Newark Beth Israel Medical Center

“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: 50613 Based on medical record review, staff interviews, review of video surveillance, and review of facility documents, it was determined that the facility failed to ensure that 1) elopement precautions are ordered for at-risk patients, in accordance with facility policy; and 2) procedures are in place concerning security staff’s responsibility to prevent the elopement of patients identified as a risk for harm to self or others. Findings include: 1. Facility policy titled, “Elopement Policy Behavioral Health Crisis/PESS units (effective date 6/20/2025)” stated, “ ... Policy Statement ... Elopement Precautions: deterrents against an unauthorized departure from the unit by a patient ... Required Action Steps ... Patient at risk for elopement of has attempted to elope ... Obtain order for elopement precautions ...” A review of Patient (P)1’s medical record revealed the following: P1 eloped from facility on 5/14/2026 at 9:45 PM, and 5/15/2026 at 10:25 PM. P1 returned to the facility on 5/18/2026 at 8:53 PM, with an arrival complaint of “Psych eval.” Patient was transferred to PESS (Psychiatric Emergency Screening Services) unit upon arrival, accompanied by security officers. At 9:04 PM, patient monitoring safety checks were ordered and initiated. On 5/19/2026 at 1:56 PM, the ED notes stated, “Patient admitted to F5. [He/she] was transferred via wheelchair at 1:54 PM with [name of nurse] and a few security officer ...” On 5/19/2026 at 2:08 PM, the Behavioral Health Inpatient Nursing Admission Note stated, “ ... Patient with elopement risk. NP will be notified ...” On 5/21/2026, at 12:36 PM, an interview was conducted with Staff (S)15, who stated that during report, it’s communicated whether the patient was suicidal, homicidal or an elopement risk. S15 explained if a patient has elopement precautions, he/she knows to watch the patient near exit doors, and to verbally redirect them away from the doors. S15 indicated, elopement precautions were also noted in the Rover device (a handheld mobile device used for chart review and clinical data entry) via a patient flag. S15 was asked if there were presently any patients that were on any additional precautions and stated that P1 had elopement precautions in place. When requested to demonstrate the flag in the Rover device, there was no flag observed. S15 then accessed P1’s electronic medical record and was unable to locate an order for elopement precautions. This finding was confirmed with S14 on 5/21/2026 at 1:52 PM. 2. A review of P2’s Medical record revealed the following: P2 presented to the ED on 5/8/26 at 10:06 AM. At 10:06 AM, the ED Provider Note, stated, “ ... History of Present Illness ... hx [history] of depression, HTN [hypertension], alcohol use, cannabis use, nicotine dependence who presents with PD [police department] for SI [suicidal ideation]. Pt [patient] is unwilling to provide the details of what has been happening over the past few days however [he/she] notes increased stress in [his/her] life. Pt denies any physical complaints, recent EtOH [alcohol] or illicit drug use. ... ED course ... 1031 [10:31 AM] Patient was seen on arrival to ED with PD escort. PESS was called however, a PESS room was unavailable. After verbal de-escalation patient was escorted to EHVBX1 [East Hall View Box 1-ED hallway bed] with 1:1, who remained with patient. Pt walked out of ED despite attempts by staff and security to stop patient. [Name of City] PD was called. ...” At 10:26 AM, the Nurse’s Note stated, “ ... Pt eloped from ER [Emergency Room]. Pt on 1:1 got up and started walking towards exit of ER. Dr [doctor] and Security alerted to pt attempting to leave. Pt passed security. [Name of city] PD called for assistance as well as Crisis Mobile Unit. Matter escalated to ED management and crisis management as well as security leadership. ...” On 5/22/26 at 11:05 AM, during an interview, S13 stated security personnel receive de-escalation training through the Iron Temple program. When asked if security staff were expected to use physical interventions to prevent a patient from eloping, S13 stated that physical measures were only expected if the patient poses an immediate threat to themselves or others. In those instances, security personnel are authorized to use physical measures to stop the patient. S13 stated, security officers should have physically intervened in attempt to prevent P2 from eloping. At 11:29 AM, an interview was conducted with S25, who was present in the ED when P2 eloped. S25 explained that P2 arrived at the ED via EMS (emergency medical services) with suicidal ideation (SI). S25 stated, when P2 eloped, the ED physician instructed security officers “[He/She] cannot leave,” and the security officers responded, “we can’t touch [him/her].” S25 stated, the doctor kept telling the security officers that P2 cannot leave and he/she was here for SI. At 12:38 PM, a telephone interview was conducted with S21, who was present when P2 eloped on 5/8/26. S21 explained P2 was already “worked up” when he/she arrived to assist. S21 stated, “I think a nurse let me know the patient was suicidal and couldn’t leave.” I stepped behind the patient to attempt to block the ambulance entrance doors. P2 was irate and wouldn’t listen to the security officers. S21 indicated S25, said we can’t let [P2] leave we need to get him/her to PESS or medicated. S21 indicated he/she was an extra staff, and he/she does have training in how to physically restrain a patient but, they did not restrain P2. S21 explained P2 stated, “if anyone puts hand on me there is going to be problems.” S21 stated that once P2 ran out of the ambulance entrance doors, the security officers were told to chase him/her, and P2 eventually got away. S21 stated, “I’m not sure if we are supposed to chase a patient, what if [he/she] gets hit by a car?” On 5/22/2026 at 10:47 AM a review of the ED video surveillance video was conducted in the presence of S2, S3, S5, S13 and S14. The video surveillance reviewed had no audio. Video surveillance titled, “ED2-Emergency Department C1” dated 5/8/26 revealed: At 10:20 AM: S8 and S27 appeared to be having a conversation in the ambulance entrance vestibule. P2 entered the vestibule, and S19 and S20 appeared to talk to the patient. Multiple staff entered the vestibule and attempted to talk to P2. 10:22 AM: S29 was speaking with P2. Multiple staff remained in the vestibule speaking with P2. 10:23 AM: P2 walked back into the ED. 10:26 AM: S19, S20, and S21 standing in ED vestibule near door. P2 entered the vestibule from the main ED and exited the ambulance bay doors. Staff did not prevent P2 from exiting the facility. S19, S20, and S21 followed P2 until they were out of view of video surveillance. 10:27 AM: Multiple staff members appeared and exited through the ambulance bay doors. Upon review, the facility’s elopement policy and procedures did not specify procedures and security staff’s responsibility when a suicidal patient attempts to elope. These findings were confirmed with S11 and S13 on 5/22/2026 at 1:01 PM.”

