Highlands Behavioral Health System

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 46674 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.55 Emergency Services, was out of compliance. A-1100 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. Based on observations, interviews, and documents reviewed, the facility failed to ensure staff assessed a patient who presented to the facility to determine whether the patient had a medical emergency. Findings include: Facility policies: The Emergency Medical Treatment and Labor Act (EMTALA) policy read, with respect to an individual who presents on hospital property other than the dedicated emergency department (DED) and a request is made on the individual’s behalf for examination or treatment for an emergency medical condition (EMC), or the appearance or behavior of the individual would cause a prudent layperson observer to believe the individual needed such examination or treatment, the onsite personnel will initiate screening and stabilizing care, within their capabilities, where the individual presented on hospital property and escort, transport, or arrange for the transportation of the individual to the DED for a medical screening examination (MSE) in a manner that is safe and appropriate under the circumstances (including calling 911 if warranted). Onsite personnel shall follow the hospital’s Code Blue policy. A prudent layperson observer is a legal standard descriptive of a careful, attentive and diligent individual who is not a medical professional, who, theoretically, believes, based on the individual’s appearance or behavior, that the individual present in a DED needs an examination or treatment for a medical condition or the individual present on hospital property, other than the DED, needs an examination or treatment for an EMC. According to the Code Blue policy, each crash cart contains an automated external defibrillator (AED), suction, airway management, portable oxygen device, and emergency medical supplies. All clinical staff maintain CPR or basic life support (BLS). The first person to discover a medical emergency assesses the need for CPR (unresponsive, cessation of and/or no carotid (neck) or femoral (groin) pulses palpable). The first person shall call for help and tell the next person arriving to call, “code blue”. Do not leave the victim. On hearing “code blue” the emergency cart and vial sign machine is brought to the immediate area. For all codes in the lobby or parking areas, the first floor supplies will be delivered to the code location. Follow American Heart Association BLS protocols. The following personnel shall immediately go to the site of the emergency: any physician in the hospital, nursing supervisor on duty, designated registered nurse (RN) from each unit in the hospital, pharmacist if in the hospital. The Incident Report-IR/Incident Reporting Process policy read, the purpose of an incident reporting process is to support timely and accurate reporting of serious injuries and unexpected outcomes, to ensure immediate actions are taken to prevent potential for further incident/injury or incident reoccurrence, to investigate incidents in a timely manner to identify and implement patient safety improvement and prevention strategies, to provide and implement a standardized and consistent reporting process within each facility to improve patient safety, to provide a database for trending analysis of reported incidents to improve patient safety. The Incident Report-IR/Incident Reporting Process is the reporting methodology used to track incidents, outcomes, or issues that potentially represent patient safety concerns or questionable clinical practices. The reporting process supports each facility’s patient safety efforts. Incident: An event, outcome, or situation that is not consistent with routine care of patients and/or the desired operations of the facility and results in or could have resulted in (near miss) unexpected medical intervention, unexpected intensity of care, or unexpected physical or mental impairment. The facility risk manager assumes overall responsibility for the IR/Incident Reporting process to ensure timely and accurate reporting, and data entry of all incidents. 1. Staff failed to assess a patient who presented to the facility to determine whether the patient had a medical emergency. a. Observations of video footage revealed, on 9/21/25 from 4:24 a.m. to 4:46 a.m., a woman approached the facility and stood at the entrance door. A car pulled up to the front entrance, spoke to the woman, and then entered the parking lot. The woman walked up to the doorbell, turned toward the doorbell, and then walked away from the door. A behavioral health technician (BHT) exited through the front door, stood in the doorway, and then walked back inside. The woman walked back to the front door with a pill bottle in her hand. Intake counselor (Counselor) #1 walked to the front door and spoke to the woman outside. The woman walked away from the front door and Counselor #1 reentered the building. House supervisor (Supervisor) #2 approached the front door and entered from the exterior of the building. Supervisor #2 then exited the building and stood in the doorway. Ambulance lights were observed entering the parking lot. The BHT and Counselor #1 were not observed leaving the facility to determine if there was a medical emergency. b. On 9/30/25 at 11:42 a.m., an interview was conducted with Counselor #1. Counselor #1 stated the woman told them her boyfriend had overdosed on a bottle of pills. Counselor #1 stated they told the woman 911 needed to be contacted, and the 911 call was placed by facility staff. c. On 9/30/25 at 12:34 p.m., an interview was conducted with Supervisor #2. Supervisor #2 stated they received a call from intake stating a person had experienced a drug overdose. Supervisor #2 stated they walked outside to ensure a violent situation had not occurred and no staff, other than themselves, had gone outside during the event. Supervisor #2 stated no one went outside to assess the patient because they were not trained to treat an overdose. This was in contrast to the EMTALA policy which read, if an individual presented on hospital property and a request was made on the individual’s behalf for examination or treatment for an EMC, or the appearance or behavior of the individual would cause a prudent layperson observer to believe the individual needed such examination or treatment, onsite personnel would initiate screening and stabilizing care, within their capabilities, where the individual presented on hospital property. This was also in contrast to the Code Blue policy which read, all clinical staff maintained CPR or BLS. The first person to discover a medical emergency assessed the need for CPR (unresponsive, cessation of and/or no carotid or femoral pulses palpable). The nursing supervisor on duty and designated RNs from each unit in the hospital should have immediately gone to the site of the emergency. d. On 10/1/25 at 9:23 a.m., an interview was conducted with nurse manager (Manager) #3. Manager #3 stated the facility had a medical response team (MRT) that assessed patients and ensured their safety. Manager #3 stated a code blue/MRT was called if a patient experienced a change in condition. Manager #3 stated a code blue would then be called if the patient was not breathing and did not have a pulse. Manager #3 stated a code blue/MRT could be called for anyone on the facility’s property, including the parking lot. Manager #3 stated it was important to assess patients to ensure the patient was alive, to keep them safe, and to ensure the patient received treatment as soon as possible. e. On 9/29/25 at 12:48 p.m., review of the facility’s incident reporting log revealed an incident report had not been completed for the event on 9/21/25. This was in contrast to the Incident Report-IR/Incident Reporting Process policy which read, an incident was an event, outcome, or situation that was not consistent with routine care of patients and/or the desired operations of the facility and results in, or could have resulted in, unexpected medical intervention, unexpected intensity of care, or unexpected physical or mental impairment. A timely and accurate report should have been completed for all incidents. f. On 9/30/25 at 9:48 a.m., an interview was conducted with the risk management director (Director) #4. Director #4 stated the house supervisors completed a report which included significant patient events that occurred during their shift. Director #4 stated the report was provided to the chief nursing officer (CNO), and if a significant event occurred, the report would have been provided to themselves. Director #4 stated the event on 9/21/25 had not been included in the house supervisor’s report.