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Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation (CoP) of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
1) failure to properly observe 1 (#1) of 9 (#1, #R9 - #R16) patients during exterior, courtyard time (See Findings Tag A0144);
2) failure to properly observe 3 (#2, #R1, #R2) of 9 (#2, #R1-#R3) patients on 1:1 observation status (See Findings Tag A0144);
3) failure to ensure 1 (#2) of 3 (#1 - #3) patient's plan of care included written modification for the use of restraints (See Findings Tag A0166);
4) failure to ensure 1 (#2) of 3 (#1 - #3) patients were properly monitored per hospital policy while being restrained (See Findings Tag A0175);
5) failure to properly restrain 1 (#2) of 3 (#1 - #3) patients (See Findings Tag A0194); and
6) failure to ensure documented completion of competency education in restraint chair usage by 3 (S7RN, S8LPN, S10MHT) of 5 (S6MHT, S7RN, S8LPN, S9MHT, S10MHT) staff members. (See Findings Tag A0196).

Based on observation, record review, and interview the hospital failed to ensure the patient's right to receive care in a safe setting. This deficient practice was evidenced by:
1) failure to properly observe 1 (#1) of 9 (#1, #R9 - #R16) patients during exterior, courtyard time; and
2) failure to properly observe 3 (#2, #R1, #R2) of 9 (#2, #R1-#R3) patients on 1:1 observation status.
Findings:

1) Failure to properly observe 1 (#1) of 9 (#1, #R9 - #R16) patients during exterior, courtyard time

A review of hospital policy, "HR-201: Behavior of Employees," with an effective date of 1998 and last revised/reviewed on 02/2025, revealed in part, "Purpose: To ensure efficient operation of the company and safety of employees by defining certain rules and regulations regarding employee behavior. Policy: Conduct that interferes with operations, discredits the company or is offensive to guests or fellow employees will not be tolerated. Procedure: Employees are expected at all times to conduct themselves in a positive manner so as to promote the best interests of the company. Such conduct includes: Refraining from behavior or conduct deemed offensive or undesirable, or which is contrary to the company's best interests; Performing assigned tasks efficiently and in accordance with established quality standards. The Following conduct is prohibited and will subject the individual involved to disciplinary action, up to and including termination: Unauthorized use of personal computers, cell phones, or personal electronic devices while working."

Observations during a walk though of the hospital on 04/14/2025 from 2:10 PM to 2:40 PM, with S1CEO and S2DON present, revealed the exterior courtyard being enclosed by a wooden fence approximately 10 feet tall. There were two, secured exit gates that would lead to unsecured areas of the facility's grounds. Gate #1 would open to the yard at the rear of the building. Gate #2 would open to the right side of the building and the parking lot with the fronting highway in immediate view. Both of these gates are approximately 8 foot in height and made of the same wood material as the fence. Above the gated areas, the wooden fence continued upwards to the height of the continuous 10 feet stationary, wood fencing. Where the top of each gate met the stationary fencing, there was an approximate 1 - 2 inch space/gap between the gate fencing and the stationary fencing. Gate #2 was not in the line of site of the building entry door. This surveyor stood within 5 feet of the entry door of the building and was unable to visualize Gate #2. An MHT that would stand at the entry door monitoring patients exiting and entering the building would not be able to visualize Gate #2 or the immediate area around Gate #2 if they remained stationary at the entry door.

Observations of video recorded on 03/24/2025 from 12:25 PM to 12:36 PM with S1CEO navigating the computer and S2DON available to assist with the identification of staff and patients revealed simultaneous camera angles on the exterior courtyard. Camera 20 was angled to capture Gate #2 and Camera 21 was angled to capture the courtyard at the entry door of the building. S6MHT was observed standing in a stationary position within reach of the entry door to the building and remained in this area until courtyard time was completed. Camera 20 captured Patient #1 pacing the area close to Gate #2, continuously looking towards the area where S6MHT was standing and back towards Gate #2. It appeared Patient #1 was analyzing the gate and fence. Patient #1 was seen in this area for approximately 5 minutes prior to him scaling the fence. At approximately 12:35:35 PM, Patient #1 is seen approaching the gate, standing on his toes and reaching both hands up to the space between the gate and wood fence, pulling himself up to a level that he could hold his body with one hand and use his other arm/hand to grab the top of the wood fence and continued to pull himself up and over the fence. Beginning at approximately 12:33 PM, S6MHT appeared to be looking at his clipboard and remained looking down at his clipboard until approximately 12:38:26 PM. This would include the time Patient #1 scaled the wood fence and eloped. The camera angle capturing S6MHT allowed a zoom-in feature, which identified a cell phone laid upon the top of the clipboard in S6MHT's hands. It also appeared S6MHT's left thumb was moving in a continuous scroll-like movement/pattern of the telephone's screen during this time frame. S6MHT was observed walking the area that was not in the line of sight of his continuous location after all the patients had re-entered the building at approximately 12:40:45 PM.

In an interview on 04/14/2025 and during the review of recorded video, S1CEO and S2DON confirmed the above mentioned findings, confirmed S6MHT had his cell phone present and staff had been instructed against personal belongings being in patient care areas. Both further confirmed the staff should be observing and monitoring the entire exterior courtyard while patients were present.

In an interview on 04/16/2025 at 12:41 PM, S6MHT confirmed he first recognized Patient #1's disappearance when the patient's reentry head count was not correct.

