Eagle View Behavioral Health

“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: 50440 Based on document review, Patient Rights and Responsibility documents, Policies and Procedures, review of recorded video evidence, review of medical records, and staff interviews, the survey team concluded that the facility was not operating in compliance with conditions of participation: 42 CFR 482.13 Patient Rights and failed to provide care in a safe setting for two out of eighteen patients sampled (Patient #2 and Patient #3). Patient #2, who was placed on vulnerability precautions beginning on 4/25/25 at 1:30 pm, and Patient #3, who was placed on sexual acting out (SAO) precautions on 5/1/25 at 12:10 pm, were both placed at risk for serious injury or harm, when patients were not observed during a violation of the hospital’s boundary guidelines. Patient #3 entered Patient #2’s bedroom for 5 minutes without staff supervision or approval and proceeded to engage in a reported sexual activity. Based on medical record review, policy review, observations, and staff interviews, the hospital failed to provide patients care in a safe environment for 2 of 18 sampled patients (Patient #2 and Patient #3). Failure to provide patients with supervision within the hospital’s capabilities places patients at risk for unsafe interactions that can result in serious harm or injury in their health and wellbeing, including a potential risk for death Findings include: 1. Review of policy, “Staffing Plan for Provision of Care” effective 6/12/2020, revised 6/2023, revealed in part, Definition of Nursing Practice: “The practice of nursing means those functions...which help people cope with difficulties in daily living associated with their actual or potential health ... and treatment ... Nursing practice includes ... the following, but is not limited to:” a. “Observation of signs and symptoms ... general behavior or general condition.” b. “Determinations of whether such signs, symptoms, reactions, behavior or general appearance exhibits abnormal characteristics; and c. “Implementation, based on observations of appropriate reporting ... changes in treatment regimen in accordance with standardized procedures ...” Purpose: “To identify nursing care needs of the patient using the nursing process. ...registered nurses shall use the assessment skills initially and on an ongoing basis to determine the level of care; necessary interventions will be evaluated for effectiveness ...” 2. Review of medical records from Patient #2 on 4/25/25 at 1:10 am revealed 14-year-old, Patient #2, was admitted to the adolescent behavioral health unit with a chief complaint of depression and a danger to themselves. Patient #2 was identified at risk for vulnerable to intimidation related to male father figure’s alcoholism and suicide attempt in front of children including themselves. Patient #2 witnessed and endured physical abuse as a child. Patient #2 was assigned to a bedroom close to the nursing station and a 1-hour bathroom lockout after meals and snacks as an intervention to their vulnerability risk screen. a. On 4/25/25 at 11:57 am revealed daily shift assessment for Patient #2 showed the patient’s observation level as ordered for every 5 minutes (Q5) safety checks (staff uses a tablet device and application called “Observ Smart” (tablet device used for safety checks on patients’ locations and activities) to check in on patients’ location and status). b. On 4/26/25 at 10:03 pm revealed end of shift notes showed Patient #2 had Q15 in place. c. On 4/27/25 at 11:50 am revealed an observation level of Q5 for Patient #2’s daily shift assessment. 3. Review of medical records from Patient #3 on 4/25/25 at 11:31 am revealed 17-year-old, Patient #3, was admitted to the behavioral health unit with a chief complaint of suicide attempt by trying to hang self with elastic bands. Patient #3 alerted family members immediately after the attempt failed. Patient #3 has a history of self-harm by cutting themselves a couple of times. Patient #3 had increased depression issues and thoughts of self-harm. Patient #3’s chart revealed a history of autism. a. On 4/25/25 at 2:23 pm revealed Patient #3’s SAO and vulnerability screen for risk factors were none. b. On 4/25/25 at 11:29 pm revealed daily shift assessment for Patient #3 had an observation level of Q5 ordered c. On 4/27/25 revealed Patient #3 denied any suicidal ideation, homicidal ideation, or auditory and visual hallucinations. Documentation revealed Patient #3 had Q15 minute observations maintained during the shift. d. On 5/1/25 at 6:54 pm revealed Patient #3 had allegations of being sexually inappropriate were in motion to investigate. Documentation revealed Patient #3 had Q15 minute safety checks maintained. e. On 5/1/25 at 10:35 pm revealed Patient #3 was calm, cooperative, and Q5 minute safety checks were maintained throughout the shift. 