Bergen New Bridge Medical Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48414 Based on observation of video surveillance, review of medical records and facility documents, and staff interview, it was determined the facility failed to ensure: 1) items identified on the BG unit Environmental Risk Assessment (ERA) as a risk to be thrown or used as a weapon are not available to patients (A0144); 2) rooms with items identified on the ERA as a risk to be thrown or used as a weapon are monitored as per facility policy (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to patients. The IJ was identified on 5/31/24 at 2:15 PM and an acceptable IJ removal plan was received and verified on 6/3/24 at 12:03 PM. On 6/3/24, implementation of the IJ removal plan was verified during an on-site visit and included the following: a tour of the BG unit to confirm the chairs identified as a risk to be thrown or used as a weapon were removed, review of staff re-education sign-in sheets, review of updated ERA and policy, and staff interviews regarding the facility’s process for monitoring the community rooms, and use of sturdy, non-liftable chairs on the unit. The IJ was lifted on 6/3/24 at 12:03 PM. Cross Reference: 482.13(c)(2) - Patient’s Rights: Care in a Safe Setting”

“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: 33557 Based on medical record review, staff interview, review of facility documents, and review of video surveillance, it was determined the facility failed to provide care in safe setting by: 1) ensuring that items identified on the Environmental Risk Assessment (ERA) as a risk to be thrown or used as a weapon are not available to at risk patients; 2) ensuring that rooms with items identified on the ERA as a risk to be thrown or used as a weapon are monitored as per facility policy; and 3) failing to ensure that measures are in place to mitigate areas of risk identified on the Safety Risk Assessment. Findings include: 1) The BG Unit Environmental Risk Assessment (ERA) from 3/29/24, identified “chairs” as a risk, indicating they “should be sturdy and heavy as possible to minimize likelihood of patients throwing or using as a weapon.” The BG unit Patient Census for 5/30/24 identified five of 19 patients with a “H/O [History of] Aggressive Behavior.” This was confirmed with Staff (S)3 on 5/30/24 at 2:21 PM. The Information for Use (IFU) for the ModuMaxx Armless Activity Chair provided 5/31/24, states, “ ...If additional weight is necessary, ModuForm’s exclusive Ballast Access System can be easily added ...Features: Hollow Core that can Ballasted if Needed for Additional Security ...” The Information for Use (IFU) for the Integra Chair provided on 5/31/24, states, “ ...These good are sold by [company name] for institutional use only and not as consumer products. The design characteristics of this product are not intended to replace or substitute the need for necessary supervision or other necessary protective measures to protect those who may be at risk. ...It is the customer’s responsibility to ensure that products purchased from [company name] and installed are suitable for the environment in which they are installed. ...”. On 5/29/24 at 11:07 AM, medical record review was conducted with S5 (Information Technologist). Patient (P) 1’s medical record revealed he/she was admitted on 3/25/24 at 5:06 PM, with a diagnosis of schizoaffective disorder, and bipolar disorder. The Behavioral Health (BH) History and Physical (H&P) on 3/25/24 at 7:45 PM, stated, “ ...Contributing Past Psychiatric History: History per patient and records; ...History of verbal and physical aggression; History of property destruction reported; History of physical aggression towards parents resulting in legal charges and history of physical aggression towards [facility name] staff. ...”. The Attending BH Event Note on 5/16/24 at 5:42 PM, stated, “ ...Dr. Strong security code was called for patient’s agitation and aggression. As per nursing staff the patient was sitting calmly in day room when [he/she] suddenly unprovoked got up and punched another patient [patient initials] on the arm and attempted to threw [sic] a chair at peer [initials] which grazed [his/her] arm. Patient subsequently left the day room and pushed both hands against the day room window which ultimately broke. ...” On 5/29/24 at 1:55 PM, a tour was conducted on the BG unit with S2 (Senior Vice President, Chief of Quality and Equity Officer), S3 (Director of Nursing) and S13 (Director