Reid Health

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48704 Based on document review, interview, and observation, the facility failed to provide care in a safe setting for 2 of 10 patients (Patients 1 and 4) medical records reviewed and the facility failed to verbally report an inpatient suicide within 24 hours of occurrence in 1 of 1 (Patient 1) medical records reviewed. Findings include: 1. Facility policy titled, Patient Bill of Rights, Policy #149, approval date 04/18/2025, under V. Procedure, 6. Provision of care in a safe setting. 2. Facility policy titled Contraband Search, Policy #: PM2-177, approved 08/03/2016, under II. Definitions, 4. Contraband search must be completed by ED staff prior to bringing the patient into any inpatient unit. Under III. Procedure Contraband Search - Body and Personal Adult Psychiatric Unit, under 4. Ask or assist patient to remove all clothing., under 9. Search personal items: A. Clothing examples: shoes, socks, belts, hems, waistbands, pockets, soles, heels, and lining. 3. Facility policy titled Patient Observation Levels, Policy #: PM2-522, approved 04/09/2025, under IV. Procedure, 7. The patient’s room door must remain open at all times unless safety concerns or isolation precautions require otherwise. 4. Review of Patient 1’s medical record indicated the following: a. The patient presented to the Emergency Room (ER) on 04/19/2025 for possible suicide attempt and the patient was placed on suicide precautions in the ER; medical record lacked documentation of a contraband search. b. On 04/19/2025, the patient was admitted to the psychiatric unit at 4:40 p.m. and at 6:59 p.m., the patient was found in the patient’s bathroom with a self-inflicted injury by hanging. 5. Review of Patient 4’s medical record indicated the following: a. The patient presented to the ER on 04/14/2025 for suicidal ideations and the patient was placed on suicide precautions. b. Medical record lacked documentation of a contraband search in the ER. 6. Review of Incident Report of event dated 04/19/2025 for patient 1 indicated the charge nurse entered the patient bathroom, found patient hanging by string and patient was unresponsive. The incident report indicated the patient suffered from an anoxic brain injury, terminally weaned, and passed on April 24, 2025. 7. Video observation on 05/08/2025 at approximately 11:20 a.m of 04/19/2025 indicated patient 1’s window blind remained closed from approximately 4:36 p.m. to approximately 6:57 p.m. and the room door did not remain open at all times during the same time period. 8. Interview with N1 (Registered Nurse) on 05/07/2025 at approximately 12:38 p.m. confirmed they were assigned patient 1 on 04/19/2025 in the ER. N1 confirmed patient 1 was not asked to remove their gym shorts under the paper scrubs and the gym shorts remained on the patient when they were transferred to the psychiatric unit. 9. Interview with A2 (Risk Management Director) on 05/07/2025 at approximately 1:02 p.m. confirmed the facility did not verbally report the patient’s death to the state department of health. 10. Interview with N2 (Registerd Nurse) on 05/07/2025 at approximately 4:00 p.m. confirmed patient 1 had black underwear/shorts on under their paper scrubs and indicated the shorts were not removed and remained on the patient. 11. Interview with A3 (Senior Director of Nursing) on 05/08/2025 at approximately 10:40 a.m. confirmed patients 1 and 4’s MR lacked documentation of the contraband search.”

“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: 48704 Based on document review and interview, nursing services failed to obtain provider orders for 1:1 observation for 5 of 10 (Patients 1, 6, 7, 8, and 10) medical records reviewed. Findings include: 1. Facility policy titled Patient Observations Levels, Policy #: PM2-522, approved 04/09/2025, under IV. Procedure, 2. Provider order is required for initiation of observation. 2. Review of Patient 1’s medical record indicated the following: a. The patient presented to the Emergency Room (ER) on 04/19/2025 and the patient was placed on 1:1 observation by nursing at 1:45 p.m. b. Medical record lacked documentation of a provider order for 1:1 observation. 3. Review of Patient 6’s medical record indicated the following: a. The patient presented to the ER on 04/14/2025 and the patient was placed on 1:1 observation by nursing at 5:00 p.m. b. Medical record lacked documentation of a provider order for 1:1 observation. 4. Review of Patient 7’s medical record indicated the following: a. The patient presented to the ER on 04/12/025 and the patient was placed on 1:1 observation by nursing at 12:07 a.m. b. Medical record lacked documentation of a provider order for 1:1 observation. 5. Review of Patient 8’s medical record indicated the following: a. The patient presented to the ER on 04/30/25 and the patient was placed on 1:1 observation by nursing at 2:30 p.m. b. Medical record lacked documentation of provider order for 1:1 observation. 6. Review of Patient 10’s medical record indicated the following: a. The patient presented to the ER on 04/25/25 for suicidal ideations and the patient was placed on 1:1 observation by nursing at 10:45 p.m. b. Medical record lacked documentation of provider order for 1:1 observation. 7. Interview with A3 (Senior Director of Nursing) on 05/08/2025 at approximately 10:40 a.m. confirmed that patients 1, 6, 7, 8, and 10’s MR lacked documentation of the provider order for 1:1 observation.”

