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Based on staff interview, medical record review, and policy review, the hospital failed to ensure a comprehensive lethality assessment was completed upon admission and physical assessments of patients were completed following an assault and/or injury. (A395).

Based on observation, document review, and staff interview, the hospital failed to provide the state hotline number contact information to file a complaint. This had the potential to affect all patients receiving services at the hospital. The census was 17.

Findings include:

During a tour of the 20 bed inpatient unit with Staff D on 03/21/19 starting at 10:05 AM, observation of nurses' station revealed a sign that read "Ohio Department of Health" and a 614- number, but the sign did not include any additional information. The sign did not indicate the number was available to call if a complaint needed to be filed.

Review of the facility's policy titled "Rights and Responsibilities of the Individual" Reference RI-0030A, Revised 02/27/17 revealed the absence of the Ohio Department of Health Hotline number to file a complaint.

Review of the facility's admission packet revealed the absence of the Ohio Department of Health Hotline number to file a complaint.

Review of the facility's "Programs and Services" information revealed the absence of the Ohio Department of Health Hotline number to file a complaint

These findings were confirmed with Staff D in an interview on 03/22/19 at 3:30 PM.

Based on medical record review, staff interview, and policy review, the hospital failed to ensure physician orders were obtained for patients placed in a physical restraint for two of two patients reviewed with physical restraints (Patient #6 and #9). The sample size was ten. The active census was 17.

Findings include:

Review of the policy and procedure titled "Use of Restraint" Number PC-0020A (Revised 06/05/15) revealed "the use of a restraint must be in accordance with the order of a physician or other licensed independent practitioner (LIP) permitted by the state and hospital to order a restraint." "In the case that the restraint is an emergent situation, the charge nurse on the unit may initiate a restraint until an LIP can be contacted to obtain an order. If the original order was not given by the patient's assigned psychiatrist, then the charge nurse must notify the attending psychiatrist as soon as possible."

1. Review of the medical record for Patient #6 revealed the patient was admitted for suicidal ideation on 10/29/18 after wanting to cut his/her throat. Review of an incident report dated 11/18/18 at 10:45 PM revealed a peer to staff assault in which the staff used a physical restraint by placing the patient's arm behind his/her back. The medical record lacked evidence of a physician order for the use of a restraint as per policy. This finding was confirmed in an interview with Staff D on 03/22/19 at 10:55 AM.

2. Review of the medical record for Patient #9 revealed the patient was admitted on 01/01/19 for suicidal and homicidal ideation. Review of an incident report dated 01/05/19 at 2:40 PM revealed the patient was involved in a peer to peer altercation. The patient was placed in hold restraint (Brace-standing) by a staff member. The restraint packet was completed by the registered nurse; however, it lacked a physician's signature for the order. Staff D stated in an interview at the time of the review that this was emailed to this practitioner several times for signature; however, it was never signed as per policy.

Based on staff interview, policy review, and review of incident reports, the hospital failed to ensure the quality assessment and improvement program (QAPI) measured, tracked, and analyzed physical restraints for utilization review for two of two patients reviewed with physical restraints (Patient #6 and #9). The census was 17.

Findings include:

Review of the policy and procedure titled, "Incident Notification and Review" Revised 02/11/15 revealed "the employee witnessing and/or discovering a critical reportable or non-critical incident shall complete and forward an Incident Report to the nurse as soon as possible to the time of the incident and/or before the end of the assigned shift or workday. The nurse shall review the Incident Report for completeness and accuracy and notify the shift supervisor immediately. The shift supervisor shall review the Incident Report for completeness and accuracy, sign off for review and place the report in the designated are prior to the end of the shift. The Director of Compliance or designee shall pick up the Incident Report(s) from the designated area the next business day." "The Director of Compliance or designee shall complete an internal fact finding, when applicable. The Director of Compliance or designee shall submit the completed fact finding report to the Executive Committee to determine the finding." "The Director of Compliance shall notify the Client Rights Committee of all incidents and/or allegations of patient neglect, abuse, sexual assault, and/or other client rights violations for Committee review and recommendations to the Quality Improvement Committee. The Quality Improvement Committee shall review monthly reportable and non-reportable incidents and, in accordance with Health and Safety and Client Rights Committee recommendations, take actions to correct deficiencies and enhance the physical and emotional well-being of patients, employees and visitors."

1. Review of the medical record for Patient #6 revealed the patient was admitted for suicidal ideation on 10/29/18 after wanting to cut his/her throat. Review of an incident report dated 11/18/18 at 10:45 PM revealed a peer to staff assault in which the staff member used a physical restraint by placing the patient's arm behind the patient's back. Staff B stated in an interview on 03/22/19 at 11:10 AM the mental health associate completed an incident report; however, he/she failed to give it to the registered nurse therefore the incident report was never tracked as a physical restraint.

2. Review of the medical record for Patient #9 revealed the patient was admitted on 01/01/19 for suicidal and homicidal ideation. Review of an incident report on dated 01/05/19 at 2:40 PM revealed the patient was involved in a peer to peer altercation. The patient was placed in a hold restraint (Brace-standing) by a staff member. There was no incident report documented for the involved patient.

Based on medical record review, staff interview, and policy review, the hospital failed to ensure a comprehensive lethality assessment was completed upon admission for nine of ten patient medical records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8 and #10) and physical assessments of patients were completed following an assault and/or injury for four of ten patient medical records reviewed (Patient #3, #4, #6, and #10). The census was 17.

Findings include:

Review of the policy and procedure titled, "Nursing Standards of Care" Revised: 06/04/12, 01/05/14, 05/27/15 revealed "Standard of Care: The patient is assessed by the nurse in a timely, comprehensive, accurate, and systematic manner. Standard of Nursing Practice: The nurse continuously and systematically collects, records, and analyzes data that are comprehensive and accurate."

