Oregon State Hospital Distinct Part

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 17281 Based on record review, policy review, and interview, the facility failed to ensure a face to face assessment was completed in accordance with the “Seclusion and Restraint” policy for one (Patient (P) 8) of eight patient records reviewed in a total sample of eight patients. This deficient practice had the potential to affect all patients receiving services at the facility. Findings include: Review of the facility’s policy titled, “Seclusion and Restraint,” dated 07/17/25, revealed, “ ...Assessments: Providers are required to perform a face- to -face evaluation within 1 hour of the initiation of restraint/seclusion ...If a trained RN [registered nurse] with documented competencies is available, they may perform the initial face-to-face assessment ....” P8’s medical record was presented in paper form by the facility quality staff. Review of P8’s “Face Sheet” revealed P8 was admitted to the facility on 07/23/25 with diagnoses that included bipolar 1 disorder with psychotic features and catatonic disorder due to another medical condition. Review of the “Oregon State Hospital Seclusion/Restraint Orders,” dated 08/10/25 at 8:33 AM, revealed seclusion was initiated because P8 was exit seeking, not following staff direction, and redirection .... Review of the “Oregon State Hospital S&R [Seclusion and Release] Assessment & Release Criteria,” dated 08/10/25 at 9:30 AM, revealed P8 met criteria for release of seclusion at 9:30 AM. Review of P8’s entire medical record failed to reveal a face to face assessment was completed per facility policy on 08/10/25 when seclusion was initiated. During an interview on 09/12/25 at 7:50 AM, the Chief Nursing Officer (CNO) stated a trained RN, or practitioner completes the face to face assessment when seclusion/restraint is initiated. The CNO confirmed the face to face assessment for the 08/10/25 seclusion was not located in the patient’s medical record. During an interview on 09/12/25 at 10:00 AM, the Director of Standards and Compliance (DSC) stated P8’s medical record was reviewed, and he/she was unable to locate documentation of a face to face assessment for the seclusion initiated on 08/10/25.”

“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 that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 17281 Based on record review, policy review, and interviews, the Interdisciplinary Team (IDT) failed to ensure patient Treatment Plans were kept current for seclusion, restraint, and/or falls and failed to follow the physician’s order for a physical and occupational therapy evaluation for three (Patient (P) 5, P8, and P1) of eight patient records reviewed in a total sample of eight patients. This deficient practice had the potential to affect all patients receiving services at the facility. Findings include: Review of the facility’s policy titled, “Treatment Care Plan” dated 06/13/25 revealed, “ ...For every patient, the IDT must develop and maintain an individualized treatment care plan (TCP) in collaboration with the client. The TCP must include all active treatment provide to the patient based on discipline recommendations ...The TCP will be updated with significant changes in a patient’s condition (e.g., acute medical condition, sexual acting out) the following business day by members of the treatment team ...Nursing staff will complete a TCP addendum for active/acute problems and notify treatment team (preferred method of notification is the 24- hour Nursing Report ...Active treatment means a clinical process involving ongoing assessment, diagnosis, interventions, evaluation of care and treatment, and planning for discharge and aftercare ...Active treatment occurs when the patient receives clinical interventions that are delivered under the direction of the attending psychiatrist or psychiatric mental health nurse practitioner (PMHNP), and which address specific patient strengths and conditions requiring clinical intervention as identified in the treatment plan ...Significant changes in condition (acute/active problems) require a treatment plan of care developed or a review/revision if a current problem ....” 1. P5’s medical record was presented in paper form by the facility quality staff. Review of P5’s “Face Sheet” revealed P5 was admitted to the facility on 06/18/25 with diagnoses that included schizophrenia. Review of the “Oregon State Hospital Seclusion/Restraint Orders” revealed seclusion was initiated on 07/17/25 at 2:30 PM due to increased agitation and risk for assaults. Review of the “Oregon State Hospital S&R [seclusion and restraint] Assessment & Release Criteria, dated 07/19/25 at 3:30 PM, revealed criteria for release of seclusion was met and the patient was released from seclusion. Review of the “Oregon State Hospital Seclusion/Restraint Orders” revealed seclusion was initiated on 08/13/25 at 2:00 PM due to increased agitation and risk for assaults. Review of the “Oregon State Hospital S&R Assessment & Release Criteria, dated 08/14/25 at 9:45 AM, revealed criteria for release of seclusion was met and the patient was released from seclusion. Review of the “TCP,” dated 08/12/25, revealed a risk for violence due to severe aggression and violence towards others. Interventions included if a risk is identified staff will notify the RN immediately. Staff will follow all seclusion and restraint policies and procedures if patient is in seclusion to maintain safety during restraint and/or seclusion. Review of the “TCP” failed to reveal the plan was revised to include the active interventions of seclusion on 07/17/25 and 08/13/25. 2a. P8’s medical record was presented in paper form by the facility quality staff. Review of P8’s “Face Sheet” revealed P8 was admitted to the facility on 07/23/25 with diagnoses that included bipolar 1 disorder with psychotic features and catatonic disorder due to another medical condition. Review of the admission “Fall Risk Assessment,” dated 07/23/25 at 12:02 PM, revealed a fall risk score of 55 which identified P8 was assessed as a moderate fall risk. Review of the “TCP,” dated 07/31/25, revealed, a moderate fall risk with a score of 55 with interventions that included staff will monitor environment and will reasonably address potential fall hazards, keep environment clutter free as possible, remove unnecessary items from room and walkway that can inadvertently cause a fall, wipe spills off floors, encourage no-skid socks, and reinforce fall education and importance of no-skid socks. Review of the “Oregon State Hospital TCP Addendum- High Risk, Status Post Fall,” dated 08/02/25 revealed, “ ...pt falling from chair ...Intervention: Nursing will instruct patient on use of need assistive devices and assist patient with ADLs as needed and requested by patient. Nursing will encourage proper footwear each shift, and Nursing will educate patient and family regarding fall precautions throughout stay and prior to discharge ...” Review of the “Oregon State Hospital TCP Addendum- High Risk, Status Post Fall,” dated 08/07/25 revealed, “ ...pt reported falling off chair in room ... Intervention: Nursing will instruct patient on use of need assistive devices and assist patient with ADLs as needed and requested by patient. Nursing will encourage proper footwear each shift, and Nursing will educate patient and family regarding fall precautions throughout stay and prior to discharge ...” Review of the “Oregon State Hospital TCP Addendum- High Risk, Status Post Fall” dated 08/17/25 revealed, “ ...fall from fitness room from insufficient strength ... Intervention: Nursing will instruct patient on use of need assistive devices and assist patient with ADLs as needed and requested by patient. Nursing will encourage proper footwear each shift, and Nursing will educate patient and family regarding fall precautions throughout stay and prior to discharge ...” Review of the “TCP,” dated 09/04/25, revealed, patient had several falls recently. He/she is unsteady/weak gait and has two qualifying medical conditions contributing to fall risk and a current a moderate fall risk. Interventions included staff will monitor environment and will reasonably address potential fall hazards, keep environment clutter free, as possible remove unnecessary items from room and walkway that can inadvertently cause a fall, wipe spills off floors, encourage no-skid socks, and reinforce fall education and importance of no-skid socks. Review of the Treatment Care Plan dated 09/04/25 and the “Oregon State Hospital TCP Addendum- High Risk, Status Post Fall” documents failed to reveal new interventions were implemented after P8 sustained falls on 08/02/25, 08/07/25, and 08/17/25. b. Review of the “Oregon State Hospital Seclusion/Restraint Orders,” dated 08/10/25 at 8:33 AM, revealed seclusion was initiated because P8 was exit seeking, not following staff direction, and redirection ....” Review of the “Oregon State Hospital S&R Assessment & Release Criteria,” dated 08/10/25 at 9:30 AM, revealed P8 met criteria for release of seclusion at 9:30 AM. Review of the “TCP,” dated 09/04/25, failed to reveal the TCP was revised to include the active intervention of seclusion on 08/10/25. During an interview on 09/12/25 at 9:40 AM, Treatment Care Plan Specialist (TCPS) 1 stated the TCP should include a seclusion/restraint event to develop goals and interventions to minimize future events/incidents. TCPS 1 stated the TCP should include interventions when a Fall Risk assessment score is moderate or high risk. TCPS 1 stated the TCP is not revised between scheduled care meetings unless a member of the IDT notifies a Treatment Care Specialist. TCPS 1 stated after a patient fall, the nurse completes the paper TCP addendum. TCPS 1 stated he/she is not a clinician, and it is the clinicians responsibility to add new interventions based on their assessment of the patient after a fall or when there is a seclusion/restraint event. c. Review of the “Client Doctor Orders,” dated 08/08/25, revealed an order to obtain PT (physical therapy) and OT (occupational therapy) evaluation due to multiple falls and fall risk. Review of the “Occupational Therapy Assessment,” dated 08/25/25, revealed, “Per most recent RN Functional Falls Assessment, patient is identified as a moderate fall risk patient, leading to an OT/PT functional fall assessment ...Based on the patient falls not related to a functional impairment that physical therapy can address no formal OT/PT assessment or intervention is indicated at this time ....” During an interview on 09/12/25 at 9:00 AM, Quality Staff (QS) 1 stated the OT/PT evaluation was missed because the nurse did not fill out the referral form. During an interview on 09/12/25 at 9:08 AM, Psychiatric Mental Health Nurse Practitioner (PMHNP) 1 stated the PT/OT evaluation was ordered because the patient was at an increased risk for falling. PMHNP 1 stated he/she was not aware the PT/OT evaluation was not done until 08/25/25. 3. Review of P1’s medical record, provided in paper form without tab dividers by the hospital’s quality staff, indicated P1 was admitted on 07/17/25 with a legal status of “Court Order (161-370) - Aid & Assist” for competency restoration. Review of P1’s medical record indicated P1 was placed in restraint and/or seclusion on 07/17/25, 08/03/25, 08/05/25, 08/10/25, 08/12/25, 08/16/25, 08/20/25, 08/26/25, and 08/27/25. Review of P1’s “TCP,” dated 07/31/25, indicated no documentation related to the use of restraint and/or seclusion. Review of P1’s “TCP,” dated 07/31/25, indicated no documentation related to the use of restraint and/or seclusion. During an interview on 09/10/25 at 9:59 AM, Chief Nursing Officer (CNO) stated the nurse completes the “S&R Event Addendum” after the event, such as a fall or restraint and/or seclusion, and files it in the patient’s chart. CNO stated the interdisciplinary team reviews the addendum and determines how and what to enter into the patient’s treatment care plan. CNO stated he/she saw multiple treatment care plans since events of restraint and/or seclusion, and there was no addition to the plan related to seclusion and/or restraint. CNO stated some staff document the addendum during the event, but it must be completed post event. 25065”

“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: 08621 ****************************************************** Based on observation, review of video recordings, interviews, review of incident and medical record documentation for 17 of 17 patients (Patients 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21), review of OSH internal investigation documentation, review of training documentation for 4 of 5 LIPs (MD A, DO B, MD N and MD O) and 23 of 23 Direct Care nursing staff (RN C, RN D, RN E, RN F, RN G, RN R, RN T, RN U, RN W, RN Z, RN AA, RN EE, LPN H, LPN P, LPN Y, MHT J, MHT S, MHT Q, MHT V, MHT X, MHT BB, MHT CC, and MHT DD), review of training curriculum and training media, review of governing body and medical staff bylaws, and review of P&Ps it was determined that the governing body of the hospital was not organized or effective and failed to ensure that the hospital operated in accordance with current and complete governing body bylaws, medical staff bylaws and rules and regulations, and medical staff and hospital P&Ps that ensured patients received safe and appropriate care in the hospital. The failures potentially contributed to harm and death of Patient 3 and created the likelihood of harm to other patients. 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. The failures included that hospital staff failed to initiate medical emergency response procedures for Patient 3 in a timely manner and the patient subsequently died on the seclusion room floor. Further, anteroom and RN staff failed to provide 1:1 constant observation, monitoring, response, and assessment for Patient 3 related to two falls that occurred within approximately an hour prior to the third fall and the medical emergency event. On 03/31/2025 the hospital was notified that an IJ situation had been determined to exist. Refer to Tag A-093 for the details of the IJ identification, IJ notification, IJ Removal Plan approval, and IJ Removal Plan Verification Visits. A third IJ Removal Plan Verification Visit was conducted on 05/12/2025 and the IJ was determined to be removed. Findings include: 1. The hospital’s Governing Body Bylaws dated 04/22/2020 were unclear, incomplete and not current. A Preamble, and Articles 1, 2, 3, and 11 as described below were the extent of the bylaws: *Article 1 of the bylaws stated “The Governing Body is the Director of the Oregon Health Authority (OHA). The Director of the Oregon Health Authority promulgates Administrative Rules and Management Directives to establish policies and procedures.” *Article 2 of the bylaws stated “The Superintendent is appointed by The Governing Body (ORS 179.331). The Governing Body authorizes the Superintendent to make final decisions on behalf of the Governing Body regarding granting applications for membership or clinical privileges or granting renewal of MAPHS membership or clinical privileges.” *Article 3 of the bylaws was titled “Responsibilities of the Govering [sic] Body.” The article stated, “The Governing Body of the Oregon State Hospital shall be responsible for the operation of the facility, the selection of the medical staff and the quality of care rendered in the facility.” - The responsibilities listed did not include all of the responsibilities of the governing body specified by the hospital CFRs and OARs. For example: CFR 482.12(a)(10) requires that “The governing body must consult directly with the individual assigned the responsibility for the organization and conduct of the hospital’s medical staff, or his or her designee. At a minimum, this direct consultation must occur periodically throughout the fiscal or calendar year and include discussion of matters related to the quality of medical care provided to patients of the hospital.” There were no provisions for this direct consultation in the bylaws. -Further, the bylaws did not contain specific information about how the governing body would ensure its responsibilities for those that were listed. *Article 11 followed Article 3 and was titled “Adoption of the governing body bylaws.” A handwritten entry recorded on the last page was of a partial date “2/21 (Revised)” with no indication of what was revised, and underneath were the illegible and undated initials of one individual. 2. Refer to the findings cited under this CoP, CFR 481.12 (a)(4) - Standard: Governing body approval of medical staff bylaws and rules and regulations. Those findings reflected the medical staff bylaws and rules and regulations were not current, clear, or complete, and had not been approved by the governing body that was in place at the start of this investigation (Tag A-048). 3. Refer to the findings cited under this CoP, CFR 482.12(f)(2) - Standard: Emergency Services. Those findings reflect that provisions for timely and appropriate medical emergency response for patients in seclusion were not fully developed and implemented. The hospital’s failures potentially contributed to harm and the death of Patient 3 and created the likelihood of harm to other patients (Tag A-093). 4. Refer to Tag A-115, CFR 482.13 - CoP: Patient’s Right. The hospital failed to ensure patients were informed of their health status (Tag A-131). 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 seclusion and restraint (Tag A-154). The hospital failed to ensure patients in seclusion were monitored and observed to ensure their safety (Tag A-175). The hospital failed to ensure staff training related to seclusion and restraint was conducted appropriately (Tag A-199 and Tag A-206). 5. Refer to Tag A-1600, CFR 482.60 - CoP: Special Provisions for Psychiatric Hospitals. Those findings reflect that he hospital failed to comply with all CoPs specified in CFRs 482.1 through 482.23 and CFRs 482.25 through 482.57 (Tag A-1605). 6. Unsolicited, numerous department, program, and unit medical staff and leaders came forward to speak to the surveyors. Those staff provided permission for the concerns they shared to be used in the survey report. To ensure as much as possible the protection of the identity of those staff, specific interview dates and times are not provided in this report. The concerns that were shared included, but were not limited to: * Patient 3’s death, and other sentinel events that included patient deaths and serious patient harm that were investigated by the SA during the past two years, including for Patient 1 who died in seclusion, resulted after numerous warnings and problems were brought to the attention of hospital executive leadership by department, program, and unit leaders. Those concerns were largely ignored and dismissed. There were multiple reports that it is was specifically the OSHS/CMO who responded in those ways. * During the SA’s investigation of the prior incidents referenced above, staff were coached as to what and what not to say to surveyors. After the hospital was found back in compliance with the CoPs, a number of corrective actions and monitoring activities were discontinued, and processes returned to pre-investigation status. * Another example of the overuse of seclusion and challenge of releasing patients from seclusion was Patient 2 who was admitted to the hospital in early 2025 in seclusion and restraints. Although RNs assessed the patient to be ready for release from seclusion within two days and released the patient, the patient’s LIPs expressed anger about that decision and insisted that the RNs needed to keep patients in seclusion until they consulted with the provider, contrary to hospital policy. * Operational and communication systems involving hospital departments, programs, and units are fragmented, broken, or non-existent. * Patients are sicker and more medically complex than patients in prior years. * Medical staff and clinical P&Ps are out of date. * Medical clinic communication with the patient units is lacking. Clinic scheduling of patient appointments and visits is disorganized and not efficient. * Documentation and diagnostic testing results from patient specialty visits and consultations to providers in the community outside of the hospital are not communicated to inpatient units, nor incorporated into the patient’s medical record timely. * Psychology and social work needs of patients are not responded to timely or not met. For example psychology behavioral plans are not developed and updated as needed. Clinical notes are not written as required. * There are no standards for medical clinical documentation & corrective action plans developed in response to the last SA investigation to address some of those issues did not continue. * Patient care and clinical failures or gaps are not reported to or addressed by the medical staff and the existing peer review processes are not capturing the problems. * Medical staff who provided direct care of patients for whom sentinel events occurred have been involved in the hospital’s investigations of those events. That has created barriers to impartial and objective investigation and decision-making regarding deficient practices and corrective actions. * There is an empathy problem and staff do not know how to interact with patients to provide for a therapeutic milieu. * Modeling and coaching of therapeutic interactions with patients, attempted in real time by experienced trainers, have often been dismissed and rejected by unit leaders and other hospital staff. Including for Patient 3. * Staff training is primarily in the form of attestations that a policy and procedure has been read. Staff are numb to attestations. * Training is insufficient in both content and in-person teaching. * The newest, least experienced, and most under-trained staff are assigned to the Anchors and Lighthouse units in the Harbors Program where the patients with the highest acuity reside. ******************************************************”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 08621 ****************************************************** Based on observation, review of video recordings, interviews, review of incident and medical record documentation for 17 of 17 patients (Patients 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21), review of OSH internal investigation documentation, review of training documentation for 23 of 23 Direct Care nursing staff (RN C, RN D, RN E, RN F, RN G, RN R, RN T, RN U, RN W, RN Z, RN AA, RN EE, LPN H, LPN P, LPN Y, MHT J, MHT S, MHT Q, MHT V, MHT X, MHT BB, MHT CC, and MHT DD), review of training curriculum and training media, and review of P&Ps it was determined that the hospital failed to fully develop and implement P&Ps that ensured patients’ rights were protected and promoted. The hospital’s failures potentially contributed to harm and death of Patient 3 and created the likelihood of harm to other patients. 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. The failures included that hospital staff failed to initiate medical emergency response procedures for Patient 3 in a timely manner and the patient subsequently died on the seclusion room floor. Further, anteroom and RN staff failed to provide 1:1 constant observation, monitoring, response, and assessment for Patient 3 related to two falls that occurred within approximately an hour prior to the third fall and the medical emergency event. On 03/31/2025 the hospital was notified that an IJ situation had been determined to exist. Refer to Tag A-093 for the details of the IJ identification, IJ notification, IJ Removal Plan approval, and IJ Removal Plan Verification Visits. A third IJ Removal Plan Verification Visit was conducted on 05/12/2025 and the IJ was determined to be removed. Findings include: 1. Refer to the findings cited under this CoP, CFR 482.13(b) - Standard: Exercise of Rights. Those findings reflect the hospital failed to inform a patient of their health status in a timely manner and failed to have system to ensure that for all patients (Tag A-131). 2. Refer to the findings cited under this CoP, CFR 482.13(c) - Standard: Privacy and Safety. Those findings reflect the hospital failed to ensure the provision of care setting (Tag A-144). 3. Refer to the findings cited under this CoP, CFR 482.13(e) - Standard: Restraint or seclusion. The hospital failed to ensure patients’ rights to be free from seclusion and restraint (Tag A-154). 4. Refer to the findings cited under this CoP, CFR 482.13(e) - Standard: Restraint or seclusion. The hospital failed to ensure that patients in seclusion and restraint were monitored and observed to ensure their safety (Tag A-175). 5. Refer to the findings cited under this CoP, CFR 482.13(f) - Standard: Restraint or seclusion. The hospital failed to ensure that training related to seclusion and restraint was conducted appropriately (Tag A-199 and Tag A-206). ******************************************************”

“Special Provisions for Psychiatric Hospitals CFR(s): Special Provisions Applying to Psychiatric Hospitals - Psychiatric hospitals must... This Condition is not met as evidenced by: 08621 ****************************************************** Based on observation, review of video recordings, interviews, review of incident and medical record documentation for 17 of 17 patients (Patients 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21), review of OSH internal investigation documentation, review of training documentation for 4 of 5 LIPs (MD A, DO B, MD N and MD O) and 23 of 23 Direct Care nursing staff (RN C, RN D, RN E, RN F, RN G, RN R, RN T, RN U, RN W, RN Z, RN AA, RN EE, LPN H, LPN P, LPN Y, MHT J, MHT S, MHT Q, MHT V, MHT X, MHT BB, MHT CC, and MHT DD), review of training curriculum and training media, review of governing body and medical staff bylaws, and review of P&Ps it was determined that the governing body failed to ensure the hospital complied with the special provisions that applied to psychiatric hospitals. The failures potentially contributed to harm and death of Patient 3 and created the likelihood of harm to other patients: Findings include: 1. Refer to the findings under this CoP, CFR 482.60 - CoP: Special Provisions Applying to Psychiatric Hospitals. The governing body failed to ensure the hospital complied with all applicable CoPs for hospitals as the CoPs for Governing Body and Patient’s Rights were determined to be out of compliance (Tag A-1605). ******************************************************”

“LICENSURE OF HOSPITAL CFR(s): 482.11(b) The hospital must be - o Licensed; or o Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. This Standard is not met as evidenced by: 29708 ****************************************************** Based on interview, review of P&Ps and review of other documentation it was determined that the hospital failed to ensure it was in compliance with applicable State laws and rules related to hospital licensing and radiology services. Hospital licensing OAR 333-500-0032 requires that psychiatric hospitals have available on-site or through contract radiology services and have radiology staff on-site or on-call 24/7. Hospital licensing OAR 333-520-0040 requires that all hospitals have on-site or contract radiology services that support the hospital’s medical and other services, are available on a timely basis, and have on-site or in-house radiology staff available 24/7. The hospital failed to comply as follows: * The hospital failed to ensure available radiology services and radiology staff were on-site or on-call 24/7 and the hospital transported patients to another hospital for radiology services when radiology staff were not scheduled or otherwise available. Findings include: 1. Refer to the findings cited at Tag A-529 under CFR 482.26(a) - Scope of Radiologic Services that reflects the hospital failed to ensure available radiology services and radiology staff were on-site or on-call 24/7 and the hospital transported patients to another hospital for radiology services when radiology staff were not scheduled or otherwise available. ******************************************************”

“MEDICAL STAFF - BYLAWS AND RULES CFR(s): 482.12(a)(4) [The governing body must] approve medical staff bylaws and other medical staff rules and regulations. This Standard is not met as evidenced by: 08621 ****************************************************** Based on interview, review of medical staff bylaws, and review of policies and procedures it was determined the Governing Body failed to ensure the medical staff operated under current and approved medical staff bylaws, that medical staff rules and regulations had been developed and approved, and that the medical department and medical clinic policies and procedures were fully developed, approved, current, and implemented. Findings include: 1. The “Oregon State Hospital Medical And Allied Health Professional Staff Bylaws” were reviewed. The cover page reflected “Approved and adopted on: January 30th, 2020.” The approval signature page contained four signature and date blocks to indicate approval by the four individuals listed. Those were: * “President, Medical and Allied Health profession Staff Oregon State Hospital, 2019” * “Chief Medical Officer” * “Superintendent” * “Director of Oregon Health Authority” The four individuals listed were no longer at OSH or were not in the position assigned to their name. The spaces for signatures and dates for each of those individuals to reflect approval of the bylaws were blank. 2. The “Oregon State Hospital Medical And Allied Health Professional Staff Bylaws” included Article10.8 for the “Bylaws Committee.” That article required “The Bylaws Committee shall meet as often as necessary at the call of its chair but at least annually ...” and “The duties of the Bylaws Committee shall include: (a) conducting a biennial review of the staff bylaws; (b) submitting recommendations to the Executive Committee for changes in these documents as necessary to reflect current staff practices ...” There was no evidence to reflect that the bylaws had been reviewed at least every two years since January 2020. The Bylaws were not annotated with the date of last review and initialed or signed by the responsible person(s). 3. The Bylaws referenced “Medical And Allied Health Professional Staff” (MAHPS) “rules and regulations” 13 times. For example: * In the Preamble, Item 4 stated that the organization shall “establish and maintain rules and regulations for self-governance of the [MAHPS].” * Article 2.4 included that the MAHPS membership constituted agreement to “abide by the MAHPS bylaws, rules and regulations, and administrative memoranda.” * Article 3.1 included that applicants for MAHPS membership agree to “comply with the ... bylaws and rules and regulations as they exist and as they may be modified.” * “Rules and regulations” were also referenced under Articles 3.4; 3.6; 4.1; 4.5; 6.4; 10.4; and 11.3. There were no MAHPS rules and regulations provided. In an email received from the DSC on 04/10/2025 at 1224 they stated in regard to the request for MAHPS rules and regulations that “We have written protocols for each department.” 4. Article 2.12 of the Bylaws titled “Chief Medical Officer and Directors of Clinical Disciplines” included “Roles and Responsibilities” identified at (a) through (n). For example: “(g) coordinate and integrate interdepartmental and intradepartmental services;” and “(h) develop and implement policies and procedures that guide and support the provision of care, treatment, and services.” Article 5 of the Bylaws included a statement that stated, “Additional requirements for completing a medical history and physical examination are found in the Medical Department Policies and Procedures and the Medical Clinic Policies and Procedures.” 5.a. All Medical Department and Medical Clinic policies and procedures were requested. There were 15 “Medical Department Protocols” provided of which 12 had been last reviewed or approved between 02/04/2015 and 03/16/2020. There were 21 “Medical Clinic Protocols” provided of which 18 had been last reviewed or approved on 10/07/2016. Several of those (at least eight) were not related to medical staff practice and were related instead to department and clinic operations such as hours, funding for services, scheduling of patient appointments, and equipment use or maintenance. 5.b. “Medical Department Protocol: 1.009” was titled “Medical Care of Patients” and was dated 02/24/2015. There was no evidence of review of the protocol since that date more than 10 years ago. The protocol included direction that “The MOD shall also be available for telephone consultation with the OSH-Portland POD ...” The OSH-Portland campus was closed on 03/31/2015. 5.c. The “Medical Clinic Protocol: X.XXX [sic]” for “Approval of Medical Services, Devices, and Procedures” had an approval date of “XXXXXX [sic].” The “Revision History” at the end of the protocol reflected it had last been reviewed on 10/07/2016. It was not clear that the protocol had been approved or that 2016 practices were still current. 5.d. The “Medical Clinic Protocol: X.XXX [sic]” for “Minor Surgery” had an approval date of 10/07/2016. The protocol was not surgical procedure specific and contained unclear information. The generic protocol written as “one-size fits all” did not ensure the provision of safe and appropriate “minor surgery” care for patients. For example: *Under “Definitions” it reflected “’Minor Surgery’ for the purposes of this protocol includes, but is not limited to: I and D of abscesses, matrix, punch biopsies, and skin tag removal.” The scope of surgical procedures allowed to be performed in the medical clinic was not specified. * Under Section A for “Equipment” was listed “Any electrical equipment needed.” There was no indication as to what specific “electrical equipment” was needed for each different type of procedure performed. *Under the “Equipment” section it listed “Sterile instruments, as needed.” There was no indication as to what specific “sterile instruments” were needed for each different type of procedure performed. * Under the “Equipment” section it listed “Hydrogen Peroxide” and “Antiseptic solution for washing skin” and “Formalin” and “Betadine swabs” and “Alcohol prep pads.” The list was not procedure specific. It was unclear what “antiseptic solution” was to be used. It was unclear if those five solutions were all to be used for each minor surgical procedure. *Under the “Equipment” section it listed “Injectable lidocaine” and “Anesthetic, per M.D.” It was unclear what types of “anesthetic” were allowed to be administered to patients in this medical clinic that was not part of a general hospital. * Under Section B for “Method/Description” it included “Obtain any medications or solutions that will be required during the procedures.” It was unclear what “medications or solutions” were required for each type of procedure performed. * The “Method/Description” reflected “Use masks, goggles and gowns for the physician and staff if there is a potential of splatter or contamination by body substances.” * The “Method/Description” reflected “Position the patient according to type and location or surgery performed.” It was unclear what the positioning requirements were for each type and location of surgery performed. * The “Method/Description” reflected “Sanitize after surgery a. With gloves on, after the patient leaves, sanitize reusable instruments and supplies, dispose of disposable, clean and prepare room. B. Clean all instruments for sterilization, sterilize, and return them to proper storage area. C. Wash hands.” There were no specific instructions for “sanitizing” and “cleaning” and “sterilizing” instruments and supplies. *The protocol also stated, “Clinic Protocol, National Patient Safety Goals, will be adhered to as applicable.” However, it was unclear what National Patient Safety Goals from 2016 were being referred to, what “as applicable” meant, and whether those were still current in 2025. Further, There were no other policy and procedure references at the end of this protocol and there was no indication that the hospital’s Infection Preventionist had been involved in the development of the protocol to ensure appropriate and effective infection prevention practices during invasive procedures and during the processing of instruments and supplies. 5.e. The “Medical Department Protocol: 1.002” was titled “Orders” and was dated 03/02/2020. Under Section B were listed “Required Orders” that included “6. Seclusion and Restraint - must use the Seclusion & Restraint order form.” Under the “References” section at the end of the protocol it reflected “Policy and Procedure 6.003, Seclusion or Restraint Process.” *Review of the P&P “6.003 ... Seclusion and Restraint” dated 02/12/2024 revealed it contained no reference to a “Seclusion & Restraint order form.” *The “Policy Attachment Procedures B: Restraint or Seclusion Orders and Assessment by Physician/Nurse Practitioner ... 6.003” dated 02/12/2024 contained no reference to a “Seclusion & Restraint order form.” 5.f. The “Radiology Department” Policy and Procedure “PL1.00 ... Radiology Department Hours” was dated as last revised 05/13/2013. The space for “Approved By: was blank. The document reflected “The radiology technologist is on duty from 7:30 AM to 4:30 PM, Monday through Friday. If a radiographic exam is needed outside these hours, the OSH staff have two options: [although three options were listed] 1. Salem Hospital [address] 2. Salem Hospital MRI/CT Center [address] 3. The patient may be sent to the Salem Hospital Emergency room for the necessary exam.” That was the entirety of the Policy and Procedure. *During interview with the Deputy Medical Nursing Officer on 04/11/20225 beginning at 1000 they stated that the hospital currently has one Xray technician and that person works 4, 10-hour shifts. The current hours of operation are generally Tuesday through Friday 0630 to 1700. After hours, and at other times the Xray tech is not available such as for leave, the hospital uses a portable Xray company or sends the patient to Salem Health hospital. This current practice was not reflected the the Radiology Department P&P. *There were four other “Radiology Department” P&Ps provided (PL4.00, PL 6.00, PL 13.00 and PL 14.00). Those were each last reviewed or revised on 05/13/2013. The DMNO confirmed that the Radiology P&Ps were not current. *During interview, the DMNO also stated that the hospital did not have a functioning Xray machine for more than a year prior to December 2022. All Xray needs during that time were carried out by third-party Xray suppliers or by Salem Health hospital. 5.g. There were no policies, procedures, or protocols for the use and management of a sufficient oxygen supply for those patients who required oxygen and for use during medical emergency responses. ******************************************************”

“EMERGENCY SERVICES CFR(s): 482.12(f)(2) If emergency services are not provided at the hospital, the governing body must assure that the medical staff has written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate. This Standard is not met as evidenced by: 08621 ****************************************************** Based on observation, review of video recordings, interviews, review of incident and medical record documentation for 2 of 2 patients (Patient 3 and 16), review of OSH internal investigation documentation, review of training documentation for 4 of 5 LIPs (MD A, DO B, MD N and MD O) and 23 of 23 Direct Care nursing staff (RN C, RN D, RN E, RN F, RN G, RN R, RN T, RN U, RN W, RN Z, RN AA, RN EE, LPN H, LPN P, LPN Y, MHT J, MHT S, MHT Q, MHT V, MHT X, MHT BB, MHT CC, and MHT DD), review of training curriculum and training media, and review of P&Ps and other hospital protocols it was determined that the governing body of the hospital failed to fully develop and implement P&Ps that ensured that patients received care in a safe setting, including timely and appropriate medical emergency response. The hospital’s failures potentially contributed to harm and death of one patient and created the likelihood of harm to other patients. The failures related to the death of Patient 3 while they were in locked seclusion on 03/18/2025 included: * Failures of staff to initiate a timely and appropriate medical emergency response for Patient 3 who fell while standing on the toilet seat in the seclusion room bathroom and hit their head on the floor. The fall was witnessed and reported immediately to the RN on the unit by the 1:1 staff in the seclusion room anteroom. However, the first emergency response staff arrived to the seclusion room bathroom where the patient had laid unresponsive since the fall and checked for a pulse more than four minutes after the fall. CPR compressions were not started until five minutes and ~ 40 seconds after the fall. * Failure to ensure oxygen was readily available for treatment during medical emergencies. * Failure to complete clear, complete, and accurate documentation of code blue occurrences. * Failure to ensure staff were competent to perform assigned duties to provide appropriate and timely assessment of patient condition and identification of the need for medical emergency response. * Failure to develop and implement clearly written, effective policies, procedures, and staff training that ensured patient safety and security, and safety of others during seclusion events. * Failure to develop and implement clearly written, effective policies, procedures, and staff training that ensured patient safety and security, during Code Blue incidents involving patients who were in locked seclusion and under the direct supervision of hospital staff. * Failure to ensure clinical staff completed organized and documented Code Blue and CPR trainings that ensured clinical and procedural competency for patient care operations in that department. * Failure to ensure training curriculum for Seclusion and Restraint was in accordance with hospital P&Ps and offered First Aid as required by CMS regulations. Findings 1.a. through 1.e. of this Tag reflect it was determined that an IJ situation existed based on findings that hospital staff failed to initiate medical emergency response procedures for Patient 3 in a timely manner and the patient died on the seclusion room floor. On 03/31/2025 the SA survey team and Survey Manager met to review possible IJ for Tag A-093. On 03/31/2025 IJ was called and hospital leadership staff were presented with the IJ template. Between 04/02/2025 and 04/07/2025 the hospital submitted four versions of the IJ Removal Plan for Tag A-093. The fifth version of the IJ Removal Plan was submitted on 04/08/2025, and was approved with an implementation date of 04/11/2025. On 04/14/2025 an onsite IJ Removal Plan Verification Visit was conducted. The hospital was notified on 04/15/2025 that it was determined the hospital had not fully implemented the IJ Removal Plan. On 04/17/2025 the hospital submitted an IJ Removal Plan Update Amendment and on 04/18/2025 they sent an email to confirm they would be ready for a Verification Visit on or after 04/22/2025. The IJ Removal Plan Update Amendment was approved. On 04/24/2025 a second onsite IJ Removal Plan Verification Visit was conducted. The hospital was notified on 04/25/2025 that it was determined the hospital had not fully implemented the IJ Removal Plan. The survey team conducted the survey exit conference on 04/30/2025. On 05/06/2025 CMS issued the IJ CMS 2567 report to the hospital with the 23-Day Termination letter. On 05/07/2025 the hospital submitted the signed IJ CMS 2567 with the previously approved IJ Removal Plan Update Amendment and a new implementation date of 05/06/2025. On 05/12/2025 the third onsite IJ Removal Plan Verification Visit was conducted. After conferring with the Survey Manager on the afternoon of 05/12/2025 the survey team notified the hospital that it was determined the IJ Removal Plan had been fully implemented and that the recommendation to CMS was that the IJ for Tag A-093 was removed. Findings include: 1.a. During interviews on 03/26/2025 beginning at ~ 1045, again at ~1145, and at ~ 1345 hospital staff that included the DS, CNO, DCNO, DSC, DQM, DOIM, DOS, DHR, and others confirmed that on 03/18/2025 Patient 3 died unexpectedly in the LH2 treatment mall seclusion room. The following information was provided during those sessions: * Patient 3 had been in seclusion, in multiple different seclusion rooms, for several months. * Patient 3 had behaviors that included urinating and defecating on the floor, inducing vomiting, and masturbating. The floors and walls in the seclusions rooms and seclusion room bathrooms the patient had occupied became soiled with urine, feces, vomit, and other bodily fluids. It was reported that the patient’s violent and assaultive behaviors towards staff limited the times that those rooms could be cleaned. * Patient 3 had behaviors of self-harming that included dunking their head in the toilet and intentionally jumping and falling off of the seclusion room bathroom sink counter and toilet. The patient was identified as a high fall risk. * On the afternoon of 03/18/2025 Patient 3 was moved from a LH2 unit seclusion room to a seclusion room on the treatment mall. * At the direction of the attending psychiatrist, MD A, the door to the bathroom in the seclusion room on the treatment mall was to be unlocked, allowing the patient access to the bathroom sink counter and toilet. * Unit staff were assigned to 1:1 constant observation of the patient through the windows in the seclusion room ante room. Those staff were to call the RN at the nurse’s station to report incidents and changes of condition. * On 03/18/2025 between ~ 2132 and 2234 Patient 3 had three falls in the seclusion room bathroom. During the first and second fall the patient got up from the floor on their own and continued to ambulate in the room. After the third fall the patient did not rise from the floor and lay without voluntary movement on the bathroom floor. * There was a delay in the emergency response to Patient 3 because of past behaviors of “playing possum” and then assaulting staff when they arrived to provide assist or care. * The hospital’s internal investigation was initiated immediately after Patient 3’s death on 03/18/2025 and was ongoing at the time of the survey. * Concerns identified by the hospital included the emergency response delay. 1.b. The policy titled “Code Blue Medical Emergency” dated as last approved on 06/24/2024 including the following information and requirements: “[OSH] will provide immediate response to any medical emergency that presents anywhere on campus ... If the situation appears to be life threatening or life altering to the person, staff must call a Code Blue ... A physician, nurse practitioner (NP), or registered nurse (RN) must assess the person to determine whether an emergency medical condition exists and determine whether they need additional emergency care ... Once initiated, staff must continue CPR until authorized to terminate CPR by an OSH physician, responding community paramedic, or when the person recovers from cardiac arrest ... Definitions ... ‘Code Blue’ means a request for immediate response to any apparent emergency medical condition that could be either potentially life threatening or life altering ... ‘Emergency medical condition ... means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in - a. Placing the health of the individual ... in serious jeopardy; b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part ...” The Code Blue “Policy Attachment - Procedures A: Code Blue Medical Emergency Response” dated as last approved 06/24/2024 included the following: The “First Responder” duties included “1. If a person appears to be experiencing an emergency medical condition, evaluation the situation, do not leave the person. 2. Call for ‘Code Blue’, if needed ... 3. Request staff bring the emergency medical equipment. 4. Initiate emergency medical intervention(s) within the responder’s scope of practice or training.” The “Physician/NP/RN” duties included “1. Assess the person to determine whether they are experiencing an emergency medical condition.” 1.c. Video-recording of the medical emergency response for Patient 3 was reviewed on 03/26/2025 beginning at 1145, and again on 03/27/2025 beginning at 1330. The video revealed the following emergency response timeline: * At 2234:10 the patient crawled up to stand on the toilet seat. * At 2234:14 the patient fell off the toilet seat and clearly hit their head with impact on the floor. The patient made no attempt to get up off of the floor and did not demonstrate any purposeful or voluntary movements. * At 2235:04 the video showed that a multitude of staff responded to the LH2 unit and gathered in the hallway outside of the seclusion room. Staff who gathered included the psychiatrist on duty. * At 2235:42 the psychiatrist on duty entered the seclusion room anteroom. * At 2237:56 the door to the seclusion room was opened * At 2237:57 the first staff entered the seclusion room * At 2238:07 staff opened the seclusion room bathroom door * At 2338:22 two staff approached the patient who laid on the bathroom floor. The patient’s carotid pulse was checked. Sternal rub was conducted to which the patient did not respond. * At 2239 the code cart arrived * At 2239.52 staff started chest compressions * At 2249:30 EMS arrived and moved patient from the bathroom floor onto the seclusion room floor where there was more space for resuscitation efforts, equipment, and personnel. 1.d. An undated document titled “Code Blue Timeline - with review by [RN L]” was reviewed. The “Timeline” contained a detailed review of the video for the Code Blue response for Patient 3 and RN L’s comments about the response. Examples from the Timeline include: “22:34:15 [Patient 3] fell back and hit [their] head on the door/floor. [They] lay in a supine position.” “22:35:30 - 22:36:00 ... [DO B, RN G] and two staff arrived at the open ante room. [DO B] entered the ante room. [RN L’s comment:] They should be in seclusion assessing the patient by now.” “22:36:00 - 22:36:30 [RN L’s comment:] No one brought the code cart. It should have been brought with the first staff who ran to the seclusion room. Seven people were in the ante room, four people in the hall ... [RN L’s comment:] There are so many people in the hall, and no one is going into the seclusion room.” “23:36:30 - 22:37:00 11 staff entered hall from the stairwell by LH2 and 11 staff came from the other direction AN2.” “23:37:00 - 22:37:30 11 more responders arrived in the hall” “22:37:30 - 22:38:00 ... Someone brought a vitals machine to the scene from LH2 ... Seven security staff arrived in the hall. At 22:37:55 the seclusion room door opened from the hall.” “22:38:00 - 22:38:30 [RN G] opened the bathroom door and looked at the patient. [RN G] propped the door open.” “At 22:38:20 an agency RN knelt down to check the patient’s pulse at [their] carotid artery. [RN G] began giving sternal rubs. The vitals machine was wheeled into the seclusion room. [RN L’s comments:] The vitals machine is unnecessary. It’s located next to the code cart. They should have brought the code cart instead ...” “22:38:30 - 22:39:00 The agency RN and [RN G] turned the patient onto [their] side in a recovery position. [RN L’s comment:] They turned [the patient] over because they may be trying to clear secretions. They are rubbing [the patient], I’m not sure why. They should have immediately begun CPR. We need to train staff to pull the patient out of this area (bathroom) into a larger area (seclusion room). Staff pulled the code cart out of the exam room on LH2.” “22:39:00 - 22:39:30 [DO B] entered the seclusion room. The vitals machine was brought to the patient. The code cart was wheeled into the seclusion room. The vitals machine was wheeled away.” “22:39:30 - 22:40:00 [RN L’s comment:] The code cart was not cracked until 22:39:50. Staff grabbed suction from the code cart. The vitals machine was wheeled back over to the patient. The patient was rolled over from recovery to a supine position.” “At 22:39:54 [RN G] began chest compressions from a standing position. [RN L’s comments:] [RN G’s] doing CPR while standing up due to the stuff on the floor. [RN G] should not be standing up. [DO B] is the leader. [DO B] should be directing the code and telling staff to get the AED. [DO B is] just standing there.” “22:40:00 - 22:40:30 Staff attached a pulse oximeter to the patient’s finger. [RN L’s comment:] That’s unnecessary. [Patient 3 isn’t] breathing ... If someone started CPR then someone should be giving breaths with the ambu bag.” As the “Timeline” progressed RN L’s observations and comments from 2240:30 through 2244:00 also included: “Staff used the ambu bag. Staff removed a nasal canula from the cart ... The AED has been present since the cart arrived. It should have been used. They don’t need the nasal canula as the patient isn’t breathing ... An oxygen tank was wheeled into the seclusion room. The oxygen should have been brought with the cart ... Staff set up the AED ... It should have been used immediately if [the patient] had no pulse ... Someone should have been assigned to start compressions. They should swap out chest compressions every five cycles or when the AED cues you to. It looks like they are switching every three cycles ...” The “Timeline” concluded with the following: “22:49:00 - 22:50:00 EMTs arrived in the hall and entered the seclusion room. Staff in the bathroom continued chest compressions until EMTs arrive and moved the patient into the seclusion room.” 1.e. During interview on 03/26/2025 beginning at ~ 1045 with staff that included the CNO, DCNO, DSC, DQM, DOS, DHR, and others the following information about the hospital’s actions in response to the concern about the delayed emergency response was that “significant” resources for Code Blue and emergency response systems had been approved. Seven new position for Code Blue RNs had been approved and three RNs had been hired. During interview on 03/28/2025 beginning at ~ 1150 with the DCMO and others the DCMO stated that an RCA was in process for the delay in Code Blue response for Patient 3. They stated that actions taken were that there was a “new” Code Blue team, and that the DCMO was calling all psychiatrists who worked on nights and speaking with them about medical emergency response. There was no information provided that reflected any formal immediate mitigation actions had been implemented by the hospital in response to the problem that resuscitation efforts for a patient in locked seclusion were not initiated for five minutes and ~ 40 seconds while the patient laid unresponsive on the seclusion room bathroom floor after a fall during which they hit their head. The actions described during the interviews did not mitigate the immediacy of the problem. There was no indication that the likelihood of serious injury, serious harm, or death for other patients in locked seclusion had been removed while the underlying systems’ problems were identified and long-term corrective actions developed and implemented. 1.f. The policy titled “Code Blue Medical Emergency” dated as last approved on 06/24/2024 included the requirement that “Code Blue incidents must be reviewed by the Code Blue team and the Chief of Medicine (COM) to determine opportunities for systemic improvements. This review must include a completed ‘Code Blue Review Form’ which must be securely stored and retained for 3 years by the Code Blue Team.” The policy did not ensure that the Code Blue Flowsheet was maintained as part of the patient’s medical record as required for documentation of all aspects of care and services provided during a patients hospital encounter. The policy included a “Policy Attachment Procedures A” that specified that the “Recorder” was responsible to “1. Complete the Code Blue Flowsheet: a. Give the white copy to responding EMTs or emergency department. b. File the yellow copy in the patient ’ s medical record or give it to the person if they are not a patient. c. Send the pink copy to the [Chief of Medicine].” There was no other information regarding the completion of the flowsheet and it was not clear what was meant “give the white copy to ... emergency department” when this psychiatric hospital did not have an emergency department. 1.g. Documentation on the Code Blue Flow Sheet for Patient 3 was unclear and incomplete. For example: * Entries in the vital signs section of the form were incomplete, had write-overs or were otherwise illegible and unclear. A “Time” entered as “224[?]” was illegible; and another “Time” was recorded as “22.” * “Yes” was recorded for both “AED utilization” and “Defibrillation.” However, the space for “How many times” and “Successful:” were blank. * The spaces for the following were blank: - “Time of onset:” - “Time of code blue:” - “Chief Complaint:” - “Physician/nurse practitioner called hospital at:” - “Patient transported by:” - “Disposition of patient:” - “Emergency contacted called:” - “Relationship:” - “Team captain:” - “Title:” - “Recorder ... Signature:” - “Date:” - “Time:” * Further, the distribution instruction on the policy attachment identified above for the white and yellow copies of the flowsheet was not consistent with the distribution direction on the Code Blue Flowsheet itself, nor applicable to this psychiatric hospital. The distribution on the flowsheet was specified as: - “Original - Emergency Room “ - “Yellow - Consultation Section” - “Pink - Chief of Medicine”. 29708 2. Review of an IRF regarding Patient 16 with incident date 03/22/2025 reflected “... MHT was standing at the patient’s room and reported that [patient] fell but did not witness the fall. Observed patient on the floor of the entrance to the bathroom. Assessed patient for head injury, no apparent head injury. Patient asked for assistance, awaited for more staff to assist. Assisted patient back to [their] feet and onto [the] bed. Patient did not appear to be in any pain ... Code blue called during 3rd hourly Neuro assessment, patient’s O2 Sats ranging from 88%-91% ... Immediate Action(s) ... Code blue called, given Narcan and 2L of O2, Sats increased ... continue to monitor SpO2, SpO2 96% on 2L O2 ...” The “Document immediate actions taken:” section reflected “... code blue called on 3rd hourly assessment as patient was hard to wake and [oxygen] was in the lower range 88-91% ... Oxygen provided: concerns over availability of O2. Initially 2 liters ordered however order changed to 1 liter due to lack of available oxygen. Reported that there was no available oxygen, PNM reports that they found 5 full containers on the empty rack and over 30 empty cannisters [sic] ...” 3. Observations of the hospital’s oxygen storage area near Sally Port 6 with DMNO, DSC and other hospital staff on 04/08/2025 at 1450 revealed: * An entry door leading to an oxygen storage area. * Inside the oxygen storage area to the right of the entry door, approximately 19 portable oxygen tanks were observed in a storage rack. On the wall above the oxygen tanks, “FULL” and an arrow pointing downward toward the tanks in red paint was observed. * Inside the oxygen storage area to the left of the entry door, approximately 14 portable oxygen tanks were observed in or near a storage rack. On the wall above the oxygen tanks, “EMPTY” and an arrow pointing downward toward the tanks in black paint was observed. * A binder was observed in the oxygen storage area. The cover read “Log Book: O2 tanks. Signature required ... with credentials please ... Please leave the pen ... Use cart to transport Oxygen tanks”. The binder contained instructions titled “Grab ‘n Go Portable Oxygen System” that included information about oxygen set up, delivery and safety considerations. The binder also included an oxygen tracking sheet. 4. During interview with the DMNO on 04/08/2025 at the time of the observations in finding 2 in this tag, the DMNO stated: * Oxygen tanks are kept with code carts on patient units. When a tank is empty, “unit staff” are responsible for bringing the empty tank to the oxygen storage area and replacing it with a full tank. * The oxygen supply room near Sally Port 6 has a backup supply of 23 full oxygen tanks. When the backup supply drops below 50% or gets down to 11 tanks “we re-order more”. * Medical Clinic “Outside Scheduler” staff are responsible for making sure oxygen is available in the hospital when needed. They check the supply of oxygen in the oxygen supply room once a week. They also check the gauges on the oxygen tanks to make sure they are full. * The DMNO stated there was “a recent issue where we got pretty low [on oxygen]”. The DMNO stated they did not have any further information about the issue. 5. The P&P titled “Oxygen Therapy” dated approved 05/15/2023 and last reviewed 01/04/2021 was reviewed. The P&P was not fully developed as it did not include the hospital’s current practice regarding Medical Clinic “Outside Scheduler” staff checking the hospital’s oxygen tank supply and gauges to make sure they were available and full as described in Finding 4 in this tag. 6. Review of a “Standard Work Instructions” titled “Portable Oxygen Tank Management” with revision date 04/04/2025 reflected: * “Goal ... Delineate roles and responsibilities of portable oxygen tank management.” * “Purpose ... Improve understanding of portable oxygen tank management.” * “Who ... Outside Scheduling staff ... What ... Review and document O2 tank supply weekly on the Salem campus.” * “Who ... Outside Scheduling staff ... What ... OSH Salem campus will have a max supply of portable oxygen tanks not to exceed 23 tanks (one for each unit minus BY1 - who has access to wall oxygen).” * “Who ... Outside Scheduling staff ... What ... OSH Junction City campus will have a max supply will be 12 tanks (current maximum capacity). OSH Junction City campus medical clinic will notify the Outside Scheduling office when reordering is needed.” * “Who ... Outside Scheduling staff ... What ... Oxygen tanks will be reordered when the total supply drops below 50%. Standard for JC and Salem.” * “End of Process” The P&P was not fully developed as it did not include all stated practices described and observed. For example, it did not include: * That Medical Clinic “Outside Scheduler” staff would check oxygen tank gauges to make sure they were full as described in Finding 4 above. * Information about designated spaces for full and empty oxygen tanks in the oxygen storage room as described in Finding 3 above. 44104 7.a. The P&P titled, “Staff Training and Development ... Policy: 9.002” dated: April 23, 2024” was reviewed and reflected: * “Oregon State Hospital (OSH) provides staff with education and training ... to promote the acquisition of knowledge and skills while employed at OSH ... This policy applies to all staff.” * “Training provided by OSH must meet applicable state and federal regulations. When required by policy or regulations, staff must demonstrate competency before a training is considered complete.” * “All staff must complete annual training as indicated in Attachment A and as required by state, federal, or other regulations. OSH Executive Team must approve trainings before they are designated as mandatory unless the training is required by regulation.” * “Staff must complete mandatory training within the designated time period as required by policy, regulation or by the OSH Executive Team.” * “Training directed by this policy must be documented in the OSH-designated learning management system, Human Resources, supervisory, or Complementary Personnel Database (CPD) files.” * “Oregon State Hospital (OSH) follows all applicable regulations, including federal and state statutes and rules; Oregon Department of Administrative Services (DAS), Shared Services, and Oregon Health Authority (OHA) policies; and relevant accreditation standards. Such regulations supersede the provisions of this policy unless this policy is more restrictive.” * “Staff who fail to comply with this policy or related policy attachments or protocols may be subject to disciplinary action, up to and including dismissal.” * “Definitions ... ‘Staff’ includes employees, volunteers, trainees, interns, contractors, vendors, and other state employees assigned to work at Oregon State Hospital (OSH).” 7.b. The P&P titled, “Attachment A ... Annual Mandatory Training ... Policy Number: 9.002” dated “November 25, 2024” was reviewed and reflected: * A three-column table with the following headers, Training Title, Required Staff, and Due Date, listed the following training requirements: - “OHA - OSH Online: [YEAR] Annual Education - Code Blue ... All staff ... December 31 [Year]” - “Code Blue Drill ... Nursing ... Twice Annually” - “OSH American Heart Association (AHA) BLS CPR ... Staff according to OSH Policy 9.001 ... Annually for Nursing or staff working overtime for Nursing Every 2 years for non-Nursing staff”. 8. A document titled “Nurse Staffing Plan-Salem Campus” dated “June 4, 2024” was reviewed and reflected: * “Definitions ... ‘Agency staff’ means nursing staff who are contracted from external staffing agencies to meet staffing needs that cannot otherwise be met by available OSH employees ... ‘Nursing staff’ means a Registered Nurse (RN), Licensed Practical Nurse (LPN), and Mental Health Therapy (MHT) staff.” * “Nurse Staff Position Requirements and Qualifications ... Staff who fail to maintain required qualifications will not be allowed to work on patient care units ... Failure to maintain required qualifications may result in disciplinary action. Nursing staff qualifications are documented and maintained in their credentialing file which is maintained by Nursing Administration.” * Two tables, each with three columns titled: Position, Requirements and Authorized Work Location contained the following information for RNs, LPNs, and MHTs ... Requirements and Work location, respectively: “Annual Competencies ... All programs”. * “Nursing Staff Trainings and Competencies ... The training and competencies identified below apply to all units and levels of care at the Oregon State Hospital ... If trainings are not completed in the required time window, the employee will be scheduled time off the unit to complete the required trainings. Staff will not be allowed to work on the patient care units until all required competencies are in compliance ... Failure to complete the necessary competencies and maintain position requirements within the allotted time windows may result in disciplinary action.” * “Training and competency completion is documented within the Workday Learning Module. Required annual competency verification and documentation is kept in the employee credentialing file and maintained and stored by Nursing Administration.” * “New Employee Orientation (NEO) Required Trainings ... for All Nursing Staff ... Code Blue ... NEO Trainings are only required for staff hired after January 1, 2020. These are in addition to the annual competency requirements.” 9. The P&P titled, “Contracted ... Nursing Staff ... Protocol: 2.010” dated “October 2, 2023” was reviewed and reflected: * “The purpose of this protocol is to describe the expectations and procedures related to the use of contracted (agency) nursing staff at Oregon State Hospital (OSH).” * “Agency nursing staff meet the same minimum qualifications and requirements for credentialing as hospital-employed nursing staff working in equivalent positions.” * “Agency nursing staff must adhere to all OSH policies, procedures, and protocols.” * “Staff in the above-named department who fail to comply with this protocol may be subject to disciplinary action, up to and including dismissal.” 10.a. The P&P titled, “Basic Life Support ... Cardiopulmonary Resuscitation ... Training and Certification ... Policy: 9.001” dated 06/28/2023 was reviewed and reflected: * “This policy established Oregon State Hospital (OSH) procedures and requirements for Basic Life Support (BLS) Cardiopulmonary Resuscitation (CPR) certification for staff ... This policy applies to all staff.” * “ ... OSH designates staff who must maintain BLS CPR certification appropriate to their position.” * “All staff working in the capacity of one of the positions listed in Attachment A of this policy (including overtime shifts) must maintain AHA BLS CPR certification.” * “Employees listed in Attachment A are responsible for maintaining their own certification and must avoid any lapse in certification.” * “Supervisors are responsible for verifying staff compliance with this policy at performance reviews.” * “Staff who fail to comply with this policy or related policy attachments or protocols may be subject to disciplinary action, up to and including dismissal.” * “’Staff’ includes employees, volunteers, trainees, interns, contractors, vendors, and other state employees assigned to work at Oregon State Hospital (OSH).” 10.b. The P&P titled, “Attachment A ... Required BLS CPR Certification List ... Policy: 9.001” dated 06/28/2023 was reviewed and reflected: * “Clinical ... Physician Specialist ...” * “Nursing ... Nurse Practitioner ... Psychiatric Mental Health Nurse Practitioner ...” 11.a. The P&P titled, “Policy: 8.038 ... Code Blue Medical Emergency” dated “June 24, 2024” was reviewed and reflected: * “Oregon State Hospital (OSH) will provide immediate response to any medical emergency that presents anywhere on campus and requires a coordinated team effort by staff trained in American Heart Association Health Care Provider Basic Life Support cardiopulmonary resuscitation (CPR) and first aid. In accordance with OSH licensing requirements, OSH will offer reasonable basic life safety emergency response to stabilize the person, if possible, and transfer their care to an acute-care facility when needed ... This policy applies to all staff, including employees, volunteers, trainees, interns, contractors, vendors, and other state employees assigned to work at OSH.” * “A physician, nurse practitioner (NP), or registered nurse (RN) must assess the person to determine whether an emergency medical condition exists and determine whether they need additional emergency care.” * “Staff listed in Attachment A must complete Code Blue training annually.” * “Mental Health Registered Nurses, Licensed Practical Nurses, and Mental Health Therapy classifications are required to complete Code Blue drills twice annually.” * “Staff who fails to comply with this policy or related procedures may be subject to disciplinary action, up to and including dismissal.” * “Definitions ... ‘Staff’ includes employees, volunteers, trainees, interns, contractors, vendors, and other state employees assigned to work at Oregon State Hospital (OSH).” 11.b. The P&P titled, “Attachment A ... Code Blue Training List ... Policy: 8.038” dated “June 24, 2024” was reviewed and reflected: * “In accordance with OSH Policy 8.038, every employee working in the capacity of one of the positions listed below must complete Code Blue training annually”. * “Nursing ... Mental Health Registered Nurse ... Mental Health Supervising Registered Nurse ... MHT1 ... MHT2 ... MHTT ... Nurse Manager ... Any employee working in a RN license-required or LPN license-required position”. * “Clinical ... Nurse Practitioner ... Physician, Primary Care ... Physician, Psychiatrist ... Supervising Physician ... Clinical Psychologist 1& 2 ...” 12.a. During interview and review of training documentation, including Medical Staff education/training records with the DSC, CS, SE/OPA2, DHR, and other hospital staff on 03/31/2025 beginning at 1315, hospital staff provided the following information: * Regarding MD A, with hire date of 01/31/2017, training/education records reflected there were no Annual Code Blue trainings documented for 2021, 2022, 2023, or 2024. Documentation reflected: - A “Policy Review - 8.038 Code Blue ... Updates (04/09/2025)” was completed on 04/09/2025. - A “Policy Review - 8.038 Code Blue” was completed on 11/17/2024. - The most recent Code Blue “classroom training” was completed on “06/03/2015”. * Regarding Medical DO B, with hire date 01/28/2013, and who responded to the 03/18/2025 Code Blue event for Patient 3, training/education records reflected there were no Annual Code Blue trainings documented since 2015. Documentation reflected: - A “Policy Review - 8.038 Code Blue ... Updates (04/09/2025)” was completed on 04/10/2025. - A “Policy Review - 8.038 Code Blue” on 06/24/2024 was “Not Started”. - A “Policy Review - 8.038 Code Blue” on 05/09/2024 was “Not Started”. - The most recent Code Blue “classroom training” was completed on “05/29/2015”. * Regarding Medical MD N, with hire date 09/14/2020, training/education records reflected there were no Annual Code Blue trainings documented for 2021, 2022, 2023, or 2024. Documentation reflected: - A “Policy Review - 8.038 Code Blue ... Updates (04/09/2025)” was “Not Started” as of 04/10/2025, 11 working days after the start of the survey. - A “Policy Review - 8.038 Code Blue” on was completed on 06/25/2024. - A “Policy Review - 8.038 Code Blue” on was completed on 06/04/2024. - An “Annual Code Blue ... Online Training” was completed on “09/17/2020”. - Additionally, training records for MD N reflected that their BLS certification expired on 03/15/2025, and MD N was still providing direct care to patients. * Regarding Medical MD O, with hire date 07/06/2009, training/education records reflected there were no Annual Code Blue trainings documented for 2021, 2022, 2023, or 2024. Documentation reflected: - A “Policy Review - 8.038 Code Blue ... Updates (04/09/2025)” was completed on 04/09/2025. - A “Policy Review - 8.038 Code Blue” on was completed on 07/31/2024. - A “Policy Review - 8.038 Code Blue” on was completed on 05/15/2024. - An “Annual Code Blue ... Online Training” was completed on “10/01/2020”. - The most recent Code Blue “classroom training” was completed on “05/29/2015”. 12.b. Nursing staff Annual Code Blue training records related to nursing staff requirements were not complete for all direct care staff. Review of employee training documentation reflected the following: * Agency RN D, with hire dates 04/04/2022 and 10/23/2023, reflected one but not two Code Blue training drills for 2024, as required by hospital policy. * Regarding RN F, an agency RN with hire date 12/11/2023, and who was present during Patient 3’s Code Blue event, training/education records reflected Annual Code Blue trainings were not completed every year as required. Documentation reflected: - An “Online: 2025 Annual Education-Code Blue” was completed on “02/28/2025”. - A “Policy Review - 8.038 Code Blue” was completed on 07/01/2024. - A “Policy Review - 8.038 Code Blue” was completed on 05/27/2024. - An “Online: 2023 Annual Education-Code Blue” was completed on “12/15/2023”. * RN U, a regular full-time staff with hire date 08/08/2008, reflected no evidence of Code Blue training drills for 2024 as required by hospital policy. * Agency RN Z with hire date 09/27/2021, reflected no evidence of Code Blue training drills for 2024 as required by hospital policy. * LPN P, a regular full-time staff with hire date 10/09/2023, reflected one but not two Code Blue training drills for 2024, as required by hospital policy. * LPN Y, a regular full-time staff member with hire date 07/25/2022, reflected one but not two Code Blue training drills for 2024, as required by hospital policy. Additionally, a medical emergency assessment test was not available for review and had not been retained in the Workday Learning Module or in the employee credentialing file per policy. * MHT CC, a regular full-time staff member with hire date 04/08/2019, reflected one but not two Code Blue training drills for 2024, as required by hospital policy. * There was no evidence of two Code Blue training drills for 2024 as required by policy for the following five other regular direct care staff: - RN W with hire date 12/12/2016. - RN EE with hire date 12/04/2017. - MHT X with hire date 04/06/2020. - MHT BB with hire date 01/22/2024. - MHT DD with hire date 07/31/2023. The hospital failed to provide safe care for Patient 3 who had an emergency “Code Blue” event while in seclusion and died. The hospital’s failure to provide safe care included a lack of trained direct care clinical staff who responded to the Code Blue event which included DO B and at least one agency RN F, both of whom had not completed Annual Code Blue trainings as required by hospital P&Ps. Refer to Findings 12.a. and 12.b, staff competency records, and Finding 11.a., the Code Blue Emergency P&P that reflected, “Staff listed in Attachment A must complete Code Blue training annually ...” and Finding 11.b., “Attachment A ... positions listed below must complete Code Blue training annually ... Nursing ... MHT[s] ... Any employee working in a RN license-required or LPN license-required position ... Clinical ... Nurse Practitioner ... Physician, Primary Care ... Physician, Psychiatrist ... Supervising Physician ... Clinical Psychologist 1& 2 ...” Additionally, four of five LIPs responsible for assessing “the person to determine whether an emergency medical condition exists and determine whether they need additional emergency care” as required by the Code Blue P&P, Finding 11.a., had not completed annual Code Blue training for greater than four years, and DO B, the LIP present during Patient 3’s event, had not completed Code Blue training for almost 10 years. Additionally, 16 direct care staff, including the LIPs, RNs (agency and regular staff), and MHTs did not have up-to-date Code Blue training, and were still providing direct care to patients contrary to hospital P&Ps, which reflected, “If trainings are not completed in the required time window, the employee will be scheduled time off the unit to complete the required trainings. Staff will not be allowed to work on the patient care units until all required competencies are in compliance ...”, refer to Finding 8, Nurse Staffing Plan. Refer also to Findings 7.a., 9., 10.a., and 11.a., “Staff who fail to comply ... may be subject to disciplinary action, up to and including dismissal.” Leadership failed to fully implement training P&Ps, and failed to verify compliance with CPR and BLS requirements as directed by hospital P&Ps, and allowed a provider with an expired CPR certification, MD N, to provide direct care to patients. Refer to Finding 10.a, Required CPR Certification P&P, “Supervisors are responsible for verifying staff compliance with this policy at performance reviews ... [and] Staff who fail to comply with this policy or related policy attachments or protocols may be subject to disciplinary action, up to and including dismissal.” 12.c. Findings 12.a and 12.b. were confirmed at the time of the training review by the SE/OPA2. 12.d. An email from the COP to the CS on 04/10/2025, confirmed that MD N had been “actively working” at the hospital with an expired CPR certification since 03/15/2025. 12.e. An email dated 04/11/2025 from the DCMOA reflected, “[MD N’s] BLS/CPR certification expired on 3/15/25 and [they] is currently scheduled to re-certify on 4/15/25 ...”one month after the expiration date. 12.f. There were no training records for First Aid for any of the direct care nurses, as the hospital did not provided First Aid training specific to patients who were secluded or restrained. 13.a. The hospital failed to provide training for Seclusion and Restraint that adhered to hospital P&Ps. The curriculum provided did not reflect training for First Aid specific to a restrained or secluded patient as required by CFR 482.13(f)(2)(vii). For example: 13.b. The P&P titled, “Use of Seclusion Room Bathroom ... Protocol: 2.220” dated “August 1, 2023” was reviewed and refelcted: * “The purpose of this protocol is to give nursing staff at Oregon State Hospital (OSH) directions regarding the safety monitoring required when a patient uses the Seclusion Room bathroom.” * “When a patient is in locked seclusion, the door to the bathroom may be either locked or unlocked based on the assessment of the Register Nurse (RN) regarding the patient’s ability to safely utilize the bathroom.” * “When a patient is utilizing the unlocked Seclusion Room (e.g., for Voluntary Movement Restriction [VMR]) and is not under direct observation, the door to the bathroom must be locked.” 13.c. The P&P titled, “Policy: 6.003 ... Seclusion and Restraint” dated “February 12, 2024” was reviewed and reflected: * Purpose And Applicability ... Oregon State Hospital (OSH) is committed to supporting a patient’s right to be free from inappropriate seclusion or restraint while protecting the physical safety of patients, staff, and others ... This policy applies to all staff, including employees, volunteers, trainees, interns, contractors, vendors, and other state employees assigned to work at OSH.” * “Seclusion or restraint may only be used when clinically justified by a behavioral emergency (as defined in this policy) when other interventions have been determined to be ineffective. When used, restrictive interventions must be discontinued as soon as possible.” * “Unless safety demands immediate physical response, staff must first consider non-restrictive interventions such as engagement, disengagement, offering a therapeutic item or medication to aid with calming or symptom management, verbal redirection, asking the patient to remove themselves from the milieu or an RN offering Voluntary Movement Restriction, calling for a show of concern, or other de-escalation to prevent a situation from escalating to the point of using seclusion or restraint.” * “Staff must apply the least restrictive interventions incrementally and no more than what is necessary to safely manage the behavioral emergency ... Seclusion or restraint may not be used as a substitute for an activity or treatment,or as a means of coercion, discipline, convenience, or retaliation by staff ... Chemical restraint may not be used at any time.” * “... if efforts such as de-escalation, disengagement, or evasion are not possible or fail and a patient is engaging in physical aggression imminently directed at another person, trained staff may act in self-defense or immediate defense of another person if reasonably necessary to prevent harm to that person. This includes but is not limited to ... Before the arrival of a physician/NP or RN, staff may manually restrain the patient or seclude the patient by preventing the patient from physically leaving any room. (Note: Staff may not direct the patient to walk to a designated seclusion room or initiate mechanical restraint. These require the authorization of an RN, NP, or physician.) ... This temporary restrictive intervention may only continue until a RN, NP,or physician is notified, assesses, and provides direction about continuation or discontinuation of the restrictive intervention(s).” * “A face-to-face assessment must be conducted by a physician/NP within one hour of the initiation of a seclusion or restraint event per Procedures B ... If a Physician or NP is unavailable to complete the assessment, a trained Nurse Manager, Program Nurse Manager, or Program Lead RN may be delegated to conduct the assessment per Procedures B.” * “OSH follows all applicable regulations, including federal and state statutes and rules; Oregon Department of Administrative Services (DAS), Shared Services, and Oregon Health Authority (OHA) policies; and relevant accreditation standards. Such regulations supersede the provisions of this policy unless this policy is more restrictive.” * “Staff who fail to comply with this policy or related policy attachments or protocols may be subject to disciplinary action, up to and including dismissal.” * “Definitions ... ‘Behavioral emergency’ in this policy means a situation in which ... the patient presents an imminent danger of harm to self or others (as defined in this policy), and ... nonphysical interventions are not viable, and ... safety concerns require an immediate physical response.” * “’Chemical restraint’ means a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.” “’De-escalation skill set’ in this policy includes interpersonal communication and conflict resolution skills to de-escalate a potentially dangerous situation without using seclusion or restraint and to develop or maintain a positive relationship with the person(s) involved.” * “’Imminent danger of harm’ in this policy means a substantial likelihood of immediate physical harm to the patient or others, an immediate and substantial likelihood of significant property damage, or an immediate and serious disruption of the activities of other patients in the area.” 13.d. The P&P titled “Procedures B ... Restraint or Seclusion Orders and Assessment by Physician/Nurse Practitioner ... Policy: 6.003” dated “February 12, 2024” was reviewed and reflected: * “Implementing a more restrictive intervention (e.g., moving a patient from seclusion to mechanical restraint or adding a chest strap to a patient in mechanical restraint) requires a ... face-to-face assessment by a physician/NP.” * “All manual restraints require ... [a] face-to-face assessment by a physician/NP ... If the manual restraint occurs after the patient is already in seclusion or mechanical restraint ... a new face-to-face assessment by the physician/NP is required.” * “Orders following initiation of seclusion or mechanical restraint ... Following a face-to-face assessment, the physician/NP may order continued seclusion or mechanical restraint if indicated. This order may not exceed three hours and begins at the time that the previous telephone order expires, irrespective of the time that the face-to-face order is written ... If the physician/NP is present and conducts a face-to-face assessment during the process of seclusion or mechanical restraint, the initial order may not exceed four hours.” * “Subsequent orders if [sic] seclusion or restraint continues after the initial four hours ... If four hours have passed since initiation of the restrictive intervention (or since the previous face-to-face assessment by the physician/NP, for events lasting longer than eight hours), the RN must contact the physician/NP to obtain a telephone order to continue seclusion or restraint ... If eight hours have passed since initiation of the restrictive intervention or since the previous face-to-face assessment by a physician/NP, an order for continued seclusion or mechanical restraint must be written by a physician/NP following a new face-to-face assessment ... A physician/NP may conduct a face-to-face assessment and write a new order earlier than eight hours since initiation of the restrictive intervention or the previous face-to-face assessment. In such cases, if seclusion or restraint continues to be required four hours after that face-to-face assessment was conducted, the RN must obtain a telephone order to continue seclusion or restraint.” * “A physician/NP must conduct a face-to-face assessment of the patient within one hour of the initiation of seclusion or any kind of restraint, including manual restraint ... If the Psychiatrist on Duty (POD) is not able to complete the assessment within one hour they may assign this duty to a Nurse Manager (NM), Program Nurse Manager (PNM), or Program Lead RN (PL) who has been trained and deemed competent ... The NM/PNM/PL must conduct the face-to-face assessment within one hour after seclusion or restraint is initiated; then ... The NM/PNM/PL must immediately call the POD to discuss the assessment, the need for other interventions or treatment, and the need to continue or discontinue seclusion or restraint. The NM/PNM/PL must document the assessment and discussion with the POD ... The POD must conduct a face-to-face assessment no later than two hours after the initiation of seclusion or mechanical restraint. If continued seclusion or mechanical restraint is indicated, the order may not exceed two hours, and begins when the second telephone order expires, irrespective of the time that the face-to-face order is written.” * “The physician/NP must document the following in a progress note no later than the end of their work shift: 1. The time they conducted the face-to-face assessment ... The patient’s condition or symptom(s) and specific behavior(s) that justified using the intervention ... The restrictive intervention used and the patient’s response to the intervention ... Patient quotes from the interview during the in-person interaction or an explanation as to why the patient was unable to participate in a discussion ... A summary of the patient’s relevant history related to the current behavior and mental status, including documentation of any patient injury during the event ... The circumstances around any expired orders, if applicable ... The plan to reduce the intervention; and ... Any consultation obtained during the restrictive event.” 13.e. The P&P titled, “Attachment D ... Training Requirements ... Policy: 6.003” dated “February 12, 2024” was reviewed and reflected: * “Oregon State Hospital (OSH) will provide training to staff about restrictive interventions which meets regulatory requirements and as directed by OSH’s Education Department ... All staff with direct patient care responsibilities and any other staff involved in the use of seclusion or restraint must receive ongoing training and demonstrate competency and understanding of the following ... OSH philosophy, goals, and policies regarding the use of seclusion or restraint ... Cardiopulmonary resuscitation (CPR); and ... First aid techniques.” * “Designated Nurse Managers/PNMs/Program Leads must be trained once every two years and demonstrate competency to complete the one-hour face-to-face assessment on behalf of the Physician/NP as described in OSH Policy 6.003, “Seclusion or Restraint”. Training must also include content to ... Evaluate the patient’s immediate situation ... The patient’s reaction to the intervention ... The patient’s medical and behavioral condition (including a complete review of systems assessment, behavioral assessment, review and assessment of the patient’s history, medications, most recent lab results, etc.), and ... The need to continue or terminate the restraint or seclusion.” The P&Ps on Seclusion and Restraint contained unclear and inaccurate information about Face-to-Face assessments and First Aid training required. For example, on 04/10/2025, documentation of Face-to-Face training was requested for RNs who performed Face-to-Face assessments from the sample list of RNs selected for record review as the P&P for Seclusion and Restraints reflected, “If a Physician or NP is unavailable to complete the assessment, a trained Nurse Manager, Program Nurse Manager, or Program Lead RN may be delegated to conduct the assessment ...” refer to Findings 13.c. and 13.d., Seclusion and Restraint P&Ps, and 7.e. training requirements for S&R. However, during communication about the P&Ps for Seclusion and Restraint related to the practice of Face-to-Face assessments by nurses, the DSC reported to the survey team that Face-to-Face assessments by nursing staff only occur on the Junction City campus, and not on the Salem campus. The DSC further acknowledged in an email dated 04/23/2025 that “We understand that this is in policy. Our current practice in Salem is to only have providers do face-to-face. OSH has it in policy for NMs PNMs and PLs to cover in Junction City because the amount of staffing to support Junction City is different. We are in the process of updating our policy to better reflect this.” Refer also to Finding 15.b., Slide 27 S&R training that discusses Face-to-Face training and does not distinguish between campuses. Also refer to Findings 15.a., 15.b. and 15.c. regarding S&R training curriculum and the lack of specific First Aid training as described in hospital policy “Training Requirements ... Policy: 6.003”, Finding 13.e., “All staff with direct patient care responsibilities ... involved in the use of seclusion or restraint must receive ongoing training and demonstrate competency and understanding of ... First aid techniques.” 14.a. The P&P titled, “Enhanced Supervision ... Policy: 6.010” dated “February 28, 2024” was reviewed and reflected: * “This policy establishes guidelines for enhanced supervision at Oregon State Hospital (OSH) ... by minimizing the occurrence of aggressive, suicidal, or self destructive behavior ... This policy applies to all OSH staff.” * “The least intrusive means of providing effective treatment must be used, with the goal of helping patients regain the ability to maintain safety toward self and others without the need for an increased staff presence.” * “Any limitation to a patient’s rights must be clinically justified ...” * “’1:1 supervision’ means a staff member must be assigned to monitor a patient ’ s location and activities at all times. The assigned staff member must maintain constant visual contact and consistent physical proximity, as well as verbal contact while the patient is awake, within parameters specified by the ... order and as described on the Intervention Card. The psychiatrist or PMHNP must specify additional parameters, as appropriate, in the order.” 14.a. The P&P titled, “Staff Responsibilities ... Policy: 6.010” dated “February 28, 2024” was reviewed and reflected: * “Additional considerations for staff assigned to 1:1 supervision ... Staff must continuously visualize the head, neck, and hands of any patient on 1:1 suicide/self-harm supervision, including during patient use of bathroom and shower ... Staff must remain approximately two (2) arm lengths from the patient (in the doorway if the patient is in their bedroom) unless the supervision order or acute safety considerations require otherwise ... Staff must provide their attention to the patient and direct other patients to be assisted by other available staff ...” 15.a. A document titled, “Safe Together for Nurses Facilitation Guide” updated “1.31.2025” was reviewed and reflected: * “Learning Objective ... By the end of the lesson, learners develop a sense of welcome and support by peers and instructors through discussion and perspective sharing.” * “Learning Objective ... During group discussion and application, learners develop confidence in assessing restraints to improve safety and effectiveness of restraints ... After participating in downgrade, learners compare options to increase safety when team [sic] move from restraints to seclusion.” * “Share a quick overview of the tasks you are going to accomplish (restraint assessment, 5- point restraint, downgrade, and shields).” * “Only a provider or RN may authorize a restrictive intervention, least restrictive options attempted first, etc. (Policy 6.003)” * “RN/LPN must supervise staff actions in person during application of restraints. LPNs can do so because application of restraints is a focused assessment. Assess and correct staff positioning as needed. Ensure no direct pressure on patient’s joints, spine, face, neck. Assess your staff safety as well - look for signs of needing to be switched out. Pain, fatigue, stress. Assess patient breathing, circulation, skin integrity, injuries.” * “Mechanical Restraints Applied ... Assess all four points, counterclockwise. Keep observations to yourself. Coach observes processes used to assess (two finger method still being used, etc.) Nurses demonstrate proficiency by using proper assessment techniques and by pointing out errors in restraint application, as well as proper methods for correcting improper restraint placement. Wrist restraints: ask staff to lift pt’s hand so license can view gap between pts skin and the restraint. Goal is to see no light through the gap. Safely contain pt’s hand; grab locking mechanism strap and slowly twist the soft restraint. It should move slightly, if not, it is too tight. Ankle restraints: ask staff holding pt’s leg to allow license to see through any gap between the restraint and the skin. There should be no light showing through. Nurses should assess the tightness of the waist belt as the fifth point of restraint. Using a flat hand, pointing toward the head of the patient, starting at the patient’s hip and moving inward, ensuring that its seatbelt tight. Check for contraband prior to exiting the room. Talking point: What is allowed in seclusion? Shoes - RN discretion, pedal pulse considerations, ability to use heels to dig in, etc. Who can offer the wedge? What other reasons would we use the wedge?” * “Upgrade to 5 Point - Chest Strap ... Reason for upgrade? Risks? Requires a separate order unless it is complete prior to closing the seclusion room door, in which case it can be added to the initial order. If occurring after the door has been shut, an RN or LPN can call for the order and the upgrade can occur after the call is made ... Reasons? (Rocking, thrashing, self-harm.) Process: After RN assesses need for chest strap, nurse assesses placement, lining the strap up with the slot directly aligned with the patient’s eyes and ears. Placement of the chest strap is above the nipple line. The label on the strap must be centered on the chest.” * The facilitation guide described the physical process of employing the 5 point restraint, similar to the talking points outlined in the previous technical description of the four-point restraints above. * “Downgrade” Similarly, the talking points contained a technical description of the process. * “Most Restrictive Downgrade”. Similarly, the talking points contained a technical description of the process, including how to remove the bed from the Seclusion room. The description then stated, “... remove the restraints buckle side first. When finished with this step, they [staff] will step back and all arm staff to assist pt to the bathroom, or to a sitting or lying position. When it is safe to do so, all staff exit the room. The two staff touching the patient or holding the bathroom door closed exit last and the seclusion room door is then locked. Downgrade can be straight from restraints to milieu. In this instance, procedures will be much less restrictive.” * “Shields ... Learning Objectives ... During hard shield discussion, learners review procedures to understand roles and responsibilities when using the safety device ... After soft shield discussion, learners identify changes to accommodate use of soft shields to decrease chance of injury.” * “Hard Shield ... Item vs. weapon verbiage Code Purple Roles: Provider, RN, Shield Lead -Discuss Responsibilities of each, required collaboration between the three. Requirements to be a Shield Lead -Only Security and TSO currently. 4 Hour Annual, quarterly etc. Risks of Shield Use: Patient? Staff? The Planning Process -Considerations? (Secluding Patient, Verbal De-escalation, Pursuing Least Restrictive) Appropriateness? (age, trauma/abuse history, medical/psychiatric condition). Overview -Provide a quick example, from real experience or hypothetical, of what that planning process might look like. Documentation required of each role -Manual Restraint order (Provider), Incident Reports (All staff involved except Provider), Progress Note detailing least restrictive attempts (RN), S & R required documentation (RN). The incident report filled out by hard shield lead must be done whether shield was deployed or not, and must contain who requested the hard shield, the reason for retrieving it, and whether security was notified.” This was followed by a review of debriefing, after action review and administrative follow up on the use of the shield. * “Soft Shields ... Soft Shield Requirements (RN approval removed) - ‘any behavioral emergency where there are conditions of dangerous behavior and means of harm’ and agreement between both staff capturing arms. We still also require the team and plan; we do not use them in emergent situations. Following code green with soft shield deployment, RN must document in a progress note the less restrictive interventions attempted and why they were unsuccessful. IRs should be filled out by all involved if it is a reportable incident (staff or patient injury, etc.). IRs are also encouraged when soft shields are deployed in successful interventions as support to illustrate why we have them as a safety tool.” * “Wrap Up ... Cover any questions ...” The Facilitation Guide failed to provide emphasize the use of “least restrictive interventions” and mention of “First Aid” techniques were non-existent. For example, it was unclear from the Facilitation Guide whether “... least restrictive options attempted first, etc. (Policy 6.003)” actually covered the policy or whether other interventions such as “... engagement, disengagement, offering a therapeutic item or medication to aid with calming or symptom management, verbal redirection, asking the patient to remove themselves from the milieu or an RN offering Voluntary Movement Restriction, calling for a show of concern, or other de-escalation to prevent a situation from escalating to the point of using seclusion or restraint...” as reflected in the hospital’s P&P 6.003, were discussed or practiced. Further, the Facilitation Guide did not include any mention of First Aid for patients in distress or injured, and only addressed patient injuries in the following sentence, “Assess patient breathing, circulation, skin integrity, injuries.” 15.b. A 46-slide power point titled, “S&R for Nursing Licenses” dated “4.3.25” was reviewed and reflected: * Slide 2 notes discussed the course objectives, “We will be asking judgement questions and provide scenarios to provide for open discussion ... The goal is to have open discussions about assessments and how people view safety, what imminent harm is to them, and how to utilize least restrictive options. The goal of this class is to cover material to provide a space to become more comfortable with what is expected of licenses, and to protect staff, and patients from harm.” * Slide 3 noted, “Decisions ... Are seclusion or restraints needed ... Is an upgrade or downgrade needed and was it completed ... What other options are available for the patient that are least restrictive”. * Slide 4 noted, “RNs must justify why an S&R is needed and assess ... Documentation is required”. * Slide 5 listed documentation times for tasks such as obtaining orders, completion of forms and assessments. * Slide 10 noted, “No direct pressure may be placed on the patient’s joints, spinal column, neck, or eyes, mouth or nose, per OSH policy 6.003 ... A nurse needs to assess pt. breathing, circulation, skin integrity, injuries, etc. Assess, adjust, and provide care as needed.” * Slide 11 described downgrading a patient from restraints to Seclusion. It reflected, “After the nurse has assessed for safety, the team will enter the seclusion room ... Arms on arms, legs on legs, shadowing the limbs or providing light contact as needed ... The RN will verbally walk the patient through the process of downgrading ... Downgrading to seclusion ... The arm staff on the opposite side will sit next to the patient and gently hook the patient’s arm ... When the patient is ready, allow a full minute for blood circulation and ensure the patient is not dizzy and to prevent falls, help them stand up regaining balance ... Lead will make sure everything is out of the room ... Lead or RN will ask the patient what they would like to do so the arms staff can leave the room safely ... We can ask the patient to go into the bathroom, sit, or lie down ... Do not ask a patient to kneel. If a patient chooses to kneel remind them, they do not have to kneel and document in a Progress Note ... Arm staff will maintain contact and assist the patient into a sitting or lying position, or into the bathroom, verify they have a clear exit, and then exit the room.” * Slide 13 included updated changes to the power point which were added during the survey and will not be considered as part of the training review. * Slide 17 was titled “Care of patient in the side room”. * Slide 18 reflected, “Nurses are required per OARs to obtain an order ahead of time when able, and per the nursing act to know if they can restrain a patient when it is not for imminent harm, such as medication administration/IMBU ... Restrictive events increase the potential of injury and trauma to both patients and staff ... Is the forced medication really needed? This is up to the practitioner to decide ... Even if there is an IMBU order in the eMar ... This order is for the medication, not for restraining a pt.” * Slide 19 presented scenarios for offering least restrictive options for a “Disruptive Milieu”, that included “Naked Patient ... Racial Slurs ... [and] Masturbating in milieu”. * Slide 20 titled, “Enhanced Supervision” and reflected, “The staff’s focus is and should only be the 1:1/patient”. * Slide 22 noted the following about VMR, “The seclusion room bathroom door must always be locked while the patient remains unsupervised.” * Slides 23 - 41 were focused on documentation that included but limited to: monitoring and reporting forms, data entry, and shift-to-shift communication. * Slide 26 included a form titled, “Additional Considerations”. This form had one line about patient injuries under the section titled “The RN Assessment of the Patient in S&R includes” and then “1. respiration, skin color, injuries”. * Slide 27 reflected, “If a trained RN is completing the initial face-to-face within the first hour, treat the RN as if they are a practitioner that can’t write orders ... If continuation of S&R is needed a floor nurse must get an additional 1 hr order from the practitioner”. * Slide 29 included a form titled, “Emergency Seclusion or Restraint Entry Note” and a section for “Least Restrictive Methods Offered/Utilized Prior to Restrictive Event”. This was followed by 10 check boxes, one of which included “Other” for freehand text. Options included: 1:1 Counseling, Problem Solving, Limit Setting, PRN medications, Disengaged, Given Space, patient’s room, quite space, and Diversionary activity. Presenter notes included, Be specific on least restrictive methods attempted, interventions used, and what led to the restraint or seclusion”. * Slide 40 reflected the following as an example of a Seclusion event in a “Unit Nursing Shift to Shift” report, “Pt became argumentative prior to going to breakfast. He was educated that he needed to change his shirt due to it being ripped. Pt began to yell, threaten staff, and postured at staff. Staff went hands on using Safe Containment at 0754. Pt continued to struggle against staff and had difficulty with being safe. Pt was placed in S&R, provider notified, PRN medications administered, pt. let put of S&R at 1134. Pt stated he wanted to go to his room to rest and be left alone. Lunch was taken to him in his room. Pt stayed in his room for the remainder of the shift.” * Slide 41 included a form titled, “Seclusion and S&R Event Audit”. The audit did not include whether the least restrictive interventions were employed. * Slide 43 described justifications for “hands on”. This included the following, “Can staff go hands on, even if a patient is not swinging? OSH is teaching least restrictive, but this is where RN assessment comes in ... What is the safest option for staff and patients? Imminent harm ... Do the patient’s actions pose a safety threat to themselves, staff, or other patients? Is yelling a safety threat? Milieu disruption - annoying or a safety concern? Is there property damage or does damaged property pose a safety concern, not a concern for the property, but for safety of staff, the patient, or other patients ... Imminent harm (self/others). We have time and property is just property. Property can be replaced. It is when use of an item becomes a means to perform harm to others or significant self-harm that it is considered imminent harm ... Unless there is excessive property damage.” The power point presentation included unclear information, some of which was not supported by hospital P&Ps. For example, Slide 40 provided an example of shift to shift communication that described a patient seclusion for behavior that did not meet the hospital’s clinical justification of a “behavioral emergency” or its provision that “Seclusion or restraint may not be used as a substitute for an activity or treatment, or as a means of coercion, discipline, convenience, or retaliation by staff ...” Refer to Finding 13.c, the Seclusion and Restraint policy, 6.003. The severity of the patient’s behaviors described in the example were, “Pt began to yell, threaten staff, and postured at staff.” This behavior did not meet the policy definition of a “Behavioral emergency” which defined a behavioral emergency as “a situation in which ... the patient presents an imminent danger of harm to self or others”. Further, after “Staff went hands on” and secluded the patient, “PRN medications [were] administered.” Hospital P&Ps reflected that “Chemical restraint may not be used at any time.” Refer again to Finding 13.c, the S&R P&P. The presentation also included a slide about Face-to-Face Assessments by nurses (Slide 27) and did not call out that this practice only occurred on the Junction City campus, refer to Findings 13.c, 13.d, and 13.e. the S&R P&P and training requirements. There was no First Aid training addressed in the presentation and only a brief mention of assessing patients for injuries, “A nurse needs to assess pt. breathing, circulation, skin integrity, injuries, etc.” on slide 10, and “The RN Assessment of the Patient in S&R includes ... respiration, skin color, injuries” on slide 26. The training failed to provide first aid techniques as described in the hospital’s P&P, “Training Requirements ... Policy: 6.003”, Finding 13.e., “All staff with direct patient care responsibilities ... involved in the use of seclusion or restraint must receive ongoing training and demonstrate competency and understanding of ... First aid techniques.” Lastly, presentation focused mainly on hands on, restraint and seclusion techniques, as well as documentation of the event; there were 18 of 46 slides devoted to documentation alone. It was unclear whether the hospital emphasized the importance of other, less restrictive interventions be tried and documented, or whether alternatives were considered and determined to be insufficient and documented. For example, slide 41 included a leadership audit document that did not verify whether other, least restrictive interventions were utilized prior to S&R. 15.c. A 17-slide power point titled, “Safe Together for Licenses Refresher” last updated “4-2025” was reviewed and reflected: * Slide 1, presenter notes reflected, “Learning Objectives: LO 1: By the end of the lesson, learners develop a sense of welcome and support by peers and instructors through discussion and perspective sharing”. * Slide 4 titled, “Actual Code Green Event” included video review with the following introduction, “We are going to watch an actual code green event that went very well.” Notes also included: - “Patient is on a 1:1 enhanced supervision, there is a PNM (on left of screen) and 2 MHTs (one on the 1:1 enhanced observation and one on Milieu Management).” - “There are not clear black and white answers for many of these points (although there are some clearly WRONG things)” - “... 15.19.34 ... discuss ... (specifically position staff is in [bent at waist with head in patient’s midriff] ... “ - “... 15.19.38, discuss arm placement on shoulder (PNM puts hand on right shoulder of patient rather than in proper placement)” - “... 15.20.00 What would we put for “ ...description of patient behavior leading to a more restrictive intervention and patient’s response? What less restrictive options were offered after initial restrictive intervention?” - “... 15.20.44 This is a great time to bring up the contraband check on the Entry Note, did they do one? (No)” - “***Make sure to summarize that this was a GOOD code. It was handled quickly and efficiently, and staff supported each other well.***” - “Discuss use of side room Bathroom: Should it remain locked? This is dependent on RN assessment. If patient has a high risk of self-harm, the door should remain locked. If the patient is at risk for self-harm, there must be a safety plan documented in the hourly RN assessment. If no assessment is completed by RN regarding bathroom use, default is to leave it locked. RN is also to assess if side room is clean ... “ * Slide 14 was titled “Care of patient in the seclusion room” and presenter notes reflected, “Review only, this is covered filling out of flow sheet during code green review portion ... Assess the patient. Don’t go into the seclusion room alone.” There was no mention of assessing the patient for injuries. The training presentation was very brief and lacked First Aid training. Although the presentation notes discussed several concerns with the video portion of the presentation, other policy concerns were not addressed. Refer to Finding 15.d. below, review of the training video that was used for both power point presentations and S&R trainings. 15.d. A video titled, “Video for Safe Together for Licenses 2025” was reviewed and reflected: * The video was tagged, “AN3-E-Hall (G01-3E) COR 2024-09-10 15.19.34.648”. * At “00:00” the video reflected a patient in a blue shirt, khaki pants and bare feet sitting in a chair directly across from two staff members, who were talking with another staff member who was standing approximately three feet behind the seated patient. None of the staff were engaged with the patient or looking at them. * At “00:05” the patient suddenly stood up and raised their right hand in a fist and attempted to hit a staff member who was standing across the hall. The staff member ducked, and it was unclear whether the left hand of the patient made contact with the staff member. The right hand did not make contact. * At “00:06” the other two staff members had hands on the patient’s shoulders and a manual restraint had been initiated. * At “00:07” the staff member who was the target of the patient aggression moved clear of the patient and the other two staff members began to gain control of the patient. * At “00:10” a staff member has a hand on the back of the patient’s neck, and the second staff member had control of the patient’s arm. They both have the patient against the wall. The staff who was the target of the attack moved behind the patient and attempted to take control of the second arm. * At “00:13” three other staff members arrived, and the targeted staff moved back. The other two staff have gained full control of the patient’s arms. The patient did not appear to be struggling. * At “00:31” the patient was removed from the wall and staff walked the patient down the hall to the seclusion room. The patient was not observed to be struggling against the hold. * At “01:04” one of the staff members holding the patient’s arm was seen turning back, with their face turned toward the patient’s head, and speaking with another staff member who was walking behind the escorted the patient. * At “01:13” the staff escorts had the patient face the wall down the hall from the seclusion room while the bed was being removed. Patient has still not been observed struggling. * At “01:51” the Seclusion room bathroom was unlocked. * At “02:08” staff held open the bathroom door while an escorting staff released the patient’s left arm. The second staff escort was in the bathroom doorway and out of camera view with the patient. * At “02:12” the two other staff quickly exit the bathroom doorway and the staff who released the left arm closed the bathroom door behind the patient with patient inside the bathroom. * At “02:16” all staff exited the Seclusion room, and the door was closed. The video ended at “02:19” with the patient still inside the bathroom. The S&R event depicted in the video failed to demonstrate a clinical justification for the use of seclusion in a cooperative patient who exhibited aggressive behavior. The video further demonstrated the direct care staff and leadership’s failure to implement the hospital’s S&R P&Ps, as well as following and implementing the P&P for Enhanced Supervision. For example, the patient was on ES 1:1, as described in Finding 15.c., however, the staff supervising the patient was engaged in conversation with another MHT and a PNM. The PNM failed to demonstrate leadership by engaging in conversation with a staff who was on a ES 1:1, contrary to policy and the PowerPoint training presentation in Finding 15.b., slide 20, which reflected, “The staff’s focus is and should only be the 1:1/patient”. This was not called out in Finding 15.c., review of the video as a learning tool. Additionally, when the staff began the “hands on” event, the PNM briefly placed their hand on the patient’s neck, contrary to the hospital’s training as described in Finding 15.b., slide 10 which noted, “No direct pressure may be placed on the patient’s joints, spinal column, neck ... per OSH policy 6.003.” The review of the video in Finding 15.d., did not address the PNM’s hand on the patient’s neck, but described it as “PNM puts hand on right shoulder of patient “. More importantly, after the aggressive behavior, the patient was escorted by two staff members using a manual hold technique, however, the patient was not seen struggling against the staff escorts. It was was unclear whether Seclusion was the correct intervention for the patient at that time, or whether the seclusion was being used as punishment for the aggression toward staff, contrary to hospital policy, 6.003 in Finding 13.c. 16.a. During interview and review of training documentation with the DSC, CS, SE/OPA2, DHR, and other hospital staff on 03/31/2025 beginning at 1315, the SE/OPA2 confirmed that First Aid training specific to Seclusion and Restraint (Safe Together) was not offered. They stated that nurses, by training, already had the skills neccessary to render first aid to a patient in the event of an injury while in seclusion or restraint. 16.b. An email to the TDM on 04/11/2025, the TDM was asked whether First Aid education was offered in the “Safe Together” classes. The TDM responded on 04/11/2025 at 1647, “Safe together does not cover that. It is my understanding that we have CPR for all staff through LDD we do not have standardized, first aid training in addition to that as far as I know. The reasoning that I have heard was that every MHT is working under the license of a nurse who has more training than basic first aid therefore it’s covered.” ******************************************************”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 40575 ****************************************************** Based on interview, review of incident documentation for 1 of 1 patient (Patient 22), and review of other documentation it was determined the hospital failed to fully develop and implement clearly written policies and procedures to ensure the patient’s right to be informed of their health status. Results of outpatient testing completed were not provided to the patient in a timely manner. 1. Incident report with “Incident ID” “81190” reflected “On 3/12/2025, [Patient 22] went to an outside medical appointment at Salem Health for an ultrasound. On 3/27/2025, [Patient 22] became verbally upset, stating that it has been two weeks since Salem Health sent the results of [their] ultrasound to OSH, and [they have] not been notified of the results. [Patient 22] had called Salem Health to check on the status of [their] appointment. [NM] then walked to the medical clinic, and asked the staff if they had the results of the ultrasound, and they were able to immediately print me off the results. [NM] immediately notified [Patient 22] of the results, and [they] remained agitated that no one has let [them] know for the past two weeks. [NM] reviewed [Patient 22’s] Avatar chart, lab results, progress notes, client health maintenance, and [Patient 22’s] blue chart, and there was no documentation of the results of [their] ultrasound anywhere.” 2. During interview with DMNO on 04/08/2025 starting at 1400 they provided the following information regarding the process for how patients that had outpatient testing receive results: *The process is to have the medical clinic MD notify the patient by going to the unit or making an appointment for the patient to come to the clinic. *The MD is supposed to document an “MD General Note” in Avatar that they gave the patient the results or any other meeting with a patient. *This is not a new process and the only issue was results being sent to email instead of the medical clinic receiving a fax. *There are no policies and procedures describing the process. 3. An undated document titled “Clinic communication from units survey” reflected: *”It is public knowledge that when a patient has a medical concern or request to call the medical clinic. The provider, after they view the results, schedules an appointment with MA.” *”The below are the results from a survey sent to Trails, Crossroads, Bridges, Pathways NM & UAs.” *Question: “Is this your understanding of the process (make appointment with the provider to obtain results)? If so, how is it working?” “A. This is not my understanding of the process. I have worked on many units.” “B. No, each provider that I have worked with seems to have a different understanding of what the process is and how they would personally like things to work. I have worked here for 14 years and there has never been a clear process with the clinic. Many times, clinic processes will be decided within the clinic, but not communicated to the units. I would also like to point out, if the unit is unaware that procedural results have been received, how would they know to make a follow-up appointment.” “C. While making an appointment to review results makes sense and would be ideal this only works if the results are sent to the unit so they know results are in to make an appointment. Also there’s the challenge that covering providers may not be willing/able to review results with patients and defer to regular provider ...” “D. During monthly meetings with providers, the provider will review the recent results sometimes, like if they are for medication levels or ones they have ordered. If not, I am not sure how the patients are notified.” “E. For years it has involved calling the clinic over and over again, trying to contact the providers directly, typically unsuccessfully. Leaving messages only sometimes receiving a response.” “F. It is hard to get our patients in to see a provider in the clinic and I don’t think they schedule appts to review ... the lab results.” “G. It was not my understanding that it’s the responsibility of the unit to schedule a follow-up appointment with the med clinic provider to review results. A hospital-wide communication sharing a med clinic process update would be helpful.” *Question: “Is there a process? Is it working?” “A. It is not working.” “B. There is no process ...” “C. There isn’t a standard process.” “D. Current state, result is being printed on unit printer, RN put it in the unit provider box, Unit provider review, sign and OS2 filling them. If it is urgent, RN notify provider immediately ... Medical provider goes over result with patient ...” “E. Whatever the process is, it does not work.” ******************************************************”

