UPMC Chautauqua at Wca

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 48506 Based on policy review, document review, medical record review, and interview, in 12 of 12 medical records reviewed, the facility did not ensure emergency department (ED) patients were informed of their Patient Bill of Rights. Findings include: Review of the policy “Patients’ Notice and Bill of Rights and Responsibilities,” dated 07/18/25, revealed the patients’ notice and bill of rights and patient responsibilities is made available to patients, their family members, and representatives via patient information materials and postings. Staff is responsible to assure that this information is also made available upon request. Review of the policy “New York State (NYS) Addendum to Corporate Policy Patient’s Notice and Bill of Rights and Responsibilities,” dated January 2024, revealed NYS provides specific bills of rights for patients in the hospital. These notices are made available to patients, their family members and representatives via patient information materials and postings. Review of the document “UPMC Consent For Treatment, Payment and Health Care Operations,” dated October 2022, and “UPMC Notice of Privacy Practices,” dated 01/19/26, revealed no evidence an electronic signature is required for the Patient Bill of Rights. Review of medical records for Patients #1 to Patient #12 revealed no evidence the patients were informed and/or provided a copy of the Patient Bill of Rights. Interview on 01/28/25 at 03:15 PM with Staff (BB), Administration, revealed the electronic signature required for the Patient Bill of Rights is the notice of privacy practices. Interview on 01/28/26 at 03:30 PM with Staff (A), Administration, verified these findings.”

“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: 48506 Based on policy review, video review, medical record review, document review, and interview, in one of 12 medical records review, the hospital failed to ensure all patients receive care in a safe setting. Specifically, emergency department (ED) staff failed to inspect/remove all clothing to eliminate the risk of contraband for Patient #1. Findings include: Review of the policy “Psychiatric Evaluation of Patients in the Emergency Department (ED),” dated 03/22/24, revealed the patient is to remain under constant observation (will remain in direct line of sight when in bathroom) until an appropriate level of lethality and needed level of observation is assessed. ED staff escorts patients to area, assists patients in changing into hospital three-hole gown, and secures personal belongings in a locker. Patients and their belongings are checked for contraband and with security assistance who wands (handheld metal detector) the patient. Review of the “ED Video for Admission of Patient #1,” date 01/11/26 revealed at 10:02 PM, Patient #1 and a visitor were escorted into ED room #107 by the triage nurse. At 10:04 PM to 10:08 PM, security staff entered ED room #107 with a bag (belongings for Patient #1 to change into). Patient #1 walked to the ED bathroom in front of Staff (W), Registered Nurse (RN) with the bag. Staff (W) stood in the opened doorway of the bathroom with their back against the door jamb looking into the bathroom as Patient #1 was in the bathroom. Staff (W) walked into the bathroom, out of camera view, and then walked out with a bag (Patient #1’s belongings) and Patient #1. Patient #1 was wearing a hospital gown and hospital pants (interview and document review indicated Patient #1 had their socks, bra, and a tank top, under the hospital gown and ears/nose piercings, not initially inspected by staff). At 10:09 PM, Staff (W) handed the bag (Patient #1’s belongings) to a security guard in the hallway outside of the bathroom. The security guard used a wand to Patient #1’s chest, waist, front of arms, legs, back, and back of arms. Staff walked Patient #1 back into ED room #107. Review of Patient #1 medical record revealed on 01/11/26 at 09:47 PM, Patient #1 presented to the emergency department (ED) with complaints of a mental health problem and depression. At 10:01 PM, Patient #1 denied homicidal thoughts and had no risk of violence. Patient #1 scored high risk for suicide on the Columbia Suicide Severity Rating Scale (CSSR-S - a six-question screening tool designed to assess the severity and immediacy of an individual’s suicide risk). At 10:12 PM, Staff (Y), Security Guard, scanned Patient #1 with a metal detector. Patient #1’s collected belongings were listed as boots, pants, sweatshirt, and a shirt. At 11:40 PM, Staff (W), RN, documented Patient #1 was changed into a psychiatric gown (three-hole gown with no ties) and psychiatric pants (no ties) for safety. Patient #1 was informed to remove everything except their underwear including jewelry. Patient #1 was then scanned by security, and all belongings were given to security. (Interview on 01/27/26 at 05:39 PM with Staff (W), RN, revealed this was a late entry note. Patient #1 was changed as soon as they were roomed into ED room #107). On 01/12/26 at 12:11 AM, Staff (V), Patient Care Technician (PCT), note documented Patient #1 still had a bra and tank top on under the psychiatric gown. Patient #1 took an eyebrow razor from their bra and handed it to Staff (V). Patient #1 had the razor in their bra the entire time even when security checked them (with a metal detector wand). At 12:13 AM, Staff (X), RN, documented Patient #1 was provided with their personal belongings from security to change into for discharge. Patient #1 was taken to the restroom with a 1:1 sitter standing outside of the room due to suspicious behavior. Patient #1 then pulled a sharp item out of their waistband that was not found during initial changing and wanding. Patient #1 cut themselves on the right side of the neck. It was discovered that during initial security changing, Patient #1 was not made to take off their bra and the object was stored there. Review of the occurrence report, dated 01/13/26 at 01:12 AM, revealed Patient #1 still had their personal socks, bra, and tank top on under the psychiatric gown after the initial changing into a hospital gown and belongings check. Telephone interview on 01/27/26 at 02:15 PM with Staff (M), Physician Assistant, revealed Patient #1 scored high risk for suicide. Staff (M) did not recall if a Safe-T suicide assessment was performed, but Patient #1 did require constant 1:1 observation. On assessment, Patient #1 was in a psychiatric gown and pants. Staff (M) was unaware Patient #1 had a bra on. Staff (M) was made aware that Patient #1 cut their neck in the bathroom with a small eyebrow razor when changing into their clothes after discharge. Telephone interview on 01/27/26 at 02:53 PM with Staff (N), RN, revealed Patient #1 scored high risk for suicide and a 1:1 staff member was provided. Staff (N) walked Patient #1 to ED room #107 where Staff (W), RN, was waiting for them with security. Staff (N) heard Staff (V), PCT, yelling that Patient #1 had cut themselves in the bathroom. After Patient #1 cut their neck, they did not want to give hospital staff the razor. Patient #1 stated they had the razor with them the entire time and cut themselves because they did not want to go back to the group home. Interview on 01/27/26 at 04:00 PM with Staff (D), Administration, verified staff failed to inspect/remove all clothing to eliminate contraband. Telephone interview on 01/27/26 at 05:15 PM with Staff (V), PCT, revealed they had a feeling that Patient #1 was going to do something and quickly followed Patient #1. Patient #1 had locked themselves in the bathroom. Staff (V) asked Patient #1 to open the door, when Patient #1 did not open the door, Staff (V) called out for security to open the door. Patient #1 did open the door and Staff (V) saw blood on Patient #1’s neck. Patient #1 was walked to ED room #107 and changed into a new psychiatric gown, while changing, it was noted that Patient #1 still had on their bra and a tank top. When Patient #1 removed their bra and tank top they handed an “eyebrow razor” to Staff (V). Telephone interview on 01/27/26 at 05:39 PM with Staff (W), RN, revealed they escorted Patient #1 to the bathroom and watched as Patient #1 changed (upon admission). Staff (W) did not stare directly at Patient #1 while they were changing but was always able to see Patient #1. Staff (W) was unaware that Patient #1 did not remove their bra. Patient #1 was wanded by security after changing into hospital clothing, but the wand did not alert that Patient #1 had any metal on their person. Interview on 01/27/26 at 05:52 PM with Staff (X), RN, revealed Staff (V), PCT, went with Patient #1 to the bathroom due to Patient #1’s odd behavior when being told about their discharge. Staff (X) was told by another staff member that Patient #1 had cut themselves. Staff (X) went to room #107 and assisted with changing Patient #1 again and removing any additional jewelry. Staff (X) was surprised to see that Patient #1 had their bra and tank top on under the psychiatric gown. When a patient is on a 1:1 constant observation sitter, security will bring the safe clothing and the property bag to the patient, the nursing staff will tell the patient how to change while security waits outside the room, afterwards security will wand the patient and inventory the items in the patient’s belonging bag. High risk patients are allowed to keep their underwear, if their bra has metal in it, they are not allowed to keep that. Telephone interview on 01/28/26 at 09:00 AM with Staff (Y), Security Guard, revealed Patient #1 walked through a metal detector (security archway designed to detect concealed metallic items, like weapons) in the ED waiting room on arrival to the ED. Patient #1 did not set off the alarm on the metal detector. Staff (Y) brought Patient #1 a paper bag with a hospital psychiatric gown and pants to change into on arrival to room #107 in the ED. Staff (W), RN, went to the bathroom with Patient #1 and watched them change from the doorway. After Patient #1 was in the hospital clothing, Staff (Y) wanded Patient #1 and collected their belongings to be placed in a secured belongings room. The wand did not alert that Patient #1 had any metal on their person. Wanding procedure is to go over a person’s chest, stomach, waistline, legs, arms, back, and hair line if a patient has their hair up in a bun or ponytail with the wand about an inch away from the person’s body. Patients are allowed to keep their underwear on, but typically not a bra. When Patient #1 was provided with their belongings, they ran to the bathroom to change and locked the door. Staff (V), PCT, followed Patient #1 to the bathroom and asked them to unlock the door. Patient #1 did unlock the door and then was noted to have cut their neck. Nursing staff assisted in caring for Patient #1 and had Patient #1 change into another psychiatric gown and removed their bra. Patient #1 had handed a razor to clinical staff. Staff (Y) wanded Patient #1 again with no alert of metal. Interview on 01/28/26 at 12:25 PM with Staff (B), Administration, verified this finding.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 48506 Based on policy review, medical record review, and interview, in one of 12 medical records reviewed, emergency department (ED) staff failed to follow established policies and procedures based on Patient #1’s clinical presentation/assessment. Specifically, staff did not document an environmental risk assessment (removal of potential hazards for a suicidal patient); did not order constant 1:1 observation and/or performed a Safe-T Suicide Risk Assessment (suicide risk assessment) based on the suicide severity assessment score; and did not provide wound care instructions at discharge (Patient #1). Findings include: Review of the policy “Psychiatric Evaluation of Patients in the Emergency Department (ED),” dated 03/22/24, revealed the patient is to remain under constant observation (will remain in direct line of sight when in bathroom) until an appropriate level of lethality and needed level of observation is assessed. ED staff escorts patients to area, assists patients in changing into hospital three-hole gown, and secures personal belongings in a locker. Patients and their belongings are checked for contraband and with security assistance who wands (handheld metal detector) the patient. Review of the policy “Admission to ED, Transfer/Discharge from ED,” dated 08/09/24, revealed the provider will determine disposition of the patient based on medical exams and inform the patient of disposition. The physician will discharge the patient with appropriate discharge instructions. Nursing/physician/physician assistant/nurse practitioner will provide the patient with the discharge instructions to the patient/patient representative. Instructions will be reviewed, and questions answered prior to departure. Review of the policy “Assessing Patient Risk for Suicide,” dated 09/27/25, revealed patients who are being evaluated or treated for behavioral health conditions as their primary reason for care, will be screened for suicidal ideation using the validated Columbia-Suicide Severity Rating Scale (CSSR-S - a six-question screening tool designed to assess the severity and immediacy of an individual’s suicide risk). A provider may also initiate precautions for a patient, in lieu of completion of a CSSRS. If a provider initiates suicide precautions for a patient, the nurse should complete a CSSRS. A staff member may also complete a CSSRS form at any time when there is an identified/potential concern for suicide with a patient. If a patient screens positive for suicide after completion of a CSSRS, a “Safe-T Suicide Risk Assessment” form will be completed by trained staff to determine the suicide risk level of the patient (high, moderate, low). High risk patients will have a constant observation or special constant observation ordered, utilize a ligature resistant bathroom and if not available, observe the patient while the patient is in the bathroom, assess the physical environment and remove contraband, including unsafe items not necessary for patient care, place patient in hospital attire, and when appropriate have a psychiatry consult, provide patient with information on counseling and follow up care at discharge, including providing the telephone number of crisis call centers. The environmental hazards assessment tool will help complete an environmental assessment for patients at risk of suicide. Review of the medical record for Patient #1 (Hospital #1) revealed on 01/11/26 at 09:47 PM, Patient #1 presented to the ED with complaint of a mental health problem and depression. At 09:59 PM, Staff (N), Registered Nurse, assigned Patient #1 an acuity of two (potentially life-threatening/high-risk conditions who require prompt medical evaluation) and a group home staff member was present with Patient #1. From 01/11/26 at 10:00 PM to 01/12/26 at 01:30 AM, Patient #1 had a continuous 1:1 observation sitter with documented checks every 15 minutes (no order was found for constant 1:1 observation). At 10:01 PM, Patient #1 denied homicidal thoughts and had no risk of violence. Patient #1 scored high risk for suicide on the CSSRS (no Safe-T Suicide Risk Assessment was performed due to Patient #1’s high suicide risk). At 10:12 PM, Staff (Y), Security Guard, scanned Patient #1 with a metal detector. Patient #1’s collected belongings were listed as boots, pants, sweatshirt, and a shirt (no environmental hazards assessment was documented). On 01/12/26, at 12:13 AM, Staff (X) documented Patient #1 was provided with their personal belongings from security to change into for discharge. Patient #1 was taken to the restroom with a 1:1 sitter standing outside of the room due to suspicious behavior. Patient #1 then pulled a sharp item out of their waistband that was not found during initial changing and wanding. Patient #1 cut themselves on the right side of the neck. It was discovered when Patient #1 was initially changing their clothes, they were not made to take off their bra and the object was stored there. At 12:51 AM, Staff (M), prepped, numbed, and placed 10 sutures on Patient #1’s right neck. At 01:25 AM, Patient #1’s after-visit summary discharge paperwork was printed. The after-visit summary did not contain wound care instructions. At 01:45 AM, Patient #1 was discharged home with group home staff. Telephone interview on 01/27/26 at 02:15 PM with Staff (M), ED Physician Assistant, revealed Patient #1 was verbally defiant, threatening self-harm on presentation to the ED. Patient #1 scored high risk for suicide. Staff (M) did not recall the Safe-T Suicide Risk Assessment, but Patient #1 did require constant observation (1:1 sitter). Staff (M) did not recall placing wound orders in the computer. Nursing staff would relay discharge orders to Patient #1 and the group home staff. Interview on 01/27/26 at 04:00 PM with Staff (D), Adminstration, verified staff failed to document an environmental risk assessment; order constant 1:1 observation or performed a Safe-T Suicide Risk Assessment; and did not provide Patient #1 or group home staff with wound care instructions at discharge.