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.


Based on facility document review, policy review, video recording review, medical record review, observations and interview, the hospital's Chief Executive Officer (CEO) failed to assume responsibility to manage and direct hospital leaders and staff to make sure hospital policies and procedures and the hospital's Immediate Jeopardy Removal Plans were being carried out correctly. The CEO failed to control the day-to-day operations of the hospital, making sure patient care was being met in compliance with federal regulations and continually sought to improve procedures, processes and systems for patient safety, and protection.

The CEO's failure to manage the hospital functions, improve processes to ensure quality of care and ensure an environment of a culture of safety resulted in 5 of 5 (Patients #1, #2, #3, #4 and #5) sampled patients not receiving protective care, safety care and preventative care from the hospital.

The findings included:

1. Review of the Governing Board Bylaws revealed, "...The Hospital is owned and operated by the Company...The Company is managed by a Board of Directors that have been appointed by the owner of the Company. The Governing Board, as constituted by these Bylaws, serves as the governing body of the Hospital to the extent that the Board of Directors has delegated authority to it...The Governing Board is ultimately accountable for the safety and performance improvement of care, treatment and services. The primary function of the Governing Board is to assure that the Hospital and its Medical Staff create a culture of safety and provide quality medical care that meets the needs of the community...The CEO [Chief Executive Officer] is responsible for the overall management of the facility...The CEO's duties and powers include, but are not limited to...creating a culture of safety and performance improvement throughout the organization and maintain that culture by regularly evaluating safety and performance improvement standards, prioritizing and implementing changes prompted by such evaluation, ensuring regular communication between Hospital Leadership and the Governing Board regarding issues of quality and safety, using data and information to guide decisions and to understand variations in the performance of processes supporting safety and performance improvement, providing opportunities for all facility personnel to participate in safety and performance improvement initiated and ensuring that all personnel are able to openly discuss issues of safety and performance improvement, developing a code of conduct that defines acceptable, disruptive, and inappropriate behaviors and implementing a process for managing disruptive and inappropriate behaviors, ensuring that all facility personnel receive education focused on safety and performance improvement, and establishing a team approach to safety and performance improvement among all guide and support the care and treatment provided by the Hospital...ensuring that an integrated patient safety program is implemented throughout the Hospital which or more qualified individuals or an interdisciplinary group assigned to manage the organization wide safety program...integration into and participation of all components of the organization into the organization wide program...procedures for immediately responding to system or process failures, including care, treatment, or services for the affected individuals(s), containing risk to others, and preserving factual information for subsequent analysis...developing and implementing policies and procedures for care, treatment, and services, including policies that guide and support patient care, treatment, and services and ensuring that such policies and procedures are consistently implemented..."

2. Review of the CEO Job Description revealed, "...The Chief Executive Officer shall serve as the executive officer with day-to-day responsibility for the management and operation of the hospital. The CEO has primary responsibility for the development, implementation, and achievement of the hospital's strategic business plan in conjunction with routine operations to include: quality of care, staff development...continuous performance improvement...Manages day-to-day operations and staff so that the hospital achieves its objectives in all of the following key performance areas...effective patient care outcomes..."

3. Review of the Chief Operating Officer (COO) Job Description revealed, "...Purpose Statement: Provide management oversight and direction for the day-to-day operational activities of the facility. Essential Functions...Manage and implement programs to ensure all employees are committed to quality and service...Actively participate in strategic planning and corresponding development activities including regulatory preparedness and quality improvement..."