2) Failure to properly observe 3 (#2, #R1, #R2) of 9 (#2, #R1-#R3) patients on 1:1 observation status

A review of hospital policy, "PC-1013: Levels of Patient Observation," with an effective date of 07/10/2012 and a revised date of 07/31/2012, revealed in part: "Policy: All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient's assessed psychiatric condition. Procedure: A) Routine Levels of Observation: 1) All patients are monitored a minimum of every 15 minutes. B) Special Levels of Observation: An increased degree of monitoring is applied to patients whose psychiatric condition is assessed as needing more intense external controls and/or increased frequency of staff contact for patients to be able to maintain their internal controls. Patients assessed as needing any other following increased levels of observations are to be maintained in the hospital. Special Levels of Observation are as follows: 2) One-to-One (1:1) Supervision: a. This is an extreme level of observation reserved for patient who are an imminent suicide risk or whose psychiatric state is that control/safety cannot be maintained otherwise. b. A staff member is assigned to this patient and remains in physical proximity at all times."

A review the hospital's staff for 03/15/2025 day shift revealed in part, S7RN, S8LPN, S6MHT, S9MHT and S10MHT. A review of assignments revealed S6MHT assigned to Patients #2, #R3 -#R8 (all routine levels of observation). S9MHT was assigned to Patient #R1 (1:1). S10MHT was assigned to Patient #R2 (1:1).

A review of the hospital's bed board for 03/15/2025 revealed a total of 9 (#2, #R1 - #R8) patients. Patient #R1 and #R2 were identified on this bed board as 1:1 level of observation. A review of Patient #R1's medical record revealed a provider order on 3/14/2025 for 1:1 level of observation for active suicidal ideations. A review of Patient #R2's medical record revealed a provider order from 03/14/2025 for 1:1 level of observation for the level of medical care needed.

A review of the hospitals incident logs revealed an incident occurring on 03/15/2025, at an unknown time involving Patient #2. Patient #2 alleged she had been sexually assaulted while restrained. A review of recorded video from 03/15/2025 from approximately 8:03 AM to 8:25 AM with S1CEO navigating the computer and S2DON assisting with identification of employees revealed in part, a situation involving Patient #2 being restrained and removed from Room "c". During the time of Patient #2 being restrained and transferred to Room "a", the remaining 8 (#R1 -#R8) patients were in Room "c". The situation required all staff to control and move Patient #2 to Room "a". Also, during the time Patient #2 was moved to Room "a" (8:06 AM to 8:07 AM) and during a subsequent interval in which Patient #2 was able to free herself from the restraint chair and the need of all staff to return her to the restraint chair (8:17 AM to 8:20 AM), 2 (#R1, #R2) of 8 (#R1 - #R8) patients were not properly observed per provider orders. Recorded video failed to reveal hospital staff within physical proximity of Patient #R1 or R#2 during the before mention times of Patient #2's need of all staff assistance. Further, from 8:11 AM to 8:16 AM, S9MHT began outdoor smoke break for patients and did not remain within physical proximity of Patient #R1. Other observations of recorded video from 03/15/2025 failed to reveal assigned hospital staff within physical proximity of Patient #R1 during the following time frames: 8:02 AM to 8:10 AM (approximately 8 minutes), 8:11 AM to 8:40 AM (approximately 29 minutes), 8:40 AM to 8:43 AM (approximately 3 minutes), 8:53 AM to 8:56 AM (approximately 3 minutes), 9:06 AM to 9:14 AM (approximately 8 minutes) and 9:16 AM to 9:23 AM (approximately 7 minutes).

Further review of recorded video from 03/15/2025 from approximately 8:03 AM to 9:40 AM with S1CEO navigating the computer and S2DON assisting with identification of employees revealed in part, the following times Patient #2 was left unobserved in Rooms "a" and "b" while restrained in the restraint chair: 8:06:34 AM Patient #2's arrival to Room "a" in the restraint chair; 8:06:52 AM to 8:11:46 AM left unobserved (approximately 4 min 54 seconds); 8:22 AM, Patient #2 moved in the restraint chair to Room "b" and remained restrained; 8:22 AM to 8:28 AM (approximately 6 minutes) left unobserved in Room "b"; 8:33 AM to 8:49 AM (approximately 16 minutes) left unobserved in Room "b"; 8:49 AM to 8:52 AM (approximately 3 minutes) left unobserved in Room "b"; 8:53 AM to 9:01 AM (approximately 8 minutes) left unobserved in Room "b"; 9:03 AM to 9:06 AM (approximately 3 minutes) left unobserved in Room "b"; and 9:18 AM to 9:40 AM (approximately 22 minutes) left unobserved in Room "b". Patient #2 was left unobserved for approximately 54 of the 97 minutes of recorded video reviewed. Per staffing sheet and Patient Observation Record from 03/15/2025, S6MHT was assigned to Patient #2 and was identified on video as the MHT that was partially monitoring Patient #2.

A review of Patient Observation Records for Patient #2 and #R1 - #R8 revealed documentation of S6MHT performing patient observations from 8:00 AM to 11:30 AM and being assigned to 1:1 observation of Patient #2 as follows:
Patient #2 (1:1): 8:15 AM to 11:30 AM;
Patient #R1 (1:1): 8:00 AM to 8:30 AM;
Patient #R2 (1:1): 9:30 AM;
Patient #R3: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM;
Patient #R4: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM;
Patient #R5: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM;
Patient #R6: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM;
Patient #R7: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; and
Patient #R8: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM.

