Broadlawns Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 50212 Based on medical record review, policy and competency review, and interviews with patients and staff, the Acute Care Hospital (ACH) ’ s administrative staff failed to ensure Inpatient Behavioral Health (IBH) staff adhered to hospital policies and procedures pertaining to the monitoring and supervision of IBH patients identified to be at risk of self-harm. Failure to adhere to said policies resulted in the following: 1) an IBH patient (Patient #2) attempting suicide through self-strangulation with a ligature during a 12-minute lapse in monitoring (see A-0144); 2) 2 IBH patients (Patients #3 and #8) receiving safety checks at a frequency incongruent with hospital policy (see A-0144); 3) 2 IBH patients (Patients #3 and #8) not receiving routine, hourly safety checks by designated nursing staff, per hospital policy (see A-0144); 4) 2 IBH patients (Patients #3 and #8) not receiving appropriate acuity-based safety precautions in accordance with their respective physician-ordered observation levels (see A-0144). The cumulative effect of these deficient practices and systemic failures resulted in an inability of the ACH ’ s administrative staff to implement and maintain appropriate safeguards against actual and potential harm to all patients-including vulnerable populations most at risk of serious harm up to and including death.”

“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: 50212 Based on medical record review, policy and competency review, and interviews with patients and staff, the Acute Care Hospital (ACH) ’ s administrative staff failed to ensure 3 of 15 sampled Inpatient Behavioral Health (IBH) patients received care in an environment in which a reasonable person would consider to be safe from potential harm. Failure to provide appropriate safeguards for the physical safety and security of all patients could result in serious injury and adverse health outcomes (e.g., intentional or inadvertent self-harm) up to and including disability or death. Findings include: 1. Review of Patient #2 ’ s 12/3/24 medical record revealed the following: a. On 12/3/24 at 5:02 PM, Patient #2 presented to the Emergency Department (ED) approximately one hour after attempting suicide via self-inflicted left wrist laceration (deep cut) with a kitchen knife. Upon presentation, the patient reported ongoing suicidal ideations (SI), homicidal ideations (HI), and auditory verbal hallucinations (AVH) of “ demons “ instructing the patient to harm themself and others. At 10:19 PM, staff admitted the patient to the IBH unit due to ongoing SI, AVH, and borderline personality disorder (BPD). b. On 12/4/24 at 4:18 AM, Staff HH (IBH Registered Nurse (RN)) documented the patient had an extensive history of self-harm, identified the patient as a high suicide risk, and noted the patient ’ s safety precautions included continuous video monitoring and safety checks every 10 minutes. At 11:00 AM, Staff M (Psychiatrist) documented the patient reported continued suicidality with a plan to lacerate their throat to “ kill [the patient ’ s] demons. Staff M noted the patient ’ s medical history included over 20 previous psychiatric hospitalizations and “ numerous “ suicide attempts, which included a previous attempt to self-strangulate while hospitalized. At 5:57 PM, Staff OO (IBH RN) documented the patient attempted to harm themself by banging their head on the hospital wall, and at 8:37 PM, Staff PP (IBH RN) documented the patient received intramuscular (IM) sedative medication due to “ severe self-harm behavior and suicidal thoughts and actions. “ c. On 12/5/25 at 10:00 AM, Staff K (Psychiatry Resident) documented the patient reported continued AVH urging self-harm and “ compulsions for suicide, “ and the patient required additional IM sedation and antipsychotic therapy for psychosis. At 10:46 AM, Staff J (IBH RN) documented the patient stated they did not want to stop hurting themselves and wanted to die. At 10:50 AM, Staff K documented the patient required physical restraints due to being an immediate risk to themself and others. At 12:05 PM, Staff J documented the patient continued to endorse SI, appeared to be in “ extreme emotional distress, “ and reported hearing “ demons “ instructing the patient to “ kill everyone. “ d. On 12/6/24 at 1:31 AM, Staff QQ (IBH RN) documented the patient continued to endorse SI, HI, and AVH, and at 9:00 AM, Staff J (IBH RN) identified the patient to be a high risk for suicide. At 9:40 AM, Staff M (Psychiatrist) documented the patient remained at “ current, severe, imminent risk of serious harm to self or others “ and recommended the patient continue with inpatient psychiatric hospitalization for their safety. At 2:20 PM, Staff J documented the patient reported they preferred the door to their room be left open due to concerns “ the shadows will be able to get [the patient] when the door was closed. “ At 2:27 PM, Staff J documented the patient required placement in a restraint chair due to the patient remaining an immediate risk to