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The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Based on a review of medical records, Hospital polices and procedures, surveillance video, and staff interviews, for one (Patient #3) of 15 sampled patients, it was determined that the Hospital failed to ensure staff compliance with established procedures to enhance patient safety. On 6/15/25, staff failed to follow the Electronic Device Policy and Patient #3 had unsupervised access to a cell phone in their room and used it to self-harm, requiring transfer to the Emergency Department for evaluation and treatment.

The Hospital also failed to ensure restraints were implemented according to Hospital policy for five patients (#3, #4, #5,#6 and #10) out of a total sample of 15 patients. 1. Patient #4 was maintained in a prolonged physical hold in a prone position on the ground. 2. Patient #5 was physically restrained in a restraint chair without constant observation of the Patient being maintained. 3. Patient #3 was placed on a constant observer for approximately 11 hours without a physician order. 4. Patient #10 was placed in seclusion without a physician order and had no continuous observer assigned allowing Patient #10 to get out of seclusion and enter the nurses station. 5. Patient #6 was physically restrained in a restraint chair and placed in the seclusion room without constant observation of the Patient being maintained.

Cross Reference: Patient Rights:
-Care in a Safe Setting (Tag 144).
-Use of Restraint or Seclusion (Tag 154).

The Condition of Participation: Quality Assessment and Performance Improvement (QAPI) Program was not in substantial compliance.

Based on records reviewed and interview the Hospital failed for seven Patients (#3, #4, #5, #6, #7, #8 and #10) out of a total sample of 15 patients, to ensure the Quality Assessment and Performance Improvement (QAPI) Program implemented actions identified for the Hospital's performance improvement following safety events involving multiple patients; (Patient Rights for monitoring/maintaining a safe environment and restraint use against Hospital policy 115); (Nursing Services for nursing staff failure to follow Hospital policy and procedure 385).

Cross Reference:
- QAPI: Quality Improvement Activities (Tag 283)
- Patient Rights: Care in a Safe Setting (Tag 144).
- Patient Rights: Use of Restraints or Seclusion (Tag 154).
- Nursing Services: Supervision of Contract Staff (Tag 398).

The Hospital was out of compliance for the Condition of Participation for Nursing.

Based on a review of medical records, Hospital policy and procedures, observations, and staff interviews, the hospital failed to ensure nursing staff adhered to established Hospital policies and procedures for four (Patient #3, #5, #7, and #8) of 15 sampled patients. 1. Patient #3 was left alone with a cellphone and able to self-harm, 2. Patient #7 was involved in patient-to-patient altercation without physician notification, 3. Patient #5 was involved in patient-to-patient altercation without physician notification, 4. Patient #8 was refused at the admitting inpatient psychiatric unit and unnecessarily transferred back to the Hospital's Emergency Department (ED), delaying care.

Cross Reference: Patient Rights: Supervision of Contract Staff (Tag 398).

Based on a review of medical records, Hospital polices and procedures, and staff interviews, for one (Patient #3) of 15 sampled patients, it was determined that the Hospital failed to ensure staff compliance with established procedures to enhance patient safety. On 6/15/25, Patient #3 was seen coming of his/her room with blood all over his/her chest, bilateral forearms, hands, and neck. Patient #3 said he/she broke his/her [cell] phone and used it to cut him/herself with a desire to kill him/herself after an upsetting phone conversation. Patient #3 was emergently transferred the Emergency Department (ED) and received 14 stitches on his/her forearm and 13 stitches on his/her right forearm.

Findings include:

Review of the Hospital's policy titled Use of Patient Electronic Device Policy, dated 5/25/22, indicated Patient's use of personal electronic devices, which included cell phones, was restricted to media groups and in order to enhance a safe and therapeutic environment and to protect the privacy of patients, each unit will designate specific public areas for use of electronic devices.

Review of Patient #3's medical record indicated he/she presented to the Hospital reporting a manic episode and "dark thoughts," with a known history of Bipolar Disorder. Patient #3 requested a psychiatric evaluation, resulting in a voluntarily admission for inpatient psychiatric care. Patient #3 also reported multiple past suicide attempts.

A further review indicated that on 6/15/25 at approximately 11:12 A.M., Patient #3 had an upsetting phone call and began to pull out the fire extinguisher, throwing chairs, hitting walls, ripping hand sanitizers off the wall, screaming, and yelling. Patient #3 was physically restrained in a restraint chair and administered medication restraint.

Review of the Hospital's Internal Investigation indicated that on 6/15/25 at approximately 7:08 P.M., Patient #3 was seen coming of his/her room with blood all over his/her chest, bilateral forearms, hands, and neck. Patient #3 said he/she broke his/her [cell] phone and used it to cut him/herself with a desire to kill him/herself after an upsetting phone conversation. Patient #3 was placed on a constant observer and staff called 911 to transfer Patient #3 to the ED. Patient #3 returned to the behavioral health unit at approximately 10:12 P.M., with 14 stitches on his/her forearm, 13 stitches on his/her right forearm, and neck lacerations with small amounts of bleeding.

There was no documentation to support that the Hospital developed or implemented system-wide corrective actions after staff failed to follow the Electronic Device Policy on 6/15/25. On that date, Patient #3 had unsupervised access to a cell phone in their room and used it to self-harm, requiring transfer to the emergency department for evaluation and treatment.

During an interview on 8/21/25 at 8:45 A.M., the Market Director of Behavioral Health said she was aware of Patient #3's self-harm event on 6/15/25. The Director said staff failed follow several Hospital policies related to Patient #3's safety event.

