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Based on document review and interview, it was determined that the Hospital failed to protect and promote a patient's rights by failing to adhere to the Hospital's abuse and restraint policies. As a result, the Conditions of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure that a Notice of Restriction of Rights for restraints form was completed, as required. See deficiency at A-117.

2. The Hospital failed to conduct behavioral observation rounds every 15 minutes, as required. See deficiency at A-144.

3. The Hospital failed to initiate an investigation of an abuse allegation or completing an incident report. See deficiency at A-145

4. The Hospital failed to ensure that there was clinical justification for a chemical restraint on a patient. See deficiency at A-160.

5. The Hospital failed to ensure that there was clinical justification and an order in place for patients placed in seclusion. See deficiency at A-168.

Based on document and interview, it was determined that for 2 of 4 (Pt #1, Pt #12), clinical records reviewed for restraints and seclusion, the Hospital failed to ensure that a Notice of Restriction of Rights for restraints form was completed, as required.

Findings include:

1. The Hospital's policy titled, "Restriction of-Rights ", dated 2/13/2020, was reviewed, and required, "1. Inform the patient of restriction of rights and Nursing reason thereto, and record in the patient care record...Instruct the patient to sign an AUTHORIZATION FOR RELEASE OF INFORMATION to notify designated person if patient desires him/her to be informed...Record in patient's care record."

2. The clinical record for Pt #1 was reviewed on 6/28/2023. Pt. #1 was admitted to the Inpatient Behavioral Unit on 4/20/2023, with a diagnosis of schizophrenia (severe mental illness). Pt #1's record included:
- Pt #1's medication orders, dated 4/20/2023, included, Haldol (anti-psychotic medication) IM (intramuscular) injection 5 mg (milligrams) every 4 hours, as needed for severe agitation.
- Pt #1's MAR (Medication Administration Record) was reviewed and included Haldol 5 mg given on the following dates: 4/25/23 at 10:54 AM-(IM), 4/26/23 at 10:20 AM-(IM), 5/1/23 at 10:15 AM -(PO/oral), and 5/1/23 at 10:32 AM-(IM).
- Pt #1's Restriction of Rights forms (indicated use for when restraint or emergency medications are applied or given), were reviewed. The clinical record lacked this required documentation when Pt #1 received Haldol as an emergency medication on: 4/25, 4/26, and 5/1/2023.

3. The clinical record for Pt #12 was reviewed on 6/29/2023. Pt #12 was admitted on 4/20/2023. Pt #12's rounding sheet on 4/21/2023 included documentation that Pt #12 was in the seclusion room from 12:15 AM-6:45 AM. The clinical record lacked the required Restriction of Rights form, when Pt #12 was placed in the seclusion room.

4. On 6/28/2023 at 2:00 PM, an interview was conducted with the BHU Charge RN (E #6). E #6 stated that when restraints are used on a patient, there needs to be a Restriction of Rights form completed.

Based on document review and interview, it was determined that for 2 of 17 (Pt #1, Pt #11) clinical records reviewed for rounding sheets on the Behavioral Health Unit, the Hospital failed to provide care in a safe setting by failing to conduct observational rounds every 15 minutes, as required.

Findings include:

1. The Hospital' policy titled, "Level of Observations" (dated 6/20), was reviewed, and required, "...Every 15-minute observation: This is moderately restrictive toward the patient and involves continuous monitoring every 15 minutes on the Close Observation Record, by completing the code and the initials of the staff member who is conducting the observation..."

2. The clinical record for Pt #1 was reviewed on 6/28/2023. Pt. #1 was admitted to the Inpatient Behavioral Unit (BHU) on 4/20/2023 with a diagnosis of schizophrenia (severe mental illness). Pt #1's physician orders included assault safety precautions, requiring observation rounds every 15 minutes. Pt #1's rounding sheets lacked the required documentation of the patient's place; behavior/activity; and the staff's initials on 4/21/23 (from 2:30 AM-3:30 AM) and on 5/3/2023 (from 11:45 PM-12:30 AM).

