The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SSM HEALTH ST JOSEPH HOSPITAL-ST CHARLES 300 1ST CAPITOL DR SAINT CHARLES, MO 63301 April 14, 2016
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review, the facility failed to individualize interventions and/or goals for five of five patients (#8, #10, #11, #14 and #34) care plans reviewed. These failures had the potential to affect all patients by having unidentified patient needs which could lead to poor patient outcomes. The facility census was 172.

Findings Included:

1. Record review of the facility policy titled, "Care Planning Policy" revised 06/2014 showed the following:
- The care plan outlines the interdisciplinary care to be provided to a patient. It is a set of actions to be implemented to resolve problems identified by initial and ongoing assessments.
- The Registered Nurse (RN) is responsible for development/revision of the nursing aspects of care.
- The care plan will include individualized measurable goals with interventions identified to help the patient reach the established goals/outcome.
- Planning for care, treatment and services is individualized to meet the patient's unique needs.
- To continue to meet the patients unique needs, the plan is maintained and revised based on the patient's response.

2. Record review of Patient #8's History and Physical (H&P) showed the patient had a diagnosis of [DIAGNOSES REDACTED].

Record review of the patient's Care Plan showed no problem, goal or interventions related to the CABG or the hypertension.

3. Record review of Patient #10's H&P showed he had a diagnosis of [DIAGNOSES REDACTED] medication or nutrition).

Record review of Patient #10's Care Plan showed no individualized interventions to address the potential for infection of the patient's arm incision, indwelling urinary catheter or the Central Venous Catheter incision.

4. Record review of Patient #11's H&P showed she had a diagnosis of [DIAGNOSES REDACTED]

Record review of Patient #11's Care Plan showed no individualized goals or interventions to address her pain, elimination, mobility or nutrition (which can be compromised by the masses.)

5. Record review of Patient #14's H&P showed he had a diagnosis of [DIAGNOSES REDACTED].

Record review of Patient #14's Care Plan showed no individualized interventions to address the bed restraint. The Care Plan included a plan
for maintaining or improving his skin integrity. Patient #14 had no skin integrity issues.

6. Record review of Patient #34's H&P showed she had a diagnosis of [DIAGNOSES REDACTED]

Record review of Patient #34's Care Plan showed no individualized interventions to address her COPD and bronchitis.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to provide a medical screening examination (MSE) within its capacity and capability to determine if one (#1) of 21 patients who presented to the hospital Emergency Department (ED) seeking care, suffered from an emergency medical condition (EMC), out of a sample selected from March 8 through April 11, 2016. The Emergency Department (ED) has an average of 3701 emergency visits per month.

Findings included:

Review of the facility policy titled, "Emergency Department Management of Behavioral Health Patients," dated 05/2014, showed that all patients presenting with signs and symptoms of behavioral issues and found to be in need of acute medical attention, those concerns will be addressed concurrent with behavioral health interventions.

Review of the facility policy titled, "EMTALA: Provision of Care," dated 03/2016, showed that each individual will receive a medical screening examination sufficiently detailed to determine whether he or she has an EMC. An EMC includes severe pain, psychiatric disturbances and substance abuse, such that the absence of immediate medical attention could reasonably result in serious jeopardy.

Review of Patient #1's ED record (initial visit) showed that the patient arrived to the ED by Law Enforcement on 04/09/16 at 12:53 AM. Staff A, ED Physician, documented examination at 1:19 AM, showed the patient had suicidal ideations after she had been drinking, and presented with multiple (self-inflicted) superficial cuts (cuts to the surface of the skin) to the wrist, forearm and left antecubital (region of the arm in front of the elbow, where blood is drawn), as well as several superficial neck abrasions. The patient's history, "limited as patient is intoxiated", showed depression and anxiety, drug abuse and alcoholism, with a previous suicide attempt after she jumped from a three story balcony. During the examination, the patient required a sternal rub (deep pressure applied to the center of the chest to produce pain) to wake the patient, but the patient still refused to answer any of Staff A's questions. At 1:32 AM, Staff A documented that the patient was fit for confinement (stable for incarceration), medically cleared for discharge (39 minutes after arrival), and released into law enforcement custody. The patient's was diagnosed with alcohol intoxication, suicidal ideation and lacerations of multiple sites of the left forarm.

During an interview on 04/13/16 at 9:30 AM, Staff B, Registered Nurse, stated that when Patient #1 arrived at the hospital with law enforcement, she struggled, and was non-compliant with the officer. When Staff B assessed Patient #1, he believed she was intoxicated and found multiple cuts to her left forearm and neck area, some of which had broken the skin. Staff B attempted to clean and bandage the wounds, but the patient fought with him, was non-compliant, and would not let staff touch her, or answer any questions. The patient's psychiatric stability was not assessed by a Mental Health Professional (MHP), and she was discharged to Law Enforcement, where she struggled and was non-compliant with the officer when she walked out of the ED.

During a telephone interview on 04/13/16 at approximately 10:00 AM, Staff A, ED Physician, stated that Patient #1 came to the ED in Law Enforcement custody. The patient was intoxicated, reported she had taken some of her psychiatric medications (alleged overdose), and was somnolent (strong desire to sleep) "from the alcohol, and possibly the drugs too". The patient required a sternal rub to wake, and when she woke, the patient refused to answer what drugs she took, how many she took, or when she took them. "She told us she wanted to kill herself, which was why she took the pills". "In a clinical standpoint, she was stable. She was intoxicated, but at the same time she was playing it up." Staff A stated he did not order laboratory tests on the patient and he did not know the patient's alcohol level, history, psychiatric history, or if she was taking her prescribed psychiatric medications before he discharged her to police custody. Staff A stated that he did not request a mental health professional to come and assess the patient's psychiatric stability, because her psychiatric stability would be addressed when the patient was discharged to police and placed on suicide watch at the jail. "She wasn't talking so there wouldn't have been much of an evaluation". and if she had been evaluated and required psychiatric admission, "it wouldn't have happened with her, because she was under arrest". Staff A stated that if the patient presented with the same symptoms, but was not in the custody of the police, "We would have to make sure (the patient's) ETOH (blood alcohol level) was less than 200 (80 is legally intoxicated), or hold them until it reaches less than 200, so they can be evaluated" by a mental health professional for possible psychiatric admission.