of facilities). Both community rooms, room B031 (TV room) and room B021 (Day room) were observed. Approximately ten ModuMaxx armless activity chairs, and eight Integra plastic chairs were observed in the community rooms available to all patients. S9 (Licensed Practical Nurse) was observed using an Integra plastic chair while conducting patient monitoring. On 5/30/24 at 10:35 AM, medical record review was conducted with S5. P4 was admitted on 5/9/24 at 1:08 AM, with a diagnosis of schizophrenia. The BH Event Note on 5/12/24 at 12:00 AM, stated, “ ...Dr. Strong security code was called for patient’s agitation and aggression. As per nursing staff the patient walked out of [his/her] room demanding discharge, verbally aggressive, punched plexiglass and threw chair on the window. Upon evaluation patient remained agitated, shouting racial slurs at staff, and was not re-directable. ...” On 5/30/24 at 12:48 PM, time stamped video surveillance review of the “BG RN Desk” for P4 was conducted in the presence of S1 (Chief Nursing Officer), S2, S3, and S7 (Director of Security). The video did not contain any audio. Review of the video surveillance dated 5/11/24 revealed the following: 11:55 PM: A staff member is observed sitting in an office chair with wheels in front of the nurse’s station. S3 confirmed that staff was monitoring the community rooms. 11:56 PM: P4 was observed to walk up to the nurse’s station and punch the window. The staff member monitoring the community rooms was observed to stand up from the office chair with wheels and back away, leaving the chair unattended. P4 was then observed to pick up the office chair with the wheels and throw it. Pieces of the chair were seen to break off onto the floor. On 5/30/24 at 1:00 PM, time stamped video surveillance review of the “BG RN Desk” for P1 was conducted in the presence of S1, S2, S3, and S7. The video did not contain any audio. Review of the video surveillance dated 5/16/24 revealed the following: 5:17 PM: One staff member was observed sitting in an office chair with wheels in front of the nurse’s station. An unoccupied plastic chair was observed next to the staff member. The door for room B021 and B031 appeared to be open. S3 indicated the staff member observed was monitoring both community rooms. 5:20 PM: The staff member in the office chair with wheels was observed to stand up and walk behind the nurse’s station. The two chairs were observed to be unoccupied. S3 confirmed no staff was observed to be monitoring the community rooms at that time. 5:24 PM: P1 was observed pacing the hallway, then grabbed the office chair with wheels and pushed it down the hallway. P1 is observed to shove P3, then proceeded to pick up a plastic chair and throw it at P3. On 5/30/24 at 1:43 PM, a tour was conducted on the BG unit. Upon entering the unit, an unoccupied office chair with wheels was observed in front of the nurse’s station, accessible to patients. Approximately ten ModuMaxx armless activity chairs, and eight Integra plastic chairs, were observed in the community rooms. On 5/31/24 at 10:40 AM, S13 indicated, the ModuMaxx armless activity chairs can be moved for infection control reasons and to be able to rearrange room. On 5/31/24 at 11:04 AM, an interview was conducted with S12 (Mental Health Associate [MHA]). S12 stated when he/she is monitoring the community rooms, “I use one of the chairs from the nurse’s desk, a computer chair.” S12 indicated he/she was assigned to monitor the kitchen at the time of the incident with P1 on 5/16/24. S12 stated, “I was coming out of the kitchen and saw [P1] throw the chair, I tried to talk to [P1] but [P1] said the voices were telling [him/her] to hit people.” S12 indicated in the past three to four months, he/she has observed two patients’ lift the ModuMaxx armless activity chairs. S12 stated, “[patients name] picked up the chair and used it to work out.” On 5/31/24 at 1:12 PM a phone interview was conducted with S14 (Director of Special Operations), who indicated the Integra plastic chairs were bought so they can be moved for cleaning purposes and to have the ability to reconfigure the rooms. During this interview, S2 stated, “[Integra plastic chairs] can be thrown.” 