Montrose Behavioral Health Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 52901 Based on document review, video review, observation, and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13 Patient Rights. Findings include: 1. The hospital failed to ensure that appropriate level of precautions was in place for a patient demonstrating increase self-injurious behaviors. Subsequently this led to inappropriate level of monitoring on a suicidal patient (Pt. #1) who committed suicide.The hospital implemented a corrective action plan; however, unable to demonstrate sustained compliance. See A-144.”

“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: 52901 Based on document review, observation and interview, for 1 of 5 (Pt. #1) patients reviewed for suicide precautions, the hospital failed to ensure that appropriate level of precautions was in place for a patient demonstrating increase self-injurious behaviors. Subsequently this led to inappropriate level of monitoring on a suicidal patient (Pt. #1) who commiteed suicide. The hospital implemented a corrective action plan; however, unable to demonstrate sustained compliance. Findings include: 1. The hospital’s policy titled, “Suicide Risk Assessment” (revised 11/2023) was reviewed and required, “Patients and Residents may be reassessed using the Safe-T protocol with C-SSRS (Columbia Suicide Scale Risk Score-rating scale for suicide risk level) at any point during hospitalization, such as in the event of a change in suicidality... The licensed psychiatric practitioner shall order the appropriate level of observation based on patient history, behavior knowledge and any results of a suicide risk assessment. If the practitioner determines that a higher level of observation is not indicated for a patient at moderate or high risk, the practitioner will document the rational for the level of observation.” 2.The hospital’s policy titled, “Observations- Patient” (date of last revision 3/2025) was reviewed and included, “Level of observations can be increased by the RN (Registered Nurse) any time there is a concern but only a psychiatric practitioner may decrease the level ... The RN may increase the level of observation if the patient’s condition changes. The psychiatric practitioner will be contacted soon as possible for notification of the change in condition and to obtain an order for the observation level.” 3. The clinical record of Pt. #1 was reviewed on 01/06/26. Pt. #1 was admitted to the adult behavioral health unit on 12/19/2025 at 4:22 AM, with a diagnosis of bipolar disorder [mental illness causing extreme mood swings], current episode depressed, severe without psychotic features [symptoms that signal a loss of touch with reality]. The clinical record included the following: - The Psychiatric Evaluation (MD#1), dated 12/19/2025 at 11:41 AM, “(Pt.#1) with a past psychiatric history of bipolar, presenting with worsening depression and suicide attempt via hanging in the context of missing Abilify [antipsychotic medication that helps treat several kinds of mental health conditions] last dose ...Mental Status Examination: Attitude: Guarded and withdrawn; Mood: Depressed and Hopeless; Affect: Depressed, Blunted; Risk Factors: Suicidal: ideations [thoughts of dying by suicide], intent, plan and behavior ...” -The Physician’s Orders, from 12/19/25-12/24/25 were reviewed and indicated: on 12/19/2025 at 11:39 AM, “Suicide Precautions, Fall Precautions, Seizure Precautions and Elopement [to leave without authorization] Precautions, Observation Q15 [every 15 minutes].” On 12/20/2025 to 12/24/2025, Observation level was changed to 1:1 [one-to-one- when a staff is assigned to watch that one patient] monitoring for high suicide risks. On 12/24/2025, the level of observation was changed back to Q5 (every 5 minutes) The Nursing Shift Assessments/Progress notes, dated 12/20/2025 - 12/25/2025, were reviewed and included the following: -12/20/2025 at 6:18 PM, “(Pt#1) was found by unit nurse with a long piece of bedding that had ripped off, wrapped tightly around neck ...conscious when found but lightly gasping for air; vitals (vital signs) immediately assessed, and the patient was stable ... According to the BHA [Behavior Health Associate] acting as the 1:1 (one staff assigned to monitor one patient at all times) immediately following the attempt, the patient confided that (Pt.#1) live very close to [the hospital], and this was part of the plan to be medically sent out so (Pt.#1) could escape during the transfer. Patient did not discuss/divulge this with the nurse ... Will be medically sent out via ambulance this evening to be assessed.” -12/21/2025 at 3:30 AM, “ ...Patient reportedly tried to elope from the ED [emergency department] but was redirected back ... Patient upon arrival to the unit became agitated and verbally threatening staff... Patient remains on 1:1 for safety.” -12/24/2025 at 10:00 AM, “Patient seen by psychiatric provider [MD#1]. Orders received to take patient off one-to-one monitor closely Q5. Patient verbalizes that (Pt#1) feels better and can use coping skills to manage negative thoughts like harming self ...” -The Nursing Shift Assessments/Progress notes,12/24/25-12/26/2025 included various occasions of Pt. #1 increase in self-injurious behavior such as banging fist and head on the walls, yelling, crying, threatening to harm self if placed on one to one. Pt #1 level of observations were not changed and continued Q5 monitoring. -The suicide risk assessments, dated 12/20/2025-12/24/2025, were reviewed and indicated that staff were conducting the assessments/reassessments. However, the indicators (i.e. suicide risk and self-injury) indicated the need for Pt.#1 to continue the one-to-one monitoring. There was no change in the level of observation. -The Psychiatric Progress Notes (Nurse Practitioner/ E#10) dated 12/25/2025 at 9:40 AM included, “ ... Patient remains psychiatrically unstable with ongoing aggression toward others, self-injurious behaviors and inability to participate meaningfully in treatment. The recent physical assaults on staff, combined with active self-harm behaviors and refusal to engage in evaluation, indicate severe behavioral dysregulation [struggling to manage emotional responses leading to reactions that are too intense, prolonged or inappropriate for the situation] and impaired insight and judgment. Despite removal from 1:1 monitoring, the patient continues to present a high risk for harm to self and others ...” -On 12/26/2025 at 4:13 AM, nursing progress note (E#1), included, “Around 3:50 AM the BHA was rounding on patients called for assistance. Writer run to the room, called the patient’s name but was not responding ...started CPR [cardiopulmonary resuscitation- emergency lifesaving procedure that combines rescue breathing and chest compressions] ... 911 called ... EMT [emergency medical technician] arrived ... On call MD and psych (psychiatrist) were called ... Family member notified.” -The discharge summary, dated 12/26/2025, was reviewed and indicated, “On 12/26/2025, during routine safety rounds, the patient was found unresponsive with socks tied around neck. A code blue (medical emergency) was initiated immediately. CPR was performed and resuscitative [describes actions, procedures or interventions aimed at reviving someone from unconsciousness or not breathing] efforts were continued by EMS (emergency medical system) upon arrival. The patient was pronounced deceased by Cook County medical examiner at 5:36 AM.” 4. On 1/7/2026, the Hospital presented a Root Cause Analysis (RCA) and implemented corrective action plan. The action plan consisted of educating staff on linen restrictions, use of flashlights, purchase order for ankle length socks (target date 1/13/2025). CPR training of staff (target date 1/12/2025) and monitor documentation trends related to continuity, handoff and observation practices and provide targeted feedback (target date 1/9/2026). CPR training has a start date of 1/12/26 and drills started on 1/6/25, no debriefing or follow-up available for review. 5. An interview was conducted with the Chief Executive Officer (CEO/E#11) on 01/06/26 at approximately 10:15 AM. E#11 stated that they were notified immediately of the incident with (Pt.#1) and was onsite within the hour of notification. E#11 stated that it was determined that an RCA (Root Cause Analysis) would be immediately initiated which included interviews, video review, assess schedules for appropriate staffing, and a clinical record review. E#11 stated that there were some areas that indicated room for improvement, including the removal of the hospital issued socks, which is what (Pt.#1) used. The hospital sent out a memorandum to all leaders to inform them to restrict socks that go over the ankle to any patient with high risk for suicide, use alternative footwear until the new style socks arrive. Staff scheduled CPR training even if not expired, since it is not common for staff to use their CPR training, we want to ensure that all staff feel prepared when needed. Code blue drills will be conducted on all units at different shifts to capture all staff also to help staff feel prepared and confident. Flashlights ordered for staff to use while conducting safety rounds for better visualization. Staff will need to inform all patients that while rounds are conducted at night, heads, neck, and hands must be seen, which may require staff to pull down covers. E#11 stated that for providers, the Chief Medical Officer will be reviewing with all providers to ensure when handing off to covering staff, they are required to provide clear and current information about their patients to ensure continuity of care. All unit leaders, champion (higher experience staff) will continue to round on the units to evaluate for any safety concerns and address them. Staff nurses were reminded that the hospital’s policy allows for the nurse to increase level of observation or to initiate 1:1 for patients with changes in behavior prior to getting an order. 6. An interview was conducted with the Nurse Practitioner (E #10) on 01/07/2026 at 10:17 AM via phone. E#10 stated that (E#10) rounded on Pt.#1 that morning (12/25/2025). E#10 stated that (Pt.#1) refused to speak with E#10. E#10 stated that (E#10) met with the nurses, that same day, and recalled staff saying that Pt#1 was trying to self-harm, but staff were able to de-escalate and (Pt.#1) calmed down and did not require to increase level of observation. 7. An interview was conducted with the Behavioral Health Associate (E#3) on 01/07/2026 at 10:30 AM via phone. E #3 stated that Pt. #1 had punched a wall and had become agitated and upset with the nurse and doctor. E#3 stated that (E#3) rounded on Pt.#1 around 4:00 AM and (E#3) noticed that there was no connection with Pt.#1’s beacon (device placed on either the patient’s wrist or leg and must be within a certain distance of the patient in order to conduct/complete the rounding documentation on the device). E#3 stated to have remove Pt. #1’s blanket to uncover the arm and noticed some type of ligature on the neck. E #3 stated to have notified the RN (E#1) that came to the room and removed the ligature around Pt. #1’s neck. CPR initiated but Pt. #1 was not responding. Following the incident, E#3 stated that the facility has implemented new trainings regarding linen restrictions i.e. restriction of use of hospital issued socks and patient rounding’s i.e. visual cues such as making sure to check for rise and fall of chest. 8. An interview was conducted with the Registered Nurse (E#1) on 01/07/2026 at 11:00 AM. E#1 stated that Pt.#1 was upset with (E#1) during the shift because E#1 did not send Pt.#1 out for medical checkup following a previous incident that occurred earlier in the day. E#1 stated that (E#1) reached out to the on-call physician who did not want Pt.#1 sent out. E#1 stated that Pt.#1 was sleeping, facing the wall, with the blanket covering up to the neck area. E#1 stated that (E#1) was notified by E#3 that, around 4:00 AM, to come to Pt.#1’s room. E#1 stated that (E#1) entered Pt.#1’s room and noticed the ligature which (E#1) untied. E #1 stated CPR initiated, code blue (medical emergency) and 911 was called. E#1 stated that since the incident the facility has implemented new trainings and posted memos on the units indicating restrictions on hospital issued socks and safety points on observational rounding (such as the rise and fall of the chest, able to visualize the patients face, neck and arms). E#1 stated that, recently, leadership has had discussions/reminders, with nurses, about the hospital policy that allows for nurses to increase a patient’s level of observation based upon the patient’s changed behavior. 9. An interview was conducted on 1/8/2026 at approximately 12:30 PM, with the Chief Nursing Officer (CNO/E#12). E #12 stated that the hospital has been conducting video surveillance audits daily to ensure that staff are conducting rounding as required and that they are entering patient rooms to visualize the patient. All patients on suicide precautions will be provided with ankle length socks or an approved alternative footwear. E#12 stated that all nursing staff were reminded that they have the ability to increase the level of observation or place a patient with a sitter. E#12 is rounding daily on all units to monitor for compliance. The audits were not available for review. 10. From 1/6/2026 through 1/7/2026, observational tours were conducted to all in-patient units of Adult Hospital (3 East Female and 2 East Acute Male) and Children Hospital 3rd Floor Pediatrics (5-12 years of age Co-ed) and 4th Floor Adolescent Girls and the Adults 2-East (Acute Male unit). All patients on suicidal precautions were on linen restrictions; they were wearing paper gowns with ankle length non-slip socks and had the required suicidal risk reassessments. Ankle socks and flashlights were available Staff were interviewed from the Adult and Children’s Hospital. E #7, E #8 (BHA’s) and E #9 (RN) and at the Adult’s hospital and E #13, E #14. BHAs and E #15 (RN). Staff indicated that they had received training after the Pt. #1 on ensuring that patients that were on suicide precautions had the appropriate interventions in place such as ankle socks, paper gowns and linen restrictions. In addition, that during safety rounds they have to ensure that they have to observe that patients are breathing. The observation includes the face, neck and arms. E #9 and E #15 stated that they can increase the level of observations to 1:1 if a patient is a danger to self, and ensure patient safety at anytime and then inform the physician.”

