HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to:
- Ensure contraband (items that are illegal, forbidden, or that can be used to harm self or others) was secured and ligature-risks (anything which could be used for the purpose of hanging or strangulation) removed on two of two Behavioral Health Acute Care (BHAC) units observed; (A-0144)
- Ensure cabinets and drawers containing contraband items were locked and secure from patient access on two of two BHAC units observed; (A-0144)
- Ensure contraband items were monitored and accounted for on two of two BHAC units observed; (A-0144)
- Ensure a metal ceiling access panel, located above the bed in the seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) room, was secured on one of two BHAC units observed; (A-0144)
- Ensure a temporary construction wall was fastened with psychiatric (relating to mental illness)-safe screws on two of two BHAC units observed; (A-0144)
- Ensure the hard plastic corner wall trim was intact and not broken on one of two BHAC units observed; (A-0144)
- Ensure the patients were not in multiple layers of hospital gowns, scrubs or non-psychiatric safe clothing on two of two BHAC units observed; (A-0144)
- Ensure all furniture was psychiatric-safe on one of two BHAC units; (A-0144)
- Ensure all staff were educated following the elopement of two discharged patients (#32 and #33) of two elopements reviewed. (A-0144)
- Complete an incident report for a peer-to-peer assault for one discharged patient (#32) of one patient with an unreported event reviewed; and (A-0145)
- Ensure a thorough investigation was performed following an event report with allegations of abuse and neglect for two discharged patient (#32 and #40) of two allegations of abuse reviewed. (A-0145)

These failed practices resulted in the noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 02/11/25, the hospital provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included the removal of all contraband items from patient accessible areas and educated all current and oncoming BHAC unit staff regarding a psychiatric safe environment for behavioral health patients.

Please refer to A-0144 and A-0145.

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure contraband (items that are illegal, forbidden, or that can be used to harm self or others) was secured and ligature-risks (anything which could be used for the purpose of hanging or strangulation) removed on two of two Behavioral Health Acute Care (BHAC) units observed;
- Ensure cabinets and drawers containing contraband items were locked and secure from patient access on two of two BHAC units observed;
- Ensure contraband items were monitored and accounted for on two of two BHAC units observed;
- Ensure a metal ceiling access panel, located above the bed in the seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving) room, was secured on one of two BHAC units observed;
- Ensure a temporary construction wall was fastened with psychiatric (relating to mental illness)-safe screws on two of two BHAC units observed;
- Ensure the hard plastic corner wall trim was intact and not broken on one of two BHAC units observed;
- Ensure the patients were not in multiple layers of hospital gowns, scrubs or non-psychiatric safe clothing on two of two BHAC units observed;
- Ensure all furniture was psychiatric-safe on one of two BHAC units; and
- Ensure all staff were educated following the elopement of two discharged patients (#32 and #33) of two elopements reviewed.

Findings included:

Review of the hospital's policy titled, "Contraband on BHAC Units," dated 04/12/23, showed staff would conduct environmental rounds a minimum of once per shift, in addition to completing the environmental rounding form. Staff would document in the medical record when contraband was identified as belonging to a particular patient. Contraband or unauthorized items, such as items with sharp edges, torn sheets or clothing, alcohol and/or alcohol-based products (perfume), ligature risks (ropes, cords, scarves longer than six inches), any office supplies and any personal grooming devices. These items are not all inclusive but may be considered contraband if the item can be used by patients to harm themselves or someone else, or if the item poses a safety risk and/or interferes with the rights of others.

Review of the hospital's policy titled, "Rounds-Behavior Observation Record," dated 02/08/23, showed the hospital provided a safe and therapeutic milieu (a person's social environment) for all patients hospitalized on BHAC units (C and D). A trained BHAC staff member was assigned to monitor the location and behavior of all patients every shift on the BHAC units. The staff member assigned to conduct rounds, would observe, and monitor the overall milieu, the safety of the environment, the presence of contraband and the presence of extra linens.

Review of the hospital's document titled, "BHAC Environmental Rounds," dated 02/10/25, showed, on the BHAC Unit D, there was no contraband in patient rooms.

Review of the hospital's document titled, "BHAC Environmental Rounds," dated 02/11/25, showed, on the BHAC Unit D, there was no contraband in patient rooms.

Although requested, no environmental rounding documentation was provided for BHAC Unit C on 02/10/25 or 02/11/25.