2) Facility policy titled, “Constant Observation and Levels of Observation Including Safety Watch (SW)” reviewed 8/22, states, “ ...Policy: It is the policy of [facility name] to provide protection when a patient’s behavior represents a danger to self or others. ...Levels of Observation: ...6. Monitor Patient Activity: Staff will monitor patients in hallways and community rooms. ...” On 5/29/24 at 1:55 PM, a tour was conducted on the BG unit with S2, S3 and S13. Both community rooms, room B031 (TV room) and room B021 (Day room) were observed. Approximately ten ModuMaxx armless activity chairs, and eight Integra plastic chairs were observed in the community rooms available to all patients. At 2:00 PM, S9, confirmed a staff member must always be monitoring both rooms. On 5/30/24 at 1:00 PM, time stamped video surveillance review of the “BG RN Desk” for P1, was conducted in the presence of S1, S2, S3, and S7. The video did not contain any audio. Review of the video surveillance, dated 5/16/24, revealed the following: 5:17 PM: One staff member was observed sitting in an office chair with wheels in front of the nurse’s station. An unoccupied plastic chair was observed next to the staff member. The door for room B021 and B031 appeared to be open. S3 indicated the staff member observed was monitoring both community rooms. 5:20 PM: The staff member in the office chair with wheels, was observed to stand up and walk behind the nurse’s station. Two chairs were observed to be unoccupied. S3 confirmed no staff was observed to be monitoring the community rooms at that time. Video surveillance review of the “BG TV Room” for P1, dated 5/16/24, revealed the following: 5:24 PM: P1 was observed to enter room B031 and punch his/her peer in the right arm and exit the room. S3 confirmed no staff was observed to be present in room B031 during this time. Video surveillance review of the “BG RN Desk” for P1 dated 5/16/24 revealed the following: 5:24 PM: P1 was observed pacing the hallway, then grabbed the office chair with wheels and pushed it down the hallway. P1 was observed to shove P3 then proceeded to pick up a plastic chair and throw at P3. S7 indicated P1 broke the window in room B021 at this time, although it is unable to be visualized by video surveillance. On 5/30/24 at 1:43 PM, a tour was conducted on the BG unit. Upon entering the unit, an unoccupied office chair with wheels was observed in front of the nurse’s station. Approximately ten ModuMaxx armless activity chairs, and eight Integra plastic chairs were observed in the community rooms. S2 indicated S11 (MHA) was assigned to monitor the community rooms. During an interview with S11, when asked if he/she was assigned to monitor the community rooms, S11 stated, “I am assigned to do the patient rounding.” S11 was observed to be performing patient rounding at that time. S11 indicated all staff are aware that the community rooms have to be monitored but it is not on the assignment sheet, it is verbally discussed. On 5/31/24 at 10:11 AM, in the presence of S1, S2, S3, S4, and S13, a discussion concerning monitoring of patients took place. S3 confirmed that all patients have access to the community rooms. S3 confirmed community room monitoring entails a staff member sitting outside the nurse’s station, in the hallway between the community rooms, in order to be able to view both community rooms. S3 confirmed that staff are assigned to monitor the rooms with a verbal request and not officially assigned on schedule. On 5/31/24 at 11:04 AM, an interview was conducted with S12 (MHA). S12 indicated the community rooms need to be monitored at all times. S12 stated, the monitoring is done by sitting in a chair in front of the nurse’s station to be able to monitor the two rooms, as well as the hallways. S12 indicated the rooms needs to be monitored due to patients getting too close and kissing or hugging each other and the potential for violence in those rooms. On 5/31/24 at 1:10 PM, when S2 was asked if the plastic chairs are approved to be on the behavioral health units, S2 stated, “the rooms need to be ligature resistant as long as the rooms are observed, we can have those chairs.” S3 confirmed through unit observation and video surveillance, these rooms are not being monitored at all times. 