themself and others. At 2:46 PM, Staff J documented the patient vocalized they continued to need restraints due to the intensity of their hallucinations. At 11:14 PM, Staff RR (IBH RN) documented the patient reiterated their preference to leave the door to their room open at all times and requested a staff member stand near the restroom while the patient showered to mitigate the risk of the patient harming themself while in the restroom. e. On 12/7/24 at 11:11 AM, per documentation by Staff N (IBH RN), the patient requested to leave the door to their room closed for privacy while in the restroom. Upon approval of this request, the patient attempted suicide via self-strangulation by tying long socks around their neck, which remained tied around the patient ’ s neck until a subsequent 10-minute safety check at 11:23 AM. Staff N noted the patient appeared to be blue at the time of discovery and-upon removal of the makeshift ligature-the patient exhibited tachycardia (elevated heart rate), dyspnea (difficulty breathing), and hyperventilation (abnormally rapid respirations). Staff N documented the patient began vomiting blood and food, experienced respiratory distress, and required admission to the Intensive Care Unit (ICU) for advanced care. Staff N noted the patient and suicide attempt had been visible to the assigned video monitor staff during the incident. f. On 12/7/24 at 12:28 PM, Staff G (Hospitalist) ordered computed tomography (CT) imaging of the patient ’ s head and brain due to “ concern for anoxic brain injury “ (tissue damage of the brain resulting from lack of oxygen) and ordered the placement of a nasogastric tube (NGT). At 3:59 PM, Staff S (Internal Medicine (IM) Physician) documented the presence of “ trauma injury from hanging attempt “ and cited evidence of bruising on the patient ’ s neck. On 12/10/24 at 12:25 PM, Staff GG (Psychiatrist) documented the 12/7/24 self-strangulation attempt resulted in altered mental status (AMS), seizure-like activity, and eventual intubation of the patient due to apnea (transient cessation of breathing). g. On 12/11/24 at 3:06 PM, Staff S (IM Physician) documented the following assessment and plan: “ Acute Hypoxic Respiratory Failure requiring mechanical ventilation. Respiratory failure has been deemed secondary to the events that led to [the patient] becoming apneic . . . Given [the patient ’ s] initial apnea, [the patient] was placed on the ventilator, which [the patient] remains on. [Hospital staff] have yet to be able to liberate [the patient] from the ventilator. “ At 3:22 PM, Staff T (Pulmonologist) documented consulting with Staff S regarding “ respiratory failure following self-induced cervical ligature injury . . . intermittent convulsive activity . . . [and] possible Laryngeal Edema “ (swelling of larynx associated with trauma to this segment of the throat). h. On 12/12/24 at 10:02 AM, Staff Q (Neurologist) documented reviewing electroencephalogram (EEG) imaging of the patient ’ s brain and noted the presence of “ moderate to moderately severe [abnormality] suggestive of a global encephalopathy “ (serious brain dysfunction due to trauma or infection); however, on 12/13/24 at 2:59 PM, Staff LL (IM Physician) noted the clinical impression of the EEG had been “ significantly skewed by the multiple sedation medications [the patient] was on while undergoing the EEG. “ 2. Review of the ACH ’ s internal investigation report revealed the following: a. On 12/7/24 at 12:40 PM, Staff I (Chief Nursing Officer (CNO)) documented receiving notice of the 12/7/24 suicide attempt in which Patient #2 tied socks around their neck to form a ligature, resulting in the patient ’ s admission to the ICU for advanced care and placement on a ventilator for respiratory support. b. Upon review of video surveillance of the patient ’ s room, Staff I approximated the duration of the self-harm event to be 11 minutes and noted multiple instances in which the socks and the patient ’ s manipulation of the socks to form a ligature had been visible on the video monitor. c. Upon review of video surveillance of the nurses ’ station, Staff I noted, “ It was clearly apparent that [Staff B (IBH HCT) was engaged in a conversation with [Staff C (IBH RN)] “ during the event and “ did not appear to be paying attention . . . [they] seemed focused on the conversation. “ 3. Review of the ACH ’ s root cause analysis (RCA) of the 12/7/24 self-harm event revealed the following: a. “ [Patient #2] was admitted for suicidal ideation on 12/3/24 to the PICU hallway. At 11:11 on 12/7, the patient asked to have the door to [their] room closed for privacy to use the bathroom . . . [The patient] then exited holding a sock around [their] neck . . . [The patient] continued tying an addition sock around [their] neck . . . [The patient] could be seen twisting the socks tighter around [their] neck. “ b. “ It was noted on video footage of the nurse station that [Staff B] and [Staff C] were conversing from 1111 until event was reported at 1123 “ . . . “ [Staff B] was talking with [Staff C] and not fully focused on the