Review of staffing and on-call rosters for 04/08/16 at 7:00 AM through 04/09/16 at 7:00 AM, showed multiple MHPs were available to the ED for psychiatric assessments, as well as a Psychiatrist.

During an interview on 04/14/16 at 10:20 AM, Staff C, Lead Behavioral Health Assessor, stated that MHPs are available to the ED 24 hours a day, with a Psychiatrist on-call 24 hours a day. Staff C stated that they evaluate ED patients who have a behavioral health risk, especially those patients who verbalized suicidal ideation or have attempted suicide. Staff C stated that if the patient was intoxicated, Psychiatric Services would evaluate the patient once the patient's blood alcohol was less than 200 or when the patient was alert and oriented (understand and can verbalize) to person, place, time, and recent events. Staff C stated that if a patient was in the custody of Law Enforcement, MHP followed the same protocol as they would for a patient who was not in custody, and would assess the patient and contact the Psychiatrist on-call for potential admission. Staff C added that the facility had the ability to admit patients for psychiatric care who were in Law Enforcement custody through voluntary (agreeable to admission) or involuntary (refuses admission) admission.

The patient was documented as intoxicated, to the point she required a stermal rub to wake. The patient's history was limited as she refused to answer questions relevent to an appropriate MSE, but did express suicidal ideations, and presented with self inflicted injuries. The patient was discharged to Law Enforcement prior to a psychiatric assessment, which could have been completed once the patient was sober, as Behavioral Health Assessors and a psychiatrist were on call and available to the ED.

Review of Patient #1's medical record dated 04/09/16 (return visit) showed the following:
- The patient was taken from jail back to the hospital by a local ambulance at 11:08 PM, after the patient fell from a toilet and struck her head during a seizure that lasted approximately one minute.
- The patient reported that she drank a 5th of Vodka daily for the previous five years and had a history of withdrawal seizures.
- The patient initially declined treatment in the ED and did not want to be admitted , but when Staff I, RN went to discharge the patient, she requested to be admitted for alcohol detoxification.

- A signed affidavit received from the correctional facility on 04/10/16 at 12:13 AM, documented that on 04/09/16 at approximately 6:00 AM, 8:00 AM and at 9:30 PM, the patient stated she didn't care if she died and had no reason to live, and a Central Intake Assessor (BHP, Behavioral Health Professional) was contacted to completed a psychiatric assessment.

- Central Intake Assessment documentation showed she was a risk to self, after the patient reported she hated life and didn't see the point of living anymore, was suicidal with suicidal behaviors and planned to cut herself and hit an artery and die.
- The patient was admitted to observation with a diagnosis of alcohol intoxication, alcohol withdrawal seizure and suicidal ideation.

- The order for a psychiatric consult was not placed until 04/10/16 at 1:37 PM, approximately 14 hours after the patient's second arrival to the ED.

- A Psychiatric Examination on 04/10/16 at 1:54 PM by Psychiatrist D, documented that the patient was disheveled with elevated blood pressures, admitted she cut herself and drank alcohol to reduce chronic physical pain she felt, stopped taking her psychiatric medications when she was placed in jail (04/09/16), was anxious, and Staff D recommended that the patient transfer to psychiatric care when she was medically cleared, because she was not safe to discharge.
- The patient was documented to have significant pain and crying throughout her observation admission as well as elevated blood pressures.

- A Psychiatric Examination on 04/11/16 at 12:21 PM by Psychiatrist E, documented the patient's blood pressure was elevated at 146/105, there was no need for psychiatric admission, and the patient could be discharged when medically stable.
- There was no medical examination documented on 04/11/16.
- There was no blood pressure documented prior to discharge.
- The patient was discharged on [DATE] at 4:22 PM.

During a telephone interview on 05/25/16 at 6:30 PM, Central Intake Assessor K, stated she was called to the ED on 04/10/16 at 1:00 AM for a psychiatric assessment on Patient #1. The patient was sad and tearful and said that she hated life, did not want to live anymore and was cutting herself with a plan to hit an artery and die.

During a telephone interview on 05/14/16 at 6:30 PM, ED Physician A, stated that when the patient returned to the ED, she had an Emergency Medical Condition (EMC) based on seizure activity and suicide risk, but he did not request a psychiatric evaluation on the patient while she was in the ED, because the psychiatric evaluation would have been done inpatient. "Once they leave the ER (ED), I'm not involved with the patient or the patient's care". ED physician A added that the patient should have been admitted as a full admission, and if she wasn't, it was a mistake on his part.

During a telephone interview on 05/25/16 at 3:30 PM, Hospitalist J, stated that she was aware of the patient's elevated blood pressure, but believed it was related to the patient's alcohol withdrawal, and expected the patient's blood pressure to lower as the patient's withdrawal ended.

During a telephone interview on 05/24/16 at 7:40 PM, Psychiatrist D, stated that although she was the psychiatrist on call when Patient #1 returned, she wasn't consulted until 04/10/16 at 1:37 PM (approximately 14 hours after presentation) to evaluate the patient for her suicidality and chemical dependency. Psychiatrist D stated that during the evaluation, the patient was sedated due to detoxification medications, and Psychiatrist D was unsure if the patient's mental capacity was clear at the time, so she recommended the patient be admitted to Psychiatric Services once she was medically cleared and stable. "I felt she would engage in a better risk assessment once she was medically detoxed". Psychiatrist D stated that the patient had a significant psychiatric history with significant pain related to her previous suicide attempt (jumping off a three story building), and that she drank to help with the pain. Psychiatrist D also added that she believed Patient #1 had suddenly stopped her Gabapentin (medication to control pain or seizures), which placed the patient at seizure risk, and Paxil (medication used to treat depression), which can cause emotional instability.

During a telephone interview on 05/25/16 at 2:30 PM, Staff H, Case Management, stated that Patient #1 complained of pain and drank alcohol to control her pain.

During a telephone interview on 05/26/16 at 5:00 PM, Psychiatrist E, stated he saw the Patient #1 on 04/11/16 around 12:00 PM, as a psychiatric consult follow-up. Psychiatrist E stated he was aware of the patient's history, which included jumping from a three story building, and added that if the patient had pain or elevated blood pressure, it would be followed by the medical physician and not the psychiatrist. Psychiatrist E stated that he did not communicate with the medical physician before he cleared the patient psychiatrically.

