."

"The following areas will always remain locked. Patients will always be under direct supervision while in these areas: a. Laundry rooms, b. West 1 group room..."

b. The policy and procedure titled "Elopement Precaution" dated as last reviewed "5/2019" reflected that "Patient who are assessed to be at risk of attempting to leave the hospital without release by a medical authority are placed on Elopement Precaution.(sic)...In general, a person on Elopement Precaution may not leave the secure perimeter of the Cedar Hills Hospital...Staff Interventions for Elopement Precautions: Treatment plan problem sheet for aggression with specific interventions is created for the patient and communicated with direct care staff...Place patient in the most secure unit available...Be alert during high risk times..."

c. The policy and procedure titled "Contraband" dated as last reviewed 04/16/2019 reflected that "This policy applies to all Cedar Hills Hospital workforce members (employees and non-employees). Cedar Hills Hospital will enhance safety by identifying and preventing dangerous items (contraband) from entering into the therapeutic environment...a list of contraband items, no matter how exhaustive, cannot replace staff vigilance as the primary mechanism for maintaining a safe environment."

"Contraband...Any item that poses a safety risk may be considered contraband...Items that are specifically named in the contraband list below are not permitted in any patient care area...List of items (representative, but not all inclusive)." The contraband list was lengthy and included items such as: knives, box cutters, lighters, matches, pills, awls, camera phones, letter openers, cigarettes, etc.

"Monitored...Items that may be used by patients under direct supervision of staff members. Items are monitored by staff and kept in a safe place on the unit when not in use." The list of items to be "monitored by therapy staff in structured therapy groups and activities" included "safety scissors."

"When any staff member notices an item that could be considered contraband they will take immediate actions to address any related safety issues."

d. The policy and procedure titled "Patient Belongings" dated as last reviewed 05/06/2019 reflected that "Cedar Hills Hospital will insure (sic) all patient belongings are searched for contraband and properly documented on appropriate inventory forms...When a prospective patient is taken to an assessment room, the individual taking them to the room will lock up all their belongings in the lockable cabinet. Patients will be asked to remove items from their pockets, and place them in a plastic tub. Patient will be scanned with medal (sic) detecting wand."

"Home Medications...will be inventoried by assessment nurse and put into medication drop box in the assessment center. Pharmacy will pick these medications up and handle in accordance with 'Patient Home Medication Storage, Tracking, and Release' Policy and Procedure."

"The security specialist will search and inventory all items...Items will be separated into three categories...2. Restricted medical device such as a CPAP - placed in paper bag marked with restricted and patients (sic) name. 3. Contraband...Placed in a red or yellow vinyl bag with patient's name, and security seal applied...Security seal number recorded on...Only Security or Nurse Supervisor are allowed access to patient belongings storage and break this seal prior to a patient discharging."

"It is important to search clothing, shoes, and luggage in areas that offer hiding potential. These include, but are not limited to: a. Socks-search...b. Shoes-search...c. Pants-pockets, hems and waistbands. d. Shirts-pockets,hems, collars and sleeves/cuffs. e. Underwear-bands and bra cups..."

2. An IJ situation was identified and the hospital failed to submit an acceptable IJ removal plan prior to the conclusion of the survey as follows:

a. On 09/24/2019 beginning at 1415 the DON and the DPI were interviewed and observations of the CSU patio were made. The DON and DPI stated that Patient 1 was on the covered, outdoor CSU patio with a staff person present on 09/19/2019 at 2030. They stated that Patient 1 jumped up and grabbed the top/ledge of the 10 foot fence and pulled him/herself up onto the hospital roof. The patient ran across the roof and jumped to the ground and eloped off of the hospital's premises. They indicated that although the CSU patio was up against the hospital building and covered there was identified to be a small opening between the overlap of the patio cover and the hospital roof that the patient was able to move his/her body through. They indicated that alterations had been made to reduce the gap to prevent future elopements.

Review of the medical record of Patient 1 reflected that physician's orders on admission, dated 09/09/2019 included "Precaution - Elopement." Those orders were current on 09/19/2019 at the time the patient eloped from the hospital.

