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Based on record review and interview, the psychiatric hospital failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice is evidenced by failure to report and investigate the case of a threat against a nurse involving a firearm.
Findings:

Pursuant to LA RS 40:2199.16 acts of workplace violence at licensed healthcare facilities reporting required. A. Each regulated entity shall report to the proper authority, as required by the entity's workplace violence prevention plan, any instance of workplace violence that occurs on its property. B. If an instance of workplace violence at a regulated entity's facility results in injury, involves the use of a firearm or other dangerous weapon, or presents an urgent or emergent threat to the welfare, health, or safety of facility personnel, the regulated entity shall report the incident within twenty-four hours.

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.

On 12/03/2024 at 3:10 p.m., a request was made for the psychiatric hospital's policy on workplace violence prevention and reporting requirements. S1DON indicated that the hospital did not have a policy on work place violence and required reporting.

Review of hospital document titled "Case: 990-Internal Incident/Unusual Occurrence Form/Workplace Violence and Safety: Aggressive/Violent Behavior by Patient", initiated on 11/08/2024, revealed in part: On 11/08/2024 at 1:00 p.m., Patient #R1 was demanding to see MD. When informed that MD was not in the hospital, he began threatening staff and pounding on partition surrounding nurses' station. PRN medication was administered. Patient #R1 then stated that he would "call his people" and "catch the nurse in the parking lot". Patient #R1 made threatening statements that he would shoot S7RN when he was discharged and "leave him on a stretcher".

In an interview on 12/02/2024 at 3:05 p.m., S1DON indicated she did not submit a self-report for this incident because no harm came to S7RN. S1DON confirmed the hospital did not call the police regarding this threat made to S7RN. S1DON stated there was no need for further analysis of the situation "because patients threaten to shoot nurses everyday".

Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
1) failure of the hospital to provide continuous line of sight and 1:1 supervision as ordered by the physician for 3 (#2, #7 and #R3) of 3 (#2, #7 and #R3) psychiatric patients with physician orders for line of sight and 1:1 supervision (See findings under A-0144);
2) failure to provide a focused assessment on Patient #1 following a claim of sexual assault (See findings under A-0145);
3) failure to ensure patients did not have access to items that could cause harm to themselves (See findings under A-0144);
4) failure to test glucometer controls to meet the safety needs of the patients (See findings under A-0144);
5) failure to ensure each patient received an armband for accurate identification per hospital policy (See findings under A-0144); and
6) failure to ensure the patient /patient representative was included in the development and implementation of the patient's plan of care for 5 (#1, #3-#6) of 5 (#1, #3-#6) patients reviewed for care plan participation. (See findings under A-0130).

Based on record review and interview, the psychiatric hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure the patient /patient representative was included in the development and implementation of the patient's plan of care for 5 (#1, #3-#6) of 6 (#1- #6) patients reviewed for care plan participation.
Findings:

Review of the psychiatric hospital's policy titled "Patient Rights ", Revised: 03/21/2018, revealed in part: "Policy: ...In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to: ...7. Participate in the development and implementation of his or her plan of care".

Review of Patient #1's medical record revealed an admission date of 10/30/2024 with diagnosis of bipolar, schizophrenia, homicidal ideations, auditory hallucinations, visual hallucinations and urinary tract infection.

Review of Patient #1's medical document titled "Master Treatment Plan" initiated on 10/30/2024, failed to reveal evidence of Patient #1's signature or Patient #1 representative's signature indicating participation in her plan of care.

Review of Patient #3's medical record revealed an admission date of 11/06/2024 with diagnosis of bipolar disorder, current episode manic severe with psychotic features.

Review of Patient #3's medical document titled "Master Treatment Plan" initiated on 11/06/2024, failed to reveal evidence of Patient #3's signature or Patient #3 representative's signature indicating participation in his plan of care.

Review of Patient #4's medical record revealed an admission date of 11/01/2024 with diagnosis of suicidal ideations.

Review of Patient #4's medical document titled "Master Treatment Plan" initiated on 11/01/2024, failed to reveal evidence of Patient #4's signature or Patient #3 representative's signature indicating participation in his plan of care.

Review of Patient #5's medical record revealed an admission date of 11/02/2024 with diagnosis of bipolar disorder, current episode depressed, severe, with psychotic features and adverse effect of amphetamines, sequela.

Review of Patient #5's medical document titled "Master Treatment Plan" initiated on 11/02/2024, failed to reveal evidence of Patient #5's signature or Patient #3 representative's signature indicating participation in his plan of care.

Review of Patient #6's medical record revealed an admission date of 11/01/2024 with diagnosis of bipolar disorder, current episode depressed, severe, with psychotic features, depression, and suicidal ideations.