In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings, confirmed staffing was not appropriate on 03/15/2025, and confirmed S6MHT (assigned to Patient #2) and S9MHT (assigned to Patient #R1) failed to remain within physical proximity of their assigned patient at all times.

Based on record review and interview, the hospital failed to ensure a written modification to the patient's plan of care for the use of restraints or seclusion. This deficient practice was evidenced by the failure to ensure 1 (#2) of 3 (#1 - #3) patients' plan of care included written modification for the use of restraints.
Findings:

A review of hospital policy, "PC-1502: Restraints and Seclusion Use," with an effective date of 07/16/2013 and no revisions revealed in part: "Monitoring: (G) When restraint or seclusion is used, there must be documentation in the patient's medical record of the following: h. revisions to the plan of care."

A review of Patient #2's medical record revealed the use of restraints and the restraint chair on 03/15/2025 from approximately 8:10 AM to 10:30 AM. A review Patient #2's treatment plan titled, "Compass Health Treatment Plan," failed to reveal documentation related to use of restraints and the restraint chair. This had the potential to negatively affect patient care related to the communication of restraint use to the entire treatment team.

In an interview on 04/15/2025 at 10:00 AM, S1CEO and S2DON confirmed the above mentioned findings.

Based on observation, record review and interview, the hospital failed to ensure the patient who is restrained or secluded is monitored by a physician, other licensed practitioner or trained staff that have completed training criteria per hospital policy. This deficient practice was evidenced by the failure to ensure 1 (#2) of 3 (#1 - #3) patients were properly monitored per hospital policy while being restrained.
Findings:

A review of hospital policy, "PC-1502: Restraints and Seclusion Use," with an effective date of 07/16/2013 and no revisions revealed in part: "Purpose: The hospital uses restraint and seclusion only to protect the immediate physical safety of the patient, staff, or others. Policy: It is the Policy of the hospital to use the least restrictive form of restraint or seclusion only to protect the immediate physical safety of the patient, staff, or others. The hospital does not use restraint or seclusion as a means of coercion, discipline, convenience, or staff retaliation. The hospital uses restrain or seclusion only when less restrictive interventions are ineffective. The hospital discontinues restraint or seclusion at the earliest possible time, regardless of the scheduled expirations of orders. Definitions: Restraint is (A) 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 Physical Hold is considered a restraint and requires adherence to the restraint policy and procedure. Monitoring: (A) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioner, or trained staff that have completed the training criteria specified under Staff Training Requirements in this policy. (D) Simultaneous restraint and seclusion use is only permitted if the patient is continually monitored: a. Face-to-face by an assigned, trained staff member; or b. By trained staff using both video and audio equipment. This monitoring must be in close proximity to the patient. Staff Training Requirements: (A) Training Intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraints or seclusion- a. Training will occur as part of initial employee orientation, annually, and before staff perform restraint or seclusion interventions. (B) Staff education and training will include: d. The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia); f. Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1 hour face-to-face evaluation."

A request for a hospital policy related to restraint chair use was initiated, however the hospital was unable to provide.

A review of video recorded on 03/15/2025 from approximately 8:03 AM to 9:40 AM with S1CEO navigating the computer and S2DON assisting with the identification of employees revealed in part, the following times Patient #2 was left unobserved in Rooms "a" and "b" while restrained in the restraint chair: 8:06:34 AM Patient #2's arrival to Room "a" in the restraint chair; 8:06:52 AM to 8:11:46 AM left un unobserved (approximately 4 min 54 seconds); 8:22 AM, Patient #2 moved in the restraint chair to Room "b" and remained restrained; 8:22 AM to 8:28 AM (approximately 6 minutes) left unobserved in Room "b"; 8:33 AM to 8:49 AM (approximately 16 minutes) left unmonitored in Room "b"; 8:49 AM to 8:52 AM (approximately 3 minutes) left unobserved in Room "b"; 8:53 AM to 9:01 AM (approximately 8 minutes) left unobserved in Room "b"; 9:03 AM to 9:06 AM (approximately 3 minutes) left unobserved in Room "b"; and 9:18 AM to 9:40 AM (approximately 22 minutes) left unobserved in Room "b". Patient #2 was left unobserved for approximately 54 of the 97 minutes of recorded video reviewed. Per staffing sheet and Patient Observation Record from 03/15/2025, S6MHT was assigned to Patient #2 and was identified on video as the MHT that was partially observing this patient during the before mentioned recorded video review.

A review of a nursing note from 03/15/2025 and submitted at 11:38 AM by S7RN revealed, in part: "10AM - Pt placed in restraint chair, for her safety and safety of others, fighting the entire time, scratching staff member. Dr. notified, order written. Pt give B52, placed in front of nurses station where she could be observed entire time."

Review of the recorded video of the event above did show Patient #2 being placed within the nurses' station view, however, this view was outside the nurses' station's closed doors and across the hall in Room "b". Although Patient #2 was within eyesight of the nurses, a staff member was not within physical proximity of the patient and there was no auditory device in use to be able to hear Patient #2 within Room "b".

In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings and further confirmed Patient #2 was not being properly observed and monitored during the time of restraint use. S1CEO also confirmed the hospital did not have a policy related to restraint chair use.

In an interview on 04/16/2025 at 12:41 PM, S6MHT confirmed he was assigned to Patient #2 during the time of the above mentioned restraint use. He further confirmed when a patient is placed in restraints, the patient becomes a 1:1 level of observation and the MHT should "remain within arms-reach of the patient and not left alone or unmonitored."