3) On 5/30/24, a review of the Environmental Risk Assessment (ERA) dated 3/29/24, windows/glass was identified as a risk. The ERA reads, “Interior and exterior should not yield sharp shards of glass when broken that can be used as a weapon.” The ERA states the location of these windows as, “Most exterior walls and interior doors.” The ERA states, “Nursing performs Q [every]15/Q30 minutes rounding throughout the unit on a regular basis based on the patient acuity.” During an interview at 11:15 AM, S13 (Director of Facilities), confirmed the ERA language from the 3/29/24 report is the same language that was included in the ERA that was in effect during the calendar year 2022 and 2023. At 11:20 AM on 05/30/24, S13, states, “The safety tempered glass and wired tempered glass is being replaced with laminated glass because the windows are breakable, and glass falls out. We are replacing windows as they break.” A review of incident reports from 2023 and 2024, detailed the following incidents where windows were broken on the Behavior Health Units: 11/17/23, Unit BH-AG, P16, “Pt. witnessed by MHA banging on the window in [his/her] room with [his/her] plastic bed frame until the window glass got shattered. The patient was agitated and demanded discharge. Patient was noticed to having superficial abrasion to the right and left knuckles. ROC saw patient and ordered stat X-Ray which was negative for fractures.” 02/21/24, Unit BH-BG, P15, “At around 6:20 PM, Patient started punching the ceiling without any provocation while standing on the table in the dayroom. Staff asked [him/her] to stop and then patient took out [his/her] shirt and postured that [he/she] was ready to fight to anyone. [He/She] then grabbed the chair and threw it twice to the window glass resulting to shattered glass. Dr. Strong was initiated, and restraint was ordered . . .” 04/28/24, on Unit BG-12A, P14, “Patient was found missing during 18:30 Headcount. The glass window in [his/her] room was found shattered with pieces on the floor. The window screen was also missing. Security and ADN were immediately notified. Security Officer said that the patient was in the ER. ROC was also notified.” 5/16/24, on Unit BH-BG, P1, “...Pt [patient] hit and broke window with both hands. ...”. On 05/30/24 at 12:00 PM, a review of the window inventory for Unit BG, provided by the Director of Facilities, identified forty-one (41) as “safety Tempered” and nine (9) as “Wired Tempered.” On 5/30/24 at 4:29 PM, S7 (Director of Security), provided a picture of the broken window on Unit BG, from 5/16/24. The picture showed visible glass debris on the windowsill. 48414”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48414 Based on medical record review, staff interviews, review of facility documents, and review of video surveillance it was determined that the facility failed to provide care in safe setting by 1.) failing to conduct levels of observation per facility policy (A0144); 2.) failing to mitigate risks identified on the Environment Risk Assessment (ERA) according to facility’s plan (A0144); 3.) failing to implement safety measures for patients on the unit (A0144); and 4.) failing to conduct a body, clothing, and belongings search for two of two patients (P1 and P3) upon return to the facility (A0144). Cross Reference: 482.13(c)(2) Patient Rights: Care in Safe Setting”

“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: 48414 Based on medical record review, staff interviews, review of facility documents, and review of video surveillance, it was determined that the facility failed to provide care in safe setting by 1) failing to conduct levels of observation per facility policy; 2) failing to mitigate risks identified on the Environment Risk Assessment (ERA) according to facility’s plan; 3) failing to implement safety measures for patients on the unit; and 4) failing to conduct a body, clothing, and belongings search for two (2) of two (2) patients (P1 and P3) upon return to the facility. Findings Include: 1.) Facility policy titled, “Constant Observations and Levels of Observation Including Safety Watch” reviewed 8/22, states, “ ...Policy: It is the policy of [facility name] to provide protection when a patient’s behavior represents a danger to self or safety of others. ...Levels of Observation: 1. Constant Observation (CO, 1:1) is used for ...destructive behavior. CO is constant visual contact whereas the staff member remains in close proximity of the patient at all times so that the staff may immediately respond to a change in the patient’s status. A ratio of a minimum of one staff member to one patient shall always be maintained ...Process/Procedure: Initiation of CO 1. [facility name] Staff identifies that a patient is verbalizing suicidal or homicidal, or destructive acts and notifies the Charge Nurse immediately. The Charge Nurse will notify the Assistant Director of Nursing (ADN)/Nurse Manager. 