During a telephone interview on 05/25/16 at 2:00 PM, Hospitalist G, stated that the only time he saw Patient #1 was the day she went home, that he examined her but did not document the examination in the medical record, and could not remember the examination. Hospitalist G stated that on the day of discharge, Patient #1's blood pressure was high at 148/104, but believed she was medically stable and could go home because, "They (nursing staff) did not call me at the time of discharge, so I assume that the patient's blood pressure was down."

During a telephone interview on 05/24/16 at 7:00 PM, Telemetry RN F, stated that she was the primary nurse for Patient #1 during the day shifts on 04/10/16 and 04/11/16 and discharged the patient. Telemetry Nurse F stated that the patient reported she had chronic pain from a previous suicide attempt where she jumped off a three story building, and drank alcohol to control the pain. Telemetry Nurse F stated that Patient #1's blood pressure was elevated through 04/10/16 at 7:18 PM, but added that there were no further blood pressures documented in the patient's medical record, and therefore could not determine if the patient's blood pressure was normal or remained elevated before she discharged the patient to her home by cab. Telemetry Nurse F did not know why there were no blood pressures documented in the medical record beyond 04/10/16.

The patient was documented to have elevated blood pressure and complaints of pain due to injuries sustained from a previous suicide attempt. The pain was so significant that the patient abused alcohol to control the pain. Neither the patient's elevated blood pressure, nor the patient's pain was evaluated and therefore, the MSE was not sufficient.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to stabilize an Emergency Medical Condition (EMC) for one patient (#1) of 21 patients who presented to the hospital Emergency Department (ED) seeking care for an emergency medical or psychiatric condition, out of a sample selected from March 8 through April 11, 2016. The Emergency Department (ED) has an average of 3701 emergency visits per month.
Findings included:
Record review of the facility policy titled. EMTALA: Provision of Care," dated 03/2016, showed that:
- An Emergency Medical Condition (EMC) was a medical condition manifesting itself by acute symptoms of sufficient severity, such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.
- The hospital will provide care within the extent of its capabilities to patients suffering from an EMC.
- Capability included services normally available to any patient in any area of the hospital, and included available ancillary services.
- Capacity included the ability to treat the patient, including availability of staff, beds, and equipment, and the hospitals past practices of accommodating additional patients in excess of its occupancy limits.

Record review of the facility policy titled, "Emergency Department Management of Behavioral Health Patients," dated 05/2014, showed that all patients presenting with signs and symptoms of behavioral issues and is found to be in need of acute medical attention, those concerns will be addressed concurrent with behavioral health interventions..

Patient #1's medical record dated 04/09/16 was reviewed and showed the following:
- The patient presented to the ED at 12:53 AM by Law Enforcement, after the patient had been drinking, expressed suicidal ideations and possible ingestion of several of her prescription pills.
- The patient was in the custody of Law Enforcement, who sought ED care to ensure that the patient was medically/psychologically stable for confinement in jail (fit for confinement).
- Nursing documented the patient was non-compliant, crying and tearful, had suicidal thoughts of cutting herself, a history of suicidal thoughts and was at immediate risk for suicide.
- The ED Physician documented the patient was unable to respond to questions about her medical or psychological history or current condition because she was intoxicated.
- The ED Physician documented he attempted a sternal rub on the patient, to wake the patient, but the patient still would not answer questions.
- The ED Physician documented the patient had multiple superficial cuts to her wrist, forearm and left antecubital (inner elbow) space, along with several superficial neck abrasions.
- The patient's diagnosis was alcohol intoxication, suicidal ideation and lacerations of multiple sites of left arm.
- The patient was discharged to jail on suicide watch at 1:32 AM (39 minutes after the patient arrived).

During an interview on 04/13/16 at 9:30 AM, Registered Nurse (RN) B, stated that when Patient #1 arrived at the hospital with Law Enforcement, he believed she was intoxicated and found multiple cuts to her left forearm and neck area, some of which had broken the skin.

During an interview on 04/13/16 at approximately 10:00 AM, ED Physician A, stated that Patient #1 came to the ED in Law Enforcement custody. The patient was intoxicated, reported she had taken some of her psychiatric medications, and was somnolent (strong desire to sleep) "from the alcohol, and possibly the drugs too". The patient required a sternal rub to wake, and when she woke, the patient refused to answer what drugs she took, how many she took, or when she took them. "She told us she wanted to kill herself, which was why she took the pills". Staff A added that if the patient required a psychiatric admission, "it wouldn't have happened with her, because she was under arrest".

During an interview on 04/14/16 at 10:20 AM, Lead Behavioral Health Assessor C, stated that the facility had the ability to admit patients for psychiatric care who were in Law Enforcement custody through voluntary (agreeable to admission) or involuntary (refuses admission) admission.

The patient was documented as intoxicated, to the point she required a stermal rub to wake. The patient's expressed suicidal ideations, and presented to the ED with self inflicted injuries. The patient was not stabilized prior to her discharge to Law Enforcement custody.

Review of Patient #1's medical record dated 04/09/16, showed the following:
- The patient fell from a toilet and struck her head during a seizure that lasted approximately one minute and returned to the ED.
- A signed affidavit received from the correctional facility on 04/10/16 at 12:13 AM, documented that on 04/09/16 at approximately 6:00 AM, 8:00 AM and at 9:30 PM, the patient stated she didn't care if she died and had no reason to live.

- Central Intake Assessment documentation showed she was a risk to self, after the patient reported she hated life and didn't see the point of living anymore, was suicidal with suicidal behaviors and planned to cut herself and hit an artery and die.

- The patient was placed in observation status on 04/10/16 at 12:00 AM, with a diagnosis of alcohol intoxication, alcohol withdrawal seizure and suicidal ideation.