“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: 08621 ****************************************************** Based on observation, interview, review of video recordings, review of incident and medical record documentation for 17 of 17 patients (Patients 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21), and review of P&Ps it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient’s right to receive care in a safe setting. The hospital’s failures included: * Patient 3 was in long-term locked seclusion for several months and on multiple occasions during that timeframe they were restrained with 4-point mechanical restraints while in locked seclusion. Provisions were not made to ensure a safe and clean EOC and the patient sustained numerous falls with injuries that were not consistently assessed. Staff failed to provide constant monitoring and observation, and failed to identify patient falls and report those to the inpatient RN for assessment. Further, staff failed to respond timely and effectively after another fall during which they hit their head and became unresponsive. The patient subsequently died on the seclusion room floor. * Failure to observe and monitor patients in seclusion to prevent the presence of contraband, prohibited items, and the alteration of items in the seclusion room that could be used for patient self-harm or as potential weapons. * Failure to ensure that patients without behaviors and physician’s orders for locked seclusion were not subject to locked seclusion. Patient 11 was accidentally locked into a seclusion room overnight, and no provisions to prevent recurrence were planned. * Failure to ensure that oxygen was readily available for medical emergencies. * Failure to provide for the vision and optometry needs of patients to ensure patient safety. * Failure to provide safe and appropriate care that prevented patient injury and harm. The hospital failed to provide necessary DME to prevent injury during seizures. * Failure to timely assess and reassess patients who were on Enhanced Supervision to ensure patient safety for medical issues and concerns. * Failure to thoroughly assess and reassess patients after falls, and to implement corrective actions to prevent recurrence. * Failure to ensure that complex patients with medical comorbidities were assessed timely and monitored by a medical physician 24 hours a day, seven days a week. * Failure to ensure medical documentation was accurate, timely and available for other clinical staff providing direct care to patients with medical comorbidities. Findings include: 1. For Patient 3 refer to the findings under Tag A-093 that reflect the lack of a timely and appropriated medical emergency response after they became unresponsive after a fall. 2. For Patient 3, 4, 5, and 6 refer to the findings under Tag A-175 that reflect the lack of safe and appropriate care in locked seclusion. 3. For Patient 11 refer to the findings under Tag A-154 that reflect this patient who had no behaviors or orders that required locked seclusion was “accidentally” locked in a seclusion room for several hours overnight. 4. Patient 9 had a fall in a seclusion room on 02/10/2025 at 2221. The Falls Assessment dated and signed on 02/11/2025 at 0422 was incorrectly completed and failed to capture relevant information to inform the fall risk score. The history of falls was recorded as “No”; and the number of medication classifications contributing to fall risk was recorded as “0.” However, the patient had a fall 02/10/2025; and they were on at least four medications that could increase fall risk. 5. Patient 10 had access to the bathroom in the locked seclusion room and was allowed to engage in the unsafe behaviors of standing on the toilet and covering the monitoring camera with wet toilet paper. The 1:1 staff assigned to the seclusion room anteroom documented on the “Emergency Seclusion or Restraint Flowsheet” for 01/17/2025 during the 1400 hour that the patient “Placed toilet paper on camera placing an abundance of toilet paper in toilet and continuously flushing ... wet toilet paper and is trying to cover cameras ... standing on toilet. Hitting head on door and punching face.” 6. Patient 12 was allowed to possess unsafe items that created a risk for harm to themselves and others. The 1:1 staff assigned to the seclusion room anteroom documented on the “Emergency Seclusion or Restraint Flowsheet” for 03/06/2025 at 0645 that the patient was “using a spoon as a knife and stabbing the [anteroom] window ... using spoon to puncture mattress.” A progress note signed by an RN later that same day, on 03/06/2025 at 1555, reflected that “Patient remains in locked seclusion ... Staff ... removed a broken plastic spoon and a urinal handle that had been broken off the urinal.” 7. Patient 13 was allowed to possess altered items in the seclusion room that they used for self-harm, or that had potential for harm to self and others. On 03/26/2025 at 1600 incident documentation reflected that the patient had an “altered patient toothbrush ... used by [Patient 13] to self harm on their arm.” On 03/28/2025 at ~ 0900 multiple incident reports reflected that the patient had a “white cylindrical object with a pointed end and [they] struck the metal bathroom counter with force. The object did not bend or break.” The incident documentation described the object as a patient pen that had been wrapped in multiple layers of paper and soaked in an unknown brown substance that created a rigid cylindrical object with a pointed end. 29708 8. Refer to the findings cited at Tag A-0093 under CFR 482.12(f)(2) Emergency Services that reflect the hospital failed to develop and implement P&Ps that ensured oxygen was readily available for medical emergencies, including for Patient 16. 9.a. Review of an IRF regarding Patient 14 with incident date 03/19/2025 reflected “... patient approached myself and MHT’s during Lead viability rounds, complained of bleeding on the center/parietal side of [their] head. Observed what seemed to be dried up blood of unknown origin ... Brought patient to the exam room ... assessed and cleaned area, unit provider notified ... Observed mild redness and tenderness on the surrounding tissue. Observed dark and dried blood and scabbing ... Patient reports pain from area upon palpation. Patient was alert and oriented X 4 ... Continues on fall protocol for possible unwitnessed seizure/fall on previous shift ... Patient to be referred to medical clinic for follow up on wound care.” 9.b. In an email regarding Patient 14 sent to Physician K from a DNS, the DNS wrote “I wanted to bring up a situation that I am hoping to be able to get a solution to. Flower 3 has a patient [Patient 14] who has a known seizure disorder. [Patient] has had a few seizures since coming to OSH a few weeks ago. We are working as everyone knows on the soft helmet and other interventions to keep [them] safe when [their] seizures occur but one thing that both [the patient] and [their parent] mentioned were that [they need] glasses and that potentially the lack of appropriate glasses can be triggering [their] seizures. [Their parent] is unable to supply [their] glasses however I was wondering if it is possible to expedite a optometry appointment for [them] so that [they] can potentially have less seizures ... At this point [they are] saying that [they] can’t read anything or concentrate. We attempted readers but those weren’t successful and caused [them] to have an increase in auras. Please let me know if this is an option that we could provide or if anyone has any other thoughts on how we could expedite any solutions. 9.c. The response to the DNS’ email in finding 3 from Physician K dated 03/28/2025 at 1109 reflected only “I do not know if any glasses corrected vision need [sic] that triggers seizures. So if the [parent] would like to supply me with some education materials that would be great.” 9.d. During interview with the DMNO on 04/08/2025 beginning at 1330 regarding the Medical Clinic’s optometry services, the DMNO stated that the “wait list is quite lengthy” and “it could take up to 8-10 weeks to get an appointment.” 9.e. Review of Medical Clinic optometry services P&Ps reflected they were outdated and did not ensure current optometry needs of patients would be met. Examples included: 9.f. The P&P titled “Optometry Clinic” dated last revised 12/02/2011 and last reviewed 10/07/2016 reflected: * “Scheduling appointments in the Eye Clinic Appointment Book on Tuesday and Thursday mornings ... Follow-up intra-ocular pressure checks, eye infections, or other non-exam appointments can be scheduled as well generally in the 10:30 a.m. slot ... Schedule repairs, dispensing and adjustments as the clinic schedule allows ... Call the unit the day before the appointment to verify.” * “Ordering ... When the exam is complete, check the patient’s exam form to see if glasses were prescribed ... If glasses were not prescribed, file the form ... If there is a prescription indicated, determine whether the patient is requesting any non-medically necessary options ... Patients are typically entitled to one pair of glasses with frames and lenses per year. Exceptions can be made at the discretion of the interdisciplinary treatment team or social worker on a case-by-case basis.” * “Dispensing ... When the glasses come in, place the glasses in the correct tray and call the unit to arrange for pick-up ...” The P&P had not been reviewed or revised in nearly 10 years and did not ensure current needs of patients would be met. 9.g. The P&P titled “Optometry Funds” dated last revised 05/13/2013 and last reviewed 10/07/2016 was reviewed. The P&P had not been reviewed or revised in nearly 10 years and did not ensure current optometry needs of patients would be met. 40575 10.a. For Patient 14 who had a history of seizures the hospital failed to ensure that a protective helmet was provided in a timely manner. 10.b. Incident review form with “Incident Report Number 80879” for Patient 14 reflected that on 03/19/2025 “During the top of the 1500 hour, patient approached [staff member] and MHT’s during Lead viability rounds, complained of bleeding on the center/parietal side of [their] head. Observed what seemed to be dried up blood of unknown origin. Patient reported that [they noticed] this when [they were] combing [their] hair. Brought patient to the exam room and [RN] assessed and cleaned area, unit provider notified ... Continues on fall protocol for possible unwitnessed seizure/fall on previous shift. Patient has been compliant with Neurological assessments. Assessments within normal range.” “Document immediate actions taken: Wound Asseded [sic], Unit Provider notified, Med clinic notified 3/19 and 3/20, Patient all ready [sic] on Close Observation, Patient has an approved fitted helmet.” 10.c. During interview with DMNO on 04/08/2025 starting at 1326 they provided the following information regarding the process for obtaining DME: *There is a new process. Staff on the units used to order equipment but now the order is faxed to the medical clinic. *If it is in stock, the item is delivered such as an arm sling. *If the item is not stocked the CM takes the order and works with the MD to find the right item on the vendor website. An order to the vendor is placed. Usually takes 1-2 weeks to get the item. *A product risk assessment is completed. When the item arrives, it is taken to the unit by the CM with the Risk Mitigation Form completed by the safety department that describes unit recommendations for potential patient specific self-harm or harm to others. *The CM completes teaching with the patient and staff, including the Lead RN and Unit Manager. The CM documents to close the loop, in Avatar, who was educated and who received the item. *There is no policy for this process currently. It is still being built. 11.a. There were no clear provisions for two-way hand-held Siyata radios to ensure the radios are maintained, checked out or tracked on each unit. The hospital had not developed or implemented a policy for assigning, distributing, or maintaining the radios. 11.b. During interview with FL3 CN on 04/08/25 starting at 1500 the following information was received: The following staff should have a radio on their shift; an MHT if transporting patients; MHT in an anteroom watching a seclusion patient and any staff going outside the unit with a patient or patients. 11.c. During interview with DCNO on 04/08/2025 at 1506 they stated there is no process for assigning, distributing, or maintaining the radios. Staff “grab them as they need them” and nobody is assigned to make sure they are charged. They also stated that because CMS came, OSH was allowed to order radios for each unit’s anteroom. 44104 12. Refer to Tag A-450 for Patients 14, 15, 16, 17, 18, 19, 20, and 21 that reflected the following failures for those patients: * Failure to provide safe and appropriate care that prevented patient injury and harm. The hospital failed to provide necessary DME for Patient 14 to prevent injury during seizures. * Failure to timely assess and reassess patients who were on Enhanced Supervision for medical issues and concerns. * Failure to thoroughly assess and reassess patients after falls, and to implement corrective actions to prevent recurrence. * Failure to ensure medical documentation was accurate, timely and available for other clinical staff providing direct care to patients with medical comorbidities. * Failure to ensure that complex patients with medical comorbidities were assessed timely and monitored by a medical physician 24 hours a day, seven days a week. ******************************************************”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 08621 ****************************************************** Based on interview, review of incident and medical record documentation for 9 of 9 patients (Patients 3, 4, 5, 6, 9, 10, 11, 12, and 13), review of training documentation for 23 of 23 nursing staff (RN C, RN D, RN E, RN F, RN G, RN R, RN T, RN U, RN W, RN Z, RN AA, RN EE, LPN H, LPN P, LPN Y, MHT J, MHT S, MHT Q, MHT V, MHT X, MHT BB, MHT CC, and MHT DD), review of training curriculum and media, and review of P&Ps it was determined that the hospital failed to ensure patients’ rights to be from seclusion or restraint, that restraint or seclusion was imposed only to ensure the immediate physical safety of the patient or others, and that when imposed it was discontinued at the earliest possible time. The hospital’s failures related to patients in seclusion or restraint included: * Patient 11’s right to be free from seclusion was grievously violated when they were “accidentally” locked into a seclusion room overnight, and no provisions to prevent recurrence were planned. * Patient 3 was in long-term locked seclusion for several months and on several occasions during that timeframe they were restrained with 4-point mechanical restraints while in locked seclusion. Justification for the ongoing seclusion and additional application of mechanical restraints was not clear. Observation and monitoring of the patient was inconsistent. Provisions were not made to ensure a safe and clean EOC and the patient sustained numerous falls with injuries that were not consistently assessed. Staff failed to respond timely and effectively to the patient in the seclusion room after a fall during which they hit their head and became unresponsive and they subsequently died on the seclusion room floor. * Documentation of justification for locked seclusion, observation and monitoring, and RN assessment for other patients in long-term seclusion was unclear and inconsistent. * Patients in seclusion were allowed to possess contraband. * Staff did not always exhibit behaviors that demonstrated understanding of the gravity of seclusion events, and it was not always clear that locked seclusion or the application of mechanical restraint was not a form of discipline, punishment, retaliation, or convenience. * Failure to develop and implement clearly written, effective policies, procedures, and staff training that ensured patient safety and security, and safety of others during seclusion events. * Failure to ensure training curriculum for Seclusion and Restraint was in accordance with hospital P&Ps and offered First Aid as required by CMS regulations. Findings include: 1.a. Review of incident documentation for Patient 11 reflected that on 02/18/2025 at 0530 on the LH3 unit the “[seclusion room] that was unlocked with patient resting in it was locked without staff knowing. Thus restricting patient without orders ... RN unlocked [seclusion room] door as soon as it was discovered to have been locked by accedent [sic] ... [Patient 11] slept through the shift with no notable observed behavioral or medical issues. Patient attempted to leave [seclusion room] at 0535 and found the door had been locked sometime during the shift. Immediate Action(s) RN unlocked the [seclusion room] door for patient at 0540. RN reported incident to PNM and OD.” 1.b. On 02/18/2025 at 0740 an RN signed a progress note that reflected “1:1 BP [sic] maintained this shift. Received patient in unlocked side room. Patient slept through the shift with no notable observed behavioral or medical issues. Patient attempted to leave side room at 0535 and found the door had been locked sometime during the shift. RN unlocked the side room door for patient at 0540. Slept 6+ hours.” 1.c. On 02/18/2025 at 1612 a DO signed a psychiatry note that reflected “The patient was seen with the treatment team today. On multiple occasions, [the patient’s] responses were initially relevant and reality based before becoming illogical and disorganized ...” The note contained no reference that reflected Patient 11 had spent the night in a locked seclusion room. The DO’s notes signed on 02/19/2025 at 0826 and 02/19/2025 at 1531 also lacked reference to the seclusion room. 1.d. Patient 11’s Treatment Care Plans and Treatment Care Plan Addendums were reviewed: * Patient 11’s Treatment Care Plan signed on 01/23/2025 at 0832 lacked reference to the patient use of unlocked seclusion room for “resting.” * Patient 11’s Treatment Care Plan signed on 02/20/2025 at 1432, after the patient’s right to be free from seclusion was violated, included no reference to that incident and no provisions to ensure it did not recur. The plan of care stated, “Diarrhea - [Patient 11] is experiencing diarrhea multiple times daily ... [In their] room multiple pieces of clothing contaminated with fecal matter scattered on the floor as well as fecal matter spots on the bed frame and floor. When out of [their] room, the patient had been sitting in the common areas, including on tables and counters, in clothing contaminate with feces. Additionally, [they have] not maintained personal or hand hygiene and has been reported to remain in soiled clothing for prolonged periods of time ... the patient’s room was moved to the unlocked side room as means of limiting contamination of the common areas, potential exposure to infection, and biohazard risk. The patient was also placed on 1:1 observation to assist in prompting [them] to maintain hand hygiene and to change from soiled clothing.” * Treatment Care Plan Addendums dated 11/22/2024, 11/28/2024, 12/10/2024, 12/17/2024, 12/26/2024, 01/01/2025, 01/07/2025, 02/12/2025, 02/24/2025, 03/07/2025, and 03/13/2025 all lacked any indication that the patient was “moved to the unlocked [seclusion room].” * The plans of care and plan of care addendums failed to identify when this significant plan of care change had been made; failed to describe a clear plan for use of the seclusion room as the patient’s room including the use of furniture, a bed, and patient belongings; and failed to ensure there was a plan to prevent the patient from being inadvertently locked in the seclusion room. Once the incident had occurred on 02/18/2025 the plan of care and addendums failed to address that incident and further failed to include plans to prevent recurrence. 1.e. Review of the “Unit Patient Census and Status Flowsheet” rounding record dated 02/18/2025 for the hours of 0000 to 0600 reflected for Patient 11 that their status at the top of each hour was “S.” The flowsheet “Key” specified that “S = Seclusion Room (Locked or Unlocked).” There was no documentation on the record to reflect whether the seclusion room was required to be locked or unlocked, nor documentation to reflect whether the seclusion room was actually locked or unlocked at each of those checks. 1.f. An OSH internal email from the LH3 Unit Administrator to the staff assigned to 1:1 observation of Patient 11 in the unlocked seclusion room was dated 02/19/2025 at 1606. It stated “This is a follow-up to our conversation we had regarding the incident of the Unintended Locked [seclusion room] Door on Monday, 2/17/25 at 2243. I shared that on Video we can see you open the [seclusion room] Door for [Patient 11], [they go] and [lay] down, you say something to [them], then you close the door and lock it and return to the Ante Room to continue the 1:1 Observation. [Patient 11] attempted to exit the room on Tuesday, 2/18/25 at 0530 but the door was locked. The [night RN] unlocked the door and submitted the Incident Report, which led me to watch the Video. You admittedly said you did not even realized you had locked the door until I explained the event, step by step, then you pictured in your mind the exact moment when you locked the door. You shared that you ‘remembered that you opened the door for [Patient 11] and left your keys in the door while holding the door open for [them] then after closing it you turned the key to lock, just in habit, then returned to the Ante Room’. You shared that ‘you were very sorry and that you will make sure that this will not happen again’. I assured you that mistakes happen, but we can only fix them if people are willing to admit to them so that we can figure out where the breakdown occurred. Again, you do not have to share this with anyone of your coworkers, but I will be sure to follow-up with the [night shift] to assure that the SSM [Unit Safety and Security Management] Checks are getting done correctly. From 2300-0500, the SSM Checks were scheduled and done. However, none of which caught the fact that the [seclusion room] Door was locked. So this was also a systems breakdown, as this should have been caught shortly after it had happened.” 1.g. Incident review documentation dated 02/20/2025 and untimed reflected “[Patient 11] is currently using the unlocked seclusion room due to medical issues. Pt. is currently on a 1:1 medical. Pt. had been in the unlocked seclusion and then came out and sat in the hallway. At approximately 2243 Pt. returned to seclusion room. Staff locked the seclusion room after patient entered. Pt. slept until approximately 5:45 and tried to exit the seclusion room and found it locked. Staff unlocked the door and Pt. exited. Viability checks were performed through Ante room window. 1:1 staff had constant visual of Pt. It appears that staff (out of habit) locked the door after the pt. entered.” The documentation reflected the following investigation and outcome: * “Immediate actions taken:” were documented as only “Pt seclusion room unlocked” and “Interview/ Education with staff.” * In the section for “Select all contributing factors identified during this review” the only boxes checked were under the heading of “Human Factors” and were “Distraction/Interruptions” and “Procedures not followed.” Factors not identified as contributing included “Communication Factors” and “Environmental Factors” and “Management/Supervisory/Workforce Factors” and “Task/Process Factors” and “Team Factors.” * For “How did you investigate those factors?” was listed “Staff interview” and “Document review” and “Video review.” * “Immediate Actions Reviewed” was checked and the question “Were actions appropriate to provide added patient or staff safety?” was answered “Yes.” * For “What additional actions were taken in response to this incident in order to resolve the incident and prevent reoccurrence?” The only action identified was “Event documented in [electronic health record].” * For “Safety and Risk Mitigation” the only action was “Staff education.” There was no indication that policies, procedures, processes, communication, and other systems had been evaluated to identify gaps that led to the patient being inappropriately locked in seclusion. The incident investigation did not include that there were other staff also assigned to the 1:1 observation of Patient 11 during the night after the staff person who had locked the patient in the seclusion room and that none of those staff identified that the seclusion room was locked. Patient 11’s right to be free from seclusion was violated for several hours and there were no corrective actions taken to ensure that did not recur for that patient or for other patients who may use the seclusion rooms voluntarily. 1.h. In response to the request for a hospital policy and procedure “that addresses use of a seclusion room to replace the patient’s regular inpatient room” the DSC stated in an email received on 04/23/2025 at 1157 that “We don’t have an OSH policy or protocol that addresses using the Seclusion Room in lieu of the patient’s bedroom.” 2. For Patients 3, 4, 5, 6, 9, 10, 12, and 13 refer to the findings identified under Tag A-175 that reflect the seclusion and restraint occurrences, events, and incidents for those patients. 3. Throughout the survey it was noted that staff used the term “side room” in place of “seclusion room” frequently during interviews and interactions, in medical record documentation, and in training materials. It was unclear why the hospital chose to use “side room” when policies and procedures and protocols used the term “seclusion room.” The use of “side room” verbiage may have eliminated the stigma of a “seclusion room” and as a result downplayed the significance of patients’ rights to be free from seclusion. That language may have contributed to the overuse of seclusion, the use of long-term seclusion, and the lack of staff and patient recognition and awareness that when patients were in those rooms their rights were potentially being violated. The absence of understanding the critical patients’ rights significance of the use of seclusion and restraint, and the inherent risks to patient safety, may have potentially contributed to the lack of staff attention to their duties and responsibilities to those patients. 4. Regarding lack of staff training specific to seclusion and restraint refer to Tag A-199 and Tag A-206. ******************************************************”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 08621 ****************************************************** Based on review of video recordings, interviews, review of incident and medical record documentation for 8 of 8 patients who were in locked seclusion (Patient 3, 4, 5, 6, 9, 10, 12, and 13), review of OSH internal investigation documentation, and review of P&Ps and other hospital protocols it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient’s right to receive care in a safe setting and to be treated with dignity and respect, including to provide for ongoing monitoring and assessment of the patient, and appropriate staff response, when seclusion or restraint had been imposed. The hospital’s failures potentially contributed to harm and the death of Patient 3 and created the likelihood of harm to other patients. The failures for patients in seclusion included: * Failure to prevent staff distractions and ensure staff assigned to the seclusion room anteroom for 1:1 observation provided constant observation and monitoring of patients. The anteroom 1:1 LPN failed to observe Patient 3 fall in the seclusion room bathroom, during which the patient hit their head as seen during video-review, and therefore failed to report the fall to the inpatient unit RN for assessment. * Failure to respond to and assess patient condition after falls in the seclusion room. The inpatient unit RN failed to respond to a report from the seclusion room anteroom 1:1 MHT that Patient 3 had fallen in the bathroom a second time, ~ 55 minutes after the first fall. The RN acknowledged the MHT’s report and declined to go to the seclusion room to assess the patient’s condition. * Failures of RN and LIP staff to maintain situational awareness of patients’ activities in the seclusion room bathroom and to lock the seclusion room bathroom door for Patient 3 and other patients when there were repeated falls with injuries in the bathroom, self-harm behaviors with injuries in the bathroom, and other unsafe behaviors in the bathroom such as accessing the bathroom light fixtures and cameras. Further, on one occasion staff locked Patient 3 into the seclusion room bathroom where the greatest safety risk for the patient existed. * Failure to prevent the presence of contraband, prohibited items, and the alteration of items in the seclusion room that could be used for patient self-harm or as potential weapons for Patient 3 and other patients. * Failures of nursing and LIP staff to monitor the seclusion room and bathroom EOC and intervene timely for Patient 3 and other patients to ensure floors, walls, and surfaces for patients were free of feces, urine, vomit, other bodily fluids, garbage, food, and contraband that created an increased risk for falls, infection, and self-harm while in seclusion. * Failure to develop coordinated plans in advance for Patient 3 and other patients in seclusion to respond to falls and incidents, self-harm behaviors, unsafe and unsanitary conditions in the EOC, and the use of physical restraints. Staff demonstrated the lack of organized and coordinated plans throughout the patient’s seclusion experience, including when they locked Patient 3 in the seclusion room bathroom so that they could come up with a plan to intervene for the patient’s unsafe behaviors in the bathroom. * Failures of 1:1 staff and RN staff to clearly and accurately document patient’s seclusion and restraint occurrences, including observation, monitoring, response, and assessment of their condition and behaviors, and the application and discontinuation of mechanical restraints, on the “Emergency Seclusion or Restraint Flowsheets” and in progress notes for Patient 3 and other patients. *Failure to ensure that Patient 3 and other patients were provided with, or offered, aspects of patient care such food and fluids, mobility and ROM, and toileting, and that their physical condition and extremities were monitored and assessed during the additional application of 4-point mechanical restraints while they were in locked seclusion. Findings 2.a through 2.f. of this Tag reflect it was determined that an IJ situation existed based on findings that seclusion room anteroom and unit RN staff failed to provide 1:1 constant observation, monitoring, response, and assessment for Patient 3 related to two falls that occurred in the seclusion room bathroom while they were in locked seclusion. After a third fall in the seclusion room bathroom, which was the second time the patient hit their head, the patient made no voluntary movements and subsequent attempts to resuscitate the patient were unsuccessful. On 03/31/2025 the SA survey team and Survey Manager met to review possible IJ for Tag A-175. On 03/31/2025 IJ was called and hospital leadership staff were presented with the IJ template. Between 04/02/2025 and 04/07/2025 the hospital submitted four versions of the IJ Removal Plan for Tag A-175. The fifth version of the IJ Removal Plan was submitted on 04/08/2025, and was approved with an implementation date of 04/11/2025. On 04/14/2025 an onsite IJ Removal Plan Verification Visit was conducted. The hospital was notified on 04/15/2025 that it was determined the hospital had not fully implemented the IJ Removal Plan. On 04/17/2025 the hospital submitted an IJ Removal Plan Update Amendment and on 04/18/2025 they sent an email to confirm they would be ready for a Verification Visit on or after 04/22/2025. The IJ Removal Plan Update Amendment was approved. On 04/24/2025 a second onsite IJ Removal Plan Verification Visit was conducted. The hospital was notified on 04/25/2025 that it was determined the hospital had not fully implemented the IJ Removal Plan. The survey team conducted the survey exit conference on 04/30/2025. On 05/06/2025 CMS issued the IJ CMS 2567 report to the hospital with the 23-Day Termination letter. On 05/07/2025 the hospital submitted the signed IJ CMS 2567 with the previously approved IJ Removal Plan Update Amendment and a new implementation date of 05/06/2025. On 05/12/2025 the third onsite IJ Removal Plan Verification Visit was conducted. After conferring with the Survey Manager on the afternoon of 05/12/2025 the survey team notified the hospital that it was determined the IJ Removal Plan had been fully implemented and that the recommendation to CMS was that the IJ for Tag A-175 was removed. Findings include: 1.a. The policy titled “Seclusion and Restraint” dated as approved 02/12/2024 was reviewed. It included the following: * “Seclusion or restraint may only be used when clinically justified by a behavioral emergency (as defined in this policy) when other interventions have been determined to be ineffective. When used, restrictive interventions must be discontinued as soon as possible.” * “Staff must protect a patient’s dignity and protect them from self-injury or injury by others while in seclusion or restraint.” * “The bathroom door may remain unlocked or locked per RN direction or assessment.” * “Before a patient is placed in seclusion or mechanical restraint, a nurse must evaluate the patient in person to determine what items they have in their possession. The nurse may allow the patient to keep or to be given an object considered to be safe if the object assists the patient to deescalate, or if the removal of the object would further escalate the patient. 1. Contraband items must be removed from a patient’s possession during a restrictive event. 2. Other items may be removed only if there is an imminent safety concern as evaluated by a nurse, psychiatrist, or PMHNP.” * “Patients in seclusion or restraint must be continuously monitored. 1. The RN may delegate continuous monitoring and 15-minute checks to trained, qualified staff. 2. Staff must continuously, directly watch one patient at a time and monitor their agitation, aggression, and physical status. 3. A patient’s environment while in seclusion or restraint must be made as comfortable as reasonably possible to aid in reregulation (e.g., elevating the patient’s head, providing a blanket or pillow).” * The “Restrictive Intervention Tasks Timeline” attachment to the policy directed staff to “Throughout the entire event: Continuously monitor, contact RN as needed.” 1.b. The policy titled “Use of Seclusion Room Bathroom” dated as approved 08/01/2023 was reviewed. It included the following: * “The purpose of this protocol is to give nursing staff at Oregon State Hospital (OSH) directions regarding the safety monitoring required when a patient uses the Seclusion Room bathroom.” * “Due to the unavailability of adequate ligature-resistant door hinges and closure devices, doors to Seclusion Room bathrooms present a safety risk that requires mitigation through direct observation.” * “When a patient is in locked seclusion, the door to the bathroom may be either locked or unlocked based on the assessment of the Register [sic] Nurse (RN) regarding the patient’s ability to safely utilize the bathroom. If the door is unlocked: 1. staff must continue required observations if the patient accesses the bathroom ...” 1.c. The policy titled “Restrictive Event Documentation and Reporting” dated as approved 07/22/2024 was reviewed. It included the following: * “The use of any restrictive intervention as defined in OSH policy 6.003, “Seclusion and Restraints” must be closely monitored, documented, and reported.” * “Assigned nursing staff must continuously monitor the patient, verbally check-in with the patient when indicated, and document the patient’s status utilizing the Emergency Seclusion or Restraint Flowsheet. a. The patient’s levels of agitation, aggression, and physical status must be monitored and documented within, but no later than, every 15 minutes. i. For the patient’s physical status, staff must monitor their breathing, their comfort level, whether the patient is hot or cold, if they have any numbness or tingling in their hands or feet (if in restraints), and if there are any new signs or complaints of injury. ii. All observations and responses that are unexpected or out of the norm require intervention (within the staff ‘s scope and training) and notification to the RN. iii. Upon notification of any of the above, the RN must assess the patient and document their assessment on the flowsheet or in a progress note in the patient’s EHR b. The patient’s needs for nutrition, hydration, elimination, and exercise must be monitored, met, and documented at least every two hours. c. Throughout the seclusion or restraint event, as appropriate, nursing staff must attempt to complete a review with the patient of the criteria for release, as determined by the RN. Staff must document all attempts to review criteria for release, along with the patient’s response, on the flowsheet. d. Patient status, including any attempted review of release criteria, along with the patient’s response, must be reported to oncoming monitoring staff. 4. The RN must assess and document the patient’s overall status at least once every 60 minutes. This assessment and documentation must include: a. the patient’s mental status; b. the patient’s physical health and comfort; c. the patient’s current risk to harm self or others; d. a determination of whether or not the patient is ready for release, or to be moved to a less-restrictive intervention; e. a review with the patient of the criteria for release and the patient’s response; f. patient’s level of cooperation; g. a review of the monitoring and care provided and documented by assigned nursing staff; and h. a plan to address any patient needs that have not been met. Note - When documenting hourly status checks of a patient who is not ready for release, the RN must address any instances from the past hour when the patient was rated as 0-1 for Agitation and 0 for Aggression on the same 15 minute check. 1.d. The policy titled “Enhanced Supervision” dated as approved 01/15/2025 was reviewed. It included a “Policy Attachment - Procedures B: Supervision Practices” also dated 01/15/2025 that included the following: “Supervision During Episodes of Seclusion or Restraint 1. During any episode of seclusion or restraint patients must be supervised at the level of 1:1, irrespective of their supervision order before the seclusion or restraint episode occurred.” 2.a. During interviews on 03/26/2025 beginning at ~ 1045, again at ~1145, and at ~ 1345 hospital staff that included the DS, CNO, DCNO, DSC, DQM, DOIM, DOS, DHR, and others confirmed that on 03/18/2025 Patient 3 died unexpectedly in the LH2 treatment mall seclusion room. The following information was provided during those sessions: * Patient 3 had been in seclusion, in multiple different seclusion rooms, for several months. * All patients in seclusion are assigned a 1:1 staff person who is to observe and monitor the patient continuously through the seclusion room anteroom windows. * Patient 3 had behaviors that included urinating and defecating on the floor, inducing vomiting, and masturbating. The floors and walls in the seclusion rooms and seclusion room bathrooms the patient had occupied became soiled with urine, feces, vomit, and other bodily fluids. It was reported that the patient’s violent and assaultive behaviors towards staff limited the times that those rooms could be cleaned. * Patient 3 had behaviors of self-harming that included dunking their head in the toilet and intentionally jumping and falling off of the seclusion room bathroom sink counter and toilet. The patient was identified as a high fall risk. * On the afternoon of 03/18/2025 Patient 3 was moved from a seclusion room on the LH2 inpatient unit to a seclusion room on the LH2 treatment mall. At the time of the move to the treatment mall seclusion room the inpatient unit seclusion room was covered with feces, urine, vomit, and likely other bodily fluids. * At the direction of the attending psychiatrist, MD A, the door to the bathroom in the seclusion room on the treatment mall was to be unlocked, allowing the patient access to the bathroom sink counter and toilet. * Unit staff were assigned to 1:1 constant observation of the patient through the windows in the seclusion room ante room. Those staff were to call the RN at the nurse’s station to report incidents and changes of condition. * On 03/18/2025 between ~ 2132 and 2234 Patient 3 had three falls in the seclusion room bathroom. During the first and third fall the patient had potential head strikes. * There were no immediate responses by staff for the first and third falls. * The 1:1 LPN H assigned to the seclusion room at the time of the first fall reported in an interview during the hospital’s internal investigation that they didn’t see the patient fall, but saw the patient get up off of the floor. LPN H did not report a fall to the LH2 unit RN. * The 1:1 MHT J assigned to the seclusion room at the time of the second fall reported in an interview during the internal investigation that they called RN G on the LH2 unit who declined to respond to the seclusion room to assess the patient because the patient did not hit their head and that the MHT didn’t need to do anything. * After a third fall during which the patient hit their head and did not get back up, although MHT J called RN G there was a delay in the emergency response to Patient 3 because of past behaviors of “playing possum” and then assaulting staff when they arrived to provide assist or care. * The hospital’s internal investigation was initiated immediately after Patient 3’s death and was ongoing. Identified concerns were related to the cleanliness of the seclusion room environment, assessment and reassessment for the use of seclusion and restraint, safe use of the seclusion room bathrooms, assessment and reassessment of falls, and emergency response. 2.b. Video recording of Patient 3’s falls in the seclusion room bathroom on 03/18/2025 were reviewed on 03/26/2025 beginning at 1145, and again on 03/27/2025 beginning at 1330. The video revealed the following: * At ~ 2122 the patient was observed to be eating an apple in the seclusion room bathroom. * At ~ 2125 the patient walked into the seclusion room. * At ~ 2127 the patient returned to the bathroom. * At ~ 2132:42 the patient fell onto the floor after they had climbed to a standing position on the toilet seat. Although the video was not fully clear, it appeared that the patient hit their head on the wall or door as they fell to the ground. * At ~ 2133 the patient stood up on their own and their gait was visibly unsteady and staggered as they walked around. * At ~ 2134 the patient climbed back onto the toilet and sat on the counter above the toilet. From that position they urinated on the floor. * At ~ 2227:53 the patient stood on the bathroom floor and faced the anteroom window. From that position they fell backward onto their back and bent their neck forward so did not hit their head on the floor. * At ~ 2228 the patient stood up on their own and walked around. * At ~ 2234:10 the patient crawled up to stand on the toilet seat. * At ~ 2234:14 the patient fell off the toilet seat and clearly hit their head with impact on the floor. The patient made no attempt to get up off of the floor and did not demonstrate any purposeful or voluntary movements. Rather, their limbs were observed to make jerking and twitching movements that appeared to be involuntary. At no time were any staff observed on video to respond to Patient 3 after the first two falls in the seclusion room bathroom. As described in findings at Tag A-093, the medical emergency response for Patient 3 after the third fall was not timely or appropriate. 2.c. Review of Patient 3’s medical record “Emergency Seclusion or Restraint Flowsheets” completed for 2100 and 2200 hours on 03/18/2025 contained the following documentation by the assigned 1:1 constant observation staff: * LPN H documented the following during the 2100 hour. There was no reference to the patient’s first fall at ~ 2132:42 and no indication that the fall was reported to any unit RN: “2100 ... pt masturbating in the bathroom.” “2115 ... pt walking around eating snack” “2130 ... pt sitting on matress [sic] drinking ensure -“ “2145 ... pt is [sic] the bathroom sitting on the counter.” * MHT J documented the following during the 2200 hour. There was no reference to Patient 3’s second fall at ~ 2227:53 and no indication the MHT reported the fall to any unit RN. Further, there was no reference to the patient’s third fall at ~ 2235:04, no reference to the report of the fall to a unit RN; and no documentation as to what action the MHT took: “2200 ... Sitting on sink pt peed on floor” “2215 ... Pt is awake in bathroom sink sitting” “2219: pt is standing on toilet pulled down [their] pants and pooped on floor” “2230 ... Pt is awake sitting on bathroom sink” “2245 [all flowsheet spaces are blank].” 2.d. During interview on 03/26/2025 beginning at ~ 1045 with staff that included the CNO, DCNO, DSC, DQM, DOS, DHR, and others, information about the hospital’s actions in response to Patient 3’s death in the seclusion room was provided and included: * There were preliminary investigation activities started the night of 03/18/2025 after leadership staff were notified of Patient 3’s death. * On 03/18/2025 the investigation was begun and immediate corrective actions taken. * A seclusion and restraint consult team was immediately implemented to address patients who were in seclusion for more than 24 hours. * Rounding of all seclusion room anterooms was done to identify and correct issues with visibility through the anteroom windows that was limited by papers, signs, and equipment that blocked some of the view. * An evaluation of camera views in the seclusion rooms and seclusion room bathrooms was conducted and no issues were identified. * It was unclear whether 1:1 staff in the anteroom had been carrying a hand-held two way radio. * Staff support was provided. * Notifications to CMS, the JC, and other agencies were made. * Review of the patient’s medical record was conducted. * Extensive video review of the seclusion room and seclusion room bathroom was conducted. * Eleven staff, that included unit staff involved in the care of Patient 3 on 03/18/2025, were interviewed. LPN H’s agency contract was terminated and other staff were “duty stationed” at home pending the investigation. * Five multi-disciplinary “response teams” were developed to focus on the following five areas: Safety and cleanliness of seclusion room EOC; Falls assessment and reassessment; Assessment and reassessment for the use of seclusion; Use of the seclusion room bathroom; and medical emergency response. 2.e. Video recording of the hallway outside of the LH2 treatment mall seclusion room and anteroom on 03/18/2025 was reviewed on 03/27/2025 beginning at 1447. During interview staff stated video of this view of the hallway door to the anteroom had not been reviewed by hospital staff. The video revealed significant traffic in and out of the small anteroom by other staff, including groups of staff. In addition, there were multiple observations of staff, including medical staff, who opened the door from the hallway and leaned their head into the room to likely speak to the person in the anteroom. That would likely require the 1:1 observation staff in the anteroom to turn their back to the windows to speak to the person in the hallway. The multiple distractions included the following examples: * During the 2000 hour prior to Patient 3’s falls, on 03/18/2025, for 14 minutes beginning at ~ 2044 and ending at ~ 2058, various staff were in and out of the seclusion room anteroom. Staff were observed to enter and exit the anteroom, or lean their head into to anteroom from the hallway at the following approximate times: 2044:17, 2044:36, 2047:18, 2047:35, 2047:59, 2048:00, 2048:27, 2048:41, 2057:36, 2058:13. * During the 2100 hour on 03/18/2025 there were ~ eight occasions during which staff were in and out of the seclusion room anteroom or leaned their head into the room. * At ~ 2100:46 RN C opened the door from the hallway into the seclusion room anteroom, leaned their head into the room momentarily, then closed the door and moved down the hallway. At ~ 2100:50 LPN H assigned as the 1:1 observer in the anteroom was seen to open the anteroom door and stick their head out of the room into the hallway in the direction of RN C who then stopped and turned back towards the anteroom door. RN C and the opposite gender LPN H were observed smiling and laughing at each other for the next few seconds. LPN H closed the anteroom door at ~ 2101:02. Beginning with RN C who leaned their head into the anteroom, for ~ 16 seconds LPN H did not have their full attention on the seclusion room and left Patient 3 unobserved. LPN H was the assigned 1:1 staff who reported they did not see the patient fall through the anteroom windows into the bathroom at the time of Patient 3’s first fall at ~ 2132:42. The interaction with RN C ~ 30 minutes prior clearly demonstrated that LPN H failed to understand their duty to provide the required 1:1 constant observation of the patient in the seclusion room. That interaction also demonstrated that RN C failed to understand their duty and role to supervise the provision of care and model appropriate behavior and practice to other nursing personnel. * During the 2200 hour prior to the second fall at ~ 2227:53 there were ~ seven occasions during which staff were in and out of the seclusion room anteroom. While it is necessary for other nursing and medical staff to enter the seclusion room anteroom for various reasons while a patient is in seclusion, it is reasonable to expect that all staff will be trained and mindful of the need to ensure safety for the patient in seclusion and minimize possible distractions to the staff assigned to the crucial 1:1 constant observation role. 2.f. During interview on 03/28/2025 beginning at ~ 1035 with numerous staff that included the DCNO, DSC, DOIM, DS, COP, and many others, additional information was provided about the hospital’s immediate actions in response to the findings that seclusion anteroom staff and unit staff failed to observe, report, and respond to Patient 3’s falls in the seclusion room bathroom. Staff shared numerous actions planned or in progress related to the five areas listed above and more. However, there was no information provided that reflected any formal immediate mitigation actions had been implemented by the hospital in response to the problem that the seclusion room 1:1 constant observation staff failed to continuously observe the patient to identify the patient’s fall and report the patient’s fall to the RN, and that the RN on the unit failed to respond to the report of a fall from another 1:1 constant observation staff. The actions described during the interviews did not mitigate the immediacy of these problems. There was no assurance that patients in locked seclusion, with bathroom doors locked or unlocked, would be continuously observed to ensure falls and other incidents were immediately reported and responded to, and that the likelihood of serious injury, serious harm, or death for other patients in locked seclusion had been removed while the complex underlying systems’ problems were identified and long-term corrective actions developed and implemented. 2.g. Review of hospital investigation documentation reflected that LPN H was interviewed on 03/19/2025 at 1300 by hospital staff. Information provided by the LPN included: * LPN stated they were an “Agency” nurse “at OSH since [12/2023] ... I’m in school right now to get my BSN. If I get my BSN, I’d want to transition as [permanent] staff here. School is online.” * In response to the question “how familiar [are you] with [Patient 3]?” LPN H replied, “Not too much.” * “I don’t usually go to [seclusion room], usually assigned to med pass.” * “There’s a phone in [the anteroom].” * “I don’t know [if there’s a hand-held radio in the anteroom].” * “I saw [Patient 3] trip in the bathroom, from standing to trip on [their] feet, lowered self on ground. [Their] left shoulder, hit floor, [they] lowered self to floor. Then [the patient] stood up as [they] usually [do]. [Patient] sat on sink, I said, that’s not safe, [they] came down and moved to [seclusion room], paced a bit and went back into bathroom, around 9:40-9:50 [pm] [they] came back to Bathroom. We talked for awhile. Then [patient] climbed on sink again, I asked [them] to come down, [they] said, I want to stay here a bit then go back to my room. and [sic] asked if [they were] OK. [They] said [they were] OK. When I’m in [seclusion room], I always stand and walk around as I watch through the window.” * In response to the question were there “any other falls while watching [Patient 3]?” LPN H stated, “No.” * “If [the patient had] a fall fall [sic], and if [they struggled] to stand, or if [they grimaced] or holds part of [their] body, then I tell nurse. [I did] not tell nurse [Patient 3] had tripped.” * In response to the question whether the LPN had “Any concerns about [Patient 3] in seclusion?” LPN H stated, “I don’t know, I’m just a float.” The interview revealed that LPN H had knowledge and observation gaps and they inferred that was in part because they were “just a float.” LPN H’s story about Patient 3’s “trip ... from standing ... lowered self to ground ...” did not depict the patient’s fall from standing on the toilet seat and hitting their head at ~ 2132, as seen on video and described under Finding 2.b. above. Their responses clearly reflected that they had not observed the patient stand on the toilet and fall to the floor as they should have in accordance with the 1:1 constant observation assignment. Further, LPN H failed to document the incident they described on the “Emergency Seclusion or Restraint Flowsheet” for the 2100 hour described under Finding 2.c. above. It was also noted in the interview documentation that there were no questions for LPN H regarding what activities the LPN was engaged in that caused distractions during that assignment and whether they had observed Patient 3 constantly. 2.h. Review of hospital investigation documentation information reflected that MHT J was interviewed on 03/19/2025 at 1610 by hospital staff. Information provided by the MHT included: * MHT was assigned to Patient 3 in the seclusion room for the 2200 hour. * “... bathroom door unlocked [Patient 3] sitting on the sink, feet on the toilet, touching [their] face not talkative. Down from the toilet then back up multiple times. [2219] Pooped and peed on the floor documented on the flowsheet. [RN F] assessed at the [2230] let the nurse know, asked if we should move [Patient 3], [RN F] said are you crazy its late at night ... [MD B] arrived, I explained the urine and feces on the floor hoping the doctor would override the nurse decision. [MD B] didn’t respond. [Patient 3] asked for the time and then stared. [RN F] and [MD B] leave.” * “Called [RN G], told [the RN that Patient 3] fell, first fall between 1019 and 1034, [RN G] asked if [patient] hit [their] head, I said no, [RN G] said don’t chart it on the flowsheet.” * “[Patient 3] fell second time off the toilet backwards heads to the door, called [RN G] and told [them] to call code blue, [RN G] arrived in a minute, then went in, [RN G] stated “oh shit this is real”. * “Lead nurse said it was doctors [sic] orders to have the bathroom door open. I think it was [MD A].” * “[2230ish] fall. [Patient’s] foot slipped in the [toilet] bowl and [they] fell back, shaking turned red then saw white stuff on [their] mouth after [they] landed on the floor. Called [RN G] right after [patient] landed on the floor.” * “[RN C] was the lead nurse that day. I asked [RN F] if we should tell [RN C] about the feces and urine on the floor and the bathroom door being unlocked, lead nurse, and [RN F] said “tell [RN F] what”. * In response to the question “Was there a radio?” the MHT stated, “No, usually a radio in the anteroom but not this time.” * “[Patient 3] has a history of head diving, that’s why we always locked the bathroom door. Bedpan or urinal instead of the bathroom. [Patient 3] does have ideations to do things ... I don’t think [the patient] did this on purpose ... it looked [like the patient] was trying to get on the sink to sit down not like [their] normal head diving which was face first to the floor.” The “Emergency Seclusion or Restraint Flowsheet” for the 2200 hour described under Finding 2.c. above did not reflect the two patient falls observed by MHT J. The flowsheet also did not reflect the MHT’s reports to and interactions with RN F, MD B, and RN G, nor the responses of those staff. 2.i. Review of incident documentation for Patient 3 revealed other occasions on which it was evident that the 1:1 staff assigned to the seclusion room anteroom had not observed the patient constantly, or it was unclear whether the constant observation had occurred. In addition the documentation demonstrated the lack of tracking and systems to ensure the seclusion room bathroom door was locked to ensure Patient 3’s safety. For example: *Incident documentation reflected that on 12/14/2024 at 2015 Patient 3 fell onto their left hip in the treatment mall seclusion room. There was no documentation to reflect what staff observed and the circumstances around the fall. Therefore it was unclear whether the 1:1 staff had been observing the patient at the time of the fall. *Incident documentation reflected that on 12/21/2024 “at about 1646 [Patient 3] became aware that [the seclusion room] bathroom door was left unlocked. [The patient] then began to climb on top of the sink in the bathroom. I asked [the patient] to get down from the sink. [They] did not acknowledge what I had said. I attempted several more times to ask [them] to come down from the sink. [They] continued to refuse to return to the ground. At 1650 [Patient 3] fell from the sink onto the ground. I did not visualize this. Seconds before [the patient] fell staff entered the Anteroom and I looked away to visualize who they were. BR door was [then] locked.” *Incident documentation reflected that on 01/11/2025 at 1118 Patient 3 “seemed to have fallen in [seclusion room]. Appeared to have slip and fall.” There was no documentation to reflect what staff observed and the circumstances around the fall. The use of the language “seemed to” and “appeared to” rendered the report to be unclear about whether the 1:1 staff had been observing the patient at the time of the fall. Further, review of the “Emergency Seclusion or Restraint Flowsheet” for 01/11/2025 reflected the only reference to a fall was at “1118: pacing, fell appear to have hitting [sic] [their] face.” There was no other fall related information, including whether the inpatient unit RN had been notified and assessed the patient. The only documentation by the RN was an “RN 60 [minute] assessment,” signed and dated on 01/22/2025 at 1145, ~ 30 minutes after the fall, that contained no specific reference to a fall and no indication of injuries, but included the statement that “neuro checks unremarkable.” 2.j. Although the investigation information provided during the 03/26/2025 interview with staff identified under Finding 2.d. above addressed some sources of potential visibility barriers in the seclusion room anteroom, the hospital’s investigation information did not reference potential distractions for the assigned 1:1 observation staff. For example: *Refer to Finding 2.e. above that reflects video review of Patient 3’s 03/18/2025 incidents showed significant traffic in and out of the small seclusion room anteroom by other staff, including groups of staff. There were multiple observations of staff, including medical staff, who opened the door from the hallway and leaned their head into the room to likely speak to the person in the anteroom. That would likely require the 1:1 observation staff in the anteroom to turn their head away from the windows to speak to the person in the hallway. Additionally, the video showed LPN H open the anteroom door and lean their head out into the hallway to engage with RN C, during which time LPN H was not observing Patient 3. * During interview on 03/27/2025 at ~ 1040 with the DOQ, DSC, and DCNO they stated that staff had “unfettered access” to outside lines on the anteroom desk telephone, and to the internet on the computers in the anterooms. They reported that all computers and keyboards were removed from seclusion rooms the day of the interview, on 03/27/2025, and that just the monitors remained in the rooms on which the seclusion room camera views could be seen. *There was no reference to staff use of personal cell phones during 1:1 seclusion room observation assignments and whether personal cell phone use could have been a source of distraction for the 1:1 LPN H who did not observe Patient 3 fall. Hospital staff were asked if the use of personal cell phones during 1:1 seclusion observation assignments was allowed. They stated that staff were not allowed to have personal cell phones while on duty. Review of the “Protocol” titled “Use of Personal Portable Electronic Devices” that was dated 03/03/2025 revealed the requirement that “Staff may not access or interact with [personal portable electronic devices] while on assignment in a patient care role or while working on a patient living unit ... All non-hospital issued [personal portable electronic devices] must be turned off or set on silent mode and safely stored, preferably in the employee’s locker, during the work shift ... If the employee chooses to carry their [personal portable electronic device] on their person, the following rules apply ...The device ... must not be visible to a patient ... The staff member must not answer, or otherwise interact with, the device in a primary patient care area or in the presence of patients ... staff member must not leave a patient care assignment to answer ... without ensuring adequate coverage during the staff’s absence ... ‘Personal portable electronic devices ...’ include, but are not limited to: cellular phones, hand-held computers, book viewers, music players, games ...” The “Protocol” was unclear as it contained clear language that prohibited “access” to and “interaction with” personal cell phones and other personal electronic devices, and it also included language reflecting a preference that staff store those in their lockers, and allowed staff to “choose to carry” those. There was no indication of any system to ensure staff did not use personal portable electronic devices during their patient care assignments, including when assigned to 1:1 observation for patients in seclusion. 2.k. Seclusion, and restraint occurrences for Patient 3 prior to 03/18/2025 were reviewed. Unclear, incomplete, combined entries, and late entries by LIP and nursing staff on documents that included progress notes, assessments, S&R flowsheets, and incident reports, rendered review of Patient 3’s experiences in seclusion difficult to clearly and readily track. Those included falls, injuries, application and discontinuation of mechanical restraints in addition to seclusion, when the bathroom door was locked and unlocked, when the EOC was cleaned, and when the patient was moved from one seclusion room to another. Further, there was no evidence of systems to accurately identify, track, and communicate to all staff what the status of the seclusion room bathroom was to be, nor evidence of cleaning routines or plans to ensure the seclusion room EOC was clean and safe while those rooms were in use. Findings included, but were not limited to the following: * On 12/02/2024 at 1604 an RN signed a progress note that stated Patient 3 “in locked seclusion. Patient covered in feces, feces and trash spread throughout room. Puddles of urine visible on floor. Patient not participating in assessments, often kneeling and appearing to pray. Patient was asked to move to clean room at 1030.” * On 12/04/2024 at 1625 an RN signed a progress note that reflected “Time of Fall: approximately 1615. Location of Fall: LH2 [treatment mall] locked seclusion room. Client Activity Prior/During Fall: Patient poured milk on side room floor and slipped on it. Description of Fall if Known: staff assigned to patient’s [seclusion room] room called nurses station to report patient had fallen in locked seclusion room by slipping on milk [they] had poured on the floor and hitting the back of [their] head on the padded floor. Describe Any Injuries: patient struck the back of [their] head on the padded floor. Contributing Factors: patient poured milk on the floor and slipped on it.” There was no corresponding incident documentation for this fall. * On 12/05/2024 at 1543 an RN signed a progress note that reflected “[Patient 3] was observed to be taking [their] feces and smearing it throughout the side room. Feces was covering the wall, door handle, and anteroom door as well as on the floor and mattress. Pt was also noted to have feces smeared across [their] body, face, and in [their] eyelids. RN offered pt a wash cloth to wipe off pts face, pt refused. When RN asked pt what [they were] doing, pt replied “Playing with my poop”. RN asked pt why [they were] smearing poop across the room and pt replied “Because you all don’t want me to”. Pt was naked throughout the day and was frequently moving around [the] room. Pt was not willing to engage in RN assessment and would oftentimes [sic] ignore RN and continue to play with [their] feces.” * On 12/06/2024 at 0912 incident documentation reflected that Patient 3 “was jogging around [seclusion room]. The ground was covered in feces and urnine [sic]. When [they] went to turn [they] slipped and fell on to [their] left side. [They] did not appear to hit [their] head. I ask [sic] [patient if they were] okay. [They] did not respond but got up and began jogging around the room again. I informed the Lead RN ...” The EOC was described as “Patient [has] feces smeared on walls and floor. Patient also had urine along with other things on the floor.” * On 12/06/2024 at 1408 incident documentation reflected that Patient 3 “stated that [they] wanted to [sic] moved to a cleaner room. Security called and the plan is to move at 13:30. Approx 14:08 staff went hand [sic] on and then assisted patient to the ground with the mat. Pt placed in mechanical restraints and transferred to the [seclusion room] on the unit.” Although the narrative provided no indication that the patient exhibited assaultive or aggressive behaviors, it reflected that patient was taken to the ground and placed in mechanical restraints. * On 12/06/2024 at 1628 an RN signed a progress note that reflected “pt stated that [they] wanted to [sic] moved to a cleaner room. Security called and the plan is to move at 13:30. Approx 14:08 staff went hand [sic] on and then assisted patient to the ground with the mat. Pt placed in mechanical restraints and transferred to the [seclusion room] on the unit. Pt administered a bedbath ...” The RN progress note also contained no indication that the patient exhibited assaultive or aggressive behaviors and it was therefore unclear why the patient was physically restrained. * On 12/08/2024 at 0731 an RN signed a progress note that reflected “Bathroom remains locked for safety; urinal and bedpan in place.” * On 12/09/2024 at 1450 incident documentation reflected that “while running around and singing in the locked seclusion room, [Patient 3] fell on the ground with NO head strike. This was a witnessed fall. [RN] went to patient’s anteroom to assess patient through the door due to safety concerns from patient charging the door earlier today. Patient reported that [their] neck hurt 5/10 from the fall. Patient is alert and oriented x3 with baseline behaviors. Patient is walking and talking without difficulty and is not showing any new neurological deficits or symptoms at this time. During assessment, [RN] noticed patient had trash scattered on the ground throughout the seclusion room that [they] refused to discard of properly or allow staff to safely discard of.” However, there was no indication of methods staff used to communicate with the patient regarding clearing the room of the “trash.” * On 12/10/2024 at 1050 incident documentation reflected that Patient 3 “attempted to physically assault staff during a seclusion room move required due to level of feces/urine/food smeared on all surfaces. Soft shields where [sic] utilized and made contact with [the patient], and during the containment phase, a minor injury to staff occurred (graze punch to forehead and attempted unsuccessful bite through [personal protective equipment]).” * On 12/13/2024 at 1818 an RN signed a progress note that reflected “Pt was observed pacing in seclusion, demanding music ‘play the music bitch’ and ‘play the music [other expletive].’ Pt alternated between angry/demanding and ignoring staff. Pt had thrown [their] food and drinks against the walls and floor. Pt defecated and urinated on the floor. Pt received a bible upon request and allowed a favorite staff member to enter seclusion to clean the floor.” * On 12/14/2024 at 2015 incident documentation reflected that “Staff notified RN that [Patient 3] fell onto [their] L hip. Pt denied pain/discomfort. No noted redness/bruising.” However, there were no 1:1 staff observations of the fall nor circumstances and contributing factors described. * On 12/14/2024 at 2036 an RN signed a progress note that reflected “At approx 2015 staff in anteroom reported that pt appeared to have fallen on [their] right hip. POD notified, no new orders. Pt denied pain/discomfort. Pt asked to take a shower. RN explained that it was safe at this point and gave [the patient] a washcloth with soap, one for rinse, and two towels.” Although the note was not clearly written it inferred that the seclusion room bathroom door was open to allow the patient access to the shower in the bathroom. In addition, as indicated in the Finding immediately above this, there was no additional information to reflect the 1:1 staff observations of the fall nor circumstances and contributing factors to the fall. The RN wrote staff reported the pt “appeared” to have fallen which inferred the 1:1 staff did not observe that fall as they should have. * On 12/16/2024 at 1702 an RN signed a progress note that reflected “[Patient 3] was able to agree to safe use of bathroom when assessed by MD. Patient bathroom was opened at 1425, provided with shower supplies and clean clothing. Patient food and fluid intake is adequate. Patient was minimally responsive to RN assessments this shift, often choosing not to engage even when clearly awake. Continues to tell staff to fuck off. Patient stumbled as [they were] lowering [themself] to lie down. Initially had been reported as a fall, but when RN assessed/spoke with staff and patient, it was apparent that it was not ... continue to monitor/ limit access to BR if patient begins unsafe behaviors / head in toilet.” * On 12/16/2024 at 2126 an RN signed a progress note that reflected “[Patient 3] received in locked seclusion, noted naked with repeated showering, pacing in and out of bathroom and non compliant with staff redirection was asking for shampoo which was not provided d/t risk for fall with repeated showering. Staff reported patient noted bending over the toilet and appears to be drinking from the toilet, patient redirectable, requested for [sic] juice and water, offered and compliant. Room noted with wet floor, attempted to clean room, patient non compliant, refused to go to the bathroom and allow staff to dry floor, patient remained planted at the anteroom door and would not move. Staff continued to monitor and remind patient of wet floor. 1935 hourly assessment, RN requested patient to stand in the bathroom to provide snack and dry floor, took multiple redirection, kept focusing on the door to open, snack was placed and most floor cleaned out safely. Patient ate [the] snack and went to lay on [the] mattress.” * On 12/17/2024 at 2132 an RN signed a progress note that reflected “Bathroom door is open but pt hasn’t been using it appropriately. Pt is urinating on the floor. Had a BM on pan but was able to give it staff before [they] made a big mess out of it. Pt was able to follow few cues and cleaned a little bit of trash in the room.” * On 12/19/2024 at 1946 an RN signed a progress note that reflected “[Patient 3] awake in [seclusion room] throughout the shift, pacing back and forth from side room to bathroom. Patient putting clothes on and disrobing on and off throughout the shift. Patient was to be moved [seclusion rooms] [sic] due to the floor being slippery and wet. Provider gave okay for patient to have one cup of noodles if [they] moved [seclusion rooms] safely. Patient put clothes on, picked up [their] mattress, and walked safely to the large [seclusion room] on the unit without issues.” * On 12/20/2024 at 1639 an RN signed a progress note that stated “Bathroom door unlocked.” *On 12/20/2024 for the 1700 hour, 1:1 RN documentation on the “Emergency Seclusion or Restraint Flowsheet” included: “1700 ... putting cups into toilets” “1730 ... putting blankets into toilets, pushing down” “1735: pt stood on the toilet sink, Pulled on light, sliped [sic]d fell, Landed on [their] bottom on toilet seat, then to shoudler [sic] on ground and [illegible] wall” “1750: Fell again from sink top Landed on the mattress, [sic]” *On 12/20/2024 at 1744 Patient 3’s attending psychiatrist, MD A, signed a “Psychiatry General Note ... Seclusion/Restraint Note” that combined two encounters and indicated “Time of Face-To-Face Assessment: 1145 AM, 3:35 PM.” The note reflected “saw [Patient 3] for assessment of Locked seclusion at times listed above. At the time of my initial assessment [they were] laying down, covered by a blanket, visibly breathing, but did not respond to any of my questions. [They] allowed for me to clean a bit in the [seclusion room] including some food trays and such. [They] did not appear to be in any distress but also did not appear to be in the mood to discuss anything. When I returned later to assess [the patient], [they were] awake, standing, naked from the waist down. [They] initially cursed at me and flipped me off, but then was willing to engage in some brief conversation. I informed [Patient 3] that the on-call psychiatrist tonight was the chief medical officer and that [the CMO] would be involved in some decision-making regarding [the patient’s] progress, and that it would be helpful for [the patient] to discuss with [the CMO] how [they are] doing and what [their] goals are and plans for coming out to be around others despite [their] frequent behavioral difficulties. I discussed with [Patient 3] the overall plan for [them] to start engaging in safe behavior with others outside of the [seclusion room]. [The patient] had limited reception to this, frequently cursed at me and flipped me off, but said that [they] would try and be awake for [the CMO] when [they came] by for assessment ... Pertinent Patient History: Long history of aggression, psychosis, cerebral palsy. Mental and/or Physical Status Exam: [Patient 3] was initially laying down on the mattress. [They were] mostly covered by a blanket. [They] did not appear to be in any distress and [their] breathing was easily visible. [They] did not respond to any of my questions and I cannot characterize [their] thought processes were content for this assessment. When I saw [the patient] later, [they were] awake, nude from the waist down. [They] did not appear to be in distress but did appear to be irritable. [They] expressed hostility toward me and staff who were present, cursing at us. Thought processes were perseverative in that regard. [They continue] to express hyper religious paranoid thought content and appears frequently to respond to unseen others. [The patient] has poor insight and judgment. [They] regularly expresses thoughts of hurting other people during my assessment as well as with nursing staff. Assessment/Plan: Continue seclusion for up to four hours.” *On 12/20/2024 for the 1800 hour, 1:1 staff documentation on the “Emergency Seclusion or Restraint Flowsheet” included: “1815 ... pt. standing on top of the sink” “1816: Fell again from sink top.” “[illegible time between 1816 and 1843]: standing on the sink” “1843: fell on the floor in the restroom” “1845 ... pt. standing on top of the sink” The “RN 60 [minute] assessment” section on the flowsheet was signed by the RN at 1845 contained no information related to the patient’s fall risk behaviors or falls. *On 12/20/2024 for the 1900 hour, 1:1 staff documentation on the “Emergency Seclusion or Restraint Flowsheet” included: “1900 Pt Standing on the Sink and jumping on bed ... Standing on the toilet sink and jumping” “1915 Pt trying to take bed out of bathroom ... pacing around room & bathroom” “1930 Pt trying to push the bed out of the bathroom ... Standing on the bathroom countertop” “1945 Jumping from sink in bathroom” “1955 Pt Jump on the bed” The “RN 60 [minute] assessment” signed by the RN at 1945 stated “patient standing on sink jumped down onto mattress landing on both feet ... redness on upper right should blade ... continued risk of harm” *On 12/20/2024 for the 2000 hour, 1:1 staff documentation on the “Emergency Seclusion or Restraint Flowsheet” included: “Has toilet full of garbage trying [sic]” “2000 ... Fell on counter 19:55” “2006 Fell backwards and hit head on wall” The “RN 60 [minute] assessment” signed by the RN at 2045 included no reference to the 2006 fall when the patient hit their head and stated only “Jumping from counter attempting to hurst self this hour.” *The flowsheet documentation described in the findings above reflected the patient had at least six falls at 1735, 1750, 1816, 1843, 1955, and 2006. However, incident documentation and the RN progress note in the two findings that follow this indicated the patient had five falls at 1735, 1815, 1955, 2000, and 2007. * On 12/20/2024 Patient 3 had five falls in the unlocked seclusion room bathroom at 1735, 1815, 1955, 2000, and at 2007 they hit their head on the wall during the fall. Incident documentation reflected that the “Patient standing on sink in bathroom and messing with light above. Patient fell from sink, onto toilet, and onto bottom at 1735. No apparent injuries. Staff called this nurse who notified [POD] and was told that putting patient in restraints wasn’t worth the risk of harm to staff. This nurse placed mattress in bathroom as fall precaution. Patient fell onto mattress at 1750. No apparent injuries. Patient would take mattress out of bathroom and nurse would go in and place mattress back in bathroom when patient climbed onto the sink. Patient would attempt to spit on nurse. [POD] notified each time patient jumped off sink. Patient ‘fell’ onto mattress at 1815, 1955, 2000, and 2007. Staff reported patient hit head on wall at 2007. [POD] updated. Patient appears in no apparent physical distress other than a red mark on upper right shoulder blade. Neuro checks deferred for safety.” The report reflected that “contributing factors” were “Patient repeatedly jumped off bathroom sink onto mattress.” The patient exhibited self-harm and high-risk behaviors in the bathroom that included climbing onto the sink, and jumping and falling off that resulted in at least one hit to the head. Further, they were able to access the bathroom light fixture while standing on the sink. However, the bathroom door was left unlocked so that the patient could continue those high-risk behaviors. * On 12/20/2024 at 2211 an RN signed a progress note that reflected “[Patient 3] standing on sink in bathroom and messing with light above. Patient fell from sink, onto toilet, and onto bottom at 1735. No apparent injuries. Staff called this nurse who notified [POD] and was told that putting patient in restraints wasn’t worth the risk of harm to staff. This nurse placed mattress in bathroom as fall precaution. Patient fell onto mattress at 1750. No apparent injuries. [POD] notified. Patient eating dinner clamshell and down from sink as of 1800. Patient repeatedly climbing onto sink and jumping on mattress. Patient ‘fell’ onto mattress at 1815, 1955, 2000, and 2007. Staff reported patient hit head on wall at 2007. [POD] updated. Neuro assessments initiated and also deferred for safety due to patient stating ‘fuck you bitch’ and giving staff the middle finger. Patient appears in no apparent physical distress other than a red mark on upper right shoulder blade. Respirations even and unlabored. Patient laid down on mattress in the bathroom around 2010, where [they have] since remained.” * On 12/20/2024 at 2224 the RN signed a progress note that described the patient’s falls identified in the Finding immediately above and that stated, “[POD] updated each time patient jumped from sink ... Recommendations: Lock bathroom in [seclusion room] as soon as possible for safety.” However, the RN did not lock the seclusion room bathroom door. * On 12/21/2024 at 0145 the RN signed the “RN 60 [minute] assessment” section on the “Emergency Seclusion or Restraint Flowsheet” that reflected the patient had continued access to the bathroom. The RN wrote “pt lying on mattress on their left side on mattress in bathroom.” * On 12/21/2024 at 0335 the POD, MD FF, gave a telephone order to an RN for continued seclusion for four hours. The “indication” for the seclusion was “jumping from counter bathroom when awake.” However, at 0335 the “Emergency Seclusion or Restraint Flowsheet” reflected the “pt. appears asleep.” The psychiatrist signed the order on 12/21/2024 at 0720. The order further reflected that the bathroom door to the seclusion room was allowed to remain open in spite of the patient’s falls and fall risk behavior. *On 12/21/2024 at 0556 an RN signed a progress note that reflected “Received in locked seclusion, requested snacks and Ensures, PRN Benadryl, remains naked, typical responses “fuck you bitch”, attempting to get special snack items not offered to other patients on the unit and [they were] given the same snacks offered to everyone. Did finally appear to therapeutically rest and refrain from self harm behavior of jumping from bathroom counter.” * On 12/21/2024 at 0743 the POD, MD FF, signed a “Psychiatry General Note ... Seclusion/Restraint Note” that combined two encounters and indicated “Time of Face-To-Face Assessment: 12/20 @ 2335 and 12/21 @ 0720.” The noted reflected “pt remains in prolonged seclusion. Per RNs [patient] was standing on sink counter in seclusion bathroom; slipped once but did not injure [themselves], so mattress was placed on the floor. [Patient 3] then began jumping off sink counter onto mattress repeatedly, again without apparent injury. Spitting at staff if they entered room, so was not able to be redirected back to seclusion room. Eventually tired and lay [sic] down on mattress; slept on mattress in bathroom overnight ... pt appeared to be sleeping both times I saw [them]; I did not wake [them] ... Mental and/or Physical Status Exam: 12/20: naked, laying on mattress in seclusion bathroom without a blanket, eyes closed, breathing evenly. 12/21: laying on mattress in seclusion bathroom, covered by blanket, eyes closed, breathing evenly ... Assessment/Plan: Schizophrenia -- pt continues to engage in behavior that is risky to self and others. Spoke with RNs multiple times when pt was jumping off counter and advised that so long as [the patient] was jumping onto mattress and not injuring self, to continue to observe; manual intervention by staff would have led to mechanical restraint, possibly for long duration. Continue seclusion for up to 4 hours.” The note contained no references to the patient’s multiple falls and referred only to the patient’s high-risk behavior of “jumping.” There was no mention of the occasions on which the patient hit their head and other body parts. There was no indication that MD FF conferred with unit staff to formulate a plan to safely prevent the patient’s access to the bathroom and it was not clear why it was assumed that any interventions to prevent the patient’s access to the bathroom would result in long-term mechanical restraint while in locked seclusion. It was not clear how an observation of a sleeping patient in seclusion or restraint could be considered a “Face-To-Face Assessment” and confirmed that the physician did not respond to the seclusion room to evaluate the patient after their falls. Further, there was no indication in MD FF’s note that referenced the information MD A wrote in their note on 12/20/2024 at 1744 about their conversation with Patient 3 that stated specifically “I informed [Patient 3] that the on-call psychiatrist tonight was the chief medical officer and that [the CMO] would be involved in some decision-making regarding [the patient’s] progress, and that it would be helpful for [the patient] to discuss with [the CMO] how [they are] doing and what [their] goals are and plans for coming out to be around others despite [their] frequent behavioral difficulties ... [The patient] had limited reception to this, frequently cursed at me and flipped me off, but said that [they] would try and be awake for [the CMO] when [they came] by for assessment.” The CMO’s failure to follow-up with Patient 3 after the patient’s attending physician MD A had assured the patient that the CMO would talk to them was contradictory to a therapeutic environment. *On 12/21/2024 for the 1000 hour on the “Emergency Seclusion or Restraint Flowsheet” the 1:1 staff recorded the following: - “1000 ... awake, laying on floor” - “1015 ... charged at staff “ - “1030 ... in restraints in [seclusion room]” - “1045 ... appears asleep” * On 12/21/2024 between 0556 and 1202 there were no RN progress notes written in the medical record. * On 12/21/2024 at 1020 incident documentation reflected “[Patient 3] noted to be sleeping on [their] mattress that is wedged between the bathroom door to seclusion room. [The patient] was reported to be jumping off of the bathroom counter last night and hitting [their] head on the ground multiple times. Due to [the patient’s] behavior with bathroom last night and extensive history of unsafe behaviors with bathroom (i.e. putting [their] head in the toilet for extended periods of time when there are urine and feces present in toilet water, jumping off of the bathroom counter, head banging on bathroom counter), with approval from [POD, two RNs, and security staff], formulated plan to lock the bathroom in [Patient 3’s seclusion room]. When security staff and RNs entered [the patient’s seclusion room, they] became verbally aggressive with staff and refused to leave bathroom to allow staff to safely lock bathroom. [The patient] then came toward security staff attempting to physically attack [security staff]. Security staff were able to deflect patient’s blows with soft shield use. Manual hold initiated at 1018. [The patient] was assisted to the padded seclusion room floor. Mechanical restraints applied. Spit hood applied as [the patient] was spitting at staff. [Patient 3] placed in locked seclusion on restraint bed in mechanical restraint secured to restraint bed.” It was unclear why Patient 3 was mechanically restrained to the restraint bed after the bathroom door was locked and locked seclusion continued. In the absence of documented rationale it was not clear whether the continued application of mechanical restraints was for the purpose of punishment, discipline, or retaliation. *On 12/21/2024 at 1050 a form titled “Emergency Seclusion or Restraint Entry Note” was signed by an RN and reflected “Event Initiated Date: 12/21/24 Time: 1018 Type of Restraint used: ... Seclusion ... Mechanical ... Manual ...” It included the following information: - In response to the statement “Patient’s response to least restrictive methods prior to restrictive event:” the RN wrote “Pt was asked to safely allow staff to lock [the seclusion room] bathroom. Pt refused and attempted to attack security staff.” It was not clear how asking the patient to allow staff to lock the door was a therapeutic less restrictive intervention. - In response to the statement “RN objective description of patient behavior leading to a more restrictive intervention and patients’ [sic] response:” the RN wrote “Pt was asked to safely allow staff to lock [seclusion room] bathroom [due to] pt clogging toilet with food and trash and jumping off bathroom counter and hitting [their] head on the ground last night. Pt attempted to physically attack security staff. Pt placed in manual hold.” There was no indication that the RN and security staff attempted therapeutic communications and interactions that might have led to the use of less restrictive interventions. - “Manual restraint” was applied at “1018.” - “Mechanical restraint” was applied at “1019.” - “Stryker stretcher/Backboard with mechanical restraints” was checked as done. - “Seclusion” was applied at “1027,” although it was unclear what that meant as the patient was already in seclusion. - In response to the statement “Criteria for release (Must be specific and achievable):” the RN wrote “Pt must agree to be safe to [themself] and others physically and verbally. Pt must agree to be safe with [seclusion room] bathroom and use bathroom appropriately. Pt must agree to be clothed in milieu.” However, the documentation reflected the patient was in “Mechanical restraints” on a “Stryker stretcher” while in seclusion. It was unclear whether the “criteria for release” was for release from mechanical restraints on the Stryker bed, or seclusion, or both. It was unclear how verbal behaviors were an indication for seclusion and mechanical restraints, and additionally, how appropriate use of the seclusion room bathroom was an indication for seclusion and mechanical restraints when the seclusion room bathroom could be locked. * On 12/21/2024 for the 1100 hour on the “Emergency Seclusion or Restraint Flowsheet” the 1:1 staff recorded the following: - “1103 ... pt laying appears asleep” - “1115 ... pt laying appears asleep” - “1130 ... pt laying appears asleep” - “1145 ... pt laying appears asleep” The RN signed the “RN 60 [minute] assessment” section of the flowsheet at 1145 and wrote: - “Imminent harm to self/others? Yes - Agitation; unpredictable behavior” - “Release criteria reviewed with patient and their response “Yes - ignoring RN” - “Patient cooperation: No - ignoring RN” - “Ready for release/downgrade & plan? No - continue to monitor and assess in locked seclusion and mechanical restraint.” It was unclear what behaviors the patient was exhibiting at that time when they were mechanically restrained that created an “imminent harm to self/others” and why the absence of behaviors was not an indication for release from the mechanical restraints while in seclusion. Further, there was no documentation on the flowsheet by the 1:1 staff or the RN that Patient 3 had been provided with, or offered any aspect of patient care, and there was no evidence that their extremities and physical condition had been assessed as a result of continued application of 4-point mechanical restraints. * On 12/21/2024 at 1202 an RN signed a progress note that described the events identified in the incident document immediately above. At the end of the note the RN wrote “Patient verbally abusive to staff throughout restraint process--calling staff insulting names, cussing, and yelling ... Patient continues in locked seclusion and mechanical restraints at this time.” It was unclear why [Patient 3] remained in 4-point restraints secured to a restraint bed for verbally abusive behaviors after entry into the new seclusion room. *The next RN progress note was not written until 12/22/2024 at 0554, ~ 18 hours later. * On 12/21/2024 for the 1200 hour on the “Emergency Seclusion or Restraint Flowsheet” the 1:1 staff recorded the following: - “1200 ... pt laying appears asleep” - “1215 ... pt in restraints” - “1230 ... pt in restraints” - “1245 ... pt in restraints” The documentation by the RN signed at 1245 on the “RN 60 [minute] assessment” was nearly identical to the documentation for the 1100 hour and concluded with “Ready for release/downgrade & plan? No - continue to monitor and assess in locked seclusion.” Further, as during the 1100 hour, there was no documentation that aspects of patient care had been provided and that the patient’s extremities and physical condition had been assessed. * On 12/21/2024 for the 1300 hour on the “Emergency Seclusion or Restraint Flowsheet” the 1:1 staff recorded the following: - “1300 ... pt appears asleep” - “1315 ... pt appears asleep” - “1330 ... pt appears asleep” - “1345 ... pt appears asleep” The documentation by the RN signed at 1345 on the “RN 60 [minute] assessment” was nearly identical to the documentation for the 1100 and 1200 hours and concluded with “Ready for release/downgrade & plan? No - continue to monitor and assess in locked seclusion.” There was no indication by the 1:1 staff or the RN whether the patient remained in mechanical restraints, and there was no RN progress note written until 12/22/2024 at 0554. Further, the only documentation that aspects of patient care had been provided or that the patient’s extremities and physical condition had been assessed was at 1345 where the RN initialed the space for “Food/Fluid (Offered/Given).” * On 12/21/2024 for the 1400 hour on the “Emergency Seclusion or Restraint Flowsheet” the 1:1 staff recorded the following: - “1400 ... pt laying on bed, awake” - “1415 ... pt laying down, awake” - “1430 ... pt laying on mattress, awake” - “1445: food/fluid available, movement unrestricted, bathroom locked, urinal and bedpan available ... pt laying down” The RN signed the “RN 60 [minute] assessment” section of the flowsheet at 1445 and wrote: - “Mental status ... laying on mattress not engaging in RN assessment. Quiet, calm” - “Imminent harm to self/others? Continued risk of harm to others” - “Release criteria reviewed with patient and their response “no safe exit plan per [illegible]” - “Patient cooperation: not cooperative” - “Ready for release/downgrade & plan? Continued risk of harm to others” It was unclear what behaviors the patient was exhibiting at that time that created an “imminent harm to self/others.” Further, there was no documentation by the 1:1 staff or the RN that described the circumstances and the time at which Patient 3 was released from the mechanical restraints alluded to in the 1445 entry by the 1:1 staff, and there was no RN progress note written until 12/22/2024 at 0554. * On 12/21/2024 for the 1600 hour on the “Emergency Seclusion or Restraint Flowsheet” the 1:1 staff recorded the following: - “1650 Pt fell from bathroom counter onto floor” - “1653 Pt fall from bathroom counter onto mattress” There was no indication by the 1:1 staff of what body parts the patient hit during the fall, or of injuries, or that they had notified the RN of the falls. The RN signed the “RN 60 [minute] assessment” section of the flowsheet at 1645. There was no documentation by the 1:1 staff or by the RN to reflect why the seclusion room bathroom door had been unlocked when it was last documented to be locked at 1445 on the flowsheet for the 1400 hour, and there was no RN progress note written until 12/22/2024 at 0554. * On 12/21/2024 at 1650 one of multiple incident reports for this incident event reflected that “I was assigned to [Patient 3] in the [seclusion room]. At about 1646 [the patient] became aware that [their] bathroom door was left unlocked. As soon as I noticed [them] going into the restroom, I called LH2 Unit using the phone in the Anteroom. [RN] answered the phone, and I informed [them] that [the patient] was in the bathroom putting [their] clothing in the toilet. [The patient] then began to climb on top of the sink in the bathroom. I asked [them] to get down from the sink. [They] did not acknowledge what I had said. I attempted several more times to ask [them] to come down from the sink. [The patient] continued to refuse to return to the ground. At 1650 [Patient 3] fell from the sink onto the ground. I did not visualize this. Seconds before [they] fell staff entered the Anteroom and I looked away to visualize who they were. [Two RNs and the PNM] had entered. [The patient] then got off the ground and began climbing back onto the bathroom sink. [The two RNs] went into the [seclusion room] and pulled [the] mattress into the bathroom in attempted to prevent further injury. [Patient 3] fell from the sink again at 1653. [They] landed on the mattress but slightly hit [their] head on the wall. [They] got up and began standing in the far corner of the bathroom.” * On 12/21/2024 at 1645 another one of the multiple reports for this incident event of “Self Harm, Jumping off sink in bathroom onto hard floor x4” reflected that “On Saturday 12/21/24, this nurse was called from [Patient 3’s seclusion room] around 1645 asking “Isn’t [Patient 3’s] bathroom supposed to be locked?” Bathroom was supposed to be locked due to patient jumping off the sink onto [their] mattress the night before. Patient was moved to a new [seclusion room] during the day and bathroom had not been locked when patient was moved. Staff stated patient was putting clothes in the toilet. This nurse told lead nurse and PNM and walked to the LH2 treatment mall [seclusion room]. Upon entering the door, a loud ‘thud’ was heard as patient jumped off the sink landing on the hard floor at 1650. Patient stood up and again crawled up onto sink in bathroom. This nurse entered the [seclusion room], grabbed patient’s mattress and dragged it into the bathroom so patient would have something to land on if [they] jumped again. Patient spit on me as I was placing the mattress in the room. Patient jumped and landed onto the mattress, but rolled back into the wall, hitting [their] head at 1653. Lead nurse went to call security and the doctor with a plan to go hands on and place patient in restraints so staff could lock [the] bathroom, preventing patient from jumping off the sink. While staff and security were making a plan, [the patient] dragged [the] mattress from the bathroom back into the [seclusion room]. Security placed a fall mat outside of the [seclusion room] in the hallway. Security entered the room and shut patient in the bathroom so staff could wipe up the urine on the floor, to prevent staff or patient from falling. Patient had climbed back up onto sink and was standing on the sink. Security entered the room again and opened the bathroom door. Patient jumped off the sink onto the floor landing on [their] side and back, hitting [their] head. Patient assisted [themself] onto [their] knees where [they] remained for a moment. This nurse went out into the hallway to tell security to place patient in a manual hold while [the patient] was on [their] knees as [there] was less risk of assault to staff while in this position and this would prevent [the patient] from further self-harm. Security told this nurse that they would not enter the bathroom because it was too small of a space to safely restrain patient. This nurse encouraged security to place patient in a manual hold. Security declined to take this opportunity despite RN direction, and I was not the lead nurse. Patient then stood up, turned [their] back to staff, climbed back up onto the sink, and jumped off the sink onto the floor, landing on [their] back, side, and general body inside the bathroom. Security then placed their hands on patient while [the patient] was on the ground in the bathroom after the second jump in efforts to place [them] in restraints. Patient swung at security staff while on the ground. Patient was placed in four point mechanical restraints for safety at 1720. Patient jumped off the bathroom sink three times onto the hard floor and once onto the mattress. Patient struck head during two of those falls. Patient has small scattered bruises to left hip area, left shoulder, and throughout general body areas. Patient has a large lump on [their] forehead and swelling and pain to [their] right foot.” * On 12/21/2024 at 1650 another one of the reports for the incident described in the two findings immediately above reflected that “Security was requested on [LH2] for assistance with upgrading [Patient 3] to active self-harm. The [LH2] nurses gave us a briefing over the situation at hand and informed us that [the patient] was actively getting on the seclusion room sink and purposely throwing [themself] on their back to self-harm. Security staff swiftly put together a plan with multiple alternate plans in preparation of the situation changing. Once arriving to the outside of the seclusion room where [the patient] was secluded, we observed [them] pulling the mattress that was placed on the bathroom floor to soften the impact of [their] falls out to the main room of the seclusion room and returning into the restroom. In anticipation that [the patient] would attempt to assault us while attempting de-escalation tactics due to [their] violet [sic] past, with Nurse’s approval, I went into the seclusion room and held [the] bathroom door shut while another security member locked it and allowed for other staff to clean the urine off the floor due to the slip hazard it presented and also removed the mattress from the room in order to avoid any obstruction in the event [the patient] charged at us. Once the objective of clearing any potential obstacles was completed, we exited the room closing the door behind us to gather ourselves and prepare for the intervention plan. Immediate Action(s): Security staff stationed themselves on the outside of the seclusion door before being cued to go back into the seclusion room to intervene [the patient’s] self-harm attempts. We entered the room with I and [another staff] meeting [the patient] at the doorway and initiating verbal de-escalation tactics in hopes that we could get [the patient] to get down from the bathroom sink. After attempting to keep [Patient 3] engaged in a conversation about [their] hobbies and likes, we saw [them] throw [themself] onto [their] back and land harshly on the ground. At this moment asked [the patient] if we could safely enter the room to come to [their] aid to which [they] stood back up and got back onto the bathroom sink. Shortly thereafter [the patient] once again jumped off the sink backwards but seemingly absorbing more of the blow on [their] feet before falling onto [their] back, with Nurse’s approval I and [another staff] moved in to contain [the patient] and stop any further attempt at self-harm. At this moment I asked the nurse for approval to move [Patient 3] out [of] the bathroom onto the main room floor where the floor was much softer and would allow enough space for the security team to move forward with upgrading [them] into restraints. It was at this moment [Patient 3] jolted [their] arm out of my hold and punched [the other staff person] in the shoulder. I contained the arm once more and with nurse approval we moved [the patient] onto the main room floor. [Patient 3] was upgraded into 4-point restraints and moved to a new seclusion room and placed onto a restraint bed and medicated. Nothing further to report.” According to this report staff locked the patient inside of the bathroom, where they were at greatest risk of harm and injury from jumping and falling off of the sink and toilet, for an undetermined amount of time while they made plans for their next steps. This incident and those steps included the repeated application of 4-point restraints which potentially could have been avoided had staff verified that the bathroom door was locked as intended. It was unclear why Patient 3 remained in mechanical restraints and the restraint bed once they were in the new locked seclusion room they were moved into. In the absence of documented rationale it was not clear whether the mechanical restraints were for the purpose of punishment, discipline, or retaliation. In addition, there was no indication staff verified that the bathroom door in the new seclusion room was locked. Further, there was no documentation to reflect the date and time the patient was released from the 4-point mechanical restraints and Stryker bed after that move. Although in the finding immediately below, the 1:1 staff documentation reflected that at 1700 the patient was moving in and out of the seclusion room bathroom, which was supposed to be locked. * On 12/21/2024 for the 1700 hour on the “Emergency Seclusion or Restraint Flowsheet” the 1:1 staff recorded the following: - “1700 ... Trying to take mattress out of bathroom” - “1710 Pt jumping from counter in the bathroom” - “1713 Pt standing on the bathroom counter” - “1715 ... Pt fell from bathroom counter” - “1730 Pt putting on restraint ... Pt putting on restraint bed resting” [sic] - “1745: ROM/food/fluid deferred for safety ... Laughing, and [illegible] spit at nurse, resting in bed” The RN signed the “RN 60 [minute] assessment” section of the flowsheet at 1745 and wrote: - “Mental status ... In 4 pt restraints ...” - “Ready for release/downgrade & plan? No - attempting to spit at nurse” This documentation at 1700, 1710, and 1713 that reflected the patient was not in restraints and was freely moving in the bathroom, did not align with the incident reports that reflected the patient was placed in 4-point restraints between 1645 and 1700. It was unclear when the restraints had been discontinued and why the bathroom door was unlocked after the events that had occurred during the 1600 hour. It was additionally unclear what was meant by “Pt putting on restraint” at 1730. There was no documentation to reflect why the patient was back in 4-pt restraints or why spitting was a justification for the use of continued application of 4-pt restraints according to the RN’s 1745 assessment, and there was no RN progress note written until 12/22/2024 at 0554. *On 12/21/2024 at 1830 a form titled “Emergency Seclusion or Restraint Entry Note” was signed by an RN and reflected “Event Initiated Date: 12/21/24 Time: 1720 Type of Restraint used: ... Mechanical ...” It included the following information: - For “Least Restrictive Methods Offered/Utilized prior to Restrictive Event:” the RN wrote “1:1 Counseling” and “Offered noodles, popcorn.” - For “Patient’s response to least restrictive methods prior to restrictive event:” the RN wrote “Did not respond, remained standing on sink. Pt jumped off sink.” - For “Description of less restrictive option offered after initial restrictive intervention and patients’ [sic] response:” the RN wrote “Food.” - “Manual restraint” was applied at “1725.” - “Mechanical restraint” was applied at “1720,” prior to manual restraint. - “Stryker stretcher/Backboard with mechanical restraints” was checked as done. - “Seclusion” was applied at “1739,” although it was unclear what that meant as the patient was already in seclusion. * On 12/21/2024 for the 1800 hour on the “Emergency Seclusion or Restraint Flowsheet” the 1:1 staff recorded the following: - “1800 ... Quiet and laying in restraint” - “1815 ... Quiet and laying in restraint” - “1830 ... Quiet and laying in restraint” - “1845 ... Patient complaining of head pain, notified [illegible]” The RN signed the “RN 60 [minute] assessment” section of the flowsheet at 1845 and wrote: - “Mental status ... remains in 4pt restraints, cooperative, calm” - “Physical health and comfort ... small bruises to left hip, redness to right shoulder, head pain 6/10” - “Imminent harm to self/others? Continued risk of harm to others” - “Release criteria reviewed with patient and their response: pt understands release criteria” - “Patient cooperation: cooperative” - “Ready for release/downgrade & plan? No - continued risk of harm to others” According to the assessment the patient was calm and cooperative and understood release criteria. It was not clear why the patient remained in the 4-point mechanical restraints at that time, and there was no RN progress note written until 12/22/2024 at 0554. * On 12/21/2024 for the 1900 hour on the “Emergency Seclusion or Restraint Flowsheet” the 1:1 staff recorded the following: - “1900 ... Quiet and laying in restraint” - “1915 ... Quiet and laying in restraint” - “1930 ... Quiet and laying in restraint” - “1945 ... Patient complaining of head pain, notified [illegible]” The RN signed the “RN 60 [minute] assessment” section of the flowsheet at 1945 and wrote: - “Mental status ... pt states [they don’t] want to come out [sic] restraints” - “Physical health and comfort ... [no apparent distress].” There was no indication the RN assessed the patient’s complaints of head pain. - “Imminent harm to self/others? assaultive [illegible] and unpredictable” - “Release criteria reviewed with patient and their response: does not want to come out [sic] restraints” - “Patient cooperation: Somewhat cooperative” - “Ready for release/downgrade & plan? Criteria not met per OSH” * On 12/21/2024 for the 2000 hour on the “Emergency Seclusion or Restraint Flowsheet” the 1:1 staff recorded the following: - “2000 ... pt laying down awake” - “2015 ... pt awake” - “2030 ... pt laying on bed awake” - “2045 ... pt awake” The RN signed the “RN 60 [minute] assessment” section of the flowsheet at 2045 and wrote: - “Mental status ... pt [illegible] appears to be awake” - “Physical health and comfort ... [no apparent distress]” - “Imminent harm to self/others? Unpredictable and assaultive” - “Release criteria reviewed with patient and their response: ‘what?’” - “Patient cooperation: Somewhat cooperative” - “Ready for release/downgrade & plan? Criteria not met per OSH” There was no reference in the note to the 4-point restraints, it was unclear why the patient remained in those, and there was no RN progress note written until 12/22/2024 at 0554. * On 12/21/2024 for the 2100 hour on the “Emergency Seclusion or Restraint Flowsheet” the 1:1 staff recorded the following: - “Pt complaining of pain in right foot and left side of stomach.” - “2100 ... pt laying down awake” - “2115 ... pt laying down awake” - “2125: downgraded to seclusion.” - “2130 ... pt pacing eating dinner” - “2145: fluid available, bathroom unlocked. Movement unrestricted ... Pt laying down awake” The RN signed the “RN 60 [minute] assessment” section of the flowsheet at 2145 and wrote: - “Mental status ... standing by anteroom door singing, minimally participating in RN assessment” - “Physical health and comfort ... pain in ‘back, ass’ 5/10 - lump on forehead, right foot swollen, large scrape on back” - “Imminent harm to self/others? risk of harm to others” - “Release criteria reviewed with patient and their response: no safe exit plan per [illegible]” - “Patient cooperation: minimal” - “Ready for release/downgrade & plan? risk of harm to others” It was unclear who released the patient from restraints at 2125 when the RN assessment did not occur until 2145. In addition, the RN failed to complete an appropriate assessment of the patient’s physical complaints of “pain in right foot and left side of stomach.” The stomach pain was not addressed at all, and the only information related to the right foot pain was that it was “swollen.” This after having been in 4-point mechanical restraints for several hours. There was further no objective description of the “lump on forehead” or the “scrape on back,” and no further evaluation of the back and bottom pain. It was also unclear why the seclusion room bathroom was unlocked at 2145, when the reason the patient was in the 4-point mechanical restraints on two occasions that day for several hours was because of unsafe behaviors in the bathroom. * On 12/21/2024 on the “Emergency Seclusion or Restraint Flowsheet” there was no documentation that patient care had been provided during the 1800 hour, the 1900 hour, the 2000 hour, and the 2100 hour until 2130 after it was documented that the patient had been released from the restraints at 2125. Additionally, there was no assessment of the patient’s limbs and circulation by the RNs. *On 12/21/2024 at 2140 an MD signed a progress note that reflected ~ four and 1/2 hours earlier: “Time of Face-to-Face Assessment: 1720+ ... [Patient 3] had been in Restraints earlier today for jumping off structures in [their seclusion room] bathroom. [They were] released from restraints and] downgraded to Seclusion, but the bathroom door had not been locked, and after [the patient] had been in the bathroom, [they] had urinated on the floor, and jumped 4 times, landing on [their] back. The first jump had been from the counter, then jumps were from the sink. [They] landed very hard on [their] back multiple times. [The MD] had been notified early of the jumping and plan to upgrade to restraints, and came LH2 [treatment mall] and unit. The Manual Restraint was 5 minutes before [they were] placed on the Stryker for movement from the [treatment mall] Seclusion room near LH2 to the LH2 first Seclusion room upon entry to the unit ... Mental and/or Physical Status Exam: [Patient 3] was quiet amidst the transfer to the clean LH2 Seclusion room, and tolerted [sic] the transfer. [They] did not speak to me then, or after [they were] fully in Restraints. [They were] naked throughout. I watched staff check [their] restraints. When [they were] turned for the IM injections, [they] remained still and it was obvious that, [they] had a non-bleeding 1 O” x 1” scrape on [their] back that was around the T3 or 4 level/shoulder blades below. Both buttocks were reddened, and the area of [their] back between the reddened buttocks and the scrape had a flushed appearance. After fully in Restraints, [they] did not look at me or speak ... [Patient 3] has thrown [themselves] to the floor 4 times landing on [their] back. [The DCMO] was notified, and plans to see [the patient] tomorrow.” *Although all medical notes were requested for 2024 and 2025 there was no medical note that corresponded to the DCMO’s plans, as reported by the MD in the note immediately above, to see the patient on 12/22/2024. *On 12/22/2024 at 0554 the RN signed a progress note, ~ 18 hours after the previous RN progress note. It stated only “Received in locked seclusion. Up off and on. Neuros unremarkable from observation. Slept 5+ hours. Did not participate in RN assessments.” * On 12/22/2024 at 1150 the next RN progress note was signed and written for events that occurred nearly ~ 19 hours earlier on 12/21/2024 at 1645. “At approx. 1645, Staff notifed [sic] that [Patient 3’s] bathroom was unlocked and [they were] jumping off of [the] sink. Staff put [the] mattress in the bathroom. Security was assisting. Staff reported that [the patient jumped] off the sink and then threw [their] mattress out of the bathroom into the main part of other [seclusion room]. Security closed the door to clean the urine on the floor and then opened the door. During this time pt got back up on the sink and jumped off again despite staff offering [them] noodles, popcorn, and imploring for [their] safety. Pt then started masturbating and sticking a finger in [their] anal area. Staff reported that Pt jumped again staff unable to get pad. When [they] landed security asked for [the patient] to be assessed as [they had] hit the floor. 1500 RN determined that to limit self-harming behaviors it was prudent to pull [the patient] out of the bathroom. As pt was resisting pt was placed in mechanical restraints. [Physician] was able to assess and it was noted that [the patient’s] upper back and buttocks presented with redness. IM medication was administered at that time. During the next assessment RN noted that pt presented with a lump on [their] forehead. During next assessment pt stated that [they were] not ready to get out of seclusion. Pt stated that [they] wanted pain medication. RN called [POD] who ordered to call [MOD], who stated that it would be okay to give APAP. Pt administered APAP and downgraded from mechanical restraints at 2120. RN noted that [patient] had an abrasion on [their] right shoulder, complaining of stomach pain that [their] [sic] not like [they are] hungry and [their] right foot [their] [sic] swollen to nearly twice it’s [sic] regular size. Pt c/o stomach pain when asked as [they were] eating. Pt walking around on food [sic] while eating despite being advised to lay on [their] mattress upon which [they] peed on as soon as the seclusion door was closed. Pt not actively complianing [sic] of pain. [POD] notified who again told RN to notifiy [sic] [MOD]. [MOD] at first advised Ibuprofen but pt has a history of holding medication hostage. [MOD] then ordered IM toradol but reminded that staff would have to go hand [sic] on. [MOD] advised that [patient] actively complains of pain to notify [MOD]. MD stated that [they] would be in to assess [the patient] in the morning. Neuro checks performed but patient administered medication that is sedating making it hard to determine. Pt asking for sandwiches, towels, and blankets which were given. Food and fluids offered and available. Bed pan and urinal in room with bathroom door locked. Pt remains in locked seclusion at the end of the shift.” The note, with significant information related to the patient’s seclusion and restraint experience on 12/21/2024 was late, disorganized, and unclear. It was difficult to track the course of events on that shift as it started off by describing events at 1645, then at 1500, then at 2120. It also reflected at the end of the note that the seclusion room bathroom door was locked. However, the last documentation related to the bathroom door on 12/21/2024 was at 2145 on the “Emergency Seclusion or Restraint Flowsheet” and reflected “bathroom unlocked.” * On 12/23/2024 at 0450 late incident documentation for Patient 3 reflected that “At aproxamtely [sic] 1650 on 12/21/2024, ~ 36 hours earlier, LH2 requested security assistance with the patient in the 2nd floor lighthouse treatment mall [seclusion room]. The report was that when we previously downgraded the patient from mechanical restraints on the bed to just locked seclusion, the bathroom was accidentally unlocked. The reported issue with the bathroom being unlocked is, the patient was climbing onto the counter in the bathroom to either jump or fall off the counter. When the patient would jump or fall off the counter, [they]would be landing on the tile like floor and land on [their] back and hit [their] head. Before coming up with a plan we requested that the nurse call the on-call doctor to ask what they would like us to do given the risk of the patient severally [sic] hurting themselves and the history of the patient hurting staff. The report was that [the physician] wanted us to upgrade the patient into mechanical restraints and lock the bathroom door. With the doctor’s request, security came up with a plan on the safest way to upgrade the patient to mechanical restraints. The plan that was put together was, to open the main [seclusion room] door and let the patient come out of the [seclusion room] to us so we could safely escort [them] to the ground. If the patient didn’t come out of the bathroom, we would shut the bathroom door and lock it. The reason for that was to clean the room and get the mattress that the patient peed on and took out of the bathroom. We did this so we could escort the patient to the softer floor to prevent injuries for the patient and the staff. After cleaning the room, we would restation [sic] arms and legs, then unlock the [seclusion room] and have the patient come to us since the bathroom would be an unsafe place to go hands on due to the size of the room and the hard floor along with the metal toilet and counter. We than would go hands on when the patient charged at us coming out of the bathroom. Immediate Action(s): When we approach the [seclusion room] the patient was pulling the mattress out of the bathroom and leaving it in the [seclusion room]. The patient than climbed onto the bathroom counter and fell off backwards landing [sic] the tile like floor on [their] back. We than [sic] opened the [seclusion room] and tried to talk to the patient but [they] remained in the bathroom. We than [sic] locked the bathroom to clean the room. After we cleaned the room [another staff] and I who were arms [sic] stationed our selves [sic] right outside the bathroom door, we than [sic] opened the door. I than saw the patient on top of the counter with [their] back to us while holding onto the light [fixture]. For roughly about 3 minutes, we attempted to [deescalate] the patient trying to have [them] safely come down off the counter and come out of the bathroom. The patient refused to come out and told us to “fuck off” and “fuck you”. The patient than proceeded to let go of the light [fixture] and fall [sic] backwards onto the floor. When the patient landed, it appeared that [they were] in pain and remained on the floor. In the moment it was deemed unsafe by the arms and legs, to go into the bathroom to attempt to upgrade [the patient] to mechanical restraints. It was deemed unsafe due to the patient extensive history of assaulting staff, and it was a small room with metal [sic, end of report]” * On 12/23/2024 at 1535 incident documentation reflected that at 1545 Patient 3 “attempted to physically assault staff during [a Long-Acting Injectable Antipsychotic administration] and move to a clean seclusion room due to being covered in feces, urine, food, etc (room and body). Immediate Action(s): - Restraints checked ...” There was no other information related to “restraints” in the incident documentation. It was unclear what restraints were used, why, and if other less restrictive interventions had been attempted. As identified in the findings above, the previous application of mechanical restraints had been discontinued on 12/21/2024 at 2125. *On 12/23/2024 at 1647 an RN signed a progress note that reflected that Patient 3 was “Received in locked seclusion. Patient spent time resting on [their] mattress, pacing, and singing in locked seclusion this shift. Patient is naked but has clothing available to [them]. Trash, urine, and feces scattered throughout patient’s seclusion room. Patient noted to be staring at [opposite gender] staff in ante room and masturbating this shift. Patient agitated during hourly RN assessments--cussing at RNs, not focusing on safety planning, and demanding various things from staff. Late order obtained for patient’s [Zyprexa] injection per provider. Patient provided with meals, fluids, and snacks throughout the shift. Patient has bedpan and urinal available to [them] for elimination. Patient continues in locked seclusion at end of shift.” That RN note contained incomplete and inaccurate information about the events that occurred an hour earlier beginning at 1545 that were described in the incident documentation immediately above. Those critical events included the application of 4-point mechanical restraints on a Stryker bed, were not documented for ~ five more hours by another RN, and are described in the finding immediately below. The contradictions and inaccuracies between the two notes included that the 1647 note gave no indication that the patient was placed in 4-point mechanical restraints on a Stryker bed as a result of staff attempt to administer the Zyprexa injection at 1545 or that the patient was transported to another seclusion room. *On 12/23/2024 at 2128 an RN signed a progress note that reflected “[Patient 3] received in locked seclusion. [They were] heard yelling, screaming, singing in an excited manner. Pt continues to be naked which is a precursor for aggression. Around 1545, staff went to offer prescribed long acting Zyprexa as ordered. A plan was formed prior to the event and soft shield and spit hood taken due to pt’s history of attacking and spitting. As soon as the door was open, pt came out naked running with fists up and clenched. [They were] running towards staff. Soft shield was utilized and manual hold ensued. Pt was spitting so spit hood was applied. Pt was lowered to the mat and restraints was [sic] applied. [Patient] was yelling, cursing, kicking and moving [their] head aggressively. Pt had feces in [their] buttocks and staff cleaned [the patient] up after restraints was [sic] applied. [Patient] was stabilized and wasn’t kicking so because [they were] laying in prone position, the long acting injectable was administered and as it was being administered there was some resistance causing the medication in the syringe to explode splattering into 5 staffs [sic] faces. The residue was wiped and pt was placed on the backboard and Stryker used to transport to [treatment mall seclusion room]. While there [the patient] was observed and heard cursing ‘go to hell demon, fuck you bitch”. During assessment [patient] would start spitting as soon as RNs open the door. Pt kept asking for the time and refused ROM. Around 1940, [they] asked for [their] dinner. Pt was fed while in restraints and was appropriate, [they] again [were] asked about getting ready to be downgraded and [they] stated ‘go to hell demon, God wants me in restraints’. Flood and fluids offered. [Patient] was offered a urinal but [they] refused. Pt continues to be linear when [they want] for staff but speak gibberish during some assessments. Pedal pulses palpable, no signs of distress, pt is alert and able to make needs known. Notable scabbed bruises noted to the right shin. RN attempted ROM at 2045, pt agreed to be safe and not spit at RN. As soon as RN was assessing for radial pulses, [they] started spitting endlessly. RN exited the room. Pt continues to refuse to be downgraded. [Patient 3] remains in restraints at the end of the shift. Nursing staff will monitor and document any changes.” * The “Emergency Seclusion or Restraint Flowsheets” reflected that Patient 3 was placed in 4-point mechanical restraints on 12/23/2024 at 1550, transported to a different seclusion room at 1554, the mechanical restraints were attached to the restraint bed at 1557, and the seclusion room door was locked at 1558. Although the patient was in a locked seclusion room they remained in 4-point mechanical restraints in the locked seclusion room from 12/23/2024 at 1550 through at least 12/24/2024 at 0245. (That was the last page of the 12/2024 flowsheets requested for the survey sample.) The flowsheets contained the following information about the patient’s condition during those hours: - On 12/23/2025 at 2225 the 1:1 staff recorded “Pt moved half of [their] body around.” There was no indication of staff or RN response to that movement which increased the risk of injury in the restraints. - On 12/24/2024 at 0103 the 1:1 staff recorded “Right hand began to turn purple in color on [video monitor], RN assessed and [illegible] loosened restraint.” There was no corresponding RN assessment documented. *On 12/24/2024 at 0724 an RN signed a progress note that reflected “Received in restraints. Attempted downgrade at 0005; back in restraints at 0015. Kicking, spitting and fighting with security when manual hold still in place. Had a plate of snacks ready for [patient] and getting menus per [their] request once released; yet, continued to resist. Cussing and spitting during assessments; labile.” *On 12/24/2024 at 1600 an RN signed a progress note that reflected the patient was released from the mechanical restraints earlier that day at 1007 and the “bathroom remains locked at this time.” * On 12/27/2024 at 1807 a FNP signed a “Medical Doctor/NP” note that reflected Patient 3 “was seen for a follow-up after throwing [themselves] on the floor over the weekend on 12/22-12/23/24. Over the weekend the medical on-call provider attempted to assess the patient, however patient did not cooperate with assessment. Today, the exam is limited due to the patient being in seclusion. The patient was observed through the seclusion window, [they were] naked and seen cleaning [their] trash off the floor and then approaching the window to talk ... No lump was observed on [their] forehead as reported on 12/22/24. The patient’s skin was dry and intact. No obvious deformities were noted ... No apparent physical injuries observed. Plan: -Maintain patient safety interventions to address and prevent self-harming behavior. -Continue to monitor patient, report any changes or new symptoms.” However, it was not clear what patient safety interventions to prevent self-harming behavior were in place. In spite of all of the falls and injuries described in this report for Patient 3 while they were in seclusion and mechanical restraints, there was only one other medical note since December 2024 for reasons other than “Reassessment of enhanced medical supervision.” It was the only medical note for 2025 and was an FNP note on 02/13/2025 at 0950 for “Chief Complaint: Cough and Congestion.” * On 01/09/2025 at 1915 incident documentation reflected that Patient 3 “was pacing the seclusion room steadily. [They] slipped in liquid/urine on the floor many times. This time [they were] walking too fast not paying attention to where [they were] walking and walked into the corner of the wall then lost balance, slipped on urine/liquid and fell down landing on [their] right side, it look as if the side of [their] head and face hit the floor. [They] quickly got up and continued pacing, I tried to tell talk to [the patient] and encourage [them] to slow down, but [they] ignored me and continued walking and slipping on floor. I called up to LH2 RN station and let them know what happened. 19:19- [Patient 3] fell again only 4 minutes after falling the first time. [They] did not hit [their] face or head this time and got right back up, [they] cussed loudly after [they] got up, I tried to get [their] attention and encourage [them] to sit, when I did get [their] attention [they] said to me “Shut the Fuck Up”. Kept walking and still slipping. RN came in, I let [them] know what had happened. [Then RN] tried assessing [the patient] but [they] ignored RN, [RN] called the doctor to inform them of what happened.” * On 01/11/2025 at 1118 incident documentation reflected that Patient 3 “seemed to have fallen in the [seclusion room]. Patient appeared to have slip and fall. Immediate Action(s): Staff notified the RN and RN came to the [seclusion room] to asses the patient.” * On 01/16/2025 at 1115 incident documentation reflected “LH2 requested assistance with moving [Patient 3] to a new seclusion room. This was communicated as an order due to how filthy the seclusion room [they were] being housed in was.” A second incident report for that date and time reflected that Patient 3 was covered in feces, and having smeared feces on windows, walls within the seclusion room.” * On 02/02/2025 at 1200 multiple incident reports reflected that Patient 3 was moved to a clean seclusion room because the seclusion room they were in was covered in feces, urine, and trash. The documentation reflected the scene was chaotic, disorganized without a clear plan or leader, and resulted in patient self-harm and assaultive behavior toward staff. For example: One incident report stated that “Staff were in seclusion room on the floor containing [Patient 3] who was struggling. Scene was chaotic with several people screaming for items and to reposition control of limbs. After successfully containing pt into 4 points, question arise [sic] of what had happened. Per Lead [RN], [they] opened ante room door to have [Patient 3] talk to [their parent] who was on Nextel phone. This was per request of [the patient] who was earlier banging [their] head on the rubber wall. [The RN] further reported that as soon as [they] opened the ante room door, [the patient] grabbed [the RN] and punched [another staff] on the face. Then it was immediately called. Several staff got hurt during this incident ...” * On 02/04/2025 at 1645 incident documentation reflected that “During the 1645 RN assessment, [Patient 3] observed standing naked at the [seclusion room] bathroom door. Nursing staff could see that [the patient] was making a rhythmic motion with object in [their] hand. When nurse attempted to assess [the patient they] stated “I’m making a shank” and then told nurse “I’m going to fucking kill you!”. Nurse able to convince [the patient] to come to window to talk to [patient] [sic]. Nursing staff observed what appeared to be a top off of [their] salad [clam-like container] from meals. Upon further assessment, It was noted that [the patient] had the lid to [their] urinal in [their] hand in which [they] tore off and was in the process of making a sharp item. [Patient 3] took the lid and gestured at [their] neck as if [they were] going to cut [themself]. [The patient] then took the lid and gestured at [their] wrist demanding staff to bring [them] the telephone. [The patient] performed this act at least 3 times as [they] threatened to kill [themself] as well as the nurse. After about 10 minutes of encouragement, [the patient] placed part of the lid under the door for nurse to take. [The patient] held onto the lid until it tore. Nurse was able to obtain part of the lid that had sharp edges from [the patient] alterating [sic] item. [The patient] had the other part of the lid which contained what looked like sharp edges. Again, [they] threatened to hurt [themself] if the phone wasn’t given to [them]. Nursing finally able to convince [the patient] to give staff the other piece of the lid.” It was unclear how Patient 3 could have torn off the urinal lid in order to make a weapon for self-harm while 1:1 staff in the anteroom constantly observed and monitored them. Further it was unclear why a patient in seclusion would be provided a patient care supply that could easily be altered. * On 02/27/2025 at 2115 incident documentation reflected that Patient 3 “was pacing thre [sic] seclusion room and slipped landing with [their] head, neck and shoulders on [the] mattress but bottom half on seclusion floor. [The patient] fell again on [their] bottom and got right back up, I suggested [they] sit down so [they wouldn’t] fall again, but ignored my suggestions. [The patient] fell 2 more times, both resulting in [them] jumping back up and continuing to pace. I checked on [them] and asked if [they were] okay [they] stated [they were] and when I asked if [they] hurt anywhere [they] stated “No”. RN did assessment but [the patient] was showing signs of triggers and it was not safe to do a full physical assessment on [them] during that time.” The report reflected “Contributing Factors: Wet floor due to [Patient 3] urinating on the floor.” 2.l. The hospital protocol for “Use of Seclusion Room Bathroom” described under Finding 1.b. above stated “When a patient is in locked seclusion, the door to the bathroom may be either locked or unlocked based on the assessment of the Registered Nurse (RN).” On 12/20/2024, on 03/18/2025, and on other occasions described for Patient 3 in this Tag, it was unclear why the RN, given authority by policy to make such a decision, failed to take necessary action to lock the seclusion room bathroom door, in spite of the direction from LIP staff. However, there were no provisions in the protocol for the RNs to initiate the hospital chain-of-command to assert the authority given to them should an LIP or unit or program leadership staff decline to comply or provide contradictory direction related to this patient safety intervention. 2.m. As identified in Finding 2.l. above, documentation on the “Emergency Seclusion or Restraint Flowsheets” for Patient 3 was unclear and incomplete as described. In addition, the flowsheet documentation contained other gaps and inconsistencies that contributed to the lack of a clear and complete record of the monitoring and observation of patients in seclusion and restraint, particularly when those restrictive interventions were used for extended periods. For example: *The “Emergency Seclusion or Restraint Flowsheets” contained space and entries for one hour of seclusion and/or restraint use. * The date and time seclusion was initiated was not identified on the form, unless a staff member happened to record it. * The date and time mechanical restraint was initiated, and the date and time it was discontinued, was not identified on the form, unless a staff member happened to record it. * The seclusion room number, location, and unit were not identified on the form. Nor were the dates, times, and room numbers of seclusion rooms clearly or consistently recorded when the patient was moved from one seclusion room to another. * The criteria for patient release from seclusion and/or restraint was not identified on the form. * There was no indication whether the seclusion room bathroom door was required to be locked or unlocked, and when either of those actions was initiated, unless a staff member happened to record it. * Documentation by 1:1 staff did not consistently or clearly identify what body parts were impacted during falls and incidents, nor that the RN was notified of those. * The number of falls documented on the flowsheets did not always align with the number of falls identified in nursing progress notes and incident reports. * The flowsheets contained numerous write-overs, alterations, illegible entries and names of 1:1 staff and RN staff, and lack of signatures to identify the initials used by the 1:1 staff. *On 12/17/2024 on the “Emergency Seclusion or Restraint Flowsheet” for the 0200 hour the 1:1 RN staff recorded that at each of the “15 min” checks at 0200, 0215, 0230, and 0245 the patient’s “Agitation Scale” was “0” at those times which meant “Eyes, closed, sleeping;” the patient’s “Physical Status” at those times was “0” which meant “Breathing evenly, states they are comfortable, or no signs of distress;” and under “Comments” at each of those times they wrote “Appears Asleep.” Contradictory to that information, the 1:1 RN also recorded at each of those times that the patient’s “Aggression Scale” was “1” which meant “Unpredictable, tense, irritable.” Further, although the RN recorded at the 2200 hour that the patient was asleep, they also documented that “Food/Fluid (Offered/Given)” and “Exercise/ROM (Offered/Given)” and “Elimination (Offered/Given).” The same 1:1 RN also signed the “RN 60 [minute] assessment” section of the flowsheet on 12/17/2024 at 0235. That assessment included: -“Mental Status: Appears Asleep ...” -“Imminent harm to self/others? Yes - risk for violence” -“Release criteria reviewed with patient and their response: Appears Asleep” -“Patient cooperation: None” It was unclear how the patient demonstrated “imminent harm ...risk” while they were asleep. And how being asleep at 0235 constituted a lack of “cooperation.” *On 12/17/2024 on the “Emergency Seclusion or Restraint Flowsheet” for the 0300 hour the 1:1 staff whose title was not identified, recorded that at each of the “15 min” checks at 0300, 0315, 0330, and 0345 the patient’s “Agitation Scale” was “0” at those times which meant “Eyes, closed, sleeping;” the patient’s “Physical Status” at those times was “0” which meant “Breathing evenly, states they are comfortable, or no signs of distress;” and under “Comments” at each of those times they wrote “Appears to be sleeping.” Contradictory to that information, the 1:1 staff also recorded at each of those times that the patient’s “Aggression Scale” was “1” which meant “Unpredictable, tense, irritable.” *On 12/17/2024 on the “Emergency Seclusion or Restraint Flowsheet” for the 0500 hour the 1:1 staff whose title was not identified, recorded that at each of the “15 min” checks at 0500, 0515, 0530, and 0545 the patient’s “Physical Status” at those times was “0” which meant “Breathing evenly, states they are comfortable, or no signs of distress;” and under “Comments” at each of those times they wrote “Appears asleep.” Contradictory to that information, the 1:1 staff also recorded at each of those times that the patient’s “Agitation Scale” was “1” at those times which meant “Lies, sits, or talks in usual tone, rhythm, volume;” and their “Aggression Scale” was “1” which meant “Unpredictable, tense, irritable.” *On 12/17/2024 on the “Emergency Seclusion or Restraint Flowsheet” the 1:1 staff whose title was not identified, recorded that at each of the “15 min” checks at “0600 ... 0415 ... 0430 ... 0445” [sic] the patient’s “Physical Status” at those times was “0” which meant “Breathing evenly, states they are comfortable, or no signs of distress;” and under “Comments” at each of those times they wrote “laying on mattress breathing.” Contradictory to that information, the 1:1 staff also recorded at each of those times that the patient’s “Agitation Scale” was “1” at those times which meant “Lies, sits, or talks in usual tone, rhythm, volume;” and their “Aggression Scale” was “1” which meant “Unpredictable, tense, irritable.” Further, the RN signed the “RN 60 [minute] assessment” on 02/17/2024 at 0635. The actual times of the 15 minute observations and the RN assessment of the patient were not clear. *On 12/17/2024 on the “Emergency Seclusion or Restraint Flowsheet” for the 0800 hour the 1:1 staff whose title was not identified, recorded that at each of the “15 min” checks at 0800, 0815, 0830, and 0845 the patient’s “Physical Status” at those times was “0” which meant “Breathing evenly, states they are comfortable, or no signs of distress.” Contradictory to that information, the 1:1 staff also recorded at each of those times that the patient’s “Aggression Scale” was “1” which meant “Unpredictable, tense, irritable;” at 0800 and 0815 they recorded the patient’s “Agitation Scale” was “1” which meant “Lies, sits, or talks in usual tone, rhythm, volume;” and at 0830 and 0845 they recorded the “Agitation Scale” had increased to a “2” which meant “Frequent mood swings, restless, pacing, is able to respond to limit setting.” However, their “Physical status” remained a “0.” *On 12/20/2024 on the “Emergency Seclusion or Restraint Flowsheet” for the 1700 hour the 1:1 RN recorded that at each of the “15 min” checks at 1700, 1715, 1730, and 1745 the patient’s “Physical Status” at those times was “0” which meant “Breathing evenly, states they are comfortable, or no signs of distress.” Contradictory to that information, the 1:1 RN also recorded at each of those times that the patient’s “Aggression Scale” was “2” which meant “Verbal threats, threatening postures;” and the patient’s “Agitation Scale” was “2” at those times which meant “Frequent mood swings, restless, pacing, is able to respond to limit setting.” The RN also recorded the following “Comments:” - “1700 ... putting cups into toilet” - “1715 ... calling staff [expletives]” - “1730 ... putting blankets into toilets, pushing down” - “1735: pt stood on the toilet sink, Pulled on light, sliped [sic] and fell, Landed on [their] bottom on toilet seat, then to shoudler [sic] on ground and [illegible] wall” - “1750: Fell again from sink to Landed on the mattress, [sic]” However, contrary to the “Aggression Scale” and “Agitation Scale” and “Comments,” during the entire hour the patient’s “Physical status” remained a “0” for “Breathing evenly, states they are comfortable, or no signs of distress.” *On 03/18/2025 on the “Emergency Seclusion or Restraint Flowsheet” for the 1800 hour the 1:1 staff recorded that at each of the “15 min” checks at 1800, 1815, 1830, and 1845 the patient’s “Aggression Scale” at those times was “0” which meant “No threats, sleeping, follows direction;” the patient’s “Physical Status” at those times was “0” which meant “Breathing evenly, states they are comfortable, or no signs of distress;” and under “Comments” at each of those times they wrote “Appears Asleep.” Contradictory to that information, the 1:1 staff also recorded at each of those times that the patient’s “Agitation Scale” was “1” at those times which meant “Lies, sits, or talks in usual tone, rhythm, volume.” Further, although the 1:1 staff recorded at the 1830 hour that the patient was asleep, they also documented that “Food/Fluid (Offered/Given)” and “Exercise/ROM (Offered/Given)” and “Elimination (Offered/Given).” The RN signed the “RN 60 [minute] assessment” section of the flowsheet on 03/18/2025 at 1830. That assessment included: -“Mental Status: Patient resting on floor with eyes closed.” -“Imminent harm to self/others? Unpredictable, high risk for aggression” -“Release criteria reviewed with patient and their response: No response to nurse at this time” -“Patient cooperation: No cooperation” It was unclear how the patient demonstrated “imminent harm ... risk” while they were asleep, and how being asleep constituted a lack of “cooperation.” *The policy titled “Restrictive Event Documentation and Reporting” identified in Finding 1.c. above in this Tag required that “When documenting hourly status checks of a patient who is not ready for release, the RN must address any instances from the past hour when the patient was rated as 0-1 for Agitation and 0 for Aggression on the same 15 minute check.” The RN failed to identify and address those instances on the “RN 60 [minute] assessment” section of the “Emergency Seclusion or Restraint Flowsheet.” Examples of dates and times included: - On 12/16/2024 at 2100, 2115, 2200, 2230, and 2245 when all “Agitation” and “Aggression” scores were “0.” - On 12/18/2024 at 0215, 0230, 0245, 2200, 2215, 2230, 2245, and 2300 when all “Agitation” and “Aggression” scores were “0.” - On 03/09/2025 at 1300, 1315, 1330, and 1345 when all “Agitation” scores were “1” and all “Aggression” scores were “0.” - On 03/10/2025 at 1500, 1515, 1530, and 1545 when all “Agitation” scores were “1” and all “Aggression” scores were “0.” - On 03/17/2025 at 1630, 1645, and 1700 when all “Agitation” and “Aggression” scores were “0.” - On 03/17/2025 at 1800, 1815, 1830, and 1845 when all “Agitation” scores were “1” and all “Aggression” scores were “0.” - On 03/18/2025, the day of their death, at 1200, 1215, 1230, and 1245 when all “Agitation” and “Aggression” scores were “0.” - On 03/18/2025 at 1800, 1815, 1830, and 1845 when all “Agitation” scores were “1” and all “Aggression” scores were “0.” *Unclear, incomplete, and contradictory documentation was evident for the majority of the hourly “Emergency Seclusion or Restraint Flowsheets” reviewed for Patient 3 during seven (7) selected weeks in December 2024, January 2025, February 2025, and March 2025 including the week of the patient’s death. 2.n. Patients 4, 5, and 6 had also experienced long-term seclusion episodes since December of 2024. Similar findings to those described under Finding 2.m above, related to the lack of clear and complete documentation on “Emergency Seclusion or Restraint Flowsheets,” were found for those patients in their medical records. 2.o. Refer to Tag A-144 that further reflects that the provision of safe care for other patients in seclusion was not ensured: * For Patient 9 who had falls in seclusion. * For Patient 10 who accessed the cameras in the seclusion room bathroom and covered them with wet toilet paper. * For Patient 12 who had a fall in seclusion, made a ligature from their shirt, was allowed to possess a spoon to puncture the bed mattress, and possessed a broken plastic spoon and broken urinal handle, both with sharp edges. * For Patient 13 who was allowed to possess an altered patient toothbrush that they used for self-harm, and a patient pen wrapped in multiple layers of paper soaked in unknown substance that created a rigid cylindrical object with a pointed end. ******************************************************”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(2) Training content. 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: (i) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. This Standard is not met as evidenced by: 44104 ****************************************************** Based on interviews, observations (training video), training curriculum, P&Ps, and other documentation, it was determined that the hospital failed to fully develop and implement training techniques to identify, prevent and manage patients’ aggressive behaviors in accordance with policies and procedures to ensure patients’ rights to receive safe care by trained staff. Findings include: 1. Refer to Tag A-093, Findings 13.a. through 16.b., for review of P&Ps and Seclusion and Restraint training curriculum. ******************************************************”