2. Institutes CO precautions, 1:1 staff to patient ratio, and notifies the LIP [Licensed Independent Practitioner] for the necessity to evaluate within one hour. ...5. The CO orders must be written as one of the following: ...b. 1:1 staff to patient ratio: “Close visual contact” (within eight feet) for patients deemed more at risk for agitated/destructive behavior. ...d. 2:1 staff to patient ratio: For highly agitated/destructive/impulsive behavior. ...Q15, Q30 and Patient Safety/Risk of Fall (Safety Watch) Procedure 1. Q15 checks are appropriate for patients who do not display demonstrated overt ...destructive behavior ...c. Q30-Minute Checks is the standard level of observation on ...12A ... This level would be for patients assessed to be clinically and behaviorally stable, not presenting as an imminent risk to self, others, or property. ...”. On 5/6/24 at 1:58 PM, medical record review was conducted with S8 (Unit Manager). P1 was admitted to 12A on 6/14/23 at 3:08 PM, with a diagnosis of Schizophrenia and Intellectual Disability. P1 had Physicians Orders dated 6/14/23 at 4:53 PM, for “Level of Observation: Q30 MIN”. The RN Progress Note on 4/28/24 at 7:26 PM, stated, “Patient was found missing during 1830 [6:30 PM] headcount. The glass window in [his/her] room was found shattered with pieces on the floor. The window screen was also missing ...”. The RN Progress Note on 4/28/24 at 9:39 PM, stated, “At approximately 8:45 PM, patient returned from [facility name] ER via stretcher accompanied by [facility name] nursing supervisor and RN. ... Patient right hand (palm) with laceration measuring 5 x 3 cm and abrasion to left thumb. Affected area cleansed and covered with dry dressing. Seen by [doctors name] ROC. Will continue to monitor. ...”. The RN Progress Note on 4/29/24 at 12:33 AM, stated, “Patient was AAOx3 (awake, alert, and oriented), received at 11pm start of shift, comfortable sitting in recliner, denies any discomfort or distress, denies any pain. Nursing CO (constant observation) was implemented due to patient safety and risk of another elopement. Patient was seen by [doctors name] to assess laceration wound on [his/her] hand but was unable to suture ...will defer to surgery team to do it later today.” 4/29/24 at 8:34 PM, P1 was admitted to unit A1 (Acute Care) and had Physician’s order for “Level of Observation: Q15 MIN”. On 5/6/24 at 1:58 PM, S8 stated, “Nursing CO, is nursing close observation, there is no order for this, no documentation form and it is not in any policy, but it is done when a nurse thinks a patient needs to be observed more closely.” S8 confirmed Nursing CO is not the same as Constant Observation. On 5/6/24 at 2:00 PM, S2 (Chief Nursing Officer) and S3 (Director of Nursing) reviewed the facility policy, titled, “Constant Observation and Levels of Observation Including Safety Watch” and confirmed that P1 demonstrated destructive and impulsive behavior by breaking a window, and a 1:1 or Constant Observation should have been ordered. S3 confirmed P1 did not have an order for 1:1 observation or Constant Observation once he/she returned to 12A after eloping. On 5/7/24 at 2:26 PM, an interview was conducted with S7 (Chair of Psychiatry). S7 stated, “ ... [the elopement] was a single event but not baseline for this patient. [P1] is intellectually disabled and impulsive.” The facility failed to implement Constant Observation (CO, 1:1) as per facility policy for P1 who was identified as impulsive and/or destructive after breaking a window with a nightstand and eloping. 2) Facility policy titled, “Constant Observations and Levels of Observation Including Safety Watch” reviewed 8/22, states, “ ...15-minute Checks (Q15) are used for all BHS [Behavioral Health Service] inpatient units as the admission level of precaution, with the exception of non-acute units (see Q30 Procedure). Thereafter, level of precaution is based on the acuity and clinical status of the patient. 3. 