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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on observations, interviews and document review, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure detox patients were transferred to a medical facility for medical clearance by secure transportation. The failure was identified in four of five records reviewed of patients who were transferred out of the facility (Patient #5, #6, #7, #9).

Based on observations, interviews and document review, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure detox patients were transferred to a medical facility for medical clearance by secure transportation. The failure was identified in four of five records reviewed of patients who were transferred out of the facility (Patient #5, #6, #7, #9).

Findings include:

Facility policies:

The Transfer of Patient policy read, transfer patients to an appropriate medical facility when medical care and procedures are required which are not available at the facility. Copies of all medical and other information which may be useful or required will be provided. A transfer form will be completed and will accompany the patient to the receiving medical facility, if requested. The facility will arrange for transportation to the receiving medical facility and will accompany the patient if requested by the receiving medical facility.

The Emergency Transfer policy read, the facility would provide emergency care to patients who exhibit symptoms of medical distress. Patients will be transferred to an emergency room via ambulance if the patient's condition indicates. Staff would document in the Progress Notes the patient's status, interventions and procedures done, patient's response to interventions and/or procedures, report called to receiving hospital emergency department (ED) and ED staff receiving report, time ambulance service contacted, time ambulance arrived, and the transfer of the patient (by whom, time, and where).

1. The facility failed to ensure patients were transported in a secured transportation with guidance from the provider to a medical facility for medical care.

a. Upon review of patients' medical records, it revealed patients in need of medical clearance were transported to a medical facility, however there was no evidence of a transfer form documented in the medical records indicating if the patient transported by ambulance or if the risks of transporting by private vehicle were discussed with the patient by the provider.

i. Review of Patient #6's medical record revealed the patient was in need of medical clearance prior to admission. Patient #6 needed medical clearance due to her vomiting blood and a medical history of alcohol withdrawal induced seizures. According to the EMTALA log, Patient #6 transferred by car to receive medical clearance. The medical record did not reveal a transfer form which would include mode of transportation to a medical facility for medical clearance. There also was no evidence of the patient refusing to transfer by ambulance, of a discussion of the risks of transferring by car, or of a provider's knowledge or order to transfer by car.

ii. Review of Patient #5's record revealed the patient presented to the facility in need of a detox program. Patient #5 was in need of medical clearance prior to admission to the facility. According to the EMTALA log, Patient #5 transferred by car to receive medical clearance. The medical record did not contain a transfer form which would include the mode of transportation required for transfer to a medical facility for medical clearance. There also was no evidence of the patient refusing to transfer by ambulance, of a discussion of the risks of transferring by car, or of a provider's knowledge or order to transfer by car.

iii. Upon review of Patient #7 medical record it revealed Patient #7 presented to the facility in need of a detox program and in need of medical clearance prior to admission. According to the EMTALA log, Patient #7 transferred by car to receive medical clearance. The medical records did not reveal a refusal of ambulance transportation and acknowledgment of patient risks transported by private vehicle without medical supervision. There also was no evidence of the patient refusing to transfer by ambulance, of a discussion of the risks of transferring by car, or of a provider's knowledge or order to transfer by car.

iv. Upon review of Patient #9 medical record it revealed Patient #9 presented to the facility in need of a detox program and in need of medical clearance due to a high heart rate and high level of intoxication prior to admission. According to the EMTALA log, Patient #7 transferred by car to receive medical clearance. The medical records did not reveal a refusal of ambulance transportation and acknowledgment of patient risks transported by private vehicle without medical supervision. There also was no evidence of a discussion of the risks of transferring by car, or of a provider's knowledge or order to transfer by car.

b. On 5/11/22 at 12:49 p.m., an interview with the Chief Clinical Officer (CCO) #10 was conducted. CCO #10 stated nursing staff and providers made the discussion on transferring by ambulance or private vehicle and the decision was expected to be documented in the medical record. CCO #10 stated risks of transportation in a private vehicle should be discussed with patients as it was their right to be informed. CCO #10 state patients were expected to sign a refusal of treatment form when patients were transported by private vehicle. CCO #10 stated patients were at risk if patients were not monitored and their condition could worsen. CCO #10 reviewed medical records and was unable to provide the transfer forms or patient refusal forms in the medical records reviewed.

c. On 5/11/22 at 3:37 p.m., an interview with the Medical Doctor (MD) #3 was conducted. MD #3 explained detox patients could present with signs and symptoms of acute kidney injury and neurological disorders. MD #3 stated patients with alcohol withdrawal may present with high blood pressure and heart rate, nausea, vomiting, anxiety, may affect the liver and cause jaundice, Wernicke syndrome (degenerative brain disorder linked to alcoholism), tremors and seizures. MD #3 added patients with opioid withdrawal may present gastrointestinal pain, body ache, nausea, vomiting and confusion.

