Providence Portland Medical Center

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 29708 Based on review of hospital Security Officer (SO) body camera footage, interviews, review of medical record documentation for Patient 6 who was handcuffed by hospital SOs and Patient 8 who was tased and handcuffed by hospital SOs, review of security report and/or incident documentation for 7 of 7 patients who were handcuffed by hospital SOs (Patients 4, 6, 8, 9, 11, 12 and 13), review of training materials, review of P&Ps and other documentation it was determined that the governing body of the hospital failed to ensure that P&Ps and processes were fully developed and implemented that ensured the provision of safe and appropriate care to patients in the hospital and compliance with the Conditions of Participation. The hospital’s failures included: * The hospital failed to prevent non-law enforcement hospital SOs from applying handcuffs to patients, using excessive force during handcuff application, and detaining patients in a security area hold room until law enforcement arrived. These failures contributed to injuries of at least one patient, Patient 6, and created the likelihood of harm to other patients. The failures related to Patient 6 included: The patient presented to the ED on 03/29/2025 by EMS in four-point restraints with suicidal thoughts, aggressive behavior, and acute agitation. The patient was discharged the next day. Prior to leaving the ED, the patient was banging on walls and spit at an RN. Multiple SOs escorted the patient out of the ED. The patient was described as “verbally inappropriate” toward a SO as they were walking away from the hospital. Security Officers failed to attempt de-escalation techniques and instead escalated the situation by telling the patient to “get your shit and go, dude, bye.” The patient turned to face the SO and spit or motioned to spit at the SO, then continued leaving at which point SOs took the patient to the ground on a wet, cement staircase. While holding the patient down one or more SOs punched the patient’s torso area at least twice and held the patient’s head directly onto a cement stair, first with an open hand, then a knee, and then by stepping on the patient’ head. The patient was crying out and stated, “please stop.” The patient’s neck was near or on the edge of the stair during these activities which lasted approximately 90 seconds. Security Officers told the patient they were “under arrest” and applied metal handcuffs to the patient while still in this position. The patient’s head was visibly bleeding after these activities. An ED nurse came out of the ED and briefly assessed the patient’s head. The patient was then taken to a security area “hold room” for three hours with handcuffs still in place and held by SOs without monitoring their head injury and other potential injuries until law enforcement arrived. The hospital subsequently determined the use of force was “outside policy.” * The hospital failed to prevent non-law enforcement hospital SOs from deploying tasers on patients for non-criminal activities and applying handcuffs after tasing. The hospital’s failures created the risk of harm to at least one patient, Patient 8, and created the risk of harm to other patients. The failures related to Patient 8 included: The patient presented to the ED with complaints that included auditory hallucinations, delusions, and paranoia. The patient was brought in from a mental health program facility by a “caregiver” of that facility. The employee slipped a note to the triage RN stating the patient was being checked in for SI/HI, and for paranoia and hallucinations. At no time during the triage process were SOs alerted to this patient and their associated risks. The patient went through metal detector screening upon entering the ED and an RN took the patient to a room without SO knowledge or presence. The patient was not on a physician hold and when they saw the room, they ran out the ED entrance. At least three SOs followed the patient. Approximately 10 seconds after leaving the ED, the patient stopped in a parking area and turned towards one of the SOs. The patient’s right hand was observed behind their back, their left hand was holding a red sack, and the SO was observed to have a taser pointed toward the patient. The patient moved both hands to the front of their body and up toward their chest and head in a flinching, defensive posture. Approximately one second later the patient put both hands behind their back, dropped the red sack and appeared to pull up their pants. The SO was not observed or heard to attempt de-escalating the patient at any time and yelled, “Back the fuck up now or you’re going to get tased. Don’t reach for anything.” Approximately two seconds later, the patient was observed falling toward the ground after the SO released the taser prongs. The patient stated, “I was pulling my pants up.” Three SOs pinned the patient face down on the asphalt ground, applied metal handcuffs, put the patient in a wheelchair with the handcuffs still intact, and returned the patient to the ED. The patient did not have a weapon. The patient did not commit a criminal activity, and the incident was not handled as a criminal activity as the patient was not placed in law enforcement custody. The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care. On 06/26/2025 at 1350 the hospital was notified that two IJ situations had been determined to exist. Refer to Tag A-144 for the details of the identification of two IJ situations, IJ notifications, IJ Removal Plan approvals, and IJ Removal Plan Verification Visit. An IJ Removal Plan Verification Visit was conducted on 07/23/2025 and the two IJ situations were determined to be removed. Findings include: 1. Refer to Tag A-115, CFR 482.13 - CoP: Patient’s Rights. The hospital failed to ensure the provision of care in a safe setting (Tag A-144). The hospital failed to ensure patients’ rights to be free from all forms of abuse and harassment (Tag A-145). 2. Refer to Tag A-263, CFR 482.21 - CoP: Quality Assessment and Performance Improvement Program. The hospital failed to thoroughly investigate, analyze, trend and develop corrective actions of adverse patient events (Tag A-286). Events included: * Non-law enforcement hospital SOs handcuffing patients, using excessive force during handcuffing, and detaining injured patients in a security area hold room without appropriate exam and monitoring. * Non-law enforcement hospital SOs tasing patients who had not committed a criminal activity. **************”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 29708 Based on review of hospital Security Officer (SO) body camera footage, interviews, review of medical record documentation for Patient 6 who was handcuffed by hospital SOs and Patient 8 who was tased and handcuffed by hospital SOs, review of security report and/or incident documentation for 7 of 7 patients who were handcuffed by hospital SOs (Patients 4, 6, 8, 9, 11, 12 and 13), review of training materials, review of P&Ps and other documentation it was determined the hospital failed to ensure that P&Ps and processes were fully developed and implemented that ensured patients received care in a safe setting. * The hospital’s failures caused injuries to Patient 6 who was leaving the ED when SOs applied handcuffs to the patient and used excessive force including stepping on the patient’s head and punching the patient’s torso area during handcuff application; and detained the patient while still handcuffed in a security area hold room for approximately three hours without appropriate examination and monitoring of the patient’s injuries. * The hospital’s failures created the likelihood of serious harm to Patient 8 who was leaving the ED when SOs tased and handcuffed the patient. The patient was not engaging in criminal activity when this occurred. * The hospital failed to develop and enforce P&Ps to ensure patients’ rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough and complete investigations and follow up actions of potential abuse or neglect, as defined by CMS, to ensure those incidents did not recur. * The governing body failed to ensure, through the Quality Assessment and Performance Improvment Program (QAPI), the prevention and reduction of adverse events that included complete and thorough investigations, analyzing findings, and implementing actions to prevent recurrence of those. This Condition is determined to be out of compliance based on findings that hospital staff failed to attempt de-escalation techniques for Patient 6 who had been discharged and was leaving hospital property. The patient was “verbally inappropriate” and instead of attempting de-escalation, SOs verbally provoked the patient leading to increased behaviors. In response to these behaviors, SOs applied handcuffs, and used excessive force including holding the patient’s head and neck on or near a cement stair ledge by stepping on their head. The patient sustained head injuries and was then detained in a security hold room for three hours without appropriate examination, treatment and monitoring of their injuries. Regarding Patient 8, the hospital failed to ensure an ED nurse notified SOs of the patient’s behavioral health risks and attempt de-escalation techniques before tasing and handcuffing the patient. The patient had gone through a metal detector in the ED, did not have a weapon, and was not on a physician hold. The patient left the ED and SOs went after the patient. Although the patient had not committed a criminal act, an SO tased and handcuffed the patient and then returned them to the ED. The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care. On 06/26/2025 at 1350 the hospital was notified that two IJ situations had been determined to exist. Refer to Tag A-144 for the details of the IJ identification, IJ notification, and submission of unsuccessful IJ Removal Plans prior to the exit conference. Findings include: 1. Refer to the findings cited under this CoP, CFR 482.13(c)(2) - Standard: Privacy and Safety. Those findings reflect that provisions for appropriate management and response of patients with behavioral health symptoms, including but not limited to failure to attempt de-escalation, application of handcuffs by non-law enforcement SOs and tasing patients were not fully developed and implemented and resulted in injury and harm to Patient 6 and likelihood of serious injury and harm to Patient 8 and other patients experiencing similar symptoms (Tag A-144). 2. Refer to the findings cited under this CoP, CFR 482.13(c)(3) - Standard: Privacy and Safety. Those findings reflect that hospital failed to develop and enforce P&Ps to ensure patients’ rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough and complete investigations and follow up actions of potential abuse or neglect, as defined by CMS, to ensure those incidents did not recur. (Tag A-145). 3. Refer to the findings cited under CoP, CFR 482.21 - QAPI. Those findings reflect that the governing body failed to ensure, through the QAPI program, the prevention and reduction of adverse events that included complete and thorough investigations, analyzing findings, and implementing actions to prevent recurrence of those (Tag A-263).”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 29708 Based on review of hospital Security Officer (SO) body camera footage, interviews, review of medical record documentation for Patient 6 who was handcuffed by hospital SOs and Patient 8 who was tased and handcuffed by hospital SOs, review of security report and/or incident documentation for 7 of 7 patients who were handcuffed by hospital SOs (Patients 4, 6, 8, 9, 11, 12 and 13), review of training materials, review of P&Ps and other documentation it was determined that the governing body failed to ensure, through the QAPI program, the prevention and reduction of adverse events, complete and thorough investigations, analyzing findings, and formulating and implementing actions to prevent recurrence of those. The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care. Findings include: 1. Refer to the findings cited under this Condition at Tag A-286 under CFR 482.21(a), (c)(2), (e)(3) - Standard: Patient Safety, that reflects the QAPI program failed to ensure that incidents and adverse patient events were clearly investigated and analyzed, and that corrective actions were subsequently planned and implemented to prevent recurrence of those, to promote learning, and to establish clear expectations for patient safety. Those failures reflect the incidents involving Patients 6 and 8 had not been thoroughly investigated and analyzed to determine corrective actions and corrective actions planned and implemented to address gaps. Patient 6 was injured when handcuffed by non-law enforcement hospital SOs, and Patient 8 was at high likelihood of serious harm when tased and handcuffed by non law-enforcement hospital SOs. 2. Refer to the findings cited at Tag A-115, CFR 482.13 - CoP: Patient’s Rights, that reflects the QAPI program failed to ensure each patient’s rights were protected and promoted, including the right to receive care in a safe setting. Those failures created an unsafe environment that caused patient harm for Patient 6 and created the likelihood of harm to Patient 8 and other patients. Patient 6 was injured when handcuffed by non-law enforcement hospital SOs, and Patient 8 was at high risk for injuries and harm when tased and handcuffed by non law-enforcement hospital SOs (Tag A-144). The hospital further failed to conduct clear and complete investigations of adverse events that addressed all potential gaps and deficient practices, and failed to subsequently develop and implement corrective actions to prevent recurrence for Patient 6, Patient 8, and other patients (Tag A-145).”

“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: 29708 Based on review of hospital Security Officer (SO) body camera footage, interviews, review of medical record documentation for Patient 6 who was handcuffed by hospital SOs and Patient 8 who was tased and handcuffed by hospital SOs, review of security report and/or incident documentation for 7 of 7 patients who were handcuffed by hospital SOs (Patients 4, 6, 8, 9, 11, 12 and 13), review of training materials, review of P&Ps and other documentation it was determined the hospital failed to ensure that P&Ps and processes were fully developed and implemented that ensured patients received care in a safe setting as follows: * Regarding Patient 6: The hospital’s failures caused injuries to the patient who was leaving the ED when SOs applied handcuffs to the patient and used excessive force including stepping on the patient’s head and punching the patient’s torso area during handcuff application; and detained the patient while still handcuffed in a security area hold room for approximately three hours without appropriate examination and monitoring of the patient’s injuries. The failures related to the injuries of Patient 6 who was handcuffed on 03/30/2025 included: - The patient presented to the ED on 03/29/2025 by EMS in four-point restraints with suicidal thoughts, aggressive behavior, and acute agitation. The patient was discharged from the ED the next day. - Prior to discharge, the patient was banging on walls and spit at an RN. - Multiple SOs escorted the patient out of the ED. - The patient was described as “verbally inappropriate” toward an SO as they were walking away from the hospital. Security Officers failed to attempt de-escalation techniques and instead escalated the situation by telling the patient to “get your shit and go, dude, bye.” - The patient turned to face the SO and motioned to spit or spat at the SO, then continued leaving at which point SOs took the patient to the ground on a wet, cement staircase. While holding the patient down one or more SOs punched the patient’s torso area at least twice and held the patient’s head directly onto a cement stair, first with an open hand, then a knee, and then by stepping on their head. The patient was crying out and stated, “please stop.” The patient’s neck was near or on the edge of the stair during these activities which lasted approximately 90 seconds. Security Officers told the patient they were “under arrest” and applied metal handcuffs to the patient in this position. - The patient’s head was visibly bleeding after these activities. - An ED nurse came out of the ED and briefly assessed the patient’s head. - The patient was then taken to a security area “hold room” for three hours with handcuffs still in place and held by SOs without monitoring of their head injury and other possible injuries until law enforcement arrived. - The hospital subsequently determined SOs’ use of force was “outside policy.” * Regarding Patient 8: The hospital’s failures created the likelihood of serious harm to the patient who had left the ED when SOs tased and handcuffed them. The failures related to Patient 8 who was tased and handcuffed on 04/06/2025 included: - The patient presented to the ED with complaints that included auditory hallucinations, delusions, and paranoia. - The patient went through metal detector screening upon entering the ED. - The patient was brought in from a mental health facility by an employee of that facility. The employee slipped a note to the ED triage RN stating the patient was being checked in for SI/HI, paranoia and hallucinations. At no time during the triage process were SOs alerted to this patient and their associated risks. - An RN took the patient to an ED room without SO presence or knowledge. - The patient was not on a physician hold. - When the patient saw the ED room, they ran out the ED entrance, and at least three SOs followed the patient. - Approximately 10 seconds after leaving the ED, the patient stopped in a parking area and turned towards one of the SOs. The patient’s right hand was observed behind their back, their left hand was holding a red sack, and the SO was observed to have a taser pointing toward the patient. The patient moved both hands to the front of their body and up toward their chest and head in a flinching, defensive posture. - Approximately one second later the patient put both hands behind their back, dropped the red sack and appeared to pull up their pants. The SO yelled, “Back the fuck up now or you’re going to get tased. Don’t reach for anything.” - Approximately two seconds later, the patient was observed falling toward the ground after the SO released the taser prongs. The patient stated, “I was pulling my pants up.” - Three SOs pinned the patient face down on the asphalt ground, applied metal handcuffs, put the patient in a wheelchair with the handcuffs still intact, and returned the patient to the ED. - The patient did not have a weapon. - The patient did not commit a criminal act, and the incident was not handled as criminal activity as the patient was not placed in law enforcement custody. - No attempts to de-escalate the patient’s behaviors prior to tasing and applying handcuffs were observed or heard. * The hospital failed to develop and enforce P&Ps to ensure patients’ rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough and complete investigations and follow up actions of potential abuse or neglect, as defined by CMS, to ensure those incidents did not recur. As described above in this tag and at findings 1.a. through 4.a. below in this tag it was determined that two IJ situations existed, one involving Patient 6 and one involving Patient 8. On 06/24/2025 at ~ 1305 the SA survey team met with the SA Survey Manager to review survey findings for potential IJ. On 06/26/2025 at 1430, hospital leadership staff were presented with two IJ templates. Two IJ Removal Plans submitted on 06/30/2025 (with an “amendment” submitted for one of those on 07/01/2025) and 07/03/2025 were not approved. An exit conference for the full survey was conducted on 07/11/2025 at 1000 before an acceptable IJ Removal Plan was received by the hospital. IJ Removal Plans submitted on 07/11/2025 at 1554, and 07/16/2025 were not acceptable and were not approved. The fifth IJ Removal Plans submitted on 07/17/2025 were determined to be acceptable and were approved. The details of the approved IJ Removal Plans with implementation dates of 07/22/2025 at 1200 included: The IJ Removal Plan regarding Patient 6 included but was not limited to: * “Handcuffs will not be used by staff on the hospital campus/property. Handcuffs will no longer be carried by any security officers.” * “Patients with behavioral health symptoms in the hospital with an already identified electronic medical record Risk for Violence (RFV) alert, or those that have a newly identified need for this RFV alert to be placed, will trigger an immediate notification by the direct care RN (DCN) to the charge RN, who will initiate a huddle with the supervising security officer and the hospital nursing supervisor or nurse leader ... to develop a proactive patient safety plan (to include triggers, de-escalation tips, team approach, and patient specific interventions to maintain safety, etc.). This interprofessional team (DCN, charge RN, security supervisor, hospital nursing supervisor or nursing leadership) will utilize the Pre-Code Gray process to develop a proactive patient safety plan ...” * “The proactive patient safety plan will utilize a paper checklist that will be shared with security, patient access services/registration, and involved nursing teams ...” * “Education regarding this IJ Removal Plan will be provided and attested to by security, hospital nursing supervisors, nurses, patient access services/registration staff, ED providers, hospitalists, and psychiatrists at the start of their next respective shifts ...” * “Security officer education will include ... De-escalation techniques with emphasis of the importance of their use ... Prioritizing retreat and/or back away and the importance of de-escalation tactics ...” * “Education will be provided to nurses, hospital nursing supervisors, nurse leaders (nurse managers, assistant nurse managers, and nursing directors) specific to identifying patients presenting with behavioral health symptoms and who have been determined to be at risk for violence and the process of notifying the hospital nursing supervisor or nurse leader and supervising security officer ...” * “Education for the patient access/registration team ...” * “An overview of the proactive patient safety plan process and the cessation of handcuff use will be provided to ED providers, hospitalists, and psychiatrists as part of the IJ Removal Plan provider education.” * “The hospital implemented an executive and security huddle. This executive and security huddle started on April 23, 2025, occurs daily ... and includes at least one of: the chief executive officer, chief nursing officer (or designee), chief medical officer, or chief operating officer, plus the quality director (or designee) and security manager (or designee). At least one member of the huddle team will be a RN. The review will additionally now include a review of security reports and confirmation that responses were in alignment with the IJ removal plan ...” The IJ Removal Plan regarding Patient 8 included but was not limited to: * “Tasers will only be used when an individual is threatening with a weapon or actively physically assaulting in a manner that is a threat to life (such as choking another individual in a way that presents an imminent risk of serious bodily injury or death, brandishing a lethal weapon or actively stabbing another individual) and that cannot be managed using the standard de-escalation methods ... Tasers will not be used to manage spitting, hitting, yelling, agitation, or elopement. Following taser deployment, the individual will be taken to the Emergency Department and offered a medical screening exam, to comply with EMTALA requirements. Law enforcement will be immediately notified, as will security leadership and the hospital nursing supervisor.” * “In the Emergency Department, patients that present to the ED with behavioral health symptoms, such as a risk of harm to self or others, will trigger an immediate notification by the ED RN to the ED charge RN, who will partner with the security team to develop a proactive plan to safely transition the patient to an appropriate treatment space ...” * “If the ED RN has concerns that the patient may elope prior to arriving to the room, this would be included in the ED RN and security team communication and documentation, a plan will be put into place prior to transitioning the patient to their room, and escalation to an ED provider for immediate assessment will occur. The security officer involved will radio communication to other security officers in the ED, alerting to the presence and location of an elopement risk patient. The ED RN and security team communication will be documented on a paper checklist and kept with the security officer located at the ED security triage desk ... Security will convey this checklist information with their team during handover and shift reports ...” * “Handcuffs will not be used by staff on the hospital campus/property. Handcuffs will no longer be carried by any security officers.” * “These expectations will be outlined in a document that will be reviewed and attested to by security, ED nurses, hospital nursing supervisors, ED leadership, patient access services/registration staff, and ED providers during their respective shifts.” * “The hospital implemented an executive and security huddle. This executive and security huddle started on April 23, 2025, occurs daily ... and includes at least one of: the chief executive officer, chief nursing officer (or designee), chief medical officer, or chief operating officer, plus the quality director (or designee) and security manager (or designee). At least one member of the huddle team will be a RN. The review will additionally now include a review of security reports and confirmation that responses were in alignment with the IJ removal plan ...” An onsite IJ Removal Verification Visit was conducted on 07/23/2025 and the SA determined that the two IJ Removal Plans had been implemented. Findings include: 1.a. Patient 6’s medical record was reviewed and reflected the patient presented to the ED on 03/29/2025 at 1654 by ambulance with chief complaints that included suicidal thoughts and aggressive behavior. * An RN note dated 03/29/2025 at 1658 reflected “Thoughts of Violence Towards Others Any Threats or Attempts to Harm Others this Shift?: Yes ... ([patient] has demonstrated behaviors that [patient] will be a risk for violence towards staff. [Patient] unwilling to agree to be safe at this time.) ... Attention Span: Distracted Mood: Angry; Agitated; Irritable; Labile Affect: Hostile Thought Process: Rambling; Impaired judgement; Irrelevant Thought Content: Preoccupied Behavior: Agitated; Aggressive.” * An RN note dated 03/29/2025 at 1706 reflected “[Patient] agrees to be medicated but refuses zyprexa. When RN offers the zyprexa, the [patient] purposefully knocked medication out of RNs hands.” * An RN note dated 03/29/2025 at 1707 reflected “Medication Not Given ... [patient] knocked it out of RNs [sic] hand and refused to take it. Security with RN at this time.” * A Social Worker note dated 03/29/2025 1717 reflected the patient “... appears to be responding to internal stimuli as evidenced by [them] talking and gesturing to [themselves] ... [They are] oriented to self and place but cannot give any additional orienting information. [They struggle] with relaying history, [are] internally preoccupied and [appear] increasingly agitated and aggressive as the interview progresses. I attempt to obtain a lay caregiver, [they tell] me ‘call Cascadia,’ [they then spit] and [hit their] pillow on the bed ... Mental Status Exam ... Dress/Grooming/Appearance: disheveled, older than stated, and unkempt Behavior: psychomotor agitation, hyperactive, agitated, restless and fidgety, and grimacing Attitude and Participation: guarded, hostile, and aggressive Mood: irritable and agitated Affect: increased in intensity, inappropriate laughter, and heightened Orientation: self/place Speech: rambling, mumbled, and Impoverished Thought Processes: disorganized and Impoverished Thought Content: delusional and suicidal Insight and Judgement: suspect impairment due to substance use and actions demonstrate poor judgement.” * An RN note dated 03/29/2025 at 1730 reflected “[Patient] is escalated banging on the door with [their] fists and yelling out nonsensical words. [Patient] unable to be redirected. [Patient] posturing and spitting at the RN while continuously yelling ...” * An RN note dated 03/29/2025 at 1924 reflected “Safety/[Behavioral Health] Potential for violence during this ED visit? ... Yes Per report of previous RN, [patient] slapped med out of hands and was spitting at staff ... Standby Staff: Security”. * An RN note dated 03/29/2025 at 2033 reflected “Violence Risk Mitigation Note for use with Risk for Violence (RFV) FYI Alert ... Lengthy history of arrests for domestic violence, assault, public indecency ... history of violence and inappropriate sexual behaviors in medical settings towards peers and staff as well as in the community. [Patient] has a diagnosis of schizoaffective disorder vs. Bipolar with psychosis and substance abuse.” * An RN note dated 03/30/2025 at 0800 reflected “... [patient] out of room, agitated, demanding coffee, asking to go to the restroom. [Patient] went to bathroom and declined to provide a urine specimen. [Patient] more agitated and screaming expletives at staff. MD aware of this and medications to be ordered. [Patient] noted to come out of room and posture at staff, [sic] [Patient] secluded in room and sitter at bedside ...” * An RN “Violent Restraint or Seclusions Face to Face Assessment” note dated 03/30/2025 at 0831 reflected “Patient displayed the following behaviors verbal threats; physical threats ... Patient will remain in restraints until they meet criteria for discontinuation including no displays of harm to self or others.” * A Social Worker note dated 03/30/2025 at 1205 reflected the patient “... is now presenting as cooperative, and denies SI, HI, AH/VH, and paranoid ideation. Substances seem to have metabolized ... The patient does not meet criteria for [physician hold] and will be discharged home ... [Patient] was discharged to return to the Salvation Army shelter via public transportation.” * An RN note dated 03/30/2025 at 1751 reflected “Patient discharged ... verbalizes understanding of instructions ... Denies [homicidal ideation and suicidal ideation]. Refused to clean feet when offered, wanted to take shower, when informed that the shower was out of order [they were] noted to call this writer a “[expletive] with green blood.” Security on standby to escort patient out of ambulance bay ...” * The record reflected the patient discharged on 03/30/2025. Although the medical record reflected the patient had a known history of challenging behaviors and violence, and exhibited behaviors throughout their ED encounter, including spitting at staff, aggression, knocking medications out of a nurse’s hands, posturing, yelling, banging on a door, and verbally inappropriate comments, there was no documentation of plans or communication between ED staff and SO staff to manage and de-escalate those behaviors during SO escort from the ED. 1.b. Review of SO body camera footage on 06/16/2025 beginning at ~ 1500 with hospital staff that included the CMO, DON, DAR, QD and SDS confirmed that on 03/30/2025: * Patient 6 was escorted out of the ED by SOs and was leaving the hospital property. * The patient approached a wet, cement staircase outside. * The patient made a verbal comment to an SO. The SO responded, “Get your shit and go, dude ...” * The patient turned to face the SO and spit or motioned to spit at the SO, then continued leaving. * Multiple SOs took the patient to the ground on the cement staircase. While holding the patient down, one or more SOs punched the patient at least twice in the torso area. The patient was crying out and stated, “Please stop” as SOs were holding the side of the patient’s head directly onto a cement stair with their hand and then their knee; and then stepping on the patient’s head with the left side of the patient’s head directly on the cement stair. The patient’s neck was near or on the edge of the stair during these activities which lasted approximately 90 seconds. An SO stated, “You’re under arrest.” No efforts to de-escalate the patient’s behaviors were observed at any time during these activities. * SOs applied metal handcuffs to the patient and then assisted them to a standing position and into a wheelchair with the handcuffs still in place. The left side of the patient’s head was visibly bleeding. * An ED nurse came out of the ED and appeared to assess the patient’s head. * The patient was not observed to be taken back inside the ED at any time. 1.c. Incident documentation for Patient 6 was reviewed and reflected that on 03/30/2025 at 1730 “Patient was discharged from ED, being escorted out by security officers. Patient was verbally inappropriate toward officers and was leaving property. Security Officers [name] made a comment to the patient in a derogatory manner which prompted the patient to stop. Patient turned, spat at officer [name], then turned again and began leaving. Officers [two names] initiated arrest, taking patient to the ground, landing on staircase at edge of property leading from Ambulance Bay to Glisan street. Patient sustained injury to [their] face, and was arrested. Patient sustained two punches to the side, by officer [name], and [their] head was stepped on by officer [name]. Patient was seen for facial injury briefly by ED staff, then taken to be held until Police arrival.” The “Manager Review” section reflected “A use of force review was completed for this event ... The use of force was deemed outside policy.” 