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.

LEGACY EMANUEL MEDICAL CENTER 2801 N GANTENBEIN AVENUE PORTLAND, OR 97227 April 20, 2020
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observations, review of recorded video footage, interviews, email communications, review of incident and medical record documentation for 21 of 21 psychiatric patients (Patients 1 through 21), review of training records for 5 of 14 staff (Staff Q, K, L, M and W), review of policies and procedures, review of building floor plans and other documentation related to safety and physical environment risk, it was determined that the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital that complied with the Conditions of Participation.

Staff failures to prevent patient access to unsafe items, failures to prevent elopement, failures to provide supervision, failures to appropriately manage behaviors and prevent unnecessary restraint use, and failures to protect patient privacy resulted in actual and potential harm to patients, and investigations to ensure such incidents did not recur were not timely or complete.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care and is a repeat deficiency previously cited on surveys completed on 08/08/2019, 07/30/2018 and 05/22/2018.

Findings include:

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

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

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

4. Refer to the findings cited under Tag A701, CFR 482.41(a) - Standard: Buildings.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, review of recorded video footage, interviews, email communications, review of incident and medical record documentation for 21 of 21 psychiatric patients (Patients 1 through 21), review of training records for 5 of 14 staff (Staff Q, K, L, M and W), review of policies and procedures, review of building floor plans and other documentation related to safety and physical environment risk, it was determined that the hospital failed to fully develop and implement policies and procedures that ensured that patients' rights to safe care, freedom from abuse and neglect, freedom from restraint, and privacy and dignity were recognized, protected and promoted. As a result, patients experienced actual and potential harm:
* Patients were allowed access to unsafe items. Those incidents included a case where an inpatient was provided with unsafe items which the patient used to attempt suicide, and two cases where patients removed smoke detectors from the ceiling in the secure unit.
* Patients were not protected from elopement from secure units and the secure facility. Those incidents included two cases where inpatients were allowed to elope from the secure facility.
* Patients were not supervised and observed to ensure safety. Two patients were allowed to engage in sexual intercourse and other sexual acts on the floor of a locked bathroom in the emergency services unit.
* A patient was not protected from the use of unnecessary restraint and seclusion.
* Patients were not afforded auditory and visual privacy during the provision of care that included one case where a video recording of an inpatient was posted on Facebook by another inpatient who was allowed to use a cell phone with a camera without supervision.
* Investigations of and response to patient incidents were not timely or complete to prevent recurrence of similar events.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care and is a repeat deficiency previously cited on surveys completed on 08/08/2019, 10/05/2018, 07/30/2018 and 05/22/2018.

Findings include:

1. Refer to the findings cited under Tags A143, A144 and A145, CFR 482.13(c) - Standard: Privacy and Safety. Those findings reflect that hospital's failure to ensure all patients were afforded personal privacy, safe care and freedom from abuse and neglect.

2. Refer to the findings cited under Tag A154, CFR 482.13(e) - Standard: Restraint or seclusion. Those findings reflect the hospital's failure to ensure all patients were afforded freedom from restraints.

3. Refer to the findings cited under Tag A199, CFR 482.13(f) - Standard: Restraint or seclusion: Staff training requirements. Those findings reflect the hospital's failure to ensure all staff completed training to identify, prevent and manage patient behaviors.

4. Refer to the findings cited under Tag A701, CFR 482.41(a) - Standard: Buildings. Those findings reflect the hospital's failure to ensure the building was maintained for the safety and well-being of the patients.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observations, interviews, review of incident and medical record documentation for 2 of 2 psychiatric patients for who privacy concerns were identified (Patients 7 and 13) and review of policies and procedures it was determined that the hospital failed to fully develop and implement policies and procedures that ensured that patients' rights to privacy were recognized, protected and promoted as follows:
* Patients were allowed unsupervised and unmonitored possession of cell phones with no provisions to ensure photographic images were not taken of other patients and posted to social media or other Internet sites. A video recording of an inpatient in the safety suite was filmed by another inpatient and posted on Facebook.
* ED triage, exams and care were provided in chairs in the open corridor directly in front of the ED triage area without provisions for auditory or visual privacy, and where other patients, hospital staff, non-hospital personnel and visitors would wait or pass through.

Findings include:

1. The P&P titled "Patient Rights and Responsibilities" dated as last revised "05/17" included the following:
* "To assure that patients receiving health care services at any Legacy facility and their families are treated with dignity and respect ... Legacy Health (Legacy) recognizes and respects the dignity and individuality of each person admitted to or treated within our facilities. All members of our workforce (employees, volunteers, medical staff, residents, students, contracted personnel and vendors) are expected to provide considerate and respectful care, meeting the cultural, spiritual, emotional, and personal dignity needs of each individual patient and their family."
* "Patient's have the right to personal privacy and safety in accordance with state and federal law and Legacy policies."
* "Legacy provides for environmental privacy ... The environment is created to provide for auditory, visual and olfactory privacy and comfort."

2. The P&P titled "Use of Electronic Equipment on Adult Psychiatric Units" dated as last reviewed "[DATE]" included the following information:

* "Personal Devices:"
- "On Inpatient ADULT Units ... Personal electronic equipment including cell phones, tablets and laptops may be used, monitored by staff in accordance with written guidelines communicated to the patient."
- "On Inpatient PEDIATRIC/ADOLESCENT Units ... No use of personal electronic equipment in the PES (sic) will be allowed."

* "Hospital Owned Devices, including but not limited to headphones, computers, MP3 players, DVD players:"
- "Use of personal electronics may be permitted at staff discretion or Charge RN discretion with assessment for confidentiality (Internet access, camera), safety and communication to the team on a case by case basis."
- "Patients will agree to the following milieu rules regarding personal cell phone/computer use: The use of electronic devices will not interfere with the prescribed milieu activities ... Electronic devices are used in the patient's room, not in public areas such as dining rooms or hallways ... Electronic devices should not be utilized in groups or after 10 pm ... Electronic devices must be returned to the staff by 10 pm for recharging ... Personal devices will not be shared with other patients."
- "Personal devices will not be used to take pictures."
- "The staff assigned to a patient during a designated shift is responsible for the check-out of electronics and for the general oversight of the patient and equipment."

The P&P was not clear. For example:
- It reflected that on the "PEDIATRIC/ADOLESCENT Units" patients were not allowed use of personal electronic equipment but it unclearly referenced the "PES."
- Under "Hospital Owned Devices" it was unclear whether the hospital owned cell phones and cameras that would be checked out to patients.
- It did not reflect how and when staff were to monitor cell phone and camera use except for "general oversight."

3. The P&P titled "Management of Personal Belongings and Potentially Unsafe Items" dated as last revised "Sep 2018" was reviewed. It included the following information:
* "Items fall into four categories: never, supervised, group only, and unmonitored. Appendix A includes examples of items which will be deemed as never available, available only in a therapeutic group setting, available under supervision, and unmonitored."
* The Appendix A "Never" column included:
- Phone chargers
* The Appendix A "Unmonitored" column included:
- Cell phones

This P&P was not consistent with the P&P identified under Finding 2 above in relation to monitoring of patient cell phone use.

4. Incident documentation received on 10/15/2019 reflected that on 10/10/2019 on Unit 2 Patient 9 was allowed possession of cell/smart phone, video recorded Patient 7 in the safety suite and posted those images on Facebook. The documentation revealed no evidence of follow-up or investigation at that time. Additional incident documentation received on 10/28/2019 reflected "work done on file." The documentation reflected that Patient 9 "was the patient doing the recording of [Patient 7]. It was a Facebook live stream. [Another] patient showed the RN writer the video on [his/her] own Facebook feed, as [he/she] is now 'friends' with [Patient 9]. The video was taken of [Patient 7] through a door. [Patient 9] is noted on the video that [he/she] was 'recording this conversation; this is live right now' ... [Patient 9] is admitted with a diagnosis of bipolar, manic episode. [He/she] is on an NMI, presenting as delusional, manic, disorganized, and psychotic. [He/she] has been irritable, demanding, impulsive, and intrusive. [He/she] has been tech and cyber focused since admission. In the afternoon of this day, [Patient 9] had [his/her] technology access restricted due to calling the Secret Service."

The investigation was not timely or complete and did not conclude that Patient 7's privacy rights had been allowed to be violated. In fact, the incident documentation noted that although Patient 9's behaviors towards Patient 7 were intrusive and unacceptable, and that Patient 9 was on a NMI and experiencing demanding, impulsive and intrusive behaviors, Patient 9's cell phone was not "restricted" until he/she called the Secret Service. Further, "[Patient 9] was increasingly agitated and not accepting of [his/her] limitations initially. Once [he/she] was reassured that [he/she] would be able to have minimal supervised use of phone/Internet, [he/she] was more agreeable."

Refer to the findings for Patient 7 described in Tag A144 of this report that reflect he/she had attempted suicide with zip ties on 10/06/2019.

5. During tour with Staff CC on 10/15/2019 beginning at 1500 the following observations were made:
* Patients on Unit 5 who were not in their rooms and were in the milieu were observed in possession of cell phones with cameras contrary to the P&P under Finding 2.
* Patients on Unit 2 who were not in their rooms and were in the milieu were observed in possession of cell phones with cameras contrary to the P&P under Finding 2.
* Posters/signs affixed to the walls on those units and throughout the facility reflected "Items that are NOT PERMITTED inside Unity Center." Other language on the poster reflected "Certain items ... are not permitted within our secure areas for everyone's safety. If you have those items and cannot send them home, notify staff so that we may secure them or provide off-unit lockers." Under that wording there were eight images of items over each of which a large X was placed. The first image was of a cell phone. Wording under the image of the cell phone with an X over it was:
"cell phone* cords (including headphones and chargers)"
The * was explained at the bottom of the poster and reflected *Exceptions may be made please notify the patient treatment team."
* During interview with Staff CC during the tour he/she stated that patients could have camera phones "unless they are inappropriate."

The poster was not consistent with the P&Ps identified under Findings 2 and 3 above in relation to cell phones on patient care units.

