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Based on document review, observation and interview, the facility failed to ensure patient care in a safe setting by failing to implement Q (every) 15 minutes and/or 1:1 (one-to-one) observations for 7 patients (#3, #4, #5, #6, #7, #8 and #10); failed to ensure freedom from patient-to-patient assaultive-combative behavior for 7 patients (#3, #4, #5, #6, #7, #8 and #10); failed to ensure freedom from patient-to-staff assaultive-combative behavior from 1 patient (#3); and failed to ensure freedom from sexual abuse for 2 patients (#10 and unable to determine female patient). (See Tag 144)

The cumulative effect of these systemic problems resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review, observation and interview, the facility failed to ensure patient care in a safe setting by failing to implement Q (every) 15 minutes and/or 1:1 (one-to-one) observations for 7 patients (#3, #4, #5, #6, #7, #8 and #10); failed to ensure freedom from patient-to-patient assaultive-combative behavior for 7 patients (#3, #4, #5, #6, #7, #8 and #10); failed to ensure freedom from patient-to-staff assaultive-combative behavior from 1 patient (#3); and failed to ensure freedom from sexual abuse for 2 patients (#10 and unable to determine female patient).

Findings include:

1. The facility policy titled, "Patient Rights and Responsibilities", PolicyStat ID 13517670, revised 9/2021, indicated on page 3 of 6, under Procedure section, You have the right to ...18. Receive care in a safe setting, free from verbal or physical abuse or harassment.

2. The facility policy titled, "Assaultive-Combative Patients", PolicyStat ID 12195122, revised 1/2020, indicated on page 2 of 2, under Policy section, In the event that a patient escalates and becomes assaultive/combative, all safety measures shall be provided to the patient, other patients and staff, with the least restrictive interventions possible based on the level of acuity and patient needs.

3. The facility policy titled, "Patient Observation", PolicyStat ID 12931622, revised 1/2023, indicated:
A. On page 1 of 3, under Procedure section, point 1. All patients will be admitted to the patient care unit with a minimum of "every 15 minutes" observation level.
B. On page 2 of 3, under 3. Level III - 1:1 Observation, point 1. The patient is to be under constant visual observation by an assigned staff member, regardless of other unit activities.

4. The facility policy titled, "Patient Abuse and Neglect", PolicyStat ID (none listed on policy), revised 4/2024, indicated on page 1 of 4, under Policy section, All patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected. Allegations or information indicating that abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate action taken.

5. Review of patient Medical Records (MRs) on 12/19/2024 beginning at approximately 12:30 pm and as needed throughout the entire survey, indicated:
A. Patient #3 was admitted on 11/24/2024 for autism with intermittent explosive disorder; presenting with acute physical aggression, verbal aggression, and impulsive behaviors.
a. Patient Safety Observation Rounds indicated 1:1 observation.
b. IR (Incident Report) #616 dated 11/24/2024 at 8:30 am indicated patient #3 attempted to physically attack another patient (unable to determine which patient from the IR).
c. IR #966 dated 11/25/2024 at 9:32 am indicated patient #3 was physically aggressive toward staff (unable to determine which staff from the IR).
d. IR #969 dated 11/26/2024 at 10:50 am indicated patient #3 was physically aggressive toward provider.
e. IR #970 dated 11/27/2024 at 8:45 am indicated patient #3 was physically aggressive toward staff (unable to determine which staff from the IR).
f. IR #971 dated 11/28/2024 at 1:40 pm indicated patient #3 was physically aggressive toward two other patients (unable to determine which patients from the IR).
g. IR #985 dated 12/6/2024 at 9:30 pm indicated patient #3 slapped patient #8 across the face.
h. IR #992 dated 12/7/2024 at 9:00 pm indicated patient #3 had multiple incidents of impulsive, threatening, aggressive and destructive behaviors. After staff placed patient into seclusion room per provider order, patient ran into the seclusion room door until it broke. Agitation continued to progress, unable to be redirected and 911 called. Patient taken into custody by police officers.