“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: 44104 ****************************************************** Based on email communications, review of training records for 4 of 5 LIPs (MD A, DO B, MD N and MD O) and 23 of 23 Direct Care nursing staff (RN C, RN D, RN E, RN F, RN G, RN R, RN T, RN U, RN W, RN Z, RN AA, RN EE, LPN H, LPN P, LPN Y, MHT J, MHT S, MHT Q, MHT V, MHT X, MHT BB, MHT CC, and MHT DD), review of training curriculum and training media, and review of P&Ps and other hospital protocols it was determined that the governing body of the hospital failed to fully develop and implement P&Ps that ensured that patients received care in a safe setting, including timely and appropriate medical emergency response. It was determined that hospital staff failed to complete training in First Aid techniques specific to patients in Seclusion and Restraints in accordance with policies and procedures to ensure patients’ rights to receive safe care by trained staff. Findings include: 1. Refer to Tag A-093, Findings 13.a. through 16.b., for review of hospital training curriculum. ******************************************************”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 44104 ****************************************************** Based on interviews, review of P&Ps, medical record documentation for 8 of 8 patients (Patients 14, 15, 16, 17, 18, 19, 20, and 21), and other documentation, it was determined that the hospital failed to ensure that electronic and handwritten medical record entries were accurate, complete, dated, timed, and authenticated in the following areas: * Fall Risk Assessments, reassessments and dcoumentation were not completed in accordance with hospital P&Ps. * Medical ES 1:1 assessments and reassessments for justification of ES 1:1 continuation documentation was not completed in accordance with hospital P&Ps, and orders were not entered timely. * Treatment Care Plans did not contain complete and accurate information and Addendums were incomplete and were not incorporated into the patient’s TCPs in accordance with P&Ps. * Medical record documentation for medically complex patients was not timely, was incomplete or nonexistent and was not available for direct care staff providing clinical care. Medical record documentation was not completed in accordance with hospital P&Ps. Findings include: 1. A P&P titled, “On-Duty Physician ... Protocol: 1.011” dated September 5, 2024, was reviewed and reflected: * “Oregon State Hospital provides physician coverage 24 hours daily to care for hospitalized patients ... During regular business hours, the medical ... needs of OSH patients are attended to by Psychiatrists/Psychiatric Mental Health Nurse Practitioners (PMHNPs) and Primary Care Practitioners ... On-duty Physicians provide coverage during night, weekend, and observed holidays, as well as times when regular physicians/PMHNPs are unavailable.” * “The POD and MOD, when on campus, must respond to see a patient on a unit when requested by the nursing staff or by another physician/nurse practitioner.” * “POD-Specific Duties ... Respond to all medical emergencies, including falls requiring a physician assessment ... This includes notifying the MOD of the medical emergency, the interventions that have been undertaken (including describing the physical exam you have performed), and requesting their advice in the further management of the patient. Such conversation will be documented by the POD ... Personally assess any patient in seclusion or restraint ... Assess patients as necessary for medical symptoms or enhanced supervision.” * “MOD-Specific Duties ... Respond to all medical emergencies when on site ... Round in person on all gero-psych units on weekends and holidays.” 2.a. A P&P titled, “Medical Clinic Provider Documentation Standards ... Protocol: 1.017” dated March 14, 2024, was reviewed and reflected: * “Purpose Create a standard for workplace documentation and timeliness for completion of Notes.” * “After provider evaluates patient, a SOAP note will be completed in electronic health record.” * “Note will be written expeditiously as defined below ... Establish care visit to be done within two weeks of admission: 72 hours ... Non-urgent stable chronic conditions/Health maintenance: 72 hours ... Urgent or Same-day Visit: 24 hours ... Emergency Visit: Immediately following visit, at the latest end of clinic day”. * “Staff in the above-named department who fail to comply with this protocol may be subject to disciplinary action, up to and including dismissal.” * Definitions for “SOAP Note ... Staff ... Urgent Visit ... Establish Care Visit ... Emergency Visit” were included in the policy. There was no definition for “Non-urgent stable chronic conditions/Health maintenance”. 2.b. A P&P titled, “Clinical Documentation ... Policy: 6.045” dated March 9, 2023, was reviewed and reflected: * “A patient’s medical record is systematic documentation about a patient’s condition, care, and treatment. Clinical documentation chronicles information about patients and their medical history; their responses to care, treatment, and services; and progress towards treatment goals. It is maintained for purposes of communication, accountability, and coordination of care and services.” * “This policy establishes clinical documentation requirements, processes, and style guide information. This policy also describes draft note reports as found in the electronic health record (EHR).” * “This policy applies to all staff.” * “Staff must complete and document required assessments as indicated by applicable regulations, discipline-specific standards of practice, and department protocols.” * “Staff must document clinical findings and observations about patients’ response to treatment and their progress towards treatment plan goals generally on the date of service/observation. If staff cannot document on date of service, the entry must be labeled as a late entry per this policy.” * “Staff are responsible for the accuracy and necessity of their documentation.” * “Staff must document with their own unique electronic medical record log-in. They may not share their log-in information with anyone else.” * “Staff must clearly identify when care has been rendered by another person. They may not document an entry for another staff member.” * “Every document filed in the paper medical record must include, at minimum, the patient’s first and last name and medical record number on both front and back of the form.” * “All EHR draft status entries must be finalized within 48 hours of initiating the entry. Staff should follow Procedures A to process draft documents.” * “The Doctor of Medicine or osteopathy responsible for the care of the patient, Nursing, and Social Work must document progress notes at least weekly for the first 2 months and at least one a month thereafter; and ... All disciplines significantly involved in active treatment modalities must document progress notes per frequency of services provided and as necessary as determined by the condition of the patient (i.e., as indicated per acuity of clinical presentation).” * “Late Entries ... It is expected that staff document notes on the date of service/observation. However, extenuating circumstances may prevent this from happening on occasion. Any progress note or group note not finalized on the date of service/observation must be identified as a late entry ... Late entries must be clearly identified at the beginning of the entry and reference the actual date and time of the service provided, observation, and/or event.” * “Staff who fail to comply with this policy or related policy attachments or protocols may be subject to disciplinary action, up to and including dismissal.” 3.a. A P&P titled, “Fall Risk Assessment ... Protocol: 2.200” dated December 1, 2023, was reviewed and reflected: * “The purpose of this protocol is to give directions to nursing staff at Oregon State Hospital (OSH) regarding assessing a patient’s risk of falling, as well as maintaining the safety of a patient who is at risk for falls.” * “Within four hours of admission or transfer from one campus to another (i.e., an inter-campus transfer), the admitting or receiving Registered Nurse (RN) must assess and document the patient’s fall risk using the Fall Risk Assessment.” * “The RN must use the information in the Scoring section to convert the numeric Total Score into a one-word description of the patient’s assessed fall risk (No, Low, Moderate, High) and then select the corresponding Risk Level radio button.” * “The RN must complete another Fall Risk Assessment between Day 6 and Day 10 following admission or campus-to-campus (i.e., inter-campus) transfer, even if the patient received a score of “No” or “Low” on the initial assessment.” * “Throughout the remainder of the patient’s hospitalization, the RN must reassess and document the patient’s fall risk level using the Fall Risk Assessment ...” * “Based on the patient’s most recently assessed fall risk level, the RN must reassess the patient as follows. [sic] a. Risk Level “No” (score of 0 - 24 points)- reassess in 12 months. b. Risk Level “Low” (score of 25-49 points) - reassess in six months. c. Risk Level “Moderate” (score of 50-74 points)- reassess in 90 days. d. Risk Level “High” (score of 75-120 points)- reassess in 60 days.” * “Note - Any change to the patient’s assessed fall risk level will change the timeline for the next reassessment.” * “The RN must reassess the patient’s fall risk following any significant change in their mental status or treatment interventions which the RN reasonably expects will increase or decrease their fall risk.” * “The RN must reassess the patient’s fall risk after any actual or suspected fall.” * “The RN must notify the practitioner (psychiatrist on duty [POD] after-hours) of any changes to the patient’s assessed fall risk ... The manner and timing of this notification is at the RN’s discretion, depending on the severity of the change and the implications for the patient’s safety.” * “This notification must be documented in the patient’s EHR.” * “As noted previously, following completion of the Fall Risk Assessment ... for any other reason, the RN must perform all required follow-up actions ... Ensure the immediate safety of the patient ... Communicate pertinent fall risk level data and required safety measures to nursing staff ... and to others ... Report pertinent findings to the practitioner (POD after-hours) ... Provide education to the patient ... regarding their fall risk, interventions in place to help maintain their safety, and ways they can help themselves be safe. Patient education ... must be documented in a progress note in the EHR ... Develop and document a nursing plan of care addressing the patient’s fall risk.” * “For a current patient, do one of the following ... Utilize the Treatment Care Plan Addendum (TCPA) form to either document the new nursing plan of care or, if applicable, to amend an existing Treatment Care Plan (TCP) related to falls ... Meet with the patient’s Interdisciplinary Treatment Team (IDT) and incorporate the issue into the patient’s TCP, provided that the IDT is immediately available to do so.” * “Staff in the above-named department who fail to comply with this protocol may be subject to disciplinary action, up to and including dismissal.” 3.b. A P&P titled, “Post-Fall Assessment and Monitoring ... Protocol: 2.205” dated June 15, 2023, was reviewed and reflected: * “The purpose of this protocol is to give directions to nursing staff at Oregon State Hospital (OSH) regarding assessing and monitoring a patient following an actual or suspected fall.” * “If a patient is found on the ground, or if other factors suggest that a fall may have occurred, nursing staff must investigate in an effort to determine what happened. In the absence of evidence suggesting otherwise, staff must assume a fall has occurred.” * “Patient falls (actual or suspected) ... Nursing staff present must complete the following actions. [sic] ... At least one staff must remain with the patient until released by a Register Nurse (RN) ... Immediately report the fall to an RN ... Provide assistance to the RN during the assessment, treatment, and movement of the patient, as indicated and requested ... Call a ‘Code Blue’ ... if it appears warranted.” * “The RN must complete the following actions, not necessarily in the order provided ... Ensure that at least one staff remains with the patient ... The RN completing the assessment may count as the remaining staff ... Do not release the remaining staff until an assessment is completed and either ... the RN determines that the patient’s condition is stable and does not require this level of supervision; or ... the patient leaves the care of the RN for transportation to an acute care facility.” * “For all falls ... it is expected that the RN will assess the patient at the scene of the fall, whether or not this requires the RN to leave their primary work assignment location.” * “Assess the patient’s vital signs and pain ...” * “Assess the patient’s neurological status ...” * “If a reliable reporter states that the patient hit their head, the patient’s neurological status must be assessed. This assessment is required even if there is no observable sign of a head injury.” * “If there was no reliable reporter present, and so it cannot be positively determined that the patient did not hit their head, the patient’s neurological status must be assessed.” * “If a reliable reporter states that the patient did not head their head, the RN is not required to assess the patient’s neurological status, although the RN may choose to do so, based on their clinical judgment.” * “Neurological assessment findings must be documented in a progress note in the patient’s EHR by the person who performed the assessment, prior to the end of the shift during which it was performed.” * “Additional required RN actions for all falls, regardless of location ... explain to the patient the timeline and rationale for ongoing post-fall assessment and monitoring to encourage compliance ... Notify the practitioner (psychiatrist on duty [POD] after-hours) of pertinent findings from the post-fall assessment. The manner and timing of this notification is at the RN’s discretion, depending on the urgency of the situation ... If the patient is on anticoagulation therapy, this information must be included ... If the RN suspects the patient has sustained a significant injury, which requires medical intervention beyond first aid, this information must be included in the notification ... If the RN feels that a face-to-face assessment of the patient by the practitioner is warranted, the RN must include this request in the notification.” * “Whether or not a system template provides a specific area for the information, post-fall assessment documentation must include ... the circumstances of the fall, including any known or suspected contributing factors ... that continuous staff supervision was provided post-fall ... assessment findings, including whether findings reflect a change from the patient’s baseline (specific vital sign results do not need to be recorded in the progress note, unless indicated for clarity or comparison purposes) ... care provided, including risk mitigation actions taken and safety measures implemented ... recommendations for further care, monitoring, or environmental adjustments, as applicable ... notifications made (e.g., practitioner, anti-coagulation pharmacist, guardian), including attempts ... patient education provided, along with patient’s response; and ... initiation of Alert Charting.” * “Following the initial RN post-fall assessment of the patient, the nurse must complete the following patient monitoring and indicated actions ... If it is known that the patient did hit their head, or if it is not known whether or not the patient hit their head, assess vital signs and neurological status ... at least once every hour for the next four hours (i.e., more four times);[sic] and then ... at least once every four hours for the next 16 hours (i.e., four more times) ... Notify the lead RN of any significant changes, as applicable. ... Notify the practitioner (POD after-hours) of any significant changes ... Document the assessment(s) in a nursing progress note immediately following completion. For documentation purposes, the cadence of required patient monitoring following the initial post-fall assessment is referred to as the ‘Fall Protocol’.” * “Following any actual or suspected patient fall, the RN must reassess the patient’s fall [sic] Risk Level using the OSH Fall Risk Assessment and complete all indicated actions.” * “Staff in the above-named department who fail to comply with this protocol may be subject to disciplinary action, up to and including dismissal.” 3.c. A document titled “Attachment C Post-Fall Checklist” dated “6/2023” was reviewed and reflected: * “Assess for Injuries and Provide 1st Aid” * “Call ‘Code Blue’ (if applicable)” * “Assess VS (T, P, R, BP, 02 Sat) and Pain (if within scope of practice) Person Who Assessed Must Document”. * “Assess Neuro Status if Hit Head or Unknown” * “Notify Practitioner (POD after-hours) of ALL Falls, Include Anticoagulant Tx Info”. * “Document Fall in Nursing Progress Note” * “Complete Fall Risk Assessment” * “Create a Treatment Care Plan Addendum to Address Newly Identified Conditions (if applicable)” * “ALL Nursing Staff Who Witness a Fall Must Complete an Incident Report” * “If Patient Did Not Hit Head ... Assess and Document VS 8 hours x 3”. * “If Patient Did Hit Head or Unknown ... Assess and Document VS and Neuro Status Hourly x 4 ... Then every 4 hours x 4 ... Document Assessments Upon Completion in Avatar Using Nursing Progress Note and Templates”. 3.d. A P&P titled, “Fall Prevention Program: Fall Risk Assessment and Management ... Policy: 6.046” dated November 5, 2021, was reviewed and reflected: * “ ... OSH will establish a patient fall risk assessment and management process to address individual patient needs and mitigate safety risks.” * “In this policy, a fall means a sudden, independent movement to the ground or lower surface that is unintentional, uncontrolled, or involuntary. It may be witnessed or not witnessed, with or without injury. A fall resulting from an aggressive interaction with another individual is not included in this definition. (NOTE: although fall monitoring processes would apply, such falls are reported separately.)” * “A patient who falls must be appropriately assessed, evaluated, and monitored per procedures attached to this policy and Nursing Services Department processes.” * “This policy applies to all staff, including employees, volunteers, trainees, interns, contractors, vendors, and other state employees assigned to work at OSH. Staff who fail to comply with this policy or related procedures may be subject to disciplinary action, up to and including dismissal.” 3.e. A P&P titled, “Fall Risk Assessment and Reassessment ... Policy Number 6.046” dated November 10, 2021, was reviewed and reflected: * “Patient falls (actual or suspected) inside the secure perimeter (on- and off-unit) ... Nursing staff present must complete the following actions ... At least one staff must remain with the patient until released by a Register Nurse (RN).” * “Immediately report the fall to an RN ... Do not leave the patient alone to make this notification.” * “Until the patient is assessed by the RN, make every effort to maintain the patient in their current position, while reassuring the patient that they are safe and that additional help is coming ... If the patient insists on moving, maintain the patient’s safety as much as possible by assisting the patient to their desired position, while continuing to discourage further movement ... While waiting for the RN and throughout the post-fall assessment, remain aware of the immediate environment and takes steps to mitigate any identified risks, whether environmental, physical, or related to other patients ... Prior to the arrival of the RN, and depending on the patient’s status and staff availability (there must always be at least one staff with the patient), retrieve needed equipment (including writing materials) and obtain a full set of vital signs (temperature, pulse, blood pressure, respirations, and oxygen saturation via pulse oximetry), and assess for pain if within scope of practice, with results to be provided to the RN on their arrival. (Vital signs and pain rating must be documented in the patient’s electronic health record [EHR] by the person who collected them, prior to the end of the shift during which they were collected ... Provide assistance to the RN during the assessment, treatment, and movement of the patient, as indicated and requested ... Call a ‘Code Blue’, per OSH policy 8.038, ‘Code Blue Medical Emergency’, if it appears warranted.” * “The RN must complete the following actions, not necessarily in the order provided ... Ensure that at least one staff remains with the patient ... The RN completing the assessment may count as the remaining staff ... Do not release the remaining staff until an assessment is completed and either: the RN determines that the patient’s condition is stable and does not require this level of supervision; or ... the patient leaves the care of the RN for transportation to an acute care facility.” * “Assess the patient for injuries ... For all falls within the secure perimeter, it is expected that the RN will assess the patient at the scene of the fall, whether or not this requires the RN to leave their primary work assignment location.” 4.a. A P&P titled, “Patient Care ... Enhanced Supervision ... Policy: 6.010” dated February 28, 2024, was reviewed and reflected: * “This policy establishes guidelines for enhanced supervision at Oregon State Hospital ... This policy applies to all OSH staff.” * “The Psychiatrist or Psychiatric Mental Health Nurse Practitioner ... using clinical input from other members of the ... IDT ... must determine the type and level of enhanced supervision necessary to safeguard patients and staff. The IDT must collaboratively plan and implement therapeutic interventions to address dangerous, self-destructive, and or suicidal behavior, or needs associated with medical illness.” * “Any limitation to a patient’s rights must be clinically justified, explained to the patient, and documented in the patient’s medical record.” * “Staff who fail to comply with this policy or related policy attachments or protocols may be subject to disciplinary action, up to and including dismissal.” * “Enhanced supervision is careful monitoring and/or intervention characterized by types that indicate the primary behavior or condition and levels that describe the frequency with which staff contact the supervised patient ... Medical Supervision provides enhanced monitoring and supervision for patients who are medically ill; to prevent patients with medical conditions from inadvertently harming themselves; or to ensure protection of medical equipment or safe delivery of necessary medical treatment.” 4.b. A P&P titled, “Staff Responsibilities for Enhanced Supervision ... Policy: 6.010” dated February 28, 2024, was reviewed and reflected: * “Patient Education About Enhanced Supervision ... Unless clinically contraindicated, the psychiatrist or PMHNP, nurse, or a designee must explain the type and level of enhanced supervision to the patient, describe both the staff and the patient’s responsibilities, and provide the patient education handout to the patient ... The person who provides education to the patient about enhanced supervision must document this in a progress note, including an assessment of the patient’s understanding of what they have been told.” * “Review of Enhanced Supervision ... This review must include review of the Enhanced Supervision Flow Sheets completed since the previous day ... Following this reevaluation, if the IDT members determine that no change to the enhanced supervision is indicated, a note must be written by one of the following IDT members: psychiatrist or PMHNP, psychologist, or any nurse. The note must address the following ... the rationale for ongoing supervision ... effectiveness of existing interventions ... changes made to the event Intervention Card, if any.” * “The psychiatrist or PMHNP must conduct a face-to-face assessment and write the above note under either of the following circumstances ... at least once every five (5) days following the initiation of 1:1 supervision ... When the IDT determines that a significant change to the enhanced supervision order may be indicated.” * “Initiation of enhanced supervision ... Medical supervision may be ordered following face-to-face assessment or in consultation with the nurse. The psychiatrist or PMHNP or medical physician must personally evaluate the patient if there is a question about the type and level of supervision, or any other relevant therapeutic interventions to be utilized. If a personal evaluation is necessary, the findings must be documented in a progress note. * “Reassessment of enhanced supervision ... If any patient is started on enhanced supervision by a covering psychiatrist, PMHNP, or designee, the patient must be reassessed by the attending psychiatrist or PMHNP the next business day, with the assessment documented in a progress note.” * “If a patient remains on 1:1 supervision for five (5) consecutive days following the previous face-to-face assessment, the attending or covering psychiatrist or PMHNP or medical physician (in the case of medical supervision) must personally reassess the patient. This assessment must be documented in a progress note. If supervision continues to be deemed appropriate, a rationale for ongoing supervision and interventions to help the patient become safe must be documented.” * “If a patient is on 1:1 supervision for 14 consecutive days, the attending or covering psychiatrist or PMHNP or medical physician (in the case of medical supervision) must inform the supervisor and Chief of Psychiatry, Chief Medical Officer ... or their designee. This discussion must include review of the treatment provided to the patient, and the patient’s progress towards safety. The practitioner must document this discussion (including rationale for ongoing supervision, alternatives considered, and any change in interventions provided based on supervisor review) in a progress note. This must be repeated at each consecutive 14 days. Their patient remains on 1:1 supervision.” 5.a. During a review of 8 of 8 patient medical records (Patients 14, 15, 16, 17, 18, 19, 20, and 21) on 04/10/2025 beginning at 10:05 with the CS, SP(H), SC/OPA3, and others, information provided indicated that nursing staff failed to follow assessment and reassessment protocols after patient falls, and update TCPs using the TCP Addendum form per policy. For example: 5.b. Regarding Patient 14’s medical record documentation: * A Fall Risk Assessment (FRA) written by an OSH RN on 03/17/2025 at 14:23 included the following: “Type of Assessment: Admission ... History of Fall (a fall occurred within last 3 months): Yes ... Vision: Patient reported that [they] lost ... glasses ... and ... has difficulty seeing without glasses ... ADLS ... Patient able to maintain balance during shower and dress after shower. No unsafe behaviors noted. Patient does have history of seizures and has fallen several time [sic] injuring [themselves] to include some facial fractures ... Clinical Justification Summary: Patient has multiple recorded falls related to seizures. Patient had to wear a helmet given the injuries suffered with the falls. Patient did not bring the helmet ...” Clinically indicated risk level “Moderate”. * “Patient Progress Notes” written by an OSH RN on 03/19/2025 at 10:47 included the following: “Time of Fall Protocol Assessment: 1010 ... Location of Fall: Pt room ... Client Activity Prior/During Fall: [Patient 14] had just left the IDT room and returned to [their] room where [they] had a seizure ... Fall was unwitnessed by staff, so neuro checks initiated. Neuro assessment WNL ... Seizure activity is consistent with [Patient 14’s] reports of ongoing seizures. Close Medical precautions initiated ...” * A Fall Risk Assessment (FRA) written by an OSH RN on 03/19/2025 at 12:44 PM included the following: “Type of Assessment: Other ... Reason for Assessment: Post seizure involving unwitnessed fall ... Qualifying active medical problems ... Uncorrected vision changes ... Vision: Patient reported that [they] lost ... glasses ... and ... has difficulty seeing without glasses ... ADLS ... Patient able to maintain balance during shower and dress after shower. No unsafe behaviors noted. Patient does have history of seizures and has fallen several times injuring [themself] to include some facial fractures ... Clinical Justification Summary: Patient has known seizure disorder with an extensive history of falls resulting from seizures ... “ Clinically indicated risk level “Moderate”. * “Patient Progress Notes” written by an OSH RN on 03/19/2025 at 16:58 included the following: “Met with RN, TCPS, and unit psychologist briefly this morning to talk about ... initial goals and plan ... A few moments later, pt’s roommate alerted staff that [they] found [Patient 14] on the floor of their room seizing “for about five seconds.” Nurses arrived to assess [Patient 14], who was sitting up on the floor near ... bathroom ... VS were stable ... pulse remains elevated at baseline. [Patient 14] reported being a bit tired and appeared disoriented. Staff provided reassurance, assessed for injury, which [Patient 14] denied, and promoted rest. Neuro assessments initiated since fall was unwitnessed and were WNL throughout the shift. Psych and medical providers notified. Close Medical Precautions initiated at 1030. Order to obtain soft helmet to protect head is in process. Around 1500 [Patient 14] approached RN and said “I had a seizure this morning and I didn’t even realize it was coming. I hate those types of seizures.” RN offered therapeutic listening and reassurance. [Patient 14] again denied pain from the fall ...” * “Patient Progress Notes” written by an OSH RN on 03/19/2025 at 18:14 included the following: “Time of Fall Protocol Assessment: 1725 ... Nursing actions taken, if any, with patient response: Will continue to monitor, patient in agreement to allow RN to complete Neuro assessments ... Provider and RN notification, as indicated: NA ... List of Behaviors: Medical/Physical, Fall Protocol”. * “Patient Progress Notes” written by an OSH RN on 03/19/2025 at 19:49 included the following: “Behavior/Observation Narrative: Maintained on close observation MP for safety concerns. During the top of the 1500 hour, patient approached myself and MHT’s during Lead viability rounds, complained of bleeding on the center/parietal side of [their] head. Observed what seemed to be dried up blood of unknown origin. Patient reported that [they] noticed this when [they were] combing [their] hair. Brought patient to the exam room and ... RN assessed and cleaned area, unit provider notified. I assessed area during the 1800 hour. Observed mild redness and tenderness on the surrounding tissue. Observed dark and dried blood and scabbing on 1” X .5” asymmetrical wound. Patient reports pain from area upon palpation. Patient was alert and oriented X 4 throughout the shift. Continues on fall protocol for possible unwitnessed seizure/fall on previous shift. Patient has been compliant with Neurological assessments. Assessments within normal range. Patient to be referred to medical clinic for follow up on wound care.” * “Patient Progress Notes” written by an OSH RN on 03/19/2025 at 21:42 reflected the following: “Behavior/Observation Narrative: Time of Fall Protocol Assessment: 2130 Assessment findings ... Elevated pulse 109, all other VS within normal range, refused to allow me to assess ... pupils/eye movement. Pt responded to simple commands, asked ... to smile and ... did so. Speech clear, reported feeling tingling in ... right foot, foot strength equal/full. Significant changes from prior assessments, if any: tingling in ... right foot ... Nursing actions take, if any, with patient response: Patient refused to open eyes but appeared to be asleep prior to assessment, attempted to encourage patient and [they] spoke about how [they have] doing this for 7 year, [sic] provided validation and understanding ... Provider and RN notification, as indicated: NA”. * A “Patient Progress Notes” written by an DO B on 03/20/2025 at 23:05 was reviewed and reflected: “ID/CC/Subjective: 3/20/25, 2241 ... met with patient this afternoon in south hall consult room for apprx 20 minutes or so. we discussed [their] two seizures in past two days, [their] depakote level ... and the decision to increase [their] depakote today ... also discussed possible addition of klonopin if we cannot get [their] seizures nuder [sic] better control with high depakote dose and while [they] remains on [their] zonisamime [sic] ... pt is convinced the seroquel has been a good med for [them] and has not increased [their] seizure frequency ... this morning i discussed via text messages with [CoM] the above med changes and [they] agreed. for now we’ll just increase depakote and hold off on adding klonopin for now. [Surveyor Note: all lower-case words are as they appeared in the original text.] ... VITAL SIGNS ...” - “03/17/25 12:55, T: 96.7 F ... P: 108 ... R: 18 ... BP: 123/83 ... spO2: 99 %” - “03/17/25 13:25, T: 97.7 F ... P: 111 ... R: 16 ... BP: 129/78 ... spO2: 98 %” - “03/18/25 11:38, T: 97.8 F ... P: 116 ... R: 18 ... BP: 131/81 ... spO2: 98 %” - “03/19/25 10:14, T: 97.7 F ... P: 115 ... BP: 139/85 ... spO2: 96 %” - “03/19/25 17:25, T: 97.5 F ... P: 87 ... R: 14 ... BP: 113/72 ... spO2: 100 %” - “03/19/25 21:34, T: 97.7 F ... P: 109 ... R: 12 ... BP: 129/83 ... spO2: 98 %” - “03/20/25 03:15, P: 70 ... R: 14 ... BP: 121/69 ... spO2: 97 %” - “03/20/25 09:39, T: 97.5 F ... P: 106 ... R: 20 ... BP: 122/79 ... spO2: 100 %” - “Assessment/Plan: ... re seizures, has had 2 in last 2 days in context of somewhat low depakote level ... increased today ... will cont zonisamide ... consider adding klonopin in near future if necessary vs maximizing ... zonisamide dose ... which we could also consider if necessary ... also, pt ... placed on close medical obs a couple days ago because of the frequency of seizures at this time ... psychosis appears stable. PLAN: cont seroquel ... re trial competency: was not restored at 2022 admission. not clear to me whether [they are] likely to be restored ... is on 3X the amount of seroquel now vs then, however, and perhaps we can get ... seizures under better control also. will cont to assess over time whether this is improving or likely to improve ... re suicide risk: appears low at this time over the short term. pt has indicated ... mood is stable and ... does not feel depressed nor experiencing any suicidal thinking nor wishing [they were] dead ... violence risk currently appears to be low ... dc plan: return to jail when trial competent or reaches eoc.” [Surveyor Note: all lower-case words are as they appeared in the original text.] * “Patient Progress Notes” written by an OSH PMHNP on 03/25/2025 at 12:40 included the following: “ID/CC/Subjective: [Patient 14] had a seizure this morning about 11:29 am, which was reported by ... roommate to staff. Staff timed it for approximately 2 minutes and 46 seconds. [They were] postictal when I arrived and was unable to respond verbally for nearly 30 minutes until [they were] ready to lie down in bed. There was blood noted on ... pillow and RN thought that [they] saw blood from ... mouth but ... was not able to follow simple directives to open ... mouth to let us assess. [Patient] remains on close medical observation.” * “Patient Progress Notes” written by an OSH RN on 03/25/2025 at 13:14 included the following: “Time of Fall: 1128 ... Location of Fall: Patient’s bathroom. [Their] legs were in the bathroom and upper body was in [their] room ... Description of Fall if Known: Pt was found lying on floor of [their] bathroom and upper body was in [their] room in a prone position and actively seizing ... Describe Any Injuries: approximate 1 inch irregular abrasion noted on right parietal; scant amount of blood noted on pillow that was placed under [their] head which appeared to come from the inside of [their] mouth since no visible injury was noted outside of [their] mouth/lips. Will assess when out of post ictal [sic] phase ... Neurological Assessment ... VS obtained ... PERRLA/ 3mm ... List of Behaviors: Medical/Physical, Fall, Fall Protocol”. * A Fall Risk Assessment (FRA) written by an OSH RN on 03/25/2025 at 13:25 included the following: “Type of Assessment: Other ... Reason for Assessment: patient fell during seizure activity ... Qualifying active medical problems ... Uncorrected vision changes ... Vision: Patient reported that [they] lost ... glasses ... and ... has difficulty seeing without glasses ... ADLS ... Patient able to maintain balance during shower and dress after shower. No unsafe behaviors noted. Patient does have history of seizures and has fallen several times injuring himself to include some facial fractures ... Clinical Justification Summary: “Clinical Justification Summary: Despite being compliant with current medication regimen for seizures, pt has fallen twice since day of admission 3/17/25.” ... Clinically indicated risk level “Moderate”. * “Patient Progress Notes” written by an OSH RN on 03/25/2025 at 17:00 included the following: “Behavior/Observation Narrative: At 1340 neuro check, [Patient 14] reported that [they] had bitten [their] tongue in the back on the right side. [Patient 14] also reported some left elbow soreness. Med Clinic contacted and medical provider saw [them] on the unit at 1600.” * “Patient Progress Notes” written by an OSH RN on 03/25/2025 at 21:14 included the following: “Patient was seen by Dr. ... from med clinic at about 1605 and placed ... on medical 1:1 due to seizures and risk of falls. [Patient 14] was moved from room ... into ... with access to the bathroom close to room door. No seizures noted, neuro checks unremarkable.” * A document titled, “Enhanced Supervision Active Order Details” with an “Order Start Date/Time: 03/25/25 1909” was reviewed and reflected ...Order End Date/Time: 03/25/26 19:08 ... Order Duration: 365 ... Order Text: Around the clock. On and off the unit. Staff to remain within visual and comfortable speaking distance. Use discretion re: appropriate distance to meet patient needs at the moment ... Patient can attend Treatment Mall, Visits, Religious Services, Cafeteria and Quad. Patient may keep all property ... Describe Reason: Primary Behavior(s) of concern: fall risk”. * “Patient Progress Notes” written by the DCMO on 03/27/2025 at 00:15 included the following: “Late entry for 3.25.25 Cross cover note ... Saw [Patient 14] in [their] room with staff present to assess [Patient 14] after [their] seizure earlier in the day. [Patient 14] does not recall having the seizure but the seizure episode was witnessed by [their] roommate ... [Patient 14] bit ... tongue during the event and also had a laceration on ... head (likely from falling). [Patient 14] denies any headaches, changes in vision, shortness of breath, chest pain, feeling fatigued, or any paresthesias ... Ordered Medical 1:1 until reassessment with regular medical provider ... Will message medical clinic RN case manager to follow up on the order for ... soft helmet ... VITAL SIGNS ...” - “03/17/25 12:55, T: 96.7 F ... P: 108 ... R: 18 ... BP: 123/83 ... spO2: 99 %” - “03/17/25 13:25, T: 97.7 F ... P: 111 ... R: 16 ... BP: 129/78 ... spO2: 98 %” - “03/18/25 11:38, T: 97.8 F ... P: 116 ... R: 18 ... BP: 131/81 ... spO2: 98 %” - “03/19/25 10:14, T: 97.7 F ... P: 115 ... BP: 139/85 ... spO2: 96 %” - “03/19/25 17:25, T: 97.5 F ... P: 87 ... R: 14 ... BP: 113/72 ... spO2: 100 %” - “03/19/25 21:34, T: 97.7 F ... P: 109 ... R: 12 ... BP: 129/83 ... spO2: 98 %” - “03/20/25 03:15, P: 70 ... R: 14 ... BP: 121/69 ... spO2: 97 %” - “03/20/25 09:39, T: 97.5 F ... P: 106 ... R: 20 ... BP: 122/79 ... spO2: 100 %” - “03/24/25 11:10, T: 98.0 F ... P: 111 ... R: 16 ... BP: 120/75 ... spO2: 99 %” - “03/25/25 02:15, T: 97.7 F ... P: 77 ... R: 16 ... BP: 113/68 ... spO2: 97 %” - “03/25/25 11:40, T: 98.0 F ... P: 126 ... BP: 131/96 ... spO2: 96 %” ...” - “03/25/25 12:40, P: 111 ... spO2: 96 %” - “03/25/25 13:40, T: 97.5 F ... P: 96 ... BP: 116/83 ... spO2: 96 %” - “03/25/25 14:45, T: 97.0 F ... P: 99 ... BP: 117/74 ... spO2: 100 %” - “03/25/25 18:55, T: 97.3 F ... P: 104 ... R: 16 ... BP: 118/72 ... spO2: 97 %” - “03/26/25 06:25, T: 98.0 F ... P: 79 ... R: 14 ... BP: 107/70 ... spO2: 98 % ... **End of Note**” * “Patient Progress Notes” written by an OSH PMHNP on 03/27/2025 at 13:52 included the following: “[Patient 14] was raised from a close observation to 1:1 medical status per medical department after ... last seizure. [They have] since changed rooms where ... now has a room [by themselves] with staff members available to monitor ... safety. Mats were located by the PET team to place on the floor near ... bed ... [Patient 14] informed me that [their parent] would possibly be able to bring the soft helmet ... received from OSH during ... last stay. I have made several attempts today to reach ... [parent] ... I informed the unit staff that if [parent] were to call back ... please either ... call me or ask if ... able to bring the soft helmet and eye glasses if ... available. The nursing supervisor located a medium sized soft helmet, unfortunately when [Patient 14] tried it on ... the helmet was too small, didn’t fit ... ears well and snug around ... adam’s apple. The nurse supervisor stated that they are making attempts to locate a larger helmet which may need to be ordered. Another note, it was discussed today that [Patient 14] is a low-risk for falls, even though [they] ... had 3 seizures over the past couple of weeks which have resulted in 2 head abrasions. The team does not agree with the computed risk and have made safety plans that will help eliminate further injury from falls that occur with seizure activity-namely the fall mat, ordering a soft helmet (if not able to get one from ... parent), 1:1 medical observation. [Patient 14] understands all of the proposed plans and agrees with them. [They] verbalized appreciation to staff.” * “Patient Progress Notes” written by an OSH PMHNP on 03/27/2025 at 16:23 included the following: “ID/CC/Subjective: 3/27/25-1600 Spoke to [Patient 14’s parent] to find out if [they] had access to [Patient 14’s] soft helmet or glasses. [Parent] has the soft helmet and old glasses that are out of date and not current. [Parent] is unable to bring them ... I asked [parent] to not worry about the helmet at this time because we are already in the process of trying to order a new one. [Parent] offered to call the eye doctor and get the prescription information. I told [them] that when we had more information we would reach out to [them] again, and if at a later date we find that there are difficulties getting another helmet, we would let [them] know. I shared that [Patient 14] is on 1:1 medical.” * “Patient Progress Notes” written by an OSH RN on 03/28/2025 at 1627 included the following: “Behavior/Observation Narrative: Pt remains on 1:1 medical ... Pt did not demonstrate any seizure like activity nor have any seizure episodes during shift ... At 1645, med clinic delivered soft helmet to unit for pt use. Pt was provided helmet and fit ensured, pt states ‘It feels good’. Pt observed to be pacing unit with helmet ...” Provider notes were not timely, were incomplete and failed to document justification for ES 1:1 medical for Patient 14. For example, no provider reassessment notes were provided for the justification of continuing Patient 14’s ES 1:1 medical every 5 days as required by policy. Specifically, there were no reassessment notes provided for 03/30/2025, 04/04/2025, or 04/09/2025, the dates when a reassessment was due. The hospital failed to document the “effectiveness of existing interventions to reduce or eliminate those symptoms or behaviors which require enhanced supervision” as required by policy 6.010, Procedures A, Staff Responsibilities. Furthermore, Patient 14’s EHR lacked a 14-day reassessment of the need to continue the ES 1:1 medical progress notes documenting leadership notification, discussions of “rationale for ongoing supervision, [or] alternatives considered” as required in policy, and which “must be repeated at each consecutive 14 days their patient remains on 1:1 supervision.” The hospital’s clinical staff failed to fully implement fall P&Ps and failed to document nursing assessments in a timely manner per the hospitals P&Ps. Nursing staff failed to fully document FRAs “immediately” after the assessments as required by policy. For example, the fall on 03/19/2025 was noted to have occurred at “10:10” and the FRA assessment was time stamped at “12:44”, two and a half hours after the fall. Additionally, nursing progress notes were unclear as to whether Patient 14 had a second fall at “17:25”, or whether that encounter was a continuation of the fall and neurological assessments protocol. There were no progress notes indicating that vital signs and neurological assessments occurred “Hourly x4”. For instance, the unwitnessed fall occurred at 10:10 and per protocol, neurological assessments and vital signs were due at: ~1100, 1200, 1300 and 1400, and then every 4 hours x4 afterwards; ~ 1800, 2200, 0200 and 0600. Only four sets of vital signs were documented after the fall on that shift: 1014,1725, 2134, and 0315. Only 4 neurological assessments were noted in nursing progress notes and two of those notes alluded to “assessments” being within normal limits but failed to document the times or observations of those assessments. Additional examples include: - 03/19/2025: The Patient Progress note on 03/19/2025 at 1949 reflected that the patient would be referred to the “medical clinic for follow up on wound care.” However, Patient 14 was seen by an LIP on 03/20/2025, and the patient’s wounds were not assessed at that time. Patient’s wounds were not assessed by an LIP until 03/25/2025, 6 days after a provider had been notified of the wounds. Additionally, it was unclear how many neurological assessments were conducted after the 03/19/2025 fall, or at what time those assessments were determined to be “within normal range.” The progress note at 2142 reflected “significant changes from prior assessment”, however, the RN did not notify the POD/MOD per policy. Refer to Finding 3.b., “Post-Fall Assessment and Monitoring ... Protocol: 2.205”. - 03/20/2025: A provider assessment occurred at 2241 ~36h after Patient 14’s fall on 03/19/2025 and ~ 31 hours after the unit nurse notified a provider. The DO progress note did not discuss the fall or any fall related injuries as noted in the 03/19/2025 RN Progress Notes. - On 03/25/2025: Patient 14 was noted to have fallen at “11:28” and the FRA assessment was time stamped at “13:14”, ~ two hours after the fall. Further, it was unclear whether the information “pt has fallen twice” included the fall for this FRA, or whether two falls had occurred prior to this FRA. Nursing Progress notes on 03/25/2025 failed to demonstrate that vital signs and neurological assessments occurred “Hourly x4” per the fall assessment protocol 2.205. For example, the RN note at 1700 documented a “1340 neuro check” for an unwitnessed 1128 fall, two hours and 10 minutes after the documented fall. Additionally, the RN Progress note at 2114 failed to document the times that “neuro checks [were] unremarkable”, or whether the 2114 note was the documentation of the 2130 neuro check. For instance, the unwitnessed fall occurred at 11:28 and per protocol, neurological assessments were due at: ~1230, 1330, 1430, 1530, and then every 4 hours x4 afterwards; ~ 1930, 2330, 0330 and 0730. Only five sets of vital signs were documented after the fall on that shift: 1140,1240, 1340, 1445, and 1855. The only neurological assessment was documented at 1942. Nursing progress notes did not reflect that vital signs or neurological assessments were completed and documented “in a nursing progress note immediately following completion.” A PMHNP assessment was documented at “12:40”, however, the progress note does not clearly state whether a neurological assessment was conducted at that time. There were no “Nursing Fall Notes by Patient” provided. - On 03/27/2025: The DCMO’s note at 0015 note did not specify the time of service for the late entry as required by the hospital’s policy, “Clinical Documentation ... 6.045” which reflected, “reference the actual date and time of the service provided, observation, and/or event.” 5.c. During a follow up medical record review with the CS, SP(H), SC/OPA3 on 04/10/2025 beginning at 1005, Finding 5.b. was confirmed. The SP(H) acknowledged that there were no LIP notes justifying the continuation of the ES 1:1 medical. When asked to “pull up” LIP progress notes for the medical justification, the SP(H) stated, “It doesn’t pull up. I don’t see one.” 5.d. Regarding the availability of Durable Medical Equipment for Patient 14: * Patient 14, a previously admitted patient with a known fall risk who required specialized Durable Medical Equipment (DME) and glasses was admitted on 03/17/2025. Patient 14’s admission FRA also reflected “Clinically indicated risk level “Moderate”, and that “Patient does have history of seizures and has fallen several times injuring [themselves] to include some facial fractures ... Patient has multiple recorded falls related to seizures. Patient had to wear a helmet given the injuries suffered with the falls. Patient did not bring the helmet ...” However, despite the known fall risk and previously documented “facial fracture” injuries due to falls, the patient did not receive their helmet for 11 days during which time Patient 14 suffered two documented falls, and possibly three, which resulted in patient injury. * An email string provided to the surveyors reflected the following information: * “On March 28th, Director of Nursing, sent an email to [CoM] @ 8:13am ... Good Morning, I wanted to bring up a situation that I am hoping to be able to get a solution to. [OSH Unit]3 has a patient [Patient 14] who has a known seizure disorder. [Patient] has had a few seizures since coming to OSH ... We are working ... on the soft helmet and other interventions to keep [them] safe when ... seizures occur but one thing that both [patient] and [parent] mentioned were that [patient] needs glasses and that potentially the lack of appropriate glasses can be triggering ... seizures. [Patient’s parent] is unable to supply ... glasses however I was wondering if it is possible to expedite a optometry appointment for [patient] so that [they] can potentially have less seizures and prepare for [their] evaluation. At this point [patient] is saying that [they] can’t read anything or concentrate. We attempted readers but those weren’t successful and caused [patient] to have an increase in auras. Please let me know if this is an option that we could provide or if anyone has any other thoughts on how we could expedite any solutions. [DNS]” *An email dated 03/28/2025 at 1109 from the CoM to the DNS in response to their email reflected: * “Subject: Re: Expedited optometry appointment?” * “I do not know if any glasses corrected vision need that triggers seizures. So if the [parent] would like to supply me with some education materials that would be great. [CoM]” 5. e. A document that contained a follow up email from the DCN to the DNS dated 03/28/2025 at 252 reflected: * “Just to confirm, you still have been unable to get an appointment correct?” * The document included a note on the last page which reflected, “April 3rd: patient has yet to be seen and still does not have glasses. [Their] apt [sic] is not until April 17th.” This was 33 days after the patient was admitted. 5.f. Patient 14’s Treatment Care Plans: * Patient 14’s TCP dated 03/24/2025 was reviewed and reflected: “Reason for Review ... 10 Day TCP Review ... Plan Started: 03/24/2025 ... Did the patient participate in the development of this plan?: No ... Plan Type: Scheduled Review ... Problems listed included” - “Encounter for competency evaluation” - “Seizure disorder” - “Long Term Goal” ... [Patient 14] will be free from injury from seizures over the next 6 months ... Feedback from me: ... ‘I’ve got scars from falling’ reports it has been a while since [they] wore a helmet and that the fit was uncomfortable due to the chin strap has had mat on the floor to cushion fall if [they] fall out of bed”... Feedback from my team: ... will have PT properly fit the soft helmet”. - Eleven interventions were listed, including “Nursing staff will remove glasses if possible ... Start Date: 03/24/2025”. - “Electronically signed by ... PMHNP on 03/25/2025 at 10:59 AM”. * A 2-page document titled, “Oregon State Hospital Treatment Care Plan Addendum” dated 03/24/2025, had Patient 14’s first and last name handwritten at the top of the first page and lacked a patient DOB. It was reviewed and reflected: - The form lacked an “Addressograph Label” affixed to either page 1 or page 2 of the document as required by policy. - The form lacked a medical record number as required by policy. - On the first page of the document the “Problem” section had a box with an “X” next to “From current TCP-Date:” and the space following this date was blank. - The section “Goal (Long Term) had a box with an “X” next to “From current TCP” and for “Target Date:” was “Pt will be free of injury from seizure”. There was no target date written. - The section “Short-Term Goals” had a box with an “X” next to “From current TCP” and for “Target Date:” was “follow all recommendations of medical clinic to manage seizure disorder”. There was no target date written. - Under the section “Services/Interventions and Frequency/Duration” was: “1. Enhanced Supervision 1:1 medical due to seizures [sic] Follow intervention card [sic] 2. Fall mats placed on either side of bed”. Also in this section with darker and thicker ink was “3. Note time seizure begins monitor length of time with stop-watch I provided or pt clipboard”. The initials next to this entry were illegible. - A printed staff name with signature was at the bottom of page one and was dated “3/27/25” at “1:03” and there were no identifying credentials associated with the name/signature. - Under the staff signature was a line for patient comments, signature, whether the patient understood and agreed to the addendum, as well as a date line. These areas were all blank. - The second page lacked Patient 14’s first and last name and did not include the patient’s medical record number as required by policy. - At the top of the second page was a section that reflected: “If patient is unwilling or unable to participate in this TCP addendum or refuses to sign, provide comment and sign below. Comment: Agreed to 1:1 as making him feel safer agreed to mats on the side of bed”. This was followed by a “Staff Printed Name ... Staff Signature ... Date ... [and] Time”. It was signed by the same staff who filled out the first page and was dated “3/24/25”. It did not reflect the timing of the seizures, stopwatch or patient’s clipboard. - A line followed with “Guardian notified of addendum Yes ... No ... N/A” and N/A had an “X” next to it. Date and Time were blank. - “After Completion, scan & send electronically to IDT members”. The information under this section was blank, and included: - “IDT Reconciliation with Treatment Care Plan ... Approved and Added to TCP ... Yes ... No ... If yes, Date ... Time ...” - “Comments (If not approved, provide reason)” - “MD/PMHNP Printed Name” - “MD/PMHNP Signature ... Date ... Time ... “ - “RN Printed Name” - “RN Signature ... Reviewed by IDT Date ... Time ...” * Patient 14’s TCP dated 03/27/2025 was reviewed and reflected: “Reason for Review ... amendment: Enhanced supervision ... Plan Started: 03/27/2025 ... Did the patient participate in the development of this plan?: No ... Plan Type: Unscheduled Review ... Problems listed included” - “Encounter for competency evaluation” - “Seizure Disorder: [Patient 14] has a long history of seizures. Since admission on 3/17/25, [Patient 14] has had 3 seizures, 2 of which resulted in striking [their] head. [They] have been provided with a soft helmet and was placed on enhanced supervision 1:1 Medical ... Feedback from me: ... requested helmet”. - “Changes we are making ... Enhanced Supervision 1:1 Medical helmet will request a medical bed”. - “Long Term Goal” ... [Patient 14] will be free from injury from seizures over the next 6 months”. - “Electronically signed by: ... [DO B] on 04/07/2025 at 10:58 AM” * Patient 14’s TCP dated 04/04/2025 was reviewed and reflected: “Reason for Review ... amendment ... Plan Started: 04/04/2025 ... Did the patient participate in the development of this plan?: No ... Plan Type: Unscheduled Review ... Problems listed included” - “Encounter for competency evaluation” - “Seizure Disorder: [Patient 14] has a long history of seizures. Since admission on 3/17/25, [Patient 14] has had 3 seizures, 2 of which resulted in striking [their] head. [They] have been provided with a soft helmet and was placed on enhanced supervision 1:1 Medical. [Their] Nightstand [sic] and Bed [sic] were removed, [their ] mattress was placed on the floor with fall mats beside it all to mitigated [sic] risk of injury from falls ... Feedback from me: ... did not participate - amendment”. - “Changes we are making ... removed nightstand and be [sic] mattress on the floor fall mats beside mattress”. - “Long Term Goal” ... [Patient 14] will be free from injury from seizures over the next 6 months”. - “Electronically signed by: ... [DO B] on 04/07/2025 at 10:59 AM” Patient 14’s TCPs did not contain all elements as required by policy, contained inaccurate information, and did not clearly reflect when interventions began. For example, the falls were not listed as a separate TCP problem although Patient 14 had a history of injuries from falls and had suffered two known falls, and possibly three falls with injuries since admission. Additionally, the TCP dated 03/27/2025 incorrectly noted: “He has been provided with a soft helmet” although EHR documentation clearly reflected that Patient 14 did not receive a helmet until 03/28/2025 at 1645, one full day after the 03/27/2025 TCP had “started”, refer to Finding 5.b., RN Progress Note dated 03/28/2025 at 1627. Under the intervention section of the seizure disorder “problem” the ES Medical 1:1 start date was listed as “03/31/2025” when the actual order date was 03/25/2025 at 1909. The TCP dated 03/24/2025, reflected that nursing would remove Patient 14’s glasses, when the admission FRA reflected that patient “lost ... glasses” and “has difficulty seeing without glasses.” Refer to Finding 5.b., FRA dated 03/17/2025 at 1423. Further, this vision concern from the admission FRA was not listed as one of Patient 14’s medical problems on their TCP. Additionally, the TCPA form was incomplete and did not contain all patient identifiers as required by the hospital’s documentation policy. It was unclear when the patient agreed to the TCP addendum interventions listed on page one. For example, staff who filled out the second page comments for Patient 14 who was “unwilling or unable to participate in this TCP addendum or refuses to sign ...” dated their comments on 03/24/2025, one day prior to the MD assessment and order for Enhanced Supervision 1:1 Medical, three days prior to the information noted on page one on 03/27/2025, and three days prior to the PMHNP education as documented in the progress note below on 03/27/2025 at 1352. Additionally, the added information on page one was initialed by an unknown person, was not dated, and was not included in the comments on page two. Further, it was unclear whether IDT involvement was solicited as LIP signature lines on the TCP Addendum were left blank and undated. Refer to Finding 3.a., the Fall Risk Assessment P&P, 2.200, which reflected, “Meet with the patient’s Interdisciplinary Treatment Team ... and incorporate the issue into the patient’s TCP”. 5.g. During a follow up medical record review with CS, SC/OPA3, and SP(H) on 04/10/2025 beginning at 1005, Finding 5.f. was confirmed. The SP(H) was asked to show where Patient 14’s TCP addressed falls. The SP(H) confirmed that falls were only mentioned under the listed “Seizure Disorder” problem. Further, when asked to confirm whether Patient 14 had their helmet on 03/24/2025 as reflected on the TCP of the same date, the CS confirmed that it was incorrect. 6. Regarding Patient 15: the hospital failed to provide radiological services for a medical patient 24/7, and medical x-ray was not available for 2 days. Two LIPs noted radiological services were not available until from 04/01/2025 through 04/03/2025. * “Patient Progress Notes” written by an OSH PMHNP on 04/01/2025 at 1639 included the following: “ID/CC/Subjective: Status update” [:] - “On 3/29/25, RN reported, ‘It was reported that the patient has a tea colored urine, stomach pain, no blood in the urine, no burning sensation, and a little lethargic. Vital signs taken ... patient has a soft abdomen, and not distended. Patient states ‘feeling not good’, ‘my stomach feels pretty swollen and I’m a little dizzy’, ’ I haven’t poop [sic] since I came here’ ... Updated the medical on call provider through voicemail ... The provider went to see the patient on the unit and will order some medications...’”. - “On 3/30/25, RN wrote, ‘Staff reports brown colored urine, reddish-brown clots. States 6/10 pain near anus and lower intestines. Vitals taken ... Replied ‘yes’ when asked if ... had frequent urges of urination. UA ordered by on-call.’” - “On 4/1/25, RN wrote, ‘Pt screaming around 0850 ... C/O pain in lower abdominal area, states ... is having a miscarriage. Admission lab draw results are negative for pregnancy. Pt had episode of incontinence, including feces ... PRN meds given. Pt has long history of constipation ... pt continued to c/o pain. PRN Tylenol given ... Multiple attempts were made by different staff to have pt sit on toilet to try and have a BM ... Med clinic called and stated they are aware of a long history of constipation, pt has poor history of giving accurate accounts of medical issues. Will continue to monitor patient.’” - “S: PMHNP met with pt in ... room with 2 RNs present. Pt ... reported 10/10 rectal pain and 5/10 bladder pain. Pt allowed PMHNP to assess, no hemorrhoids visualized, no impaired skin integrity. Stool visible at rectal opening. With regards to bladder pain: pt denies urinary urgency, frequency or pain upon urination, but reports 5/10 bladder pain ... continues to be incontinent intermittently, chux pad placed on bed, pt remains on close obs ... Per RN report, pt has had approximately two small BMs today ... RN noted that it is difficult to determine presence of distention and bloating due to large abdominal girth. Per RN, bowel tones audible right lower quadrant, barely audible in right upper, none heard anywhere left upper or lower. Upon palpation: firm in bilateral lower quadrants. Pt has not been noted with emesis ... PMHNP notified clinic FNP via TEAMS and completed consult with information highlighted above. FNP ... asked about possible imaging at ED due to unavailability of imaging at OSH until 4/3/25. After further discussion, FNP asked for staff to continue to monitor; PMHNP asked RNs to notify OD if pt’s presentation worsens and/or unable to produce BM following mag citrate.” * “Patient Progress Notes” written by an OSH NP on 04/01/2025 at 1757 included the following: - “Subjective: Patient reported to unit nurse 10/10 rectal pain (no hemorrhoids) and bladder pain 5/10. Upon unit nurse assessment, patient has soft abdomen, not distended. Denies blood in urine, or dysuria ... Notify MOD for worsening symptoms: fever, chills, rectal bleeding, vomiting. XR imaging is not available until Thursday. Consider referring to SHED for abdominal XR if symptoms persists or worsen.” The PMHNP progress notes were not timely and failed to include all information as required by hospital policy. For example, PMHNP notes did not specify the times of service for entries dated 03/29/2025, 03/30/2025, and 04/01/2025 as required by the hospital’s policy, “Clinical Documentation ... 6.045” which reflected, “reference the actual date and time of the service provided, observation, and/or event.” Therefore, it was unclear documentation whether “physician coverage” was provided “24 hours daily to care for hospitalized patients ... During regular business hours,” or whether Patient 15 was “attended to by Psychiatrists/Psychiatric Mental Health Nurse Practitioners (PMHNPs) and Primary Care Practitioners” in accordance with the hospital’s policy. It was not clear whether a POD, MOD, MD or PMHNP was available to “respond to see a patient on a unit when requested by the nursing staff”. The EHR for Patient 15 demonstrated that Patient 15 experienced significant complaints of abdominal pain for 3 days prior to an assessment by a medical doctor or PMHNP. Additionally, the “S” (Subjective) documentation did not clearly identify for which encounter the PMHNP conducted an assessment, times when nursing staff noted the abnormal urine on 03/29/2025 and 03/30/2025 were omitted in the PHMHNP progress notes, and so it was unclear whether the time of day, i.e., after hours vs. business hours, was a factor in the delayed assessment. 7.a. Regarding Patient 16’s medical record documentation: * A Fall Risk Assessment (FRA) written by an OSH RN on 03/06/2025 at 1207 included the following: “Type of Assessment: Other ... Reason for Assessment: Post fall on 3/5/25 ... History of Falls (a fall occurred within last 3 months): Yes ... Vision: previous assessment: Optometry appt scheduled for 6/26 ... Transfers: Ambulates slowly, shuffling gait ... Medication Use: [Patient 16] has been adherent with taking ... schedule medications ... Mobility/Gait: Unsteady/Weak ... Mobility: short steps, ambulates slowly ... ADLS ... at times wearing socks when ambulating, encourage ... to wear appropriate footwear ... Risk Level: Moderate”. * A Fall Risk Assessment (FRA) written by an OSH RN on 03/12/2025 at 1619 included the following: “Type of Assessment: Other ... Reason for Assessment: Patient fell ... History of Falls (a fall occurred within last 3 months): Yes ... Vision: previous assessment: Optometry appt scheduled for 6/26 ... Transfers: Ambulates slowly, shuffling gait ... Medication Use: [Patient 16] has been adherent with taking ... schedule medications ... Mobility/Gait: Unsteady/Weak ... Mobility: short steps, ambulates slowly ... ADLS ... at times wearing socks when ambulating, encourage ... to wear appropriate footwear ... Risk Level: Moderate”. * “Nursing Fall Notes by Patient” written by an OSH RN on 03/22/2025 at 0357 reflected the following: - “2235 VS obtained, T-98.2 P-110 R-16 BP-121/87 SpO2 91-92% on RA. Sternal rub was performed to arouse patient, alert but continues to have difficulty keeping his eyes open. PNM notified about patient’s current status. 0010 patient awoke on ... own while myself and ... LPN entered the room. Patient unable to form words and attempting to speak with a raspy voice. VS obtained, T-98.2 P-114 R-16 BP-129/92 SpO2 92%. OD notified, order obtained to hold the remainder of ... HS medications for over sedation and since patient is unable to comply with PO meds. During 0100 rounds, I was walking around with staff performing my Lead viability checks and an MHT called for my assistance ... MHT was standing at patient’s room and reported that [patient] fell but did not witness the fall. Observed patient on the floor of the entrance to the bathroom. Assessed patient for head injury, no apparent head injury. Patient asked for assistance, awaited for more staff to assist. Assisted patient back to ... feet and onto ... bed. Patient did not appear to be in any pain as we manually assisted ... back to ... bed. OD/ PNM notified. Fall protocol initiated, fall risk assessment completed, patient is now at high risk. Assessed head, no signs of head injury.” - “Time of Fall: 0100-0105”. - “Neurologic Assessment if Hit Head: 0110 - Did not appear to have any head injury, unknown if hit head, Neuro check completed, VS obtained T-97.8 P-122 R-20 BP-132/89 SpO2-95% on RA, PERRL and unable to assess accomodation[sic], slurred speech, has had difficulty with speech since 3/21/25 afternoon administration of Suboxone, A+O X 2 to person, place, full/equal grip strength bilateral upper extremities, diminished/weak strength bilateral lower extremities”. -“Time of Fall Protocol Assessment: 0210”. - “Assessment ... Asleep during assessment, difficult to wake, sternal rub awoke patient ... Significant changes from prior assessments ... diminished SpO2 91% on RA, no significant changes from presentation throughout previous shift and the start of NOC shift ... Nursing actions take [sic] ... Continue to monitor ... Will notify OD for any significant changes”. * “Patient Progress Notes” written by the Sup/CMO on 03/22/2025 at 0407 reflected the following: - “Code blue called at 0315. Pt awoke briefly earlier and attempted to get up to the bathroom, fell (unwitnessed). RN reports fall risk elevated to high on reassessment, neuro checks WNL except what cannot be evaluated due to sedation. Pt too sedated to take HS meds, and O2 sats dropping to low 90s by 0030. Per RN, O2 sat dropped below 90% on room air, so code blue called. Pt placed on O2 2L by NC by RN.” - “Assessment/Plan: Sedation most likely cause of drop in O2 sat, given shallow breathing. O2 sat improved with 2L by NC. Pulse mildly elevated but steady, consistent with readings earlier in the evening. Administered Narcan 4 mg intranasally x1, given that increased sedation began after Suboxone dose yesterday, without observable change. - continue O2 2L by NC - 1:1 medical supervision to monitor O2 sat and safety with ligature (cannula) - if pt declines any further, send to Salem Hospital ED. Pt to be seen by medical OD tomorrow.” * “Nursing Fall Notes by Patient” written by an OSH RN on 03/22/2025 at 0450 reflected the following: - “Time of Fall Protocol Assessment: 0310”. - “Assessment findings ... SpO2 88-91% RA, Code blue called, patient barely responsive, aroused by a firm sternal/chest rub, patient not responsive to verbal commands ... Significant changes from prior assessments, if any: see above ... Nursing actions take [sic] ... Code blue called, 2L oxygen administered, Narcan administered. Patient placed on 1:1 medical precautions, continue to monitor pulse/oxygen saturation. Continue fall protocol. Plan is to continue to monitor and report any changes in presentation to [Sup/CMO]. Provider and RN notification, as indicated: [Sup/CMO] present, PNM present ...” * “Nursing Fall Notes by Patient” written by an OSH RN on 03/22/2025 at 1418 reflected the following: - “Throughout the swing shift and Noc shift [Patient 16] seemed overly sedated. First dose of Suboxone given during day shift of 3/21/25. Throughout the day sedation continued. Staff found [Patient 16] had fell in ... room and was lying on the ground around approx 0100 and hourly neuro checks initiated. During the 0300 hour neuro check [Patient 16’s] oxygen saturation was floating between 88 and 91. We decided to call a code blue due to the low O2 sats. All other vitals within normal limits. Code blue called, Suboxone was discontinued, Nacran administered, and administered 2L of o2 [sic] via nasal canula. O2 sats bumped up to 96-97 on o2. [Patient 16] was placed on a 1:1 medical for falls and ... over sedation. During the 0400 hour, LPN was on rounds and was flagged by the 1:1 to assist. Upon arrival [Patient 16] was trying to get out of ... bed. [Patient] had urinated the bed and was very weak when trying to assist [them] up in bed. MHT and LPN were able to successfully change ... soiled clothing and linens. Applied antislip socks and assisted [them] back to ... bed.” * “Patient Progress Notes” written by an the MCD on 03/22/2025 at 1434 and finalized on 04/07/2025, reflected the following: - “Late Note ... ON CALL NOTE CODE BLUE FOLLOW UP”. - “Subjective: Patient was evaluated on the unit in [their] room with nursing staff present and 1:1. Received a telephone call from POD ... regarding flowers three patient this morning to follow up on patient after code blue ... On 3/21/25 patient seemed overly sedated throughout the day per nursing staff after first dose of Suboxone 2 mg sublingual had been given at noon ... was then was found on the floor of ... room around 1 o’clock which initiated hourly neuro- checks. Around 3 o’clock a code blue was called due to low oxygen saturation and 2 L of oxygen was administered via nasal cannula which was able to improve [their] saturation up to 97%. Then naloxone/Narcan 4 mg nasal spray was administered at 322 due to decreased arousal and oversedation of medication effects. Continue to have decreased arousal at bedside requiring physical touch and repeated verbal commands before patient responded. When ... oxygen was removed ... oxygen saturation on room air drops to 88%. Advised staff to replace the oxygen via nasal cannula at 1 L which improves stats up to 97%. Patient remained stable at 97% during my physical examination. Patient reports feeling a little bit tired. Denies any further positive review of symptoms ...” * “Nursing Fall Notes by Patient” written by an OSH RN on 03/22/2025 at 1620 reflected the following: - “Time of Fall Protocol Assessment: 1610”. - “Assessment ... All VS and brief Neuro assessment within normal range, Clear speech, responds to verbal commands, asked to smile and [Patient 16] gave me a big smile, PERRLA, full and equal grip strength in upper extremities, full and equal strength in lower extremities ... Nursing actions take [sic] ... Will continue to monitor and assess per policy”. - A Fall Risk Assessment (FRA) written by an OSH RN on 03/24/2025 at 1525 included the following: “Type of Assessment: Other ... Reason for Assessment: Fall ... History of Falls (a fall occurred within last 3 months): Yes ... Vision: States ... has ‘blind spots’, often squinting; optometry appt scheduled for 6/26 ... Transfers: Ambulates slowly, shuffling gait, stumbles at times ... Medication Use: Patient took Suboxone ... earlier in the day of the fall ... Mobility/Gait: Unsteady/Weak ... Behaviors: Patient often insists ... is fully capable of taking the stairs despite gait disturbance and elevator-only order ... stumbles and catches [themselves] on walls ... Environment ... struggles with keeping belongings tidy. Sleeps with numerous blankets ... has been seen getting tangled in when getting out of bed ... ADLS ... at times wearing only socks when ambulating and insists on wearing oversized sandals ... Risk Level: High”. The hospital failed to document nursing FRAs in a timely manner in accordance with hospital policy. A fall was noted on 03/05/2025, however a FRA assessment was not documented until 03/06/2025 and did not include the time of the fall. Further, a “Nursing Fall Notes by Patient” progress note was not provided for the 03/05/2025 fall. A FRA after 03/22/2025 fall was not provided by the hospital and documentation of the 03/22/2025 0500 hourly neuro checks, as well as the 0900, 1300, 1700 then 2200 neuro checks were not provided. 7.b. Patient 16’s Treatment Care Plans: * A 2-page document titled, “Oregon State Hospital Treatment Care Plan Addendum” had Patient 16’s first and last name printed at the top along with their MRN. A DOB was not noted. It was reviewed and reflected: - The form lacked an “Addressograph Label” affixed to either page 1 or page 2 of the document as required by policy. - On the first page of the document the “Problem” section had a box with an “X” next to “New”, and under this was noted: “Pt experienced an unwitnessed fall in bathroom without head injury. Pt currently a high fall risk, risk score of 75 on fall screening. 1:1 initiated. Date identified: 03/02/2025 Status: [was blank]” - The section “Goal (Long Term) had a box with an “X” next to “From current TCP” and for “Target Date:” was blank. - The section “Short-Term Goals” had a box with an “X” next to “From current TCP” and the “Target Date:” was blank. - Under the section “Services/Interventions and Frequency/Duration” was: “Nursing staff will assure [Patient 16] to ask for assistance prior to attempting to stand and will further inform staff when experiencing any weakness and/or dizziness”. - A printed RN name with signature was at the bottom of page one and was dated “3/22/25” at 0500”. - Under the staff signature was a line for patient comments, signature, whether the patient understood and agreed to the addendum, as well as a date line. These areas were all blank. - The second page lacked Patient 16’s first and last name and did not include the patient’s medical record number as required by policy. - At the top of the second page was a section that reflected: “If patient is unwilling or unable to participate in this TCP addendum or refuses to sign, provide comment and sign below. Comment:”, which was blank. This was followed by a “Staff Printed Name ... Staff Signature ... Date ... [and] Time”. This section too was blank. - A line followed with “Guardian notified of addendum Yes ... No ... N/A” and all were blank. - “After Completion, scan & send electronically to IDT members”. The information under this section was blank, and included: - “IDT Reconciliation with Treatment Care Plan ... Approved and Added to TCP ... Yes ... No ... If yes, Date ... Time ...” - “Comments (If not approved, provide reason)” - “MD/PMHNP Printed Name” - “MD/PMHNP Signature ... Date ... Time ... “ - “RN Printed Name” - “RN Signature ... Reviewed by IDT Date ... Time ...” The TCPA form was incomplete and did not contain all patient identifiers as required by the hospital’s documentation policy. It was unclear when the patient agreed to the TCP addendum interventions listed on page one. For example, the form had no patient signature, and the second page comments for Patient 16 who was “unwilling or unable to participate in this TCP addendum or refuses to sign ...” was blank. Further, it was unclear whether IDT involvement was solicited as LIP signature lines on the TCP Addendum were left blank and undated. Refer to Finding 3.a., the Fall Risk Assessment P&P, 2.200, which reflected, “Meet with the patient’s Interdisciplinary Treatment Team ... and incorporate the issue into the patient’s TCP”. 8.a. Regarding Patient 17’s medical record documentation: * A Fall Risk Assessment (FRA) written by an OSH RN on 03/12/2025 at 1329 included the following: “Type of Assessment: Admission ... History of Falls (a fall occurred within last 3 months): Yes ... Vision: Pt experiences difficulty with seeing objects and signs ... Transfers: Pt appears impulsive, requires 2 person assist with transfers Pt utilizing wheel chair for ambulating ... Mobility/Gait: Impaired: Requires assistance/supervision ... Mobility: Requires supervision ... ADLS ... Requires total assist with ADLs ... Risk Level: High”. - “Electronically Signed by: [an OSH RN] on 03/12/2025 at 01:29 PM PDT Author” - “Date Appended: 03/20/2025 at 10:11 AM ... Document submitted under [an OSH RN] in error; assessment completed and documented by [a second OSH RN] ... Electronically Signed by: [the second OSH RN] on 03/20/2025 at 10:11 AM ... Appended Author”. * A “Psychiatric Admission Assessment” by an OSH PMHNP dated 03/12/2025 at 1903 reflected the following: - “Assessment (include reasoning for suicide/violence risk assessment) ... [Patient] is at high risk for falls as ... had a fall in January in which [they] hit [their] head resulted in two subdural hematomas. Due to this fall risk ... has been placed on 1:1 Medical Precautions.” * A “Patient Progress Notes” written by an OSH MD dated 03/20/2025 at 1244 reflected the following: - “[Patient 17] stated that [they] wished to receive ECT so ... could return to [their spouse] ... [Patient 17’s spouse] was surprised by the fact that ECT was not offered by OSH as that was the primary reason for [patient’s] admission, adding that they even had an ECT appointment with OHSU they had to cancel.” - “[Patient] is at high risk for falls as ... had a fall in January in which [they] hit [their] head [sic] resulted in two subdural hematomas. Due to this fall risk, [patient] has been placed on 1: 1 Medical Precautions.” - “[patient] is ... primarily focused on receiving ECT and discharging. I’m unsure whether ECT is still indicated. The IDT is exploring the possibility of discharging [Patient 17] and continuing ECT in the community.” * A Fall Risk Assessment (FRA) written by an OSH RN on 03/21/2025 at 1409 included the following: “Type of Assessment: 10-day ... History of Falls (a fall occurred within last 3 months): Yes ... Vision: Pt experiences difficulty with seeing objects and signs ... Transfers: Pt appears impulsive. Requires 1p SBA with transfers. Uses FWW for mobility on unit and wheelchair for longer distances off unit ... Mobility/Gait: Impaired: Requires assistance/supervision ... Mobility: Requires supervision and use of adaptive devices ... ADLS ... Requires staff assist with ADLs ... Risk Level: High”. * A “Patient Progress Notes” by an OSH MD dated 03/27/2025 at 1338 reflected the following: - “Late entries for 3/17/25, 3/24/25, 3/25/25”. - “S On 3/17/25 writer met with patient in ... room with staff present. [Patient] was lying in bed with ... wheelchair in the corner. On 3/24/25, observed [Patient 17] using ... walker to in the halls for ... OT sessions. On 3/25/25, [patient] was sitting comfortably in the milieu. [Patient] used ... walker to ambulate from ... room to the milieu. No current complaints.” - “O General: no acute distress, well appearing, cooperative, pleasant HEENT: normocephalic atraumatic sclera anicteric, no conjunctival injection, PERRL, EOMI no nystagmus, lids normal. Nares without exudate. Moist oral mucosa, uvula midline. Heart: S1, S2 heard, no murmurs, rubs or gallops Lungs: equal excursion bilaterally, no accessory muscle usage, speaking in full sentences, CTA bilaterally Abdomen: ,softnormal [sic] active bowel sounds present, non-distended, non-tender, no rebound/guarding/rigidity Neck: AROM Extremities: Moves all. Uses wheelchair and walker for ambulation. No calf tenderness, noncyanotic, no pedal edema appreciated, ] [sic] Integumentary: warm, dry, intact, good skin turgor”. - “A/P Medical 1:1 Justification [Patient 17] initially strictly used ... wheelchair for ambulation. [They are] ... progressively increasing ... endurance using ... walker. 1:1 is still needed because ... at risk for a fall Appreciate OT, SLP, and Dietitian recs ... Discussed assessment and treatment care plan with unit nurses ... VITAL SIGNS ...” - “03/12/25 11:30, T: 97.2 F ... P: 79 ... R: 15 ... BP: 125/87 ... spO2: 97 %” - “03/12/25 12:00, T: 97.2 F ... P: 79 ... R: 15 ... BP: 125/87 ... spO2: 97 %” - “03/12/25 16:13, T: 97.9 F ... P: 94 ... R: 18 ... BP: 106/73 ... spO2: 94 %” - “03/13/25 11:15, T: 97.1 F ... P: 66 ... R: 18 ... BP: 109/73 ... spO2: 94 %” - “03/13/25 15:00, P: 68 ... R: 16 ... spO2: 97 %” - “03/14/25 11:01, T: 97.8 F ... P: 72 ... R: 16 ... BP: 113/69 ... spO2: 94 %” - “03/21/25 07:15, T: 97.3 F ... P: 68 ... R: 18 ... BP: 118/79 ... spO2: 96 %” * A “Patient Progress Notes” written by am OSH MD dated 03/28/2025 at 0936 reflected the following: - “ASSESSMENT & PLAN ... Enhanced Precautions: Changed to 1: 1 Medical for fall risk during day and swing shift & Close Medical during noc shift ... Discharge ... back home with outpatient follow-up and ECT (if needed)”. The DCMO’s progress notes were not timely and failed to include all information as required by hospital policy. For example, the DCMO notes dated 03/27/2025 did not specify the times of service for the late entries as required by the hospital’s policy, “Clinical Documentation ... 6.045” which reflected, “reference the actual date and time of the service provided, observation, and/or event.” Therefore, it was unclear for which encounter the general “O” was written. Additionally, progress notes reflecting the justifications for the continuation of the ES 1:1 medical were required every 5 days after initiation of the order: 03/17/2025, 03/22/2025, and 03/27/2025. Although the DCMO note reflected, “A/P Medical 1:1 Justification ... 1:1 is still needed because [they are] ... at risk for a fall,” the note did not clearly reflect on which encounter date and time the assessment for continued ES 1:1 medical was conducted. Furthermore, Patient 17’s EHR lacked a 14-day reassessment of the need to continue the ES 1:1 medical progress notes documenting leadership notification, discussions of “rationale for ongoing supervision, [or] alternatives considered” as required in policy, and which “must be repeated at each consecutive 14 days their patient remains on 1:1 supervision” which was required on 03/26/2025. The progress notes were unclear as to the date(s) and time(s) the MD “Discussed assessment and treatment care plan with unit nurses”. Additionally, the MD progress note dated 03/28/2025 failed to provide a rational for Patient 17’s change in ES 1:1 medical parameters from 24 hours around the clock to “Close Medical” during NOC shift in accordance with hospital policy. Policy 6.010, Procedures A, staff responsibilities reflected, “Patient assessment ... and rationale for ... change of enhanced supervision orders must be documented in a progress note”. A separate Progress Note documenting whether a “Patient assessment,” as required by policy when ES is changed or modified, was not provided. There was no documentation in Patient 17’s EHR that they received ECT treatments. Nursing staff failed to fully implement the hospital policy, Clinical Documentation Policy: 6.045. For example, the FRA dated 03/12/2025 at 1329, reflected that findings were documented under another RN’s name and EHR account login credentials. The error was not discovered or corrected for ~ 8 days. 8.b. An email sent on 03/24/2025 at 1005 from the MCD to the DCMO reflected, “The following Medical 1:1 notes are overdue ... [Patient 17] was due on 3/17/25 ... Please complete notes as soon as possible.” 8.c. Emails dated 03/26/2025 at 1806 and provided to the surveyors during the survey confirmed Finding 8.a.: - “Today to [MCD and DCMO) ... Good morning. In [CoM’s] absence, [Sup/CMO] mentioned that you were covering ... [Patient 17] ... an expedited admission for catatonia and head injury due to significant falls. [They have] been on a medical 1:1 since admission. I let [CoM] know there were no notes from the clinic and [they] said [they] would let you know. we [sic] checked today and there are still no notes. can [sic] we get some notes into [Patient 17’s] chart please? ... [MCD]: Thank you for letting me know.” - “To [PsychSup] related to my 1:1 audit on Sunday ... [Patient 17] ... I went back to 3/13; admission 3/12 expedited civil: no medical notes, no notes re 1:1 ... “. 8.d. During a follow up medical record review with CS, SC/OPA3, and SP(H) on 04/10/2025 beginning at 1005, Finding 8.a. was confirmed. The SP(H) stated “I don’t see a note on 3/31/[25]” regarding reassessment for ES 1:1 medical. 8.e. Patient 17’s Treatment Care Plans: * Patient 17’s TCP dated 03/20/2025 at 1613 was reviewed and reflected: -“Reason for Review ... 10 Day Review ... Plan Started: 03/20/2025 ... Plan Type: Initial Review ... Did the patient participate in the development of this plan?: Yes ... My understanding of why I am here ... ‘I’m supposed to be here for ECT.’ ... Problems listed included” - “Catatonia ... Feedback from my team: [Patient 17] was admitted under expedited civil commitment for treatment of catatonia, specifically for ECT treatment.” - “Fall Prevention. Fall Risk: High (3/12/25) ... Feedback from my team: [Patient 17] is at high risk for falls ... has not fallen at OSH, but ... reports 2 serious falls prior to hospitalization ... Interventions ... Enhanced supervision to help avoid falls and to prevent a fall/injury ...” - “Osteoarthritis involving multiple joints on both sides of body”. - “Medical: Heart disease. Hypertension, hyperlipidemia, and obstructive sleep apnea ... Followed and managed by OSH Medical Clinic providers.” - “Electronically signed by: ... MD on 03/20/2025” at 1629. Patient 17’s TCP dated 03/20/2025 further confirmed that Patient 17 was admitted for ECT treatment, which did not occur. 9. Regarding Patient 18’s medical record documentation: * On 03/24/2025 an email sent at 1005 from the MCD to the DCMO reflected, “The following Medical 1:1 notes are overdue ... [Patient 18] was due on 3/20/25 ... Please complete notes as soon as possible.” * On 03/26/2025, the first day of the survey, an email string provided to surveyors reflected the following information: - “Today [03/26/2025] ... To [PsychSup] related to my 1:1 audit on Sunday: [Patient 18]; ES for 68 days; last note re medical 1:1 was 3/9 - fall risk and limited mobility; seems like we should have it more closely related to the actual medical needs and feeding tube and what contributes to fall risk ... [OSH Unit]1 and [OSH Unit]2 have been giving a lot of info to [PsychSup] and [Unit DNS]. But it seems like these concerns are going no where ...” * On 04/11/2025 a “Patient Progress Notes” with the same date written by the DCMO at 0615 was provided, one day after MD notes were requested by the surveyor. These were reviewed and reflected: - “Late entries for 3.17.25, 3.26.25, 4.8.25 with update in Plan on 4.10.25”. - “S” On[:] ... 3.17.25 saw and assessed [Patient 18] in ... room with staff present. [Patient] is making progress is communicating, moving from ‘yes’ or ‘no’ replies to using short sentences to express himself. [Patient] notes the PT session helping increase ... range of motion and also expressed ... increased need to rest after ... sessions.” - “3.26.25 Nurses reported soft, loose stools.” - “On 4.8.25 saw and assessed [Patient 18] on the unit with staff present. [Patient] was seated comfortably in ... wheelchair in the TV room. Writer noted improvement in maintaining control of the special spoon utensil while eating dinner the previous the previous evening. [Patient] is able to express ... thoughts more clearly and states ... is feeling better. Denies having any current complaints.” - “On 4.10.2025 writer briefly saw and interacted with [Patient 18] in the milieu. [Patient] was reading the newspaper and shared how much [they] enjoyed March Madness (college basketball finals), [sic]” - “O” [:] ... On 3.17.25 Gen No acute distress ... HEENT: normocephalic atraumatic sclera anicteric, no conjunctival injection, moist oral mucosa, nares without exudate ... CV: regular rate and rhythm ... Lungs: clear to auscultation, no wheezes, rhonchi , or crackles ... Abd: soft, nontender in all quadrants, Jtube in place ... Musk: contracted lower extremities and upper extremities. Upper extremities able to partially passively extend, hands able to lightly grasp.” - “On 3/26.25 Gen No acute distress ... Lungs: clear equal excursion bilaterally, no accessory muscle usage, unlabored respirations ... Abd: soft, nontender in all quadrants, Jtube in place”. - “On 4.8.25 Gen No acute distress, cooperative ... HEENT: normocephalic atraumatic sclera anicteric, no conjunctival injection, moist oral mucosa, nares without exudate, decreased ptyalism, appreciable , nontender, right submandibular lymph node, no longer able to appreciate left submandibular nodule ... CV: regular rate and rhythm ... Lungs: clear equal excursion bilaterally, no accessory muscle usage, speaking in full sentences slowly, CTA Bilaterally ... Abd: soft, nontender in all quadrants, Jtube in place ... Musk: contracted lower extremities and upper extremities with improved range of motion (increased range of flexion and extension of the upper extremities, able to lift flex legs at the hips while seated). Hand grip improving”. - “A/P”[:] ... 3.17.25 1:1 medical supervision is still needed due to limited mobility of the patient. Appreciate the recs from PT/OT/SLP/Dietitian/Wound Care teams HTN well controlled with amlodipine 5mg daily”. - “3.26.26 Loose/ soft stools Dc’d Miralax, lactulose Ordered daily Lactobacillus capsules for gut biome protection”. - “4.8.25 Submandibular nodules ... 3/20/25 U/S of neck / submandibular area result revealed bilateral large reactive level I submandibular nodules ... Ordered referral to ENT to assess with biopsy. 1:1 medical supervision is still needed due to fall risk”. - “4.10.25 Hours for 1:1 medical supervision adjusted for day and swing shift, when [Patient 18] is normally awake and out of bed for fall risk. Ordered close medical for overnight hours 10pm-7am the following morning. Orders for q2hrs, turning if patient is in bed is still in place ... Appreciate the recs from PT/OT/SLP/Dietitian/Wound Care teams Discussed assessments and treatment care plans with unit nurses.” The MD progress notes were not timely or thorough, and failed to include all information as required by hospital policy. For example: - MD notes did not specify the times of service for encounters dated 03/17/2025, 03/26/2025, 04/08/2025 and 04/10/2025 as required by the hospital’s policy, “Clinical Documentation ... 6.045” which reflected, “reference the actual date and time of the service provided, observation, and/or event.” Therefore, it was unclear whether “physician coverage” was provided “24 hours daily to care for hospitalized patients ... During regular business hours,” or whether a POD, MOD, MD or PMHNP was available to “respond to see a patient on a unit when requested by the nursing staff” after hours. The assessment of the “Jtube” did not include additional assessment information of the site such as skin integrity issues, or signs of infection, redness, swelling, or discharge, and only included “Jtube in place”. - MD notes for the 03/17/2025 encounter were written 25 days after the MD assessment, and notes for the 03/26/2025 encounter were written 16 days after the MD assessment; neither were available for the clinical staff providing direct care for the patient well outside 72 hours. Hospital policy 1.017, “Provider Documentation Standards” reflected, “After provider evaluates patient, a SOAP note will be completed in electronic health record ... Note will be written expeditiously as defined below ... Non-urgent stable chronic conditions/Health maintenance: 72 hours”. - MD reassessment notes justifying the continuation of Patient 18’s ES 1:1 medical were not thorough or completed as required by policy. Specifically, Patient 18 had been on ES 1:1 medical for 68 days, however, per the email dated 03/24/2025, a reassessment for ES 1:1 medical was overdue on 03/20/2025. Using that date, the five-day reassessments for ES 1:1 medical would then be due 03/25/2025, 03/30/2025, and 04/04/2025; and a 14-day reassessment would have been due 04/03/2025. The hospital failed to document the “effectiveness of existing interventions to reduce or eliminate those symptoms or behaviors which require enhanced supervision” as required by policy 6.010, Procedures A, Staff Responsibilities. Furthermore, Patient 18’s EHR lacked a 14-day reassessment of the need to continue the ES 1:1 medical progress notes documenting leadership notification, discussions of “rationale for ongoing supervision, [or] alternatives considered” as required in policy, and which “must be repeated at each consecutive 14 days their patient remains on 1:1 supervision.” The progress notes for the ES 1:1 medical modification on the entry dated “4.10.25” did not contain an assessment or rationale for the modification as required by policy, 6.010 “Procedures A ... Staff Responsibilities.” The policy reflected the following when “discontinuation or change” of ES occurs: “Patient assessment ... and rationale for discontinuation or change of enhanced supervision orders must be documented in a progress note.” It was inferred from the 03/26/2025 email that the above examples, beginning on 03/20/2025, were a reflection of the documentation which occurred throughout the 68 days on which Patient 18 had ES 1:1 medical ordered. 10.a. Regarding Patient 19’s medical record documentation: * On 04/10/2025 at 1458 the surveyor requested Patient 19’s “medical provider notes for ES Medical 1:1 justification for falls. (03/11/20250[sic]-present)” via email. No MD notes were provided. * On 04/11/2025 at 1220 the surveyor again requested Patient 19’s “medical provider notes for ES Medical 1:1 justification for falls. (03/11/20250[sic]-present)” via email. * On 04/11/2025 at 1415, the DSC provided the following response, “uploaded into the Onedrive”. * The only document uploaded to the “Onedrive” was a document titled, “Client Profile - Single Order Detail”. It was reviewed and reflected, “Order Date ... Time ... 2/18/2025 10:45 ... Order Type: Enhanced Supervision ... Order Description: 1:1 Medical ... Order Text: Around the clock. On and off the unit. Staff to remain within visual and comfortable speaking distance. Use discretion re: appropriate distance to meet patient needs at the moment ... Special/Additional Instructions: Patient can attend Treatment Mall, Visits, Religious Services, Cafeteria and Quad. Patient may keep all property ... Reason: Primary Behavior(s) of concern: uses a wheelchair and is a significant fall risk, particularly given neurocognitive disorder and limited problem solving ... Start Date/Time: 02/18/2025 10:45 ... Stop Date/Time: 02/18/2026 10:44 ... Last Update ... [MD name] ... 03/25/2025 10:25 ... Last Action Taken: Discontinue ... “ * No MD progress notes were provided for the time period 03/09/2025 through 04/11/2025 as requested by the surveyor. 10.b. An email dated 03/26/2025 at 1806 and provided to the surveyors the first day of the survey reflected the following information: * “Today [03/26/2025] To [PsychSup] related to my 1:1 audit on Sunday ... [Patient 19]; ES for 34 days; 4 MIs 2017-2024; last note i [sic] saw was from [CMD] 3/11 and the 1:1 is related to ambulation ... [OSH Unit]1 and [OSH Unit]2 have been giving a lot of info to [PsychSup] and [Unit DNS]. But it seems like these concerns are going no where ...” The MD progress notes were not timely or thorough, and failed to include all information as required by hospital policy. For example: - There were no MD notes provided for Patient 19 and it was unclear whether “physician coverage” was provided “24 hours daily to care for hospitalized patients ... During regular business hours,” or whether a POD, MOD, MD or PMHNP was available to “respond to see a patient on a unit when requested by the nursing staff” after hours. Hospital policy 1.017, “Provider Documentation Standards” reflected, “After provider evaluates patient, a SOAP note will be completed in electronic health record ... Note will be written expeditiously as defined below ... Non-urgent stable chronic conditions/Health maintenance: 72 hours”. Therefore, because of the lack of clinical documentation, it was unclear whether Patient 19 was thoroughly evaluated, or whether their chronic medical conditions were being monitored by a medical provider. - Provider reassessment notes justifying the continuation of Patient 19’s ES 1:1 medical were not provided. Patient 19 had been on ES 1:1 medical for 34 days, however, per the email dated 03/26/2025, the last provider notes about reassessment for ES 1:1 medical were on 03/11/2025. Using that date, the five-day reassessments for ES 1:1 medical would then have been due 03/16/2025 and 03/21/2025; and a 14-day reassessment would have been due 03/25/2025, the day the ES 1:1 medical was discontinued. The hospital failed to document the “effectiveness of existing interventions to reduce or eliminate those symptoms or behaviors which require enhanced supervision” as required by policy 6.010, Procedures A, Staff Responsibilities. Furthermore, the hospital failed to provide documentation that Patient 19’s 14-day reassessments that justified the continuation of ES 1:1 medical progress were completed. Lastly, the hospital’s policy reflected the following when “discontinuation or change” of ES occurs: “Patient assessment ... and rationale for discontinuation or change of enhanced supervision orders must be documented in a progress note” and no provider progress notes were provided to substantiate the change in supervision. 11.a. Regarding Patient 20’s medical record documentation: * An email sent on 03/24/2025 at 1005 from the MCD to the above DCMO reflected, “The following Medical 1:1 notes are overdue ... [Patient 20] was due on 3/19/25” ... Please complete notes as soon as possible.” * On 04/10/2025 at 1458 the surveyor requested Patient 20’s “medical provider notes for ES Medical 1:1 justification for falls. ([beginning] 03/11/2025)” via email. No MD notes were provided. * On 04/11/2025 at 1220 the surveyor requested Patient 20’s “medical provider notes for ES Medical 1:1 justification for falls. ([beginning] 03/11/2025)” a second time via email. * On 04/11/2025 at 1415, the DSC provided the following response, “uploaded into the Onedrive”. 11.b. “Patient Progress Notes” written by the DCMO dated 04/11/2025 at 0945, a day after the notes had been requested, reflected: * “Notes Field: Late entries for 3/12/25, 3/24/25, 4/2/25,4/3/25, 4/9/25, 4/10/25”. * “S”[:] ... 3/12/25 Still complains of constipation, does not consistently use medications for bowel regimen.” - “3/24/25 [Patient 20] is scheduled to have ... sleep study tonight. Reports improvement of ... lower back pain following [their] bilateral medial branch block ... last month.” - “On 4/2/25 Reported increased cloudiness of urine. Requested to extend order for Robitussin. Nursing also requested aid to increase [Patient 20’s] ability to wash feet during ... baths. No longer complains of constipation.” - “On 4/3/25 Requested to have left leg wound assessed because [they are] concerned it is worsening.” - “4/9/25 Discussed antibiotic change with [Patient 20].” - “4/10/25 Assessed [them] in the morning following spilling a cup of hot water (while preparing tea) on [their] person the previous evening.” * “O”[:] ... 3/12/25 Gen No acute distress,cooperative [sic] ... Heart: S1, S2 heard, no murmurs,rubs [sic] or gallops ... Lungs: equal excursion bilaterally, no accessory muscle usage, CTA bilaterally ... LE: uses wheel chair for ambulation. Moves all. No calf tenderness, noncyanotic”. - “On 4/2/25 Gen No acute distress ... Resp: decreased bs on left lower lobe, no crackles, rhonchi audible ... Abd: lower abdominal (suprapubic) tenderness”. - “4/3/25 Gen No acute distress, cooperative Ext: left leg wound appears to have normal granulation tissue, nonerythematous, still tender on palpation, no swelling or induration or discharge.” - “4/10/25 Gen No acute distress ... Abd: soft, mild tenderness and erythematous area roughly 2inches by 1 inch at the level of the umbilicus, no bullous formation ... Ext:B/L LE 1-2+ edema; left foot: tender on palpation on the medial half of the dorsal surface of the foot, normal skin appearance”. - “4/7 CXR Results: mild left lower lobe pneumonia vs atelectasis”. * “A/P”[:] ... 2/25/25 Type 2 DM Although [Patient 20’s] recent A1C ... was 6.3 , in the pre-diabetes range, [they] had a random glucose reading of 221 ... 2/21/25. Initiated Trulicity 0.75mg sq weekly for Type 2 DM and possible weight loss effects”. - “3/12/25 ... Constipation Continue to encourage bowel regimen, had declined much of the medications ordered and have many PRNs to accommodate when ... agrees to some. Mineral oil enema q daily, prn Magnesium citrate (grape flavored) q daily prn Senna 7.2 mg bid Miralax BID Lactobacillus capsule for gut biome health 1:1 Justification for fall risk”. - “3/25/25 1:1 Medical supervision order adjusted from round the clock to only on day and swing shift, with close medical supervision during the NOC shift. Encourage [Patient 20] to use walker when ... is in ... room and especially when navigating in ... private bathroom”. - “4/2/25 Ordered long washing device to aid with patient’s ability to wash ... own feet during baths (encourage independent ADL) Ordered UA for increased uring [sic] cloudiness, currently on titrofurantoin prophylaxis and cranberry capsules Ordered cxr , she continues to complain of cough at night”. - “4/3/25 Left leg wound Provided reassurance that wound is healing appropriately.” - “4/4/25 UTI Initiated Septra DS BID on 4/4/25 and switched to cefepime 1g IM TID on 4/9/25 once C&S results showed that the organism Klebsiella pneumoniae was resistant to Septra and susceptible to cefepime. Ordered Benadryl 25 mg initially twice a day, then increased to three times a day to be coadminstered with antibiotics due to patient report of pruitus with septra and concern for pruritus with cefepime. Seasonal allergies Continue zyrtec10mg po daily Possible pna vs atelectasis Both septra and cefepime ordered for the UTI provide coverage”. - “4/9/25 Discussed the antibiotic change described above with [Patient 20]”. - “4/10/25 1st degree burns on dorsum of left foot and left abdomen at the level of umbilicus Pt spilled cup containing hot water (in preparation for making tea) the previous evening on self. There are no skin changes noted on left foot, but pt reports tenderness on palpation of the dorsal area. Left abdomen noted to have a erythematous area roughly 2inches by 1 inch at the level of the umbilicus Silvadene was initiated by MOD overnight and writer will continue order and adjust order to apply to affected areas on both foot and abdomen. Will continue to monitor. Discussed assessment and treatment care plans with unit nurses.” * On 04/15/2025 at 0917, the hospital uploaded a document for Patient 20 titled, “Enhanced Supervision Active Order Details.” It was reviewed and reflected, “Enhanced Supervision Order: 1:1 Medical ... Order Start Date/Time: 04/14/25 10:43 ... Order End Date/Time: 04/13/26 10:45 ... Order Text: From 07:00am to 21:59pm only. On unit when not in ... room and off the unit. To use walker while in ... room and restroom. Staff to remain within visual and comfortable speaking distance. Use discretion re: appropriate distance to meet patient needs at the moment. Will be on close observation from 22:00 to 06:59. On and off the unit. Staff to remain within visual and comfortable speaking distance. Use discretion re: appropriate distance to meet patient needs at the moment ... Special/Additional Instructions: Patient can attend Treatment Mall, Visits, Religious Services, Cafeteria and Quad. Patient may keep all property. Describe Reason: Primary Behavior(s) of concern: [this was blank].” - A second, separate order for “Close Medical” was also included. - It was unclear whether an order for ES 1:1 medical had been entered per policy. The only 1:1 order provided was written on 04/14/2025 and included the modified order times which, according to the DCMO’s progress notes, were updated on 03/25/2025, 20 days prior to the order date. The hospital failed to follow its policy on “Late” entries. For example, four dated entries were not identified as “Late” and did not align with policy 6.045, “Clinical Documentation” which reflected “Late entries must be clearly identified at the beginning of the entry and reference the actual date and time of the service provided, observation, and/or event.” These dates were: 02/25/2025, 03/25/2025, 04/04/2025, and 04/07[no year]. The notes were not completed within the hospital policy timelines. Policy 1.017, “Provider Documentation Standards” reflected, “After provider evaluates patient, a SOAP note will be completed in electronic health record ... Note will be written expeditiously as defined below ... Non-urgent stable chronic conditions/Health maintenance: 72 hours”. Therefore, it was unclear whether Patient 20’s chronic health issues had been thoroughly evaluated, or whether their chronic medical conditions were being consistently monitored by a medical provider, and those assessments available for clinical staff providing direct care to the patient. For example, the 02/25/2025 note was entered 45 days after the encounter. The 03/25/2025 note was entered 17 days after the encounter. Both of these notes were well outside the 72 hour timeline as required by policy. The hospital failed to follow its policy on clinical documentation. None of the 10 entries on 02/25/2025, 03/12/2025, 03/24/2025, 03/25/2025, 04/02/2025, 04/03/2025, 04/04/2025, “4/7”, 04/09/2025, or 04/10/2025 had times of encounters. Some of the dated entries from the “SOA/P” format did not align with each other. For example: - There were 6 entries under the “S” narrative dated: 03/12/2025, 03/24/2025, 04/02/2025, 04/03/2025, 04/09/2025, and 04/10/2025; - There were 5 entries under the “O” narrative dated: 03/12/25, 04/02/25, 04/03/25, 04/10/25, and “4/7”[no year]; and - There were 8 entries under the “A/P” narrative dated: 02/25/2025, 03/12/2025, 03/25/2025, 04/02/2025, 04/03/2025, 04/04/2025, 04/09/2025, and 04/10/2025. - The “A/P” narrative dated “4/4/25” reflected a medication that was “switched ... on 4/9/25”, 5 days after that entry. The DCMO’s progress notes were not timely or thorough, and failed to include all information as required by hospital policy. For example, there were no physician notes provided for Patient 20 until 04/11/2025 and those notes were entered that same morning at 09:45. Based on that note and the order dated “04/14/25”, it was unclear how it was determined that an ES 1:1 medical reassessment was due on “03/19/25”, or whether “physician coverage” was provided “24 hours daily to care for hospitalized patients ... During regular business hours,” or whether a POD, MOD, MD or PMHNP was available to “respond to see a patient on a unit when requested by the nursing staff” after hours. For example, Patient 20 sustained a burn from hot tea on 04/09/2025, however the MD note from 04/09/2025 did not reflect an assessment of the burn and the MD assessment of the burn did not occur until 04/10/2024. The times of the encounters were not noted on either of these entries and it was unclear when Patient 20’s burns were assessed, on which shift, how long they had waited to have those burns assessed by a medical provider, or whether a provider was available to assess the patient after the incident. Additionally, Provider reassessment notes justifying the continuation of Patient 20’s ES 1:1 medical were not completed as required by policy. As of 03/24/2025, the date of the email reminder to the DCMO, Patient 20 had been on ES 1:1 medical for at least 12 days, since 03/12/2025, the first time the DCMO noted “1:1 Justification for fall risk” in their notes. Using that date, the five-day reassessments for Patient 20’s ES 1:1 medical would have been due 03/17/2025, 03/22/2025, 03/27/2025, 04/01/2025, 04/06/2025, and 04/11/2025. Fourteen-day reassessments would have been due 03/26/2025 and 04/09/2025. The hospital failed to document the “effectiveness of existing interventions to reduce or eliminate those symptoms or behaviors which require enhanced supervision” for Patient 20’s ES 1:1 medical as required by policy 6.010, Procedures A, Staff Responsibilities. Furthermore, the hospital failed to provide documentation that Patient 20’s 14-day reassessments justifying the continuation of ES 1:1 medical progress were completed. Lastly, the hospital’s policy reflected the following when “discontinuation or change” of ES occurs: “Patient assessment ... and rationale for discontinuation or change of enhanced supervision orders must be documented in a progress note” and although the DCMO’s progress notes on 03/25/2025 documented a modification, an order for that modification was not entered until 04/14/2025, 20 days after the modification, and the progress note was not entered until 04/11/2025, 17 days after the modification. Therefore, it is unclear whether clinical staff providing direct care for Patient 20 were aware of the ES 1:1 medical order, the order’s parameters, or the updated changes made on 03/25/2025. 12.a. Regarding Patient 21’s medical record documentation: * MD notes were requested for Patient 21’s ES medical 1:1 on 04/10/2025. No MD notes were provided. * A document titled, “Treatment Care Plan” dated 03/10/2025 reflected: “Admit Date: 11/22/2024 ... Plan Name: 30 Day Review ... Patient Did Not participate [was checked] ... Problem Statement ... Fall Prevention. Fall Risk: Moderate (03/11/25). [Patient 21] reported a fall on 3/11/25, unwitnessed by staff, no injury. [Patient] reported feeling dizzy or light-headed ... has had some medication changes; staff will continue to monitor.” - “Intervention ... MD to meet with [Patient 21] to follow up after fall, and review medications and how they may affect gait ... How long/often ... 1+ times, as indicated x 30 days ... Staff Responsible: DCMO”. - “Other things that are important to my health ... Substance Use: Alcohol use disorder, severe ... Medical: Cataract.” - “Reviewed by ... [MD] - Final Approver (Accepted) On 03/13/2025 At 8:40”. * A Fall Risk Assessment (FRA) written by an OSH RN on 03/11/2025 at 1636 included the following: “Type of Assessment: Other ... Reason for Assessment: fall 3/11/25 ... Qualifying active medical problems ... Arthritis ... Anemia ... Seizure disorder, Uncorrected vision changes, Other ... Vision: Patient reports need for glasses ... has glasses, but inconsistent with wearing them ... reports that glasses do not help with feelings of dizziness ... ADLS ... Independent ... Select Risk Level “Moderate”. * An email requesting Patient 21’s medical documentation was sent to the DSC on 04/11/2025 at 1229, “ ... it would be appreciated if notes from the latest complaint patient could also be uploaded.” The DSC responded at 1302, “No MD progress notes.” * An email requesting Patient 21’s ES 1:1 medical order was sent to the DSC on 04/14/2025 at 1659, “I know there were no MD notes, but was there an order for 1:1 medical ES?” The DSC responded on 04/15/2025 at 1024, “-no active orders for 1:1 medical ES”. The hospital failed to fully implement its P&P and failed to provide “physician coverage 24 hours daily to care for hospitalized patients ... During regular business hours, the medical ... needs of OSH patients are attended to by Psychiatrists/Psychiatric Mental Health Nurse Practitioners (PMHNPs) and Primary Care Practitioners” as described in the hospital policy, “On-Duty Physician ... Protocol: 1.011”, refer to Finding 1. There were no notes that indicated the patient was assessed by a medical provider after the fall as described in the TCP after the 03/11/2025 fall. It was unclear whether Patient 21 was placed on an ES 1:1 medical as no order was provided and there were no medical notes provided. The hospital failed to fully implement interventions as described on Patient 21’s TCP and all medical conditions as listed on the 03/11/2025 FRA were not identified. Although Patient 21 was admitted on 11/22/2024 with medical issues and an identified Fall Risk of “Moderate”, medical notes had not been documented in the patient’s EHR. ******************************************************”

