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Based on observations, review of recorded video footage, interviews, review of grievance, incident and medical record documentation for 22 of 26 patients (Patients 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 and 23), review of P&Ps and review of PERA documentation it was determined that the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all Conditions of Participation.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care, and is a repeat deficiency cited previously on surveys completed on 12/13/2018, 02/28/2019, 09/27/2019 and 02/06/2020.

Findings include:

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

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

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

4. Refer to the findings cited at Tag A700 under CFR 482.41 - CoP Physical Environment.

5. Refer to the findings cited at Tag A1640 under CFR 482.61(c)(1) - Standard Treatment Plan.





44104

Based on observations, review of recorded video footage, interviews, review of grievance, incident and medical record documentation for 22 of 26 patients (Patients 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 and 23), review of P&Ps and review of PERA documentation it was determined that the hospital failed to fully develop and implement P&Ps that recognized and protected each patient's right to:
* Provision of care in a safe setting.
* Timely and complete response to complaints and grievances.
* Freedom from restraint and seclusion.

Those failures allowed patients to elope from the secure facility and secure units, and to attempt suicide and self-harm.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care, and is a repeat deficiency cited previously on surveys completed on 12/13/2018, 02/28/2019, 09/27/2019 and 02/06/2020.

Findings include:

1. Refer to the findings cited at Tags A118, A122 and A123 under CFR 482.13(a)(2) - Standard: Patient Grievances.

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

3. Refer to the findings cited at Tags A168 and A171 under CFR 482.13(e) - Standard: Restraint or Seclusion.

Based on interview, review of grievance documentation for 10 of 10 patients (Patients 12, 13, 14, 15, 16, 17, 18, 19, 20 and 21), and review of hospital P&Ps, it was determined that the hospital failed to fully implement grievance P&Ps that ensured patients' rights were recognized, protected, and promoted in regards to grievance response, investigation and documentation:
* Responses to and investigations of patient grievances were not clear, complete or timely.
* A written grievance notice that contained the required elements including the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion was not provided to each patient/patient representative who submitted a grievance.

Findings include:

1. The P&P titled "Patient and Family Grievances / The Role of the Patient Advocate " dated last revised "06/20" was reviewed. It included the following stipulations:
* "It is the responsibility of each staff member to respond promptly to any concern or grievance voiced by patients and their families no matter how trivial the complaint may appear to be."
* "If a patient care concern cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance."
* "A written complaint is always considered a grievance ... an email or fax is considered 'written.'"
* "All verbal or written complaints regarding abuse, neglect, patient harm, and/or compliance with CMS requirements are considered grievances and receive a prompt response."
* "The grievance resolution/follow up will be documented completely and accurately in a timely manner as follows ... The Patient Advocate will respond to the patient no later than the following day of receiving the Patient Grievance form. An investigation will be conducted into the complaint/grievance and actions taken will be documented to ameliorate the grievance with any patient, patient representative, and/or family member/significant other immediately ..."
* "A written notice will be sent to the patient within seven (7) days of the grievance's receipt and will provide a summary of the actions taken and the final resolution ... If the grievance cannot be resolved with seven (7) days and the Patient Advocate needs additional time for the investigation, the 7-Day Letter will be sent to the patient informing them of the need for an additional 30 days from the date of the 7-Day Letter to resolve the complaint/grievance. A final resolution later will be sent to the patient no later than 30 days from the date of the 7-Day Letter ..."
* "Patient Advocate responsibilities ... Begins investigation of grievances within one working day of receiving the Patient Grievance form ... Any verbal or written grievance regarding abuse, neglect, patient harm, or patient rights will be addressed with CEO, CNO, Director of Clinical Services and/or Administrator on Call immediately and will not wait until the next working day ..."

2.a. Refer to the findings for Patient 12 identified under Tag A145, Finding 3, that reflect the hospital's failure to conduct an investigation of a potential alleged rape that was submitted by phone on 01/22/2021 on the day of the patient's discharge. The grievance also included an concern about the medications provided to the patient for home. Although an investigation of the rape had not been conducted the Patient Advocate sent the patient's representative a letter dated 01/28/2021.

2.b. The grievance response letter dated 01/28/2021 reflected the following: "Your Concerns: You inquired about a question your [son/daughter] had asked you and about [his/her] medication. Steps taken to resolve: Spoke with the Nurse on duty and the Mental Health Technicians about your concerns. Notified the Director of Nursing about your concerns. Notified the Risk Manager about your concerns. Notified the Director of Performance Improvement about your concerns. Results/Resolution: Thank you for reporting your concerns to the facility. The Administrative Care Team wanted you to know that your concerns have been investigated. More information would be required to perform a more detailed investigation. In regards to safety and security our staff performs 15 minute rounds on every patient and the Nurses complete safety checks through out the day 24 hours a day. We also have cameras. You also inquired about [Patient 12's medication]. This was handed to [him/her] at discharge."

There was no other documentation related to Patient 12's concern about rape, and contrary to the 01/28/2021 letter provided to the patient's representative, there was no evidence of an investigation of this serious concern expressed by a vulnerable hospital psychiatric patient.

The response letter did not appropriately address the grievance/allegation of rape and there was also no information provided to the patient's representative about how the Patient Advocate determined that the medication had been "handed to" the patient at discharge.

2.c. During interview with the CNO, RM and the Patient Advocate on 04/22/2021 at the time of the review of grievances beginning at 1545, they confirmed that the written response was unclear and incomplete. The Patient Advocate verified that the written response did not address the allegation of rape. Additionally, the RM confirmed that an investigation to determine whether the allegation was substantiated had not been conducted and the allegation of abuse had not been entered into the incident reporting system.

3.a. Review of a "Patient Complaint / Grievance Submission" form dated "3/3/22 (sic)" for Patient 13 reflected that "My face mask (cloth) with an irreplaceable patch on it, is nowhere to be found ..." The form included the following:
* "Received 03/04/2021."
* "03/04/2021 ... Immediate Steps Taken on Behalf of the Patient: [Patient Advocate] called Pt @ phone number and got busy signal. 03/05/21 ... will mail a letter to pt for more information."
* "Additional Steps Taken to Resolve Issue(s): 03/24/2021 Letter for more info sent. 04/15/2021 Cleaning Lost & Found and found pt's mask ... called pt to notify and verify address."
* "Resolution Letter Sent On: 03/24/2020 (sic)."

3.b. The grievance response letter dated 03/24/2021 reflected the following: "Your Concerns: You are missing a cloth face mask with an irreplaceable patch. Steps taken to resolve: Spoke with the Nurse on duty and the Mental Health Technicians about your concerns. Spoke with assessment and security. Reviewed your inventory sheet. Notified the Director of Performance Improvement about your concerns. Results/Resolution: Thank you for reporting your concerns to the facility. We have tried to reach you by phone without success. Could you please contact us so that I may get a description of your mask for my search."