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 50463 1104 Based on observation, policy review, medical record review, document review, and interview, in 12 of 12 medical records reviewed, the hospital failed to ensure clinical staff implemented established policies and procedures, and the medical staff did not conduct ongoing assessment of the medical care in the emergency department (ED). Specifically, patients presenting to the emergency department (ED) for a mental health evaluation, are not screened for violence/homicidal ideation; do not receive a coordinated psychiatric consultation assessment by qualified professional staff communicated between services; the ED provider, the psychiatrist, and the behavioral health navigator do not hold a conference to discuss patient information to determine treatment and/or disposition; the ED provider and on-call psychiatrist do not review 9.41/9.45 paperwork (the Director of Community Services/designee authorizes the involuntary transport of a patient with mental illness for emergency assessment for immediate observation, care, and treatment, who is likely harm themselves or others), collateral information, and mental health assessments by the behavioral health navigator, leaving the responsibility on the Behavioral Health Navigator (non-licensed practitioner) to report out to them and make recommendations; and the psychiatrist does not document a consultation and/or made treatment/disposition recommendations in the medical record after being consulted.(Patient #1 to Patient #12). Findings include: Review of the policy “ Medical Staff Bylaws, Policies, and Rules and Regulations,” dated 04/01/24 revealed consulting staff members may evaluate and treat patients in conjunction with other members of the medical staff. When providing a consultation, the consulting practitioner will review the patient’s medical record, brief the patient on the consulting practitioner’s role, and examine the patient in a manner consistent with the requested consultation. Any plan for ongoing involvement by the consulting practitioner will be directly communicated to the requesting practitioner through a note in the electronic medical record, by phone call, or by secure text message. Once the consulting practitioner is involved in the care of the patient, the requesting practitioner and consulting practitioner are expected to review each other’s notes in the patient’s medical record on a regular basis to assure continuity of care until the consulting practitioner has signed off on the case or the patient is discharged. Consultation reports will be completed in a timely manner and documented in the electronic medical record or dictated/legible written notes. The consultation report will contain the date and time of the consultation, opinions based on relevant findings and reasons, and recommendations by the consulting practitioner. Review of the policy “Emergency Department Mental Health Unit Coverage,” dated 03/08/24 revealed counselors (behavioral health navigators or designated Registered Nurses-RN) are scheduled to provide behavioral health evaluations in the ED. The on-call psychiatrist works with ED counselors/RNs in their case-by-case interactions to develop the counselor’s assessment and communications skills. Review of the policy “Psychiatric Evaluation of Patients in the Emergency Department,” dated 03/22/24, revealed a person in need of a mental health evaluation may come to the ED. An ED provider will write an order for a psychiatric evaluation to be initiated. The ED counselor (Mental Health Counselor /Behavioral Health Navigator) will assess the patient upon arrival and with ED staff determine level of security required to manage the patient (the need for seclusion, where to interview patient, appropriate room). The ED counselor will interview the patient, family, significant others, custodians and complete an evaluation. A conference will occur between the ED provider, ED counselor, and psychiatrist to review care. The ED counselor will call the unit charge nurse to discuss evaluation and disposition options. The ED counselor will discuss evaluation findings and psychiatrist recommendations with the ED physician and charge nurse. The ED physician/Physician Assistant will medically clear the patient. The ED physician will note agreement with the evaluation disposition on ED record. If ED physician does not agree with the disposition, the physician may discuss the disposition with the on-call psychiatrist or request the psychiatrist to come to the ED for a face-to-face evaluation. If after evaluation, the counselor, charge nurse, ED physician and on-call psychiatrist determine a patient may be discharged with referrals to outpatient mental health/chemical dependency program, or to the patient’s present linkage, the ED counselor will give the patient discharge instructions and make appointments for outpatient services. The ED counselor will complete a behavioral health evaluation and document the evaluation findings/disposition in the ED record. (This policy does not address the need for a licensed healthcare professional to review the ED counselor’s assessments and/or the need for the ED provider or on-call psychiatrist to document their recommendations for the treatment and/or disposition of mental health patients). Review of the policy “Assessing Patient Risk for Suicide,” dated 01/27/25 revealed patients who are being evaluated or treated for behavioral health conditions as their primary reason for care, will be screened for suicidal ideation using the Columbia-Suicide Severity Rating Scale (C-SSRS). If a patient screens positive for suicide after a completed C-SSRS, a SAFE-T Suicide Risk Assessment form will be completed by trained staff in order to determine the suicide risk level of the patient. (This policy does not address violence/homicidal patient screening. No policy was found for violence/homicidal screening). Review of ED medical record for Patient #1, dated 09/11/25, revealed the following: At 10:30 AM, the 9.45 Mental Hygiene Law paperwork revealed Patient #1’s case manager contacted the Director of Community Services, who contacted the local police department to have Patient #1 transported to the facility for an emergency admission under the Mental Hygiene Law (the Director of Community Services/designee authorizes the involuntary transport of a patient with mental illness for emergency assessment for immediate observation, care, and treatment, who is likely harm themselves or others). The 9.45 Mental Hygiene Law paperwork addendum (not timed) revealed Patient #1 was a danger to themself and others, specifically their roommate and other residents in the building. Patient #1 had a plan to use a machete. Patient #1 was potentially violent due to their paranoia and belief that they needed to defend themself. Patient #1 had several knives and a machete available to them as a weapon. Patient #1 reported that they had not been home due to the fear that others were plotting against them. Patient #1 was fearful that when they arrived home, they would attempt to protect themselves with a machete or end their own life by overdosing. At 10:59 AM, Patient #1 presented to the ED for a mental health examination on a 9.45 Mental Hygiene Law request for examination. Patient #1 signed the consent for treatment. At 11:39 AM, Staff (K), Registered Nurse, performed a triage assessment that indicated Patient #1 presented for a 9:41 mental health exam from home. Patient #1’ s complained of occasional paranoia especially when using methamphetamine (meth) and stated they were worried about hurting others when they used. Patient #1 stated they had a history of a home invasion, had PTSD, and had possible paranoid schizophrenia (persistent delusions and auditory hallucinations). Patient #1 denied suicidal ideation. Patient #1 was assigned an ESI Level Two- urgent (triage patient conditions based on severity. One is most urgent, five is least urgent). Patient #1 scored low risk for suicide on the C-SSRS and denied suicidal thoughts in the past month. Patient #1 was a current substance user of cocaine/crack and crystal meth, three to five times a week and experienced withdrawals. Vital signs were within normal limits, Patient #1 denied pain. (No violence or homicidal screening was performed). At 11:40 AM, Staff (L), Physician, performed a medical screening exam that indicated Patient #1 presented to the ED for a mental health evaluation and admitted to methamphetamine use that made them paranoid. Patient #1 stated they currently did not have any suicidal or homicidal thoughts. Patient #1 had rapid speech, but was in no acute distress and did not look acutely intoxicated. Patient #1 had a normal physical examination and was alert and oriented in no acute distress. Patient #1 was cooperative and had an appropriate mood and affect. Patient #1 had a negative suicide risk screen and had no thoughts of death, no plan, intent, or behavior. Patient #1 was seen by the Behavior Health Navigator (an unlicensed mental health counselor) who saw and cleared Patient #1 for discharge (Patient #1’s mental health assessment was not performed until 05:50 PM by the behavioral health navigator or BHN). Patient #1’s symptoms were clearly from using methamphetamine. Patient #1 was not acutely intoxicated and was encouraged to stop using. Given their outside resources, Patient #1 was discharged in stable condition. The discharge diagnosis was listed as methamphetamine use disorder. At 01:00 PM, 03:00PM, and 05:00 PM, the medical record indicated “re-evaluation” that was “unchanged” was documented. At 05:40 PM, Staff (L), Physician, ordered Patient #1 to be discharged. The “Discharge Clinical Summary” and “Discharge Instructions “indicated a discharge diagnosis of methamphetamine use disorder. Vital signs were listed, no new prescriptions were given, and no laboratory data had resulted. Information for substance abuse disorder with specific instructions were given to Patient #1 and they were to follow-up with their primary care provider within three to five days. The crisis services phone number was provided. (Staff (L) discharged Patient #1 home prior to the mental health evaluation, the violence screening, and recommendation for discharge by the psychiatrist). At 05:43 PM, by Staff (P), Registered Nurse, reviewed and signed off the discharge order. At 05:50 PM, Staff (M), Behavior Health Navigator, documented a mental health evaluation that indicated Patient #1 presented at the ED on a 9.45 mental health evaluation request from the mobile crisis team after their probation officer (PO) initiated and called the request in. The PO was concerned Patient #1 was suicidal last month, using meth recently, and had increased paranoia from it. The PO was concerned Patient #1 would harm someone else. Staff (M) documented Patient #1 had history of psychiatric hospitalization (most recent hospitalization was 08/08/25 to 08/27/25 at this hospital), no history of violence, no history of suicide attempts, and was a heavy/frequency user of amphetamine for seven years. Patient #1’s risk factors for suicide and homicide include current /symptomatic psychiatric illness, and inadequate or overwhelmed coping. Patient #1 had internal protective factors of future planning, identified reasons for living, and had positive coping skills. Patient #1 was willing to access treatment and support. Patient #1 has an unknown primary care physician. An outpatient clinic for chemical dependency, and an outpatient clinic for mental health are documented with contact information. Patient #1 completed a 28-day rehab program. Patient #1 lives alone in permanent housing. Patient #1 stated they know the paranoia is from meth use but they are struggling to reality test at this point. Patient #1 had pressured speech and is tangential (erratic) with repeated stories from previous evaluations they had done. Patient #1 thinks there is a group of people spying on them, videoing them in their apartment, and posting to social media. There is no outside evidence this happened. Patient #1 admitted to using meth yesterday and prior to their arrival to the ED. This appeared to be the “typical baseline when they use meth and present to the ED.” Patient #1 denied suicidal and homicidal ideations but said they are fearful when they use. Staff (M) documented the medical provider and Staff (L), Psychiatrist, were consulted and agreed to discharge Patient #1 to current outpatient services at this time. (This assessment does not include information from the 9.45 paperwork indicating Patient #1 was a danger to self and others, specifically mentioning their roommate; had a plan for homicide to defend self; had access to knives and a machete; and had not been home for fear of committing homicide and/or suicide by overdose upon arrival at their home. The ED physician and the on-call psychiatrist did not review this assessment. Staff (M) did not receive the psychiatrist’s recommendation for discharge until 07:00 PM. Patient #1 was discharged at 06:26 PM). At 06:26 PM, Staff (K), Registered Nurse, documented Patient #1 was discharged unaccompanied to home or self-care, ambulatory, in stable condition. At 07:43 PM, Staff (M), Behavior Health Navigator, documented the following violence risk assessment: Patient #1 answered “yes” to owning or having access to firearms or other weapons. Patient #1 stated they have knives and a machete. Patient #1 has poor impulse control and a legal history. Patient #1 has a psychiatric history that included PTSD, suicide/self-injury, psychotic disorder and prescribed psychiatric medications. Patient #1 answered “NO” to they and others who know Patient #1 report that Patient #1 has been having thoughts of harming others. Patient #1 denied making a statement of the intent to kill or harm others. Patient #1 denied focused threats on a specific person. Patient #1 denied attempting or inflicting serious or intentional harm to a person. Patient #1 denied recent loss or significant changes in life. Patient #1 answered “YES” to they or others who know the Patient #1 report that Patient #1 is in danger because of disturbed thinking. Patient #1 has a psychiatric diagnosis consistent with the development of psychotic process. Patient #1 exhibited, or others reported impairment in capacity to reality test. Patient #1 answered “NO” to reporting expressions of hallucinations specific to harming self or others. Patient #1 denied exhibiting or others report impairment in ability to make rational, life preserving judgements. (The ED physician or the on-call psychiatrist did not review this assessment). Review of the TEAMS (unsecure, online messaging system) message on 09/11/25 at 05:49 PM by Staff (M), Behavior Health Navigator (BHT) to Staff (N), Psychiatrist revealed the message contained Patient #1’s name and they presented to the ED on a 9.45 from mobile crisis after their probation officer (PO) called in. Collateral information from the PO (PO left a voice message, Staff (M) did not speak to them) was they were concerned since Patient #1 was suicidal last month, as well as using meth recently, and had increased paranoia from it. The PO stated they were concerned Patient #1 will harm someone else. Patient #1 stated they know the paranoia is from meth and are struggling to reality test at this point. Patient #1 had pressured speech with tangential and repeated stories from previous evaluations they had completed on them. Patient #1 stated they think there is a group of people spying on them, videoing them in their apartment, and posting it on social media. There is no evidence this is happening. Patient #1 admitted to using meth yesterday and today, prior arriving to the ED. Staff (M) documented “think we are at the typical baseline when they use meth and presents here.” Patient #1 denied suicidal ideations/homicidal ideations currently, but did say they are fearful when they use. Patient #1 stated they are now friends with Patient #10 (homicide victim) since they spent time together on the inpatient unit recently. Patient #10 has been staying with them. “Can we discharge?” At 06:21 PM, Staff (M), BHN, sent an additional message to Staff (N), Psychiatrist, with Patient #2’s name with history and “Can we discharge?” At 06:21 PM, Staff (L), Psychiatrist, replied “OK to discharge.” At 06:22 PM, Staff (M), BHT, replied “OK to discharge both?” At 07:00 PM, Staff (L), Psychiatrist, replied “Yes please.” Interview on 09/24/25 at 02:30 PM with Staff (O), Hospital Administrator, revealed that a violence risk screen is done by the behavioral health navigators (an unlicensed mental health counselor). The screening will be documented on paper and scanned into the electronic medical record. Staff (O) verified that Patient #1 ’ s violence risk screen assessment was timed and dated after Patient #1 was discharged from the hospital. Staff (O) stated the registered nurses complete the C-SSRS to assess suicide risk but there is no current process in place for assessing homicidal ideation. Interview on 09/24/25 at 02:35 PM and 03:04 PM with Staff (J), Hospital Administrator, revealed there was no formal process or procedure for nursing staff to ask a patient about homicide or if they intend to harm others during triage. Nursing staff use the ED Triage assessment that does not have homicidal questions. Interview on 09/24/25 at 03:25 PM and 09/25/25 at 02:44 PM with Staff (N), Psychiatrist, revealed methamphetamine use caused Patient #1 to be paranoid. Patient #1 was familiar to them. On 09/11/25, Patient #1 did not present psychotic that day, but it is possible they could have been psychotic upon discharge. The plan for Patient #1 was to follow/continue the previously set up outpatient services after the 08/27/25 inpatient psychiatric unit discharge. Staff (N) did not evaluate Patient #1 in person but reviewed the “TEAMS” message chat from Staff (M), Behavioral Health Navigator (BHN), who recommended the discharge disposition. Staff (N) gave the okay to discharge Patient #1 via “TEAMS” message to Staff (M), BHN. Staff (N), has access to the electronic medical record but did not review Patient #1’s 9.45 paperwork or the violence risk assessment, indicating that is the responsibility of the BHN to review