During an interview on 8/25/25 at 2:15 P.M., and throughout the Survey, the Market Director of Clinical Quality Improvement and the Risk Manager provided documentation of the Hospital's Internal Investigation and review of Patient #3's self-harm event on 6/15/25, however, they said there was no documentation at the time of Survey to support the Hospital implemented system-wide corrective actions related to following the Patient Electronic Device Policy to supervise patients electronic device use in designated public areas.

Based on record review, surveillence footage review, and interviews, the Hospital failed to ensure restraints were implemented according to Hospital policy for five patients (#3, #4, #5,#6 and #10) out of a total sample of 15 patients. 1. Patient #4 was maintained in a prolonged physical hold in a prone position on the ground. 2. Patient #5 was physically restrained in a restraint chair without constant observation of the Patient being maintained. 3. Patient #3 was placed on a constant observer for approximately 11 hours without a phyician order. 4. Patient #10 was placed in seclusion without a physician order and had no continuous observer assigned allowing Patient #10 to get out of seclusion and enter the nurses station. 5.Patient #6 was physically restrained in a restraint chair and placed in the seclusion room without constant observation of the Patient being maintained.

Findings include:

1. The Hospital's Policy titled "Restraint and Seclusion", dated 12/28/23, indicated the following:
-Staff will apply restraint or seclusion only when less restrictive interventions are ineffective.
-Staff will use the least restrictive form of restraint or seclusion that protects the physical safety of the patient, staff, or others.
-Staff must discontinue restraint or seclusion at the earliest possible time, regardless of the scheduled expiration of the order.

The Hospital's behavioral medicine policy titled "Restraint and Seclusion Policy", dated 11/15/23, indicated the following:
-Patients have the right to be free from any form of restraint that is not medically necessary.
-Restraints and seclusion will only be utilized in an emergency situation in which there is imminent risk for self-harm and/or harm to staff or others.
-Physical restraint may only include bodily holding of a patient with no more force than is necessary to limit the patient's movement.
-The Registered Nurse (RN), Social Worker, and other clinical team members are responsible for obtaining information on all patients, that might indicate causes of behavioral escalation and techniques used to avoid or manage such behavioral events. The Safety Tool will be used to document and communicate this data.
-Restraint or seclusion use is LIMITED TO EMERGENCIES when there is imminent risk of physical harm to the patient or others and only when other less restrictive measures have been found to be ineffective.
-Alternative methods include but are not restricted to: appropriate medication, including PRN medication.
-Documentation will include: rationale for restraint or seclusion.
-The Patient's privacy and dignity must be safeguarded at all times.
-The patient shall be placed in a position that allows airway access and does not compromise respiration. A face down position shall not be used unless: there is a specified preference and there is no psychological or medical contraindication to its use; or there is an overriding psychological or medical justification for its use that shall be documented.
-The patient will be on a constant observation while in restraint or seclusion by a qualified staff member.
-The patient's privacy and dignity will be maintained while in restraints or seclusion. The patient in restraints must not be visible to other patients and must not be visible from common areas.
-The Patient must be advised of the criteria for release when they are initially placed in restraints or seclusion and staff must assist the patient in achieving such criteria.
-The patient and staff participate in a debriefing session regarding the restraint or seclusion episode.
-The debriefing episode is used to: identify triggers that led to the incident and what could have been handled differently to prevent the use of restraint and seclusion; ascertain that the patient's physical wellbeing, psychological comfort, and right to privacy were addressed.
-Each episode of restraint or seclusion is recorded.

Patient #4 was admitted to the Hospital's Child Development Unit (CDU) on 7/1/25 with diagnoses of adjustment disorder and aggressive behavior.

Review of Patient #4's medical record indicated the Patient presented to the Hospital's Emergency Department on 6/30/25 after assaultive behavior towards staff at his/her residential program. Patient #4 was transferred to the Hospital's CDU for an inpatient psychiatric admission for evaluation, treatment, psychopharmacology consultation, and disposition planning. On 7/12/25 at 6:55 P.M., a code green was called on the CDU for Patient #1 for seclusion, chair, intramuscular (IM) medication, and a physical hold for assaultive behavior towards staff. Patient #4 was punching ceiling tiles out in the unit hallway and put another Patient (#10) on his/her shoulders so they could both punch ceiling tiles out. During this time another Patient (#5) was in the unit atrium in a restraint chair; Patient #4 attempted to release Patient #5 from the restraint chair, and when staff intervened, he/she assaulted multiple staff. It was documented by RN#8 that Patient #4 punched, headbutted, and kicked staff during physical hold, was placed in the chair (restraint chair) and given IM medications of Ativan 1mg (milligram), Haldol 5mg, and Benadryl 50mg. The time of Patient #4's restraint was 58 minutes.

Review of Patient #4's Emergency Restraint or Seclusion Form, dated 7/12/25 at 7:22 P.M., indicated the Patient was assaultive to multiple staff. Patient #1 was first placed in a physical restraint, then a mechanical restraint (restraint chair), then placed in seclusion, and then administered a medication restraint. Patient #4 received IM Benadryl, Ativan, and Haldol at 8:05 P.M. on 7/12/25. Patient #4 was released from restraint on 7/12/25 at 8:20 P.M.

Review of Patient #4's Patient Debriefing and Comment form, dated 7/13/25, indicated Patient #4 had a complaint regarding his/her restraint on 7/12/25. Patient #4's complaint regarding his/her restraint on 7/12/25 was that he/she was on the ground and a staff member refused to move his arm and the Patient could not breathe; the staff member told the Patient he/she was complaining.