Review of Patient #6's medical document titled "Master Treatment Plan" initiated on 11/01/2024, failed to reveal evidence of Patient #6's signature or Patient #3 representative's signature indicating participation in his plan of care.

During an interview on 12/03/2024 at 3:00 p.m., S1DON confirmed the Master Treatment Plans for Patients #1, and #3-#6 failed to reveal patient/patient representative signatures indicating participation in the plans of care.

Based on observation, record review, and interview, the psychiatric hospital failed to ensure patients received care in a safe setting as evidenced by:
1) failure to provide continuous line of sight and 1:1 supervision as ordered by the physician for 3 (#2, #7 and #R3) of 3 (#2, #7 and #R3) psychiatric patients with physician orders for line of sight and 1:1 supervision;
2) failure to ensure patients did not have access to items that could cause harm to themselves.
3) failure to test glucometer controls to meet the safety needs of the patients; and
4) failure to ensure each patient received an armband for accurate identification per hospital policy.
Findings:

Review of psychiatric hospital's policy titled "Patient Rights", revised 03/21/2018, revealed in part: "Policy, in part: In accordance with Louisiana Licensing Regulations for Hospitals §9319 every patient has the right to, in part: 19. Receive care in a safe setting."

1) Failure to provide continuous line of sight and 1:1 supervision as ordered by the physician for 3 (#2, #7 and #R3) of 3 (#2, #7 and #R3) psychiatric patients with physician orders for line of sight and 1:1 supervision.
Review of psychiatric hospital's policy titled "Levels of Observation", revised 06/13/2024, revealed in part: "Policy, in part: The safety of patients is a priority during hospitalization. Beacon Behavioral Hospital's inpatient program ensures patient safety through a level of monitoring and observation matched to patient's need and assessed risk. In the inpatient setting, surveillance of common areas (such as hallways, dayrooms, etc.) may be monitored via camera (i.e., video surveillance). At no time is this type of surveillance to be used as a replacement of the levels of observation for any patient, who must be directly observed, in-person, according to prescriber orders. Procedure, in part: Line of Sight: Observation is defined as always maintaining visual observation of a patient. One-to-One (1:1): Observation is maintained when a patient is considered at high risk and requires observation by a staff member dedicated only to that patient (One staff member to Obne patient). The staff member assigned to 1:1 cannot be assigned any other patients or tasks during that period. Assessment and Determination of Needs, in part: 6. Patient rounds will be assigned to specific staff members on each shift by the Charge RN. "

Review of psychiatric hospital document titled "Daily Nursing Assignment Sheet", dated 10/26/2024 PM shift, revealed S11MHT was assigned to Patients #R4-#R9 and #R20. Continued review revealed S3MHT was assigned only to Patient #R3 who was on observation level 1:1.

Review of psychiatric hospital document titled "Daily Nursing Assignment Sheet", dated 10/26/2024 PM shift, revealed Patients #R4-#R10, #R17 and #R20 were assigned to Hallway 'A'. Patients #7, #R1, #R11, #R13 and #R21 were assigned to Hallway 'B'. Patients #R3, #R10, #R12, #R14, #R15, #R16, #R18, and #R22 were assigned to Hallway 'C'.

Review of psychiatric hospital document titled "Daily Nursing Assignment Sheet", dated 11/09/2024 PM shift, failed to reveal patients were assigned a mental health technician.

Patient #2
Review of psychiatric hospital document titled "Hospital / Licensed Provider Abuse/Neglect Initial Report", submitted 11/17/2024, revealed documented video observations dated 11/09/2024 detailing the following:
8:30 p.m.-8:34 p.m.-Patient #1 and Patient #2 observed in the dayroom (lights off with limited visual). Close in proximity.
8:34 p.m.-8:36 p.m.-S3MHT, who was assigned to Patient #2 for Line of Sight observations, entered dayroom standing in the doorway as Patient #1 and Patient #2 approached him in conversation. (No audio). S3MHT then walked out of the dayroom. Patient #1 and Patient #2 danced in the entryway. Patient #2 hands on waist turned Patient #1 and hugged her from behind as they continued dancing. They then walked down towards the smoke break area.
9:02 p.m.-Patient #1 and Patient #2 are seen shuffling quickly down Hallway 'B' entering Patient #1's assigned room. Patient #2 remained in her room for 30 seconds and then exited. He is seen running down the hall back to his assigned room.

Review of psychiatric hospital document titled "Line of Sight Close Observation Form", dated 11/09/2024 for Patient #2, failed to reveal observations completed between 7:15 p.m. and 6:45 a.m.