The response letter was not clear, complete or timely. For example:
* It did not include information that resulted from those parties the Patient Advocate "spoke with."
* It did not include information that resulted from review of the "inventory sheet."
* It was not timely as it was not sent until 03/24/2021, 20 days after the grievance had been received.
* It was not a "resolution letter" as the letter sent asked the patient to call back with more information.
* It was not clear why the "Lost and Found" had not been checked as part of an investigation of this grievance until 04/15/2021, 42 days after the grievance was submitted.

3.c. During interview with the CNO, RM and the Patient Advocate on 04/22/2021 beginning at 1545 they confirmed that the written response was unclear, incomplete and not timely. The Patient Advocate also verified that the "Lost and Found" was not checked until 42 days after the complaint had been submitted and after the letter had been sent to the patient.

4. A "Patient Complaint / Grievance Submission" form was submitted by Patients 16 and 17 together on 03/31/2021 and reflected their room was "extremely cold" and freezing. The form reflected that "Resolution Letter Sent On: [not applicable]." There was no documentation of written resolution response to those patients who submitted a written grievance.

5. An email from the Patient Advocate to other hospital staff dated 03/31/2021 at 1629 reflected that Patients 18 and 19 had verbally reported verbal abuse by an RN. There was no documentation of an investigation and written response to Patients 18 and 19 allegation of verbal abuse.

6. A "Patient Complaint / Grievance Submission" form was submitted by Patient 20 on 04/05/2021 and reflected a grievance about a "Passive Aggressive Charge Nurse" who took away the chair the patient was sitting on. The form reflected that "Resolution Letter Sent On: [not applicable]." There was no documentation of written resolution response to the patient who had submitted a written grievance.

7. Similar findings of unclear and incomplete investigation and written responses were also identified for written grievances submitted for Patient 14 on 03/21/2021, Patient 15 on 03/28/2021 and Patient 21 on 04/07/2021.

8. During interview with the CNO, RM and the Patient Advocate on 04/22/2021 beginning at 1545 they also confirmed that the findings for Patients 16, 17, 18, 19 and 21.

Based on interview, review of grievance documentation for 10 of 10 patients (Patients 12, 13, 14, 15, 16, 17, 18, 19, 20 and 21), and review of hospital P&Ps, it was determined that the hospital failed to fully implement P&Ps that ensured patients' rights were recognized, protected, and promoted in regards to timeliness of grievance review and response.

Findings include

1. Refer to the findings cited at Tag A118 under CFR 482.13(a)(2) - Standard: Patient Grievances.

Based on interview, review of grievance documentation for 10 of 10 patients (Patients 12, 13, 14, 15, 16, 17, 18, 19, 20 and 21), and review of hospital P&Ps, it was determined that the hospital failed to fully implement P&Ps that ensured patients' rights were recognized, protected, and promoted in regards to the written grievance notice to patients or their representatives.

Findings include

1. Refer to the findings cited at Tag A118 under CFR 482.13(a)(2) - Standard: Patient Grievances.



44104

Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 9 of 13 patients reviewed for elopement and other incidents (Patients 1, 2, 3, 4, 7, 8, 9, 10 and 11), review of P&Ps and review of PERA documentation it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient's right to receive care in a safe setting. Failures that created an unsafe EOC that resulted in actual and potential patient harm included:
* Failure to provide appropriate observation and supervision of patients.
* Failure to provide appropriate safety, elopement and suicide/self-harm precautions.
* Failure to ensure door security measures were followed.
* Failure to identify risks in the EOC and to maintain it free of hazards.
* Failure to develop and follow individualized, comprehensive treatment plans.
* Failure to follow LIP orders.
* Failure to investigate incidents to identify causes and to plan and implement corrective actions to prevent recurrence for the affected patient and other patients.

Those failures allowed patients to elope from the secure facility and secure units and to attempt suicide and self-harm.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care, and is a repeat deficiency cited previously on surveys completed on 12/13/2018, 02/28/2019, 05/16/2019, 09/27/2019 and 02/06/2020.

Findings include:

1. P&Ps reviewed included the following:

1.a. The P&P titled "Elopement Precautions" dated as "Last approved: 08/2020" was reviewed. It reflected: "Individuals being evaluated for treatment ... are placed on Elopement Precaution if they are: ... deemed a potential danger to self or others ... Indications that suggest an individual should be placed on elopement precaution include but are not limited to: ... Aggressive language and/or gestures directed at hospital staff ... Suicidal/homicidal ideation accompanied by ambivalence regarding in-patient treatment ... The individual is on an involuntary hold ... Verbalization of intent to elope ... Loitering near unit and/or any exits ... All patients are monitored for potential elopement risk ... Staff Interventions ... Be alert during high risk times (sleeping hours, shift change, meals, etc.)"

1.b. The P&P titled "Suicide Precautions, IP" dated as "Last Approved: 08/2020" was reviewed. It reflected: "Patients who are assessed to be at risk of suicide are placed on Suicide Precautions ... All in-patients are monitored for potential suicidal behavior. Behavioral ... data that might indicate increased potential for suicide ... include but are not limited to ... Changes in behavior ... Sudden changes in mood ... Staff Interventions: Bold Interventions are required. Strict Adherence to linen policy; no spare linens; Consider suicide blanket. Patient's room inspected for contraband daily. No single rooms unless otherwise indicated." Those interventions were in bold type. The P&P interventions continued and additionally included: "Consider increasing observation level (1:1). Be alert during high risk times ... Patient is encouraged to spend time out of bedroom; Consider locking bedroom door ..."

1.c. The P&P titled "Patient Observation Rounds" dated as last approved "05/2020" reflected: "Purpose: To routinely identify the location of patients and monitor and document their behavior, safety and well-being ... The Charge/Lead RN is responsible to ensure the Patient Observation Rounds are occurring as ordered ... that ordered precautions and observation levels are accurately transcribed to each patient's Observation Rounds form ... Staff assigned to conduct Observation Rounds ... Review and update Patient Observation forms, reflecting any changes in individual patient precautions levels ... Observe each patient a minimum of every 15 minutes and/or according to precaution/observation level ... Identify and report any hazards or other findings while conducting observation rounds to the Charge/Lead RN e.g. ... Unsecured doors that should be locked ..."

1.d. The P&P titled "Facility Access and Key Control" dated as last approved "10/2020" reflected: Under the section titled "Workforce Traffic flow and Door Awareness" it stipulated that staff will "Exercise door awareness and conduct a 360 degree observation before walking in or out of a locked door in a patient care area. Staff must ensure a patient is not in the immediate vicinity of the door on either side of the door prior to opening it. They will not open a door if patients are in the immediate area ..."

1.e. The P&P titled "Admission Process" dated as last revised "03/2021" reflected: "When the patient arrives at this facility ... Patients will be monitored by staff with line-of-sight observations during admission process ... Once back in the secured assessment area, the patient will be assigned to an assessment room. If a room is unavailable, patient will wait in the secured assessment waiting area until a room is available."