Observation on 02/11/25 from 8:40 AM through 10:30 AM, in the BHAC Unit C showed:
- Unlocked drawers at the patient monitoring station, located in the center of the unit, containing 10 items of clothing (cloth hospital gowns, scrub shirts and pants) 10 wash cloths; an abundance of non-psychiatric safe toothbrushes, hair combs, hair brushes and travel sized toothpastes; a bag of 100, 12-inch plastic zip-ties; one bottle of alcohol based hand sanitizer; three pairs of rubber gloves; a five-inch round metal ring with four keys; a half of a bottle of alcohol-based perfume spray; one box of 100-count alcohol wipes; an abundance of toilet paper rolls; an abundance of brown paper sacks and a four-inch roll of plastic trash bags.
- Seven of 18 patients were dressed in multiple layers of cloth hospital gowns and scrubs or non-psychiatric-safe clothing.
- The hallway between the activity room and the kitchen/common room area was under construction. A temporary wall was in place, made of four pieces of sheet rock with a metal door. The sheet rock was attached with non-psychiatric-safe screws.
- In the seclusion room, above the bed, a four-foot by eight-foot metal utility access panel located in the ceiling. There was a ½ inch gap between the panel and the ceiling creating a ligature risk.
- In patient room 54, one hard plastic hairbrush, four toothbrushes, one 12-inch hair comb and several piles of loose notebook paper and notebooks were noted.
- In patient room 57, one hard plastic hairbrush, one toothbrush and one 12-inch hair comb were noted.
- In patient room 61, one toothbrush was noted.
- In patient room 49, one toothbrush and one 12-inch hair comb were noted.
- In patient room 66, one hard plastic hairbrush, one toothbrush and one 12-inch hair comb were noted.
- In patient room 63, one hard plastic hairbrush and one toothbrush were noted.
- In patient room 86, one hard plastic hairbrush and one 12-inch hair comb were noted.
- In patient room 89, a plastic mattress cover with a 15-inch tear was noted.
- In patient room 93, one 12-inch hair comb was noted.
- In patient room 94, one toothbrush and one one-ounce hard plastic medication cup were noted.
- In patient room 97, one hard plastic hairbrush, one toothbrush, one 12-inch hair comb and two one-ounce hard plastic medication cups were noted.

Observation on 02/11/25 from 8:40 AM through 10:30 AM, on the BHAC Unit D, showed:
- Within the monitoring station, located in the center of the unit, three non-psychiatric-safe chairs, multiple unlocked drawers and cabinets that contained: one bag of 100 12-inch plastic zip ties; one metal key ring with four keys; five bottles of alcohol-based hand sanitizer; one box of rubber medical gloves; two stacks of hand towels and wash clothes; an abundance of cloth hospital gowns, scrub shirts and pants; five containers of chemical disinfectant wipes; four pairs of non-slip socks; and an abundance of travel sized toothpastes were noted.
- Five of 22 patients, were dressed in multiple layers of cloth hospital gowns and scrubs or non-psychiatric-safe clothing.
- In one occupied patient room, three toothbrushes, hairbrushes, combs, a stack of one-ounce plastic medication cups, multiple travel sized toothpaste tubes and three hard plastic containers of personal lubrication were noted.

During an interview on 02/24/25 at 1:35 PM, Staff RRR, Chief Nursing Officer (CNO), stated that she would expect the patient monitoring station drawers in the BHAC units to be locked. She was unaware of any policy that indicated the number of personal hygiene items each patient could have in their possession, or if they should be recorded and/or accounted for. The expectation would be for personal hygiene items, patient gowns and scrubs to be psychiatric safe. She unaware that plastic medication cups in the BHUC units were prohibited, but she would expect the plastic medication cups to be removed from the patient rooms after their medications were given. There should be no gaps between the utility access panel and the ceiling. The wall trim and corner wall trim should be fully intact.