MD #3 stated alcohol and drug withdrawals could be considered a medical emergency, due to the possibility of possibly causing patient injury and even death. MD #3 explained Patients with seizures may stop breathing and would need medical and airway stabilization.

Upon review of Patient #8's medical record, MD #3 stated Patient #8 was unstable to be transported in a private vehicle due to Patient #8's reported symptoms that included vomiting blood and a medical history of alcohol withdrawal induced seizures. MD #3 stated detox patients should be medically cleared prior to facility admission in order to keep patients safe.

MD #3 then stated patients presenting at the facility for the detox program should be transported by ambulance to a hospital for medical clearance. MD #3 stated patients needing medical clearance should not be transported by private vehicle because it could place patients at risk because they were medically unstable. MD #3 stated if a patient refused the facility's transportation by ambulance, patients must be made aware of the risks of transporting by private vehicle and sign refusal forms.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 Quality Assessment and Performance Improvement Program, was out of compliance.

A-0286 Patient Safety, Medical Errors & Adverse Events §§482.21(a)(1), 482.21(a)(2), 482.21(c)(2), & 482.21(e)(3) §482.21(a) Standard: Program Scope. (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ....§482.21(c) Standard: Program Activities ...(2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. §482.21(e) Standard: Executive Responsibilities. The hospital ' s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ...(3) That clear expectations for safety are established. Based on interviews, document review and record review, the facility failed to ensure patient safety events were reported, investigated and analyzed in order to identify contributing factors and implement preventive actions in six of nine medical records reviewed of patients who had safety events (Patient #1, #5, #6, #7, #8, #9).

Based on interviews, document review and record review, the facility failed to ensure patient safety events were reported, investigated and analyzed in order to identify contributing factors and implement preventive actions in six of nine medical records reviewed of patients who had safety events (Patient #1, #5, #6, #7, #8, #9). (Cross-reference A0144, A0395)

Findings include:

Facility policies:

The Quality and Performance Improvement Plan for 2022 read, the plan shall be the program used to systematically design, assess, monitor and improve processes, structures, outcomes and patient safety. This program shall provide consistent, systematic evaluation of patient services, performance processes and performance improvement across all departments.

The Quality and Performance Improvement Program is to improve the safety and quality of care, treatment and services at the facility by monitoring, aggregating, analyzing and comparing data and using the date to make improvements, as appropriate.

A Patient Safety Event is an event, incident, or condition that could have resulted or did result in harm to an individual served or a patient.

The Incident Reporting and Severity Classification policy read, the purpose is to enable facility leadership to take corrective action, reducing the losses and improving the quality of care provided in the facility.

Information to be entered on the incident report must include: interventions or treatments given, nursing assessment of pain or injury, review of incident report, risk level and signature of risk manager or designee. All Incidents involving patients should be charted in the patient's treatment record. Patient Injury: any injury to the patient that does not fit in the above categories
Classifying Severity: all incident reports received by the risk manager or designee will be assigned a severity classification level in accordance with established criteria approved by a committee of the whole/governing body.

1. The facility failed to investigate and analyze patient safety events and implement preventive actions involving patients in need of medical clearance who were transferred by private vehicle.

a. Facility patient safety events were reviewed in conjunction with patient medical records. Multiple patient safety events as defined by facility policy were identified in patient medical records, however the events were not monitored, analyzed and data collected to make improvements.

i. Review of Patient #5's and Patient #6's record revealed both patients presented to the facility in need of a detox program. Patient #5 and Patient #6 were in need of medical clearance prior to admission. The medical records did not contain a transfer form which would include mode of transportation to a medical facility for medical clearance.

Review of the patient safety event staff reported Patient #5 and Patient #6 were transported in a private vehicle to a medical facility for medical clearance.

ii. Review of Patient #8's record revealed the patient was placed on M1 hold (72 hours mental health hold) and in need of medical clearance prior to admission. The medical record did not reveal a transfer form which would include mode of transportation to a medical facility for medical clearance.