B. Patient #4 was admitted on 12/6/2024 for bipolar disorder and physically, verbally aggressive.
a. Patient Safety Observation Rounds indicated Q15 minutes observation.
b. IR #990 dated 12/7/2024 at 8:30 pm indicated patient #4 choked a patient and pulled out a plug of patient's hair (unable to determine which patient from the IR).
c. IR #997 dated 12/11/2024 at 8:30 pm indicated patient #4 physically attacked patient #7 and after being put into the seclusion room on Unit 100, patient #4 broke down the seclusion room door, kicked ambulance bay door window repeatedly until it broke and crawled through the opening, punched fire alarm box until alarm went off and all the doors in the facility opened. Eloped into parking lot and was apprehended by police.

C. Patient #5 was admitted on 12/6/2024 for suicidal ideation, impulsive behaviors, harm to self and others.
a. Patient Safety Observation Rounds indicated Q15 minutes observation.
b. IR #983 dated 12/6/2024 at 2:10 am indicated patient #5 got into an altercation with another patient (unable to determine which patient from the IR).
c. IR #991 dated 12/7/2024 at 8:30 pm indicated patient #5 got into an altercation with two other patients (unable to determine which patients from the IR).

D. Patient #6 was admitted on 11/28/2024 for suicidal ideation.
a. Patient Safety Observation Rounds indicated Q15 minutes observation.
b. IR #984 dated 12/6/2024 at 2:10 am indicated patient #6 walked up to another patient and punched patient in the head (unable to determine which patient from the IR).

E. Patient #7 was admitted on 11/24/2024 for acute verbal aggression, impulsive behaviors.
a. Patient Safety Observation Rounds indicated Q15 minutes observation.
b. IR #998 dated 12/11/2024 at 8:30 pm indicated patient #7 was physically attacked by patient #4 who was put into seclusion room on Unit 100. Patient #4 broke down seclusion room door, kicked out ambulance bay door window, punched fire alarm box until alarm went off and all the doors in the facility opened. Eloped into the parking lot and apprehended by police.

F. Patient #8 was admitted on 12/6/2024 for suicidal ideation.
a. Patient Safety Observation Rounds indicated Q15 minutes observation.
b. IR #986 dated 12/6/2024 at 9:30 pm indicated patient #3 slapped patient #8 across the face.

G. Patient #10 was admitted on 12/17/2024 for suicidal ideation.
a. Patient Safety Observation Rounds indicated Q15 minutes observation.
b. IR #1004 dated 12/17/2024 at 7:40 pm, indicated patient was seen by staff in bed with a female patient (unable to determine from IR who this patient was).

6. Video review on 12/19/2024 at approximately 5:18 pm, showed patient #4 on 12/11/2024 at approximately 10:08 pm to 10:10 pm pacing around in the area by the Ambulance Bay of Unit 100 after breaking out of the seclusion room door on Unit 100. Patient picked up garbage can and threw it across the area, then kicked the ambulance bay door window repeatedly until it broke and crawled through the opening. Patient continued to punch the fire alarm box until the alarm went off and all the doors in the facility opened. Patient eloped into the parking lot. Four Nursing Staff: P19 (Nurse Supervisor), P20 (Nurse Supervisor), P21 Behavioral Health Associate [BHA], and P22, BHA remained in the Nurses Station with the doors closed during this incident, opening the doors once for several seconds at approximately 10:09 pm to allow in P12 (BHA) who came from Unit 200.

7. Staff P3 (Chief Executive Officer) was interviewed on 12/20/2024 at approximately 1:50 pm and confirmed:
A. After the incident with patient #3 on 12/7/2024, "none" no staff education has been provided related to the incident. What was put into place, was assessing the seclusion room (SR) doors on Unit 100 & 200 and ordering the doors that will be installed next week.
B. After the incident with patient #4 on 12/11/2024, no staff education has been provided related to the incident. P3 Spoke with P19, P20, and P15 (Registered Nurse) about engaging SR deadbolt after a patient is put in SR. This information was not provided to other staff and/or staff has not been educated pertaining to engaging the SR deadbolt.