During an interview on 02/25/25 at 9:00 AM, Staff S, BHAC Director of Nursing (DON), stated that everyone was responsible for patient safety in the BHAC units. She was responsible for all nursing aspects in the BHAC units. The drawers and cabinets, located at the patient monitoring station, were not locked and she knew they were not locked. The unlocked drawers and cabinets could pose a safety risk for the patients. Each patient should only have one of each personal hygiene item at a time. She did not consider it a patient safety risk if a patient had multiple personal hygiene items. She expected staff to utilize the hospital provided personal care items. All staff on the unit assessed for patient safety. The mental health technician's (MHTs) checked on patients four times an hour and that would identify any safety risk associated with the personal hygiene items. She did not expect all patients to be in paper gowns, that was undignified. No patient population, in a group setting, needed to be in a paper gown with the rounding and patient setting that was provided. The utility access panel and ceiling to be flush, without gaps. She was unaware that psychiatric safe screws should be used in the construction withing psychiatric units. All of the wall trim and corner trim should be fully intact.

During an interview on 02/11/25 at 9:40 AM, Staff V, Clinical Team Manager (CTM), stated that the goal of the unit was to ensure a staff member was always present at the patient monitoring station. Staff could be out on the unit as long as they could still see the desk. The staff assigned to the monitoring station were responsible for monitoring the common areas. The staff were expected to complete environmental rounds and look for contraband in patient rooms every shift. Personal care items and linens were kept at the patient monitoring station, along with food and toiletries. Personal care items were allowed to be kept in the patient's rooms unless there was a concern for hording or dangerous behaviors. Those patients would be placed on one to one (1:1, continuous visual contact with close physical proximity).

During an interview on 02/11/25 at 10:10 AM, Staff II, CTM, stated that patients were provided cloth hospital gowns or pants, but could also wear their own clothing. Personal hygiene items, such as toothbrushes, toothpaste, combs, hairbrushes, lotions, deodorant, and soap were given to the patients upon admission. If a patient needed extra personal hygiene items, they would just ask for them at the desk. Environmental rounds were completed twice a day by the MHTs. They looked for extra linens, extra personal hygiene items and anything harmful. The patients did not have to exchange or turn anything in to receive additional personal hygiene items. The staff did not inventory how many personal hygiene items were given to each patient. There was a potential for a patient to have multiple personal hygiene items in their room. It was expected for the MHTs to remove multiple hygiene items if they were found in a patient rooms during rounding.

Review of the hospital's policy titled, "Adverse Event Response," revised 05/13/22, showed adverse events would be promptly, effectively, and efficiently responded to ensure patient safety and reduce risk of reoccurrence. An adverse event was an event involving patient care which results in or has the potential to result in negative consequences for the patient or in some instances, staff, or visitors.

Review of the hospital's document titled, "Medical Staff Bylaws, Doing Business as University Health," revised 12/06/24 showed the duties of the Ethics Committee included providing education, awareness, and management of ethical issues; to assist in the development of policies addressing ethical issues; and define a process to consult staff, patients and families dealing with ethical issues.

Review of Patient #32's medical record showed:
- On 06/19/24, she was a 27-year-old female admitted to the BHAC unit related to her schizoaffective disorder and destructive behavior in jail. She was pregnant. Police witnessed her punch herself in the stomach.
- Her chart was labeled "violent offender" related to her history of unpredictable and violent outbursts.
- On 10/15/24, a court ordered one-year hold was granted. She was not to leave the hospital.
- On 01/23/25, she was transferred from the BHAC to an inpatient medical/telemetry unit related to COVID-19 (highly contagious, and sometimes fatal, virus). She was on isolation precautions (techniques used to prevent the spread of highly contagious or high-risk infections) and Elopement Precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury).
- On 01/26/25 at 5:28 PM, the order for a physical sitter was discontinued.
- On 01/26/25 at 9:29 PM, nursing placed a continuous video monitor order.
- On 01/29/25, she eloped from the hospital.

Review of the hospital's document titled, "Event Summary," dated 01/29/25, showed:
- The event involved the elopement of Patient #32.
- The patient was on a one-year hold (court order to remain under psychiatric care for one year) related to schizoaffective disorder (mental health disorder where speech and thought are disorganized, and a person may find it hard to function socially and at work and may experience hearing voices that are not real). She was designated a violent offender.
- On 01/23/25, she transferred to an inpatient medical/telemetry unit related to Covid-19, (highly contagious, and sometimes fatal, virus).
- On 01/26/25, her status changed from 1:1 to continuous video monitoring (a mobile camera focused on the patient's closed door from the hallway).
- On 01/29/25 at 3:45 PM, Staff S, BHAC DON, left after a visit with the patient.
- At 3:56 PM, video review showed the patient left the room.
- At 4:01 PM, video review showed the patient left the hospital.
- At 5:00 PM, nursing staff announced a meal delivery inside the room and heard no response. She recommended the primary nurse go check on the patient.
- At 5:21 PM, a "Code Elopement" was announced without success.
- Law enforcement was notified.
- Proposed actions included BHU patients wearing green gowns prior to transfer and placing sitters (person assigned to continuously observe a patient within close proximity, to ensure their safety) outside their doors. Patients who refused green gowns would have physical sitters.
- Directors reminded staff during huddles to be aware of patients following directly behind them when exiting a unit, floor, or the hospital.
- Staff I, Medical/Telemetry Director, addressed observation status and hourly rounding expectations with her unit regarding BHU patients.