Review of the patient safety event revealed staff reported Patient #8 was transported by ambulance. The facility was unable to provide evidence of a mode of transportation for the patient.

iii. Upon review of Patient #7 medical record it revealed patient presented to the facility in need of a detox program and in need of medical clearance prior to admission. The medical records did not reveal a refusal of ambulance transportation and acknowledgment of patient risks transported by private vehicle without medical supervision.

iv. Upon review of Patient #9 medical record it revealed presented to the facility in need of a detox program and in need of medical clearance prior to admission. The medical records did not reveal a refusal of ambulance transportation and acknowledgment of patient risks transported by private vehicle without medical supervision.

c. On 6/24/21 at 9:15 a.m., an interview with the Director of Quality, Compliance and Risk (Director) #11 was conducted. Director #11 stated she was responsible for the quality program, compliance adherence and risk management. Director #11 stated she monitored and evaluated risk utilizing the Quality and Performance Improvement Plan. Director #11 stated her responsibilities included investigation, evaluation and tracking of adverse patient events.

Director #11 stated all reported events were important to investigate for patient and staff safety Director #11 stated she reviewed the events to determine if there was a trend or if there was a breakdown in staff communication.

Director # 11 acknowledged the number of patient transfers by private vehicle were tracked with the patient safety event reports. However, she confirmed a review of the patients' medical records was not conducted when investigating the safety event reports. Director #11 stated she was unaware that patients in need of medical clearance were transferred by private vehicles. Director #11 then stated the facility was responsible for safe patient care which included patient transfers to another facility.

2. The facility failed to ensure patient safety events were reported by staff members.

a. Facility patient safety events were reviewed in conjunction with patient medical records.

i. Review of Patient #1's medical record revealed on 3/22/22 at 9:02 am, a provider note documented a hand assessment and pain even to light touch over the right 5th metacarpal (finger) which was a probable boxer fracture (a break in the neck of the 5th finger bone of the hand) to the right hand. The provider notes further documented Patient #1 and the nurse were instructed to advise the patient's parent that the patient must be seen by a primary care physician or urgent care after discharging for x-rays as the facility could not obtain x-rays prior to discharging from the facility on 3/22/22.

A patient safety event document was not entered until six days after the event occurred. Statements in the patient safety report by staff were in contrast to documentation in the patient's medical record. For example: Patient #1's medical record revealed no evidence of a nursing assessment showing swelling of Patient #1's hand following Patient #1's report to staff of a hand injury. This was not identified by the facility according to documentation in the safety event document.

b. On 5/11/22 at 9:46 a.m., an interview with Registered Nurse (RN) #2 was conducted. RN #2 stated Patient #1's hand injury was looked at by the provider and the family was aware of the injury. RN #2 was unable to provide evidence of a nursing assessment showing swelling of Patient #1's hand following Patient #1's hand injury. In addition, RN #2 was unable to provide evidence of any interventions provided after Patient #1's request for an ice pack or the change of condition of hand swelling was noted. Furthermore, RN #2 was unable to provide evidence of the physician or Patient #1's parent being notified of the injury.

c. On 6/24/21 at 9:15 a.m., an interview with the Director of Quality, Compliance and Risk (Director) #11 was conducted. Director #11 stated when Patient #1's family submitted a complaint, she reviewed the medical record and spoke with staff about the incident. Director #11 stated staff did not report a patient safety event after Patient #1's hand injury. Director #11 stated staff were educated on when patient safety events should be completed. However, the facility was unable to provide evidence on staff education.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §416.46 NURSING SERVICE, was out of compliance.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on observation, interviews and document review, the facility failed to ensure staff addressed a patient's injury and failed to ensure nursing assessments were conducted in accordance with facility policy in two of two patients reviewed who sustained injuries at the facility (Patient #1 and Patient #4).

Based on interviews and document review, the facility failed to ensure staff addressed a patient's injury and failed to ensure nursing assessments were conducted in accordance with facility policy in two of two patients reviewed who sustained injuries at the facility (Patient #1 and Patient #4). (Cross reference A-0286)

Findings include:

Facility policies:

According to the Reassessment of Patient policy, once a patient is admitted to the hospital, reassessments will occur on a regular basis to ensure proper care and treatment planning occurs during their stay. Reassessment: each patient is reassessed daily, every shift, and as the patient's condition/needs warrant by an RN. Patients requiring additional reassessment include, but are not limited to: a. Pain management - reassessed every shift based on pain score and medical intervention.