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44751 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 PATIENT RIGHTS was out of compliance. A-0144 PATIENT RIGHTS: CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. Based on interviews and document review, the facility failed to ensure a safe patient care environment. Specifically, staff did not complete patient safety events for two of three patients reviewed who intentionally self-harmed (Patients #2 and #4). Additionally, the facility failed to implement mitigation (actions taken to reduce harm and prevent recurrence) for two of the three patients reviewed who intentionally self-harmed (Patients #2 and #3).”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44751 Based on interviews and document review, the facility failed to ensure a safe patient care environment. Specifically, staff did not complete patient safety events for two of three patients who intentionally self-harmed (Patients #2 and #4). Additionally, the facility failed to implement mitigation (actions taken to reduce harm and prevent recurrence) for two of the three patients who intentionally self-harmed (Patients #2 and #3). Findings include: Facility policies: The Incident Report-IR/Incident Reporting Process policy read, the purpose of the incident (patient safety event) reporting process is to ensure immediate actions are taken to prevent the potential for further incident/injury or incident reoccurrence. The policy defined an incident as an event, outcome, or situation that is not consistent with routine care of patients and/or the desired operations of the facility and results in or could have resulted in unexpected medical intervention, unexpected intensity of care, or unexpected physical or mental impairment. The facility Risk Manager assumes overall responsibility for the IR/Incident Reporting process and conducts the follow-up and investigation to ensure appropriate actions are taken to prevent further incident/injury and/or reoccurrence. The Special Precautions/Levels of Observation policy read, increased levels of observation/special precautions require an MD order. All precautions should be clearly indicated on the rounds sheet and in all handoff communication. Patients who require increased levels of supervision are placed on precautions throughout their hospitalization. High-risk behaviors may include, but are not limited to, suicidal ideations (SI), threats, or attempts, and may include self-mutilating or self-harm behaviors. The Patient Observation Rounds policy read, patient bedroom doors, as well as hallway bathrooms, are locked when not in use. Patient bedroom doors were closed and locked during the day. According to the Q15 minute checks observation level, all patients shall be monitored every 15 minutes through the rounds/milieu observation process. The 1:1 observation level read, the Charge Nurse will initiate the 1:1 treatment plan form and interventions, and educate the patient on skills to increase safety. Interdisciplinary staff will update the treatment interventions and plan as necessary. RN’s must reassess any patients on 1:1’s every shift and document in the progress notes the patient’s progress, response, and recommendations for continued levels of increased supervision or plans for discontinuation. The 1:1 treatment plan form will be completed daily to document justification until 1:1 is discontinued. References: Quality Assurance & Performance Improvement (QAPI) 2025 Plan read, the plan’s objective was to provide a culture where care is delivered in a safe environment, promote safety, and prevent untoward occurrences (safety events). QA metrics for Risk Management patient safety event report findings are analyzed to identify significant events and/or opportunities to improve patient outcomes, and include specific actions and follow-up necessary to prevent and/or correct identified events and improve patient care. Safety was defined as avoiding patient harm by reducing risks in the care environment and applying patient interventions. 1. Staff failed to enter patient safety events for patients who engaged in self-harm (behaviors that caused physical harm to themselves). A. Medical record reviews identified examples of self-harm that staff failed to report as patient safety events. i. On 3/29/25 at 11:55 a.m., Patient #4 was admitted to the Discovery Unit (adolescent unit) after attempting to hang themselves with a metal hanger at home. During a psychiatric evaluation at 3:00 p.m., Provider #3 documented that Patient #4 was suicidal and had engaged in self-harm. a. Review of the Psychiatric Progress Note entered on 4/2/25 at 9:10 p.m., Psychiatric Nurse Practitioner (PNP) #2 documented nursing staff had informed them Patient #4 engaged in self-harm by banging their head on the wall on the evening of 4/1/25. Upon request, the facility was unable to provide evidence a patient safety event had been completed. ii. On 2/19/25 at 3:16 p.m., Patient #2 was admitted to the Discovery Unit after the patient presented to the facility endorsing suicidal thoughts and a plan to overdose. According to the psychiatric evaluation performed by Provider #3 on 2/20/25 at 9:30 a.m., Patient #2 was suicidal and had engaged in self-harm. According to the Psychiatric Progress Note entered on 2/24/25 at 3:00 p.m., PNP #2 documented that nursing staff informed them Patient #2 had used a piece of wood to engage in self-harm, resulting in injuries to the forearm. The facility was unable to provide evidence a patient safety event had been entered on 2/24/25 for Patient #2. These events contrasted with the Incident Reporting Process policy, which stated staff were to complete a patient safety report to ensure immediate actions were taken to prevent recurrence and reduce the risk of further harm. B. Interviews with staff revealed that they failed to complete safety event reports when patients engaged in self-injurious behaviors. i. On 4/3/25 at 3:03 p.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated safety event reports were not always completed after episodes of patient self-harm. RN #2 further stated the decision to complete a safety event report was subjective and based on the judgment of the nurse and the severity of the harm caused by the patient’s behavior. RN #2 further stated a suicide attempt warranted reporting, while superficial scratches did not. However, if a patient dug deeply into their skin and caused significant bleeding, staff were expected to enter a safety event report. RN #2 stated that self-injurious behaviors could result in serious harm to the patient. ii. On 4/2/25 at 10:31 a.m., an interview was conducted with nurse manager (Manager) #4. Manager #4 stated when a patient engaged in self-injurious behavior, staff assessed the patient and determined whether wound care was needed. Manager #4 stated a patient safety event was not completed unless the self-injurious behavior resulted in severe harm, and the patient needed to be transferred out for further medical evaluation. Manager #4 stated staff were trained to complete a safety event report only if medical interventions were required beyond basic first aid. Manager #4 stated that staff reported safety events to help prevent further harm. Manager #4 stated safety event reports were important to ensure safety interventions were implemented to prevent further harm from occurring. These interviews were in contrast with the Incident Reporting Process policy, which stated a safety event was to be completed by staff for events that resulted in an actual injury, nearly resulted in an injury, or had the potential to result in an injury to a patient. 