“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: 47131 Based on staff interview, document review, and review of one of ten medical records (Patient (P)1), it was determined that the facility failed to ensure oral care is provided in accordance with the hospital’s procedures for oral care. Findings include: Facility document titled, “Lippincott Procedures-Oral Care” stated, “ ... Introduction: ...Without effective oral care, a patient can develop hospital-acquired pneumonia or another infection and decreased nutritional intake, which can increase mortality and length of stay at a health care facility. ...Implementation: ...For a patient who can’t expectorate or is dependent for oral care: ...Alternatively, moisten a suction toothbrush in oral rinse and then brush the patient’s teeth, gums, and tongue with the toothbrush attached to continuous suction to prevent aspiration. ...using a moistened swab, apply oral rinse to reduce microbial colonization. Using a swab, apply moisturizer to the oral mucosa and lips every 2 to 4 [two to four] hours to reduce oral inflammation and improve oral health. ... Documentation: Documentation associated with oral care includes: date and time of oral care; ...type of oral care administered; ...” Upon review of the “Daily Cares/Safety” flowsheets from 08/15/25 through 11/14/25, located in the medical record for Patient (P)1, the following was discovered: In the Activity and Hygiene Care section, the medical record lacked documentation that oral care was provided on the following dates: 08/28/25, 8/29/25, 8/30/25, 8/31/25, 09/06/25, 09/12/25, 09/13/25, 09/14/25, 09/22/25, 09/25/25, 09/20/25, 10/01/15, 10/02/25, 10/03/25, 10/09/25, 10/10/25, 10/12/25, 10/17/25, 10/20/25, 10/21/25, 10/22/25, 10/24/25, 10/25/25, 10/30/25, 11/08/25, 11/09/25, 11/10/25, 11/11/25, 11/12/25, 11/13/25, 11/14/25. On 01/22/26 at 1:30 PM, Staff (S)4 confirmed that there was no documented evidence that P1 received oral care on the above mentioned dates.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 50602 Based on a review of two of ten medical records for Patients(P)2 and P9, staff interview, and review of facility documents, it was determined the facility failed to ensure that complete assessments of pressure injuries are documented in accordance with facility policy. Findings include: Facility Procedure titled, “Pressure Injury and Skin Tear Management and Treatment Procedure” effective date 02/25/25, stated, “ ... DOCUMENTATION: Pressure Injury 1. Assessment of pressure injury; includes initial assessment and every shift ...6. Pressure injuries are assessed with each ordered dressing change and documentation should be as follows ... Exudate ... Location ... Outcome-done every seven (7) days ... Percentage of Necrotic Tissue ... Pressure injury description and stage-initially and then every seven (7) days ... Size-initially and then every seven (7) days, measured in centimeters L x W x D. Undermining and tunneling can occur with Stage 3 or Stage 4 injuries ... Surrounding tissue- color and condition ...” During an interview on 01/21/26 at 11:03 AM, S10 stated that when they admit a new patient to the unit, they assess the skin with another nurse and always take pictures of the skin as part of their skin assessment, even if the skin is intact. They also do a daily assessment of skin with the Braden score. During shift changes, the day shift and night shift nurse will both lay eyes on the patient and complete a skin assessment together and document in the medical record. Skin assessments are documented every shift. On 01/21/26 at 12:46 PM, S2 stated that the facility uses a combination of pictures and documentation to track pressure injuries, and that wound assessment documentation should be completed for the relevant areas in the flowsheets. On 01/22/26, medical records were reviewed in the presence of S4 and S5 with assistance from S6. In P2’s medical record, the following wounds were documented upon admission on 10/22/25 at 06:50 PM in the ‘Wound Assessment/Care’ flowsheet: “ ...Wound 10/22/25 Heel Left ...Wound 10/22/25 Heel Right ...Wound 10/22/25 Coccyx ...Wound 10/22/25 Thigh Right; Posterior; Medial ...” For all wounds listed above, the flowsheet lacked documentation of, but not limited to the following: “Non-staged wound description ...Pressure Injury Stage ...Pressure Injury Stage Verified by: (Full Name of Second Observer) ...PeriWound Assessment ...Wound Length (cm) ...Wound Width (cm) ...Wound Depth (cm) ...” A wound consult note for P2 with a “Date of Service: 10/20/25 6:20 AM” stated, “ ...Reason For Consult- stage IV sacral decubitus ulcer [pressure injury on the bony prominence at the base off the spine] presents with history of sacral decubitus ulcers ...Physical Exam ...Wound across sacrum and buttocks with nearly all of wound being epithelialized ...Posterior[backside] to the right sacroiliac joint [joint between lower base of spine and hip bone] there is osseous [bone tissue] erosion concerning for osteomyelitis [bone infection] based on the MRI [Magnetic Resonance Imaging- diagnostic imaging using a strong magnetic field to create detailed images of the internal structures of the body] that was read on 1027 ...Zinc oxide [topical medication used to promote wound healing] to the wound every 8 hours in the sacral and buttock areas ...” In P9’s medical record, the following wound was documented on 01/14/26 at 06:22 PM in the ‘Wound Assessment /Care’ flowsheet, “ ...Wound 01/14/26 Pressure Injury Heel Right ...” For the pressure injury listed above, the flowsheet lacked documentation of, but not limited to the following: “Non-staged wound description ... Pressure Injury Stage Verified by: (Full Name of Second Observer) ...PeriWound Assessment ...Wound Length (cm) ...Wound Width (cm) ...Wound Depth (cm) ...” On 01/22/26, S4 confirmed the above findings at the time of the discovery.”

“DELIVERY OF SERVICES CFR(s): 482.56(b)(2) The provision of care and the personnel qualifications must be in accordance with national acceptable standards of practice and must also meet the requirements of §409.17 of this chapter. This Standard is not met as evidenced by: 47131 Based on a review of one of ten medical records (Patient (P)1), staff interview, and review of facility documents, it was determined that the facility failed to ensure physical therapy and occupational therapy sessions are implemented in accordance with the patient’s plan of care. Findings include: On 01/21/26 at 12:24 PM, Patient (P)1’s medical record was reviewed with S2, S3, S5, and S6 and the following was revealed: P1 is a 39-year-old who arrived at the hospital’s Emergency Department (ED) on 08/13/25 via transfer from another facility for coffee ground emesis (vomit) (medical symptom indicating bleeding in the upper gastrointestinal (GI) tract.) P1 was diagnosed with an Upper GI (gastrointestinal) bleed and admitted to the ICU (Intensive Care Unit.) The patient’s medical history included: “ ...left intracranial hemorrhage SP [status/post] craniectomy, ... ESRD [End Stage Renal Disease] on dialysis, ...PE [Pulmonary Embolism], ...CVA [Cerebrovascular accident], ...PEG [percutaneous endoscopic gastrostomy] [feeding tube inserted directly into the stomach through the abdominal wall.] P1 was transferred from the ICU to a medical/surgical floor on 08/27/25, and discharged to a long term care facility on 11/14/25. The Physical Therapy consultation note written on 09/25/25 indicated P1 was to receive physical therapy two to three times per week. Review of physical therapy (PT) notes indicated that the patient did not receive physical therapy for five weeks. The medical record lacked documented evidence that physical therapy saw the patient as ordered, on the following weeks: 09/28/25-10/04/25; 10/05/25-10/11/25 (one note written 10/10/25); 10/12/25-10/18/25; 10/26/25-11/01/25; 11/02/25-11/08/25; 11/09/25-11/14/25 (patient discharged). The Occupational Therapy consultation note written on 10/10/25 indicated P1 was ordered to receive OT one to three times per week. On 11/05/25, the OT note stated, “ ... Pt (patient) OTF (off the floor) at HD (hemodialysis) at the time of attempt. ...” During an interview on 01/21/26 at 2:09 PM, S16 stated, “I remember this patient. [He/she] did not receive PT as frequently due to [his/her] physical condition. The therapist should have entered a note to indicate he/she attempted to meet with the patient and was unable to complete the session for each attempt.” On 01/21/25 at 2:15 PM, S16 confirmed P1 did not receive physical therapy two to three times per week for five weeks during the admission as indicated in the patient’s Plan of Care. At that time, S16 confirmed the medical record lacked any Physical Therapy notes for the weeks indicated above. On 01/21/26 at 11:26 AM, surveyors requested the facility’s policies for Physical Therapy and Occupational Therapy. On 01/21/26 at 1:56 PM, Staff (S)4 confirmed the facility does not have a policy for Physical Therapy or Occupational Therapy concerning the standards for PT/OT and the expectations of the facility regarding consultations.