1.d. “Use of Force Review” documentation regarding Patient 6 included: * “Review Summary ... Officers affected an arrest on a discharged patient who spit at an officer. Upon investigation of the event, it was found that possibly inappropriate force was used during the arrest, and that the arrest was the cause of prior interaction from security officers.” * Documentation of an interview with an SO who was involved in the incident reflected: - “What was your impression of the other involved officers’ response to the event? ‘I tried to pull [SO name] off [Patient 6]. [SO name] appeared to be hitting [Patient 6] in the back and ribs out of frustration. I was shocked ...” - “Did you witness any unnecessary use of force in your opinion? ‘Yes. [SO name] was violent.’ ’[SO name] said in the office when we were talking about it that [they] punched [Patient 6] in the kidney.’ [In regard to [SO name] foot being on the subject’s head] ‘You could tell pressure was being placed, you could see the skin on [Patient 6’s] face moved and it was white.’” 1.e. During interview on 06/16/2025 at 1515 the QD provided the following information regarding Patient 6: * The SOs involved in the handcuff incident were non-law enforcement hospital SOs. * After the handcuff incident, staff never took the patient inside the ED and the patient was never evaluated by a physician or other LIP following the incident. * Security Officers took the patient to a security area hold room where they were “held” until police arrived and removed the patient from the hospital campus. * The QA had no information about the patient’s outcome after being taken to the security hold room, including consideration of the head injury and “two punches to the side” the patient incurred during the incident. 1.f. Email documentation from the QD dated 07/09/2025 at 1255 reflected that Patient 6 was in the security area hold room for three hours before law enforcement arrived. 1.g. Email documentation from the QD dated 07/10/2025 at 0737 reflected: * In response to the question, “Were any staff assigned to monitor the patient while they were in the security hold room? If so, what was their title and what sort of monitoring occurred ...” the QD wrote “Yes, there was a Senior Security Officer (SSO) assigned to monitor the individual that was in the hold room the entire time. One SSO was relieved by another SSO during shift change but [Patient 6] was being monitored the entire time so constant visual monitoring. The SSO checked for capillary refill to ensure the handcuffs were not too tight and double checked to ensure the handcuffs were double locked which ensures the handcuffs can’t tighten. Capillary refill was in good range which is 1-3 seconds.” There was no documentation that reflected hospital staff monitored the patient’s head injury or other potential injuries incurred during the handcuff incident including but not limited to being punched by a SO in the torso area, nor monitoring related to having handcuffs applied for at least three hours, such as impaired skin integrity. * In response to the question, “Did the patient remain handcuffed while in the security hold room?” the QD wrote, “Yes, the practice is that handcuffs remain on the individual until law enforcement arrives.” * In response to the question, “Does the hospital have a [P&P] for how patients are managed and monitored while in the security hold room? If so, please provide. If not, please confirm” the QD wrote “No policy that specifically addresses the PPMC security hold room. The arrests by Security Officers policy ... outlines post arrest protocols.” 2.a. Patient 8’s medical record was reviewed and reflected the patient presented to the ED on 04/06/2025 at 2017 with a caregiver and chief complaint of anxiety. * An RN triage note 04/06/2025 at 2018 reflected “Denies any SI or HI. Per caregiver, [patient] is AH, delusions and paranoia. Stated difficulty getting [patient] to come to ER ... Providence has a no weapons policy, Do you currently have any weapons, of any type, in your possession: no ... Has the patient had metal detection screening via metal detector or wand?: yes.” * An RN note dated 04/06/2025 at 2035 reflected “RN brought [patient] back to the room, [patient] calm and cooperative [sic], when [patient] saw the room [they] said “oh fuck no” and turned around and proceeded to walk towards the exit and when RN stated ’... you cannot leave you need to be seen by a doctor,’ [patient] said ‘this is where they [tortured] my son,’ [patient] saw security at metal [detector] and started running, due to safety concerns of this incident and escalating behavior of the [patient], RN informed security [patient] could not leave without being assessed by MD code grey called. Per security, [patient] appeared to reach behind towards the back of [their] waist band, security then tazed [patient] transferred to wheel chair and brought to room to be medically cleared.” * A Social Worker note dated 04/06/2025 at 2224 reflected “Presenting Problem: Patient ... with a primary mental health history of meth induced psychosis, Bipolar Disorder, and Meth Use Disorder who was brought in by case manager with a chief complaint of increasing anxiety, difficulty urinating ... and abdominal pain ... Patient then began discussing how security tased [them] and how mad [they were]. Patient exclaimed [they have] a heart problems [sic] and [security guard] knows that patient struggles with a heart condition ... patient tried to elope from ED tonight and fled to the parking lot where an altercation ensued and patient was tased. Access to weapons: Patient denied having access to a weapon.” * A Social Worker note dated 04/07/2025 at 0946 reflected “... [Patient] reports belief that the security officer who tazed [them] did it on purpose right at [their] heart with knowledge that [they have] heart problems. The [patient] said that [they are] going to sue the hospital for [their] being tazed and forced to stay against [their] will ... I consulted with Dr. [name] who evaluated the [patient] and agrees that the [patient] does not meet criteria for continued hold in the hospital against [their] will ... The patient does not meet criteria for [physician hold] and will be discharged home ...” * An RN note dated 04/07/2025 at 0956 reflected “Patient discharged safely to Home ... [Patient] ambulates out of [ED] with a steady gait.” 2.b. Review of SO body camera footage regarding Patient 8 on 06/16/2025 beginning at ~ 1520 with hospital staff that included the CMO, DON, DAR, QD and SDS confirmed that on 04/06/2025: * The patient ran out of the ED entrance and at least three SOs went after the patient. * Approximately 10 seconds after leaving the ED, the patient stopped and turned towards one of the SOs. The patient’s right hand was observed behind their back, their left hand was holding a red sack, and an SO was observed to have their taser pointing toward the patient. * The patient moved both hands to the front of their body and up toward their chest and head in a flinching, defensive posture. * Approximately one second later, the patient put both hands behind their back, dropped the red sack and appeared to pull up their pants. * The SO was not observed or heard to attempt de-escalating the patient and yelled, “Back the fuck up now or you’re going to get tased. Don’t reach for anything.” Approximately two seconds later, the patient was observed falling towards the ground after the SO released the taser prongs. * The patient stated, “I was pulling my pants up.” * Three SOs pinned the patient face down on the asphalt ground, applied metal handcuffs and put the patient in a wheelchair with the handcuffs still intact. * The patient was not observed committing a criminal activity prior to being tased or at any time. 2.c. Incident documentation for Patient 8 was reviewed and reflected that on 04/06/2025 “... [patient] checked into ED with caregiver from outpatient bridge program. Per EPIC triage note: ’[Brought in by] caregiver. [Complaints of] increasing anxiety. No relief [with] meds. Denies any SI or HI. Per caregiver, [patient] is AH, delusions and paranoia. Stated difficulty getting [patient] to come to ER.’ The patient denies any weapons in their possession and did go through the metal detector. The patient was triaged with [chief complaint] of Hallucinations, Paranoid [and] Anxiety. ESI Level 2. Denied HI/SI to triage RN. Per the notes it appears that the patient was walked to Room [number] where [they] decided that [they] did not want to stay and turned to leave. The patient was able to walk out of ED, past the metal detector, with ED staff following. The security officers in the breezeway were told the patient couldn’t leave and they ran after the patient to get [them] to return. The patient was tased in the parking lot and returned to the ED.” * The “...extent of harm at time of event” section reflected “Temporary or minor/moderate injury.” * The “Which category best describes the type of event or unsafe condition” section reflected “Patient Security.” * The “Manager Review” section reflected “QM review initiated after report at safety huddle. Event remains under review. A thorough use of force review is currently underway for the taser deployment. Security was not informed of this patient after arrival to ED, or about this patient being checked in for suicidal/homicidal ideation. Security was first alerted to this patient as [the patient was] walking out the ED front entry, [followed] by a nurse advising [the patient that they] could not leave. The nurse then told 2 security officers that were at the metal [detector] that [Patient 8] was not safe to leave. When the patient heard this, [the patient] proceeded to run ... two security officers perused [sic] on foot after the patient in attempt to detain and bring back to the ED. The patient then stopped running, turned towards Security, stated, ‘What’s up motherfucker,’ and began walking towards the two security officers. At the same time, the patient began reaching behind [their] back towards [their] waistline area. One officer drew [their] taser, fearing the patient may produce a weapon and have intent to cause physical harm. Security commanded to patient to stop ... Due to perceived threat, the patient was tased ... security officers responded and assisted with placing the patient into handcuffs for their safety. A wheelchair was retrieved, and the patient was brought back inside the ED ... Security notified the House Supervisor, as well as Portland Police to alert them of the taser deployment. Police took the info but did not respond. After being brought back to the ED, it was then learned by Security this patient was brought in from a mental health facility by an employee of that facility. That employee slipped a note to the triage RN stating the patient was being checked in for SI/HI, and for paranoia and hallucinations. At no time during the triage process was Security alerted to this patient and [their] associated risks. Nursing staff escorted the patient to room [number] without Security knowledge or presence, the patient saw room [number] and refused to go in and then eloped towards the ED entry. I feel this is a gap in communication between nursing and security. The initial use of force review has been completed and the use of taser force has been deemed justified.” 2.d. During an interview on 06/23/2025 at 0905 with SDS, QD and MOS, the following information was provided regarding Patient 8: * MOS stated the caregiver who brought the patient to the ED “slipped a note” to the triage nurse about the patient’s symptoms. Typically security is alerted when this happens for general awareness, to monitor the patient, and to walk with the nurse and patient to an ED room. The MOS acknowledged this did not happen. Refer to finding 2.c. above in this tag that reflects there was a gap in communication between nursing and SO staff because SO staff were not notified of the patient’s SI/HI and other risks. * The QD stated the process of ED staff alerting SOs of patients at risk of leaving the ED is described in the AMA policy. Refer to finding 3.d. in this tag regarding the AMA policy. * MOS stated the patient was handcuffed after being tased because they were “verbally adamant” and the SOs perceived this as a threat. The MOS stated “It [handcuffing] was a measure to ensure safety because we didn’t know how [the patient] would respond after being tased” and “We allow the officers to do what they perceive in that moment for their safety. It is officer discretion.” The MOS was asked if the SOs took any de-escalation actions before they tased and handcuffed the patient, and MOS stated, “Not to my knowledge.” * In response to the question “Does [SO] training include what to do if a patient reaches behind themselves” the MOS stated they did not know. * The SDS stated that SO training includes “a whole host of issues. If a security officer feels threatened or gives commands, then it’s their discretion whether to use a taser.” This was inconsistent with the P&P titled “PSHG-RESO-1404 Use of Tasers” in Finding 3.b. below in this tag which reflects that “Providence will utilize Tasers in a manner that is consistent ...” It was not clear how tasers would be used in a consistent manner if it was left up to SOs to use their discretion each time a taser was used. 3.a. The P&P titled “Arrests by Security Officers - OR Security Services” dated last revised “04/2023” referenced in finding 1.g. in this tag was reviewed and included the following information: * “Objective: To identify the scope of authority for private security or private persons when detaining or placing an individual under arrest for a criminal act and to describe the justifiable use of force that can be used when detaining or placing an individual under arrest.” * “All Security Officers will be trained and abide by Oregon Revised Statutes and department guidelines when making a citizen’s arrest. A private person (Security Officer) may arrest another person for any crime committed in the presence of the private person if the private person has probable cause to believe the arrested person committed a crime.” * “Affecting an Arrest 1. When appropriate, a Security Officer may take into custody an individual who has committed a criminal act and detain the individual for law enforcement. Prior to taking custody of another and if practical: a. Officers will identify themselves and warn the offender of the intent and the basis for the arrest. b. Notify an on-duty security supervisor. c. Attempt verbal methods of gaining compliance prior to using physical force. d. Will not threaten the arrest of another without the lawful justification to do so. e. When Providence Health & Services is the victim of a criminal action (i.e. theft, criminal mischief, fraud), Security Officers may act on behalf of the organization and initiate an arrest and criminal prosecution. f. The total circumstances of the event should be considered.” * “B. Post Arrest 1. Notify the Providence Security Operations Center (PSOC) of the arrest and request they notify a security supervisor and the appropriate law enforcement agency to respond. The security office on-scene may take this action if safe to do so. 2. Employ appropriate measures to protect the detained individual, themselves, and others. 3. Unless circumstances dictate otherwise, move the detained individual to a private location visible by camera while waiting for law enforcement [so as not to] cause a disturbance or disruption to patient care in the area of the arrest. 4. Upon arrival, provide law enforcement with complete information regarding the circumstances and actions taken. 5. Comply with subsequent law enforcement/legal requirements ... 6. Complete the appropriate department reports. 7. Supervisors shall make timely notification to a Security Manager of the arrest and complete a Use of Force Review (i.e, use of handcuffs).” The P&P was unclear, not fully developed and permitted the use of handcuffs which is prohibited by CMS for use on patients. Examples included: * The P&P was not clear regarding what constituted a “criminal act”, what “physical force” would be used, and what actions would be taken to “detain” individuals. * Although the P&P reflected SOs would “Attempt verbal methods of gaining compliance prior to using physical force,” it was not clear what “verbal methods” meant and whether de-escalation strategies were expected prior to using “physical force.” * The P&P failed to describe why law enforcement would not be called instead of SOs applying handcuffs on patients. * There were no provisions for managing and monitoring patients after being “arrested” and detained in a security area hold room by SOs. * It was not clear when handcuffs would be used during “arrest” activities particularly since handcuffs are prohibited by CMS for use on patients. * There was no further information about where “a private location visible by camera” was located and how patients taken to that area would be appropriately monitored and kept safe. It was not clear what “appropriate measures to protect the detained individual” meant, particularly after incidents when patients or other individuals were injured or potentially injured during the course of SOs arresting them. 3.b. The P&P titled “PSHG-RESO-1404 Use of Tasers” dated last revised “09/2023” was reviewed and reflected: * “Providence will utilize Tasers in a manner that is consistent, effective, and aligned with the organizational goals and mission ... Tasers provide a less-lethal self-defense option. Tasers can only be used in self-defense or in defense of others ... If a Taser is used by security or law enforcement personnel on a person on Providence property (patient, caregiver, workforce member, or visitor) to protect people or Providence property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement ...” * “Any time a Taser is deployed, security leadership will contact law enforcement and make an official report ... The officer will relate any pertinent information regarding the incident including probe penetration and make notification to Law Enforcement. Any follow-up care shall be determined by the responding medical provider and law enforcement.” The P&P was unclear and not fully developed. For example, it was not clear as it states that tasers can only be used in self-defense or in defense of others, but it also states that tasers can be used to protect Providence property. There was no information in the P&P regarding whether de-escalation or other strategies should be attempted prior to deploying a taser. It was not clear what constituted situations warranting “self-defense” and “defense of others.” including whether reaching behind oneself met these criteria. There was no information in the P&P suggesting that reaching behind oneself was a criminal activity and warranted taser deployment. Refer to findings 2.a. through 2.c. in this tag that reflects Patient 8 was tased after they moved their hand or hands toward their back/waistline and appeared to pull their pants up. It was not clear whether patients or other individuals would be evaluated by a provider after being tased. 3.c. The P&P titled “ PSJH-RESO-1402 Use of Defensive Tools” dated effective “09/2023” was reviewed and reflected: * “While on duty a Providence security officer may be called upon to use force to resolve a threatening situation. Providence security officers are issued specific defensive tools and given specific training so that this force and these defensive tools will be applied in a legally recognized manner.” * “Conducted Energy Weapon (CEW), commonly referred to as a Taser, is a device that uses propelled wires or direct contact to electrically stun and incapacitate a person temporarily. It delivers an electric shock aimed at temporarily disrupting muscle functions and/or inflicting pain without causing significant injury. TASER is a brand of CEW, and different CEW models are widely used across Providence. Hereafter, TASERS and CEWS shall collectively be referred to as ‘Tasers’.” * “The use of defensive tools as a means of subduing a patient in order to place that patient in a restraint or seclusion is not appropriate. If a defensive tool is used to protect people or property from harm, the situation should be handled as a criminal activity and law enforcement should be notified. No defensive tool shall be applied to any person without legal justification.” * “Providence security officers may utilize authorized individual defensive tools in accordance with this policy, PSJH-REH-1403 Use of Force Policy, and all applicable laws and regulations.” * “Providence security officers are approved to use and carry the following after completing all required training ... Handcuffs ... Zip Tie Restraints ... Chemical Defense Tools ... Utility Knives ... Body Armor ... Conducted Energy Weapons (Tasers).” * “Security Leadership will notify law enforcement following the use of a defensive tool as necessary and in accordance with all laws and regulations.” The P&P was unclear and not fully developed. For example, it stated, “these defensive tools will be applied in a legally recognized manner” but did not further describe what “legally recognized manner” meant. The P&P reflected that a “defensive tool is used to protect people or property from harm, the situation should be handled as a criminal activity” but did not specify what a criminal activity involved. For example, whether spitting, moving hands toward back/waistline, refusing to leave hospital property, or choosing to leave hospital property as Patient 8 was doing was considered criminal activity warranting use of defensive tools, handcuffs and tasers. Refer to Findings 1.b. through 1.d regarding Patient 6 who was handcuffed after spitting or motioning to spit toward a SO. Refer to findings 2.a. through 2.c. regarding Patient 8 who was tased and handcuffed after moving their hand or hands toward their back/waistline. It was additionally not clear when defensive tools could be used as the P&P stated defensive tools could be used to protect property from harm but the P&P titled “PSHG-RESO-1404 Use of Tasers” in Finding 3.b. above in this tag stated that tasers could only be used in self-defense or in defense of others. 3.d. The P&P titled “Discharge of Patient against Medical Advice (AMA)” dated effective “03/2023” was reviewed and reflected “Endangered/High-Risk Patient: A patient who does not have decision making capacity or is incapacitated because of frailty, physical or mental impairment. Patients are considered endangered/at risk but not limited to if they have any of the following ... Are considered a danger to self or others ... Patients who are legally their own decision makers are able to leave the hospital against medical advice without completing treatment after being informed of the risks of leaving ... A patient with decision making capacity may not be held against their will without a legal hold process such as Police Officer hold or Notification of Mental Illness (NMI) [physician hold] ... When a patient indicates their intent to leave the facility AMA ... Nurse acknowledges the patient’s desire to leave and contacts the LIP about the patient’s wishes ... Nurse notifies the Charge Nurse, Manager, and/or Hospital/ Nursing Supervisor of the situation ... Nurse and care team attempt to resolve the patient’s concerns ... Nurse identifies if the patient has a Notice of Mental Illness (NMI), police hold, or guardianship. If so, Nurse ensures that the patient is not allowed to leave the facility and enlists security support as needed ... Nurse calls LIP to assess the patient’s decision-making capacity in-person or, if needed, via phone ... LIP identifies if the patient has decision-making capacity. If it is determined that the patient lacks decision making capacity, the Nurse ensures that the patient is not allowed to leave the facility and enlists security support as needed ... Nurse and LIP identify if there are concerns about the patient leaving AMA due to physical limitations (e.g. patient has decision making capacity and wishes to leave, but cannot independently move themselves off the premises). If so, the care team huddles to discuss the logistics of the patient leaving AMA and ways to mitigate risk as much as possible ... Facilitate development of a patient safety plan specific to the patient situation, such as availability of discharge medications, transportation needs, level of physical assistance outside of the building, etc. ... Consider reporting to Adult Protective Services (APS) or requesting a police welfare check if concerned for patient’s safety ... Nurse contacts Security Dispatch (x57777) for assistance. When the security officer arrives, they will ask the Nurse, “Is the patient free and safe to leave?” The security officer will act on the Nurse’s direction for need to detain patient ...” Refer to findings 2.a. and 2.c. in this tag regarding Patient 8. Those findings failed to demonstrate that the hospital followed this P&P as there was no documentation that reflected the ED nurse contacted the LIP about the patient’s wishes to leave the ED, notified the charge nurse, manager, and/or hospital/ nursing supervisor, nor that the nurse and care team attempted to resolve the patient’s concerns. 4.a. Review of SO training materials titled “OC & Handcuffing User Course” reflected: * “Defensive Tools are not part of a Healthcare Intervention (PMAB). Cannot be part of a pre-plan, pre-code gray, or used, or threatened to be used, to influence patient compliance. Officers may use physical force including defensive tools in ... Self-defense or defense of another person ... To prevent an assault and when a risk of injury is imminent ... After all other means of physical control have failed, or; When the situation rapidly escalates, and clinical measures are believed to be ineffective.” * “What turns a patient into a criminal? When the individual has committed an act of violence where he or she could be charged with a crime. If the event escalates to the point where defensive tools are needed and used, officers need to be able to articulate their reasoning ...” * “Handcuffs are restraint devices designed to secure an individual’s wrists together. There are 3 primary types of handcuffs ... Chain ... Hinged ... Rigid ... Providence Regional Security allows for Hinged or Chain.” * “Handcuffing Suspects ... Everyone who is arrested should be handcuffed ... Criminals get handcuffed ... Code of Federal Regulations Condition of participation: Patient’s rights. 482.13(e) - ’... such devices [handcuffs] are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients ...’” The training materials did not include information about patients reaching towards their back/waistline, nor leaving the ED AMA and whether those actions were considered an act of violence where they could be charged with a crime. Refer to findings 2.a. through 2.c. in this tag regarding Patient 8 who was tased and handcuffed after moving their hand or hands toward their back/waistline after leaving the ED. Further, there was nothing in the training materials that suggested spitting, motioning to spit, or leaving the ED was considered a crime warranting “arrest” and application of handcuffs by SOs. Refer to findings 1.b. through 1.d. in this tag regarding Patient 6 who was handcuffed after leaving the ED and then spitting or motioning to spit on a SO. 40575”