Based on observation, record review, and interview the hospital failed to ensure the patient's right to the safe implementation of restraint or seclusion by trained staff. This deficient practice was evidenced by the failure to properly restrain 1 (#2) of 3 (#1 - #3) patients.
Findings:

A review of hospital policy, "PC-1502: Restraints and Seclusion Use," with an effective date of 07/16/2013 and no revisions revealed in part: "Purpose: The hospital uses restraint and seclusion only to protect the immediate physical safety of the patient, staff, or others. Policy: It is the Policy of the hospital to use the least restrictive form of restraint or seclusion only to protect the immediate physical safety of the patient, staff, or others. The hospital does not use restraint or seclusion as a means of coercion, discipline, convenience, or staff retaliation. The hospital uses restrain or seclusion only when less restrictive interventions are ineffective. The hospital discontinues restraint or seclusion at the earliest possible time, regardless of the scheduled expirations of orders. Definitions: Restraint is (A) 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 Physical Hold is considered a restraint and requires adherence to the restraint policy and procedure. Monitoring: (A) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioner, or trained staff that have completed the training criteria specified under Staff Training Requirements in this policy. (D) Simultaneous restraint and seclusion use is only permitted if the patient is continually monitored: a. Face-to-face by an assigned, trained staff member; or b. By trained staff using both video and audio equipment. This monitoring must be in close proximity to the patient. Staff Training Requirements: (A) Training Intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraints or seclusion- a. Training will occur as part of initial employee orientation, annually, and before staff perform restraint or seclusion interventions. (B) Staff education and training will include: d. The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia); f. Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1 hour face-to-face evaluation."

A request for a hospital policy related to restraint chair use was initiated, however the hospital was unable to provide.

A review of video recorded on 03/15/2025 from approximately 8:03 AM to 8:15 AM with S1CEO navigating the computer and S2DON assisting with identification of employees revealed in part, 8:03 AM S6MHT approach Patient #2 standing in the doorway of exterior exit door of Room "c". 8:03:51 AM S6MHT, S8LPN, S9MHT and S10MHT attempt to place Patient #2 in the restraint chair in Room "c". Patient #2 was fighting the 4 staff and kicking legs. The staff manage to restrain Patient #2's bilateral arms at the wrist/forearm area. Her bilateral legs were not properly secured to the chair, however they were secured enough to prohibit her from kicking staff. Patient #2 appeared to be secured to the chair by 8:05:53 AM and immediately rolled via the restraint chair to Room "a" with arrival by 8:06:34 AM. Patient #2 was alone in Room "a" with live video capture from the nurses' station, however the room is not equipped with auditory capability. At approximately 8:11:27 AM, simultaneous recorded video review revealed Patient #2 in Room "a" removing left arm and bilateral legs from the restraints and recorded video of the nurses' station camera revealed S6MHT identifying Patient #2 becoming unrestrained via the nurses' station live video feed of Room "a". S6MHT responded to Room "a" and appeared to attempt to reapply the restraint to Patient #2's left arm, however Patient #2 was able to escape S6MHT's hold and stand up. Patient #2's right wrist/forearm remained attached to the restraint chair, with S6MHT attempted to hold and move the patient back to the restraint chair. S6MHT was unsuccessful at redirecting Patient #2's return to the restraint chair and he holds Patient #2 until S7RN and S8LPN enter Room "a" at 8:15:05 AM. S7RN and S8LPN attempted to assist with returning Patient #2 to the restraint chair and were unsuccessful. S7RN requested help from S9MHT and S10MHT. All staff converge to Room "a" and successfully return and properly secure Patient #2 to the restraint chair with all restraints in place.

In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings and further confirmed Patient #2 was not properly restrained in the restraint chair. S1CEO also confirmed the hospital did not have a policy related to restraint chair use.

In an interview on 04/16/2025 at 12:41 PM, S6MHT confirmed he was assigned to Patient #2 during the time of the above mentioned restraint use. He further confirmed Patient #2 was not properly restrained in the restraint chair and this was the first time the staff had used the restraint chair after being in-serviced on its use.

Based on observation, record review, and interview the hospital failed to ensure staff were trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. This deficient practice was evidenced by the failure to ensure documented completion of competency education in restraint chair usage by 3 (S7RN, S8LPN, S10MHT) of 5 (S6MHT, S7RN, S8LPN, S9MHT, S10MHT) staff members.
Findings:

A review of hospital policy, "PC-1502: Restraints and Seclusion Use," with an effective date of 07/16/2013 and no revisions revealed in part: "Purpose: The hospital uses restraint and seclusion only to protect the immediate physical safety of the patient, staff, or others. Policy: It is the Policy of the hospital to use the least restrictive form of restraint or seclusion only to protect the immediate physical safety of the patient, staff, or others. The hospital does not use restraint or seclusion as a means of coercion, discipline, convenience, or staff retaliation. The hospital uses restrain or seclusion only when less restrictive interventions are ineffective. The hospital discontinues restraint or seclusion at the earliest possible time, regardless of the scheduled expirations of orders. Definitions: Restraint is (A) 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 Physical Hold is considered a restraint and requires adherence to the restraint policy and procedure. Monitoring: (A) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioner, or trained staff that have completed the training criteria specified under Staff Training Requirements in this policy. (D) Simultaneous restraint and seclusion use is only permitted if the patient is continually monitored: a. Face-to-face by an assigned, trained staff member; or b. By trained staff using both video and audio equipment. This monitoring must be in close proximity to the patient. Staff Training Requirements: (A) Training Intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraints or seclusion- a. Training will occur as part of initial employee orientation, annually, and before staff perform restraint or seclusion interventions. (B) Staff education and training will include: d. The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia); f. Monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1 hour face-to-face evaluation."