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 50613 Based on observation, staff interviews, review of facility documents, and a review of nationally recognized guidelines, it was determined the facility failed to ensure that hand hygiene practices are adhered to by all staff members. Findings include: Facility policy titled, “Hand Hygiene Step by Step Procedure & Indications When to Perform (Effective Date 09/16/2025)” stated, “ ...If hands are not visibly soiled, use an alcohol-based hand rub (preferentially) or use antimicrobial soap or non-antimicrobial soap and water (alternatively) for routinely decontaminating hands for the following clinical situations ... Before and after handling an invasive device ... regardless of whether or not gloves are worn ...” On 01/13/2026 at 10:10 AM, while in the Clean Work Room, accompanied by Staff (S)7 and S9. During an observation, S11, with gloved hands, removed an endoscope that was manually cleaned from a basin and placed it into the OER-Elite Reprocessor. S11 then entered information into the touchpad on the OER-Elite Reprocessor. S11 then proceeded to a second basin, removed a second endoscope, and place it into the second reprocessor. S11 did not remove and change gloves between touching the surface of the OER-Reprocessor and handling the second endoscope. At 10:11 AM, during an interview, S11 confirmed that his/her gloves had not been changed between handling each endoscope.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 50613 Based on observation, staff interviews, and review of manufacturer’s instructions for use (IFU), it was determined that the facility failed to ensure that endoscopes are properly cleaned and disinfected prior to patient use, in accordance with facility policy and manufacturer’s instructions for use. Findings include: Facility policy titled, “The Care and Use of Non-Sterile Flexible Endoscopes Policy (Effective Date 10/05/2023)” stated, “ ... K. Storage ... [name of facility] maximum storage time is 7 days ...Any flexible endoscope not used within facility-specific maximum storage time must undergo full reprocessing before next patient use ...” On 01/13/2025 at 10:14 AM, while in the Clean Work Room, accompanied by Staff (S)7 and S9, S11 was observed removing an endoscope from the Olympus OER-Elite Endoscope Reprocessor. Documentation related to the reprocessing cycle was requested. S11 provided the OER printout strip and a reprocessing record that included the scope type, serial number, and cycle number. Other reviewed records included patient identifiers, however this record was labeled “rewashed.” When asked to explain the notation, S11 stated the endoscope had been hanging for more than 7 days and therefore required reprocessing. When asked if manual cleaning was completed prior to high level disinfection, S11 stated that because the endoscope had not been used on a patient and was being reprocessed due to exceeding the facility’s seven day storage policy, manual cleaning was not performed; only leak testing was completed prior to high-level disinfection. An interview was conducted with S7 and S9 at 1:24 PM. S7 confirmed that when endoscopes are reprocessed due to exceeding the 7 day storage policy, the endoscopes are not manually cleaned prior to high level disinfection. A review of the Olympus OER-Elite Operation Manual stated, “ ...Intended use. ... Endoscopes must be cleaned by the user prior to reprocessing; however, use of the OER-Elite enables the user to perform modified manual cleaning of some endoscopes prior to automated cleaning and high-level disinfection in the OER-Elite ... 6.2 Precleaning, leak testing, and manual cleaning ... Modified manual cleaning process for preparing endoscopes for processing in the OER-Elite. Endoscopes must be subject to cleaning by the user prior to reprocessing in the OER-Elite. However, when using the OER-Elite, the endoscope can be reprocessed according to the modified procedure described below. Warning. The cleaning steps for external surfaces and reusable parts must be performed according to the reprocessing instructions provided in the endoscope manual. ... Otherwise, effectiveness of the reprocessing may be compromised ... Follow the modified manual cleaning procedure exactly as describe in the “Manual cleaning (procedure performed in reprocessing area)” ... Omitting any steps according to the “Manual cleaning (procedure performed in reprocessing area)” may lead to insufficient reprocessing ... Manual cleaning (procedure performed in reprocessing area). After completing the leakage test, perform manual cleaning according to the procedures described below ... Manual cleaning of the external surfaces. Perform manual cleaning of the external surfaces in accordance with the reprocessing instructions provided in the endoscope manual. ...” The facility policy titled, “The Care and Use of Non-Sterile Flexible Endoscopes Policy (Effective Date 10/05/2023)” was reviewed with S7 and S9. Upon interview, S7 and S9 confirmed that facility policy stated all scopes should undergo full reprocessing if they are stored for more than seven days.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 41646 Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to ensure the provision of a sanitary environment to avoid sources and transmission of infections and communicable diseases as evidenced by: failure to identify the extent of water infiltration following a leak in the sterile storage room, in order to determine possible water contamination of sterile instrument trays and provide appropriate environmental cleaning and decontamination (A0750). Cross Reference: 482.42(a)(3)- Infection Prevention, Control, and Surveillance.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 41646 Based on observation, staff interview, and review of facility documents, it was determined that the facility failed to identify the extent of water infiltration, following a leak in the sterile storage room ceiling, in order to determine possible water contamination of sterile instrument trays and provide appropriate environmental cleaning and decontamination. Findings include: Reference: ANSI/AAMI ST79:2017 & 2020 Amendments A1, A2, A3, A4 (Consolidated Text) Comprehensive guide to steam sterilization and sterility assurance in health care facilities, section 11.1.1, stated, “...Storage facilities...Sterile storage area should be kept clean and dry. ...Shelving, carts, and bins used for sterile storage should be maintained organized, clean, and dry. ...Rationale: ...Sterile items that become wet are considered contaminated because moisture brings with it microorganisms from the air and surfaces. ...” Facility Procedure titled, “Storage of Sterile Supplies,” Effective Date 12/31/24, stated, “...3. Procedure: ...4. Sterile packs shall not be subjected to sharp objects, moisture, ...or any other activity which could affect the sterility of the device. ...” On 2/20/25 at 10:30 AM, a tour was conducted of the sterile processing room with Staff (S)3, S4, and S5. At 10:43 AM, an interview was conducted with S12, who stated that a leak had occurred from the ceiling of the sterile storage room during the early morning hours on Sunday, 2/16/25. An interview with S6, revealed that when he/she arrived to work on Sunday, 2/16/25 at 7:00 AM, the water was leaking “really hard,” a “large bin” had been placed to capture the water, and he/she was told that the leak began around 11:00 PM. S6 stated that the leak occurred over the prepared case carts for Monday’s operating room (OR) cases, and that all the contents and carts had been removed to be decontaminated during the night and resterilized during the day. S6 stated that he/she did not pull any additional trays contaminated by water, because “they were already pulled. Night shift did that part.” S6 stated that when arriving to work, the racks of sterile trays on wheels had been pushed to the back of the room away from the water but were not covered. S6 stated, “I covered all the racks to make sure water didn’t splash on the trays.” S6 confirmed that there was no cover placed over the racks before he/she arrived at 7:00 AM. S6 stated around the leak “there were huge plastic bags coming from the ceiling, coming from high to the bottom” but he/she was not aware of the time the plastic was placed. When asked if there were any other leaks that occurred in the sterile storage room, S6 and S12 both stated, “there was only