- A Psychiatric Examination on 04/10/16 at 1:54 PM by Psychiatrist D, documented that the patient was disheveled with elevated blood pressures, admitted she cut herself and drank alcohol to reduce chronic physical pain she felt, stopped taking her psychiatric medications when she was placed in jail (04/09/16), was anxious, and Staff D recommended that the patient transfer to psychiatric care when she was medically cleared, because she was not safe to discharge.
- The patient was documented to have significant pain and crying throughout her observation admission as well as elevated blood pressures.
- A Psychiatric Examination on 04/11/16 at 12:21 PM by Psychiatrist E, documented the patient's blood pressure was elevated at 146/105, there was no need for psychiatric admission, and the patient could be discharged when medically stable.
- There was no medical examination documented on 04/11/16.
- The patient was discharged on [DATE] at 4:22 PM.

During a telephone interview on 05/25/16 at 3:05 PM, ED RN I, stated that Patient #1's blood pressure was elevated in the ED to 141/94 (normal range is less than 140/90).
During a telephone interview on 05/24/16 at 6:30 PM, ED Physician A, stated that when Patient #1 returned to the ED, she had an EMC based on seizure activity and suicide risk, and admitted the patient (to observation).
During a telephone interview on 05/25/16 at 6:30 PM, Central Intake Assessor K stated that when she assessed Patient #1, she was sad and tearful and said that she hated life, did not want to live anymore and was cutting herself with a plan to hit an artery and die.
During a telephone interview on 05/25/16 at 3:30 PM, Hospitalist J, stated that she was the admitting physician for Patient #1, and believed the patient had an EMC. Hospitalist J stated the patient's blood pressure was elevated, the patient had evidence of self-mutilation and reportedly made suicidal statements according to the jail workers.
During a telephone interview on 05/24/16 at 7:40 PM, Psychiatrist D, stated that when she evaluated Patient #1, she recommended the patient be admitted to Psychiatric Services. The patient had a significant psychiatric history with significant pain related to her previous suicide attempt (jumping off a three story building), and she drank to help with the pain. Psychiatrist D also added that she believed Patient #1 had suddenly stopped her Gabapentin (medication to control pain or seizures), which placed the patient at seizure risk, and Paxil (medication used to treat depression), which can cause emotional instability.
During a telephone interview on 05/25/16 at 2:30 PM, Case Management Staff H, stated that Patient #1 changed from observation status to full admit on 04/11/16 at 12:00 PM by Hospitalist G. Staff H added that the patient complained of pain and that she drank to control her pain.
Record review of "ADT Orders" showed that the patient was admitted as an inpatient on 04/11/16 at 12:00 PM.
During a telephone interview on 05/26/16 at 5:00 PM, Psychiatrist E, stated he saw Patient #1 on 04/11/16 around 12:00 PM and released her to the care of medical services. Psychiatrist E stated that if the patient experienced abnormal vital signs, such as an elevated blood pressure, or pain, it "falls back to the medical doctor".
During a telephone interview on 05/25/16 at 2:00 PM, Hospitalist G, stated he examined Patient #1 on 04/11/16 and discharged her, but did not document the examination in the medical record, and could not remember the examination. Hospitalist G stated that on the day of discharge, Patient #1's blood pressure was elevated (148/104), but assumed the patient's blood pressure went down before she was released from the hospital.
During a telephone interview on 05/24/16 at 7:00 PM, Telemetry RN F, stated that she was the primary nurse for Patient #1 during the day shifts on 04/10/16 and 04/11/16. Telemetry RN F stated that the patient reported she had chronic pain from a previous suicide attempt where she jumped off a three story building, and drank alcohol to control the pain. Telemetry RN F added that Patient #1's blood pressure was elevated throughout the patient's observation admission.
Record review of the Psychiatrist on-call schedule, showed that a Psychiatrist was on-call and available to the ED for psychiatric evaluations during the Patient #1's first and second presentation.

Record review of the psychiatric unit census for 04/09/16 through 04/11/16, showed there was capacity for the patient to be admitted to a psychiatric unit during Patient #1's first and second presentation.

The facility failed to stabilize the patient's EMC which included elevated blood pressures and significant pain.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, record review, and policy review the facility failed to ensure:
- Protection of one of one patient (#48) on the Senior Care Behavioral Health Unit (a unit dedicated to the treatment of elderly psychiatric patients) when two staff members dragged a patient approximately 40 feet to a room used to restrain (to prevent freedom of movement) patients. (Refer to A145)
- Personal privacy for one of one patient (#48) when staff exposed her breasts, during a manual restraint, in the Senior Care Behavioral Health Unit (Refer to A142)
- Protection of patients in the Senior Care Behavioral Health Unit by allowing alleged perpetrators (Staff PP and Staff SS) to continue to work following an incident of alleged physical and emotional abuse. (Refer to A144)
- Staff obtained a physician's order for a manual hold to restrain one of one patient (#48) in the Senior Care Behavioral Health Unit. (Refer to A154)
These failed practices had the potential to put all psychiatric patients in the Senior Care Behavioral Health Unit at risk for inappropriate restraint techniques and lack of patient privacy. The facility census was 172. The unit census was 20.

As a result of this survey, the complaint was substantiated and the Condition of Participation: Patient Rights was found to be out of compliance. Please see the 2567.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review and policy review the facility failed to ensure personal privacy when two of two staff (PP and SS) exposed the breasts one of one patient (#48) during a manual restraint episode. This failure increased the potential for lack of patient privacy and dignity for all patients in the Senior Care Behavioral Health Unit. The facility census was 172. The Senior Care Behavioral Health Unit census was 20.

Findings included:

1. Record review of the Psychiatric Evaluation dated 02/10/16, for Patient #48 showed on 02/09/16 at approximately 11:30 PM, the [AGE] year old female, was admitted to the Senior Care Behavioral Health Unit. Patient #48 presented with increased aggression towards family, with hallucinations (seeing or hearing things which are not there) and delusions (false ideas about what is taking place or who one is, despite evidence to the contrary).
Record review of a nursing progress note dated 02/11/16, showed at approximately 7:45 AM (in the day room), Patient #48 walked over to a female peer (Patient #49) and choked, licked her face and bit her cheek. Staff were unable to redirect the patient. Staff put hands on (manual restraint)Patient #48 to remove her from Patient #49 and a code strong (called over the intercom for all available staff to respond for assistance) was called. Staff took the patient to the restraint room and placed her in four point (both arms and legs) restraints.