1.f. The P&P titled "Incident Reporting" dated as last approved "09/2020" reflected: "The Healthcare Peer Review (HPR) Reporting (Incident Reporting) is a function of the Risk Management program at Cedar Hills Hospital ... Occurrence (Incident Type): that which is not consistent with the routine care of a patient and/or the desired operations of the facility. The results of this event require or could have required (near miss) unexpected medical intervention, unexpected intensity of care, or causes or had the potential to cause an unexpected physical or mental impairment ... The [RM] will investigate all HPR incidents for process failures and areas to improve patient safety ...

1.g. Refer also to the P&P identified under Tag A145, Finding 1.a. related to investigation of occurrences of neglect

2. Patient 1, who was placed on a NMI and civilly committed on 11/25/2020, during his/her hospitalization, was allowed to attempt suicide, allowed to have prohibited items in his/her possession after the SA and was allowed to elope from the secure facility. LIP orders were not followed, and a clear and complete treatment plan was not developed and implemented. This resulted in psychological harm and potential physical harm. Further, the lack of investigation of those incidents to prevent recurrence created a potential for additional harm to Patient 1 and to other patients. The findings for Patient 1 included:

2.a. Review of Patient 1's medical record revealed the following information:

* Patient 1 was admitted on 10/15/2020 with increasing suicidal thoughts after a prior SA and he/she was discharged on 01/29/2021.

* LIP orders included:
- "Level of Observation" ordered on 10/15/2020 at 1759 was for "Every 15 minutes" and was in effect through date of discharge.
- "Precautions" ordered on 10/15/2020 at 1759 were for "Suicide Precautions," "Self-Harm Risk" and "Sexual Victimization Risk" and were in effect through date of discharge.
- "May only have scrubs" ordered on 10/28/2020 at 1220 was in effect until discontinued on 11/14/2020 at 1237.
- "Suicide blankets only" ordered on 10/28/2020 at 1219 was in effect until discontinued on 11/14/2020 at 1237.
- "No linens, safety blanket only, paper scrubs only" ordered on 11/14/2020 at 1237 was in effect until discontinued on 12/28/2020 at 1748."
- "Precautions Elopement Risk" ordered on 12/30/2020 at 1900 was in effect through date of discharge.

* On a "Precautions" document dated 10/15/2020, checkboxes next to the following "Precautions" had checkmarks in them: Suicide, Self Harm, Sexual Victimization. "Observation Level" was identified as "Q15" minutes. There were no changes documented on the document at any time during the patient's stay.

* The "Master Treatment Plan, Part 1" dated 10/24/2020 by the LIP, the "Multidisciplinary Master Treatment Plan, Part 2" dated 10/28/2020 and the "Individual Treatment Plan" dated 10/28/2020 all identified patient problems of self-harm, SI and "recent SA." Pre-printed interventions with boxes next to each in which a checkmark had been entered included: "Encourage patient to seek out staff if having thoughts of harming self ... Mouth checks ... Removal of personal items to prevent self-injurious behavior ... Conduct room checks for contraband ..."

There were no individualized interventions identified on any of those documents and no interventions related to observation levels. The only pre-printed intervention related to observation levels was "1:1 observation level" and the box next to that was blank to indicate it was not an intervention for Patient 1. The treatment plans did not include any other entries related to patient observation.

* Regarding the observation level for Patient 1, there was no documentation in the record, in LIP orders, LIP notes, nurse's notes, observation rounds forms, social services notes, the treatment plan, etc. that the observation level was ever increased to 1:1 or more than every 15 minutes.

* Daily "Patient Observation Rounds" forms were reviewed. The form had three "Observations Levels" identified on it. Those were "Q15" minutes, "1:1 distance" and "1:1 arm's reach." The form had spaces in 15-minute increments for staff initials and observation notes for the 24-hour period from 0000 or midnight through 2345.

The "Patient Observation Rounds" forms for 12/17/2020 through 01/03/2021 all identified Patient 1's "Observation Level" as "Q15" minutes. The checkboxes on the form next to each of the two "1:1" levels were blank.

* A nurse's note dated 12/19/2020 at 1116 by an RN reflected "During a round this morning the pt was found in [his/her] room, 137, with a flannel T-shirt wrapped around [his/her] neck, and [he/she] had attempted to attach it to the door handle, with an attempt to strangle [him/herself] when staff entered room, the pt was compliant with removing flannel from [his/her] neck, MHT notified RN staff, RN debriefed with pt who states 'I just don't want to live anymore' and states 'I want to be dead' - [he/she] states [he/she] had severe nightmares through the night as well as severe [illegible] this morning. The pt personal - clothing removed, and [he/she] is provided paper scrubs. The pt and roommate have black safety blankets. Pt room checked by RN for safety. Pt asked to remain in the milieu for increased observation ... [Nurse Practitioner] notified. No further interventions instructions given. RN requesting Pt be moved rooms, from east hall - to South hall to help promote increased observation. Pt has been identified as a suicide risk, and will remain on these precautions ... Nursing staff will continue to monitor pt and ensure no clothing items provided to pt until - approved by psychiatrist - (sic)"

* A "Master Treatment Plan Update" form dated 12/21/2020 reflected "significant incidents/behavioral changes" as "12.19.20 Found with shirt around neck attempting to hang or strangle self ... Staff entered patient's room [and] discovered the patient in the process of attempting to hang/strangle self 'I want to be dead (sic)'"

The "Problems" section of the plan included only one problem as "Disorganization with VAH [and] SI." The entry under that problem was "DC previous goal. Initiate: [Patient 1] will not attempt to harm self or act on suicidal thoughts for 1 week. Continue to meet 1:1 w/ therapy staff to process trauma."

There was no documentation to reflect that therapy staff had met with Patient 1 for 1:1 sessions "to process trauma" as specified on the 12/21/2020 treatment plan update. After 12/21/2020 the first Social Services note of a session with Patient 1 was on 12/31/2020, the prior note being on 12/18/2020. There was no other documentation of 1:1 therapy sessions with Patient 1.

* A nurse's note dated 12/22/2020 at 2200 by an RN reflected "It was discovered that the patient was dressed in a flannel gown instead of paper scrubs. Because there was no order for regular clothing but there is an order for paper scrubs, [his/her] nightgown was confiscated, placed in contraband and [his/her] paper scrubs were given to her."

As described in the LIP orders above, the orders in place at the time included "No linens, safety blanket only, paper scrubs only" ordered on 11/14/2020 and discontinued on 12/28/2020. The order for "paper scrubs only" had not been followed.

* There was no documentation that the treatment plan had been reviewed or revised as result of the discovery that the patient had a prohibited item in his/her possession on 12/22/2020.

* A nurse's note dated 12/30/2020 at 1448 by an RN reflected "Pt. is on self-harm, sexual victimization, suicide and cheeking precautions ... Pt. moved to CSU after elopement. More information below."