4. Review of the Chief Nursing Officer (CNO) Job Description revealed, "...Chief Nursing Officer is responsible for directing, planning, coordinating, monitoring and supervising the effective and efficient use of the operations of nursing and other departments and the delivery of behavioral health and nursing services. Collaborates with interdisciplinary treatment teams, other departments, and with administration to ensure that all residents physical, bio psychosocial, age, developmental and cultural needs are met. Provides leadership to assure compliance with local, state, federal regulations and nursing practice standards. Essential Functions...Manage the daily operations of nursing services...Integrate nursing functions with clinical and programs, assuring efficient and effective operations...Evaluate service needs and staffing requirements to assure needs of people supported are met...Provide effective staff management...that assures utilization of personnel to best meet the needs of the people receiving support and services. Develop and implements health care related training that assures the best possible delivery of health related supports and services. Reviews training at least annually and makes modifications as needed. Develop and maintains documentation systems for continuity of care...Monitor unit/floor functioning by making frequent rounds. Intervene in crisis situations and investigate incidents. Develop and implement tools to measure, assess and improve quality of nursing care, treatment and services...Oversee nursing services documentation to ensure it meets all standards..."

5. Review of the facility policy titled, "Patient Rights and Responsibilities reviewed in June 2018, revealed, "...Personal Safety...The patient has the right to expect reasonable safety insofar as the hospital practices and environment..."

6. Review of the facility policy titled "Patient Observation Levels" revealed, "...All patients admitted for behavioral health treatment will [be] placed on an appropriate level of observation per physicians order depending on the intensity of the thoughts, feelings, behaviors related to self-harm, suicide or thoughts of harming others...An RN [Registered Nurse] may independently place a patient on enhanced observations and document if the patient is assessed at an increased risk. The physician will be contacted as soon as possible to be notified of the patient's status...15-Minute Checks All patients who are admitted for behavioral health treatment will be placed on safety observations. A 15-minute check requires the unit staff to observe and document the patient's location, behavior, and activity on the Patient Observations- 15 minutes, every 15 minutes...A 5-minute check requires the unit staff to observe and document the patient's location, behavior, and activity on the "Patient Observations- 5 minutes, every 5 minutes...1:1 Observation...The patient will be assessed by the R.N. [Registered Nurse] or physician and is determined to be an imminent risk to self or others. The 1:1 observation is most restrictive type of observation due to the significant likelihood of harm to the patient or others...A staff member will be assigned to stay within a reasonable distance to ensure safety while on a 1:1 status...the assigned staff member should be able to directly see and hear the patient at all times and have the ability to quickly intervene if necessary...The treatment plan will be updated by the assigned clinical services therapist and presented to the treatment team for additional recommendations..."

7. Review of the facility policy titled, "Incident Reporting-Risk Management Program" revised 1/2020 revealed, "...It is the policy of [Hospital #1] to utilize the Risk Management Program techniques to promote safety, pro-actively focus on loss prevention, and detect hazardous events and circumstances. It must provide a systematic, multi-disciplinary approach to managing and reporting incidents of injury, damages, and loss...The Incident Report is a risk management tool that raises awareness of potential exposures to perils that may/did cause harm. It enables the facility to manage risk, increase safety, and improve the quality of health care provided in the facility through risk control interventions and monitoring the effectiveness of the interventions and corrective action plan. An "incident" is an unanticipated event which was not consistent with the standard of care and/or operation of the facility and my have occurred due to a violation of policy and procedure. It results in, or nearly causes, a negative impact on a patient(s) receiving care at the facility, or visitor(s) at the facility. Any harm caused can be temporary, long-term, or permanent and range in severity from no obvious or significant injury up to death. The Incident Report will help the various facility committees and administration in identifying potential areas of risk and implementing measures to improve the overall quality of care throughout the facility...If the incident involves a patient, staff must chart relevant information in the patient's medical record. When documenting incidents in the medical record, staff will chart precisely what happened without making reference to an "error" or that an Incident Report was completed...Facility Risk Manager will investigate and/or will document the investigation under Level "I" and "II"...The facility Risk Manager or Designee will notify appropriate agencies of reportable incidents as required...Boundary Violation...Patient/Patient-Any allegation of action, behavior, or relationship between Pt/Pt that could interfere with a safe, therapeutic environment and care at the facility. The interaction may or not be sexual in nature...Misconduct/Body Exposure...Patient/Patient - Any allegation of deliberate action where a patient's genitals were exposed to, or touched by, another patient. Includes kissing and other physical interaction that is interpreted as sensual in nature...It is the expectation that part of reporting the incident includes describing the actions taken to mitigate damages and/or prevent further loss. Every incident reported requires that the interventions be identified...The following severity classifications shall be used...Level I - Tragic: Incidents which are considered sentinel or considered tragic in nature...Level II - Serious: Major injury or impairment in which the patient or visitor's function is altered requiring outside medical intervention..."