“SCOPE OF RADIOLOGIC SERVICES CFR(s): 482.26(a) [§482.26 Condition of Participation: Radiologic Services The hospital must maintain, or have available, diagnostic radiologic services...] §482.26(a) Standard: Radiologic Services The hospital must maintain, or have available, radiologic services according to the needs of the patients. This Standard is not met as evidenced by: 29708 ****************************************************** Based on interview, review of P&Ps and review of other documentation it was determined that the hospital failed to develop and maintain documentation of the hospital’s radiological services. Radiological and other P&Ps were outdated and did not reflect the hospital’s current scope and complexity of radiological services. Findings include: 1. The following information was provided during an interview with the DMNO on 04/08/2025 beginning at 1330: * The hospital got a new Xray machine two years ago. * The hospital currently provides Xray services onsite four days per week, from 6:30 AM to 5:00 PM, Tuesday through Friday. The hospital has no Xray services available outside those days and hours. If a patient needs an Xray outside of those days and hours, they are sent to the ED at another hospital for their Xray. * If the Xray technician is sick or otherwise off work, the hospital has a contract with a third party Xray technician who comes to the hospital and performs Xray services. * The hospital does not provide any other imaging services. If a patient needs an MRI, US or other imaging service they are sent to the ED at another hospital for those. 2. The following information was provided during follow-up interview with the DMNO on 04/11/20225 beginning at 1000: * The hospital currently has one Xray technician and that person works 4, 10-hour shifts. The current hours of operation are generally Tuesday through Friday 6:30 am to 5:00 pm. After hours, and at other times the Xray tech is not available such as for leave, the hospital uses a portable Xray company or sends the patient to Salem Health hospital. * The P&P “Radiology Department Hours” dated as last revised 05/13/2013 was provided and reflected “The radiology technologist is on duty from 7:30 AM to 4:30 PM, Monday through Friday. It a radiographic exam is needed outside these hours, the OSH staff have two options: 1. Salem Hospital ... 2. Salem Hospital MRI/CT Center ... 3. The patient may be sent to the Salem Hospital Emergency room for the necessary exam.” That was the extent of the P&P and it did not reflect the current hours and operations described. 3. There were four other “Radiology Department” P&Ps provided. Those were: * “Department Staffing - Radiological Technologist II” dated last reviewed 05/13/2013 and last revised 12/02/2011. * “Patient Care in the Radiology Department” dated last reviewed 05/13/2013 and last revised 12/03/2012. * “Staff Safety in the Radiology Department” dated last reviewed 12/02/2011 and last revised 05/13/2013. * “Radiology Department Compliance With Regulatory Bodies” dated last reviewed 12/02/2011 and last revised 05/13/2013. None of those included the hospital’s current radiology hours or operations and they had not been reviewed or revised for more than ten years. * The DMNO confirmed that the radiology P&Ps were not current. 4. The following additional P&Ps were provided regarding imaging scope of services and operations, including but not limited to those provided by the hospital, type of imaging conducted onsite, number of machines, hours of operation, radiology technician staffing, and radiologist coverage for reading/interpreting Xrays: * “Outside Medical Services” dated approved 07/01/2024. * “Transfer of Patient to an Acute Care Facility” dated approved 01/06/2025. * “Approval of Medical Services, Devices, and Procedures.” Page 1 reflected the P&P was dated “XXXXXX” and the “Revision History” on page 6 reflected it was last revised 09/03/2015 and last reviewed 10/07/2016. * “Medical Referrals Outside OSH”, “Protocol: X.XXX” dated last revised 07/09/2013 and last reviewed 10/07/2016. * “Patient Care”, “Protocol: X.XXX” dated last reviewed 06/23/2015 and last revised 10/07/2016. The additional P&Ps provided were outdated and none included the hospital’s current radiology scope, complexity and hours and operation. 5. Review of the hospital’s organizational chart titled “Oregon State Hospital - Peter Courtney Salem Campus Organizational Structure” dated “Last Updated 2/24/25 for March 2025” reflected it did not include imaging or radiologic services. 7. In an email dated 04/09/2025 at 1508 regarding the P&Ps in Finding 4 in this tag, the DSC confirmed there were no further P&Ps that depicted the hospital’s current scope and complexity of radiologic services. The DSC wrote “Those would be the documents that we have.” No further description or P&Ps regarding imaging services were provided. ******************************************************”