According to the Minor Emergency Treatment policy, 1. The RN assesses the minor emergency including injuries/illnesses not severe enough to warrant admission to a hospital but requiring evaluation or treatment on an immediate basis or at least within the next few hours and it is beyond the capabilities of this facility. Example: lacerations requiring stitches, sprains, or possible fractures. 2. The Charge nurse notifies: 2.1 administrator on call, 2.2 attending physician or physician on call, 2.3 parent or legal guardian if the patient is a minor, 2.4 Unit Manager or Supervisor on duty. 5. RN documents the accident or incident in the progress notes.

According to the Nursing Care of Medical Physical Health Emergencies policy, the facility responds to physical health emergencies in such a manner as to provide for optimal health and safety of patients. The facility offers reasonable care in determining whether an emergency exists, renders lifesaving first aid, and makes appropriate referrals to the nearest facilities capable of providing needed services. Patients, staff or visitors who are involved in an accident or incident and sustain injuries requiring treatment or evaluation beyond the capabilities of this facility will be transferred to an Emergency Room the hospital has agreements with. Procedure: 1. Notify the attending physician or medical director of all injuries. 2. Notify administrator on call (AOC) and director of nursing (DON or nurse administrator of all injuries. 3. Contact the physician and ask her/him if she/he wishes to contact the family or to delegate this responsibility. Document in the chart if the physician delegates this to the nurse and document in the medical record that the notification occurred and the family's response. 9.6 Suspected joint injuries and suspected fractures: 9.6.1 immobilize and elevate the affected joint. 9.6.2 Apply cold compress, if tolerated. 9.6.5 Notify the attending physician.

According to the Body Search policy, body searches shall be done on patients whenever there is suspicion of possession of contraband. Follow these guidelines regardless of timing by which it means be it an admission, off-site appointment, or returning from a transfer out.

According to the Admission of Patient policy, before leaving the assessment room the patient must be scanned with the metal detector, pockets emptied, shoes and hair checked and separated from personal belongings. Once the patient is found to have no contraband on them; they may be taken to the unit. Immediately upon the arrival to the unit, the staff is to check the patient for possession of non-allowable or potentially dangerous items. This is to include checking shoes, pockets, clothing and belongings for items which could present a potential risk to the patient or others. Non-allowable items: personal medications, street drugs, T.V., stereos, recording devices, cameras, sharps, syringes, needles, knives, pot aerosol cans, firearms, bullets, fireworks, explosives, expensive jewelry, and large amounts of cash.

According to the Unit Searches policy, the attending physician will be notified of any contraband found.

Reference:

According to the Product and Services Agreement - mobile imaging services, the provider will provide all services under the agreement in a timely manner.

1. The facility failed to ensure staff accurately assessed, treated, and notified the physician and parent in accordance with facility policy after a patient sustained an injury to her hand.

a. According to a medical record review, on 3/13/22 at 1:08 p.m., Patient #1 was admitted to the facility with a diagnosis of suicidal ideation (SI) with a plan.

i. On 3/22/22 at 9:02 am, a provider note documented there was marked edema (swelling) and pain even to light touch over the right 5th metacarpal (finger) which was a probable boxer fracture (a break in the neck of the 5th finger bone of the hand) to the right hand. The provider note further documented Patient #1 and the nurse were instructed to advise the patient's parent that the patient must be seen by a primary care physician or urgent care after discharging for x-rays as the facility could not obtain x-rays prior to discharging from the facility on 3/22/22.

ii. According to the psychiatric progress note, on 3/22/22 at 12:39 p.m., Patient #1 rated her depression and anxiety at a level of 10 out of 10 and had punched a wall.

iii. On 3/22/22 at 5:50 p.m., the nursing discharge note documented Patient #1 was picked up by a parent. The Registered nurse (RN) discussed with Patient #1 and her parent the patient's complaint of hand pain. The parent verbalized understanding and Patient #1 told her father she had recently punched the wall, therefore bruising her hand.

b. An interview with RN #1 was conducted on 5/11/22 at 8:02 a.m. RN #1 reported patient assessments were expected to be completed by the RN once per shift. RN #1 stated if there was a patient fall or injury, the RN was expected to conduct another assessment. RN #1 further stated after the completed RN assessment, the RN was expected to call the doctor if the injury was serious, and the RN would report the injury and assessment to the doctor. RN #1 then stated if the doctor decided the injury was serious, the patient would be sent to the emergency department (ED) immediately.