That note was the first reference to an elopement and the first nurse's note written since the previous note by an LPN dated 12/29/2020 at 2000.

* The next nurse's note was dated 12/30/2020 at 1650 by an RN and reflected "Pt went to yoga @ 1030. Pt took keys and eloped through front door. Police were notified immediately. Police broaught (sic) pt back to facility. Pt cooperated. Pt transferred to CSU."

* The next nurse's note was dated 12/30/2020 at 1700 by an RN and reflected "When checking on pt and following up on incident pt informed LN that [he/she] was attempting to elope to reach the [commuter train] tracks to comit (sic) suicide by being hit by the [commuter train] r/t racing, impulsive voices telling [him/her] to do so."

Those three notes contained the only RN documentation in the nurse's notes about the elopement incident. None of those contained information about implementation of increased observation levels or other elopement precautions.

* A "Master Treatment Plan Update" form dated 12/30/2020 reflected "significant incidents/behavioral changes" as "12.30.20 Elopement ... [Patient 1] took keys from staff [and] left the building. Staff was able to catch up to [Patient 1]. [He/she] returned without incident." The "Precautions" section of the plan was blank as was the "Psychiatrist Update."

The "Problems" section of the plan included only one problem as "Disorganization with VAH [and] SI." The entry under that problem was "[Patient 1] will continue [his/her] treatment goal of not attempting to harm [him/herself] or act on suicidal thoughts for the upcoming week."

The Treatment Plan form itself did not include elopement under the pre-printed section of the form for "Current Precautions" as it did for "Suicide" or "Fall" or "Homicide" for example. There was no other information on the Treatment Plan related to elopement.

2.b. Incident documentation for Patient 1's 12/19/2020 SA was reviewed.

2.b.i. An "Investigation Note" form reflected that on 12/19/2020 "While [MHT] was doing round, (sic) [he/she] found pt with [his/her] long sleeve flannel TShirt wrapped around [his/her] neck and attempted to be tied to door handle, when MHT moved door the flannel was not actually attached to door, the MHT notified nurse. Pt removed the flannel from [his/her] neck. [Patient 1] was given paper scrubs, already had black blankets, roommate received (sic) black blankets, pt provided scheduled and PRN meds, and asked to be present in milieu so staff could monitor. Pt cooperative with staff interventions."

The "Nursing Supervisor Notes on Incident" on the "Investigation Note" form reflected the following undated documentation by an RN: "Education provided to staff about remaining with pt and calling for staff assistance. No injury to pt."

A second entry in that section of the form was recorded by the RM and was dated 12/21/2020. The RM recorded only "Camera reviewed. Staff followed rounding policy and caught patient in planning stage of attempt."

There was no other documentation of an investigation related to this SA.

2.b.ii. The investigation was not clear and complete. For example:
* It failed to identify that LIP orders in place between 11/14/2020 and 12/28/2020 included "paper scrubs only" that had not been followed.
* It failed to explore how the patient had prohibited clothing items in his/her possession.
* It failed to identify that the patient observation level after the incident remained "Q15" minutes, that there was no change in observation level and whether that should have occurred.
* It failed to explore whether it was appropriate for nursing staff to make the patient responsible to remain "in milieu so staff could monitor" and inferred that staff would not monitor if patient was in his/her bedroom.
* There was no information related to whether the door handle was determined to be a ligature risk.

2.b.iii. During interview with the RM on 04/22/2021 beginning at 1430 he/she stated that he/she had reviewed the medical record, had talked to staff, the patient had been placed "back on linen restrictions" and was "placed on 1:1 for a while." The RM confirmed that there was no documentation of any of that or any other aspects of an investigation or corrective actions.

2.c. Incident video recording and documentation for Patient 1's 12/30/2020 elopement was reviewed.

2.c.i. Review of video recordings from various camera views on 04/21/2021 at 1400 with the RM revealed the following:
* At 1030 four persons inside the gym were standing near an exit door. Those were described as three patients, including Patient 1, and the yoga instructor. Although in that view it was difficult to observe detail due to the distance from the camera to the exit door, the four persons were observed to be standing in an unorganized manner and were not observed to be prepared to exit the security door out of the gym door in an orderly fashion. Patient 1 was observed to stand immediately next to the exit door within arm's length of the yoga instructor who faced the door. A second patient was several steps behind the yoga instructor and the third patient stood on the left side of the yoga instructor.
* As the gym door opened Patient 1 was observed to be the first to quickly exit through the door at a quick run. The yoga instructor grabbed Patient 1's shirt and something was observed in Patient 1's right hand, although on video the item was not clearly seen. According to the medical record documentation the patient had taken staff's keys.
* From the gym, Patient 1 ran down a short corridor and opened a door to the interior courtyard. That door did not require a key/fob. The yoga instructor followed.
* Once in the courtyard the patient used the key/fob to exit the nearby security door from the courtyard out to the hospital's unfenced exterior.
* The yoga instructor followed Patient 1 out to the exterior into a narrow space behind the building and had hold of the patient's clothing.
* At 1031 the yoga instructor aggressively attempted to keep hold of the patient's clothing while the patient aggressively struggled to free him/herself from the yoga instructor's grip.
* The patient eventually was able to slip out of the clothing item the yoga instructor had hold of and ran away, off the hospital premises and out of camera view.
* The yoga instructor was observed to use a walkie-talkie in his/her possession to communicate with someone.
* At 1050 the patient was observed to be returned to the hospital by police.

2.c.ii. An "Investigation Note" form reflected that on 12/30/2020 at 1030 Patient 1 "went to yoga" and "while there pt took keys and eloped through the front door."

The "Nursing Supervisor Notes on Incident" section of the form reflected the following undated documentation by an RN: "Located Code 10 Called 911 Coordinated police to location of patient. Escorted patient to CSU and completed skin check. Told staff wear (sic) to locate lost keys. Added elopement precautions. Placed pt on 1:1 and allocated staff."

There was no other documentation on the form.