one leak.” At 10:50 AM, in the sterile storage room, with S3, S4, and S5, S4 stated, “yes, there was a water leak. We placed a protective barrier around to cover it. The dry water spots stopped about here ...” S4 indicated that water stopped prior to reaching a shelf which was bolted to the floor and contained sterile processed instruments, observed with sterilization dates prior to the water leak. “We protected the area and had an infection control person in on the weekend. It began after midnight, and by the morning a protective barrier was placed. All single use items were discarded. Our EVS [environmental services] cleaned up the area. A company is coming this evening to do additional cleaning.” S3 stated “Our EVS already cleaned the area, but the outside company is repeating some processes to ensure we didn’t miss anything.” S8 was identified as the Infection Control person who responded on site Sunday morning, 2/16/25. When asked if any other leaks had occurred in the sterile storage area in the last week, S4 stated “no.” At 11:22 AM, an interview occurred with S8, in the presence of S3, S4, S5, and S7. S8 stated that the water started on the C4 unit above the Sterile Storage room. He/she stated that a toilet had been “tied into stormwater” and that rain had backed the toilet up, causing the leak. S8 stated that where the water came down to the sterile storage area “we built up a containment barrier around the leaking and continued with cleaning.” S8 stated that he/she arrived to the sterile storage room on Sunday morning, 2/16/25, “around 11 AM. [Named S6] was still covering the shelves along with the charge nurse from the OR.” On the stationary rack, observed within proximity of where the leak was noted to have been, five shelves with sterile instrument trays were observed. S3, S4, S5, and S8 confirmed the rack, which did not have wheels, was not moved away from the leak. At 12:07 PM, S3 stated that he/she “would not dispute that 70% [of the trays on the rack] were there that day [while the leak was occurring].” Instrument packs on the shelves were observed with sterilization dates occurring prior to 2/16/25, including but not limited to an “NBI Gyn Clamps Labey” tray with a date of 12/30/24 and an NBI Gyn Biopsy Punch” tray with a date of 10/3/2024. When asked which area was cleaned, S4 indicated the area directly under where the leak had been, where the case carts were presently set up. When asked if anything around that area was cleaned, S4 stated “No.” S4 indicated that a dumpster had been placed to contain the water. At 11:39 AM, down the center of the sterile storage room, discolored stain spots were observed on the lower shelf. A request was made to speak with Environmental Services (EVS) staff. At 11:41 AM, in a supply room next to the sterile storage room, an interview occurred with S9 and S10 in the presence of S3 and S8. S9 stated that as a result of the water leakage that occurred on the morning of 2/16/25, “the area was draped off and remediated. We cleaned from this door all the way down to the barrier using 2 hospital grade germ aids. We pre-cleaned on Sunday at 3:00 PM, then did another cleaning that night.” S9 stated that the 3:00 PM pre-cleaning was done “to the affected area,” which S9 confirmed was the area underneath where the water leaked. On Sunday morning, “the plastic went up down to the floor. Debris and ceiling tiles were on the floor. We picked them up and out of the way. We removed the bulk of the debris. The carts were covered.” S10 stated that he/she “moved the dumpster to clean underneath.” After the 3:00 PM pre-cleaning, S9 and S10 confirmed that other than the normal nightly cleaning, no additional cleaning had been done to the sterile storage area. When asked if the shelves were wiped down within proximity to the water, S9 stated that EVS is not responsible for cleaning the shelves. At 11:56 AM, when asked who cleans the shelves in the sterile storage area, S3 stated, “EVS does” and S9 stated, “I don’t do your shelves, sir.” When asked if the stationary rack of shelves within proximity to the water leakage was cleaned, S3 stated, “We don’t consider that area contaminated.” S4 stated that the depth of the dumpster placed would have prevented splashing onto that rack. When asked when the dumpster was placed, he/she stated, “sometime Sunday.” No one was able to identify the time the dumpster was placed. When asked what was being done to prevent the splashing from the time the water leak began [around midnight] until the time the dumpster was placed, S8 stated, “we used towels, blankets.” Upon interview, at 12:56 PM, S3 and S5 confirmed that they do not have any documentation of who cleans the shelves in the sterile processing area, or of the last time they were cleaned. At 12:19 PM, a second interview was conducted in the sterile storage area with S6. S6 stated that “around 9 AM, I covered the carts with plastic. There were towels and blankets on the floor.” S6 confirmed that plastic barriers were not placed around the racks until he/she was able to do it around 9 AM. A staff member [S13] entered the sterile storage room, and S6 stated that S13 had been working on Sunday, the day of the leak. S13 stated he/she came into work around 7:30 AM and had been told the leak started around 11 PM. S13 stated, “At 7:30 when I came in, the dumpster was here. There were towels, blankets all over. The water was halfway down the room.” At 12:30 PM, an ICRA (Infection Control Risk Assessment) for the Sterile Storage area was requested. S4 indicated that one had been completed for the C4 unit, but not for the Sterile Storage area. At 3:00 PM, review of the invoice for the contracted cleaning company revealed that the area to be cleaned tonight is “Post Flood Clean Up: Technicians to clean all ceilings, walls, floors, and equipment found in the flood area.” The facility failed to provide documentation or evidence that the flood area was restricted to the area underneath the leak only, and that water did not contaminate or splash the surrounding instrument trays or shelving. At 5:27 PM, during exit conference, S5 stated that the cleaning invoice had been adjusted to include the entire sterile storage room. A request was made to provide documentation via email. Documentation was received on 2/20/25 at 5:56 PM, and now stated the following: “Sterile Storage Room Service: Clean all vertical and horizontal surfaces of the racks. Clean insides of all bins on shelf.” On 2/21/25 at 10:22 AM, during a telephone interview, the following was revealed by S19: There were two incidents in the past week where the ceiling had leaked in the sterile storage area. The first occurred on Thursday, 2/13/25 around midnight, with water leaking from the ceiling above where the prepared case carts are placed. S19 stated that water was not pouring directly on the trays, but with the impact of water gushing, there could be splatters of water that dry but still contaminate. S19 stated, “The water smelled. Staff had to put on plastic bags to cover themselves.” S19 stated that “if any kind of water goes in sterile storage, the trays are to be reprocessed,” but that sterile processing staff were instructed to hold off on reprocessing anything that was not wet until the water was evaluated. S19 stated that Plant and Engineering notified sterile processing staff that the water was sewage water, that leadership was notified, and sterile processing staff were instructed only to reprocess the case carts which were directly under the leak. S19 stated the water leak stopped in the early morning. S19 further stated that another leak occurred on the night of Saturday, 2/15/25, in the same area of the sterile storage area. He/she stated that in the morning of 2/16/25, “the flood was still bad. Water was splashing all over the place.” S19 stated he/she was told that the water was “category 3 [contaminated] water, coming from a toilet.” S19 stated that staff were again notified by leadership that until they were able to tell if the water was clean or dirty, they did not need to reprocess the instruments, and that a hygienist was coming to check the water. On Monday, 2/17/25, during a huddle with leadership and infection control, sterile processing staff were notified that the trays within proximity to the leak did not need to be reprocessed. On 2/24/25 at 10:20 AM, an interview occurred with S17. The following was revealed: There were two water leaks in the ceiling of the sterile storage area; one on Thursday night, 2/13/25, and one on Saturday night, 2/15/25. The leak on Thursday also originated from the unit on the 4th floor. S17 stated that on 2/14/25, upon opening the ceiling in the Sterile Storage Room on the 3rd floor, they learned that the plumbing from the 4th floor toilet was incorrectly