RN #1 stated, if an injury required an x-ray, the nurse would let the provider know, obtain an order and call the mobile x-ray company. RN #1 reported the turnaround time for x-rays could be up to 8 hours for a stat (immediate) order, but RN #1 stated he had seen x-rays be completed as soon as 2-3 hours.

RN #1 then reported if a patient verbalized pain to the nurse, the RN was expected to check the patient's chart to see if there were orders for pain medication. RN #1 stated if there was not an order for pain medication, the RN was expected to call the doctor.

RN #1 recalled providing care to Patient #1 on the night shift of 3/21/22. RN #1 stated during shift change report at 7:00 p.m., he was told Patient #1 had punched the wall in the afternoon on day shift. RN #1 reported he performed a physical assessment of Patient #1 and noted a little swelling to her right hand.

Upon review of Patient #1's medical record, RN #1 was unable to provide evidence of a nursing assessment showing swelling of Patient #1's hand following Patient #1's report to staff of a hand injury. In addition, RN #1 was unable to provide evidence of any interventions provided after the Patient #1's request for an ice pack or the change of condition of hand swelling was noted. Furthermore, RN #1 was unable to provide evidence of the physician or Patient #1's parent being notified of the injury.

ii. An interview with RN #2 was conducted on 5/11/22 at 9:46 a.m. RN #2 recalled taking care of Patient #1 on day shift on 3/21/22. RN #2 stated she took over the unit at 11:00 a.m. and received a shift report. RN #2 stated she did not receive a report of any hand injury when taking over. RN #2 stated she was giving report to RN #1 and Patient #1 came up to the nurse's station window during the change of shift. RN #2 stated she notified patient RN #1 was taking over for the night shift, and RN #2 introduced RN #1 to Patient #1. RN #2 stated Patient #1 asked for an ice pack and RN #2 said she recalled handing Patient #1 an ice pack.

There was no documentation noted about an assessment completed for Patient #1's request of an ice pack, nor was there documentation that revealed an ice pack was administered to the patient.

This was in contrast to the Reassessment of Patient policy which read, each patient is reassessed daily, every shift, and as the patient's condition/needs warrant by an RN. Patients requiring additional reassessment include, but are not limited to: a. Pain management - reassessed every shift based on pain score and medical intervention.

iii. An interview with physician #3 was conducted on 5/11/22 at 3:38 p.m. The physician reported the providers were expected to conduct a patient medical assessment upon admission and then once a day. Physician #3 reported it was expected for the RN to notify the provider about changes in the patient's emotional or physical condition. Physician #3 reported the provider was expected to determine if a patient's condition could be handled at the facility, or if the patient would need to be sent to the emergency department (ED). Physician #3 stated if a patient had an injury which occurred while in the facility, the nurses were expected to report to the provider a proper picture of the nature of the injury and if it is life-threatening. Physician #3 reported the nurses were expected to notify the provider of concerns by direct phone call as the preferred method.

This was in contrast to Patient #1's medical record which showed no evidence a physician was noted of the patient's injury.

2. The facility failed to ensure facility policies were followed regarding the physical assessment and physician notification of contraband.

a. According to a medical record review, Patient #4 was admitted to the facility on 2/9/22 at 7:39 p.m. with the chief complaint of suicidal behavior requiring sutures, and on an M1 (involuntary emergency mental health hospitalization) for concern for accidental death.

On 2/9/22 at 8:23 p.m., RN #4 noted Patient #4 had multiple lacerations to the left upper extremity, with three wounds that required sutures and staples prior to admission to the facility. RN #4 further noted one laceration had seven sutures and one laceration had two sutures and an additional laceration had six staples. RN #4 documented the unit nurse would monitor staples every shift for placement related to Patient #4's self-injurious behavior. RN #4 further documented during a skin check, Patient #4 had a razor blade in her hair. RN #4 documented the contraband razor was removed and the unit staff were notified.