2. Observation on 04/12/16 at 11:00 AM, of a recorded video dated 02/11/16 at 7:44 AM, showed Staff PP, Clinical Partner, was behind Patient #48 (patient back side in front of staff) with his arms extended and his hands on both of Patient #48's upperarms. The patient's left arm was extended up above her head and Staff SS, Clinical Partner, pulled on the patient's left hand. Staff pulled Patient #48 backward with her heels on the floor and in a seated position (bottom did not touch the floor). Then after approximately 20 feet, the staff stopped and the patient was repositioned to an upright position. The patient's shirt had slid up and her bare breasts were exposed. The patient remained backward and Staff PP held the patients upper arms and Staff SS continued to hold the patient's left hand. The patient's bare breasts continued to be exposed as staff dragged her backward to the restraint room with her feet slightly touching the floor.

3. Record review of the facility policy titled, "Restraint Utilization (Violent, Self-
Destructive)," dated 01/2014, showed directives for staff to consider whether the application or initiation of a restraint respects the patient as an individual and the modesty and visibility to others are maintained.

4. Record review of Staff L's, Director of Behavior Health Services, chart review, video review, and summary as noted in an e-mail dated 02/11/16 to Staff II,Vice President Behavioral Health Services; Staff ZZ, Administrator; and Staff AA, Patient Safety, Quality, Risk, and Regulatory Coordinator and copied to Staff H, Team Leader of Senior Health Behavioral Health Unit showed no documentation of the patient's exposed breasts.

During an interview on 04/12/16 at 2:10 PM, Staff SS, stated that she could not remember if Patient #48's shirt came up or not, but she recalled that she and Staff PP stopped part way to the restraint room to get a better grip on Patient #48 before they continued to the restraint room.

The restraint method performed by Staff PP and Staff SS failed to protect the privacy of the patient and take into consideration the patient's modesty and visibility to others.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, and policy review, the facility failed to provide a safe environment in the Senior Care Behavioral Health Unit (unit used to treat psychiatric illnesses of the elderly) when they failed to remove two alleged perpetrators (Staff PP and Staff SS) from patient care during an investigation of an incident of alleged physical and emotional abuse of one of one patient (#48). The failure to remove the alleged perpetrators from patient care resulted in an unsafe environment for all patients and had the potential to place all patients admitted for treatment in the Senior Care Behavioral Health Unit at risk for abuse. The facility census was 172. The unit census was 20.


Findings included:

1. Record review of the facility's policy titled, "Assessment, Investigation, and Reporting of Suspected Abuse/Neglect," dated 05/02/14 showed:
- Abuse of an adult (elder or disabled) was defined as the infliction of physical, sexual, or emotional injury or harm.
- Eligible adult was defined as any adult, aged 60 or older or 18-59 with a disability, defined as a mental or physical impairment that substantially limits one or more major life activities, whether the impairment was congenital or acquired by accident, injury or disease, where such impairment was verified by medical findings.
-Staff members were to assess, investigate, and report abuse and neglect to the appropriate State agencies.
-The Clinical Support Nurse (CSN) or department equivalent should immediately notify their Administrative Supervisor after ensuring the safety of the patient, which shall include immediate removal of the involved staff from patient care.

2. Record review of the Psychiatric Evaluation dated 02/10/16, for Patient #48 showed on 02/09/16 at approximately 11:30 PM, the [AGE] year old female, was admitted to the Senior Care Behavioral Health Unit (BHU.) Patient #48 presented with increased aggression towards family, with hallucinations (seeing or hearing things which are not there) and delusions (false ideas about what is taking place or who one is, despite evidence to the contrary.)

Record review of a nursing progress note dated 02/11/16, showed at approximately 7:45 AM (in the day room), Patient #48 walked over to a female peer (Patient #49) and choked her, licked her face and bit her cheek. Staff were unable to redirect the patient. Staff put hands on (manual restraint) Patient #48 to remove her from Patient #49 and a code strong (called over the intercom for all available staff to respond for assistance) was called. Staff took the patient to the restraint room and placed her in four point (both arms and legs) restraints.

3. Observation on 04/12/16 at 11:00 AM, of a recorded video dated 02/11/16 at 7:44 AM, showed Staff PP, Clinical Partner, was behind Patient #48 (patient back side in front of staff) with his arms extended and his hands on both of Patient #48's upperarms. The patient's left arm was extended up above the patients head and Staff SS, Clinical Partner, pulled on the patient's left hand. Patient #48 was pulled backward with her heels on the floor and in a seated position (bottom did not touch the floor). Then after approximately 20 feet, the staff stopped and the patient was repositioned to an upright position. The patient's top had slid up and her bare breasts were exposed. The patient remained backward and Staff PP held the patients upper arms and Staff SS continued to hold the patient's left hand. The patient's bare breasts continued to be exposed and staff dragged her backward to the restraint room with her feet slightly touching the floor.

During an interview on 04/13/16 at 10:35 AM, Staff AA, Patient Safety, Quality, Risk, Regulatory Coordinator, and Staff L, Director of Behavioral Health Services, confirmed the distance from the day hall to the restraint room was approximately 40 feet.

During an interview on 04/12/16 at 3:35 PM, Staff L, stated that she reviewed part of the video mid-morning on 02/11/16 and was unsure of Staff PP's actions.

During an interview on 04/13/16 at 3:30 PM, Staff L stated that on 02/11/16:
- She requested Staff H, Team Leader of Senior Care (BHU), to visit with staff on the Senior Care BHU and see if the staff felt Staff PP was abusive.
- Staff L then reviewed the video again.
- She then completed a chart review and a summary that was sent to Staff ZZ, Administrator, Staff II, VP Behavioral Health Services, and Staff AA, Patient Safety, Quality, Risk, Regulatory Coordinator.
- The investigation was completed by Staff AA.

4. Record review of Staff L's chart review, video review, and summary as noted in an e-mail dated 02/11/16 to Staff II, Staff ZZ, Staff AA, and copied to Staff H showed:
- Patient #48 requested a hug from Patient #49 and Patient #49 pushed at Patient #48.
- Patient #48 choked Patient #49 and licked and bit her face.
- The event occurred in the day room, but the actual event was obscured by pillars.
- Staff were seen responding.
- Staff had difficulty separating the two patients due to Patient #48's bite.