monitors. Staff did not report [the patient ’ s] self-harm. [Staff B] failed to follow established policies . . . time between staff rounds on the patient was 12 [minutes] . . . Staff are to have in-person visual contact with the patient a minimum of every 10 [minutes] in the PIC hallway . . . There was a delay in communication of the event as [Staff B] failed to observe and report the event . . . [The patient] had been reporting suicidal ideation . . . [Staff B] was at monitor station located in nurse station and had the opportunity to observe the event and communicate to other staff for patient assistance. “ 4. During an interview on 2/4/25 at 4:15 PM, Patient #2 reported intentionally cutting their left wrist with a knife on 12/3/24-approximately one hour prior to their arrival-and confirmed they again attempted suicide on 12/7/24 while admitted to the PICU by utilizing long socks as a ligature to attempt self-strangulation. The patient reported they obtained the socks from IBH staff despite long socks being restricted to the patient due to their history of self-harm and risk status. 5. During an interview on 2/5/25 at 12:45 PM, Staff A (Manager of Performance and Process Improvement) identified Staff B (IBH HCT) as the staff member responsible for monitoring videos of the patients ’ rooms during the self-harm attempt. Staff A reported observing Staff B conversing with Staff C (IBH RN) and appearing visibly distracted from their duties as video monitor. Staff A reported IBH staff may have reacted to the self-harm incident immediately had Staff B closely monitored the videos as expected. 6. During an interview on 2/4/25 at 2:45 PM, Staff X (IBH HCT) recalled Patient #2 requested to close their door for privacy while using the restroom on the day of the self-harm event, which staff permitted. Staff X reported they checked on the patient shortly thereafter and found the patient with socks tied around their neck and a blue skin hue (indicating a lack of circulation). 7. During an interview on 2/3/25 at 4:30 PM, Staff M (Psychiatrist) reported Patient #2 endorsed active SI (thoughts of committing suicide with a plan or intention) due to increased auditory hallucinations, which worsened in severity if the patient remained alone for “ even a couple of minutes. “ Staff M reported awareness of previous self-harm attempts by the patient while hospitalized, which contributed to the decision to admit the patient to the PICU for enhanced supervision, including continuous video monitoring of the patient ’ s room and safety checks every 10 minutes. 8. During an interview on 2/4/25 at 12:30 PM, Staff O (Psychiatrist) identified Patient #2 as high-risk with a history of chronic suicidality and impulsivity and reported the patient should not have had access to the long socks used as a ligature to attempt self-strangulation. Staff O noted the ACH provided Psychiatric services for Behavioral Health patients of the highest level of acuity and vulnerability, indicated “ [the PICU] is for patients in immediate danger, “ and underscored the importance of maintaining patient safety on the unit by positing “ If they ’ re not safe, then we ’ re not doing our job. “ 9. During an interview on 2/5/25 at 1:30 PM, Staff V (Nursing Director, IBH & Crisis Hallway) reported IBH staff identified Patient #2 as a high risk for self-harm due to their history of previous Psychiatric admissions and auditory hallucinations encouraging the patient to harm themself and others. Staff V stated they expected the assigned video monitor to report “ anything out of the norm “ to nursing staff, which the staff member failed to do. Additionally, Staff V acknowledged, given the patient ’ s high-risk status, IBH staff should not have permitted the patient to close the door to their room and noted the patient should not have been provided with long socks as these were prohibited to patients in paper scrubs (i.e., high-risk IBH patients). Despite the ACH ’ s administrative staff conducting an investigation of the suicide attempt, Staff V reported they were unable to determine how the patient obtained the socks used as a ligature in the suicide attempt. 10. During an interview on 2/5/25 at 12:00 PM, Staff W (House Supervisor) reported participating in the investigation of the 12/7/24 suicide attempt and concluded Staff B “ very clearly was not engaged in watching [Patient #2] “ and “ was conversing with another staff. “ Staff W confirmed hospital policy prohibited staff assigned to the video monitor from conversing with other staff during the assignment. Staff W reported IBH staff could have immediately intervened in the suicide attempt if Staff B had performed their duties as expected. 