The security surveillance footage of the CDU outdoor atrium area dated 7/12/25 at 7:02 P.M. was reviewed. Patient #4 was in the open area with Patients #5 and #10. The Patients ripped paneling off one of the atrium's walls. Multiple staff began to intervene, and three restraint chairs were brought into the outdoor area. Patients #5 and #10 were being restrained in restraint chairs. Patient #4 was placed in a physical hold by staff about nine minutes into the video; three staff members held Patient #4 prone on the ground. 15 minutes into the video, Patients #5, #10, and another patient were restrained in the restraint chairs and moved inside the CDU; Patient #4 remained prone on the ground with three staff holding him/her down. Patient #6 entered the CDU outside area and remained outside. At 33 minutes and 22 seconds of the video, another staff member brought a restraint chair to the outside area; Patient #4 was still being held prone on the ground. 36 minutes and 30 seconds into the video, the staff members holding Patient #4 on the ground released the Patient, he/she stood up on his/her own, walked to the restraint chair on his/her own, and sat in the chair. Staff then restrained Patient #4 in the restraint chair and brought the Patient into the CDU. Patient #4 was in a physical hold, prone on the ground for approximately 27 minutes and 30 seconds without any position change or other intervention.

During an interview with Physician #2 on 8/20/25 at 9:12 A.M., he said he did not recall many details about Patient #4. He said physical holds are typically short, around one minute, and used to initially get control of a patient, get the patient medication, and get the patient to a safer restraint. He said typically once the Hospital staff establish a physical hold on a patient, the staff will get a restraint chair and call a physician for medication orders. He said maintaining a physical hold on a patient for over 20 minutes is excessive.

During an interview with RN #3 on 8/20/25 at 2:30 P.M., she said the weekend of 7/12/25 and 7/13/25 was chaotic with multiple incidents and restraints. She said multiple staff were floated to the CDU to staff it, particularly on 7/13/25. She said the Hospital has had many new nurses hired and the group of patients on the unit during that time period were challenging.

During an interview with the Behavioral Health Nurse Educator on 8/21/25 at 9:20 A.M., she said all staff involved in the 7/12/25 incident were retrained on CPI techniques (de-escalation/restraint training). She said the CDU staff were still receiving training on chair restraints and physical holds to chair restraints, and the training would also be taken house wide. She said security staff were also to be retrained on chair restraints. She said she reviewed the security footage of the CDU outside area/atrium dated 7/12/25 and saw the physical hold of Patient #4. She said the Hospital staff should not perform physical holds like that. She said once a patient is brought to the ground, staff should attempt to sit the patient up and prepare to either medicate the patient or move to another restraint. She said the Hospital staff are not trained to perform prone physical holds on patients and a hold in that manner requires specialized training. She said Patient #4 was able to get up in control after he/she was released from the physical hold, and the use of the restraint chair was unnecessary at that time.

During an interview with the Market Director of Clinical Quality Improvement on 8/21/25 at 9:00 A.M., she said a root cause analysis was performed by the Hospital regarding the events occurring on the CDU during 7/12/25 and 7/13/25 including multiple code greens and patient restraints. She said multiple action items were identified for performance improvement during the root cause analysis. She said while multiple items were completed from the action plan developed from the root cause analysis, some items were still not completed including staff re-education for the Hospital and disciplinary actions for staff members involved.

RN #8 was not available for interview.

The Hospital failed to ensure Patient #4 was restrained according to Hospital policy and procedure.

2. Patient #5 was admitted to the Hospital CDU on 7/2/25 with diagnoses of ADHD (Attention-deficit/hyperactivity disorder), PTSD (Post Traumatic Stress Disorder), and aggressive behaviors.

Review of Patient #5's medical record indicated the Patient was admitted to the CDU on 7/2/25 after presenting to the Hospital's Emergency Department following a physical altercation with staff at his/her group home. On 7/13/25 Patient #5 was involved in a physical altercation with Hospital staff; Patient #13 was restrained in a restraint chair and chemically medicated.

Review of Patient #5's Emergency Restraint or Seclusion Form dated 7/13/25 indicated the Patient was restrained starting at 7:45 P.M. on 7/13/25 due to Patient #5 punching Hospital staff. It was documented order of interventions indicated Patient #5 was first given a physical restraint, put in seclusion, given a medication restraint of IM Benadryl 25 mg and IM Zyprexa 0.5 mg, then put in a restraint chair. Patient #5 received the IM medications at 8:55 P.M. on 7/13/25. Patient #5 was monitored by RN # 10 from 7:40 P.M. to 9:05 P.M. on 7/13/25; Patient #5 was released from restraints at 9:05 P.M.

During an interview with RN #3 on 8/20/25 at 2:30 P.M., she said the weekend of 7/12/25 and 7/13/25 was chaotic with multiple incidents and restraints. She said multiple staff were floated to the CDU to staff it, particularly on 7/13/25. She said the Hospital has had many new nurses hired and the group of patients on the unit during that time period were challenging.

During an interview with SO #2 on 8/25/25 at 9:15 A.M., she said she was working on the CDU on the evening of 7/13/25. She said there was a lot going on during her shift on the CDU. She said Patients #5 and #6 had been restrained in restraint chairs. She said Patients #5 and #6 were transferred in restraint chairs to separate rooms. She said patients who are restrained require 1 to 1 observation; she was not sure who was providing the monitoring/constant observation to either Patient #5 or #6.

During an interview on 8/25/25 at 10:15 A.M., SO#4 declined to talk with the surveyor and referred the surveyor to his HR representative who could not be reached.