6. Refer to the findings for Patient 13 described in Tag A154 of this report regarding the location of the patient's triage and examination in the ED. The ED record for Patient 13 reflected that on 11/26/2019 at 1536 "Patient roomed in ED To room PES TR1" for triage and examination. When the patient returned to the ED triage area later that day on 11/26/2019 at 1816 the ED record reflected "Patient roomed in ED To room PES TR1." However, review of recorded video footage at both of those times reflected the medical record was inaccurate as the video showed that Patient 13 was triaged and examined and administered care in the open corridor in front of the triage nurses station without any auditory or visual privacy. Patient 13 was not "roomed in" to a triage or exam room.

During interview with the BHT Q on 03/05/2020 at approximately 1630 with the CNO, the PES NM and ACC1 present he/she stated that there were no triage rooms in the ED Triage area and those present concurred. An explanation was provided that for the EPIC EHR they have to select a room for the medical record so they select "Roomed in TR1" or "Roomed in TR2" or "Roomed in TR3," and that if they need privacy during triage or examination they use a vacant seclusion/hold room.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observations, review of recorded video footage, interviews, email communications, review of incident and medical record documentation for 21 of 21 psychiatric patients (Patients 1 through 21), review of training records for 5 of 14 staff (Staff Q, K, L, M and W), review of policies and procedures, review of building floor plans and other documentation related to safety and physical environment risk, it was determined that the hospital failed to fully develop and implement policies and procedures that ensured that patients' rights to safe care were recognized, protected and promoted, and patients experienced actual and potential harm:
* Patients were allowed access to unsafe items. Those incidents included a case where an inpatient was provided with unsafe items which the patient used to attempt suicide, and two cases where patients removed smoke detectors from the ceiling in the secure unit.
* Patients were not protected from elopement from secure units and the secure facility. Those incidents included two cases where inpatients were allowed to elope from the secure facility.
* Patients were not supervised and observed to ensure safety. Two patients were allowed to engage in sexual intercourse and other sexual acts on the floor of a locked bathroom in the emergency services unit.
* A patient was not protected from the use of unnecessary restraint and seclusion.
* Investigations of and response to patient incidents were not timely or complete to prevent recurrence of similar events.

This is a repeat deficiency cited previously on surveys completed on 08/08/2019, 10/05/2018, 07/30/2018 and 05/22/2018.

Findings include:

1. The P&P titled "Patient Rights and Responsibilities" dated as last revised "05/17" included the following:
* "To assure that patients receiving health care services at any Legacy facility and their families are treated with dignity and respect ... Legacy Health (Legacy) recognizes and respects the dignity and individuality of each person admitted to or treated within our facilities. All members of our workforce (employees, volunteers, medical staff, residents, students, contracted personnel and vendors) are expected to provide considerate and respectful care, meeting the cultural, spiritual, emotional, and personal dignity needs of each individual patient and their family."
* "Patient's have the right to personal privacy and safety in accordance with state and federal law and Legacy policies."
* "Safety of the environment of care is a primary focus for all Legacy staff. Periodic education in environmental safety, equipment management, infection control and physical security is a requirement. Drills, auditing and monitoring are carried out on a routine basis to ensure that staff awareness is high and response is appropriate."
* "Staff are trained in the identification of abuse, neglect or harassment of patients and processes are in place to ensure timely reporting and response ..."
* "Patients have the right to be free from all forms of abuse and harassment."
* "Patients have the right to be free from restraint or seclusion and corporal punishment. Legacy protects the right of patients to be free of restraint or seclusion when restraint or seclusion is not indicated for the protection of the patient's health or the safety of the patient, staff or others."

2. The P&P titled "Management of Personal Belongings and Potentially Unsafe Items" dated as last revised "Sep 2018" was reviewed. It included the following information:
* "To assure patient safety by defining a process to identify and restrict patient access to personal belongings and potentially unsafe items in the care milieu."
* "Patients may be allowed to wear their own clothing and to retain possession of personal items except when items pose a threat to safety."
* "KEY POINT: Patients at risk for suicide during hospitalization may have additional personal belongings limitations."
* "Items fall into four categories: never, supervised, group only, and unmonitored. Appendix A includes examples of items which will be deemed as never available, available only in a therapeutic group setting, available under supervision, and unmonitored."
* "Personal belongings that pose a safety risk such as items with straps will only be made available to patients upon their request and under direct supervision."
* "Environmental safety checks will be conducted twice daily on patient care areas. The environmental safety check includes an examination of all patient rooms and communal living areas for potentially unsafe items."
* "Appendix A: Items which a patient may NEVER have access to while hospitalized are items that are illegal, weapons, items that are intentionally hard and sharp or easily turned into a cutting implement when broken, flammable items, and items that are easily used for strangulation ... This is not a comprehensive list ..."
* The Appendix A "Never" column contained:
- Weapons or drugs
- Backpacks and purses with long straps
- Smoking materials or lighters
- Belts, cords, or shoelaces
- Alcohol products
- Aerosol products
- Intentionally sharp items (knives, non-electric razors, metal nail files)
- Heavy boots with steel toes
- Phone chargers
- Plastic bags
- Paracord survival bracelets
- Golf pencils
- Clothes hangers
* The Appendix A "Therapeutic Group" column for those "items that are used in the presence and direction of therapeutic and recreation staff" included:
- Long pens, pencils, paintbrushes
* The Appendix A "Supervised (direct observation)" column included:
- Grooming supplies and nail polish
- Breakable or short string for jewelry
* The Appendix A "Unmonitored" column included:
- Hygiene items (ex. toothbrush, toothpaste, shampoo)
- Cell phones
- Hair picks
- Scrubs/clothes
- Radio/DVD player
- Patient computers
- Jewelry
- Linen and bedding

Appendix A did not clearly or consistently classify "unsafe items." For example:
- The "Never" column included "... purses with long straps" but did not define "long" and what length of strap would not be considered unsafe.
- The "Unmonitored" column included "jewelry" which is a general, broad category that includes items with pins, cords, plastic string, beads and other small items, sharp edges, etc.
- The "Unmonitored" column included "Hygiene items ... hair picks" that were items that could be made of metal or be broken with resulting sharp edges.
- The "Unmonitored" column included "Radio/DVD player ... Patient computers" that were items that may have cords.
- The "Unmonitored" column included "Scrubs/clothes" that were items that may include straps and strings and cords.

3.a. During interview on 10/14/2019 beginning at 1600 the LEMC UCBHP stated that in regards to Patient 7 there had been "a significant incident last Sunday," on 10/06/2019, at the LEMC UCBH.

On 10/14/2019 beginning at 1640 the UCBHP, Unit 5 NM, RM, PESMD, DOS, Interim UCBHP, and the QI&CCM were interviewed and the following information was provided:
* On admission during the past week Patient 7 had verbalized threats to harm him/herself, had thoughts of suicide and was on hourly observation checks.
* At approximately 0600 on Unit 5 a BHT was doing hourly observation rounds and found Patient 7 in his/her room bathroom with multiple zip ties interconnected around his/her neck. The patient was still talking and directed the BHT to a suicide note in the room.
* An RN responded and removed the zip ties with trauma scissors.
* The patient was evaluated by the PES provider and transferred to LGSMC ED for evaluation.
* Patient 7 returned from the ED later that day with no new orders.
* The patient was transferred to another adult inpatient unit at UCBH, was on 1:1 observation for two to three days and was currently on Q15m observation checks.
* Zip ties were used at LEMC UCBH on pants and shoes to replace patient's belts and shoelaces.
* The patient had obtained zip ties and had connected four of them together to create a ligature around his/her neck.
* The patient reported that he/she used the zip ties that were on his/her pants.
* The UCBHP and the PESMD reported to UCBH that day to address the incident.
* Actions taken included elimination of the use of zip ties completely in the facility, staff education and addition of zip ties as a ligature risk to the physical environment risk assessment.
* None of the zip ties used or removed from the facility were kept, no pictures of the zip ties were taken nor was there a physical description of them including the length.
* However, the RM disclosed that, unknown to the rest of the team present, that he/she did have one or more of the zip ties in his/her possession.

Observation on 10/14/2019 of two zip ties provided by the RM revealed they were 6 and 1/4 inches long and were off white in color.

3.b. The medical record of Patient 7 was reviewed and reflected that he/she (MDS) dated [DATE] and was admitted as an inpatient on 09/19/2019.

The CMO, the UCBHP, Interim UCBHP, Unit 5 NM, QI&CCM and the ACC2 were present during the medical record review and provided the following information:
* Patient 7 had no "serious" SAs in the past.
* Patient 7 was assessed every day for suicidality.
* The patient had a fantasy about hanging him/herself from a bridge.
* Patient 7 was "not seriously trying to kill [him/herself]" during this incident.
* The patient had "totally regressed" as result of the incident. He/she had "turned a corner with that event" and would "probably" go to the State psychiatric hospital from UCBH.
* P&Ps require that RNs document the C-SSRS about each patient's suicide risk at least once every shift.
* P&Ps require that LIPs document a suicide risk evaluation for each patient at least once every day.