8. Review of the facility's policy titled, "Admission" revealed, "...Admission to a Behavioral Health unit is indicated for adults suffering from an acute psychiatric condition(s) or from an acute exacerbation of a chronic condition. Such patients will also require intensive psychiatric intervention with different levels of medical treatment...Senior Care Unit...Admission Criteria Admission to the Senior Care Unit is indicated for patients who have a diagnosis from the current version of the DSM [Diagnostic and Statistical Manual of Mental Disorders] and, in addition, meet one or more of the following criteria...Suicidal behavioral and/or ideation, with poor impulse control and/or little or no support from their environment...Combative or assaultive behavior or ideation, which poses a threat to others...Potential or actual self-mutilation behavior...An acute onset of or intensification of delirium or disorientation, bizarre or delusional behavior that results in the patient being incapable of performing activities of daily living, or becoming grossly disruptive in the environment. In addition, the conditions not amenable to treatment at a lower level of care, or require specialized diagnostic procedures not available in another setting...Acute onset or intensification of severe agitated behaviors....Inability to perform activities of daily living with at least two of the following...Psychomotor retardation agitation...Failure to thrive/refusal to eat...Insomnia...Recurrence of psychosis which has not responded to outpatient treatment...Toxic effects from therapeutic and non-therapeutic psychotropic medication...Patient has a medical condition or medication sensitivity which complicates treatment of the mental disorder outside a hospital...Recent change in mental status...Emergency Department referral - Nursing home requesting a psychiatric evaluation and refusing to accept patient back until evaluated by a psychiatrists...Exclusion Criteria...Patients requiring airborne and droplet precaution, full contact isolation..."

9. Review of the Governing Board 4th Quarter Meeting Minutes dated 1/22/2020 revealed the Risk Management report was reviewed and determined all Level I incidents should contain documentation of what actions were taken going forward.

10. The Quality Council Meeting Minutes were reviewed after obtaining permission from the facility's Chief Operations Officer (COO) and revealed the following:
In December 2019 the Quality Council identified an upward trend in the number of physical confrontations between patients and/or staff and video monitoring indicated day rooms did not always have a mental health tech with the patients.
Actions to be taken included having the nurse managers working with each unit ensuring all patient hallways and day rooms had a mental health tech present with the patients.

In February 2020 the Quality Council review of the Risk Management Report indicated 9 patients had been attacked by another patient, with actions to monitor for trends, investigate incidents and look for opportunities to promote safety and safe catches. There was no documentation of implementation of a process for managing disruptive and inappropriate behaviors.

In March 2020 the Quality Council used camera observations and determined there was a need on focused unit compliance to rounding was necessary with actions to continue to monitor and report on compliance with every 15 minute rounding. The Risk Management Report indicated a total of 12 patients had been attacked by another patient. There were no new interventions or actions listed on the minutes; in fact, the actions were identical to the actions listed in February meeting minutes.

The meeting minutes had not been completed for the April and May meetings; however, the COO allowed surveyors to review the power point presentation from the meetings.
The presentation for the month of April 2020 indicated a total of 12 patients had been attacked by another patient.
The presentation for the month of May 2020 indicated a total of 7 patients had been attacked by another patient.
The presentation further indicated the facility had been cited an Immediate Jeopardy by the Department of Health and an acceptable removal plan had been implemented and accepted.
The presentation did not include any further details of the citation. There was no documentation the hospital identified issues with quality and safety, or hospital systems had been evaluated for safety and protection of the patients and evaluated for the staff's awareness and implementation of a culture of safety.