tied into a 4-inch storm drain. S17 indicated that they were able to unclog the drain, and the water receded, so they believed that the clog was repaired. However, on Saturday into Sunday, water entered through the storm drain and caused another leak, making the facility aware that further repair was needed. When asked if the plumbing had been corrected, S17 stated “yes” however, he/she was unable to provide a work order and indicated that he/she would have to reach out to the vendor. S17 indicated that the facility does not keep internal work orders when leaks are repaired. The vendor work order, indicating the plumbing repair, was not received by survey exit on 2/24/25. When asked if the facility performed any type of water testing, S17, stated “no, the water was cold and visually clear.” At 11:12 AM, a telephone interview occurred with S21 [facility’s contracted construction staff member]. S21 stated that when his/her employee was here on Sunday morning (2/16/25) around 7:30 or 8 AM, “water was overflowing [from the toilet on C4] coming from the toilet seal...wouldn’t stop, we were HEPA vacuuming it until the plumbers got here.” S21 stated that when he/she arrived to the sterile storage area around 10 AM, “I went down and [named employee] already set up containment. Somebody from the hospital already put a garbage disposal [there]. There was some water on the floor. S21 stated, “the water coming from the toilet was pretty clean. But whenever you see a seal broken [from a toilet] or overflow you treat it like a category 3.” When asked if anyone from the facility was notified that the water was category 3, S21 stated, “Everyone saw water coming from the toilet. I didn’t think I had to tell anyone. [Named S8] was there. [Named S8] saw the water overflowing.” At 1:14 PM, during an interview with S4 he/she stated when staff are unsure if water was in contact with an instrument, “when in doubt, we should reprocess.” S4 stated the decision to reprocess instruments is made by “Central Sterile [named S3 and named S5] or Infection Control would make the decision.” S4 confirmed that following the flood beginning on Saturday 2/15/25 around 11 PM, the day and afternoon staff were interviewed regarding the extent of the water infiltration, and the night staff was not interviewed. When asked if there was an ICRA (Infection Control Risk Assessment) for the sterile storage room, S4 stated he/she completed the ICRA for the sterile storage room on Thursday, 2/20/25, after it was requested by the surveyors, and confirmed that “once the repair started, we should have had the ICRA.” The ICRA was provided to the surveyors on 2/24/25. At approximately 4:00 PM, S1 stated that following surveyor tour on 2/20/25, the SPD staff had begun reprocessing the instruments on the stationary rack within proximity to the leak, out of an abundance of caution. On 2/24/25 at 4:26 PM, a tour was conducted of the sterile storage room. The stationary rack with 5 shelves, located in proximity to the leak, now contained sterile processed trays all dated beginning 2/20/25. A request was made to view the sterilization records from the reprocessed items. The sterilization records provided documented that on 2/20/25, the sterilization trays began decontamination between 3:34 PM and 4:27 PM, following surveyor tour of the sterile storage area. The facility failed to identify the potential for water contamination of the stationary rack until 2/20/25, four days after water exposure. The facility failed to identify the exposure of the instrumentation surrounding the water leak from the time it began, approximately 2/15/25 at 11:00 PM, until the time the leak was contained, on 2/16/25 between 7:45 AM and 9 AM.”

“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: 47686 Based on staff interview, and review of facility video footage, Medical Record #1 (MR1), and facility documents, it was determined the facility failed to ensure the patient’s right to receive care in a safe setting. Findings include: Reference: Facility policy titled “Patient Rights” (last reviewed 2021) states, “ ... Personal Needs ... To receive care in a safe setting ... .” On 4/4/24 at 10:15 AM, an entrance conference was conducted with Staff #1 (S1), Director of Standards and Regulatory, Staff #2 (S2), Chief Nursing Officer (CNO), and Staff #3, Manager of Standards and Regulatory. S1, S2, and S3 confirmed that an incident involving a security officer and an adolescent patient took place on 3/16/24 at approximately 2:12 PM. Video footage of the incident that occurred on 3/16/24, was reviewed on the following dates and times: 4/4/24 at 2:08 PM, in the presence of Staff #5 (S5), Assistant Vice President of Operations, and Staff #28 (S28), Discharge Coordinator; 4/5/24 at 10:10 AM, in the presence of Staff #26 (S26), Sergeant of Security; and 4/8/24 at 9:45 AM, in the presence of Staff #27 (S27), Vice President of Quality, Safety, and Experience. Review of video footage revealed the following: 1:21 PM: Patient #1 (P1) had a white sheet covering his/her shoulders and was accompanied by Staff #17 (S17), Security Officer, and Staff #18 (S18), Mental Health Associate (MHA). All three individuals were walking toward the classroom. 1:22 PM: P1 walked into the classroom with S17 and S18 walking behind him/her. 2:11 PM: P1 walked out of the classroom with a white sheet draped over his/her head. S17 and S18 walked behind him/her. P1 stopped to speak to individuals in the hallway (patients and visitors) and then continued to walk down the hallway toward the nurse’s station. S17 and S18 continued to follow P1. 2:12 PM: P1 entered the nurse’s station followed by S17 and S18. At this time, P1, S17, and S18 were out of the camera’s view. S17 then walked backwards out of the nurse’s station with his/her arms wrapped tightly around P1’s forehead, neck, and shoulders, while dragging P1 across the hallway, toward Room #515. P1 was quickly kicking his/her legs back and forth, as he/she was being dragged into Room #515 by S17. S17 did not release his/her arms from the forehead, neck, and shoulders of P1, until P1 was inside Room #515. 2:13 PM: S17 walked out of Room #515, stood outside the room, and pointed toward the inside of the room. Staff #6 (S6), Security Lieutenant, arrived to Room #515. P1 exited the room and verbally engaged with S17. S6 stood between P1 and S17 and redirected S17 away from P1. S6 and P1 then walked into the nurse’s station. P1 and S6 are not fully in the camera view at this time. S6 and P1 then walked out of the nurse’s station and began walking toward the Day Room. S17 followed S6 and P1 as they were walking toward the Day Room, stopping in front of Room #515. Staff #22 (S22), Security Officer, arrived to the unit and verbally engaged with S17. 2:14 PM: Staff #21 (S21), Security Officer, arrived to the unit and stood with S17 and S22. P1 was verbally engaging with S6 and pointing towards S17, S21, and S22. S19 (Registered Nurse) and S20 (Registered Nurse) were verbally engaging with P1. S17 walked toward the nurse’s station. 2:15 PM: S19, S20, and S21 were in the Day Room verbally engaging with P1. P1 was sitting in a chair. 2:18 PM: S17 left the unit. The findings of the video footage were confirmed by the following staff on the following days: 4/4/24: S5 confirmed on the video footage, the identity of staff and the events observed, that took place on 3/16/24 from 2:11 PM to 2:13 PM. 4/5/24: S26 confirmed the identity of staff observed on the video footage and the events that took place on 3/16/24, beginning at approximately 2:12 PM. 4/8/24: S27 confirmed the identity of staff observed on the video footage and the events that took place on 3/16/24, from 1:21 PM to approximately 2:49 PM. Review of MR1, on 4/5/24 at 2:10 PM, revealed the following: A Physician assessment, documented on 3/16/24 at 2:51 PM, states, “ ... [P1] has three abrasions on [his/her] face and neck related to the recent altercation and has pain in the neck as a result ... .” A Nursing progress note documented on 3/16/24 at 6:44 PM states, “ ... Security guard then grabbed pt (patient) face ... Pt walked out of room hyperventilating and crying... Pediatrician evaluated patient, who had three scratches on [his/her] temple, jaw, and back of neck ... .” During an interview on 4/5/24 at 11:17 AM, Staff #26 (S26), Security Sergeant, stated he/she viewed the video footage of the incident which took place on 3/16/24. S26 stated the physical restraint technique used by S17 on P1 is not in compliance with “Best Training” (de-escalation and restraint training given to all security, emergency department, and behavioral health unit staff). During an interview on 4/5/24 at 12:23 PM, S22 confirmed the restraint technique used by S17 on P1 is not in compliance with “Best Training.””