The medical record included the following information:

* On 09/19/2019 at 1705 the psychiatrist's "Psychiatry Inpatient Admission Attending Initial Evaluation" reflected that Patient 7 was a "low risk of suicidal behavior while in the hospital."
* On 09/20/2019 at 1321 an order for "Observation Frequency ... Hourly Rounding" was initiated.
* On 10/01/2019 at 0808 the psychiatrist's "Psychiatry Attending Daily Inpatient Progress Note" reflected that Patient 7 was a "low risk of suicidal behavior while in the hospital."
* On 10/01/2019 at 1108 an RN documented on the C-SSRS that the patient stated he/she had suicidal thoughts.
* On 10/01/2019 at 2338 an RN documented on the C-SSRS that the patient stated he/she had suicidal thoughts.
* On 10/02/2019 at 1657 the psychiatrist's "Psychiatry Attending Daily Inpatient Progress Note" reflected that Patient 7 was a "low risk of suicidal behavior while in the hospital."
* On 10/03/2019 at 2018 the psychiatrist's "Psychiatry Attending Daily Inpatient Progress Note" reflected that Patient 7 was a "low risk of suicidal behavior while in the hospital."
* On 10/04/2019 at 0941 and again at 0947 an RN documented on the C-SSRS that the patient stated he/she had suicidal thoughts and at 1009 the RN documented that he/she notified the LIP and the "LIP Response" was "Monitor."
* On 10/04/2019 at 1840 an RN progress note reflected that the patient "Endorsed not wanting to live and SI with plans outside of the hospital. Provider informed."
* On 10/04/2019 at 1841 the psychiatrist's "Psychiatry Attending Daily Inpatient Progress Note" reflected that Patient 7 was a "low risk of suicidal behavior while in the hospital."
* On 10/04/2019 at 2205 an RN documented on the C-SSRS that the patient stated he/she had suicidal thoughts.
* On 10/05/2019 at 0155 an RN progress note reflected, "Assumed care at 1930 ... Endorses SI, continues to verbalize [he/she] dreams of jumping off the steel (sic) bridge ..."
* On 10/05/2019 at 1045 an RN documented on the C-SSRS that the patient stated he/she had suicidal thoughts.
* On 10/05/2019 at 1102 an RN progress note reflected, "Thought content - Suicidal ideation ... [He/she] continues to endorse SI consistent with past assessment stating that [he/she] can't see how [his/her] life can improve and stating that [he/she] 'might as well jump off a bridge.'"
* There was no documentation to reflect the LIP was notified of the SI Patient 7 expressed on 10/04/2019 at 2205 or on 10/05/2019 at 0155 and at 1102.
* On 10/05/2019 at 1324 the psychiatrist's "Attending Weekend Cross-Cover Note" reflected that Patient 7 was a "low risk of suicidal behavior while in the hospital."
* On 10/05/2019 at 2304 an RN progress notes reflected "At around 0458, [Patient 7] came to nursing station and reported SI with no plan and intent ... On call provider notified, no order received."
* On 10/06/2019 at 0458 an RN documented on the C-SSRS that the patient stated he/she had suicidal thoughts and at 0504 the RN documented that he/she reported that to the LIP and no orders were received.
* On 10/06/2019 at 0520 an RN progress note reflected, "Pt requested to speak to the CRN at approximately 0500 ... When asked about SI pt stated 'I don't want to kill myself here, you guys are smarter than that. I just want to know what I have to do to be transferred to a place that tell (sic) me about assisted suicide which is legal in Oregon."
* On 10/06/2019 at 0600 an RN progress note reflected, "Pt has been monitoring, (sic) during 6:00am round, patient hands a note to staff asking [his/her parent] be call (sic) about wanting to attempt suicide. This writer when (sic) to check patient and found pt in (sic) sitting on the toilet with zip tie around [his/her] neck. The writer cut off the zip tie. Patient was not unconscious, VSS, no respiratory distress ... Patient transported to Good Sam around 6:33am by ... EMTs."
* On 10/06/2019 at 0610 a physician progress note reflected, "I was called earlier on shift (but had not yet documented) that pt had ongoing SI. I was previously aware of the pt from prior stays in PES and have known that [he/she] often has SI, discussed with nursing staff and agreed no additional supervision appeared warranted. Called to floor at approximately 0600 due to pt suicide attempt. Per nursing, pt had been in the bathroom on the toilet, hands visible, stating [he/she] was suicidal. Nursing staff reported concerns that [his/her] suicidality seemed to be increasing and when they promptly returned to check in on [him/her he/she] had tied zipties (sic) around [his/her] neck and was purple/blue. [He/she] fell to the floor and hit [his/her] head, zipties (sic) cut and reperfused. VSS. I was called promptly and arrived on the floor with pt conversant, lying on the floor, appeared tremulous but alert ... pupils equally round, EOMI, no abrasions or lacerations ... Given that pt was found cyanotic and hit [his/her] head when falling forward during the attempt, though [he/she] appears neurologically intact [he/she] is withdrawn, called Legacy Good Sam and elected to transfer for medical clearance."
* On 10/06/2019 at 0800 the psychiatrist's "Psychiatric Attending Inpatient Discharge Summary" reflected that Patient 7 was "at high risk of imminent suicide."
* A "Clinical Photo" of Patient 7's "Suicide note" was dated as entered into the EHR on 10/06/2019 at 0856. The note stated, "Please call my [parent] at [phone number] promptly at 9:00 am to inform [him/her] of my hopefully successful suicide attempt. All my love to ... [Patient 7's signature] 10-6-2019 @ 5:47 am."
* A LGSMC ED RN progress note dated 10/06/2019 at 0703 reflected that Patient 7 had a "Red line on throat from zip tie ..." Patient 7 was examined, medically cleared and returned to LEMC UCBH to continue his/her inpatient admission.
* On 10/06/2019 at 1651 the psychiatrist's "Psychiatric Inpatient Admission Evaluation" after Patient 7's return to UCBH reflected that he/she "is at extreme risk of suicidal behavior while in the hospital, and necessary hospital precautions at this time should include 1:1 within 10 feet and safety interventions as per orders."

3.c. Incident documentation reflected that on 10/06/2019 on Unit 5 Patient 7 made a "Suicide Attempt." The documentation reflected "... during 6:00am round, patient hands a note to staff asking [his/her parent] be called about wanting to attempt suicide. This writer when (sic) to check patient and found pt in (sic) sitting on the toilet with zip tie around [his/her] neck. The writer cut off the zip tie. Patient was not unconscious, VSS, no respiratory distress ... Patient transported to Good Sam around 6:33am by ... EMTs."
The only follow-up or investigation documentation was "Linked this iCare to iCare [#] which will be primary iCare. Please refer to [iCare #] for full investigation follow up. Closing this iCare."

Incident documentation linked to the documentation referenced immediately above reflected that on 10/06/2019 on Unit 5 Patient 7 made a "Suicide Attempt." The documentation reflected: "upon (sic) doing 0600 hr rounds. (sic) when (sic) entered room this staff noted pt. to be in the bathroom with the curtain open. staff (sic) spoke with pt. asked how [he/she] was and approached the bathroom door. staff (sic) was able to visualize pt. was naked and sitting on the toilet. Pt. had both hands clearly visible in [his/her] lap and was speaking to staff in full sentences. Pt. stated 'you really suck at your job. I'm fine.' staff (sic) asked if pt needed anything and [he/she] stated 'no.' as (sic) staff was leaving the room pt. stated 'there is a note on the desk'. Staff turned around and found the note. The note was a suicide not. Pt. was still talking at staff. Staff took note directly to pt's RN. RN and staff returned to pt. room to find pt. had a chain of zip ties around [his/her] neck. staff (sic) yelled for help and attempted to relieve pressure of ties until they could be cut. pt.(sic) ties were cut. Pt. fell from toilet to bathroom floor. security (sic) called Code M and Dr and nursing supervisor notified. vitals (sic) obtained."

Documentation dated 10/08/2019 reflected that "Investigation started ... 10.06.19" and was "Immediate safety plan: Assessment and securement of zip ties throughout the units. Communication to staff during staff huddles and bedboard that only Charge RNs are authorized to provide and apply zip ties. Communication included proper process of applying and cutting off excess 'tail' on zip tie. Meeting scheduled for 10.09.19 to decide on longer term solution." There was no other investigation documentation that included, but was not limited to: how and why the patient had the zip ties, whether those were allowed items and whether they had been evaluated as part of the physical environment risk assessment, what the "process of applying and cutting off excess 'tail'" meant and whether that "process" was described in a written policy and procedure for use of zip ties, or whether a written policy and procedure for use of zip ties existed.

A separate document titled "Action Plan Unsafe Items in Patient Care Area's/Facility (sic)" and dated as "Date Action Plan Ready to Launch: 10/06/2019" and "Date all Actions (sic) Plan are Complete: 12/06/2019 (sic)" and "Last Update 10/10/19." The "Action Plan" contained 13 rows with an action item in each row. Six (6) of those were identified as "Complete" and the others were "In-process."

One of the actions was "Leadership team meet (sic) to discuss safety of zip ties at Unity. Determinded (sic) not appropriate for our environment. Recommended removal of all zip ties from facility ... [Due Date] 10/6/2019 ... [Status and Date] Complete 10/06/2019." However, the next action item was "Staff Communication on need to eliminate use of zip ties ... [Due Date] 10/9/2019 ... [Status and Date] Complete 10/09/2019," three days after it was decided that all zip ties would be removed."

Twenty-nine undated forms titled "Legacy Health Patient Safety Conversation Zip Tie Use at Unity" were provided. The forms contained the following language "The use of zip ties in the behavioral health setting poses a potential ligature risk if not used in a supervised manner. Patients can link ties together which creates even greater risk. Patient can stockpile zip ties without rigorous practices in place to control access. At Unity 8-inch white zip ties are used as an alternative to belts for holding up pants and instead of shoelaces to keep shoes on. Background - The use of zip ties across Unity is not consistent. Not all units are using zip ties; some units have moved to the use of wristbands for the same purpose. Access to zip ties is not restricted to specific individuals. The process for applying zip ties is not consistent across all staff who may have access to zip ties. Short-term immediate change - Zip ties will be placed in one centralized location on each unit where they are in use and stored in a locking drawer inside the nurse's station. Charge Nurses will be the only staff member to access and apply the zip ties if needed to keep patient clothing secure. We have chosen to restrict the use of zip ties as a short-term safety measure until a long-term decision can be made with a broader group regarding this ligature risk. Charge nurses shall assess the need and risk for each patient. Zip ties will be physically applied by the charge nurse and made as small as possible with all ends cut off so no tail is hanging." At the bottom of the form were rows and columns of staff names, signatures and dates signed.

Although the "Action Plan" document reflected a decision to eliminate use of zip ties was made on 10/06/2019, the "Patient Safety ... Zip Tie Use ..." forms that described a process for continuing to use zip ties were signed by approximately 167 staff and dated on 10/06/2019, 10/07/2019, 10/08/2019, 10/09/2019, 10/10/2019 and 10/16/2019. For signatures of approximately 40 staff there was no date recorded so it was unclear when they received the information.

3.d. The undated "Ongoing BH Environmental Risk Assessment and Mitigation Plan" addressed unsafe areas and items and included the following:
* "'No tie' shoelace substitutes (Image B43). Evaluated to be a risk when multiple rubber pieces are tied together ... Unit 2 ... Remove from units ... Completion Date 9/18/2018."
* "zip ties ... 5, 1E, 1W ... Date identified 10/6/2019 ... remove use of zip ties across Unity ... Educate nursing to use wristbands in lie (sic) of zip ties ... Completion Date 10/9/2019."

