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Based on document review and interview, the facility failed to ensure safety protocols were in place related to patient elopement in two (2) instances (Tag 142), failed to ensure patients were provided care in a safe setting related to abuse in four (4) instances (Tag 144), failed to ensure staff to patient abuse was reported to the necessary agencies in three (3) instances, and failed to ensure a staff member had a current CPI (Crisis Prevention and Intervention) certification in one (1) instance (Tag 196).

The cumulative effects of the above prevented the facility from protecting and promoting patient rights.

Based on document review, the facility failed to ensure safety protocols were in place in three (3) instances. (Patient # 8 and Patient # 11)

Findings include:

1. The hospital policy titled, "Safety", PolicyStat ID 12197124, indicated the purpose was to have established rules and guidelines regarding safety concerns while ensuring a safe and secure environment of care. Nursing shift reports communicate the potential for elopement risk. This policy was last revised in 01/2020.

2. The hospital policy titled, "Code Yellow - Patient Elopment Procedure", PolicyStat ID 8844844, indicated all patients admitted to the hospital will be supervised and have secure care and guide the systematic and efficient return of the patient to a safe environment and to assist with the prevention of elopement (defined as the intentional/unintentional unauthorized absence of an admitted patient from the boundaries of the assigned inpatient care unit).

3. The hospital policy titled "Patient Rights and Responsibilities", PolicyStat ID: 10359862, last revised 09/2021, indicates on number 29, Patients have the right to receive humane care and protection from harm.

4. Review of facility incident report dated 09/24/2022 for patient # 10 while on the 300 unit, the patient was agitated, pacing around and threatening staff. The patient continued to be increasingly agitated. The BHA stated that the patient stated he/she would kill him/her with his/her bare hands. The patient ran to the fire door, busted out the box over the alarm and ran out the door into the woods. The staff chased the patient, police were called and were finally able to catch him/her. At that time the patient was transported to H # 3 (Acute Care Hospital) for evaluation.

5. Review of facility incident report dated 10/04/2022 Patient # 8 agitated standing near 300 unit doors, staff opened the door and patient pushed thier way through and had an altercation with the staff member. The security doors were then broke and he/she exited the building.

6. Review of facility incident report dated 10/21/2022 Patient # 8 agitated on the 200 unit pacing near the 200 unit door to the the main hallway. Patient # 8 was able to exit 200 unit into the main hall way. Staff attempted to redirect patient without success. He/she became more aggressive and assaulted three (3) staff members. He/she went to the double doors leading to the outside of facility pried the glass sliding doors and eloped the facility. Police were called to help locate Patient # 8.

Based on document review and interview, the facility failed to ensure care in a safe setting in four (4) instances. (Patient # 1, Patient # 2, Patient # 4 and Patient # 11).

Findings include:

1. The hospital policy titled, "Patient Rights and Responsibilities", PolicyStat ID 10359862, indicated patients had the right to receive care in a safe setting. This policy was last revised in 09/2021.

2. The hospital policy titled, "Patient Abuse and Neglect", PolicyStat ID 11795580, indicated abuse was an act that results in pain including, but not limited to, rough handling, hitting, slapping, pinching, pushing, shoving, kicking, and controlling behavior through punishment. An act which defies the sexual integrity of a patient through physical actions such as inappropriate touching of private body parts and/or sexual assault was defined as sexual abuse. This policy was last revised in 01/2020.

3. The hospital policy titled, "Disruptive Person Plan (Code Armstrong)", PolicyStat ID 9509316, indicated to initiate Code Armstrong in the event of an emergency situation requiring help or assistance by a fellow employee or from the police with a disruptive person. This policy was last revised in 01/2020.

4. Patient # 1's medical record (MR) lacked any documentation related to an abuse incident.

5. Patient # 2's MR indicated the following:
a. Nurses note dated 10/31/2022 at approximately 12:30 pm, indicated the patient was increasingly louder and had begun walking and threatening staff. Patient attempted to raise his/her hand at another patient and staff prevented it. Then the patient became angry with the staff calling him/her names and threatening what he/she could do to them.
b. Nurses note dated 10/31/2022 7:00 pm to 7:00 am - patient was in milieu and began to get agitated with staff. Patient hit staff member in face. A Code Armstrong was called and MD (Medical Doctor) ordered an intramuscular (IM) injection and seclusion.
c. Provider orders dated 11/01/2022 indicated to send patient out on a non-emergent basis due to patient possibly swallowing a badge. Radiology report was negative.
d. The MR lacked any documentation related to the staff to patient abuse altercation incident.