“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: 29708 40575 Based on interviews, review of security report and/or incident documentation for 7 of 7 patients who were handcuffed by hospital Security Officers (SOs) (Patients 4, 6, 8, 9, 11, 12 and 13), review of P&Ps, and review of other documentation, it was determined that the hospital failed to develop and enforce P&Ps to ensure patients’ rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough and complete investigations and follow up actions of potential abuse or neglect, as defined by CMS, to ensure those incidents did not recur. Findings included: 1. The P&P titled “Event Reporting and Response Policy and Procedure” dated last revised “01/2024” was reviewed. It reflected: * “Each of us play a critical role in ensuring patient, caregiver, and organizational safety. All Providence Workforce Members are expected to follow our High Reliability behavior of Speaking Up for Safety. In doing so, together we can move towards reliability and zero harm for all.” * “This policy describes the expectations and procedures for identifying and responding to Safety Concerns including reporting, analyzing, tracking, trending, resolving, and following up on events with established committees, boards, and state/federal agencies. The intent of this policy is to reinforce consistent processes and practices with the goal of reducing risks and improving safety for all.” * “Event Reports are investigated, and actions are taken to reduce risk and increase safety. Specific actions may include (but are not limited to) corrective and/or preventative actions and action plans, cause analysis RCA or ACA), performance improvement and/or tracking and trending.” * “The department’s core leader or their designee is responsible for reviewing every Event Report generated within their department to ensure thorough understanding and response to each. Additional reviewers may be assigned to contribute to the investigation and follow-up for events as needed.” * “Workforce Members should report any Safety Concerns including any occurrence or condition that is a deviation from generally accepted performance standards and/or inconsistent with safe operations of the health care system or the safe care of a particular patient.” * “All events are investigated at the department level by the department core leader or their designee. Events that meet state or regulatory criteria are escalated for investigation by the Quality Team. Unit/department core leaders will request consultation from the Quality Team if additional support is necessary or the investigation uncovers complexities that need further attention and expertise.” * “After the electronic Event Report has been entered, it is assigned to the designated core leader(s) of the unit(s)/department(s) involved for review, investigation, and appropriate follow-up. The department where the incident or near miss occurs will document the investigation and any follow-up actions in the ERS. If the ministry/facility allows core leaders to lock (close) an event, those core leaders would utilize the Safety Event Classification scale to classify event and complete additional fields prior to locking the event.” 2. The P&P titled “PHSOR Workplace Violence Prevention” dated last revised “05/2024” was reviewed. It reflected: * “PHSOR is committed to preventing workplace violence (WPV) and to maintaining a safe work environment. As such, PHSOR has adopted the following policy regarding violent behaviors, identifying our expectation for responding to, mitigating, and reporting violence in the workplace.” * “In keeping with our mission and values, PHSOR is committed to providing a safe and secure workplace and an environment free from violence. PHSOR does not tolerate violence. Violent incidents are taken seriously and thoroughly investigated.” * “Security: Security will be responsible for conducting an immediate post event team debrief following every Code Gray event. Security will also conduct a threat assessment when a potential risk is proactively identified, as needed.” 3. The P&P titled “Use of Defensive Tools” dated last revised “09/2024” was reviewed. It reflected: * “Purpose: While on duty a Providence security officer may be called upon to use force to resolve a threatening situation. Providence security officers are issued specific defensive tools and given specific training so that this force and these defensive tools will be applied in a legally recognized manner. This policy provides oversight for Providence security officers utilizing authorized defensive tools.” * “Threat means any person, animal, or object controlled by a person that is presenting a danger to themselves or others, or; any person resisting arrest or being lawfully controlled ...” * “Restraints are specific equipment designed for restraint to include chained or hinged metal handcuffs as well as medical restraints or Posey devices.” * “If a defensive tool is used to protect people or property from harm, the situation should be handled as criminal activity and law enforcement should be notified. No defensive tool shall be applied to any person without legal justification.” * “Notification and Reporting: In the event that a defensive tool is used or presented for use, as soon as practical, the security officer will notify Security Leadership. Security Leadership will notify law enforcement ... A Security Incident Report will be completed prior to the end of the reporting officer’s shift ... This report will document the conditions and rational for the use ... Security Leadership will conduct a formal review of these events in timely manner.” 4.a. Workplace Violence Incident documentation for Patient 4 was reviewed and reflected on 03/03/2025 “Patient was disruptive in the ED and bypassing access control into the department. After staff verbally enforced expectations and policy, [they] threw [their] blanket at and shoved security. [Patient 4] was then placed under arrest, during which [they] hit and kicked [SO] until handcuffs were secured.” * The “General Type of Injury” section reflected “Workplace Violence.” * The “Workplace Violence Event Category” section reflected “Physical Attack without weapon.” * The “Physical Attack without weapon” section reflected “Kicking, Punching/Slapping.” * The “Manager Review” section reflected “[Manager name] found no gaps is [sic] procedures in my investigation of this event. This patient was upset at the long wait time in the ED.” 4.b. “Use of Force Review” for Patient 4 was reviewed and reflected: * The “Review Summary” section reflected “A patient in the emergency department triage lobby assaulted a security officer and was arrested.” * Three SO’s Interview Summaries. * The “Witness Interview Summary” section reflected “None.” * The “Review Findings:” section reflected “... the entire Security team present at the event, acted within ... Providence Policy - Yes, Providence Mission and Core Values - Yes.” The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital’s P&Ps. For example: * The documentation was unclear whether the patient had an EMC. * There was no documentation that reflected if there was harm to the patient. * The “Use of Force Review” did not reflect that body camera footage was reviewed and did not have any witness listed. * The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs. * There was no investigation that reflected whether abuse and neglect were ruled out. * There was no documentation of further follow up actions. 5.a. Refer to finding 1.b. under Tag A-144 that reflect: * Patient 6 was escorted out of the ED by SOs and was leaving the hospital property. * The patient approached a wet, cement staircase outside. * The patient made a verbal comment to an SO. The SO responded, “Get your shit and go, dude ...” * The patient turned to face the SO and spit or motioned to spit at the SO, then continued leaving. * Multiple SOs took the patient to the ground on the cement staircase. While holding the patient down, an SO punched the patient at least twice in the torso area. The patient was crying out and stated, “Please stop” as SOs were holding the side of the patient’s head directly onto a cement stair with their hand and then their knee; and then stepping on the patient’s head with the left side of the patient’s head directly on the cement stair. The patient’s neck was near or on the edge of the stair during these activities which lasted approximately 90 seconds. An SO stated, “You’re under arrest.” No efforts to de-escalate the patient’s behaviors were observed at any time during these activities. * SOs applied metal handcuffs to the patient and then assisted them to a standing position and into a wheelchair with the handcuffs still in place. The left side of the patient’s head was visibly bleeding. * An ED nurse came out of the ED and appeared to assess the patient’s head. * The patient was not observed to be taken back inside the ED at any time following these activities. 5.b. Incident documentation for Patient 6 was reviewed and reflected that on 03/30/2025 at 1730 “Patient was discharged from ED, being escorted out by security officers. Patient was verbally inappropriate toward officers and was leaving property. Security Officers [name] made a comment to the patient in a derogatory manner which prompted the patient to stop. Patient turned, spat at officer [name], then turned again and began leaving. Officers [name and name] initiated arrest, taking patient to the ground, landing on staircase at edge of property leading from Ambulance Bay to Glisan street. Patient sustained injury to [their] face, and was arrested. Patient sustained two punches to the side, by officer [name], and [their] head was stepped on by officer [name]. Patient was seen for facial injury briefly by ED staff, then taken to be held until Police arrival.” * The “... extent of harm at time of event” section reflected “Temporary or minor/moderate injury.” * The “Which category best describes the type of event or unsafe condition” section reflected “Patient Behavior.” * The “Manager Review” section reflected “A use of force review was completed for this event ... The use of force was deemed outside policy.” The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital’s P&Ps. For example: * The documentation was unclear whether the patient involved in the incident was examined and the specific type of injury or injuries. * The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs. * There was no investigation that reflected whether abuse or neglect were ruled out. * There was no documentation of further follow up actions. 6.a. Incident documentation for Patient 8 was reviewed and reflected that on 04/06/2025 “35yo [sex] pt checked into ED with caregiver from outpatient bridge program. Per EPIC triage note: ‘BIB caregiver. C/o increasing anxiety. No relief c [sic] meds. Denies any SI or HI. Per caregiver, pt is AH, delusions and paranoia. Stated difficulty getting pt to come to ER.’ The patient denies any weapons in their possession and did go through the metal detector. The patient was triaged with CC of Hallucinations, Paranoid & Anxiety. ESI Level 2. Denied HI/SI to triage RN. Per the notes it appears that the patient was walked to Room #14 where [they] decided that [they] did not want to stay and turned to leave. The patient was able to walk out of ED, past the metal detector, with ED staff following. The security officers in the breezeway were told the patient couldn’t leave and they ran after the patient to get [them] to return. The patient was tased in the parking lot and returned to the ED.” * The “...extent of harm at time of event” section reflected “Temporary or minor/moderate injury.” * The “Which category best describes the type of event or unsafe condition” section reflected “Patient Security.” * The “Manager Review” section reflected “QM review initiated after report at safety huddle. Event remains under review. A thorough use of force review is currently underway for the taser deployment. Security was not informed of this patient after arrival to ED, or about this patient being checked in for suicidal/homicidal ideation. Security was first alerted to this patient as [they were] walking out the ED front entry, following by a nurse advising [them they] could not leave. The nurse then told 2 security officers that were at the metal detection that [Patient 8] was not safe to leave. When the patient heard this, [they] proceeded to run ... two security officers perused [sic] on foot after the patient in attempt to detain and bring back to the ED. The patient then stopped running, turned towards Security, stated, “What’s up motherfucker and began reaching behind [their] back towards [their] waistline area. One officer drew [their] taser, fearing the patient may produce a weapon and have intent to cause physical harm. Security commanded the patient to stop ... Due to perceived threat, the patient was tased ... security officers responded and assisted with placing the patient into handcuffs for their safety. A wheelchair was retrieved, and the patient was brought back inside the ED ... gap in communication between nursing and security. The initial use of force review has been completed and the use of taser force has been deemed justified.” The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital’s P&Ps. For example: * There was no investigation that reflected Security Officers were interviewed. * The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs. * There was no investigation that reflected whether abuse and neglect were ruled out. 6.b. Refer to finding 2.b. cited under Tag A-144 that reflects: Review of SO body camera footage regarding Patient 8 on 06/16/2025 beginning at ~ 1520 with hospital staff that included the CMO, DON, RD, QD and SDS confirmed that on 04/06/2025: * The patient ran out of the ED entrance and at least three SOs went after the patient. * Approximately 10 seconds after leaving the ED, the patient stopped and turned towards one of the SOs. The patient’s right hand was observed behind their back, their left hand was holding a red sack, and an SO was observed to have their taser pointing toward the patient. * The patient moved both hands to the front of their body and up toward their chest and head in a flinching, defensive posture. * Approximately one second later, the patient put both hands behind their back, dropped the red sack and appeared to pull up their pants. * The SO was not observed or heard to attempt de-escalating the patient and yelled, “Back the fuck up now or you’re going to get tased. Don’t reach for anything.” Approximately two seconds later, the patient was observed falling towards the ground after the SO released the taser prongs. * The patient stated, “I was pulling my pants up.” * Three SOs pinned the patient face down on the asphalt ground, applied metal handcuffs and put the patient in a wheelchair with the handcuffs still intact. * The patient was not observed committing a criminal activity prior to being tased or at any time. 7.a. Incident documentation for Patient 9 was reviewed and reflected that on 04/22/2025 “Workplace violence event filed due to visitor trespass event. In debrief of event it was noted that the visitor was taken to the ED due to question about mental health concerns. Security report has significant detail on patient behavior and verbal threats yet ED documentation does not reflect this, nor state that the patient refused/did not want evaluation. Dispo was marked LWBS yet the note states pt was arrested by security, nothing about patient offered/declined treatment.” * The ...extent of harm at time of event” section reflected “No evident harm.” * The “Manager Review” section reflected “Reached out to Triage RN [Manager name] have nothing to add here. A separate WPV report was filed, and [Manager name] included my review in that report.” 7.b. “Use of Force Review” for Patient 9 was reviewed and reflected: * The “Review Summary” section reflected “... was asked to leave the property after the patient [they were] visiting became uncomfortable with [their] presence. [Patient 9] refused to participate in conversations about how caregivers can best serve [them].” * Three SO’s Interview Summaries. * The “Witness Interview Summary” section reflected “None.” * The “Manager’s Review” dated 04/24/2025 section reflected “... confirm that security officers utilized patience and exercised core values in their attempts to assist this individual to check in to PPMC’s ED. It was not until the person made threatening comments and gestures of physical violence that the arrest was affected.” The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital’s P&Ps. For example: * The documentation was unclear whether the patient involved in the incident had an EMC that needed to be ruled out. * There was no documentation that reflected whether there was harm to the patient. * The documentation was not clear regarding the results of reaching out to Triage RN. Was the Triage RN interviewed and what information was received? * The “Use of Force Review” did not reflect that body camera footage was reviewed and did not have any witnesses listed. * The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs. * There was no investigation that reflected whether abuse and neglect were ruled out. 8. “Use of Force Review” for Patient 11 was reviewed and reflected: * The “Review Summary” section reflected “An individual came through the Main Entrance metal detector. Drug paraphernalia was shown in [their] backpack by x-ray detection. Officers informed [them they] can’t come into the hospital with it ... cursed at officers and grabbed [their] backpack and walked briskly toward the Cancer Center. [They were] uncooperative with Security’s request to remove the item from the building. The individual made several attempts to push past the officers and them attempted to physically shove the Lead Officer. [They were] subsequently arrested.” * Narratives of the security report authored by Lead Security Officer for the section “Officer Involved Interview Summary.” * The “Witness Interview Summary” section reflected “All statements were removed from the narrative of the report authored by Security Officer [SO name].” It continued “The [patient] began to walk towards integrated medicine for an appointment ... the [patient] would not stop and talk ... repeated multiple times the [patient] needed to leave the property ... the [patient] stepped towards my direction ... continued and pushed into [SO name]. [SO name] pushed back ... the [patient] then grabbed [SO name] right arm. [SO name] removed the [patient’s] hand from [their] right arm ... the [patient] continued to escalate. The [patient] responded with an explosive push ... At which point [SO name], and I assisted the [patient] to the ground ... advised the [patient they were] under arrest ... [SO name] yelled call a code and radioed the code grey. [SO name] arrived and contained the [patient’s] legs. [SO name] began to apply the handcuffs ... House Supervisor [name] arrived at the hold room and asked the [patient] if he needed any medical attention. The [patient] advised [they] needed a full work up in the emergency department ED [sic]. Injuries to report [patient] contusion to the forehead and [their] right knee.” * The “Coaching Opportunity” section reflected “Although these actions are deemed to be justified by policy ... we don’t always need to act on an individual’s refusal to cooperate with Providence SOPs, given that the paraphernalia brought in was not considered to be dangerous and could have been overlooked.” * The “Manager’s Review” dated 04/30/2025 section reflected “I, [manager name], agree with the finding above. I will add that I have also coached both Officers [SO name and SO name] that in these types of situations it is best practice to notify the House Supervisor and the Security Supervisor and ask them to respond to help form a plan of appropriate next steps. Both officers were receptive to this coaching and direction.” The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital’s P&Ps. For example: * There was no incident/event report documentation per the hospital’s P&P. * The “Use of Force Review” did not reflect that body camera footage was reviewed. * The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs. * There was no investigation that reflected whether abuse and neglect were ruled out. * There was no documentation of further follow up actions. 9.a. The security report was reviewed for Patient 12 and reflected that “On April 28th, 2025, at 0240, I, [SO name] responded to a radio call to ED21 with [SO name]. Upon arrival the Patient [name] was yelling at nurse [name] and nurse [name]. Pt stated [they] did not want to leave. [They] then kicked the nurse on [their] right side between [their] ribs and hip at which point SO [SO name] and I took control of the limbs so that [they] could not kick anymore. Pt sated multiple times [they] would kill someone if let out ... Pt stated [they] would rather go to jail then be let out on to the street ... Pt was placed in handcuffs ...” 9.b. Workplace Incident Violence documentation for Patient 12 was reviewed and reflected that on 04/28/2025 “... a patient arrived via ambulance after reportedly falling at a convenience store. Upon arrival, the patient complained of hip pain and was unable to ambulate ... the patient is typically ambulatory without issue ... The patient underwent a full medical workup, including a CT scan, and was administered Tylenol. Discharge was planned at 0237 hrs. Upon being informed of discharge by Primary RN, [RN name] ...the patient became agitated and began demanding methadone and Dilaudid. Staff explained that these medications were not indicated and that discharge instructions had been provided. The patient then refused to leave, requesting to speak with a social worker. Staff informed the patient that social work services were not available ... the patient became physically aggressive and kicked the nurse, causing [them] to strike the wall of the room. Security personnel, already stationed near ED Room 21, responded immediately and Code Grey was called. Security intervened physically to restrain the patient ... The patient was detained in a hospital holding area ...” * The “Workplace Violence Event Category” section reflected “Physical Attack without weapon.” * The “Physical Attack without weapon” section reflected “Kicking.” * The “Were there any current injuries or an event that may require future medical treatment” section reflected “No.” 9.c. “Use of Force Review” for Patient 12 was reviewed and reflected: * The “Review Summary” section reflected “Security affected an arrest on a discharged patient after they kicked a nurse and spit on security staff.” * The “Officer Interview Summary” reflected a summary of an interview of the lead officer for the shift during which the arrest occurred. * The “Witness Interview Summary” section reflected “Please see the attached reports from SO’s [names of five SO’s involved].” The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital’s P&Ps. For example: * The “Use of Force Review” did not reflect that body camera footage was reviewed. * The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs. * There was no investigation that reflected whether abuse and neglect were ruled out. * There was no documentation of further follow up actions. 10.a. Workplace Violence Incident documentation for Patient 13 was reviewed and reflected on 05/17/2025 “Patient was being walked out with security towards the ambulance bay. Patient pulled the fire alarm disturbing the entire emergency department and hospital. Patient was then arrested for [sic] by security staff. Then shortly after was taken into custody by Portland police.” * The “General Type of Injury” section reflected “Workplace Violence.” * The “Workplace Violence Event Category” section reflected “Verbal Intimidation/Harassment/Bullying.” * The “Verbal Intimidation/Harassment” section reflected “Threat of Property Damage.” * The “Manager Review” section reflected “Patient was arrested by Portland Police. No harm to caregivers.” 10.b. The “Use of Force Review” for Patient 13 was reviewed and reflected: * The “Review Summary” section reflected “Discharged patient being escorted out of the ED by Security, chose to pull the fire alarm on the way out of the ambulance bay ... [they were] arrested.” * Four SO’s Interviews from excerpts from narratives of officer reports. * The “Review Findings:” section reflected “After reviewing all of the pertinent reports, as well as viewing body-warn camera video of the arrest ,,, this arrest, the subsequent use of physical control and hand-cuff application were justified and well within guidelines ...” The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital’s P&Ps. For example: * There was no documentation that reflected if there was harm to the patient. * The documentation did not include a review to consider CMS regulatory requirements that prohibit the use of handcuffs. * There was no investigation that reflected whether abuse and neglect were ruled out. * There was no documentation of further follow up actions. Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for these patients and other patients.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 29708 Based on review of hospital Security Officer (SO) body camera footage, interviews, review of medical record documentation for Patient 6 who was handcuffed by hospital SOs and Patient 8 who was tased and handcuffed by hospital SOs, review of security report and/or incident documentation for 7 of 7 patients who were handcuffed by hospital SOs (Patients 4, 6, 8, 9, 11, 12 and 13), review of training materials, review of P&Ps and other documentation it was determined that the hospital failed to ensure that incidents and adverse patient events were thoroughly investigated and analyzed, and that corrective action plans were developed to prevent recurrence and to establish clear expectations for patient safety including compliance with CMS. Findings include: 1. Refer to the findings for Patients 4, 6, 8, 9, 11, 12, and 13 cited at Tag A-145, CFR 482.13(c)(3) - Standard: Freedom from Abuse, that reflects the investigations of patients handcuffed and/or tased on hospital property were unclear and incomplete. All potential gaps or concerns related to those incidents had not been thoroughly investigated and analyzed to determine potential trends, whether corrective actions were indicated, and whether CMS regulatory requirements were met. 2. Refer to the findings for Patients 6 and 8 cited at Tag A-144, CFR 482.13(c)(2) - Standard: Privacy and Safety, that reflects Patient 6 was harmed when handcuffed by non-law enforcement hospital SOs, and Patient 8 was at high likelihood of harm when tased and handcuffed by non law-enforcement hospital SOs. 3. The P&P titled “PSJH-CLIN-1212 Event Reporting and Response Policy and Procedure” dated effective “01/2024” reflected: * “Adverse Events: One of several types of Safety Concerns reported through the Event Reporting System. Defined as an event in which care resulted in an undesirable clinical outcome - an outcome not caused by underlying disease - that prolonged the patient stay, required life-saving intervention, caused permanent patient harm, or contributed to death ...” * “Event Reporting System (ERS): ...electronic tool used by all Providence Workforce Members to report any Safety Concern that is thought to be a deviation from generally accepted performance standards and/or inconsistent with safe operations of the health care system or the safe care of a particular patient. The tool provides the framework for reporting, analyzing, tracking, trending, resolving, and following up on events with established committees, boards, and state/federal agencies to ensure appropriate actions are taken to prevent future harm.” * “GAPS: Generally Accepted Performance Standards (GAPS) are determined by comparing actual performance to expected performance ...” * “Patient Safety Plan: The Patient Safety Plan is an integral component of the quality assessment and performance improvement structure for each ministry and encourages non-punitive reporting of patient safety concerns and opportunities, and the use of evaluative processes that support learning from incidents and system failures to assess for, anticipate, and prevent future events. The plan should be reviewed annually and updated based on themes or trends related to quality and safety.” * “Quality Program: An ongoing, long-term, proactive set of focused activities designed to monitor, analyze, and improve the quality of processes to achieve better healthcare outcomes in an organization. By gathering and analyzing data in key areas, a ministry/facility can effectively improve outcomes for patients ...” * “The data gathered through the ERS are reported to the designated review committee(s) of each ministry/facility ... Each ministry/facility utilizes Event Report data to proactively identify opportunities for performance improvement and to track and trend processes that have been the subject of improvement activities such as Root Cause Analysis (RCA), and Failure Mode and Effects Analysis (FMEA). Such discussions are recorded in the minutes of respective review committees of each Quality Program. The outcome of safety events, safety trends, corrective and preventative action plans are shared with respective boards at a reliable cadence”. * “Event investigation is completed on behalf of the Quality and Safety Improvement Committee, (QSIC) or equivalent of each ministry/facility’s Quality Program ... All events are investigated at the department level by the department core leader ... Events that meet state or regulatory criteria are escalated for investigation by the Quality Team. Unit/department core leaders will request consultation from the Quality Team if additional support is necessary or the investigation uncovers complexities that need further attention and expertise.” All aspects of the P&P were not carried out as the QAPI program failed to ensure that incidents and adverse patient events involving patients who were handcuffed and tased by non-law enforcement hospital SOs were thoroughly investigated and analyzed, and that corrective action plans were developed to prevent recurrence and to establish clear expectations for patient safety including compliance with CMS. 40575”