“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: 40079 Based on document review and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.23, Nursing Services. Finding include: 1. The Hospital failed to ensure the provision of nursing services by failing to ensure the adequate number of registered nurses and/or personnel were available. See deficiency cited at A-392.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 40079 Based on document review and interview, for 6 of 6 Behavioral Health Units (2-East, 3-East, 4-East, 3rd Pediatrics, 4th Adolescent, and 5th Adolescent) reviewed for staffing, the hospital failed to ensure the adequate number of registered nurses and/or personnel were available to meet patient care needs. Findings include: 1. On 10/31/2025, the hospital’s policy titled, “Staffing Plan for Nursing Services” (revised 3/2025) was reviewed and required, “ ...The minimum staffing needed for each skill level (RNs, Behavioral Health Associates (BHA), others) is determined by the nurse-patient ratio guidelines and patient care needs of the population ...Staffing ratios are determined according to the population served ...Generally adolescents are staffed at 1:4 ration, and adults are staffed at a 1:5 ratio ... The nurse-to-patient ratio is generally 1 to 12 for all units ...”. 2. On 10/31/2025, the ‘Child and Adolescent & Acute Adult Service Unit Staffing Guidelines’ for the Behavioral Health Units (undated) was reviewed. The staffing grid required the following staff to patient ratio: Day & Evening census 1 to 8 (1 RN, 1 BHA); census 9 to 12 (1 RNs and 2 BHAs); census 13 to 16 (2 RNs and 2 BHAs); and census 17 to 20 (2 RNs and 3 BHAs). The grid did not account for 1:1 staff, which required an additional staff member per 1:1 patient. 3. The staffing schedules from 10/15/2025 through 10/31/2025 for the units at the adult hospital and the children/adolescent hospital were reviewed. The following dates indicated that there were staff shortages: Adult Hospital (Hospital A): 2-East (male) Unit: -10/15/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/16/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/24/2025 7:00 AM - 7:00 PM: Short 1 RN -10/24/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/25/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/26/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/26/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/27/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/27/2025 7:00 PM - 7:00 AM: Short 1 RN -10/28/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/28/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/29/2025 7:00 AM - 7:00 PM: Short 1 BHA 3-East (female) Unit: -10/21/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/26/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/26/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/27/2025 7:00 AM - 7:00 PM: Short 1 BHA 4-East Acute Coed Unit: -10/15/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/17/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/18/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/21/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/23/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/23/2025 7:00 PM - 7:00 AM: Short 1 BHA & 1 RN -10/25/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/25/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/26/2025 7:00 PM - 7:00 AM: Short 1 BHA & 1 RN -10/30/2025 7:00 AM - 7:00 PM: Short 1 BHA Children’s Hospital (Hospital B): 3-Pediatric Coed Unit: -10/16/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/16/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/17/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/18/2025 7:00 PM - 7:00 AM: Short 1 BHA & 1 RN -10/24/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/25/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/26/2025 7:00 PM - 7:00 AM: Short 2 BHA -10/27/2025 7:00 PM - 7:00 AM: Short 1 RN -10/28/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/29/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/31/2025 7:00 AM - 7:00 PM: Short 1 BHA 4-Adolescent Girls Unit: -10/15/2025 7:00 AM - 7:00 PM: Short 2 BHA -10/15/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/16/2025 7:00 AM - 7:00 AM: Short 1 BHA -10/17/2025 7:00 AM - 7:00 APM: Short 1 BHA -10/18/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/18/2025 7:00 PM - 7:00 AM Short 1 BHA -10/19/2025 7:00 AM - 7:00 PM Short 1 BHA -10/21/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/24/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/25/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/25/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/26/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/26/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/27/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/27/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/28/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/28/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/29/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/29/2025 7:00 PM - 7:00 AM: Short 1BHA -10/30/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/31/2025 7:00 AM - 7:00 PM: Short 2 BHA 5-Adolescent Boys Unit: -10/15/2025 7:00 AM - 7:00 PM: Short 2 BHA -10/18/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/19/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/27/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/28/2025 7:00 PM - 7:00 AM: Short 1 BHA -10/29/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/29/2025 7:00 PM - 7:00 AM: Short 1.5 BHA -10/30/2025 7:00 AM - 7:00 PM: Short 1 BHA -10/31/2025 7:00 AM - 7:00 PM: Short 1 BHA & 1 RN 4. On 10/31/2025 at approximately 10:05 AM, an interview with the Chief Nursing Officer (E #1) was conducted. E #1 stated that E #1 has been informed of and has assessed that there are some staffing concerns, and the hospital has been trying to address the concerns. E #1 stated that when units are short staffed, the usual reason is due to call-offs, and the unit leaders will reach out to unscheduled staff to cover, or we re-evaluate the staffing on other units and may have to flex staff to other units. E #1 stated that when there are call-offs the supervisors and the administration team provide assistance on the units. E #1 stated that with unit shortages, coverage for 1:1 patients is prioritized and that there is always a minimum of one nurse per unit. E #1 stated that the hospital has hired new staff and will be cross trained for both hospitals.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 40079 Based on document review and interview, it was determined that for 1 of 5 (Pt.#1) clinical records reviewed for monitoring, the hospital failed to ensure that the level of observation was increased after a report of change in patient behavior to ensure patient is free from abuse. Findings include: 1. On 6/06/2025, the hospital’s policy titled, “Precautions, Sexual Acting Out” (revised 03/2025), was reviewed and required, “Patients are assessed for risk of sexual acting out behavior ... 1. Upon admission, patients will be assessed for any history of sexual acting out behavior including ... psychosis with sexual preoccupation or promiscuity ... 2. During hospitalization, all patients will be assessed and observed for behavior which may increase potential for sexual act out behavior (i.e., inappropriate touching or sexual comments, etc.). 3. Any changes in behavior ... potential for sexual acting out behavior are to be reported. 4. The Charge Nurse will assess the patient and contact the attending physician/covering practitioner to communicate the change in behavior. 5. The practitioner shall order level of observation and precautions consistent with the assessed level of risk ...” 2. On 6/06/2025, the hospital’s policy titled, “Observations-Patient” (revised 03/2025) was reviewed and required, “In order to maintain patient safety ... staff makes and documents routine safety rounds ... Levels of observations can be increased by the RN any time there is a concern ... if the patient’s condition changes. The psychiatric practitioner will be contacted as soon as possible for notification of the change in condition and an order for the observation level.” 3. On 6/06/2025, the clinical record of Pt.#1 was reviewed. Pt.#1 was admitted to the Adult Behavioral Health Unit (3-East) on 05/27/25 through 06/02/25. The clinical record included the following: -Psychosocial Assessment dated 05/27/25, “Trauma Assessment: (Pt.#1) was sexually abused by mother ... would make (Pt.#1) perform oral sex in front of others ... Reports a hx (history) of sexual abuse by biological father ... “ -Physician Orders dated 05/27/25, “Suicide Precautions, Assault Precautions, Q (every) 5 Minutes Monitoring.” -Psychiatric Evaluation (MD#1) dated 05/28/25 at 11:13 AM, “(Pt.#1) with a past medical history of bipolar disorder presenting with decompensated mania and psychosis including paranoid and persecutory delusions ... seen pacing in room ... observed talking to self and appeared to be responding to internal stimuli ... (Pt.#1) immediately went on a very long tangent about human trafficking and stated feels they have been human trafficked since the age of 3 ... states that boyfriend and parents are currently involved in trafficking (Pt.#1) ... Plan: Start Seroquel for mood stabilization ... Monitor for self-injury and safety; Psychotherapy, Milieu and Group therapy.” -Psychiatric Progress Note dated 05/29/25 at 10:20 AM, “(Pt.#1) pacing in the hallways ... continued to be disorganized with flight of ideas with various topics including ... leaving the hospital, concerns about human trafficking ... denies having any psychiatric illness ...” -Nursing Progress Note (E#9) dated 05/30/25 at 5:29 AM, “Current Shift Assignment for 7PM-7AM; Appearance: Neat, well-groomed; Behavior: Attention Seeking/Hyperactive; Active Medical Problems: No active medical Problems ... Skin: Normal ... Pain: No; Narrative Note: (Pt.#1) alert and oriented ... No complaints of pain or distress. Pt denies SI (suicidal ideation)/HI (homicidal ideation) and free of harm to self and others.” The nursing progress note did not include documentation indicating the staff (E#2) reported to the nurse that (Pt.#1) was making inappropriate sexual comments and fixated on staff (E#2) during shift, or to notify the Attending Psychiatrist of the change in behavior and an order to increase level of observation. 4. On 6/06/2025 at 10:45 AM, an interview was conducted with a BHA (E#2). E#2 stated that during their shift (05/29/25) throughout the night it was calm, there was another BHA (E#6) and a Nurse (E#9) working that night. E#2 reported that during rounding (Pt.#1) was pacing hallways and approached (E#2) several times and was being inappropriate towards E#2 by asking personal questions such does (E#2) having a girlfriend, (Pt.#1) at one point was handed a snack and a drink and (Pt.#1) rubbed (E#2’s) hand inappropriately and asked (E#2) to sit on (Pt.#1’s) lap. E#2 redirected (Pt.#1) and set boundaries several times and explained that this was inappropriate behavior. E#2 reported (Pt.#1’s) behavior to the Nurse (E#9) and the other BHA (E#6). E#2 was told by the Nurse that they would keep an eye on (Pt.#1), and E#6 stood near (E#2) throughout the shift. E#2 stated that during rounding when necessary to observe (Pt.#1) while in their room E#2 was not in the room longer than a couple of seconds, rounding was alternated between E#2 and E#6. 5. On 6/06/2025 at 12:55 PM, an interview was conducted with a BHA (E#6). E#6 stated that E#6 worked on 05/29/25 with (E#2). E#6 stated that (E#2) informed E#6 and the Nurse (E#9) that (Pt.#1) was constantly being inappropriate with (E#2). E#6 stated they observed (Pt.#1) approach (E#2) approximately 6 times asking for water, asking inappropriate questions and making inappropriate remarks to (E#2). E#6 stated that the patient was not on SAO precautions, including after the nurse (E#9) was notified of the patient’s behavior. 6. On 6/07/2025 at 11:22 AM, an interview was conducted with the Attending Psychiatrist (MD#1). MD#1 stated that on admission the patients are assessed for history of SAO behavior and/or sexual preoccupation. MD#1 stated that initially MD#1 did not feel that (Pt.#1) required to be on SAO precautions, (Pt.#1) was not making any active allegations or acting inappropriately. (Pt.#1) was fixated on having been trafficked their whole life. Precautions for SAO can be initiated by the nurse.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 40079 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt.#2) clinical records reviewed for nursing assessments, the hospital failed to ensure that the nurse supervised and evaluated patients’ care by failing to complete the nursing reassessments after an injury due to an altercation (patient to patient) and to notify the medical doctor. Findings include: 1. The Registered Nurse Job Description, dated 1/1/2020, included, “Responsible for providing professional nursing care to patients... Essential Functions... Provide and coordinate care by assessing physical and behavioral needs of patients... Ensure patients’ status is assessed on an ongoing basis and pertinent information gathered is documented... Notify physician of significant changes in status... etc. “ 2. The hospital’s policy titled, “Change in Condition” (revised 06/2022) was reviewed and required, “ ... Registered Nurse will provide assessment data to the physician/covering practitioner who will then give orders for treatment or additional assessment ... 22. Any concerns regarding the patient’s medical condition where nursing staff believes a delay may cause a negative outcome.” 3. The hospital’s policy titled, “Assessment and Reassessment” (revised 06/2022) was reviewed and required, “ ... 9b. Reassessments are completed by the Registered Nurse (RN) on day and evening shifts and documented on the Nursing Reassessment form ... the RN will document more descriptive details in the progress portion of the note ... In addition, each patient is reassessed as necessary based on the patient’s plan for care or change in their condition ...” 4. Incident Report Form (completed by E#3/RN), dated 02/10/2025, at 6:30 PM, “Incident Date/Time/Location: 2/10/25 at 5:44 PM, Day Room 2-East ... Witnesses ... (name of Behavioral Health Associate/BHA E#9) ... Other Parties Directly Involved: (names of Pt.#6 and Pt.#7) ... Physical Confrontation: Patient attacked by other Patient ... Facts Summary of Event: Patients were in dayroom watching TV. Per BHA (E#9) (Pt.#2) made remarks ... peers run up to (Pt.#2) and hit multiple times ... (Pt.#2) refused to get sent out. Request ice pack ... request to call 911 and report incident ... (name of MD#5/psychiatrist) notified 2/10/25 at 6:50 PM.” The incident form lacked documentation that the nurse assessed (Pt.#2) for pain or any injuries observed and that a medical physician was notified. 5. On 04/08/2025 at approximately 12:45 PM, the video footage from the dayroom in 2-East on 02/10/25 at 5:26 PM to 5:52 PM was reviewed. The video footage showed the following: -At 5:17 PM, (Pt.#2) and other patients are observed in the dayroom having dinner. There is a Behavioral Health Associate (BHA/E#9) in the day room observing the patients and another staff is observed doing safety rounds. -At 5:27:29 PM. (Pt.#2) is sitting closer to the television, there are other patients watching TV and appear to be having a conversation. Two patients (Pt.#6 and Pt.#7) approach (Pt.#2) while (Pt.#2) is sitting on a chair and start to hit (Pt.#2). At 5:27:35 PM, (E#9) is observed running out the door and returns at 5:27:59 PM (24 seconds later) with two other staff (RN/E#10 and BHA/E#20). The staff separate the patients and remove all the patients except (Pt.#2) from the day room. -At approximately 5:31 PM, two staff enter the dayroom (E#3 and E#10) and speak with (Pt.#2). (Pt.#2) removes their shirt the two nurses (E#3 and E#10) appear to inspect (Pt.#2) then exit the day room. 6. The clinical record for Pt.#2 was reviewed on 04/08/2025. Pt.#2 was admitted to the Acute Adult Male unit 2-East on 02/04/2025 and discharged on 02/10/2025. Nursing Notes were reviewed for dates 02/10/2025 day shift (7AM to 7PM), night shift (7PM to 7AM), and 02/11/2024. The nursing notes lacked documentation that (Pt.#2) was involved in an altercation and sustained injuries, a post incident nursing assessment, and that (Pt.#2) was offered a medical evaluation and refused. The nursing notes did not include documentation that the psychiatrist or medical physician were notified of the incident. 7. An interview was conducted with a Licensed Social Worker (E#8) on 04/08/2025 at 9:40 AM. E#8 was told by another patient that (Pt.#2) was hit by another patient while they were watching a movie in the day room. The other residents (Pt.#6 and Pt.#7) became upset over a comment made by (Pt.#2). E#8 spoke with (Pt.#2) about the incident (Pt.#2) had bruising on forehead and redness to upper left face area. E#8 stated that (Pt.#2) had refused to get treatment by staff or physician. However (Pt.#2) did filed a police report. 8. An interview was conducted with an RN (E#23) on 04/09/2025 at 9:40 AM. E#23 stated that for patient-to-patient altercations, staff will separate them as soon as possible. The patients are assessed for injury and the attending psychiatrist and the on-call medical physician are notified. The medical physician will evaluate the and decide if the patient needs to be sent out for further medical evaluation. The patient has the right to refuse a medical examination, the nurse is required to document in the progress note that the patient refused. The nurse should document if there were any visible injuries in the clinical record. 9. An interview was conducted with a Nurse Practitioner (E#24) on 04/09/2025 at 11:07 AM. E#24 stated that they met with (Pt.#2) briefly on the day of discharge. E#24 did not recall any facial bruising on (Pt.#2) and was not aware of an altercation the previous day. E#24 stated that staff are expected to report any situation with altercations involving patients to the providers.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 32741 Based on document review, observation and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights. Findings include: 1. The hospital failed to prevent 3 adolescent patients who were able to obtain a fire alarm key, activate the fire alarm, open a locked exit door and elope from the hospital and failed to conduct a root cause analysis of the event to prevent future elopements from the hospital. See deficiency A-144. 2. The hospital failed to ensure change in behaviors were monitored; failed to ensure appropriate interventions were in place; failed to adequately supervise patients and follow the physician’s order for a patient that required higher level of monitoring to prevent abuse of 5 patients and failure to investigate incidents. See deficiency at A -145 (A). 3. The hospital failed to have a sexual abuse policy. See deficiency at 145 (C). An immediate jeopardy began on 3/1/2025, due to the Hospital’s failure to prevent the elopement of three adolescent patients who were able to obtain a fire alarm key, activate the fire alarm, open a locked exit door and elope from the hospital; and failure to conduct a root cause analysis of the event to prevent future elopements. The IJ was identified on 3/6/2025 at 42 CFR 482.13 Patient Rights. The elopement IJ was announced on 3/6/2025 at 4:30 PM during a meeting with the Chief Executive Officer [CEO] and Quality Director and was removed by the survey exit on 3/13/2025. In addition, an immediate jeopardy was identified on 3/12/2025 at 42 CFR 482.13 Patient Rights, due to the facility’s failure to ensure change in behaviors were monitored; failed to ensure appropriate interventions were in place; failed to adequately supervise patients and follow the physician’s order for a patient that required higher level of monitoring to prevent abuse of 5 patients and failure to investigate incidents. The IJ was announced on 3/12/2025 at 10:45 AM during a meeting with the CEO and Quality Director. This IJ was not removed by survey exit date 3/13/2025.”

“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: 50411 Based on document review, video surveillance review, observation and interview, it was determined that for 3 of 3 adolescent female patients (Pt #1, Pt. #4 and Pt. #5) clinical records reviewed for elopement, the hospital failed to stop their elopement. These patients were able to obtain a fire alarm key to pull fire alarm, open exit door and subsequently elope from the hospital and failed to conduct a root cause analysis of the event to prevent future elopements. This could potentially affect 27 of 39 patients currently on elopement precautions and future patients at the hospital. Findings include: 1. On 3/6/2025, the hospital’s policy titled, “Elopement Precautions and Response” (dated 6/2022) was reviewed and indicated, “Staff shall provide appropriate assessment and observation of inpatients who have either verbally or non-verbally expressed a desire to elope from the hospital. Communicate Code Green (elopement) through the telephone paging system, walkie-talkie or face-to-face with staff on the unit.” 2. On 3/6/2025, Pt. #1’s clinical record (dated 1/30/2025 through 3/1/2025) was reviewed. Pt. #1 was admitted to the hospital on 1/30/2025 with the diagnoses of major depressive disorder and post traumatic stress disorder. Pt. #1 was on elopement precautions, suicide precautions and assault precautions (every 5-minute monitoring). Pt. #1’s rounding sheets documented on 3/1/2025 noted Pt. #1 was last monitored prior to elopement on 3/1/2025 at 2:35 PM. 3. On 3/6/2025, Pt #4’s clinical record (dated 12/17/2024 thru 3/1/2025) was reviewed. Pt. #4 was admitted to the hospital on 12/17/2024 with the diagnosis of post traumatic stress disorder. Pt. #4 was on elopement precautions and sexually acting out precautions (every 5-minute monitoring). Pt. #4’s rounding sheets documented on 3/1/2025 noted Pt. #4 was last monitored prior to elopement on 3/1/2025 at 2:35 PM. 4. On 3/6/2025 Pt. #5’s clinical record (dated 2/1/2025) was reviewed. Pt. #5 was admitted to the hospital on 2/1/2025 with the diagnoses oppositional defiant disorder and disruptive mood dysregulation disorder. Pt. #5 was on elopement precautions, suicide precautions and assault precautions (every 5-minute monitoring). Pt. #5’s clinical record dated 2/1/2025 noted that Pt. #5’s history was eloping from home. Pt. #5’s rounding sheets documented on 3/1/2025 noted Pt. #5 was last monitored prior to elopement on 3/1/2025 at 2:35 PM. 5. On 3/6/2025, the hospital’s incident report dated 3/1/2025 noted, “Pt. #4 snatches lanyard which includes keys off Behavioral Health Associate (BHT/E #7). Pt. #4 throws keys to Pt. #1. Pt. #1 opens the fire alarm station and Pt. #4 pulls out the key to trigger the fire alarm. Fire alarm sounds which unlocks all doors. Pt. #1, Pt. #4 and Pt. #5 run out the stairwell from 4th floor which empties onto alley.” No investigation was conducted. 6. On 3/6/2025, a video footage review was conducted of the 4th floor Adolescent Girls unit dated 3/1/2025 at 2:37 PM to 2:38 PM. Pt. #4 is noted grabbing keys from the E #7. Pt. #4 is seen throwing the keys down the hall to Pt. #1. Pt. #5 is seen running down the hall and Pt. #1, Pt. #4 and Pt. #5 are seen opening the door and leaving the unit. E #7 is seen in the video footage watching Pt. #1, Pt. #4 and Pt. #5 using the fire alarm key to pull the fire alarm and exiting the door without trying to stop the patients. 7. On 3/6/2025 between 10:30 AM and 11:00 AM, an observational tour was conducted on each unit of the Hospital (3rd floor - pediatric unit and 4th floor adolescent female unit and 5th floor adolescent male unit. The 3rd floor had a census of 12. The Registered Nurse (E #9) and the BHT (E #9), each had a lanyard around their neck with keys to open doors. The 4th floor had a census of 14. The BHT (E #10) had a lanyard around E #10’s neck with keys to open doors. The 5th floor had a census of 13. The Activity Therapist (E #11), the Medical Records Clerk (E #13) and the Therapist (E #12) had a neck lanyard around their neck with keys to open doors. 8. On 3/6/2025 at approximately 11:00 AM, an interview was conducted with the Risk Director (E #1). E #1 stated that the hospital has not conducted a root cause analysis yet. E #1 stated that E #1 is going to propose that staff do not wear the lanyard with the keys to the door around their neck. E #1 stated that 1 patient has returned (Pt. #1) but the other 2 patients are still missing. E #1 stated that the hospital is working with the police who have released a city wide search for Pt. #4 and Pt. #5.