2. The facility failed to ensure mitigation efforts, safety interventions, and preventative measures were implemented following patient safety events to reduce the risk of recurrence. A. Review of patient safety event reports provided by the facility revealed the following: i. On 1/16/25 at 12:15 p.m., Patient #3 became upset and tearful on the unit and took off their long-sleeved shirt. Patient #3 then wrapped the sleeves of the long-sleeved shirt around their neck. Staff observed Patient #3’s behavior and reached the patient before the patient tightened the shirt around their neck. Staff initiated a code green (alert for immediate assistance for a patient experiencing a psychiatric or behavioral emergency). According to the risk management note in the patient safety event report, the safety interventions and preventative measures implemented for Patient #3 included increased observations, a room change near the nurses ’ station, and a daytime room lockout. This contrasted with Patient #3’s medical record, which revealed no evidence of a provider order for increased observations or a room relocation closer to the nurse’s station. ii. On 2/24/25 at 8:06 p.m., nursing staff found Patient #2 in their room with a bed sheet around their neck. Nursing staff intervened and removed the sheet. According to the risk management note in the patient safety event report, Patient #2 was placed on suicide precautions and a daytime room lockout as safety measures to prevent recurrence. The risk management note contrasted with Patient #2’s medical record, which revealed Patient #2 had already been placed on suicide precautions when the safety event occurred. Additionally, although the risk management notes indicated a daytime room lockout had been implemented as an intervention for Patients #2 and #3, this contrasted with the Patient Observation policy, which stated daytime room lockouts were standard practice for all patients. B. Interviews with staff revealed a lack of compliance with facility policy and the implementation of preventative measures after patient safety events occurred. i. On 4/7/25 at 12:02 p.m., an interview was conducted with the interim director of risk management (Director) #5. Director #5 stated the risk manager’s responsibilities included reviewing and investigating patient safety events. They also stated that the risk manager verified which interventions and precautions were implemented after a patient safety event and documented them in the risk management notes. Furthermore, Director #5 stated that the interventions listed in the risk management note reflected the preventative measures implemented and were not recommendations for preventative measures. ii. On 4/7/25 at 3:49 p.m., an interview was conducted with chief nursing officer (CNO) #6. CNO #6 stated that they could not locate evidence of the safety interventions and precautions listed in the risk management notes in the medical records for Patients #2 and #3. The interview with Chief Nursing Officer (CNO) #6 contradicted the facility’s QAPI 2025 Plan, which stated the risk manager analyzed, reviewed, and monitored patient safety events and follow-ups to prevent, correct, and enhance patient outcomes and care delivery. Additionally, the plan defined safety as the avoidance of patient harm through risk reduction in the care environment and the application of patient interventions.”

“COMPLIANCE WITH LAWS CFR(s): 482.11 Compliance with Federal, State and Local Laws This Condition is not met as evidenced by: 47959 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.11 Compliance with Federal, State, and Local Laws was out of compliance. A-0021 - The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. Based on document review and interviews, the facility failed to report occurrences to the Department and law enforcement as required by state statute. Specifically, the facility failed to report occurrences of physical abuse and sexual abuse.”

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 47959 Based on document review and interviews, the facility failed to report occurrences to the Department and law enforcement as required by state statute. Specifically, the facility failed to report occurrences of physical abuse and sexual abuse. Findings include: Facility policy: The Occurrence/Critical Incident Reporting to External Agencies policy read, a critical incident is any significant event or condition that must be reported within twenty-four (24) hours to the Department that is of public concern and/or has jeopardized the health, safety and/or welfare of individuals. Reference: The Health Facilities and Emergency Medical Services Division (HFEMSD) Occurrence Reporting Manual (2018), retrieved from https://drive.google.com/file/d/14h1U8zVP59HM9pusTeN08hjhRCGJsb63/view read, any occurrence involving physical abuse of a patient or resident, as described in Section 18-3-202, 18-3-203, and 18-3-204...C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility.” Section 25-1-124(2)(d), C.R.S. Two elements needed: Intent, or, knowingly or recklessly, and, bodily injury and/or serious bodily injury, and/or unreasonable confinement or restraint. Any occurrence involving sexual abuse of a patient or resident, as described in section...18-3-402, 18-3-403, 18-3-404, or 18-3-405 C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility.” Section 25-1-124 (2)(d) C.R.S. Three elements needed: Knowingly, and, consent not given, and sexual intrusion or penetration or, touching intimate parts or the clothing covering the intimate parts or, examiners or treats resident/patient for other than bona fide medical purposes or, observes or photographs another person’s intimate parts or, physical force/threat. In addition to the report to the department for an occurrence described in paragraph (d) of subsection (2) of this section, the occurrence shall be reported to a law enforcement agency. Section 25-1-124 (8) C.R.S. It is the allegation of the event, not the outcome of the provider’s investigation, which makes it reportable. 