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 47686 Based on staff interview, review of video footage, Medical Record #1 (MR1), and facility policies and procedures, it was determined the facility failed to ensure patients are only restrained in the least restrictive manner necessary to ensure their immediate physical safety, in accordance with facility policy. Findings include: Reference #1: Facility policy titled “Restraints” (effective 2022) states, “Recognizing that all patients have the right to freedom from restraint of any form and that use of restraint can only be utilized to ensure the immediate physical safety of the patient, the staff, or others it is the philosophy of [Name of facility] that the use of restraint will: a. Only be utilized when they are clinically appropriate and adequately justified to protect the patient, staff, or others. b. Utilize the least restrictive and most effective method of restraint ... d. Never used as a means of coercion, discipline, convenience, or retaliation ... . “ Reference #2: Facility policy titled, “Restraints-Violent and Non-Violent Self Destructive” (effective 2022) states, “... Physical Holding: Holding a patient in a manner that restricts the patient’s movement against the patient’s will is considered a restraint. This includes holds that physically restrain a patient by holding them for limited period to control their behavior ... With the exception of an emergency situation a patient should not be restrained until being seen and evaluated by a LIP [Licensed Independent Practitioner] ... De-escalation: ... staff members will attempt de-escalation techniques designed to help the patient regain control of behaviors ... .” On 4/4/24 at 10:15 AM, an entrance conference was conducted with S1, S2, and S3. S1, S2, and S3 confirmed an incident involving a security officer and an adolescent patient took place on 3/16/24 at approximately 2:12 PM. Video footage of the incident occurring on 3/16/24 was reviewed by the surveyor, on 4/4/24 at 2:08 PM, 4/5/24 at 10:10 AM, and 4/8/24 at 9:45 AM, and revealed the following: 1:21 PM: P1 had a white sheet covering his/her shoulders and was accompanied by S17 (Security Officer) and S18 (MHA). All three individuals were walking towards the classroom. 1:22 PM: P1 walked into the classroom with S17 and S18 walking behind him/her. 2:11 PM: P1 walked out of the classroom with a white sheet draped over his/her head. S17 and S18 walked behind him/her. P1 stopped to speak to individuals in the hallway (patients and visitors) and then continued to walk down the hallway towards the nurse’s station. S17 and S18 continued to follow P1. 2:12 PM: P1 entered the nurse’s station followed by S17 and S18. At this time, P1, S17, and S18 were out of the camera’s view. S17 then walked backwards out of the nurse’s station with his/her arms wrapped around P1’s forehead, neck, and shoulders, while pulling P1 towards Room #515. P1 was kicking his/her legs as he/she was being pulled down the corridor, into Room #515 by S17. 2:13 PM: S17 walked out of Room #515, stood outside the room, and points toward the inside of the room. S6 (Security Lieutenant) arrived to Room #515. P1 exited the room and verbally engaged with S17. S6 stood between P1 and S17, redirecting S17 away from P1. S6 and P1 then walked into the nurse’s station. P1 and S6 are not fully in the camera view at this time. S6 and P1 then walked out of the nurse’s station and began walking toward the Day Room. S17 followed S6 and P1 as they were walking toward the Day Room, stopping in front of Room #515. S22 (Security Officer) arrived to the unit and verbally engaged with S17. 2:14 PM: S21 (Security Officer) arrived to the unit and stood with S17 and S22. P1 was verbally engaging with S6 and pointing towards S17, S21, and S22. S19 (Registered Nurse) and S20 (Registered Nurse) were also verbally engaging with P1. S17 walked towards the nurse’s station. 2:15 PM: S19, S20, and S21 were in the Day Room verbally engaging with P1. 2:18 PM: S17 exited the unit. Review of MR1 on 4/5/24 at 2:10 PM revealed the following: Physician assessment documented on 3/16/24 at 2:51 PM states, “ ... [P1] has three abrasions on [his/her] face and neck related to the recent altercation and has pain in the neck as a result ... .” Nursing progress note documented on 3/16/24 at 6:44 PM states, “ ... Security guard then grabbed pt (patient) face ... Pediatrician evaluated patient, who had three scratches on [his/her] temple, jaw, and back of neck ... .” During an interview on 4/5/24 at 11:17 AM, S26 stated he/she viewed the video footage of the incident which took place on 3/16/24. S26 stated that the physical restraint technique used by S17 on P1 is not in compliance with the facility’s “Best Training” (de-escalation and restraint training given to all security, emergency department, and behavioral health unit staff). During an interview on 4/5/24 at 11:30 AM, S6 (Security Lieutenant) stated the physical restraint technique used by S17 on P1 was not in compliance with the facility’s “Best Training.” During an interview on 4/5/24 at 12:23 PM, S22 confirmed that the restraint technique used by S17 on P1 is not in compliance with the facility’s “Best Training.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 37432 Based on staff interviews, medical record review, and review of facility documents, it was determined the facility failed to ensure that patients are cared for in a safe setting. Findings include: 1. The facility failed to ensure that a mechanism to identify the presence of weapons entering the facility is in place. (Cross refer to Tag A-144) 2. The facility failed to ensure that processes addressing visitor access to locked patient care units, are implemented. (Cross refer to Tag 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: 37432 Based on staff interviews, medical record review, and review of facility documents, it was determined the facility failed to ensure that: 1) a mechanism to identify the presence of weapons entering the facility is in place; 2) processes addressing visitor access to locked patient care units, are implemented. Findings include: 1) Reference: Facility policy titled, “Weapons Detection Policy” (effective 9/10/23) states, “ ... [Name of facility] is committed to providing a safe, secure environment for its employees, patients, physicians, visitors, vendors and volunteers. To that end, [name of facility] Security and Office of Emergency Management team works to maintain an environment that is free from weapons. This is consistent with the [name of facility] Nonviolence in the Workplace policy that specifically prohibits introduction into any company building, vehicle, or event firearms, bullets, explosives, or any knife or other device intended to be used as a weapon. ... In an effort to keep weapons including firearms and large knifes [sic] from being carried into our facilities, Weapons Detection Systems are authorized for deployment. ... .” During the entrance conference on 12/11/23 at 10:00 AM, in the presence of Staff #1 (Standards Director), Staff #2 (Standards), Staff #3 (Chief Nursing Officer), and Staff #4 (Vice President, Quality & Safety), Staff #4 confirmed that on 12/8/23, a visitor entered the Pediatric Intensive Care Unit (PICU) and when told to leave, used a large knife to assault three staff members. The visitor was disarmed by a security officer and held until police arrived. Upon interview, Staff #4 stated, “The investigation is ongoing. We still don’t have all the details.” Upon