On 09/24/2019 at 1612 recorded video footage of the elopement of Patient 1 from the CSU patio was reviewed with the DON and DPO. The review of the footage of the incident reflected that on 09/19/2019 at 2019 one RN and one patient were present on the patio. At least four stool/chairs were positioned on the patio. The RN was observed to be handling an electronic music playing device that the patient had possession of. The RN was then observed to be tapping his/her foot and moving his/her body as if to the music while looking straight ahead. At 2021 a second patient arrived. At 2022 a third patient arrived. The RN was observed to not engage with, communicate with, or look at the patients and generally was gazing straight ahead and periodically moving his/her body as if to music. At 2024 Patient 1 presented to the patio and immediately began pacing and looking upwards toward the top of the patio fence and wall and the building roof. Only parts of the patient's head were visible at times as the one end of the patio was not fully covered by the camera. He/she repeatedly moved back and forth quickly, in and out of camera view. The RN was observed to look over at Patient 1 briefly and then return to his/her gazing. When the RN looked again his/her facial expression had a look of surprise as Patient 1 eloped onto the roof.

The RN was negligent and failed to provide the supervision required to assess Patient 1's escalating activity and provide appropriate interventions. This failure resulted in harm to Patient 1 as it led to the patient's successful elopement from the secure hospital and the likelihood of harm from potential self-harm or injury secondary to elopement.

b. On 09/25/2019 at 1635 an overhead page alerted staff that there was a "Code 10" in the courtyard. The surveyor proceeded to that area and observed several staff physically holding Patient 2 up against the wall of the courtyard outside of the South unit. The DON and the Medical Director were in attendance. The surveyor discontinued direct observations at that time to reduce the number of individuals at the scene.

During interview with the DON on 09/25/2019 at 1750 he/she indicated that the "Code 10" called at 1635 was a result of a MHT failure to follow door security procedures that allowed Patient 2 to exit from the secure South unit.

On 09/26/2019 at 1045 recorded video footage of the incident was reviewed with the DON and DPI. The video revealed that the MHT approached the South unit door from the courtyard and opened the door to the unit while Patient 2 who was in the unit was in the immediate proximity of the door. Patient 2 was observed to exit the South unit into the courtyard when the MHT opened the door.

The staff person was negligent and failed to comply with "door security" procedures to prevent Patient 2's elopement from the secure unit. This failure resulted in harm for Patient 2 as it led to the the use of hands-on physical restraint by multiple staff and to the patient's further behavior escalation and the incident that occurred at 1720 described below.

c. On 09/25/2019 at 1720 an overhead page alerted staff that there was a "Code 10" at the "Point of entry through South door." The surveyor proceeded to that area with the DPI and observed Patient 2 through the South unit exit door window. Patient 2 was exhibiting aggression, was kicking and hitting the exit door with significant force and was repeatedly yelling at staff to "open this door." Numerous staff were observed through the door window in the South unit hallway, including the DON, the ADON and the Medical Director. The surveyor concluded direct observations at that time to reduce the number of individuals at the scene.

During interview at 1750 with the DON he/she stated that staff did go "hands on" at his/her direction as the patient's behavior escalated further and he/she started to hit and attempt to damage the electronic "fob" door reader that allows staff to enter and exit the secure unit doors. The DON stated that the patient was transferred to the CSU unit where IM Haldol and IM Ativan were administered.

On 09/26/2019 at approximately 1100 recorded video footage of the incident was reviewed with the DON and DPI. The video revealed Patient 2's escalated behavior and that at 1724 five staff members used hands-on physical restraint to carry Patient 2 from the South unit hallway to the CSU unit "pod" room where two seclusion rooms were located. The patient was placed in one of the seclusion rooms with the door open and the door continued to be open throughout the observation. At 1728 five staff members used hands-on physical restraint to hold Patient 2's arms and legs and body down on the bed while a nurse was observed to administer two IM injections. Patient 2 continued to exhibit agitated and aggressive behaviors in the secure "pod" area such as banging on the closed, secure doors, trying the handle, and slamming shut the open door of the seclusion room.