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 32741 A. Based on document review, video surveillance and interview, it was determined that for 1 of 1 patient (Pt. #3/alleged perpetrator) involved in multiple incidents of abuse, the hospital failed to ensure change in behaviors were monitored; failed to ensure appropriate interventions were in place; failed to adequately supervise patients and follow physician’s orders for a patient (Pt. #3) that required higher level of monitoring to prevent abuse; the hospital also failed to conduct an investigation following each incident. This failure resulted in sexual assaults and physical abuse by Pt. #3 to 5 vulnerable behavioral health patients (Pt. #2, Pt. #6, Pt. #7, Pt. #13 and Pt. #14). Findings include: 1. On 3/6/2025, the hospital’s policy titled, “Abuse and Neglect” (dated 8/2023) was reviewed and required, “Patient-to-patient abuse - The registered nurse will place the patient committing the offense on every 5-minute observations or 1:1 observation ...” 2. On 3/6/2025, the hospital’s policy titled, “Precautions, Sexually Acting Out” (dated 12/2022) was reviewed and required, “In the event that sexual intercourse between patients does occur or is strongly suspected, the following procedure is required: Patients need to be separated immediately, placed on 1:1 (one staff to one patient). 3. On 3/6/2025, Pt. #2’s clinical record (dated 11/12/2024 through present) was reviewed and indicated: Pt. #2 was admitted to male adolescent unit on 11/12/2024 with diagnosis of schizophrenia. Pt. #2 was on assault and suicide precautions (every 15-minute monitoring). 4. On 3/6/2025, Pt. #3’s clinical record (dated 10/14/2024 through 2/28/2025) included Pt. #3 was admitted to Male Adolescent unit on 1/12/2025 with diagnosis bipolar disorder (mental health disorder). Pt. #3 was on SAO - sexually acting out, suicide, elopement and assault precautions (every 5 minutes monitoring). Pt. #3 was assigned to different rooms and units throughout Pt. #3’s admission. Pt. #3’s rounding sheets dated 11/15/2024, 11/27/204, 11/29/2024, 2/25/2025 through 2/28/2025 noted that it was not documented that Pt. #3 was was on 1:1 monitoring as ordered on 11/27/2024 or every 5 minutes as ordered on 1/12/2025. -10/14/2024 through 11/27/2024: Pt. #3 was on the Adolescent Boys unit. Pt. #3 had a blocked room (no roommate). -11/27/2024: Pt. #3 was moved to the Pediatric (boys and girls) unit due to an incident (unknown-not documented on incident log or Pt. #3’s clinical record) on the Adolescent Boys unit. Pt. #3’s clinical record had a physician’s order dated 11/27/2024 for 1:1 monitoring (one staff to one patient). The rounding sheets indicated that Pt. #3 was on every 15 minutes rounding not on 1:1 monitoring. The clinical record failed to include that appropriate supervision per physician’s order for 1:1 monitioring were followed. In Pt. #3 clinical record there is no indication that the order for 1:1 monitoring was discontinued. -12/10/2024: Pt. #3 was moved back to the Adolescent Boys unit on 12/10/2024 following sexual abuse incident on Pediatric unit. Pt. #3 was on every 5 minute monitoring for SAO precautions, elopement precautions and assault precautions. On 2/28/2025 at 10:05 PM, Pt. #3 was discharged from the hospital to police custody. This was done per Pt. #2’s family request to call the police after Pt. #2 reported the allegation of abuse by Pt. #3. 5. Pt. #3 was involved in multiple allegations of abuse. The following incidents included: -Pt. #6’s Incident Report dated 11/7/2024 at 12:00 AM noted, “On 11/7/2024, Pt. #6 stated that on 11/5/2024 “in middle of the day, Pt. #3 came into Pt. #6’s room, said “shut the door” then proceeded to shut the door himself (Pt. #3). Pt. #6 alleged that Pt. #3 then approached Pt. #6 who was laying in bed and put a hand on Pt. #6’s throat, and then “yanked Pt. #6’s dick a few times.” Then Pt. #6 says Pt. #3 “punched Pt. #6 in the balls.” There were no interventions or increased precautions for Pt. #3 following this incident. There was an incident report but no investigation. -Pt. #7’s (pediatric patient) Incident Report dated 12/4/2024 at 3:00 PM noted, “It was reported today from Pt. #7 that Pt. #3 fingered peer last Wednesday. It’s unclear when it happened. MD (physician) notified and Patient Advocate notified.” Pt. #3 was moved back to the Adolescent Boys unit following this incident on 12/10/2024. The result of the hospital investigation is that Pt. #3 was moved back to the Adolescent Boys unit. -Pt. #14’s Incident Report dated 12/14/2024 at 8:42 PM noted, “Pt. #3 went after Pt. #14. Pt.#3 wrapped Pt. #3’s hands tightly around Pt. #14’s neck. Staff immediately separated Pt. #3 and Pt. #14 and redirected. MD aware and prn (as needed) medications ordered were administered. Patients were unharmed. Pt. #14 denied pain and discomfort related to the incident. DCFS (Department of Children and Family Services) case manager aware for Pt. #3 and Pt. #14. There were no additional interventions or increase in precautions for Pt. #3 following this incident. -Pt. #13’s Incident report dated 12/24/2024 at 10:30 AM noted, “Pt. #3 attacked Pt. #13 in the dayroom at approximately 10:30 AM. Pt. #3 kicked Pt. #13 in Pt. #13’s face, placed Pt.#13 in a choke hold. A code gray (emergency management of aggressive behavior - action necessary to ensure patients or staff are not injured) was called. Pt. #3 escorted from dayroom before forcefully leaving dayroom, threw a chair and hit peer (unknown), grabbed a piece of table and attempted to stab a peer (unknown). Staff intervened; Pt. #3’s behavior relayed to MD, ordered Zyprexa (antipsychotic medication) 10 mg IM (intramuscular) stat (immediately).” There was no increase in precautions ordered for Pt. #3 following this incident. -Pt. #2’s Incident report dated 2/26/2025 noted, “Tech walked into room and witnessed Pt. #3 choking Pt. #2 in Pt. #2’s room. Staff intervened and patients were separated. The MD (physician) was called and Pt. #3 received stat (immediately) medication.” There was no documentation in Pt. #3’s clinical record that any changes or increased monitoring was put in place for Pt. #3. There was no update to Pt. #2 or Pt. #3’s treatment plan. -Pt. #2’s Incident Report dated 2/28/2025 noted, “Pt. #2 reported Pt. #3 inserted Pt. #3’s fingers into Pt. #2’s rectum, on 3 occasions, once today when Pt. #2 was attacked by Pt. #3. 6. On 3/6/2025, the hospital’s video footage from the adolescent male unit dated 2/28/2025 from 1:58 PM to 4:20 PM was reviewed with E #5 (Risk Manager). Pt. #3 is seen going into Pt. #2’s room at 3:58 PM. Pt. #2 and Pt. #3 had separate rooms across the hall from each other. The video footage shows Pt. #2’s door gets closed. The Behavioral Health Technician (BHT/E #6) goes into Pt. #2’s room approximately 35 seconds later per video review and Pt. #3 is witnessed choking Pt. #2 (per interview with E#2 - Registered Nurse). Pt. #3 then leaves Pt. #2’s room and paces in the hallway until 4:20 PM. Pt. #3 is seen pushing E #6 as Pt. #3 continues to pace in the hallway. 7. On 3/6/2025 at approximately 10:00 AM, an interview was conducted with Pt. #2 with translator. Pt. #2 stated that Pt. #3 had attacked Pt. #2 three times. Pt. #2 stated that Pt. #3 entered Pt. #2’s room, touched Pt. #2’s private parts and try to choke Pt. #2. Pt.#2 stated that after the last incident on 2/28/2025, Pt. #2 fainted. Pt. #2 stated that Pt. #2 told Pt. #2’s mother and Pt. #2’s mother called the unit to report the incident. Pt. #2 stated that Pt. #2 did not report anything to the staff because Pt. #2 was afraid. Pt. #2 stated that Pt. #2 does not feel safe at the hospital. Pt. #2 stated that Pt. #2 went to the hospital the day after the last incident to get checked out and everything was ok. 8. On 3/10/2025 at approximately 9:00 AM, an interview was conducted with the BHT (E #9). E #9 stated that E #9 works on the Pediatric unit (boys and girls up to age 12). E #9 stated that E #9 cannot remember the exact date, but sometime last November 2024, Pt. #3 was on 1:1 monitoring (one staff to one patient) on the Pediatric unit because Pt.#3 had been touching Pt. #2 on the Adolescent Boys unit. E #9 stated that Pt. #3 “fingered Pt. #12 (pediatric female) in the day room and hallway. E #9 stated that the 1:1 staff member was redirecting another patient and so Pt. #3 was able to “finger Pt. #12.” E #9 reported the incident to the nurse and Pt. #3 was moved back to the boys unit the next day. 9. On 3/10/2025 at approximately 3:00 PM, an interview was conducted with the BHT (E #6). E #6 stated that E #6 was doing every 5 minute rounds for Pt. #3 and every 15 minute rounds for Pt. #2 on 2/28/2025. E #6 stated that E #6 went into Pt. #2’s room (door was closed) and found Pt. #3 choking Pt. #2. E #6 stated that Pt. #2 was blue in color and Pt. #2’s arms were limp. E #6 stated E #6 yelled for help and removed Pt. #3’s arm from Pt. #2’s neck. E #6 stated that the police was called and Pt. #3 was arrested. E #6 stated that Pt. #3 almost killed Pt. #2. 10. On 3/6/2025 at approximately 1:50 PM, an interview was conducted with Registered Nurse (E#2). E#2 stated that a tech (BHT) reported to her that the tech (BHT) saw Pt.#3 choke Pt.#2. E#2 stated that E#2 assessed Pt.#2 who was on the bed and conscious and had turned blue. E#2 stated that attempts to redirect Pt.#3 were unsuccessful and an order to administer PRN (as needed) medication was obtained which the CNO (Chief Nursing Officer) manage to convince Pt.#3 to take willingly. E#2 stated that E#2 reported the incident to Pt.#2’s mother who then informed E#2 that Pt.#2 informed Pt.#2’s mother that Pt.#3 locked Pt.#2 in the room and forced Pt.#2 to perform oral sex on Pt.#3. E#2 reported the incident to the Supervisor who then called the police. E#2 stated that Pt.#2 and Pt.#3 were kept away from each other. E#2 stated that neither Pt.#2 or Pt.#3 were placed on 1:1 monitoring. 11. On 3/10/2025 at approximately 11:15 AM, an interview was conducted with MD #1. MD #1 stated that MD #1 cared for Pt. #2 and Pt. #3. MD #1 stated that Pt. #3 was placed on every 5 minute monitoring for physical and sexual acting out behaviors. MD #1 stated that a patient should be placed on 1:1 monitoring if the patient is a danger to others. MD #1 stated that MD #1 felt that every 5 minute monitoring was adequate for Pt. #3. MD #1 stated there was no need to put Pt. #3 on 1:1 monitoring. 12. On 3/11/2025 at approximately 9:45 AM, an interview was conducted with the Director of Risk (E #1). E #1 stated that after reviewing the video footage with Pt. #2 and Pt. #3, E #1 felt that everything was done appropriately. E#1 stated that Pt. #2’s mother wanted to press charges and have the police called. E #1 stated that a patient advocate communicates daily (since the incident on 2/28/2025) with Pt. #2 to see if Pt. #2 any concerns. E #1 stated that an investigation should be conducted following each incident. B. Based on document review and interview, it was determined that for 1 of 2 adolescent male patients (Pt.#3) clinical records reviewed for monitoring, the hospital failed to ensure that patient’s ordered observation level was marked accurately, according to physician’s order on the rounding/observation sheets to ensure patient safety. Findings include: 1. On 3/6/2025, the clinical record of Pt. #3 was reviewed. Pt. #3 was admitted to the hospital on 10/14/2024 with a diagnosis of Disruptive Mood Dysregulation Disorder. Pt.#3 was placed on sexually acting out, elopement, assault, blocked room precautions and admitted to the 5th floor Adolescent Boys unit. On 11/27/2024, Pt.#3 was transferred to the 3rd floor Pediatric unit. MD #1’s order (dated 11/27/2024) was entered to place Pt.#3 on 1:1 observation (Q15) [every 15 minute] due to Pt#3 exhibiting sexually acting out behaviors towards staff, physically aggressive and destructive behaviors while on the Adolescent Boys unit. 2. On 3/11/2025, Pt. #3’s Patient Observation Record (dated 11/27/2024 to 12/9/2024) was reviewed and indicated that the observation records for Pt.#3 on 11/28/2024, 12/1/2024, and 12/2/2024 did not indicate the appropriate observation level as required. 3. On 3/11/2025, the hospital’s policy titled “Observations, Patient” (Last Revision 11/2024) included “...i. Staff documents all levels of observation on each patient’s observation form...Each entry is to include the following... - level of observation...” 4. On 3/11/2025 at approximately 9:43 AM, an interview was conducted with the Risk Manager (E#5). E#5 stated that the patient observation levels should be indicated on the patient’s observation record. C. Based on document review and interview, it was determined that the hospital failed to have a sexual abuse policy. Findings include: 1. On 3/11/2025, the hospital failed to have a sexual abuse policy. 2. On 3/12/2025 at 2:00 PM, an interview was conducted with the Risk Manager (E #5). E #5 stated that the hospital follows the general abuse policy. E #5 stated that the hospital does not have a sexual abuse policy.”