Although the risk assessment reflected that on 09/14/2018, over a year prior to the Patient 7 incident, similar "no tie" substitutes for shoelaces had been identified to have the potential to be attached together to form a ligature, the zip ties were not similarly evaluated and on 10/06/2019 Patient 7 was provided the zip ties to use as a belt. After Patient 7 had attached multiple zip ties together to fashion a ligature and attempt suicide the zip ties were added to the risk assessment. However, the zip ties entry on the risk assessment was not clear as it reflected that all zip ties were removed on 10/09/2019 whereas the "... Zip Tie Use at Unity" form, identified under Finding 3.e. above, reflected zip ties were stored on units for use by charge nurses.

An internal UCBH email memo dated 10/09/2019 at 1647 titled "Important Notice of Practice Change at Unity ..." related to a change in the use of zip ties, was reviewed. It reflected that the "no tie" shoelace substitutes referred to in item #135 of the risk assessment as removed from units on 09/14/2018, were in fact found on a unit on 10/09/2019. The memo reflected, "Additional unsafe item - 'no tie shoelaces': When rounding on the units this morning, 'no tie shoelaces' were found on one of the units ... 'No tie shoelaces' have ... deemed to be unsafe. If 'no tie shoelaces' are found, please remove and notify leadership."

In addition, the "wristbands" referenced on the "Legacy Health Patient Safety Conversation Zip Tie Use at Unity" form in use on some units to replace belts and shoelaces, and on the zip tie entry on the physical environment risk assessment, were not addressed on the risk assessment to determine if those had been evaluated for safety and how risk of forming a ligature from multiple "wristbands" would be prevented.

3.e. Although Patient 7 had increasingly expressed suicidal thoughts staff provided him/her with zip ties that he/she used to create a ligature with which he/she attempted suicide. Although a similar item used as a shoelace substitute had been evaluated as a part of the environmental risk assessment to be unsafe, the zip ties were put into service without such an evaluation. The incident resulted in physical and mental harm for the patient as he/she fell and hit his/her head on the floor and was transferred to another hospital's ED for evaluation where red ligature marks around his/her neck were identified. Upon return to UCBH his/her behaviors escalated, psychiatric condition worsened and suicide risk increased resulting in increased suicide precautions.

4.a. The undated "Ongoing BH Environmental Risk Assessment and Mitigation Plan" addressed other unsafe items that included:
* "Toothbrushes ... All units ... All patient rooms ... Items are allowed unmonitored unless an elevated or extreme risk has been identified by staff or provider ... Completion Date 5/20/2018."
* "Nail polish ... All units ... Kept at nurse's station ... Nail polish will be only used with staff supervision (direct line of sight) ... Completion Date 5/20/2018."
* "Other writing utensils (examples: colored pencils, gel pens) ... Group rooms ... Other writing utensils will only be used with staff supervision during groups ... Completion Date 5/20/2018."
* "Paintbrushes ... All units ... All rooms ... Paintbrushes will be removed from general milieu and only used during groups ... Completion Date 5/20/2018."
* "Writing Utensils used by staff ... All areas ... Staff writing utensils will be kept in their possession while in patient accessible areas ... Completion Date 5/20/2018."
* "pillow was found with a plastic bag covering it ... Unit 6 ... verify all of the pillows in all of the rooms to make sure we had not left any other plastic cover (sic) ... Completion Date 9/3/2018."
* "Shower caps can present risk for suffocation ... All units ... Remove from units ... Completion Date 9/14/2018"
* "apples in stretchy plastic bags ... All units ... 2/15/2019 ... evaluate options for delivery of apples ... Completion Date 4/1/2019 ... Changed to new vendor with non stretchy plastic for apples." It was not clear whether the non stretchy plastic used by the new vendor had been evaluated for safety.

4.b. Incident documentation reflected that on 08/01/2019 on Unit 6 Patient 21 "obtained a piece of paintbrush while in unit classroom and refused to give it to staff. Pt used metal paintbrush piece to superficially scratch L wrist and L thigh." Follow-up documentation dated 08/02/2019 reflected that "... patent will now only be allowed to use all plastic paint brushes and staff will double check classroom for potentially unsafe items before entering with pt ... Just Culture findings: Paint brushes are allowed to be used with 1:1 supervision and patient had not taken one apart previously, staff followed protocol correctly." However, there was no investigation to confirm that staff followed protocol as there was no information about how the patient "obtained" the metal piece of paintbrush and how the patient was being supervised at the time he/she "obtained" the metal piece of paintbrush. It was unclear how the patient could have "obtained" the unsafe item while being directly supervised 1:1.

Incident documentation reflected that on 08/05/2019 on Unit 6 Patient 21 had a second incident that involved a paintbrush. The documentation reflected "Accidentally broke a paintbrush in the classroom and later took a small piece of metal from the paintbrush. Returned to room and superficially self-harmed on lateral aspect of right calf and left forearm." Follow-up documentation dated 08/07/2019 reflected "Human error - staff forgot about metal on paint brush restriction, not a repetitive error ... Provider orders followed: no, paintbrush with metal given ... Standard of care followed: yes ... Repeated event: yes ... No failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. No reasonable belief that neglect occurred." As on 08/01/2019 there was no information to reflect an investigation into the level and quality of supervision of the patient that allowed him/her conceal a metal piece of the paintbrush having "accidentally" broken it in the classroom while under 1:1 supervision. It was unclear how the "Standard of care" was determined to be followed and how it was determined that no neglect occurred when the patient had been allowed to access an unsafe item, the same unsafe item used for self-harm twice in a four-day period.

4.c. Incident documentation reflected that on 08/17/2019 on Unit 1E Patient 1 was found with a bag of marijuana and a lighter. The documentation reflected that "Investigation started: 9/3/19" and "Investigation status: complete" on 09/03/2019. However, the investigation was not timely nor complete and did not conclude how the patient in a secure unit came to be in possession of drugs and a lighter, both of which a patient is to "NEVER" have in their possession according to the P&P related to unsafe items. There was no deficient practice identified and no actions taken to prevent recurrence.

4.d. Incident documentation reflected that on 08/18/2019 on Unit 1E Patient 2 was found with a lighter, marijuana and an " I cigarette stick" and the patient's room "smelled like 'weed.'" The documentation reflected that "Investigation started: 9/5/19" and "Investigation status: complete" on 09/06/2019. However, the investigation was not timely or complete and did not conclude how the patient in a secure unit came to be in possession of a lighter, marijuana and an "I cigarette stick," items a patient is to "NEVER" have in their possession according to the P&P related to unsafe items. There was no deficient practice identified and no actions taken to prevent recurrence.

4.e. Incident documentation reflected that on 09/05/2019 on Unit 2 Patient 3 was found to have matches and marijuana and his/her room "smelled of marijuana." The documentation reflected that the "Investigation started: 9/5/19" and "Investigation status: complete" on 09/19/2019. However, the investigation was not timely or complete and did not conclude how the patient in a secure unit came to be in possession of drugs and matches, items a patient is to "NEVER" have in their possession according to the P&P related to unsafe items. There was no deficient practice identified and no actions taken to prevent recurrence.

4.f. Incident documentation reflected that on 09/07/2019 on Unit 2 Patient 4 was found with "containers of Pringles that have metal bottoms and pt had placed glass bottles of nail polish under potato chips. Pt also noted to have a 1 liter bottle of Pepsi, an entire bag of cereal, and big plastic bag of candy. Pt. was placed in seclusion soon after discovery d/t inability to remain safe and escalating bx. Staff need to be more aware of what they give patients. Pt could have fashioned weapons with the items that staff members allowed this patient to have and could have seriously injured someone." The documentation reflected that "Investigation started: 09/20/19" and "Investigation status: complete" on 09/20/2019. However, the investigation was not timely or complete and although video footage reviewed reflected the patient's possession of those items it did not clearly conclude how he/she came to be in possession of them, including items a patient is to "NEVER" have in their possession and items patients may only have under direct supervision, according to the P&P related to unsafe items. There was no deficient practice identified and no actions taken to prevent recurrence.

4.g. Incident documentation reflected that on 09/08/2019 on Unit 2 Patient 5 was found with a lighter and writing pen in his/her room. The documentation reflected that "Investigation started: 09/20/19" and "Investigation status: complete" on 09/20/2019. However, the investigation was not timely or complete and did not clearly conclude how the patient in a secure unit came to be in possession of a lighter and a writing pen, items a patient was to "NEVER" have in their possession according to the P&P related to unsafe items. There was no deficient practice identified and no actions taken to prevent recurrence, except for "Implemented a full search on each re
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on observations, review of recorded video footage, interviews, email communications, review of incident and medical record documentation for 21 of 21 psychiatric patients (Patients 1 through 21), review of training records for 5 of 14 staff (Staff Q, K, L, M and W), review of policies and procedures, review of building floor plans and other documentation related to safety and physical environment risk, it was determined that the hospital failed to fully develop and implement policies and procedures that ensured that patients' rights to freedom from abuse and neglect were recognized, protected and promoted as follows:
* Staff failures to prevent patient access to unsafe items, failures to prevent elopement, failures to provide supervision, failures to appropriately manage behaviors and prevent unnecessary restraint use, and failures to protect patient privacy resulted in actual and potential harm to patients. Investigations of, and response to, those incidents of actual or potential abuse or neglect were not timely or complete to ensure those did not recur.

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

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

This is a repeat deficiency previously cited on surveys completed on 08/08/2019, 10/31/2018, 10/05/2018, 07/30/2018 and 05/22/2018.

Findings include:

1. Refer to the findings cited under Tags A143 and A144, CFR 482.13(c) - Standard: Privacy and Safety, and Tag A154, CFR 482.13(e) - Standard: Restraint or seclusion. Those findings reflect the hospital's failure to conduct timely and complete investigations of incidents of actual and potential abuse and neglect to prevent recurrence.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of recorded video footage, interviews, email communications, review of incident and medical record documentation for 1 of 1 psychiatric patient who was physically and chemically restrained and secluded (Patient 13), review of training records for 5 of 14 staff (Staff Q, K, L, M and W) and review of policies and procedures, it was determined that the hospital failed to fully develop and implement policies and procedures that ensured that patients' rights to freedom from restraint and seclusion were recognized, protected and promoted as follows:
* While in the ED Patient 13 experienced a change of condition in relation to behaviors that were not managed appropriately in accordance with P&Ps, by staff who did not have required training. The patient's condition was allowed to worsen and resulted in the use of multiple forms of physical restraint, including handcuffs, and chemical restraints and seclusion. According to staff, the patient's PTSD was triggered during the encounter and his/her mental health condition continued to deteriorate. The patient also experienced physical change of condition and injury. Patient 13 was subsequently admitted as an inpatient at UCBH for three months, court-committed and transferred to OSH at the end of February 2020.