2.c.iii. An undated and unsigned "Investigation Summary" included the following incident description and "Investigation Details:"
* Patient 1 "was completing a yoga therapy session in the gym, when [he/she] ripped the keys away from the instructor as they were exiting and ran out through an emergency exit in the courtyard. Multiple staff quickly followed [him/her] but [patient] managed to make it off property for almost 30 min. before being corralled and picked up by law enforcement. [Patient] was promptly returned without further injury or incident."
* Patient was "placed on an involuntary NMI hold soon after admission because of continued SI. On 10/28/20, [patient] attempted suicide on site by strangulation in the shower."
* Patient "... has remained on suicide, self-harm, and elopement precautions since the start of [his/her] stay, and recently has gone back on linen restrictions due to continued SI.
* "The morning of the incident, [Patient 1] had specifically requested to participate in yoga with [yoga instructor] ... had asked for permission to wear [his/her] regular clothing again, and had put on several layers under the guise of it being cold on the walk through the courtyard to the gym.
* The patient "completed yoga without incident ... [yoga instructor] had [his/her] keys attached to a small wrist bungee, and when [yoga instructor] fobbed [his/her] way out of the gym, [Patient 1] quickly grabbed onto the bungee and ripped the keys out of [yoga instructor's] hands. [Patient 1] then bolted through the door and into the corridor to the courtyard ... used the key fob to get through the courtyard emergency exit ... took off running."
* Upon return to the facility the patient "said [his/her] plan with elopement was to complete suicide by running in front of a nearby commuter train."
* Under the section of the "Investigation Summary" titled "Documentation Review (Include Discrepancies Addendums):" the only documentation was "[RM] reviewed the incident report, progress notes, and LIP's orders. No discrepancies present."
* Under the section titled "Who was Interviewed?" the documentation reflected that only the yoga instructor was interviewed and he/she said '[Patient 1] had asked me specifically if I was teaching yoga this morning, which [he/she] had never done ... (sic) [Patient 1] saw I had my keys on a bungee around my wrist and grabbed them as soon as I used the fob to get us out of the gym, I was pulling at [his/her] sweater trying to get my keys back, but [he/she] slipped out and ran off. I called for help but forgot to say where I was at or where [Patient 1] had gone."
* Under the section titled "Contributing Factors:" the documentation reflected "Patient 1 ... had time to study staff patterns and specific weaknesses. [Patient 1] was also extremely suicidal and determined to execute [his/her] plan since prior attempts had been thwarted by staff."
* Under the section titled "Immediate Mitigation Plan in Place:" the documentation reflected "[Patient 1] was returned to the facility where [he/she] was assessed for injury and further SI. [He/she] was placed on the CSU for unit restriction, 1:1 observation, and given paper scrubs to wear."
* Under the section titled "Corrective Action Plan:" the documentation reflected "RM educated [yoga instructor] on the proper method of carrying [his/her] keys and maintaining door control with patients present. Nursing will also retrain [yoga instructor] on handle with care and procedure for calling a code by 1/31/21. Yoga will no longer be held in the gym, and take place exclusively on the units. Staff will communicate elopement and self-harm precautions to all staff to limit access to off-unit areas when applicable."
* Under the section titled "Staff HR Files (Were Staff involved in Incident Up to Date on Yearly Training?):" the only documentation was "Yes."
* Under the section titled "Policies Reviewed Related to Incident (Did we follow policy? Does policy need to be amended?:" the only documentation was "RM reviewed the patient supervision policy and determined that staff did not act within the guidelines. Recommend changing yoga location policy."

2.c.iv. During interview with the RM on 04/22/2021 at 1430 he/she stated there was no additional investigation documentation.
He/she also stated that the yoga instructor was a non-employee contractor and that there was no documentation of education for the yoga instructor, but that "verbal counseling" was provided "in the moment." Further he/she stated that the unit MHTs had communications about the patient's precautions but "MHTs don't document narratives, they report to the nurses who do the documentation."

2.c.v. On 04/22/2021 the training documentation provided for the contracted yoga instructor was:
* An undated, untitled written statement that reflected: "In light of elopement incident that occurred on Wednesday, December 30th, 2020, [yoga instructor] has received education in the following areas: 1. Keys ... 2. Supervisor reviewed basic 'Handle With Care' technique ... 3. In the advent of any future incidents ... will call the correct code by name and specify where on the campus ..."
* An unsigned, untitled written statement that reflected: "Immediately following the patient elopement event of 12/30/20 the Director of Risk Management and I reviewed the code procedures with [yoga instructor name] ..." The name of the CNO was typed under that wording along with the date and time of "12/30/20 1130." The CNO stated at the time the statement was provided that the review of code procedures was conducted on 12/30/2020 but the written statement was not documented until day two of the survey, 04/22/2021.

2.c.vi. Although the documentation reflected that video was reviewed, the yoga instructor was interviewed and the "patient supervision policy" was reviewed, the investigation of this incident that resulted in patient harm, including follow-up actions planned and implemented were not clear, accurate or complete. For example:
* There was no information to reflect who gave "permission" for the patient to wear regular clothing on 12/30/2020 and whether that decision was based on an assessment and LIP's orders.
* There was no information about an assessment, prior to the patient leaving the unit for yoga, of the patient's sudden request to participate in yoga and the unusual amount of clothing he/she wore.
* The investigation failed to address whether activities off the unit were permitted for this patient as result of the 12/19/2020 incident and who was on continued suicide precautions.
* There was no information to reflect whether it was appropriate and in compliance with hospital policies that only one staff was present to escort multiple patients back and forth between the secure unit and the gym through an outside courtyard.
* There was no information to reflect whether a contracted yoga instructor was in compliance with hospital policies and appropriate to be the sole person to escort patients, including at least one, Patient 1, on suicide precautions.
* The investigation failed to determine whether the contracted yoga instructor had been oriented and trained for the tasks of escorting patients, door security, key management, situational awareness, calling a code, etc. prior to 12/30/2020 and if so, what was provided, when did it occur and whether it was adequate.
* The documentation reflected that only one policy was reviewed, the "patient supervision policy," and it was "determined that staff did not act within the guidelines." It was not clear what specific policy that was, by title and version, and what "guidelines" had not been followed. In addition, no other applicable P&Ps were reviewed.
* The investigation contained inaccurate information as it reflected in the "Investigation Summary" above that Patient 1 "... has remained on ... elopement precautions since the start of [his/her] stay ..." However, that was not consistent with LIP orders nor the 12/30/2020 "Investigation Note" that reflected "Added elopement precautions."
* Other inaccurate information was related to the "Mitigation Plan" that reflected the patient was placed on 1:1 observation level after return to the hospital. However, there was no documentation in the record to reflect that had been done.
* There was no information related to the retrieval of the hospital keys/fob that the patient had taken except for the "Investigation Note" documentation dated 12/30/2020 that reflected the patient "Told staff wear (sic) to locate lost keys."
* The investigation failed to address that while the yoga instructor was in pursuit of the patient outside of the facility, no one was supervising the other two patients.
* The investigation failed to explore whether the yoga instructor's significant struggle and attempt to hold on and physically restrain the patient was appropriate and in compliance with policies and training.
* The "Corrective Action Plan" regarding education for the yoga instructor did not specify how and when he/she was "educated" after the incident and who conducted that training. Further it was not clear why education for some topics, including calling a code, was not planned for earlier than 30 days after the incident.
* The action plan to not hold yoga in the gym was not clear as to how that would prevent the underlying problems that led to the elopement. It was not evident that the location of the yoga class was the problem versus the failures described in this report.
* Regarding the action plan for "Staff will communicate elopement and self-harm precautions to all staff to limit access to off-unit areas when applicable," it was not clear what that meant, how and when that would occur, and which "staff" would communicate to "all staff."