“Personnel - Treatment Plans CFR(s): [The hospital must employ or undertake to provide adequate numbers of qualified professional, technical, and consultative personnel to:] Formulate written individualized, comprehensive treatment plans; This Standard is not met as evidenced by: 50411 Based on document review and interview, it was determined that for 2 of 2 patients (Pt #2 and Pt.#3) reviewed for treatment planning, the hospital failed to ensure that treatment plan was updated, per hospital policy. Findings include: 1. The hospital’s policy titled Treatment Planning (Date of Approval 6/2022) included “...Procedure...g. A review of the patient’s Interdisciplinary Treatment Plan following any major clinical change shall be conducted, and appropriate modifications made...” 2. The hospital’s policy titled Observations, Patient (Last Revision 11/2024) included “... k. The Interdisciplinary Treatment Plan will include or be revised to include the 1:1 observation...” 3. On 3/10/2025, the incident log was reviewed and indicated that an incident occurred on 12/4/2024 involving Pt.#3. It was documentation included: “...It was reported today from [Pt.#3] the patient [Pt.#3] fingered peer last Wednesday and [peer] was playing with [Pt.#3]...MD [physician] notified and patient advocate notified...” 4. On 3/10/2025, the clinical records for Pt.#3 (dated 10/14/2024 to 2/28/2025) was reviewed and indicated: - Pt.#3 was admitted to the hospital on 10/14/2024 with a diagnosis of Disruptive Mood Dysregulation Disorder. - Pt.#3 was placed on sexually acting out, elopement, assault, blocked room precautions and admitted to the 5th floor Adolescent Boys unit. Pt.#3 was placed on 1:1 monitoring on 11/27/2024. - Pt.#3’s treatment plan for 12/5/2024 does not indicate an updated treatment plan to address the incident on 12/4/2024. 5. On 3/10/2025, the incident log (dated 8/2024 through 3/2025) was reviewed and indicated: - An incident on 2/26/2025 involving Pt.#2 was documented which indicated that Pt.#1 was being choked by Pt.#3 - An incident on 2/28/2025 involving Pt.#2 was documented which indicated that Pt#3 had inserted his finger into Pt.#1’s rectum. 6. On 3/10/2025, the clinical record for Pt. #2 (dated 11/12/2024 to 3/6/2025) was reviewed and indicated: - Pt.#2 was admitted to the hospital on 11/12/2024 with a diagnosis of schizophrenia (mental disorder characterized by hallucinations, delusions, disorganized thinking and behavior and flat or inappropriate affect). - Pt.#2 was placed on assault precautions and Q15 [every 15] minute observation and admitted to the 5th floor Adolescent Boys unit. Pt.#1’s treatment plan does not indicate an updated treatment plan to address the incidents on 2/26/2025 and 2/28/2025. 7. On 3/11/2025 at approximately 8:40 AM, an interview was conducted with the CNO (Chief Nursing Officer - E#4). E#4 stated that the patient’s treatment plan should be updated whenever an incident occurs involving the patient. 8. On 3/11/2025 at approximately 10:05 AM, an interview was conducted with the Therapist (E#15). E#15 stated that the patient’s treatment plan should be updated after an incident involving the patient.”

“Adequate Staffing CFR(s): There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient’s active treatment program. This Standard is not met as evidenced by: 50411 Based on document review and interview, it was determined that for 1 of 3 Behavioral Health Units (5th floor Adolescent Male unit) reviewed for staffing, the hospital failed to failed to ensure the unit had the appropriate number of nurses and mental health workers in order provider the nursing care listed in each patient’s active treatment program per hospital policy. Findings include: 1. The hospital’s policy titled “Plan for Nursing Services” (Date of Approval 6/2022) included “... B. Acute Care: Core coverage includes ensuring there is always 1 RN (Registered Nurse) on each unit and that there is at minimum 2 staff on each unit at all times...” 2. The hospital’s staffing schedule for February 3, 2025 indicates that the Adolescent Girls unit was staffed with 1 RN (Registered Nurse) from 7:30am to 10:15 AM; 1 RN from 10:00 AM to 10:30 AM; 1 RN from 10:30 AM to 5:15 PM; 1 BHT (Behavioral Health Technician) from 6:45 AM to 7:45 PM; 1 BHT from 7:15 AM to 7:30 PM; 1 BHT from 7:30 AM to 9:45 AM; 1 RN from 7:15 PM to 11:00 PM; and 1 RN from 7:30 PM to 7:45 AM. The schedule for February 3, 2025 indicates that there was no RN on the unit from 5:15 PM to 7:15 PM. The census on the Adolescent Girls unit on February 3, 2025 was 16 patients. 3. The hospital’s staffing schedule for March 1, 2025 indicates that the Adolescent Girls unit was staffed with 1 RN (Registered Nurse) from 7 PM to 3 AM; 1 RN from 7 PM to 4 AM; 1 BHT from 7 PM to 9:15 PM; 1 BHT from 7 PM to 3:45 AM; 1 BHT from 7:30 PM to 3:30 AM; and 1 BHT from 11PM to 7:30 AM. The schedule indicates that there was no RN on the unit from 4 AM to 7 AM and only 1 BHT from 3:45 AM to 7 AM. The census on the Adolescent Girls unit on March 1, 2025 was 19 patients. 4. On 3/11/2025 at approximately 8:40 AM, an interview was conducted with the Chief Nursing Officer (CNO/E#4). E#4 stated that one nurse should always be present in the unit and there should always be 2 staff working on the unit, one of which should always be an RN.”

“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: 39802 385 Based on document review, video surveillance review and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.23, Nursing Services. Findings include: 1. The hospital failed to ensure that appropriate number of staff was available to respond to a Cod Grey (emergency code for management of aggressive patients’ behavior). Subsequently, 4 patients (Pt. #1, Pt. #2, Pt. #3 and Pt. #4) were able to elope from the hospital. See deficiency cited at A-392.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 50411 Based on document review, video review, and interviews, it was determined that for 1 of 2 emergency codes (events) reviewed, the hospital failed to ensure that appropriate number of staff was available to respond to a Cod Gray (emergency code for management of aggressive patients’ behavior). Subsequently, 4 patients (Pt. #1, Pt. #2, Pt. #3 and Pt. #4) were able to elope from the hospital. Findings include: 1. The hospital’s policy titled, “Staffing Plan for Nursing Services” (dated 6/2022) was reviewed and required, “ ...One staff person cannot be left alone on an inpatient, Adolescent Unit ...Code response: For acute care facilities, three staff members should always be available to respond; cross-trained staff can be utilized ...” 2. The hospital’s policy titled, “Emergency Codes” (dated 1/2022) was reviewed and required, “ ...2. It is the responsibility of all staff members to know all emergency codes and to respond when indicated ...” 3. The incident report log for 7/2024 to 10/2024 was reviewed and indicated an entry for 9/30/2024 which includes, “[Pt.#1]...elope-not returned - Patients (Pt. #1, Pt. #2, Pt. #3 and Pt. #4) became agitated and repeatedly attempted to break down dayroom door to attack select peers. Staff had to relocate peers through nursing station and into the hallway behind the breakroom due to fear of patients breaking dayroom door. Patients became aggressive towards staff by threatening and endorsing intent to attack staff and take their badge. When unable to attack hallway staff, patients relocated near stairwell doors and began exit door until it broke, resulting in patients successfully eloping from unit down the stairwell and outdoors approximately [11:13 PM].” 4. The Patient Care Assignment Sheets for Unit 3 (Pediatric), 4 (Adolescent Girls), and 5 (Adolescent Boys) for 9/30/2024 were reviewed. The patient care assignment sheets indicated that Unit 3 was staffed with 2 RNs (Registered Nurses) and 1 BHA (Behavioral Health Associate). Unit 4 was staffed with 1 RN and 1 BHA. Unit 5 was staffed with 2 RNs. 1 BHA was scheduled to work at Unit 5 at 11:15 PM. Each assignment sheet designated one staff member to respond to Code Grey. 5. On 10/16/2024 at approximately 2:00 PM, a video surveillance for the 5th floor adolescent boys behavioral unit was reviewed for an incident that occurred on 9/30/2024 between approximately 10:30 PM and 11:30 PM. The video surveillance showed that there were 2 RNs (E#3 and E#4) staffed on the unit and that patients (Pts.# 1, 2, 3, and 4) began displaying aggressive behavior towards 3 other patients. At approximately 10:40 PM, E #5 (RN) from another unit came to respond/assist. The video surveillance showed that the behavior of Pts#1, 2, 3, and 4 continued to escalate at which point E#3 enters the nurses’ station for his safety. The video surveillance showed that Pts#1, 2, 3, and 4 then go to the stairwell door and start to kick and hit the door. The patients (Pt. #1, #2, #3 and #4) succeed in opening and they eloped from the hospital. 6. An interview was conducted with the Registered Nurse (E#3) on 10/17/2024 at approximately 9:30 AM. E#3 stated that on 9/30/2024 at approximately 10:30 PM, E#3 noted aggressive behavior displayed by 3 patients (identified as Pts #2, 3, and 4) towards 3 other patients. Later on, Pt.#1 joined. E#3 stated that E#3 attempted to de-escalate the situation. When E#3 noted the escalation of aggressive behavior of Pts. #1, 2, 3, and 4, E#3 called a Code Grey (Emergency Management of Aggressive Behavior) and placed the 3 patients in the dayroom and locked the door. E#3 stated that only RN/E#5 responded. E#3 stated that there was no night supervisor on duty that evening. E#3 stated that E#4 was in the nurses’ station making phone calls to doctors and supervisors and AOC (administrator on call). E#3 stated that when the situation could no longer be de-escalated and fearing for their own safety, E#3 went inside the nurses’ station to join E#4 and E#5. E#3 stated that Pts.#1, 2, 3, and 4, then directed their attention towards breaking down the stairwell door and open it and eloped the unit and eventually the hospital. E#3 stated that their normal protocol is for a staff from each unit to respond to the Code Grey. E#3 stated that there should always be 1 RN and 1 BHA on the unit. E#3 stated that if the unit is staffed bare minimum (1 RN and 1 BHA), no other staff can respond when a code is called. E#3 stated that if they were staffed better, more staff could have responded. 7. An interview was conducted with Registered Nurse (E#5) on 10/17/2024 at approximately 10:30 AM. E#5 stated that on 9/30/2024, E#5 responded to a Code Grey called by E#3 at approximately 10:30 PM. E#5 stated that E#5 attempted to de-escalate the situation and later went in the nurses’ station to assist E#4 in making phone calls to the supervisor and the AOC. E#5 stated that the patients being targeted by Pts.#1, Pt. #2, Pt. #3, and Pt. #4 were moved from the dayroom to the hallway behind the nurses’ station through an adjoining door since they noted that the dayroom door was about to break open. E#5 stated that Pts.#1 and 2 had previous history of eloping from other facilities and were considered the worst wards in DCFS (Department of Child and Family Services). E#5 stated that when a Code Grey is called, their usual protocol is for at least 1 staff member from each unit to respond. E#5 stated that if the intake staff is not busy, the intake staff also responds to the Code Grey. E#5 stated that if a supervisor is present, the supervisor also responds to the Code Grey. E#5 stated that there was no one else available that evening to respond except E#5.”

“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: 40079 Based on document review, video surveillance review and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.23, Nursing Services. Findings include: 1. The hospital failed to ensure that the nursing service had adequate numbers of licensed Registered Nurses (RNs) to provide nursing care to all patients as required. See deficiency cited at A-392. 2. The hospital failed to ensure that the unit was always supervised by a licensed registered nurse (RN). See deficiency A-393. The immediate jeopardy (IJ) was identified on 08/02/2024 at 42 CFR 482.23, Nursing Services, due to the hospital’s failure to ensure appropriate supervision on 1 of 3 Behavioral Health Units by a licensed Registered Nurse. The IJ was announced on 08/02/2024 at 3:30 PM, during a meeting with the Chief Executive Officer (CEO), Director of Risk, Risk Manager, and Vice President of Quality and Patient Safety. The IJ was removed based on document review, interviews, and observation by the survey exit date of 08/05/2024.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 40079 Based on document review and interview, it was determined that for 2 of 3 Behavioral Health Units (2-East and 3-West) reviewed for staffing, the hospital failed to ensure that the nursing service had adequate numbers of licensed Registered Nurses (RNs) to provide nursing care to all patients as required. Findings include: 1. The hospital’s policy titled, “Staffing Plan for Nursing Services” (dated 6/2022) was reviewed and required, “ ...The minimum staffing needed for each skill level (RNs, Behavioral Health Associates (BHA), others) is determined by the nurse-patient ratio guidelines and patient care needs of the population ... The exact nurse to patient ratio may differ by population and level of needs but generally there is one nurse per 12 patients.” 2. The Staffing grid for the Adult Behavioral Health Units (undated) was reviewed. The staffing grid required the following staff to patient ratio: Day & Evening census 1 to 10 (1 RN, 1 BHA) 11 to 21 (2 RNs and 2 BHAs). The 2 East (Adult Male) Unit Staffing Assignment sheets from 7/1/2024-7/31/2024 were reviewed and indicated that there was only 1 RN and 2 BHAs working the night shifts from 7/17/2024-7/20/2024 with the census between 13 to 20 patients. 3. The 3 West (Adult Male/Female) Unit Staffing Assignment sheets from 7/1/2024 - 8/1/2024 were reviewed and indicated that there was 1 RN and 2 BHAs working on the following days 7/27/2024 - 7/29/2024, with the census between 15-18 patients. 4. On 08/02/2024 at approximately 11:30 AM to 11:45 AM, interviews were conducted with three RNs (E #14, E #15, and E #16), all RNs stated that there are occasions that the units are short staffed with one RN to cover greater than 13 patients on their unit.”