8. Staff P3 was interviewed on 12/20/2024 at approximately 2:52 pm and 3:50 pm and questioned about why nursing staff stayed in the Nurses Station and did not attempt to de-escalate the situation with patient #4 on 12/11/2024, but instead watched the destruction and elopement unfold while watching through the glass doors of the Nurses Station. P3 replied cannot 100% (percent) prevent these incidents from happening again and that it's stated in the Code of Conduct policy if staff don't feel safe they may call security, which is 911. This is what staff was doing while in the Nurses Station. We don't have security staff on the facility premises.

9. Staff P1 (Director Quality & Compliance) on 12/20/2024 at approximately 3:50 pm, confirmed no staff education is documented on the Root Cause Analysis and staff education is not on the schedule currently.

Based on document review and interview, the facility failed to ensure adequate staffing per policy for 2 patient care units (Units 200 and 300); and failed to supervise accurate Incident Report documentation for 16 (#616, #966, #969, #970, #971, #982, #983, #984, #985, #986, #990, #991, #992, #997, #998 and #1004) Incident Reports reviewed. (See Tag 392 and 398)

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review, the facility failed to ensure adequate staffing per policy for 1 patient care unit (Unit 200).

Findings include:

1. The facility policy titled, "Clinical Staff (Nurse) Staffing Plan", PolicyStat ID (none on policy), revised 9/2024, indicated:
A. On page 1 of 6, under Purpose section, This policy is to establish guidelines for providing sufficient numbers and mix of staff necessary to provide multi-disciplinary patient care that is consistent with the assessed needs of the population served ...
B. On page 4 of 6, under Staffing Plan section, point B. Clinical staff members include Registered Nurses (RNs), Licensed Practical Nurses (LPNs) ...Behavioral Health Techs (BHAs) ...There must be at least one (1) RN on every unit at all times. There must be at least two (2) total clinical staff members assigned to every unit at all times ...B. For each patient placed on 1:1 level of observation, one additional staff will be added to the unit staffing.

2. Review of Staffing Grid & Staffing Pattern Worksheet (midnight census) on 12/20/2024 at approximately 3:30 pm, indicated for Unit 200:
A. On 11/24/2024:
a. During 7:00 am to 3:30 pm for patient census of 25, required number of staff equals 6: 1 Registered Nurse (RN), 1 LPN (Licensed Practical Nurse)/RN, and 4 Behavioral Health Associate (BHA) plus 2 for two 1:1 patients, which equals 8; staffed with 1 RN, 1 LPN and 5 BHAs, which equals 7; lacked 1 extra staff member due to 2 patients on 1:1 observation.

b. During 3:00 pm to 11:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, 4 BHAs plus 2 for two 1:1 patients, which equals 8; staffed with 1 RN, 1 LPN and 5 BHAs, which equals 7; lacked 1 extra staff member due to 2 patients on 1:1 observation.

c. During 11 pm to 7:30 am for patient census of 25, required number of equals 3: 1 RN, 1 LPN/RN, 1 BHA plus 2 for two 1:1 patients, which equals 5; staffed with 2 RNs and 2 BHAs, which equals 4; lacked 1 extra staff member due to 2 patients on 1:1 observation.

B. On 11/25/2024:
a. During 7:00 am to 3:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, and 4 BHA plus 2 for two 1:1 patients, which equals 8; staffed with 2 RNs and 4 BHAs, which equals 6; lacked 2 extra staff members due to 2 patients on 1:1 observation.

b. During 3:00 pm to 11:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, 4 BHAs plus 2 for two 1:1 patients, which equals 8; staffed with 2 RNs and 5 BHAs, which equals 7; lacked 1 extra staff member due to 2 patients on 1:1 observation.

C. On 11/26/2024:
a. During 7:00 am to 3:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, and 4 BHA plus 2 for two 1:1 patients, which equals 8; staffed with 2 RNs and 4 BHAs, which equals 6; lacked 2 extra staff members due to 2 patients on 1:1 observation.

b. During 3:00 pm to 11:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, 4 BHAs plus 2 for two 1:1 patients, which equals 8; staffed with 2 RNs and 5 BHAs, which equals 7; lacked 1 extra staff member due to 2 patients on 1:1 observation.