In an interview on 12/03/2024 at 9:48 a.m., S1DON confirmed the above findings.

Patient #7
Review of psychiatric hospital document titled "Behavioral Health-Patient Observation Sheet", dated 10/26/2024 revealed Patient #7 was on Line of Sight (LOS) observations. S11MHT observed Patient #7 (on Hallway 'B') at 7:34 p.m., 7:43 p.m., 7:58 p.m., 8:12 p.m., 8:23 p.m., 8:33 p.m., 8:43 p.m., 8:53 p.m., 9:04 p.m., 9:16 p.m., 9:27p.m., 9:36 p.m., 9:46 p.m. and 9:58 p.m.
S3MHT observed Patient #7 at 10:13 p.m., 10:22 p.m., 10:35 p.m., 10:49 p.m., 11:02 p.m., 11:16 p.m., 11:31 p.m., 11:46 p.m., 11:57 p.m., 12:12 a.m., 12:27 a.m., 12:40 a.m., 12:54 a.m., and 1:07 a.m.

Review of psychiatric hospital document titled "Behavioral Health-Patient Observation Sheet", dated 10/26/2024 revealed S11MHT also observed Patient #R10 (on Hallway 'C') at 7:30 p.m., 7:40 p.m., 7:55 p.m., 8:09 p.m., 8:25 p.m., 8:35 p.m., 8:46 p.m., 8:53 p.m., 9:04 p.m., 9:19 p.m., 9:31 p.m., 9:44 p.m. and 9:57 p.m. while on line of sight observation duty for Patient #7.
S3MHT observed Patient #R10 at 10:11 p.m., 10:21 p.m., 10:33 p.m., 10:48 p.m., 11:01 p.m., 11:15 p.m., 11:30 p.m., 11:45 p.m., 11:55 p.m., 12:11 a.m., 12:26 a.m., 12:39 a.m., 12:53 a.m., and 1:06 a.m. while on line of sight observation duty for Patient #7 and 1:1 observation duty for Patient #R3.

Review of psychiatric hospital document titled "Behavioral Health-Patient Observation Sheet", dated 10/26/2024 revealed S11MHT also observed Patient #R22 (on Hallway 'C') at 7:29 p.m., 7:39 p.m., 7:53 p.m., 8:08 p.m., 8:21 p.m., 8:34 p.m., 8:46 p.m., 8:53 p.m., 9:04 p.m., 9:13 p.m., 9:17 p.m., 9:31 p.m., 9:44 p.m. and 9:57 p.m. while on line of sight observation duty for Patient #7.
S3MHT observed Patient #R22 (on Hallway 'C') at 10:11 p.m., 10:21 p.m., 10:33 p.m., 10:48 p.m., 11:01 p.m., 11:15 p.m., 11:30 p.m., 11:46 p.m., 11:45 p.m., 11:55 p.m., 12:11 a.m., 12:25 a.m., 12:39 a.m., 12:52 a.m., and 1:06 a.m. while on line of sight observation duty for Patient #7 and 1:1 observation duty for Patient #R3.

Review of psychiatric hospital documents titled "Behavioral Health-Patient Observation Sheet", dated 10/26/2024 revealed S11MHT also observed Patients #R4-#R9 and #R12-#R22 in the same time span as he was observing Patient #7 on LOS.

Review of psychiatric hospital documents titled "Behavioral Health-Patient Observation Sheet", dated 10/26/2024 revealed S3MHT also observed Patients #R4-#R9 and #R12-#R22 in the same time span as he was observing Patient #7 on LOS and Patient #R3 on 1:1.

Patient #R3
Review of psychiatric hospital document titled "Close Observation Form", dated 10/25/2024 revealed Patient #R3 (on Hallway 'C') was on observation level 1:1. Further review failed to reveal he was observed during the timeframe between 11:00 p.m. and 1:00 a.m.

Review of psychiatric hospital document titled "Close Observation Form", dated 10/26/2024 revealed Patient #R3 was on observation level 1:1. Further review revealed S3MHT initialed 1:1 observations every 15 minutes between 7:15 p.m.-6:45 a.m.

Review of psychiatric hospital documents titled "Behavioral Health-Patient Observation Sheet", dated 10/26/2024 revealed S3MHT also observed Patients #7, #R4-#R9 and #R12-#R22 in the same time span as he was observing Patient #R3 on a 1:1 level.

In an interview on 12/02/2024 at 11:55 a.m., S1DON reported the hospital utilizes electronic system 'D' to keep track of patients and observations. The hospital is able to access the system and note when patients are observed. The system can track 1:1 and note when the patient is not being observed. All of the data is uploaded to a cloud and can be accessed at anytime.