interview at 12:30 PM, Staff #4 confirmed that the facility does not have metal detectors to screen for weapons. Staff #4 stated, “We do not screen for weapons. We only screen behavioral health patients. We use a wand (handheld metal detector) for them.” An interview was conducted on 12/11/23 at 1:25 PM with Staff #10 (Director of Security). Staff #10 confirmed the facility does not have metal detectors. When asked if the facility identified a need for metal detectors Staff #10 stated, “We identified the need for metal detectors a while ago, but I’m sure there will be a push to get them now. I’m not sure why we haven’t gotten them yet.” Staff #10 was asked if security was seeing an increase in weapons being brought into the facility. He/she stated, “We are seeing an increase in knives, but not really any other weapons.” An interview was conducted with Staff #27 (Security Officer) on 12/11/23 at 2:06 PM. Staff #27 was asked how he/she screens for weapons. He/she stated, “We screen law enforcement or undercover officers for weapons visually. If they are armed, we ask them to remove their firearm and we secure it for them until they leave. To screen everyone else, we look for bulges. Otherwise, there is no way for us to know if anyone has a weapon.” Staff #27 was asked if he/she was given additional instructions or training on weapons screening since the incident occurred. He/she stated, “We were told to be more vigilant and we have more awareness, but we don’t do anything differently.” During a tour of the ED on 12/12/23 at 10:25 AM, an interview was conducted with Staff #12 (Armed Security Officer). When asked how he/she screens visitors or patients for weapons, Staff #12 stated he/she looks for weapons by “looking for bulges around the waist.” When asked if his/her screening process for weapons changed after the incident that occurred on 12/8/23, Staff #12 stated, “No. I’m not doing anything differently.” At 10:44 AM, an interview was conducted with Staff #13 (Security Officer). When asked how he/she screens for weapons, Staff #13 stated, “You look for bulges. If we don’t see anything, then there is no way for us to know that weapons are present.” Staff #13 stated that he/she does not ask visitors or patients if they are carrying weapons. Staff #13 stated that his/her process for screening for weapons did not change after the incident that occurred on 12/8/23. At 11:40 AM, an interview was conducted with Staff #10 (Director of Security). Staff #10 was asked if the facility’s process for screening for weapons included asking persons entering the facility if they have weapons. Staff #10 stated, “No.” Staff #10 was asked if the process for screening for weapons had changed after the incident that occurred on 12/8/23. Staff #10 stated, “No.” On 12/12/23, review of an incident report entered on 3/11/23 indicated the following: On 3/10/23 at 11:45 PM, Patient #2 (P2) arrived to the ED via ambulance with reports of having “homicidal ideation towards teachers, classmates and dad.” When changing into paper scrubs, the patient “took off [his/her] hoodie then proceeded to lift up [his/her] shirt ... and pulled out a kitchen knife that is 11.5 in (inches) long and initially tossed on the bed then picked it back up quickly and stated ‘I am going to need this.’” Security was called for assistance and removed the knife from the patient. The incident report states, “ ... 41. Post Incident Review Comments: There is an increase in need for support with security measures when it comes to weapons in the Emergency Department. ... 45. Recommendation Comments: Metal detectors.” Upon interview on 12/12/23 at 11:45 AM, Staff #10 was asked if he/she was aware of the incident indicated on the incident report. Staff #10, “I am involved with incidents and follow-up that involve security concerns or violence in the workplace. Incidents involving violence in the workplace are discussed in the Violence in the Workplace Committee. Our Assistant Director of Security tracks and trends the incidents and reports them to HR (Human Resources).” Upon interview at 11:49 AM, Staff #4 stated, “Verge reports (incident reports) go to [Staff #10] if they are related to security or workplace violence.” 2) Reference #1: Facility policy titled, “Visitor Management Policy” (effective 6/30/23) states, “All people presenting to a [name of hospital system] hospital or business office without an authorized [name of hospital system] identification badge will receive a visitor badge upon entering the building. Visitors will be instructed to visibly display the badge on their person at all times. Each affiliate will use FAST-PASS as the designated Visitor Management system to record all persons entering the building with the exception of clinical vendors. FAST-PASS will be installed at the affiliate Main Entrance and additional points of entry as assessed by local security/leadership to ensure compliance with the policy. ... Visitation is restricted for those in custody (forensic patients) and the forensic patients name and information shall not be published or shared on the daily in-patient directory.” Reference #2: Facility policy titled, “Visitor Management Procedure” (effective 9/3/23) states, “ ... 3. Procedure ... Performed By: Reception Desk (desk employee, security personnel and/or volunteer) ... Required Action Steps: Patient/visitor welcomed to facility and asked to provide appropriate ID ... Visitor is asked to provide reason for visit: visiting inpatient, has appointment, unannounced visit, etc. ... Confirm validity of visit reason per local affiliate level visitation policy via one of the following: ... Inpatient: access EMR (electronic medical record) to confirm patient room location/visitation permitted.” Reference #3: Facility policy titled, “Patient Visitation” (effective 2/3/23) states, “ ... Behavioral Health, Labor and Delivery, NICU (Neonatal Intensive Care Unit), PICU (Pediatric Intensive Care Unit), and Pediatrics have visitor guidelines that address specific patient safety issues.” During the entrance conference on 12/11/23 at 10:00 AM, in the presence of Staff #1, Staff #2, Staff #3, and Staff #4, Staff #4 confirmed that on 12/8/23, a visitor entered the Pediatric Intensive Care Unit (PICU) and when told to leave, used a large knife to assault three staff members. Staff #4 stated that the PICU is a locked unit, with a security officer assigned to a post outside the unit at all times. When asked about the visitation process, Staff #4 stated that when visitors present to the main lobby desk requesting to visit a patient in PICU, the receptionist must first call the unit and receive approval for the visitor to come to the unit, prior to giving the visitor a pass. A tour of the PICU was conducted on 12/8/23 at 10:30 AM, in the presence of Staff #2 and Staff #5 (AVP Nursing). The unit was closed and there were no patients or staff observed on the unit. Staff #5 stated, “Peds and PICU are all locked units. For safety, there is also only one set of elevators that have access to the 5th floor where those units are located. There is a camera outside the door of the PICU and there is a security officer assigned to the floor. No one has access unless you have business there.” An interview was conducted with Staff #7 (Security Officer) on 12/11/23 at 10:54 AM. Staff #7 was the security officer currently assigned to the 5th floor, which includes PICU, General Pediatrics, and the Mother/Baby Unit. All of the units are locked units. When asked what his/her role was, Staff #7 stated, “I’m