“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: 48704 Based on document review and interview, the facility failed to provide care in a safe setting for 1 of 10 patient (Patient 2) medical records reviewed. Findings include: 1. Facility Policy titled, Patient Bill of Rights, Policy #149, last approved 10/01/2024, indicated under V. Procedure, Patient Bill of Rights address the following: 6. The patient has the right to receive care in a safe setting. 2. Review of Patient 2’s medical record on 11/22/2024 at 11:48 a.m. in the provider note, patient 2 reported wakening to find another patient in their room naked from the waist down and a possible assault. 3. Review of Patient 3’s medical record on 11/22/2024 at 5:40 a.m. indicated patient was found in another patient’s room naked from the waist down attempting to sexually assault patient. 4. Review of Incident Report dated 11/22/2024 indicated the following: a. S2 (Security Associate) falsified charting in 15-minute observation checks in patient 2’s medical record. The 15-minute observation checks were not completed as documented during the time of the incident. b. Video surveillance indicated patient 3 went into patient 2’s room and was in patient 2’s room for approximately 20 minutes before staff found patient 3 assaulting patient 2. 5. Interview with A2 (Director of Nursing Inpatient, Emergency Department, and Urgent Care) and A6 (Clinical Manager of Adult Psychiatric Unit) on 01/02/2025 at approximately 4:00 p.m. confirmed the above information related to the assault on patient 2 on 11/22/2024.”

“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: 48704 Based on document review and interview, nursing services failed to monitor patient resulting in an assault for 1 of 10 patient (Patient 2) medical records reviewed; and failed to obtain and/or document 1:1 observation orders for 1 of 10 patient (Patient 3) medical records reviewed. Findings include: 1. Facility Policy titled, Patient Observation Levels, Policy #: PM2 - 522, last approved 06/30/2022, indicated under III. Procedure, 1. Physician order may be placed for 1:1, eye sight, or Q15 observation level for patients that present with but not limited to: Suicidal Ideation with or without a plan (*NOTE: please refer to policies Suicide identification and management and Psychiatric services policy Suicide Risk assessment reassessment observation and interventions for psychiatric patients and Assault Precautions Policy), Exit seeking behaviors, Aggressive behaviors, Acute confusion, High fall risk. NOTE: An RN can initiate an observation level order but only a physician can discontinue or decrease an order. 2. Review of Patient 2’s medical record on 11/22/2024 at 11:48 a.m. in the provider note, patient 2 reported wakening to find another patient in their room naked from the waist down and a possible assault. 3. Review of Patient 3’s medical record indicated the following: a. On 11/22/2024 at 5:40 a.m. indicated patient was found in another patient’s room naked from the waist down attempting to sexually assault patient. b. Medical record lacked order for 1:1 observation. c. Nursing note on 11/22/2024 at 7:19 a.m. indicated patient was on 1:1 observation. d. Provider note on 11/23/2024 indicated to continue 1:1 supervision with sitter for patient’s safety. 4. Review of Incident Report dated 11/22/2024 indicated the following: a. S2 (Security Associate) falsified charting in 15-minute observation checks in patient 2’s medical record. The 15-minute observation checks were not completed as documented during the time of the incident. b. Video surveillance indicated patient 3 went into patient 2’s room and was in patient 2’s room for approximately 20 minutes before staff found patient 3 assaulting patient 2. 5. Interview with A2 (Director of Nursing Inpatient, Emergency Department, and Urgent Care) on 01/02/2025 at approximately 11:35 a.m. confirmed in interview with S2, S2 confirmed they falsified the documenation regarding the 15-minute observation checks for patient 2 during the time of the incident, the 15-minute checks were not completed, and patient 2 was assaulted during this time. 6. A6 (Clinical Manager of Adult Psychiatric Unit) on 01/02/2025 at approximately 2:30 p.m. indicated nursing can initiate an order for observation levels and communicate with the provider. The medical record orders should reflect the 1:1 order and patient 3’s medical record did not have an order for 1:1 observation.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 48704 Based on document review and interview, facility failed to ensure accurate documentation in 1 of 10 patient (Patient 2) medical records reviewed. Findings include: 1. Review of Patient 2’s medical record indicated on 11/22/2024 15-minute observation checks were completed as ordered between 5:00 a.m. and 6:00 a.m. 2. Review of Incident Report dated 11/22/2024 indicated S2 (Security Associate) indicated staff falsified 15-minute observation check documentation in patient 2’s medical record and the 15-minute checks were not completed as documented during the time of the incident. Video surveillance indicated patient 3 was in patient 2’s room for approximately 20 minutes before staff entered patient 2’s room. 3. Interview with A2 (Director of Nursing Inpatient, Emergency Department, and Urgent Care) and on 01/02/2025 at approximately 11:35 a.m. confirmed S2 during the investigation indicated they did not complete the 15-minute checks as ordered and documented that they were completed.”