4. Review of video evidence part #1 (starts at 8:25 pm - 8:31 pm ends) on 4/27/25 at 8:25 pm revealed Patient #2, Patient #3, and Staff B, Registered Nurse (RN), observed on camera. Staff B was alone in the nursing station. Patient #2 went to their room and entered their room on the right side of the unit near the nursing station while Staff B walked inside of the nursing station and sat on a chair at 2 monitors near to the camera view. At 8:27 pm, Staff B responded to 2 patients and walked to the other side of the nursing station near Patient #3’s bedroom. Patient #3 exited their room at 8:27 pm and walked to the clean linen room off camera. Staff B was engaged with another patient while their back was to Patient #3’s bedroom. At 8:28 pm Patient #3 walked past Patient #2’s bedroom door and slightly pushed the door open more as they walked by the room. Patient #3 continued to walk around the nursing station to the left and back to Patient #2’s bedroom at 8:29 pm and entered the room. Patient #2’s bedroom door remained open. Staff B turned to disengage the other patient after Patient #3 entered the room. Staff B returned and sat in the chair near the camera view at 8:29 pm. Review of video evidence part #2 (starts at 8:31 pm - 8:45 pm ends) on 4/27/25 at 8:34 pm revealed Patient #3 appeared and exited Patient #2’s bedroom while Staff B sat in the chair with their back to the patients’ bedrooms, facing the 2 monitors near to the camera view. Patient #3 walked back to the day area to the left out of the camera’s view. At 8:35 pm, Staff A, RN entered the camera view and walked into the nursing station. At 8:36 pm, Staff A walked to the far side of the nursing station away from the camera view and sat down. At 8:37 pm Patient #3 walked back to the far side of the nursing station, appeared to move a chair then walked back to the day area out of the camera view. At 8:38 pm Patient #3 observed on camera, walked back to the far side of the nursing station and sat on a chair. At 8:39 pm, Staff C, Behavioral Health Assistant (BHA), was observed and entered the nursing station on the right. Patient #3 stood up and walked back to their bedroom. At 8:40 pm Patient #3 exited their bedroom and returned to the chair near the far side of the nursing station as Staff C exited the nursing station and out of the camera’s view. At 8:41 pm, Staff D, Lead BHA 3, was observed on the camera and entered the nursing station on the right. Staff D walked to the far side of the nursing station and sat down next to Staff A, facing Patient #3 and another patient. At 8:44 pm, Patient #2’s roommate leaned into their bedroom and appeared to look behind the partially opened door for about 4 seconds, then turned away from the door, and returned to the day area when the other patients entered the camera view at 8:45 pm. At 8:45 pm Patient #2 exited their bedroom while holding linen or clothing. 5. During an interview on 6/23/25 at 8:00 am, Staff B RN, reported they believed Patient #2 and Patient #3 were on Q15 minute safety checks and did not recall if patients #2 and #3 were on Q5 precautions. Staff B reported they did not believe either Patient#2 and Patient #3 were on SAO precautions. Staff B said they did not believe they received the information regarding the precautions in report. The surveyor asked how staff would be able to find out patients’ precaution levels if they did not receive a verbal report. Staff B reported when they do charting, they would be able to see the patients’ precautions. 6. During an interview on 6/24/25 at 12:03 pm Staff A RN, reported patient precaution levels were put in place when they check in and determined by what patients have encountered in life. Staff A reported vulnerability precautions could be for patients with a history of abuse or lived on the streets, and patients that were probably trafficked. Staff A said some patients could be in vulnerable situations from other patients. Staff A revealed if patients committed anything or had allegations like behind sexually assaulted or assaultive, they would be put on SAO. Staff A reported staff would pay attention to who patients are buddying up to and they are hypervigilant about what patients are doing on the unit and which patients they are in close proximity to. Staff B said hindsight is 20/20 and believed they made corrections that prevent something from happening again. Staff B revealed, everyone comes in at Q15 and they can change it to Q5 or 1:1 if there are issues. Staff B reported Patient #3 was “very interested in the females”. Staff B said Patient #3 was someone they were “watching” and was not aware the incident occurred until the next day. The surveyor asked regarding why documentation for Patient #3 reveals orders for the patient to be on Q5 observation while some of the charting showed Q15 was being maintained. Staff B reported they did not know if that was just in charting and realized the next day when they reviewed their charting. Staff B reported all of their charting indicated they are all on Q15 as a basic observation and the staff happened to click that box. Staff B reported the staff can check Observ Smart to identify patients’ current observation status. Staff B revealed that charting could be different than what was displayed on the tablet and the tablet could be accurate but nurses charting could be off. Staff B revealed staff were not assigned to watch the cameras but there was usually someone watching. 7. During an observation of the Observ Smart tablet and interview on 6/25/25 at 12:00 pm, Staff S Assistant Director of Nursing (ADON), explained the observation application on the tablet could be set to perform an audible alert when patients are due for safety checks. Staff S reported when the patient identifier on the tablet is down to 1 minute, the indicator graphic turns from white to red. Staff S reported the orders from the doctor alert the nursing staff to update the observations status of patients. Staff S confirmed there is no way to view already discharged patients’ information on the tablet.”