5. Record review of "Time Detail," (time cards) showed Staff SS and Staff PP continued to provide patient care during the investigation of alleged abuse of Patient #48. The time cards showed:
Staff SS worked:
- On 02/11/16 from 7:05 AM until 7:16 PM;
- On 02/15/16 from 7:00 AM until 7:28 PM;
- On 02/19/16 from 7:02 AM until 7:34 PM.

Staff PP worked:
- On 02/11/16 from 6:49 AM until 7:10 PM;
- On 02/12/16 from 6:52 AM until 7:17 PM;
- On 02/16/16 from 7:00 AM until 7:30 PM.

During an interview on 04/12/16 at 4:05 PM, Staff AA stated that:
- She received an e-mail on 02/11/16 from Staff L, but was at another facility.
- The video was reviewed on the following Monday (02/15/16).
- Interviewed staff on 02/15/16.
- She wrote a summary of her interviews.
- She reviewed the information with Staff II and stated that Staff II agreed with her analysis of the incident.

During an interview on 04/11/16 at 3:55 PM and 04/13/16 at 10:36 AM, Staff PP stated that he had not been told he had done anything wrong during the incident. He stated that the crisis prevention program instruction was just a foundation and not an exact science. Staff PP felt this patient's behaviors were too escalated for him to use the crisis prevention techniques (verbal de-escalation and physical holds to control a patient) he was trained to use. He stated that he continued to work after the incident.

During an interview on 04/11/16 at 9:00 AM, Staff H, Team Leader of Senior Care Behavioral Health Unit (BHU), stated that Staff PP and Staff SS were not removed from patient care (during the investigation of alleged patient abuse.)

The facility failed to remove the alleged perpetrators, Staff PP and Staff SS, from patient care during the investigation of alleged patient abuse, which put all patients in the Senior Care BHU at risk for potential abuse.

6. Record review of the facility's letter to the State Agency, dated 02/24/16, showed no documentation of removal from patient care of Staff PP or Staff SS (alleged perpetrators) during the facility investigation.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, and policy review the facility failed to prevent abuse of one of one patient (#48) on the Senior Care Behavioral Health Unit (unit for the treatment of elderly psychiatric patients) when staff members dragged a patient backwards to move her to a room used to restrain (to prevent freedom of movement) patients. The facility failed to recognize this incident as abuse. This failure had the potential to place all patients admitted to the facility at risk for abuse. The facility census was 172. The unit census was 20.

Findings included:

1. Record review of the facility's policy titled, "Assessment, Investigation, and Reporting of Suspected Abuse/Neglect," dated 05/02/14 showed:
- Abuse of an adult (elder or disabled) was defined as the infliction of physical, sexual, or emotional injury or harm.
- Eligible adult was defined as any adult, aged 60 or older or 18-59 with a disability, defined as a mental or physical impairment that substantially limits one or more major life activities, whether the impairment was congenital or acquired by accident, injury or disease, where such impairment was verified by medical findings.
-Staff members were to assess, investigate, and report abuse and neglect to the appropriate State agencies.
-The Clinical Support Nurse (CSN) or department equivalent should immediately notify their Administrative Supervisor after ensuring the safety of the patient, which shall include immediate removal of the involved staff from patient care.

2. Record review of the Psychiatric Evaluation dated 02/10/16, for Patient #48, showed on 02/09/16 at approximately 11:30 PM, the [AGE] year old female, was admitted to the Senior Care Behavioral Health Unit (BHU.) Patient #48 presented with increased aggression towards family, with hallucinations (seeing or hearing things which are not there) and delusions (false ideas about what is taking place or who one is, despite evidence to the contrary.)

Record review of a nursing progress note dated 02/11/16, showed at approximately 7:45 AM (in the day room), Patient #48 walked over to a female peer (Patient #49) and choked her, licked her face and bit her cheek. Staff were unable to redirect the patient. Staff put hands on (manual restraint) Patient #48 to remove her from Patient #49 and a code strong (called over the intercom for all available staff to respond for assistance) was called. Staff took the patient to the restraint room and placed her in four point (both arms and legs) restraints.

3. Observation on 04/12/16 at 11:00 AM, of a recorded video dated 02/11/16 at 7:44 AM, showed Staff PP, Clinical Partner, was behind Patient #48 (patient back side in front of staff) with his arms extended and his hands on both of Patient #48's upperarms. The patient's left arm was extended up above her head and Staff SS, Clinical Partner, pulled on the patient's left hand. Staff pulled Patient #48 backward with her heels on the floor and in a seated position (bottom did not touch the floor). Then after approximately 20 feet, the staff stopped and the patient was repositioned to an upright position. The patient's top had slid up and her bare breasts were exposed. The patient remained backward and Staff PP held the patients upper arms and Staff SS continued to hold the patient's left hand. The patient's bare breasts continued to be exposed and staff dragged her backward to the restraint room with her feet slightly touching the floor.

During an interview on 04/13/16 at 10:35 AM, Staff AA, Patient Safety, Quality, Risk, Regulatory Coordinator, and Staff L, Director of Behavioral Health Services, confirmed the distance from the day room to the restraint room was approximately 40 feet.

During an interview on 04/12/16 at 3:35 PM, Staff L, stated that she reviewed part of the video mid-morning on 02/11/16 and was unsure of Staff PP's actions.

During an interview on 04/13/16 at 3:30 PM, with Staff L and Staff H, Team Leader of Senior Behavioral Health, Staff L stated that on 02/11/16 she requested Staff H to visit with staff on the Senior Care BHU and see if the staff felt Staff PP was abusive. Staff L then reviewed the video again. Staff H stated that an incident like this would not happen again.

Staff L failed to recognize patient abuse after reviewing a video of two staff members dragging a patient backward for approximately 40 feet.