Review of the policy and procedure titled, "Lethality/Suicide Risk Assessment" Revised 07/19/16 revealed the policy was "to assure the safety of each patient served in the acute inpatient hospital. A Comprehensive Lethality/Suicidal Risk Assessment must be completed within the first eight hours of admission. A Daily Lethality Assessment will be completed every shift or as frequent as necessary during the stay."

Staff E stated in an interview on 03/22/19 at 10:45 AM the facility migrated to an electronic health records system in April 2018. Further, the Comprehensive Suicide/Homicide Risk Assessment that was developed for the electronic health records system when built included the lethality assessment. Once the system went live the lethality assessment was not included into the electronic form. Staff were using a separate form to complete the lethality assessment which was not being completed upon admission. Staff E stated there may be a computer glitch in the the electronic health records system.

1. Review of the medical record for Patient #1, completed on 03/22/19, revealed the patient was admitted to the residential unit on 05/16/18 and transferred to the Medicare certified inpatient unit on 01/03/19 at 4:11 PM. The patient had a history of aggressive behaviors and sexual misconducts, and the patient was a registered sex offender. Review of the medical record revealed the lethality assessment was not completed until 01/05/19 at 9:57 AM. This finding was confirmed with Staff D on 03/22/19 at 10:55 AM.

2. Review of the medical record for Patient #2 revealed the patient was admitted to the inpatient psychiatric unit on 01/02/19 from an emergency department due to suicidal ideation. The patient had a prior suicide attempt several months prior by cutting/self injurious behaviors. Review of the medical record revealed the lethality assessment was not completed until 01/04/19. This finding was confirmed with Staff D on 03/20/19 at 3:45 PM.

3. Review of the medical record for Patient #3 revealed the patient was admitted to the inpatient psychiatric unit on 01/21/19 from an emergency department due to suicidal ideation. The patient reported being a target for physical attacks due to being homosexual. The patient also reported flashbacks, nightmares, and hypervigilence due to being sex-trafficked at the age of ten. Review of the medical record revealed no comprehensive suicide/homicide risk assessment upon admission. In addition, the lethality risk assessment was not completed until 01/23/19. Review of an incident report dated 02/11/19 revealed a peer to staff assault. The medical record lacked evidence the patient was assessed for injury following the incident. These findings were confirmed in an interview with Staff D on 03/20/19 at 3:55 PM.

4. Review of the medical record for Patient #4 revealed the patient was admitted on 11/12/18 following an overdose of pills. The medical record revealed the lethality assessment was not completed until 11/14/18. In addition, review of an incident report dated 11/13/18 noted the patient "tripped" in the day room and chipped a piece of his/her tooth. Review of a nutrition assessment on 11/15/18 revealed the patient did in fact have a chipped tooth and several loose teeth. The medical record lacked evidence the nurse notified the physician of the injury as the patient was not examined by a licensed practitioner until 11/16/18. These findings were confirmed with Staff D on 03/22/19 at 10:32 AM.

5. Review of the medical record for Patient #5 revealed the patient was admitted for suicidal and homicidal ideation on 02/10/19. The patient reported he/she was going to bang his/her head on the wall along with cutting his/her wrists to commit suicide. The patient also reported homicidal gestures towards siblings in the residence such as wanting to suffocate his/her brother with a pillow and scare his/her sister with an axe. The medical record revealed the lethality assessment was not completed until 02/12/19. This finding was confirmed with Staff D on 03/22/19 at 10:43 AM.

6. Review of the medical record for Patient #6 revealed the patient was admitted for suicidal ideation on 10/29/18 after wanting to cut his/her throat. The medical record revealed the lethality assessment was not completed until 10/31/18. In addition, review of an incident report dated 11/18/18 at 10:45 PM revealed a peer to staff assault in which the staff used restraint by placing the patient's arm behind the patient's back. The medical record lacked evidence the patient was assessed for any injury following the incident. This finding was confirmed with Staff D on 03/22/19 at 10:55 AM.

7. Review of the medical record for Patient #7 revealed the patient was transferred to the facility for an emergency admission from an emergency department on 11/24/18. The patient reported his/her best friend committed suicide two months previously by shooting himself/herself in the head. Per the mother's report the patient was becoming more depressed, increased drug use, and reporting he/she was going to commit suicide by overdosing on pills and/or " blowing his brains out just as the friend did." The medical record revealed the lethality assessment was not completed until 11/25/18. This finding was confirmed with Staff D on 03/22/19 at 11:08 AM.

8. Review of the medical record for Patient #8 revealed the patient was incarcerated in a juvenile detention facility and attempted suicide by hanging. The patient reportedly was rescued by two guards and was found turning blue. The patient was then transferred to a higher observation level in the detention facility where the second suicide attempt was made by hanging. The patient was then transferred to a local hospital for further evaluation where he/she was admitted for several days. Once discharged from the hospital the patient was transferred to the inpatient psychiatric unit on 03/18/19 where the patient voiced a clear suicide plan to the nurse on admission. The medical record revealed the lethality assessment was not completed until 03/20/19. This finding was confirmed with Staff D on 03/22/19 at 11:16 AM.

9. Review of the medical record for Patient #10 revealed the patient was admitted on 02/11/19 for suicidal ideation. The patient reportedly had an altercation with his/her mother and the mother made a rottweiler dog attack the patient. The patient then began cutting his/her self and posted a picture on social media of the self injurious behaviors stating he/she was going to commit suicide. Review of the medical record revealed the lethality assessment was not completed until the following morning on 02/12/19. Further, Patient #10 was physically assaulted by another patient on 02/17/19, but the patient was not assessed for any injury following the incident. This finding was confirmed with Staff D on 03/22/19 at 10:43 AM.