11. Review of the Governing Board Annual/1st Quarter Meeting Minutes dated 4/27/2020 revealed, "...Clinical and Compliance Report...We've had 2 complaint surveys results pending on both...Reviewed risk report..." There was no other documentation regarding the complaints, implementation of changes or any issues identified with the quality of care.

12(a). Medical record review for Patient #1 revealed an admission date of [DATE] with diagnoses that included Schizoaffective Disorder Bipolar Type. People with the condition experience psychotic symptoms, such as hallucinations or delusions, as well as symptoms of a mood disorder.

Review of the Treatment Referral Form dated 5/27/2020 at 1:45 PM revealed, "...Additional Risk Note: Aggressive behaviors with staff, sexually inappropriate with other resident, and becomes verbally aggressive and threatening to kill nurse..."

Review of the telephone Admission Order signed by Nurse #2 dated 5/28/2020 at 3:00 PM revealed "...Level of Observations: Q15 [every 15 minutes]. The section on the order indicating what/if any precautions were required was not completed. Nurse #2 obtained the admission order prior to Patient #2's arrival to the facility and before the patient underwent a Medical Screening Exam (MSE) and Intake Assessment to determine the patient's safety needs and precautions.

Review of the Medical Screening Exam (MSE) of Patient #1 completed by Nurse #1 dated 5/28/2020 at 7:11 PM revealed, "...aggressive, violent, going to other residents room taking briefs off...responding to internal stimuli..."

Review of the Intake assessment dated [DATE] at 7:15 PM revealed Patient #1 was referred to the facility from a nursing facility due to "HI [homicidal ideations] threats made to nursing staff, taking off other residents briefs, grabbing at female residents, physical and verbal aggression, and refusing redirection. Pt [patient] is currently a danger to self and others at this time and is in need of stabilization treatment...Threatened to kill a nurse verbally and physically aggressive...wandering into other residents room trying to take off another residents brief grabbing at female residents physically aggressive...increased agitation...sexually inappropriate with another resident...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight...Potential danger to self or others..."

Review of the High Risk Notification Form signed by Intake Assessor #1 and Nurse #3 dated 5/28/2020 at 7:30 PM revealed, "...threatening to kill nurse...increased agitation; refusing redirection, cursing...wandering into other residents rooms...trying to take off another residents brief, verbally & [and] physically aggressive...grabbing at other residents..."

Review of the Patient Observations - 5 Minutes sheet initiated by Intake Assessor #1 dated 5/28/2020 revealed Patient #1 was placed on "Assault, Fall, and Sexual Acting Out" Precautions and was observed every 5 minutes in the Intake area from 7:10 PM until 7:30 PM when he was transferred to the Senior Care Unit (SCU).

Review of the undated and untimed RN Medical Review Form signed by Nurse #2 and #3 revealed, "Patient Appropriate for SCU...Aggressive behavior with biting and kicking. Patient exhibiting anxiety with depressive affect..." There was no documentation that Patient #1 was admitted with sexually inappropriate behaviors or was "Sexual Acting Out."

Review of the Behavioral Health (BH) Initial Treatment Plan (Nursing) completed by Nurse #4 dated 5/28/2020 at 9:00 PM revealed, "...Impulsivity As Evidenced By forgetfulness, reaching in peers briefs, going into others room, wandering...Interventions...Set limits with patient. Offer choices of appropriate options..."

Review of the BH Interdisciplinary Treatment Plan Psych Problems completed by Nurse #4 dated 5/28/2020 at 9:00 PM revealed, "...Psychiatric Problem Impulsivity As Manifested By...reaching into other Resident briefs...#1 Psychiatric Problem Disturbed thought - Dementia As Manifested By...This is a 78 y/o [year old]...M [male] admitted from nursing home after repeatedly being sexually inappropriate with female peers...Interventions - What staff will do to to Assist the Patient Achieve Goals...Nursing will administer medications daily and alert MD [medical doctor] regarding any change in behavior..."