1. The facility failed to ensure occurrences were reported to the Department and law enforcement as required by state statute or regulation. a. Review of the adverse event log revealed occurrences of physical and sexual abuse. Examples included: i. Review of the adverse event log revealed on 10/12/24 at 4:10 p.m., a patient suddenly pushed a peer to the ground as they passed by one another. ii. Review of the adverse event log revealed on 10/30/24 at 9:20 p.m., a patient kicked a peer in the groin which caused the peer to groan. iii. Review of the adverse event log revealed on 11/24/24 at 3:40 p.m., a patient reported a peer touched them on the leg which made them uncomfortable. The peer also attempted to touch the peer’s chest without contact. iv. Review of the adverse event log revealed on 11/25/24 at an unspecified time, a patient slapped a peer on the buttocks. b. Review of the state agency’s occurrence reporting database on 1/13/25 revealed no occurrences were reported for the events of 10/30/24, 11/24/24 and 11/25/24. When requested, the facility was unable to provide evidence of law enforcement notification for the event which occurred on 10/12/24. This was in contrast to the HFEMSD Occurrence Reporting Manual which read any occurrence involving physical abuse of a patient by another patient should have been reported if two elements were met: Intent, or, knowingly or recklessly, and, bodily injury and/or serious bodily injury, and/or unreasonable confinement or restraint had occurred. Any occurrence involving sexual abuse of a patient by another patient should have been reported if three elements were met: Knowingly, and, consent not given, and sexual intrusion or penetration or, touching intimate parts or the clothing covering the intimate parts. c. On 1/15/25 at 2:37 p.m., an interview was conducted with behavioral health technician (BHT) #2. BHT #2 stated the registered nurses or the manager reported occurrences to the police. BHT #2 stated they followed patient precautions and helped reinforce boundaries the patients needed to ensure safety on the unit. d. On 1/15/25 at 10:43 a.m., an interview was conducted with milieu manager (Manager) #1. Manager #1 stated they reported any physical or sexual assault to the police, regardless of whether it actually happened. e. On 1/16/25 at 9:02 a.m., an interview was conducted with director of risk management (Director) #3. Director #3 stated alleged sexual, physical, or verbal abuse as well as neglect constituted a reportable critical incident. Director #3 stated staff notified them when incidents happened and ensured law enforcement received the report immediately and the state agency received the report within 24 hours. Director #3 stated they were unsure why the incident on 10/12/24 at 4:10 p.m. was not reported to law enforcement as required by state statute. Director #4 stated they reported the incident on 10/30/24 to law enforcement, but not to the Department because their investigation revealed the patients did not have malicious or sexual intent, despite the kicked patient who moaned in pain. Director #3 stated they reported the incident on 11/24/24 to law enforcement, but not to the Department because the peer touched the patient just above the knee, despite the patient complaining the touch (and the attempted touch of their breast) made them feel uncomfortable. Director #3 stated they reported the incident on 11/25/24 to law enforcement, but not to the Department because their investigation revealed there was no intent to sexually assault the patient. This was in contrast to the Occurrence/Critical Incident Reporting to External Agencies policy which read, a critical incident was any significant event or condition that must be reported within twenty-four (24) hours to the Department that was of public concern and/or jeopardized the health, safety and/or welfare of individuals. Additionally, this was in contrast to the guidance of the HFEMSD Occurrence Reporting Manual (2018) which read, it was the allegation of the event, not the outcome of the provider’s investigation which made it reportable.”

“COMPLIANCE WITH LAWS CFR(s): 482.11 Compliance with Federal, State and Local Laws This Condition is not met as evidenced by: 46674 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.11 Compliance with Federal, State and Local Laws was out of compliance. Based on document review and an interview, the facility failed to report occurrences to the Department as required by state statute. Specifically, the facility failed to report occurrences of physical abuse, sexual abuse, and a missing person. Findings include: Facility policy: The Critical Incident/Unexpected Event Response policy read, a critical incident is any significant event or condition that must be reported within twenty-four (24) hours to the Department that is of public concern and/or has jeopardized the health, safety and/or welfare of individuals. References: The Health Facilities and Emergency Medical Services Division (HFEMSD) Occurrence Reporting Manual (2018) retrieved from https://drive.google.com/file/d/14h1U8zVP59HM9pusTeN08hjhRCGJsb63/view read, any occurrence involving physical abuse of a patient or resident, as described in Section 18-3-202, 18-3-203, and 18-3-204...C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility.” Section 25-1-124(2)(d), C.R.S. Two elements needed: Intent, or, knowingly or recklessly, and, bodily injury and/or serious bodily injury, and/or unreasonable confinement or restraint. Any occurrence involving sexual abuse of a patient or resident, as described in section...18-3-402, 18-3-403, 18-3-404, or 18-3-405 C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility.” Section 25-1-124 (2)(d) C.R.S. Three elements needed: Knowingly, and, consent not given, and sexual intrusion or penetration or, touching intimate parts or the clothing covering the intimate parts or, examiners or treats resident/patient for other than bona fide medical purposes or, observes or photographs another person ’ s intimate parts or, physical force/threat. Any time that a resident or patient of the facility cannot be located following a search of the facility, the facility grounds, and the area surrounding the facility and there are circumstances that place the resident ’ s health, safety or welfare at risk or, regardless of whether such circumstances exist, the patient or resident has been missing for eight hours.” Section 25-1-124(2)(c), C.R.S. Element (only 1 needed): At risk and missing after search conducted, or, missing more than eight hours, regardless of risk. 1. The facility failed to ensure occurrences were reported to the Department as required by state statute or regulation. a. Review of the adverse event log revealed occurrences of physical abuse. Examples included: i. Review of the adverse event log revealed, on 5/20/24 at 6:35 p.m., two peers began to fight and fell to the ground. One of the peers had a bloody nose and first aid was administered. ii. Review of the adverse event log revealed, on 6/21/24 at 6:52 p.m., a patient bumped into another patient walking down the hall. Other peers became aggressive and began to attack the patient by hitting, kicking, and pulling hair. The patient was on the ground when other peers were attacking. Bruises were noted on the back of their neck, top of their left shoulder, there was minor missing hair on their scalp, with redness on top of their head where hair was pulled. The patient was sent to the emergency department for evaluation. iii. Review of the adverse event log revealed, on 6/21/24 at 7:20 p.m., a patient was punched in the back of the head by a peer. The patient complained of double vision, flickering eye, and a headache. The patient was transferred to a hospital for medical clearance. b. Review of the adverse event log revealed, on 6/5/24 at 4:30 p.m., an occurrence of sexual abuse occurred. The adverse event log revealed a patient was found in another patient’s room having sexual intercourse. The patient had no recollection of events afterward. The other patient was documented as stating, “Why did you tell on us?” The patient was confirmed positive for trichomoniasis (a sexually transmitted disease) after the event and treatment was initiated. c. Review of the adverse event log revealed, on 5/30/24 at 12:55 pm., a patient was in the cafeteria courtyard and climbed the fence. The police were notified. The patient had run to a grocery store but was unable to be found. On 6/1/24, the patient called the hospital to request their belongings. d. Review of the state agency’s occurrence reporting database on 8/6/24 revealed no occurrences had been reported since 7/3/23. This was in contrast to the HFEMSD Occurrence Reporting Manual which read any occurrence involving physical abuse of a patient by another patient should be reported if two elements were met: Intent, or, knowingly or recklessly, and, bodily injury and/or serious bodily injury, and/or unreasonable confinement or restraint had occurred. Any occurrence involving