This incident resulted in harm for Patient 2 as it led to two instances of hands-on physical restraint by multiple staff, two forced IM chemical restraints, and placement in a higher acuity unit.

d. On 09/26/2019 at 0930 an RN was observed escorting a patient out of the hospital through the main lobby secure front door. The RN failed to comply with "door security" procedures as he/she did not maintain his/her hands on the door until the door had completely closed.

e. On 09/26/2019 at approximately 1351 a frantic sounding overhead page alerted staff that there was a "Code 10" at the CSU nurses station. The paging system was not disconnected after the page was made for some time and therefore the sounds of chaotic events in the unit at that time could be heard overhead by all.

The surveyor was in the process of review of other recorded video footage with the DPI at that time and directed the DPI to switch to live video footage of the Code 10 in progress. During review of the live video footage of the CSU nurse's station at 1357 the surveyor observed a huddle of staff physically holding a patient down on the floor by the CSU nurse's station. The huddle of staff were observed to move the patient from that location to the CSU "pod" room and place the patient, recognized as Patient 2, in a seclusion room. A minimum of seven staff were observed to use hands-on physical restraint while a nurse administered two IM medications at 1359 and 1401.

At approximately 1415 on 09/26/2019 recorded video footage of the events leading up to the physical restraint and take down of Patient 2 was reviewed with the DON and the DPI. It was observed that at 1351 Patient 2 grabbed an object out of the back pants pocket of a staff person whose upper body was lying over the top of the nurses's station counter and who had his/her back to Patient 2. The DPI identified the staff person as a MHT.

The video footage reflected that the patient immediately attempted to run from the scene after having grabbed the object, however, was stopped by several staff who physically took Patient 2 down to the ground.

Further review of recorded video footage, prior to when Patient 2 grabbed the object, reflected that the object in the MHT's back pocket was a pair of scissors with the handles protruding from the top of the pants pocket. Beginning from at least 1338 the MHT was observed to have the scissors in his/her back pocket as he/she casually walked in the hallway around and near the CSU nurse's station and Patient 2. On occasion the MHT leaned in and laid his/her upper body over the nurse's station counter with his backside facing patients. The MHT had the scissors in his/her back pocket for at least 13 minutes prior to 1351 when Patient 2 grabbed and took the scissors. During those 13 minutes Patient 2 is observed to look at the object in the MHT's back pocket several times as he/she walked slowly around and behind the MHT.

The MHT was negligent and failed to prevent Patient 2 access to scissors that could be used to harm him/herself and others. This failure resulted in harm for Patient 2 as it led to the use of hands-on physical restraint by multiple staff, two forced IM chemical restraints, and seclusion.

f. Other observations made during the survey included staff wearing walkie-talkies and keys dangling loosely from their hips and walking throughout patient units with cell phones accessible in back pockets.

g. On 09/26/2019 at 1620, in accordance with the procedures in CMS SOM Appendix Q, the surveyor informed the hospital in writing, using the CMS IJ Template, that it had been determined that two immediate jeopardy (IJ) situations existed based on the observations made on 09/24/2019, 09/25/2019 and 09/26/2019.

h. On 09/27/2019 at 0928 a staff person was observed coming through two sets of secure doors, from the West 1 unit into the Intake and Admission unit, and from the Intake and Admission unit into the main lobby. In one hand the staff person was carrying a metal commuter coffee cup and a name badge with the lanyard dangling towards the floor. In the other hand he/she was carrying a plastic milk crate type box full of documents sideways by one handle. He/she walked through both sets of doors and failed to comply with "door security" procedures at both doors. He/she did not do a 360 degree observation of his/her surroundings and did not maintain his/her hands on the doors until they were closed as his/her hands were full.

i. On 09/27/2019 at 1415 an IJ Removal Plan was submitted by the hospital while the surveyor was onsite. The plan was not approved by the SA and the IJ continued. The survey was concluded on 09/27/2019.