During an interview with RN #10 on 8/25/25 at 3:50 P.M., she said she was not providing constant observation for either Patients #5 or #6 during their restraints on 7/13/25. She said Patient #6 was restrained in the restraint chair and brought to the seclusion room but was unsure where Patient #5 was brought to after being restrained in a restraint chair. She said she had been behind the nursing station desk at that time on 7/13/25.

The Hospital failed to ensure Patient #5 was maintained under constant observation while physically and mechanically restrained as required by Hospital policy.


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Review of the Hospital's policy titled Constant Observer for Patients Under Harm, dated 6/15/22, indicated the Hospital would use competent constant observers (CCO) to provide continuous observation of a patient under suicide/self-harm and harm to other precautions to support safety. If a patient was at risk of suicidal/at risk of self-harm or others, the Facility should assign a CCO immediately. After completing a medical screening exam, the level of constant observation is ordered by a qualified medical provider.

Review of Patient #3's medical record indicated he/she presented to the Hospital reporting a manic episode and "dark thoughts," with a known history of Bipolar Disorder. Patient #3 requested a psychiatric evaluation, resulting in a voluntarily admission for inpatient psychiatric care. Patient #3 also reported multiple past suicide attempts.

Review of the Hospital's Internal Investigation indicated that on 6/15/25 at approximately 7:08 P.M., Patient #3 was seen coming of his/her room with blood all over his/her chest, bilateral forearms, hands, and neck. Patient #3 said he/she broke his/her [cell] phone and used it to cut him/herself with a desire to kill him/herself after an upsetting phone conversation. Patient #3 was placed on a constant observer and staff called 911 to transfer Patient #3 to the Emergency Department. Patient #3 returned to the behavioral health unit at approximately 10:12 P.M., with 14 stitches on his/her forearm, 13 stitches on his/her right forearm, and neck lacerations with small amounts of bleeding.

The Nurse Progress Notes, dated 6/16/25, indicated Patient #3 was on a constant observer until 11: 30 A.M. and then placed on five-minute checks after meeting with a physician.

There was no documentation in the medical record to support a physician ordering a constant observer for Patient #3 from 6/15/25 to 6/16/25, following the self-harm event.

During an interview on 8/20/25 at 1:14 P.M., Physician #1 said staff failed to notify him of Patient #3's safety event on 6/15/25 and failed to obtain a physician ' s order for Patient #3's constant observer implemented following the event.

During an interview on 8/25/25 at 2:15 P.M., and throughout the Survey, the Market Director of Clinical Quality Improvement and the Risk Manager provided documentation of the Hospital's Internal Investigation and review of Patient #3's self-harm event on 6/15/25, however, they said there was no documentation at the time of Survey to support the Hospital implemented system-wide corrective actions related to obtaining an physician order for a patient constant observer.



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4. Patient #10 was admitted to the CDU on 6/25/2025 with diagnoses including Diabetes Mellitus Type 1, Post Traumatic Stress Disorder (PTSD) and disruptive mood disorder.

Review of Patient #10's medical record indicated the Patient presented to the Emergency Department on 6/23/2025 with Department of Children and Families (DCF), for medical clearance after running away for three days. Patient #10's chief complaint included Suicidal Ideation.

Review of Patient #10's medical record indicated the Patient was restrained on 7/13/2025 from 8:49 P.M. to 8:50 P.M. for assaulting staff. Restraint documentation indicated Patient #10 was first physically restrained and then medications including Zyprexa 2.5 mg Intramuscularly (IM) and Benadryl 50 mg IM.

Review of a Nursing Narrative dated 7/13/2025 at 11:13 P.M., indicated Patient #10 was involved in a violent event with peers towards staff on the CDU. The event required three code green events to be called, as well as 911. Staff were physically injured, one required treatment at the Emergency Department.

Review of Hospital events on 7/13/2025 indicated Patient #10 began assaulting staff and was brought back to the seclusion room. Staff did not secure the door properly to the seclusion room and Patient #10 was able to exit, enter the nursing station and began assaulting staff.

During an interview on 8/21/2025 at 9:40 A.M., The Behavioral Health Nurse Educator said during the riot event on 7/13/2025, Patient #10 was brought into the seclusion room as a restraint to attempt to deescalate the Patient.

During an interview on 8/25/2025 at 9:15 A.M., Security Officer #2 said during the events of the 7/13/2025 evening shift, Patient #10 was brought to the seclusion room. She said she was not sure who brought Patient #10 to the seclusion room, but the Patient was able to get out through the door in between the seclusion room and nurses ' station back hallway. She said typically, that door is locked.

During an interview on 8/25/2025 at 2:20 P.M., the Market Director Clinical Quality Improvement said Patient #10 was placed into an improper physical hold and placed into seclusion during the events on 7/13/2025. The Surveyor requested the restraint documentation for Patient #10 for the discussed events. At 3:15 P.M., The Marketing Director Clinical Quality Improvement was unable to find an additional restraint event on 7/13/2025.

The hospital failed to follow the Restraint Policy by not obtaining a Physician order for restraint/seclusion, not providing constant observation while in seclusion and not documenting the restraint events for Patient #10.

5. Review of Patient #6 ' s medical record indicated he/she was admitted because of non-compliance with critical anticoagulant medication. On 7/13/2025 Patient #6 was involved in a physical altercation towards staff. Patient #6 was restrained with physical restraints, seclusion, a restraint chair and with medication.

Review of Patient #6 ' s Emergency Restraint or Seclusion Form dated 7/13/2025, indicated restraint began at 8:10 P.M., for assaulting staff including biting and kicking. The record indicates Patient #6 was first physically restrained, put in seclusion, medicated with Zyprexa 5 mg intramuscularly (IM), Benadryl 50 mg IM and then placed in a mechanical chair restraint. Patient #6 was released from mechanical restraint at 9:00 P.M.. The restraint record indicated RN #10 was responsible for continuous observation while the Patient was in the chair restraint.