“Meet Hospital CoPs CFR(s): [Psychiatric hospitals must] Meet the Conditions of Participation specified in§§482.1 through 482.23 and §§482.25 through 482.57; This Standard is not met as evidenced by: 08621 ****************************************************** Based on observation, review of video recordings, interviews, review of incident and medical record documentation for 17 of 17 patients (Patients 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21), review of OSH internal investigation documentation, review of training documentation for 4 of 5 LIPs (MD A, DO B, MD N and MD O) and 23 of 23 Direct Care nursing staff (RN C, RN D, RN E, RN F, RN G, RN R, RN T, RN U, RN W, RN Z, RN AA, RN EE, LPN H, LPN P, LPN Y, MHT J, MHT S, MHT Q, MHT V, MHT X, MHT BB, MHT CC, and MHT DD), review of training curriculum and training media, review of governing body and medical staff bylaws, and review of P&Ps it was determined that governing body failed to ensure the hospital complied with all CoPs specified in CFR 482.1 through CFR 482.23 and CFR 482.25 through CFR 482.57 as the following CoPs were determined to be out of compliance. The failures potentially contributed to harm and death of Patient 3 and created the likelihood of harm to other patients: * CFR 482.12 - CoP: Governing Body * CFR 482.13 - CoP: Patient’s Rights Findings include: 1. Refer to Tag A-043, CFR 481.12 - CoP: Governing body. Governing body bylaws were not current and complete. Medical staff bylaws and rules and regulations were not current, clear, or complete, and had not been approved by the governing body that was in place at the start of this investigation (Tag A-048). Provisions for timely and appropriate medical emergency response for patients in seclusion were not fully developed and implemented (Tag A-093). 2. Refer to Tag A-115, CFR 482.13 - CoP: Patient’s Right. The hospital failed to ensure patients were informed of their health status (Tag A-131). 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 seclusion and restraint (Tag A-154). The hospital failed to ensure patients in seclusion were monitored and observed to ensure their safety (Tag A-175). The hospital failed to ensure staff training related to seclusion and restraint was conducted appropriately (Tag A-199 and Tag A-206). ******************************************************”

“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: 08621 ****************************************************** It was determined that the governing body failed to ensure the provision of safe and appropriate care to the hospital’s vulnerable psychiatric population in a manner that complied with all Conditions of Participation. 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. This CoP refers to the following CoPs which are out of compliance. * Tag A-115, CFR 482.13 - CoP: Patient’s Rights * Tag A-263, CFR 482.21 - CoP: QAPI * Tag A-385, CFR 482.23 - CoP: Nursing Services * Tag A-700, CFR 482.41 - CoP: Physical Environment * Tag A-1600, CFR 482.60 - CoP: Special Provisions for Psychiatric Hospitals ****************************************************** 29708”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 08621 ****************************************************** It was determined that the governing body 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 of Care (“EOC”) that likely contributed to patient harm and death and created the likelihood of harm to other patients. The hospital failed to screen visitors; monitor in-person visits between patients and visitors; prevent contraband; observe and monitor patient condition, status, and location to ensure patients were safe and alive (Tag A-144). It further failed to conduct clear and complete investigations of adverse events that addressed all potential gaps and deficient practices; and failed to implement and monitor corrective actions to prevent recurrence for other patients (Tag A-145). ****************************************************** 29708”

“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: 08621 ****************************************************** It was determined that the governing body failed to ensure, through the QAPI program, the prevention and reduction of adverse events analyzing findings, and implementing actions to prevent recurrence of those (Tag A-286). 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 planned and implemented to prevent recurrence of those, to promote learning throughout the hospital, and to establish clear expectations for patient safety. Those failures reflect the investigation of the unexpected death of Patient 1 was unclear and incomplete. All potential gaps or concerns evident in documentation related to Patient 1’s death had not been analyzed to determine whether corrective actions were indicated, and corrective actions planned to address gaps that had been identified had not been implemented. 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 EOC that likely contributed to patient harm and death for Patient 5 and created the likelihood of harm to other patients. The hospital failed to screen visitors; monitor in-person visits between patients and visitors; prevent contraband; observe and monitor patient condition, status, and location to ensure patients were safe and alive (Tag A-144). It further failed to conduct clear and complete investigations of adverse events that addressed all potential gaps and deficient practices; and failed to implement and monitor corrective actions to prevent recurrence for other patients (Tag A-145). Refer to the findings cited at Tag A-385, CFR 482.23 - CoP: Nursing Services, that reflects the QAPI program failed to ensure patient nursing and safety needs were met by nursing personnel, under the supervision of the RN. The RN responsible for the care of each patient failed to ensure ongoing assessment, observation, monitoring, and provision of care and services. Those failures occurred during in-person visitation sessions between patients and visitors, and on the inpatient units. (Tag A-395). Refer to the findings cited at Tag A-700, CFR 482.41 - CoP: Physical Environment, that reflects the QAPI program failed to ensure the physical environment was maintained and arranged to provide a safe EOC. The hospital failed to ensure safety and security measures were sufficient to prevent the presence of drugs and other unsafe contraband in the EOC. Those measures were not fully developed, security personnel were not trained, and the failures occurred during visitor check-in, screening, and during in-person visitation sessions between patients and visitors (Tag A-701). In addition, screening equipment or devices had not been subject to preventive maintenance to ensure those operated as intended (Tag A-724). Refer to the findings cited at Tag A-1600, CFR 482.60 - CoP: Special Provisions for Psychiatric Hospitals, that reflects the QAPI program failed to ensure the hospital complied with all CoPs specified in CFRs 482.1 through 482.23 and CFRs 482.25 through 482.57 as the following CoPs were determined to be out of compliance. (Tag A-1605). ****************************************************** 29708”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 08621 ****************************************************** It was determined the governing body failed to ensure patient nursing and safety needs were met by nursing personnel, under the supervision of the RN. The RN responsible for the care of each patient failed to ensure ongoing assessment, observation, monitoring, and provision of care and services. Those failures occurred during in-person visitation sessions between patients and visitors, and on the inpatient units. (Tag A-395). It was determined that the RN responsible for the hospital’s nursing services failed to ensure that the nursing and safety needs of the hospital’s vulnerable psychiatric patients were met and those failures likely contributed to patient harm and death and created the likelihood of harm to other vulnerable psychiatric patients. ****************************************************** 29708”