3. Documentation of five other incidents that resulted from staff failures to follow "Door security" or failures to provide appropriate supervision in the last three months were reviewed. Those included:

a. Medical record and incident documentation for Patient 3 was reviewed. A medical record "nurse progress note" dated 09/20/2019 at 1950 reflected that "Pt seen exiting laundry room by [him/herself approximately] 1840. Pt. unharmed and wanded by security." An "Incident Investigation Summary" dated 09/20/2019 reflected "This RN was at nurse's station and saw pt. exit the laundry room unaccompanied...Pt asked who let [him/her] into the laundry room and pt replied 'housekeeper.'" There was no evidence of an investigation at the time of this survey.

b. An "Incident Investigation Summary" dated 08/28/2019 reflected staff failure to follow door security policies allowed Patient 4 to elope from the secure unit.

c. An "Incident Investigation Summary" dated 08/13/2019 reflected that three patients were found in the courtyard without any staff presence in the courtyard, an area restricted to patients without staff supervision.

d. An "Incident Investigation Summary" dated 07/09/2019 reflected that Patient 5 was allowed to elope from the secure facility with his/her visitors.

e. Medical record and incident documentation for Patient 6 reflected that on 07/08/2019 staff failure to follow door security policies allowed the patient to elope from the secure unit.

4. Documentation of 16 other incidents that resulted from staff failures to follow policies and procedures to prevent patient access to unsafe items in the last three months were reviewed. Those included:

a. Incident documentation for Patient 8 was reviewed. An initial "Incident Investigation Summary" dated 09/22/2019 reflected "New admit in [assessment center] refusing to give up belongings...Was placed on a hold...pt asked to use bathroom & smoked a ciggerette (sic) in the bathroom. After pt belongin (sic) were taken away...This writer took ciggerettes (sic) & lighter from pt..." There was no evidence of a final investigation at the time of this survey.

b. Medical record and incident documentation for Patient 9 was reviewed. A medical record "Event Progress Note" dated 09/21/2019 reflected that "Pt was admited (sic) on unit West 1 tonight and phone was on [his/her] person. An initial "Incident Investigation Summary" dated 09/21/2019 reflected "Pt. admitted on unit and had [his/her] phone in [his/her] room." There was no evidence of an investigation at the time of this survey.

c. Medical record and incident documentation for Patient 1 was reviewed. A medical record "nurse progress note" dated 09/19/2019 at 0740 reflected that "At 0650 pt. asked for Ativan at the nurses station, when nurse approached the window pt. had a lighter in [his/her] hand, [he/she] was lighting it up...Pt had/got [his/her] phone and refused to give it back, Staff encouraged [him/her] to return it. Pt. got upset and slammed it on the counter/threw against the wall and shattered [his/her] phone, completely (sic) broke." An initial "Incident Investigation Summary" dated 09/19/2019 reflected "RN...saw the patient was playing with a lighter...also discovered that the bag of [his/her] personal belongings was sitting next to [him/her]. We did a security check and we found nothing on [him/her]. [His/her] phone is missing from [his/her] personal belonging...With the help of the supervisors, the patient removed the phone from [his/her] sock...Education provided to staff about keeping safe bags out of reach of pts at the counter...No follow up necessary." There was no evidence of a final investigation into how and why the patient was allowed access to those contraband items at the time of this survey.

d. Medical record and incident documentation for Patient 10 was reviewed. A medical record "nurse progress note" dated 09/07/2019 at 1030 reflected that "Patient admitted on 9/3/19...for sexual victimization and suicide..." The next note dated 09/07/2019 at 1500 reflected "Patient moved beds to be in CPAP area...That has locked CPAP cupboard." An initial "Incident Investigation Summary" dated 09/07/2019 reflected "Witnessed patient wearing pants with strings...Patient stated [he/she] was given them when [he/she] admitted (her property). Patient also had CPAP machine on room floor this a.m. Patient stated nurse late last night set it up for her...It is unknown who set the CPAP up last night or provided the pants with strings. No follow up necessary." A final "Incident Investigation Summary" dated and signed by the DPI on 09/16/2019, nine days after the incident, reflected no investigation into the admission process for this patient that resulted in the patient having possession of contraband items, no investigation into how the patient had that unsafe item undetected by staff from 09/03/2019 until 09/07/2019, and no investigation into how a CPAP was set up in a room without a locked CPAP cupboard. Those failures resulted in potential harm for the patient. The only entry under "Process/Policy Change(s) Needed:" was "A review of the 'Contraband' policy and procedure found it to provide appropriate guidance to staff; no revisions are recommended at this time." However, the admission processes related to patient belongings are not included in the "Contraband" policy and procedure but in the "Patient Belongings" policy and procedure as identified in finding 1 above in this citation.