11. During an interview on 2/12/25 at 10:25 AM, Staff B (IBH HCT) reported receiving instructions to closely monitor Patient #2 on 12/7/24 due to the patient ’ s high risk for suicide and history of multiple suicide attempts. Staff B recalled the patient had been provided with paper scrubs (indicating an elevated risk of self-harm) and noted IBH staff should not have permitted the patient to close the door to their room, nor should the patient have been in possession of long socks. Staff B stated they were assigned to the video monitor at the time of the suicide attempt and confirmed they had been conversing with Staff C (IBH RN) during this time. Staff B denied that the conversation distracted them or resulted in a lapse of monitoring of the patient; however, Staff B acknowledged, “ I should ‘ve caught [the self-harm event], so I will take accountability for that. I did miss it. “ 12. During an interview on 2/3/25 at 3:30 PM, Staff C (IBH RN) recalled IBH staff provided Patient #2 with paper scrubs, which served as an indication that staff identified the patient to be at high risk for self-harm. Staff C acknowledged they had been conversing with Staff B-the assigned video monitor at the time of the self-harm event-despite confirming awareness of hospital policy prohibiting such. 13. During an interview on 2/4/24 at 1:15 PM, Staff CC (IBH RN) reported Patient #2 ’ s medical history included a previous suicide attempt on the main IBH unit within the past year and indicated one-to-one supervision may have been appropriate given the patient ’ s extensive history of self-harm. Staff CC confirmed the staff member assigned to monitor the video feed of the patient at the time of the suicide attempt had been distracted by conversation, which they characterized as “ loud “ and related to “ personal things, not about work. “ Staff C noted they expected Staff B to report any signs of self-harm behaviors by the patient but failed to do so. Staff CC recalled the patient displayed difficulty communicating, episodes of intermittent apnea (transient cessation of breathing), and hyperventilation (abnormally rapid respirations) upon discovery of the 12/7/24 suicide attempt. 14. During an interview on 2/3/25 at 3:30 PM, Staff Z (IBH RN) reported Patient #2 ’ s medical history included previous suicide attempts while admitted to the ACH; however, Staff Z recalled the staff member assigned to monitor the video of the patient at the time of the event had been conversing “ non-stop “ about non-work-related topics of discussion during the time of the 12/7/24 suicide attempt despite being aware of hospital policy prohibiting conversing while assigned to the video monitor. 15. During an interview on 2/4/25 at 9:30 AM, Staff BB (IBH HCT) confirmed the expectation of the assigned video monitor included maintaining supervision of patients at all times, notifying nursing staff if unable to see a patient for more than one or two minutes, and reporting any behavioral changes or self-harm attempts to nursing staff to prompt an additional safety check of the respective patient(s). 16. During an interview on 2/4/25 at 2:00 PM, Staff AA (IBH HCT) reported the expectation for staff assigned to the video monitor included reporting any unusual behaviors, such as those displayed by Patient #2 during the 12/7/24 suicide attempt; however, Staff AA stated the staff member assigned to the video monitor (Staff B) had been conversing with another staff member during this time. Staff AA reported all IBH staff were aware of hospital policy prohibiting staff from conversing while assigned to the monitor and confirmed the patient had a known history of SI and previous suicide attempts. 17. During an interview on 2/4/25 at 9:45 AM, Staff N (IBH RN) reported Patient #2 endorsed continual auditory hallucinations of voices instructing them to harm themself and others and characterized the patient as “ very unpredictable. “ Staff N reported the staff responsible for video monitoring the patient (Staff B) had been conversing with another staff member during the 12/7/24 suicide attempt, which resulted in a failure to promptly identify the self-harm event. Staff N reported assessing the patient upon discovery of the attempted suicide and noted the patient displayed elevated blood pressure (BP) and tachycardia (elevated heart rate), appeared to be gasping for air, and became intermittently unresponsive. 18. During an interview on 2/4/25 at 11:15 AM, Staff Y (IBH HCT) reported hospital policy prohibited conversations with other staff members while assigned to the video monitor and confirmed the staff member assigned to the video monitor at the time of the self-harm incident had been distracted by conversation with another staff member. Staff Y reported the assigned staff member would likely have identified the suicide attempt had they not been distracted during the event. 19. Review of the hospital ’ s Corrective Action Plan regarding the 12/7/24 self-harm event revealed the following: “ [Staff V (IBH Director)] to standardize process hospital-wide that all patients in green scrubs are to wear non-skid ankle socks, updating policy/procedure and educating staff as appropriate . . . Complete 12/30/24. “ 20. On 2/4/24 at 4:15 PM, the SA observed a patient in the IBH unit wearing long socks, which the ACH ’ s administrative staff prohibited as part of the aforementioned Corrective Action Plan. The ACH ’ s administrative staff identified a completion date of 12/30/24 for the corrective action-37 days prior to the observation date. 21. During an interview on 2/5/25 at 1:30 PM, Staff V (Nursing Director, IBH & Crisis Hallway) confirmed Behavioral Health patients were presently prohibited from wearing or retaining long socks on the IBH unit; however, Staff V confirmed IBH staff failed to take possession of the prohibited socks from an additional Behavioral Health patient, which the survey team identified during observations. 