Findings include:

1. On 03/03/2020 beginning at approximately 0945 an ED encounter for Patient 13 was discussed during interview with the LEMC UCBH President, the CNO, the CMO, ACC1 and ACC2 and the following information was provided:
* Patient 13 was well known to hospital staff and had a history of methamphetamine/drug use and mental illness.
* Staff stated that LEMC UCBH is licensed as a psychiatric hospital and "meth intoxication is not an appropriate reason for hospitalization ."
* Patient 13 presented to the hospital ED three (3) times in 18 hours on 11/25/2019 and 11/26/2019.
* On 11/26/2019, during the third ED visit, the decision was made to send the patient to CHIERS.
* CHIERS is a "Sobering station" to which patients are transferred for intoxication issues.
* Staff called CHIERS transportation line, "waited several hours" and were "then told [CHIERS] didn't have a driver" and were directed to call PPB.
* "Typically," a secure van is used to pick up patients for transport to CHIERS. When a van isn't available PPOs transport patients.
* Patient 13 "became combative" when staff moved him/her from the triage area to the lobby to wait for secure transport.
* SSO's were "present as escorts."
* When the patient went out the front doors and started "kicking cars" SSOs "put [Patient 13] in handcuffs for [his/her] safety" and placed him/her in the ambulance bay.
* UCBH staff do not "put hands on" patients that are not in the building or not in the lobby.
* Staff stated "we don't engage, we call Project Respond" or another agency for encounters that are outside of the building when assistance is needed.
* UCBH has a "zone map protocol" that describes how staff are to respond in the lobby and outside of the building - "It's our policy."
* There is a process for SSOs to notify PPB when they use handcuffs on an individual.
* It was not known if SSOs called PPB on that day for Patient 13.
* PPO's did arrive, but it was not known how long Patient 13 was outside before they were on scene, "maybe 45 minutes."
* When Patient 13 was outside with PPOs the ED provider on duty requested a second opinion and the CMO and the EDMD responded and determined the patient did meet mental health criteria, placed him/her on an NMI and directed the patient be brought back into the hospital.
* At the conclusion of that third ED encounter Patient 13 was admitted to LEMC UCBH as an inpatient, had a three-month hospitalization , and was transferred to the Oregon State hospital on [DATE].
* Incident reports were filed about the encounter, a "process review" of the encounter was done and there were discussions and follow-up, but there was "no investigation" and they were unsure if there was recorded video footage of any of the encounter.

2. During interview on 03/03/2020 beginning at 1415 the SS and DSS were interviewed. The UCBHP, the CNO, and the ACC1 were present. The following information was provided:
* Patient 13 "committed a crime" of "harassment" when he/she "put [his/her] hands on someone unlawfully."
* Patient 13 "hit the RN and spit on them."
* PPOs did not charge the patient with a crime.
* Legacy SSOs are certified by DPSST as "Security Officers."
* The SSOs carry handcuffs and "never use on patients unless they've committed a crime."
* When they "arrest a person who's committed a crime" they can handcuff the person.
* The SSOs carry out "arrest by private person" also referred to as "citizen's arrest."
* There are no restrictions or limitations as to the locations on hospital property where SSOs can "arrest" and handcuff patients, the only restrictions are related to the "situation."
* The SS and DSS were asked if UCBH patients on inpatient units exhibited behaviors similar to those it was reported Patient 13 exhibited, would those patients be arrested and handcuffed. The SS stated that they would "if it was safe to do that" but they "wouldn't go blazing in."
* It was "rare" and "out of the ordinary" for an inpatient to be "arrested" by SSOs.
* Patient 13 was "arrested" and handcuffed for the behaviors he/she exhibited because he/she "wasn't a patient any longer."
* The SS stated that it was "not necessarily" the case that only discharged patients could be "arrested."
* The UCBHP added that they were "not clear amongst ourselves" what happened.
* The UCBHP stated that the clinical staff has physical boundaries on the hospital property where they can intervene for a patient.
* Staff "didn't want [Patient 13] walking off into the street" and wanted to "hold [him/her] until PPOs arrived."
* Clinical staff boundaries are defined on the "zone map."
* SSOs boundaries are all areas on the hospital's property.
* SSOs "wear two hats, security versus safety" and operate under their safety hat as support to clinical staff.
* "No smoking on campus" is allowed at UCBH, but patients smoke in front of the entrance doors.

3.a. The "Zone Map protocol" described as "our policy" was reviewed. The document was one-page and was untitled and undated. Approximately 3/4 of the page contained a floor-plan image of the LEMC UCBH interior main lobby/waiting room (highlighted pink in color), the exterior sidewalks in front of the lobby/waiting area and the ambulance bay (highlighted blue in color) and the parking lot in front of the facility (highlighted purple in color). At the bottom of the page, under the image were three columns.

The first column had a header of "Lobby Zone: Pink - What you can do:" and under that was the following:
* "Encourage them to come in and assess the situation/condition"
* "Use De-Escalation skills to meet person's needs/meet the needs of our space"
* "Have the patient check in for a new or worsened condition if recently discharged [Patient Access Staff]"
* "Bring someone back for triage and evaluation either willing or unwillingly (Call LIP immediately)"
* "Document what you have done: Have staff create a visit, SSO you can chart if not registered [Patient Access Staff]"
* "Call Security for criminal activity"

The second column had a header of "Front of building Zone: Blue - What you can do:" and under that was the following:
* "Encourage someone to come inside for care"
* "Document your encounter with them"
* "Bring someone inside for triage care, if they are:
Currently checking in
discharged within the past 12 hours"
* "Meet the threshold of Good Samaritan laws: offers legal protection to people who give reasonable assistance to those who are, or they believe to be injured, ill in peril, or otherwise incapacitated."
* "Stop intervention and consider 911 before Code Grey"
* "Call Security for criminal activity"

The third column had a header of "Parking lot Zone: Purple - What you can do:" and under that was the following:
* "Encourage someone to come inside for care"
* "Call 911 if medical care is needed and the person is unwilling/able to come inside"
* "Call Project Respond via 503-998-4888 is (sic) someone needs a possible hold to come inside"
* "Call CHEIRS (sic) for sobering if needed"
* "Call Security for criminal activity"
* "Who can do these things?
House Supervisor-Lead
CIS and/or Provider
Unity Leadership"

On 03/12/2020 at 1330 follow-up email communication from ACC1 regarding the date the "Zone Map" was effective reflected the map "is a guideline. Originated in early July." The information further reflected that "Staff were assigned an online learning module SLM" and that there was "no" other written P&P for the "Zone Map" information.

3.b. The SLM training content titled "[UCBH] Legacy Emanuel Intervention Zones" was dated "August 2019" and consisted of 26 slides. It contained the following information for staff:
* "People experiencing a behavioral health crisis are often mistaken for individuals engaged in intentional deviancy when presenting to healthcare facilities for help ... When healthcare facilities make this mistake, people who should be in the hospital could end up losing access to the mental health treatment they need."
* "The following groups collaborate within Intervention Zones to produce the best possible outcome for everyone presenting to Unity: Patient Access Staff - Security Staff Officers ... Nursing ... Providers."
* "Parking Lot Zone ... Recommended Interventions: Encourage the individual to check in to receive care ... In the event of a behavioral emergency and the individual is unable or unwilling to enter and may require a legal hold, call Project Respond ... If the individual appears to be intoxicated, call CHEIRS ... If the individual is engaged in concerning behavior (ie: breaking into a car in the parking lot), call Security ... Staff should call Security if the individual is actively engaging in unsafe behaviors to self or other ... Follow the intervention zone guidelines for the Parking Lot whenever an individual is present in that zone, regardless of how they arrived there ..."
* "Front of Building Zone ... Recommended Interventions: Encourage the individual to enter inside for care ... If the individual is clearly engaged in criminal activity (ie: breaking into a car in the parking lot), call Security ... Clinicians should consider the following when assessing the need for assessment: Is the patient currently checked in? Was this patient recently hospitalized ? If the answer to these questions is 'yes', it is likely that the patient would benefit from triage assessment."
* "Lobby Zone ... Recommended Interventions: Encourage them to come in and assess the situation/condition ... Recommend patient check in for a new or worsened condition if recently discharged ... Use De-Escalation skills to maintain safety while addressing the individuals (sic) needs. If you believe the patient is escalating, notify Nursing Supervisor and PES Clinicians immediately ... The Nursing Supervisor and other PES CRN, CIS and Providers present will determine if the individual requires assessment and should be escorted to triage (either voluntarily or involuntarily) ... Immediately call Security for criminal activity or if the individual present unsafe behaviors to self or others ..."
* "Roles and Responsibilities within Intervention Zones" included for "Security" to "Encourage individual to check in for assessment" and "Coordinate with team & support safety" in all three zones.
* "KEY POINT: Going 'Hands-on' - It is better to spend more time and resources on de-escalation if doing so prevents going 'hands-on' ... Going 'Hands-on' is a form of physical restraint, and should only be used as a last resort ... NEVER go hands-on alone and without a Code Team in place (follow Code Gray process) ... In the Parking Lot Zone (Purple): DO NOT initiate 'hands-on.' In the Front of Building Zone (Blue) AND Lobby Zone (Pink): a team may initiate 'hands-on' in the event of an extreme risk to safety."

The training contained unclear information, including, but not limited to:
* There was no information to reflect how staff would discern at that moment if an "individual appears to be intoxicated" versus having a "behavioral emergency."
* There was no information to discern the difference between "concerning behavior" exhibited in the parking lot zone versus "criminal activity" exhibited in the front of the building zone for which security staff were to be called, particularly when the example for both was "breaking into a car in the parking lot."