and report the findings. The BHN makes a discharge recommendation to the psychiatrist via “ TEAMS,” and the psychiatrist makes a discharge recommendation to the ED physician via the BHN. The ED physician has the ultimate decision regarding the discharge disposition of the patient from the ED. It is not common for the psychiatrist to speak to the ED physician unless a patient was a “complicated case” where the ED physician disagreed with the psychiatry recommendation. Staff (N) was aware the BHN are not licensed, are only able to complete data collection, and cannot perform assessments. There is no requirement for psychiatrist documentation of the discharge recommendation. Staff (N) makes that recommendation to the BHN who will document it. A patient brought to the ED for a 9.45 must be evaluated by a provider. If a BHN is unavailable, the ED physician would be responsible for the evaluation. It is very uncommon for the psychiatrist to present to the ED for an evaluation. The only time that would occur is if the ED physician requested the psychiatrist to do an in-person evaluation. Interview on 09/24/25 at 04:11 PM and 09/25/25 at 04:16 PM with Staff (L), Physician, revealed that the initial evaluation of Patient #1 was completed while Patient #1 sat in a hallway chair across from the nursing station. Patient #1 was calm, and directable. Patient #1 stated they had an increase in paranoia when they used methamphetamine and confirmed meth use that morning. Patient #1 was not “high” and did not show signs of methamphetamine psychosis, which varies. Patient #1 was cooperative, had capacity (answered all questions) despite their methamphetamine use, and was easily cleared medically. Staff (L) was aware of Patient #1 ’ s presenting complaint to harm others, however, Patient #1 never expressed suicidal or homicidal ideations upon their assessment. Staff (M), Behavioral Health Navigator (BHN), completed their evaluation and informed Staff (L) that Patient #1 was able to be discharged. After that conversation, Staff (L) ordered the discharge of Patient #1. Once the BHN/mental health counselor is involved, the ED provider waits for the psychiatric disposition. Staff (L) did not re view the 9.45 paperwork for Patient #1. There was no conversation between Staff (M), BHN, Staff (N), Psychiatrist, and Staff (L). Staff (L) does not review the BHN’ s documentation and does not obtain collateral information. It is rare for the ED physician to speak directly to the psychiatrist; the conversation is always held with the BHN. This process has been in place for at least six years. Patient #1 was previously set up with outpatient community services when they were discharged from the inpatient setting in August 2025. Patient #1 was previously provided chemical dependency rehab and was set up for outpatient substance abuse rehab in the community. Discharge education was provided to Patient #1 for substance use disorders and to follow up with their mental health providers in the community. Further mental health discharge instructions regarding appointment times would be provided by the BHN. Patient #1 was cleared by psychiatry and not intoxicated by methamphetamines. Staff (L) felt comfortable with the discharge of Patient #1. Interview on 09/25/25 at 08:10 AM with Staff (K), Registered Nurse, revealed that Patient #1 presented on a 9.41 with police. Patient #1 was triaged across from the nursing station with a complaint of feeling confused and paranoid. Patient #1 had PTSD, and their paranoia worsened when they used methamphetamine. Patient #1 heard voices and stated they “didn’t want to hurt anyone” by listening to the voices. Patient #1 was calm, not twitchy or nervous, and directly answered questions. Patient #1 did not have the desire to hurt themselves or anyone else. Staff (K) does not remember reviewing the 9.41/9.45 paperwork for Patient #1 but usually does. During triage, the police officer mentioned they were familiar with Patient #1 and when Patient #1 wanted help, they would reach out to the police department or their counselor. Staff (K) did not recall Patient #1 mentioning anything about a machete, but they stated they wanting to harm others when they used methamphetamine. Patient #1 was non-committal to when they last used methamphetamine, eventually stating it was “days ago.” Staff (K) stated there are no homicidal questions that are a part of the triage process. Staff (K) discharged Patient #1 and provided substance use education. Interview on 09/25/25 at 11:19 AM with Staff (R), Hospital Administrator, revealed that the hospital does not have any policies in place to assess homicidal risk. Interview on 09/25/25 at 11:31 AM with Staff (O), Hospital Administrator, revealed that behavioral health navigators (BHN) are not licensed staff. They can collect data and gather information for the psychiatrist. The psychiatrist does not sign-off on the BHN notes and does not provide a consultation note. The ED physician, BHN, and the psychiatrist will have a three-way conversation in rare, specific patient circumstances. Interview on 09/25/25 at 12:26 PM with Staff (M), Behavioral Health Navigator (BHN), revealed they are not licensed in New York State. Patient #1 was brought into the hospital by the police for a mental health evaluation. Patient #1 was calm and cooperative. Patient #1 stated walking in the streets all night after using methamphetamine, which caused them to see shadows. Patient #1 called their probation officer and was concerned they would go to go to jail for the prohibited drug use. Staff (M) was familiar with Patient #1 from past evaluations. Patient #1 appeared to be at their baseline. Patient #1 had no current homicidal or suicidal ideations, but stated they were afraid when they were high on methamphetamine that they would hurt someone. Patient #1 admitted to having access to knives and a machete. Patient #1 had carried a large hunting knife in the past but self-surrendered the knife to security when they came to the hospital because of the fear others were going to harm them. The mental health evaluation process includes a review of previous admission or evaluations, asking the patient questions from the evaluation form, obtaining collateral information, messaging the on-call psychiatrist via “TEAMS” chat messaging, and speaking to the ED physician in person. If the psychiatrist did not reply in the “TEAMS” chat, they would attempt to call them. Staff (M) updated Staff (N), Psychiatrist, through “TEAMS” chat for Patient #1. The message included the evaluation, collateral information collected, and Staff (M)’s recommendation for discharge. Staff (N), Psychiatrist agreed with the recommendation and responded it was okay to discharge. If the psychiatrist disagreed with the recommendation, they would provide their recommendations to be communicated to the ED physician by the BHN. The violence risk assessment questions are completed during the patient evaluation; however, Staff (M) documents and signs the form when they have time during their shift. Patient #1 ’ s violence risk assessment documentation was signed after Patient #1 left the ED. Patient #1 stated they lived alone with a dog. Staff (M) was unaware that Patient #1 had a roommate. Patient #1 stated they should not use methamphetamines anymore but was not interested in substance abuse rehab. Staff (M) stated a conference call between the BHN, the ED physician, and the psychiatrist does not occur. The only time the ED physician would speak directly to the psychiatrist would be if they disagreed with each other. On discharge from the hospital, Patient #1 appeared to be at their baseline mentation. Staff (M) obtained collateral information from a voicemail left by Patient #1 ’ s probation officer, and did not recall speaking directly to the probation officer.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48608 Based on policy review, medical record review, document review, video surveillance review, and staff interviews, it was determined that for 9 of 25 medical records reviewed the facility failed to protect and promote the rights of all patients as evidence by: the hospital failed to provide constant observation or special constant observation for two of two patients (Patient #1 and #2) at moderate or high risk for suicide in the emergency department (Tag A-0144). Additionally, a physician order was not obtained for constant observation for moderate/high-risk suicidal patients for 9 of 25 patients (Patient #1, #2, #3, #5, #6, #7, #8, #9, and #12) (Tag A-0144). Reference: 482.13(c)(2) Patient Rights: Care in a Safe Setting. 482.13(c)(3) Patient Rights: Free from all Forms of Abuse or Harassment.”

“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: 48608 Based on policy review, medical record review, video surveillance review, and staff interviews, the facility failed to provide care in a safe setting. 1. The hospital failed to provide constant observation for two of two emergency department patients (Patient #1 and #2). This resulted in the inappropriate touching of Patient #1 by Patient #2. 2. The hospital failed to ensure physician orders were obtained and interventions implemented for constant observation and special constant observation in the emergency department for 9 of 12 patients (Patient #1, #2, #3, #5, #6, #7, #8, #9, and #12). This resulted in the inappropriate touching of Patient #1 by Patient #2. Findings #1: Review on 06/18/24 of the policy “Psychiatric Evaluation of Patients in the Emergency Department,” last reviewed 03/22/24, revealed a person in need of a mental health evaluation may come to the emergency department and a psychiatric evaluation will be initiated. The patient is to remain under constant observation (staff continuously observing and keeping a patient in sight with hands visible at all times) until an appropriate level of lethality (capacity to cause death or serious harm) and needed level of observation is assessed. Review on 06/17/24 of the policy “Assessing Patient Risk For Suicide,” dated 11/29/23, revealed “constant observation staff continuously observes, keeping the patient in sight at all times. The patient’s hands must be visible at all times. Constant observation must be completed in the bathroom and for any medical testing. Patients on constant observation may have issues that jeopardize their safety or the safety of others. If a patient’s screen or assessment is positive for suicide after completion of a Columbia Suicide Severity Rating Scale (an assessment tool that helps to determine an individual’s suicide risk) or if a provider orders a psychiatric care attendant, suicide precautions and interventions will be determined by the identified suicide risk level (high, moderate, or low). Monitoring should be constant, and a staff member should be assigned to observe only one patient at all times (one staff member to one patient), that would allow the staff member, or other staff member, to immediately intervene should the patient attempt self-harm.” Review on 06/18/24 of the policy “Care Attendant Utilization and Observation of Patients,” dated 02/01/24, revealed “a psychiatric care attendant provides constant observation or special constant observation to assigned suicidal or behavioral health patients under the direction of the registered nurse, physician, or provider with prescriptive authority. The request for a psychiatric care attendant for suicidal or behavioral health patients requires the order from a physician. Nurses may initiate constant observation or special constant observation of a patient for the safety of a patient until an order is secured. Discontinuation of a psychiatric care attendant can only be completed with a physician’s order. The psychiatric care attendant will have limited direct care responsibilities so that the patient remains in direct eyesight or as ordered, within arm’s reach at all times. As a result, the psychiatric care attendant may not complete other care or activities of daily living for the patient that would require the psychiatric care attendant to leave the room or turn their back on the patient. Staff functioning in the psychiatric care attendant role will be informed of the reason that the patient requires a psychiatric care attendant by the assigned nurse. The use of radios, headphones, and/or any other electrical device by the care attendant for personal use is prohibited. Psychiatric care attendants may be used in non-behavioral health departments. Constant observation staff continuously observes and may interact individually with the patient while keeping the patient in sight at all times. The patient ’ s hands must be visible at all times to the observation staff. Constant observation must also be completed in the bathroom and when the patient leaves for any medical testing. Special constant observation staff continuously observes the patient within arm’s distance. Additionally, the patient’s hands must be visible at all times to the staff. Special constant observation must also be completed in the bathroom and when the patient leaves for any medical testing. This level of observation is used when it is necessary to have the staff close to the patient to prevent the patient from injuring themselves. Constant observation or special constant observation is to be maintained without disruption, so the patient is in direct eyesight at all times. For patients identified at high or moderate risk for suicide, with constant observation, utilize a ligature resistant (modified to reduce the number of points that may be used for hanging/strangulation) bathroom, if not available, observe the patient while the patient is in the bathroom. For patients identified at high or moderate risk for suicide, with special constant observation, observe the patient while in the bathroom.” Review on 06/18/24 of the medical record for Patient #1 revealed the following: On 06/09/24 at 02:17 PM, Staff (FF), Registered Nurse documented a triage note indicating Patient #1 (minor under the age of 18) presented via ambulance to the emergency department under the authority of Section 9.41 of the Mental Hygiene Law of New York State (mental hygiene law that permits police officers or peace officers to take into custody any individual who is demonstrating behavior which is likely to result in harm to self or others and have the individual transported to a hospital or comprehensive psychiatric emergency program for psychiatric evaluation and treatment.) for attempts to throw themselves out of a second story window. When Patient #1’s guardian stopped them, Patient #1 attempted to throw themselves into moving traffic. Patient #1 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale (a unique suicide risk assessment tool that supports suicide risk assessment through a series of simple, plain-language questions that anyone can ask). On 06/09/24 at 02:50 PM, Staff (TT), Physician placed an order for Patient #1 to be admitted to the inpatient behavioral health unit for the diagnosis of impulse control disorder (a group of behavioral conditions that make it difficult to control one’s actions or reactions). From 06/09/24 at 03:00 PM through 06/10/24 at 09:00 PM, Staff (K), Patient Care Technician documented constant observation checks every hour. Review on 06/18/24 of the medical record for Patient #2 revealed the following: On 06/10/24 at 01:00 AM through 10:00 AM, the “Constant Observation Flowsheet” revealed hourly constant observation documentation completed by Staff (K) Patient Care Technician. On 06/10/24 at 01:25 AM, Staff (QQ) Registered Nurse documented a triage note indicating Patient #2 presented with the police department to the emergency department under the authority of section 9.41 of the Mental Hygiene Law of New York State for hearing voices and having thoughts of hurting themselves and others. Patient #2 would not elaborate on their thoughts. On 06/10/24 at 01:31 AM, Patient #2 screened moderate risk for suicide on the Columbia Suicide Severity Rating Scale. On 06/10/24 at 09:37 AM, a nurse practitioner placed an order for Patient #2 to be admitted to the inpatient behavioral health unit for the diagnosis of schizophrenia. Review on 06/18/24 of security surveillance video of the behavioral health hallway located within the emergency department, dated 06/10/24 revealed: At 05:40:06 AM, Staff (K), Patient Care Technician was sitting at a stationed desk, eating, and looking at a cell phone that was positioned on the desktop, while Patient #1 appeared to be asleep on a stretcher in the hallway across from the desk. At 05:41:00 AM, Patient #2 entered the hallway from a patient room adjacent to Patient #1. Patient #2 approached the desk where Staff (K) sat and appeared to speak to Staff (K) who looked up at Patient #2 briefly and then back down at the cell phone multiple times. At 05:42:05 AM, Patient #2 is seen standing close to the head of the stretcher where Patient #1 appeared to be asleep, looking at Patient #1. Staff (K) was seated at the desk looking down at the cell phone positioned on the desktop when Patient #2 approached Patient #1 on the gurney. At 05:42:08 AM, Patient #2 rested a hand upon Patient #1’s shoulder. Patient #2 removed the hand from Patient #1 and turned back to approach Staff (K) who was sitting at the desk with their head down looking at their phone, spoke to Staff (K) and was seen walking away from the desk, leaving the video frame. At 05:42:28 AM, Patient #2 re-entered the video frame, approached the desk and appeared to be speaking to Staff (K). At 05:42:37 AM, Patient #2 turned from the desk and approached the gurney where Patient #1 appeared to be asleep. At 05:42:37 AM, Staff (K) was seen visualizing Patient #2 touch the