Review of the hospital's document titled, "Forward: Physical Sitter Cancellations," dated 01/31/25, showed an email that outlined the process of discontinuing a physical sitter. Registered Nurses (RNs) used clinical judgment and collaborated with the CTM, Director or Director of Shift Operations (DSO), using the prescribed chain of command. The email was sent to Telemetry Services Leadership Group to be read during huddles.

Review of the hospital's document titled, "Telemetry Weekly Huddle," dated 01/31/25, showed a reminder to staff to watch for tailgating and to not allow patients to walk off the unit behind them. All behavioral health inpatient admits brought to the unit were to have a physical sitter. Signatures of staff were obtained from 01/29/25 through 02/03/25.

Review of the hospital's undated document titled, "University Health Medical Surgical Departments Staff Communication Sheets," showed Medical Surgical CTMs addressed staff daily at shift changes for a period of 10 days from 01/31/25 through 02/09/25. Only CTM signatures were obtained.

Review of the hospital's undated document titled, "Elopement Patients," showed a typed summary that instructed staff to pay attention when entering or exiting units to ensure no patients followed. The units would be locked going forward and "random people" were not to be on the unit. They must provide a name when seeking to visit a patient.

Although requested, no other evidence of staff education regarding elopement was provided. The previous stand-alone document was not addressed to any individual and contained no staff signatures or attestation.
Review of the hospital's document titled "Event Summary," dated 12/27/23, showed:
- The event involved the elopement of Patient #33.
- The patient expressed a desire to leave the hospital. The physician documented the patient was medically cleared and not a threat to himself or to others; but he had a guardian. The medical team encouraged the patient to stay and reviewed the risks of leaving without secured housing.
- On 12/27/23 at 12:25 PM, the patient was "allowed to leave AMA" and the patient's guardian was notified.
- Proposed actions included nursing and social work leadership re-education on policies surrounding guardianship and decision-making, and re-education of the physician involved about guardianship and decision-making.

Although requested, no documentation of nursing staff, social work staff, or the physician involved in the elopement of Patient #33 was provided. The education provided to the physician was in the form of a verbal discussion.

Review of Patient #33's medical record showed the following:
- On 12/12/23, a 61-year-old male presented to the Emergency Department (ED) with complaints of cold exposure related to being homeless, low back pain, pain in both legs, cough, fever, chills, and body aches.
- His past medical history included schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly), depression and housing insecurity.
- Patient #33's guardian requested that the hospital hold the patient and assist with attempts at placement in a long-term care (LTC) or locked residential care facility (RCF, a nonmedical facility that provides a home-like environment for individuals who are unable to live independently, but do not require 24-hour nursing care) due to his continued noncompliance of leaving secured housing and "borderline intellectual functioning".
- Patient #33 was evaluated by the hospital's social work team and referrals were placed for Level 2 (a sub-acute level of care in a locked facility where the patients are on a conservatorship and length of stay depends on their behavior) LTC facilities. He did not meet their admission criteria so additional referrals were sent to locked RCFs.
- On 12/27/23, he reported to the social work team he did not want to go to either a LTC facility or a RCF and wished to leave the hospital. Staff OO, Licensed Clinical Social Worker (LCSW), documented they spoke with Patient #33's guardian who reported if the patient left the hospital AMA, the guardian would execute an arrest warrant. The SW documented a discussion with the patient about the risks of leaving the hospital, including the guardian's directive of an arrest warrant and Patient #33 left the hospital. Staff OO documented the patient understood all explanations before leaving and the guardian was informed the patient left the hospital AMA.
- Discharge summary documentation showed he was assessed by more than two physicians who determined he demonstrated full decision-making capacity. He was aware that the medical team and his guardian recommended placement in a nursing home, but he did not want to pursue the placement. He denied current suicidal ideation (SI, thoughts of causing one's own death) or homicidal ideation (HI, thoughts or attempts to cause another's death) and was not a risk to himself or others. His thought content was appropriate, and EP were discontinued. Staff MM, Medical Resident, encouraged him to stay in the hospital until placement was secured. The patient "eloped without therapeutic reason." Staff MM documented "Due to his capacity to make decisions, albeit unwise, he left the unit without notifying medical team of his plan to leave," presumably to avoid placement in LTC.
- An addendum documented by Staff NN, Attending Physician, showed the purpose of the note was to outline the events on 12/27/23 when Patient #33 "eloped without therapeutic reason while team was coordinating referrals to LTC nursing home placement."
- A form titled, "Release AMA," signed by Patient #33 on 12/27/23 at 12:00 PM and witnessed by Staff MM, RN, was included in the medical record. The signature line showed the form was to be signed by the patient or legal representative in the case of a patient who was not mentally competent.