e. Medical record and incident documentation for Patient 11 was reviewed. A medical record "nurse progress note" dated 09/05/2019 at 1300 reflected that "This supervisor was notified that a pint of vodka (empty) was found in patients (sic) room by housekeeping...staff LPN...reported pt stated 'I drank it last night & snuck it in my pants.'" A final "Incident Investigation Summary" dated and signed by the DPI on 09/13/2019, eight days after the incident, reflected no investigation into the admission process for this patient that resulted in the patient having possession of the contraband item. That failure resulted in potential harm for the patient. The only entry under "Process/Policy Change(s) Needed:" was "A review of the 'Contraband' policy and procedure found it to provide appropriate guidance to staff; no revisions are recommended at this time. A review of the 'Skin Checks' policy and procedure found it to provide appropriate guidance to staff; no revisions are recommended at this time. It is noted that the patient reported shoving the bottle in [his/her] pants the previous night, which happened to be the night of her admit. It is unclear at what point in the admission procedure [he/she] was able to do this." Had an investigation into whether the admission process policies and procedures were followed for this patient been investigated that matter may have been made clear.

f. Incident documentation for Patient 12 was reviewed. An initial "Incident Investigation Summary" dated 09/03/2019 reflected "I was walking on to the North Unit from the lobby. I found on the floor by the lobby door 2 pills. I went on to North to give the pills to a nurse. I...found on the floor in front of the nurse station 10 more pills. Unit staff told me that the patient had dropped [his/her] items on [discharge] and they must of fell out (sic)." An RN note on the form dated 09/03/2019 reflected "Education to staff about monitoring pt all the way until they exit the building." A final "Incident Investigation Summary" dated and signed by the DPI on 09/09/2019, six days after the incident, reflected no investigation into how those pills came to be on the floor of the secure unit and other locations in the hospital. The DPI wrote only "Staff reported that a discharging patient had accidentally dropped [his/her] belongings while completing discharge and the pills must have fallen out at that point." There was no investigation to confirm that that was the case. There was no investigation into the admission process for this patient that resulted in the patient having pills in his/her belongings, nor an investigation into the discharge process that resulted in the patient dropping pills onto the floor of the secure unit. Further there was no evaluation of processes that allowed a patient who was still in the secure unit to have contraband items in their possession contrary to the policy and procedure. However, the DPI wrote that there were no revisions needed to the "Contraband" and "Patient Belongings" policies and procedures.

g. Medical record and incident documentation for Patient 13 was reviewed and reflected that on 08/28/2019 at 1845 the patient was found on the floor of his/her bathroom room with the shower curtain detached from the ceiling and wrapped four times around his/her neck. The bathroom floor was flooded. The final "Incident Investigation Summary" dated and signed by the DPI on 09/06/2019, nine days after the suicide attempt, reflected no investigation into how and why the incident occurred and into whether staff was providing the appropriate level of supervision and observation to ensure he/she was safe. The documentation only identified the actions that were taken in response to finding the patient.