On 2/9/22 at 11:58 p.m., mental health technician (MHT) #5 documented Patient #4 had spent the majority of the evening in the room picking at her arm. MHT #5 further noted she went into the room to talk with the Patient #4 and Patient #4 stated she was very depressed, and she just wanted to die, and she was not going to stop cutting herself. MHT #5 further documented MHT #5 had to ask Patient #4 throughout the night to stop picking at her arm and Patient #4 refused.

On 2/10/22 at 1:40 a.m. Nurse Practitioner (NP) #6 documented the transfer of Patient #4 from the facility to the outside ED via ambulance for a left front wrist laceration repair.

On 2/10/22 at 5:42 a.m. RN #7 documented Patient #4 had returned to the facility from the outside hospital at 5:00 a.m.

There was no documentation of a skin assessment or body search being completed upon the patient's return from the outside hospital. This was in contrast to the Body Search policy which read, body searches shall be done on patients: at admission; whenever there is suspicion of possession of contraband. Follow these guidelines regardless of timing by which it means be it an admission, off-site appointment, or returning from a transfer out.

On 2/10/22 at 4:08 a.m., mental health technician (MHT) #5 documented she went back to Patient #4's room and found that Patient #4 had a razor blade in her hand and had cut herself. MHT #5 documented she took the razor out of Patient #4's hand.

On 2/10/22 at 12:36 p.m., RN #8 documented Patient #4 had razors hidden in the groin area. There was no evidence in the medical record showing that a physician was notified of the razor blades found with Patient #4. This was in contrast to the Unit Searches policy which read, the attending physician will be notified of any contraband found.

b. An interview with RN #7 was conducted on 5/16/22 at 9:10 a.m. RN #7 stated he recalled he had taken care of Patient #4 on the night shift of 2/9/22. RN #7 stated he had not done a body scan when Patient #4 had come back to the unit when Patient #4 was first admitted because another RN had done a body scan during the facility intake before Patient #4 was brought back to the facility's inpatient unit. This was in contrast to the Admission of Patient policy which read, before leaving the assessment room the patient must be scanned with the metal detector, pockets emptied, shoes and hair checked and separated from personal belongings. The policy further read that immediately upon the arrival to the unit, the staff was to check the patient for possession of non-allowable or potentially dangerous items.

RN #7 then reported he recalled Patient #4 had been found in the bathroom by an MHT and had been pulling at her staples and had been bleeding. RN #7 further stated he called the nurse supervisor who called the provider and the provider ordered Patient #4 be sent to an outside ED to readdress Patient #4's wound and the patient was sent to the ED. RN #7 further reported the provider wanted the staff to redo the body scan. There was no evidence in the medical record of any additional body scans being performed after the initial body scan during intake.

RN #7 further stated after Patient #4 returned from the ED, he recalled an MHT reported to the nurses Patient #4 had been found in her room with a razor blade and was cutting herself.

iii. An interview with the director of nursing (DON) #12 was conducted on 5/16/22 at 11:36 a.m. DON #12 stated the unit staff were expected to conduct another contraband assessment after the intake skin assessment to ensure a patient did not come into the unit with contraband.

iv. An interview with the director of quality (Director) #11 and DON #12 was conducted on 5/16/22 at 3:38 p.m. The director of quality reported the nursing staff were expected to conduct and document a nursing assessment and another skin assessment in the chart after the intake process and after returning from an outside facility. Upon review of Patient #4's medical record with Director #11 and DON #12, there was no evidence a body search had been conducted immediately after Patient #4 was brought to the inpatient unit from the facility's intake room. Upon further review of Patient #4's medical record with the Director #11 and DON #12, DON #12 was unable to find evidence in the medical record that a body search for contraband had been conducted after Patient #4 returned to the inpatient unit from the outside ED or after Patient #4 had been found with the contraband razor. Furthermore, there was no evidence in the record a body search had been conducted after Patient #4 had been found with contraband. In addition, there was no evidence the provider was informed after razor contraband had been found on Patient #4 after she returned to the facility's inpatient unit from the outside ED.

This was in contrast to the Body Search policy which read, body searches shall be done on patients whenever there is suspicion of possession of contraband. Follow these guidelines regardless of timing by which it means be it an admission, off-site appointment, or returning from a transfer out.