During a telephone interview on 02/24/25 at 1:30 PM, Staff RRR, CNO, stated that she was not familiar with Patient #33's specific event. The event summary indicated nursing was educated. She believed the education most likely occurred at a departmental level. There were a variety of ways the education could have occurred and that would have been the responsibility of that units' leadership. After a serious event, the hospital's education department coordinated and provided needed education. There would be a method to track the staff that received the education and how it was disseminated. She confirmed virtual sitters were used on all inpatient units. Education with regard to the monitoring of a patients on EP should have been provided to all staff on all inpatient units following the elopement of Patient #32.

During a telephone interview on 02/26/25 at 3:00 PM, Staff TTT, Executive Chief Clinical Officer, stated that the situation surrounding Patient #33's elopement was quite unique. He could not "say another physician would not have come to the same conclusion" as the physician who permitted the patient to leave without consent of the guardian.

During a telephone interview on 02/19/25 at 1:00 PM, Staff NN, Physician, stated that he was the attending physician for Patient #33 during his hospitalization of 12/13/23 through 12/27/23. Staff NN stated that during the hospital stay there were conversations held with the ethics committee and legal departments regarding Patient #33's situation. Considering what occurred, involvement of psychiatry might have been of benefit to further demonstrate the patient's capacity and to document an agreement between medical and psychiatry surrounding his safe discharge. Additionally, continued conversations with the patient's legal guardian surrounding the patient's assessed capacity and appropriate discharge plans may have proved beneficial.

During an interview on 02/24/25 at 12:30 PM, Staff NNN, Patient Safety and Accreditation Director, stated that no other education documentation for Patient #32 or #33's elopement events was available aside from what was previously provided.

During an interview on 02/11/25 at 11:24 AM, Staff I, Telemetry Director, stated that she verbally educated the primary nurse and two monitor techs assigned to Patient #32. The unit received education through huddles and a staff meeting.

During a telephone interview on 02/24/25 at 7:29 PM, Staff GGGG, RN, stated that she was a nurse for Patient #32. She had not received education regarding elopement and was not aware Patient #32 had eloped.



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Based on interview, record review and policy review, the hospital failed to complete an incident report for a peer-to-peer assault for one discharged patient (#32) of one patient with an unreported event reviewed. The hospital also failed to ensure a thorough investigation was performed following an event report with allegations of abuse and neglect for two discharged patient (#32 and #40) of two allegations of abuse reviewed. These failed practices placed all patients admitted to the hospital at increased risk for their safety.

Findings included:

Review of the hospital's policy titled, "Abuse and Neglect," revised 08/11/23, showed:
- If a patient complains verbally or in writing to a staff member regarding about any potential abuse and/or neglect, or a staff member observes any potential abuse, neglect, or harassment they must report that to their supervisor, the department leader, or Director of Shift Operations (DSO) and complete a Patient Safety Event (PSE) report.
- A supervisor receiving any reports must notify the manager of the unit where the potential abuse, neglect, or harassment occurred. The manager must immediately begin gathering information using the potential abuse and neglect checklist and interview form.
- If any portions of the potential abuse and neglect checklist are answered yes, the manager should immediately call the DSO or Administrator on Call (AOC). The DSO or AOC should notify the patient safety/risk manager (PSRM) on call.
- The PSRM should initiate a prompt investigation in collaboration with the AOC and DSO in accordance with the adverse event response policy.