During an interview with SO #2 on 8/25/2025 at 9:15 A.M., she said she was working on the CDU on the evening of 7/13/2025. She said there was a lot going on during her shift on the CDU. She said Patients #5 and #6 had been restrained in restraint chairs. She said Patients #5 and #6 were transferred in restraint chairs to separate rooms. She said patients who are restrained require 1 to 1 observation; she was not sure who was providing the monitoring/constant observation to either Patient #5 or #6.

During an interview on 8/25/2025 at 3:50 P.M.,RN #10 said she was not providing constant observation for Patient #6 while in restraints on 7/13/2025. She said Patient #6 was restrained in the restraint chair and brought to the seclusion room. She said she had been behind the nursing station desk at that time on 7/13/2025. 

 The hospital staff failed to follow the Hospital ' s Restraint and Seclusion Policy for Patient #6 by not providing continuous one-to-one observation during restraint/seclusion.

Based on records reviewed and interview the Hospital failed for seven Patients (#3, #4, #5, #6, #7, #8 and #10) out of a total sample of 15 patients, to ensure the Quality Assessment and Performance Improvement (QAPI) Program implemented actions identified for the Hospital's performance improvement following safety events involving multiple patients; (Patient Rights for monitoring/maintaining a safe environment and restraint use against Hospital policy 115); (Nursing Services for nursing staff failure to follow Hospital policy and procedure 385).

Findings include:

Review of the Hospital's policy titled "Patient Care Assessment Program (PCAP) Plan 2025", dated January 2025, indicated the Hospital was committed to the provision of quality patient care and understands there must be ongoing critical review of all aspects of the provision of care to identify problems and implement preventative measures designed to minimize or eliminate substandard practice.

Further review of the PCAP Plan indicated the Quality and Patient Safety Committee (QPSC) was responsible for aligning the Performance Improvement Plan activities throughout the hospital, with identified quality and safety priorities and goals. The committee was co-chaired by the Director of Quality and Patient Safety and has responsibility for identifying and reducing risks to patients who are under our care at the Hospital. Key functions of the committee include:
-Oversight of the performance improvement education for appropriate stakeholders.
-Identify and prioritize safety improvement initiatives.
-Provide monitoring oversight to the implementation of action plans based on a variety of sources such as peer review, sentinel events, and root cause analysis.

Review of the Hospital's Performance Improvement Plan: Quality and Patient Safety, dated 2025 indicated performance improvement may be achieved, depending on the complexity of the work process, through individual actions or by means of formal improvement teams. These teams were recommended when the process selected for improvement was intra-departmental or divisional. All improvements require making changes, but not all changes result in improvement. Organizations therefore must identify the changes that are most likely to lead to improvement.

Review of the Hospital's policy titled Safety Event Management, dated 12/3/21, defined a sentinel event as a patient safety event not primarily related to the natural course of illness or underlying condition that reaches a patient and results in death, sever harm, or permanent harm. The Policy indicated a root cause analysis would be completed within 14 days to investigate, determine the cause, develop and implement actions to prevent further occurrences. A complete investigation, follow-up, and closure to all events would be completed within 21 days of documentation of the event, and if unable to close, document the reason.

The Hospital reported a patient safety event which occurred on 6/15/25, when Patient #3 had unsupervised access to a cell phone in their room and used it to self-harm, requiring transfer to the emergency department for evaluation and treatment. There was no documentation to support the Hospital identified that staff failed to follow the Hospital's Electronic Device Policy and supervise patients during electronic device use during the root cause analysis of the event. The Hospital also reported multiple patient and staff safety events which occurred on 7/12/25 and 7/13/25 on the Hospital's Child Development Unit (CDU) involving Patients #4, #5, #6, #7, and #10. The Reports indicated that during the events staff used improper restraint use, did not obtain a physician orders for constant observation, did not appropriately respond to physical altercations to prevent harm to patients and staff, and left a seclusion room door unsecured on the CDU. The Hospital failed to provide evidence that all action items identified during the root cause analysis were completed for performance improvement following the events.

During an interview with the Behavioral Health Nurse Educator on 8/21/25 at 9:20 A.M., she said all staff members involved in the 7/12/25 incident had been re-educated following the event on Crisis Prevention and Intervention (CPI) techniques for de-escalation and restraint training. She said the CDU staff were still receiving ongoing re-education on chair restraints and physical holds to chair restraints, and the training would also be taken to house-wide staff as restraints can happen anywhere in the Hospital. She said security staff were also to be re-educated on properly using chair restraints. She said she reviewed the security camera footage from 7/12/25, showing CDU outside area/atrium and saw staff members physically hold Patient #4 in a prone position. She said the Hospital staff should not perform physical holds like that. She said once a patient was brought to the ground, staff should attempt to sit the patient up and prepare to either medicate the patient or move them to another restraint. She said the Hospital staff are not trained or authorized to perform prone physical holds on patients and a hold in that manner requires specialized training and not utilized in a healthcare setting. She said Patient #4 was able to independently get up from the ground in control after he/she was released from the physical hold, and therefore, the use of the restraint chair was unnecessary at that time.