“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: 40575 Based on observation, interviews, review of physical environmental risk documentation, review of hospital policies and procedures, and review of other documentation, it was determined that the hospital failed to fully develop and implement P&Ps to ensure each patient’s right to the provision of safe care in the hospital. The hospital’s failures included the following: * A patient’s spouse made a verbal threat to shoot hospital staff and was allowed to return to the hospital the next day. * Failure to develop and implement clearly written, consistent and effective policies and procedures that ensured all patients, visitors, vendors and other people entering the facility were screened for weapons and other prohibited items. Findings include: 1. The P&P titled, “PHSOR Workplace Violence Prevention” dated “Last Revised 05/2024” reflected: * “PHSOR is committed to preventing workplace violence (WPV) and to maintaining a safe work environment. As such, PHSOR has adopted the following policy regarding violent behaviors, identifying our expectation for responding to, mitigating, and reporting violence in the workplace.” * “Healthcare workers are at a significant risk of workplace violence from physical and verbal assault (OSHA, 2015).” * “Workplace Violence (WPV): An act or threat occurring at the workplace that can include any of the following: verbal, nonverbal, written, or physical aggression (regardless of intent or injury); threatening, intimidating, harassing, or humiliating words or actions; bullying ... involving staff ... or visitors.” * “In keeping with our mission and values, PHSOR is committed to providing a safe and secure workplace and an environment free from violence. PHSOR does not tolerate violence. Violent incidents are taken seriously and thoroughly investigated.” * “Administration will foster and support a culture where workplace violence is not accepted, tolerated, nor considered part of the job. It is the belief of administration that caregiver safety and security is essential to and equally important as patient safety.” * “WPV incident reports are collected and maintained on the High Reliability ‘Speak up for Safety’ Platform. Any caregiver, leader or provider may submit a report. At least one report should be submitted per event ... Workplace violence incidents will be reviewed and investigated to identify opportunities to mitigate risk and support caregivers.” 2. During interview on 04/16/2025 beginning at 1120 with DON the following information was provided: * Spouse of patient was upset about patient care and said “Who do I have to shoot” at RN station on 4L on Thursday night (04/10/2025). The House Supervisor and Security officer came to the unit and de-escalated the situation. Spouse was sent home. * Spouse returned to 4L the next day. * Some staff did not feel comfortable having spouse on unit after making verbal threat. CN notified DON. * DON, Security and House Supervisor all met and agreed to have spouse sign “visitation agreement” that required spouse to check in with security and go through metal detector upon arriving to the hosptital. Also, spouse was to refrain from yelling, posturing at, insulting or threatening members of staff. * Spouse was allowed to be present from 1900-0700. * A background check was done on spouse. Security increased rounding on unit. * DON checked with CN and they felt supported but some staff were still uncomfortable. Three staff members went home early due to feeling uncomfortable. DON was not notified of this until the next day. * Spouse was appropriate and cooperative after initial event took place. The hospital stated that contributing factors were the spouse was elderly and English is their second language. Spouse denied that they made a verbal threat. * Patient’s adult child began visiting instead of spouse to limit staff discomfort. Hospitalist expedited discharge. * Patient discharged home on Monday, four nights after the initial incident took place. * Some staff members were upset that the visitor was let back into the hospital after making a verbal threat which contradicted the P&P above that reflects “PHSOR does not tolerate violence.” The visitor went through the metal detection screening station when entering the facility but did not immediately report to the unit. Some staff members were concerned that the visitor could have gone back outside to their vehicle and was bringing a weapon onto the unit. 3. A document titled, “Providence Portland Medical Center (PPMC) Security Services Standard Operating Procedure” dated “Approved: 12/9/22” reflected: * “Purpose: To prevent prohibited weapons and contraband from entering the hospital.” * “Screening methods include: Walk-through metal detector, Hand-held metal detectors, X-ray machine, Physical inspection of clothing, bags, bacpacks, purses.” * “This Standard Operating Procedure (SOP) applies to Security screening at the Emergency Department (ED) main entrance as well as the ambulance entrance. Main entrance of the hospital. Cancer center entrance.” * “This SOP applies to the PPMC campus, to include the Professional Plaza; Child Center; parking garages; parking lots ...” * “All patients, visitors and contractors are screened ...” * “X-Ray Screening Process: All items coming into the building are subject to inspection and/or x-ray (e.g., baggage, briefcases, purses, backpacks, sacks, baby carriers, medical supplies).” * “All persons who leave and later seek re-entry at any screening station will be screened again.” The SOP is not consistant with the current practices at PPMC. 4. During observation on 04/16/2025 starting at 1000 the following was observed: * A sign in the parking garage skybridge entrance that reflected: “Attention Patients, Family and Visitors Security screening required for all patients and visitors at Providence Portland Medical Center. The following are not allowed in the hospital and will be confiscated at the screening station: - Weapons, including guns, knives, and pocketknives - Narcotics - Chemical deterrents such as pepper spray Threats, verbal abuse, or acts of physical violence will not be tolerated and may result in removal from premises and criminal prosecution.” * The entrance from the skybridge does not have any security officers present, a metal detection screening station or anyone directing people that enter to the other entrances with screening staff present. 5. During interview with SM on 04/16/2025 starting at 1205, the following information was provided: * The ED entrance is staffed for metal detector screening 24 hours a day, 7 days a week. * The main entrance and cancer center entrances have staff from 0600 to 1900 when there is enough security to staff the metal detectors. After hours, everyone must enter through the ED and go through the screening. * The ambulance entrance has a wand that can be used for patients entering with EMS and not able to walk through the screening station. * The skybridge does not have a metal detector screening station. * There was not enough security staff working today to staff the main entrance metal detector screening station. * There is limited security staff and not enough security officers to backfill for sick calls. There were 11 officers scheduled for dayshift today and they only have 8 working with 3 sick calls. * People with blue Legacy [Health System] badges and vendor badges are able to bypass the screening stations. The facility has entrances that do not have security screening stations and there are times when the entrances that do have screening stations do not have enough security officers to run them. Patients, visitors and other people entering the facility may bring in weapons or other contraband items that could potentially cause harm to themselves or others, including patients.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 29708 Based on observations, interviews, review of recorded video monitoring, review of live video surveillance, review of medical record documentation for 6 of 6 patients who received inpatient BHU services (Patients 2, 3, 4, 7, 10 and 13), review of incident documentation for 14 of 14 patients involved in incidents on the inpatient BHU (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14), review of staff training/education records for 8 of 8 BHU employees (Employees 1, 2, 3, 4, 5, 6, 7 and 8), review of staff training/education materials, review of environmental rounds documentation, review of physical environment risk documentation, review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all Conditions of Participation. This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care. Findings include: 1. Refer to the findings cited at Tag A115 under CFR 482.13 - CoP: Patient’s Rights. 2. Refer to the findings cited at Tag A263 under CFR 482.21 - CoP: Quality Assessment and Performance Improvement. 3. Refer to findings cited at Tag A700 under CFR 482.41 - CoP: Physical Environment.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 29708 Based on observations, interviews, review of recorded video monitoring, review of live video surveillance, review of medical record documentation for 6 of 6 patients who received inpatient BHU services (Patients 2, 3, 4, 7, 10 and 13), review of incident documentation for 14 of 14 patients involved in incidents on the inpatient BHU (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14), review of staff training/education records for 8 of 8 BHU employees (Employees 1, 2, 3, 4, 5, 6, 7 and 8), review of staff training/education materials, review of environmental rounds documentation, review of physical environment risk documentation, review of hospital P&Ps, and review of other documentation, it was determined that: * The hospital failed to ensure each patient’s right to freedom from all forms of abuse and neglect. * The hospital failed to ensure hospital staff involved in restraint/seclusion were trained and had demonstrated competency in the use of first aid techniques that may be needed during patient restraint and seclusion. * The hospital failed to ensure each patient’s right to receive care in a safe setting. Patient 13, admitted to the inpatient BHU with suicidal ideation, draped a bed sheet over the door between their room and hallway, and used it to hang themselves and died. Refer to Tag A000 at the beginning of this SOD report for IJ identification, notification, removal plans approval, and verification of removal. This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care. Findings include: 1. Refer to the findings cited at Tag A144 under this CoP, CFR 482.13(c)(2) - Standard: Care in a Safe Setting. Those findings reflect the hospital’s failure to ensure Patient 13’s right to receive care in a safe setting and represented an IJ situation. 2. Refer to the findings cited at Tag A145 under this CoP, CFR 482.13(c)(3) - Standard: Freedom from Abuse. 3. Refer to the findings cited at Tag A206 under this CoP, CFR 482.13(f)(2)(vii) - Standard: Restraint or seclusion: Staff Training Requirements. 4. Refer to the findings cited at Tag A701, CFR 482.41(a) - Standard: Buildings.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 29708 Based on observations, interviews, review of recorded video monitoring, review of live video surveillance, review of medical record documentation for 6 of 6 patients who received inpatient BHU services (Patients 2, 3, 4, 7, 10 and 13), review of incident documentation for 14 of 14 patients involved in incidents on the inpatient BHU (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14), review of staff training/education records for 8 of 8 BHU employees (Employees 1, 2, 3, 4, 5, 6, 7 and 8), review of staff training/education materials, review of environmental rounds documentation, review of physical environment risk documentation, review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to ensure that the QAPI program was effective to ensure the provision of safe and appropriate care to hospital patients. This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care. Findings include: 1. Refer to the findings cited at Tag A115 under CFR 482.13 - CoP: Patient’s Rights. 2. Refer to findings cited at Tag A700 under CFR 482.41 - CoP: Physical Environment.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 29708 Based on observations, interviews, review of recorded video monitoring, review of live video surveillance, review of medical record documentation for 4 of 6 patients who received inpatient BHU services (Patients 4, 7, 10 and 13), review of incident documentation for 4 of 14 patients involved in incidents on the inpatient BHU (Patients 4, 7, 10 and 13), review of staff training/education materials, review of environmental rounds documentation, review of physical environment risk documentation, review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to fully develop and implement P&Ps to ensure patients received care in a safe physical environment as follows: * The hospital failed to ensure patients on the inpatient BHU were provided care in a safe, physical environment that was free of ligature risks, and unsafe items, and areas. Environmental risks had not been identified and/or mitigated and created the risk for self-harm. * Patient 13, admitted to the inpatient BHU with suicidal ideation, draped a bed sheet over the door between their room and hallway, and used it to asphyxiate themselves and died. Those conditions resulted in actual harm for Patient 13 and risk for serious harm or death to other patients including but not limited to access to ligature risks. These findings were determined to represent an IJ situation. Refer to Tag A000 at the beginning of this SOD report for the details of the IJ identification, notification, removal plan approval, and verification of removal. This Condition-level deficiency represents a limited capacity on the part of the hospital to provide safe and adequate care. Findings include: 1. Refer to the findings cited under this CoP at Tag A701, CFR 482.41(a) - Standard: Buildings. Those findings reflect the hospital’s failure to ensure care in a safe physical environment and represented an IJ situation. 2. Refer to the findings cited at Tag A144, CFR 482.13(c)(2) - Standard: Care in a Safe Setting regarding Patient 13. 3. Refer to findings cited at Tag A145, CFR 482.13(c)(3) - Standard: Free From Abuse/harassment regarding Patients 4, 7 and 10.”

“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: 29708 Based on observations, interviews, review of recorded video monitoring, review of live video surveillance, review of medical record documentation for 6 of 6 patients who received inpatient BHU services (Patients 2, 3, 4, 7, 10 and 13), review of incident documentation for 14 of 14 patients involved in incidents on the inpatient BHU (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14), review of staff training/education records for 8 of 8 BHU employees (Employees 1, 2, 3, 4, 5, 6, 7 and 8), review of staff training/education materials, review of environmental rounds documentation, review of physical environment risk documentation, review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to fully develop and implement P&Ps to ensure each patient’s right to receive care in a safe setting in the following areas: * Failure to develop and implement clearly written, consistent and effective policies and procedures that ensured patients on the inpatient BHU at risk for suicide or self harm were appropriately assessed, monitored and prevented access to unsafe items in the physical environment. Patient 13, admitted to the inpatient BHU with suicidal ideation, draped a bed sheet over the door between their room and hallway, and used it to hang themselves and died. Those conditions resulted in actual harm for Patient 13 and potential harm to other patients. Refer to Tag A000 at the beginning of this SOD report for the details of the IJ identification, notification, removal plan approval, and verification of removal. * Failure to ensure patients on the inpatient BHU were provided care in a safe, physical environment that was free of ligature risks, and unsafe items and areas. Risks had not been identified and/or mitigated and created the opportunity for self-harm. Those included but were not limited to gaps inside closets, holes in underside of bathroom sinks, entry doors to patient rooms, and patient bathroom door (hinges). Those conditions resulted in actual harm for Patient 13 and risk for serious injury or death to other patients including but not limited to access to ligature risks. These findings were determined to represent an IJ situation. Refer to Tag A000 at the beginning of this SOD report for the details of the IJ identification, notification, removal plan approval, and verification of removal. * Failure to ensure staff responses to patient incidents included timely, clear and complete investigations to identify causes and to plan and implement corrective actions to prevent recurrence for the affected patients and others. Incidents include but are not limited to failure to prevent patients from accessing unsafe items and self harming, suicidal patients from placing a sheet or blanket around their neck, patient altercations, falls, inappropriate touching between patients, and reported neglect related to incontinence. Findings include: 1. During interview on 11/28/2023 beginning at 1335 the PNM confirmed that on 11/17/2023 a patient admitted to the inpatient BHU tied a knot in a bed sheet, put the sheet over the door between their room and hallway, closed the door and used the sheet to commit suicide by asphyxiation. 2. Incident documentation for Patient 13 reviewed included that on 11/17/2023 at 1520 “Pt [was] found down with sheet found around [their] neck and not responsive. Code blue initiated and unsuccessful.” * “[Patient] was admitted with standard precautions to monitor patient and environment for safety. [Patient] had 15-minute safety checks ...” * “[No date] At 1010, a nursing communication was placed that allowed checks by monitor every 15 minutes ...” * “[No date/time] A nursing note indicates that [patient] would not contract for safety after endorsing suicide plan ‘since you put me on an NMI [mental illness hold]’. Concern for safety was emphasized with the patient.” * “On 11/17/2023, [patient] refused [their] morning 450mg of Lithium at 0826.” * “[No date/time] ... was notably anxious and unwilling to be interviewed by MD.” * “The following timeline was obtained from video footage ...: - “12:20:52 Patient pulled a sheet out of [pillowcase] and then put it back ...” - “12:22:50 Pulled out sheet from pillowcase again and replaced it in the pillowcase ...” - “15:02:20 Patient retrieved the sheet from [their] pillowcase ...” - “15:02:38 Patient placed the rolled sheet with a tied knot on the end over the room door ...” - “15:02:56 Patient placed the sheet around [their] neck, then slowly sat down ...” - “15:03:06 Patient rolls away from line of sight of camera ...” - “15:05:42 Patient rolls back in view of camera.” - “15:08:33 Caregiver did a check in the alcove area ...” - “15:19:57 Caregiver at alcove again ...” - “[No time recorded] Caregiver visually rounding on camera - saw patient. Ran down hallway called code blue ...” - “15:20:56 Room camera activated recording as clinical staff open door to patient on the floor with sheet around neck ... CPR commenced ...” - “15:24:01 Code Blue team enters [BHU] hall” - “[No time] Patient was found on the floor pulseless and not breathing. CPR started ... Code stopped at 15:45 and the patient was pronounced deceased.” * “According to PolicyStat, Use of Routine & Special Observation for Patient Safety ... q15 Minute Safety Checks: Direct observation of patient ensuring safety and location of patient on unit. Any unsafe behaviors and/or conditions will be addressed immediately and reported to assigned RN ... Staff assigned responsibility for conducting routine or special observations are to ... Routinely assess environment for potential risk factors impacting safety ... Staff assigned observation responsibilities are to notify patient’s assigned RN or Charge RN immediately of any changes in patient’s condition or environment that could potentially elevate safety risk for patient or others and intervene as clinically appropriate ... Patient’s assigned RN or Charge nurse remains accountable for the decision to delegate patient observations. The RN must ensure that the staff member is sufficiently knowledgeable and competent to undertake observation responsibilities ... All patients admitted for inpatient care are subject to initial and ongoing multi-disciplinary risk assessments. The outcome of these individualized risk assessments will determine the level of observation, support and treatment prescribed. Ideally, a multi-disciplinary team should always make the decision about the level of safe and supportive observation needed. However, decisions may be made jointly by the physician and nurse. There may be the need to increase the level of observations in an emergency ... It is important to remember that all patients should be considered at risk ... High level of observation may be indicated, but not limited to, assessment of following factors ... History of previous suicide attempts ... When the patient is expressing thoughts and ideas about harming themselves ... Expressions of specific plans or intentions to harm themselves ... Patients who are withdrawn and/or difficult to engage ...” 3.a. Recorded video monitoring of the inside of Patient 13’s room was reviewed on 11/29/2023 at 1220 with the PPM and PNM. It revealed: * On 11/17/2023 at ~ 1101, no top sheet was observed on the patient’s bed. This was confirmed with the PPM on 11/29/2023 at the time of this review. * On 11/17/2023 at ~ 1502, the patient retrieved a sheet from [their] pillowcase, opened the room door, placed the sheet around their neck, and slowly sat or layed down. * On 11/17/2023 at ~ 1521, staff entered the room and began CPR on the patient. 3.b. Recorded video monitoring of the inside of Patient 13’s room and the hall outside of Patient 13’s room recorded on 11/17/2023 from 0700 through the time of the incident was reviewed with the PNM on 11/29/2023 at 1445. It revealed: * On 11/17/2023 at ~ 1508 and 1519, an MHA was observed at the alcove directly outside the door to the patient’s room. There was no indication the MHA was aware of or noticed a sheet “with a tied knot on the end over the room door.” * No staff were observed going into Patient 13’s room and conducting BH shift environmental rounds from 0700 through the time of the incident. These findings were confirmed with the PNM on 11/29/2023 at the time of this review. 4. During an interview on 11/30/2023 at 1615 the EDO stated the hospital’s ongoing internal investigation that included review of recorded video monitoring revealed that Patient 13 removed a bed sheet from their bed and placed it inside their pillowcase the day before the incident, on 11/16/2023 at 1500. 5. Patient 13’s medical record was reviewed and reflected the patient was admitted to the hospital’s inpatient BHU on 11/13/2023 with diagnoses that included suicidal ideation and PTSD. The medical record included the following: * A nursing communication dated 11/13/2023 at 2150, and electronically signed by a physician on 11/14/2023 at 1010 reflected “May do checks by monitor.” * An RN note dated 11/13/2023 at 2223 reflected: - “... ‘I don’t know how to bring myself back from an episode (panic attack) and all I can think of is to kill myself ...’ Pt states [they] had a plan ... Pt has healed scars on L arm/antecubital area from past SA ... states [they have] PTSD from past trauma and states [they are] triggered by door opening on checks. Will do checks by monitor ...” - “Suicide Risk: [Moderate]” - “Providence Portland Medical Center Adult Inpatient Psychiatry Suicide/Non-Suicidal Self-Injurious Behavior (NSSIB) Risk Reduction Protocol” followed by: “STANDARD Precautions” and three interventions, “SW to establish Safety support/Relapse plan with family/significant others,” “SW to evaluate access to firearms,” and “Monitor patient & environment for safety.” * A DO Psychiatry H&P note dated 11/14/2023 at 1323 reflected: - “Patient was brought in by self to the emergency department stating that [they were] experiencing suicidal ideation with plans to jump off of an overpass. Patient was admitted to PPMC inpatient behavioral health for safety and further stabilization ... “ - “[Patient] found lying in bed in the dark ... states [they believe] [they need] to be in the hospital for safety and treatment and inquired about perhaps being civilly committed ... states [they are] worried [they] will attempt to leave the hospital before [they are] ready to go ...” - “Risk Assessment: Recent self harm, Impulsivity, Persistent SI, and Fearful of Self-harm impulses” - “Risk Level is estimated to be: Elevated” - “Mental Status Examination: ... Eye contact is poor ... Mood/Affect: depressed and blunted Suicidal Thoughts: Active plan ... Thought Content: hopeless, helpless, and fear.” * An RN note dated 11/14/2023 at 2332 reflected “... Pt endorsed SI with a plan outside of the unit, pt would not disclose said plan. Pt verbally contracts for safety on the unit ... Safety checks q15 minutes.” * An RN note dated 11/15/2023 at 0956 reflected: - “... [Patient] is mostly withdrawn to [their] room ... Endorsing thoughts of SI to jump off bridge ... contracts for safety on the unit ... Attended some evening groups.” - “Providence Portland Medical Center Adult Inpatient Psychiatry Suicide/Non-Suicidal Self-Injurious Behavior (NSSIB) Risk Reduction Protocol” followed by: “STANDARD Precautions” and three interventions, “SW to establish Safety support/Relapse plan with family/significant others,” “SW to evaluate access to firearms,” and “Monitor patient & environment for safety.” * A DO Psychiatry note dated 11/15/2023 at 1542 reflected: - “... Patient found lying in bed in the dark at the time of today’s visit ... Patient reports that [they] did not sleep well overnight, which [they attribute] to noise from 15 minute checks as well as the door at the end of the hallway being opened and closed repeatedly. Patient reports that [they continue] to feel suicidal. Feels safe in the hospital but not safe outside of the hospital ... Assessment TODAY: Patient appears depressed and was difficult to engage in interview ...” - “Risk Assessment: Impulsivity, Persistent SI, and Fearful of Self-harm impulses” - “Risk Level is estimated to be: Elevated. This is due to continued severity of symptoms, continued suicidality ... dependence on the structure of the inpatient unit for safety.” * An RN “C-SSRS Daily/Shift Screen” dated 11/16/2023 at 0200 reflected “[unable to assess] pt asleep.” * An RN “C-SSRS Risk Assessment” dated 11/16/2023 at 0200 reflected: - “Plans to Mitigate Risk for Suicide ... Checks every 15 minutes” - “Clinical Team/LIP Overall Assessed Suicide Risk ... Moderate Risk” * An RN note dated 11/16/2023 at 0225 reflected: - RN Handoff Note ... Thoughts of Suicide: Yes ... Psych Precautions in Place: Suicide risk Safety Rounding: Q15.” - “Presentation: Behavior: Quiet ... Thought Process: Pressured, Impaired judgement ... Engagement with staff Interaction with Staff: Minimal ... Interaction with Peers: Withdrawn ...” - “Providence Portland Medical Center Adult Inpatient Psychiatry Suicide/Non-Suicidal Self-Injurious Behavior (NSSIB) Risk Reduction Protocol” followed by the same standard precautions and three interventions: STANDARD Precautions” and interventions, “SW to establish Safety support/Relapse plan with family/significant others,” “SW to evaluate access to firearms,” and “Monitor patient & environment for safety.” * An RN note dated 11/16/2023 at 1422 reflected: - “... [Patient] was up late this morning, c/o poor sleep last night and feeling tired ... denies SI/HI, ‘not right now’ ... was later seen pacing the hallways, reports anxiety, ‘in my head and chest’ ... accepted zyprexa, vistaril and tylenol, reports not helpful, requested for ‘more medications’, MD notified. Pt later requested to discharge, was placed on NMI [mental illness hold], accepted information without any incident.” - “Providence Portland Medical Center Adult Inpatient Psychiatry Suicide/Non-Suicidal Self-Injurious Behavior (NSSIB) Risk Reduction Protocol” followed by the same standard precautions and three interventions: STANDARD Precautions” and interventions, “SW to establish Safety support/Relapse plan with family/significant others,” “SW to evaluate access to firearms,” and “Monitor patient & environment for safety.” There was no documentation that reflected the RN evaluated the standard precautions and interventions and determined they remained appropriate considering the patient was placed on an NMI (mental illness hold). A DO Psychiatry note dated 11/16/2023 at 1623 and electronically signed by the DO 11/16/2023 at 1629 reflected: * “Time patient seen: 0930 and 1430” * “... Patient found lying in bed in the dark at the time of today’s visit ... Continues to feel depressed and suicidal, does not feel safe outside the hospital ... Later in the day, this author was notified that patient wish [sic] to leave the hospital. Presented to patient’s room for reevaluation. [Patient] states that [they are] experiencing pain and anxiety and would like to leave ... Discussed with patient that given recent report of active SI and concerns about impulsivity/impaired judgment, [they] would be placed on NMI [mental illness hold]. Asked patient if [they] would like this author to restart Lyrica, which [they] had taken in the past, however [they] stated that medication did not work and did not definitively answer ...” * “Mental Status Examination ... Patient seen in patient’s room ... Suicidal Thoughts: Active plan” * “Current level of care need: Patient meets the following criteria for continued stay: Danger to Self or Others and Need for close Medication Management” * “Assessment TODAY: Patient continues to appear depressed and continues to report active suicidal ideation. Patient later requested to discharge however given ongoing SI, will place on NMI [mental illness hold] ... In reviewing the overall clinical picture, patient appears to be showing no change in symptoms today.” * “Chemical Dependency ... Continue Safety Checks per our protocol.” * “Risk Assessment: Impulsivity, Persistent SI, and Fearful of Self-harm impulses ... Risk Level is estimated to be: Elevated. This is due to continued severity of symptoms, continued suicidality, dependence on the structure of the inpatient unit for self care, and dependence on the structure of the inpatient unit for safety.” Although the DO documentation reflected the patient was placed on an NMI (mental illness hold) due to “recent report of active SI and concerns about impulsivity/impaired judgment,” there was no documentation that reflected the precautions and interventions in place at that time were evaluated, and determined still appropriate. * An RN “C-SSRS Daily/Shift Screen” dated 11/16/2023 at 2030 reflected: - “Thoughts of Suicide ... Yes” - “Since you were last asked, have you actually had thoughts about killing yourself? ... Yes” - “Have you been thinking about how you might kill yourself? ... Yes” - “Have you had these thoughts and had some intention of acting on them? ... No” - “Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? ... No” - “Have you done anything, started to do anything, or prepared to do anything to end your life? ... No” - “Describe: ... will not elaborate and states will not talk to staff upset about NMI [mental illness hold].” The suicide screen documentation failed to describe what aspects of the suicide screen the patient would not talk about. * An RN “C-SSRS Risk Assessment” dated 11/16/2023 at 2030 reflected: - “Plans to Mitigate Risk for Suicide ... Checks every 15 minutes.” - “Clinical Team/LIP Overall Assessed Suicide Risk ... Moderate Risk.” There was no documentation that reflected the RN evaluated the plan to mitigate the patient’s risk for suicide and determined it was still appropriate taking under consideration that the patient would “not elaborate” and would not talk to staff during the C-SSRS Daily/Shift Screen. * An RN note dated 11/16/2023 at 2136 and filed at 2142 reflected: - “... [Patient] has been pacing, appears anxious, depressed and is guarded and irritable. Minimal contact with peers. C/o pain in back and denies interventions ‘nothing you can give me works, what’s the point?’ [Patient] endorses SI with plan which [they] will not disclose and further states that [they] would not contract for safety since ‘you put me on an NMI [mental illness hold]’. This writer emphasizes our concern for [their] safety ...” - “Providence Portland Medical Center Adult Inpatient Psychiatry Suicide/Non-Suicidal Self-Injurious Behavior (NSSIB) Risk Reduction Protocol” followed by the same standard precautions and three interventions: “STANDARD Precautions” and three interventions, “SW to establish Safety support/Relapse plan with family/significant others,” “SW to evaluate access to firearms,” and “Monitor patient & environment for safety.” Although the patient endorsed SI with a plan, would not disclose the plan, and would not contract for safety, there was no documentation that reflected the RN evaluated the precautions and interventions in place at that time and determined they remained appropriate. There was no documentation that reflected the RN notified the charge nurse or physician of the patient’s refusal to talk to staff during the C-SSRS Daily/Shift Screen, nor that the patient endorsed SI with a plan and would not contract for safety. There was no documentation that reflected the RN evaluated whether the patient should use a safety blanket or the bathroom door should be locked for “Moderate Risk” in accordance with the “Standard Work Document” titled “OPH IP BH Mitigation Plans for Ligature Points” in finding 10.h. There was no documentation that reflected the RN evaluated the current plan of standard precautions with optional remote monitoring, to ensure it remained appropriate. * A “Behavioral Health Observation Form” dated 11/16/2023 was reviewed and was incomplete and failed to identify the patient’s risk for suicide and the sheet inside the patient’s pillowcase. Examples included: - The top of the forms had pre-printed “Risk for:” Just below this there were check boxes next to each of the following: “Suicide” “Self-Harm” “Violence” “Wandering” “Sexual” “Behavior” “Fall” “Elopement” and “Observed Behavior(s).” All of the check boxes were blank. Although the patient had been withdrawn, appeared depressed, and acknowledged thoughts of suicide, none of the check boxes at the top of the form were checked indicating the patient’s risk, including risk for suicide. Another section on the top of the form had pre-printed patient location codes. Those were: “D = Day room” “SH = Shower” “IR = Interview Room” “SR = Seclusion Room” “S = Sensory Room” “R = Room” “BR = Bathroom” “GP = Group Room” “H = Hallway” “MW = Med Window” “Off = Off Unit” The form included pre-printed times every 15 minutes from 0000 through 2345. After each 15-minute time, there were spaces for recording patient location code, patient behavior code, and staff initials. “R” for “[Patient] Room” and staff initials were recorded indicating staff made observations approximately 26 times between 11/16/2023 at 1500, the time the patient put a sheet inside their pillowcase, and 11/16/2023 at 2345. However, there was no documentation that staff noticed the sheet or removed the sheet during any of those times. * An RN note dated 11/17/2023 at 0620 reflected: - “Behaviors this shift: slept ... Assumed care for pt from 2300-0730 hrs. Slept mostly during shift. No unsafe behavior noted. Denies SI/HI/AVH.” - “Providence Portland Medical Center Adult Inpatient Psychiatry Suicide/Non-Suicidal Self-Injurious Behavior (NSSIB) Risk Reduction Protocol” followed by the same precautions and interventions: “STANDARD Precautions” and three interventions, “SW to establish Safety support/Relapse plan with family/significant others,” “SW to evaluate access to firearms,” and “Monitor patient & environment for safety.” * A DO Psychiatry noted dated 11/17/2023 at 1123 and electronically signed by the DO 11/17/2023 at 1615 reflected: - “Time Seen: 0930” - “Patient found lying in bed in the dark at the time of today’s visit. Greeted patient however [they] did not answer. Walked around to direction patient was facing to assess whether or not [they were] sleeping. Patient’s eyes noted to be open and blinking. Attempted to engage patient in interview again however [they] replied that [they] did not feel like speaking today. Patient did not answer any assessment questions asked.” * “Mental Status Examination ... Patient seen in patient’s room ... Eye contact is poor ... Speech: slow and quiet ... Mood/Affect: depressed and blunted ... Suicidal Thoughts: Would not answer ... Homicidal Ideations: Would not answer ...” * “Assessment TODAY: Patient poorly engaged in interview today. Appeared to be irritable and depressed and would not answer assessment questions. Terminated interview shortly after contact. Will continue current medications at current doses for today and continue to assess ... In reviewing the overall clinical picture, patient appears to be showing no change in symptoms today.” * “ADDENDUM: This author was paged later in the afternoon by patient’s nurse, informing this author that patient had been found hanging from a bedsheet in [their] room. Patient seen by rapid response team and stabilization was attempted however patient ultimately died.” Although the documentation reflected the patient was depressed, would not answer any assessment questions, including those related to suicidal thoughts, there was no evaluation of the current plan and interventions which included the same standard precautions with monitoring every 15 minutes and optional “checks by [video] monitor.” * An RN note dated 11/17/2023 at 1554 reflected “Code Blue called at 15:23. Pt found on the floor pulseless and not breathing ...” * Review of a “Behavioral Health Observation Form” dated 11/17/2023 included the same pre-printed information as above. Similarly, all of the check boxes after “Risk for:” were blank including “Suicide. “R” for “[Patient] Room” and staff initials were recorded indicating staff made observations approximately 57 times between 11/17/2023 at 0000 and 11/17/2023 at 1515 (eight minutes before the code blue was called). However, there was no documentation that staff noticed the sheet inside the pillowcase or removed the sheet during any of those 57 times. 6. During interview on 11/30/2023 at 1300 with a Psychiatrist and other hospital leadership present the following information was provided: * The Psychiatrist stated Patient 13 had a lot of risks for suicide including family history of suicide, SI, and houselessness. * The Psychiatrist stated increased monitoring should be considered when a patient has “red flags.” The Psychiatrist stated “red flags” included when a patient “is having active suicide,” “says they have a [suicide] plan,” “cannot contract for safety,” and “has a change of status.” * Regarding the RN note filed on 11/16/2023 at 2142, the Psychiatrist stated this was a change for the patient, the best person to address this was the nurse, and there was no documentation that reflected the nurse notified the physician of this change. 7. During interview and review of Patient 13’s medical record on 11/30/2023 at 1400 with EDO, CNO, ANM and other hospital leadership the following information was provided: * Patient 13 was on “standard” every 15 minute observation monitoring at the time of the incident, and the medical record included an order that permitted staff to conduct every 15 minute observation monitoring by video monitor. * Regarding the RN note filed on 11/16/2023 at 2142, the RN should have notified the charge nurse and the physician about the patient’s suicide risk including that the patient endorsed SI with a plan, and would not contract for safety. * The ANM confirmed there was no documentation that reflected the RN notified the charge nurse or the physician that the patient endorsed SI with a plan, and would not contract for safety. * The ANM confirmed there was no documentation that reflected the RN evaluated the patient for possible increased monitoring or other interventions regarding the patient’s change and risk for suicide, nor that the care plan had been modified. 8.a. A “Behavioral Health Shift Environmental Rounds” form for the inpatient BHU dated 11/17/2023 was reviewed and was incomplete and failed to identify the missing sheet on the patient’s bed and the sheet inside their pillowcase. Examples included: * Instructions at the top of the form reflected “The below form is completed at the start of each shift (0700 & 1900) and placed in the Environmental Rounds binder kept in the nurses station. Documentation of this rounding form is to be completed by two staff, both staff need to print name, initial and put time this was completed.” * The form included spaces for recording staff initials and specific times BH shift environmental rounds were completed. One of sections on the form included, “All Patient rooms and bathrooms visualized for safety concerns ... Obstacles blocking entrance ... Contraband items ... Possible ligature risks ... [e.g.], knotted sheets, torn towels).” The form had only one set of initials and no time recorded under “0700 Initials/Time.” There were no initials and no time recorded under “1900 Initials/Time.” * The bottom of the form reflected “2 Staff Initials” followed by one set of initials, and “2 Staff Print” followed by one staff name and title. There was no documentation that reflected the rounding form was completed by two staff in accordance with the instructions at the top of the form. 8.b. During an interview on 11/29/2023 at 1430 the PNM stated BH shift environmental rounds should be conducted by staff each shift. The PNM stated that when staff conduct environment rounds “They should be looking around the [patient’s] room.” The PNM also stated staff should notice if a sheet is inside a pillowcase. 8.c. Although the “Behavioral Health Shift Environmental Rounds” form in finding 8.a. was initialed and dated indicating one staff had conducted environmental rounds on 11/17/2023 at or around 0700, review of recorded video monitoring of the inside of Patient 13’s room in finding 3.b. revealed no staff conducted BH shift environmental rounds inside Patient 13’s room from 11/17/2023 at 0700 through 11/17/2023 at the time of the incident. 8.d. During interview on 11/30/2023 at 1615, the EDO stated they spoke with staff and confirmed that although documented as having been conducted, staff had not conducted BH unit environmental rounds on 11/17/2023 at or around 0700. 9.a. A “Purposeful Rounding Log” dated 11/17/2023 for Patient 13 was reviewed and was incomplete and failed to identify the patient’s risk for suicide and knotted sheet inside their pillowcase. Examples included: * The top of the form had pre-printed “Risk:” followed by a space. There was nothing recorded in this space nor anywhere else on the log that reflected the patient’s suicide risk. Just below this there were check boxes next to each of the following: - “Suicide” - “Self-Harm” - “Violence” - “Wandering” - “Sexual” - “Behavior” - “Fall” - “Elopement” and - “Observed Behavior(s).” The form included pre-printed times every hour from “07” through “23.” After each one hour time, there was a space for recording: - “Time” in minutes to complete the pre-printed hour time. - “[Staff] Initials” - “Patient Activity” - “Location” - “Behavior” - “[C] Comfort & Pain” - “[A] Anticipate Needs” - “[R] Risks/Assessment” - “[E] [Environment]/Elimination” and - “[S] Sensitivity & Safety” For “07” spaces for recording the following were blank: - “Time” in minutes to complete the pre-printed hour time. - “Patient Activity” - “[C] Comfort & Pain” - “[A] Anticipate Needs” - “[R] Risks/Assessment” RN initials were entered next to “07”. “[E] [Environment]/Elimination” and “[S] Sensitivity & Safety” were checked. However, there was no documentation that reflected the RN noticed the missing sheet from Patient 13’s bed or the knotted sheet inside the patient’s pillowcase. For “0828,” spaces for recording the following hourly rounding were blank: - “Patient Activity” - “[C] Comfort & Pain” - “[A] Anticipate Needs” - “[R] Risks/Assessment” - “[E] [Environment]/Elimination” and - “[S] Sensitivity & Safety” RN initials were entered next to “0828” There were similar blank spaces and RN initials next to 0915, 1003, 1112, 1202, and 1305. All spaces for recording hourly rounding at 1400 and 1500, were blank. Refer to finding 2 that reflects the patient retrieved a sheet from their pillowcase at 1502 and CPR commenced at 1520. The bottom of the form had initials and names of two RNs. A section below this reflected “Other Known Risk(s)” followed by: - “Suicide” - “Self-Harm” - “Violence” - “Wandering” - “Sexual Behavior” - “Fall” - “Elopement” - “Observed Behavior(s): All of these were preceded by a blank check box, including “Suicide.” 9.b. During interview and review of purposeful rounding documentation with hospital staff on 11/28/2023 at 1420, they stated CARES rounding was documented hourly by nurses on the “Purposeful Rounding Log” in finding 9.a. 10.a. An undated “Standard Work Document” titled “OPH IP BH Day Charge RN Workflow,” Version 1.0, reflected “Start of Shift ... Ensure that Environmental Rounds are assigned.” 10.b. An undated “Standard Work Document” titled “OPH IP BH Evening Charge RN Workflow,” Version 1.0, reflected “Start of Shift ... Ensure that Environmental Rounds are assigned.” 10.c. An undated “Standard Work Document” titled “OPH IP BH MHA Noc SW,” Version 1.0, reflected “MHA Night Routine ... Complete environmental rounds at start of shift ...” 10.d. The “MHA Orientation Packet” provided included a document titled, “Behavioral Health Shift Environmental Rounds” dated “Oct 2018.” It reflected “The Behavioral Health Shift Environmental Rounds will be conducted at the onset of each shift. Responsibility of completion of this form can be a MHA or RN and assigned by the charge nurse ... The purpose of the environmental rounds is to review all areas of the unit to assess for and [sic] safety concerns as they could potentially cause patient harm. After completion of the 24-hour form they will be stored in a designated binder and housed in the Nurse Manager’s office ... Begin October 29, 2018.” 10.e. A P&P titled, “Searches of Patient Environment” dated “Effective 10/2021” reflected: * “Searches are considered a necessary practice to protect the safety and security of patients, staff and visitors on the Behavioral Health Unit.” * “Search guidelines are intended to maximize safety of the unit ...” * “Search Categories:” - “A. Routine: Standard and scheduled searches that are conducted to maintain the ongoing safety of the unit. Routine searches include assessments of the environment for safety hazards and identification of unsafe items ...” - “B. For Cause: Searches that are conducted when a patient has demonstrated behaviors that place themselves or others at risk, and are suspected of having contraband in their possession ...” * “Search Types:” - “A. Body Search: An inspection of the patient’s body” - “B. Belongings Search: A search of a patient’s personal items” - “C. Room Search: Physical search of a patient’s room.” * “Contraband: A. Any item that could serve as a weapon or device to perform self-harm or harm to others B. Any item improperly used by a patient if it poses a threat to a safe environment ...” The P&P was not clear as it did not include how often routine searches of the environment were required to be conducted, including of patient rooms, nor who was responsible to complete them. In addition, it was not clear if “Routine searches ... of the environment for safety hazards” were the same or in addition to “Environmental Rounds” in findings 8.a. and 8.b. 10.f. A document titled “Providence Portland Medical Center Observation Guidelines” dated “Revised Jan 2019” was reviewed and reflected: * “... The implementation of routine or special observations allow for effective monitoring of the patient’s behavior and mental state, while providing the opportunity to facilitate a rapid response by staff, to any change by patient or within environment that creates unsafe conditions ...” * “ALL patients will be monitored every 15 minutes through-out their hospital stay ... Although closed circuit Video surveillance is available as an additional tool for unit safety, it may not be utilized in place of active face-to-face observation and engagement of patients in the performance of assigned patient observation checks ... The purpose of every 15 minute observation levels is to be done for the reason of General Safety, which should be indicated on the Observation Log ... If the patient has other indications, including suicide risk, elopement, wandering, or violence to others, then those indications also be checked on the Observation Log in order for the observer to be cognizant of possible defined safety issues.” * There are 15 minute times printed on each Observation Log Form. An initial in that time will indicate that the patient was visualized within a 6-minute window before or after that time block initialed.” This guideline was inconsistent with the hospital’s practice as it reflected “Although closed circuit Video surveillance is available ... it may not be utilized in place of active face-to-face observation. Refer to findings 2 and 5 that reflected Patient 13 had an order that allowed staff to perform every 15 minute observation “checks by monitor.” 10.g. An undated “Standard Work Document” titled “OPH IP BH Safety Guidelines_ Inpatient Behavioral Health Units SW,” Version 1.0, reflected “Patient Rounding ... When making rounds for patient monitoring, actively assess physical environments for all potential hazards and risks (e.g., broken items, contraband, trip hazards, extra sheets in patient rooms, etc.) ...” 10.h. An undated “Standard Work Document” titled “OPH IP BH Mitigation Plans for Ligature Points,” Version 1.0, reflected: * “[The BHU] original observation competency has been revised ... The addendum details best practice for charting observations by recording accurate times, performing observations in person and not via monitors ...” * “Every shift, RNs chart on suicide risk level for patients who are positive for suicide. The risk levels are Low/Moderate/High ... Patients who are assessed as Low Suicide Risk will be on Q15 minute or QHour [sic] observation checks, determined by the treatment team ... Patients who are assessed as Moderate Suicide Risk will be on Q15 [sic] minute observation checks, may have their bathroom door locked, and could be using a safety blanket, all determined by treatment team ... Patients who are assessed as High Suicide Risk will have a 1:1 and may be in a safety room.” This standard work document was unclear as it indicated that low risk patients could be on Q hour observation checks. However, this was inconsistent with the “Providence Portland Medical Center Observation Guidelines” in finding 10.f. that reflects “ALL patients will be monitored every 15 minutes through-out their hospital stay.” 10.i. The P&P titled “Adult and Pediatric Psychiatry Universal Assessment, Care Planning, and Discharge” dated last revised “12/2017” reflected: * “Upon assumption of care and with changes to the patient condition ... Ensure environmental safety. (See addendum A) ... Perform and document purposeful rounds to assure patient safety is maintained ... Perform and document an individualized focused assessment. The frequency and comprehensiveness of assessments and interventions should be adequate to detect changes early enough in the course of the patient’s stay to treat and/or allay undesirable outcomes ... Perform and document an individualized focused assessment. The frequency and comprehensiveness of assessments and interventions should be adequate to detect changes early enough in the course of the patient’s stay to treat and/or allay undesirable outcomes ... Assess the C-SSRS Screening each shift or on assumption of care and make changes to precaution levels and individualized plan of care as appropriate.” * “Other Safety and Essential Interventions ... Cares Rounding designed for inpatient adult psychiatry is available in Addendum H.” * “Addendum A” was reviewed and included “Addendum A2: Patient Environment Safety.” Review of Addendum A2 reflected it was a document titled “Safety Check List for Inpatient Adult Psychiatry” dated “Updated August 9, 2017.” It included: - “Safety Room Checks occur at minimum once each shift ... Visually inspecting room ... Search patient desk ... Manually search every clothing article-there should not be more than 15 pieces ... Feel for objects in every article ... Lift up mattress and inspect top, sides, underneath. Inspect around bed frame, including blankets and pillow cases ... Inspect items on floor. Remove any items not allowed ... Inspect patient bathroom ... Return toiletry items to bathroom or unit bin if needed. Lock bathroom door ... Remove or return any extra items including checked out items, cups food wrappers or packaging, towels, utensils, linens, garbage, over 3 books, etc. ... Document findings ... Fill out any UOR if needed.” - “Patient Safety Checks occur throughout shift and as needed ... Observe patient for any hazards on clothing they are wearing such as sharps, belts, strings ... Document findings ... Fill out any UOR if needed ... Room Safety Sweeps occur during bedside care or assumption of care, 15 minute checks, after each visit, cares rounding, and as needed ... Visually inspect patient self and room for unsafe items or behaviors ... Walk in and inspect room including trash for any unsafe items or hygiene hazards ... Walk in bathroom and inspect ... Remove any unsafe items, fill out UOR if needed ... Document findings.” - “Unit Safety Checks ... All empty patient rooms should remain locked ... Laundry room has items stocked and is locked ... Cabinets remain locked when not in use in all patient rooms, hallways, groups rooms, art room/interview room, meal room, exam room and quiet rooms ... All group rooms doors to remain locked when shut ... Doors to nurse’s station remain shut ... Unsafe items out of reach of patients in nursing station ... patient medication/supplies stored in Pyxis, sliding window locked when not in use.” The P&P indicated “Safety Room Checks” occurred “minimum once each shift” and “Patient Safety Checks occur throughout shift and as needed.” However, it was not clear how often “Unit Safety Checks” should occur. It was also not clear if any of these checks were the same or in addition to BH shift environmental rounds in findings 8.a. and 8.b. * Addendum H was a “Purposeful Rounding Log” dated “REV 08.07.2017.” The log was inconsistent with the “Purposeful Rounding Log” in finding 9.a. For example, items in Addendum H that were not in the “Purposeful Rounding Log” in finding 9.a. included “Risk Codes ... SR: Suicide Risk ... SH: Self Harm (Non-Suicidal) ... Q15: Every 15 Minute Observation ... RO: Routine Observation ... RO: Routine Observation ... RO: Routine Observation.” 10.j. The P&P titled “Assessment and Management of Suicide Risk in Inpatient Psychiatry,” dated “06/2020” reflected: * “Assigned RN will complete the C-SSRS Screening Shift Assessment each shift or assumption of care and make changes to precaution levels and individualized plan of care as appropriate ...” * “Progress in treatment will be assessed regularly by MD and treatment team ...” * “The formulation of potential suicide risk is to be achieved through a complete interview with the patient. In addition to the patient interview, a review of all possible information sources ... suicide risk assessment and formulation will drive the implementation of immediate safety interventions and development of the individualized plan of care to meet the patient needs. Considerations to include ... Frequency of patient observation, including need for 1:1 observation, will be determined based upon suicide risk and documented on the unit’s close observation form ... Pertinent areas covered in risk reduction protocol include, but are not limited to the following ... What is the appropriate level of observation ... Need for Environmental Safety measures such as locking of bathroom door, removing linens, finger foods ...” 11. Following are findings related to the hospital’s failure to ensure patients on the inpatient BHU were provided care in a safe, physical environment. Refer to the findings cited at Tag A701, CFR 482.41(a) - Standard: Buildings. 12. Following are findings related to the hospital’s failure to ensure staff responses to patient incidents included timely, clear, complete and thorough investigations, and follow-up actions: Refer to the findings cited at Tag A145, CFR 482.13(c)(3) - Standard: Freedom from Abuse.”