3.a. Medical record documentation for Patient 2 included the following:
* A nurse's note by an RN dated 02/03/2021 at 1414 reflected "At approximately 1330 this RN was notified pt's window was broken and pt had eloped ... Police brought patient back at 1400."
* A nurse's note by an RN dated 02/03/2021 at 1748 reflected that the "pt c/o pain in right shoulder rated 5/10 where [he/she] reportedly hit it on the window ... The pt reports when [he/she] eloped [he/she] did not have intent to harm [him/herself], but that [he/she] 'just wanted to go home.'"

3.b. A note on an incident "Investigation Note" form reflected that on 02/03/2021 at 1330 "staff was notified pts window was broken and pt had eloped. Nursing sup, MD notified. Police called, brought pt back to CHH in less than an hour Pt moved to CSU for pt safety."

The "Nursing Supervisor Notes on Incident" section of the form reflected the following undated documentation by an RN: "Responded to code 10. Called 911. Instructed staff to follow pt. Assisted staff in completing skin check. Pt moved to CSU. Spoke [with] therapist who updated family. Had conversation [with] patient about doing reality checks [with] staff. Spoke [with] med nurse to give PRN. Assisted staff to get NMI paperwork."

The RM recorded on the form "Reviewed footage at time of incident. Staff conducted rounds according to policy. Patient did not make elopement intentions known prior. Window repaired." The date of this note was illegible.

3.c. There was no incident "Investigation Summary" document as described for Patient 1 under Finding 2 above in this Tag and the investigation documentation provided was not clear or complete. For example:
* There was no information to reflect whether the patient had been appropriately supervised prior to the elopement in accordance with LIP orders and nursing assessment.
* There was no information or description as to what was meant by "broken" and to what extent the patient had "broken" the window, such as was the entire window knocked out, was it partially broken, etc.
* There was no information related to the EOC factors that caused the patient to be able to break the window in this secure psychiatric hospital.
* There was no information to reflect whether other windows in that room or in other patient rooms had been evaluated to determine whether they also were at risk of being "broken."

There was no other documentation related to this incident that resulted in patient harm, including identification of factors that allowed the incident to occur and actions to prevent recurrence

3.d. During interview with the CNO and DPO on 04/21/2021 at 1135 they stated that Patient 2 had broken one of the large windows in his/her ground floor room by running into it. The windows were "tempered glass", and the patient was able to break the window seal allowing the window to be dislodged and he/she was able to exit through the opening to the ground. During the interview they stated that the room was closed and locked

Based on observations, review of video recordings, interviews, review of incident, grievance and medical record documentation for 2 of 4 patients reviewed for allegations of sexual abuse (Patients 5 and 12) and 9 of 13 patients reviewed for allegations of neglect (Patients 1, 2, 3, 4, 7, 8, 9, 10 and 11), review of P&Ps and review of PERA documentation it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient's right to be free from all forms of abuse and neglect. Investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur.

The CMS Interpretive Guidelines for this requirement at CFR 482.13(c)(3) reflects "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Further, the CMS Interpretive Guidelines reflect those components necessary for effective abuse protection include, but are not limited to:
o Prevent.
o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care, and is a repeat deficiency cited previously on surveys completed on 12/13/2018, 02/28/2019, 05/16/2019, 09/27/2019, 02/06/2020 and 09/09/2020.

Findings include:

1.a. The P&P titled "Reporting of Abuse/Neglect & Abuse/Neglect: Reporting an Investigation" dated last reviewed 02/24/2020 was reviewed. The P&P included the following:
* The policy "is intended to establish clear guidelines for employees concerning mandated obligations to report abuse, neglect, harm, and/or criminal activity ... Cedar Hills investigates and - when required by law/regulations - reports all cases of suspected abuse, neglect, harm and criminal activity ..."
* "Abuse means any act or failure by a person in this facility rendering care or treatment which was performed, or which was failed to be performed, knowingly, recklessly, or intentionally and which caused or may have caused injury or death to the individual with mental illness and includes acts such as: a. the rape or sexual assault of an individual with mental illness ..."
* "Neglect is a negligent act or omission by any individual responsible for providing services in a facility rendering care or treatment which caused or may have caused injury or death to a (sic) individual with mental illness or which placed a (sic) individual with mental illness at risk of injury or death, and includes an act or omission such as the failure to establish or carry out an appropriate individual program plan or treatment plan for a (sic) individual with mental illness, the failure to provide adequate nutrition, clothing, or health care to a (sic) individual with mental illness, or the failure to provide a safe environment for a (sic) individual with mental illness, including the failure to maintain adequate numbers of appropriately trained staff."
* "When an issue involving the disclosure of actual or possible abuse, neglect, harm, and/or criminal activity occurs, the Cedar Hills employee who initially becomes aware of the information notifies the facility's Risk Manager and provides all relevant information to him/her."
* "The Facility Risk Manager Officer then: conducts an investigation into the details of the disclosure to obtain as much information as possible ... Documents the investigation process and any consultation recommendations in the patient's medical records."
* "For purpose of investigating claims of abuse or neglect ... the investigation will include (at a minimum): Reviewing the complaint. Reviewing the Abuse/Neglect/Allegation Checklist. Determining an initial course of action. Assigning investigation responsibilities to group members or others. Initiating an incident analysis, special cause analysis or root cause analysis. Any staff member believed to have been involve (sic) in the abuse, neglect or exploitation of a patient shall be suspended immediately pending an investigation of the circumstance ... All formal investigations into abuse or neglect allegations are considered to be investigation in anticipation of possible litigation, and are conducted by the Director of Risk Management under the instructions of corporate legal counsel ..."

1.b. The P&P provided titled "Sexual Allegations Response/Investigation" dated as last revised "12/2020" included the following: "It is the policy of Cedar Hills to investigate all allegations of patient/patient sexual familiarity." The P&P only addressed incidents for "clients who are alleged to have engaged in sexual behavior or who have the potential to engage in such behavior." The terms "sexual familiarity" and "sexual behavior" were not clear and were not defined in the P&P. There was no information related to allegations of sexual abuse or rape of patients by staff or by other patients.

2.a. Medical record documentation for Patient 5 included the following:
* A nurse's note dated 02/15/2021 at 1708 reflected that "Patient approached the nurses station with a grievance stating ... delusional allegations against [doctor]. Patient wrote 'I am complaining that [physician name] is mastrabating (sic) my private parts and anus when I was in bed trying to sleep on February 13th and 14th 2021. The electronic device used along with the [level or lever] of is (sic) only permitten (sic) in correctional facility [illegible] state prison. I want this stopped now the mastrabatin (sic) went on all night you are not permitted to do the to (sic) a patient in a mental hospital in the State of Oregon.' House supervisor notified, and social services, guardian was notified and stated 'this is a normal delusional statement and is part of patients (sic) baseline.'"