A request for a hospital policy related to restraint chair use was initiated, however the hospital was unable to provide.

A review of video recorded on 03/15/2025 from approximately 8:03 AM to 8:15 AM with S1CEO navigating the computer and S2DON assisting with identification of employees revealed in part, 8:03 AM S6MHT approach Patient #2 standing in the doorway of exterior exit door of Room "c". 8:03:51 AM S6MHT, S8LPN, S9MHT and S10MHT attempted to place Patient #2 in the restraint chair in Room "c". Patient #2 was fighting the 4 staff and kicking her legs. The staff manage to place Patient #2 in the restraint chair and restrain her bilateral arms at the wrist/forearm area. Her bilateral legs were not properly secured to the chair, however they were secured enough to prohibit her from kicking staff. Patient #2 appeared to be secured to the restraint chair by 8:05:53 AM and immediately rolled via the restraint chair to Room "a" with arrival by 8:06:34 AM. Patient #2 was alone in Room "a" with live video capture at the nurses' station, however the room was not equipped with auditory capability. At approximately 8:11:27 AM, simultaneous recorded video review revealed Patient #2 in Room "a" removing left arm and bilateral legs from the restraints and recorded video of the nurses' station camera revealed S6MHT identifying Patient #2 becoming unrestrained via the nurses' station live video feed of Room "a". S6MHT responded to Room "a" and appeared to attempt to reapply the restraint to Patient #2's left arm, however Patient #2 was able to escape S6MHT's hold and stand up. Patient #2's right wrist/forearm remained attached to the restraint chair, with S6MHT attempting to hold and move the patient back to the chair. S6MHT was unsuccessful at redirecting Patient #2's return to the restraint chair and he holds Patient #2 until S7RN and S8LPN enter Room "a" at 8:15:05 AM. S7RN and S8LPN attempted to assist with returning Patient #2 to the restraint chair and were unsuccessful. S7RN requested help from S9MHT and S10MHT. All staff converge to Room "a" and successfully return and properly secure Patient #2 to the restraint chair with all restraints in place.

A review hospital assigned educational modules revealed the course titled, "Compass Health: S & R Restraint Chair" being assigned on 01/07/2025 and having a due on date of 01/12/2025. A review of 3 (S7RN, S8LPN, S10MHT) of 5 (S6MHT, S7RN, S8LPN, S9MHT, S10MHT) staff's assigned educational module transcripts failed to reveal a completion date for this course.

In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings and further confirmed Patient #2 was not properly restrained in the restraint chair, the hospital did not have a policy related to restraint chair use and the above mentioned staff had not completed the assigned educational module on restraint chair use.

In an interview on 04/16/2025 at 12:41 PM, S6MHT confirmed he was assigned to Patient #2 during the time of the above mentioned restraint chair use. He further confirmed Patient #2 was not properly restrained in the restraint chair and this was the first time the staff had used the restraint chair after being in-serviced on its use.

Based on record review and interview, the hospital failed to ensure the QAPI program analyzed adverse patient events that impacted patient safety and quality of care. This deficient practice was evidenced by:
1) failure to conduct a thorough investigation involving the observation of 2 (#R1, #R2) of 8 (#2, #R1 - #R8) patients identified on recorded video of an unrelated incident; and
2) failure to conduct a thorough investigation involving the elopement of Patient #1.
Findings:

1) failure to conduct a thorough investigation involving the observation of 2 (#R1, #R2) of 8 (#2, #R1 - #R8) patients identified on recorded video of an unrelated incident

A review of hospital policy, "PC-1013: Levels of Patient Observation," with an effective date of 07/10/2012 and a revised date of 07/31/2012, revealed in part: "Policy: All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient's assessed psychiatric condition. Procedure: A) Routine Levels of Observation: 1) All patients are monitored a minimum of every 15 minutes. B) Special Levels of Observation: An increased degree of monitoring is applied to patients whose psychiatric condition is assessed as needing more intense external controls and/or increased frequency of staff contact for patients to be able to maintain their internal controls. Patients assessed as needing any other following increased levels of observations are to be maintained in the hospital. Special Levels of Observation are as follows: 2) One-to-One (1:1) Supervision: a. This is an extreme level of observation reserved for patient who are an imminent suicide risk or whose psychiatric state is that control/safety cannot be maintained otherwise. b. A staff member is assigned to this patient and remains in physical proximity at all times."

A review of hospital policy, "Performance Improvement Plan," no policy number available, an effective date of 07/2012 and last revision 01/2025, revealed in part: "Purpose: It is the responsibility of the hospital to provide quality care in an environment where patient safety is of the utmost importance. Responsibilities: The Performance Improvement Committee maintains the responsibility to: a. Ensure processes and activities (those that affect out comes, patient safety, and/or organizational functions most significantly) within the hospital are measured, assessed, and improved systematically; d. Ensure that the hospital's established mechanism for identification, reporting, analysis and prevention of sentinel events is followed; j. Provide and/or arrange for staff training in the basic approaches to and methods of performance improvement, stressing that nay staff can express an idea for improvement that is department-specific or organizationally focused.