“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: 29708 Based on interviews, review of medical record documentation for 5 of 6 patients who received inpatient BHU services (Patients 2, 3, 4, 7, and 10), review of incident documentation for 13 of 14 patients involved in incidents on the inpatient BHU (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 14), review of P&Ps, review of environmental rounds documentation, and review of other documentation, it was determined that the hospital failed to develop and enforce P&Ps to ensure patients’ rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough and complete investigations and follow up actions of potential abuse or neglect, as defined by CMS, to ensure those incidents did not recur. The CMS Interpretive Guideline for this requirement at CFR 482.13(c)(3) reflects “Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.” Further, the CMS Interpretive Guideline reflects that components necessary for effective abuse protection include, but are not limited to: o Prevent. o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. o Protect. The hospital must protect patients from abuse during investigation of any allegations of abuse or neglect or harassment. o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment. o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law. Findings included: 1. The P&P titled “Event Reporting Using DATIX (Unusual Occurrence Reporting - UOR)” dated “02/2023” was reviewed and included the following: * “When an unusual occurrence is discovered, the individual involved in the event and/or the individual discovering the event will complete a Datix Event Record as soon as possible so that details will not be forgotten. It is expected that anytime an event of serious consequences occurs, the person who becomes aware of the event will notify their supervisor/manager immediately to provide assistance and take actions, if appropriate. The supervisor/manager should contact Quality Management as soon as possible. Action will be taken as appropriate to reduce any immediate danger to patients, visitors, or staff.” * “The Datix Event Record will be reviewed by the unit manager or department head (or designee) who is responsible to investigate the situation, take actions as indicated, follow-up with applicable staff, and document their findings on the Datix Event Record. This individual also reviews the Datix Event Record for completeness and accuracy and submits the completed record within 30 days.” 2. Regarding Patient 1, incident investigation documentation reflected that on 01/04/2023 at 1957 “Patient [1] approached another patient that was watching the TV and strikes/attached [sic] [them] 3 times unprovoked.” * The “Date closed (MM/dd/yyyy)” reflected “02/13/2023” * The “Contributing Factors section reflected “Cognitive Impairment/Dementia” * The “Harm Level” section reflected “No Detectable Harm” * “List witnesses and/or others involved including their role ... List names and how involved” was followed by “[Another patient] was the patient attached [sic] by [Patient 1]. [Patient 1] attacked him thrice [sic] before [they] pushed [them] away. [The other patient] pushed [Patient 1] away the first time but [Patient 1] was still coming ... then [the other patient pushed Patient 1] to the floor a second time.” * The “Investigation Components” section was followed by seven items: - “Conducted Interview(s)” - “Discussed with Care Team” - “Discussed with Patient” - “Examined Physical Location” - “Reviewed Policies/Procedures” - “Reviewed Chart” - “Other” The only item checked was “Discussed with Care Team”. * The “Investigation Findings” section reflected “Please summarize the investigation findings (Who, What, Why, and How the event occurred).” This was followed by “02/13/2023 Per reports the incident appeared to be unprovoked and the two patients had minimal interaction. No injury to assaulted patient. Patient was moved to a different floor. Security (code grey) called and patient was escorted away from the situation after unsuccessful attempts by staff.” * The section “Submitter’s Actions Taken and Recommendations for Prevention” reflected “APS report done, code grey called and email sent out to BH staff. [Patient 1] was told not to walk on E hallway” * The section “Deviation from GAPS” reflected “None” * The section “Action” reflected “APS filed Code grey called Seclusion for attacker Separated patients to two separate floors Medicated attacking patient” The documentation lacked a clear and timely investigation. For example: * The incident occurrence date was 01/04/2023. Investigation findings were dated “02/13/2023,” more than 30 days later. The documentation lacked evidence the investigation was completed within 30 days in accordance with hospital policy. * The “List witnesses ...” section did not include witness name and how involved. * The “Investigation Components” section reflected “Discussed with Care Team.” It was unclear what was discussed and the outcome of the discussion. * The documentation reflected “Per reports the incident appeared to be unprovoked.” However, it was not clear who reported, what was reported and when. * There was no investigation that reflected whether abuse or neglect were ruled out. Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for these patients and other patients. 3.a. Regarding Patient 2, incident investigation documentation reflected that on 01/09/2023 at 1530 “Pt with feces in [their] depends. Possibly for several days ... [Patient’s representative] said that [they] had just talked to [patient] ... [patient] told [them] that [they had] been incontinent and had been lying in [their] own feces for several days. I immediately went down to [their] room to check on [them]. [They] did have feces in [their] depends. [They were] given a shower. RN checked ... to make sure all feces were cleaned up ... Bedding was changed ... Pt reported ... that [they] did not know that [they were] having a bowel movement ...” * The “Harm Level” section reflected “No Detectable Harm” * The “List witnesses and/or others involved including their role” section was blank. * The “Investigation Components” section was followed by seven choices: - “Conducted Interview(s)” - “Discussed with Care Team” - “Discussed with Patient” - “Examined Physical Location” - “Reviewed Policies/Procedures” - “Reviewed Chart” - “Other” Only “Reviewed Chart” was checked. * The “Investigation Findings” section reflected “Please summarize the investigation findings (Who, What, Why, and How the event occurred).” This was followed by only “No progress notes.” * The “Deviation from GAPS (Generally Accepted Performance Standards)” section reflected “Please describe any deviations in practice (GAPS) found during your investigation.” This was followed by “protocol.” * The “Actions” section reflected: - “patient was assessed by the RN and CRN” - “Assisted with ADLs” - “Communicated bowel concerns with MD” The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital’s P&P. For example: * The documentation reflected the patient reportedly had been lying in [their] own feces for several days. However, there was no investigation that reflected BHU staff were interviewed or other follow up investigation to determine when staff had last checked the patient for elimination and hygiene needs. * There was no investigation that considered the patient’s history of laying in feces and urine. Refer to finding 3.c. below. * There was no investigation that reflected the incident was evaluated for compliance with hospital P&Ps as applicable. For example, P&Ps related to elimination and hygiene needs, RN evaluation and supervision, and care planning. * There was no evaluation of potential deviation from GAPS, nor follow-up if deviations had occurred. * There was no investigation that reflected whether abuse and neglect were ruled out. * The only follow up actions were patient-specific and did not address how similar incidents would be prevented for other patients. * There was no documentation of further investigation or follow-up actions. Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for this patient and other patients. 3.b. Review of a log of BHU incidents from 01/01/2023 through 11/17/2023 reflected the incident involving Patient 2 was categorized as “Neglect.” 3.c. The medical record for Patient 2 reflected the patient was admitted to the BHU on 12/24/2022 with diagnoses that included major depressive disorder. The medical record included: * An MSW note dated 12/25/2022 at 1525 reflected “... In the last month, patient has been laying in bed, going to the bathroom, and then continuing to lay in feces and urine for days. Patient reports that [they] can’t control [their] bowel movements ...” * An MD note dated 01/05/2023 at 1218 reflected “Complains of constipation. We will start fiber supplement ...” * Flowsheet documentation dated 01/07/2023 at 0404 reflected “Hygiene ... Level of Assistance ... Declined by patient.” * An RN note dated 01/07/2023 at 0623 included no information about the patient’s elimination or personal hygiene needs. * Flowsheet documentation dated 01/07/2023 at 1208 reflected “Hygiene ... Level of Assistance ... Declined by patient.” * An RN note dated 01/07/2023 at 1807 reflected: “Personal hygiene/ADLs” followed by a blank space. “Compliance with care/meds” followed by a blank space. * Flowsheet documentation dated 01/07/2023 at 2049 reflected “Hygiene ... Level of Assistance ... Declined by patient.” * An RN note dated 01/08/2023 at 0606 reflected “Personal hygiene/ADLs ... Declines; Needs prompting.” * Flowsheet documentation dated 01/08/2023 at 0848 reflected “Disheveled ... Poor hygiene.” * An RN note dated 01/08/2023 at 1735 reflected: “Personal hygiene/ADLs” followed by a blank space. “Compliance with care/meds” followed by a blank space. “... refusing to use urinal ...” * An RN note dated 01/09/2023 at 0622 reflected: “Personal hygiene/ADLs” followed by a blank space. “Shift Note: ... Mostly [isolative] to room ... Expressed no issues voiding.” * Flowsheet documentation dated 01/09/2023 at 1728 reflected “Disheveled ... Poor hygiene.” An RN note dated 01/09/2023 at 1825 reflected “DCN received a phone call from [patient’s representative]. [Patient’s representative] stated that pt told [them] that [they had] been incontinent and [had] been lying in [their] own feces for several days. DCN checked in with pt. [Patient] could not say why [they] had not told staff that [they were] having incontinence or that it had been there. [Patient] was asked to take a shower to clean up. Large amount of solid feces in [their] depends and some on the shower room floor ...” The care plan was generic and lacked individualized, patient-specific goals and interventions based on a comprehensive RN assessment of the patient’s elimination and hygiene needs. Examples included: * Flowsheet care plan documentation dated 12/27/2022 at 1547 reflected “Individualized Care Needs ... need reassurance and prompted for daily self care ...” * Flowsheet care plan documentation dated 01/11/2023 at 1442 reflected “Care Plan Interventions ... Supportive Measures ... active listening utilized; decision-making supported; positive reinforcement provided; self-care encouraged; verbalization of feelings encouraged.” * Flowsheet care plan documentation dated 01/12/2023 at 1424 reflected “Care Plan Interventions ... active listening utilized; decision-making supported; positive reinforcement provided; self-care encouraged; verbalization of feelings encouraged.” * Flowsheet care plan documentation dated 01/26/2023 at 0948 reflected “Care Plan Interventions ... active listening utilized; decision-making supported; goal-setting facilitated; positive reinforcement provided; self-care encouraged; self-reflection promoted; self-responsibility promoted; verbalization of feelings encouraged.” * Additional Care Plan documentation reflected: - “Problem: Constipation” - “Goal: Effective Bowel Elimination” - “Intervention: Promote Effective Bowel Elimination” - “Promote activity and mobility. Establish regular, unhurried time for elimination. Promote privacy and comfort; position to facilitate elimination. Continue home bowel regimen, if possible. Encourage fluid intake and adequate dietary fiber. Evaluate factors that may contribute to constipation (e.g., iron supplement, opiate, pain, fear); anticipate need for stool softener. Monitor stool characteristics, abdominal girth, bowel sounds, expression of symptoms and relief.” The care plan lacked patient-specific, individualized goals and interventions related to the patient’s history of and ongoing incontinence, need for hygiene assistance. The care plan also did not include the patient’s refusal of hygiene and individualized interventions to address this. 3.d. During an interview and review of the incident documentation with the PNM and other hospital leadership on 12/01/2023 at 1445, the PNM confirmed there was no investigation that reflected how long the patient “had been lying in [their] own feces” as reported. 3.e. During an interview and review of the medical record with the ANM and other hospital leadership on 12/01/2023 at 1725, the ANM confirmed the lack of individualized, patient-specific nursing care plan regarding the patient’s elimination and hygiene needs. 4.a. Regarding Patient 3, incident investigation documentation reflected that on 01/28/2023 at 1845 the patient was ambulating in the hallway “when another patient pushed [them], causing [them] to fall and hit [their] head.” * The “Harm Level” section reflected “Initial impression of the extent of harm at the time of the event ... Minimal Harm” * The “List witnesses and/or others involved including their role” section was blank. * The “Investigation Components” section was followed by the same seven choices as the above findings. “Discussed with Care Team” and “Reviewed Chart” were checked. * The “Investigation Findings” section reflected “Please summarize the investigation findings (Who, What, Why, and How the event occurred).” This was followed by “Situation ... [another patient] pushed [Patient 3] in the hallway which resulted in [Patient 3] hitting [their] head on the wall.” * The “Actions” section reflected “Redirect [Patient 3] to [their] room, Vitals stable, Neuro checks WNL, given pain medication, and monitoring.” * The “Recommendations for prevention” section was blank. * The “Deviation from GAPS (Generally Accepted Performance Standards)” section reflected “Please describe any deviations in practice (GAPS) found during your investigation.” This was followed by “n/a.” The “Recommendations” section reflected “Code Grey, locked seclusion for [other patient] ... [other patient] given IM medications ... APS contacted, filed report ... [Patient 3] medicated and assessed: No additional orders submitted for any injuries. Patient c/o HA, but declined any other discomfort ... VS stable, Neuro checks WDL ... [Patient 3] did not want to press any charges ... Current hallways safest for each patient, increasing staff rounding and staff presence in hallways ... Behavioral plans adjusted a [sic] clinically required ...” The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital’s P&Ps. For example: * The documentation was unclear whether the other patient involved in the incident was injured. * There was no investigation that reflected the incident was unavoidable. * There was no investigation that reflected whether abuse or neglect were ruled out. * There was no investigation that reflected the incident was evaluated for compliance with hospital P&Ps, as applicable. Although the documentation reflected “Neuro checks WDL” there was no investigation that reflected whether appropriate P&Ps were followed. For example, implementation of locked seclusion and neuro checks considering Patient 3 fell and hit their head. 4.b. The medical record of Patient 3 reflected the patient was admitted to the BHU on 12/03/2022 at 1215 with a diagnosis of schizoaffective disorder. An RN note dated 01/28/2023 at 1943 reflected “Today at 1845 [Patient 3] was pushed by [another] patient ... causing [Patient 3] to fall. [Patient 3] reported hitting [their] head but denied other concerns ... neuro checks WNL, and [they were] ambulating without difficulties. Given pain medication ...” There was no further assessment of the patient after the fall, including assessment of their head for injuries or ROM. The first RN documentation of a neurological assessment after the incident was 01/28/2023 at 1945, an hour after the incident and it reflected: - “Cognitive/Neuro/Behavioral ... WDL except; orientation” - “Orientation ... disoriented to; situation” Although the neurological assessment suggested the patient’s “orientation” was not within defined limits, and the patient was disoriented to “situation,” there was no RN documentation of a follow up neurological assessment for at least the next 24 hours. The next RN note dated 01/29/2023 at 0057 reflected “Patient was pacing the halls this evening with blunted restricted affect ... took cyclobenzaprine prn neck/shoulder pain/spasms/tightness. Patient is seen walking with hunched over back ...” 4.c. During an interview and review of Patient 3’s medical record with the ANM and other hospital leadership on 12/01/2023 at 1715, the ANM confirmed the lack of RN assessment, including head, neurological, and ROM. 5.a. Regarding Patient 4, incident investigation documentation reflected that on 02/11/2023 at 1915 “When doing the 15 min checks I opened [Patient 4’s] door and [they were] sitting at the bedside holding a sheet that [they] tied a knot into like a noose. I alerted charge RN and other night shift staff. Patent was moved to [seclusion room] and given a safety blanket and a pillow and was asked to remain in [seclusion room] for safety concerns. I removed all personal bedding from [room number] (room where patient is assigned).” * The “Contributing Factors” section reflected “... Other ... hearing voices.” * The “Harm Level” section reflected “Near Miss/Good Catch.” * The “Investigation Components” section was followed by seven choices: - “Conducted Interview(s)” - “Discussed with Care Team” - “Discussed with Patient” - “Examined Physical Location” - “Reviewed Policies/Procedures” - “Reviewed Chart” - “Other” Only “Discussed with Care Team” was checked. * The “Investigation Findings” section reflected “Please summarize the investigation findings (Who, What, Why, and How the event occurred).” This was followed by only “Patient made noose from sheet.” * The “Deviation from GAPS (Generally Accepted Performance Standards)” section reflected “n/a.” * The “Actions” section reflected “Unit suicide interventions were taken: patient moved to a safety room with no linen, and the linen from their room have been replaced. Patient on Q15 monitoring. Safety blanket provided for comfort/warmth. Patient staying in safety room with safety blanket.” There was no documentation of further investigation or follow-up actions. The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital’s P&P. For example: * Although the documentation reflected the patient was observed “sitting at the bedside holding a sheet that [they] tied a knot into like a noose,” there was no investigation that reflected when staff last checked the patient and what the patient was doing at that time including whether they had previously exhibited unsafe activities involving sheets. * There was no investigation that reflected BHU staff were interviewed or other follow up investigation to determine when staff had last checked the patient. * There was no investigation that reflected whether recorded video monitoring was reviewed. * There was no investigation that reflected whether BH shift environmental rounds had been conducted prior to the incident and whether any unsafe items, such as knotted sheets, had been identified in the patient’s room and whether actions had been taken, if any found. * There was no investigation that reflected what the patient’s self-harm and suicide risk were before the incident. * There was no investigation that reflected the incident was evaluated for compliance with hospital P&Ps as applicable. For example, P&Ps related to self-harm and suicide risk including C-SSRS suicide risk level, patient access to bed sheets, observation and monitoring, BH shift environmental rounds; and RN evaluation, supervision, and care planning. * There was no evaluation of potential deviation from GAPS, nor follow-up if deviations had occurred. GAPS documentation reflected only “n/a..” * There was no investigation that reflected whether abuse and neglect were ruled out. * The only follow up actions were patient-specific and did not include an evaluation of possible gaps in P&Ps or staff actions that may have contributed to the incident. Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for this patient and other patients. 5.b. Review of a log of BHU incidents from 01/01/2023 through 11/17/2023 reflected the incident involving Patient 4 was categorized as “Self Harm.” 5.c. The medical record for Patient 4 was reviewed and reflected the patient was admitted to the BHU on 02/10/2023 with diagnoses that included bipolar, psychosis, suicidality, and SI. The medical record included: * An RN note dated 02/11/2023 at 1927 reflected “[Patient] was in [their] room most of the shift, isolative and restrictive ... in a depressed mood and has flat hostile affect ... pt decline [sic] to attend groups, at 1915 pt was having suicidal ideation ... crying and stated ‘I am hearing voices, the voices are telling me to hung [sic] myself’ ...” * The next C-SSRS Suicide Risk Level was documented by the RN on 02/11/2023 at 2200. That documentation reflected “Self Injurious Behavior ... during shift change, patient was observed testing self-harm methods. placed in safety room ...” 5.d. Review of BH shift environmental rounds documentation reflected no documentation that those had been conducted in accordance with hospital P&Ps during the entirety of Patient 4’s BHU hospitalization from 02/10/2023 through 02/14/2023. Refer to Tag A144 that reflects BH shift environmental rounds were to be completed and documented by two staff each shift and were intended to identity unsafe items in the physical environment, including knotted sheets and other items in patient rooms and throughout the BHU. 5.e. During an interview and review of the incident documentation with the QA RN and other hospital leadership on 12/01/2023 at 1245, QA RN confirmed there was no further investigation documentation. 6. Regarding Patient 5, incident investigation documentation reflected that on 05/25/2023 at 1445 “Named patient [Patient 5] went into group without permission and when asked to leave struck another ... patient on the back or back of head with an open hand while leaving group room.” * The “Harm Level” section reflected “No Detectable Harm” * The “Contributing Factors section reflected “Altered Mental Status ... Cognitive Impairment/Dementia” * The “Investigation Components” section was followed by seven items: - “Conducted Interview(s)” - “Discussed with Care Team” - “Discussed with Patient” - “Examined Physical Location” - “Reviewed Policies/Procedures” - “Reviewed Chart” - “Other” Only “Other ... Duplicate event” was checked. * The “Investigation Findings” section reflected “Please summarize the investigation findings (Who, What, Why, and How the event occurred).” This was followed by - “05/30/2023 See linked incident for review and investigation findings.” The section “Submitter’s Actions Taken and Recommendations for Prevention” reflected: - “APS notified @1649 ...” - “Datix” - “Leadership” - “Order for patient to be on 1:1” - “MD increasing medications” - “No groups for patient at this time” - “Offered for patient assaulted to file charges” - “Talked with patient to reinforce unit expectations, Medicated Pt” The section “Recommendations for prevention” reflected: “Keep group room locked when in session” The section “Linked Records ... Linked Event (1)” reflected: “[Patient 6] was sitting participating in group and unprovoked a ... peer struck [Patient 6] in the back of ... head with ... hand. [Patient 6] denies any injury and does not believe the patient meant ... harm ... and believed that [Patient 5] was joking. Staff separated them, [the] peer was medicated and spent time in the room while the team safety planned. APS was notified and the peer was placed on 1:1. [Patient 6] at this point does not want to press charges. [Staff] Reports [they] did a UOR on the peer.” The documentation was unclear and inconsistent. For example: * The incident was reported in two separate incident reports, each with a different incident time. The time of the incident recorded for Patient 6 in Finding 7 was 1500. The time of the incident recorded for Patient 5 was 1445. It was not clear whether an incident occurred at 1445, 1500 or both times. If an incident occurred at 1445 and 1500, it was unclear if actions were taken after the 1445 incident to prevent reoccurrence at 1500. * Investigation findings reflected that Patient 5 “has been presenting with intrusive behaviors ...” This information was not reflected in Patient 5’s incident report but was reflected in the incident report for Patient 6. * There was no investigation that reflected whether abuse and neglect were ruled out. Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for these patients and other patients. 7. Regarding Patient 6, incident investigation documentation reflected that on 05/25/2023 at 1500 “[Patient 6] was sitting participating in group and unprovoked a ... peer struck [Patient 6] in the back of ... head with ... hand. [Patient 6] denies any injury and does not believe the patient meant ... harm ... and believed that [Patient 5] was joking. Staff separated them, [the] peer was medicated and spent time in the room while the team safety planned. APS was notified and the peer was placed on 1:1. [Patient 6] at this point does not want to press charges. [Staff] Reports [they] did a UOR on the peer.” * The “Harm Level” section reflected “Minimal Harm” * The “Investigation Components” section was followed by seven items: - “Conducted Interview(s)” - “Discussed with Care Team” - “Discussed with Patient” - “Examined Physical Location” - “Reviewed Policies/Procedures” - “Reviewed Chart” - “Other” Three of the seven items were checked: “Conducted Interview(s) ... Discussed with Patient ... Reviewed Chart”. * The “Investigation Findings” section reflected “Please summarize the investigation findings (Who, What, Why, and How the event occurred).” This was followed by - “05/26/2023 Situation: [Patient 5] ... assaulted [Patient 6] as [they] were leaving the group room by hitting [Patient 6] on the back of [their] head.” - “Background: [Patient 5] with reported psychiatric history of ... at the time of incident, was on a NMI [mental illness hold] due to altered mental status. Patient has a history of violence prior to admission, throwing objects at others, disrobing ... [Patient 6] ... with reported psychiatric history of ... worsening AH. Patient is voluntary and has been compliant with [care] ... attends groups and is medication compliant, with a violence history, but no presentation of aggressive behaviors towards staff/peers during this admission.” - “Assessment: [Patient 5] has been presenting with intrusive behaviors during this admission ...” - “Recommendations: Placed on official 1:1 ... Psychiatrist increased medications ... Removed from group, and groups withheld until further notice ... APS report filed ... [Patient 6] did not want to press charges ...” * The “Actions” section reflected “05/26/2023 Placed on official 1:1 ... Psychiatrist increased medications ... Removed from group, and groups withheld until further notice ... APS report filed ... [Patient 6] did not want to press charges ... Datix submitted” The documentation was unclear, and the investigation did not address specific findings or behavioral concerns on the part of Patient 6 which may have contributed to this incident. For example: * Investigation findings reflected that Patient 5 “has been presenting with intrusive behaviors ...” The investigation does not verify whether any previous interactions had occurred between Patient 5 and Patient 6 which may have contributed to the incident. * The follow up actions reflected “Placed on official 1:1 ... Psychiatrist increased medications ... Removed from group, and groups withheld until further notice ...” reflected actions that were taken for Patient 5. However, there were no actions taken for Patient 6 and it was unclear whether any actions were needed. It was additionally unclear what “official 1:1” meant. It was unclear whether the patient was on unofficial 1:1 or other monitoring prior to the incident. * The documentation was patient-specific and lacked investigation that reflected the incident was evaluated for compliance against applicable P&Ps. For example, policies related to observations, monitoring and supervision. * There was no investigation that reflected whether abuse and neglect were ruled out. Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for these patients and other patients. 8.a. Regarding Patient 7, incident investigation documentation reflected that on 05/30/2023 at 1830 “Pt. was secluded at 1745 for aggression at time of admission. Shortly after [they were] observed punching ceiling in seclusion room. [Patient] had then concealed a safety screw that [they] had dislodged from ceiling around light fixture and proceeded to scratch both security cameras to completely obstruct view. As pt. admitted with active suicidal ideation and hx of assault it was determined that the screw needed to be removed from the pt. ASAP.” * The “Harm Level” section reflected “Initial impression of the extent of harm at the time of the event ... No Detectable Harm.” * The “Investigation Components” section was followed by seven items: - “Conducted Interview(s)” - “Discussed with Care Team” - “Discussed with Patient” - “Examined Physical Location” - “Reviewed Policies/Procedures” - “Reviewed Chart” - “Other” All items were checked except “Discussed with Patient.” * The “Investigation Findings” section reflected “Please summarize the investigation findings (Who, What, Why, and How the event occurred).” This was followed by: - “Video Footage review showed no self harm with the screw retrieved from the ceiling.” - “Violent BH patient recently transferred from [ED] to [BHU seclusion room], hit the ceiling of [BHU seclusion room] with [their] head, and a 1-inch sheet metal screw popped out of the ceiling onto the floor, and patient used the screw to etch the domes of both room cameras. After patient complied and dropped the screw onto the floor, Security breeched the room, and gained control of the patient.” - “While the patient was secluded [they] ... also kicked at the door and the observation window ... Code Gray was called ... many Security Officers [were] present ... a plan was developed ... I requested permission from the 5L Charge RN to bring a Taser onto the floor, in the event it became necessary to assist the patient in releasing the screw to prevent injury to officers ... Charge RN [name] gave the go ahead on the Taser ... After about 15 minutes of communication with the patient through the door, [they] finally released the screw ...” - “Recommendation ... Engineering assesses the secure rooms for safety and tightness of all screws ... 5L Clinical staff to call for a PCG on all cares with this patient.” * The “Deviation from GAPS (Generally Accepted Performance Standards)” section was blank. * The “Actions” section reflected “Submitted work order to replace screws in safety room, and assure all other screws are secured ... Submitted work order to assure all screws are safety behavioral health screws. Changed rooms for the patient to a different safety room. Debrief to occur regarding the presence of taser during a locked seclusion. The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital’s P&P. For example: * The documentation reflected video was reviewed and there was “no self harm with the screw retrieved from the ceiling.” The initial impression was that the patient experienced no detectable harm. However, there was no documentation that included whether the patient was assessed for harm subsequent to the initial impression with consideration that they repeatedly struck the the door, observation window and ceiling, including with their head. * The documentation was not clear whether the taser was used on the patient. * The documentation reflected “Engineering assesses the secure rooms for safety and tightness of all screws.” However, there was no investigation that reflected when that was last done. * The documentation reflected “Submitted work order to assure all screws are safety behavioral health screws.” It was not clear if the screw the patient accessed from the ceiling was a “safety behavioral health screw.” * There was no documentation of the outcome of the debrief that was planned regarding the “presence of a taser during a locked seclusion.” * There was no evaluation of potential deviation from GAPS, nor follow-up if deviations had occurred. * There was no investigation that reflected the incident was evaluated for compliance with hospital P&Ps, as applicable. For example, P&Ps related to tasers, BH shift environmental rounds, and maintenance of the physical environment. * The only follow up actions were patient-specific and did not include an evaluation of possible staff actions or gaps in P&Ps that may have contributed to the incident. Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for this patient and other patients. 8.b. Review of a log of BHU incidents from 01/01/2023 through 11/17/2023 reflected the incident involving Patient 7 was categorized as “Self Harm.” 8.c. The medical record for Patient 7 was reviewed and reflected the patient was admitted to the BHU on 05/30/2023 with diagnoses that included history of schizoaffective disorder, SI, anxiety, complaint of hitting head, and recent methamphetamine use. The medical record included: * An RN note dated 05/30/2023 at 2253 reflected: - The patient was placed in seclusion on 05/30/2023 at 1744 and “... pacing ... pounding on walls and jumped up on the bed ... Appeared to be looking around the room for something. Shortly after, [they were] standing on the bed and began rubbing something on the camera. Given verbal warning to stop ... Upon closer look, it was noted that [they] had obtained a screw and was scratching the camera lense [sic]. Code Grey initiated. Continued to make verbal threats and refused to drop the screw. Code silver initiated.” The medical record contained no documentation regarding a taser. The patient was discharged on 06/05/2023. 8.d. Review of BH shift environmental rounds documentation reflected no documentation that those had been conducted in accordance with hospital P&Ps during the entirety of Patient 7’s BHU hospitalization from 05/30/2023 through 06/05/2023. 9. Regarding Patient 8, incident investigation documentation reflected that on 07/07/2023 at 1740 “During group [Patient 8] welcomed a peer to the group and grabbed peer by the head and gave [them] a kiss on the cheek.” * “Event Category” reflected “Sexual Contact Between Patients” * The “Harm Level” section reflected “No Detectable Harm”. * The “Contributing Factors section reflected “Cognitive Impairment/Dementia” * The “Other People Involved” section reflected “List witnesses and/or others involved including their role ... List names and how involved” and included the name of one person. * The “Investigation Components” section was followed by seven items: - “Conducted Interview(s)” - “Discussed with Care Team” - “Discussed with Patient” - “Examined Physical Location” - “Reviewed Policies/Procedures” - “Reviewed Chart” - “Other” Items checked included “Conducted Interview(s) ... Discussed with Care Team ... Reviewed Chart ...” * The “Investigation Findings” section reflected “Please summarize the investigation findings (Who, What, Why, and How the event occurred).” This was followed by: - “09/07/2023 ... Most recent note re: patient [8] ... Admit not completed today and remainder will be passed in RN to RN including decision to place a risk for violence flag, personalized careplanning [sic] any [sic] anything remaining on the nursing admit tab. Cooperative with admit. Poor memory, poor understanding. Frequently re-oriented. On arrival told not to visit in [their] room with any patient, talk to each other in the common areas. Per therapist ... [Patient 8] kissed a ... peer on the cheek in group. Soon after that, before I knew we watched patient walking down the hall with the is [sic] peer and entered ... room together. I followed immediately, [Patient 8] had gone into the restroom and the peer was standing in the space. Both were fully clothed and not thought to have touched in there. They were redirected and then the team learned about the physical contact ... contacted mental health APS and left the information requested charge RN ... and house supervisor ... Notified ...” - “Emailed caregivers for additional information and actions taken.” * The section “Submitter’s Actions Taken and Recommendations for Prevention” reflected: - “08/15/2023 ... This MHP reflected rules for safety on the unit which includes not touching each other.” - “Recommendations for prevention” reflected: “This MHP will state rules clearly at the beginning of each group as a reminder.” * The section “Deviation from GAPS (Generally Accepted Performance Standards)” reflected “Please describe any deviations in practice (GAPS) found during your investigation” and noted: - “none” * Under “Actions Please describe any actions taken” was noted - “Separate Halls ... APS called, filed report ... Updated behavioral plan” The documentation lacked a clear, complete and thorough investigation to determine whether this behavior had been addressed in a timely fashion. For example: * The incident report was dated “07/07/2023” and the follow up notes were dated “08/15/2023” and “09/07/2023”. It was unclear whether the “08/15/2023” note reflects current “rules for safety” or whether those rules were reinforced with Patient 8 at the time of the incident. * The note dated “09/07/2023” reflected actions which occurred approximately 2 months prior, and it was unclear whether Patient 8 kissing other patients or inviting other patients into their room was isolated to the time of the incident or whether it continued to be a concern. * It was unclear whether the “witness” listed was a staff member or a patient. * There was no investigation as to whether the other patient suffered any psychological harm from the incident. * There was no investigation which reflects whether recorded video monitoring was reviewed. * There was no investigation that reflected whether abuse or neglect was ruled out. Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for these patients and other patients. 10. Regarding Patient 9, incident investigation documentation reflected that on 07/11/2023 at 1808 “Heard yell for help. [Patient 9] was hitting peer and another peer was attempting to pull [Patient 9] away from situation. Staff intervened and escorted pt to seclusion area, pt was cooperative with walking. When at seclusion room pt refused to go in and started to hit/kick and scratch at staff. Code grey was called (had been attempted while walking with vocera with no luck). Pt with nursing staff was able to be seated on bed in seclusion and staff was able to get out of room to lock door.” * The “Contributing Factors” section reflected “Altered Mental Status” * The “Harm Level” section reflected “Moderate Harm” * The “Investigation Components” section was followed by seven items: - “Conducted Interview(s)” - “Discussed with Care Team” - “Discussed with Patient” - “Examined Physical Location” - “Reviewed Policies/Procedures” - “Reviewed Chart” - “Other” The only two items checked were “Discussed with Care Team” and “Reviewed Chart” * The “Investigation Findings” section reflected “Please summarize the investigation findings (Who, What, Why, and How the event occurred).” This was followed by: - Documentation recorded by Charge RN on 07/15/2023 reflected “Report from hand off.” - Documentation recorded by ANM on 09/07/2023 reflected “A new admission to the department, did not show any previous actions to warrant an expectation of assault.” * The section “Submitter’s Actions Taken and Recommendations for Prevention” reflected “Pt unpredictable, pt attacked peer with no precipitating factors” * The section: “Deviation from GAPS” reflected “None. new [sic] admit, unpredictable.” * The “Actions” section reflected “Code Grey initiated ... Seclusion/Restraint ... IM Medications ... Updated behavioral plan ... APS contacted, report filed ... No physical injuries noted” The documentation lacked a clear, complete and thorough investigation to determine whether this incident had been addressed in a timely fashion and whether precipitating events had been investigated. For example: * The incident report was dated “07/11/2023” and the ANM follow up notes were dated “09/07/2023”. The notes reflected actions which occurred approximately 2 months prior, and it was unclear how it was determined that “no precipitating factors” were present when no interviews were conducted, and the incident was not discussed with the patient(s) at the time of the incident. * There was no investigation which reflected whether recorded video monitoring was reviewed. * There was no investigation which reflected whether the assaulted patient had been assessed for injuries or how it was determined harm was “moderate.” There was no description of “moderate” harm including whether blood was present as a result of the attack, whether potential bloodborne pathogen exposure was a concern, and if so, whether follow-up was warranted for either patient. * There was no investigation which reflected whether the other peer who was “attempting to pull [Patient 9] away from situation” suffered any injuries. * There was no investigation that reflected whether the malfunctioning “vocera” had been reported, replaced or whether further follow up was needed. 11.a. Regarding Patient 10, incident investigation documentation reflected that on 08/03/2023 “During 15 minute checks at 2140, pt was found with a blanket around their neck, appearing unresponsive in their bathroom. Pt had a pulse with stable respirations. Staff was able to arouse pt, with slightly elevated vitals. Pt was alert and oriented. On-call MD was notified. Pt was cooperative walking down to an unlocked safety room and spending the night there. Staff removed patients [sic] glasses because of self harm concerns. Pt stated they are still feeling suicidal and would not commit to safe behaviors. While being monitored pt was seen self harming with a fork they had in their scrubs. Staff removed fork from patient. Pt continued to refuse PO medication. Pt was tearful in the safety room and later began hitting themselves in the head with their palms. Pt would not agree to stop harming themselves. Staff approached pt with security presence, offered PO medication, pt refused and was given PRN injection 10mg Zyprexa. Pt was cooperative with IM administration with no hands on. Pt appeared to go to sleep shortly after medication.” * The “Contributing Factors” section was blank. * The “Harm Level” section reflected “Initial impression of the extent of harm at the time of the event ... Minimal harm.” * The “Investigation Components” section was followed by seven items: - “Conducted Interview(s)” - “Discussed with Care Team” - “Discussed with Patient” - “Examined Physical Location” - “Reviewed Policies/Procedures” - “Reviewed Chart” - “Other” The only item checked was “Discussed with Care Team.” * The “Submitter’s Actions Taken” section reflected “Pt moved to safety room, all items that patient could self harm with or commit suicide with removed. Pt given medication” * The “Recommendations for Prevention” section was blank. * The “Deviation from GAPS (Generally Accepted Performance Standards)” section reflected “none.” * The “Actions” section reflected: - “Pt assessed - no injury reported” - “Placed in an unlocked safety room for overall safety” - “IM medications administered” - “MD notified” - “Behavioral Plan updated” - “Removed glasses to avoid further self injurious behaviors” - “Proper steps followed for increased suicidal behavior/presentation” There was no further investigation documentation. The documentation lacked a clear, complete and thorough investigation and follow up actions in accordance with the hospital’s P&P. For example: * It was unclear what time the incident occurred as the RN note and incident report reflected it occurred at 2140, but the MD note in finding 11.b. reflected the same or a similar incident occurred at “130.” * There was no investigation that reflected when the patient was last checked before the incident and whether they were exhibiting any unsafe behaviors at that time. * There was no investigation that reflected how tight the blanket was around the patient’s neck nor whether it was attached to a ligature point. It was unclear whether the blanket was around the patient’s head, neck or both. It was additionally unclear whether a blanket or sheet was used as an OT note in finding 11.b. indicated a sheet was used. * The documentation reflected the patient was self harming with a fork while in a safe room. However, there was no investigation that reflected a description of the fork, including whether it was permitted on the BHU, or whether the patient’s care plan allowed them possession of a fork considering their history of self harming. * There was no investigation that reflected how the patient was able to access a fork when they should have been checked for unsafe items before going into the safe room in accordance with the hospital’s stated practice in finding 11.e. * The documentation reflected the patient had “minimal harm” and “no injury reported.” It was unclear whether the patient was injured including extent of injuries. * There was no investigation that reflected the incident was evaluated for compliance with hospital P&Ps, as applicable. Although the documentation reflected “Proper steps followed for increased suicidal behavior/presentation,” there was no investigation that reflected whether appropriate P&Ps were followed leading up to the incident. For example, checking patients for unsafe items, BH shift environmental rounds, observation and supervision. * There was no investigation that reflected whether abuse and neglect were ruled out. * The only follow up actions were patient-specific and did not include an evaluation of possible gaps in P&Ps or staff actions that may have contributed to the incident. Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for this patient and other patients. 11.b. The medical record for Patient 10 was reviewed and reflected the patient was admitted to the BHU on 07/29/2023 with a diagnosis of depression. The medical record included: * An MD note dated 07/31/2023 at 0822 reflected “Patient ... admitted yesterday to the unit for suicide goal ideation and self-harm.” * An MD note dated 08/02/2023 at 0809 reflected “Today seen in room, depressed despondent withdrawn. States they feel more suicidal ...” * Flowsheet documentation dated 08/02/2023 at 1659 reflected “patient still with SI and thoughts of self harm, scratching self on wrist with nails.” * An MD note dated 08/03/2023 at 1155 reflected “ ... endorses worsening depression and ongoing suicidal ideation. They are barely able to safety plan ... They report they do not really care about life. They report they have been scratching and cutting on themselves and not telling anybody about it ...” * An RN note dated 08/04/2023 at 0141 reflected “During 15 minute checks [08/03/2023] at 2140, pt was found with a blanket around their neck, appearing unresponsive in their bathroom. Pt had a pulse with stable respirations. Staff was able to arouse pt, with slightly elevated vitals. Pt was alert and oriented. On-call MD was notified. Pt was cooperative walking down to an unlocked safety room and spending the night there. Staff removed patients [sic] glasses because of self harm concerns. Pt stated they are still feeling suicidal and would not commit to safe behaviors. While being monitored pt was seen self harming with a fork they had in their scrubs ...” There was no RN documentation that described how tight the blanket was around the patient’s neck nor whether it was attached to a ligature point. There was no documentation that reflected the RN assessed the patient’s neck after they were found. There was no RN documentation that reflected how long the patient “appeared unresponsive.” There was no documentation that reflected where on the patient’s body they were “self harming with a fork” and no documentation that reflected the RN assessed the patient for injuries related to their self harming. * MD notes dated 08/04/2023 at 0857 reflected “... Patient was found in room at about 130 this morning with a blanket wrapped around [their] head and was generally unresponsive ...” * An OT note dated 08/04/2023 at 1157 reflected “Significant Event Review ... Pt attempted to strangle self by wrapping a sheet around [their] neck ...” * An RN note dated 08/05/2023 at 1812 reflected “Shift Note ... endorses thoughts of harming self and dying. They feel safer sitting in the dayroom around other people ... attended one full group and left early in another due to anxiety and feeling overwhelmed ... admitted to scratching their wrists superficially.” * A DO note dated 08/07/2023 at 0928 reflected “... is using the safety blanket as tried to use [regular] blankets to hang self last week ...” The patient was discharged on 08/17/2023. 11.c. Review of a log of BHU incidents from 01/01/2023 through 11/17/2023 reflected the incident involving Patient 10 on 08/03/2023 was categorized as “Self Harm.” There was no incident or investigation documentation on the log regarding the RN note dated 08/02/2023 that reflected the patient was self harming with their fingernails nor the MD note dated 08/03/2023 that reflected the patient had been self harming and not telling anyone. 11.d. Review of BH shift environmental rounds documentation reflected no documentation that BH shift environmental rounds had been conducted in accordance with hospital P&Ps during the entirety of Patient 10’s BHU hospitalization from 07/29/2023 through 08/17/2023. 11.e. During an interview and review of the incident documentation with the QA RN, PNM, ANM and other hospital leadership on 12/01/2023 at 1305, the following information was provided: * The QA RN confirmed the lack of investigation documentation. * The ANM stated patients were to be searched for contraband prior to being placed in a safety/seclusion room. 11.f. During an interview and review of Patient 10’s medical record with the ANM and other hospital leadership on 12/01/2023 at 1635, the ADM confirmed the lack of RN assessment. 12. Regarding Patient 11, incident investigation documentation reflected that on 08/10/2023 at 1930 “Approximately at 1930 [Patient 14] reported that [Patient 11] kissed [them]. It was unwitnessed but [Patient 11] confessed that [they] really did kissed [Patient 14]. RN explained that they need to maintain a safe distance with each other [sic] both pt verbalized understanding and follow [sic] redirection. No ... other physical contact observed. [Patient 14] stated ‘I feel okay though I just felt that I need to tell you about what happened’. CRN made aware. Will continue to monitor “ * The “Harm Level” section reflected “No Detectable Harm” * The “Investigation Components” section was followed by seven items: - “Conducted Interview(s)” - “Discussed with Care Team” - “Discussed with Patient” - “Examined Physical Location” - “Reviewed Policies/Procedures” - “Reviewed Chart” - “Other” Items checked included, “- “Discussed with Care Team ... Discussed with Patient ... Reviewed Chart” * The “Investigation Findings” section reflected “Please summarize the investigation findings (Who, What, Why, and How the event occurred).” This was followed by - “08/11/2023 Situation: [Patient 11] kissed ... [Patient 14] around 1930 on 8/10/23. - Background: [Patient 11] ... admitted with a hx of paranoid schizophrenia, violence, and agitation r/t medication non-compliance. Pt has not [sic] previous history of peer physical contact while in inpatient admission ... [Patient 14] ... admitted with dx of bipolar disorder, PTSD, dissociative identity disorder, manic behaviors, and psychosis. [Patient 14] has not presented with any unsafe behavior during [their] admission ... Presentation on the unit is labile, disorganized, and occasional delusions. [Patient 14] reports that [they have] known this patient for a long period of time and that [Patient 11] needed some hygiene products. [Patient 14] reported that [they] retrieved these items for [Patient 11], and when [they] returned them, [Patient 11] leaned in a [sic] kissed [Patient 14]. [Patient 11] backed away right away and [Patient 14] told [Patient 11] to never do that again. It is unconfirmed as to [Patient 14’s] previous hx of relationships [sic] with [Patient 11]. When [Patient 14] was asked about pressing charges [Patient 14] stated, ‘Oh no, we know each other for a long time, [Patient 11] is very nice. Don’t want [Patient 11] to get into trouble’.” - “Assessment: There does not appear to be any history of presented behavior from [Patient 11] during ... admission, and this situation appears to be an outlier.” - “Recommendations: APS report filed Pt room [sic] are now in opposite hallways Adjusted behavioral plan for both pts [to] avoid the other hallway No charges being pressed: [Patient 14] request” * The section “Submitter’s Actions Taken and Recommendations for Prevention” reflected: - “Approximately at 1930 [Patient 14] reported that [Patient 11] kissed [them]. It was unwitnessed but [Patient 11] confessed that [they] really did kissed [Patient 14]. RN explained that they need to maintain a safe distance with each other [sic] both pt verbalized understanding and follow [sic] redirection. No ... other physical contact observed. [Patient 14] stated ‘I feel okay though I just felt that I need to tell you about what happened’. CRN made aware. Will continue to monitor” * The section “Deviation from GAPS” reflected: - “None.” * The section “Action” reflected: - “See investigation findings” The documentation lacked a clear, complete and thorough investigation. For example: * The documentation reflected Patient 11 retrieved hygiene products for Patient 14. There was no investigation that reflected where Patient 11 got the hygiene products. There was no documentation that reflected what the hygiene products consisted of and whether they were permitted items on the BHU. There was no investigation which reflected whether the distribution of “hygiene products” between patients violated any unit P&Ps or protocols, and if so, whether both patients had been informed of those prior to or after this incident. * The investigation did not include any further details regarding the kiss, including where on Patient 14’s body they were kissed, how long, and whether there was an exchange of bodily fluids. * There was no investigation that reflected whether recorded video monitoring was reviewed. * There was no investigation that reflected whether abuse or neglect were ruled out for either patient. Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for these patients and other patients. 13. Regarding Patient 12, incident investigation documentation reflected that on 09/08/2023 at 1500 “Pt stood up in group and spit on peer. Both peers were split up by staff and pt was escorted to safety room.” * The “Contributing Factors” section contained no notations. * The “Harm Level” section reflected “Moderate Harm” * The section “Other People Involved ... List witnesses and/or others involved including their role ...” reflected “Pt spit on peer ...” * The “Investigation Components” section was followed by seven items: - “Conducted Interview(s)” - “Discussed with Care Team” - “Discussed with Patient” - “Examined Physical Location” - “Reviewed Policies/Procedures” - “Reviewed Chart” - “Other” The only item checked was “Discussed with Care Team”. * The “Description” section reflected “Pt stood up in group and spit on peer. Both peers were split up by staff and pt was escorted to safety room.” * The “Investigation Findings” section reflected “Please summarize the investigation findings (Who, What, Why, and How the event occurred).” This was followed by “09/13/2023 Unprovoked assault. APS notified.” * The section “Submitter’s Actions Taken and Recommendations for Prevention” reflected “Pts room moved to other hallway and pt in that hallway only. PRNs given. Pts both talked to - de escalated [sic] and debriefed” * The section “Recommendations for prevention” reflected “Group instructors to be informed of pts behaviors and hx between pts” * The section “Deviation from GAPS” reflected “none” * The section “Action” reflected “ [Patient 12] was moved to 5E hall ...” The documentation lacked a clear, complete and thorough investigation. For example: * The investigation failed to state where spittle landed on the other patient; whether it made contact with intact skin, on mucous membranes or conjunctiva. * There was no investigation that reflected whether witnesses were present and interviewed. * The documentation reflected “Pt stood up in group and spit on peer. Both peers were split up by staff ...” There was no investigation that reflected whether these two patients had experienced prior altercations. It was not clear how long it took staff to intervene and separate the patients. * The documentation reflected “Moderate Harm.” However, it was not clear what that consisted of as there was no further description aside from “Pt spit on peer.” * The documentation reflected both patients “were talked to.” However, it was not clear if those discussions included investigation information, and if so, what was discussed. * The “Recommendations for prevention” reflected “Group instructors to be informed of pts behaviors and hx between pts.” It was not clear how this would prevent recurrence. * There was no investigation that reflected whether abuse or neglect were ruled out. Due to the lack of thorough investigation and follow-up actions, there was no assurance similar incidents would be prevented for these patients and other patients. 44104”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2)(vii) [The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following:] (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. This Standard is not met as evidenced by: 29708 Based on interview, review of staff training/education records for 8 of 8 BHU employees (Employees 1, 2, 3, 4, 5, 6, 7 and 8), review of staff education/training materials, and review of other documentation, it was determined that the hospital failed to ensure patients’ rights were recognized, protected and promoted as follows: * Staff were not trained and did not demonstrate competency in the use of first aid techniques that may be needed during patient restraint and seclusion. Findings include: 1. Staff orientation and annual training materials provided were reviewed and did not include staff training and competencies that addressed restraint related first aid techniques. Examples included: * The “Providence Health & Services PMAB Practical Learning Curriculum” hands on skills training dated “Revised 09_2022” was reviewed and reflected no information regarding restraint related first aid techniques training and competencies. * Review of the MHA “Seclusion & Restraint (SR) Checklist” dated “Revised 11/10/2021” included no information regarding restraint related first aid techniques training and competencies. * Review of MHA orientation training materials included a document titled “Thinking Critically About Restraints,” dated “August 2019.” It reflected “Risks associated with restraint use ... death from strangulation, asphyxiation, or trauma ... increased risk for falls ... bruising, swelling, redness, skin tears, scrapes ...” The document did not include information regarding restraint related first aid techniques training and competencies. 2. Review of staff education/training records with the ND, HRG and other hospital staff on 12/06/2023 beginning at 1340 reflected they contained no staff training and competencies for first aid techniques related to patients who were restrained or secluded, including appropriate first aid required if a restrained or secluded patient was in distress or injured for the following employees: Employee 1, MHA with hire date 02/10/2014 Employee 2, MHA with hire date 12/06/1994 Employee 3, CNA/MHA with hire date 12/02/2019 Employee 4, RN with hire date 06/10/2019 Employee 5, MHA with hire date 03/21/2022 Employee 6, RN with hire date 03/13/2023 Employee 7, RN with hire date 03/28/2022 Employee 8, RN with hire date 03/27/2023 3. During an interview with the ANM on 12/06/2023 at the time of the staff education/training records review in finding 2, the ANM stated Employees 1, 2, 3, 4, 5, 6, 7 and 8 participated in restraint and seclusion activities. 4. In an email from EDO dated 12/20/2023 at 1227, they confirmed the lack of employee first aid training in findings 1 and 2.”

“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: 29708 Based on interview, medical record and incident documentation for 4 of 4 patients admitted to the inpatient BHU reviewed for provision of nursing services (Patients 3, 4, 10 and 13), review of environmental rounds documentation, review of P&Ps, and review of other documentation, it was determined that the hospital failed to ensure the RN supervised and evaluated patients to ensure the provision of safe and appropriate care in accordance with hospital policies and procedures including: * Regarding Patient 13, the hospital failed to ensure the RN evaluated and supervised the patient’s care. The patient, who was at risk for suicide and experiencing increased suicide statements, accessed a sheet and used it to commit suicide by asphyxiation. In addition, the hospital failed to ensure the RN notified the charge nurse and physician regarding Patient 13’s increased suicidal statements. * Regarding Patient 10, the hospital failed to ensure the RN assessed the patient for injuries after the patient was found with a sheet or blanket around their neck and self harming with a fork. * Patient 4, who was admitted with SI and was isolating in their room, was found holding a sheet knotted into a noose, and the hospital failed to ensure the RN assigned and ensured environmental rounds, intended to identify unsafe items, were completed. * Regarding Patient 3, the hospital failed to ensure the RN evaluated the patient for injuries after they fell and hit their head, including head and neurological assessment. * Environmental rounds were not completed and documented in accordance with hospital P&Ps. * CARES rounds were not complete and documented in accordance with hospital P&Ps. Findings include: 1. Refer to the findings cited at Tag A144 regarding the hospital’s failure to ensure the RN evaluated, supervised and prevented a patient from using a bed sheet to commit suicide by asphyxiation; and failure to ensure the RN notified the charge nurse and physician related to the patient’s increased suicidal statements. 2. Refer to the findings cited at Tag A145 regarding the hospital’s failure to ensure the RN evaluated patients after they engaged in self harm behaviors. 3. Refer to the findings cited at Tag A145 regarding the hospital’s failure to ensure the RN appropriately evaluated patients after they fell. 4. Refer to the findings cited at Tags A144 and A145 regarding the hospital’s failure to ensure RN assigned and ensured environmental rounds and CARES rounds were complete and documented in accordance with hospital P&Ps.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. The nursing care plan may be part of an interdisciplinary care plan This Standard is not met as evidenced by: 29708 Based on interview, medical record and incident documentation for 2 of 2 patients reviewed for nursing care plan development (Patients 2 and 13), it was determined the hospital failed to ensure the RN developed and kept current a nursing care plan based on an assessment of the patient’s individualized needs related to bowel incontinence and suicide risk. Findings include: 1. Refer to Tag A144 related to the hospital’s failure to ensure the RN developed and kept current Patient 2’s care plan related to the patient’s bowel incontinence. 2. Refer to Tag A144 related to the hospital’s failure to ensure the RN developed and kept current Patient 13’s care plan related to the patient’s suicide risk. 3. The P&P titled “Adult and Pediatric Psychiatry Universal Assessment, Care Planning, and Discharge” dated last revised “12/2017” reflected: * The nursing care shall be the responsibility of a registered nurse (RN).” * “Plan of Care: ... Document goal outcome summary that evaluates the patient’s progress toward goals once a shift ... with significant change in condition ... Update the CPG, goals, and interventions so they reflect the patient’s current condition and needs.” * “Assess the C-SSRS Screening each shift or on assumption of care and make changes to precaution levels and individualized plan of care as appropriate.””