The Nurse Educator said that on 7/13/25, the door inside the CDU seclusion room was not locked as staff assumed it was locked and did not test it which enabled Patient #10 to escape into the nurses' station. She said the 1:1 constant observer for patients placed in the seclusion room were required to stand at that door for supervision; however, she was unsure of who was assigned to be the constant observer for Patient #10 when he/she escaped through the unsecured door of the seclusion room. She said two nurses who worked on the CDU on the evening of 7/13/25 were floated from another unit and may have been afraid to respond to the patient to patient and patient to staff physical altercations as they occurred on the evening of 7/13/25. She said she was responsible for staff education and training but not responsible for any disciplinary actions identified for staff.

During an interview with the Market Director for Clinical Quality Improvement on 8/21/25 at 9:00 A.M., and throughout the Survey, she said the corrective action items developed during the root cause analysis following the patient safety events on 7/12/25 and 7/13/25 were not all completed including nursing staff discipline/counseling, re-education/re-training of Hospital staff for checking to make sure doors are secured on the CDU, obtaining physician orders for a constant observer, and chair restraint and physical holds.

The Market Director of Clinical Quality Improvement said there was no documentation at the time of Survey to support the Hospital developed or implemented system-wide corrective actions following Patient #3's self-harm event on 6/15/25 related to staff not following the Patient Electronic Device Policy to supervise patient's electronic device use in designated public areas.

Cross Reference:
- Patient Rights: Care in a Safe Setting (Tag 144).
- Patient Rights: Use of Restraints or Seclusion (Tag 154).
- Nursing Services: Supervision of Contract Staff (Tag 398).

Based on a review of medical records, Hospital policy and procedures, observations, and staff interviews, the hospital failed to ensure nursing staff adhered to established Hospital policies and procedures for four (Patient #3, #5, #7, and #8) of 15 sampled patients. 1. Patient #3 was left alone with a cell phone and able to self-harm, 2. Patient #7 was involved in patient-to-patient altercation without physician notification, 3. Patient #5 was involved in patient-to-patient altercation without physician notification, 4. Patient #8 was refused at the admitting inpatient psychiatric unit and unnecessarily transferred back to the Hospital's Emergency Department (ED), delaying care.

Findings include:

Employee Conduct and Work Rules, dated 5/11/18, indicated the purpose was to assure orderly operations to provide the best possible work environment, the hospital expects employees to follow rules of conduct that will protect the interest and safety to all patients, employees, and the facility.

Review of the Hospital's policy titled Safety Event Management, dated 12/3/21, defined a sentinel event as a patient safety event not primarily related to the natural course of illness or underlying condition that reaches a patient and results in death, sever harm, or permanent harm. The Policy indicated the following:
- An actual or potential sentinel event, the Facility's chain of command must be immediately implemented, including notifying the patient's attending physician.
- A root cause analysis would be completed within 14 days to investigate, determine the cause, develop and implement actions to prevent further occurrences.
- The complete investigation, follow-up, and closure to all events within 21 days of documentation of the event, and if unable to close, document the reason.

Employee Performance Management, dated 1/31/23, indicated the purpose was to provide supervisors/managers with general guidelines for the resolution of various types of employee performance problems such as unacceptable job performance including, but not limited to below-standard performance and misconduct. The policy indicated the following:
- Employee Performance Management Form (EPMF) guided the supervisors in conducting and documenting corrective action process in response to employee performance or conduct that does not meet the expectations or standards.
- The EPMF would define the issues and define the expected change in behavior, with the employees input to include the expected change in behavior. A date for the next review of the employee ' s improvements should be set and signed by the employee and staff.
- Human Resources would provide assistance, guidance, and support to supervisors and employees throughout the Performance Management process.

Corrective, Remedial, and Disciplinary Actions for violations of Compliance Standards, dated 1/31/23, indicated the purpose was to establish a consistent procedure where corrective, remedial, or disciplinary action was appropriate to address an employee's failure to comply with the Facility's code of conduct, policies and procedures, laws, and regulations. The Policy indicated the following:
- The Corporate Ethics and Compliance Department shall be notified by the Hospital Compliance Officer (HCO) or Human Resources Department of any violation of any component of the compliance standards and the appropriate disciplinary action taken.
- The HCO, in coordination with appropriate departments, shall develop and implement a plan as soon as reasonably practicable to mitigate any known or reasonably anticipated adverse effects from illegal or improper activity. Such plan would be promptly communicated to all affected employees as appropriate.
- The supervisor in consultation with Human Resources Department is responsible for ensuring that the Hospital ' s disciplinary and remedial policies were enforced consistently for an employees involved in or responsible for a violation.
- Regardless of discipline issued, all compliance related events will be documented by HR in the employee file.

1. Review of Patient #3's medical record indicated he/she presented to the Hospital reporting a manic episode and "dark thoughts," with a known history of Bipolar Disorder. Patient #3 requested a psychiatric evaluation, resulting in a voluntarily admission for inpatient psychiatric care. Patient #3 also reported multiple past suicide attempts.

Review of the Hospital's Internal Investigation indicated that on 6/15/25 at approximately 7:08 P.M., Patient #3 was seen coming of his/her room with blood all over his/her chest, bilateral forearms, hands, and neck. Patient #3 said he/she broke his/her [cell] phone and used it to cut him/herself with a desire to kill him/herself after an upsetting phone conversation. Patient #3 was emergently transferred to the ED and received 14 stitches on his/her forearm, 13 stitches on his/her right forearm.

There was no documentation in the medical record to support that a physician was notified after Patient #3's self-harm incident and transfer to a higher level of care on 6/15/25. Additionally, there was no documentation of a physician ordering a constant observer after the event.

During an interview on 8/20/25 at 1:14 P.M., Physician #1 said staff failed to notify him of Patient #3's safety event on 6/15/25 and failed to obtain a physician's order for Patient #3's constant observer implemented following the event.