h. Medical record and incident documentation for Patient 14 was reviewed. A medical record "nurse progress note" dated 08/08/2019 at 1545 reflected that "At approximately 1300 Pt was found in [his/her] room having removed an electrical outlet from the wall. A staff member obtained the outlet wiring and box from the patient and was able to block the patient from accessing the opening in the wall. The power was shut off to the outlet in question...A pillow was found in the room with what appeared (sic) to be a burn mark. Pt stated later that [he/she] had planned to cut [him/herself] with the wall plate from the electrical outlet. Pt had previously made similar comments to support staff..." The final "Incident Investigation Summary" dated and signed by the DPI on 08/16/2019, eight days after the incident, reflected that "Self Harm, Suicide, Aggression and Elopement Precautions were initiated following similar incidents earlier in [his/her] admission." However, there was no investigation into the 08/08/2019 incident. There was no investigation into how the patient was able to remove the electrical outlet from the wall, how he/she was able to unscrew the outlet wall plate, how burn marks got on the pillow and how he/she could have done that undetected. There was no investigation into whether staff had provided the appropriate level of supervision and observation to ensure he/she was safe, particularly when the patient had made previous comments about harming him/herself with the electrical outlet and had other prior incidents.

i. Similar findings that reflected untimely and incomplete investigations were identified for the following incidents:

* An "Incident Investigation Summary" dated 07/09/2019 for Patient 18 who was found with a ligature he/she had made from torn clothing on 07/01/2019.

* An "Incident Investigation Summary" dated 07/16/2019 for a narcotic medication found in Patient 16's room on 07/05/2019.

* An "Incident Investigation Summary" dated 07/16/2019 for five unidentified pills found in an empty paper oatmeal pouch in Patient 16's sweater pocket on 07/13/2019.

* An "Incident Investigation Summary" that was not dated and signed for unidentified medications found in a contact lens case in Patient 17's room on 07/06/2019.

* An "Incident Investigation Summary" dated 08/05/2019 for torn blanket strips found in Patient 15's room on 07/31/2019 that he/she stated he/she intended to harm self with.

* An "Incident Investigation Summary" that was not dated and signed for Patient 14 who was found with torn blanket strips around his/her neck on 08/05/2019.

* An "Incident Investigation Summary" dated 08/14/2019 for Patient 14 who was again found with torn blanket strips under his/her mattress on 08/06/2019.

* An "Incident Investigation Summary" dated 08/14/2019 for Patient 14 who was again found with torn bath towel strips on 08/07/2019.

Although Patient 14 had three incidents that involved torn strips from linens to create ligatures on 08/05/2019, 08/06/2019 and 08/07/2019, and was found with a ligature around his/her neck on the first occasion, there were no investigations documented until 08/14/2019, after all three incidents had occurred, and those were not adequate.

5. Documentation of 25 incidents that resulted from staff's negligence to follow safe and appropriate medication administration procedures in the last three months were reviewed. Refer to the findings cited under Tag A405, CFR 482.23(c), CoP Nursing Services - Standard: Preparation and administration of drugs.

6. Other failures to follow policies and procedures developed to ensure safe care were observed:

a. The policy and procedure titled "Facility Access, Door Security and Key Control" dated as last reviewed 03/14/2019 reflected that "Professional visitors will: a. Sign in with Receptionist, b. Display their agency identification while in the hospital in addition to the Cedar Hills Visitor Sticker..."

On 09/24/2019 at approximately 1400 the surveyor presented to the hospital's main entrance reception desk and was not prompted to sign in nor provided with a visitor sticker.

On 09/25/2019 at approximately 0915 the surveyor presented to the hospital's main entrance reception desk and was not prompted to sign in nor provided with a visitor sticker. Just prior to being escorted from the main lobby to the secured administration area the surveyor initiated that process and was provided a visitor sticker at that time.

b. The policy and procedure titled "Smoking and Tobacco Use" dated as last reviewed 01/07/2019 reflected that "Cedar Hills Inpatient Hospital campus...is tobacco-free...Tobacco products, which include electronic cigarettes, are not allowed on the inpatient hospital campus or in any of the facility vehicles, by staff, patients or guest (sic)...guests will be required to leave the campus in order to smoke."