Review of the hospital's policy titled, "Adverse Event Response," revised 05/13/22, showed adverse events should be promptly, effectively and efficiently responded to, to ensure patient safety and reduce risk of reoccurrence. Adverse events that do not meet criteria for immediate response may be managed by staff on-site at that time or at the departmental level.

Review of the hospital's policy titled, "Observation Status - Behavioral Health Acute Care Units," revised 12/23/24, showed patients placed on one to one (1:1, continuous visual contact with close physical proximity) observation must be observed by assigned nursing staff within line of sight (LOS, continuous visual contact with the patient) at all times. A patient on routine observation would be monitored per the "Rounds - Behavioral Observation Record" policy.

Review of the hospital's policy titled, "Rounds - Behavioral Observation Record," revised 02/08/23, showed all patients on routine observation would be monitored at least four times per hour with 10-20 minutes between each round.

Review of the hospital's undated document titled, "PR 02. Aug 24-Feb 25 Abuse Neglect Investigations," showed:
- On 10/14/24, Patient #32 made several vague allegations against staff members.
- On 10/16/24, Patient #32 made allegations of sexual abuse against several staff and an attorney.
- Patient #40 was not included in the 10/14/24 report of potential abuse and there were no reports of potential staff abuse towards them.

Review of the hospital's undated document titled, "Patient #32's PSE's," showed there was no report of abuse on 07/15/24 related to Patient #32's assault of another patient.

Review of the hospital's document titled, "Potential Abuse and Neglect Checklist," dated 10/14/24, related to Patient #32, showed:
- At 7:30 PM, Staff FFF, Clinical Team Manager (CTM) was notified of a patient grievance.
- The section titled, "Indicator of Potential Failure to Protect from Abuse," under the subsection titled, "non-consensual sexual interactions: e.g. sexual harassment, sexual coercion, sexual assault," was marked "alleged."
- At 8:00 PM, Patient Safety Staff HHHH, DSO, was notified by a phone of the event.
- On 10/15/24 at 2:30 AM, the checklist was completed and signed by Staff FFF.

Review of the hospital's document titled, "PSE Patient #32," dated 02/18/25, showed:
- On 10/14/24 at 7:30 PM, Patient #32 reported to Staff EEE, RN, at shift change that Staff HHH, Mental Health Technician (MHT), had sexually harassed her and had been sexually abusive to another female patient.
- Staff FFF, CTM, documented that he contacted Staff HHHH, DSO. Staff HHHH spoke with Staff JJJ, PSRM, who would follow up and speak to the patient on 10/15/25. Staff HHH was assigned to another Behavioral Health Unit (BHU) on 10/15/25.
- On 10/21/25, Staff S, Behavioral Health (BH) Director of Nursing (DON), documented that she and the patient safety team determined that since Patient #32 was unable to provide any specific information regarding the time or the content of the alleged abuse, they would "continue to monitor" and move Staff HHH to another BHU.

Review of Patient #32's medical record showed:
- On 06/19/24, a 27-year-old female was admitted to the BHU. She was brought in by law enforcement for disorganized behavior, aggression, and destruction of property.
- On 07/15/24 at 3:07 AM, nursing documentation indicated Patient #32 had yelled and cursed at another patient. She then entered the dayroom, continued to be rude, then "she slapped another patient's hand and spilled her drink."
- On 10/15/24 at 2:24 PM, nursing documentation indicated that Patient #32 was cooperative, spent time in the milieu (a person's social environment), but stayed in her room most of the day. She speech was appropriate tone, volume, and cadence. She verbalized understanding to inform staff if she felt worse or overwhelmed.
- On 10/17/24 at 6:41 PM, nursing documentation indicated Patient #32 walked the hallways making accusations concerning abuse towards her and other patients.
- On 01/29/25 at 7:07 PM, she eloped (when a patient makes an intentional, unauthorized departure from a medical facility) from the hospital.

Review of Patient #40's medical record showed:
- On 04/15/24 at 9:30 PM, a 23-year-old female was admitted to the BHU for suicidal/suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideation (HI, thoughts or attempts to cause another's death).
- On 10/14/24 at 9:16 AM, an order was placed for routine observation.
- At 9:58 AM, physician documentation indicated that nursing staff agreed to discontinue 1:1 observation.
- At 2:45 PM, nursing documentation indicated that the physician had removed 1:1 observation that morning.
- On 11/04/24 at 12:00 AM, she was discharged.