In an interview on 12/03/2024 at 9:45 a.m. and 10:30 a.m., S1DON confirmed the above findings indicating patient observations were not safely implemented per physician orders and hospital policy. S1DON stated the video for the 10/26/2024 timeline was no longer available. S1DON verified S3MHT had been terminated.


2) Failure to ensure patients did not have access to items that could cause harm to themselves.
Review of psychiatric hospital's policy titled, "Admission to an Inpatient Program", revised on 05/01/2024 revealed in part: "Procedure, in part: Once the Patient is Accepted, in part: 6. A registered nurse meets with the patient (and accompanying individuals according to the patient's preference and the registered nurse's clinical judgement) in a room that affords privacy (not earshot of other patients and/or visitors and free of items that could cause harm to themselves or others) and conducts the Nursing Admission Assessment and obtains the patient's signatures on consents and forms, as indicated.

Review of psychiatric hospital's policy titled, "Control of Contraband and Dress Code", revised on 03/21/2018 revealed in part: "Policy, in part: Beacon Behavioral Hospital utilizes a number of methods for controlling the existence of Contraband, including, but not limited to, in part: Ensuring that patients do not have access to high-risk items. Contraband, in part: 1. Restricted items, in part: This category includes any items that a patient will be permitted to access during his hospitalization on a limited basis or with supervision. Items may be secured in a designated locked room or in the nurses' station. Generally included in this category are, in part: a. Toiletries: Toothpaste and Toothbrush. 2. Prohibited Items, in part: This category includes any items that a patient will not be permitted to access at any time while on the unit. Beacon Behavioral Hospital makes every attempt to send these items home with family. If that disposition cannot be accomplished, these items should be secured in a manner that does not allow patient access to them. c. Items that may be used for Asphyxiation, in part: Plastic bags.

On 12/02/2024 at 9:18 a.m., a shower chair made of PVC-type piping was observed unattended in the women's shower room located on Hallway 'B'. S12DM confirmed the finding stating the chair should not be left unattended in the shower room due to ligature risk and should be cleaned and bagged and placed in the equipment room after use.

On 12/02/2024 at 9:23 a.m., a toothbrush and tube of toothpaste were observed on a shelf in patient room 'c'. S12DM confirmed the findings and stated the items should be in a bucket with the patient's name in a locked closet with the other patient buckets.

On 12/02/2024 at 9:40 a.m., a shower chair made of PVC-type piping and linen cart also made of PVC-type piping were observed unattended in the men's shower room located on Hallway 'B'. S12DM confirmed the finding stating the unattended chair and linen cart should not be in the shower room due to ligature risk and should be cleaned and bagged and placed in the equipment room after use.

On 12/02/2024 at 9:45 a.m., pieces of thick plastic approximately 4 feet long and bubble wrap with potential for ligature risk were observed hanging out of a box against the wall of the Intake Room accessible to patients who are newly admitted. S12DM confirmed the findings and stated the box with the long pieces of plastic and bubble wrap contained medical equipment that will eventually be installed on the wall but should be removed immediately in case of an admission.

On 12/02/2024 at 9:48 a.m., a hard plastic toilet paper dispenser that was hanging open creating a ligature risk was observed in the shower room of Hallway 'C'. S12DM confirmed the findings and stated the entire dispenser should be removed considering there is no commode in the shower room.

On 12/02/2024 at 9:53 a.m., the nurses' station door in the dayroom was observed open and unattended with 2 bottles of bleach cleaner in the entryway accessible to the 4 patients using the dayroom. S12DM confirmed the nurses' station door was open and unattended and contained 2 bottles of bleach cleaner accessible to patients and should be locked in a cabinet to prevent patient access. S12DM verified the nurses' station door in the dayroom should always be locked and attended when patients are using the dayroom.

3) Failure to test glucometer controls to meet the safety needs of the patients.
On 12/02/2024 at 9:30 a.m., review of the hospital's Glucometer Calibration and Control Logs located in the medication room failed to reveal documentation that quality controls were consistently performed.

Review of psychiatric hospital document titled "Blood Glucose Daily Quality Control Log", dated, December, failed to reveal documentation that quality controls were performed on 12/01/2024 and 12/02/2024.

Review of psychiatric hospital document titled "Blood Glucose Daily Quality Control Log", dated, November, failed to reveal documentation that quality controls were performed on 11/04/2024 thru 11/05/2024; 11/08/2024 thru 11/15/2024; and 11/17/2024 thru 11/27/2024.