“RN/LPN STAFFING CFR(s): 482.23(b)(1) The hospital must provide 24-hour nursing services furnished or supervised by a registered nurse, and have a licensed practical nurse or registered nurse on duty at all times, except for rural hospitals that have in effect a 24-hour nursing waiver granted under o488.54(c) of this chapter. This Standard is not met as evidenced by: 40079 Based on document review, video surveillance review and interview it was determined that for 1 of 3 Behavioral Health Units (BHU), the hospital failed to ensure that the unit was always supervised by a registered nurse (RN). This has the likelihood to cause serious harm to any patient that presents to the hospital. Findings include: 1. The hospital’s policy titled, “Staffing Plan for Nursing Services” (dated 6/2022) was reviewed and required, “ ...The minimum staffing needed for each skill level (RNs, Behavioral Health Associates (BHA), others) is determined by the nurse-patient ration guidelines and patient care needs of the population ... Acute Care: Core coverage includes ensuring there is always 1 RN on each unit and that there is at minimum 2 staff on each unit at all times when there is lower census ... To secure optimal patient care, these guidelines outline staffing expectations to be observed by all service lines. Acute Service Line: An RN must always be on the unit. Neither an RN House Supervisor nor LPN (Licensed Practical Nurse) can service as the RN on the unit ...” 2. The “Chief Nursing Officer Job Description” (revised 1/1/2020) was reviewed and required, “... Evaluate service needs and staffing requirements to ensure needs of patients are met ... Assist with direct care as needed.” 3. On 08/01/2024, a video surveillance of 3-West, 3-East, administration corridor and employee parking lot for 7/19/24 between 2:43 AM to 4:09 AM, was reviewed with the Director of Risk Management (E#8) and the Risk Manager (E #9). The video showed that at on 07/19/24 at 3:22 AM, the Chief Nursing Officer (CNO/E #1) leaves 3-East and enters 3-West at 3:24 AM. E #1 is observed speaking to a staff (RN/E #6). At 4:09 AM, E #1 is observed getting into an elevator, then exits to the employee parking lot and gets into a car and drives away. 4. The 3-East (Female Adult) Unit Staffing Assignment for 07/18/24 7:00 PM to 7/19/24 7:00 AM, indicated that the census was 11, with one RN and two BHAs. 5. The 3-West (Adult Male/Female) Unit Staffing Assignment for 7/18/24 7:00 PM to 7/19/24 7:00 AM, indicated that the census was 9, with one RN (CNO/E#1), one BHA, and sharing one BHA with 3-East. The patients on both units were on safety precautions that included, Suicide Risk high and low, Assault, Elopement, fall risk, and every 5-minute checks. 6. Interviews were conducted with the Chief Nursing Officer (CNO/E#1) on 8/1/2024, at approximately 12:00 PM and on 8/2/2024 at 11:40 AM. E #1 stated that a nurse called off July 18 for the 7 PM to 7 AM, shift and the day shift nurse (E #4) called E #1 to report that there was no nurse to cover the PM shift. E #1 came in at approximately 8PM to cover the shift on 3-West, there was another nurse (E #6) working on 3-East, which is next to 3-West and is separated by a locked door. E #1 stated census was low, there were approximately 7 patients on 3-West and E #1 worked until around 5 AM, the nurse (E #6) covered 3-West when E #1 left. E #1 stated there were 3 BHAs (3-East & 3-West), there was one BHA on the 2nd floor unit. E #1 stated that typical staffing is based on census and acuity, and there are usually 1-2 nurses. The nurse to patient ratio is 1 nurse to 13 patients. E #1 stated that the hospital is using agency nurses while the hospital is trying to fill current vacancies. E #1 stated that E #1 did not try to get staff to cover the unit prior to E #1 leaving. E #1 stated that the nurse (E #6) was fine covering both units with a total of 20 patients. 7. A telephone interview with the Registered Nurse (E#4) was conducted on 08/01/24 at 2:45 PM. E #4 stated that only one nurse orientee (E #3) showed up to work on 7/18/24 7:00 PM to 7:00 AM. E #4 stated that (E #3) didn’t have access to the medication cabinet and there was only one nurse scheduled on the other units, which would serve as a resource to (E #3). (E #3) didn’t feel comfortable working alone and refused to take report and left. E #4 stayed on the unit until about 9 PM. E #4 notified (E #2/Staff Coordinator) and (E #1/CNO) ended up coming in to take report and covered the unit. E #4 stated that E #4 became aware that (E #1) left around 3:00 AM, and the unit was left without a nurse until the next shift. E #4 stated that another staff notified Human Resources about this situation but was not aware if this was investigated or resolved.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 37971 Based on document review and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights. Findings include: 1. The hospital failed to ensure that patients were visually monitored for safety as required and that staff assigned to monitor the patients were aware of the patients’ suicide risks. See deficiency A-144-A. 2. The hospital failed to ensure that 1:1 intervention assessments were completed by the nurse as ordered, to evaluate the patient’s needed for continued monitoring. See deficiency A-144 B. 3. The hospital failed to ensure that a patient observational rounds were documented/completed timely as required. See deficiency A-144 C. 4. The hospital failed to ensure that a suicide risk level was reassessed after a patient attempted suicide.See deficiency A-144-D. 5. The hospital failed to ensure that patient was medically evaluated after a suicide attempt. See deficiency A-144-E. 6. The hospital failed to ensure that routine room and unit checks were completed as required. See deficiency at A-144-F. The immediate jeopardy (IJ) was identified at 7/12/2024 at 42 CFR 482.13 Patient Rights, due to the hospital’s failure to ensure appropriate supervision for 2 of 2 patients (Pt. #1 and Pt. #11) on high suicide risk. Subsequently, four attempts of suicide attempts occurred. The IJ was announced on 7/12/2024 at 1:35 PM, during a meeting with the Chief Executive Officer, Chief Medical Officer, Director of Risk, Manager of Risk, Director of Clinical Services, and Director of Marketing. The IJ was not removed by the survey exit date of 7/12/2024.”

“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: 39802 A. Based on document review, video review, and interview, it was determined that for 2 of 2 (Pt. #1 and Pt. #11) patients reviewed for suicide attempt, the hospital failed to ensure that patients were visually monitored for safety as required and that staff assigned to monitor the patients were aware of the patients’ suicide risks. Subsequently, 4 incidents of suicide attempts occurred. Findings include: 1. The hospital’s policy titled, “Observations, Patient” (dated 6/2022) required, “Documentation of the observation is to be completed once the patient has been observed ... 7. Q 5 Minute Rounds: ...During times of personal hygiene, toileting and other self-care needs, the staff should be in visual and hearing range of the slightly opened bathroom door ... 8. 1:1 Observation: ...Staff are to remain within visual range and close proximity (easy reach) of patient at all times. There should be nothing between the patient and assigned staff ...” 2. The Hospital’s policy titled, “Suicide Risk Assessment” (revised 11/2023) required, “Suicide risk, level of observations and/or placement of Suicide Precautions will be communicated to all staff ...” 3. The clinical record of Pt. #1 was reviewed. On 6/15/2024, Pt. #1 was admitted with a diagnosis of major depressive disorder. The clinical record included: - The On-call Psychiatrist/Chief Medical Officer (MD #2) physician’s order dated 06/16/2024 at 9:53 PM, included, “ ...Observation Q 15 [every fifteen-minutes] ...suicide high now ...”. -On 06/25/2024 at approximately 2:45 PM, Pt. #1’s incident report dated 06/21/2024 at 2050 [8:50 PM] was reviewed and included, “ ...Type of incident: Suicide Attempt; Location: 3 East Patient [Pt. #1’s] Room Doorway; Fact Summary: At approximately 2050 [8:50 PM] during med (medication) pass, Behavioral Health Associate[BHA/E #6] screamed that we need a nurse. Upon arriving [Pt. #1] was found on the floor, in the doorway, unresponsive, face was flushed, and clothing was soaked. Patient [Pt. #1] noted to have a pulse and noticed green string around the neck. Nurse [E #2] cutting the string while myself [E #1] and BHA [E #6] was pulling the string away from her [Pt. #1’s] neck. [Pt. #1] was given paper scrubs, place on 1:1, Q5’s observations and management notified and doctor ...Was client injured: Yes ...redness around neck .... If yes, was outside medical treatment required? No ...Actions taken: Placed on 1:1 ...”. 4. The clinical record of Pt. #11 was reviewed on 7/9/2024. Pt. #11 was admitted on 6/27/2024 at 1:38 AM, to the 4th Floor Adolescent Girls Behavioral Health Unit, with a chief complaint of suicidal ideation and a diagnosis of recurrent, severe major depressive disorder. - Pt #11’s suicide risk assessment on admission intake (6/27/2024 at 2:52 AM) indicated that Pt #11 was a high risk for suicide. Physician’s (MD #4) admission orders (6/27/2024 at 3:28 AM) included precautions for high suicide risk, assault, and elopement with Q5 (every 5) minute observations. - Nursing House Supervisor E#17’s note, dated 6/27/2024, included “At approximately 11:40 [AM], BHA completing [Pt #11’s] q5 observation round, BHA knocked on bathroom door, no response heard. BHA opened door pt laying on the bathroom floor with paper scrub pants tied around pt neck. BHA called for assistance; staff immediately removed the paper scrub pants around pt’s neck.” - The Patient Observation Rounding sheet, dated 6/27/2024, indicated that Pt. #11 was noted to be in the bathroom at 11:25 AM, 11:30 AM, and 11:35 AM by BHAs E#19 and E#24. No round was document at 11:40 AM (approximate time of incident). - The record indicated Pt. #11 was placed on 1:1 monitoring and linen restrictions after the incident on 6/27/2024. These orders were discontinued on 6/29/2024 at 2:21 PM by the Registered Nurse (RN/E #23) per verbal order of MD #3, and Pt. #11’s level of monitoring was changed to Q5 minutes. - Nurse E#18’s progress note, dated 7/2/2024, included “Around 2:35 PM, [Pt. #11] went into the community bathroom. After two minutes we heard patient coughing, RN knocked on door and patient did not respond. RN opened the door and saw patient on the ground with [Pt. #11’s] pants tied around [Pt. #11’s] neck. RN told [Risk Management E#15] to call a code. RN and BHA [E#20] turned [Pt. #11] over to untie the pants.” - The record indicated that Pt. #11 was placed on 1:1 monitoring, linen restrictions, and hallway bathroom restriction after the incident on 7/2/2024. 5. On 07/10/2024, Pt. #11’s incident report dated 06/27/2024 at 11:40 AM was reviewed and included, “ ...Type of incident: Suicide Gesture; Location: Bathroom; Fact Summary: ... (Pt. #11) observed in bathroom with paper pants wrapped around (Pt. #11’s) neck ...removed paper pants from (Pt. #11’s) neck, assessed pulse. Vitals obtained, were within normal limit. (Pt. #11) sat up, (Pt. #11) refusing to answer assessment and CSSR [Colombia-Suicide RiskRating Scale] questions. (Pt. #11) immediately placed on 1:1. Medical provider notified, gave order to send to (outside hospital). Psych (psychiatric) provider gave order 1:1, linen restriction, blocked room ...Evaluation: was injury observed: No ...was outside treatment necessary: Yes ...Notification: ...6/27/2024 at 11:45AM Physician (MD #3) ...” 6. On 07/10/2024, Pt. #11’s incident report dated 7/02/2024 at 1435 (2:35 PM) AM was reviewed and included, “ ...Type of incident: Suicide Attempt; Location: Community Bathroom; Fact Summary: ... (Pt. #11) went into community bathroom after 2 mins (minutes) we (staff) heard (Pt. #11) coughing. RN knocked on door and no response. RN opened door and found (Pt. #11) on the ground with pants tied around neck. RN and BHA untie pants. RN stayed with (Pt. #11) and took vitals. Vitals WNL (within normal limits). (Pt. #11) placed on 1:1, linen restriction and placed in paper scrubs ...Evaluation: was injury observed: No ...was outside treatment necessary: No ...Notification: ...7/02/2024 at 1440 (2:40PM) Physician (MD #3).” 