“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: 08621 ****************************************************** It was determined the governing body failed to ensure the physical environment was maintained and arranged to provide a safe EOC. The hospital failed to ensure safety and security measures were sufficient to prevent the presence of drugs and other unsafe contraband in the EOC. Those measures were not fully developed, security personnel were not trained, and the failures occurred during visitor check-in, screening, and during in-person visitation sessions between patients and visitors (Tag A-701). In addition, screening equipment or devices had not been subject to preventive maintenance to ensure those operated as intended (Tag A-724). Review of hospital directives, review of equipment inventory lists and manufacturer’s instructions, and review of OSH internal investigation documentation, it was determined that the hospital failed to maintain an EOC free of hazards and risks to ensure the safety and well-being of the hospital’s vulnerable psychiatric population and those failures likely contributed to patient harm and death and created the likelihood of harm to other vulnerable psychiatric patients. ****************************************************** 29708”

“Special Provisions for Psychiatric Hospitals CFR(s): Special Provisions Applying to Psychiatric Hospitals - Psychiatric hospitals must... This Condition is not met as evidenced by: 08621 ****************************************************** It was determined that the governing body failed to ensure the hospital complied with all CoPs specified in CFRs 482.1 through 482.23 and CFRs 482.25 through 482.57 as the following CoPs were determined to be out of compliance (Tag A-1605): * CFR 482.12 - CoP: Governing Body * CFR 482.13 - CoP: Patient’s Rights * CFR 482.21 - CoP: QAPI * CFR 482.23 - CoP: Nursing Services * CFR 482.41 - CoP: Physical Environment Refer to each CoP cited in this 2567 for the failures included in A1600. ****************************************************** 29708”

“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: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and patient care documentation for 19 of 23 patients (Patients 1, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23), review of P&Ps, review of hospital directives, review of equipment inventory lists and manufacturer’s instructions, and review of OSH internal investigation and corrective action plan documentation, it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient’s right to receive care in a safe setting. The hospital’s failures to monitor and observe patients’ condition and location, to screen and monitor in-person visitation between patients and visitors, to prevent drugs and other contraband, to thoroughly investigate adverse events and to implement corrective actions, likely contributed to patient harm and death and created the likelihood of harm to other vulnerable psychiatric patients. Those failures included: * For Patient 5 and other patients, failure to ensure situational awareness and diligent observation and monitoring of patient condition and status, including whether patients were alive and breathing. * For Patient 22, failure to ensure situational awareness and diligent observation and monitoring of patient location to ensure patients were not in unauthorized areas. * Failure to ensure diligent and consistent registration/check-in of visitors prior to in-person patient visitation sessions. * Failure to ensure diligent and consistent screening of visitors prior to in-person patient visitation sessions to prevent the entry of drugs and other contraband into the hospital, and to prevent the passing of those from visitor to patient. * Failure to ensure situational awareness and diligent observation of patient and visitor behaviors and interactions during in-person visitation sessions to prevent the passing of drugs and other contraband from visitor to patient. * Failure to investigate causes of the recurring presence of, and patient possession of, drugs and other contraband that created an unsafe EOC in the hospital. Findings 1.a. through 1.j. of this Tag reflect it was determined that a possible IJ situation existed based on findings that staff failed to conduct continuous rounds as required to ensure that patients were alive and breathing on the shift prior to Patient 5’s death and on subsequent shifts after Patient 5’s death, and that staff failed to ensure during continuous rounds that patients did not enter unauthorized areas and allowed Patient 22 to enter an unauthorized room. On 06/05/2024 the SA survey team and manager met to review possible IJ. On 06/06/2024, hospital leadership staff were presented with the IJ template. IJ Removal Plans submitted on 06/13/2024 and 06/24/2024 were not acceptable and were not approved. The third IJ Removal Plan submitted on 07/03/2024 was determined to be minimally acceptable after clarifications were provided at the request of the SA and was approved. The details of the IJ Removal Plan with a plan implementation date of 07/12/2024 at 2359 are described further in Finding 1.j. of this Tag. An onsite IJ Removal Verification Visit was conducted on 07/23/2024 and 07/24/2024 and the SA determined that IJ Removal Plan had been implemented. Tag A-144 is a repeat deficiency previously cited on complaint and revisit surveys completed on 01/17/2022, 08/01/2022, 11/17/2022, 10/05/2023, 03/14/2024, and 05/06/2024. Findings include: 1.a. During interview on 05/29/2024 beginning at 1115, hospital staff that included the Chief Medical Officer/Interim Oregon State Hospital Superintendent/Administrator (“CMO/Interim OSHS”), Interim Director of Security (“DS”), Chief Nursing Officer (“CNO”), Chief of Psychiatry (“COP”), Director of Quality Management (“DQM”), Director of Standards and Compliance (“DSC”), Program Director (“PD”), Director of Security (“DOS”), and OSH’s DOJ Assistant Attorney General (“AAG”) confirmed that on 05/24/2024 Patient 5 died unexpectedly on the Flowers 2 unit @ OSH-Salem (“FW2”). They provided the following information: * Patient 5 had an in-person visitation with their parent during the evening on 05/23/2024. * The next morning on 05/24/2024 at ~ 0815 Patient 5 was found unresponsive in their bed. * A code blue [response to a medical emergency] was initiated by hospital staff, and Emergency Medical Services (“EMS”) was called and responded. Resuscitation efforts were not successful and EMS pronounced Patient 5 deceased. * During the resuscitation efforts, another patient on the FW2 Unit reported to staff that the night before on 05/23/2024 Patient 5 had told them they had received something from their parent during visitation that might be drugs. * Powder residue was found at Patient 5’s bedside and was seized by Oregon State Police (“OSP”). * The hospital suspended in-person patient visitation until further notice on 05/24/2024 during their internal investigation into whether drugs were passed during visitation. * Several staff who worked on the FW2 Unit the night shift after the patient visitation had been “duty-stationed” as there were questions about whether staff were performing rounds and checking patients during the night as required. 1.b. An untitled summary of actions taken dated and timed as 05/29/2024 at 1244 was provided as result of the interview conducted at 1115 above and reflected: “* Suspended all on-site visits on both campuses before scheduled visitation was due to start on 5/24/2024. * Notified patients * Notified all people scheduled to visit * Notified staff * Notified press * Posted notification on OSH social media page * Posted notification on OSH Internet page * Security department searched Flower 2 for contraband on Friday, 5/24/2024, and on Saturday, 5/25/2024. * Confirmed the patient did not interact with patients on other units following the visit on 5/23/2024. Between the visit, and the time patient returned to the unit, and the time of the medical emergency the patient did not have opportunities to receive or pass substances to other patients on other units. Because of this, no search of other units was done. * Draft of a directive to staff is underway to enter patients’ rooms if the patient is asleep to verify viability if it cannot be determined from the door. * Communication to patients regarding change to viability checks is underway. * Security staff who were involved have been removed from patient contact. This was the screener and security staff supporting visitation. Occurred 5/29/24 in the AM after a discussion with [Human Resources (“HR”)]. Not in response to [Centers for Medicare & Medicaid Services (“CMS”)] arrival, just a coincidence. One staff works swing shift and will be notified at 1400 on 5/29/24. * Nursing staff who were involved have been duty stationed (on the unit, after the visitation, working during the night/day crossover on 5/24, prior to the medical emergency). Notice was given to staff at night on 5/24 - some staff work night shift. * Clinical Administrative Debrief Meeting (CADM) was initiated on 5/28/2024.” During the interview on 05/29/2024 at 1115 the CMO/Interim OSHS confirmed that no other actions had been taken up to that time. 1.c. The 18-page “Protocol” titled “2.020 Continuous Rounds, Census, and Milieu (RCM) Management.pdf” dated as revised on 02/27/2024, included detailed direction for staff in relation to continuous rounds, including, but not limited to: * “The purpose of this protocol is to establish performance expectations for nursing staff at Oregon State Hospital (OSH) related to conducting continuous rounds for the purpose of monitoring and verifying patients’ status and whereabouts.” * Definitions included: “ ‘Continuous’ means on-going at all times.” “ ‘Viability’ means the quality of being alive and breathing adequately to sustain life.” * “A. Nursing staff must perform continuous rounds focused on census and milieu management (RCM) at all times on each unit when patients are present.” * “C. ... No matter how scheduled, RCM assignments must cover all times during a shift and the following activities must be completed and documented on the RCM Flowsheet. i. Hourly Patient Census and Viability Checks, within 10 minutes of the top of every hour. ii. Hand-off report, at each change in RCM staff assignment, as described in this protocol.” * “D. Between swing and night shifts, and between night and day shifts, an off-going RN (or Lead LPN) and an on-coming RN (or Lead LPN) must conduct a collaborative patient viability round. (This round is not required to be completed between day and swing shifts.) 1. The off-going nurse and the on-coming nurse must together visualize each patient to verify both identity and viability. This verification may require pulling back the covers on a patient whose head is covered by bed linens or removing articles of clothing that may obstruct proper identification. a. The off-going nurse and the on-coming nurse must document the successful completion of these rounds by signing on the indicated signature lines at the top of the on-coming nurse’s RCM Flowsheet.” * “E. The RN (or Lead LPN) must verify that RCM duties are being continuously and accurately performed and documented by observing the RCM’s actions and reviewing the RCM Flowsheet at least twice per shift. This verification does not require documentation.” * “J. RCM staff must maintain awareness of the location and status of all patients assigned to the unit, including knowing if and when individual patients are off unit. This information must be accurately reflected on the RCM Flowsheet.” * “K. RCM staff must verify that patients are remaining in authorized areas of the unit and must intervene if patients enter, or attempt to enter, unauthorized areas.” * “L. RCM staff must verify that patients are not engaging in unsafe or unlawful behavior and must intervene if such behavior is noted. This includes but is not limited to: ... monitoring for potential sexual contact between patients and intervening ...” * “M. RCM staff must verify the presence and viability of each patient on the unit at least once per hour, at random intervals (within 10 minutes before or after the top of each hour). These checks must be documented on the RCM Flowsheet. 1. Verbal contact is not required during these checks, as long as visual verification of the patient’s status is made. 2. To determine viability when a patient has their eyes closed or is non-verbal, staff must unobtrusively stand by to either visually or audibly confirm patient respirations. 3. When a patient is using a bathroom or shower, verbal confirmation of presence and status is sufficient to verify viability ... For staff and patient safety, when entering patient bedrooms to perform patient checks, it may be preferable to utilize two staff, one stationed at the door and the other entering the room ... 6. RCM staff must document census and viability rounds on the RCM Flowsheet as follows ...” * “P. The primary responsibility of RCM staff is the thorough completion of the RCM duties described previously.” 1.d. Video observations of nursing staff continuous and hourly rounds and milieu presence protocols to ensure patients were alive and breathing were not followed during the night shift on 05/24/2024 prior to discovery of Patient 5 who was found unresponsive, cold to the touch, and not breathing in their room ~ four and ½ hours after they had last been observed alive. * As described under Finding 1.c. above in this Tag, the hospital protocol for “Continuous Rounds, Census, and Milieu (RCM) Management” required staff to conduct “continuous rounds” for the purpose of monitoring and verifying the “status and location” of every patient and that “Hourly Patient Census and Viability Checks, within 10 minutes of the top of every hour” were to be conducted. “Viability” was defined as “the quality of being alive and breathing adequately to sustain life” and “To determine viability when a patient has their eyes closed or is non-verbal, staff must unobtrusively stand by to either visually or audibly confirm patient respirations.” * The 05/24/2024 patient census report for the FW2 South Hall reflected that four of the South Hall rooms had one patient each, and the other four of those rooms had two patients each, for a total of 12 patients on that hall. Video review of four hourly rounds of those eight patient rooms during the night shift on 05/24/2024 between the hours of 0415 and 0830 showed staff who conducted those rounds to stand in the hallway outside closed patient room doors, look momentarily through door windows into darkened rooms, and then move to the next rooms. As an example: On 05/24/2024 the rounds that began at 0457:51 at the first room were concluded when the staff person walked away from the last room and the 12th patient at 0458:28, for a total of 37 seconds. Those 37 seconds also included the time required to navigate from room to room down one side of the hall and back on the other side of the hall. Although a reasonable person could conclude that staff could not have both navigated the hallway and confirmed patient respirations visually or audibly for 12 patients during a 37 second period of time, the staff recorded on the RCM flowsheets that each of the 12 patients had “Eyes closed, [Respirations] Confirmed.” * The hospital protocol also stipulated that at shift change between evening shift and night shift, and between night shift and day shift, “the off-going nurse and the on-coming nurse must together visualize each patient to verify both identity and viability. This verification may require pulling back the covers on a patient whose head is covered by bed linens or removing articles of clothing that may obstruct proper identification.” * The video for 05/24/2024 South Hall shift change showed for rounds conducted by RN 2 and RN 7 at ~ 0700 only one RN looked through door windows or briefly opened some patient room doors while the other RN stood in the hallway and held a clipboard. In addition, although RN 2 and RN 7 recorded that at 0700 eight of the 12 patients had “Eyes closed, [Respirations] Confirmed” at that time, documentation on the back of the report reflected that at 0700, seven of those eight patients departed for an “Off-Unit,” “2nd floor Leisure” activity. 1.e. Video observations of Patient 5 and their room, Room 225, for 05/24/2024 night shift showed the following: * ~ 0421 Patient 5 was observed to walk back into their room, Room 225, after they had spent time outside of their room walking around the unit. They were not seen to exit their room after that until they were moved from the room into the hallway after 0900 by EMS during unsuccessful resuscitation attempts. * ~ 0457:51 video showed continuous rounds began. Mental Health Therapy Technician (“MHTT”) 9 approached the door windows of patient Rooms 222 and 224 for 2/10th of a second then turned toward Room 225 on the opposite side of hallway took three steps toward Patient 5’s Room 225 to within ~ 2 feet of the door, glanced toward the door window for 1/10th of a second then proceeded down the hall. MHTT 9 recorded on the RCM flowsheet that Patient 5 was in their room and had “Eyes closed, [Respirations] Confirmed” at that time. * ~ 0556 video showed continuous rounds began. Those were conducted similarly to the 0457 rounds and MHTT 8 similarly recorded that Patient 5 was in their room and had “Eyes closed, [Respirations] Confirmed” at that time. * ~ 0700 video showed continuous rounds began. Those were conducted by RN 2 and RN 7 as described above in Finding 1.d. and the RNs recorded that Patient 5 was in their room and had “Eyes closed, [Respirations] Confirmed” at that time. * During interview on 05/30/2024 at 1520 with day shift RN 2 the following information was provided regarding Patient 5: - RN 2 stated at “probably” 0655 or 0700 they did shift change viability rounds with night shift RN 7, who was an agency nurse. During the rounds, RN 7 visualized the patients and they, RN 2, did the writing on the RCM continuous rounds report. RN 2 told RN 7 “I’ll do the writing and you do the visualization.” - RN 2 stated they “obviously” had no interactions with the patient. - RN 2 stated RN 7 opened the door and “I believe” used a flashlight and said the patient was sleeping “so I wrote down [they were] sleeping and carried on.” RN 2 stated “I visualized [the patient] and could see [they were] laying there.” RN 2 stated the patient “looked like [they] always [do], curled up in bed with blankets.” RN 2 stated they did not go into the patient’s room to see if they were breathing. - RN 2 stated later in the shift they went out to cue patients who still needed their medications (“meds”) and they went to the patient’s room, opened the door and said “It’s Friday ... time for meds ... biscuits and gravy for breakfast.” They stated the patient did not respond and that was typical for the patient. They stated the patient “plays possum” and usually gets up on their own. RN 2 stated the patient did not respond, they did not see the patient move, and they did not go into the room. Refer also to RN 2’s incident documentation under Finding 1.f. below. * ~ 0800 video showed that no rounds were conducted. However, MHTT 1 recorded that at 0800 Patient 5, and six other patients on that hall, were in their rooms and had “Eyes closed, [Respirations] Confirmed” at that time. * ~ 0806 video showed that MHTT 3 approached Patient 5’s door, knocked on the door, opened the door, closed the door, then without urgency walked to check another patient (“pt”) room then walked back down the hall to the Nurses Station (“NS”). * During an interview with MHTT 3 on 5/31/2024 beginning at 1300, the following information was provided regarding Patient 5: - MHTT 3 stated they remembered the incident involving the patient. They normally worked day shift on FW2 and they came into FW2 at 0715 on the day the patient “passed away”. - MHTT 3 stated that they normally conducted rounds, called “visual rounds” every hour and those were documented on RCM forms. Their responsibilities during rounds were “Just to see if the patient is OK and what they are doing and check for breathing and stuff like that.” The MHTT stated that during rounds they walk by each patient room and “only open the door if I can’t see them moving from the [door] window.” If they saw a patient moving from the window, they would document a “C” on the RCM which meant “active.” If they did not see the patient moving, they would open the door, say the patient’s name “to get their attention” and if the patient did not respond, they would get a second staff person to go check the patient with them. After getting a second staff person, they would both go in the room and tap the patient to check for breathing. The MHTT stated they were not allowed to go in patient rooms by themselves. - MHTT 3 stated that “around 8:00ish the LPN told me a few patients had not gotten their meds so I went to Patient 5’s room and I opened the door.” The MHTT stated that the light was not on in the room. MHTT 3 stated, “I said Patient 5’s name three times.” The patient had headphones on so they didn’t think the patient could hear them call their name. The MHTT stated the patient “looked totally normal.” The patient was in bed “kind of sitting up, lying down but with [their] head up on the pillow, on [their] back.” MHTT 3 did not think they could see the patient’s eyes because “It was pretty dark in the room.” - The MHTT stated the patient had clothes on and they were “pretty sure” they had a blanket over them. The MHTT stated they did not go inside the patient’s room at any time. - The MHTT was asked by the surveyor if they could tell if the patient was breathing and they stated, “No, I didn’t look for that.” The MHTT stated that when the patient didn’t answer, they let the License Practical Nurse (“LPN”) know that they would have to take the patient’s meds to them. The MHTT stated they did not say anything else to the LPN about the patient. The MHTT was asked by the surveyor if they saw anything suspicious in the room such as contraband and they stated, “No, I didn’t look around.” Refer also to MHTT 3’s incident documentation under Finding 1.f. below. * ~ 0825 video showed continuous rounds began. Those rounds by MHTT 1 who documented they conducted rounds at 0800. During those rounds the MHTT 1 did not look into or open the door to Patient 5’s room. * ~ 0834 video showed that the day shift RN 2 approached Patient 5’s door, looked in the window, opened the door and looked in, closed the door, then without urgency walked away from the room and back down the hall. * ~ 0847 video showed that LPN 5 approached Patient 5’s door, opened the door, entered the room, and left the room with urgency after which staff began to urgently respond to Patient 5’s room. * On 05/30/2024 beginning at ~1320, during video review of the 05/24/2024 incident involving Patient 5, interviews with hospital staff present that included the CMO/Interim OSHS, the DS, CNO, Chief of Operations (“CFO/COO”), DQM, DSC, Incident Reporting System Incident Director “IRSID”, DNS and others confirmed the following: - Regarding checking for respirations if patient appeared asleep, staff stated “Protocol could include pulling down the blanket. They have to see the chest rise and fall.” - Regarding RCM rounds that began at ~ 0401 the video showed that the Mental Health Therapist (“MHT”) walked up and down the South Hall and barely glanced in rooms, in some cases for less than one second, as they walked by. The DNS stated, “I don’t think that is sufficient. We’re in agreement.” - Regarding viability rounds at the beginning of each shift, staff stated that two RNs were required to conduct those rounds and “Both nurses should assess viability.” However, regarding the RN viability rounds observed on video that began at ~ 0653 the DNS and DQM stated that viability checks by the two RNs was not happening and confirmed that the video showed that only one of the two RNs was looking into patient rooms to evaluate viability. - Staff confirmed the video showed that no RCM rounds were conducted at 0800. RCMs did not happen until 0825 and the staff that conducted those rounds did not open Patient 5’s door. 1.f. Incident documentation related to Patient 5 was reviewed and included the following: * An incident report with incident date and time 05/24/2024 at 0900 was written by MHTT 1 and reflected the following: They were “tasked with RCM imedietly [sic] after at 0800 and was starting viabilitly [sic] with the RCM which included 3 close observations. I had started to do my check at 0800 ... I had walked down into the south hallway where one of my close observations was, looked into their room and they were awake so I went directly across the hall to look into the room which was Patient 5’s room. When I looked into [their door window] the light was off and [they were] sitting upright as [they do] typically everyday at different points through the day. I have observed [them] previously in this position and it appeared to be [their] most preferred sleeping position. [Patient 5’s] eyes were closed and [their] room darkened but not dark enough to not be able to see. As I was looking into [their] room one of my close observations from the room behind me came out of [their] room and said to me ‘goodmorning’ [sic] so I turned to [them] and replied ‘good morning, it’s good to see you.’ At that point I was turned from [Patient 5’s] bedroom window and I continued on checking the next room. I had finished viability and continued to do my close observation checks throughout the hour.” * An incident report with incident date and time 05/24/2024 at 0830 was written by RN 2 and reflected the following: “At about 0830 I spoke with LPN who was passing meds, and got a list of what patients who still needed their medications. I proceeded to [Patient 5’s] room, and opened the door. The room was dark, and I said ‘hey [Patient 5], it’s time to get up for medication’. ‘It is buscuit [sic] and gravy day for breakfast’. There was no response, which is typical of [them], who doesn’t respond at times. When I returned to the nurses station I informed the LPN we should just delivery [sic] [their] meds to [their] room. Shortly later, about 0840ish, staff yelled ‘We need a nurse to [Patient 5’s] room right now’. Myself and [another staff] ran to [Patient 5’s] room, and found [Patient 5] unresponsive. [Cardiopulmonary resuscitation (“CPR”)] was immediately started ...” * An incident report with incident date and time 05/24/2024 at 0840 was written by MHTT 3 and reflected the following: “Around 8am the LPN had asked me to get certain patients up to take their meds. [Patient 5] was one of those patients, I then went to knock on [their] door and said [their] name three times, I saw that [they had their] headphones in and assumed that’s why [they] could not hear me. We are not allowed to go into patient bedrooms alone, so I told the LPN [Patient 5] was not getting out of bed. So [the LPN] could bring [them their] meds.” * An incident report with incident date and time 05/24/2024 at 0847 was written by MHTT 4 and reflected the following: At 0847 “The [LPN 5] and I ... knocked on [Patient 5’s] door so the Nurse can give [them their] medications. We opened the door and called out [Patient 5’s] name but no response. [They were] laying in bed in a upright postion [sic] with headphones in [their] ears. So we turned on [the room] light and knocked on [the] wall to try and wake [them] up and still no response. I noticed then that [Patient 5] looked pale and stated to the nurse, ’[Patient 5] looks pale.’ I then went into [their] room and shook [their] shoulder and called [their] name once more but no response. At that time [Patient 5’s] left arm went limp and fell to [their] side. I then felt [their] hand and [Patient 5] was really cold. I continued to check [their] pulse and notice that [they were] not breathing. I told the nurse [Patient 5] was not breathing and called a code blue and looked out the door and told the RN to come. RN rushed to the room and and [sic] stated, ‘Call a code blue.’ CPR was started right away at 0848 AM By [sic] LPN on the bed where [the patient] was lying ...” * An incident report with incident date and time 05/24/2024 at 0845 was written by LPN 5 and reflected the following: “During AM medication pass, writer noticed [Patient 5] did not come to med window and nursing staff requested floor staff to prompt patient. After noticing that patient did not come, writer decided to bring [the patient’s] AM medication to [them]. Writer requested assistance from floor staff due to writer not being familiar with unit or patient. Writer and [MHTT 4] approached patient’s room and knocked on the door. Writer called out to patient that its time for [their] medications and can [they] please sit up. Patient did not respond after multiple attempts from both writer and [MHTT 4]. Writer turned on the light and [MHTT 4] approached the patient to try to get [them] to wake up. [MHTT 4] turned to writer, said [Patient 5’s] cold and tried to shake [the patient] awake. Writer closed the door to the patient room, cleared the hallway, called down to the hub to call the charge nurse and initiated CPR while patient was on the bed. [MHTT 4] called the code blue over the walkie.” * An incident report with incident date and time 05/24/2024 at 0847 was written by Nurse Manager (“NM”) 6 and reflected the following: “Arrived in response to CODE BLUE. Found in room between two patient beds with staff performing CPR. Multiple doctors, nurses, and floor staff in room and immediate area to assist with emergency. Staff were actively moving other patients off unit. EMS notified and on the way. Arrived around 0900. CPR continued in room until EMS arrived. EMS staff on site, took over scene a little after 0900. [Emergency Medical Technicians (“EMTs”)] noted rigor mortis had set in pt’s jaw causing what looked like difficulty intubating pt. CPR continued until patient [death] called by EMTs @ 09:09:40. While in the nurses station, I overheard staff saying this patient had a visit last evening and there was a discussion about the possibility family passed the patient something, potentially contraband. While walking out of room after code over, EMT noted rolled up currency and what appeared to be a small amount of white powder noted. Room secured by [Security Manager] and [another] security staff. This information passed along to [Security Manager].” 1.g. Attempts to resuscitate Patient 5 by hospital staff and EMS who responded to the patient unit were not successful and Patient 5 was pronounced dead at 0909. Had continuous rounding been conducted as required by hospital protocol during the hours after Patient 5 re-entered their room at 0421, Patient 5 may have been identified to be in distress, struggling to breath, or unresponsive earlier and may have survived. However, Patient 5 was not “visualized” per the protocol during continuous rounds. Further, when Patient 5 was “visualized” at 0806, 0825, and 0834 and was unresponsive to staffs’ verbal communications and had closed eyes, staff did not approach the patient’s bedside to determine whether the patient was alive and breathing, rather they walked away with no sense of urgency to conduct other business. Only at 0847 when staff finally approached the patient’s bedside and determined that they were “cold” and “not breathing” did staff respond. 1.h. On 05/29/2024, five days after Patient 5’s death, and after the State Agency (“SA”) investigation had been initiated, an email from the CNO was dated and timed as sent on 05/29/2024 at 1354. The “Subject” was “Nursing RCM Reminder” and an “Attachment” was identified as “2.020 Continuous Rounds, Census, and Milieu (RCM) Management.pdf” The email reflected: “This email is intended for all OSH Nursing staff. Good afternoon OSH Nursing, Last week we experienced the loss of a patient. This has been incredibly hard and traumatizing to people across the hospital. Please reach out to your manager if you need support. We have on-site and virtual support options. This event is under investigation, so details cannot be shared yet. What we want to highlight for now, is the importance of viability checks while doing RCM rounds. It is particularly tough when the patient is in bed. Being able to confirm respiration by watching for the rise and fall of the chest from the doorway is difficult at best. As a reminder, anyone assigned to RCM rounds must enter the patient’s room to assure viability if that cannot be obtained from the doorway. Please use a second staff to enter when needed. We know this will likely result in sleep disruption for the patients as we begin to enter the room more frequently. We hope this will be a short-term directive as we are looking for a technology solution. Thank you, [CNO]” There was no other evidence provided that other actions had been taken after the patient’s death to monitor and observe staff practice to ensure staff were conducting RCM continuous rounds as required to determine “viability” or that patients were alive and breathing. 1.i.i. Video recordings and documentation of incidents that occurred after Patient 5’s 05/24/2024 death and after the 05/29/2024 email referenced under Finding 1.h. above in this Tag had been sent to staff were reviewed. Those reflected that nursing staff hourly rounding and milieu presence processes to monitor and confirm patient condition and status showed minimal improvement. The rounding processes which were also required to monitor and confirm patient location were additionally not effective as a patient was allowed to enter and remain in the room of two opposite gender patients during the middle of the night. 1.i.ii. Video review of 17 RCM continuous rounds on the night shifts of 06/01/2024 and 06/02/2024 on the FW2 South Hall showed minimal to no change in the way staff conducted the continuous rounds and assessed “viability” or whether the patients were alive and breathing, in comparison with how those were conducted on 05/24/2024. The time taken and the proximity of RCM staff in relation to the patients, from the hallway looking through windows of closed doors into darkened patient rooms, were not sufficient to assess whether patients were alive and breathing. * During review of the FW2 06/01/2024 and 06/02/2024 videos on 06/05/2024 beginning at 1105, with staff present that included the DSC, CNO, DNS, and CMO/Interim OSHS, the following information was provided: - It was expected that during RCM rounds staff should “see” each patient’s chest rise and fall or “hear” respirations. - At the closed patient room door in the hallway staff were to look to see if each patient’s eyes were closed. If so, staff were to look through the door window for the chest rise and fall. If staff can’t see patient respirations they are to approach the patient to listen for respirations and pull covers back if needed. - If staff can’t confirm “viability” they are to go into the patient’s room. - In regard to the video review that showed minimal change to staff RCM practices from the 05/24/2024 video described in the Findings 1.d. and 1.e. above, the DNS stated, “I agree that the two nurses are not doing viability rounds” as required and that “only one RN was checking for viability.” - The DNS stated that the RCM video review showed observations for patient viability at patient room doors were “very brief” and “there are opportunities ... this is for benefit of patient safety.” - At ~ 1250 the DNS stated that we didn’t need to look at more video and “we understand what you’re showing us.” 1.i.iii. Review of the hospital’s incident log or “tracker” included an incident that occurred on 06/02/2024 for Patient 22 identified with “Incident Type” of “Sexual Contact.” * Incident documentation reflected that on 06/02/2024 on Flowers 1 unit @ OSH-Salem (“FW1”) at “0350-0355. While doing RCM/[Safety and Security Management (“SSM”)] rounding Nurse noticed [Patient 22] coming out of [the room of two opposite gender patients] on the South Hall. Nurse asked [Patient 22] what are you doing coming out of their room? [Patient 22] stated ‘I was asking them to fix my [portable music (“MP3”)] Player’. Writer informed [Patient 22 that they were] not allowed to enter other patients [sic] room. [Patient 22] stated ’[They were] fine, and nothing happen [sic].’ I spoke with [the two opposite gender patients] and asked them what happen [sic]; and why was [Patient 22] in there.? [sic] They stated ’[Patient 22] came in and they asked [Patient 22] to leave, and [Patient 22] was there for 10 [minutes (“mins”)]’ “. * Review of the RCM “Unit Patient Census and Status Flowsheet” dated 06/02/2024 for night shift showed that Patient 22 was observed at 0301 in their “Bedroom - Eyes closed, [Respirations] Confirmed” and at 0400 Patient 22 was observed in their “Bedroom - Eyes closed, [Respirations] Confirmed.” * During interviews at the time of incident and video reviews that occurred on 06/04/2024 beginning at 1105 and on 06/05/2024 beginning at 1105, with staff that included the DSC, CNO, DNS, and CMO/Interim OSHS, they confirmed that patients were not allowed to be in other patients’ rooms. * Review of the FW1 floorplan and patient room assignments showed that Patient 22’s room was near the middle of the East Hall, Room 138. The room of the two opposite gender patients was the room furthest from the NS at the end of the South Hall, Room 131. In order for Patient 22 to get to the other Room 138 they would have to walk down the East Hall past two other patient rooms, a laundry room, a kitchenette, and a large patient activity/common area to the front of the NS. From the front of the NS the patient would have to walk down the South Hall past a second large patient activity/common area, a kitchenette, a laundry room, and three patient rooms before arrival at the fourth patient room, Room 138, at the far end of the South Hall. * According to RCM Protocol instructions delineated at Finding 1.c. above in this Tag, staff who conducted the RCM activities should have maintained a continuous presence in the milieu to be able to observe Patient 22’s movements between unit hallways during the middle of the night to prevent Patient 22 from entering Room 31 in order to protect Patient 22 from potential sexual contact and other risks. 1.j. Although the email referenced under Finding 1.h. above in this Tag was sent to staff to remind them to follow RCM processes on 05/29/2024, that action had not been sufficient to ensure staff were confirming patient condition/status and location as required by the RCM protocol and the email. In response to the continuous rounds process findings identified under Finding 1.i. above the hospital was notified on 06/06/2024 that an IJ situation existed. Additional immediate action was determined to be required to ensure that the condition/status and locations of patients were monitored and confirmed, and that observations of patients who had their eyes closed were sufficient to confirm that those patients were alive. The IJ Removal Plan submitted on 07/03/2024 had an implementation date of 07/12/2024 at 2359 and was approved. It included the following actions: * “OSH will issue an administrative directive, effective July 8th, requiring direct observation by a Registered Nurse acting as lead to observe no less than three viability checks per shift. The RN will confirm respirations with the person assigned to RCM and validate accuracy of observations. The RN will document on the RCM flowsheet each time they observe viability checks.” * “The RN is to observe the accuracy of the viability check by ensuring the staff member does the following ... At the top of the hour, two staff must complete the Patient Census and Status Flowsheet to verify the location and status of each patient. While doing so, if they observe a patient who is non-verbal or who is not up and moving about, both staff must verify two respirations (as evidenced by chest rise and fall) for a minimum of 2 respirations ... If the patient is in a room with a large window ... and the patient’s positioning allows for it, staff may observe for respirations through the window. If the patient cannot be clearly observed through the window, staff must move to a location which allows the patient’s respirations to be visually or audibly confirmed ... If the patient is [sic] their bedroom and the door is closed, staff must look through the window to observe if the patient is awake, up/moving, or communicating with staff or peers. If the patient is laying down and they are not spontaneously verbal, staff must observe the patient for 10 seconds and visualize 2 respirations. If 2 respirations cannot be confirmed by both staff, staff must quietly open the door ... if respirations cannot be confirmed by both staff from the open doorway, or from where they are observing the patient, staff must enter the room and move close enough to the patient for both staff to observe 2 respirations. If staff are still unable to confirm respirations, they must physically place their hand on the patient and attempt to rouse the patient. If unable to rouse the patient, staff must immediately call the unit RN into the room for further assessment.” * “OSH Staff who perform RCM rounds or supervise staff involved in RCM rounds have been notified and trained to the updated processes ... All Nursing staff will be instructed both verbally and in writing about the updated Continuous Rounds, Census, and Milieu (RCM) Management protocol, which include the observation requirements stated above. Staff will confirm in writing that they received, understood, and will follow the updated protocol, and that they will seek guidance and clarification from a supervisor for any questions, via attestation ... RNs acting in the lead capacity on each shift have received additional in-person training, including competency verification, regarding viability checks and the Continuous Rounds, Census, and Milieu Management protocol.” * The “three viability checks per shift” will be three “full RCM [rounds] of ‘viability checks’ of all patients on the unit.” 2.a. After the code response for Patient 5 an incident report with incident date and time 05/24/2024 at 0900 was written by a Treatment Mall (“TXM”) Activities Coordinator and reflected that they were “approached by flowers 2 client, [Patient 24]. [They] stated to me .. ’[Staff name], my friend [Patient 5], I think is going to die. I’m not a Nark. I should have said something last night. [They] offered me drugs & told me [they] got them at [their] visitation last night. I think it was [their parent] & It looked like Fentanyl. I told [Patient 5] no way.’ This writer told [Patient 24], ‘to not worry, It is not your fault and you did the right thing telling me.’ This writer immediately took [Patient 24] back to TXM and then went on to flowers 2 unit & reported to Manager ... [Manager] & I shared the conversation in the nurses station with [Security Manager] of what was exchanged with [Patient 24] and myself. I at that time went and got [Patient 24] and took [them] to [Security Manager] so they could speak, and after their conversation ended, I returned patient to TXM.” 2.b. An email from the CMO/Interim OSHS was dated and timed as sent on 05/24/2024 at 1506. The “Subject” was “READ NOW: Urgent visitation pause” and an “Attachment” was identified as “Patient update- visitation 5-24-24.pdf” That email reflected: “This email is intended for all OSH employees. Dear OSH Team, Because of a significant incident related to passing of contraband from a visitor to a patient, we are pausing in-person visitation effective immediately, beginning with the 2 p.m. visits scheduled today, Friday, May 24. This was a decision the Executive Team did not make lightly. We know how important inperson visits are to patients and those who love them, and we know we are making the decision on a Friday before a holiday weekend. We will keep this pause as short as we can while we review our visitation policies and procedures and make improvements to ensure in-person visits are safe for patients, families and staff. Reception Center staff will contact visitors to let them know about this change. Unit managers will also ensure patients receive this information, beginning with patients who had visits scheduled this weekend. Below you will find a script to use when sharing this information with patients. Attached is a handout you can give to patients explaining the pause. Video visits remain available. Please continue to use our standard procedures for scheduling and facilitating video visits. We apologize again for the inconvenience to patients and their loved ones, and we will update you when we have information about how we plan to resume in-person visitation. Sincerely, [CMO/Interim OSHS].” The email continued with “Script for discussing in-person visitation pause with patients: We are very sorry to share some difficult news. Because the hospital had a significant incident where a visitor passed contraband to a patient, we are pausing all in-person visitation effective immediately, beginning with visits at 2 p.m., Friday, May 24. We know this is disappointing and frustrating. We know you were looking forward to a visit, and we know your visitors were looking forward to seeing you. Our Reception Center team is contacting your visitors and letting them know a video visit is an option. We are going to review our visitation policies and procedures and make adjustments so we can return to safe in-person visits as soon as we can. We will let you and your visitors know when we are ready to resume in-person visits, including any new requirements.” 2.c. During interview on 05/29/2024 at 1130 with DQM, DOS, PD, and other hospital staff present the following information was provided: * The DOS stated an incident involving Patient 5 occurred on 05/23/2024 in the evening. * DQM stated that the investigation was still in process. * The PD stated Patient 5’s room was in FW2 Unit. The patient had a visit with a family member on 05/23/2024. The morning after the visit at about 0815 or 0830, the patient was found unresponsive in their room. A Code Blue was called, staff responded, and CPR was started. EMS arrived and the patient was pronounced dead. * DOS stated after the code, Patient 24 wanted to talk to a security staff. Patient 24 told the staff that Patient 5 had told them that they received “drugs or something to that effect” from the family member who had visited the patient. * PD stated, “a powder residue” in tin foil was found on the floor at Patient 5’s bedside and “state police took it.” * DOS stated visitors make appointments for their visits, so the hospital knows ahead of time who is coming. Patient 5’s visitor had an appointment at 1800 but they did not arrive “to get screened” until 1855. Patient 5’s visitor went through the visitor screening process. * DOS stated that the hospital has a visitation log of approved visitors who come into the hospital. * DQM stated that all visitation occurs in Kirkbride Café. Nursing staff and security staff provide “eyes on” during patient visits. During interview on 05/29/2024 at 1205, DQM stated they did not know what the powdery substance was that was found in Patient 5’s room. 3.a. Processes and documentation for registration and check-in of visitors who arrived for in-person visitation sessions with Patient 5 and other patients on 05/23/2024 were found to be inconsistent, unclear, and incomplete. 3.b. During interview on 05/29/2024 beginning at ~ 1315, with staff that included the DQM, DSC, IRSID, the CMO/Interim OSHS, CNO, and Risk Manager (“RM”), the following information was provided: * Security staff run background checks of individuals who request patient visitation as part of an “approval” process to be able to participate in in-person visitation. Upon approval those names are added to the patient’s medical record as an approved visitor. * Approved visitors are scheduled for visitation on specific dates and times and must check in at the hospital’s main reception desk to register and sign-in. * There are two reception windows where all visitors must register, be signed-in on the visitor log for the window they presented to, and receive a visitor badge that must be worn during the duration of their visit. * From reception, visitors move to the secure main lobby to be screened for contraband and prohibited items before being escorted to the designated visitation area in the Kirkbride Café where up to 11 patients at a time may have visitation sessions. 3.c. Review of the two “Visitor Sign-In” logs for 05/23/2024 revealed the following: * The “Visitation” schedule for the “Kirkbride Café” 05/23/2024 showed that 19 individuals were scheduled for visitation sessions beginning at 1600. However, the two “Visitor Sign-In” logs dated 05/23/2024 showed that 17 individuals arrived at the hospital for visitation sessions. However, the names of visitors scheduled did not align with the names of those who arrived. - For a “Time In” entry at 1600 the name of a visitor identified on the “Visitor Sign-In” log did not match any names identified on the “Visitation” schedule. - The “Time In” entry for 1914 reflected the first names only for two persons. Those names were not found on the “Visitation” schedule. * “Time-In” entries on the logs were not in chronological time order. The log for “Window # 1” showed that visitors presented in the following order on that day: 1100, 1020, 1543, 1544, 1547, 1555, 1600, 1604, 1616, 1706, 1100, 1846, 1855, 1914, 0815, 1150. * Multiple entries contained more than one name of a visiting person entered on one line of the log. “Time In” entries recorded at 1543, 1555, 1846, 1914 each contained the names of two persons entered on one line. The “Badge ID #” space for those four entries showed two badge #s, however, it was not clear which of the two persons was assigned which badge #. * The two “Visitor Sign-in” logs reflected that on 05/23/2024 36 individuals registered and checked-in for a variety of reasons, including for patient visitation sessions. However, 29 of those 36 entries lacked the visitors “Time Out” of the hospital and evidence they had returned the visitor badge. 3.d. During interview at the time of the visitor log review on 05/29/2024 beginning at 1315, staff confirmed the visitor logs contained unclear and missing information, including that each visitor was supposed to be documented on a separate line. 3.e. The findings regarding visitor check-in processes were consistent with surveyors’ varied experiences during visitor check-in on the mornings of 05/29/2024 and 05/30/2024. Those included that the check-in process was concluded after the name of a surveyor, and presumably the time of entry and badge #, were written on a piece of torn scratch paper versus the “Visitor Sign-In” log. 4.a. Observations of the visitor check-in and screening areas with DSC and other hospital staff on 05/29/2024 at ~ 1020 when the survey team arrived at the hospital revealed: * Observation of the main hospital entry included two visitor check-in windows and a secure door leading to the visitor screening area. * The visitor screening area was located in the hospital’s main lobby. * Inside the visitor screening area, an X-ray scanner unit with a pass-through section used for screening items was observed. * A thin black mat with two solid yellow foot shapes that indicated foot location and stance was observed on the floor in front of the X-ray unit. * Stackable box style metal lockers with locks were observed near the X-ray unit. * Seating for multiple individuals was observed across the room from the X-ray unit. * A Security Staff (“SS”) member had a handheld metal detector wand. 4.b. During interview on 05/29/2024 at ~ 1035 with a SS member at the visitor screening station, the following information was provided: * Before visitors come to the hospital, they are told what needs to happen with their belongings upon their arrival. * When they arrive, “we tell them to please lock up their belongings in a locker.” * Visitors are only allowed to bring a credit/debit card or cash inside so they can purchase food in the hospital café. * If there is “something on a person” the metal detector wand will make a beeping noise. * If the battery in the wand is low, the wand “doesn’t work right” and “doesn’t pick up anything.” * The SS member stated that “visitors go through with stuff in their pockets all the time.” 4.c. During interview on 05/29/2024 at ~ 1120 the DOS stated that all visitors must go through the visitor screening area in the hospital’s main lobby. 4.d. Video review of the screening of visitors in the hospital’s main lobby on 05/23/2024, the date of Patient 5’s visitation with their parent, showed that visitor wanding and screening measures were insufficient and inadequate for the purpose of drug and contraband detection. For example: * Video beginning at 1559:14 showed a SS member completed the security screening and wanding process for nine visitors in a moving line at 1559:52. During those 38 seconds, the wanding time for some of the visitors was ~ 2 - 3 seconds. The screenings consisted of a cursory pass of the wand near the front and back of the persons’ torso only, the back pass for some was conducted as the visitors walked away. There was no indication of any verbal communication between security and each visitor. None of the visitors were prompted to stand on the black mat. * Video of a visitor screening showed that the SS member passed the wand briefly over the person beginning at 1850:43 and ending at 1850:47. The visitor was not standing on the black mat. * Video of another visitor screening showed that the SS member passed the wand briefly over the person beginning at 1850:52 and ending at 1850:58. The visitor was not standing on the black mat. * Video showed that Patient 5’s parent arrived at the hospital, at 1851:20 approached the first check-in window at the reception desk, at 1852:00 entered the main lobby through the secure doors, and then entered a restroom in the main lobby. After they exited the restroom at ~ 1853:10 Patient 5’s parent was observed to place a phone and other items removed from their pockets into one of the lockers. At 1853:49 a SS member began to run the wand briefly over the parent while the parent was still walking forward. The SS member moved the wand from the left shoulder to right shoulder, to mid right forearm, then one wave down the torso to the left knee area. The SS member walked around to the person’s backside and moved the wand from left shoulder down to the left calf. That concluded the screening and both walked away from each other. The wand was not passed over all body areas, including the feet, the parent did not stand on the mat, and the wand was noted to be inches away from the areas that the wand was passed over. At 1854:20 the parent entered sally port with SS member to proceed to the visitation area. * Video showed that two adult visitors entered the main lobby and approached the lockers at 1904:32. No one else was observed in the main lobby at that time. They milled around near the lockers and at 1904:53 the first visitor was observed to approach the second visitor closely and began touching the second visitor underneath the second visitor’s long, untucked baseball type shirt near where the beltline or top of the pants would be. The visitor continued to actively touch and handle that area underneath the shirt while the second visitor looked around the room. This went on for ~ 23 seconds, when at 1905:16 the first visitor removed their hands from the second visitor’s body and stepped away. Both visitors then sat in chairs. The video showed that the SS member conducted a cursory wand screening for the first visitor that began at 1906:19 and ended at 1906:25. The wand screening for the second visitor began at 1906:25, consisted of a cursory 3-second pass across the visitor’s stretched-out arms, erratic wand movements several inches away from the front of the visitor’s body, and ended at 1906:32 after the back of the visitor’s arms and legs were wanded. It was not evident that the visitor’s torso or beltline area was wanded during the screening. Neither visitor was prompted to stand on the black mat. Those two visitors were most closely aligned to the two visitors who were signed in on the “Visitor Sign-In” log with first names only and who were not on the “Visitation” scheduled as identified in Finding 3.c. above. * Video observations showed that screening wands were passed at distance of greater than one inch away from the person being screened, contrary to directions in the Manufacturer’s User Manual described under Findings 4.f. below, and raised questions about whether drugs and other contraband could be detected with the brief and cursory screenings observed. In the case of the visitors who presented to the lobby at 1904 their behaviors raised further questions about whether drugs or contraband were potentially being arranged or adjusted at the second visitor’s beltline to avoid or prevent detection. In addition, it was unclear what purpose the black mat observed next to the screening station served as it was not observed being used during the video observations. 4.e. During interview on 06/03/2024 beginning at 1700 during the review of visitor screening video with staff that included the IRSID, the DQM, and DSC, staff agreed that the behaviors of the two visitors who arrived in the lobby at 1904 were “weird” and concerning. 4.f. The Manufacturer’s “User Manual” for the Garrett “Super Scanner V” screening wand included the following information related to use and maintenance: *There were three methods of “Alerts” for metal detection that were lights, an audible sound, and vibration. * “When the Super Scanner V is operating, it will detect metal only while it is in motion. Move the instrument within approximately one inch from the person (object) being inspected. A sound will be heard or vibration felt and the Red Alert Light will illuminate whenever metal is detected. Operation is completely automatic. No ‘retuning’ is ever necessary. All conductive metals will be detected including ferrous, non-ferrous and stainless steel.” * “DETECTION PRINCIPLES AND CAPABILITIES - The Super Scanner V is an active hand-held metal detector with very high sensitivity to all metals including ferrous, non-ferrous and stainless steel. Detection and alarming takes place when the instrument is passed in close proximity to metal objects. Detection range is dependent upon the size and conductivity of the metal object. The larger the object, the greater the detection distance. The Super Scanner V is factory preset to nominal sensitivity with no operator adjustments required. This ensures that the detector will be used at the proper operating level established for the particular security need. Should nearby, stationary metal objects (floor rebar, metal walls or cell bars) cause interference to the scanning process, an Interference Elimination Button is available to momentarily reduce sensitivity so as to ignore the interfering nearby metal and permit precise scanning of the individual or object being scanned. When metal objects are encountered, the red [Light-Emitting Diode (“LED”)] is activated along with an audible alarm or the vibration alarm (depending upon user setting). An optional earphone may be used by the operator. Further convenient LEDs include green for ‘Power ON’ status and amber for ‘Low Battery” indication.’” * “Maintenance - Periodic maintenance should include a daily check for battery condition, verification that the Super Scanner V detects metal and there are no loose or missing parts. A daily test standard can be established by using the [Flat Test Piece (“FTP”)] or [Operational Test Piece (“OTP”)] test piece available from Garrett, or simply by selecting an object the size of a large coin and noting the expected detection distance. A formal test program may be establish[ed] using the Test Kit [Hand Held Metal Detector (“HHMD”)] [part number (“p/n”)] 1626100 available from Garrett.” * “CAUTION: Always verify that the Super Scanner V is set to the desired sensitivity level by testing with appropriate targets anytime the sensitivity adjustment is changed. Do not affix metallic labels (or any material that might cause the detector to alarm) to the detection area of the Super Scanner V. Doing so might cause an imbalance within the detection field and thereby reduce scanning effectiveness. If the equipment is used in a manner not specified by the manufacturer, the protection provided by the equipment may be impaired. Use carbon, alkaline, or [Nickel-Metal Hybride (“NiMH”)] batteries only. Operate within the specified temperature ranges of the battery.” * A “Recommended Body Scanning Procedure” diagram showed the manufacturer’s instructions for the body position of a person being scanned, the position of the wand and the route of scanning front and back of persons, and the position of the wand and method for scanning feet. 4.g. Video observations described above were not in conformance with the diagram elements. For example: Observations showed that many visitors were only scanned front and back of torso areas and arms or feet were not scanned; The diagram showed the position of the arms to be at a person’s side, slightly extended from the body, while the video observations showed visitors’ arms raised to shoulder level and stretched straight out; The diagram showed the position of the wand over the visitor’s body was always horizontal to the floor and the position of the wand over the feet to be vertical to the floor, while the video observations showed no consistent wand position used. 4.h. Refer to Finding 6 below that reflected the hospital had no written P&Ps or protocols for use and maintenance of those sensitive and important screening devices. A “Master Inventory” list of wands and locations reflected the hospital had 11 of the screening wands in operation. 5.a. During interview on 05/29/2024 beginning at 1115 with staff that included the CMO/Interim OSHS, the CNO, CFO/COO, DQM, DSC, AAG, PD, and DOS, the DOS stated that the Security Department “owns the visitation process” and indicated that nursing “also has their eyes on it.” During interview with DQM on 05/29/2024 at ~ 1515 they stated there were supposed to be two SS members and two nurses present during patient visitation sessions in Kirkbride Café. However, the DQM stated the second SS member “showed up later” after Patient 5’s visit had started. 5.b. The “Patient Log for Visitation Date:” 05/23/2024 reflected the Patient 5 arrived in the visitation area at 1900 and was picked up for escort back to their unit at 2000. In addition the log showed that three other patients had visitation sessions at the same time and all four of the patients were picked up for return to their units at 2000. 5.c. Video review of the in-person visitation between Patient 5 and their parent on 05/23/2024 that began at ~ 1900 and ended between ~ 1950 and 2000 showed the following: * Initially there was one SS member seated at a table at one end of the café, and two nursing staff members seated at a table at the other end of the café. In between those staff were several round, square, and smaller rectangular tables with chairs grouped closely together for the patients and their visitors. Later during the visitation, a second SS member joined the one seated at the one table, and a third nursing staff member joined the two seated nursing staff members at the other table. The second SS member, the third nursing staff member, and one of the two other nursing staff members were not present in the visitation room at all times during the visitation as they periodically came and went, and the third nursing staff member did not return. There were multiple times when only one SS member and one nursing staff member were present in the visitation room. Periodically throughout the visitation the SS members were observed to direct their attention away from the visitation, face each other, and engage in conversation. Similarly, that was observed between the nursing staff members. At times, both the SS members and the nursing staff members’ attention was observed to be directed away from the visitation at the same time. One of the SS members was observed to talk on a cell phone during the visitation. * It was not clear how staff members were able to visualize and observe the behaviors and actions of all the patients and visitors in the room from their seated positions. For example: One patient, seated at a small rectangular table, whose back was to the nursing staff members, sat directly across from one of their visitors. That visitor’s back was to the SS members seated on the other side of the room. The front of the patient and visitor, their arms when they were on the table, and the table space in between the two of them could not be visualized as those were blocked from staff views by their bodies. * Patient 5 and their parent sat at a round table in the café that had seating capacity for four. During the visitation the two of them were observed to focus attention on their feet under the table, shuffled and fidgeted their feet, looked downward toward the floor and feet, fidgeted with their pants. The SS members and nursing staff members failed to intervene or approach Patient 5 and their parent when they demonstrated those behaviors. Twice during the visitation both Patient 5 and their parent walked together out of the visitation space and down to the end of the corridor to the vending machines. On one of those occasions, the second SS member followed the pair. On the other occasion, it was not possible to observe their behaviors and interactions because of the inadequate camera view described further below. * A second patient who had two visitors sat at another round table that had seating capacity for four. * Although there were three other round tables and a square table each with seating capacity for four, a third patient who also had two visitors sat at a small rectangular table with seating capacity for two, significantly smaller than the round and square tables. One visitor sat directly across the table from the patient while the second visitor sat on a couch that was positioned up against the wall adjacent to the table. Those visitors were the two observed in the main lobby video described under Finding 4.d. above. Eventually during the visitation the second SS member got up from their seat, approached the second visitor, pulled up a chair from the round table next to the rectangular table, and prompted the visitor to sit in that chair at the narrow, shorter edge of the table that was not designed to accommodate a chair. Later during the visitation, the second SS member got up from their chair and walked partway along the perimeter of the room near the center of where the visitation tables were grouped. The SS member looked in the direction of the patient with two visitors that sat at the rectangular table, then turned and walked back away to their seat. In response to that, the second visitor immediately pushed their chair back away from the rectangular table on which they had had their arms positioned. *Neither the first SS member or any of the three nursing staff members approached patients or visitors during the visitation. *Camera views in the visitation café did not capture all parts of patient, visitor, and staff bodies and behaviors. For example: In one camera view only the upper half of Patient 5 and their parent’s body and the lower half of three seated nursing staff members at the other end of the room could be visualized. In the other camera view only the back upper half of two of the nursing staff members bodies were visualized. In both views a patient and a visitor sat directly across from each other while each of their backs directly faced one of the camera views. The front of both of those persons, their arms, and the space in between the two of them could not be visualized. Two other camera views captured the corridor between the café entrance door and the main café area where the visitation occurred. Vending machines were located at the beginning of the corridor just inside the café entrance door. Although patients and visitors were observed to make trips to the vending machine during visitation the camera views provided only partial, barely visible views of the machines and individuals who stood in front of them 5.d. An incident report with incident date and time 05/23/2024 at 1900 was written by a SS member on 05/24/2024 and reflected the following: “On 05-23-2024, around 1900 while assigned to visitation in Kirkbride Cafe with [Mental Health Security Technician (“MHST”)] when [Patient 5] was visiting [their parent] At the beginning of the visit, when [their parent] asked [the patient] how [they were] doing, [they told their parent they were] doing good, that [they] had a lot of money and could go buy $10.00 worth of food a week from the market right there. [Patient 5] further stated that [they] could have $50.00 a week that [they] could draw $30.00 on Tuesday and Thursday and was paid on Wednesday’s [sic]. This was a very odd comment that I have never head in visiting and so I started to watch them more closely. [Patient 5] then glanced at me and asked [their parent] about [their] green shoes, with the short socks. Saying [the patient] really like them and asking where [the parent] got them. They both leaned over and looked at the shoes which [the parent] pointed out things about and them [sic] after a short time they sat up and went and got a pop from the vending machine. There was no other odd behaver [sic] during the visit.” There was no indication that the SS member who wrote this incident report after the patient’s death the following day had intervened at the time of the suspect behaviors, or at that time reported those to a manager or other leader on duty in the hospital who could come to the visitation area to evaluate and intervene as necessary. 5.e. During interview on 05/29/2024 beginning at 1115 and again on 06/05/2024 beginning at 0905 staff confirmed that the hospital had no special required qualifications or training requirements for SS members or nursing staff members who were assigned to monitor the in-person visitation sessions. 6. Review of a document titled “CMS Survey OR50743 Documentation Not Provided” dated as “Last updated 6/13/24” reflected the following in response to surveyors’ requests for the hospital’s written P&Ps and protocols related to visitor screening and patient visitation and revealed a lack of written P&Ps for screening activities and tasks: * In regard to “Security- role/responsibility tied to visitations/is it listed in PD’s or protocol,” the “Reason Not Provided” was “We don’t have any protocols specific to visitation. New wanding/pat down protocols almost ready to deploy alongside skill-based training. New protocols will be launched in the coming week.” * In regard to “Nursing Protocols on screening or visitation,” the “Reason Not Provided” was “We do not have them.” * In regard to surveyor request for “... [Visitor to Patients] policy (8.026) and attachment [Procedures C] references to ‘Screen the visitor and visitor belongings for contraband according to Security Department protocols.’ Please provide those [Security Department] protocols that were in place on and prior to 05/23/2024 ... we’ve asked for this before and were told there were none ... want to further confirm.” The “Reason Not Provided” was “We are working on a protocol now; currently have 3.007 which does not go into detail as to what that searching process is, only that it will happen ...” * In regard to “[Visitors to Patients] Policy 8.026, Procedure C Attachment, references that staff are to ‘Make a reasonable effort to staff the visit in accordance with Nursing and Security Guidelines.’ Please provide the ‘Nursing and Security Guidelines’ that were in place on and prior to 05/23/2024 ... we’ve asked for this before and were told there were none ... want to further confirm.” The “Reason Not Provided” was “... Nursing follows [Policy 6.024 Transportation and Supervision Ratios]. Nursing has no other protocols/guidelines regarding this. Also, Security does not have a current visitation protocol that covers things like staffing and expectations for standard work. We currently have one under construction ...” * In regard to “Security wand maintenance records,” the “Reason Not Provided” was “We do not have them.” 7.a. Review of other incident reports for incidents/events that occurred after Patient 5’s death on 05/24/2024 reflected that contraband and prohibited items were allowed to be in patients’ possession, and demonstrated that investigations of prior contraband related occurrences had not been effective to prevent patients from accessing those. 7.b. Review of the incident log for the period of 05/29/2024 to 06/03/2024 revealed for that five-day period incident reports included the following: * 23 instances “Contraband/prohibited items” * Eight instanced of “Medication diversion” or “Medication found” * Seven instances of “Sexual contact” * Seven instances of “Tools/sharps missing/unattended” * Four instances of “Unattended/Wandering Patient” 7.c. Incident report documentation reflected the following examples: * On 05/24/2024 at 1330 on FW2 a second staff person wrote “Code Orange, Possible Fentanyl spill in [Patient 6’s] clothing ... white powder was found: 1) On the Patients clothes that were in a laundry basket; 2) At the bottom of the laundry basket; 3) On the corner near the laundry basket. Coffee creamer and Splenda packets (Contraband in patients room) was found in the shoes of [Patient 6] that was being stored in the closet.” * In addition for Patient 6, on 05/24/2024 at 1330 on FW2 staff wrote “Patient Possession Prohibited Item ... When searching [Patient 6’s] desk area I found white substance in a laundry basket and on [the patient’s] desk. The substance appeared to be posibly [sic] creamer or splenda ... We finished searching locked the door and notified security.” * On 05/24/2024 at 1300 on FW2 in Patient 7’s room staff found “Patient Possession Prohibited Item ... a suspicious white powder ‘spilled’ on the side table by the bed ... decision made to lock and seal the room and ask for [OSP] to respond to investigate ... [OSP Officer] seized the powder from the table and released the room back to security.” * On 05/24/2024 at 1200 staff wrote “Contraband, Patient Possession Prohibited Item” and during a search in Patient 8’s room “... due to the volume of items the patient has in [their] room ... 3 plastic bookmarks were moved to [the patient’s] long-term storage, and 10 condoms were thrown away.” * On 05/26/2024 at 0949 on FW2 “... a ligature item was found in [Patient 9’s room] ... The item appeared to be 2 white stretchable bands tied onto a pair of patient pants to make the pants tighter.” * On 05/29/2024 at 0800 on Anchors 2 unit @ OSH-Salem (“AN2”) a MHT “... found [a] pill in [Patient 11’s] ... bed ... pharmacist ... informed me that the pill is Depakote ... The Pill is being processed as evidence at this time.” * On 05/29/2024 at 1455 on Mountain 3 unit @ OSH-Junction City (“MN3”) in Patient 12’s room “... on the top shelf hidden behind books, I found a water bottle containing a liquid and fruit. Based on it’s appearance, I believed it to be pruno.” Pruno is also known “prison-wine,” it is a dangerous alcoholic beverage home-made from a variety of ingredients including fruits, hard candy and other ingredients. * On 05/30/2024 at 0930 on FW1 staff wrote “... a strange object was noted on the desk of [Patient 13]. Upon inspection it was observed to be 2 pen casings (outer shells) taped together to make a straw, laying next to what appeared to be a trace amount of coffee creamer.” * On 05/30/2024 at 1755 on Flowers 3 unit @ OSH-Salem (“FW3”) Patient 14 “... was in possession of a rectangular shaped take out plastic dish [they] said [they] picked out a [sic] trash bin when [they were] out in the yard today.” * On 05/30/2024 at 0830 on AN2 in Patient 15’s room staff found “... a clear ziplock baggie sitting on [the patient’s] shelf next to [their] desk.” * On 05/31/2024 at 0830 on AN2 staff wrote “I discovered a latex glove in [Patient 16’s] sink. It appeared to be tied in a knot at the end and had liquid inside it.” * On 05/31/2024 at 0910 on Lighthouse 2 unit at OSH-Salem (“LH2”) staff in Patient 17’s room “... found three white pills on the floor. Nursing identified the pills as depakote [Extended Release].” * On 05/31/2024 at 0930 on Mountain 2 unit @ OSH-Junction City (“MN2”) in Patient 18’s room staff wrote they “found the following contraband: - wire wrapped in paper in an ‘L’ shape bent in the middle; the paper portion appeared to form an inch long handle of sorts leaving about 1 1/4 inch of open wire. Ink residue was visible on the wire portion. It appears that the wire had come from a medical mask. - torn blue fabric hospital blanket and parts of the blanket. A hemmed portion of the blanket had been removed and had been seperated [sic] into two lengths of fabric that were about 12-14 inches in length. - strandard [sic] office pen, not a ‘flexy’ style pen but a hard plastic pen. - ‘voodoo’ style doll made from thread that appears to match the blue color of the torn blanket.” * On 06/01/2024 at 1030 on FW3 an RN wrote that an MHT had seen “... a regular pen (not a patient pen) 6-7 inches long ... fall out of [Patient 19’s] pants pockets from a pair of pants while doing laundry in the laundry room.” The MHT reported that when they told the patient “... that patients are not allowed to have non-pt. pens, that [Patient 19] seemed to be trying to quickly rip off some scotch tape that was on the pen wrapped around a receipt-looking paper that has information on it before handing the pen over to [the MHT].” * On 06/01/2024 at 1800 on Tree 3 unit @ OSH-Salem (“TR3”) “... staff identified contraband tied in a loop, measuring in length of about 20inches [sic], a rope like artifact, ripped from an article of clothing ... Both [Patient 20 and Patient 21] were observed using it as a head band on the crown of their head.” * On 06/02/2024 at 1120 on TR3 staff “... discovered a torn portion of a bra in the possession of [Patient 20].” * On 06/02/2024 at 1155 on FW1 staff wrote that “at approx. 1055 during rounds [Patient 23] was observed standing in the bathroom in [their] room leaned over the window sill with white powder visible on the window sill and a splenda packet standing upright against the window, [their] head was leaned over the window sill with something in [their] hand touching [their] face with it. The staff that witnessed it addressed [Patient 23] and confiscated the splenda packet, when [the patient] brought the packet to the staff it was noted that what was in [their] hand was a rolled up ten dollar bill rolled which looked like a straw.” 7.d. Review of the hospital’s P&Ps regarding contraband and prohibited items included the following: * The P&P titled “Contraband and Prohibited Items” dated 12/18/2017 reflected that “[OSH] will provide a safe treatment environment where items considered to be prohibited are restricted, and items considered to be contraband are not allowed on OSH property unless exempted in this policy ... Contraband is forbidden at all times on OSH property, including in patient-care areas ... Prohibited items are not allowed in patient possession in areas specified on the ‘Prohibited Items’ lists ... [Staff] may not provide prohibited items to a patient outside the provisions of this policy.” * The “Attachment A - OSH Patient Property-Item Access List” dated 07/06/2022 reflected the following items were included on the lengthy list titled “Contraband” or “Prohibited Items: No Access Allowed”: - “Drugs” - “Foil, tin and aluminum” - “Items that are manipulated or altered into something other than original, intended use” - “Non-issued pens/pencils/markers (must be ‘mini’ length)” - “Non-issued tape” - “Plastic bags or plastic wrap” - “Prescription or over-the-counter drugs ...” - “Tattooing ... devices” - “Wire, cables, cords, or rope longer than 9 inches” * The “Superintendent Directive” dated 06/15/2022 reflected it was issued to convey the OSHS’s “directive that, effective July 6, 2022: ... Food may not be stored in patient rooms or in the Patient Property room.” 7.e. Findings for Patients 6, 7, 13, and 23 above in this tag revealed the discovery in patient rooms of white powder substances, and Splenda and dry coffee creamer packets. The documentation was unclear whether the “packets” found were open or closed, and reflected in some cases that white powder substances were speculated to be sweetener or dry coffee creamer. 7.f. During interview at the time of the incident review on 06/04/2024 beginning at 1105 hospital staff present indicated that some patients were known to replicate behaviors of drug “snorting” by using other powder substances as a substitute for the drugs. Staff present were initially not sure whether sweetener and coffee creamer packets were allowed in patient rooms. As the discussion progressed, the DQM and IRSID confirmed that patients could have those in their possession to use during “coffee time” in the milieu, but that no, those condiments were “not allowed in patient rooms.” 8. Refer to the findings for Patient 1 cited at Tag A-145, CFR 482.13(c)(3), Standard: Freedom from Abuse. Those findings reflected that the hospital failed to conduct a clear and complete investigation of the unexpected death of Patient 1 that identified and addressed all potential gaps, and further failed to implement corrective actions it had planned to address gaps it did identify. The failure to conduct complete investigations or implement corrective actions contributed to an unsafe environment and created risk of potential harm for other patients. ****************************************************** 29708”