Review of psychiatric hospital document titled "Blood Glucose Daily Quality Control Log", dated, October, failed to reveal documentation that quality controls were performed on 10/02/2024 thru 10/03/2024; 10/05/2024 thru 10/11/2024; 10/13/2024; 10/16/2024; 10/19/2024 thru 10/23/2024; and 10/27/2024 thru 10/31/2024.

Review of psychiatric hospital document titled "Blood Glucose Daily Quality Control Log", dated, September, failed to reveal documentation that quality controls were performed on 09/02/2024 thru 09/03/2024; 09/07/2024; 09/11/2024; 09/21/2024 thru 09/24/2024; and 09/27/2024 thru 09/30/2024.

During an interview on 12/02/2024 at 9:30 a.m., S13LPN and S12DM confirmed the above findings. S13LPN stated the quality controls were to be perfomed every day. S13LPN verified she had several patients on the census requiring accuchecks.

On 12/02/2024 at 9:30 a.m. surveyor requested a list of patients on the census requiring Accuchecks from S13LPN.
On 12/02/2024 at 3:30 p.m. surveyor requested a list of patients on the census requiring Accuchecks from S1DON.
On 12/03/2024 at 2:15 p.m. surveyor requested a list of patients on the census requiring Accuchecks from S1DON.

Surveyor was not provided a list of patients on the census requiring Accuchecks as requested 3 times.

4) Failure to ensure each patient received an armband for accurate identification per hospital policy.
Review of psychiatric hospital's policy titled "Medication and Treatment Administration", approved 01/25/2024, revealed in part: "Procedure-Inpatient, in part: 4. As each patient approaches the medication nurse, the nurse will identify the patient by the following methods, in part: c. Check the patient's wristband."

On 12/02/2024 at 9:20 a.m., an armband was observed laying on a shelf in room 'c' with Patient #R23's name.

In an interview on 12/02/2024 at 9:21 a.m., Patient #R23 stated the armband was from the previous hospital she was admitted to before she was admitted to the psychiatric hospital. She stated she had not received a new armband since admission on 11/25/2024. Patient #R23 verified she was administered medications and was not asked to show her armband for identification purposes.

In an interview on 12/02/2024 at 9:23 a.m., S12DM and S13LPN both verified the hospital had not used armbands for over a year. S13LPN reported the process to identify a patient for medication administration included the nurse writing the name of each patient on a Styrofoam cup. The nurse would look at the picture of the patient in the computer to identify the patient and then administer the medication in the Styrofoam cup. S12DM indicated the hospital should be using armbands and are in the process of implementing there use.

Based on observation, record review and interview, the hospital failed to ensure all patients were free from all forms of abuse or neglect. This deficiency is evidenced by failure to provide a focused assessment on Patient #1 following a claim of sexual assault.

Review of psychiatric hospital's policy titled "Ongoing Nursing Assessments", revised 03/21/2018, revealed in part: "Policy, in part: In addition to the comprehensive assessment conducted on each shift, the registered nurse will conduct focused assessments in response to the patient, in part: Demonstrating or verbalizing indications that the patient has been assaulted or has engaged in high-risk behavior during hospitalization."

Review of Patient #1's medical record revealed an admission date of 10/30/2024 with diagnosis of Bipolar, Schizophrenia, Homicidal ideations, Auditory hallucinations, Visual hallucinations and Urinary tract infection (UTI). Patient #1 noted with history of trauma involving sexual abuse as a child.

Review of nursing note dated 11/10/2024 at 8:00 a.m., S5RN documented that Patient #1 was having a verbal altercation with male peer, accusing him of coming into her room and sexually assaulting her on the previous shift. Patient was interviewed to determine what actually happened and when. Patient #1 reported that the incident happened on the night of 11/09/2024 when the male peer went into her room. Patient #1 stated, "He flipped his dick out and because I am a meth addict, I sucked it." She then stated, I want to report what he did and I want to press charges against him." Psychiatry and Medical, along with DON notified of this incident. No new orders noted.

Review of Patient #1's medical record failed to reveal a focused assessment in response to the patient demonstrating and verbalizing indications that she had been assaulted during her hospitalization.

During an interview on 12/03/2024 at 2:50 p.m., S1DON confirmed the medical record failed to reveal a focused assessment in response to Patient #1 demonstrating and verbalizing indications that she had been assaulted during her hospitalization.