4. Record review of Staff L's chart review, video review, and summary as noted in an e-mail dated 02/11/16 to Staff II, Staff ZZ, Staff AA, and copied to Staff H showed:
- Patient #48 requested a hug from Patient #49 and Patient #49 pushed at peer.
- Patient #48 licked and bit Patient #49 and choked her.
- The event occurred in the day room, but the actual event was obscured by pillars.
- Staff were seen responding.
- Staff had difficulty separating the two patients due to Patient #48's bite.
- Patient #48 continued to hit, kick, and spit at staff and was restrained.
- The physician was on the unit and assessed the patient and ordered observation of within arm's reach.
- Patient #49 was taken to the Emergency Department (ED) with abrasions, tenderness, and bruising to the left cheek at site of the bite. No sutures needed.

During an interview 04/13/16 at 10:07 AM, and 10:15 AM Staff EE, RN, and Staff FF, RN both stated that staff should not drag (pull the patient along the floor) a patient.

During an interview on 04/13/16 at 10:20 AM, Staff GG, Clinical Support Nurse (CSN), stated that dragging a patient would not be an appropriate crisis prevention technique.

Staff PP, Staff SS and the facility failed to recognize Staff PP and Staff SS physically abused the patient by dragging her backward.

5. Record review of the facility's policy titled, "Just Culture," dated 12/01/15, showed directive for a manager's roles and responsibilities included knowing the potential risks, investigating the source of errors, designing safe systems, helping employees understand safety risks within their environment, and helping the employee make safe choices. The process will guide managers to identify opportunities for system/structure improvements and assess an employee's choices that may have contributed to the event.

During an interview on 04/11/16 at 3:55 PM and 04/13/16 at 10:36 AM, Staff PP stated that he had not been told he had done anything wrong during the incident on 02/11/16. He stated that the crisis prevention program (a training program on how to deescalate a patient and use appropriate holds to control a patient) instruction was just a foundation and not an exact science. Staff PP felt this patient's behaviors were too escalated for him to use the crisis prevention techniques he was trained to use.

The facility's staff, failed to follow their, "Just Culture," policy by not helping employees make safe choices when caring for psychiatric patients and not identifying abuse when it occurred in their facility.

6. Record review of a self report letter dated 02/24/16, that the facility sent to the State Agency, showed no discussion of abuse of Patient #48 by Staff PP or Staff SS.

During an interview on 04/13/16 at 10:06 AM, Staff II, Vice President of Behavioral Services and Staff TT, Human Resource Partner, both stated that Staff PP acted correctly during the 02/11/16 incident.

Staff II and Staff TT failed to recognize that restricting the patient's movement was a form of restraint and failed to recognize that dragging a patient was patient abuse.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, and policy review the facility failed to ensure staff obtained a physician's order for a manual hold restraint for one of one patient (#48) on the Senior Care Behavioral Health Unit (unit for the treatment of elderly psychiatric patients.) This failure increased the risk for patients to be restrained inappropriately and prior to the use of least restrictive alternatives. The facility census was 172. The Senior Care Behavioral Health Unit census was 20.

Findings included:

1. Record review of the Psychiatric Evaluation dated 02/10/16, for Patient #48 showed on 02/09/16 at approximately 11:30 PM, the [AGE] year old female, was admitted to the Senior Care Behavioral Health Unit. Patient #48 presented with increased aggression towards family, with hallucinations (seeing or hearing things which are not there) and delusions (false ideas about what is taking place or who one is, despite evidence to the contrary).

Record review of a nursing progress note dated 02/11/16, showed at approximately 7:45 AM (in the day room), Patient #48 walked over to a female peer (Patient #49) and choked her, licked her face, and bit her cheek. Staff were unable to redirect the patient. Staff put hands on (manual restraint) Patient #48 to remove her from Patient #49 and a code strong (called over the facility intercom for all available staff to respond for assistance) was called. Staff took the patient to the restraint room and placed her in four point (both arms and legs) restraints.

2. Observation on 04/12/16 at 11:00 AM, of a recorded video dated 02/11/16 at 7:44 AM, showed Staff PP, Clinical Partner, was behind Patient #48 (patient back side in front of staff) with his arms extended and his hands on both of Patient #48's upperarms. The patient's left arm was extended up above her head and Staff SS, Clinical Partner, pulled on the patient's left hand. Patient #48 was pulled backward with her heels on the floor and in a seated position (bottom did not touch the floor). Then after approximately 20 feet, the staff stopped and the patient was repositioned to an upright position. The patient's top had slid up and her bare breasts were exposed. The patient remained backward and Staff PP held the patients upper arms and Staff SS continued to hold the patient's left hand. The patient's bare breasts continued to be exposed and staff dragged her backward to the restraint room with her feet slightly touching the floor.

During an interview on 04/13/16 at 10:35 AM, Staff AA, Patient Safety, Quality, Risk, Regulatory Coordinator, and Staff L, Director of Behavioral Health Services, confirmed the distance from the day room to the restraint room was approximately 40 feet.

During an interview on 04/12/16 at 2:10 PM, Staff SS stated that she remembered griping Patient #48's left upper arm or shoulder area. Staff SS stated that she and Staff PP stopped to get a better grip on the patient to get her down the hall safely.

3. Record review of the facility policy titled, "Restraint Utilization (Violent, Self-
Destructive)," dated 01/2014, showed directives for facility staff:
- In an emergency situation, a trained staff member under the supervision of a
Registered Nurse (RN) trained in the use of restraints can initiate the restraint. - An order must be immediately secured from a physician.
- A mechanical restraint is any manual method, physical method, mechanical device, material or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body.

Staff held the patient in a manner that restricted her movement which constituted a restraint.

During an interview on 04/13/16 at approximately 3:30 PM, Staff H, Staff Team Leader, Senior Care Behavioral Health Unit and Staff L, Director of Behavioral Services, stated that Staff PP utilized a restraint in an emergent situation.

4. Record review of Patient #48's physician's orders showed no order for a manual restraint.

5. Record review of Staff L's chart review, video review, and summary as noted in an e-mail dated 02/11/16 to Staff II, Vice President of Behavioral Health Services; Staff ZZ, Administrator; Staff AA, Patient Safety, Quality, Risk, and Regulatory Coordinator; and copied to Staff H showed the patient continued to hit, kick, and spit at staff and was restrained.

During an interview on 04/13/16 at 10:53 AM, Staff II, Vice President of Behavioral Health, stated that the facility policy directive for staff was that an order for a therapeutic hold was not needed and Staff PP used no therapeutic hold, but he transferred the patient. This was less restrictive than seclusion or restraint.