“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: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and patient care documentation for 19 of 23 patients (Patients 1, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23), review of P&Ps, review of hospital directives, review of equipment inventory lists and manufacturer’s instructions, and review of OSH internal investigation and corrective action plan documentation, it was determined that the hospital failed to ensure each patient’s right to be free from all forms of abuse and neglect. Prevention of, identification of, investigations of, and response to, incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur for the hospital’s vulnerable psychiatric patients. Failures included: * For Patient 1, failure to conduct and provide clear and complete investigation to identify and address all evident gaps and findings, and to document the analysis of those gaps and findings to reflect whether all potential concerns were substantiated or not. * For Patient 1, failure to implement the corrective actions planned as result of internal investigation findings. * Failure to prevent patient harm and potential harm as result of failures to provide care and services necessary to prevent the presence of contraband and prohibited items, and to assess, observe, and monitor patient condition and location. The CMS Interpretive Guidelines 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 Guidelines reflect those 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 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. Tag A-145 is a repeat deficiency previously cited on complaint surveys completed on 01/17/2022, 08/01/2022, 11/17/2022, 10/05/2023, and 03/14/2024. Findings include: 1.a. Interview with staff that included the CMO/Interim OSHS, the DQM, DSC, and IRSID on 05/30/2024 at ~ 1635 during review of patient deaths that had occurred at the hospital in 2023 and 2024 revealed that: * Patient 1 unexpectedly died on the FW2 Unit on 11/02/2023. * The patient was in a closed seclusion room at the time of their death. * During a “medical situation” the patient started having psychotic symptoms and requested to go into seclusion. * The hospital had reported the death to CMS by means of the electronic submission required for deaths associated with restraint or seclusion. 1.b. On 05/30/2024 surveyors requested incident and investigation documentation related to Patient 1’s 11/02/2023 unexpected death. The following documents were provided: * One incident report #66633 written by an RN on 11/02/2023 * Copy of an electronic form titled “CMS Report of a Hospital Death Associated With The Use of Restraint Or Seclusion” dated as submitted to CMS on 11/03/2023 at 1426. * Form CMS-10455 titled “Report of a Hospital Death Associated With Restraint Or Seclusion” 2. On 06/11/2024 at 1613 surveyors sent OSH an email with a request for the incident, internal investigation, and follow-up documentation. The email specified: * “Regarding 11/02/2023 [Patient 1’s] death: - All incident investigation and corrective actions taken - All restraint and seclusion documentation - All medical record documentation for October and November 2023 - Patient’s Treatment Plan in place for October and November 2023 - Code documentation - More will be requested as needed.” 3. On 06/13/2024 beginning at ~ 1220 with staff that included the CMO/Interim OSHS, Interim DS, DQM, DSC, COM (“Chief of Medicine”), Medical Clinic Manager (“MCM”), and AAG the following information was provided: * The DQM stated the hospital did a CADM investigation and an Root Cause Analysis (“RCA”) investigation for Patient 1’s 11/02/2023 unexpected death. * Investigation “action items” were submitted to the hospital’s Accreditation Organization (“AO”), the Joint Commission, on 01/10/2024 and “approved” on 02/20/2024. Staff stated that the Joint Commission “sets the schedule for RCA events and follow-up.” * The patient’s symptoms were “distressing” and included auditory hallucinations that were difficult to manage. The patient took medications that caused weight gain. The patient had sleep apnea and other diagnoses. * On 10/13/2023 the patient was seen in the hospital’s medical clinic for complaints of shortness of breath. Cholesterol medications were started, and a cardiac referral was made. * There were no medical clinic progress notes written for the visit at that time. * Diagnoses related to the patient’s medical conditions were not updated in their medical record. * Regarding the incident on the morning of 11/02/2023, staff provided a high-level summary of the events surrounding the patient’s death that included: the patient walked up to the NS and reported they had difficulty breathing, they fell on the floor, and bumped their head. Nursing staff members responded, took vital signs, and got a chair for the patient. The patient had a history of “somatic symptoms.” The patient got up and made threatening statements and requested seclusion. Staff helped the patient walk to seclusion and the patient fell onto their knees at the threshold of the seclusion door. The patient laid in a prone position on the floor. Staff moved the patient so the door would shut. The patient requested the seclusion room door be locked. The patient was rocking their head and rolling on the floor. The patient rolled onto their side, then stopped moving. Staff tried to wake the patient, the patient did not respond, a code was called and staff began resuscitation efforts, EMS responded, resuscitation efforts were not successful and Patient 1 died. * Gaps identified and corrective actions planned in conjunction with the Joint Commission as result of the hospital’s investigation were related to medical clinic integration with care plans, communications between the medical clinic and inpatient unit, and standardization of medical guidelines for patients with metabolic syndrome. Those corrective actions plans were to be implemented by March 2024. * The DQM stated there were no findings or corrective action related to nursing. Nursing response to the patient’s medical concerns in light of the patient’s psychiatric symptoms was considered and discussed with nursing leadership but was not a causal finding. 4. On 06/13/2024 the following documents related to Patient 1’s death were provided to the surveyors. Those did not include all of the documents requested on the 06/11/2024 email to the hospital specified under Finding 2 above: * A “CADM Questionnaire Report_Redacted final,” nine-page document titled “Clinical Administrative Debrief Meeting Process Questionnaire & Executive Report,” that had a last date of 11/09/2023. * A “ReportandActionItem_Submission_FINAL,” 38-page document titled “ALT-0 Summary Report for Sentinel Event Number 445710” that had a footer date of 01/10/2024 at the bottom of each page. There were no other dates that reflected completion of the document. * “[Attorney Client Privilege] Work Product Inc#445710 ... unexpected death” that was an email dated 03/19/2024 at 1720 from hospital staff to the hospital’s AO, the Joint Commission, regarding a 02/20/2024 conference call discussion related to Patient 1’s death incident corrective actions. * Three “Clinic Protocols”: - “Metabolic Syndrome Practitioner Care” dated as “New” on 02/20/2024. - “Medical Clinic Provider Documentation Standards” dated as “New” on 03/14/2024. - “Clinical Practice Guideline for Metabolic Syndrome” that was not dated. * “Rolling Monthly Averages, Note Submissions,” undated, one-page audit results document titled “% of Medical [Primary Care Provider (“PCP”)] OnTime Note submission.” * Seven documents related to Code Blue training and staff attendance. 5. The CADM with a final date of 11/09/2023 was reviewed. It reflected the following: * The following sections of the report were fully redacted: - “What potential immediate actions, if any, should be considered to reduce the risk of recurrence?” - “What communication and/or training needs are recommended?” - “[Clinical Advisory Team (“CAT”)] CADM Report Review Summary” * “Information sources included ... chart notes, and 19 incident reports.” * Other referenced documentation that was not provided included the “seclusion entry note” and the on-call physician’s documentation and note. * In the CADM section for “Did this event identify potential gaps in care/treatment?” the only response was “Medical clinician documentation: there was inadequate documentation of treatment and diagnosis following an appointment for complaints of chest pain on October 13. Diagnosis of hyperlipidemia was not updated in the chart and there was no treatment note. Patient did receive appropriate care and follow up and was placed on medications. Related to this, the [Treatment Care Plan (“TCP”)] was not updated to reflect new medical problem.” 6.a. The RCA or “Report for Sentinel Event Number 445710” that was dated 01/10/2024 was reviewed. It reflected “Patient is a [age] African American [gender] admitted to [OSH] on 12/22/2016 ... This was the patient’s fourth admission ... due to [the patient’s] ongoing severe psychiatric symptoms which consisted of auditory hallucinations (often of [one of their family members], which could be command in nature to harm [themselves] or others), paranoid delusions, intermittent agitation and physical aggression. [Patient 1] had undergone numerous medication trials to target [their] psychiatric symptoms. [Their] symptoms had improved over time but had continued to be quite prominent and highly distressing to the patient. Providing medications to treat [their] psychiatric symptoms was quite challenging due to [their] reluctance to agree to changes in [their] regimens as well as the patient experiencing significant side effects from the medications. Side effects included marked weight gain, prediabetes/insulin resistance, deconditioning, sleep apnea, and hyperlipidemia. When experiencing auditory hallucinations of [their family member], [they] often would take on the persona of [their family member] and at times could be highly assaultive resulting in serious staff injury. As a result, one element of [the patient’s] treatment care planning was that if the patient asked to be placed in locked seclusion, [they were] allowed to do this as it was a way [they] would keep [their self] and others safe.” 6.b. The RCA reflected “analysis” of the following four of 24 “items” : * “Question: 14. To what degree was all the necessary information available when needed? Accurate? Complete? Unambiguous? Organization Response: No process for Medical Clinic integration into treatment care planning.” * “Question: 15. To what degree is communication among participants adequate for this situation? Organization Response: No process developed for communication between unit and Medical Clinic.” * “Question: 20. What are the barriers to communication of potential risk factors? Organization Response: refer to Question #15.” * “Question: 21 . How is the prevention of adverse outcomes communicated as a high priority? Organization Response: No standardized medical guidelines for the care of patients with metabolic syndrome.” * The RCA included three “Root Cause Details ... Plan of Action ... [Measures of Success (“MOS”)]” for three “items” identified in Questions 14, 15, 20, and 21. Refer to Findings 19.a. through 19.e. below that reflect those action plans had not been implemented as of the date of this survey. * There was no analysis or organization response to the other 20 items. 7. The email dated 03/19/2024 at 1720 from hospital staff to the hospital’s AO, the Joint Commission, regarding a 02/20/2024 conference call discussion related to Patient 1’s death incident corrective actions was reviewed. The email reflected the hospital’s three actions plans identified in the RCA had been re-stated (Refer to Findings 19.b. through 19.d. below) and a fourth action plan had been added. The fourth action plan was that the hospital would “offer at least 8 Code Blue drills throughout the year to the nursing staff during the regularly scheduled Code Green [response to a behavioral emergency] Drills, focusing on providing necessary medical care to aggressive or potentially aggressive patients. The first combined drill (Code Blue + Code Green) will be completed by 04/15/2024. MOS is implementation of this item to our calendar of drills. Frequency will be once a quarter on each of two campuses. Responsible Organization Leader is CNO.” 8.a. On 07/03/2024 at 1405 the survey exit conference was conducted. Staff present included the CMO/Interim OSHS, the Interim DS, the DQM, DSC, CNO, AAG, DOS, IRSID, and others. During the exit conference preliminary findings for the survey, including related to Patient 1’s death based on the information provided by the hospital to that point, were shared with the hospital staff. Those preliminary findings included potential gaps evident during surveyors’ review of the internal investigation documentation provided by the hospital, that was also found to lack references to those potential gaps. 8.b. Hospital investigation event timelines showed that on the morning of 11/02/2023 while the pt stood at the medication window their legs buckled and they subsequently fell to the floor and complained of trouble breathing and chest pain. Staff responded to the patient and ~ 15 minutes later they were walked into the seclusion room. Upon entry to the seclusion room the description of the pt’s condition at that time included that their “skin normal but clammy; difficulties with respirations/speaking; Obvious signs of physical distress: Reports [they] can’t breathe, had chest pain, kept repeating ‘I feel like I’m going to die.’” ~ six minutes later staff entered the room and then left. ~ eight minutes later the patient stopped moving. ~ two minutes later staff responded and did sternal rub with no response. At 0754 Code Blue was initiated and CPR started at 0755. Resuscitation efforts continued, but EMS was not called for ~ seven minutes after the code was called, at 0801. EMS arrived and the pt was pronounced dead at 0845. 8.c. There was no documentation in the investigation documents provided to reflect that nursing staff member practices and management of the patient’s change of condition had been evaluated by the hospital to determine whether response to and assessment of the patient’s change of condition was timely and appropriate. That includes a gap of several minutes between the time of observation of the patient in seclusion with obvious physical distress and the time they stopped moving, and a gap of several minutes from the time a code was called to the time EMS was called. The only gaps identified by the hospital’s investigation were related to medical staff visits and documentation practices 8.d. On 07/03/2025 at the end of the exit conference, in response to the hospital’s assertion that some of the preliminary findings related to the hospital’s investigation of Patient 1’s death were unfounded, the hospital was provided an opportunity to submit additional information it believed was pertinent to the incident. They were reminded that the surveyors had made prior requests for all incident, investigation, follow-up, and corrective action documentation related to Patient 1’s unexpected death, including that all investigation documentation referenced in the CADM had also not been provided such as “... chart notes, and 19 incident reports.” 9. On 07/05/2024 the following documents related to Patient 1’s death and the hospital’s investigation, previously requested by surveyors, were provided: * 18 incident reports related to events and circumstances around Patient 1’s death on 11/02/2023, including the one solely provided to surveyors on 05/30/2024. * Nine pages of “Progress Notes 11-2-2023” written about Patient 5’s death by five nursing staff members. * “[Psychiatric Security Review Board (“PSRB”)] Hearing Notes” titled “Psychiatry PSRB Update Note dated 02/07/2023 * “Risk Review-Forensic” dated 08/24/2023 * “Forensic Risk Review” dated 08/25/2023 * “Treatment Care Plan” dated with “Plan Date” of 10/17/2023. * Fourteen pages of 11 “Patient Progress Notes” written by RN and medical staff members from 06/30/2022 through 11/01/2023 * 29 incident reports for 21 incidents that occurred between 07/17/2022 and 11/01/2023. 10. Review of Patient 1’s 10/17/2023 “Treatment Care Plan” revealed the following: * “Psychiatric - [Patient 1] has a psychiatric diagnosis of Schizoaffective disorder, bipolar type, and [they attribute] these voices with an inability to control [their] violent impulsive behaviors. Historically, [the patient] states that [they continue] to hear voices even after multiple medication trials. [The patient] has expressed a desire to maintain safety and move forward in their treatment with a short-term goal of moving to a lower acuity program of care and earning privileges after meeting with the PSRB.” * Patient 1 “attended [their] 30 day treatment team meeting. [They] shared [they were] doing ‘good.’ ‘My left leg hurts.’ ‘I’m kind of getting use [sic]to it.’ (Medications for cholesterol) Regarding interactions with peers, ‘I’m just minding my own business.’ Family visits are ‘good.’ [They] questioned ‘Are we still taking me down from that Zoloft?’ [They are] open to submitting an application for patient paid employment. [Their] personal goals include obtaining a degree in ‘psychology.’ [They have] ‘no’ thoughts to harm [themselves] nor others. Regarding symptoms, ‘First thing in the morning I hear the voices.’” * Patient 1 “is doing well. [They are] medication adherent. [They] partially [attend] social dining and will get a clamshell if [they choose] to eat on the unit. [They enjoy] engaging in valued therapeutic treatment activities such as music therapy, watching movies on [their] tablet, supported education, emotional wellness and fitness. [They engage] in 1: 1 assessments with clinical staff when requested.” * “Moderate risk of violence - Progressing - [Patient 1] has a history of physical assaults to staff and peers. [They state] that voices and command hallucinations create an inability to control impulses to physically assault others. [The patient] has been able to remain violence free for a satisfactory a [sic] period of time such that [their] need to have enhanced precautions has been discontinued and [they have] expressed a desire to remain safe and has a goal of moving forward to a lower acuity program of care and working with the PSRB to gain privileges which are currently on and off ground privileges with staff supervision.” * “RN and unit nursing staff will allow and encourage the use of the [seclusion] room for [Patient 1], as needed for reducing the risk of aggression and to allow [them] to feel safe when [they are] having trouble with urges to be physically aggressive to others ... After 9 p.m., if [they are] having significant overt symptoms causing milieu disruption staff will ask [them] to use the [seclusion] room. 1. If [Patient 1] requests to use unlock [sic] seclusion, nursing staff will let [them] in without asking questions. 2. If [Patient 1] requests to be locked in seclusion, nursing staff will lock [them] in without questions and tell RN. RN will follow seclusion and restraint procedures.” * Patient 1 “made homicidal threats 10/11/23 and requested to go to seclusion.” * “PSRB - Privileges - Risk Review approved the privileges of 2: 1 on-grounds and 2: 1 off-grounds for medical; all of these privileges must be supervised by at least one familiar staff. This approval was based on [Patient 1’s] notable improvements over the past months, including medication adherence, actively coping with known triggers, proactively requesting the [seclusion] room for safety, engaging in individual treatment, and [their] [Interdisciplinary Team’s (“IDT’s”)] familiarity with [the patient’s] risks and mitigation.” * “Other things that are important to my health (items stable with treatment) - [Patient 1] has multiple medical concerns including chronic pain, asthma, and metabolic syndrome, which are all being managed with routine care and tracked by medical clinic.” During the 10/17/2023 treatment plan session the patient complained that their “left leg hurts.” That was three days after the 10/13/2023 medical clinic appointment for which no progress notes were written. There was no indication in the treatment plan documentation that the patient’s left leg pain had been assessed or evaluated on 10/17/2023 or thereafter. 11. Review of the 29 incident reports for 21 incidents/events between 07/17/2022 and 11/01/2023 revealed the following that supported the behavioral evaluation in the Treatment Care Plan dated 10/17/2023: * Patient 1 had not assaulted other patients or staff since 02/03/2023. * On four occasions between 12/19/2022 and 02/03/2023 Patient 1 assaulted staff persons. * On seven occasions between 07/24/2022 and 01/08/2023 Patient 1 assaulted or was involved in physical altercations with other patients. * On three occasions between 10/28/2022 and 11/01/2023 Patient 1 hit themselves or banged their head against a wall. * On seven occasions between 07/17/2022 and 12/09/2022 Patient 1 requested to go to the seclusion room for reasons the patient stated that included “before [they hurt] anyone” and “voices are telling [the patient] to attack someone and that’s the only way to prevent it.” * The 10/11/2023 seclusion event referenced in the TCP under Finding 10 above was not included in the incident reports provided dated from 07/17/2022 through 11/01/2023. 12.a. On 07/12/2024 at 1305 surveyors met with hospital staff that included the CMO/Interim OSHS, the Interim DS, the DQM, DSC, CNO, AAG, and others to review the preliminary findings related to the review of the investigation documentation provided through 07/05/2024. Again, those findings included potential gaps evident during surveyors’ review of the internal investigation documentation provided by the hospital, that was also found to lack references to those potential gaps. For example: 12.b. An RN Progress Note written by [RN 13] on 11/02/2023 reflected that “At 0730 [Patient 1] came to medication window for [their] morning medications. At the window [they] stated ‘I can’t breathe. I feel like I can’t breathe.’ Patient then slumped onto the ground. This RN ran around the window to talk to patient. Patient was awake and alert per [their] norm, but lying on the ground on [their] back. [They] stated, ‘I just feel like I can’t breathe’ ... [Another RN] called the [On-Call Doctor (“OD”)] and requested they come to the unit to assess the patient due to complaints of chest pain and shortness of breath” ... [Patient 1’s] vitals were [Blood Pressure (“BP”)] 120/78, 02 was 90%, pulse 97. While obtaining vitals, 02 went up to 98% “... Assisted patient to lie on the ground. After a few moments, patient sat up and stated that [they] wanted to go the [seclusion] room and then started talking as if [they were their family member]. As [their family member they] said ‘you go to the [seclusion] room or punch everyone’ ... At one point the [Unit Administrator] walked onto the unit and patient stated ‘you’ve hit old [people] before. Hit that old [person].’ [Unit Administrator] walked away from patient and patient voiced that [they] wanted to walk into the [seclusion] room.” The note continued, reflected patient was assisted to the seclusion room and at ~ 0742 an RN “called OD again requesting that they come to see patient, again reporting that patient was complaining of shortness of breath and chest pain. A few moments later the staff in the [seclusion room] anteroom requested RN to come assess. 0753 This RN walked into the [seclusion] room and patient was lying on the ground on [their] side. [Patient 1] was not responding to voice. This RN pushed patient over onto [their] back and performed sternal rub while directing staff to grab a crash cart. A code blue was called at 0754. Staff started to respond. Patient opened [their] eyes and was breathing but lips were pale. There was a pulse initially but patient’s eyes rolled back into [their] head while waiting for the crash cart. Another RN entered the room and compressions were started at 0755 ... Three rounds of epi 0.3 [milligrams (“mg”)] were given [Intramuscular (“IM”)] left thigh per [DO 11], [Epinephrine (“Epi”)] given 0802, 0805, 0808 per instructions over the course of the code without effect. EMS called at 0801.” 12.c. Another RN’s Progress Note written on 11/02/2023 reflected that that the RN was connected with a physician on the phone and that they reported to the physician the patient had fallen and the vital signs taken. Another RN “called on call doctor again and requested that they come see patient, again reporting that patient was complaining of shortness of breath and chest pain.” Another physician was also notified by the RN of the event and per that physician the RN was directed to “call on call provider and have them see pt; on call provider notified of this request to see pt.” The note reflected that “pt stated to [themselves] ‘You’re going to die in here’”. 12.d. An MHT Progress Note written on 11/02/2023 reflected that when [Patient 1] complained of “difficulties breathing” at the NS window, the “[RN 13] grabbed the vital machine and started taking vitals. [The RN] had to do manual Blood Pressure Check ...” Further, the note reflected that the RN was “reassuring” the patient that “the On Call doctor was being notified.” 12.e. An “Emergency Seclusion Or Restraint Entry Note” was reviewed. The only staff name/signature was [RN 13] who wrote the progress note above. It was dated as signed by [RN 13] on 11/02/2023 at “0745.” The note reflected the following: - Differences in ink color and differences in handwriting reflected at least two staff’s entries on the form, and possibly three. Not all of those different entries had been signed and dated and timed. - The date and time the patient was placed in seclusion was not documented. - It was not clear if the vital signs on the form were the ones taken at the NS after the patient’s fall, or had been taken and reassessed during the time the patient was in seclusion. - Patient assessment information on the form reflected: “BP 120/78 ... Pulse 97 ... [Respiratory Rate Unable to obtain]” “Skin integrity: [Normal] ... Clammy” “Difficulties with respirations or speaking? [Yes]” “Obvious signs of circulatory compromise? [No]” “Obvious signs of injury or skin integrity issues? [No]” “Obvious signs of physical distress? [Yes]” “Reports [they] can’t breathe, has chest pain, kept repeating ‘I feel like I’m going to die’” “Patient’s mood, affect, mental status, response to emergency measures, and any significant findings from physical assessment: Patient talking as though [they were their family member] saying [they] couldn’t breathe, ‘I feel like I’m going to die’ and then alternating with ‘Go to the [seclusion] room or punch everyone,’ and made threats against [Unit Administrator] saying ‘you know I’ve made you hurt old [people] before. Hit that old [person].’” “Criteria for Release: ... Unable to discuss Patient in seclusion per request while awaiting OD to come assess further Code blue intiated [sic] at 0754 - See notes Seclusion ended at 0754.” “RN Exit Note After Release of Patient ... Seclusion ended at 0754 due to code blue. Pt expired 0845 per EMS” 12.f. The notes referenced under Findings 12.b., 12.c., 12.d., and 12.e. above raised questions about the following: * Timeliness of the on-call physician’s response to nursing staff members requests for the physician to come to the unit to see the patient. * There was no documentation of a second set of vital signs after the ones taken at the NS shortly after “0730” before the patient went into seclusion. The vital signs recorded on the Seclusion Entry Note are duplicative of those recorded in the progress notes taken at the NS. There is no evidence that vitals were taken while the patient was in seclusion and experienced further change of condition. Further the description of the patient’s threats against the Unit Administrator had occurred outside of the seclusion room. * Timeliness of the EMS call ~ seven minutes after hospital staff found the patient unresponsive and initiated CPR. * Why the RN “had to do” a manual BP check even though they had “grabbed the vital machine.” Was the vital machine not working, or broken? There was no documentation in the investigation information provided to reflect that those potential gaps had been evaluated and analyzed to determine whether there were opportunities for improvement and if corrective actions were indicated to prevent recurrence. 12.g. During the review on 07/12/2024, hospital staff confirmed that all of the potential gaps discussed during the review, including those identified above, had either not been investigated or that analysis of the potential gap had not been documented. During that review hospital staff disclosed that there was other investigation documentation of Patient 1’s death that had still not been provided, for example: Staff interview notes. This in spite of previous surveyor verbal and written requests for all of the incident and investigation documentation. The hospital was given yet another opportunity to submit that documentation by the end of day on 07/12/2024. 13. On 07/12/2024 at 1644 the DQM sent an email that stated: “OSH is in the process of providing the following documents, which will be uploaded to the shared drive by Monday morning ... - Interview notes from the RCA. - Provider notes associated with the event. - Incident reports associated with the event and pertaining to typical patient behavior that influenced staff response during this event. - Documents associated with the investigation, with the exception of those protected under Attorney Client Privilege. - Written description of this RCA process.” This email further reflected that all investigation documentation was not provided and the hospital had determined to make its own “exception” to the SA’s request. 14. On 07/12/2024 at 1710 the DSC sent an email that stated the investigation documents had been submitted and consisted of the following incident and investigation documentation related to Patient 1’s death incident. Those documents included significant previously requested documentation that had not been provided such as all investigation documentation, including the seclusion note requested on 06/11/2024 as described under Finding 2 above: * “[Seclusion-Restraint (“S-R”)] Entry,” one-page document titled “Emergency Seclusion or Restraint Entry Note” dated 11/02/2023. * Four pages of “Provider Progress Notes - 11.02.23” written by Medical Doctor (“MD”) 10, DO 11, and MD 12. * “Written description of RCA Process,” three-page undated document titled “RCA.” * Fourteen untitled “Investigation Notes” 1 through 14. * Six untitled “Documents associated with the investigation” were provided, however, it was unclear what the relevance of many of the documents was to the hospital’s internal investigation and the SA’s request: - An untitled 50-page document provided included an 11/02/2023 video timeline, Patient 1’s death certification, and chart progress notes not in chronological order from 2016, 2017, 2018, 2019, 2020, 2021, and 2022. The relevance, for example, of chart notes back as far as 2016 was unclear. - An untitled 100-page document provided also included an 11/02/2023 video timeline, Patient 1’s death certification, and chart progress notes not in chronological order from 2016, 2017, 2018, 2019, 2020, 2021, and 2022. - An untitled 102-page document provided included chart progress notes for Patient 1 not in chronological order from 2019, 2021, 2022 and 2023. Those included a “Medical Doctor/[Nurse Practitioner (“NP”)]” progress note written on 11/07/2023, five days after Patient 1’s death, for “Date of Service: 10/13/2023,” the date of the medical clinic visit for which a note had previously not been written. - An untitled 128-page document provided included chart progress notes for Patient 1 from 2018, 2019, 2020, 2021, 2022, and 2023. - An untitled 126-page document provided included assessments, and 51-pages of “Lab Results” for Patient 1 from 2017, 2018, 2019, 2020, 2021, 2022, and 2023. The relevance, for example, of lab results back as far back as 2017 was unclear. - An untitled 164-page document provided included “Unit Nursing Shift to Shift Report” forms, chart notes, Treatment Care Plans, incident reports (most of which were duplicative), historical enhanced supervision orders from 2022 and 2023, 29 pages of “Diagnosis” lists from 2022 and 2023, History & Physical (“H&P”) documentation from 2021. The document also contained seclusion/restraint event documentation for at least nine other patients. The relevance, for example, of “Diagnosis” lists back to 2022 and of seclusion/restraint documentation for other patients was unclear. * “Code Blue Medical Emergency” P&P dated 01/21/2020 was provided. 15. The “Medical Doctor/NP” progress note written on 11/07/2023, five days after Patient 1’s death, for “Date of Service: 10/13/2023” reflected “Subjective: Complaint of chest tightness, shortness of breath, some chest pain. Uses inhaler on unit. Symptoms are sporadic. Not necessarily associated with increased activity. The chest tightness/pain is new. Has not had at rest. The discomfort is fleeting. Chest discomfort does not radiate. No nausea associated with the chest discomfort. Denies palpitations, cough or [Dyspnea on Exertion (“DOE”)] ... Assessment/Plan: 1. Chest pain/[Shortness of Breath (“SOB”)] symptoms worrisome in a patient who is morbidly obese and has metabolic syndrome, hyperlipidemia and is not taking a statin. Discussed this with patient. Discussed diet. Patient consented to start taking statin. Discussed potential side effect of muscle pain and to let me know if that happens. Will plan on check fasting lipids and hepatic panel in six months. Agreed to Cardiology referral.” The note was signed and dated by an NP on 11/07/2023 at 1433. 16. Review of Patient 1’s “State of Oregon ... Certificate of Death” that was “issued” on 11/13/2023 reflected “Cause of Death” was “Bilateral Pulmonary Thromboemboli ... due to ... Venous Thromboembolism.” 17. Further, the investigation documentation provided multiple different timelines for the same events referenced by the hospital. Event timelines the CADM, the RCA, progress notes and Seclusion Entry note did not align. Although the hospital acknowledged those discrepant timelines, they failed to clearly rectify/clarify those as part of its investigation which further contributed to the unclear and disorganized internal investigation documentation that was provided by the hospital in parts on multiple dates, and included hundreds of pages of notes dating back to 2016 for which the relevancy was unclear. 18. During the 06/13/2024 review beginning at ~ 1220 with staff that included the CMO/Interim OSHS, Interim DS, DQM, DSC, COM, MCM, and AAG the following information was provided: * Gaps identified and corrective actions planned in conjunction with the Joint Commission as result of the hospital’s investigation of Patient 1’s death were related to medical clinic integration with care plans, communications between the medical clinic and inpatient unit, and standardization of medical guidelines for patients with metabolic syndrome. Those corrective actions plans were to be implemented by March 2024. 19.a. Review of the corrective action plans that were developed revealed a lack of documentation to reflect that all of those plans had been implemented. During interview at the time of the review on 06/13/2024, none of the hospital, physician, or quality leadership staff present were aware of, had been tracking, or could confirm whether all of the audits planned to be started in March 2024 had been conducted. There was speculation that an absent physician had related documentation but would not return to the hospital until the following week of 06/17/2024. As of 07/12/2024, the final date provided for the hospital to submit additional information, no additional information related to implementation of the action plans had been provided. For example: 19.b. Corrective action plan one was that the “Medical Clinic Nurse Case Managers will screen all current OSH patients to identify any who are diagnosed with 3 or more conditions meeting the criteria for metabolic syndrome who do not currently carry that diagnosis. This will be a 100% patient audit, so MOS is that the audit is complete. Target date for completion is March 30, 2024. Responsible Organization Leader is CMO.” There was no documentation or evidence that those audits had been conducted and the action plan implemented. 19.c. Corrective action plan two was to “Develop and implement standard work for provision of PCP services, including requirements for timing and frequency of on-unit and in-clinic patient visits, communication with unit nursing staff and IDT, and collaboration with clinic staff and covering practitioners. MOS is weekly audit of 50% of PCP notes expected based on records of patients seen, looking for identification of who the PCP spoke to about the assessment and plan. Target: 90% of notes have documentation of who PCP spoke to as required. Responsible Organization Leader is CMO.” Correction action documentation revealed that a new protocol for “Medical Clinic Provider Documentation Standards” was dated as approved on 03/14/2024 and included timelines for notes submission, and other content requirements. Review of the “% of Medical PCP OnTime Note submission” audit summary only reflected final % of compliance information for timely submission of medical staff notes. There was no audit information for any of the other aspects of corrective action plan two. The audit summary form additionally contained a “Note” that reflected “It was unclear if the patients scheduled were seen and not documented, if the patient refused, or if the patient was seen and not documented on.” During the 06/13/2024 review medical staff present stated that there was no expectation that medical or nursing staff document when patients refuse medical visits. In that case it was unclear how the hospital would audit whether the frequency of on-unit and in-clinic visits for patients met the standards. Further, documentation of patient response to all care and services, including their refusal of care and services, is required. 19.d. Corrective action plan three was to “Develop and implement clinical practice guideline for management of patients with metabolic syndrome diagnosis. Target: 90% of patients diagnosed with metabolic syndrome received care per guideline. MOS is completion of clinical guideline. Responsible Organization Leader is CMO.” Although the documentation reflected that the hospital had developed the clinical practice guidelines, there was no documentation or evidence that the audits to determine whether patients diagnosed with metabolic syndrome had received care per the guideline. 19.e. During interview at the time of the review on 06/13/2024 staff, including the DQM, confirmed the lack of evidence of corrective action plan implementation. 20. Refer to Findings 1.a. through 6 cited at Tag A-144 under CFR 482.13(c)(2), Standard: Privacy and Safety. Those findings reflect that the unexpected death of Patient 5 on 05/24/2024 was likely related to drug contraband provided during a patient visitation session and that staff failed to observe and monitor the patient’s condition to ensure they were alive and breathing. Findings 7 under that Tag further reflected contraband and prohibited items were found in patients’ possession for 16 other patients (Patients 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, and 23) after 05/24/2024 and that placed those patients at risk for harm. In addition, Findings 1.i.iii. under that Tag reflected that Patient 22 was not observed and monitored and was found in an unauthorized room with opposite gender patients after 05/24/2024 and was also placed at risk for harm. Those findings reflect that the hospital failed to prevent such occurrences as part of its abuse protection of patients. ****************************************************** 29708”

“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: 08621 ****************************************************** Based on interviews, review of incident and patient care documentation for 1 of 1 patient (Patient 1), review of P&Ps, and review of OSH internal investigation and corrective action plan documentation it was determined that the hospital failed to ensure that incidents and adverse patient events were clearly investigated and analyzed, and that corrective action plans it developed were implemented, to prevent recurrence of such events, to promote learning throughout the hospital, and to establish clear expectations for the safety of the hospital’s vulnerable psychiatric population. Tag A-286 is a repeat deficiency previously cited on complaint and revisit surveys completed on 01/17/2022, 08/01/2022, and 03/14/2024. Findings include: 1. Refer to the findings for Patient 1 cited at Tag A-145, CFR 482.13(c)(3) - Standard: Freedom from Abuse, that reflects the investigation of the unexpected death of Patient 1 was unclear and incomplete. All potential gaps or concerns evident in documentation related to Patient 1’s death had not been analyzed to determine whether corrective actions were indicated, and corrective actions planned to address gaps that had been identified had not been implemented. ****************************************************** 29708”

“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: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and patient care documentation for 18 of 23 patients (Patients 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23), review of P&Ps, review of hospital directives, and review of OSH internal investigation documentation, it was determined that the RNs assigned to the provision and supervision of patient care failed to ensure that each patient’s nursing and safety needs were met by ongoing assessment, observation, and monitoring, including in response to patient change of condition; and that all other nursing personnel provided care and services in a manner that ensured the ongoing health and safety of the hospital’s vulnerable psychiatric population. Tag A-395 is a repeat deficiency previously cited on complaint and revisit surveys completed on 01/17/2022, 08/01/2022, 11/17/2022, 10/05/2023, and 03/14/2024. Findings include: 1. Refer to the findings cited at Tag A-144 under CFR 482.13(c)(2) - Standard: Privacy and Safety. Those findings reflect the failures of the nursing department and personnel to ensure: * Situational awareness and diligent assessment, observation, and monitoring of patient condition and status, including whether patients were alive and breathing for Patient 5 as described in Findings 1.a. through 1.j. * Situational awareness and diligent observation and monitoring of patient and visitor behaviors and interactions during in-person visitation sessions to prevent the passing of drugs and other contraband from visitor to patient for Patient 5 as described in Findings 2.a. through 2.c., and 5.a. through 6. * Situational awareness and diligent observation and monitoring of patient location to ensure patients were not in unauthorized areas for Patient 22 as described in Finding 1.i.iii. * Failure to prevent the recurring presence of, and patient possession of, drugs and other contraband for Patients 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, and 23 as described in Findings 7.a. through 7.f. ****************************************************** 29708”

“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: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and patient care documentation for 17 of 23 patients (Patients 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, and 23), review of P&Ps, review of hospital directives, review of equipment inventory lists and manufacturer’s instructions, and review of OSH internal investigation documentation, it was determined that the hospital failed to ensure the provision of a safe EOC that was maintained to minimize security and safety risks for the hospital’s vulnerable psychiatric population. Tag A-701 is a repeat deficiency previously cited on complaint and revisit surveys completed on 01/17/2022, 08/01/2022 and 11/17/2022. Findings include: 1. Refer to the findings cited at Tag A-144 under CFR 482.13(c)(2) - Standard: Privacy and Safety. Those findings reflect the failures of the security department and personnel to ensure: * Diligent and consistent registration/check-in of visitors prior to in-person patient visitation sessions as described in Findings 3.a. through 3.e. * Diligent and consistent screening of visitors prior to in-person patient visitation sessions to prevent the entry of drugs and other contraband into the hospital, and to prevent the passing of those from visitor to patient for Patient 5 and others as described in Findings 2.a. through 2.c., 4.a. through 4.h., and 6. * Situational awareness and diligent observation and monitoring of patient and visitor behaviors and interactions during in-person visitation sessions to prevent the passing of drugs and other contraband from visitor to patient for Patient 5 as described in Findings 2.a. through 2.c., and 5.a. through 6. * Safety and security measures were not sufficient to prevent the presence of, and patient possession of, drugs and other unsafe contraband in the EOC for Patients 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, and 23 as described in Findings 7.a. through 7.f. ****************************************************** 29708”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of equipment inventory lists and manufacturer’s instructions, and review of P&Ps it was determined the hospital failed to ensure patient safety equipment/devices used for screening individuals, including visitors, for drugs and other contraband, were maintained in accordance with manufacturer’s recommendations, to ensure they operated and functioned as designed and intended, and were efficient and accurate. Tag A-724 is a repeat deficiency previously cited on the complaint survey completed on 10/05/2023. Findings include: 1. Refer to the findings cited at Tag A-144 under CFR 482.13(c) - Standard: Privacy and Safety. Those findings reflect the failures of the security department and personnel to ensure that screening equipment/devices were subject to preventive maintenance as described in Findings 4.f., 4.h., and 6. ****************************************************** 29708”

“Meet Hospital CoPs CFR(s): [Psychiatric hospitals must] Meet the Conditions of Participation specified in§§482.1 through 482.23 and §§482.25 through 482.57; This Standard is not met as evidenced by: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and patient care documentation for 19 of 23 patients (Patients 1, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23), review of P&Ps, review of hospital directives, review of equipment inventory lists and manufacturer’s instructions, and review of OSH internal investigation and corrective action plan documentation, it was determined that the hospital failed to ensure it complied with all CoPs specified in CFR 482.1 through CFR 482.23 and CFR 482.25 through CFR 482.57 as the following CoPs were determined to be out of compliance: * CFR 482.12 - CoP: Governing Body * CFR 482.13 - CoP: Patient’s Rights * CFR 482.21 - CoP: QAPI * CFR 482.23 - CoP: Nursing Services * CFR 482.41 - CoP: Physical Environment Tag A-1605 is a repeat deficiency previously cited on the complaint survey completed on 05/06/2024. Findings include: 1. Refer to the findings cited at Tag A-043, CFR 482.12 - CoP: Governing Body, that reflects the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all CoPs. 2. Refer to the findings cited at Tag A-115, CFR 482.13 - CoP: Patient’s Rights, that reflects the hospital 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 EOC that likely contributed to patient harm and death and created the likelihood of harm to other patients. The hospital failed to screen visitors; monitor in-person visits between patients and visitors; prevent contraband; observe and monitor patient condition, status, and location to ensure patients were safe and alive (Tag A-144). It further failed to conduct clear and complete investigations of adverse events that addressed all potential gaps and deficient practices; and failed to implement and monitor corrective actions to prevent recurrence for other patients (Tag A-145). 3. Refer to the findings cited at Tag A-263, CFR 482.21 - CoP: QAPI, that reflects the hospital failed to ensure, through the QAPI program, the prevention and reduction of adverse events including by conducting clear and thorough investigations of adverse events, analyzing findings, and implementing actions to prevent recurrence of those (Tag A-286). 4. Refer to the findings cited at Tag A-385, CFR 482.23 - CoP: Nursing Services, that reflects the hospital failed to ensure patient safety and nursing needs were met by nursing personnel, under the supervision of the RN. The RN responsible for the care of each patient failed to ensure ongoing assessment, observation, monitoring, and provision of care and services. Those failures occurred during in-person visitation sessions between patients and visitors, and on the inpatient units. (Tag A-395). 5. Refer to the findings cited at Tag A-700, CFR 482.41 - CoP: Physical Environment, that reflects the hospital failed to ensure the physical environment was maintained and arranged to provide a safe EOC. The hospital failed to ensure safety and security measures were sufficient to prevent the presence of drugs and other unsafe contraband in the EOC. Those measures were not fully developed, security personnel were not trained, and the failures occurred during visitor check-in, screening, and during in-person visitation sessions between patients and visitors (Tag A-701). In addition, screening equipment or devices had not been subject to preventive maintenance to ensure those operated as intended (Tag A-724). ****************************************************** 29708”

“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: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals, it was determined that the governing body 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. 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-093, CFR 482.12(f)(2) - Standard: Emergency Services. This Standard applies to hospitals that do not have a dedicated, organized emergency services department and therefore must develop and maintain written P&Ps for evaluation of emergencies, initial treatment, and referral when appropriate. The findings cited reflect that the hospital failed to fully develop and implement P&Ps and systems to ensure timely and appropriate assessment and response to individuals anywhere on campus who exhibited signs of a potential medical emergency (Tag A-093.) 2. Refer to the findings cited at Tag A-115, CFR 482.13 - CoP: Patient’s Rights, that reflects the hospital failed to fully develop and implement P&Ps that ensured each patient’s right to receive care in a safe setting. The hospital’s failures to ensure appropriate patient assessment and provisions for response to medical emergencies created an unsafe EOC that potentially contributed to harm and death of one patient and created the likelihood of harm to other patients (Tag A-144). 3. Refer to the findings cited at Tag A-385, CFR 482.23 - CoP: Nursing Services, that reflects the hospital failed to fully develop and implement P&Ps that ensured that patient needs were met by ongoing RN assessment and response to the nursing and emergency care needs of the patient population of each department (Tag A-392). 4. Refer to the findings cited at Tag A-1600, CFR 482.60 - CoP: Special Provisions for Psychiatric Hospitals, that reflects the hospital failed to comply with all CoPs specified in CFRs 482.1 through 482.23 and CFRs 482.25 through 482.57 as the following CoPs were determined to be out of compliance (Tag A-1605): * CFR 482.12 - CoP: Governing Body * CFR 482.13 - CoP: Patient’s Rights * CFR 482.23 - CoP: Nursing Services ****************************************************** 29708”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals, it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient’s right to receive care in a safe setting. The hospital’s failures to ensure appropriate patient assessment and organized response to medical emergencies created an unsafe EOC that potentially contributed to harm and death of one patient and created the likelihood of harm to other patients. As stated in Tag A-0000 of this report, based on findings that medical emergency supplies and equipment were not organized to ensure timely and efficient medical emergency response as described under Tag A-144 of this report at Findings 18 through 21.c., on 04/26/2024 the hospital was notified that an IJ situation had been determined to exist. An IJ Removal Plan was approved on 05/01/2024 and the IJ was subsequently removed on 05/02/2024 after onsite verification that the IJ Removal Plan had been implemented. 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-144, CFR 482.13(c)(2) - Standard: Privacy and Safety, that reflects that P&Ps and systems for the provision of safe care were not fully developed or implemented and failures included (Tag A-144): * Failure to ensure AD and inpatient RN staff carried out assigned duties to provide appropriate and timely assessment of patient condition and identification of the need for medical emergency response. * Failure to ensure RN staff requested the immediate presence of a physician when the patient’s unresponsive physical condition was believed to be behavioral versus medical. * Failure to ensure other staff demonstrated appropriate response to a patient whose condition indicated the need for medical emergency response. * Failure to ensure that medical emergency supplies and equipment were organized and managed to ensure availability of necessary items during a medical emergency response. * Failure to ensure an organized and coordinated medical emergency response during which: - The roles of staff who responded were not clear and demonstrated; - The tasks performed were not clearly identified and thoroughly documented, including orders for and administration of emergency medication; - Situational awareness was not maintained. * Failure to ensure AD staff practices for patient care were in accordance with, and supported by, written and approved P&Ps. * Failure to ensure AD staff completed organized and documented AD orientation and onboarding that ensured clinical and procedural competency for patient care operations in that department. ****************************************************** 29708”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals, it was determined that the hospital failed to fully develop and implement P&Ps that ensured that the nursing services provided were under the supervision of an RN, that patient needs were met by ongoing nursing assessment, and that nursing personnel responded to the nursing and emergency care needs of the patient population of each department. 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-392, CFR 482.23(b) - Standard: Staffing and Delivery of Care, that reflects the hospital failed to ensure that the nursing services provided were under the supervision of an RN, and that nursing personnel were knowledgeable regarding patient assessment to ensure appropriate and timely response to the nursing and emergency care needs of the patient population of each department (A392). 2. Refer to the findings cited at Tag A-115, CFR 482.13 - CoP: Patient’s Rights, that reflects the hospital failed to fully develop and implement P&Ps that ensured each patient’s right to receive care in a safe setting. The hospital’s failures to ensure appropriate patient assessment and provisions for response to medical emergencies created an unsafe EOC that potentially contributed to harm and death of one patient and created the likelihood of harm to other patients (Tag A-144). ****************************************************** 29708”

“Special Provisions for Psychiatric Hospitals CFR(s): Special Provisions Applying to Psychiatric Hospitals - Psychiatric hospitals must... This Condition is not met as evidenced by: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals it was determined that the hospital failed to comply with the CFR 482.60(b), Meet Hospital CoPs, under the “Special Provisions Applying to Psychiatric Hospitals,” that required the hospital meet all CoPs specified in CFRs 482.1 through 482.23 and CFRs 482.25 through 482.57 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 the findings cited under this Condition at Tag A-1605, CFR 482.60(b) - Standard: Meet Hospital CoPs, that reflects the hospital failed to comply with the following CoPs (Tag A-1605): * CFR 482.12 - CoP: Governing Body * CFR 482.13 - CoP: Patient’s Rights * CFR 482.23 - CoP: Nursing Services 2. Refer to the findings cited at Tag A-043, CFR 482.12 - CoP: Governing Body, that reflects the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all CoPs. Those findings included for this hospital that did not have a dedicated Emergency Department, failure to ensure appropriate assessment and initial treatment of individuals anywhere on the hospital’s campus who exhibited a need for a medical emergency response (Tag A-093). 3. Refer to the findings cited at Tag A-115, CFR 482.13 - CoP: Patient’s Rights, that reflects the hospital failed to fully develop and implement P&Ps that ensured each patient’s right to receive care in a safe setting. The hospital’s failures to ensure appropriate patient assessment and provisions for response to medical emergencies created an unsafe EOC that potentially contributed to harm and death of one patient and created the likelihood of harm to other patients (Tag A-144). 4. Refer to the findings cited at Tag A-385, CFR 482.23 - CoP: Nursing Services, that reflects the hospital failed to fully develop and implement P&Ps that ensured that the nursing services were under the supervision of an RN, that patient needs were met by ongoing nursing assessment, and that nursing personnel responded to the nursing and emergency care needs of the patient population of each department (Tag A-392). ****************************************************** 29708”