7. On 07/11/2024, Pt. #11’s incident report dated 07/10/2024 at 2000 (8:00 PM) was reviewed and included, “ ...Type of incident: Suicide Attempt; Location: (Pt. #11’s Room); Fact Summary: (patient) ran up to nurse’s station yelling to “call a code” there is someone choking themselves”. (Pt. #11) was found (Pt. #11) on the bathroom floor with (Pt. #11’s) scrub pants tied around (Pt. #11’s) neck. Per (E #25/Behavioral Health Associate/1:1 monitor), (E #25) allowed (Pt. #11) to use the bathroom unattended. (E #25) found (Pt. #11) strangling self ...Interventions/Treatment: ...PRN (as needed) medication ...place on 1:1 ...verbal de-escalation ...Evaluation: was injury observed: No ...was outside treatment necessary: No ...Notification: ...7/10/2024 at 8:00 PM Physician (MD #4).” 8. On 7/10/2024 hospital video footage was reviewed around time of incidents on 6/27/2024 between 11:10:00 AM and 1:15:00 PM; on 7/02/2024 between 2:20:00 PM and 2:40:00 PM. The video footage confirmed that observational monitoring was not performed as ordered, Q5 and 1:1, while Pt. #11 was in the bathroom. 9. On 7/10/2024 an interview with the BHA (E #19/ Incident #1 on 6/27/2024) was conducted. E#19 stated that if the patient remains in the bathroom during the next round, they will knock and listen for a response from the patient. E#19 stated that they don’t have to visualize the patient in the bathroom unless they are 1:1. 10. On 7/10/2024, an interview with the BHA (E #20/ Incident #2 on 7/02/2024) was conducted with BHA E#20 on 7/10/2024. E#20 stated that E#20 was not told about Pt. #11’s prior suicidal gestures. E#20 stated that when patients are on Q5 minute monitoring, the door does not need to be open, and staff do not have to stay by the bathroom. 11. On 7/11/2024 at approximately 11:46 AM, an interview with the BHA (E #25/Incident #3 on 7/10/2024) was conducted. E #25 stated that (E #25) was assigned as (Pt. #11’s) 1:1 monitor for the evening shift (7:00 PM - 7:00 AM) on 7/10/2024. E #25 stated that (E #25 and Pt. #11) were in Pt. #11’s room, (Pt. #11) had to use the bathroom, and (E #25) allowed (Pt. #11) to go into the bathroom unattended. E #25 stated that approximately two to three minutes had passed and (E #25) did not hear (Pt. #11). E #25 stated that (E #25) stood up, turned the bathroom light on, and found (Pt. #11) on the ground with paper scrubs around (Pt. #11’s) neck, choking self. E #25 stated that (E #25) should have been in the bathroom with (Pt. #11) as 1:1 monitoring is constant visualization. E #25 stated that was the first time working with Pt. #11 and E#25 was taking over 1:1 for Pt. #11 from another BHA. E#25 stated that E#25 was not told of Pt. #11’s previous suicide attempts in the bathroom when E#25 took over 1:1 monitoring for Pt. #11 and E#25 was not aware why Pt. #11 was on 1:1 prior to the incident on 7/10/2024. B. Based on document review and interview, it was determined that for 1 of 1 (Pt. #11) record reviewed for patients placed on 1:1 (one-to-one) monitoring, the hospital failed to ensure that 1:1 intervention assessments were completed by the nurse as ordered, to evaluate the patient’s needed for continued monitoring. This had the potential to affect all patients on 1:1 monitoring for safety concerns. Findings include: 1. The clinical record of Pt. #11 was reviewed on 7/9/2024. Pt. #11 was admitted on 6/27/2024 at 1:38 AM, to the 4th Floor Adolescent Girls Behavioral Health Unit, with a chief complaint of suicidal ideation and a diagnosis of recurrent, severe major depressive disorder. - Pt #11’s suicide risk assessment on admission intake (6/27/2024 at 2:52 AM) indicated that Pt #11 was a high risk for suicide. Physician’s (MD #4) admission orders (6/27/2024 at 3:28 AM) included precautions for high suicide risk, assault, and elopement with Q5 (every 5) minute observations. - Nursing House Supervisor E#17’s note, dated 6/27/2024, included “At approximately 11:40 [AM], BHA [behavioral health associate] completing [Pt #11’s] q5 observation round, BHA knocked on bathroom door, no response heard. BHA opened door pt laying on the bathroom floor with paper scrub pants tied around pt neck. BHA called for assistance; staff immediately removed the paper scrub pants around pt’s neck.” - Physician orders, dated 6/27/2024 (after the incident), included 1:1 Observation monitoring and One to One Clinical Intervention Worksheet to be completed by nurse every 4 hours until the 1:1 observation is discontinued. - One-to-One Intervention worksheets from 6/27/2024 to 6/29/2024 were reviewed and lacked documentation that these assessments were completed every 4 hours as required, to determine if Pt. #11 should continue on 1:1 or possibly be lowered in terms of level of observation. The last completed worksheet, dated 6/28/2024 at 4:04 AM, indicated that Pt. #11 was still in need of 1:1 monitoring. - The record indicated that the 1:1 order was discontinued on 6/29/2024 at 2:21 PM by the Registered Nurse (E #23) per verbal order of MD #3, and Pt. #11’s level of monitoring was changed to Q5 minutes. - Subsequently, Pt. #11 made another attempt to tie pants around Pt. #11’s neck on 7/2/2024 and Pt. #11 was placed on 1:1 monitoring again and remained in effect on 7/9/2024. - One-to-One Intervention worksheets from 7/2/2024 to 7/9/2024 were reviewed and lacked documentation that these assessments were completed every 4 hours as required between 7/2/2024 at 4:56 to 7/3/2024 at 7:59 AM; 7/3/2024 at 4:18 PM to 7/5/2024 at 12:40 AM; 7/5/2024 at 12:40 AM to 7/7/2024 at 12:11 AM; between 7/7/2024 12:11 AM to 8:55 AM, and none were completed on 7/8/2024. 2. An interview was conducted with Registered Nurse (E#23) on 7/11/2024, at approximately 10:20 AM. E#23 did not recall talking to MD#3 about discontinuing Pt. #11’s 1:1. E#23 stated that E#23 thought that Pt. #11 was on 1:1 due to aggression with peers and was not related to the strangling incident on 6/27/2024. E#23 stated that as the nurse, E#23 assesses the patients everyday and asks if they have thoughts of self-harm or behaviors. E#23 stated that the one-to-one intervention worksheet should be completed every 4 hours by the nurse to see how the patient is progressing and if there are any changes. E#23 stated that it is ultimately up to the psychiatrist what level of observation the patient should be on. E#23 stated that E#23 has never suggested any patient come off 1:1 monitoring after giving the physician E#23’s assessment of the patient. C. Based on document review and interview, it was determined that for 4 of 4 (Pts. #11, Pt. #14, Pt. #15, and Pt. #16) patient records reviewed for observational rounds, the hospital failed to ensure that patient observational rounds were documented/completed timely as required. Findings include: 1. The hospital’s policy titled, “Observations, Patient” (dated 6/2022) required, “ ...Staff documents all levels of observation on each patient’s observation form which becomes part of the patient record. Each entry is to include the following: i. Level of observation, ii. Precautions, iii. Location, iv. Behavior, v. Activity, vi. Time, vii. Staff Initial and Signature ... Documentation of the observation is to be completed once the patient has been observed ... Documentation of 1:1 observation occurs q 15 [every 15] minutes even though the patient is being observed continuously ...” 2. The clinical record of Pt. #11 was reviewed on 7/9/2024. Pt. #11 was admitted on 6/27/2024 at 1:38 AM, to the 4th Floor Adolescent Girls Behavioral Health Unit, with a chief complaint of suicidal ideation and a diagnosis of recurrent, severe major depressive disorder. The clinical record included the following: -Physician orders indicated that Pt. #11 was on Q5 (every 5 minute) monitoring from 6/29/2024 at 2:25 PM until 7/2/2024 at 2:54 PM. Pt. #11 was placed on 1:1 monitoring on 7/2/2024 at 2:54 PM following a second attempt to tie clothing around Pt. #11’s neck. -Patient Observational Rounds from 6/27/2024 to 7/9/2024 at 12:00 PM were reviewed and lacked documentation that rounding was completed timely during/at the following times: - Q5 minute rounding on 6/30/2024 at 12:25 AM, 12:40 AM, 9:10 AM, 11:30 AM, 12:55 PM, 5:35 PM, 6:25-6:55 PM, 7:15 PM, and 11:00 PM were missed. - Q5 minute rounding on 7/1/2024 at 12:55 AM, 3:45 AM, 4:00 AM, 900 AM, 3:50 PM, 7:00 PM, 7:35 PM, 7:40 PM, 8:05 PM-8:20 PM, and 10:15 PM were missed. - 1:1 patient observation documentation on 7/2/2024 was missed between 4:40 PM-7:25 PM, between 8:25 PM to 8:50 PM, and between 10:40 PM to 10:55 PM. 2. The clinical record of Pt. #14 was reviewed on 7/10/2024. Pt. #14 was admitted on 6/30/2024 at 11:52 PM, to the 4th Floor Adolescent Girls Behavioral Health Unit, with a chief complaint of suicidal ideation and a diagnosis of recurrent, severe major depressive disorder. -Physician observation orders indicated that Pt. #14 was on Q5 monitoring from 7/01/2024 at 12:58 AM until 7/3/2024 at 8:07 AM, Q15 every 15 minutes) monitoring from 7/03/2024 at 8:07 AM until 7/05/2024 at 9:52 PM, Q5 at 7/05/2024 at 9:45 PM to 7/08/2024 at 12:43 PM, and Q15 from 7/08/2024 at 12:42 PM to current (as of 7/10/2024 at 3:00 PM). -Patient Observational Rounds from 7/01/2024 to 7/10/2024 at 1:15 PM were reviewed and lacked documentation that rounding was completed timely during/at the following times: - Q5 minute rounding on 7/01/2024 at 3:45 AM, 4:10 AM, 6:45 AM, 11:10 AM, 1:25 PM, 3:55 PM, 4:45 PM, 7:40 PM - 7:50 PM, 8:00 PM - 8:30 PM, 8:40 PM, 11:10 PM, and 11:40 PM were missed. - Q5 minute rounding on 7/02/2024 at 12:30 AM, 1:55 AM, 6:25 AM, 9:10 AM, 10:55 AM, 2:35 PM, 2:55 PM, 7:05 PM, 7:15 PM, 8:15 PM, and 8:20 PM were missed. - Q5 minute rounding on 7/05/2024 at 9:45 PM to 7/06/2024 at 4:00 AM was conducted every 15 minutes, not every 5 minutes as required. - Q5 minute rounding on 7/06/2024 at 5:05 AM, 6:10 AM, 11:45 AM, and 4:05 PM to 4:20 PM were missed. - Q5 minute rounding on 7/07/2024 at 2:40 PM, 3:00 PM, 4:45 PM, 9:30 PM, 10:05 PM, 10:20 PM 11:40 PM, 11:55 PM were missed. - Q5 minute rounding on 7/08/2024 at 2:55 AM, 4:00 AM, 4:15 AM, 4:30 AM, 4:40 AM, 4:50 AM, 6:25 AM were missed. 3. The clinical record of Pt. #15 was reviewed on 7/10/2024. Pt. #15 was admitted on 7/04/2024 at 6:24 PM, to the 5th Floor Adolescent Boys Behavioral Health Unit, with a chief complaint of suicidal ideation and a diagnosis of recurrent, severe major depressive disorder. The clinical record included the following: -Physician observation orders indicated that Pt. #15 was on Q5 monitoring from 7/04/2024 at 7:20 PM until 7/05/2024 at 2:26 PM and Q 15 monitoring from 7/05/2024 at 2:26 PM to current (as of 7/10/2024 at 3:00 PM). Patient Observational Rounds from 7/04/2024 to 7/10/2024 at 1:15 PM were reviewed and lacked documentation that rounding was completed timely during/at the following times: - Q5 minute rounding on 7/04/2024 at 8:15 PM to 7/05/2024 at 4:15 PM was conducted every 15 minutes, not every 5 minutes as required. 4. The clinical record of Pt. #16 was reviewed on 7/10/2024. Pt. #16 was admitted on 7/09/2024 at 5:23 PM, to the 4th Floor Adolescent Girls Behavioral Health Unit, with a chief complaint of suicidal ideation and a diagnosis of recurrent, severe major depressive disorder.The clinical record included the following: -Physician observation orders indicated that Pt. #16 was on Q5 monitoring from 7/09/2024 at 10:37 PM to current (as of 7/10/2024 at 3:00 PM). -Patient Observational Rounds from 7/09/2024 to 7/10/2024 at 1:20 PM were reviewed and lacked documentation that rounding was completed timely during/at the following times: - Q5 minute rounding on 7/09/2024 at 10:35 PM and 10:55 PM were missed . - Q5 minute rounding on 7/10/2024 at 12:20 AM, 1:45 AM, 2:40 AM, 2:55 AM, 6:20 AM, 6:35 AM, 9:05 AM, 10:20 AM, 10:30 AM, 11:25 AM, 12:05 PM, 12:20 PM, and 1:10 PM were missed. 