Based on record review and interview, the psychiatric hospital failed to recognize patient safety issues through the Quality Assurance and Performance Improvement (QAPI) review process. The deficient practice is evidenced by:
1) failure to identify, discuss, create and implement an action plan to prevent sexual assault from occurring on site.; and
2) failure to identify, discuss, and create an action plan to ensure the assignment of a mental health technician to all patients on the census.
Findings:

Review of psychiatric hospital policy titled "Performance Improvement", revised 01/23/2024, revealed, in part: "Purpose, in part: The purpose of the organizational Quality Assurance and Performance Improvement Plan at Beacon Behavioral is to ensure that he Governing Body, medical staff, and service staff (both professional and unlicensed) demonstrate the consistent delivery of safe, effective, optimal patient care and services in an environment of minimal risk. Goals of Quality Assurance and Performance Improvement, in part: Monitor/track the status of identified problems and action plans to assure sustained improvement and/or problem resolution; systematically and routinely evaluate unusual occurrences/incidents, the findings of QAPI activities, and any adverse patient events to detect trends, patterns of performance, or potential problems that affect at least one (1) department/service. Quality Assurance and Performance Improvement Team Scope of Activities, in part: Safety management; patient care and quality control activities in the following services are monitored, assessed, and evaluated, in part: Nursing services. Assessment of the performance of the following patient care and organizational functions are included, in part: Nursing, Provision of Care, Treatment and Services, Rights and Responsibilities of the Individual. Organization, in part: The QAPI Team is responsible for the implementation and monitoring of the effectiveness of Patient Safety Initiatives. The scope of such initiatives includes ongoing assessment, the use of internal and external knowledge and experience to prevent errors from occurrence, and maintaining and improving patient safety. Patient safety information, from aggregated data reports and individual incident occurrence reports, will be reviewed by the Committee of the Whole to prioritize organizational patient safety activity efforts. Included in the duties of the Committee of the Whole will be a review of these data reports.

1) Failure to identify, discuss, create and implement an action plan to prevent sexual assault from occurring on site.

Review of psychiatric hospital document titled "Hospital/Licensed Provider Abuse/Neglect Initial Report", submitted on 11/17/2024 revealed a substantiated allegation of patient-to-patient sexual abuse. The self-report indicated an action plan that included a locking case to be installed on the light switch in the dayroom by 11/22/2024 to prevent patient access.

Review of psychiatric hospital document titled "Committee of the Whole Meeting Minutes and Agenda", dated 11/20/2024 revealed in part: Topic-Sexual Assault onsite. [Occurences] 0. Action Plan: No action needed. Unsubstantiated claim.

On 12/02/2024 at 9:56 a.m., observations of the light switch in the dayroom failed to reveal a locking case installed to prevent patient access as indicated on the self-report.

In an interview on 12/02/2024 at 9:56 a.m., S12DM verified the light switch did not have a locking case installed to prevent patient access.

2) Failure to identify, discuss, and create an action plan to ensure the assignment of mental health technicians to all patients on every shift.
Review of psychiatric hospital documents titled "Daily Nursing Assignment Sheet" for September 2024 failed to reveal patients were assigned a mental health technician on 5 shifts.

Review of psychiatric hospital documents titled "Daily Nursing Assignment Sheet" for October 2024 failed to reveal patients were assigned a mental health technician on 14 shifts.

Review of psychiatric hospital documents titled "Daily Nursing Assignment Sheet" for November 2024 failed to reveal patients were assigned a mental health technician on 17 shifts.

Review of psychiatric hospital document titled "Committee of the Whole Meeting Minutes and Agenda", dated 11/20/2024 failed to reveal the above safety issue was identified, discussed, and an action plan created to ensure the assignment of a mental health technician to all patients on the census.

In an interview on 12/03/2024 at 3:45 p.m., S1DON reported the above issues would be addressed at the next meeting in December.

Based on record review and interview the psychiatric hospital failed to ensure a registered nurse developed a written assignment of nursing care for each patient to other nursing personnel in accordance with the patient's needs. This deficiency is evidenced by failing to assign nursing personnel to each patient.
Findings:

Review of psychiatric hospital policy titled "Nursing Service", revised 08/11/2023, revealed, in part: "Policy, in part: Inpatient Units, in part: The registered nurse develops a written assignment at the start of each shift. The assignment may be updated throughout the shift, as needed. The registered nurse assigns patient care to nursing staff members based on: The individualized needs of the patient; the training and skills of the staff member; the scope of practice of the staff member; and other issues, as applicable (e.g. identified transference, etc.)."

Review of psychiatric hospital documents titled "Daily Nursing Assignment Sheet" for September 2024 failed to reveal patients were assigned a mental health technician on the following 5 shifts:
09/10/2024 AM shift.
09/13/2024 AM shift.
09/19/2024 AM shift.
09/19/2024 PM shift.
09/20/2024 AM shift.