3. The clinical record for Pt #11 was reviewed on 6/29/2023. Pt #11 was admitted to the Inpatient Behavioral Unit on 5/1/2023 with a diagnosis of schizophrenia. Pt #11's physician orders included assault safety precautions, requiring observation rounds every 15 minutes. Pt #11's rounding sheets lacked the required documentation of the patient's place; behavior/activity; and the staff's initials on 5/3/2023 (from 11:45 AM-12:30 AM).

4. On 6/28/2023 at 1:25 PM, a telephone interview was conducted with a BHU Mental Health Technician (E #11). E #11 stated that behavioral rounding sheets should be documented on every 15 minutes, and even if staff is on break, someone should cover and continue to do rounds, as required.

Based on document review and interview, it was determined that for 1 of 3 (Pt #1) patients reviewed for allegations of abuse, the Hospital failed to ensure that patients remained free from abuse, by failing to report an abuse allegation; complete an incident report; and initiate an investigation following the allegation.

Findings include:

1. The Hospital's policy titled, "CORE: Patient Abuse and Mistreatment" (dated 2/13/2020) was reviewed and required, "Prevention of abuse...Procedure: It is the direct responsibility and duty of an employee to report to the nursing manager any knowledge of abuse or alleged abuse or mistreatment, regardless of source..."

2. The Hospital's "Alleged or Confirmed Patient Abuse Checklist" (dated 7/10/20) was reviewed and required, "...Notifications: Within 30-60 minutes of allegation: Notified Nursing Supervisor, Notified Chief Clinical Officer or AOC [Administrator on Call], Notified Director of Quality Management...Documentation: Complaints/Grievance form by Nursing Supervisor, Event Tracking System by staff receiving allegation..."

3. The clinical record for Pt #1 was reviewed on 6/28/2023. Pt. #1 was admitted to the Inpatient Behavioral Unit on 4/20/2023, with a diagnosis of schizophrenia (severe mental illness). Pt #1's record included:
- Pt #1's Physician Progress Notes, from 4/20/2023-5/11/2023, documented by the Psychiatrist (MD #1), included the following:
- 4/22/2023: " ...She would not open her eyes as her name was being called though I could see her eyelids moving. Later she woke up and started saying that people are harassing her here and she is being assaulted ..."
- 4/29/2023: " ...Today, she is claiming that she is being sexually harassed ...she is covering herself in bizarre fashion with gown exposing her belly ...Exposing herself being inappropriate and sexually provocative ..."
- 4/30/2023: " ...She was asking for the name of the CEO of the hospital ...Making accusations about being harassed sexually in the unit ..."

MD #1's progress notes did not include any documentation of follow-up questions that would clarify or give more specifics on why Pt #1 felt harassed or assaulted. There was no other documentation in Pt #1's clinical record of abuse complaints to any other staff members.

5. The Hospital's Incident Reports/Abuse log from 4/2023-6/2023, were reviewed. There were no documented incident reports or abuse allegations regarding Pt #1. The Hospital was unable to provide any abuse investigation, incident report, or complaint regarding the allegations that were documented in Pt #1's clinical record in MD #1's notes.

6. On 6/28/2023 at 11:35 AM, an interview was conducted with the Psychiatrist (MD#1). MD # 1 stated that Pt #1 made allegations of being harassed, but the patient was not specific. MD #1 stated that he would ask the patient further questions if a patient verbalized general abuse allegations. MD #1 stated that since he is a mandated reporter, he would report an abuse allegation the manager of the unit so that an investigation can be done. MD #1 stated that he did not report Pt #1's allegations to the manager.

Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical records reviewed for chemical restraints, the Hospital failed to ensure that medications used as a restriction to manage the patient's behavior were not administered unnecessarily, and were given with appropriate clinical justification, to ensure the safety of the patient.