30-Minute Checks (Q30) are used for BH [Behavioral Health] patients on non-acute units as the standard level of precaution. ...5. Hourly Rounding by Registered Nurses (RN/LPN) (Behavioral Health Division only): The RN/LPN must perform hourly rounding on all patients and document on the Head Count/Evacuation Form ...” On 5/6/24, a review of the “Environmental Risk Assessment (ERA): Ligature, Suicide and Self-Harm Unit 12A” reviewed 3/30/24, revealed the following: “ ...Item Windows/Glass; Risk Interior and exterior should not yield sharp shards of glass when broken that can be used as a weapon; Location Most exterior walls and interior doors; Mitigation Plan Nursing performs Q [every]15/Q30 minutes rounding throughout the unit on a regular basis based on the patient Aquity [sic] ...Item Night Stand; Risk Should be sturdy and heavy as possible to minimize likelihood of patients throwing or using as a weapon; Location Bedrooms; Mitigation Plan Nursing performs Q [every]15/Q30 minutes rounding throughout the unit on a regular basis based on the patient Aquity [sic] ...” On 5/8/24, a review of facility documents and work orders from the 12/2023 until 5/2024 detailed the following windows were broken on the Behavior Health Units: On 12/8/23, Unit 12B, Room 33, the facility report stated, “ ...Summary on 12/8/23 housekeeper reported broken window in room 33. Patient [initials] who stayed in this room denied any involvement in this incident, stated: “the bird flew into this window.” No injury noted on patient, patient removed from the room and room was locked for safety until window will be replaced. ROC [resident on call] examined pt [patient], found to be agitated, STAT meds [medications] were given PO [by mouth].” On 1/8/24, Unit 12B, Room 32, the Work Order M-360565, stated, “ ...Problem: Window ...Reason: 12b-32 window is broken and needs to be fixed ASAP as it is an elopement risk and safety issue. ...” S1 confirmed there was no incident filed for this window, and indicated the broken window was not patient related. On 4/28/24, Unit 12A, Room 23, the facility report stated, “ ...Summary Patient was found missing during 1830 [6:30 PM] headcount. The glass window in [his/her] room was found shattered with pieces on the floor. The window screen was also missing. ...” On 5/6/24 at 10:40 AM, a tour was conducted on unit 12A. During the tour, Room 23 was observed to have six windows intact. S5 confirmed the broken window was replaced with shatter resistant glass. S5 (Director of Facilities) indicated the window that broke was not shatter resistant. S5 stated, “we replace the glass windows as they break with shatter resistant windows.” S5 stated, the window in Room 23 was repaired with “cardboard and had staff observing the room at all times.” S5 confirmed three patients were in Room 23, while the window was temporarily repaired with cardboard. Four nightstands were observed to be unsecured and movable in Room 23. All patient rooms within Unit 12A contained nightstands that were unsecured and movable. On 5/7/24 at 10:44 AM, time stamped video surveillance review of “Bldg 12A East” for P1 was conducted. The video did not contain any audio. S15 (Director of Security) confirmed room 23’s doorway was visible in the surveillance video and had a view of the hallway directed towards the nurse’s station. Review of the video surveillance dated 4/28/24 revealed the following: 5:27 PM- Staff was observed conducting patient rounding. 6:16 PM- P1’s roommate, P4, was observed walking in the hallway and enter Room 23. 6:26 PM- P4 was observed to exit Room 23 and interact with S9 (Registered Nurse-RN) who appeared to be conducting patient rounding, both S9 and P4 walked into Room 23. Upon interview, S8 confirmed S9 was performing patient rounding and, the glass in the window was identified to be broken at this time. From 6:26 PM- 6:50 PM- multiple staff members entered and exited Room 23, P2 and P4 were observed to enter and exit the room during this time as well. 6:50 PM- Two maintenance workers were observed in the hallway walking into Room 23, carrying what appeared to be a large piece of cardboard and other equipment. Review of the video surveillance dated 4/29/24 revealed the following: 7:31 AM- S8 and S9 were observed in the hallway and entering Room 23. S8 was present during video surveillance review and confirmed the window had been repaired with cardboard and three patients remained in Room 23 at that time. S8 stated, “I was doing bedside nurse report with [S9]”. When questioned if there was a staff member monitoring Room 23 when he/she was at the bedside, S8 stated, “no.” 9:37 AM- S9 was observed to set up a chair outside of Room 23. S8 confirmed this was the first time he/she observed a staff member monitoring Room 23. During the review of the video surveillance, there were no staff member observed monitoring Room 23, on 4/28/24 from 11:00 PM until 4/29/24 at 9:37 AM. This observation was confirmed by S3 and S8. S8 confirmed there was no staff member on the Staffing Assignment Sheets assigned to monitor Room 23, on 4/28-29/24 (11 PM-7 AM) or 