6. Patient # 4's MR indicated the following:
a. Nurses note dated 10/06/2022 at approximately 2:30 pm, indicated the patient was standing in the milieu when another confused patient came up behind patient # 4 and put his/her arms around patient # 4's neck and shoulder and brought patient # 4 to the ground. Patient # 4 hit his/her head.
b. Provider order dated 10/06/2022 indicated to send the patient out to the ER (Emergency Room) to evaluate and treat.

7. Patient # 11's MR lacked any documentation related to an abuse incident.

8. Review of the hospital internal investigation, indicated S # 2 (Behavioral Health Assistant-BHA) witnessed an incident involving a patient on the weekend of 10/15/2022 and/or 10/16/2022 which he/she then reported to A # 1 (Registered Nurse-RN/Director of Quality, Infection Control & Education) on 10/17/2022. An investigation was conducted. The following was documented:
a. The witness statement from S # 2, indicated that S # 1 (BHA) had inserted three (3) fingers inside of patient # 1 during incontinence care. Patient # 1 hollered in pain. S # 2 indicated he/she expressed to S # 1 that was unnecessary to be that rough and go that deep. S # 2 indicated the next shift the patient # 1 expressed that S # 1 made her vagina bleed and hurt.
b. The interview conducted by A # 1 on 10/17/2022, indicated patient # 1 stated that while being cleaned up that tall person had his/her fingers inside my private area, and it hurt.
c. The interview conducted by A # 1 on 10/17/2022, indicated patient # 11 stated that S # 1 was rough and put gloved fingers in his/her vagina. Patient # 11 had a small amount of bleeding from that area.
d. The medical record (MR) lacked any documentation related to the incident.

9. Review of the hospital internal investigation, indicated on 10/31/2022 patient # 2 charged and attacked a staff member at 8:43 pm. The next day the patient complained to the provider, that he/she had been beaten up. An investigation was conducted. The following was documented:
a. An incident report dated 11/2/2022 indicated patient # 2 began to get agitated in the milieu and with staff. The patient began hitting staff member in face. A Code Armstrong was called, physician notified and orders for intramuscular injection was received.
b. The video surveillance footage was observed by A # 2 (Chief Executive Officer-CEO) and saw the patient charge S # 3 (BHA) and hit him/her in the face. While in scuffle it was also observed that S # 3 hit patient # 2.

10. In interview on 11/03/2022 at approximately 10:50 am with administrative staff member A # 2, confirmed S # 3, while attempting a CPI (Crisis Prevention and Intervention) hold and hit patient # 2.

Based on document review and interview, the facility failed to ensure a patient incident of abuse was reported to the Division of Mental Health & Addiction (DMHA) and Adult Protective Services (APS), per policy in two (2) instances. (Patient # 1 and Patient # 11)

Findings include:

1. The hospital policy titled, "Critical Incident Reporting to Department of Mental Health & Addiction (DMHA)", PolicyStat ID 9495113, indicated any event which meets DMHA's definition of a reportable incident would be submitted to ensure compliance with the agency. This policy was last revised in 03/2021.

2. The hospital policy titled, "Patient Abuse and Neglect", PolicyStat ID 11795580, indicated the compliance officer would provide findings to external agencies as required related to abuse. He/she would notify the Division of Mental Health any time there was a confirmed case of patient abuse. Adult Protective Services would also be notified of the incident of patient abuse. This policy was last revised in 01/2020.

3. The hospital policy titled, "Patient Rights and Responsibilities", PolicyStat ID 10359862, indicated to notify government agencies of abuse. This policy was last revised in 09/2021.

4. Review of the facility investigation involving patient # 1 (S # 1-BHA/Behavioral Health Assistant had inserted 3 fingers inside the patient's vagina during incontinence care) and patient # 11 (S # 1 had been rough and put gloved fingers in the patient's vagina) which was dated 10/17/2022, indicated A # 1 (Registered Nurse-RN/Director of Quality, Infection Control and Education) concluded the internal complaint investigation was substantiated.

5. In interview on 11/04/2022 at approximately 3:25 pm with administrative staff member A # 3 (Human Resources Director), confirmed he/she had not reported the abuse to DMHA and/or APS as of 11/04/2022.

Based on document review and interview, the facility failed to ensure CPI certification was valid in one (1) instance. (S # 1-Behavioral Health Assistant)

Findings include:

1. The hospital policy titled, "Restraint or Seclusion Use", PolicyStat ID 10577449, indicated any staff member trained in CPI (Crisis Prevention and Intervention) techniques may initiate a CPI hold. This policy was last revised in 11/2021.