sexual abuse of a patient by another patient should be reported if three elements were met: Knowingly, and, consent not given, and sexual intrusion or penetration or, touching intimate parts or the clothing covering the intimate parts. Any time a patient of the facility cannot be located following a search of the facility, the facility grounds, and the area surrounding the facility and there are circumstances that place the resident ’ s health, safety or welfare at risk or, regardless of whether such circumstances exist should be reported if one element was met: Missing more than eight hours, regardless of risk. e. On 8/6/24 at 9:48 a.m., an interview was conducted with patient safety officer and director of risk management and performance improvement (Director) #4. Director #4 stated the Critical Incident/Unexpected Event Response policy did not include specific criteria for reporting to the Department. Director #4 also stated they reported occurrences to the behavioral health administration and were not aware occurrences were to also be reported to the Department. This was in contrast to the Critical Incident/Unexpected Event Response policy which read, a critical incident was any significant event or condition that must be reported within twenty-four (24) hours to the Department that is of public concern and/or has jeopardized the health, safety and/or welfare of individuals.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 46674 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QAPI was out of compliance. A0286 §482.21 (a),(c)(2),(e)(3) PATIENT SAFETY (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will identify and reduce medical errors. (2) The hospital must measure, analyze, and track adverse patient events (c) Program Activities (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities. The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: (3) That clear expectations for safety are established. Based on document review and interviews, the quality assessment and performance improvement (QAPI) program failed to ensure preventive measures were implemented and effective to prevent recurrence after adverse events occurred in two of two patients reviewed who repeatedly physically assaulted peers.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 50313 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23, Nursing Services, was out of compliance. A-0396 The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. Based on interviews and document review, the facility failed to ensure nursing staff revised and kept current a nursing care plan for each patient in three of four medical records reviewed (Patient #1, #2, and #4).”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 46674 Based on document review and interviews, the quality assessment and performance improvement (QAPI) program failed to ensure preventive measures were implemented and effective to prevent recurrence after adverse events occurred in two of two patients reviewed who repeatedly physically assaulted peers. Findings include: Facility policies: The Assault/Homicide Precautions policy read, precautions require an MD order. All precautions should be clearly indicated on the rounds sheet and in all hand off communication. The Incident Reporting Process policy read, the purpose of an incident reporting process is to ensure immediate actions are taken to prevent potential for further incident/injury or incident reoccurrence. Investigate incidents in a timely manner to identify and implement patient safety improvement and prevention strategies. An incident is an event, outcome, or situation that is not consistent with routine care of patients and/or the desired operations of the facility and results in or could have resulted in unexpected medical intervention, unexpected intensity of care, or unexpected physical or mental impairment. The facility Risk Manager assumes overall responsibility for the incident reporting process to conduct follow up and investigation to ensure appropriate actions are taken to prevent further incident and/or reoccurrence. References: The QAPI 2024 Plan read, the plan is used as a guide to design, measure, assess and improve organizational performance; identify, minimize and prevent organizational risks and ensure delivery of safe patient care. The objectives are to enhance, maintain and continually improve the quality and safety of patient care through departmental/service measurement and assessment of patient care, resolution of problems and on-going pursuit of opportunities to improve patient care; to provide a culture where care is delivered in a safe environment; to facilitate a proactive approach toward continuous performance improvement and evaluate actions taken to assure desired results are achieved and maintained; to promote safety and prevent untoward occurrences through systematic monitoring of the treatment environment to reduce facility and medical liability. Organization-wide QAPI activities include safety and risk management. Safe, is defined as avoiding harm to the patients by reducing risks in the care environment and in the application of patient interventions. The Performance Improvement Committee is the steering committee for the QAPI program. As the steering committee for the QAPI program, the committee is responsible to oversee and accomplish the following: to assure appropriate actions are implemented to effectively resolve identified problems or improve existing processes. 1. The QAPI program failed to ensure preventive measures were implemented and effective to prevent recurrence after adverse events occurred. a. Review of the adverse event log provided by the facility revealed, on 5/21/24 at 7:51 p.m., Patient #2 ran down the hallway toward a peer, grabbed the peer’s hair, threw them to the ground, and hit the peer. The adverse event log indicated interventions implemented included separating the patients and placing Patient #2 on aggression (assaultive/homicidal) precautions. Review of the adverse event log also revealed, on 5/27/24 at 8:15 p.m, Patient #2 physically assaulted another peer. The adverse event log indicated interventions implemented for Patient #2 were aggression precautions, separating the patients, and that the treatment team discussed managing Patient #2’s behavior. Review of the adverse event log further revealed, on 5/30/24 at 8:30 p.m., Patient #2 jumped over the nursing counter to attack another peer who was in a restraint. Patient #2 was able to hit the peer several times as staff intervened to pull them off. The adverse event log indicated camera footage review had been completed and coaching had been provided with staff. These interventions were in contrast to Patient #2’s medical record review which revealed no evidence of a provider’s order for aggression precautions. Also, aggression precautions were not selected on Patient #2’s patient observation rounds sheets throughout their admission. Additionally, there was no evidence in the medical record a treatment team discussion had occurred to discuss how to manage Patient #2’s aggression although this was indicated as an intervention from the adverse event log for the event that occurred on 5/27/24. b. Review of the adverse event log revealed, on 5/18/24 at 8:15 p.m., Patient #4 slapped a peer across the face. The adverse event log indicated interventions included separating the patients and aggression precautions for Patient #4. Review of the adverse event log also revealed, on 5/20/24 at 8:19 p.m., Patient #4 initiated a physical altercation with a peer. The adverse event log indicated interventions included aggression precautions, additional attention for de-escalation was recommended by the milieu manager, and there was an emergency treatment team meeting initiated to discuss Patient #4’s behavioral plan. Review of the adverse event log further revealed, on 5/21/24 