Staff II failed to recognize that restricting the patient's movement was a form of restraint.

Patient #48 could not easily remove the staff's hands and she was restricted from freedom of movement. This constituted a manual restraint by Staff PP and Staff SS.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed to ensure all staff who cared for patients that were at increased risk for combative/agitated behaviors and sexual acting out behaviors were educated in five patient care units (two adult Behavioral Health Units, BHU; one adolescent BHU; and two Emergency Departments, ED) of six units after an incident which involved the care of a combative patient, and three patient care units (two ED and one Senior Care Behavioral Health Unit) of three units after an incident which involved care of patients that had increased risk of sexual acting out behaviors. These failures had the potential for similar incidents to re-occur due to uneducated staff. The facility census was 172.

Findings included:

1. Record review of the Psychiatric Evaluation dated 02/10/16, for Patient #48, showed on 02/09/16 at approximately 11:30 PM, the [AGE] year old female, was admitted to the Senior Care Behavioral Health Unit (BHU.) Patient #48 presented with increased aggression towards family, with hallucinations (seeing or hearing things which are not there) and delusions (false ideas about what is taking place or who one is, despite evidence to the contrary.)

Record review of a nursing progress note dated 02/11/16, showed at approximately 7:45 AM (in the day room), Patient #48 walked over to a female peer (Patient #49) and choked her, licked her face and bit her cheek. Staff were unable to redirect the patient. Staff put hands on (manual restraint) Patient #48 to remove her from Patient #49 and a code strong (called over the intercom for all available staff to respond for assistance) was called. Staff took the patient to the restraint room and placed her in four point (both arms and legs) restraints.

2. Observation on 04/12/16 at 11:00 AM, of a recorded video dated 02/11/16 at 7:44 AM, showed Staff PP, Clinical Partner, was behind Patient #48 (patient back side in front of staff) with his arms extended and his hands on both of Patient #48's upperarms. The patient's left arm was extended up above the patients head and Staff SS, Clinical Partner, pulled on the patient's left hand. Patient #48 was pulled backward with her heels on the floor and in a seated position (bottom did not touch the floor). Then after approximately 20 feet, the staff stopped and the patient was repositioned to an upright position. The patient's top had slid up and her bare breasts were exposed. The patient remained backward and Staff PP held the patients upper arms and Staff SS continued to hold the patient's left hand. The patient's bare breasts continued to be exposed and staff dragged her backward to the restraint room with her feet slightly touching the floor.

3. Record review of the undated facility's education titled, "Care of the Agitated Patient, Crisis Intervention," showed directives to staff on how to recognize behavioral changes that could indicate a person becoming more agitated, to report changes to nursing staff, awareness of the need for a plan to provide for everyone's safety, identify coping skills that may be used to de-escalate situations/individuals, how to physically control a patient with two people, and how staff position themselves with a patient to transport (escort a walking patient) patient.

During an interview on 04/14/16 at 9:02 AM, Staff L, Director of Behavioral Health Services, stated that only the staff in the Senior Care Behavioral Health Unit were retrained on the "Care of the Agitated Patient, Crisis Intervention," because that was where the 02/11/16 incident occurred.

During an interview on 04/14/15 at 8:57 AM, Staff YY, Registered Nurse BHU, reported that she was not educated after the event on 02/11/16 on the Senior Care Behavioral Health Unit, but was aware of the event since she floated to that unit and it was discussed by staff.

The facility's lack of education for all staff that cared for this patient population on a regular basis (Behavioral Health and Emergency Department Staff), had the potential to lead to similar incidents of unidentified behavioral changes, inability to de-escalate situations appropriately, and improper physical control of a patient on other units.

4. Record review of the documented titled, "Regulatory Compliance and Risk Management Investigation," dated 04/08/16 showed the following:
-Patient #50 and #51 were both on Sexual Abuse Management (SAM) precautions at level two (patients placed on SAM level two precautions have a risk for major sexual acting out behaviors such as fondling, excessive talk with sexual content, inappropriate touching and also may have been a perpetrator of sexual assault, a registered sex offender, or are currently in treatment for sexual misconduct).
-On 03/28/16 at approximately 3:22 PM, Patient #50 and #51 were alone in Patient #51's shower in his room for approximately three minutes before being discovered by staff.
-Patient #51 was fully clothed and denied any intercourse. He reported he had only, "touched her (#50) between the legs."
-Patient #50 was found with her pants off, but denied any sexual interaction between herself and Patient #51.

During an interview on 04/14/15 at 8:57 AM, Staff YY, Registered Nurse (RN) BHU, stated the following:
-She was the primary RN for Patient #51.
-All staff that worked the unit on 03/28/16 was aware that Patient #50 and #51 were on SAM level two precautions.
-Observations by staff were made that concerned them that there was potential for inappropriate interactions between the two patients.
-A Safety Huddle (group meeting of staff on the unit that includes leadership) was conducted immediately after the observations occurred and the decision was made to move Patient #51 to another unit as a precaution.
-Due to the paranoid and aggressive behavior of Patient #50, staff had to wait for an opportunity to distract Patient #50 in order to make the transfer of Patient #51 a safer transition for staff and patients.
-An admission came to the floor prior to the transfer being completed, and during that time the patients were found in the bathroom.
-Patient #50 and #51 were on every 15 minute observation checks.

5. Record review of the facility's education sign-in sheets titled, "Observation Levels and Reporting of High Risk Incidents," dated 04/08/16, showed that documentation of re-education was begun for all staff that worked on the adolescent BHU, and two Adult Care BHU's. This was a direct result of the event that occurred on 03/28/16. The sign-in sheets showed no re-education was done by the facility for staff on the Senior Care Behavioral Health Unit or the ED.

During an interview on 04/14/16 at 8:32 AM, Staff W, Team Leader Behavioral Health, stated that education specific to the 03/28/16 event was only administered to the staff of the adolescent BHU and the two Adult Care BHU's. Staff W confirmed that no education was done regarding this event to the Senior Care Behavioral Health Unit or any other departments.

The lack of post-event education for all units that cared for this population placed all patients at risk for further harm due to insufficient knowledge of staff.