4.a. The P&P titled "Patient Rights and Responsibilities" dated as last revised "05/17" included the following:
* "To assure that patients receiving health care services at any Legacy facility and their families are treated with dignity and respect ... Legacy Health (Legacy) recognizes and respects the dignity and individuality of each person admitted to or treated within our facilities. All members of our workforce (employees, volunteers, medical staff, residents, students, contracted personnel and vendors) are expected to provide considerate and respectful care, meeting the cultural, spiritual, emotional, and personal dignity needs of each individual patient and their family."
* "Patients have the right to be free from all forms of abuse and harassment."
* "Patients have the right to be free from restraint or seclusion and corporal punishment. Legacy protects the right of patients to be free of restraint or seclusion when restraint or seclusion is not indicated for the protection of the patient's health or the safety of the patient, staff or others."

4.b. The P&P titled "Restraint and Seclusion for Patient Safety" dated as last reviewed "[DATE]" included the following:
* "Purpose: To provide regulatory requirements regarding appropriate restraint and seclusion use within the hospital and Emergency Department for the medical well-being of any patient. To the (sic) protect the patient's health and safety and preserve his or her dignity regardless of patient type or location. To define a procedure for the use of restraint and seclusion that focuses on the least restrictive approach."
* "Restraint - Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely ... A drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition."
* "Restraint Exclusions ... The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials ..."
* "The patient has the right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. A restraint can only be used if needed to improve the patient's well-being or in emergency situations if needed to ensure the patient's physical safety or safety of others. In either case, restraint or seclusion is only used when less restrictive interventions have been determined to be ineffective based on clinical justification."
* "Restraint or seclusion may be used when less restrictive means have been attempted and would not be effective to protect the physical safety of patients, staff members or others. Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate safety of the patient, staff members, or others."
* "Each episode of restraint or seclusion (regardless of restraint category) shall be initiated: Upon the order of the LIP who is responsible for the patient, or by a registered nurse, if necessary to protect the patient, staff members or others from harm, provided that an order is immediately obtained from a LIP responsible for the care of the patient."

4.c. The P&P titled "Emergency - Use of Force" dated as last reviewed "07/19" included the following:
* "It is the policy of Legacy Health to accomplish its security responsibilities with reasonable reliance on the use of force. The use of force is a matter of critical concern, both to the public and to the law enforcement community. Security Officers, and other Legacy staff, are involved daily in numerous and varied interactions, that when warranted may use reasonable force in carrying out their duties. This is especially true with respect to overcoming resistance while engaged in security and staff protection duties."

* "All staff should be aware that patients are there for treatment not punishment. Accordingly, it is essential that they understand the importance of de-escalation interventions in any situation. Absent an imminent threat that requires immediate use of force, MOAB, verbal de-escalation, and other interventions must be utilized in such situations before force is applied."

* "KEYPOINT: This policy applies to Legacy Health Safety/Security Officers in the performance of their job duties, while involved in a law enforcement action, such as making a private person's arrest or if it is necessary to use self-defense techniques to protect themselves or others from injury or death. All other situations requiring the use of force to control a patient, such as assisting medical/clinical staff with the application of restraints, will be performed under the supervisor of a medical or clinical staff member."

* "Factors Used to Determine the Reasonableness of Force ... These factors include, but are not limited to:
a. Immediacy and severity of the threat to Officers or others.
b. The conduct of the individual being confronted, as reasonably perceived by the Officer at the time ...
h. The availability of other options and their possible effectiveness.
i. Seriousness of the suspected offense or reason for contact with the individual ...
k. Potential for injury to Officers, suspects and others.
l. Whether the person appears to be resisting, attempting to evade arrest by flight or is attacking the Officer ...
n. The apparent need for immediate control of the subject or a prompt resolution of the situation.
o. Whether the conduct of the individual being confronted no longer reasonably appears to pose an imminent threat to the Officer or others.
p. Prior contacts with the subject or awareness of any propensity for violence.
q. Whether and to what extent that approved strategies and interventions (MOAB, verbal de-escalation, Trauma Informed Care) (sic) were employed prior.
r. Any other exigent circumstances."

* "Handcuffs shall not be used to restrain any patient unless that patient has committed a crime and is being placed under a lawful arrest by the Safety/Security Officer."

* "Any use of force by Legacy Security staff shall be documented promptly, completely and accurately in Report Exec. Legacy staff may also document the incident in ICARE. The actions or condition, which made the use of physical force necessary and a detailed description of the physical force used ..."

4.d. The P&P titled "Facilities & Safety Behavior Management" dated as last revised "08/19" included the following:
* "Inappropriate behavior is defined as acting in ways contrary to a safe, healing environment and includes, but is not limited to:
1. Public intoxication or having a strong odor of an alcoholic beverage
2. Verbal or physical threats as well as threatening gestures
3. Acts of violence
4. Use of abusive or inappropriate language ...
6. Refusal to comply with any Legacy Health policy i.e.: tobacco free campus, visiting hours, image capturing, etc ..."

* "Persons may be escorted off Legacy Health property, criminally trespassed or arrested from Legacy Health property if they are:
1. Committing a crime including but not limited to: theft, robbery, burglary, assault, trespass, possession of alcohol, unlawful possession of a controlled substance (including paraphernalia), and possession of a weapon of any kind, disorderly conduct, criminal mischief, harassment, menacing, recklessly endangering, OR intimidation. Persons may be placed under Private Persons Arrest (also known as a Citizen Arrest) if they are observed committing a criminal act on Legacy property. In all instances, individuals arrested for committing a criminal act will receive a written CTW.
2. Creating a disturbance.
3. Without valid business:
a) Loitering anywhere on property
b) Removing refuse from waste containers
c) Panhandling or soliciting
4. Acting in ways contrary to the best interest of the facility.
5. In violation of the Solicitation, Distribution and Posting policy ...
6. Unsanitary, visibly filthy, or having an offensive odor.
(sic) Refusal to consent or comply to a search of belongings or property."

* "KEY POINT: Verbal criminal trespass warnings (CTW's) are not enforceable and will not be issued in lieu of a written CTW."

* "Criminal Trespass Procedure ...
1. Security Officers issuing a written CTW will state:
You are prohibited from coming onto the property or premises of any Legacy Health Property at any time except in order to receive emergency medical care. Entry upon the premises for any other reason without permission from the Legacy Security Department may result in your arrest for criminal trespass.
Oregon (ORS 164.245) - Criminal Trespass in the second degree occurs when a person enters or remains unlawfully in or upon the premises. This is a misdemeanor ...
A copy of this notice will remain on file.
2. The Safety & Security Officer issuing a CTW is required to document the incident in a Security report. They are also required to fill out the 'comments section' and retain the yellow copy of the CTW. This will include the applicable report number, specific behaviors that resulted in the CTW, and the Safety/Security Officer's name. A photo of the individual should be taken and added to the report whenever possible. The Safety & Security Officer will attempt to give the top (white) copy of (sic) the Offender and read aloud the warning on the back. The Safety and Security Officer will advise the subject of the various Legacy properties, i.e., Emanuel, Randall Children's Hospital, Good Samaritan, Holladay Park, Meridian Park, Salmon Creek, Mt Hood, Unity Center, Silverton, Woodburn Health Center, and Legacy Medical Group Clinics and Labs."

* The "Facilities & Safety Behavior Management" P&P concluded with a section of policies unrelated to behavior management that reflected "Safe Environment to Address Allergies and Asthma - Latex free environment ... Fragrance free environment ..." It was unclear if "persons" who violated those policies were to be "criminally trespassed or arrested" in accordance with the procedures above.

4.e. The P&P titled "Psychiatric Emergency Services (PES) Standard of Care" dated as last reviewed "Sep 2018" including the following:
* "Purpose: To establish a standardized, consistent nursing practice for the care of all patients being assessed and treated in the Psychiatric Emergency Service (PES)."
* "Expected Patient Outcomes: ... Provision of a safe environment that maintains patient dignity and privacy, and incorporates emotional support ..."
* "Disposition (Determined by LIP) - For all disposition types, except discharge home or self-care: ... Reassess patient within approximately one hour of disposition."
* "Discharge: ... All patients will receive discharge education and printed After-Visit Summary (AVS) pertinent to their diagnosis or condition. Patients will receive written discharge instructions; staff will validate patient/family understanding of instructions."

4.f. The P&P titled "Unity Center for Behavioral Health: Scope of Service for Psychiatric Emergency Services (PES)" dated as last reviewed "[DATE]" included the following:
* "The PES care team in (sic) utilizes evidenced based practice, specifically, Trauma Informed Care to care for patients with mental health problems."
* "Harm Reduction Specialist: Registered nurses who specialize in the prevention of aggressive behaviors, verbal de-escalation and management of agitation."
* "Patients may come to the PES by ambulance or police transport, or may present requesting treatment at the PES entrance admission area ... In compliance with LH Policy ... PES LIPs will perform a Medical Screening Examination for every patient presenting to the PES for care ..."
* "Criteria for admission: The PES admits for care those patients who:
i. Are displaying symptoms of a psychiatric diagnosis
ii. Are experiencing an acute psychiatric crisis
iii. Have co-occurring substance use disorders ..."
* "Psychiatric emergency services may include up to 23 hours of triage and assessment, observations and supervision, crisis stabilization, crisis intervention, crisis counseling, case management, medication management, safety planning, lethal means counseling, and mobilization of peer and family support and community resources."