at 7:53 p.m., Patient #4 hit a staff member in the face and was arrested for assault. These interventions were in contrast to Patient #4’s medical record review which revealed aggression precautions had been implemented for Patient #4 since 5/16/24 at 5:11 p.m., almost 48 hours before the first event occurred. There was no evidence in the medical record of additional recommendations for de-escalation, of an emergency treatment team meeting to discuss Patient #4’s behavioral plan, and no evidence of a behavioral plan. These examples were in contrast to the Incident Reporting Process policy which read, the purpose of the incident reporting process was to ensure immediate actions were taken to prevent potential for further incident/injury or incident reoccurrence. These examples were also in contrast to the QAPI 2024 Plan which read, the purpose of the plan was to identify, minimize and prevent risks and ensure delivery of safe patient care. The objectives were to enhance, maintain and continually improve the quality and safety of patient care through assessment of patient care, resolution of problems and on-going pursuit of opportunities to improve patient care; provided a culture where care was delivered in a safe environment; facilitated a proactive approach toward continuous performance improvement and evaluated actions taken to assure desired results were achieved and maintained; promoted safety and prevented untoward occurrences through systematic monitoring of the treatment environment to reduce liability. Organization-wide QAPI activities included safety and risk management. Safe, was defined as avoiding harm to the patients by reducing risks in the care environment and in the application of patient interventions. The Performance Improvement Committee was responsible to oversee and accomplish assuring appropriate actions were implemented to effectively resolve identified problems or improve existing processes. c. On 8/7/24 at 8:30 a.m., an interview was conducted with behavioral health technician (Tech) #1. Tech #1 stated aggression precautions made staff aware the patient was assaultive and to be more careful, and there was no difference in interventions between patients who were on aggression precautions and those who were not on aggression precautions. d. On 8/8/24 at 1:01 p.m., an interview was conducted with nurse manager (Manager) #3. During the interview, Manager #3 reviewed the medical record for Patient #4. Manager #4 verified after the adverse event which occurred on 5/18/24, no additional interventions were implemented for Patient #4 other than separating the patients. Manager #3 also stated there was no evidence in the record an emergency treatment team meeting occurred after the 5/20/24 adverse event, and the behavior plan was not documented in Patient #4’s medical record. Additionally, Manager #3 stated after the physical assault events occurred, they would have expected Patient #4 to have increased monitoring, but Manager #3 stated this did not occur. e. On 8/8/24 at 10:33 a.m., an interview was conducted with chief nursing officer (CNO) #2. CNO #2 stated when an adverse event occurred, she followed up with staff and reviewed camera footage to assess what happened. CNO #2 stated she would then follow up with staff to provide education. During the interview, CNO #2 reviewed the medical record for Patient #2. CNO #2 stated they were unable to locate evidence of aggression precautions or a treatment team discussion for how to manage Patient #2’s aggression, which were listed as interventions in the adverse event log. CNO #2 stated after a physical assault event occurred, they would have expected Patient #2 to be on line of sight monitoring, however, CNO #2 stated monitoring was not increased after the events occurred. CNO #2 stated it was important to ensure interventions were implemented to keep patients safe. CNO #2 stated it was wrong for staff to continue the same interventions after repeated adverse events occurred. Furthermore, CNO #2 stated they had only begun to review the medical records of patients who experienced an adverse event within the last two weeks, after the last survey when the facility was cited for deficient practice. f. On 8/8/24 at 2:45 p.m., an interview was conducted with patient safety officer and director of risk management and performance improvement (Director) #4. Director #4 stated when an adverse event occurred, they reviewed camera footage with nurse leaders and noted opportunities for improvement. Director #4 stated the nurse leader would verify if interventions and precautions were put into place. Director #4 stated they did not verify the implementation of interventions for each adverse event as they trusted the follow up of nurse leaders. This was in contrast to the Incident Reporting Process policy which read, the purpose of the incident reporting process was to ensure immediate actions were taken to prevent potential for further incident/injury or incident reoccurrence. The facility Risk Manager assumed overall responsibility for the incident reporting process to conduct follow up and investigation to ensure appropriate actions were taken to prevent further incident and/or reoccurrence. Furthermore, Director #4 stated it was important to ensure patient specific interventions were implemented to ensure effectiveness. Director #4 stated if the interventions were not effective or not validated, there was potential for the same adverse events to occur.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 50313 Based on interviews and document review, the facility failed to ensure nursing staff revised and kept current a nursing care plan for each patient in three of four medical records reviewed (Patient #1, #2, and #4). Findings include: References: The Interdisciplinary Patient-Centered Care Planning policy read, the treatment team works to identify the patient’s assessed needs to be addressed during treatment and develop appropriate goals and interventions. The treatment team will complete a review of the treatment plan as clinically indicated, or at minimum every seven days. Identified problems will be summarized, progress toward goals will be reviewed, and new goals and interventions will be identified. The following would be cause for conducting a review of the plan and developing a revision: A new impairment/problem is identified, a major change occurs in the patient’s clinical condition, such as the use of restraint or seclusion, or the treatment team determines the patient’s current treatment plan would more appropriately by delivered on an individual basis rather than group interventions. The Patient Assessment and Reassessment Process policy read, assessment shall continue throughout the course of treatment and shall be reviewed and updated when there is a change in the person’s level of care of functioning. Treatment planning meeting are held at least weekly. During this meeting, the patient’s condition is reassessed and the treatment plan and progress goals are evaluated. Patient’s requiring more frequent reassessment are as follows: patients on a one to one, for suicide, assault, fall, elopement, or other precautions. The Staff Nurse job description read, the staff nurse will prioritize and formulate a plan of care based on patient assessment and according to policy; participate in the development of an interdisciplinary treatment plan with specific and measurable goals, objections, and inventions defining actions unique to each patient’s needs; update and revise the plan as goals/objectives are met or when the patient’s condition changes; and document both the nursing interventions on the treatment plan and the patient’s response to the intervention. The Licensed Practical Nurse (LPN) job description read, the LPN will maintain awareness of patient’s individualized plan of care including goals and interventions; provide information to the charge nurse that assists in the development and revision of the treatment plan; document the treatment plan, nursing interventions and the patient’s response to the intervention. 