Review of psychiatric hospital documents titled "Daily Nursing Assignment Sheet" for October 2024 failed to reveal patients were assigned a mental health technician on the following 14 shifts:
10/07/2024 AM shift.
10/08/2024 PM shift.
10/09/2024 AM shift.
10/13/2024 AM shift.
10/14/2024 AM shift.
10/16/2024 PM shift.
10/17/2024 AM shift.
10/22/2024 AM shift.
10/26/2024 AM shift.
10/27/2024 AM shift.
10/27/2024 PM shift.
10/28/2024 AM shift.
10/31/2024 AM shift.
10/31/2024 PM shift.

Review of psychiatric hospital documents titled "Daily Nursing Assignment Sheet" for November 2024 failed to reveal patients were assigned a mental health technician on the following 17 shifts:
11/01/2024 AM shift.
11/03/2024 AM shift.
11/05/2024 PM shift.
11/06/2024 AM shift.
11/08/2024 PM shift.
11/09/2024 AM shift.
11/09/2024 PM shift. (Of note, this is the date and shift when the incident involving patient #1's sexual assault occurred).
11/10/2024 AM shift.
11/10/2024 PM shift.
11/19/2024 AM shift.
11/20/2024 AM shift.
11/24/2024 AM shift.
11/25/2024 AM shift.
11/28/2024 AM shift.
11/29/2024 AM shift.
11/29/2024 PM shift.
11/30/2024 AM shift.

During an interview on 12/02/2024 at 12:02 p.m., S1DON indicated the mental health technicians determine which patients they are responsible for based on the completed assignment sheet provided to them by the registered nurse at the beginning of each shift. S1DON confirmed the above assignment sheets revealed patients without assigned mental health technicians.

Based on record review and interview, the psychiatric hospital failed to ensure that verbal/telephone orders were used infrequently and were not a common practice as evidenced by the consistent use of verbal/telephone orders by the admitting physician for 7 (#1-#7) of 7 (#1-#7) records reviewed.
Findings:

Review of Patient #1's Medical Record revealed admission date 10/30/2024 with verbal orders on the following dates: 10/30/2024 (admit orders), 11/01/2024, 11/02/2024, and 11/09/2024.

Review of Patient #2's Medical Record revealed admission date 11/04/2024 with verbal orders on the following dates: 11/04/2024 (admit orders), 11/05/2024, 11/08/2024, and 11/13/2024.

Review of Patient #3's Medical Record revealed admission date 11/06/2024 with verbal orders on the following dates: 11/05/2024 (admit orders), 11/06/2024 (admit orders), 11/07/2024, 11/11/2024, and 11/12/2024.

Review of Patient #4's Medical Record revealed admission date 11/01/2024 with verbal orders on the following dates: 11/01/2024 (admit orders), 11/03/2024, and 11/08/2024.

Review of Patient #5's Medical Record revealed admission date 11/02/2024 with verbal orders on the following dates: 11/02/2024 (admit orders), 11/03/2024, 11/04/2024 and 11/10/2024.

Review of Patient #6's Medical Record revealed admission date 04/01/2024 with verbal orders on the following dates: 04/01/2024 (admit orders).

Review of Patient #7's Medical Record revealed admission date 10/26/2024 with verbal orders on the following dates: 10/26/2024 (admit orders) and 10/27/2024.

During an interview on 12/03/2024 at 11:33 a.m. S5RN stated that all admission orders are verbal orders for standing orders previously approved by the physicians. S5RN reported the nurses call the physician to approve the standing orders and medications but do not usually document that the physician was notified of the admission or that the verbal orders were confirmed.

During an interview on 12/03/2024 at 12:18 p.m., S9PA and S10MD verified that all of the admit orders were verbal orders.

Based on record review and interview, the psychiatric hospital failed to ensure each patient had an individualized and comprehensive treatment plan for 3 (#1, #3, and #4) of 5 (#1, #3-#6) treatment plans reviewed. This deficiency is evidenced by failure to include all medical and psychiatric diagnoses as part of an individualized and comprehensive treatment plan.
Findings:

Review of hospital policy titled "Nursing Services", revised 08/11/2023, revealed, in part: "Policy, in part: Throughout the assigned shift, it is the responsibility of the registered nurse to, in part: Develop or update treatment plans as per hospital policy."

Review of hospital policy titled "Assessment for Abuse, Neglect, and Domestic Violence", revised 03/21/2018, revealed, in part: "Procedure, in part: 1. If, during an assessment or any other interaction, the patient discloses having been the victim or perpetrator of, or witness to, abuse, neglect, or domestic violence, the professional is expected to obtain as much information as possible without knowingly causing detriment to the patient. 5. The Multidisciplinary Treatment Plan will be updated as indicated.