assigned here my whole shift. I don’t leave unless I’m relieved for break. When visitors come off the elevator, I call them over to me and ask to see their pass. They are supposed to have a pass from downstairs in order for them to come up here. If they don’t have a pass, I send them back downstairs. Once I check their pass, I have them sign in the visitor’s log. Everyone has to sign in. Then I tell them how to get to their unit. A lot of times, the visitors get confused because we have three different units on this floor.” A request was made to Staff #7 to view the visitors’ sign-in log for 12/7/23 and 12/8/23. Review of the visitors’ sign-in log lacked evidence that the visitor involved in the incident occurring on 12/8/23, signed the visitors’ log. Upon interview on 12/11/23 at 1:25 PM, Staff #10 (Director of Security) was asked about the visitation process for the locked units on the 5th floor, specifically the PICU. He/she stated, “Visitors present to the registration desk in the Main Lobby. Someone from the desk calls the unit first to make sure its ok for them to come upstairs. The visitor gets a pass. When they get to the unit, they are buzzed in.” When asked about visitor restrictions, Staff #10 stated, “Security officers do not have access to the system, so there is a log book kept at the desk with visitor restrictions. Security and registration staff are supposed to check the log book or look in the system to make sure there are no visitor restrictions in place before they issue a pass.” Staff #10 was asked if all visitors to the locked units on the 5th floor are required to sign in with the security officer on the 5th floor. Staff #10 stated, “Yes and I can tell you that regarding the incident, that was not done. There were two instances that the security officers did not do what they were supposed to do. First, the security officer downstairs (main lobby desk) did not call the unit to verify that the visitor was allowed to come up. I spoke with the officer, who said he/she gave a pass to the visitor without calling the unit first because the officer saw the visitor before. This is not our protocol. Then, when the visitor got upstairs, the security officer did not make [him/her] sign in. Again, this was against our protocol.” Staff #10 was asked if he/she knew how the visitor gained access to the PICU, as the unit is locked. Staff #10 stated, “My understanding is that the visitor followed a tech inside the unit as the tech was walking in.” A review of the “Visitor Management Policy” and the “Visitor Management Procedure” was conducted on 12/12/23. There was no indication in either policy that main lobby desk staff or security personnel were required to call the locked units to request approval for visitors to visit those units prior to issuing a visitor’s pass. Upon interview on 12/12/23 at 9:50 AM, Staff #4 stated, “When a visitor arrives to the main lobby desk, they let the staff member know who they are here to visit. The staff member will look in the system and check the log book to see if there are any visitor restrictions for that patient. If the visitor wants to go to one of the locked units, the staff member calls the unit first to get approval from unit that the patient can come up. Usually, it’s the patient’s nurse that gives approval. Then once the unit says its ok for the visitor to come to the unit, the staff member will give the visitor a visitor’s pass. After a certain time, registration staff leave for the day and security will sit at the main lobby desk. Security follows the same procedure. I don’t know if we have a policy, but that is our process.” On 12/12/23, review of an incident report entered on 5/29/23 revealed the following: Patient #7 (P7) was an inmate from the county jail who was admitted to the facility on 5/15/23 and was currently a patient on unit B4. The incident report states, “[P7] was supposed to be on visitor restriction, but a person claiming to be [his/her] uncle came up to the unit at 11:50 AM, was stopped by the officers and was sent away. [The uncle] claimed that the patient’s mom told him the location and she was told by someone from the hospital.” On 12/12/23, review of an incident report entered on 8/21/23 revealed the following: Patient #3 (P3) was admitted to the facility on 8/20/23 and was currently a patient in the ICU (Unit C8). The incident report states, “At about 8:30 PM, the Unit Clerk received a call from the Pass Desk (main lobby desk) regarding a visitor who was claiming to be the [spouse] of the patient in C811. The patient’s chart contained an approved/restricted visitor’s list created a few hours earlier by the patient’s mother and verified next of kin. ... the Unit Clerk confirmed with the Pass Desk that the visitor was not approved to visit the patient. The Unit Clerk then advised that the visitor in question could personally contact the mother of the patient if they wanted to be added to the existing approved list. Shortly after the call ended, the visitor found their way to the unit. ... When the individual finally responded to the Unit Clerk’s inquiry and identified [him/herself] as the unapproved visitor, the Unit Clerk told [him/her] that she was not approved to visit the patient. ... the Unit Clerk alerted security about the hostile visitor, the panic button was pressed and a security officer came up and escorted the visitor off the unit... . On 12/12/23, review of an incident report entered on 10/20/23 revealed the following: Patient #8 (P8) arrived to the ED on 10/17/23. The incident report states, “Patient has a visitor restriction from October 17th 2023. Visitor restricted form handed to security and staffing on 17th. Patient complained that yesterday around 7:30 PM [he/she] had a visitor irrespective of the visitor restricted list. Security was notified and Nurse Manager [name of nurse manager] made aware.” A second incident report entered on 10/21/23 indicated that P8 again complained that visitors were allowed to come into his/her room despite signing a visitor restriction form. The incident report states, “Patient reported that visitors were allowed to come up to [his/her] room despite signing a visitor restriction. The patient’s friend visited [him/her] at 3 pm and found [him/her] sleeping, took [his/her] picture, and sent it out without [his/her] consent. This invasion of privacy greatly upset the patient, as [he/she] had explicitly signed off on visitor restrictions.” Review of P8’s medical record revealed the patient was pregnant and had a history of domestic violence at home. On the physician’s progress note dated 10/19/23 at 6:50 AM, the physician documented, “ ... 6. Suspected domestic violence ... no visitors.” On 12/12/23 at 1:30 PM, an Immediate Jeopardy (IJ) was identified for the the facility’s failure to ensure that a mechanism is in place to identify the presence of weapon(s) for all civilians entering the facility and failure to implement processes for visitor access to locked units. A copy of the IJ template was provided to the facility on 12/12/23 at 3:03 PM. An acceptable IJ removal plan was received on 12/13/23 at 10:55 AM. An on-site visit to verify implementation of the IJ removal plan was conducted on 12/13/23. Verification of the implementation of the IJ removal plan included the following: Observation of the “Fast Pass” visitor check-in process in the main lobby and the Emergency Department (ED), staff interviews, review of staff re-education, and review of the revised Weapons Detection Policy. The IJ was removed on 12/13/23 at 2:20 PM.”