22. During an interview on 2/5/25 at 12:00 PM, Staff W (House Supervisor) confirmed the ACH ’ s administrative staff prohibited patients from wearing long socks on the IBH units at the time of the observation. 23. During an interview on 2/5/25 at 12:45 PM, Staff A (Manager of Performance and Process Improvement) acknowledged an additional patient had possession of long socks comparable to those used as a ligature by Patient #2 after said socks were prohibited due to patient safety concerns. 24. Review of Patient #3 ’ s 11/5/24 medical record revealed the following: a. On 11/5/24 at 3:46 PM, Staff O (Psychiatrist) admitted Patient #3 to the IBH unit for a court-ordered admission due to psychosis. IBH staff documented the patient ’ s medical history included generalized anxiety disorder (GAD), methamphetamine abuse, psychosis, and unspecified mood disorder. At 5:29 PM, IBH staff entered a physician order from Staff BBB (Psychiatrist) for Level IV Acuity observation status with elopement precautions. From 11/5/24 to 11/14/24, IBH staff nursing staff performed daily elopement risk assessments, which included documentation that the patient ’ s observation level (Level IV Acuity) restricted the patient to the IBH unit (i.e., no courtyard privileges). The medical record did not include documentation of a superseding physician order for lower acuity precautions, nor did the record include discontinuation of elopement precautions prior to the patient ’ s discharge on 11/14/24. b. 11/11/24 at 3:00 PM, IBH staff documented implementing Level III Acuity observation status despite existing physician orders for Level IV Acuity observation with elopement precautions and without obtaining a new or appropriately modified physician order for lower acuity observation. c. 11/12/24 at 7:00 AM, IBH staff documented maintaining Level III Acuity observation status despite existing physician orders for Level IV Acuity observation with elopement precautions and without obtaining a new or appropriately modified physician order for lower acuity observation. d. 11/13/24 at 7:00 AM, IBH staff documented maintaining Level III Acuity observation status despite existing physician orders for Level IV Acuity observation with elopement precautions and without obtaining a new or appropriately modified physician order for lower acuity observation. e. On 11/12/24 at 11:00 AM, IBH staff documented permitting the patient to participate in outdoor activities; however, hospital policy prohibited patients with Level IV Acuity observation status or elopement precautions from participating in said activities. f. Records of safety checks performed from 11/5/24 to 11/14/25 did not include documentation of nursing staff performing routine, hourly safety checks in accordance with hospital policies and procedures. g. The medical record included documentation of 41 instances in which staff failed to complete safety checks until 20 or more minutes after the preceding safety checks despite hospital policy requiring a minimum frequency of every 15 minutes for safety checks on the main IBH unit. Additionally, the record included 6 documented instances in which hospital staff failed to complete safety checks until 25 or more minutes after the preceding safety checks. h. On 11/7/24 at 12:18 AM, IBH staff completed a safety check but failed to complete a subsequent safety check until 12:48 AM-30 minutes later and 15 minutes after the maximum allotted time, per hospital policy. i. On 11/8/24 at 7:00 PM, IBH staff completed a safety check but failed to complete a subsequent safety check until 7:34 PM-34 minutes later and 19 minutes after the maximum allotted time, per hospital policy. j. On 11/11/24 at 2:18 AM, IBH staff completed a safety check but failed to complete a subsequent safety check until 2:46 AM-28 minutes later and 13 minutes after the maximum allotted time, per hospital policy. k. On 11/11/24 at 5:18 AM, IBH staff completed a safety check but failed to complete a subsequent safety check until 5:49 AM-31 minutes later and 16 minutes after the maximum allotted time, per hospital policy. l. On 11/12/24 at 11:15 PM, IBH staff completed a safety check but failed to complete a subsequent safety check until 11/13/24 at 12:07 AM-52 minutes later and 37 minutes after the maximum allotted time, per hospital policy. m. On 11/13/24 at 10:45 PM, IBH staff completed a safety check but failed to complete a subsequent safety check until 11:11 PM-26 minutes later and 11 minutes after the maximum allotted time, per hospital policy. 