4/29/24 (7 AM-3 PM). Through video surveillance review, there were no staff observed to conduct patient rounds on the 12A hallway during the following times: 4/28/24 from 5:30 PM until 6:27 PM; 4/29/24 from 3:15 AM until 4:00 AM, and 4/29/24 from 6:00 AM until 7:00 AM. The hallway observed on video surveillance included patient room numbers 17,19, 20, 21, 22, and 23. The rooms had a total of 19 patients assigned, three had a Level of Observation of Q15 minute rounding, 17 had a Level of Observation of Q30 minute rounding. All patients on 12A were ordered RN hourly rounding. The “RN Hourly Safety Round” and “MHA Safety Rounds” documentation indicated the patient rounding was performed, however, review of the video surveillance lacked evidence that rounding was completed per facility policy. On 5/7/24 at 12:25 PM, these findings were confirmed with S3 and S8. The lack of patient rounding by staff on the above-mentioned rooms and including Room 23A with a window that was temporarily repaired with cardboard, lead the facility to fail in mitigating the plan for risks identified on the ERA related to the nightstands and windows. 3) On 5/6/24 at 10:00 AM, S1 indicated on unit 12A, Room 23, P1 broke a window and eloped on 4/28/24. S1 indicated the broken window was temporarily repaired with cardboard on 4/28/24. S1 confirmed three patients remained in Room 23, with one staff member assigned to sit at the room at all times for safety until the window was repaired. On 5/7/24 at 10:44 AM, time stamped video surveillance review of “Bldg 12A East” was conducted. The video did not contain any audio. Video surveillance review revealed no staff member was observed to be monitoring room 23 on unit 12A, on 4/28/24 from 11:00 PM until 4/29/24 at 9:37 AM, this observation was confirmed S3 and S8. S8 confirmed there was no staff member on the Staffing Assignment Sheets for 4/28-29/24 (11 PM-7 AM) or 4/29/24 (7 AM-3 PM). 4) Facility policy titled, “Safety Searches and Contraband” reviewed 8/22, states, “It is policy ...that the necessary precautions are taken to ensure the safety of all patients and staff. As a means of accomplishing this, searches shall be made of patients, patients’ belongings at the time of admission, upon return from pass, ...B. Documentation of the search ...will be completed in a progress note in the patient’s medical record. ...Process/ Procedure: Behavioral Health Division A. All patients admitted to a Behavioral Health Division inpatient unit or returning from a pass from Behavioral Health Division unit are required to have a body, clothing, and belongings search. ... Documentation 1. Nursing Progress Notes include: A. Reason for conducting search ...” Facility policy titled, “Elopements (Unauthorized Discharge)” reviewed 8/22, states, “ ...Policy It is the policy of [facility name] that in the event that a patient/resident [facility name] without authorization for discharge efforts will be made to locate the patient and assure that they are in a safe environment. In the event that any patient leaves the Behavioral Health Division without authorization, the following procedure will be initiated. ... Documentation on Medical Record ...d. conduction of search of patient and belongings for; drugs, alcohol, dangerous items ...” On 5/6/24 at 1:58 PM, medical record review was conducted with S8 (Unit Manager). P1 was admitted to 12A on 6/14/23 at 3:08 PM, with a diagnosis of Schizophrenia and Intellectual Disability. The RN Progress Note on 4/28/24 at 7:26 PM, stated, “Patient was found missing during 1830 [6:30 PM] headcount. ...” The RN Progress Note on 4/28/24 at 9:39 PM, stated, “At approximately 8:45 PM, patient returned from [facility name] ER via stretcher accompanied by [facility name] nursing supervisor and RN. ...” On 5/6/24 at 2:04 PM, S3 confirmed there was no documentation of a body search completed for P1 once he/she returned to the facility after eloping. S3 stated, “a body search should have been conducted and documented.” At 2:10 PM, review of P3’s medical record revealed he/she was admitted on 1/21/22 and diagnosed with major depressive disorder. The RN Progress Note on 2/2/24 at 11:10 PM, stated, “Patient returned from out on pass in a stable condition.” The RN Progress Note on 3/1/24 at 4:53 PM, stated, “Returned from pass with sister at 1625 [4:25 PM] in good spirits.” S8 confirmed the medical record lacked documentation that body/clothing and belongings search was conducted upon P3’s return to the facility.”