leg of Patient #1 and appeared to be speaking to Patient #2 who turned away from the gurney and approached Staff (K) at the desk. At 05:42:39 AM Patient #2 placed their right hand upon Patient #1’s leg near the knee and slid their hand from the knee to the buttocks before removing the hand to turn towards Staff (K) at the desk. At 05:42:49 AM, Staff (K) stood up from the chair while speaking to Patient #2. At 05:42:55 AM, Staff (K) picked up the desk telephone to make a call. At 05:43:08 AM, Staff (P), Security Officer was seen entering the video frame from a door positioned next to the desk. At 05:43:10 AM, Patient #2 approached the stretcher and tried to touch Patient #1 on the leg. Staff (P) intervened by blocking Patient #2’s right hand before contacting Patient #1. At 05:43:12 AM, Patient #2 reached over Patient #1 with their left-hand touching Patient #1’s left buttocks before Staff (P) pulled Patient #2 back and stood between the gurney and Patient #2. At 05:43:13 AM, Staff (O), Physician Assistant entered the video frame from behind the nursing station, appeared to speak to Staff (K) and Staff (P) before walking around the nursing station desk. At 05:43:25 AM, Patient #2 was escorted to a room across the hallway from the nursing station desk by Staff (P) and Staff (O) and the door was closed. Interview on 06/17/24 at 02:00 PM with Staff (A), Clinical Director Nursing/Quality revealed a high-risk suicide patient would have a 1:1 constant observation sitter. A low or moderate risk suicide patient would require line of sight monitoring so they could potentially be a 2 to 1 (two patients to one staff ratio) if line of sight is maintained. If a patient is in the hallway and another is in their room, a 2 to 1 observation would not be possible as they would not be able to maintain line of sight monitoring. Interview on 06/18/24 at 03:00 PM with Staff (D), Emergency Department Director revealed Patient #1 and Patient #2 should not have been monitored on constant observation with the same patient care technician. Findings #2: Review on 06/18/24 of the medical record for Patient #1 revealed the following: On 06/09/24 at 02:17 PM, Staff (FF), Registered Nurse documented a triage note indicating Patient #1 presented to the emergency department via ambulance for a 9.41 mental health evaluation (mental hygiene law that permits police officers or peace officers to take into custody any individual who is demonstrating behavior which is likely to result in harm to self or others and have the individual transported to a hospital or comprehensive psychiatric emergency program for psychiatric evaluation and treatment) after an attempting to jump out of a second story window, and then attempted to run into moving traffic. Patient #1 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale (an assessment tool that helps to determine an individual’s suicide risk). On 06/09/24 at 02:50 PM, Staff (TT), Physician placed an order for Patient #1 to be admitted to the inpatient behavioral health unit for the diagnosis of impulse control disorder (a group of behavioral conditions that make it difficult to control one’s actions or reactions). From 06/09/24 at 03:00 PM through 06/10/24 at 09:00 PM, Staff (K) Patient Care Technician documented hourly on the “Constant Observation (staff continuously observe and keep a patient in sight with their hands visible at all times) Flowsheet.” On 06/11/24 at 12:37 AM, Staff (PP), Physician ordered Patient #1 to be discharged. On 06/11/24 at 02:11 AM, Patient #1 was discharged home in stable condition with a legal guardian. There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #1. Review on 06/18/24 of the medical record for Patient #2 revealed the following: - On 06/10/24 at 01:00 AM through 10:00 AM, Staff (K) Patient Care Technician documented hourly on the “Constant Observation (staff continuously observe and keep a patient in sight with their hands visible at all times) Flowsheet.” - On 06/10/24 at 01:25 AM, Staff (QQ), Registered Nurse documented a triage note revealed Patient #2 presented with the local police department to the emergency department under the authority of Section 9.41 of the Mental Hygiene Law of New York State for hearing voices stating to hurt others. Patient #2 would not elaborate on the specific thoughts or what the voices said. - On 06/10/24 at 01:31 AM, Patient #2 screened as a moderate risk for suicide on the Columbia Suicide Severity Risk Scale. - On 06/10/24 at 02:21 AM, Staff (O), Physician Assistant performed a medical screening exam revealed Patient #2 was signed out to the oncoming provider for disposition after their mental health counselor examination. - On 06/10/24 at 09:37 AM, Staff (SS), Nurse Practitioner ordered admission to inpatient behavioral health for the diagnosis of schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #2. Review on 06/18/24 of the medical record for Patient #3 revealed the following: - On 04/15/24 at 06:01 PM, Staff (L), Registered Nurse documented a triage note that indicated Patient #3 presented ambulatory to the emergency department for feeling suicidal and being afraid of going into alcohol withdrawal (symptoms that may occur when a person who has been drinking too much alcohol on a regular basis suddenly stops drinking alcohol). Patient #3 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale. Staff (L) documented constant observation began and Patient #3 was brought into the behavioral health preferred hallway and changed into a safety gown with supervision. - On 04/15/24 at 06:29 PM, Staff (O), Physician Assistant performed a medical screening exam indicated that after a mental health evaluation, Patient #3 would benefit from a mental health admission. - From 04/15/24 at 07:00 PM through 04/16/24 at 12:00 PM, the “Constant Observation Flowsheet” revealed Patient #3 had hourly observation documentation. - On 04/15/24 at 10:52 PM, Staff (O), Physician Assistant placed an order for Patient #3 to be admitted to the inpatient behavioral health unit for the diagnosis of major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #3. Review on 06/18/24 of the medical record for Patient #5 revealed the following: - On 04/28/24 at 12:08 AM, Staff (W), Registered Nurse documented a triage note that indicated Patient #5 presented ambulatory to the emergency department for suicidal ideation with a plan to slice their wrists. Patient #5 stated they were drunk and got into a fight, fell, and reported pain of six out of ten (numeric pain scale with 0 equals no pain and 10 equals severe pain), in the right rib cage. Patient #5 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale. - On 04/28/24 12:20 AM, Staff (FF), Registered Nurse documented constant observation was started while Patient #5 was in triage. - On 04/28/24 at 12:24 AM, Staff (GG), Physician Assistant performed a medical screening exam revealed there was no emergency department crisis counselor available for a mental health evaluation on the overnight shift, so Patient #5 boarded in the emergency department until a mental health evaluation could be completed the next day. - On 04/28/24 at 07:23 AM, Staff (HH), Mental Health Counselor documented Patient #5 denied suicidal and homicidal ideations, auditory and visual hallucinations, delusions, and paranoia. Patient #5 stated they want to be discharged from the hospital. Psychiatry was consulted via phone and recommendations were provided for discharge. - On 04/28/24 at 08:21 AM, Patient #5 was discharged home in stable condition. There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #5. Review on 06/18/24 of the medical record for Patient #6 revealed the following: - On 04/16/24 at 12:09 PM, Staff (II), Registered Nurse documented a triage note that indicated Patient #6 presented to the emergency department for a 9.41 mental health evaluation (mental hygiene law that permits police officers or peace officers to take into custody any individual who is demonstrating behavior which is likely to result in harm to self or others and have the individual transported to a hospital or comprehensive psychiatric emergency program for psychiatric evaluation and treatment) for suicidal ideations with a plan of cutting themselves (self-injury). - On 04/16/24 at 12:00 PM to 08:00 PM, the “Constant Observation Flowsheet” revealed Patient #6 had hourly observation documentation. - On 04/16/24 at 12:10 PM, Staff (II), Registered Nurse documented that a patient care technician was in the bathroom with Patient #6 while Patient #6 changed. The patient care technician provided constant observation. - On 04/16/24 at 12:11 PM, Patient #6 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale. - On 04/16/24 at 04:45 PM, Staff (JJ), Physician performed a medical screening examination that indicated Patient #6 continued to verbalize a desire to commit suicide by cutting. A mental health evaluation was pending. - On 04/16/24 at 08:20 PM, Staff (O), Physician Assistant wrote an addendum to the medical screening exam revealed the Staff (KK), Mental Health Counselor spoke with Patient #6 and did not find any risk of lethality. The mental health counselor discussed the case with the on-call psychiatrist who stated that Patient #6 was okay to be discharged home. - On 04/16/24 at 08:30 PM, Patient #6 was discharged home. There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #6. Review on 06/18/24 of the medical record for Patient #7 revealed the following: - On 04/19/24 at 11:55 PM, Staff (FF) Registered Nurse documented a triage note that indicated Patient #7 presented with police to the emergency department for a 9.41 mental health evaluation (mental hygiene law that permits police officers or peace officers to take into custody any individual who is demonstrating behavior which is likely to result in harm to self or others and have the individual transported to a hospital or comprehensive psychiatric emergency program for psychiatric evaluation and treatment) after being found standing on the side of a building threatening to jump. Patient #7 was verbally agitated and had been drinking alcohol. Patient #7 was assigned an acuity level two (urgent). Patient #7 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale (an assessment tool that helps to determine an individual’s suicide risk). - On 04/19/24 at 11:56 PM, Staff (FF), Registered Nurse documented Patient #7 was deemed high risk for suicide and constant observation was started in triage. - From 04/20/24 at 12:00 AM through 04/22/24 at 08:00 AM, hourly observations were documented on the “Constant Observation Flowsheet.” - On 04/20/24 at 12:00 AM, Staff (MM), Physician Assistant performed a medical screening exam that indicated Patient #7 denied any suicidal or homicidal ideation, but when asked why Patient #7 was on the edge of a six-story building, Patient #7 stated “you know why I was up there”. Patient #7 was awaiting a mental health evaluation and to be more awake for a thorough evaluation. - On 04/21/24 at 11:08 AM, Patient #7 was admitted to inpatient behavioral health status. There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #7. Review on 06/18/24 of the medical record for Patient #8 revealed the following: - On 05/01/24 at 01:42 PM, Staff (NN), Registered Nurse documented a triage note that indicated Patient #8 presented ambulatory to the emergency department for suicidal ideation with a plan. Patient #8 had a history of suicide attempts. When asking about the suicide plan, Patient #8 stated “I don’t know”. - From 05/01/24 at 01:00 PM through 05/03/24 at 08:00 AM, the “Constant Observation Flowsheet” revealed Patient #8 had hourly observation documentation. - On 05/01/24 at 01:54 PM, Patient #8 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale. - On 05/01/24 at 02:00 PM, the “Constant Observation Flowsheet” revealed Patient #8 was changing into safety clothes. - On 05/01/24 at 04:00 PM, Staff (GG), Physician Assistant completed a medical screening exam that indicated Patient #8 was evaluated by the crisis counselor who recommended admission to inpatient behavioral health. Patient #8 agreed to the plan and was admitted. - On 05/01/24 at 06:43 PM, Patient #8 was admitted to inpatient behavioral health status. There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #8. Review on 06/18/24 of the medical record for Patient #9 revealed the following: - On 05/23/24 at 12:04 PM, Staff (OO), Registered Nurse documented a triage note that indicated Patient #9 presented by ambulance to the emergency department after telling their friend they were planning to overdose with pills. - On 05/23/24 at 12:14 PM, Patient #9 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale. - On 05/23/24 at 12:24 PM, Staff (JJ), Physician Assistant performed a medical screening exam that indicated Patient #9 was evaluated by Staff (HH), Mental Health Counselor who reviewed with Staff (PP), On-Call Psychiatrist. Patient #9 was deemed appropriate for involuntary inpatient behavioral health admission. - On 05/23/24 at 12:00 PM through 06:00 PM, the “Constant Observation Flowsheet” revealed Patient #9 had hourly observation documented. - On 05/23/24 at 07:14 PM, Patient #9 was transferred to another mental health facility. There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #9. Review on 06/18/24 of the medical record for Patient #12 revealed the following: - On 06/13/24 at 11:00 AM through 03:00 PM, the “Constant Observation Flowsheet” revealed Patient #12 had hourly observation documented. - On 06/13/24 at 11:28 AM, Staff (E), Registered Nurse documented a triage note that indicated Patient #12 presented ambulatory to the emergency department under the authority of Section 9.41 of the Mental Hygiene Law of New York State for verbalized suicidal ideations at their counselor’s office. Patient #12 would not fill out a safety plan and had a recent suicide attempt by jumping in front of a car. - On 06/13/24 at 11:45 AM, Staff (RR), Physician Assistant performed a medical screening examination that indicated Patient #12 was discussed with Staff (PP), On-Call Psychiatrist and would be admitted for increased depression and suicidal ideations. - On 06/13/24 at 12:18 PM, Patient #12 was screened as high risk for suicide on the Columbia Suicide Severity Rating Scale. - On 06/13/24 at 12:07 PM, Patient #12 was admitted to inpatient behavioral health status. There was no evidence found in the medical record that constant observation or special constant observation was ordered by a physician for Patient #12. Interview on 06/17/24 at 02:00 PM with Staff (A), Clinical Director Nursing/Quality confirmed these findings.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 48608 Based on medical record review, policy review, video surveillance, and staff interviews, the hospital failed to provide care in a setting free from abuse or harassment for one of one (Patient #1) record review. The hospital failed to prevent abuse (inappropriate touching) of Patient #1 (minor-under the age of 18) by Patient #2 (an adult) that occurred on 06/10/24. Additionally, the hospital failed to complete a thorough investigation into the incident to prevent reoccurrence and report the incident to required state agencies. Findings: Review on 06/18/24 of the policy “Incident Management”, last updated 03/08/24, revealed: “The adolescent and adult mental health units are required to comply with 14 NYCRR Part 524 Incident Reporting Requirements. Incident management includes identifying, documenting, reporting, and investigating individual incidents in a timely basis. Any incidents or allegations of abuse or neglect will be reported and investigated with appropriate corrective action occurring. All allegations of abuse and neglect and significant incidents will be reported to the Vulnerable Persons Central Register, the Office of Mental Health and other required authorities identified by state and federal laws. All incidents reviewable and reportable are reported to the director or administrator on duty in the absence of a director who determines if the incident is reportable to the Office of Mental Health, Justice Center, Department of Health, Joint Commission, or other regulatory organizations. Incidents classified by the Justice Center, or the Office of Mental Health as reportable incidents will be reported to those offices. If a staff has reasonable cause to suspect the patient is the victim of abuse or neglect the staff person will notify the charge nurse who will notify the director. Each mandated reporter who witnesses or hears the original suspicion of abuse or neglect makes a report with the Vulnerable Persons Central Register.” (Patient #1 was admitted to the behavior health unit but held in the emergency department to await an open bed). Review on 06/18/24 of security surveillance video of the behavioral health hallway located within the emergency department, dated 06/10/24 revealed: At 05:40:06 AM, Staff (K), Patient Care Technician was sitting at a nursing station desk, eating, and looking at a cell phone that was positioned on the desktop, while Patient #1 appeared to be asleep on a stretcher in the hallway across from the desk. At 05:41:00 AM, Patient #2 entered the hallway from a patient room adjacent to Patient #1. Patient #2 approached the desk where Staff (K) sat and appeared to speak to Staff (K) who looked up at Patient #2 briefly and then back down at the cell phone multiple times. At 05:42:05 AM, Patient #2 is seen standing close to the head of the stretcher where Patient #1 appeared to be asleep, looking at Patient #1. Staff (K) was seated at the desk looking down at the cell phone positioned on the desktop when Patient #2 approached Patient #1 on the gurney. At 05:42:08 AM, Patient #2 rested a hand upon Patient #1’s shoulder. Patient #2 removed the hand from Patient #1 and turned back to approach Staff (K) who was sitting at the desk with their head down looking at their phone, spoke to Staff (K) and was seen walking away from the desk, leaving the video frame. At 05:42:28 AM, Patient #2 re-entered the video frame, approached the desk and appeared to be speaking to Staff (K). At 05:42:37 AM, Patient #2 turned from the desk and approached the gurney where Patient #1 appeared to be asleep. At 05:42:37 AM, Staff (K) was seen visualizing Patient #2 touch the leg of Patient #1 and appeared to be speaking to Patient #2 who turned away from the gurney and approached Staff (K) at the desk. At 05:42:39 AM Patient #2 placed their right hand upon Patient #1’s leg near the knee and slid their hand from the knee to the buttocks before removing the hand to turn towards Staff (K) at the desk. At 05:42:49 AM, Staff (K) stood up from the chair while speaking to Patient #2. At 05:42:55 AM, Staff (K) picked up the desk telephone to make a call. At 05:43:08 AM, Staff (P), Security Officer was seen entering the video frame from a door positioned next to the desk. At 05:43:10 AM, Patient #2 approached the stretcher and tried to touch Patient #1 on the leg. Staff (P) intervened by blocking Patient #2’s right hand before contacting Patient #1. At 05:43:12 AM, Patient #2 reached over Patient #1 with their left-hand touching Patient #1’s left buttocks before Staff (P) pulled Patient #2 back and stood between the gurney and Patient #2. At 05:43:13 AM, Staff (O), Physician Assistant entered the video frame from behind the nursing station, appeared to speak to Staff (K) and Staff (P) before walking around the nursing station desk. At 05:43:25 AM, Patient #2 was escorted to a room across the hallway from the nursing station desk by Staff (P) and Staff (O) and the door was closed. Review on 06/18/24 of the “Public Safety Security Report,” dated 06/10/24 at 05:43 AM, revealed Staff (P), Security Officer received a call from Staff (K), Patient Care Technician who requested assistance in the behavioral health hallway of the emergency department. Upon exit of the security office, Staff (P) was immediately informed that an adult patient (Patient #2) had inappropriately touched a sleeping pediatric patient (Patient #1) on the leg. The adult patient attempted to reapproach the pediatric patient and stated, “I am a pedophile.” The adult patient was directed to back away from the pediatric patient by Staff (P). Staff (P) stepped in front of the adult patient to block access to the pediatric patient. Staff (P) gently grabbed the adult patient’s arms to stop advancement towards the pediatric patient. During the encounter, Staff (O), Physician Assistant entered the area and was briefed on the situation by Staff (K). The adult patient was directed to a room. At 05:45 AM Staff (O), Physician Assistant instructed Staff (P), Security Officer to lock the adult patient’s door. The pediatric patient was moved from the hallway into room #127, for more safety and privacy. The pediatric patient appeared to remain asleep during the incident. Staff (K), Patient Care Technician reported that the adult patient exited their room at approximately 05:42 AM and stated, “You know I’m a pedophile, right?” before approaching and caressing the pediatric patient’s leg. Staff (L), Registered Nurse and other emergency department clinical staff members were informed of the situation. Staff (L) stated Staff (N), Nurse Manager Emergency Department, would be informed as well as the pediatric patient’s parents (the grandmother is legal guardian per medical record). Review on 06/18/24 of the “Internal Safety Event Report,” dated 06/10/24 at 07:06 AM reported by Staff (L) Registered Nurse, revealed Patient #2 was witnessed attempting to make inappropriate physical contact with Patient #1 who was a minor (a person who has not attained the age of 18). Security was contacted, intervened, and placed Patient #2 into an assigned room with a locked door for seclusion. Hospital follow up was completed by Staff (N) Emergency Department Nurse Manager. Patient #1 and the legal guardian were contacted twice. The legal guardian was satisfied with the internal follow-up and did not wish to press charges or have additional reports made. There was no documentation of video surveillance review, root cause analysis, or steps taken to prevent reoccurrence for other patients. Additionally, there was no documentation of interviews with staff involved with the event. Interview on 06/17/24 at 02:11 PM with Staff (K), Patient Care Technician revealed Patient #1 was assigned a high-risk level for suicide and required constant observation (staff continuously observe and keep a patient in sight with their hands visible at all times). Patient #1 (pediatric patient) was in the hallway sleeping on a gurney in front of room #126, across from the nurse’s station. Patient #2 (adult patient) walked out of an assigned room towards Patient #1. Staff (K) told Patient #2 to stop and called security for assistance. Patient #2 rubbed Patient #1’s leg for approximately two seconds. Staff (K) was monitoring both Patient #1 and Patient #2. No other staff members were present in the behavior health area of the emergency department. Interview on 06/17/24 at 02:20 PM with Staff (N), Nurse Manager of the Emergency Department revealed they were notified of the event with Patient #1 (pediatric patient) by Staff (L), Registered Nurse. Patient #1 asked to stay in the hallway due to feeling uncomfortable in the assigned room. Patient #2 (adult patient) grazed their hand over Patient #1’s leg that was covered with a blanket. After the event, Patient #1 was moved into the assigned room with the constant observation (staff continuously observe and keep a patient in sight, with their hands visible at all times) sitter. Patient #2 was immediately redirected away by Staff (K), Patient Care Technician. Staff (N) spoke to Patient #1’s guardian on 06/10/24 at 10:30 AM. The guardian seemed content with the interventions provided and did not want to pursue any legal actions against Patient #2. Staff (N) said the guardian did not place a formal complaint to the hospital. Staff (N) said they did not make any notes about the incident or discussion with the guardian. Interview on 06/18/24 at 09:00 AM with Staff (P), Security Officer, revealed they wrote a public safety report for the incident. No investigation was conducted to confirm whether Patient #2 had a criminal history or was/was not on a public list of sex offenders through the state sex offender registry. Interview on 6/17/24 at 11:10 AM, 02:00 PM, and 3:37 PM and 06/18/24 at 10:00 AM, and 6/18/24 at 3:16 p.m., with Staff (A), Clinical Director Nursing & Quality revealed the staff members (nurse, patient care technician, and the physician assistant) that were questioned all had the same description of the event and no further investigation was completed. The hospital did not review the video surveillance until today (06/18/24) because all staff questioned had the same description of the event. Staff (A) said if they had viewed the video prior, Staff (K) Patient Care Technician would have needed immediate re-education regarding the duties of a constant observation (1:1) sitter. Staff (A) said that a report to the New York Patient Occurrence Reporting and Tracking System (a mandatory adverse event reporting system established pursuant to Public Health Law) was not completed as a “touch on the knee” did not seem to fit the category of sexual assault. Staff (A) stated in cases of abuse, law enforcement would be notified, however Patient #1’s legal guardian did not want to press charges against Patient #2, so the incident was not reported to local authorities. Additionally, Staff (A) stated The Justice Center was not contacted because Staff (A) was previously informed by The Justice Center that it does not oversee cases in the emergency department (Patient #1 was admitted to inpatient mental health).”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 32261 This CONDITION is not met as evidenced by: Based on policy review, document review, medical record review, and interview, it was determined that the facility failed to meet the emergency needs of patients in accordance with acceptable standards of practice as evidence by: Emergency department staff failed to verify the discharge location and/or contact the skilled nursing facility prior to the discharge of Patient #1. This resulted in the discharge of Patient #1 to their home/community residence instead of the rehabilitation facility (TAG-A1104). Cross Reference: 482.55(a)(3)- Emergency Services Policies”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 32261 Based on policy review, medical record review, and interview, emergency department staff failed to verify the discharge location and/or contact the skilled nursing facility prior to the discharge of Patient #1. This resulted in the discharge of Patient #1 to their home/community residence instead of the rehabilitation facility. Findings include: Review on 05/30/24 of the policy “Transfer/Discharge Transportation from the Emergency Department to Another Facility,” last revised 02/13/23, indicated if a patient is returning to a care facility, the registered nurse will call report to the appropriate facility, copy any required data (lab results, radiology reports), and seal the information in an envelope. (The policy did not include guidance on nursing staff verification of the correct discharge location/address of a patient). Review on 05/30/24 of emergency department medical record and ambulance documentation for Patient #1 dated 05/17/24 revealed the following: -At 03:24 PM, Patient #1 arrived via ambulance to the emergency department for right hip pain. -At 03:26 PM, the pre-arrival summary (from the rehabilitation facility) revealed Patient #1 was sent to the emergency department from the rehabilitation facility due to a right hip dislocation. Patient #1 was alert but not oriented. The daughter (health care proxy) was aware of the transfer to the emergency department but would not be going to the hospital. -At 03:31 PM, a medical screen examination note by Staff (E), Physician documented Patient #1 had a right hip dislocation. Patient #1 had several dislocations during the past few weeks. The plan was for Patient #1 to have a hip revision completed at another hospital; however, Patient #1 does not have an appointment yet. Patient #1 was currently staying at a rehabilitation facility. Past medical history included dementia and was prescribed Donepezil (used to treat confusion (dementia) related to Alzheimer’s disease). The neurological examination revealed Patient #1 was alert, oriented, and cooperative. -At 03:40 PM, the physician ordered a right hip and pelvic x-ray for deformity. -At 03:44 PM, a triage note by Staff (D), Registered Nurse, indicated Patient #1 ’ s chief complaint was right hip dislocation that occurred from physical therapy in the rehabilitation facility. Patient #1 was confused at baseline. -At 04:10 PM, radiological results revealed the right hip was found to be dislocated. -At 04:38 PM, Staff (E), Physician, performed a reduction of the right hip dislocation. -At 04:53 PM, radiological results revealed the right hip and hardware was in alignment. -At 05:18 PM, Staff (E), Physician, documented that an orthopedic surgeon from another hospital was consulted and stated Patient #1 would not benefit from a transfer. The orthopedic surgeon recommended Patient #1 should go back to their current living arrangement and call the office on Monday to see if appointment can be moved to a sooner date. Patient #1 was stable for discharge. -At 06:50 PM, the discharge note by Staff (D), Registered Nurse, indicated at 06:44 PM, Patient #1 was discharged via ambulance stretcher to the rehabilitation facility. The medical record face sheet indicated that Patient #1 ’ s home address as primary residence. No secondary address was listed (rehabilitation facility). (There is no documentation that the registered nurse contacted the rehabilitation facility prior to the discharge of Patient #1). The ambulance transfer form indicated Patient #1 was transported via wheelchair ambulance. The destination location listed on the form is “home” (Patient #1’s home address in the community). Review on 05/30/24 of emergency department medical record for Patient #1 dated 05/18/24 revealed the following: -At 09:29 AM, a medical screen examination note by Staff (E), Physician, indicated Patient #1 arrived by ambulance for a medical evaluation due to accidently being discharged to their home on 05/17/24, instead of back to the rehabilitation facility. Patient #1 was found in their home that morning by their child. The rehabilitation facility requested that Patient #1 be evaluated to ensure the right hip was still in a normal position and to have blood work completed. -At 10:56 AM, Staff (E), Physician documented that Patient #1 was at baseline. Patient #1 was stable for discharge back to the nursing home and to follow-up with the orthopedic surgeon. -At 12:28 PM, a discharge note by Staff (F), Registered Nurse, indicated that Patient #1 was stable. The ambulance staff were at the bedside to transfer back to the rehabilitation facility. The rehabilitation facility was contacted and made aware that Patient #1 was returning. The medical record face sheet indicated that Patient #1 ’ s home address as primary residence. Interview on 05/30/24 at 10:25 AM with Staff (C), Charge Nurse in the emergency department on 05/17/24, indicated that Patient #1 was in the emergency department a few times for hip issues. Patient #1 was temporarily living at a rehabilitation facility until they could have hip surgery. On 05/17/24, Patient #1 arrived by ambulance for a dislocated hip which was realigned. Prior to Patient #1’s arrival, the rehabilitation facility called to alert the emergency department staff that Patient #1 needed to be evaluated giving a brief description of what was going on. Patient #1 was alert and oriented, and wanted to go back home, not back to the rehabilitation facility. Patient #1 was discharged back to the rehabilitation facility, however, the ambulance transported Patient #1 back to their home in the community. Interview on 05/30/24 at 12:55 PM with Staff (D), Registered Nurse who cared for Patient #1 on 05/17/24 indicated that once Patient #1 was ready to be discharged, Staff (D) told Staff (K), Health Unit Coordinator, to “send Patient #1 back.” Staff (D) did not recall where they told Staff (K), Health Unit Coordinator to send Patient #1 back to. Staff (D) stated that they were busy when the ambulance crew arrived to transport Patient #1 back to the rehabilitation facility. Staff (D) gave the ambulance crew a brief report but did not remember if they told the ambulance crew Patient #1 was going back to the rehabilitation facility. Staff (D) forgot to call the rehabilitation facility to give report and discharge instructions prior to Patient #1 being discharged. Interview on 05/31/24 at 10:30 AM, Staff (K), Health Unit Coordinator, revealed they arranged Patient #1’s transport for discharge. Staff (D), Registered Nurse, came up to the desk and told Staff (K) that Patient #1 was ready to go home and to arrange transportation via wheelchair transport. Staff (K) checked for paperwork at Patient #1’s bedside but there was not any. Staff (K) stated they also checked for pre-arrival note in Patient #1’s medical record, but there was not a note in Patient #1’s medical record. Staff (K) verbally confirmed Patient #1’s discharge location with Patient #1 and registration. There were no incoming calls from a rehabilitation facility to check on Patient #1’s anticipated discharge. Staff (K) call the ambulance company and gave Patient #1’s home address as the destination location. Staff (K) gave the discharge paperwork to the ambulance crew transporting Patient #1, who confirmed the address (home/community) with Staff (K) and Patient #1. Interview on 05/31/24 at 11:30 AM with Staff (A), Vice President of Patient Care, confirmed these findings.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 32261 This CONDITION is not met as evidenced by: Based on medical record review, document review, policy review, and interview, the facility failed to protect and promote the rights of all patients related to providing care in a safe setting for Patient #1 and Patient #2 (A-0144). On 03/21/24 at 02:45 PM, an Immediate Jeopardy situation was identified for the CoP of Patient’s Rights. At 06:13 PM, the facility implemented immediate interventions that included: re-education of all emergency department clinical staff (Registered Nurses, Licensed Practical Nurses, Patient Care Technicians, Nursing Assistants, Physicians, Physician Assistants, Nurse Practitioners) and security staff on the “Elopement” policy, “Psychiatric Evaluation of Patients in the Emergency Department” policy, and the “Assessing Patient Risk for Suicide” policy. All security staff demonstrated competency in the use of the handheld metal detectors including daily checks and maintenance. Auditing will be conducted daily for a period of 45 days to ensure staff compliance to policy and regulations by the quality assurance department. On 03/22/24 at 09:50 AM, the Immediate Jeopardy was removed based on onsite surveyor verification of the immediate actions implemented by the facility through observations, policy review, document review, and interviews. Cross Reference: 482/13(c)(2): The patient has the right to receive 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: 32261 Based on policy review, medical record review, document review, and interview, the facility failed to provide care to Patient #1 and Patient #2 in a safe setting. 