2. The hospital policy titled, "Disruptive Person Plan (Code Armstrong)", PolicyStat ID 9509316, indicated to initiate Code Armstrong in the event of an emergency situation requiring help or assistance by a fellow employee or from the police with a disruptive person. This policy was last revised in 01/2020.

3. Review of the BHA job description indicated CPI was a requirement for the position.

4. Review of the hospital internal investigation, indicated on 10/31/2022 patient # 2 charged and attacked a staff member at 8:43 pm. The next day the patient complained to the provider, that he/she had been beaten up. An investigation was conducted. The following was documented:
a. An incident report dated 11/2/2022 indicated patient # 2 began to get agitated in the milieu and with staff. The patient began hitting a staff member in the face. A Code Armstrong was called, physician notified and orders for intramuscular injection was received.
b. The video surveillance footage was observed by A # 2 (Chief Executive Officer-CEO) and saw the patient charge S # 3 (BHA) and hit him/her in the face. While in scuffle it was also observed that S # 3 hit patient # 2.

5. Review of the personnel files for S # 3 (BHA) indicated his/her CPI certification expired 05/2022.

6. In interview on 11/03/2022 with administrative staff member A # 2, confirmed S # 3, while attempting a CPI hold hit patient # 2.

7. In interview on 11/04/2022 with administrative staff member A # 3 (Human Resource Director), confirmed staff member S # 3 should have had current CPI training certification.

Based on document review and interview, the facility failed to ensure that a sufficient number of staff members were staffed and available to meet the patients needs on three (3) of three (3) units (Unit 100, 200, and 300).

Findings include:

1. Review of the facility policy, "Staffing Plan", PolicyStat ID 12386489, indicated the that a minimum staffing level system is used at the hospital to appropriately staff in compliance with federal, state and regulatory requirements. DON (Director of Nursing) shall ensure that a staffing plan is established, implemented, documented and annually reviewed. Procedure: The hospital will take reasonable steps to ensure that there are a sufficient numbers of qualified and competent staff members available to meet the precaution level and needs of the patients. This policy was last revised in 9/2022.

2. Review of the "staffing pattern worksheet" provided by the facility dated 09/18/2022 through 11/04/2022 indicated the 100/200/300 units were short staffed including but not limited to the following dates:
a. On 09/19/2022 the patient census 100 unit was twenty-two (22). On days there were one (1) RN and one (1) LPN staffed and one (1) BHA a total of three (3) staff members. The staffing ratio indicated there should have been five (5) total staff members for day shift. On nights there were one (1) RN and zero (0) LPN staffed and two (2) BHA a total of three (3) staff members.
b. On 09/19/2022 the patient census 200 unit was fourteen (14). On days there were zero (0) RN and one (1) LPN staffed and one (1) BHA a total of two (2) staff members. The staffing ratio indicated there should have been five (5) total staff members for day shift.
c. On 09/19/2022 the patient census 300 unit was twenty (20). On days there were one (1) RN and zero (0) LPN staffed and two (2) BHA a total of three (3) staff members. The staffing ratio indicated there should have been five (5) total staff members for day shift.
d. On 09/22/2022 the patient census 100 unit was twenty-five (25). On nights there were one (1) RN and one (1) LPN staffed and two (2) BHA a total of four (4) staff members. The staffing ratio indicated there should have been six (6) total staff members for night shift.
e. On 09/22/2022 the patient census 300 unit was twenty-five (25). On nights there were one (1) RN and one (1) LPN staffed and two (2) BHA a total of four (4) staff members. The staffing ratio indicated there should have been six (6) total staff members for night shift.
f. On 09/23/2022 the patient census 100 unit was twenty-five (25). On days there were one (1) RN and zero (0) LPN staffed and two (2) BHA a total of three (3) staff members. The staffing ratio indicated there should have been six (6) total staff members for day shift. On nights there were two (2) RN and zero (0) LPN staffed and two (2) BHAs a total four (4) staff members. The staffing ratio indicated there should have been six (6) total staff members for night shift.
g. On 09/24/2022 the patient census 300 unit was twenty-three (23). On nights there were one (1) RN and zero (0) LPN staffed and one (1) BHA a total of two (2) staff members. The staffing ratio indicated there should have been six (6) total staff members for night shift.
h . On 10/02/2022 the patient census 100 unit was twenty-seven (27). On days there were one (1) Registered Nurse (RN) and one (1) Licensed Practical Nurse (LPN) staffed and three (3) BHA a total of five (5) staff members. The staffing ratio indicated there should have been six (6) total staff members for day shift.
i. On 10/03/2022 the patient census 100 unit was twenty-seven (27). On days there were zero (0) RN and one (1) LPN staffed and one (1) BHA a total of two (2) staff members. The staffing ratio indicated there should have been six (6) total staff members for day shift. On nights there were two (2) RN and one (2) BHA staffed a total of four (4). The staffing ratio indicated there should have been six (6) total staff members for night shift.
j. On 10/04/2022 the patient census 200 unit was twenty-six (26). On days there were one (1) RN and one (1) LPN staffed and two (2) BHA a total of four (4) staff members. The staffing ratio indicated there should have been six (6) total staff members for day shift. On nights there were one (1) RN and one (1) BHA staffed a total of three (3). The staffing ratio indicated there should have been six (6) total staff members for night shift.
k. On 10/05/2022 the patient census 200 unit was twenty-six (26). On days there were two (2) RN and zero (0) LPN staffed and two (2) BHA a total of 4 (four) staff. The staffing ratio indicated there should have been 6 (six) total staff for day shift.
l. On 10/09/2022 the patient census 100 unit was twenty-five (25). On days there were zero (0) RN and one (1) LPN staffed and two (2) BHAs a total of 3 (three) staff. The staffing ratio indicated there should have been 6 (six) total staff for day shift. On nights there were two (2) RN and zero (0) LPN staffed and three (3) BHA staffed a total of five (5). The staffing ratio indicated there should have been six (6) total staff members for night shift.
m. On 10/18/2022 the patient census 200 unit was twenty-seven (27) On days there were zero (0) RN and two (2) LPN staffed and one (1) BHAs a total of 3 (three) staff. The staffing ratio indicated there should have been six (6) total staff for day shift.
n. On 10/28/2022 the patient census 200 unit was twenty-six (26). On days there were one (1) RN and one (1) LPN staffed and two (2) BHAs a total of four (4) staff. The staffing ratio indicated there should have been six (6) total staff for day shift. On nights there were one (1) RN and zero (0) LPN staffed and three (3) BHA staffed a total of four (4). The staffing ratio indicated there should have been six (6) total staff members for night shift.
o. On 10/31/2022 the patient census 100 unit was twenty-four (24). On days there were zero (0) RN and one (1) LPN staffed and two (2) BHAs a total of 3 (three) staff. The staffing ratio indicated there should have been six (6) total staff for day shift. On nights there were two (2) RN and zero (0) LPN staffed and two (2) BHA staffed a total of four (4). The staffing ratio indicated there should have been six (6) total staff members for night shift.
p. On 11/01/2022 the patient census 200 unit was twenty-four (24). On nights there were two (2) RN and zero (0) LPN staffed and one (1) BHA a total of three (3) staff members. The staffing ratio indicated there should have been six (6) total staff members for night shift.