On 09/25/2019 at approximately 1815 three individuals were observed in the front of the hospital, on the hospital campus, standing in and around the parking lot near the main entrance and the barkdust in the adjacent shrubbery beds. At least one of the individuals was observed to be smoking in the barkdust area. The individual(s) extinguished the cigarette(s) and entered the hospital building at 1823. Observation of the barkdust plant beds in that area at that time readily revealed 11 extinguished cigarette butts.

Based on observations that included live and recorded video footage, interviews, review of incident and medical record documentation for 33 of 33 patients reviewed for incidents in the last three months (Patients 1 through 33) and review of policies and procedures it was determined that the hospital failed to fully develop and implement policies and procedures that ensured patients' rights to safe care were recognized, protected and promoted as follows:
* Investigations of, and response to, incidents and adverse events that reflected potential neglect were not timely, clear, complete and accurate to ensure those incidents and events did not recur.
* Those incidents and events included actual or potential harm that resulted from failure to prevent unsafe items and contraband in the environment, failure to comply with elopement prevention procedures, failure to provide appropriate supervision of patients, and failure to prevent medication errors.

The CMS Interpretive Guideline 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 Guideline reflects that 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.

This is a repeat Standard-level deficiency cited previously in surveys completed on 12/13/2018, 02/28/2019, and 05/16/2019.

Findings include:

1. Refer to the findings cited under Tag A144, CFR 482.13(c)(2), CoP Patient's Rights - Standard: Right to safe care. Those findings reflect the hospital's failure to ensure investigations of neglect were timely, clear, complete and accurate to prevent recurrence for patients reviewed who experienced incidents that resulted in potential or actual harm.

2. Refer to the findings cited under Tag A405, CFR 482.23(c), CoP Nursing Services - Standard: Preparation and administration of drugs.

Based on observations that included live and recorded video footage, interviews, review of incident and medical record documentation for 33 of 33 patients reviewed for incidents in the last three months (Patients 1 through 33) and review of policies and procedures it was determined that the QAPI program was not effective to ensure the provision of safe and appropriate care to patients in the hospital that complied with the Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

This is a repeat deficiency cited previously in surveys completed on 12/13/2018 and 02/28/2019.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13 - CoP Patient's Rights.

Based on observations that included live and recorded video footage, interviews, review of incident and medical record documentation for 33 of 33 patients reviewed for incidents in the last three months (Patients 1 through 33) and review of policies and procedures it was determined that nursing services had not been organized and managed to ensure the provision of safe and appropriate care to patients as follows:
* Patients were allowed access to contraband and unsafe items and timely and complete investigations of those incidents were not conducted to ensure those did not recur.
* "Door security" measures were not followed and supervision was not provided to prevent patients from inappropriate departure, or elopement, from the secured facility and from secured units and timely and complete investigations of those incidents were not conducted to ensure those did not recur.
* Medications were not administered in a safe manner.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care.

This is a repeat deficiency cited previously in surveys completed on 12/13/2018 and 02/28/2019.

Findings include:

1. Refer to the findings cited under Tag A395, CFR 482.23(b)(3), CoP Nursing Services - Standard: RN supervision and evaluation of nursing care for each patient.

2. Refer to the findings cited under Tag A405, CFR 482.23(c), CoP Nursing Services - Standard: Preparation and administration of drugs.

3. Refer to the findings cited under Tag A115, CFR 482.13, CoP Patient's Rights.

Based on observations that included live and recorded video footage, interviews, review of incident and medical record documentation for 33 of 33 patients reviewed for incidents in the last three months (Patients 1 through 33) and review of policies and procedures it was determined that the RN failed to supervise and evaluate the provision of safe and appropriate nursing services to patients as follows:
* Patients were allowed access to contraband and unsafe items and timely and complete investigations of those incidents were not conducted to ensure those did not recur.
* "Door security" measures were not followed and supervision was not provided to prevent patients from inappropriate departure, or elopement, from the secured facility and from secured units and timely and complete investigations of those incidents were not conducted to ensure those did not recur.
* Medications were not administered in a safe manner.

This is a repeat Standard-level deficiency cited previously in surveys completed on 12/13/2018, 02/28/2019, and 05/16/2019.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13, CoP Patient's Rights.