2.b. A "Patient Complaint/Grievance Submission" form dated 02/15/2021 at 1405 that identified that "Name of Grievant/Person Registering Concern" as Patient 5 reflected that "I am complaining that [physician name] is mastrabating (sic) my private parts and anus when I was in bed trying to sleep on February 13 or 14 2021. The electronic device used along with the level and intensity is only permitted in correctional facilities such as state prison. I want this stopped NOW! the mastrabation (sic) went on all night. You are not permitted by law to do this to patients in a mental hospital in the State of Oregon."

The "CHH ... Staff To Complete The Following Section" of the form was blank and had not been completed.

The "CHH ... Patient Advocate To Complete The Following Section" of the form was blank and had not been completed.

2.c. A note dated 02/15/2021 on an incident "Investigation Note" form reflected "Patient approached nurses station with a grievance stating delusinal (sic) allegations against Dr." The note continued with duplicate information to that recorded on the nurse's note and the grievance form identified above.

The "Nursing Supervisor Notes on Incident" section of the "Investigation Note" form reflected the following undated documentation by an RN that was only "Notified [staff name, RM name] and provider. [Staff] spoke to gaurdian (sic) stating these are baseline delusions and not to notify police. Verified pt on sexual aggression precautions. Reveiwed (sic) paperwork."

An entry by the RM on the form dated 02/16/2021 reflected only "Unsubstantiated allegation. Camera reviewed to no result."

2.d. There was no other documentation related to the patient's allegation of sexual abuse by staff and the "investigation" was egregiously incomplete and inappropriate. For example:
* The only investigative task referenced was the camera review, however, there was no information related to the review, including the time period(s) reviewed, what views were observed and what was seen.
* There were no interviews with staff who worked the shifts on which the alleged abuse occurred; there was no interview with the physician named in the allegation; there was no review of his/her work schedule and presence onsite during the time period(s) alleged; and there was no review of the medical record.
* Although the patient's "guardian" stated the patient's allegation was a "baseline delusion," there was no information to reflect that a psychiatrist had evaluated the patient and made that determination and no information to reflect that the medical record had been reviewed at all.
* Although the "guardian" directed staff "not to notify police" because of the "baseline delusion" that was not the guardian's decision to make as the hospital was responsible for the care and services provided to the patient. A patient representative's recommendation did not relieve the hospital of its responsibility to ensure safe care, to conduct a complete and thorough investigation of the allegations of a vulnerable psychiatric hospital patient and to report appropriately if indicated.
* Although an investigation had not been conducted and documented the conclusion was that the allegation was "unsubstantiated." There was no information to support that conclusion and it was unclear how that determination was made.

2.e. During interview with the RM on 04/22/2021 at 1430 he/she confirmed that there was no other investigation information or documentation related to Patient 5's allegation.

3. Similar findings related to the lack of investigation of alleged rape were identified for Patient 12.

3.a. A "Patient Complaint/Grievance Submission" form regarding Patient 12 was dated 01/22/2021 and reflected that the patient's parent contacted the hospital on the date of the patient's discharge to inform the hospital that "when they got home that (sic) [Patient 12] asked if [he/she] had been raped." The Patient Advocate documented that the parent stated that "... [Patient 12] only asked if [he/she] had been raped and gave no other information." The advocate documented that he/she "... Assured [parent] that we conduct rounds every 15 minutes, additional safety checks by nurses throughout the day 24 hours a day. PA spoke with staff and Pt spent a good amount of time in day room and hall and often would ask strange questions from time to time. Pt's father will notify us if any further details should come about."

A handwritten notation at the top of the form reflected "[checkmark] Reported to Risk Mgr."

A grievance response letter addressed to the parent dated 01/28/2021 revealed it did not include mention of Patient 12's concern about being raped. The letter reflected "Your Concerns: You inquired about a question your [son/daughter] had asked you and about [his/her] medication. Steps taken to resolve: Spoke with the Nurse on duty and the Mental Health Technicians about your concerns. Notified the Director of Nursing about your concerns. Notified the Risk Manager about your concerns. Notified the Director of Performance Improvement about your concerns. Results/Resolution: Thank you for reporting your concerns to the facility. The Administrative Care Team wanted you to know that your concerns have been investigated. More information would be required to perform a more detailed investigation. In regards to safety and security our staff performs 15 minute rounds on every patient and the Nurses complete safety checks through out the day 24 hours a day. We also have cameras."

There was no other documentation related to Patient 12's concern about rape, and contrary to the 01/28/2021 letter provided to the patient's representative, there was no evidence of an investigation of this serious concern expressed by a vulnerable hospital psychiatric patient.

3.b. During interview with the CNO, RM and Patient Advocate on 04/22/2021 at 1545 they confirmed that the allegation of potential rape had not been entered into the incident reporting system and that the allegation had not been investigated.

4. For Patients 1, 2, 3, 4, 7, 8, 9, 10 and 11 refer to the findings cited under Tag A144, CFR 482.13(c)(2), CoP Patient's Rights - Standard: Right to safe care. Those findings reflect the hospital's failure to ensure investigations of incidents that reflected potential neglect were clear, complete, and accurate to prevent recurrence for those patients who experienced actual and potential harm, and for other patients.





44104

Based on review of medical record documentation for 2 of 2 patients reviewed for restraint and seclusion (Patients 22 and 23) it was determined that the hospital failed to ensure that the use of restraint and seclusion was in accordance with LIP orders that were complete and documented in a timely manner:* LIP orders were not followed as written.
* Seclusion was carried out without an LIP order.
* LIP "telephone orders" were not authenticated by the LIP in a clear and timely manner.
* "Debriefing" processes for evaluation of restraint and seclusion episodes after they had occurred were not implemented and were not effective to identify the lack of complete and timely LIP orders.


44104


Findings include:

1. Review of two seclusion episodes in Patient 22's medical record were reviewed. Those reflected that LIP orders for seclusion were not appropriately documented and authenticated, and were not followed:

1.a. A document titled "Termination/Post Intervention Nursing Summary and Notifications" for Patient 22 was dated and signed by an RN on 02/19/2021 at 0425. It reflected that the patient had been in seclusion on 02/19/2021 beginning at 0002 until 0425, for a total of four hours and 23 minutes. LIP orders for the seclusion were as follows:

1.a.i. An LIP "telephone order" for "Seclusion ... up to 4 hours" was documented by an RN on 02/19/2021 at 0005 and reflected that the seclusion start time was 0002. Next to the "Practitioner's Signature" space on the order form was an illegible handwritten mark that was dated 03/21/2021, 30 days after the "telephone order" was taken.

1.a.ii. An LIP "telephone order" for "Seclusion ... up to 4 hours" was documented by an RN on 02/19/2021 at 0405 and reflected that the seclusion start time was 0402. The "Practitioner's Signature" space on the order form was blank. It had not been signed by the LIP as of the date of this survey.

1.b. An LIP "telephone order" for "Physical Restraint & Seclusion ... up to 4 hours" for Patient 22 was documented by an RN on 02/19/2021 at 0631 and reflected that the seclusion start time was 0610. Next to the "Practitioner's Signature" space on the order form was a stamped, printed MD's name of an LIP who was not the LIP who gave the 02/19/2021 "telephone order." The entry was not dated and timed and it was not clear whether the MD had used the stamp him/herself for authentication. There were no other orders for restraint or seclusion that followed that.