3. Review of the "Nursing Comlement" data provided by A # 3 (Human Resources Director, indicated the facility had vacancies for thirteen (13) full time equivalent (FTE's) and/or 520 hours available for Registered Nurses (RN's) and/or Licensed Practical Nurses (LPN's).

4. In interview on 11/03/2022 at approximately 4:30 pm with administrative staff member A # 2 Chief Executive Officer) confirmed the facility uses a 1 staff member including RN/LPN/BHA to 4 patients ratio for units 100, 200 and 300.

5. In interview with staff A3 confirmed the staffing data was correct on the staffing pattern worksheet and the policy/procedure was the most current up to date version.

Based on document review and interview, the registered nurse failed to ensure an incident report was completed in two (2) instances. (Patient # 1 and Patient # 11)

Findings include:

1. The hospital policy titled, "Incident Reports", PolicyStat ID 12386386, indicated an incident report would be completed no later than twenty-four (24) hours from the time the event occurred. The provider on-call and administrator on-call should be notified as soon as possible after any incident. This policy was last revised in 09/2022.

2. Patient # 1's medical record (MR) lacked any documentation related to an abuse incident.

3. Patient # 11's MR lacked any documentation related to an abuse incident.

4. Review of the hospital internal investigations, indicated S # 2 (Behavioral Health Assistant-BHA) had witnessed an incident of abuse (S # 1-BHA had inserted three fingers inside of patient # 1 during incontinence care and he/she had hollered in pain) on the weekend of 10/15/2022 and/or 10/16/2022 which he/she then reported to A # 1 (Registered Nurse-RN/Director of Quality, Infection Control & Education) on 10/17/2022. An investigation was conducted and found that S # 1 had also been rough and put gloved fingers in patient # 11's vagina which had caused a small amount of bleeding.

5. In interview on 11/4/2022 with administrative staff member A # 1, confirmed the BHA staff no longer have computer access to file an incident report, but S # 2 should have told the nurse on staff, about the incident, and had him/her file the report. As of 11/04/2022 the incident reports were not filed for the two (2) patients involved in the investigation.