Review of a Nurse Progress Note dated 5/28/2020 at 10:54 PM revealed, "...Pt arrived to senior care unit on 05/28/2020 @ [at] 1930 [7:30 PM] via stretcher/ambulance..."

Review of the Nurse Admit Assessment completed by Nurse #3 dated 5/28/2020 at 11:26 PM, revealed, "...Pt is sexually inappropriate with peers..."

Review of a Nurse Progress Note dated 5/29/2020 at 1:32 PM, revealed, "...Nurse arrive to room, see this patient being very sexual inappropriate with female patient [Patient #2], this nurse asked patient "What you're during [doing]...Your [You're] not to be touching her, please leave out of here. Second nurse arrive to assist, Patient is led from room by second nurse. this nurse and second nurse assess and assist female into fresh gown and clean pull-up. and into bed...provider is order for patient [Patient #1] to be placed on one to one observation r/t [related to] sexual aggressiveness..."

In an interview with the facility's COO on 6/8/2020 at 12:17 PM, when asked to review the facility incident report for the event, the COO reminded surveyors they were unable to provide a copy and any incident reports must be viewed in her presence.

Review of the Incident Report dated 5/29/2020 at 1:20 PM revealed, Patient #1 was found in Patient #2's room. Patient #2 had no covering or incontinence brief on and Patient #1 had his hand between Patient #2's "butt cheeks." Patient #1 was asked to stop and to leave the room, and a second nurse responded. Interventions, "...Placed on 1:1...Incident Level II."

Review of the facility's video recording of the above incident dated 5/29/2020 beginning at 12:56:09 PM revealed no patients or facility staff members were observed in the unit hallway.
At 12:56:12 PM Patient #1 is seen exiting a different patient's room next door to Patient #2's room.
Patient #1 appeared to pick something up off the floor, looked down the hallway and at 12:56:30 PM Patient #1 entered Patient #2's room.
At 12:59:16 PM, Nurse #5 was observed at the other end of the hallway exiting a patient's and began walking down the hallway toward Patient #1's room looking into the rooms as she walked.
At 12:59:39 PM, Nurse #5 opened the door to Patient #1's room and appeared to be speaking and was noted entering the room just as Nurse #6 entered the hallway at 12:59:42 PM.
At 12:59:47 PM, Nurse #5 backed out of the room and Nurse #6 entered the room.
Nurse #5 appeared to be waiting for Patient #1 to exit the room.
Patient #1 was observed exiting Patient #2's room at 12:59:56 PM and was standing in the hallway.
Nurse #5 re-entered Patient #2's room at 12:59:59 PM at which time the video recording ended.

Review of the Patient Observations sheet for Patient #1 revealed on 5/28/2020 the patient was located in his room on the SCU from 7:30 PM until 11:45 PM. Further review revealed the patient was to be checked every 15 minutes and was on "Fall" precautions. The observation sheet did not indicate Patient #1 should be observed every 5 minutes for Assault or Sexually Acting Out precautions as indicated on the Patient Observation Sheet that was started in the intake department.

Review of the Patient Observations sheet dated 5/29/2020 from 12:00 AM through 11:30 AM revealed Patient #1 should be checked every 15 minutes for "Fall" Precautions. The box for "Sexual Acting Out" precautions was not checked.
Further review revealed Patient #1 was noted to be in the Activity Room from 11:45 AM until 12:30 PM, at the nurse's station at 12:45 PM, and in the Activity room from 1:00 PM until 1:30 PM contradicting what was seen on the hospital video recording of Patient #1.