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 29708 44104 Based on observations, interviews, review of recorded video monitoring, review of live video surveillance, review of medical record documentation for 4 of 6 patients who received inpatient BHU services (Patients 4, 7, 10 and 13), review of incident documentation for 4 of 14 patients involved in incidents on the inpatient BHU (Patients 4, 7, 10 and 13), review of staff training/education materials, review of environmental rounds documentation, review of physical environment risk documentation, review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to fully develop and implement P&Ps to ensure patients received care in a safe physical environment as follows: * The hospital failed to ensure patients on the inpatient BHU were provided care in a safe, physical environment that was free of ligature risks, and unsafe items, and areas. Environmental risks had not been identified and/or mitigated and created the risk for self-harm. Those included but were not limited to gaps inside closets, holes in underside of bathroom sinks, entry doors to patient rooms, wall mounted cameras, unsecured platform beds, and patient bathroom door (hinges). * Patient 13, admitted to the inpatient BHU with suicidal ideation, draped a bed sheet over the door between their room and hallway, and used it to asphyxiate themselves and died. Those conditions resulted in actual harm for Patient 13 and risk for serious harm or death to other patients including but not limited to access to ligature risks. These findings were determined to represent an IJ situation. Refer to Tag A000 at the beginning of this SOD report for the details of the IJ identification, notification, removal plan approval, and verification of removal. Findings include: Regarding BHU P&Ps: 1.a. The policy titled “Use of Routine & Special Observation for Patient Safety” dated last approved “05/2023” was reviewed and reflected: * Under “General Requirements”, 3.d. was written, “Staff assigned responsibility for conducting routine or special observations are to ... Routinely assess environment for potential risk factors impacting safety ...” * Under “General Requirements”, 4. was written, “Staff assigned routine or special observations are responsible for the complete documentation of each check. Q15 safety checks will be documented on ‘Patient Safety Check’ Log. Constant Observation (1:1) will be documented on the ‘Constant Observation Log’ form. All entries must reflect accurate time, location of patient, and staff initials.” * Under “E. Quality Monitoring” was written, “Charge nurses will have the responsibility to ensure that systems are in place to facilitate compliance to this policy. Periodic visual inspection of staff performance and documentation will be conducted during worked shifts ... Audits of required documentation and staff implementation of Observation practices will be conducted as needed, but at a minimum of twice per year ... Nurse Manager will ensure that the responsibilities and duties associated with this policy, process for observation at different levels, training needs and record keeping are maintained ... Q15 safety logs are part of the medical record ... Patient specific behavioral health observation logs will be scanned into the patient chart upon discharge.” The policy lacked a description of where the routine BH Shift Environmental Rounds, conducted twice daily, were to be documented. The policy lacked a plan to monitor and ensure that routine BH Shift Environmental Rounds were conducted in accordance with unit practice and expectations. 1.b. The policy titled “Searches of Patient Belongings Environment,” dated last approved “10/21” was reviewed and reflected: * Under “Definitions ... Routine ...” was written, “Routine searches include assessments of the environment for safety hazards and identification of unsafe items potentially brought onto unit.” The policy lacked guidance on when or how often to conduct routine BH Shift Environmental Rounds rounds in accordance with unit practice and expectations. 1.c. The policy titled “Adult and Pediatric Psychiatry Universal Assessment, Care Planning, and Discharge” dated last approved “03/2023” was reviewed and reflected: * Under “On Assumption of Care” was written, “Ensure environmental safety. (See addendum A) ... Perform and document purposeful rounds to ensure patient safety is maintained. (See addendum H).” * Under “Other Safety and Essential Interventions” was written, “Cares Rounding designed for inpatient adult psychiatry is available in Addendum H.” Refer to Tag A144 regarding “Purposeful Rounding” and CARES rounding. 1.d. An undated document titled “Standard Work Document ... OPH IP BH Day Charge RN Workflow” Version 1.0 was reviewed and reflected: * Under “Standard Work Overview ... Desired Outcome 100% compliance” * Under “Standard Work Steps ... Start of Shift ... Update current assignment sheet ... Notes ... Ensure that Environmental Rounds are assigned ... Check with MHA’s [sic] to be sure they have the resources to perform their duties” 1.e. An undated document titled “Standard Work Document ... OPH IP BH Evening Charge RN Workflow” Version 1.0 was reviewed and reflected: * Under “Standard Work Overview ... Desired Outcome 100% compliance” * Under “Standard Work Steps ...Start of Shift ... Update current assignment sheet ... Notes ... Ensure that Environmental Rounds are assigned ... Check with MHA’s [sic] to be sure they have the resources to perform their duties” 1.f. An undated document titled “Standard Work Document ... OPH IP BH MHA NOC SW” Version 1.0 was reviewed and reflected: * The document listed “Standard Work Steps” that included but was not limited to the following MHA duties: “Milieu Management ... Conduct Q15 minute safety checks ... Participate in 1:1 observation care ... Assist with de-escalating agitated and combative patients ... Clean showers ... Observe mealtime ... Answer patient call lights ...” The document did not list routine BH Shift Environmental Rounds rounds as one of the “Standard Work Steps”. 1.g. An undated document titled “Standard Work Document ... OPH IP BH Safety Guidelines_Inpatient Behavioral Health Units SW” was reviewed and reflected: * Under “Standard Work Steps” was written, “Patient Rounding When making rounds for patient monitoring, actively assess physical environments for all potential hazards and risks ... (Reference Policy ... Use of Routine & Special Observations for Patient Safety)”. The document did not specifically address routine BH Shift Environmental Rounds. Regarding BHU physical environment risk assessment: 2. The following documents were provided in response to a request for the hospital’s BHU environmental risk assessment and mitigation strategies: * “PPMC_Mental Health Environment of Care Checklist_5thfloor 08.24” which had been conducted prior to the incident involving Patient 13 which occurred on 11/17/2023, and * “PPMC_Mental Health Environment of Care Checklist_5thfloor 11.22.2023” which had been conducted after the 11/17/2023 incident involving Patient 13. Potential risks which were not included on the hospital’s Environmental Risk Assessment tools, or which were not mitigated at the time of the survey are noted in finding 3.a. below. 3.a. Tours and direct observations of the BHU were conducted with the ANM, EDO and DA/R on 11/28/2023 beginning at 1535 and 11/29/2023 beginning at 1525. Unsafe areas, items, ligature risks, and other safety risks were observed throughout the unit which created the likelihood for patient harm and were either not identified on the hospital’s 8/24/2023 and 11/22/2023 Environmental Risk Assessment tools, or risks from these items were not mitigated prior to the date of this survey. Unidentified and unmitigated risks included, but were not limited to the following: * On 11/28/2023 at 1542, in room 5L14, surveyors observed a sink in the patient’s bathroom with loopable holes approximately 1-1.5 inches in diameter, located on the underside of the sink basin and approximately 30 inches from the floor. There were three holes on each side of the basin for a total of six holes. Surveyors were able to thread a phone charging cable on the left side of the sink from the first hole through to the second hole creating a downward ligature point. The patient bathroom was not in line of sight of the camera for patient privacy. This loopable area and ligature risk had not been identified on either of the hospital’s Environmental Risk Assessment tools dated 8/24/2023 and 11/22/2023. * On 11/28/2023 at 1542, in room 5L14, the same bathroom sink was observed with a curved faucet. Surveyors were able to loop a pair of unit-issued scrub pants over the curved faucet and put weight on it without it slipping off, creating a downward ligature risk. Although “sinks” and “plumbing” had been identified as a possible ligature risk, the hospital’s 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools noted that the mitigation of risk in patient bathrooms had been “Met”. * On 11/28/2023 at 1542, in room 5L14, a single shelf within the patient’s closet was not set flush with the cabinetry and gaps approximately 1/4 inch wide on both right and left sides of the shelf were observed. The shelf was approximately 46 inches from the floor. Surveyors were able to slip a sheet through these gaps, creating an anchor point and potential ligature risk. The closet gaps had been identified on the hospital’s 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools with a notation that risk mitigation was “Not Met”, and 3 mitigation strategies were listed: “... 15 Minute Safety Checks ... Line of Sight of Camera ... Facilities Work Order”. However, risk mitigation strategies listed did not fully mitigate the ligature risk in all patient rooms where the risk existed as some closets were not in the line of sight of the camera. This was confirmed by live video surveillance with staff present during tour of the BHU. * On 11/28/2023 at ~1555, in room 5L12, a wall-mounted camera was observed approximately 6 inches from the ceiling. The camera was not flush mounted to the wall nor was it slanted, creating an anchor point. Surveyors were able to loop a pillowcase around the camera housing and put enough weight on it to demonstrate a potential ligature risk. This ligature risk had not been identified on either of the hospital’s Environmental Risk Assessment tools dated 8/24/2023 and 11/22/2023. * On 11/28/2023 at 1600, the hallway door to room 5L14 was observed to have a small gap between the top of the door and the door frame. Surveyors verified that a bed sheet could be draped over the top of the door and the door shut creating an anchor point and ligature risk if one end of the sheet was knotted. The top right corner of the door was not visible by either of the cameras in the room or in the hallway. This was confirmed by live video surveillance with staff present during tour of the BHU. Camera “blind spots” had been identified on the hospital’s 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools, and noted as “Partially Met”. Mitigation notes on both the Environmental Risk Assessment tools reflected, “Some identified blind spots from camera in hall and alcoves. All identified blind spots are added to the 15 min check round.” Under “Mitigation Plan” was written “... 15 minute Safety Checks”. However, the top of doors or alcoves leading into patient rooms were not listed on the “15 min check” form and the risk had not been mitigated at the time of the survey. * On 11/28/2023 at 1601, an “Exit” sign was observed approximately 4 feet from room 5L14. The sign was not flush mounted to the ceiling creating loopable areas. Exit sign gaps had been identified on the hospital’s 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools and noted as “Partially Met”. Mitigation notes on both the Environmental Risk Assessment tools reflected, “... Line of sight ... 15 min checks ... facilities work order ... line of sight of care givers”. However, 5L14, and this exit sign was located on L hall which is not in the line of sight of the nursing station, or caregivers except when caregivers were in L hall. The risk had not been fully mitigated at the time of the survey. * On 11/28/2023 at 1601, a fire alarm warning light was observed approximately 6 feet across from room 5L14. The fire alarm warning light was mounted at a right angle to the wall creating a loopable anchor point. The fire alarm warning light had been identified on the hospital’s 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools and noted as “Partially Met”. Mitigation notes on both the Environmental Risk Assessment tools reflected, “... Line of sight ... 15 min checks ... facilities work order ... line of sight of care givers”. However, 5L14, and this alarm warning light was located on L hall which is not in the line of sight of the nursing station, or caregivers except when they were in the hall. The risk had not been fully mitigated at the time of the survey. * On 11/28/2023 at 1609, in room 5L10, surveyors observed another sink in the patient bathroom with loopable holes approximately 1-1.5 inches in diameter and located on the underside of the sink basin. There were three holes on each side of the basin for a total of six holes. The patient bathroom was not in line of sight of the camera for patient privacy. This loopable area and potential ligature risk had not been identified on either of the hospital’s Environmental Risk Assessment tools dated 8/24/2023 and 11/22/2023. * On 11/28/2023 at 1611, in room 5L11, a dresser with three drawers was observed next to the patient closet. The top drawer was approximately 24 inches from the floor and had a front drawer facing that created a lip that prevented looped items from sliding off the end of the drawer and provided a secure anchor point. Surveyors were able to loop a sheet and exert enough weight on this anchor point to demonstrate a ligature risk without the dresser toppling over. The drawers as anchor points had not been identified on the hospital’s Environmental Risk Assessment tool dated 8/24/2023. * On 11/28/2023 at 1615, in room 5L09, a single shelf within the patient’s closet was not set flush with the cabinetry and gaps approximately 1/4 inch wide on both right and left sides of the shelf were observed. The shelf was approximately 46 inches from the floor. Surveyors were able to slip a sheet through these gaps, creating an anchor point for a knotted sheet. The closet gaps had been identified on the hospital’s 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools, risk mitigation was noted to be “Not Met”, and 3 mitigation strategies were listed. However, risk mitigation strategies listed did not fully mitigate the ligature risk in all patient rooms where the risk existed at the time of the survey as this closet was not in the line of sight of the camera. This was confirmed by live video surveillance with staff present during tour of the BHU. * On 11/28/2023 at 1617, in room 5L09, surveyors observed a slanted bathroom door with a continuous hinge. Surveyors successfully looped a sheet around the top of the hinge and one surveyor was able to hang from the door hinge. Although “Interior Bathroom Doors” under the category titled “Bathrooms” had been identified on the hospital’s 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools, the tools noted that risk mitigation had been “Met”. On the same Environmental Risk Assessment tools, under the category of “Hinges”, the ligature risk mitigation for hinges had also been noted as “Met” for all doors except those located in the “Sensory room” where the tools noted “Partially Met”, and that a process was being developed to have hinges checked on a routine basis. Under a third category titled “Interior Doors that do not need to limit the transfer of smoke”, the hospital’s 08/24/2023 and 11/22/2023 Environmental Risk Assessment tools also noted that ligature risk mitigation had been “Met” by slanted doors. Risk mitigation strategies for this ligature risk were not fully implemented at the time of the survey. * On 11/28/2023 at 1627, in room 5L07, two wood-framed platform beds were observed. The platform beds were low to the ground but were not secured to the floor or the wall. One surveyor was able to easily lift the wooden bed without assistance and turn the bed on its side creating a long, flat surface approximately seventeen inches wide, eighty inches in length and approximately three feet high. An unmitigated risk existed for self-harm from jumping or falling from these pieces of unsecured furniture when turned on their side. Further, the wooden bed frame had no enclosed base, which created an empty, open area on the underside of the bed large enough for a patient to fully lie down and hide themselves, or within which to hide contraband. An additional potential risk existed for the two beds to be used in combination to create a barricade due to their size, weight and maneuverability. These risks had not been identified or evaluated on either of the hospital’s Environmental Risk Assessment tools dated 08/24/23 and 11/22/2023. The tools listed this type of furniture in three categories: “Furniture - general considerations”, “Furniture in private areas ... bedrooms ...” and “Platform Beds”. Further, the Environmental Risk Assessment tools noted that risk mitigation had been “Met” in all three areas. The risk assessment lacked additional comments regarding any related self-harm risks associated with this furniture. Specifically, there were no comments regarding, “jumping or falling”, “hiding of contraband or patients”, or “anti-barricade” mitigation strategies related to these beds. * On 11/28/2023 at 1604, a locked room identified as the patient belongings/laundry room and located directly across from 5L14 was observed to have a secondary door to a storage area that contained cleaning supplies. The hallway door entering the laundry room was locked, however, the entry door to the cleaning supply closet was propped open, unlocked, and a sign was posted on the door reading “5L/5E Hazard Spill Kit”. Although “Chemicals ... Utility Rooms” had been identified on the hospital’s 08/24/2023 Environmental Risk Assessment, the risk mitigation was described as “Met” and no other comments by the facility other than the standardized template language of “locked” and “supervision” were noted. The identified risk of chemicals in the “Laundry room” had mitigation notes which stated, “NA” and “No patients use the laundry room.” However, a review of the MHA Orientation Packet provided by the hospital, reflected a 1-page document titled “Behavioral Health Unit Standard Operating Procedure: Staff responsibility for the laundry room and washing machine ...” which provided guidance to staff on the supervision of patients when using the laundry room. It is unclear whether patients were ever “encouraged to do their own laundry to help maximize their independence with ADL’s [sic]’ as stated in an MHA Orientation Packet in finding 3.c. or whether the laundry room was never used by patients as indicated in an email from the EDO on 12/13/2023 at 1644, also in finding 3.c. * On 12/18/2023 at 1353, an upright refrigerator/freezer with two vertical loopable handles was observed in the main kitchen area of the BH unit. These two anchor points had not been identified on either of the hospital’s Environmental Risk Assessment tools dated 8/24/2023 and 11/22/2023. 3.b. During interview on 11/29/2023 at 1230 the ANM stated none of the patient room bathrooms have a camera inside them. Therefore, those bathrooms would not be visible from camera views in patient rooms, particularly when bathroom privacy curtains and doors were closed. 3.c. During review of an MHA orientation training/education packet, an undated 1-page document titled “Behavioral Health Unit Standard Operating Procedure: Staff responsibility for the laundry room and washing machine ...” was reviewed. It reflected: - “The following rules apply for patient use of the washer/dryer: Patient must be supervised by nursing staff. If helping a patient do their laundry on L side make sure the door is open, that you are wearing a vocera and that you have told a co-worker what you are doing. This is an isolated area and poses foreseeable risks ... Patients should be encouraged to do their own laundry to help maximize their independence with ADL’s [sic].” The document contradicts information provided by the hospital regarding the use of the laundry room by patients and the risk mitigation strategies as noted on the Environmental Risk Assessment tools in finding 4.a. In an interview conducted with the EDO on 12/13/2023 at 1644 via email, the EDO wrote: “The laundry room on 5L in the L hallway is not accessible by patients, and unit leadership confirmed that patients are never in this space. This is the most current version of the MHA orientation packet.” Regarding BH Shift Environmental Rounds: 4.a. On 12/01/2023, at 1516, documentation of the unit’s routine, twice daily BH Shift Environmental Rounds, beginning 01/01/2023 - 11/28/2023, was requested. The hospital provided 105 forms titled “Behavioral Health Shift Environmental Rounds” which contained the following instructions, “The below form is completed at the start of each shift (0700 & 1900) and placed in the Environmental Rounds binder kept in the nurses [sic] station. Documentation of this rounding form is to be completed by two staff, both staff need to print name, initial and put time this was completed.” The form contained a place to write the unit and the date, and three columns, titled, “Area ... 0700 Initials/Time ... 1900 Initials/Time”. Ten areas of observation were listed and included a corresponding “box” for staff to write “Initials/Time”. The bottom of the form contained two signature lines for four staff to sign. The form version was undated. Of the forms provided, the majority were incomplete, instructions printed on the form were not followed, and rounds were either missed or not documented. Examples include but are not limited to: * No forms were provided for the month of January 2023. * A form dated “2/3/23” reflected two staff initials in seven of ten boxes for the “0700” column. Three boxes contained only one staff’s initials in the areas of “ALL patient rooms and bathrooms visualized for safety concerns ... Hover Jack charging ... ALL cabinets/closets/lockers are locked and secure in halls, vestibules and sally-port ...”. The “1900” column reflected two staff initials in ten of ten boxes. There were no times written next to the initials in either column per the form instructions. Four MHA names and initials were written on the signature lines. * A form dated “2/25/23” reflected two staff initials in ten of ten boxes for the “0700” column. There were no times written next to the initials per the form instructions. Ten of ten boxes for the “1900” column lacked staff initials and times. Two MHA names and initials were written on the signature lines. * A form dated “2/26/23” reflected two staff initials in seven of ten boxes for the “0700” column. Three boxes contained only one staff’s initials in the areas of “Group room/Sensory room/Day room/Interview rooms ... Refrigerators locked ... Hover Jack charging ...”. There were no times written next to the initials per the form instructions. Ten of ten boxes for the “1900” column lacked staff initials and times. Two MHA names and initials were written on the signature lines. * A form dated “3/01/23” reflected the initials of one staff in ten of ten boxes for the “0700” column. There were no times written next to the initials per the form instructions. Ten of ten boxes for the “1900” column lacked staff initials and times. The first signature line contained two MHA staff initials which appeared to be identical, with only one printed first name. * A form dated “3/02/23” reflected the initials of one staff in ten of ten boxes for the “0700” column. There were no times written next to the initials per the form instructions. Ten of ten boxes for the “1900” column lacked staff initials and times. One MHA name and initials were written on the signature lines. * A form dated “3/4/23” reflected two staff initials in eight of ten boxes for the “0700” column. Two boxes contained only one staff’s initials in the areas of “Hover Jack charging ... ALL cabinets/closets/lockers are locked and secure in halls, vestibules and sally-port ...”. The “1900” column reflected two staff initials in ten of ten boxes. There were no times written next to the initials in either column per the form instructions. Four MHA names and initials were written on the signature lines. * A form dated “3/5/23” reflected two staff initials in eight of ten boxes for the “0700” column. Two boxes contained only one staff’s initials in the areas of “Hover Jack charging ... ALL cabinets/closets/lockers are locked and secure in halls, vestibules and sally-port ...”. The “1900” column reflected two staff initials in ten of ten boxes. There were no times written next to the initials in either column per the form instructions. Four MHA names and initials were written on the signature lines along with one CNA name and initials. * A form dated “3/16/23” reflected ten of ten boxes for the “0700” column lacked staff initials and times. The “1900” column reflected the initials of one staff in ten of ten boxes. There were no times written next to the initials per the form instructions. One name and initials were written on the signature lines. There was no staff title. * A form dated “4/21/23” reflected the initials of one staff in ten of ten boxes for the “0700” column. There were no times written next to the initials per the form instructions. Ten of ten boxes for the “1900” column lacked staff initials and times. One MHA name and initials were written on the signature lines. * No forms were provided for the months of May, June, July or August 2023. * A form dated “9/28/23” reflected the initials of one staff in eight of ten boxes for the “0700” column. Two boxes in the areas of “Laundry room (E & L halls) doors are locked ... Group room/Sensory room/Day room/Interview rooms ...” lacked staff initials and times. The “1900” column reflected two staff initials in ten of ten boxes. There were no times written next to the initials in either column per the form instructions. One MHA name and initials were written on the signature lines. * A form dated “10/13/23” reflected ten of ten boxes for the “0700” column lacked staff initials and times. The initials of one staff were written in nine of ten boxes for the “1900” column. The area, “ALL patient rooms and bathrooms visualized for safety concerns ...” lacked staff initials and a time. There were no times written next to the initials in the other nine boxes per the form instructions. One MHA name and initials were written on the signature lines. * A form dated “11/17/23”, the date of the incident, reflected the initials of one staff in ten of ten boxes for the “0700” column. There were no times written next to the initials per the form instructions. Ten of ten boxes for the “1900” column lacked staff initials and times. One MHA name and initials were written on the signature lines. Additionally, of the estimated 663 BH Shift Environmental Rounds required to be completed beginning day shift, 01/01/2023 through day shift, 11/28/2023, the hospital provided 125 documented BH Shift Environmental Rounds, for an averaged completion rate of 19%, well below the 100% compliance rate described in the “Standard Work Document[s]” above. 4.b. During an interview with the EDO via email on 12/13/2023 at 1640, the EDO confirmed that the hospital had provided all documentation of shift environmental rounds. Additionally, they provided the information on whether two staff were required to complete the rounds per the form instructions and staff training materials, times when the rounds occurred, and how often shift environmental rounds were required. * The EDO wrote: “EOC shift rounds - overall: a. Unable to confirm, leadership review revealed a mix of completed not documented and not completed. b. Unable to confirm second set of initials, no video footage is unavailable [sic] due to storage limitations. The practice prior to new process implementation was to have two caregivers perform, however, it was discovered this created significant challenges to operationalize and was not required by policy, thus potentially creating gaps. c. Unable to confirm time performed if not documented. d. EOC rounds are expected each shift, unable to confirm completion if not documented.””