25. Review of Patient #8 ’ s 10/4/24 medical record revealed the following: a. On 10/4/24 at 8:26 PM, Staff O (Psychiatrist) admitted Patient #8 to the IBH unit for SI with a plan to sever an artery. IBH staff documented the patient ’ s medical history included depression and anxiety. At 10:56 PM, Staff SS (IBH RN) entered an order from Staff O for Level IV Acuity observation status. The medical record did not include documentation of a superseding physician order for lower acuity precautions prior to the patient ’ s discharge on 10/11/24. b. On 10/5/24 at 6:41 AM, IBH staff documented implementing Level III Acuity observation despite existing physician orders for Level IV Acuity precautions, without obtaining a new or appropriately modified physician order for lower acuity observation, and despite hospital policy requiring all IBH patients to remain under Level IV Acuity precautions for a minimum of 24 hours after admission. c. On 10/7/24 at 3:00 PM, IBH staff documented maintaining Level III Acuity observation despite existing physician orders for Level IV Acuity precautions and without obtaining a new or appropriately modified physician order for lower acuity observation. d. On 10/7/24 at 9:16 AM, IBH staff documented permitting the patient to participate in outdoor activities despite hospital policy prohibiting patients with Level IV Acuity precautions from participating in said activities. e. On 10/9/24 at 10:30 AM, IBH staff documented permitting the patient to participate in outdoor activities despite hospital policy prohibiting patients with Level IV Acuity precautions from participating in said activities. f. On 10/10/24 at 10:33 AM, IBH staff documented permitting the patient to participate in outdoor activities despite hospital policy prohibiting patients with Level IV Acuity precautions from participating in said activities. g. Records of safety checks performed from 10/4/24 to 10/11/24 did not include documentation of nursing staff performing routine, hourly safety checks in accordance with hospital policies and procedures. h. The medical record included documentation of 39 instances in which staff failed to complete safety checks until 20 or more minutes after the preceding safety checks despite hospital policy requiring a minimum frequency of every 15 minutes for safety checks on the main IBH unit. Additionally, the record included 6 documented instances in which hospital staff failed to complete safety checks until 25 or more minutes after the preceding safety checks. i. On 10/6/24 at 4:33 PM, IBH staff completed a safety check but failed to complete a subsequent safety check until 5:02 PM-29 minutes later and 14 minutes after the maximum allotted time, per hospital policy. j. On 10/7/24 at 12:15 AM, IBH staff completed a safety check but failed to complete a subsequent safety check until 12:42 AM-27 minutes later and 12 minutes after the maximum allotted time, per hospital policy. k. On 10/7/24 at 2:15 AM, IBH staff completed a safety check but failed to complete a subsequent safety check until 2:40 AM-25 minutes later and 10 minutes after the maximum allotted time, per hospital policy. l. On 10/7/24 at 6:15 AM, IBH staff completed a safety check but failed to complete a subsequent safety check until 6:41 AM-26 minutes later and 11 minutes after the maximum allotted time, per hospital policy. m. On 10/9/24 at 5:49 AM, IBH staff completed a safety check but failed to complete a subsequent safety check until 6:15 AM-26 minutes later and 11 minutes after the maximum allotted time, per hospital policy. n. On 10/9/24 at 9:15 PM, IBH staff completed a safety check but failed to complete a subsequent safety check until 9:41 PM-26 minutes later and 11 minutes after the maximum allotted time, per hospital policy. 26. During an interview on 2/10/25 at 4:00 PM, Staff O (Psychiatrist) reported hospital policy prohibited patients under Level IV Acuity observation precautions from leaving the IBH unit, including for outdoor activities in the courtyard, whereas Level III Acuity did impose this restriction. Staff O confirmed hospital policy required nursing staff to obtain a physician order and document doing so prior to reducing a patient ’ s observation level or safety precautions. 27. During an interview on 2/11/25 at 4:00 PM, Staff AAA (IBH RN) confirmed hospital policy required nursing staff to obtain and enter a provider ’ s order into the patient ’ s electronic medical record (EMR) prior to lowering a patient ’ s acuity (observation) level. 28. During an interview on 2/11/25 at 1:35 PM, Staff SS (IBH RN) confirmed IBH staff could not place patients with elopement precautions on Level III Acuity observation status and stated the provider would first need to discontinue the patient ’ s elopement risk status before the observation status could be modified, per hospital policy. 