In an interview on 6/8/2020 at 2:33 PM the facility's COO was asked if she could explain why the Patient Observations sheet indicated Patient #1 was either in the activity room or at the nurse's station during the time of the incident and video recording and the COO stated, "I can tell you that's what's on the sheet but that's not what happened. The person that documented on the observation sheet is seen no where on the video."
The COO was asked if that was considered falsification of medical records and the COO stated, "That is correct."
The COO was asked what she discovered during her investigation of the event and the COO stated, "It looks like [Patient #1] was admitted on ,d+[DATE] [2020] came in with a history of Sexually Acting Out...was admitted to SCU and I found he was not placed on Sexually Acting Out precautions upon admit...On the day of the event he was observed wandering into another individual's room, and wandered into [Patient #2's] room about 3 minutes before [Nurse #5] started rounding on the patients. At that point, when I did go back and compare the video to the observation sheet, I did a verbal notification to the CNO [Chief Nursing Officer] that it didn't match. I probably should have typed it up..."
The COO was then asked if she reported the incident to the State and the COO stated, "What I was told to report to the State is when there is a substantiated abuse from staff to patient."

In an interview on 6/8/2020 at 3:34 PM Nurse #6 was asked to describe what he witnessed regarding the incident and the RN stated he had been off the unit and upon his return to the unit, "The nurse [Nurse #5] called for help. I went in the room and saw [Patient #2] standing there stark naked. I didn't see him [Patient #1] touching her, but he was standing there next to her. I kinda escorted him out of the room and went back and assessed [Patient #2]...she wasn't making any noise or saying 'No.' She was just standing there not speaking..."

In an interview on 6/9/2020 at 2:47 PM Nurse #5 was asked to describe what she witnessed regarding the incident and the nurse stated, "I had walked into [Patient #2's] room...[Patient #2] was standing up with her back toward the door and [Patient #1] was standing to her left side with his hand between her butt cheeks. I told him to 'stop that, what are you doing here?' I asked him to leave and another nurse assisted because he was assault precautions...I looked at her [Patient #2] and assessed bleeding...I put a gown on her and put her in the bed then I went and called my manager..."
The facility's Director of Quality Services who was present during this interview, stated, " [Patient #1] did come in on assault precautions, but should have been on Sexual Boundary precautions. That was found during chart audits..."

Review of the Patient Observation sheets for Patient #1 dated 6/2/2020 through 6/8/2020 revealed the following:
On 6/5/2020 - the patient appeared to be asleep in the bathroom from 1:55 AM until 7:00 AM.
This surveyor was given 2 different Observation sheets both dated 6/6/2020 and timed 00:00 (12:00 AM) through 11:55 AM. Both sheets indicted Patient #1 was on every 5 minute observations.
The first sheet indicated Patient #1 was on Assault and Sexual Acting Out Precautions. The patient's location, behavior, and activities were documented every 5 minutes from 12:00 AM until 7:00 AM.
The second sheet with the same dates and times, indicated the patient was on every 5 minute observations; however, there were no Precautions documented on the sheet. The patient's location, behavior, and activities were documented every 5 minutes from 12:00 AM until 11:55 AM.
Upon further review of the 2 Observation sheets with the same dates and time periods, it was noted the signatures and observations did not match.
A third observations sheet dated 6/6/2020 showed the patient's location, behavior, and activities from 7:15 PM until 11:45 PM. There were no Precautions documented, and the facility was unable to provide documentation of the patient's location, behavior, and activities from 11:55 AM until 7:15 PM.
There was no documentation a Registered Nurse reviewed or monitored the Observation Sheets every 4 hours per facility action plans to provide oversight of patient care.

12(b). Medical record review for Patient #2 revealed an admission date of [DATE] with diagnoses that included Paranoid Schizophrenia. A condition in which a person experiences symptoms of delusions and hallucinations. These symptoms blur the line between what is real and what isn't, making it difficult for the person to lead a typical life.

Review of the History and Physical dated 5/13/2020 at 11:10 AM revealed, Patient #2 was a [AGE] year old female that "...was admitted to the hospital because of paranoid schizophrenia...she is awake, lying in her bed, blinking her eyes, but not answering any questions or following any commands...She has a gastrostomy tube [PEG] [a tube inserted through the abdomen that delivers nutrition directly to the stomach], has wounds on her neck and skin graft scars on her thighs...Past Medical History...Huntington chorea [An inherited condition in which nerve cells in the brain break down over time], confusion...The patient was brought to the hospital because of psychosis and aggression towards staff and peers...At this point in time, lying in bed, appears chronically ill, older than her age. Does not answer any questions..."