Findings include:

1. The Hospital's policy titled, "CORE: Identification and Reporting of Chemical Restraints" (dated 6/2022), was reviewed, and required, "...The policy of [Hospital] is to ensure the following: 1. Chemical restraints will only be used while an unsafe patient situation exists. 2. Chemical restraints are used only after determining other alternatives; less restrictive methods are ineffective in maintaining patient safety..."

2. The clinical record for Pt #1 was reviewed on 6/28/2023. Pt. #1 was admitted to the Inpatient Behavioral Unit (BHU) on 4/20/2023, with a diagnosis of schizophrenia (severe mental illness). Pt #1's record included:
- Pt #1's medication orders, dated 4/20/2023, included, Haldol (anti-psychotic medication) IM (intramuscular) injection 5 mg (milligrams) every 4 hours, as needed for severe agitation.
- Pt #1's MAR (Medication Administration Record) was reviewed and included Haldol 5mg IM given on the following dates:
- 4/25/23 at 10:54 AM-(IM): indication for administration: "manicing with bizarre behavior"
- 4/26/23 at 10:20 AM-(IM): indication for administration: "patient delusional, acting bizarre and disorganized"
- 4/28/23 at 9:25 AM-(IM): indication for administration: "patient acting inappropriate and bizarre behavior"

The indications for administration of Haldol on the MAR for those dates, as documented by the RN (Registered Nurse), were not consistent with the order (indication: severe agitation).

3. On 6/28/2023 at 12:40 PM, an interview was conducted with a Behavioral Health Unit RN (E #4). E #4 stated that she recalls Pt #1 being restless. E #4 stated that she gave Pt #1 Haldol when Pt #1 was pacing, talking a lot, and agitated.

4. On 6/29/2023 at approximately 1:30 PM, an interview was conducted with the Director of BHU (E #3). E #3 stated that the least restrictive methods should be used before a prn (as needed) emergency medication is administered. E #3 acknowledged that Pt #1 did receive Haldol for reasons other than severe agitation.

Based on document review and interview, it was determined that for 2 of 2 (Pt #1, Pt #12), patients identified as being in seclusion during review of behavioral rounding sheets, the Hospital failed to ensure that the use of seclusion was in accordance with the order of a physician and were only placed there for the management of violent or self-destructive behavior.

Findings include:

1. The Hospital's policy titled, "CORE: Seclusion and Restraints (dated 6/2022), was reviewed, and required, "...Seclusion and/or restraint may only be ordered by a psychiatrist and only for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others after less restrictive interventions are ineffective or ruled out..."

2. The clinical record for Pt #1 was reviewed on 6/28/2023. Pt. #1 was admitted to the Inpatient Behavioral Health Unit (BHU) on 4/20/2023, with a diagnosis of schizophrenia (severe mental illness). Pt #1's behavioral rounding sheets were reviewed. On 4/20/2023 from 5:45 PM-10:15 PM, it was documented that Pt #1 was in the seclusion room. From 11:15 PM (4/20/2023)-2:00 AM (4/21/2023), Pt #1 was back in the seclusion room. From 3:30 AM-6:45 AM (4/21/2023), it was documented that Pt #1 was in the seclusion room. The clinical record lacked an order and indication for seclusion.

3. The clinical record for Pt #12 was reviewed on 6/29/2023. Pt #12 was admitted to the Inpatient Behavioral Health Unit on 4/20/2023. Pt #12's behavioral rounding sheet included documentation that on 4/21/2023, the patient was in the seclusion room from 12:15 AM-6:45 AM. The clinical record lacked an order for seclusion and indication for seclusion.

4. On 6/28/2023 at 1:25 PM, a telephone interview was conducted with a BHU Mental Health Technician (E #11). E #11 stated that generally speaking, if a patient is placed in the seclusion room, it is because they are acting out or out of control. E #11 stated that patients should only be in seclusion with an order for about 15-30 minutes. E #11 stated that less restrictive measures should be in place before placing a patient in any type of restraints and or seclusion.