A review of the hospital's bed board for 03/15/2025 revealed a total of 9 (#2, #R1 - #R8) patients. Patient #R1 and #R2 were identified on this bed board as 1:1 supervision. A review of Patient #R1's medical record revealed a provider order on 3/14/2025 for 1:1 level of observation for active suicidal ideations. A review of Patient #R2's medical record revealed a provider order for 1:1 level of observation for the level of medical care needed. Patient #R1 was assigned to S9MHT and Patient #R2 was assigned to S10MHT.

Observations of video recorded 03/15/2025 from approximately 8:03 AM to 8:25 AM with S1CEO navigating the computer and S2DON assisting with the identification of employees revealed in part, a situation involving Patient #2 being restrained and removed from Room "c". During the time Patient #2 was being restrained and transferred to Room "a", the remaining 8 (#R1 -#R8) patients were in Room "c". The situation required all staff to control and move Patient #2 to Room "a". During the time Patient #2 was moved to Room "a" (8:06 AM to 8:07 AM) and during a subsequent interval in which Patient #2 was able to free herself from the restraint chair and the need of all staff to return her to the restraint chair (8:17 AM to 8:20 AM), 2 (#R1, #R2) of 8 (#R1 - #R8) patients were not properly monitored per provider orders. Recorded video failed to reveal hospital staff within physical proximity of Patient #R1 or R#2 during the before mention times of Patient #2's need of all staff assistance. Further, from 8:11 AM to 8:16 AM, S9MHT began outdoor smoke break for patients and did not remain within physical proximity of Patient #R1. Other observations of recorded video from 03/15/2025 failed to reveal S9MHT within physical proximity of Patient #R1 during the following time frames: 8:02 AM to 8:10 AM, 8:11 AM to 8:40 AM, 8:40 AM to 8:43 AM, 8:53 AM to 8:56 AM, 9:06 AM to 9:14 AM and 9:16 AM to 9:23 AM.

A medical record review of Patient #R1's Patient Observation Record from 03/15/2025, revealed documented observations for 7:45 AM by S9MHT (assigned MHT), 8:00 AM to 8:30 AM by S6MHT (assigned to Patient #2), 8:45 AM and 9:00 AM by S9MHT, 9:15 AM by S10MHT (assigned to Patient #R2) and 9:30 AM - 9:45 AM 2 by S9MHT.

In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings, confirmed Patient #R1 and #R2 were not being properly observed and monitored as a 1:1 level of observation and S1CEO further confirmed the above mentioned findings were not identified until the review of the recorded video with this surveyor.

2) failure to conduct a thorough investigation involving the elopement of Patient #1

A review of hospital policy, "HR-201: Behavior of Employees," with an effective date of 1998 and last revised/reviewed on 02/2025, revealed in part, "Purpose: To ensure efficient operation of the company and safety of employees by defining certain rules and regulations regarding employee behavior. Policy: Conduct that interferes with operations, discredits the company or is offensive to guests or fellow employees will not be tolerated. Procedure: Employees are expected at all times to conduct themselves in a positive manner so as to promote the best interests of the company. Such conduct includes: Refraining from behavior or conduct deemed offensive or undesirable, or which is contrary to the company's best interests; Performing assigned tasks efficiently and in accordance with established quality standards. The Following conduct is prohibited and will subject the individual involved to disciplinary action, up to and including termination: Unauthorized use of personal computers, cell phones, or personal electronic devices while working."

A review of hospital policy, "Performance Improvement Plan," no policy number available, an effective date of 07/2012 and last revision 01/2025, revealed in part: "Purpose: It is the responsibility of the hospital to provide quality care in an environment where patient safety is of the utmost importance. Responsibilities: The Performance Improvement Committee maintains the responsibility to: a. Ensure processes and activities (those that affect out comes, patient safety, and/or organizational functions most significantly) within the hospital are measured, assessed, and improved systematically; d. Ensure that the hospital's established mechanism for identification, reporting, analysis and prevention of sentinel events is followed; j. Provide and/or arrange for staff training in the basic approaches to and methods of performance improvement, stressing that nay staff can express an idea for improvement that is department-specific or organizationally focused."

Observations of video recorded on 03/24/2025 from 12:25 PM to 12:36 PM with S1CEO navigating the computer and S2DON available to assist with identification of staff and patients revealed simultaneous camera angles on the exterior courtyard. Camera 20 was angled to capture Gate #2 and Camera 21 was angled to capture the courtyard at the entry door of the building. S6MHT is observed standing in a stationary position within reach of the entry door to the building and remained in this area until courtyard time was completed. Camera 20 captured Patient #1 pacing the area close to Gate #2, continuously looking towards the area where S6MHT was standing and back towards Gate #2. It appeared Patient #1 was analyzing the gate and fence. Patient #1 was seen in this area for approximately 5 minutes prior to him scaling the fence. At approximately 12:35:35 PM, Patient #1 is seen approaching the gate, standing on his toes and reaching both hands up to the space between the gate and wood fence, pulling himself up to a level that he could hold his body with one hand and use his other arm/hand to grab the top of the wood fence and continue to pull himself up and over the fence. Beginning at approximately 12:33 PM, S6MHT appeared to be looking at his clipboard and remained looking down at his clipboard until approximately 12:38:26 PM. This would include the time of Patient #1 scaled the wood fence and eloped. The camera angle capturing S6MHT allowed a zoom-in feature, which identified a cell phone laid upon the top of the clipboard in S6MHT's hands. It also appeared S6MHT's left thumb was moving in a continuous scroll-like movement/pattern of the telephone's screen during this time frame. S6MHT was observed walking the area that was not in the line of sight of his continuous location after all patients had re-entered the building at approximately 12:40:45 PM.