1.Staff failed to assess Patient #1’s suicide risk and implement appropriate precautions prior to allowing Patient #1 to use the bathroom without supervision. Patient #1 was found in the bathroom cutting their left arm with a razor blade. 2.Staff assessed Patient #2 at high risk for suicide with a plan. However, nursing staff did not conduct a SAFE-T assessment and did not implement any safety precautions including observation status. Patient #2 was allowed to use the bathroom, walked past the bathroom, and left the emergency department. Staff did not attempt to stop and/or locate Patient #2 after the elopement. 3.Security staff were not properly trained to use the handheld metal detectors for screening behavioral health patients. Staff were not performing daily checks and/or preventative maintenance. Findings #1: Review of the policy “Assessing Patient Risk for Suicide, “last updated 11/29/23, indicated that patients who are being evaluated or treated for behavioral health conditions as their primary reason of care, will be screened for suicidal ideation using the Columbia Suicide Severity Rating Scale. If a patient screens positive for suicide after completion of a Columbia Suicide Severity Rating Scale, suicide precautions will be implemented, and a SAFE-T suicide risk assessment form will be completed by trained staff (registered nurse, social worker, discharge planner, crisis staff, consultation, and liaison staff, etcetera) to determine the suicide risk level of the patient (high, moderate, low). Interventions will be determined by the identified suicide risk level (high, moderate, or low). For high-risk emergency department patients, constant observation (staff continuously observes, always keeping the patient in sight, with hands visible) or special constant observation (staff continuously observes the patient within arm ’ s reach, with hands visible) will be ordered as determined by assessment and patient need. A psychiatric care attendant will be assigned. Constant observation should be documented every hour using the constant observation flowsheet. Review of the policy “Psychiatric Evaluation of Patients in the Emergency Department,” last updated 03/08/24, indicated that a person in need of an evaluation may come to the emergency department voluntarily, with family/friends, by police on a 9.41 (Emergency assessment for immediate observation, care, and treatment; powers of certain peace officers and police), on a 9.45 (emergency admissions for immediate observation, care, and treatment; powers of directors of community services pickup order), by agency representatives, or be identified and referred by an emergency department physician. Emergency department staff will escort the patient to an area, assist the patient in changing into a hospital gown, and secure the patient’s personal belongings in a locker. The emergency department counselor will assess the patient upon arrival with emergency department staff to determine the level of security required to manage the patient (for example, the appropriate room to place patient). Staff will interview the patient and complete the evaluation. Appropriate measures shall be taken to provide a safe environment. Management of the patient in the emergency department includes, but is not limited to, patient monitoring by nursing staff or security personnel, nursing assessment of physical needs, monitoring of physical condition, maintaining safety, and the use crisis management skills. Review on 03/21/24 of electronic medical record “Columbia Suicide Severity Rating Scale (CSSR-S),” patient assessment section revealed a patient’s suicide risk is assessed by asking a series of simple “yes” or “no” questions: does the patient wish they were dead; does the patient have any thoughts of killing themselves; if so, how would they kill themselves; if the patient has ever had thoughts to kill themselves with intention of acting on thoughts; if the patient had ever started working out the details of how to kill themselves; has the patient had ever done any preparation to end their life. Patients are then scored as high, moderate, or low risk for suicide based on their answer to the questions. Review on 03/21/24 of electronic medical record “SAFE-T Suicide Risk Assessment,” patient assessment section revealed patients are assessed by a clinician. The assessment includes, but not limited to, assessing the patient for suicide and homicide risk factors (suicidal/homicidal ideation, suicide planning, current psychiatric symptoms), asking the patient if they have access to firearms and/or weapons, and assessing internal/external protective factors (patient is able to cope with stress, has family support/therapeutic relationships, positive coping skills). A risk level is assigned, and interventions are selected based on the patient’s risk level. Review on 03/20/24 of the emergency department log dated 03/11/24 revealed Patient #1 presented at 10:53 AM with a chief complaint of a “9.41” mental health evaluation (an order by the director of the community or the director’s designee, to direct peace officers to transport a person who appears mentally ill and is conducting themselves in a manner that is likely to result in serious harm to themselves or others, to a hospital designated by the Commissioner as being capable of retaining and treating individuals, for an emergency assessment for immediate observation, care, and treatment for a psychiatric evaluation). Review of emergency department medical record for Patient #1 dated 03/11/24 revealed the following: -At 11:15 AM, Staff (K), Physician, performed a medical screening examination after Patient #1 was found cutting their arm with a razor blade, which was able to be wrestled out of their arms by security. Patient #1 snuck a razor blade in past security in their underwear. When Patient #1 got in the restroom, they used the razor blades to inflict multiple lacerations to their left extremity (arm). Patient #1 has done this in the past many times, sneaking in foreign bodies, and then lacerating themself in this facility. Patient #1 is quite agitated now despite multiple medications. -At 11:19 AM, the registered nurse triage assessment revealed no evidence that a Columbia Suicide Severity Rating Scale was completed at triage. -At 11:24 AM, Staff (E), Nurse Manager, documented that Patient #1 was checked on in the bathroom and was found to have cut their left arm. Patient #1 did this with razor blades that they left in their underwear that were not found upon being wanded by security. Patient #1 had several large lacerations to their left arm with no atrial bleeding noted. The provider was at the bed side and dressed the area with gauze and wrapping. Bleeding was controlled at this time. The provider will follow up with repairs shortly. Constant monitoring will continue. The provider ordered an x-ray to make sure Patient #1 did not have any more objects hidden. -At 01:40 PM, Staff (S), Behavioral Health Counselor documented that the SAFE-T Risk Assessment was completed and identified Patient #1 at high risk for suicide with a plan to slice their throat. Patient #1 was a danger to self and needed in-patient treatment. Patient #1 was a high lethality risk at this time due to continued attempts to harm self while in the hospital. High risk suicide prevention and interventions were implemented and include placing Patient #1 on special constant observation, assessment of the psychical environment, and the assessment/removal of contraband. -At 02:49 PM, the provider ordered special constant observation. -At 02:50 PM, Staff (K), Physician, documented that Patient #1 was re-evaluated. Patient #1 continued to refuse repair their left arm lacerations. A psychiatric consult was performed to evaluate the patient and agreed with the admission of Patient #1 to the in-patient behavioral health floor. Patient #1 was bandaged and dressed appropriately for their wounds which were no longer bleeding. Patient #1 will be admitted to psychiatric unit for further management and evaluation. -At 09:45 PM, Patient #1 departed the emergency department for the in-patient behavioral health unit. Review on 03/21/24 of the document “Security Daily Event Log,” indicated that on 03/11/24 at 10:41 AM, Patient #1’s personal property was collected by Staff (N), Security Officer. At 10:50 AM, Staff (F), Security Officer, was present with a female Jamestown police office, and Staff (G), Patient Care Technician, while Patient #1 was changed into a safety gown. Staff (F) scanned Patient #1 with the handheld metal detector. Two small bottles of rum were found in Patient #1’s personal belongings which were placed in a contraband bag and secured. At about 11:09 AM, Staff (F), Security Officer, discovered Patient #1 in the bathroom cutting their right arm with a razor blade. Interview on 03/20/24 at 02:00 PM with Staff (E), Nurse Manager, revealed that Patient #1 was brought in by police from an outpatient mental health office for threatening to cut self with a razor blade. When Patient #1 arrived at the emergency department via Jamestown police, they were immediately taken to room #126. The Jamestown police officer stated that they thought all the razor blades were removed from Patient #1 but were not sure. The Jamestown police officer remained presented until Patient #1 was changed and wanded. Staff (E) told Staff (G), Patient Care Technician, to keep an eye on Patient #1. Security helped get Patient #1 changed, to remove belongings, and to “wand” Patient #2 twice. Staff (E) was notified there was an issue with Patient #1 and entered the bathroom with Staff (K), Physician. Patient #1 was found sitting on the bathroom floor with three self-inflected lacerations on their left forearm that were minimally bleeding. Patient #1 had razor blades in a plastic case in their underwear. The lacerations were bandaged. Patient #1 was placed on a strict 1:1 observation (special constant observation) within arm’s reach of staff. All three lacerations were sutured by Staff (K), Physician. At the time of the incident, Patient #1 had not been triaged. Staff (E) felt that Patient #1 was calm with police presence and denied wanting to harm self. Interview on 03/20/24 at 02:19 PM with Staff (F), Security Officer, revealed that Patient #1 was brought in by Jamestown police. Staff (F), Security Officer, assisted with bringing Patient #1 back to room #126. Staff (F) assisted Jamestown police and Staff (G), Patient Care Technician, with changing Patient #1 into a gown. Once Patient #1 was changed, Staff (F) scanned Patient #1 with the handheld (wand) metal detector. Patient #1 was permitted to keep their underwear on while scanned. The wand did not go off when Patient #1 was scanned, indicating that Patient #1 did not have any metal objects on them that could be detected. Patient #1 asked to go to the bathroom and was told yes by Staff (G), Patient Care Technician. Patient #1 went into the bathroom alone. A few minutes later, Staff (G), Patient Care Technician, and Staff (F) opened the bathroom door and saw Patient #1 on the ground bleeding. Staff (F) asked Patient #1 to give them the razor blade. Patient #1 refused and attempted to put the razor blade to their neck. Staff (N), Security Officer, responded and was able to grab ahold of Patient #1’s arm to prevent Patient #1 from harming themselves. Staff (F) was able to remove the razor blade for Patient #1’s hand and give it to the clinical staff. Staff (F) is unsure of where Patient #1 had the razor blades. There were more razor blades in a plastic case on the sink. Interview on 03/20/24 at 02:55 PM with Staff (K), Physician, revealed that Patient #1 stated that the razor blades were in their underwear in a plastic package. Staff (K) did not see Patient #1 prior to the incident. Interview on 03/21/24 at 10:15 AM with Staff (M), Registered Nurse, revealed that Patient #1 had already cut self in the bathroom before they assumed care of the patient. Staff (M) assisted with bandaging Patient #1’s arm. Triage was not completed until after Patient #1 cut their arm with the razor blade. Patient #1 was put on a 1:1 observation after the incident and an x-ray was obtained to ensure Patient #1 did not have anything else harmful internally. Interview on 03/21/24 at 10:19 AM with Staff (C), Director of Emergency Department and Staff (E), Registered Nurse, revealed that Patient #1 was alone in the bathroom. The incident occurred before Patient #1 was triaged and/or a suicide screen was completed. Staff (C) stated Patient #1 should have had a suicide screen done before being allowed to go into bathroom alone. Staff (E) confirmed that the police said they were not sure if Patient #1 had more razor blades on them. Interview on 03/21/24 at 10:28 AM with Staff (G), Patient Care Technician, revealed that Patient #1 came in with the police and was placed in room #126. Staff (E), Nurse Manager told Staff (G) of Patient #1’ s history of hiding razor blades and to keep a close eye on them. The Jamestown police officer and a security officer were in the room when Patient #1 was changed into a gown. After Patient #1 was changed, Staff (G) exited the room, leaving Patient #1 alone in the room. Staff (G) went back to the nursing station. Staff (G) was monitoring Patient #1 via the video monitor and saw Patient #1 enter the bathroom. After a few minutes Staff (G) got concerned and asked Staff (F), Security Officer to accompany them to the bathroom to check on Patient #1. Patient #1 was found on the bathroom floor covered in blood with a razor blade in their hand, cutting themselves. Patient #1 never spoke. Staff (G) then screamed for help. Patient #1 was not on 1:1 observation at the time of the incident. Staff (G) did not receive any direction from the charge nurse until after the incident occurred. Staff (G) stated if a patient is a high risk for suicide, frequent patient checks would be completed and documented every hour/as needed. Interview on 03/22/24 at 09:45 AM with Staff (N), Security Officer, revealed that Patient #1 was brought to the behavioral health area of the emergency room. Staff (N) assisted with changing Patient #1 into a hospital gown by female staff members. Staff (N) assisted with gathering Patient #1 ’ s belongings and inventoried them. During the time of the incident, Staff (N) was in the security office located across from the behavioral health rooms and heard the call that assistance was needed. Staff (N) entered the bathroom of room #126 and found Patient #1 sitting on the floor with Staff (F), Security Officer, and Staff (G), Patient Care Technician. Staff (G), Patient Care Technician, ran to get additional clinical staff. Staff (F), Security Officer, stayed with Patient #1. Patient #1 had a razor blade in their right hand. Staff (N) grabbed Patient #1 arm to prevent Patient #1 from cutting their neck while Staff (F), Security Officer, grabbed the razor blade from Patient #1 ’ s hand and gave it to clinical staff. Patient #1 attempted to grab a white plastic sleeve located on the sink that had multiple razor blades in it. Staff (N) was able to grab the plastic sleeve before Patient #1 got to it. The white plastic sleeve was two inches long, one inch wide, and a half inch in depth. When a patient arrives with contraband, the security officer would seize the contraband, and lock it up. Findings #2: Review of the policy “Assessing Patient Risk for Suicide, “last updated 11/29/23, indicated that patients who are being evaluated or treated for behavioral health conditions as their primary reason of care, will be screened for suicidal ideation using the Columbia Suicide Severity Rating Scale. If a patient screens positive for suicide after completion of a Columbia Suicide Severity Rating Scale, suicide precautions will be implemented, and a SAFE-T suicide risk assessment form will be completed by trained staff (registered nurse, social worker, discharge planner, crisis staff, consultation, and liaison staff, etcetera) to determine the suicide risk level of the patient (high, moderate, low). Interventions will be determined by the identified suicide risk level (high, moderate, or low). For high-risk emergency department patients, constant observation (staff continuously observes, always keeping the patient in sight, with hands visible) or special constant observation (staff continuously observes the patient within arm ’ s reach, with hands visible) will be ordered as determined by assessment and patient need. A psychiatric care attendant will be assigned. Constant observation should be documented every hour using the constant observation flowsheet. Review of the policy “Psychiatric Evaluation of Patients in the Emergency Department,” last updated 12/07/20, indicated that a person in need of an evaluation may come to the emergency department voluntarily, with family/friends, by police on a 9.41 (Emergency assessment for immediate observation, care, and treatment; powers of certain peace officers and police), on a 9.45 (emergency admissions for immediate observation, care, and treatment; powers of directors of community services pickup order), by agency representatives, or be identified and referred by an emergency department physician. Emergency department staff will escort the patient to an area, assist the patient in changing into a hospital gown, and secure the patient’s personal belongings in a locker. The emergency department counselor will assess the patient upon arrival with emergency department staff to determine the level of security required to manage the patient (for example, the appropriate