Metropolitan Behavioral Health

“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: 50585 Based on interview and record review, the facility failed to assign monitoring precautions in a timely manner to 1 (P-4) of 4 patients reviewed, resulting in the increased potential for harm for all patients on P-4’s unit prior to P-4 being assigned precautions. Findings include: On 11/4/2025 at 1510, a review of video footage with Director of Risk Management Staff N revealed that P-4 was sitting in a chair in the dining room on 10/21/2025 at 1129. P-4 calmly stood up and walked over to P-1 who was sitting in a chair at a table and tapped P-1 on the shoulder, then punched P-1 in the mouth. P-4 calmly walked back to their chair and sat down, while staff attended to P-1. On 11/4/2025 at 1315, COO Staff B and CNO Staff C were queried if assault precautions should be added immediately after P-4 hit P-1 and they both said “yes.” When queried why assault “precautions were added nearly 48 hours after incident, Staff B revealed it may have been caught on “chart review.” On 11/5/2025 at 0930, Nurse Practitioner Staff M was queried about the incident. Staff M revealed they left the building before the incident and received a text message that P-1 was being sent out (to an acute care hospital). When asked what you would do if your patient hit another patient, Staff M revealed request one patient be “removed from unit,” “place on 1:1” or if needed, “properly medicated.” On 10/21/2025 at 1153, P-1’s nursing note by Nurse Staff F revealed “Patient while sitting in dinning (sic), peer walk over and hit her in the face, patient sustained a right upper lip laceration with bleeding approx. ¾ length and 0.5 cm depth.” On 10/21/2025 at 1206, P-4’s nursing note by Nurse Staff F revealed “Patient hit peer while sitting in dinning (sic) room, patient sustained a small laceration of upper right lip with small bleeding. Approx ¾ length and 0.5 cm depth” an “unsafe to self and others,” Providers notified and “new orders given for anxiety/agitation. Ativan PRN IM given as directed.” On 10/21/2025 at 2035, P-4’s nursing note by Nurse Staff L revealed “Many patients are afraid of (P-4) from the incident that happened today. When (P-4) comes down the hall or into the day room, patients scatter to get away from (P-4). Keep an eye on (P-4) for agitation. (P-4) also continuously tried to get out of (their) wheelchair. Needs to be redirected often.” Staff L worked night shift and was unavailable to be interviewed. On 10/22/2025, P-4’s patient observation sheets did not have “aggressive/homicide” precautions checked. On 10/23/2025 at 1002 (more than 46 hours after P-1 was hit by P-4) P-4 had an order by CNO Staff C to initiate assault/homicide precautions. On 10/23/2025, P-4’s patient observation sheets did not have “aggressive/homicide” precautions checked nor were there any updates that Assault/Homicide” precautions were ordered on 10/23/2025 at 1002. According to the facility’s policy “Assault/Homicide Prevention and Precautions,” dated 6/2024, “It is the policy of the (Facility) to provide a safe, therapeutic environment of care which includes the prevention of Assault,/Homicide incidents, as well as any threat of assault or homicide.” The policy also revealed “Risk for assault is assessed for all individuals upon intake and via the Intake Assessment and throughout hospitalization” and the “Nursing/Unit Staff: Assesses risk factors for assaultive behavior and places patient on Assault precautions/Homicide Precautions. -Contacts the attending physician to communicate assault/homicide risk and obtain orders for: Assault Precautions and/or Homicide Precautions, Level of monitoring : 1:1 or 15 minute checks. -Communicates the precaution and level of monitoring to the unit staff and ensures the Observation Rounds Sheet accurately reflect the precaution type of and level of monitoring.” According to the facility’s policy “Patient Observation Rounds/Level of Observation,” dated 9/2025, “Staff assigned to complete patient observation rounds will: Review and update patient observation forms. Reflect changes in individual patient precaution levels, room changes, new admissions and/or discharges as they occur.””

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 45246 Based on observation, interview and record review facility failed to inform 3 patients (P-7, 9 and 10) of 3 patients interviewed, about internal grievance process, including whom and how to contact to file a grievance, resulting in lack of patients’ understanding of facility’s grievance process and potential for negative outcomes. Findings include: Upon entrance to facility on 03/19/24 at 0940 lobby was observed for patient rights and grievances/complaints signage. Posted information was observed to have incorrect name of the patient rights advocate. On 3/19/24 at 1000 during initial tour of the facility patient rights postings were observed to have incorrect name of the patient rights advocate on unit 1C and 2D. Complaint/grievance forms were available. Interviews were conducted with staff and patients during tour of the facility on 03/19/24 at 1000. P-7 was questioned if she had witnessed verbal or physical abuse on the unit. P-7 stated that she had not and that she felt safe. P-7 was next asked how she would report it if she had seen abuse. P-7 replied that she did not know how to report abuse. P-7 was standing approximately 10 feet away from the ‘recipient rights forms’ box, which was mounted on the wall behind her. Another patient standing nearby overheard the conversation and quickly retrieved a form and handed it to the patient. P-7 stated, “I didn’t know those were there or that how we could make reports.” On 3/19/24 at 1300 interview was conducted with P-10. Patient stated that he was in a facility for a week and was anticipating a discharge in a day or two. P-10 was asked if he knew how to file/submit a grievance or complaint with a facility in case he had any issues or concerns to address. Patient stated ‘no’. When asked if he saw a silver-like metal box with the complaint forms across from the unit entrance, he said “oh, nice to know, now I know how”. On 3/19/24 at 1315 P-9 was interviewed. Patient said that he was admitted to facility over the weekend, and this is his 3rd day here. Patient was asked about grievance submission/filing process and if he is familiar with it. P-9 said he did not know how to file a grievance with the facility. When asked about the metal box with grievance forms available across the unit’s entrance, P-9 said that he did not know that it was there. He said that now he knows that he can file a grievance and leave it in a box. On 3/19/24 at 1317 Staff C who was present during patients’ interviews was asked if she, as patient rights advocate representative, was aware of some patients not being informed about how they can file a grievance. Staff C stated that it was new to her to hear that from the patients. She also shared that she rounds all the units daily and refills grievance forms personally. Facility’s Patient and Family Grievances/Complaints and Role of the Patient Advocate Policy was requested and reviewed. Policy dated 12/2023 indicated: Grievance Process 2. Patient and their family members shall be informed of the patient’s rights and responsibilities upon admission, and the process by which they can voice any concerns related to their rights and/or treatment. This information includes the procedure by which a patient can submit a grievance, (including the name of the patient advocate and the method of access to this individual), the time frame for review of the grievance, and the provision of a written response to the patient within that time frame.”