5. An interview was conducted with the Informational Technology Specialist (E #28) on 7/11/2024, at approximately 11:00 AM. E #28 stated that staff are required to document rounds when they are within range of the patient at the interval that is ordered by the physician (i.e. Q5 or Q15). E #28 stated that if the patient is on 1:1 monitoring, the round sheet will show an “(M)” to indicate that it was a 1:1 staff was doing the rounds. E #28 stated that 1:1 staff are expected to document an observation of the patient at least every 15 minutes. E #28 stated that if they are late or not within range, the round will be missed on the log. E #28 stated that it is the registered nurses task to update observational monitoring in the computer system to reflect physician order. 37971 D. Based on document review and interview, it was determined that for 1 of 5 patients (Pt. #1) clinical record reviewed for suicide high risk assessments and reassessments, the hospital failed to ensure that a suicide risk level was reassessed after a patient suicidal attempt as required. Findings include: 1. On 06/26/2024 at approximately 2:40 PM, the hospital’s policy titled, “Suicide Risk Assessment” dated 06/2022 was reviewed and included, “ ...Facility screens all patients for suicidal ideation using validated screening tool ...Columbia Suicide Screen Risk Scoring (CSSRS) process is utilized for every patient upon admission ...initially screened in Intake to identify suicide ideation ... Reassessment: Patients ...may be reassessed using the SAFE-T (Suicide Assessment Five-Step Evaluation and Triage) protocol with CSSRS at any point during hospitalization, such as in the event of a change in suicidality ...suicide attempt ...” 2. On 06/26/2024 at approximately 3:00 PM, the hospital’s Suicide Risk Assessment Practitioner Examples (date unknown) was reviewed and included, “ ...Suicide High Risk: 16 or above (ideation intensity) Expected observation level 1:1 (or Q5[every 5 minutes] if no ligature risk); Moderate Risk: 6 -15; Low Risk: 5 or below...” 3. On 06/25/2024 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 06/15/2024 at 9:55 PM with a diagnosis of major depressive disorder. Pt. #1’s clinical record included the following: -The initial psychiatric evaluation by Attending Psychiatrist (MD #1) dated 06/16/2024 at 1:17 PM, included, “ ...history of MDD [major depressive disorder] presenting for increased SI [suicidal ideations] after failing residential treatment at [name of residential facility] ...worsening moods ...since medications adjusted ... led to increased depressive symptoms, feelings of rejections, and increased SI [suicidal ideation] ......Precautions: SI [suicidal ideations precautions]...” -The Intake Assessment note dated 06/15/2024 at 8:55 PM, included, “ ...Chief Complaint: Pt. [Pt. #1] note that ...feels problems began recently due to psychiatrist changing medications ...drs. [doctors] removed all medications due to frequent seizures that have been occurring ...pulled medications 4-5 days ago ...been decompensating ...and been breaking down ...feels more isolated and suicidal ...dreams of committing suicide ...stress has been causing to feel suicidal later ...was sent out (from residential facility) due to increased SI [suicidal ideation] with a plan does have hx [history] suicidal ideation...Risk Factors: ... Suicidal Thoughts: Yes ...Thoughts about Plans, and Suicidal Intent: Yes ...Frequency: Many times each day ...Duration: 4 -8 hours/most of day ...Controllability: Unable to control thoughts ...Reasons for Ideation: Equally to get attention, revenge or a reaction from others and to end/stop the pain ...Risk Stratification: High suicide risk: Suicidal ideation with intent or intent with plan in past month ...Risk Level” High Suicide Risk ...self admits high levels of suicidality ...Score: 22 [High Risk 16 or above - expected observation 1:1 (or Q5 if no ligature risk ...” -The registered nurse (E #1) [Addendum] to progress note dated 06/22/2024 at 6:26 AM, included, “ ...Approximately 2050 [8:50 PM] during med. [medication] pass BHA [Behavioral Health Associate- E #6] scream that we need nurse. Upon arriving [Pt. #1] was found on the floor, in [Pt. #1’s] doorway, unresponsive, face was flushed, and clothing was soaked ...noted to have pulse and noticed a green string around the patient neck ...Nurse [E #2] cut the string while myself [E #1] and BHA [E #6] was pulling the string away from [Pt. #1’s] neck ... Patient [Pt. #1] was assessed and vitals were WNL [within normal limits] and red marking was noted on patient neck; after green string was cut off ...began to cough and turned to side ...staff assisted [Pt. #1] to the bed ...Placed on 1:1 and Q5 for observation. Notified on-call physician/Chief medical officer (MD #2) ...patient [Pt. #1] resting comfortable throughout the night and did not display any s/s [signs and symptoms] of anxiety ...remains on 1:1 [one-to-one] and Q5 [every 5 minutes] for safety.” The registered nurse progress notes lacked the suicide risk re-assessment after a suicidal attempt. 4. On 06/26/2024 at approximately 9:00 AM, the Registered Nurse (E #1) that took care of the patient (Pt. #1) on 06/21/2024 during the incident was interviewed. E #1 stated that it all happened so fast. E #1 stated that (E #1) forgot to complete the re-assessment of suicide risk after the suicide attempt. 5. On 06/26/2024 at approximately 12:30 PM, the Nurse Manager (E #4) was interviewed. E #4 stated that the suicide risk assessment and scoring should be done upon admission and re-assessment after any event. E #4 acknowledged that there was no suicide risk assessment and scoring done after the suicide attempt by Pt. #1 on 06/21/2024. E. Based on document review and interview it was determined that for 1 of 5 patient (Pt. #1) clinical record reviewed for suicide high risk, the hospital failed to ensure that patient was medically evaluated after a suicidal attempt. Findings include: 1. The hospital’s policy titled, “Medical Emergency” dated 6/2022 was reviewed and included, “...A medical emergency is an event requiring rapid assessment and intervention ...cardiac arrest ...change in level of consciousness ...1. The first staff to recognize ...summon assistance by loudly calling “Code Blue,” “Medical Emergency” or “Help” ...Yell “Code Blue” ...transport emergency medical cart ...call the on-call medical practitioner ...Dial 911 for EMS (emergency medical system) as directed by the Registered Nurse or practitioner ...contact attending psychiatrist/designee ...” 2. On 06/25/2024, Pt. #1’s incident report dated 06/21/2024 at 2050 [8:50 PM] was reviewed and included, “ ...Type of incident: Suicide Attempt; Location: 3 East Patient [Pt. #1’s] Room Doorway; Fact Summary: At approximately 2050 [8:50 PM] during med pass, BHA (Behavioral Health Assistant/E #6) screamed that we need a nurse. Upon arriving [Pt. #1] was found on the floor, in the doorway, unresponsive, face was flushed, and clothing was soaked. Patient [Pt. #1] noted to have a pulse and noticed green string around the neck. Nurse [E #2] cutting the string while myself [E #1] and BHA [E #6] was pulling the string away from her [Pt. #1’s] neck. [Pt. #1] was given paper scrubs, place on 1:1, Q5’s observations and management notified and doctor ...Was client injured: Yes ...redness around neck .... If yes, was outside medical treatment required? No ...Actions taken: Placed on 1:1 ...” 3. On 06/25/2024, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the hospital on 06/15/2024 at 9:55 PM with a diagnosis of major depressive disorder. Pt. #1’s clinical record included the following: -The initial psychiatric evaluation by Attending Psychiatrist (MD #1) dated 06/16/2024 at 1:17 PM, included, “ ...history of MDD [major depressive disorder] presenting for increased SI [suicidal ideations]after failing residential treatment at [name of residential facility] ...worsening moods ...since medications adjusted ... led to increased depressive symptoms, feelings of rejections, and increased SI [suicidal ideation] ...increased SI in dreams and increased...Precautions: SI [suicidal ideations precautions] and AP [assault precautions] ...” -The emergency department physician notes from (the ED Acute Care Hospital) dated 06/22/2024 at 2:00 PM, included, “Chief complaint: suicidal attempt at [the Hospital] last night by hanging self with a scrub strings, came in for wellness check, denies chest pain ...as per report staff found the patient [Pt. #1] unresponsive with low blood pressure and they had to do CPR [cardio-pulmonary resuscitation] after which the patient [Pt. #1] regained consciousness and was sent here today for check-up ...per facility patient [Pt. #1] had moment of unresponsive, unclear if pt. [Pt. #1] really lost pulses, but was given chest compressions. [Pt. #1] did not go to the hospital when this happened last night ...normal vital signs while in the emergency department, complaining of throat pain and voice hoarseness, no difficulty swallowing or difficulty breathing.” Pt. #1 was sent to the Emergency Department on 6/22/2024 at 2:00 PM, to be medically evaluated, approximately 17 hours after suicidal attempt that resulted in a period of unconsciousness. 4. On 06/25/2024 at approximately 2:25 PM, the Attending Psychiatrist (MD #1) was interviewed. MD #1 stated that (MD #1) was not sure why (Pt. #1) was not sent out for medical evaluation to the nearby emergency room. MD #1 stated that (MD #1) on 06/22/2024 at approximately 11:15 AM, upon assessing the patient ordered to transfer (Pt. #1) for medical evaluation. MD #1 stated that Pt. #1 was complaining of throat pain, and hoarseness of voice was noted. 5. On 06/26/2024 at approximately 9:00 AM, the Registered Nurse (E #1) that took care of the patient (Pt. #1) on 06/21/2024 during the incident was interviewed. E #1 stated that (E #1) called the on-call physician (MD #2) and explained about the incident. E #1 stated that MD #2 advised to place (Pt. #1) on one-to-one monitoring with a sitter at the bedside. E #1 stated the physician (MD #2) did not order to transfer (Pt #1) to the emergency room for medical evaluation. 6. On 06/26/2024 at approximately 2:00 PM, the Chief Medical Officer/On-Call Physician (MD #2) was interviewed. MD #2 stated that the staff did not tell (MD #2) that chest compressions were started on Pt. #1. MD #2 stated that the nurse (E #1) had reported that Pt. #1 was doing fine and did not have any difficulty breathing or swallowing. F. Based on document review and interview it was determined that for 1 of 3 Patient Care Units (3 East: Adult Female Unit) reviewed for Environmental and Contraband rounding, the hospital failed to ensure that routine room and unit checks were completed as required. This has the potential to affect all patients on census on this unit. Findings include: 1. On 06/26/2024 at approximately 2:45 PM, the hospital’s policy titled, “Contraband” dated 06/2022 was reviewed and included, “ ...Upon admission a thorough search will be made ...2. Staff will consider the following to be contraband: ... ii. Any item with strings ...” 2. On 06/26/2024 the hospital’s 3 East - All Female Unit - BHA Environmental Rounds for Contraband Checks Log dated 06/18/2024 through 06/24/2024 was reviewed. The log lacked the environmental rounds documentation checks for the following dates and shifts: - 06/18/2024 - AM (day- shift) - no environmental rounds -06/19/2024 - AM shift - no environmental rounds -06/21/2024 - PM (evening shift) - no environmental rounds -06/22/2024 - PM shift - no environmental rounds -06/24/2024 - PM shift - no environmental rounds 3. On 06/26/2024 at approximately 12:30 PM, the Nurse Manager (E #4) was interviewed. E #4 stated that the contraband checks along with the environmental rounds should have done daily one per shift, during the beginning of each shift. E #4 stated that (E #4) was not sure why contraband checks were missing for certain days as the milieu manager handles the contraband checks on all patient rooms. E #4 stated if contraband checks are not done, it could affect patient safety.”