room to place patient). Staff will interview the patient and complete the evaluation. Appropriate measures shall be taken to provide a safe environment. Management of the patient in the emergency department includes, but is not limited to, patient monitoring by nursing staff or security personnel, assessment of physical needs, monitoring of physical condition, maintaining safety, and the use crisis management skills. Review of electronic medical record “SAFE-T Suicide Risk Assessment,” patient assessment revealed patients are assessed by a clinician. The assessment includes, but not limited to, assessing the patient for suicide and homicide risk factors (suicidal/homicidal ideation, suicide planning, current psychiatric symptoms), asking the patient if they have access to firearms and/or weapons, and assessing internal/external protective factors (patient is able to cope with stress, has family support/therapeutic relationships, positive coping skills). A risk level is assigned, and interventions are selected based on the patient’s risk level. Review of the policy “Elopement” last updated 12/2020 revealed that if a patient elopes, staff will follow specific interventions. If a patient is a danger to self and/or others, a psychiatry provider may request a 9.45 (emergency admissions for immediate observation, care, and treatment; powers of directors of community services pickup order) to be issued to have the police transport the patient to an emergency department for evaluation to assess the continued need for hospitalization. Review on 03/21/24 of the emergency department medical record for Patient #2 dated 03/03/24 revealed the following: -At 12:19 AM, Patient #2 arrived ambulatory at the emergency department by private vehicle for a mental health evaluation. -At 12:28 AM, an order was placed for an initial SAFE-T suicide risk assessment. -At 12:32 AM, the triage assessment revealed that Patient #2 was addicted to heroin and their depression had increased approaching the anniversary date of their daughter ’ s death on March 15th. Patient #2 stated that they no longer wanted to live. Patient #2 was screened as high risk for suicide according to the Columbia Suicide Severity Rating Scale (scale used to measure patients suicide risk). Patient #2 had a history of suicide attempts by hanging and slitting their own throat. Patient #2 was crying and indicated that they were “not good.” -At 01:24 AM, Staff (T), Registered Nurse documented that Patient #2 asked to use the bathroom. Patient #2 walked by the bathroom and left the facility. The emergency department charge nurse was notified. -At 01:29 AM, Patient #2 was discharged from the facility as an elopement. (There was no documentation in the medical record to indicate that a SAFE-T suicide risk assessment was completed, that constant observation or special constant observation status was ordered/implemented, that belongings were checked and contraband was removed/secured, or that measures were taken to find Patient #2 after they eloped and bring them back to the emergency department). Interview on 03/21/24 at 06:53 PM with Staff (T) Registered Nurse, revealed that Patient #2 was put into room #19, directly across from the nursing station. An environmental sweep was done of the room and all potential harmful objects were removed. Patient #2 verbalized that they were not doing well, it was close to the anniversary of their daughter’s death from a motor vehicle accident. Patient #2 was afraid of dying and leaving their son alone. Staff (T) did not recall if Patient #2 had a suicide plan. Patient #2 was not changed into hospital gown but still had their belongings with them. Approximately 90 minutes after arrival, Patient #2 asked if any staff had a phone charger to charge their phone so that they could call their son. Emergency department staff did not give Patient #2 a phone charger. Patient #2 then asked to use the restroom. Emergency department staff followed Patient #2 to the bathroom. Patient #2 proceeded to walk out of the emergency department. Staff (T) notified Staff (AA), Charge Registered Nurse. The charge nurse Staff (AA), Charge Registered Nurse stated that because Patient #2 was alert and oriented, they were allowed to leave if they wanted to. Interview on 03/21/24 at 07:21 PM with Staff (Z) Registered Nurse, revealed they triaged Patient #2. Patient #2 spoke very “broken” (emotionally and jumping from topic to topic), and verbalized an attempting to commit suicide two years ago by hanging. Staff (Z) believed that the patient care technician brought Patient #2 back to a mental health room. Staff (AA), Charge Registered Nurse would instruct the patient care technician on what room to place a patient in. A high-risk suicidal patient would be taken back to the room by 1:1 (special constant) observation, wanded by security, and changed into hospital attire. Interview on 03/21/24 at 07:31 PM with Staff (AA), Charge Registered Nurse revealed they did not recall any aspects of care or conversations with or about Patient #2. The triage nurse would update the change nurse about any high risk for suicide patients that arrived at the facility to allow the charge nurse to assign the appropriate room. Findings #3: Review of emergency department medical record for Patient #1 dated 03/11/24 revealed the following: -At 11:15 AM, Staff (K), Physician, performed a medical screening examination after Patient #1 was found cutting their arm with a razor blade, which was able to be wrestled out of their arms by security. Patient #1 snuck a razor blade in past security their underwear. When Patient #1 got in the restroom, they used the razor blades to inflict multiple lacerations to their left extremity (arm). Patient #1 has done this in the past many times, sneaking in foreign bodies, and then lacerating themself in this facility. Patient #1 is quite agitated now despite multiple medications. Interview on 03/20/24 at 02:19 PM with Staff (F), Security Officer, revealed that Patient #1 was brought in by Jamestown police. Staff (F), Security Officer, assisted with bringing Patient #1 back to room #126. Staff (F) assisted Jamestown police and Staff (G), Patient Care Technician, with changing Patient #1 into a gown. Once Patient #1 was changed, Staff (F) scanned Patient #1 with the handheld (wand) metal detector. Patient #1 was permitted to keep their underwear on while scanned. The wand did not go off when Patient #1 was scanned, indicating that Patient #1 did not have any metal objects on them that could be detected. Patient #1 asked to go to the bathroom and was told yes by Staff (G), Patient Care Technician. Patient #1 went into the bathroom alone. A few minutes later, Staff (G), Patient Care Technician, and Staff (F) opened the bathroom door and saw Patient #1 on the ground bleeding. Staff (F) asked Patient #1 to give them the razor blade. Patient #1 refused and attempted to put the razor blade to their neck. Staff (N), Security Officer, responded and was able to grab ahold of Patient #1’s arm to prevent Patient #1 from harming themselves. Staff (F) was able to remove the razor blade for Patient #1’s hand and give it to the clinical staff. Staff (F) is unsure of where Patient #1 had the razor blades. There were more razor blades in a plastic case on the sink. Review on 03/21/24 of the document “Security Daily Event Log,” indicated that on 03/11/24 at 10:41 AM, Patient #1’s personal property was collected by Staff (N), Security Officer. At 10:50 AM, Staff (F), Security Officer, was present with a female Jamestown police office, and Staff (G), Patient Care Tech, while Patient #1 was changed into a safety gown. Staff (F) scanned Patient #1 with the handheld metal detector. At about 11:09 AM, Staff (F), Security Officer, discovered Patient #1 in the bathroom cutting their right arm with a razor blade. Review on 3/20/24 of the product information for the “GARRETT Super Scanner V Wand,” no date, revealed that periodic maintenance should include a daily check for battery condition, verification that that the Super Scanner V detects metal, and there are no loose or missing parts. A daily test standard can be established by using an object the size of a large coin. (No evidence was found to indicate daily checks on the wands is performed to ensure proper functioning). Review on 03/21/23 of the security staff personnel files for Staff (F, N, O, P, Q, S, W, X, BB, CC, DD, and EE), revealed no evidence of initial and/or annual training or competency for the use of the GARRETT Super Scanner V handheld metal detector (wand). Interview on 03/20/24 at 11:52 AM with Staff (B) Chief Nursing Officer, revealed there are no preventative maintenance wand logs. Staff do not perform a daily wand checks. Interview on 03/20/24 at 02:19 PM, with Staff (F), Security Officer, revealed they were trained on how to use the wand when hired. Staff do not check the wand daily per manufacturers recommendations. Interview on 03/20/24 at 02:30 PM, with Staff (L), Security Officer Manager, revealed that there is no formal training given to security officers regarding usage of the “GARRETT Super Scanner V (wand)” upon hiring or annually. There is no documentation for security staff indicating initial or annual “wand” training/competency. Periodic maintenance and daily operation checks are not conducted on any of the “wands.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 32261 A0115 This CONDITION is not met as evidenced by: Based on medical record review, document review, policy review, and interview, the facility failed to protect and promote the rights of all patients related to the use of restraints as evidence by: facility security officers used handcuffs to restrain Patient #1 and Patient #2 (A0154). On 12/05/23 at 01:08 PM, an Immediate Jeopardy situation was identified for the CoP of Patient Rights. The facility implemented immediate interventions that included: the removal of handcuffs from all security officers and clinical staff; and re-education on the restraint/seclusion policy; and re-education on state/federal regulations related to restraint and seclusion, patient rights, and use of least restrictive methods. Auditing will be conducted daily for a period of one week to ensure staff compliance to policy and regulations by the quality assurance department. At 05:30 PM, the Immediate Jeopardy was removed based on onsite surveyor verification of the immediate actions implemented by the facility through observations, policy review, document review, and interviews. Cross Reference: 482.13(e)- Patient Rights 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.”

“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: 32261 Based on document review, policy review, medical record review, video review, and interview, the facility does not ensure that all patients have the right to be free from physical or mental abuse, corporal punishment, and restraint imposed as a means of coercion, discipline, convenience, or retaliation by staff as evidenced by: facility security officers utilized locking, metal handcuffs to subdue and restraint Patient #1 on 06/10/23 & 11/19/23 and Patient #2 on 06/21/23. Handcuffs are considered a law enforcement restraint device and not considered a safe, appropriate healthcare restraint intervention for use by hospital staff, including security officers. The use of handcuffs in the healthcare setting could result in a negative outcome to patients. Findings include: Review of the “New York State Department of Health Dear Chief Executive Officer Letter 17-13-Security Guards and Restraints,” dated 11/02/17 indicated that hospitals must ensure that security staff are specifically authorized to use restraints and are not utilizing law enforcement devices such as handcuffs, chains, manacles, leg irons, etc. to restrain patients. Review of policy “Restraint and Seclusion,” last reviewed 06/13/23 indicated that that a restraint is any manual method, physical hold or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. A mechanical physical restraint does not include devices such as handcuffs or other restrictive devices applied by law enforcement. Review of policy “Patient in Custody of Law Enforcement (Forensic Patients),” dated 07/27/23 indicated that custodial restraints such as handcuffs, shackles, etc. will only be utilized when a forensic officer (law enforcement) is present and in direct observation of the patient. Review of facility security officer and nursing staff training/education related to restraints and seclusion does not include guidance on the use of handcuffs. Review of medical record for Patient #1 revealed on 06/11/23 at 12:13 AM, the nurse documented that on 06/10/23 at 08:00 PM, Patient #1 became agitated, started yelling, throwing furniture, and attempting to barricade the doorway. Security came to the unit. The provider was contacted and ordered Ativan two milligrams and Benadryl 50 milligrams via intramuscular injection. Patient #1 was offered medications but stated “if you come in here with a needle, I’m gonna stab you in the neck.” At 09:03 PM, security officers entered the room. Patient #1 became violent and attempted to grab a security officers pepper spray. At 09:04 PM, security officers handcuffed Patient #1. At 09:05 PM, intramuscular injections were administered. At 09:19 PM, Patient #1 was walked to the seclusion room by security officers. At 09:21 PM, Patient #1 was placed in the seclusion room and handcuffs were removed. Review of the security officer report dated 06/10/23 at 08:00 PM indicated that Staff (M), Security Officer, Staff (AA), Security Officer, and Staff (FF), Security Officer reported to the adult inpatient Behavioral Health unit due to Patient #1 barricading self in their room, making several threats of physical violence towards staff, and throwing a cup of water into an electrical outlet. At 09:03 PM, Staff (M), Staff (AA), and Staff (FF) entered the room to restrain Patient #1. Staff (M), Staff (AA), and Staff (FF) went “hands on” (manual restraint) in an attempt to bring Patient #1 to the ground. All three security officers and Patient #1 fell onto the chairs that were barricading the door. As a result, Patient #1 was able to unlatch Staff (FF)’s pepper spray and attempted to pull it out. Staff (AA) and Staff (FF) were able to get Patient #1’s hand away from the spray. At 09:04 PM, Staff (M) placed Patient #1 in handcuffs. Patient #1 was escorted to the seclusion room. At 09:21 PM, Staff (M) released the handcuffs. Review of the emergency department medical record for Patient #1 revealed on 11/19/23 at 02:55 PM, Staff (G), Emergency Department Registered Nurse documented that while security officers were removing items from Patient #1’s room, Patient #1 ran from the room. Patient #1 became combative when escorted back to the room by security officers. Security officers started to do a three person restraint. Patient #1 began to punch the security officers. Security officers placed Patient #1 in handcuffs. At 03:15 PM, Staff (G), documented that the handcuffs were removed. Review of the security video for emergency department room #128 dated 11/19/23 at 02:53 PM revealed Staff (II), Security Officer, attempted to gain control of Patient #1’s legs. Staff (L), Security Officer and Staff (M), Security Officer attempted to regain control of Patient #1’s arms. Staff (M) removed handcuffs from their waist and applied the handcuffs on Patient #1’s right wrist. Patient #1 was rolled over on their stomach while Staff (M) applied the handcuffs to Patient #1’s left wrist. Patient #1 was sat up. Staff (L) and Staff (M) stood up while Staff (II) held Patient #1’s wrists. Staff (M) exited the room and stood in the doorway. Staff (II) let go of Patient #1’s wrists, stood up, and exited the room. Patient #1 stood up with their arms behind their back, handcuffs clearly visible. At 03:13 PM, the two female Jamestown police officers entered the room with a male staff member and removed the handcuffs. (Review of the video did not show that Patient #1 was swinging at security staff and/or hit and choked Staff (M). However, during the video, there is approximately 30 seconds that Staff (L), and Staff (II) obstruct visualization of Patient #1 and Staff (M) on the ground, prior to Staff (M) applying the handcuffs to Patient #1). Review of the security officer reports dated 11/19/23 at 01:48 PM indicated that Staff (L), Security Officer, was called to the emergency department by Staff (K), Patient Care Technician to assist with Patient #1. At 01:53 PM, security officers attempted to do a three person manual restraint. Patient #1 attempted to choke and punched Staff (M) in the face. At 02:59 PM, Patient #1 was handcuffed (by security officers). Security officers cleared the room and closed the door per direction of Staff (G), Registered Nurse. Patient #1 remained in their room until Jamestown Police arrived at 03:02 PM. At 03:05 PM intramuscular medications were administered. Security staff were directed to remove the handcuffs from Patient #1 by Staff (VVV) and Staff (WWW), both Emergency Department Registered Nurses. Security staff were directed by Jamestown police to keep the handcuffs on for safety. Staff (L), Security Officer, called Staff (S), Security Manager, to informed them of the situation and was directed to remove the handcuffs. At 03:12 PM, intramuscular medications were administered to Patient #1. At 03:15 PM, the handcuffs were removed, and all staff cleared the room. Interview on 12/04/23 at 11:20AM with Staff (E), Emergency Department Registered Nurse and the charge nurse on 11/19/23, was made aware by Staff (H), Registered Nurse that Patient #1 was in handcuffs. Staff (E) instructed the security officers to