29. During an interview on 2/10/25 at 2:00 PM, Staff V (Nursing Director, IBH & Crisis Hallway) confirmed hospital policy required nursing staff to complete hourly safety checks of patients on the IBH unit; however, Staff V acknowledged nursing staff did not routinely perform the rounding per policy, noting the policy that required this “ just never got changed “ once the unit had been remodeled approximately 7 years ago. Staff V indicated the remodeling allowed nursing staff to maintain sight of patients in the common areas of the IBH while at the nurses ’ station; thus, they indicated the policy had not been routinely enforced during the interim time since the remodeling occurred. 30. Review of the hospital ’ s 04/2024 policy “ Patient Rights and Responsibilities “ revealed in part: a. “ I. Policy: [The ACH] is committed to respect for and the protection of the rights of each patient. “ b. “ 5. Safety: a. The patient has the right to receive care in safe setting. Medical center staff should follow current standards of practice for patient environmental safety . . . and security. The medical center will protect vulnerable patients . . . This standard is intended to provide protection for the patient ’ s emotional health and safety as well as physical safety. “ c. “ d. The patient has the right to be free from all forms of abuse or harassment including physical, sexual or mental abuse . . . The medical center prohibits all forms of abuse, neglect (as a form of abuse) . . . Neglect is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. “ 31. Review of the hospital ’ s 10/2024 policy “ Process for Reporting and Investigation “ revealed in part: “ I. Policy: [The ACH] has a zero-tolerance policy for . . . abuse, neglect, and exploitation of patients . . . by any staff member or provider. “ 32. Review of the hospital ’ s 04/2022 policy “ Inpatient Behavioral Health Nursing Care Policies and Procedures “ revealed in part: a. “ Purpose . . . The purpose is to ensure that the patient is being treated in the least restrictive clinically appropriate environment and to provide a means of monitoring to prevent patients from harming themselves or others . . . “ b. “ 3. Documentation. a. Assigned staff will document patient whereabouts every 15 minutes (safety rounds) on the Main Unit and Lower Level, or every 10-minutes for B Hall on Ground Level. An RN will complete a safety round one time per hour, generally at the beginning of each hour but at staggered times. “ c. “ d. Level IV . . . 1. Used for: a. Patients who are at risk of harm to self or others, demonstrate impulsive or unpredictable behavior, or are otherwise thought to require constant structure and supervision on the unit . . . 3. Documentation: a. Assigned staff will document patient whereabouts every 15 minutes (safety rounds) on the main unit on Lower Level or every 10 minutes for B Hallway Ground Level. An RN will complete a safety round one time per hour . . . unless extreme circumstances prevent this. “ 33. Review of the hospital ’ s 03/2023 policy “ Safety/Equipment/Alarms “ revealed in part: a. “ I. Policy: All members of the nursing staff are expected to keep patients, visitor and employee safety upper most in mind at all times; and to be aware of and compliant to all general and specific safety regulations and policies of the facility and the Inpatient Behavioral Health (IBH) unit. “ b. “ II. Procedure . . . D. Safety Monitoring: 1. Safety Checks. a. The assigned staff person will document the patient ’ s location and behavior at least once every 15 minutes on the main unit and 10 minutes in B hall . . . d. Safety checks can be conducted more frequently, but not less frequently than the required time. “ c. “ 3. Video Monitoring . . . c. The video monitor will be watched continuously 24 hours per day, 365 days per year. d. Staff must continuously scan back and forth among all the camera angles to ensure the safety of the patients. “ 34. Review of the hospital ’ s 04/2023 competency “ Video Monitoring - IBH “ revealed in part: a. “ Applicable Staff: All IBH staff responsible for video monitoring . . . Purpose: To provide video monitoring to ensure that the patient and staff remain safe. “ b. “ Patient Observation: 1. Visually watch monitors at all times . . . 3. Does not focus on tasks other than video monitoring. “ c. “ Patient Safety: Staff recognizes and immediately reports behaviors that could place patient or others at risk of injury. 1. Self-harm or attempted self-harm. 2. Attempted suicide. “ d. “ Communication . . . Immediately reports to appropriate staff changes in behavior or condition (such as . . . self-harm, etc.). e. “ Additional safety strategies . . . 2. Reports any behavior which appears suspicious or out of the norm . . . If patient is in the restroom more than 3-5 minutes, monitor staff should request staff check on the patient. “ 35. Review of the hospital ’ s 10/2023 competency “ Safety Checks (Rounds) IBH “ revealed in part: a. “ Applicable Staff: All staff is responsible for the safety of the patients . . . Purpose: To provide monitoring to ensure that the patients, staff, and general population remain safe. “ b. “ Patient Observation: 1. Staff monitors each patient a minimum of 1x per 15 minutes on ground level room B1 and halls C, D, E. All lower-level rooms have a minimum of 15-minute safety checks. Safety checks are to be completed a minimum of every 10 minutes in the PIC hall on ground level, rooms B2 through B6. “ c. “ Patient Safety: Staff recognizes and immediately intervenes with behaviors that could place patient at risk of injury. 