In an interview on 04/14/2025 and during the review of recorded video, S1CEO and S2DON confirmed the above mentioned findings, confirmed S6MHT had his cell phone present and staff had been instructed against personal belongings being in patient care areas. S1CEO further confirmed the above mentioned findings were not identified until the review of the recorded video with this surveyor.

Based on observation, record review, and interview the hospital failed to ensure there were adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. This deficient practice was evidenced by failure to have adequate staff to observe and monitor 9 (#2, #R1 - #R8) of 9 (#2, #R1 - #R8) patients.
Findings:

A review of the hospital's staffing matrix revealed a day shift census of 9 patients, would require 1 RN, 1 LPN, and 2 MHTs.

A review of hospital policy, "PC-114: Staffing Patterns, Variances and Acuity," with an effective date of 07/10/2012 and last revised on 12/19/2024, revealed in part, "Purpose: The program is staffed in a manner to meet the various needs of the patients served. Scope: The staffing pattern for the program is based on aspects of care and services provided to facilitate a ratio of staff to patients that is conducive to providing high quality, safe, efficient and compassionate care. Responsible Party: Director of Nursing and Assistant Director of Nursing is responsible for ensuring that these patterns are communicated to department staff. Policy: It is recognized that there may always be unpredictable fluctuations in staffing needs. Therefore, it is expected that staffing be adjusted accordingly to meet patient care needs. Staff Patterns: 3. Additional staff may be called in at the discretion of the charge RN or to maintain a staffing ratio of no less than 1:5. 4. The charge nurse on duty will notify on-call nurse if additional staffing is needed. Daily Clinical Staffing and Management Report: The night charge nurse will complete the Daily Clinical Staffing and Management Report for the day. The day, evening and night shifts will document any changes/updates to the report. In the event that the census or acuity increases, additional staff members may be called in to ensure high quality, individualized care for every patient."

A review the hospital's staff for 03/15/2025 day shift revealed in part, S7RN, S8LPN, S6MHT, S9MHT and S10MHT. A review of assignments revealed S6MHT assigned to Patients #2, #R3 -#R8 (all routine level of observation). S9MHT assigned to Patient #R1 (1:1). S10MHT assigned to Patient #R2 (1:1).

A review of the hospital's bed board for 03/15/2025 revealed a total of 9 (#2, #R1 - #R8) patients. Patient #R1 and #R2 were identified on this bed board as 1:1 level of observation. A review of Patient #R1's medical record revealed a provider order on 3/14/2025 for 1:1 level of observation for active suicidal ideations. A review of Patient #R2's medical record revealed a provider order from 03/14/2025 for 1:1 lever of observation for the level of medical care needed.

A review of the hospitals incident logs revealed an incident occurring on 03/15/2025, at an unknown time involving Patient #2. Patient #2 alleged she was sexually assaulted while restrained. A review of video recorded on 03/15/2025 from approximately 8:03 AM to 8:25 AM with S1CEO navigating the computer and S2DON assisting with the identification of employees revealed in part, a situation involving Patient #2 being restrained and removed from Room "c". During the time of Patient #2 being restrained and transferred to Room "a", the remaining 8 (#R1 -#R8) patients were in Room "c". The situation required all staff to control and move Patient #2 to Room "a". Also, during the time Patient #2 was moved to Room "a" (8:06 AM to 8:07 AM) and during a subsequent interval in which Patient #2 was able to free herself from the restraint chair and the need of all staff to return her to the restraint chair (8:17 AM to 8:20 AM), 2 (#R1, #R2) of 8 (#R1 - #R8) patients were not appropriately observeded per provider orders. Recorded video failed to reveal hospital staff within physical proximity of Patient #R1 or R#2 during the before mention times of Patient #2's need of all staff assistance. Further, from 8:11 AM to 8:16 AM, S9MHT began outdoor smoke break for patients and did not remain within physical proximity of Patient #R1.

A review of staffing for 03/15/2025 day shift revealed 1-RN, 1-LPN and 3 MHTs. A review of Patient Observation Records for Patient #2 and #R1 - #R8 revealed documentation of S6MHT performing patient observations from 8:00 AM to 11:30 AM and being assigned to 1:1 observation of Patient #2 as follows:
Patient #2 (1:1): 8:15 AM to 11:30 AM;
Patient #R1 (1:1): 8:00 AM to 8:30 AM;
Patient #R2 (1:1): 9:30 AM;
Patient #R3: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM;
Patient #R4: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM;
Patient #R5: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM;
Patient #R6: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM;
Patient #R7: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; and
Patient #R8: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM.

In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings and further confirmed staffing was not appropriate on 03/15/2025. S2DON confirmed there was a staff member out with an illness for this shift.

Based on observation, record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by the failure to ensure the monitoring and observations of 9 (#2, #R1 - #R8) of 9 (#2, #R1 - #R8) patients were appropriately performed and documented.
Findings:

A review of hospital policy, "PC-1013: Levels of Patient Observation," with an effective date of 07/10/2012 and a revised date of 07/31/2012, revealed in part: "Policy: All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient's assessed psychiatric condition. Procedure: A) Routine Levels of Observation: 1) All patients are monitored a minimum of every 15 minutes. B) Special Levels of Observation: An increased degree of monitoring is applied to patients whose psychiatric condition is assessed as needing more intense external controls and/or increased frequency of staff contact for patients to be able to maintain their internal controls. Patients assessed as needing any other following increased levels of observations are to be maintained in the hospital. Special Levels of Observation are as follows: 2) One-to-One (1:1) Supervision: a. This is an extreme level of observation reserved for patient who are an imminent suicide risk or whose psychiatric state is that control/safety cannot be maintained otherwise. b. A staff member is assigned to this patient and remains in physical proximity at all times."