remove the handcuffs, but security refused citing Patient #1 was too violent and that Jamestown police instructed security officers to keep the handcuffs on Patient #1 until they (Jamestown police) arrive. Staff (E) texted Staff (F), Registered Nurse, to ask what to do. Staff (F) responded that the handcuffs must be removed. Security officers were instructed again to remove the handcuffs, which they refused. Jamestown police arrived, Patient #1 was given medications, and the handcuffs were removed. Interview on 12/04/23 at 11:28AM with Staff (I), Emergency Department Patient Care Technician stated that Patient #1 was agitated and violent in the hallway trying to leave. Patient #1 was placed on the floor by security office after acting violently and swinging at staff. Patient #1 struck one of the security officers which prompted security to handcuff Patient #1. Security officers called the Jamestown police. One of the guards removed the handcuffs after medication was administered. Interview on 12/04/23 at 11:55AM with Staff (L), Security Officer, revealed on 11/19/23, Staff (L), Security Officer, Staff (M), Security Officer and Staff (II), Security Officer responded to the emergency department to assist with Patient #1 who was making threats towards staff and threatening to leave. Staff (L), Security Officer, and the other security officers attempted a three-point restraint. Patient #1 was struggling, making it difficult to be restrained. At some point, Patient #1 punched and choked Staff (M), Security Officer, resulting in Staff (M), Security Officer, placing Patient #1 in handcuffs. Staff (L), Security Officer, did not witness Patient #1 punching or choking Staff (M), Security Officer. Once Patient #1 was placed in handcuffs, all three security staff exited the room and locked the door. The Jamestown police were contacted, by security staff and instructed the security officers to keep Patient #1 in handcuffs until their arrival. Patient #1 was in handcuffs for about 10 to15 minutes until Jamestown police arrived and Staff (G), Registered Nurse, administered medications. Interview on 12/04/23 at 01:03 PM with Staff (G), Emergency Department Registered Nurse, who stated that on 11/19/23, security officers were attempting to restrain Patient #1 when Patient #1 apparently punched one of the security staff. Patient #1 was placed in handcuffs. Two Jamestown police officers arrived, and Patient #1 was given intramuscular medications. After the medications were administered, the handcuffs were removed. Staff (G) stated security staff call Jamestown police. Telephone interview on 12/05/23 at 10:05 AM with Staff (M), Security Officer, revealed they were called to the emergency department due to Patient #1 “acting up.” Staff (M) and two other security officers attempted to talk to Patient #1, who was agitated and attempting to leave the unit. Patient #1 continued to escalate and tried to abscond. Patient #1 began to fight. Security officers decided to place Patient #1 in a physical restraint. Staff (M) stated that Patient #1 kicked, punched, and attempted to choke Staff (M). Due to Patient #1’s size and the danger to staff, Staff (M), placed Patient #1 in handcuffs. Jamestown Police were called for assistance while the other guards called their supervisor. Jamestown Police arrived and assisted with medicating Patient #1. Once Patient #1 was medicated, the handcuffs were removed. Interview on 12/05/23 at 03:05 PM with Staff (II), Security Officer, revealed that security officers responded to the emergency department because Patient #1’s behavior was escalating. Security officers were directed by Staff (G), Registered Nurse, to return Patient #1 to their room. Patient #1 became combative while security staff attempted to direct them back into their room. Patient #1 was placed in physical restraint and taken to the floor. During the physical restraint, Staff (M), Security Officer, stated to Staff (II) and Staff (L) that Patient #1 had punched and attempted to choke Staff (M). Staff (II) stated that they did not witness Patient #1 punching or choking Staff (M). Staff (M) placed Patient #1 in handcuffs. The security officers left the room and locked the door. Jamestown police were called. Clinical staff, Jamestown Police, and security officers entered the room twice to medicate Patient #1. The handcuffs were removed after the second medication administration. Review of the emergency department medical record for Patient #2 revealed on 06/21/22 at 09:55 PM, Patient #2 was brought in via ambulance for an examination of an intoxicated, impaired, or incapacitated person by alcohol and/or substances requested by the Jamestown police due to the possibility of Patient #2 being unable to care for self and placing self in dangerous situations. Patient #2 was under the influence of a narcotic/drug and had cut and burned themself and as a result. Patient #2 was unable to function without the assistance of police. At 10:06 PM Patient #2 ran out of the emergency department. Security officers attempted to stop Patient #2. Patient #2 punched a security officer in the head. Patient #2 was placed in handcuffs, put on a gurney, and brought back into the emergency department. The burn to left arm was first degree and no treatment was needed. The emergency department providers physical assessment of Patient #2 revealed Patient #2 was alert and oriented with normal heart rate and rhythm. Jamestown police were called due to Patient #2 physically assaulting staff. Patient #2 was stable and was discharged to the police. Review on 12/06/23 of the security report dated 06/22/23 revealed on 06/21/23 at 09:54 PM, Staff (GG), Security Officer, was called to assist with an absconding patient (Patient #2). Patient #2 had been brought in approximately 15 minutes before by Jamestown police via ambulance for a mental health examination and was not allowed to leave. Patient #2 began to struggle with Staff (GG), grabbed Staff (GG)’s shirt, and punched Staff (GG) multiple times in the face. This caused abrasions and light bleeding under Staff (GG)’s left eye. Patient #2 punched Staff (GG) four more times and ripped their shirt. Staff (GG) assisted Patient #2 to the ground. At 10:00 PM, Staff (GG) handcuffed Patient #2. Other security officers responded, and Patient #2 was placed on to a stretcher (handcuffed). At 10:06 PM, Jamestown police were called. Staff (GG) filed a report and pressed charges. Jamestown police arrested and left with Patient #2. Interview on 12/06/23 at 10:26 AM with Staff (B), Vice President of Patient Care/Chief Nursing Officer, and Staff (C), Clinical Director Nursing/Quality, confirmed these findings.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 32261 A0385 This CONDITION is not met as evidenced by: Based on policy review, medical record review, document review, and interview, it was determined that nursing services did not provide supervised care as evidenced by: Nursing staff did not performed assessments and/or check the feed tube placement every four hours for Patient #2, who was receiving continuous enteral tube feedings (Tag-A0395). Nursing staff did not clarify the continuous enteral tube feed order with the provider for Patient #2 (Tag-A0405). Nursing staff did not report the aspiration event/incorrect enteral tube feed order to the facility incident reporting system (Tag-A0411). This failure resulted in an aspiration event for Patient #2. Cross Reference: 482.23(b)(3)- Nursing Services: RN Supervision of Nursing Care 482.23(c)(1), (c)(i) & (c)(2)- Nursing Services: Administration of Drugs 482.23(c)(5)- Nursing Services: Reporting Adverse Reactions and Errors”

“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: 32261 Based on policy review, medical record review, and interview, nursing staff did not performed assessments and/or check the feed tube placement every four hours for Patient #2, who was receiving continuous enteral tube feedings. Lack of patient assessment places a patient at a greater risk of aspirating. Findings include: Review on 11/02/23 of policies “Enteral Tube Feeding, Gastric,” “Enteral Tube Feeding, Continuous Gastrostomy and Jejunostomy,” and “Enteral Tube Feeding, Intermittent, Gastrostomy and Jejunostomy,” all revised 11/2022 revealed nursing staff are to assess for gastrointestinal intolerance every four hours by assessing abdominal distention. Documentation for enteral tube feedings includes, but not limited to, date/time/amount of each enteral tube feeding, type of formula, infusion method and rate, patient tolerance to procedure and formula, gastric residual volume, gastrointestinal assessment, and enteral tube feeding problems or complications. Review of policy “Impaired Swallowing and Aspiration Precautions,” last revised 02/2023 revealed patients that have impaired swallowing are at high risk for aspiration. For patients with a continuous feeding, assess feeding tube placement before feeding and every four hours by either observing for a change in external feeding tube length and aspirating gastric contents from the feeding tube and observing for changes in volume/appearance/color of aspirate. Assess the patient for gastrointestinal intolerance of enteral tube feedings every four hours by assessing for abdominal distention, monitoring for abdominal pain, and observe for passage of flatus (passing gas) and stool. Review on 11/03/23 of medical record for Patient #2 revealed on 08/11/23 at 09:00 AM, nursing staff documented that feeding tube placement was checked via aspiration. Patient #2’s lung sounds were diminished. At 10:46 AM, the physician documented that Patient #2’s lung sounds were clear. At 10:48 AM, Staff (T), Physician ordered “Glucerna 1.5 tube feed, continuous, start rate 215 ml per hour, increase by 0, goal rate 5x daily, delegate tube feed modifications and modular orders to the dietician, 60 ml free water flush after each feed” and to check for residuals (hold if greater than 500 mls). At 07:45 PM, nursing staff documented that Patient #2 had coarse/rhonchi (a breath sound characterized by a low-pitch sound during breathing that occurs when fluid or mucus accumulates in the respiratory system) in the right lower lung lobe. At 10:00 PM, the nursing documented that Patient #2 had audible respirations, an elevated heart rate, and a decreased oxygen saturation. The residual check was over 600 mls. At 10:30 PM, nursing documented that Patient #2 aspirated the tube feed, and a “Condition C” (rapid response) was called. No evidence was found in the medical record to indicate nursing staff performed GI assessments and check the feed tube placement per policy every four hours following the 09:00 AM assessment until 07:45 PM. Interview on 11/02/23 at 11:00 AM with Staff (B), RN & Vice President of Patient Care/Chief Nursing Officer, and Staff (C), RN Clinical Director Nursing/Quality, confirmed these findings.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 32261 Based on policy review, medical record review, and interview, the physician ordered an enteral tube feeding administration rate as continuous instead of by bolus. The nursing staff did not clarify the enteral tube feed order with the provider for Patient #2. Patient #2 experienced an acute hypoxemic respiratory failure event, secondary to the aspiration of tube feed contents. Findings include: Review of policy “Enteral Tube Feeding, Gastric,” and “Enteral Tube Feeding, Continuous Gastrostomy and Jejunostomy,” both revised 11/2022 revealed that when implementing a tube feed, staff are to verify the practitioner’s order, the enteral feeding device, the prescribed formula, the administration method, the volume, and the rate, type, volume, and frequency of the water flushes. Review on 11/03/23 of medical record for Patient #2 revealed on 08/11/23 at 10:48 AM, Staff (T), Physician ordered “Glucerna 1.5 tube feed, Continuous, start rate 215 ml per hour, increase by 0, goal rate 5x daily, delegate tube feed modifications and modular orders to the dietician, 60 ml free water flush after each feed and to check for residuals (hold greater than 500 ml). At 11:48 AM, Staff (W), Registered Nurse, reviewed and validated the tube feed order by Staff (T), Physician in the electronic medical record. At 10:30 PM, nursing documented that Patient #2 aspirated the tube feed, and a “Condition C” (rapid response) was called. On 08/12/23 at 07:58 AM, Staff (T), Physician documented that on the night of 08/11/23, Patient #2 had an aspiration event and it appeared that Patient #2 was receiving continuous feeds rather than bolus feeds based on the order review. Interviews on 11/01/23 at 12:30 PM with Staff (L), Registered Nurse and at 12:40 PM with Staff (Q), Registered Nurse, both from floor 5D revealed that if the tube feed order was unclear, the prescribing provider would be contacted to clarify the order. Telephone interview on 11/27/23 at 09:50 AM with Staff (T), Physician revealed Staff (T) was aware Patient #2 was on home bolus feedings of Glucerna 1.5 five times a day. On 08/11/23, Staff (T) put the order in the electronic medical record for Patient #2’s home feed of Glucerna 1.5, bolus feeding of 215 ml followed by 60 ml water flush five times a day. On 08/12/23, Staff (T) learned Patient #2 had a hypoxic event on 08/11/23. Upon review of the event and the order, Staff (T) discovered that the order had defaulted to “continuous” and not “bolus” as Staff (T) stated was originally selected. A normal rate of 1.5 calorie formula for an average sized adult would be 40 ml to 55 ml per hour (40-55 ml/hr.). Staff (T) stated that 215 ml/hr. as a continuous feed is not a normal order and is too much volume. Patient #2’s feed was running continuously at 215 ml/hr. Telephone interview on 11/27/23 at 10:15 AM with Staff (II), Registered Dietician, revealed on 08/10/23, Staff (II) evaluated Patient #2 and recommended Glucerna 1.5 at 25ml/hr. with 10 ml increases every 6 hours to a goal rate of 45 ml/hr. A rate of 45 ml/hr. is a normal rate for a patient the size of Patient #2. (The enteral tube feeding was running at 215 ml/hr.). A continuous tube feed rate of 45 ml/hr. is a normal rate for a patient the size of Patient #2. Staff (II) stated that if bolus tube feeds were desired, Glucerna 1.5, 225 ml, five times a day would be appropriate. Interview on 11/02/23 at 11:00 AM with Staff (B), RN & Vice President of Patient Care/Chief Nursing Officer, and Staff (C), RN Clinical Director Nursing/Quality, confirmed these findings.”

“REPORTING ADVERSE REACTIONS AND ERRORS CFR(s): §482.23(c)(5) - There must be a hospital procedure for reporting transfusion reactions, adverse drug reactions, and errors in administration of drugs. This Standard is not met as evidenced by: 32261 Based on policy review, medical record, interview, and document review, staff did not report Patient #2’s aspiration event/incorrect enteral tube feed order that occurred on 08/11/23 to the facility incident reporting system. Failure to report adverse events has the potential for not identifying issues and implementing actions to improve the quality of patient care. Findings include: Review of policy “Initial Incident/Event Reporting”, last revised December 2022, revealed a “Reportable Event” is any incident, medication event, sentinel event, serious event, or infrastructure failure. A “Sentinel Event” is any unanticipated event in the healthcare setting resulting in death or serious physical injury to a patient not related to natural course of the patient’s illness. A “Serious Event” is an event, occurrence, or situation involving the clinical care of a patient that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health services to the patient. An individual with knowledge of a reportable patient event shall report the event immediately or as soon as possible, but no later than 24 hours after occurrence of discovery via the Initial Incident/Event Report reporting process and shall provide as much information as reasonably possible. Review of policy “Reporting Serious Adverse Events”, last revised July 2020 revealed a sentinel event is patient safety event (not primarily related to the natural course of the patient illness or underlaying condition) that reaches a patient and results in death, permanent harm, or severe temporary harm. The staff member will notify supervision at once. The supervisor will contact the Quality Department. A patient incident report and Patient Incident Review Form must be completed. Review on 11/03/23 of medical record for Patient #2 revealed on 08/11/23, a “Condition C” (rapid response) was called for Patient #2 after becoming hypoxic with high systolic blood pressure, a high pulse rate, and appearing to be in respiratory arrest. Oral suctioning and gastric contents showed tube feed solution. The tube feed was stopped, and Patient #2 was transferred to the intensive care unit (ICU). On 08/12/23, in the ICU, Patient #2 developed hypoxia again and there was a concern of recurring aspiration. At 07:58 AM, Staff (T), documented that on the night of 08/11/23, “Patient #2 had an aspiration event .... and that it appears that Patient #2 was receiving continuous feeds rather than bolus feed based on the order review.” Interview on 11/01/23 at 02:00 PM Staff (B), RN and Vice President of Patient Care/Chief Nursing Officer, and Staff (C), RN Clinical Director Nursing/Quality, revealed there were no complaints, grievances, adverse events, and/or provider reviews related to Patient #2. Review on 11/02/23 of the Adverse Events Log from 05/2023 and Complaints/Grievances Log from 05/2023 to present revealed no evidence of an event report, complaint, or grievance related to the aspiration events that occurred on 08/11/23 and 08/12/23 for Patient #2.”