Review of a Nursing Note dated 5/29/2020 at 1:35 AM revealed, "...Had to replace dressing to pt's coccyx [tailbone area], nurse reported the dressing had been removed by another patient [Patient #1]. Skin reassessed, no observable injuries noted..."

Review of a Nurse Progress Note dated 5/29/2020 at 1:40 PM revealed, "This nurse observed [Patient #1] being sexually inappropriate with this patient [Patient #2]..."

Review of a Quick Note completed by a Family Nurse Practitioner dated 5/29/2020 at 4:11 PM revealed, "I was called at 1326 [1:26 PM] about an incident that happened between [Patient #2] and [Patient #1] the nurse walked in to the pts room where [Patient #2] was standing completely naked with another pt [Patient #1] standing behind her with his finger in her buttocks. I went to the unit...assessed pt for any trauma to her anal area and her vagina. there were no visible signs of trauma. the pt was very tearful and did not say anything while we were examining her..."

Review of a Nurse Progress Note dated 5/30/2020 at 8:20 AM, revealed, "Called and spoke with spouse of [Patient #2]...informed [Patient #2's spouse] that there was an incident that occurred on yesterday when another male patient entered her room and was quickly found before any dangerous harm occurred. [Patient #2's spouse] was made aware that it is uncertain what actually occurred but that due to Risk Management, we are taking all precautions and making certain that everything was medically assessed, reported, and all interventions will be provided as necessary. [Patient #2's spouse] stated understanding and stated that usually [Patient #2] does not like to be touched..."

13. Below is a review of other patients medical records reviewed to complete the sample for the complaint investigation:

(a). Medical record review for Patient #3 revealed an admission date of [DATE] with diagnoses that included Schizoaffective Disorder, Bipolar Type.

Review of the Treatment Referral Form dated 6/4/2020 at 11:10 AM revealed, "...Risk Factors for Admission: Suicide/Self Harm Cut Wrist...Wants to Detox..."

Review of the telephone Admission Order signed by Nurse #2 dated 6/4/2020 at 11:28 AM, revealed, "...Level of Observations: Q15 [every 15 minutes]. The section on the order indicating what/if any precautions were required was not completed. Nurse #2 obtained the admission order prior to Patient #3's arrival to the facility and before she underwent a Medical Screening Exam (MSE) and Intake Assessment.

Review of the Intake assessment dated [DATE] at 2:45 AM revealed, "...Patient experiencing increase in Suicidal Ideations with plans to either jump from bridge or hang self. Patient experienced one aborted attempt on 6/5/2020 by walking the edge of her nearest bridge with intent to jump, but changed her mind before completing the act. Patient currently using cocaine, methamphetamines, and alcohol to curtail suicidal ideations...Homicidal Ideations towards "anyone" that upsets her...Med
Based on facility document review, policy review, video recording review, medical record review, observations and interview, the Governing Body failed to be effective in carrying out its responsibilities for the conduct of the hospital and ensure the hospital's ongoing compliance with all Conditions of Participation in order for quality of care to be provided to all patients. The Governing Body failed to ensure the Chief Executive Officer (CEO) assumed responsibility for the management of the hospital and ensure the hospital followed policies, procedures and Immediacy Removal Plans in order to maintain all patients in an environment of safety, protection and infection control.

The failure of the Governing Body to carry out its responsibility for the oversight of the conduct of the hospital, and the failure of the Governing Body to ensure the CEO managed the hospital responsibly resulted in the Governing Body's and CEO's failure to enforce, monitor and revise as needed their Immediate Jeopardy removal plan; and ensure all hospital policies and procedures to protect the safety and health of patients and prevent serious outcomes and infections placed all patients at risk for an IMMEDIATE JEOPARDY for their safety and well being.

Refer to 0057.