1. Self-harm or attempted self-harm. 2. Attempted suicide. “ d. “ Communication . . . Immediately reports to appropriate staff changes in behavior or condition (such as . . . self-harm, etc.). e. “ Additional safety strategies: 1. Staff report any patient concerns or behavior which appears suspicious or out of the norm to the patient ’ s nurse. “ 36. Review of the hospital ’ s 05/2022 competency “ IBH Ground Level B Hall Monitoring “ revealed in part: a. “ Applicable Staff: All staff is responsible for the safety of the patients. “ b. “ Purpose: To ensure that the staff provide monitoring of the patient(s) and staff in B hall remain safe. “ c. “ Patient Observation: 1. Visualizes patients at all times while in the B hall. 2. Staff monitor each patient a minimum of 1x per 10 minutes. “ d. “ Patient Safety: Staff recognizes and immediately reports to charge nurse behaviors that could place patient at risk of injury and intervenes. 1. Self-harm behaviors, including verbalizing self-harm. 2. Attempted suicide, including verbalizing suicidal ideation. “ e. “ Communication: Staff follows direction and communicates with patient to know patient needs . . . 3. Immediately reports to appropriate licensed staff in the area any changes in behavior or condition (such as self-harm behaviors, expressed suicidal/homicidal/elopement thoughts or gestures . . . “ f. “ Additional safety strategies . . . 5. Prevents unsupervised access to objects that can cause harm to self or others. “ 37. Review of the hospital ’ s 07/2022 competency “ Courtyard Safety - IBH “ revealed in part: a. “ Purpose: To ensure that staff provide monitoring of the patient(s) that go to the courtyard and remain safe. “ b. “ Patients that are court ordered substance abuse, change of jail . . . or those patients under elopement precautions are not eligible for level III and are not eligible to go to the courtyard. “ 38. Review of the hospital ’ s 03/2023 policy “ Elopements (Unauthorized Departures), Elopement Screening, and Missing Adults “ revealed in part: a. “ Elopement Risk Screen ...If the patient has one “ yes “ answer, the patient will be considered high risk for elopement and elopement precautions will be implemented. “ b. “ Patients on elopement precautions will be restricted to the unit, except for emergency situations. “ 39. Review of the hospital ’ s 04/2022 policy “ Patient Observation Categories - Acuity Based Level System “ revealed in part: a. “ Purpose: The purpose is to ensure that the patient is being treated in the least restrictive clinically appropriate environment and to provide a means of monitoring to prevent patients from harming themselves or others. “ b. “ I. Procedure . . . 1. Admission level will be Level IV unless a one to one (1:1) has been ordered . . . The patient will remain on Level IV for at least 24-hours after admission . . . 7. Any deviation from this policy must be approved by the Medical Director and the Nursing Director or their designees . . . 10. A patient on Elopement Precautions cannot go to a Level III or lower. “ c. “ II. Categories . . . Level III . . . b. Patient may leave the unit to go to the locked recreational court yard, but must be accompanied by staff . . . court ordered substance abuse patients or those under elopement precautions are not eligible for level III and may only leave the unit in the custody of law enforcement or for necessary medical appointments accompanied by public safety and staff . . . 2. Used for: a. Patients who are cooperative and engaged in treatment but who continue to have a level of symptoms which require supervision and redirection on a regular basis. 3. Documentation: b. Assigned staff will document patient whereabouts every 15 minutes (safety rounds) on the main unit and Lower Level or every 10 minutes for B Hall on Ground Level. An RN will complete a safety round one time per hour . . . unless extreme circumstances prevent this. “ d. Level IV . . . Used for . . . a. Patients who are at risk of harm to self or others, demonstrate impulsive or unpredictable behavior, or are otherwise thought to require constant structure and supervision on the unit . . . court ordered substance abuse patients and patients under elopement precautions may not progress beyond a level IV. 3. Documentation: a. Assigned staff will document patient whereabouts every 15 minutes (safety rounds) in the main unit on Lower Level or every 10 minutes for B Hallway Ground Level. An RN will complete a safety round one time per hour . . . unless extreme circumstances prevent this. “ The cumulative effect of these deficient practices resulted in an inability of the ACH ’ s administrative staff to ensure hospital staff provided care in a safe setting to all patients in accordance with hospital policies and procedures and acceptable standards of practice.”