During an interview on 02/24/25 at 1:35 PM, Staff RRR, Chief Nursing Officer (CNO), stated that she expected every instance of alleged abuse to be reported. After review of the nursing documentation that showed Patient #32 slapped another patient, she agreed that was a reportable event and she expected staff to complete a PSE. Staff should document abuse and neglect investigations to include interviews, or attempted interviews.

During a telephone interview on 02/19/25 at 10:09 AM and 2:06 PM, Staff NNN, Patient Safety and Accreditation Director, stated that Patient #35 refused to answer any interview questions. When asked where that was documented she indicated that it was in the PSE. She re-iterated that the documentation on 10/21/24 was to show the patient refused to be interviewed, but that the interview attempt had occurred on 10/15/24. When asked where documentation regarding that information was, she stated she and her staff had already answered that question. It was not documented and any other staff interviewed would state the same information. She disagreed that the alleged incident involving Patient #32 and Patient #40 showed risk to other patients.

During a telephone interview on 02/19/25 at 10:09 AM, Staff JJJ, Patient Safety and Accreditation Risk Manager, stated that when a staff member was accused of abuse or neglect, she would be notified and would begin to investigate specific details such as the date and time of the event and the individuals involved. Any relevant video footage would be saved and reviewed. Any patients and staff involved would be interviewed. She did not request any footage related to this event because the patient would not tell her a time or place the events allegedly occurred. At times, Patient #32 was unable to be interviewed. She attempted to interview Patient #32 several times on 10/15/25, but acknowledged there was no documentation of the attempted interviews.

During a telephone interview on 02/18/25 at 5:02 PM, Staff S, Behavioral Health DON, stated that all abuse allegations should be reported and investigated. She was responsible for conducting investigations related to allegations of abuse and neglect alongside Patient Safety. After reviewing the abuse and neglect checklist, she indicated that the CTM had completed the form incorrectly. The box next to "non-consensual sexual interactions" under the section titled, "Indicator of Potential Failure to Protect from Abuse" should have been labeled "yes" instead of "alleged." When asked if she would investigate this allegation differently because of the use of the word "alleged" she stated no, she would investigate this as an allegation of potential abuse. Investigations related to abuse and neglect should begin "within hours." When asked to point out where the documentation was that patient safety had begun an investigation and attempted to interview Patient #32 on 10/15/24, she stated "they must document somewhere else." She was unable to produce documentation to show that an attempt had been made to interview Patient #32. When asked if the time between when the allegation took place, on 10/14/24 at 7:30 PM, to the next date of documentation related to the abuse investigation, on 10/21/24, was an excessive amount of time she stated yes; however, she believed the interview took place on 10/15/24, it just wasn't documented.

During a telephone interview on 02/24/25 at 7:00 PM, Staff FFF, CTM, stated that when he was notified about an abuse allegation, he would first assess the claim and perform an informal interview. He would gather as much information as he could from the patient to include what the allegation was, who was involved, and when the event occurred. He did not remember the event with Patient #32, but remembered hearing around the unit that she had accused Staff HHH, MHT of something. He was unable to recall that he spoke with Staff HHHH, DSO, and informed her that the claim was not believable. He had not documented any of the reasons he concluded that Patient #32 was not believable, because she was well known to the clinical team. He refused to provide the name of the other patient involved in Patient #32's abuse allegation, but he knew who that patient was. Patient #40 had been on a 1:1 observation. He believed there had not been an opportunity to commit abuse. He did not include Patient #40 in the abuse allegation and did not document her information. He made the decision to move Staff HHH to another BHU.

During an interview on 02/25/25 at 1:56 PM, Staff EEE, RN, stated that he was not interviewed after he reported the abuse allegation Patient #32 made. He was unsure if Patient #32 had been interviewed but was aware she had accused a specific staff member.

During a telephone interview on 02/26/25 at 9:30 PM, Staff ZZZ, RN, stated that she did not remember the name of the other patient involved in the event on 07/15/24 and was unsure if she had completed a PSE but it should have been done.

During a telephone interview on 02/26/25 at 1:00 PM, Staff GGG, RN, stated that she could not recall Patient #32's abuse allegation, even after reading the note she documented in the medical record on 10/17/24. If a patient made an accusation of abuse, she would attempt to get more information and notify a CTM. She did not recall filing a PSE.


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