5.a. Review of the ED medical record of Patient 13 reflected that he/she arrived at the LEMC UCBH PES at 1501 on 11/26/2019. The medical record contained the following timed entries on 11/26/2019:
* 1501 - "Patient arrived in ED."
* 1501 - "Arrival Complaint" was "eval."
* 1517 by NP U - "Patient Care Initiated."
* 1531 by NP U - "Patient Evaluation."
* 1536 by BHT Q - "Patient roomed in ED to room PES TR1."
* 1536 by BHT Q - "ED Triage Notes - Pt is marginally cooperative with triage. Mood and affect are euphoric. [He/she] appears distracted by internal stimulus. One bag of belongings are gathered and stored. Vital signs are WNL."
* 1538 by BHT Q - "Vitals Assessment - Re-assess Vitals?: Yes ... Vital Signs ... Heart Rate: 110 ... BP: 141/93 ..."
* 1538 by CIS N - "Follow up/Handoff - Seven Day Follow Up/Warm Handoff - Follow up scheduled within 7 days of discharge: Refused."
* 1538 by NP U - "Patient Evaluation."
* 1538 by NP U - "Discharge Disposition Selected - ED Disposition set to Discharge."
* 1539 by CIS N - "AVS Printed - ED After Visit Summary."
* 1539 - The "Aftercare Recommendations" were printed and the documentation reflected "Thank you for coming into Unity today: It was a pleasure working with you. You met with a social worker today and the following recommendations were given: Take all Medications as prescribed. Abstain from alcohol use and illicit/illegal substances (including marijuana). Eat healthy diet and get adequate sleep. Follow up with getting a therapist. Use coping skills -- take a walk, read, notice nature. ASK FOR HELP WHEN NEEDED. SET BOUNDARIES WITH OTHERS. TAKE CARE OF YOURSELF - LET OTHERS DO FOR THEMSELVES." There was no documentation in the discharge instructions that reflected the patient was being transported to CHIERS, a sobering station, for detox, by police.
* 1540 by RN P - "Triage Start - Triage Start * Triage Start: Triage Start."
* 1540 by RN P - "SBIRT Screening."
* 1540 by RN P - "Triage Started."
* 1540 by RN P - "SBIRT Due."
* 1540 by RN P - "Triage Started."
* 1540 by RN P - "Chief Complaints Updated - + Psychiatric Evaluation."
* 1540 by RN P - "ED Triage Notes - Pt vol walk in from lobby. Made inapropriate (sic) comments and inappropriately touched a female staff member in the lobby. Pt hostile with this writer and this writer disengaged from interview with patient. Patient seen earlier today in triage. Reports SI."
* 1600 by RN P - "ED - Pain assessment ... "
* 1601 by RN P - "Psych Mental Status Assessment ... Reported Mood: Unremarkable ... Affect and Mood: Inapproprpiate (sic) to situation - Behavior: Not directable ... Thought process: Flight of ideas - Thought Content: Delusions - Hallucinations: UTA ... Confused ..."
* 1602 by RN P - "Psych Safety/History ... Have you wished you were dead, or wish to fall asleep and not wake up?" Yes ... Have you had any thoughts of killing yourself?" Yes
* 1603 by RN P - "Apply Acuity Triage Complete Patient Acuity: 2 - Emergency ... PES Levels: 3 - Semi-Urgent."
* 1603 by RN P - "Risk Assessments Infection Control ... Communicable Disease ... Functional Screen ... Nutritional Screen ..."
* 1603 by RN P - "Triage Completed."
* 1604 by RN P - "WilsonSims Fall Risk Assessment ..."
* 1604 by RN P - "SBIRT Adult Drug and Alcohol Screening ..."
* 1604 by RN P - "ED Infection Screening."
* 1604 by RN P - "SBIRT Complete."
* 1605 by PAS - "Registration Completed."
* 1620 by RN P - "ED Notes - Patient left triage angry and spat towards this writer. Patient making several threats of harm towards this writer and others. Made a swing at this writer and at one other staff on the way out the (sic) building. Patient escorted by security off the property."
* 1647 by RN P - "Care Handoff - Care Handoff Report given to: Patient went home."
* 1647 by RN P - "ED Patient Services Coordination - Psych Care Coordination * Psychiatry Care Coordination by: Social Worker ..."
* 1648 by RN P - "Departure Condition: Stable ... Departure Mode: By self."
* 1656 by RN P - "Patient discharged ."

* 1843 - A "Psychiatric ED Initial Evaluation" was authenticated and electronically "filed" by NP U. The documentation reflected "[Patient 13] ... with history of psychosis, paranoid schizophrenia who returned to PES voluntarily walk (sic) presenting with psychosis and self reported drug/alcohol use. [He/she] was seen by this provider in triage few hours ago when [he/she] presented seeking help with shower, was d/c with bus pass and food from triage. BAL at that time was 0.057 and [he/she] endorsed using 'ice' PTA. On assessment in triage with CIS, notes nothing has changed since last d/c. Actively responding to internal stim with inappropriate smile while talking to self. Denies SI/HI. Unable to elaborate why [he/she] returned to PES. Will d/c to CHIERS for sobering."

The evaluation included "Past Psychiatric History" that reflected "Previous suicide attempts: Yes ... endorses multiple attempts most recent 1 month ago [he/she] laid in the street ... Patient reports schizoaffective Disorder, PTSD ..."

The evaluation included "Social History" that included the following assessment information: "Number of children ... Year of education ... Highest education level ... Occupational History ... Financial resource strain ... Food insecurity Worry ... Food Insecurity Inability ... Transportation Needs Medical ... Transportation Needs Non-medical ... Sexual activity ... Physical activity days per week ... Physical activity minutes per session ... Stress ... Talks on phone ... Gets together ... Attends religious service ... Active member of club or organization ... Attends meetings of clubs or organization ... Relationship status ... Other Topics Concern ..." The entry recorded for each of those assessment fields was "Not on file."

The evaluation included "Review of Systems" that reflected the patient was "Positive for behavioral problems and hallucinations."

The evaluation included "Mental Status Exam" that reflected the patient was "... unkempt ... Poor eye contact, uncooperative and bizarre ... mostly mumbling ... Affect: Inappropriate and bizarre ... Thought process: Disorganized ... Thought Content: Auditory hallucinations and visual hallucinations ... Issues with attention/concentration ... Insight: Poor ... Judgement: Poor."

The evaluation included "Provider assessment based on evaluation ... [Patient 13] presents as intoxicated and psychotic actively responding to internal stimuli. Not presenting with any acute safety concern or acute psychiatric sxs (psychoitc (sic) sxs appeared to be at [his/her] baseline) that warrants PES level of care. Will d/c to CHIERS for sobering ... I have reviewed the CSSR-S and based on my safety assessment of this patient, I believe the patient is at low risk of suicidal behavior while in the Psychiatric Emergency Services, due to lack of SI ... Based on my evaluation, this patient is not at risk of acts of violence in the Psychiatric Emergency Services. Patient denies thoughts, intent, or plan for harming others, did not express levels of agitation or aggression that places others at risk ... This patient is not determined to be at imminent risk of harm to self or others or unable to care for self if discharged , due to lack of SI/HI."

The evaluation included "PES Progress: 1800 Writer was informed that pt refusing to leave with the police who came to bring him to CHIERS. Writer arrived on scene, pt was sitting in the ambulance bay surrounded by t
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0199
Based on email communications, review of training records for 1 of 7 clinical staff (BHT Q) and 4 of 7 S&S staff (SSOs K, L, M and W) and policies and procedures it was determined that hospital staff failed to complete training in techniques to identify, prevent and manage patients' aggressive behaviors in accordance with policies and procedures to ensure patients' rights to receive safe care by trained staff.

Findings include:

1. The P&P titled "Workplace Violence Prevention & Response" dated as last reviewed "07/19" included the following:
* "This policy applies to all people present on Legacy Health (Legacy) property. This includes but is not limited to employees, physicians, patients, visitors, leased office staff, contractors, and suppliers."
* "Workplace Violence - An act of aggression, regardless of the source, directed towards persons at work or on duty and ranges from offensive or threatening language to homicide. Workplace violence includes but is not limited to any physical assault, emotional or verbal abuse or threatening, harassing or coercive behavior in the work setting that causes physical or emotional harm. It includes disruptive behaviors, threatening behaviors and violent behavior.
- Disruptive behaviors - Yelling, using profanity, waving arms or fists, verbally abusing others.
- Threatening behavior - includes physical actions short of actual contact or injury (moving aggressively into another's personal space), general oral or written threats to people or property ('You better watch your back.' 'I'll get you.'), and implied threats ('You'll be Sorry.' 'This isn't over.').
- Violent behavior - includes any physical assault, with or without weapons; behavior a reasonable person would interpret as being potentially violent (throwing things, pounding one's fist on a desk or door, or destroying property), or specific threats to inflict physical harm (a threat to shoot a specific person: 'I'm going to shoot you,')."
* "All Legacy employees will complete training on how to recognize, prevent and/or respond to workplace violence. Training requirements will be based on assessed level of risk in the assigned work area ... High Risk and Extreme High Risk - MOAB Lecture and Physical Training - 8 hours. For employees who are high risk of encountering patients, family visitors or employees that exhibit aggressive or violent behavior. Required of staff that are assigned to work in the following areas: Extreme High Risk * Security * Behavioral Health * Emergency Department ... The participant will learn strategies and techniques to recognize and reduce aggressive behavior and to avoid physical harm as well as how to manage physical confrontations through demonstration of skills to safely approach, escort, direct to prone, and control individuals using reasonable force that minimizes injury."
* "New hires in these departments would be assigned upon hire with required completion within 90 days."
* "Ongoing Training ... Extreme High Risk ... recurring training of the MOAB lecture and Physical training should occur every two years ... consists of the MOAB SLM followed by the 4-hour Physical Skills class ... completion of the annual 4-hour Code Gray: Safe Management of Behavioral Escalation training, followed by the MOAB 4-hour Physical Skills."

2. The training records report dated 04/16/2020 for BHT Q with a hire date in 1999 contained no documentation to reflect that he/she had received the ongoing MOAB training described in the P&P for the time period requested, 01/01/2016 to current date. BHT Q was involved with Patient 13 on 11/26/2019 as described in Tag A154 of this report.

On 04/20/2020 at 1702 follow-up email communication from ACC1 confirmed that BHT Q had worked in BH at LEMC prior to working at UCBH, and had "worked as a behavioral health therapist throughout [his/her] Legacy tenure. The expiration date for [BHT's] MOAB was entered incorrectly into the education monitoring database. This was discovered in early March 2020 ... the next available class which was in March 2020 ... was canceled due to COVID."

It was unclear how the lack of MOAB training for a staff person in an "Extreme High Risk" department was not detected and identified by the BHT's supervisors and colleagues and the BHT him/herself over the four-year period for which the training records were requested.

3. The training records report dated 04/16/2020 for SSO K with a hire date of 10/31/2016 reflected he/she received eight hours of MOAB lecture and physical skills training on 11/13/2016 and on 01/20/2017. On 01/10/2019 he/she completed a MOAB lecture module. SSO K completed another MOAB SLM on 10/15/2019. On 11/30/2019 he/she completed a "MOAB Training 4 hour Skills Class Session" and the MOAB "SLM (4 Hour Skills Class) Curriculum." That was not until two years and ten months after the initial training, and four days after he/she was involved with Patient 13 as described in Tag A154 of this report.