D. On 11/27/2024: During 3:00 pm to 11:30 pm for patient census of 22, required number of staff equals 5: 1 RN, 1 LPN/RN, 3 BHAs plus 2 for two 1:1 patients, which equals 7; staffed with 2 RNs and 3 BHAs, which equals 5; lacked 2 extra staff members due to 2 patients on 1:1 observation.

E. On 11/28/2024:
a. During 7:00 am to 3:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, and 4 BHA plus 1 for one 1:1 patient, which equals 7; staffed with 2 RNs and 4 BHAs, which equals 6; lacked 1 extra staff member due to 1 patient on 1:1 observation.

b. During 3:00 pm to 11:30 pm for patient census of 25, required number of staff equals 6: 1 RN, 1 LPN/RN, 4 BHAs plus 1 for one 1:1 patient, which equals 7; staffed with 2 RNs and 3 BHAs, which equals 5; lacked 2 extra staff members due to 1 patient on 1:1 observation.

F. On 12/3/2024:
a. During 7:00 am to 3:30 pm for patient census of 23, required number of staff equals 6: 1 RN, 1 LPN/RN, and 4 BHAs plus 1 for one 1:1 patient, which equals 7; staffed with 2 RNs and 3 BHAs, which equals 5; lacked 2 extra staff members due to 1 patient on 1:1 observation.

b. During 3:00 pm to 11:30 pm for patient census of 23, required number of staff equals 6: 1 RN, 1 LPN/RN, 4 BHAs plus 1 for one 1:1 patient, which equals 7; staffed with 1 RN and 3 BHAs, which equals 4; lacked 3 extra staff members due to 1 patient on 1:1 observation.


3. During interview with P3 (Chief Executive Officer) on 12/20/2024 at approximately 3:50 pm, he/she stated the facility Staffing Grid was followed for staffing on Unit 200 and that the [IDOH, Indiana Department of Health] Staffing Pattern Worksheet for 11/24/2024 through 12/7/2024 showed the unit was staffed appropriately according to the grid, the patient census on the unit, and the number of patients on 1:1 observation. However, based on review of staffing documents by this surveyor and the interview with P3, the information for staffing did not appear to be congruent.

Based on document review and interview, nursing services failed to supervise and evaluate patient care related to failure to ensure accurate Incident Report (IR) documentation for 16 (#616, #966, #969, #970, #971, #982, #983, #984, #985, #986, #990, #991, #992, #997, #998 and #1004) Incident Reports reviewed.

Findings include:

1. Facility policy titled, "Incident Reports", PolicyStat ID 13033981, revised 1/2023, indicated:
A. In the Purpose section, All incident reports must be complete using the hospital's designated Incident Reporting System, Wellsky.
B. In the Completing an Incident Report section, point D ...the Incident Report will be reviewed and acknowledged by the Director of Nursing or designee and Risk Manager or designee.

2. Review of Incident Reports on 12/19/2024 at approximately 11:47 am and on 12/20/2024 at approximately 1:00pm, indicated:
A. IR's #616, #966, #969, #970, #971, #982, #983, #984, #985, #986, #990, #991, #992, #997, #998 and #1004 lacked documentation of review by CEO/DON (Chief Executive Officer/Director of Nursing) and Risk Manager. The section titled Reviewed was documented as N (equals No.
B. IR's #969, #970, #982, #992, #997 and #998 lacked check mark for Medications Ordered when medications were either ordered and/or administered to patient as described in narrative section.
C. IR #983 had a check mark in No Injury, but description of incident stated injury to patient's left ring finger.
D. IR #984 lacked a check mark for No Injury when description of incident stated no injury.
E. IR #987 and #998 lacked a check mark in the Injury section, for the type of injury, after the description of incident stated patient had been thrown to the ground, kicked in the face, and punched multiple times.

3. Interview with P1 (Director Quality & Compliance) and P4 (Quality Coordinator) on 12/19/2024 at approximately 2:06 pm (both interviewed at same time while reviewing IRs). IR's should be reviewed by CEO/DON and Risk Manager. There is an area for this on the IR form. After being reviewed by these parties, the IR automatically closes out. These have not been being marked as reviewed and/or closed due to not having a DON or QA (Quality Assessment) Director since September and October, respectively. The forms are expected to be reviewed daily the day after the incident.