During an interview on 8/21/25 at 8:45 A.M., the Market Director of Behavioral Health said she was aware of Patient #3's self-harm event on 6/15/25. The Director said staff failed follow several Hospital policies related to Patient #3's safety event. The Director said staff involved should have received counseling and/or disciplinary actions documented in the personnel file in accordance with Hospital policy; however, there was no documentation at the time of Survey to support this was completed.

2. Review of Patient #7's medical record indicated presented to the Hospital in May 2025 due to aggressive behaviors towards others and a reported suicide attempt at a trauma-informed therapeutic residential school. Patient #7 had a diagnosis of Anxiety Disorder, Congenital Deafness, Disruptive Mood Regulation Disorder, and Post Traumatic Stress Disorder. Patient #7 was admitted to the Hospital's Child Developmental Unit.

The Nurse Progress Notes, dated 7/11/25, indicated that at approximately 9:30 P.M., Patient #3 was punched in the face during an altercation with another patient, causing redness on the left side of Patient #7's face. Staff made multiple attempts, including calling a code green to redirect Patient #3 with minimal positive effects. The Nurse added Patient #3 to a list of patients for a nurse practitioner to evaluation in the morning.

There was no documentation in the medical record to support that a physician was timely notified on 7/11/25, after Patient #7's physical altercation which included being punch in the face.

During an interview on 8/25/25 at 2:15 P.M., and throughout the Survey, the Market Director of Clinical Quality Improvement and the Risk Manager provided documentation of the Hospital's Internal Investigation and review of Patient #7's physical altercation on 7/11/25; however, they said there was no documentation at the time of Survey to support the Hospital implemented system-wide corrective actions related to timely reporting patient safety events to a physician.

The Nurse Progress Notes, dated 7/13/25, indicated Patient #7 and other patients physically assaulted staff for approximately 2.5 hours. The Note indicated the Hospital was short staffed and called 911 as the event was uncontrollable.

Review of the Hospital's Internal Investigation indicated that on 7/13/25 at approximately 7:30 P.M., Patient #7 was on the floor and multiple patients were kicking him/her. The Hospital identified the event as an assault [without injury] and inquired if Patient #7 wanted to report the event to the law enforcement.

Further review of the Investigation indicated the Hospital administration reviewed the security camera footage of the event and felt this was neglect from the staff members that did not come out of the nursing station to intervene on the patients kicking Patient #7, who was lying on the ground, whether it was in a joking manner or not. In addition to reporting the serious reportable event to the Department of Public Health, the Hospital filed a report (of child maltreatment) to another State Agency due to the four nurses staying behind the nursing station neglecting to protect Patient #7. The Investigation indicated clinical leadership, compliance/risk, and the legal department were notified of the event. As of 7/22/25, HR issues were identified and disciplinary actions for the nurses who remained behind the nursing station during the event were still under consideration.

During an interview on 8/21/25 at 9:50 A.M., The Behavioral Health Nurse Educator said she supports nursing staff with scheduled education and re-education as needed. The Nurse Educator acknowledged concerns about staff remining at the nursing station while Patient #7 was on the ground being kicked by peers. The Nurse Educator said the concerns involved two older nurses, and possibly a mental health counselor, who stayed behind the nursing station as they do not typically work on the CDU and were frightened by the commotion.

During an interview on 8/21/25 at 8:45 A.M., the Market Director of Behavioral Health said she participated in the Hospital's internal investigation and root cause analysis of Patient #7's safety event on 7/13/25. The Director said the Hospital staff also consulted the legal department and determined that the four nurses who failed to intervene to protect Patient #7 during the assault, would receive a final written warning. The Director said the final written notice or performance management tasks has not been written or reviewed with the four nurses at the time of Survey.

During an interview with the Market Director of Clinical Quality Improvement on 8/21/25 at 9:00 A.M., and throughout the Survey, she said she participated in the Hospital's investigation and root cause analysis of Patient #7's safety event on 7/13/25. The Director said the Hospital developed and implemented several corrective actions; however, some action items were incomplete, including the performance management tasks and/or disciplinary actions for the four nurses who failed to intervene during the event to protect Patient #7.

During an interview on 8/25/25 at 10:35 A.M., and throughout the Survey, the Chief of Human Resources said staff non-compliance issues related to patient safety details are reviewed and depending on the level of severity, the Hospital, corporate, and legal team determine the outcomes. The Chief said concerns of staff non-compliance with policies and procedures, regulations, or laws, would be documented in staff personnel files.

The Chief of Human Resources said he participated in the Hospital's review of Patient #7's event on 7/13/25. The Chief said the four nurses who remained behind the nursing station during the event had spoken with leadership about expectations and did not warrant a suspension pending the investigation; however there is no documentation to support these decisions. The Chief said the four nurses involved may possible warrant disciplinary actions but this decision was still pending with clinical leadership.

There was no documentation at the time of Survey to support staff followed the Hospital's Code of Conduct, Safety Event Management policy, Employee Performance Management policy, or the Corrective, Remedial, and Disciplinary Actions for violations of Compliance Standard policy in response to Patient #7's assault by peers on 7/13/25, when four nurses remained behind the nursing station and failed to intervene to protect Patient #7.


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3. Patient #5 was admitted to the Hospital CDU on 7/2/25 with diagnoses of ADHD (Attention-deficit/hyperactivity disorder), PTSD (Post Traumatic Stress Disorder), and aggressive behaviors.