2. Refer to the findings cited under Tag A405, CFR 482.23(c), CoP Nursing Services - Standard: Preparation and administration of drugs.

Based on review of incident and medical record documentation for 21 of 21 patients reviewed for medication errors and incidents in the last three months (Patients 3, 11, 12, 14, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 and 33) it was determined that the hospital failed to ensure the provision of safe and appropriate care to prevent medication errors.

Medication practices did not conform with the "six rights of medication administration" to ensure that patients received care in a safe setting. Recognized standards of practice for the "rights of correct medication administration" are referenced on the Lippincott Nursing Center website on 08/06/2018 and are identified as the "Right patient...Right medication...Right dose...Right route...Right time...Right documentation."

This is a repeat Standard-level deficiency cited previously in surveys completed on 12/13/2018, 02/28/2019, and 05/16/2019.

Findings include:

1. Documentation of 25 incidents that resulted from staff's negligence to follow safe and appropriate medication administration procedures in the last three months were reviewed. Investigations of those incidents were not clear or complete. Those incidents reflected:

a. There were two medication errors for Patients 11 and 21 who received the wrong medication.

For example: A "Medication Variance Report" for Patient 21 dated 07/20/2019 reflected the patient was administered a nervous system stimulant medication in extended release pills that had been split to achieve the correct dose. Therefore the patient had received the wrong form of the medication as splitting or cutting an extended release pill negates the extended release action. The form reflected the error occurred for two days but it did not specify the dates and times. The "Type of Error" was unclearly recorded as "Documentation/Transportation." The only "Potential contributing factors" was identified as "MAR incorrect." The section for "Suggestions to Prevent Reoccurrences" was blank. The only "Additional Comment" was that "education provided r/t unable to cut extended release meds in half."

b. There were three medication errors for Patients 26, 28 and 31 who did not received ordered medications.

For example: A "Medication Variance Report" for Patient 31 reflected that on 07/25/2019 the patient did not receive the ordered anti-anxiety medication. The form indicated that 2 mg of the medication was dispensed and "Not recorded on Mar." The report reflected that the order was "Not on MAR." "Potential contributing factors" were identified as "Interruption during administration/transcription, Noise level, Staffing concern." The section for "Suggestions to Prevent Reoccurrences" was unclear and reflected "Slowdown. Ask for proper training on how to document error." The "Additional Comments" section was additionally unclear and reflected that "2 mg not given to patient. 1 mg administered." The form was not signed or dated in the "DON Review" space.

c. There were nine medication errors for Patients 19, 21, 23, 24 on two occasions, 27, 30, 32 and 33 who received the wrong doses.

For example: A "Medication Variance Report" for Patient 27 reflected that on 08/01/2019 the patient received the wrong dose of sliding scale insulin based on his/her blood sugar level. "Potential contributing factors" were identified as "Interruption during administration/transcription, Noise level, distraction." The section for "Suggestions to Prevent Reoccurrences" was blank. The "Additional Comments" section was blank. The form was not signed or dated in any of the four signature spaces for "Employee...Employee...NM/Shift Supervisor...DON Review"

d. There were two medication errors for Patients 3 and 29 whose medications were administered at the wrong times.

For example: A "Medication Variance Report" for Patient 29 reflected that on 08/01/2019 the patient received the ordered anti-psychotic medication at 0756 in the morning instead of the time it was to be given at HS or bedtime. The section for "Potential contributing factors" was blank. The section for "Suggestions to Prevent Reoccurrences" was blank. The "Additional Comments" section was blank. The form was not signed or dated in any of the four signature spaces for "Employee...Employee...NM/Shift Supervisor...DON Review"

e. There were seven unexplained medication errors that resulted in controlled substance count discrepancies for Patients 14, 20, 22, 25, 28, 31 and 32.

2. There were four instances where medication pills, including a narcotic, were found in patient rooms and elsewhere on the unit for Patients 12, 16 on two occasions and 17. Refer to the findings related to contraband medications cited under Tag A115, CFR 482.13, CoP Patient's Rights.