Patient #1
Review of Patient #1's medical record revealed an admission date of 10/30/2024 with diagnosis of Bipolar, Schizophrenia, Homicidal ideations, Auditory hallucinations, Visual hallucinations and Urinary tract infection (UTI).

Review of Patient #1's Psychiatric Evaluation dated 10/31/2024 revealed patient #1 was withdrawing from methamphetamines with the diagnoses of schizoaffective disorder, bipolar type and methamphetamine use disorder.

Review of History and Physical dated 10/30/2024 revealed Patient #1 complained she was withdrawing with a urine drug screen (UDS) positive for tetrahydrocannabinol (THC) and methamphetamine. Diagnoses included Bipolar/Schizophrenia with psychosis and homicidal ideations, THC and methamphetamine use, Hyperglycemia, Hypokalemia and UTI.

Review of nursing note dated 11/10/2024 at 8:00 a.m., S5RN documented that Patient #1 was having a verbal altercation with male peer, accusing him of coming into her room and sexually assaulting her on the previous shift. Patient was interviewed to assess what actually happened. Patient #1 reported that the incident happened on the night of 11/09/2024 when the male peer went into her room. Patient #1 stated, "He flipped his dick out and because I am a meth addict, I sucked it." She then stated, I want to report what he did and I want to press charges against him." Psychiatry and Medical, along with DON notified of this incident.

Review of Patient #1's medical document titled "Master Treatment Plan" last reviewed on 11/04/2024, revealed the following "Active Problems":
1) altered thought process related to chronic mental illness, substance abuse, severe anxiety as evidenced by impaired judgment;
2) substance abuse related to addiction as evidenced by positive drug scree, self disclosure, recent history of substance abuse; and
3) depression/hopelessness related to addiction, multiple stressors as evidenced by homicidal ideation.

Continued review of "Master Treatment Plan" failed to reveal "Active Problems" related to the following:
1) sexual assault
2) withdrawal symptoms
3) urinary tract infection
4) hyperglycemia and
5) hypokalemia

Patient #3
Review of Patient #3's medical record revealed an admission date of 11/06/2024 with diagnosis of schizoaffective disorder.

Review of Patient #3's Psychiatric Evaluation dated 11/06/2024 revealed patient #3 was admitted for violent behavior, agitation and destroying property. Diagnoses included schizoaffective disorder, bipolar type and cannabis use disorder.

Review of History and Physical dated 11/06/2024 revealed Patient #3 was diagnosed with bipolar 1 /depression with psychosis/aggression, THC abuse, nicotine dependency, leukocytosis, and seizures (orders for seizure precautions noted).

Review of Patient #3's medical document titled "Master Treatment Plan" last reviewed on 11/12/2024, revealed the following "Active Problems":
1) altered thought process related to chronic mental illness as evidenced by psychotic symptoms; and
2) danger to others related to ineffective coping skills, impulsive as evidenced by threatening behavior, poor frustration tolerance, poor impulse control, irritability, and verbal outbursts.

Continued review of "Master Treatment Plan" failed to reveal "Active Problems" related to the following:
1) seizures,
2) cannabis use disorder,
3) leukocytosis, and
4) nicotine dependency

Patient #4
Review of Patient #4's medical record revealed an admission date of 11/01/2024 with diagnosis of schizoaffective disorder and bipolar disorder.

Review of Patient #4's Psychiatric Evaluation dated 11/01/2024 revealed patient #4 was admitted for suicidal ideation with a plan and homicidal ideation without a plan. Diagnoses included schizoaffective disorder, bipolar type, suicidal ideation, homicidal ideation and alcohol dependence. Continued review revealed a medical history of hypertension, mixed hyperlipidemia and seizures.

Review of Patient #4's medical document titled "Master Treatment Plan" last reviewed on 11/06/2024, revealed the following "Active Problems":
1) altered thought process related to chronic mental illness as evidenced by delusions, hallucinations, impaired judgment, psychotic symptoms;
2) depression/hopelessness related to isolation, homelessness, ineffective role performance, loss of a loved one, multiple stressors, inability to cope, negative life events as evidenced by decreased affect lack of motivation, suicidal ideation, and homicidal ideation; and
3) cardiac output, altered related to hypertension, hyperlipidemia as evidenced by acute symptoms and history of.

Continued review of "Master Treatment Plan" failed to reveal "Active Problems" related to the following:
1) seizures and
2) alcohol dependence.

During an interview on 12/03/2024 at 3:00 p.m., S1DON confirmed the treatment plans for Patients #1, #3-#6 failed to reveal individualized and comprehensive active problems related to the needs of each patient.