Review of Patient #5's medical record indicated the Patient was admitted to the CDU on 7/2/25 after presenting to the Hospital's Emergency Department following a physical altercation with staff at his/her group home. On 7/11/25, RN #9 documented that Patient #5 instigated a confrontation with a Patient #7; Patient #7 tried to punch Patient #5, and Patient #5 struck Patient #7 in the face. RN #9 documented that RN #11 added Patient #5 to a list to be evaluated in the morning, and multiple attempts were made to redirect Patient #5 with minimal effect. Patient #5 was evaluated by Physician #2 on 7/12/25 at 2:47 P.M. Physician #2's progress note failed to indicate Patient #2 had any physical altercation with another patient on 7/11/25. On 7/12/25 at 6:55 P.M., a code green was called as Patient #5 was throwing game pieces at peers, punched out ceiling tiles, and was hitting staff requiring physical and chemical restraints.

Further review of Patient #5's medical record failed to indicate any provider was notified of Patient #5's physical altercation with Patient #7 on 7/11/25.

During an interview with Physician #2 on 8/20/25 at 9:12 A.M., he said he was working on the weekend of 7/12/25 and 7/13/25. He said he was unable to recall Patient #5, nor was he notified of any significant events for the Patient on 7/11/25. He said typically if an event with a patient is important enough the nursing staff can call him or another provider for evaluation or orders. He said if an event is not significant enough to contact a provider, the nursing staff can document the event in a patient's medical record for the provider to review the next day.

During an interview with RN #3 on 8/20/25 at 2:30 P.M., she said the weekend of 7/12/25 and 7/13/25 was chaotic with multiple incidents and restraints. She said the CDU had been difficult leading up to the weekend of 7/12/25 and 7/13/25. She said multiple staff were floated to the CDU to staff it, particularly on 7/13/25. She said the Hospital has had many new nurses hired and the group of patients on the unit during that time period were challenging.

During an interview with Nurse Manager #2 on 8/20/25 at 11:30 A.M. she said following a patient-to-patient altercation, a physician or provider should be notified.

The Hospital failed to ensure nursing staff informed any provider of Patient #11's escalating behaviors and physical altercation with another patient on 7/11/25.



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4. Review of the Hospital policy titled "Admission Procedures on Behavioral Units" dated 7/9/2025 indicated that staff would adhere to guidelines provided for admitting patients to Behavioral Medicine Units to ensure consistency and a smooth transition to in-patient admission.

General Admission Procedure: For the purposes of conditional voluntary admission to mental health units at MWMC any degree of severity of a mental disorder including alcoholism may qualify a person for admission to a mental health unit at the discretion of the facility director or designee when it is determined that such admission is necessary and appropriate.

Denial of Admission: Applicants for voluntary or conditional voluntary admission to a mental health facility shall not be denied admission without an explanation of the basis for such refusal, and alternatives shall be offered or recommended by the admitting physician where feasible.

Patient admission requirements: Patients will be admitted based on the capability of the Inpatients Behavioral Health units capability and capacity at the time of the referral.

Capacity: Patients needing single rooms will only be admitted if the hospital has the capacity to place patient in a single room. Every effort will be made to move patient ' s room to create capacity.

Enforcement: All hospital staff and Medical Staff whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy.

Review of Patient #8 ' s medical record indicated he/she presented to an outside hospital ED on 5/22/2025 at 12:11 P.M., with suicidal ideation (SI) and a history of chronic schizophrenia.

A mental health evaluation completed on 5/22/2025 at 2:15 P.M. indicated Patient #8 had passive SI, auditory/visual hallucinations, and paranoia.

Further review of the ED summary indicated Patient #8 was accepted for admission at a Behavioral Health Unit 4 (BH4) (at another Hospital). Report was provided to the receiving hospital ' s nursing and medical staff.

The ED Summary indicated on 5/22/2025 at 7:57 P.M., the receiving hospital reported an ambulance could be booked for patient transfer to the accepting Hospital ' s ED (the patient needed to present here for a History and Physical Evaluation (H&P), prior to arriving to the Behavioral Health Unit.

During an interview on 8/25/25 at 8:56 A.M., Registered Nurse (RN) #5 said she recalled Patient #8 as she was the nurse taking care of him/her in the ED, while Patient #8 awaited an H&P. Patient #8 was sent to the Behavioral Health Unit via ambulance. RN #5 said after Patient #8 left by ambulance, 15 minutes later he/she was back in the ED. RN #5 said it was reported to her the Behavioral Health Unit refused Patient #8 because there was no private room available and the patient was actively suicidal. RN#5 said she escalated the patient return to the Charge Nurse and Nursing Supervisor who facilitated the patient to go back to the Behavioral Health Unit. RN #5 said the nursing supervisor at the Behavioral Health Unit was not aware of the refusal of Patient #8 and it should not have occurred.

During an Interview on 8/21/25 at 12:20 P.M., the Assistant Chief Nursing Officer (ACNO) confirmed that on 5/23/25 that Hospital policy was not followed, and denial was not supported with appropriate documentation. The ACNO said she was called by the nursing supervisor at both Hospitals discussing the events that had occurred. The ACNO says this event should not have occurred and said there was updated education on the chain of command as well as the event was communicated in a nursing huddle.

During an interview on 8/25/25 at 11:11 A.M., Nurse Practitioner (NP) #1 said she does not recall the event on 5/23/25. NP#1 said she was a Nurse Practitioner but worked as a Staff Nurse on the Adult Behavioral Health Unit. NP#1 said a Patient should never be sent back to the ED without notifying the Nursing Supervisor and does not recall a time where this has occurred.

The Hospital failed to ensure nursing staff adhered to its own admission policy for behavioral health units, resulting in the inappropriate refusal of an accepted patient, unnecessary transfer back to an emergency department, and delay in treatment.