1. The facility failed to ensure nursing care plans were updated to reflect changes in patient condition and nursing concerns related to adverse patient safety events, health outcomes, and treatment progress. A. Document review i. A review of Patient #1’s medical record revealed Patient #1 was admitted for a diagnosis of schizophrenic form disorder (a mental health condition that causes hallucinations, delusions, paranoia, and disorganized speech) and suicidal ideations (thinking about or formulating a plan for suicide) on 5/28/24. On 5/29/24, a provider increased the frequency of patient observations from every 15 minutes to every five minutes. On 5/30/24 the provider note read that Patient #1 was exhibiting hypersexuality, and the provider ordered Patient #1 to be under sexual aggression precautions and sexual victimization precautions. The nursing note on 5/30/24 read that Patient #1 got into an altercation with another patient, punched the patient, and required emergency medication. Staff created a treatment plan on 5/31/24. The treatment plan on 5/31/24 did not include any interventions or goals to address the increased frequency of observations, incidents of aggression, or the change in order for sexual aggression and sexual victimization precautions. The provider note dated 6/2/24 read that Patient #1 threatened the provider. The provider note dated 6/3/24 read that Patient #1 was aggressive and altercating with peers, and the provider ordered aggression/homicidal precautions. The treatment plan was not updated until 6/7/24, and the updated treatment plan did not address the change in condition requiring aggression precautions. This was in contrast to the Patient Assessment and Reassessment Process policy which read, treatment planning meetings would be held at least weekly to reassess the patient’s condition and evaluate the treatment plan and progress goals. Patients requiring more frequent reassessment included patients on a one to one, for suicide, assault, fall, elopement, or other precautions. ii. A review of Patient #2’s medical record revealed Patient #2 was admitted for a diagnosis of major depressive disorder and suicidal ideations on 5/13/24. On 5/16/24 staff created a treatment plan. The provider note dated 5/19/24 read that Patient #2 was allegedly assaulted by a peer and filed a police report. The provider increased observation from every fifteen minutes to every five minutes on 5/19/24. The nursing note dated 5/22/24 read that Patient #2 assaulted another patient and had to be restrained and given emergency medications. The treatment plan was updated on 5/23/24 and there was no evidence that the treatment plan was revised to address physical aggression or the need for restraint. This was in contrast to the Interdisciplinary Patient-Centered Care Planning PC 101 policy which read, a major change in the patient’s condition, such as the use of restraint would have been a cause for developing a revision of the treatment plan. The nursing note on 5/27/24 read that Patient #2 was aggressive and physically attacked another patient, requiring a physical hold and emergency medications. The treatment plan was updated on 5/30/24. There was no evidence that new goals or interventions were added to the treatment plan regarding the incidents of physical aggression. The nursing note on 5/30/24 read that Patient #2 was physically aggressive and attacked another patient. iii. A review of Patient #3’s medical record revealed Patient #4 was admitted with a diagnosis of major depressive disorder with suicidal ideations on 5/15/24. On 5/16/24 a provider ordered that Patient #4 be placed on aggression/homicidal precautions. On 5/17/24 staff created a treatment plan. There was no mention of aggression/homicidal behavioral concerns on the treatment plan. The provider note read Patient #4 was disrupting in groups. The nursing note read Patient #4 was physically aggressive with other patients. On 5/19/24 the provider note read that Patient #4 was accused of slapping another patient. The nursing note read that Patient #4 was aggressive verbally and physically slapped another patient in the face. On 5/20/24 the provider ordered Patient #4 to be placed under sexual aggression precautions. On 5/21/24, the provider note read that Patient #4 was in a physical altercation with another patient. The provider ordered restraints and emergency medication. There was no evidence that the treatment plan was updated after 5/17/24 despite changes in patient behavior, sexual aggression precautions, and physical altercations with other patients. B. Interviews i. An interview was conducted on 8/8/24 at 8:22 a.m. with registered nurse (RN) #5. RN #5 stated interdisciplinary treatment plans (treatment plans) were defined as the master plan for patients. RN #5 stated they were not sure how often treatment plans were updated, but treatment plans should have been updated with any changes in patient status. RN #5 stated treatment plans were important for patient safety. RN #5 stated it was important to update treatment plans to ensure that the care team was on the same page and following a plan to keep patients safe until released from the facility. ii. An interview was conducted on 8/8/24 at 1:01 p.m. with nurse manager (Manager) #3. Manager #3 stated treatment plans were used in patient care and should be updated weekly or when an event occurred, like a change in condition. Manager#3 stated events that would have triggered an update in treatment plans included physical aggression, increased symptoms, increased psychosis, or self-injurious behavior. Manager #3 stated treatment plans helped to set goals for patients, and addressed why the patient was admitted and what staff were doing to help the patients. Manager #3 stated the treatment plans for Patients #1, #2, and #4 should have been updated to reflect changes in patient condition and behavior, including the need for new goals and interventions. iii. An interview was conducted on 8/8/24 at 2:49 p.m. with the director of risk management (Director) #4. Director #4 stated treatment plans were important and should have been updated when changes in condition, such as aggression events occurred. Director #4 stated updated treatment plans should have included how to address aggression to prevent additional occurrences.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 47959 Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 PATIENT RIGHTS was out of compliance. A-0144 CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. Based on document review and interviews, the facility failed to provide care in a safe setting through higher levels of patient safety monitoring and safety checks in two of two patients with multiple self-harm events. (Patients #4, and #5)”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47959 Based on document review and interviews, the facility failed to provide care in a safe setting through higher levels of patient safety monitoring and safety checks in two of two patients with multiple self-harm events. (Patients #4, and #5) Findings include: Facility policies: The Suicide Risk Assessment and Management policy read, safety measures should align with methods of suicide attempts, i.e., pencil restrictions if a pencil was used for self-harm, or special observations for linens. The Patient Observation Rounds policy read, patients placed on special precautions will be provided with increased levels of staff supervision to prevent risk of harm to self or others. This includes safety checks every 15 minutes, every five minutes, and 1:1 observations. It provides increased environmental safety by conducting regular environmental safety