1.b.i. A document titled "Seclusion/Restraint Observation Record" dated 02/19/2021 reflected that Patient 22 was in seclusion and observed every 15 minutes. The first seclusion observation was recorded in the 0615 row on the form and the last seclusion observation was recorded in the 1030 row.

The review further revealed that the handwritten observation time entries for 0815, 0830, 0845, 0900, 0915 and 0930 had been altered from the original handwritten time entries that were recorded respectively as 0845, 0900, 0915, 0930, 0945 and 1000. Those original entries had been altered by multiple cross-outs by an unknown author and with no explanation. The original timeline reflected that patient observation occurred at 0800 and not again until 0845. The accuracy of the timeline and observations at those times is not clear as result of the altered documentation.

1.b.ii. The documentation of the "telephone order" start time of 0610 and the observation record documentation reflected the patient had been in seclusion for at least four hours and 20 minutes. However, there were no LIP orders to continue seclusion for more than four hours.

1.b.iii. A document titled "Termination/Post Intervention Nursing Summary and Notifications" was dated and signed by an RN on 02/19/2021 at 1030. The documentation on this form was contradictory to the documentation on the seclusion observation record identified in the finding above as it reflected the following:
* The box next to "Seclusion" was marked.
* The "Time In" was recorded as 0610.
* The "Time Out" was recorded as 1010.
* The "Time of Termination" was recorded as 1010.
* The "Total Time of Intervention" was recorded as "4 hrs."
* In the space next to the question "Did the intervention last longer than 4 hrs?" was a box that was marked "No."

1.b.iv. A document titled "Seclusion/Restraint Patient Debriefing" contained only the date and time as 02/19/2021 at 1552 and one comment recorded as "Pt TX to OSH." It was otherwise completely blank, including the "Debriefing Lead Signature." There was no information to reflect that conformance with complete and timely LIP orders had been evaluated.

1.b.v. A document titled "Staff/Administrative/Supervisory/Debriefing" was not completed and signed and was completely blank except for Patient 22's medical record identification label. There was no information to reflect that conformance with complete and timely LIP orders had been evaluated.

2. The medical record of Patient 23 was reviewed for an episode of restraint and seclusion. It reflected that LIP orders for restraint and seclusion were not appropriately documented and authenticated, and were not followed:

2.a. An LIP "telephone order" for "Physical Restraint & Medication/Chemical Restraint ... up to 4 hours" for Patient 23 was documented by an RN on 03/18/2021 at 1835 and reflected "intervention" start time as 1830. An illegible signature was observed in the "Practitioner's Signature" space on the order form. However, it was not clear when the signature was recorded. The "date" and "time" spaces for both the RN's "telephone order" and the LIP signature were handwritten as 03/18/2021 at 1835 and were close to identical. There were no other orders for restraint or seclusion that followed that.

2.b. An undated document titled "Seclusion/Restraint Observation Record" reflected that "physical restraint initiated" at 1830 and that Patient 23 was "In seclusion" beginning at 1900. The record did not reflect what type of physical restraint was used or when it was discontinued. The record reflected that Patient 23 walked out of seclusion at 2205. There were no LIP orders for this seclusion episode.

2.c. A document titled "Termination/Post Intervention Nursing Summary and Notifications" was dated and signed by an RN on 03/18/2021 at 2210. The documentation on the form was contradictory to the LIP's orders and to the documentation on the seclusion observation record identified in the finding above as it reflected the following:
* The box next to "Physical Restraint" was checked and reflected the "Time In" as 1830 and "Time Out" as 1915.
* The box next to "Seclusion" was checked and reflected the "Time In" as 1915 and "Time Out" as 2205.

2.d. A document titled "Staff/Administrative/Supervisory/Debriefing" for the "Intervention Initiation" on 03/18/2021 at 1830 was reviewed. It was dated by an RN on 03/18/2021 at 1000, prior to the intervention. Further it was not complete. For example: the spaces for "Outcome of Intervention" and "Administrative review completed by ... (to be done within 3 days on intervention)" were blank. There was no information to reflect that conformance with complete and timely LIP orders had been evaluated.

Based on review of medical record documentation for 1 of 1 patient who was in seclusion for longer than four hours on two occasions (Patient 22) it was determined that the hospital failed to ensure that patients were not in seclusion for greater than four hours without renewed LIP orders.

Findings include:

1. Refer to the findings regarding Patient 22's seclusion episodes cited at Tag A168 under CFR 482.13(e) - Standard: Restraint or Seclusion.


44104

Based on observations, review of recorded video footage, interviews, review of grievance, incident and medical record documentation for 22 of 26 patients (Patients 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 and 23), review of P&Ps and review of PERA documentation it was determined that the QAPI program was not effective to ensure the provision of safe and appropriate care to patients in the hospital.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care, and is a repeat deficiency cited previously on surveys completed on 12/13/2018, 02/28/2019, 09/27/2019 and 02/06/2020.

Findings include:

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

Based on observations, review of recorded video footage, interviews, review of grievance, incident and medical record documentation for 22 of 26 patients (Patients 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 and 23), review of P&Ps and review of PERA documentation it was determined that nursing services had not been organized and managed to ensure the provision of safe and appropriate care to patients in the hospital.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care, and is a repeat deficiency cited previously on surveys completed on 12/13/2018, 02/28/2019 and 09/27/2019.

Findings include:

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

Based on review of medical record documentation for 2 of 2 patients reviewed for restraint and seclusion (Patients 22 and 23) it was determined that the hospital failed to ensure that verbal orders used were dated, timed and clearly and promptly authenticated by the ordering LIP.

Findings include:

1. Refer to the findings regarding verbal orders cited at Tag A168 under CFR 482.13(e) - Standard: Restraint or Seclusion.

Based on observations, review of recorded video footage, interviews, review of grievance, incident and medical record documentation for 12 of 26 patients (Patients 1, 2, 3, 4, 7, 8, 9, 10, 11, 16, 17 and 20 ), review of P&Ps and review of PERA documentation it was determined that the EOC had not been maintained to ensure the provision of safe and appropriate care to patients in the hospital.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care, and is a repeat deficiency cited previously on surveys completed on 12/13/2018 and 02/28/2019.

Findings include:

1. Refer to the applicable findings cited at Tags A115 under CFR 482.13 - CoP Patient's Rights.

Based on review of recorded video footage, interviews, review of incident and medical record documentation for 1 of 1 patient whose treatment plan was reviewed (Patient 1) and review of P&Ps it was determined that the hospital failed to ensure that an individualized and comprehensive treatment plan was developed and followed for each patient.

Findings include:

1. Refer to the findings regarding Patient 1's treatment plan cited at Tag A144 under CFR 482.13(c) - Standard: Privacy and Safety.