A review of the hospital's staff for 03/15/2025 day shift revealed in part, S7RN, S8LPN, S6MHT, S9MHT and S10MHT. A review of assignments revealed S6MHT was assigned to Patients #2, #R3 -#R8 (all routine level of observation). S9MHT was assigned to Patient #R1 (1:1). S10MHT was assigned to Patient #R2 (1:1).

A review of the hospital's bed board for 03/15/2025 revealed a total of 9 (#2, #R1 - #R8) patients. Patient #R1 and #R2 were identified on this bed board as 1:1 level of observation. A review of Patient #R1's medical record revealed a provider order on 3/14/2025 for 1:1 level of observation for active suicidal ideations. A review of Patient #R2's medical record revealed a provider order from 03/14/2025 for 1:1 lever of observation for the level of medical care needed.

A review of the hospitals incident logs revealed an incident occurring on 03/15/2025, at an unknown time involving Patient #2. Patient #2 alleged she was sexually assaulted while restrained. A review of recorded video from 03/15/2025 from approximately 8:03 AM to 8:25 AM with S1CEO navigating the computer and S2DON assisting with the identification of employees revealed in part, a situation involving Patient #2 being restrained and removed from Room "c". During the time of Patient #2 being restrained and transferred to Room "a", the remaining 8 (#R1 -#R8) patients were in Room "c". The situation required all staff to control and move Patient #2 to Room "a". Also, during the time Patient #2 was moved to Room "a" (8:06 AM to 8:07 AM) and during a subsequent interval in which Patient #2 was able to free herself from the restraint chair and the need of all staff to return her to the restraint chair (8:17 AM to 8:20 AM), 2 (#R1, #R2) of 8 (#R1 - #R8) patients were not properly observed per provider orders. Recorded video failed to reveal hospital staff within physical proximity of Patient #R1 or R#2 during the before mentioned times of Patient #2's need of all staff assistance. Further, from 8:11 AM to 8:16 AM, S9MHT began outdoor smoke break for patients and did not remain within physical proximity of Patient #R1. Other observations of recorded video from 03/15/2025 failed to reveal assigned hospital staff within physical proximity of Patient #R1 during the following time frames: 8:02 AM to 8:10 AM (approximately 8 minutes), 8:11 AM to 8:40 AM (approximately 29 minutes), 8:40 AM to 8:43 AM (approximately 3 minutes), 8:53 AM to 8:56 AM (approximately 3 minutes), 9:06 AM to 9:14 AM (approximately 8 minutes) and 9:16 AM to 9:23 AM (approximately 7 minutes).

A review of video recorded on 03/15/2025 from approximately 8:03 AM to 9:40 AM with S1CEO navigating the computer and S2DON assisting with the identification of employees revealed in part, the following times Patient #2 was left unobserved in Rooms "a" and "b" while restrained in the restraint chair: 8:06:34 AM Patient #2's arrival to Room "a" in the restraint chair; 8:06:52 AM to 8:11:46 AM left un unobserved (approximately 4 min 54 seconds); 8:22 AM, Patient #2 moved in the restraint chair to Room "b" and remained restrained; 8:22 AM to 8:28 AM (approximately 6 minutes) left unobserved in Room "b"; 8:33 AM to 8:49 AM (approximately 16 minutes) left unmonitored in Room "b"; 8:49 AM to 8:52 AM (approximately 3 minutes) left unobserved in Room "b"; 8:53 AM to 9:01 AM (approximately 8 minutes) left unobserved in Room "b"; 9:03 AM to 9:06 AM (approximately 3 minutes) left unobserved in Room "b"; and 9:18 AM to 9:40 AM (approximately 22 minutes) left unobserved in Room "b". Patient #2 was left unobserved for approximately 54 of the 97 minutes of recorded video reviewed. Per staffing sheet and Patient Observation Record from 03/15/2025, S6MHT was assigned to Patient #2 and was identified on video as the MHT that was partially observing this patient during the before mentioned recorded video review.

A review of Patient Observation Records for Patient #2 and #R1 - #R8 revealed the documentation of S6MHT performing patient observations from 8:00 AM to 11:30 AM and being assigned to 1:1 observation of Patient #2 as follows:
Patient #2 (1:1): 8:15 AM to 11:30 AM;
Patient #R1 (1:1): 8:00 AM to 8:30 AM;
Patient #R2 (1:1): 9:30 AM;
Patient #R3: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM;
Patient #R4: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM;
Patient #R5: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM;
Patient #R6: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM;
Patient #R7: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM; and
Patient #R8: 8:00 AM to 9:30 AM and 10:00 AM to 10:45 AM.

In an interview on 04/15/2025 at 11:30 AM, S1CEO and S2DON confirmed the above mentioned findings, confirmed staffing was not appropriate on 03/15/2025, and confirmed S6MHT (assigned to Patient #2) and S9MHT (assigned to Patient #R1) failed to remain within physical proximity of their assigned patient at all times.