4. The training records report dated 04/16/2020 for SSO L with a hire date of 08/20/2012 reflected he/she received eight hours of MOAB lecture and physical skills training on 12/30/2016. On 10/27/2019, not until two years and ten months after the initial training did he/she complete a MOAB SLM. He/she completed the MOAB "SLM (4 Hour Skills Class) Curriculum" three months later on 01/30/2020. That was more than three years after the initial training and two months after he/she was involved with Patient 13 on 11/26/2019 as described in Tag A154 of this report.

5. The training records report dated 04/16/2020 for SSO M with a hire date of 07/17/2017 reflected he/she received eight hours of MOAB lecture and physical skills training on 07/25/2017. He/she completed a MOAB lecture on 08/28/2018 and a MOAB SLM on 10/15/2019. SSO M completed the MOAB "SLM (4 Hour Skills Class) Curriculum" three months later on 01/10/2020. That was approximately two years and six months after the initial training and two months after he/she was involved with Patient 13 on 11/26/2019 as described in Tag A154 of this report.

6. The training records report dated 04/16/2020 for SSO W with a hire date of 05/15/2017 reflected he/she received eight hours of MOAB lecture and physical skills training on 05/19/2017. The only MOAB training received since that time was the "SLM (4 Hour Skills Class) Curriculum" on 12/09/2019, two years and seven months after the initial training. It was not clear if that was the required SLM or the required physical skills class.

7. MOAB course descriptions reflected that the MOAB "SLM (4 Hour Skills Class) Curriculum" was a "module" during which "the learner will: Describe Legacy's work ... Review Legacy's policies ... Describe techniques that can be used ... Recognize bullying and strategies ..." There was no indication in the course description that physical skills were physically practiced and demonstrated. Although in additional email communication from ACC1 on 04/21/2020 at 1216 he/she indicated that the course was a physical skills class in which the MOAB techniques were demonstrated and practiced, the training records reviewed did not clearly reflect that information.
VIOLATION: QAPI Tag No: A0263
Based on observations, review of recorded video footage, interviews, email communications, review of incident and medical record documentation for 21 of 21 psychiatric patients (Patients 1 through 21), review of training records for 5 of 14 staff (Staff Q, K, L, M and W), review of policies and procedures, review of building floor plans and other documentation related to safety and physical environment risk it was determined that the hospital failed to develop, implement, and maintain an effective QAPI program to ensure the provision of safe care and the recognition, promotion and protection of patients' rights.

Staff failures to prevent patient access to unsafe items, failures to prevent elopement, failures to provide supervision, failures to appropriately manage behaviors and prevent unnecessary restraint use, and failures to protect patient privacy resulted in actual and potential harm to patients, and investigations to ensure such incidents did not recur were not timely or complete.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care and is a repeat deficiency previously cited on surveys completed on 08/08/2019, 07/30/2018 and 05/22/2018.

Findings include:

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

2. Refer to the findings cited under Tag A385, CFR 482.23 - CoP Nursing Services.

3. Refer to the findings cited under Tag A701, CFR 482.41(a) - Standard: Buildings.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, review of recorded video footage, interviews, email communications, review of incident and medical record documentation for 21 of 21 psychiatric patients (Patients 1 through 21), review of training records for 5 of 14 staff (Staff Q, K, L, M and W), review of policies and procedures and other documentation related to safety and physical environment risk, it was determined that the hospital failed to fully develop and implement policies and procedures that ensured that nursing services were provided in a manner that ensured the provision of safe care and the recognition, promotion and protection of patients' rights.

Staff failures to prevent patient access to unsafe items, failures to prevent elopement, failures to provide supervision, failures to appropriately manage behaviors and prevent unnecessary restraint use, and failures to protect patient privacy resulted in actual and potential harm to patients, and investigations to ensure such incidents did not recur were not timely or complete.

This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care and is a repeat deficiency previously cited on surveys completed on 07/30/2018 and 05/22/2018.

Findings include:

1. Refer to the findings cited under Tag A395, CFR 482.23(b) - Standard: Delivery of care, RN supervision and evaluation. Those findings reflect the hospital's failure to ensure an RN was responsible to supervise and evaluate the care provided to each patient.

2. Refer to the findings cited under Tag A115, CFR 482.13 - CoP Patient's Rights.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on observations, review of recorded video footage, interviews, email communications, review of incident and medical record documentation for 21 of 21 psychiatric patients (Patients 1 through 21), review of training records for 5 of 14 staff (Staff Q, K, L, M and W), review of policies and procedures and other documentation related to safety and physical environment risk, it was determined that the hospital failed to fully develop and implement policies and procedures that ensured that an RN was responsible for the supervision and evaluation of each patient to ensure the provision of safe care and the recognition, promotion and protection of patients' rights.

This is a repeat deficiency previously cited on surveys completed on 08/08/2019, 10/31/2018, 10/05/2018, 07/30/2018 and 05/22/2018.

Findings include:

1. Refer to the findings cited under Tags A143, A144 and A145, CFR 482.13(c) - Standard: Privacy and Safety. Those findings reflect the RNs' failures to supervise and evaluate the provision of services provided to each patient to ensure personal privacy, safe care and freedom from abuse and neglect.

2. Refer to the findings cited under Tag A154, CFR 482.13(e) - Standard: Restraint or seclusion. Those findings reflect the RNs' failures to supervise and evaluate the provision of services provided to each patient to ensure freedom from restraints and seclusion.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on review of recorded video footage, interviews, review of incident and medical record documentation for 3 of 21 psychiatric patients (Patients 13, 16 and 17), review of building floor plans and other documentation related to safety and physical environment risk, it was determined that the hospital failed to ensure the physical plant environment was maintained to ensure the safety and well-being of patients:
* Smoke detectors in the PES were not tamper resistant and on two occasions patients were allowed to remove them from the ceilings in patient bathrooms.
* Although the ED had designated triage and exam rooms, ED triage, exams and care were provided to patients in chairs in the open corridor directly in front of the ED triage area without provisions for auditory or visual privacy.

This is a repeat deficiency cited previously on surveys completed on 10/05/2018, 07/30/2018 and 05/22/2018.

Findings include:

1.a. Incident documentation reflected that on 01/13/2020 a patient accessed and dismantled a smoke detector from the ceiling in the PES patient bathroom with room number P-101A. The smoke detector was not immediately found and was later located in the trash. There was no follow-up documentation that reflected correction or mitigation of a smoke detector that was removable by a patient and was not tamper-resistant.

1.b. Incident documentation reflected that on 01/18/2020, five days later, another patient accessed and removed a smoke detector from the ceiling in the PES patient bathroom of "Hold Room 2." Incident investigation documentation recorded 02/05/2020, 18 days later, referenced corrective actions only as: "ICARE reviewed at clinical huddle and facilities aware of issue." There was no other documentation.

1.c. The undated "Ongoing BH Environmental Risk Assessment and Mitigation Plan" included smoke detectors and reflected:
* "Smoke detector cage could be used as ligature ... all units ... Breakaway test demonstrated the mesh cage is a ligature risk. Team tested the smoke detector and deemed it to be safe without the cage ... Remove all of the mesh smoke detector cages from patient rooms and patient bathrooms ... Completion Date 9/17/2018."
* "Smoke Detector Mesh Cover P 162 and P 163 ... PES triage ... P 162 and P 163 ... immediate removal of mesh covers by facilities ... Completion Date 10/4/2018."

There were no additional or updated entries related to smoke detectors on the environmental risk assessment to reflect that once the protective "cages" or "covers" were removed the smoke detectors had been evaluated for safety and tamper-resistance.

1.d. Hospital building construction OARs for Psychiatric Patient Care Units and Rooms included OARs 335-535-0061(6) and (6)(v), Patient and Staff Safety Features. Those OARs, in effect at the time LEMC UCBH was licensed, required:
* "(6) Patient and staff safety features, security and safety devices shall not, to the extent practicable, be presented in a manner to attract or invite tampering by patients. Design, finishes and furnishings shall be designed and installed to minimize the opportunity for patients to cause injury to themselves or others. Special design considerations for prevention of self-injury and injury to staff and others shall include:"
* "(6)(v) All devices attached to walls, ceilings and floors and all door and window hardware shall be tamper resistant and be securely fastened with tamper proof screws."

1.e. Refer to the findings for Patients 16 and 17 described in Tag A144 of this report regarding the tampering and removal of smoke detectors in PES patient bathrooms.

2.a. The ED record for Patient 13 reflected that on 11/26/2019 at 1536 "Patient roomed in ED To room PES TR1" for triage and examination. The patient returned to the ED triage area later that day on 11/26/2019 at 1816 and the ED record again reflected "Patient roomed in ED To room PES TR1." However, review of recorded video footage at both of those times showed that Patient 13 was triaged and examined and administered care in the open corridor in front of the triage nurses station and was not in a triage room.

2.b. During interview with the BHT Q on 03/05/2020 at approximately 1630 with the CNO, the PES NM and ACC1 present he/she stated that there were no triage rooms in the ED Triage area and those present concurred. An explanation was provided that for the EPIC EHR they have to select a room for the medical record so they select "Roomed in TR1" or "Roomed in TR2" or "Roomed in TR3," and that if they need privacy during triage or examination they use a vacant seclusion/hold room.

2.c. The LEMC UCBH satellite location architectural firm's "State Review First Floor Plan ... Construction Documents" dated 11/08/2016 was reviewed. These building plans were approved by the SA prior to licensure of the satellite on 01/26/2017. The plans revealed that the ED was designed to include the following rooms in the patient triage area:
* A dedicated "Triage" room identified as room number P-155.
* A "Triage/Hold" room identified as room number P-166, and with an attached "Triage Toilet" room identified as room number P-156A.
* A "Triage/Hold" room identified as room number E-142.
* A dedicated "Exam" room identified as P-161.
* Two other dedicated "Hold" rooms identified as P-158 and P-159.

Although the building was built with dedicated triage and exam rooms, those had not been maintained to be used as designed and intended to ensure the privacy and well-being of patients.

2.d. Refer to the findings for Patient 13 described in Tag A154 of this report regarding the location of the patient's triage and examination in the ED.