inspections and checks of the treatment unit. 1. The facility failed to provide care in a safe setting through higher levels of patient safety monitoring and timed routine safety checks. A. Document Review i. Patient #4 was admitted to the Compass unit (low acuity, adult unit) on 3/7/24 with bipolar disorder (a mental illness that causes extreme mood swings) with suicidal ideation (thinking about or planning suicide). A review of Patient #4’s medical record revealed Patient #4 was placed on a 1:1 observation level on 3/9/24 for self-harming behaviors. The 1:1 observation level was removed on 3/11/24, and Patient #4 was placed on safety checks every five minutes. While on the five-minute safety checks, Patient #4 reached over the nurses’ station desk and grabbed a pen for the purpose of self-harm. The medical record also revealed Patient #4 obtained a plastic hairbrush on 3/16/24 and broke it for the purpose of self-harm. Additionally, Patient #4 obtained seven plastic spoons and a second broken hair brush on 3/17/24 and intended to self-harm with the plastic edges of the brush and spoons. Patient #4 was not placed on a 1:1 level of observation during this time. ii. Patient #4 was readmitted to the Compass unit on 4/13/24 with bipolar disorder with suicidal ideation. A review of Patient #4’s medical record revealed Patient #4 was placed on five-minute safety checks on 4/14/24. On 4/14/24, staff discovered Patient #4 had a broken plastic spoon and a razor blade. Patient #4 remained on five-minute safety checks. Patient #4’s medical record revealed on 4/15/24, Patient #4 banged their head against a wall and used a plastic spoon to cut themselves. An order for a 1:1 level of observation was obtained, however, documentation revealed the five-minute safety checks continued and Patient #4 was not placed with a 1:1 staff member for the higher level of observation. Patient #4’s medical record revealed on 4/16/24, Patient #4 attempted strangulation with a wall phone cord and banged their head against the wall to self-harm during the five-minute safety checks. Additionally, the medical record review revealed on 4/17/24, there was no evidence the five-minute safety checks were performed from 2:05 p.m. through 2:30 p.m. after Patient #4 attempted another wall phone cord strangulation at 11:00 a.m. Patient #4’s medical reveal no evidence the patient safety checks were performed on 4/22/24, 4/23/24, and 4/29/24. Patient #4 continued to have multiple episodes of self-harm events that involved plastic spoons, the coffee machine hot water dispenser, a shampoo bottle cap (attempted to swallow), and a tree stick from outside. The medical record review revealed Patient #4’s level of observation remained on five-minute safety checks despite additional self-harm attempts by Patient #4. This was in contrast to the patient observation rounds policy which read, patients were provided with increased levels of staff supervision to prevent the risk of harm to self or others. iii. A medical record review of Patient #5 revealed they were admitted on 2/29/24 to the Compass unit. On 3/5/24, staff learned Patient #5 had a small utility knife blade and the patient was placed on five-minute safety checks. Additional blades were found with Patient #5 on 3/6/24, 3/7/24, and 3/14/24. Patient #5 was increased to a 1:1 level of observation on 3/9/24 and was decreased back to five-minute safety checks on 3/11/24. Patient #5’s medical record review revealed on 3/13/24, the five-minute checks were missing three times on the day shift (8:15-8:30 a.m., 11:05-11:10 a.m., and 12:40-1:05 p.m.). On 3/14/24, another small utility knife blade was found in Patient #5’s pocket. Patient #5 was placed on a 1:1 level of observation till 3/16/24 when they returned to the five-minute safety checks. This was in contrast to the patient observation rounds policy which read, patients were provided with increased levels of staff supervision to prevent risk of harm to self or others. Furthermore, it was in contrast to the Suicide Risk Assessment and Management policy which read, safety measures aligned with methods of suicide attempts. B. Interviews i. On 6/20/24 at 12:28 p.m., an interview was conducted with behavioral health technician (BHT) #1. BHT #1 stated rounds were done every shift to check the environment for contraband (prohibited items patients used for harm to self or others). BHT #1 stated contraband included any items that could have been used as a weapon to harm the patient or others on the unit. Contraband included but was not limited to, razors, spoons, cords, linens, and phones. BHT #1 stated the patients had different levels of observation and the level was determined by the provider and the care team. BHT #1 stated when a patient was placed on a 1:1 observation level, there was a dedicated staff member with the patient within arm’s length at all times. BHT #1 stated patients who attempted self-harm with spoons were given finger foods to eat and not given access to the spoons. BHT #1 stated when patients went outside, they were watched for contraband but only checked the adolescent patients for contraband when they entered back into the facility. BHT #1 stated when patients who required 1:1 observation showered, they were watched on the opposite side of the shower curtain, but were still given shampoo bottles with lids on them. BHT #1 stated environment rounds and the correct level of observation were important so patients remained safe and could not hurt themselves or others. BHT #1 stated when patients did not have the correct level of observation, they were more likely to get injured or injure other patients or staff. ii. On 6/20/24 at 10:01 a.m., an interview was conducted with nurse manager (Manager) #2. Manager #2 stated the difference between a five-minute safety check and a 1:1 was the 1:1 observation level was arm’s length and the five-minute safety check had the patient in the staff member’s line of sight. Manager #2 stated it was important to have the correct level of observation because it kept patients safe from harm. Manager #2 stated if patients went unmonitored, incidents of self-harm, suicide attempts, and completed suicides had an increased risk. Manager #2 stated Patient #4 showered on 4/28/24 and had a shampoo bottle lid. Patient #4 was watched while in the shower and still attempted to swallow the lid. Manager #2 stated Patient #4 was on a 1:1 while outside on 4/29/24, but was able to get a tree stick when the staff member momentarily looked away. Manager #2 stated Patient #4 was able to get spoons from other patients during mealtime because Patient #4 was not on a 1:1 level of observation during those times. Manager #2 stated the treatment team decided the 1:1 level of observation was not therapeutic for Patient #4. This was in contrast to the medical record review for Patient #4 which revealed Patient #4 was not on a 1:1 level of observation during their entire stay. Furthermore, Patient #4 had access to spoons and other objects used for self-harm and had the opportunity for self-harm when five-minute safety checks were not performed as revealed in the medical record review. iii. On 6/20/24 at 10:45 a.m., an interview was conducted with the risk management director (Director) #3. Director #3 stated Patient #5 had several events where small utility blades were in their possession. Director #3 stated staff were unsure how Patient #5 hid multiple razors from staff. Director #3 stated Patient #5 was placed on a 1:1 level of observation until their investigation was completed. This was in contrast to Patient #5’s medical record which revealed Patient #5 had opportunities for self-harm when five-minute safety checks were not performed. Additionally, Patient #5’s medical record revealed staff found the knife blades on Patient #5 before the 1:1 level of observation was implemented and after it was discontinued.”