“EMERGENCY SERVICES CFR(s): 482.12(f)(2) If emergency services are not provided at the hospital, the governing body must assure that the medical staff has written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate. This Standard is not met as evidenced by: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps, it was determined that the hospital’s failures to fully develop and implement P&Ps that ensured appropriate and timely provisions for response to medical emergencies anywhere on campus, at this hospital that did not have a dedicated Emergency Department, included: * Failure to ensure AD and inpatient RN staff were determined to be qualified to conduct appropriate and timely assessment of patient condition and identification of the need for medical emergency response. * Failure to ensure RN staff requested the immediate presence of a physician when the patient’s unresponsive physical condition was believed to be behavioral versus medical. * Failure to provide safe and adequate initial treatment of a person who experienced a medical emergency in an organized and coordinated manner. * Failure to ensure that medical emergency supplies and equipment were organized and managed to ensure availability of necessary items during a medical emergency response. Findings include: 1. The findings that follow reflect that the hospital failed to ensure that RN staff promptly assessed Patient 1’s condition and initiated medical emergency response based on the patient’s unresponsive condition that was immediately evident upon arrival to the hospital. When AD RN first observed the patient in the law enforcement transport vehicle they stated they saw the patient’s eyes open briefly. That was the only detectable movement the patient made between the time they were transferred from the back of the transport vehicle until another RN who had accompanied the patient for transport from the AD to the inpatient unit checked for a pulse after the transport and entry into the patient’s assigned inpatient room. RNs and other hospital staff failed to respond timely to the patient’s unresponsive and motionless condition in the manner in which a reasonable or prudent layperson, or a person with BLS CPR training, would do should an individual who exhibited the same signs and condition be observed elsewhere in the hospital or in the community. The RNs responsible for the patient in the AD and en route to the inpatient unit failed to request the presence of a physician to determine whether the patient’s unresponsive condition was behavioral, as law enforcement transporters claimed, versus medical. Once the medical emergency response had been initiated in the inpatient unit, the response was not conducted in an organized and coordinated manner. Further, survey findings revealed that medical emergency supplies in the AD where Patient 1 was initially observed were not organized or managed to ensure timely response. Refer to Tag A-144 for additional information regarding Patient 1’s encounter, and the findings that resulted in identification of an IJ situation. 2.a. A document titled “OSH Office of Quality Management” was reviewed. It included the following information: * “Incident Nature: Sentinel Event - Unexpected Patient Death” * “Date/Time of Incident: 04/18/2024 1115hrs” * “At approx. 1047 hrs. access control informed admissions Douglas County jail transport were waiting with [Patient 1] for admission to OSH. Staff arrived and the country [sic] transport vehicle entered a Sally Port, at approximately 1054 hrs. Deputies told [RN 4] [that Patient 1] would need a wheelchair because [they were] ‘catatonic’ and at times ‘flops around like a fish’. This was reported to have been described to nursing staff as normal behavior by [Patient 1]. As [Patient 1] was transferred from the transport van to the wheelchair, at approximately 1101 hrs, the admission [RN 4] reported [they] observed [Patient 1’s] eyes open and close, possibly in response to light hitting [Patient 1’s] eyes. [Patient 1] was wheeled into OSH admissions at approximately 1102 hrs. Additional staff were called to the admissions area and assisted in photographing [Patient 1] for identification. Douglas County transport restraints were removed from [Patient 1] and [they were] taken, via wheelchair, to Lighthouse 1 by OSH Staff. During this process [Patient 1] was noted as not moving on [their] own accord and staff held the patients [sic] legs up with a blanket so [their] feet would not drag on the floor. Staff and the patient arrived on the unit at approx. 1107hrs. where the patient was taken directly to a patient room. As [Patient 1] was being transferred to the bed an RN decided to check the patient for a pulse and found none. Sternal rubs were done with no response and additional checks found no pulse. A Code Blue was initiated and additional staff arrived and life saving procedures were performed including the use of CPR and an AED. Narcan and epinephrine were administered and were ineffective. Paramedics arrived at approx. 1121hrs and took over life saving efforts. [Patient 1] was pronounced dead at 1156 hrs.” 2.b. In regard to Narcan and epinephrine administration, Patient 1’s medical record included a Psychiatry General Note written by psychiatrist MD 30 and dated and timed 04/18/2024 at 1451. It reflected that the Narcan was administered by OSH staff, and in regard to epinephrine administration the note reflected that “EMS arrived at approximately 1125-1126 and took over the management of the code. They continued CPR for approximately 30 more minutes and per their report, gave 5 rounds of epinephrine. Patient did not achieve return of spontaneous circulation at any point following the start of the code, and patient was eventually pronounced dead by EMS at 1156 on 4/18/24.” 3.a. During interview on 04/24/2024 at 1105 with RN 4, they stated they had worked in AD since August 2023. RN 4 provided the following information regarding Patient 1: * A “Douglas County” transport van pulled into Sally Port 8 drive-in garage. The deputies said the patient would need a wheelchair because they had not been able to get into the van themselves and had been “flopping around like a fish.” The deputies stated that was the patient’s baseline. * RN 4 stated they got a wheelchair for the patient and went to the back of the van with a security staff. The patient, who was in the back of the van, “opened their eyes and moved a little”. RN 4 introduced themselves to the patient. The deputies told the patient, “We’ll get you out [of the van]” and the patient closed their eyes. RN 4 stated “I thought [the patient was] not being cooperative” and asked for more security staff. RN 4 stated 5-6 security staff came. The deputies gave the patient a few minutes to get out of the van and when they did not, the deputies lifted the patient to the wheelchair. RN 4 stated the deputies held the patient’s legs up while they wheeled the patient backwards from the van into the AR. * RN 4 stated in the AR “we got a photo of the patient for [their] ID” and the deputies said it would be OK to remove the patient’s cuffs because they had never been aggressive. The deputies removed the cuffs. The patient was not able to hold their head up and “kept [their] eyes closed.” RN 4 stated the patient was slouched with their head to one side, and “not holding it up like a normal person holds their head.” * RN 4 stated “typically we take a temperature and ask about a cough” in the AR. RN 4 stated they did not check the patient’s temperature or any other vital signs and did not ask the patient if they had a cough. When RN 4 was asked if the patient was breathing, they stated, “I didn’t observe any chest rise and fall.” In response to the surveyor’s follow-up question in regard to indications of oxygenation such as the patient’s skin color and appearance, RN 4 additionally stated that the patient “was African American, had dry skin, and I didn’t notice anything abnormal.” * RN 4, a unit nurse, and security staff pushed the patient in the wheelchair from the AR to LH1. One of the security staff lifted the patient’s legs with a blanket so their legs wouldn’t drag. When they got to the patient’s room on the unit, the unit RN and 2 security staff laid the patient supine on the bed. RN 4 stated, “At that point, I knew something was off because there was no response from the patient, so I checked for a pulse. Nothing. I checked a sternal rub and nothing.” The patient had no pulse and was not breathing, and they called a code blue. 3.b. Incident documentation recorded by AD RN 4, dated 04/18/2024 and untimed, reflected that “Access control called the main admissions office phone at around 10:47 to report that Douglas County was waiting to get into Sally Port 8 for an admission. Douglas County was scheduled to drop off two admits to OSH today on 4/18. [Patient 26] who was scheduled to admit to FW1, and [Patient 1] was scheduled to admit to LH1. The Douglas county transport van was waiting in the circle outside of OSH for roughly 5-10 minutes, due to there being a secure transport van in Sally Port 8. [RN 3] admissions RN, went outside Sally Port 9 to talk to the Douglas county officers to find out how the pts were doing. When [RN 3] came back through Sally Port 9, [they] reported to me ([RN 4] Admissions RN) that the officers said [Patient 1] will need a ‘wheelchair’ because [the patient] ‘flops around like a fish’ and is ‘catatonic’. After secure transport left Sally Port 8. Douglas county pulled into Sally Port 8. FW3 unit staff showed up first, and [RN 3] who was assigned to admit [Patient 26] brought in [Patient 26] and introduced them to the FW3 staff and that pt was taken to FW3. [Patient 1’s] unit staff from LH1 ([RN 13] along with unit MHT) showed up next. I was assigned to admit [Patient 1] as I had done [their] pre-admit note in avatar as well as a nurse to nurse with the jail RN. The deputy standing in the admissions area adjacent to Sally Port 8 then reported to me, ’[Patient 1] won’t stand up, [they’re] catatonic. [They’ll] need a wheelchair’. RN asked the deputy ’[They] won’t stand at all?’, and deputy responded ‘No’. Wheelchair and a blanket was obtained by this RN. [MHST 18] was the security assigned to help with admissions for 4/18. As Sally Port 8 doors were opened by access control, [MHST 18] held open the doors while this RN followed deputies to the back of the van with the wheelchair. The deputies opened up both doors to the back of the van. [Patient 1] was seen sitting in a slumped position with [their] back against van partition. As soon as the van doors opened, there was sunlight that came streaming into the back of the van, and this RN could see [Patient 1’s] eye open and close. Deputies said to [Patient 1] that they needed [them] to get into the wheelchair and gave [the patient] a few seconds but pt did not make any movements or indication that [they were] going to get up. Deputies then assisted pt on either side and lifted the pt into the wheelchair. RN introduced [themselves] to [Patient 1] and explained [they were] at the hospital but pt did not respond. RN asked for pt to lift [their] legs, so [they] could be wheeled, but [Patient 1] did not lift [their] legs. Both deputies each lifted one of the pt’s legs by the pant leg so [the patient’s] heels would not be dragging, and this RN wheeled [Patient 1] backwards into the adjacent admitting room connected to Sally Port 8. [MHST 18] had called for additional security at the request of this RN, who were also present in the admitting area. A photo was obtained of [the patient] for [their] ID badge for security, but [they] did not open [their] eyes. This RN was assessing whether or not the cuffs should be removed in the admitting area, or on the unit for safety, when officers reported that they did not see [the patient] as a threat, and [they] had ‘never been physically violent’. This RN gave the directive for officers to remove the cuffs as pt was not exhibiting any signs of aggressive behaviors. Cuffs were removed by officers. Pt was wheeled by security to LH1, with one security wrapping a blanket underneath pt’s legs and lifting them up so they did not drag on the floor. Admissions RN and unit staff followed as well. Pt was taken onto LH1 unit, and down one of the first hallways on the right hand side as you enter the unit, where the pt’s assigned bedroom was. Pt was wheeled into [their] room, and staff informed [the patient] that it was [their] bedroom and [they] could get up. One staff member said ’[Patient] won’t get up, [they’re] catatonic’. Security and unit RN and another staff lifted the pt onto the bed. Pt was now in a supine position on the bed. Unit RN, [RN 13], then began doing [their] assessment. [RN 13] tried verbal stimuli, yelling pt’s name, checking radial and pedal pulse, checked for breathing. This RN checked for radial pulse on the right side, and there was no pulse felt. This RN confirmed with [RN 13] there was no pulse. Compressions were started, and a code blue was called on the radio by security. Crash cart was obtained with AED. Pt was moved to the floor in supine position for compressions and ambu bag was used for breath. 911 was called. Two OSH medical doctors arrived. AED advised no shock. EMS arrived and took over care.” 4. Incident documentation recorded by LH1 RN 13, dated 04/18/2024 and untimed, reflected that “I was the RN assigned to [Patient 1’s] admission along with [MHT2 8]. We were called to the admission Sally Port around 1100 and waited in line as the county had two patients and the first was going to a different unit. [MHT2 8] and I remained outside the Sally Port per protocol, waiting for report from the [AD RN 4]. It was reported that the pt was not cooperating, would not walk, and [AD RN 4] retrieved a wheelchair. Security arrived at the Sally Port, evidently having been paged by admissions. The pt was retrieved from the transport vehicle utilizing the wheelchair and brought into the Sally Port; I was not able to observe the pt from my vantage point outside the Sally Port. It was reported to us that the pt was continuing to be uncooperative and not responding. Two security staff wheeled the pt out of the Sally Port, one pushing [TMHA 19], the other holding the pt’s legs up with a blanket draped under [the patient’s] ankles ([MHST 20], switched with [MHST 17] at some point). We quickly made our way to LH1; I walked alongside the wheelchair, attempting to engage the pt, explain the plan. We passed the bubble on LH1 at 1111. We had decided to take [Patient 1] directly to [their] room and transfer [them] to [their] bed. On arrival to [patient’s] room, security [TMHA 19] and I immediately lifted the pt out of the wheelchair and onto the bed. During that transfer, I noted the pt was more limp than would have been expected from a simply unresponsive pt. I immediately began checking for a pulse on [their] R wrist and began calling [their] name loudly. I performed sternal rubs when I could not elicit a response verbally. When there continued to be no response I requested staff call a code blue (code was called @ 1114). I then attempted to find a pulse under [the patient’s] upper arm, carotid, pedal while continuing to attempt to rouse [them] verbally and with sternal rubs and watch for chest rise (this was difficult to assess as [the patient] was in loose fitting jail clothing). I pulled open [the patient’s] eye lid and noted a dilated pupil; I used my flashlight to test reactivity and no reactivity was seen. Staff arrived quickly and we began chest compressions (@ 1115). Staff arrived with the AED and crash cart. After applying the AED pads, we transferred the pt to the floor to have a more firm surface and continued compressions alternating with AMBU bag respirations following CPR protocol. Narcan was requested and administered by [PMHNP 23]. Various staff and medical personnel rotated through administering compressions and AMBU respirations. CPR was continued per protocol, following prompts from AED (no shock ever advised) until paramedics arrived and took over the situation.” 5. On 04/24/2024 beginning at 1155, survey team review of multiple camera views of video-recordings, without audio capability, revealed the following timeline of events that occurred on 04/18/2024 when the vehicle Patient 1 was transported in from Douglas County Jail arrived to the OSH Sally Port 8. Regarding the video review there was no camera view provided in Sally Port 8 that showed directly into the back of the transport van used to transport Patient 1 so that the entirety of the inside of the van could be visualized. The camera that showed the view at the back of the van was mounted off to the side of the Sally Port so that a side view of the right rear of the van could be visualized. With both rear van doors opened only a small portion of the inside of the back compartment could be seen. In addition, the quality and clarity of some of the video footage was poor and details of some images were not clear. Further, there were occasions during video review where video skipped several seconds when there was activity occurring. Commonly video may skip seconds or minutes when there is no activity occurring. * Between ~ 1054:52 and 1056:23 two camera views inside Sally Port 8 showed: A DC Jail transport van drove into Sally Port 8 with two DC deputies seated in the front seats. The garage door closed after the van had fully entered the Sally Port. A DC deputy walked to the back of the van, opened one of the back doors, removed two bundles of items, and walked away towards the door to the admitting room. At ~ 1056:07 Patient 26 exited the van through the passenger right side doors and walked in front of the second DC deputy towards the door to the admitting room. * Between ~ 1058:18 and 1100:20 one camera view inside Sally Port 8 showed: A DC deputy walked back to the back of the van, opened one of the back doors and looked inside momentarily, then started to close the door, then reopened it and looked inside and left it open. They stood at the back of the van and periodically looked inside through the open door. * Between ~ 1100:21 and 1102:20 two camera views inside Sally Port 8 showed: The second DC deputy approached the back of the van and joined the first deputy, immediately followed by RN 4 who pushed a w/c towards the back of the van. The deputies opened the other door so that both back van doors were open. At ~ 1100:28 only a portion of Patient 1’s lower body was visualized up against the rear left side of the van. They were positioned on the floor so that their body was facing the interior of the left rear corner side panel of the van, their left buttocks could be seen on the van floor, the left side of their body was at the very end of the floor where the door closure was, their left leg was observed to be bent at the knee and had partially fallen outside of the van. The two deputies picked Patient 1 up off the van floor and in awkward and uncoordinated movements took the patient out of the van and rotated them to place them in the w/c. There was no indication that Patient 1 was assisting or resisting. The parts of their body that could be visualized were limp. Patient 1, who was Black, was positioned in the w/c with their shoulders at the level of the top of the w/c seat back, their head slumped fully forward towards their chest, and their eyes closed. RN 4 folded a blue blanket and place it around Patient 1’s chest and shoulders and wrapped the ends around the w/c handles. At 1101:38 as the RN began to pull the w/c backward towards the admitting room Patient 1’s upper body was observed to be positioned lower in the w/c and slumped toward the left. As their head was slumped forward, the lower part of their face, including mouth and nose, was covered by the blue blanket. At ~ 1102:01 as RN 4 pulled the w/c backwards along the side of the van towards the admitting room door, both deputies bent over the patient and made movements consistent with each having picked up one of the patient’s pants legs to lift the patient’s feet off the ground. * At ~ 1102:24 one camera view inside the admitting room attached to Sally Port 8 showed: RN 4 pulled the w/c with Patient 1 backward into the admitting room. One deputy had hold of the patient’s right pant leg near the hem with their right hand. The other deputy had hold of the patient’s left pant leg near the middle of the pant leg with their left hand. Both of the patient’s bare feet were dangling slightly above the floor. The patient’s hands were cuffed in their lap. Their head was slumped forward, their eyes were closed, and their face was covered by the blue blanket that was held in place by RN 4 around their chest and shoulders and the w/c handles. * Between ~ 1102:30 and 1105:50 one camera view inside the admitting room showed: RN 4 parked Patient 1 in the w/c near the middle of the room. The deputies’ positions around the patient’s body periodically block the camera view. At this time four other staff (not including RN 4 and the two deputies) arrived into the room. The RN can be seen to lean over towards the patient on the left side of the w/c and arms are extended toward the patient although the patient cannot be seen behind one of the deputies. At ~ 1103:02 the deputies stepped away and the patient was observed to be slumped further down in the w/c, however, the patient’s face was no longer covered by the blue blanket that remained around their chest and shoulders. It looked as though RN 4 had their right hand on or near the blanket below the patient’s face as if they moved the blanket to uncover the patient’s face. The patient was motionless and their eyes were closed. At that time there were at least six other staff in the room. RN 4 stepped away and back from the w/c and was observed to address the deputies and staff that had gathered in the room who all stood and faced the patient within a few feet of the patient. Two of those staff stepped towards and leaned towards the patient and took photographs of the patient with cell phones. Then there were eight other staff in the room. The 11 people in the room (excluding the patient) were observed to talk amongst themselves and to the group while Patient 1 remained motionless in the w/c with their wrists in law enforcement transport restraints, their chin laid on their chest, and their eyes closed. Patient 1 showed no signs of movement. At ~ 1104:18 RN 4 slightly leaned toward the patient, extended their arm, and may have touched the blue blanket, the patient’s clothing near their shoulder, or the w/c. It was not clear. At ~ 1104:24 one of the staff persons approached the patient, leaned toward them, and extended their arm towards the patient. There was no visible response or movement from Patient 1. At ~ 1104:29 a DC deputy removed the law enforcement transport restraints from the patient’s wrists. At ~ 1105:08 when their right hand was free from those restraints their right forearm, wrist, and hand slid down and across their right thigh. At that time the patient was observed to have slid further down in the w/c, the blue blanket was removed, their head remained slumped fully forward with their chin on their chest, their eyes were closed, and their legs were extended straight in front of them with their bare feet on the ground. At ~ 1105:27 a staff person took the blue blanket and with assistance from another staff person positioned it under and around both the patient’s legs at the knees and formed a handle of sorts to lift the patient’s legs up off the ground. At that time the patient’s buttocks were near to sliding off of the w/c and their arms had fallen off their thighs onto the w/c seat on either side of their body. At ~ 1105:44 one staff person pushed the w/c forward and another staff person held the blanket that was around the patient’s legs to keep them off the ground and the group moved towards the door out of the admitting room into a hallway towards the inpatient unit. At no time while in the admitting room did the patient assist or resist, nor did they open their eyes or demonstrate any observable movement. At no time was there any meaningful touch or other activity by any staff that could be construed as a patient assessment component. * Between ~ 1105:50 and 1108:30 four camera views showed: The two staff who pushed the w/c and held the patient’s legs up were joined by RN 13 and six other staff as they transported Patient 1 through hospital hallways to the inpatient unit. Patient 1 remained motionless with their eyes closed and slumped to the left with their arms laid limply on the w/c seat on either side of their body and their chin laid on their chest. Overhead camera views during the transport showed that the blanket around the patient’s knees used to hold the patient’s legs up during transport had been tied and knotted or twisted. At ~ 1108:30 staff pushed the patient in the w/c into the assigned patient room on the inpatient unit and that was last video observation of Patient 1. * Video recording beginning at 1108:30 captured staff activities in the hallway outside the room after Patient 1 entered the room, and after the Code Blue response had been initiated. Those video observations are described below under Finding 8 in this Tag. ****************************************************** 6. The findings that follow reflect the hospital’s failure to ensure an organized and coordinated medical emergency response. 7. Incident documentation recorded by LH1 NM, dated 04/18/2024 and untimed, reflected that “Staff came to my office inside the nurses station to advise me that a code blue (medical emergency) was needed for this patient as the code blue was being called over the radio. I responded, running down the south hall to the patient’s room at 1115 as the code blue was being called via overhead page. When I entered the patient bedroom the patient was non-responsive, eyes closed, without respirations, without pulse (as assessed by another RN present). I advised that staff begin chest compressions and then I ran to obtain the crash cart/code blue cart. When I returned to the patient bedroom I opened the code cart, gave the code blue sheet and clipboard to unit [OS2 24] and assigned [them] to the recorder role. I then entered the patient bedroom and advised that staff move the patient from the patient bed onto the floor after the current set of chest compressions were complete. Staff used the patient’s blanket to lower this patient from [their] bed onto the floor and resumed chest compressions. More staff entered the scene and the automatic external defibrillator was brought to the scene. A nurse took a position at the patient’s head and administered 2 rescue breaths using the ambu-bag between each set of 30 compressions. I took the role of code lead and asked staff to switch out with the person administering chest compressions to prevent physical exhaustion while counting chest compressions out loud. Staff continued to administer chest compressions and rescue breaths and the AED was attached to the patient. The AED analyzed and advised no shock, chest compressions and rescue breaths continued. Medical doctors and other staff continued to arrive and rescue attempts continued. This patient was pronounced deceased by our physicians at 1156 and at that time EMTs were present. It was later reported to me that the unit nurse assigned to the admission called for the code blue as this patient was being moved from the wheelchair to the patient bed by security and admissions office staff. Per staff report, the patient was slumped down in the wheelchair unable to maintain an upright posture while [they were] being transported to the unit.” 8. Video recordings of the Code Blue medical emergency response for Patient 1 on 04/18/2024 revealed a disorganized and uncoordinated response as follows: ~ 1108:29 - Patient 1 was transported into the inpatient room in a w/c. RN 13 and other staff entered the room. Multiple staff entered and exited the room and others milled around outside the room with no demonstration of urgency. Another patient exited the patient room across the hall from Patient 1’s room. ~ 1110:34 - MHST 14 walked at a leisurely pace and without urgency down the hall from the NS toward the patient room, pushed a mobile vital signs machine on wheels, and entered the patient room ~ 14 seconds later at ~ 1110:48. ~ 1111:56 - LH1 NM and Agency LPN 21 walked down the hallway from the NS towards the patient room at a quicker pace than previous staff, however, with minimal urgency. (The video observation is contrary to the incident documentation under Finding 7 above that described the response of LH1 NM as “I responded, running down the south hall to the patient’s room ...”) ~ 1112:14 - LH1 NM ran down the hall away from the patient room toward the NS. More staff, some at a quicker pace, began to arrive and gather in the hallway outside of the patient room while some entered the room. ~ 1112:33 - Staff were observed to push a Red Emergency Cart down the hall from the NS toward the patient room. It arrived at the patient room at 1112:45 and was positioned outside the doorway of that room where it remained until it was pushed further down the hall away from the room after EMS arrived. ~ 1112:45 until the arrival of EMS at ~ 1124:01 video recording showed: More staff arrived and continued to enter the patient’s room and gather in the hall. The number of staff gathered in the hallway between the patient’s room and the NS, particularly in the vicinity of the patient’s room, created increased congestion that presented an obstacle for navigation through the hall, including for other patients whose rooms were between Patient 1’s room and the NS. At times there were 20 or more staff, and may have included patients, in the space outside the room and there was no way to determine how many were in the room as staff continued to enter and exit. The crowd that had gathered did not leave a clear pathway for EMS who arrived at ~ 1124:01 with ~ eight EMT and Fire responders, a gurney, and EMS equipment. Additionally, during the scene described above, multiple staff in the hallway were observed to do nothing, staff lined up against the hallway walls, some staff stood on their tiptoes or crowded the doorway of the room to try to see in the room, others engaged in various discussions and activities. Agency RN 26 and Agency LPN 25 were observed to open and look in, or retrieve items from drawers on the Red Emergency Cart, and then they would leave the drawers partially open. (There was no incident or medical record documentation by either Agency RN 26 or Agency LPN 25 regarding their activities and tasks during the Code Blue.) ~ 1112:46 - OS2 24 was observed to stand immediately next to the Red Emergency Cart at the patient room doorway with a clipboard to which a form was attached, looked at their left wrist, and recorded something on the form. During the video the form was discerned to be the Code Blue Flow Sheet. During the duration of this code activity captured on the video recordings until ~ 1125:17 OS2 24 never entered Patient 1’s room, and they were not positioned during much of that time to be able to observe the code activities that were being carried out in the room. For example: They were observed to wander in the hallway outside the room, they stood to the left of the doorway without a view into the room, they stood in the hallway approaching the opposite wall, they sometimes leaned forward to look into the room and sometimes that was through a number of other staff that crowded the doorway, they crouched down on their knees in the hallway to the left of the door, they sat down on the floor on their knees and lower legs in the hallway, they talked with other staff. Up until ~ 1124:39 OS2 24 had the clipboard in their possession. The video skipped ~ 10 seconds at that time. The next time recorded was ~ 1124:51 and OS2 24 was observed to walk down the hall away from the patient’s room and further from the NS without the clipboard in their possession. (On 05/09/2024 at ~ 1500 staff that included the DNS, LH1 NM, CBC, PD, DQM, and DSC confirmed that the form OS2 24 could be seen writing on in the video was a Code Blue Flow Sheet, and that it was the same Code Blue Flow Sheet provided during the survey for Patient 1.) ~ 1124:33 - Staff present demonstrated a lack of situational awareness in relation to the placement of the Red Emergency Cart. When staff began to exit the scene and hallway a staff person pushed the Red Emergency Cart further away from the patient’s room, further down the hallway from where staff were gathered, and further away from the NS. At ~ 1124:57 the only staff near the cart walked away from it and no staff looked in the cart’s direction until 1125:16. The Red Emergency Cart had a suction machine placed on the top and at least two of the cart doors were partially open. The video recording provided ended at 1125:17. 9.a. While there were medical record entries by various staff about the Code Blue response, the Code Blue Flow Sheet for the 04/18/2024 response for Patient 1 was not complete. There were only three entries made on the form in the multitude of required boxes and spaces. Those were the Date, Time, Time of Code Blue, and a checkmark on the “Yes” box for AED utilization. Otherwise, there were several short unclear entries, some with associated times, written in the margins of the form. For example, “11:26 EMS” and “gray sweatshirt” and “8th.” Nor was the form authenticated by whoever made the entries, including in the required space for “Recorder”. 9.b. Incident documentation recorded by LH1 NM, dated 04/18/2024 and untimed, reflected they “ ... gave the code blue sheet and clipboard to unit [OS2 24] and assigned [them] to the recorder role ... I took the role of code lead ... “ However, review of the Code Blue Flow Sheet reflected the following spaces on the form were blank: *”Team Captain:” and Team Captain “Title:” *”Recorder printed name:” and “Signature:” and “Date:” and “Time:” 9.c. The “Medications administered” table on the “Code Blue Flow Sheet” had columns for “Time,” “Medication,” “Dose,” “Route,” and “Effect.” Those spaces were completely blank. There was no documentation on the flow sheet related to the administration of the Narcan that was identified as given in incident and medical record documentation. Nor was the dose given found in any of that documentation. Further, the incident and medical record documentation related to the Narcan order and administration was unclear and inconsistent as follows: * A Nursing Progress Note written by LH1 RN 13 and dated and timed 04/18/2024 at 1304 reflected in regard to Narcan administration that “Narcan was requested and administered by [PMHNP 23].” * A Psychiatry General Note written by psychiatrist MD 30 and dated and timed 04/18/2024 at 1451 reflected in regard to Narcan administration that they “gave telephone order to [Agency LPN 21] RN [sic] for Narcan to be administered to the patient. [PMHNP 23] administered the intranasal Narcan prior to EMS arrival (at approx. 1125-1126). Intranasal Narcan was the only formulation we had on hand on the unit at this time, per staff report.” * A Psychiatry General Note written by psychiatrist MD 27 and dated and timed 04/18/2024 at 1838 reflected in regard to Narcan administration that “When I was informed that [Patient 1] had not received Narcan yet, I ordered the Narcan be given, presuming that both it would be safe in the absence of potential intoxication/overdose and also that it would be potentially extremely beneficial if [the patient] were intoxicated/obtunded from opioids. Nursing staff went to obtain this and it was given via intranasal route several minutes later.” * Incident documentation by Agency LPN 21, dated 04/18/2024 and untimed, reflected that “[MD 30] and [PMHNP 22] gave TO for narcan, I ran to grab the narcan and handed it to nurse that was by patient side.” * Incident documentation by Agency RN 12, dated 04/18/2024 and untimed, reflected that “Nasal Narcan administered as ordered without effectiveness result.” * An “Oregon State Hospital Non-Medication Telephone Orders” form that contained a medication order dated 04/18/2023 at 1120. The order was written as “Give Narcan 4 mg intranasal x1 now for unresponsiveness.” The handwritten entry in the “Nurse Printed Name” was barely legible [Agency LPN 21]. The handwritten entry on the “Nurse Signature” space was illegible and was followed by what may have been written as “LPN” although it was difficult to discern. The “Date” and “Time” of the nurse signature was 04/18/2024 at 1130 and there was an initial in the “Nurse ‘Readback’ Initials” space. The print and signature name of an [PMHNP 22] followed the nurse’s information and was dated and timed 04/24/2024 at 1102, six days after the event. There were no other LIP orders in the medical record. * There were no medical record or incident notes related to Patient 1 by PMHNP 22 who was identified in documentation as having ordered Narcan and who signed the Telephone Order for it. * There were no medical record or incident notes related to Patient 1 by PMHNP 23 who was identified in documentation as having ordered Narcan and as having administered it. . * Each of the medical record and incident notes written by the two MDs, an RN, and an LPN reflected that Narcan was ordered by different LIPs. * In the incident documentation by Agency LPN 21 they wrote they “grabbed” the Narcan and then handed it to another “nurse.” There was no documentation by Agency LPN 21 or the other “nurse” to reflect who that “nurse” was and what that “nurse” did with the medication. * In the incident documentation by Agency RN 12 their note was written consistent with the way a nurse who administered the medication would document and as if RN 12 had administered the Narcan. * There was no documentation of Narcan administration by the person that administered the medication in the medical record or on the Code Blue Flow Sheet. 9.d. Incident documentation recorded by [TM 34], dated 04/18/2024 and untimed, reflected that “As compressions continued, I was tasked with gathering staff’s names that were involved or present for the medical emergency ... I provided the list of staff members involved to LH1 Unit Administrator [UA 35].” It was unclear whether the names and roles of all staff who presented and gathered as observed in the video recording had been identified. There was no documentation included on or with the Code Blue Flow Sheet that identified all staff who presented or participated. 9.e. Further, the following spaces on the Code Blue Flow Sheet were blank: * “Time of onset:” * “Location:” * “Chief Complaint:” * A table with seven columns for “[time, blood pressure, pulse, respirations, temperature, pulse oximetry on room air or supplemental O2, blood glucose]” * “Pertinent physical findings:” * “Defibrillation: __No __Yes” and “How many times:” and “Successful: __No __Yes” * “EMS called at:” and “EMS arrived at:” *”Physician/nurse practitioner called hospital at:” *”Patient transported by: __N/A __OSH transport __EMS Time:” *”Disposition of patient:” *”Emergency contact called: __No __Yes Name: Relationship: Phone number:” *”Provide copies of the following to the EMS Team: __ Medication administration record __Vital signs flow sheet __ Laboratory data __Emergency medical transfer report __ Diagnostic (e.g., EKG) __ Medical H&P” 10.a. The P&P titled “Code Blue Medical Emergency” dated 01/21/2020 was reviewed. It stated that “[OSH] will provide immediate response to any medical emergency that presents anywhere on campus and requires a coordinated team effort ...” The P&P attachment, “Procedures A,” consisted of a table with two columns for “Responsible Person/Group” and “Procedures.” Those persons were listed as: - “First responder” - “Second responder” - “Security” - “Team Captain” - “Physician/NP/RN” - “Equipment Monitor” - “Airway Rescuer” - “Recorder” - “Communicator” - “Crowd Control Monitor” - “Photocopy” 10.b. Duties delineated for each role/title were vague and unclear. For example: * The “Team Captain” duties included: “Assign roles and responsibilities ... Assist with completing the Code Blue Flowsheet ...” * The “Equipment Monitor” duties included: “Verify all of the emergency equipment arrives to the scene ... Prepare and hand out equipment as needed or directed by the Team Captain ... Monitor emergency equipment throughout the incident.” * The “Recorder” duties included: “Complete the Code Blue Flowsheet.” * The “Crowd Control Monitor” duties included: “Maintain safety of the scene and milieu as necessary ... Verify essential personnel have access to the scene, person, and emergency equipment ... Request the Communicator cancel responders when sufficient responders have arrived at the scene ...” 10.c.The procedures were not clearly written to ensure staff were trained and knowledgeable to be able to competently carry out the required duties/tasks in an organized and coordinated manner. For example: * It was not clear how roles were to be assigned and how and where those were to be recorded. * It was not clear what “assist with” completing the Flowsheet meant. * It was not clear what “emergency equipment” was to arrive to the scene and what was meant by “monitor emergency equipment ...” The equipment was not specified, nor was there reference to other applicable P&Ps. * There was no direction r/t where the Recorder needed to locate themselves, and otherwise obtain the necessary information, to ensure they could clearly and completely “Complete the Code Blue Flowsheet.” * It was not clear how the “safety of the scene and milieu” was determined, who “essential personnel” were, or who and how many persons were considered “sufficient responders.” * It was not clear who was responsible to monitor and manage the presence of other patients at or near the scene to ensure safety of those patients and others. * There were no mentions of emergency medications or reference to other applicable P&Ps. It was not clear which role was to obtain and prepare Code Blue medications, from where those were to be obtained, and who was to administer them. 11. The review of the Code Blue video recording and the Code Blue documentation for Patient 1 failed to demonstrate that roles and responsibilities for all Code Blue positions had been assigned and that duties/tasks had been carried out. Further, the Code Blue Flowsheet used during Patient 1’s Code Blue did not align with the procedure requirements in Procedures A. 12.a. During interview with staff that included the DSC, DLD, and OBC on 05/06/2024 beginning at 1235 they confirmed the Code Blue training dates for the AD RNs 1 through 4 and stated there were no drills or hands-on practice, return demonstrations, or competency evaluations associated with those trainings, including during annual “refreshers.” They further stated that hospital-wide Code Blue drills had not been conducted since the Covid-19 pandemic. They stated those were recently resumed on 04/23/2024 and that on that date on the OSH-Salem campus 54 staff participated in Code Blue drills, and on 04/26/2024 on the OSH-JC campus 13 staff participated in Code Blue drills. They further confirmed that none of the four AD RNs had been present or participated in the Code Blue drills conducted on 04/23/2024 and 04/26/2024. 12.b. Review of AD RN Code Blue training records reflected the following: * For RN 1 the documentation showed that since 2020 they had a 20-minute online Code Blue training on 03/26/2020, an online Code Blue training on 04/24/2021, and a 30-minute Code Blue “refresher” on 02/27/2023 during 2023 Annual Training. * For RN 2 the documentation showed that since 2020 they had a 30 minute Code Blue “refresher” on 04/02/2024 during 2024 Annual Training. * For RN 3 the documentation showed that since 2020 they had a 20-minute online Code Blue training on 05/07/2020, an online Code Blue training on 03/12/2021, and none since. * For RN 4 the documentation showed that since 2020 they had a 20-minute online Code Blue training on 04/18/2020, an online Code Blue training on 05/08/2021, and none since. ****************************************************** 29708 13. The findings that follow reflect the hospital’s failure to ensure that medical emergency supplies and equipment were organized and managed to ensure availability of necessary items during a medical emergency response. 14. During tour of AD with DSC, PD and ADM on 04/24/2024 at 1020, observations included: * Upon entering AD hall, a secure door at the end of the hall led into the AR. From inside the AR, a secure door led into the Forensics Evaluation area. Another secure door from the AR led directly into Sally Port 8’s vehicle drive-in garage. A floor to ceiling garage door was observed between the drive-in garage and the outside of the building so that a vehicle could drive fully into the garage and have the doors closed and secured behind the vehicle. * From the AD hall, to the right of the AR entry door, a secure door lead into the AD office. A sliding window was observed between the AD office and drive-in garage so that AD staff could open the window and communicate with individuals in the garage. * From the AD hall, to the left of the entry AR door and across the hall from the AD office, a secure door led into room G04-117A. * A secure door leading to Sally Port 9 was observed near the Admissions office. Sally Port 9 had a secure door that led directly to the outside of the building and no drive-in garage. 15.a. During a second tour of AD on 04/24/2024 at 1610 with Interim DS, DSC, and RN 3, observations included: * In AD office, a portable oxygen tank and a blue duffle type Code Blue Bag. The bag had multiple zippered top and side pockets with red breakaway locks. The bag was opened and contained an Ambu bag, dressings, pulse oximeter, oxygen tubing, pen lights, and other emergency supplies. There was no inventory list observed that identified the contents of the Code Blue Bag. A clipboard with multiple copies of partially completed “Emergency Equipment Checklist” Attachment A was observed near the Code Blue Bag. * In Room G04-117A, a tackle box style Emergency Kit was observed with a green breakaway lock. The lid read “Emergency Box” in red professional type print. * An AED was observed mounted on the wall in the Forensics Evaluation area down a hall and around a corner from the AR. * Observation of the path from AR to outside AN1 nurse station involved leaving AD and going through 3 secure doors. 15.b. “Emergency Equipment Checklist” Attachment A observed in Admitting office near the Code Blue Bag was reviewed. There was no date that reflected when it had been created or revised. The top portion of the checklist had spaces for recording month and year and stated “Consult with Nursing Supervisor if any equipment problems. Every section must be completed.” The checklist had a “Date” column with rows numbered 1-31 for checking the following items each day in a month: - “Y N” for “AED Present” - “Y N” for “Code Blue Bag or Red Cart Lock Intact.” - “Y N” for “Emergency Med Box Lock Intact” - “Y N” for “Oxygen Tank = 1000 p.s.i.” - “Y N” for “Suction Machine Charged, Clean & Operational” The checklist also had spaces for recording time, comments, and signature each day. 15.c. The “Emergency Equipment Checklist, Attachment A for January 2024 dated “Month/Year: 1/2024” was reviewed and was incomplete and did not provide assurance emergency supplies and equipment were checked and available when needed. Examples included: - The spaces for documenting the time was blank every day of the month. - For 01/01/2024, 01/15/2024, 01/16/2024, 01/17/2024, 01/19/2024 and 01/31/2024, “Y” and “N” were not circled or otherwise marked for “Code Blue Bag or Red Cart Lock Intact” and “Oxygen Tank = 1000 p.s.i.” checks. In addition, spaces for documenting signature were blank for those dates. - The columns for documenting “AED Present”, “Emergency Med Box Lock Intact”, and “Suction Machine Charged, Clean & Operational” had a squiggly line drawn through each and there was no documentation that reflected those had been checked. - The spaces for documenting comments were blank every day of the month. 15.d. The “Emergency Equipment Checklist, Attachment A for February 2024 dated “Month/Year: Feb 2024” was reviewed and was incomplete. Examples included: - The spaces for documenting the time was blank every day of the month. - For dates 02/02/2024, 02/09/2024, 02/16/2024, and 02/19/2024, “Y” and “N” were not circled or otherwise marked for “Code Blue Bag or Red Cart Lock Intact” and “Oxygen Tank = 1000 p.s.i.” checks. Spaces for documenting signature were blank for those dates. - The columns for documenting “AED Present”, “Emergency Med Box Lock Intact”, and “Suction Machine Charged, Clean & Operational” had a squiggly line drawn through each. - The spaces for documenting comments were all blank. 15.e. The “Emergency Equipment Checklist, Attachment A for March 2024 dated “Month/Year: March 2024” was reviewed: - The spaces for documenting “Time” was blank every day of the month. - For 03/01/2024, “Y” and “N” were not circled or otherwise marked for “Code Blue Bag or Red Cart Lock Intact” check and the signature space was blank. - For 03/01/2024, 03/18/2024, 03/19/2024, 03/20/2024, 03/21/2024 and 03/22/2024, “Y” and “N” were not circled or otherwise marked for “Oxygen Tank = 1000 p.s.i.” checks. - The columns for documenting “AED Present”, “Emergency Med Box Lock Intact”, and “Suction Machine Charged, Clean & Operational” had a squiggly line drawn through each and there was no documentation that reflected those had been checked. - The spaces for documenting comments were blank every day of the month. 15.f. The “Emergency Equipment Checklist, Attachment A for April 2024 dated “Month/Year: April” was reviewed: - The spaces for documenting the time was blank every day through the date of this survey. - For 04/10/2024, 04/11/2024, 04/12/2024, 04/15/2024, 04/16/2024, 04/22/2024, 04/23/2024 and 04/24/2024, “Y” and “N” were not circled or otherwise marked for “Code Blue Bag or Red Cart Lock Intact” and “Oxygen Tank = 1000 p.s.i.” checks. Spaces for documenting signature were blank for those dates. - The columns for documenting “AED Present”, “Emergency Med Box Lock Intact”, and “Suction Machine Charged, Clean & Operational” had a squiggly line drawn through each and there was no documentation that reflected those had been checked. - The spaces for documenting comments were blank every day of the month. 15.g. The checklist being used in OSH-Salem AD was not the same version as the “Emergency/Medical Equipment Checklist” Attachment A with revision date “10/2023” in the P&P titled “Emergency and Multi-Patient-Use Medical Equipment” in Finding 18.c. below. For example, the checklist being used in AD reflected “AED Present”. The checklist in the P&P reflected “AED shows green check”. The checklist being used in AD included “Code Blue Bag” and “Emergency Med Box Lock Intact.” The checklist in the P&P did not include those. The checklist in the P&P included “Medical Equipment Disinfected” and the checklist being used in AD did not include a medical equipment disinfection. In addition, observations of the Code Blue Bag in Findings 15.a. and 16.a. reflected it had multiple zippered pockets with breakaway locks. However, the checklist did not provide instructions or a system for tracking each of those to ensure the bag had not been opened and emergency supplies removed without staff awareness. 15.h. During interview on 04/24/2024 at 1620, RN 3 stated: * If a patient was unresponsive in AD they would call a code blue and use the emergency supplies and medication observed in Finding 15.a. above or a “code cart might be brought from an inpatient unit.” * The Emergency Kit in Room G04-117A contained Narcan. * There was no suction equipment in AD and if a patient needed suction “a code cart would be brought from [AN1].” The closest code cart was inside the nurse’s station in AN1. * The Code Blue Bag with emergency supplies observed in Finding 15.a. should have a supplies list attached to the bag that identified the emergency supplies inside the bag. RN 3 looked for the supplies list and could not find it. * The “Emergency Equipment Checklist” observed near the Code Blue Bag should be completed “Monday through Friday”. 16.a. During tour of AD with DSC and PD on 04/25/2024 at 1230, observations included: * The door leading into AD office had an ~ 8.5 x 11 size, professional type sign on the door that read “Code Blue ... Emergency Equipment.” Handwritten entries added to the sign included “Blue bag + O2 are here AED by rm G04-121 (Forensic Eval [illegible marks] East Security hall)”. * Observation with RN 1 of a Code Blue Bag in the AD office revealed it was the same style observed during AD tour on 04/24/2024 at 1610. Four red breakaway locks were observed on the zippered top and side pockets. No inventory list was observed with the bag. The bag was opened with RN 1 and contents were observed and compared with an inventory list that had been received for the Code Blue Bag from hospital leadership earlier the same day. The inventory list was untitled, undated and had sections for “Center”, “Rt. Side” and “Lf. Side” pockets. Review of the inventory list and observation of the items in the Code Blue Bag reflected they were inconsistent and unclear. Examples included: - The inventory list reflected “Center [pocket] ... Pen Light (on lid with pens) & Steno Note Pad ... [quantity] ... 2 [and] 1” with a diagonal line crossed through “2 [and] 1”. Pen lights and steno note pad were observed in the bag. However, it was not clear how many or whether they should be in the bag as the quantities on the inventory sheet were lined out. -The inventory list reflected the “Rt. Side [pocket] ... Blood Pressure cuffs Lg/ExLg ... [quantity] ... 1 [and] 1” with a diagonal line crossed though “1 [and] 1”. Blood pressure cuffs were observed in the bag. Similarly, it was not clear whether they should be in the bag as the quantities on the inventory sheet were lined out. “Rt. Side [pocket]” also included “Stethoscope/oximeter ... [quantity] ... 1 [and] 1” with a diagonal line crossed through “1 [and] 1”. Similarly, those items were observed in the bag. - The inventory list reflected “Lf. Side [pocket] ... 3 [inch] roll gauze & 4 [inch] Coban ... [quantity] 2 and 1” with a diagonal line crossed through “2 and 1”. Similarly, those items were observed in the bag. - No protective eyewear was on the inventory list. Protective eyewear was observed in the bag. - The list included 3 oxygen tubing nasal cannulas. Two oxygen tubing nasal cannulas were observed in the bag. - The list included 2 oxygen non-rebreather face masks. One oxygen non-rebreather face mask was observed in the bag. A Yankauer Suction tip with tubing was observed in the bag. No suction machine or other suction items or equipment were observed in the bag. No Narcan or other medications were observed in the bag. These findings were confirmed with RN 1 at the time of the observation. 16.b. During interview on 04/25/2024 at 1230, RN 1 stated: * They started working in the AD about 6 months ago and AD was where they normally worked. * Most new admit patients and patients returning from medical appointments enter the hospital through Sally Port 8. Patients arriving in vehicles too large to enter Sally Port 8 and patients without behavior problems sometimes enter through Sally Port 9. * There is frequently a line of transport vehicles waiting to bring patients in through Sally Ports 8 and 9. The vehicles wait in parking spaces outside Sally Ports 8 and 9 “or wherever they can find a spot.” * Sometimes deputies call ahead and let AD staff know if a patient is “coming in hot”, meaning the patent was having behavioral issues. RN 1 stated while transport vehicles are waiting to bring patients into the hospital, they usually try to “touch bases” with the deputies by going outside and talking to the deputies about how the patients are doing. They do not start evaluating patients until patients are getting out of the vehicle. If a patient had a medical problem while waiting in a transport vehicle, they would do a “formal assessment” of the patient and if the patient had a “serious issue” they would call a code blue. * If they needed Narcan for a patient, they would get it from the Code Blue Bag or from an Omnicell in AN1. “We don’t have an Omnicell [in AD].” * If they needed suction equipment for a patient, that would be in the Code Blue Bag in AD. * Regarding the red breakaway locks observed on the Code Blue Bag, RN 1 stated that after the Code Blue Bag was opened, the Code Blue Team was notified. The Code Blue Team checked the Code Blue Bag inventory, restocked the bag, and replaced the breakaway locks on the bag. * They confirmed there was no supplies inventory sheet with the Code Blue Bag. * They were not sure who checked the AED in Forensics Evaluation area to ensure it would be present and functioning if needed. 17. A second interview was conducted with RN 1 on 04/25/2024 at 1255 after they confirmed the Code Blue Bag in Finding 16.a. did not have all equipment necessary for patient suctioning, nor Narcan. Regarding obtaining suction equipment during a patient emergency, RN 1 stated “I’d have to go to [an inpatient] unit to get it or a code team person would get it.” Regarding obtaining Narcan during a patient emergency, RN 1 stated “I’d go to the Omnicell at [AN1] or ask a deputy. If it was my patient, I’d stay with the patient and have another nurse go get it.” 18.a. During interview on 04/25/2024 at 1200, DSC stated the P&P titled “Emergency and Multi-Patient-Use Medical Equipment” in Finding 18.b. was applicable hospital-wide including in AD. 18.b. The P&P titled “Emergency and Multi-Patient-Use Medical Equipment,” dated approved 03/01/2024 included: * “The purpose of this protocol is to describe the expectations and procedures for controlling, monitoring, and disinfecting emergency and multi-patient-use medical equipment available on patient living units at Oregon State Hospital (OSH) ...” * “All Oregon State Hospital living units must have a red emergency cart that is secured with a break-away lock, a suction machine, an automated external defibrillator (AED), and a portable oxygen tank, all of which are consistently controlled, secured, monitored, and ready to use ... Daily checks of the above items are performed by a nurse and are documented on the Emergency/Medical Checklist (Attachment A) ... The Lead Nurse is responsible for ensuring that the actions described in this protocol are performed ... The actions described in this protocol are generally performed on the Night Shift, although individual units may designate another shift for this purpose ...” * “The presence of the AED, and the green check is showing, must be verified each day ... The OSH Medical Equipment Coordinator must be immediately notified of defective equipment and related issues.” * “Red emergency carts must be stocked and locked at all times when not in use ... If the lock is found to be broken or missing, the contents must be checked against the Inventory Sheet ... The Inventory Sheet is taped to the top of the cart and also to the clipboard in the top drawer of the cart ... The Code Blue Team must be notified of the need for replacement items and a new break-away lock ... Contact information for the Code Blue Team is available ... on the Inventory Sheet, available in the red emergency cart ... and ... on a sticker on the top of the red emergency cart.” * “The status of the portable oxygen tank must be verified each day ... The oxygen tank must be replaced if the amount of oxygen is less than 1000 pounds per square inch (psi).” * “The availability of the suction machine machine, and related supplies, must be verified each day ... The suction machine must be ready for use with a package of suction tubing and a package containing oral suctioning want secured in the wide black plastic band on the front of the machine ...” * “Emergency medical equipment located in areas other than patient living units and treatment malls is maintained by the Code Blue Team.” 18.c. Attachment A, titled “Emergency/Medical Equipment Checklist” dated revised “10/2023” was reviewed. The top portion of the checklist had spaces for recording unit, month and year and stated “Every section MUST be completed. Notify unit nursing management (or designee) of equipment problems.” The checklist had a “Date” column with rows numbered 1-31 for checking the following items each day of the month: * “Y/N” for “AED shows green check” * “Y/N” for “Red Emergency Cart Lock Present” * “Y/N” for “Oxygen Tank = 1000 p.s.i.” * “Y/N” for “Suction Machine Plugged In, Tubing/Wand Present” * “Y/N” for “Medical Equipment Disinfected Complete WEEKLY” The checklist also had spaces for recording comments and RN/LPN signature each day. The P&P was not clear regarding how breakaway locks were tracked to ensure security, integrity and availability of emergency supplies and equipment. For example, it was not clear if those were to be numbered, unnumbered or a specific color considering numbered, unnumbered and different colored locks were observed on emergency carts and kits during the survey. The P&P did not include further process for management of emergency supplies and equipments in areas other than living units, such as AD, including a system for tracking breakaway locks. 19.a. The P&P titled “Override Process for Medications in Emergency Situations” dated 05/05/2023 reflected: * “Purpose and Applicability ... To ensure medications are always readily and safely available for use at Oregon State Hospital (OSH), this policy ... This policy applies to all staff who order, dispense, or administer medications.” * “Staff must follow Procedures A to retrieve emergency medications from ADCs and from E-Kits when authorized in emergency situations ... Emergency medications are as listed in Attachment A and Attachment B.” 19.b. Procedures A included: * “Nurse ... Assess the patient ... Upon receipt of a verbal order from the practitioner to administer emergency medication ... Retrieve the medication(s) from the Automated Dispensing Cabinet (ADC) .... or from the Emergency Kit (E-Kit) ... Administer to the patient ... If medication from an E-Kit was used, complete the E-Lot requisition form attached to each kit and scan it to the pharmacy.” * “Pharmacy ... Upon receipt of an E-Kit requisition, deliver a replacement E-Kit and retrieve the opened E-Kit ... Prepare the opened E-Kit for redeployment ... Reconcile and replenish standard contents of E-Kits ... Review and record the expiration of all drug contents, and Stage the newly replenished E-Kit for deployment.” 19.c. Attachment A reflected “Emergency Medications Stocked in Automated Dispensing Cabinets (ADC)” and included: * “Stocked in all unit, treatment mall, and Medical Clinic ADCs on both campuses with the noted minimum quantities” followed by a list of medications: “Aspirin (Uncoated) 325 mg - 2 tablets ...” “Charcoal, Activated Suspension (Acti-Dose) 50 grams - 1 tube/bottle ...” “Dextrose/Glucose ... 40% (15 grams) - 2 tubes ...” “Diphenhydramine (Benadryl) a. 50 mg/mL - 2 vials b. 25 mg - 10 capsules c. 50 mg - 10 capsules ...” “Epinephrine (Epi-Pen) 0.3 mg/0.3 mL - 1 auto-injector syringe ...” “Glucagon 1 mg - 2 kits ...” “Haloperidol (Haldol) a. 5 mg/mL - 2 vials b. 5 mg - 10 tablets c. 10 mg - 10 tablets ...” “Lorazepam (Ativan) ... a. 2 mg/mL - 2 vials b. 1 mg - 10 tablets c. 2 mg - 10 tablets ...” “Naloxone (Narcan) 4 mg/spray - 2 devices ...” “Nitroglycerin (Nitrostat) 0.4 mg - 1 bottle ...” “Olanzapine (Zyprexa) a. 10 mg/2 mL - 2 vials ... b. 5 mg - 10 tablets c. 10 mg - 10 tablets.” * “Additionally stocked in all treatment mall and Medical Clinic ADCs on both campuses with the noted minimum quantities ... Albuterol (Proair/Proventil) a. 90 mcg (HFA) - 1 inhaler b. 3 mL nebulizer solution - 5 vials.” 19.d. Attachment B reflected “Emergency Medications Stocked in Emergency Kits (E-Kits) ... Admissions Emergency Kit ... Naloxone (Narcan) 4 mg/spray - 2 devices”. Attachment B did not include Epi Pen in Admissions Emergency Kit. Refer to Findings 20.a. and 21.a. that reflected Epi Pen was observed in Emergency Kits in OSH-Salem AD and OSH-JC Admissions area. The P&P did not include further information about how breakaway locks on E-Kits were managed and tracked. The P&P reflected additional emergency medications were stocked and available in inpatient units and other areas that were not available in Salem campus AD and JC admissions areas. P&Ps were not clear how staff in Salem campus AD and JC admissions area were to obtain those additional emergency medications should they be needed for a patient emergency. 20.a. The OSH-Salem AD was toured during the IJ verification visit with Interim DS, DSC, and ADM on 05/02/2024 at 1300. Observations inside room G04-117A with ADM included: * A 6 drawer Red Emergency Cart with one blue breakaway lock on the outside. The lock had no number or other information for tracking to ensure cart security. This created the possibility that contents could be tampered, removed and lock replaced without staff being alerted. The outside of Drawers 1, 2, 3, 4 and 6 were labeled with the contents of the drawers. Drawer 5 was not labeled and no items were observed inside the drawer. * An “Admissions Code Blue Equipment Check Sheet” inventory list dated “Updated 4/30/2024” was observed. The inventory list was separated into 6 sections for Drawers 1 through 6, with supplies/equipment in each drawer. Observation and of cart labels, cart contents, and the inventory list revealed inconsistencies between those. For example: - Sterile tongue depressors, roll gauze and Coban were observed inside Drawer 3 and were on the check sheet for Drawer 3, but were not observed on any of the drawer labels. - A label on Drawer 3 reflected “EMT scissors” and EMT type scissors were observed in Drawer 3. The check list reflected only “scissors” which could be confused with regular office type scissors. * A tackle box style Emergency Kit with breakaway lock was observed in Drawer 6. The top of the kit had a white label that read “Earliest Expiration 2/25” with a signature and a title. It was not clear whether the expiration date was intended to be February 25 or February 2025. A 2-page, front/back document titled “Admissions Emergency Kit” was observed in a plastic sleeve with the kit. Page 1 was a list that reflected two medications were in the kit, Narcan and Epi Pen. It included: - Naloxone (Narcan) 2 mg/mL syringe, quantity “2” with the following unclear expiration dates “4/24” with 3 lines marked through and no indication regarding when or why it was marked through, and below that “2/25”. The “Dosage & Administration” reflected “Adult 1 mg/1mL in each nostril” and “Indications” reflected “Suspected opiate overdose.” - “Epi pen”, quantity “1” with unclear expiration date “3/25” and no dosage, administration or indication information. The top of page 2 reflected it was a “Record of Inspection for Intact Seal and Expiration Date (Required Monthly).” The document had multiple spaces for recording signature, title, date and lock #. Review of the document reflected it was unclear and lacked evidence of seal and expiration inspections that were “required monthly”. - The first entry dated 11/10/2022 included signature, title and lock # 10572981. - The next entry dated 03/16/ 2023 included a signature, title and lock # 10572989. There was no documentation that reflected the lock (seal) and expiration date had been checked between 11/10/2022 and 03/16/2023. It was additionally not clear why the lock # had changed. - The next entry dated 04/11/2023 included a signature, title, “(inspection)” handwritten and no lock #. It was not clear what had been “inspected.” - The next entry dated 05/10/2023 included a signature, no title and lock # 10572996. It was not clear why the lock # had changed. - The next entry dated 09/12/2023 included a signature, title, and the word “date” followed by a check mark, and no lock #. It was not clear what “date” had been checked. - The next entry dated 09/15/2023 included a signature, no title and lock # 10285209. The documentation lacked evidence that reflected the lock and expiration date had been checked between 05/10/2023 and 09/15/2023. It was not clear why the lock # had changed. - The next entry dated 03/05/2024 included a signature, title and lock # 10285209. The documentation lacked evidence that reflected the lock and expiration had been checked between 09/15/2023 and 03/05/2024. * The “Emergency/Medical Equipment Checklist” dated revised “10/2023” in Finding 18.c. was observed with the cart. 20.b. During interview on 05/02/2024 at the time of the OSH-Salem IJ verification visit, ADM confirmed there was no number on the blue breakaway lock on the Red Emergency Cart. ADM stated that if the blue breakaway lock was broken, the Code Blue Team had replacement blue breakaway locks and would restock the cart and replace the lock. 21.a. During the OSH-JC IJ verification visit on 05/02/2024 beginning at 1410, the area “where admits come in” was observed by virtual remote monitoring with Interim DS, JCA, JC nursing staff and other hospital leadership. Observations included: * A 6 drawer Red Emergency Cart. The outside of Drawers 1, 2, 3, 4 and 6 were labeled indicating the contents of the drawers. Drawer 5 was not labeled and no items were observed inside the drawer. The cart had red breakaway lock # 3842072 on the outside. This was inconsistent with observations of the AD Red Emergency Cart in Finding 20.a. above which had an unnumbered blue breakaway lock. * The same “Admissions Code Blue Equipment Check Sheet” inventory list used for the AD Red Emergency Cart in Finding 20.a. above was observed. Observation of cart labels, cart contents, and inventory list revealed inconsistencies between those. For example: - A package of stethoscope ear pieces and diaphragms were observed in Drawer 2 and were not on the checklist or any of the drawer labels. - Sterile tongue depressors, roll gauze and Coban were observed in Drawer 3 and were on the check sheet for Drawer 3, but were not observed on any of the drawer labels. - A label on Drawer 3 reflected “Trauma sheers”. Similar to AD, the check list reflected only “scissors” which could be confused with regular office type scissors. - A pulse oximeter inside Drawer 3 was labeled “Tx Mall 3” which could create confusion as to where that piece of equipment should be kept. * An Emergency Medication Kit with breakaway lock # 3842071 was observed in Drawer 6. A document titled “JC Admissions Emergency Kit” was observed in a plastic sleeve with the kit and indicated Narcan and Epi pen were inside the kit. The document was similar to the document titled “Admissions Emergency Kit” observed with the Emergency Medication Kit during tour of AD during the IJ verification visit on 05/02/2024. However, there was no “Record of Inspection for Intact Seal and Expiration Date”. The document included no evidence the Emergency Kit breakaway lock # was checked to ensure the lock had not been removed, contents tampered with, and medications readily available when needed. * An “Emergency/Medical Equipment Checklist” for May 2024 dated revised “07/2021” was observed with the Red Emergency Cart. This was not the same version observed during tour of AD during the IJ verification visit on 05/02/2024 in Finding 20.a. above, nor the version in the P&P titled “Emergency and Multi-Patient-Use Medical Equipment” in Findings 18.b. and 18.c. 21.b. During interview on 05/02/2024 with OSH-JC nursing staff and other hospital staff at the time of the remote OSH-JC IJ verification visit, the following information was provided: * The hospital had a designated Code Blue Team that consisted of 2 staff. The same 2 staff covered JC and Salem campuses. * The Code Blue Team had replacement breakaway locks for the Red Emergency Carts. * The Code Blue Team tracked breakaway lock #s on Red Emergency Carts “whenever we call them”. * They confirmed “Emergency/Medical Equipment Checklist” dated “07/2021” was observed with the Red Emergency Cart. ******************************************************”

“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: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals, it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient’s right to receive care in a safe setting. The hospital’s failures to ensure appropriate patient assessment and organized response to medical emergencies created an unsafe EOC that potentially contibuted to harm and death of one patient and created the likelihood of harm to other patients and included: * Failure to ensure AD and inpatient RN staff carried out assigned duties to provide appropriate and timely assessment of patient condition and identification of the need for medical emergency response. * Failure to ensure RN staff requested the immediate presence of a physician when the patient’s unresponsive physical condition was believed to be behavioral versus medical. * Failure to ensure other staff demonstrated appropriate response to a patient whose condition indicated the need for medical emergency response. * Failure to ensure that medical emergency supplies and equipment were organized and managed to ensure availability of necessary items during a medical emergency response. * Failure to ensure an organized and coordinated medical emergency response during which: - The roles of staff who responded were not clear and demonstrated; - The tasks performed were not clearly identified and thoroughly documented, including orders for and administration of emergency medication; - Situational awareness was not maintained. * Failure to ensure AD staff practices for patient care were in accordance with, and supported by, written and approved P&Ps. * Failure to ensure AD staff completed organized and documented AD orientation and onboarding that ensured clinical and procedural competency for patient care operations in that department. As stated in Tag A-0000 of this report, based on findings that medical emergency supplies and equipment were not organized to ensure timely and efficient medical emergency response as described below in this Tag at Findings 18 through 21.c., on 04/26/2024 the hospital was notified that an IJ situation had been determined to exist. An IJ Removal Plan was approved on 05/01/2024 and the IJ was subsequently removed on 05/02/2024 after onsite verification that the IJ Removal Plan had been implemented. Findings include: 1. The findings that follow for Patient 1 reflect the hospital’s failure to ensure the provision of care and services in a safe and appropriate manner. For example: * RN staff failed to conduct appropriate and timely assessment and vital signs for Patient 1 who arrived at the hospital from jail. When AD RN first observed the patient in the transport vehicle they stated they saw the patient’s eyes open briefly. That was the only detectable movement the patient made between the time they were transferred from the back of the transport vehicle until another RN who had accompanied the patient for transport from the AD to the inpatient unit checked for a pulse after the transport and entry into the patient’s assigned inpatient room ~ eight minutes later. * AD and inpatient RN staff failed to make independent decisions using their own nursing judgement that would call for an immediate assessment and emergency response to an unresponsive and motionless person. * Other hospital staff failed to respond to the patient’s unresponsive and motionless condition in the manner in which a reasonable or prudent layperson, or a person with BLS CPR training, would do should an individual who exhibited the same signs and condition be observed elsewhere in the hospital or in the community. * RN and other staff inappropriately deferred to, believed without reasoning or questioning, and acted upon DC deputies’ characterizations of the patient’s unresponsive condition as being purposeful as in “choosing not to walk,” “won’t stand up,” and “refusal to respond,” “normal” and “usual,” and “catatonic.” * RN staff who were responsible for the patient in the AD and en route to the inpatient unit failed to requested the immediate presence of a physician when the patient’s unresponsive physical condition was believed to be behavioral versus medical. 2.a. During the entrance conference on 04/24/2024 beginning at 1035, hospital staff that included the Interim OSHS/CMO, Interim DS, COP, COM, CNO, DQM, and AAG confirmed the hospital’s 04/19/2024 self-report of an incident that occurred on 04/18/2024 that involved Patient 1. 2.b. During review of incident documentation and hospital response with staff that included the Interim DS, DQM, DSC, COP, COM, DOS, PD, BOM1, and AAG on 04/24/2024 beginning at 1440 staff described the hospital’s investigation and actions taken to date. A document titled “Investigative Memo,” dated 04/24/2024 provided a summary of the information given by staff during the incident and response review on 04/24/2024 and included the following: * “Date of incident: 4/18/2024” * “Incident Nature: Unexpected patient death” * “The purpose of this memo is to document the investigative process and immediate actions associated with the unexpected patient death on 4/18/2024, [Patient 1].” * “The following is a timeline of events, and all times are approximate: - Patient arrival, 1047 hrs. - Patient entry into sallyport in County Transport Vehicle, 1057 hrs. - Patient wheeled into Admissions area in wheelchair, 1102 hrs. - Patient on unit (1107 hrs.) and was taken to [their] room (off camera location) where [they were] transferred to [a] bed and staff took vitals. Staff called a code blue at 1114 hrs. due to no pulse found. - EMS arrived at OSH at 1118 hrs. - EMS arrived on the Unit at 1123 hrs. - Time of death called at 1156 hrs. - EMS Departed OSH at 1200 hrs. - Oregon State Police (OSP Case number: SP24-121397) was notified (1123 hrs.) and arrives at 1222 hrs. - Security and OSH Incident Report and Systems Investigation (IRSI) staff reviewed video independent of each other. - County Medical Examiner arrived 1246 hrs. (departed at 1536 hrs.) - OSH Director of Quality Management ... consulted with OSH Interim Superintendent ... and was directed to initiate Joint Commission Reporting of a Sentinel Event. - [DQM] sent email notification of the Sentinel event to OSH Legal Representation, Department of Justice - Oregon (DOJ) on 4/18/24. - IRSI Review of video and screening document was sent to DOJ and Standards and Compliance for Joint Commission Reporting.” * “Actions in response to preliminary investigative findings: Video review and policy evaluation identified no policy requirement for vitals check on new admissions. On 4/19/2024 OSH Interim Superintendent [and CMO] memorialized ‘CMO Directive - Admission vitals 4-19-24’ based on initial investigative findings that vitals were not taken of the patient upon admission.” * “At the time of this memo this event is still under investigation by Oregon State Police and is scheduled for a Root Cause Analysis by OSH Standards and Compliance.” 2.c. Review of the document on OSH letterhead, signed by the CMO/Interim OSHS and dated 04/19/2024, reflected the following: “To all OSH staff, This CMO Directive modifies and adds to OSH policy 6.058, ‘Admissions.’ To ensure that patients who may be medically unstable on arrival are promptly assessed and receive necessary medical care as soon as possible, it is my directive, effective April 19, 2024, that: * An Admissions RN must perform a brief assessment for every patient admitted to OSH, including - at minimum - vital signs and visual observation to identify any medical needs requiring immediate attention, before the patient leaves the Admissions area. This assessment must be documented in the patient’s medical record. * If a patient is not responsive to staff in the Admissions area, the possibility of a medical emergency must be immediately assessed. * If a patient is too combative to safely obtain vital signs, this must be communicated to the unit RN and documented in the medical record, along with the nature of the patient’s behavior. This directive will remain in effect until policy 6.058 is updated.” 2.d. A document titled “OSH Office of Quality Management” was reviewed. It included the following information: * “Incident Nature: Sentinel Event - Unexpected Patient Death” * “Date/Time of Incident: 04/18/2024 1115hrs” * “At approx. 1047 hrs. access control informed admissions Douglas County jail transport were waiting with [Patient 1] for admission to OSH. Staff arrived and the country [sic] transport vehicle entered a Sally Port, at approximately 1054 hrs. Deputies told [RN 4] [that Patient 1] would need a wheelchair because [they were] ‘catatonic’ and at times ‘flops around like a fish’. This was reported to have been described to nursing staff as normal behavior by [Patient 1]. As [Patient 1] was transferred from the transport van to the wheelchair, at approximately 1101 hrs, the admission [RN 4] reported [they] observed [Patient 1’s] eyes open and close, possibly in response to light hitting [Patient 1’s] eyes. [Patient 1] was wheeled into OSH admissions at approximately 1102 hrs. Additional staff were called to the admissions area and assisted in photographing [Patient 1] for identification. Douglas County transport restraints were removed from [Patient 1] and [they were] taken, via wheelchair, to Lighthouse 1 by OSH Staff. During this process [Patient 1] was noted as not moving on [their] own accord and staff held the patients [sic] legs up with a blanket so [their] feet would not drag on the floor. Staff and the patient arrived on the unit at approx. 1107hrs. where the patient was taken directly to a patient room. As [Patient 1] was being transferred to the bed an RN decided to check the patient for a pulse and found none. Sternal rubs were done with no response and additional checks found no pulse. A Code Blue was initiated and additional staff arrived and life saving procedures were performed including the use of CPR and an AED. Narcan and epinephrine were administered and were ineffective. Paramedics arrived at approx. 1121hrs and took over life saving efforts. [Patient 1] was pronounced dead at 1156 hrs.” 2.e. In regard to Narcan and epinephrine administration, Patient 1’s medical record included a Psychiatry General Note written by psychiatrist MD 30 and dated and timed 04/18/2024 at 1451. It reflected that the Narcan was administered by OSH staff, and in regard to epinephrine administration the note reflected that “EMS arrived at approximately 1125-1126 and took over the management of the code. They continued CPR for approximately 30 more minutes and per their report, gave 5 rounds of epinephrine. Patient did not achieve return of spontaneous circulation at any point following the start of the code, and patient was eventually pronounced dead by EMS at 1156 on 4/18/24.” 3. During interview on 04/24/2024 at 1030 with ADM the following information was provided: * AD normally has 4 AD RNs at all times. * Most admissions come in through Sally Ports 8 and 9. * When a transport vehicle arrives in Sally Port 8 drive-in garage, the deputy from the vehicle will check in with an AD nurse at the window between the garage and AD office. The AD nurse will talk to the deputy to find out “how the transport was” and any issues they need to know. The AD nurse tells the deputy to leave the patient in the vehicle and an AD nurse and a security staff will meet the patient at the vehicle before they get out. The AD nurse starts their assessment before the patient gets out of the vehicle by checking their behavior “to make sure they will be safe” and if needed, get a wheelchair for the patient. * After the patient is brought inside the AR, restraints are removed and and AD nurse will ask the patient if they have a cough or any illnesses, and take their temperature. ADM stated a full set of vital signs were sometimes taken in AR “[depending on] how cooperative the patient is.” * When done in AR, a minimum of an AD nurse, unit nurse, and a MHT escort the patient to the unit the patient is being admitted to. The AD nurse gives report to the unit staff as they are “walking through the hall to the unit.” When they get to the unit, staff “do vitals, weight, admissions process and shower.” * Regarding Patient 1, ADM stated 2 patients were in the transport vehicle upon arrival, Patient 1 and another patient. The deputies said Patient 1 was not being compliant so they brought the other patient in first and went through the process of checking them in before bringing Patient 1 in. After that, an AD nurse and security staff went out to the vehicle and met Patient 1 who was inside the vehicle. ADM asked the surveyor if they wanted to talk to RN 4, the AD nurse who went out to the vehicle. 4. During interview on 04/24/2024 at ~ 1205 regarding Patient 1, DQM stated the DC deputies had stopped at another location before arriving at Sally Port 8. When they arrived there were two patients in their transport vehicle, Patient 1 and another patient. 5.a. During interview on 04/24/2024 at 1105 with RN 4, they stated they had worked in AD since August 2023. RN 4 provided the following information regarding Patient 1: * A “Douglas County” transport van pulled into Sally Port 8 drive-in garage. The deputies said the patient would need a wheelchair because they had not been able to get into the van themselves and had been “flopping around like a fish.” The deputies stated that was the patient’s baseline. * RN 4 stated they got a wheelchair for the patient and went to the back of the van with a security staff. The patient, who was in the back of the van, “opened their eyes and moved a little”. RN 4 introduced themselves to the patient. The deputies told the patient, “We’ll get you out [of the van]” and the patient closed their eyes. RN 4 stated “I thought [the patient was] not being cooperative” and asked for more security staff. RN 4 stated 5-6 security staff came. The deputies gave the patient a few minutes to get out of the van and when they did not, the deputies lifted the patient to the wheelchair. RN 4 stated the deputies held the patient’s legs up while they wheeled the patient backwards from the van into the AR. * RN 4 stated in the AR “we got a photo of the patient for [their] ID” and the deputies said it would be OK to remove the patient’s cuffs because they had never been aggressive. The deputies removed the cuffs. The patient was not able to hold their head up and “kept [their] eyes closed.” RN 4 stated the patient was slouched with their head to one side, and “not holding it up like a normal person holds their head.” * RN 4 stated “typically we take a temperature and ask about a cough” in the AR. RN 4 stated they did not check the patient’s temperature or any other vital signs and did not ask the patient if they had a cough. When RN 4 was asked if the patient was breathing, they stated, “I didn’t observe any chest rise and fall.” In response to the surveyor’s follow-up question in regard to indications of oxygenation such as the patient’s skin color and appearance, RN 4 additionally stated that the patient “was African American, had dry skin, and I didn’t notice anything abnormal.” * RN 4, a unit nurse, and security staff pushed the patient in the wheelchair from the AR to LH1. One of the security staff lifted the patient’s legs with a blanket so their legs wouldn’t drag. When they got to the patient’s room on the unit, the unit RN and two security staff laid the patient supine on the bed because the patient would not get on the bed themselves. RN 4 stated, “At that point, I knew something was off because there was no response from the patient, so I checked for a pulse. Nothing. I checked a sternal rub and nothing.” The patient had no pulse and was not breathing, and they called a code blue. 5.b. Incident documentation recorded by AD RN 4, dated 04/18/2024 and untimed, reflected that “Access control called the main admissions office phone at around 10:47 to report that Douglas County was waiting to get into Sally Port 8 for an admission. Douglas County was scheduled to drop off two admits to OSH today on 4/18. [Patient 26] who was scheduled to admit to FW1, and [Patient 1] was scheduled to admit to LH1. The Douglas county transport van was waiting in the circle outside of OSH for roughly 5-10 minutes, due to there being a secure transport van in Sally Port 8. [RN 3] admissions RN, went outside Sally Port 9 to talk to the Douglas county officers to find out how the pts were doing. When [RN 3] came back through Sally Port 9, [they] reported to me ([RN 4] Admissions RN) that the officers said [Patient 1] will need a ‘wheelchair’ because [the patient] ‘flops around like a fish’ and is ‘catatonic’. After secure transport left Sally Port 8. Douglas county pulled into Sally Port 8. FW3 unit staff showed up first, and [RN 3] who was assigned to admit [Patient 26] brought in [Patient 26] and introduced them to the FW3 staff and that pt was taken to FW3. [Patient 1’s] unit staff from LH1 ([RN 13] along with unit MHT) showed up next. I was assigned to admit [Patient 1] as I had done [their] pre-admit note in avatar as well as a nurse to nurse with the jail RN. The deputy standing in the admissions area adjacent to Sally Port 8 then reported to me, ’[Patient 1] won’t stand up, [they’re] catatonic. [They’ll] need a wheelchair’. RN asked the deputy ’[They] won’t stand at all?’, and deputy responded ‘No’. Wheelchair and a blanket was obtained by this RN. [MHST 18] was the security assigned to help with admissions for 4/18. As Sally Port 8 doors were opened by access control, [MHST 18] held open the doors while this RN followed deputies to the back of the van with the wheelchair. The deputies opened up both doors to the back of the van. [Patient 1] was seen sitting in a slumped position with [their] back against van partition. As soon as the van doors opened, there was sunlight that came streaming into the back of the van, and this RN could see [Patient 1’s] eye open and close. Deputies said to [Patient 1] that they needed [them] to get into the wheelchair and gave [the patient] a few seconds but pt did not make any movements or indication that [they were] going to get up. Deputies then assisted pt on either side and lifted the pt into the wheelchair. RN introduced [themselves] to [Patient 1] and explained [they were] at the hospital but pt did not respond. RN asked for pt to lift [their] legs, so [they] could be wheeled, but [Patient 1] did not lift [their] legs. Both deputies each lifted one of the pt’s legs by the pant leg so [the patient’s] heels would not be dragging, and this RN wheeled [Patient 1] backwards into the adjacent admitting room connected to Sally Port 8. [MHST 18] had called for additional security at the request of this RN, who were also present in the admitting area. A photo was obtained of [the patient] for [their] ID badge for security, but [they] did not open [their] eyes. This RN was assessing whether or not the cuffs should be removed in the admitting area, or on the unit for safety, when officers reported that they did not see [the patient] as a threat, and [they] had ‘never been physically violent’. This RN gave the directive for officers to remove the cuffs as pt was not exhibiting any signs of aggressive behaviors. Cuffs were removed by officers. Pt was wheeled by security to LH1, with one security wrapping a blanket underneath pt’s legs and lifting them up so they did not drag on the floor. Admissions RN and unit staff followed as well. Pt was taken onto LH1 unit, and down one of the first hallways on the right hand side as you enter the unit, where the pt’s assigned bedroom was. Pt was wheeled into [their] room, and staff informed [the patient] that it was [their] bedroom and [they] could get up. One staff member said ’[Patient] won’t get up, [they’re] catatonic’. Security and unit RN and another staff lifted the pt onto the bed. Pt was now in a supine position on the bed. Unit RN, [RN 13], then began doing [their] assessment. [RN 13] tried verbal stimuli, yelling pt’s name, checking radial and pedal pulse, checked for breathing. This RN checked for radial pulse on the right side, and there was no pulse felt. This RN confirmed with [RN 13] there was no pulse. Compressions were started, and a code blue was called on the radio by security. Crash cart was obtained with AED. Pt was moved to the floor in supine position for compressions and ambu bag was used for breath. 911 was called. Two OSH medical doctors arrived. AED advised no shock. EMS arrived and took over care.” 6. Incident documentation recorded by MHST 18, dated 04/18/2024 and untimed, reflected that “I, [MHST 18], was the admissions security staff to assist during the admit with the new patient [Patient 1]. There were two patients from Douglas County admitting today and [Patient 1] was the second one to come in at approximately 1105. When the Deputies arrived, they had let us know that this patient was not talking or moving but that this was usual for [them]. They recommended that we bring a wheelchair due to [the patient] choosing not to walk but that it was “[their] normal” per the deputy. They mentioned that they had to help place [Patient 1] into the vehicle to bring [them] here to OSH. [AD RN 4] took a wheelchair to the van where the patient was sitting. The officers asked the patient to exit the vehicle a couple times to which the patient did not move. I am unsure as to who helped the patient exit the vehicle and place [them] into the wheelchair. I stood holding the door at sallyport 8 open and called for additional security. Additional security responded. [AD RN 4] introduced [themselves] when [they] entered the building, then I introduced myself and let [the patient] know I would be taking [their] photo for [their] OSH ID badge. I took [the patient’s] photo. [AD RN 4] asked [the patient] to contract for safety and there was no response. The deputies assured us that the patient would be safe and that this is just how [they were]. So [AD RN 4] gave them the go ahead to remove the cuffs. Another security staff asked, “is [the patient] catatonic?” and the deputies responded saying “pretty much.” 7. Incident documentation recorded by MHST 16, dated 04/18/2024 and untimed, reflected that “... a call came over the radio for additional security assistance at Sallyport 8 with a new admit at 11:03. As I got closer to Sallyport 8 I could see security staff and two sheriff deputies standing in a semicircle around [Patient 1], who was still out of view to me in the admissions room attached to sallyport 8. There were two unit staff, [RN 13] and [MHT2 8], standing outside the room waiting for the admit per protocol, as I tried to quietly enter the room to not disrupt anything. I could see the admissions [RN 4], standing next to [Patient 1] attempting to get [them] to respond and open [their] eyes, but [they] just sat slumped in the wheelchair, in full cuffs, and unresponsive. Someone leaned over to me to let me know that this was a behavior, and I took that to mean that this situation was going to be unpredictable due to this being a new admission with no prior hospitalization. It is protocol to hear the patient agree to safety before we can release [them] from [their] cuffs. The deputies mentioned that [the patient] hadn’t been violent, that all their assistance was because [they were] ‘catatonic’ and refused to respond. I saw that the unit staff had propped open the door to listen, so I stepped out to fill them in on what the deputies had said. When I came back into the room, they started to remove the cuffs, so I left the room again to open doors ahead of them to ease the transportation process. [TMHA 19] was pushing the wheelchair while [MHST 20] was holding [the patient’s] legs up with a blanket, so [their] feet didn’t drag on the ground. Halfway there, [MHST 17] swapped out with [MHST 20] and carried the patient’s legs in a blanket. Once we got to the patient’s new unit, LH1, [RN 13] wanted to assess the patient in [their] room (Room# G02-143) so [RN 13] and security staff lifted the patient from the chair to the bed. [RN 13] sent someone to grab the vitals machine while [they] continued to rub on the patient’s chest, tap [their] shoulders, and shout [their] name. I stood out in the hallway due to patients walking by the room, redirecting them as they came near.” 8. Incident documentation recorded by MHST 17, dated 04/18/2024 and untimed, reflected that “When I arrived at Sally Port 8, I saw the admission, [Patient 1] slouched down in a wheelchair unresponsive with closed eyes. Admission [RN 4] asked the two deputies from Douglas County how [Patient 1] has [sic] been on the way over from Douglas County? One of the deputies stated, ‘This is how [the patient] always, [sic] is unresponsive and is catatonic.’ [RN 4] was attempting to get a response from [the patient]. One of the deputies stated, ’[the patient] is not violent we just needed to get [them] out of the truck by force because [they were] not cooperating with us.’ [RN 4] stated [they] did not want to transport [Patient 1] in the wheelchair with [their] feet being dragged. [TMHA 19] stated we can use a blanket to hold [the patient’s] feet up and have someone hold the blanket while escorting the patient. [MHST 20] began to assist with holding the blanket while [TMHA 19] was pushing the wheelchair to Lighthouse 1. I relived [sic] [MHST 20] due to [them] needing a break. Once we arrived on Lighthouse 1 in the main entry hall, [the patient] continued to slide down in the wheelchair I asked security to assist me in helping move up [Patient 1] in the wheelchair. Staff then entered the south hall and went into room G02-143. [RN 13] and [TMHA 19] and I assisted [the patient] to [their] bed. [RN 13] began to do an assessment on [the patient] and began to check [their] pulse on [their] right wrist, [RN 13] stated [they were] not feeling any pulse.” 9. Incident documentation recorded by SOS 31, dated 04/18/2024 and untimed, reflected they were “Sending this incident report on the behalf of [MHST 14]. sometime early this morning before 11 o’clock security was called over the radio to assist with an admission at Sallyport 8. Myself and [MHST 32] responded. We walked into the foyer area. To the left of me, I saw [Patient 1] sitting in a wheelchair, patient was slightly slumped or slouched in the wheelchair. Eyes closed with a blanket placed around the cuff [sic] area/torso. Patient had jail clothes on with no shoes or socks. Patient had belly chain and wrist restraints, but no ankle restraints from what I saw. The deputies from Douglas County jail stated that the patient was unresponsive. I heard someone unknown to me reference the unresponsiveness to being catatonic, at which the deputies responded yes but that is normal for [the patient]. They proceeded to state that the patient is not assaultive hasn’t been since being there in the jail but that [they] just [don’t] respond. The admission nurse [RN 4] requested the deputies remove the cuffs. The cuffs were removed. [MHST 20] put a blanket underneath the patients legs, lifting them in the air to not drag on the ground. [TMHA 19] pushing the wheelchair. We got Halfway to the bubble, we stopped so that [MHST 20] could be swapped out for somebody else and repositioned the patient’s body on wheelchair. [TMHA 19] and I then lifted the patient bringing [them] back fully on the chair and proceeded to the patients [sic] room. Unit nurse [RN 13], [TMHA 19] and I lifted the patient out of the wheelchair assisting [them] to the bed. [RN 13] began checking for responsiveness. [RN 13] then requested for the vital machine and code blue to be called. Throughout the remainder of the code blue, I assisted in updating Access Control and Dispatch for on [sic] information from Salem Police and Fire Emts. Patients time of death was 1156.” 10. Incident documentation recorded by MHST 20, dated 04/18/2024 and untimed, reflected that “I responded to a call for security assistance at Sally Port 8. When I arrived, I saw Douglas County Deputies and OSH staff were standing around a patient, later identified as [Patient 1], that was in a wheelchair. The Deputies described [the patient] as being catatonic. I asked the Deputies if [the patient] had been responsive at all during the trip, they said that [the patient] was moving up and down in the back of the van. I then turned towards [the patient] and addressed [them] loudly and there was no response. I observed that there was abnormally thick but clear saliva around [their] mouth, I addressed [the patient] again and there was no response. [MHST 18], who was assigned new admissions processing then took a picture of [Patient 1], as part of the admissions process. It was then decided that since [the patient] appeared not to be cooperative with us that we would use a blanket to lift [their] legs so that we could easily transport [them] to Lighthouse 1 via the use of a wheelchair.” 11. Incident documentation recorded by TMHA 19, dated 04/18/2024 and untimed, reflected that “The admissions [RN 4] made the decision to have the deputies remove the restraints before we moved the patient to Lighthouse 1, after the restraints where removed I grabbed the wheelchair handles while [MHST 20] held up the patients’ legs with the assistance of a blanket while we moved the patient to Lighthouse 1. On arrival to the unit, we moved [the patient] into [their] assigned room (unknown number), the unit nurse who accompanied us from admission to the unit [RN 13] asked that we move [the patient] on the bed. [MHST 14] grabbed the patients left shoulder while I grabbed the right shoulder and [RN 13] grabbed [the patient’s] legs and we move [sic] the patient from the wheelchair on to the bed. The patient was still [sic] appeared to be in [sic] catatonic at that time. After assisting with the movement, I left as I was already late for my assigned lunch period.” 12. Incident documentation recorded by LH1 NM, dated 04/18/2024 and untimed, reflected that “[LH1 NM] is writing this incident report on behalf of [MHT 33]: I was doing the RCM/SSM checks - I saw [Patient 1] being taken to [their] room via wheelchair and [they] looked lifeless - security pushing [them] in a wheelchair - [the patient’s] hands were hanging out to the sides and staff were holding [their] legs to keep [them] in the wheelchair.” 13. Incident documentation recorded by LH1 RN 13, dated 04/18/2024 and untimed, reflected that “I was the RN assigned to [Patient 1’s] admission along with [MHT2 8]. We were called to the admission Sally Port around 1100 and waited in line as the county had two patients and the first was going to a different unit. [MHT2 8] and I remained outside the Sally Port per protocol, waiting for report from the [AD RN 4]. It was reported that the pt was not cooperating, would not walk, and [AD RN 4] retrieved a wheelchair. Security arrived at the Sally Port, evidently having been paged by admissions. The pt was retrieved from the transport vehicle utilizing the wheelchair and brought into the Sally Port; I was not able to observe the pt from my vantage point outside the Sally Port. It was reported to us that the pt was continuing to be uncooperative and not responding. Two security staff wheeled the pt out of the Sally Port, one pushing [TMHA 19], the other holding the pt’s legs up with a blanket draped under [the patient’s] ankles ([MHST 20], switched with [MHST 17] at some point). We quickly made our way to LH1; I walked alongside the wheelchair, attempting to engage the pt, explain the plan. We passed the bubble on LH1 at 1111. We had decided to take [Patient 1] directly to [their] room and transfer [them] to [their] bed. On arrival to [patient’s] room, security [TMHA 19] and I immediately lifted the pt out of the wheelchair and onto the bed. During that transfer, I noted the pt was more limp than would have been expected from a simply unresponsive pt. I immediately began checking for a pulse on [their] R wrist and began calling [their] name loudly. I performed sternal rubs when I could not elicit a response verbally. When there continued to be no response I requested staff call a code blue (code was called @ 1114). I then attempted to find a pulse under [the patient’s] upper arm, carotid, pedal while continuing to attempt to rouse [them] verbally and with sternal rubs and watch for chest rise (this was difficult to assess as [the patient] was in loose fitting jail clothing). I pulled open [the patient’s] eye lid and noted a dilated pupil; I used my flashlight to test reactivity and no reactivity was seen. Staff arrived quickly and we began chest compressions (@ 1115). Staff arrived with the AED and crash cart. After applying the AED pads, we transferred the pt to the floor to have a more firm surface and continued compressions alternating with AMBU bag respirations following CPR protocol. Narcan was requested and administered by [PMHNP 23]. Various staff and medical personnel rotated through administering compressions and AMBU respirations. CPR was continued per protocol, following prompts from AED (no shock ever advised) until paramedics arrived and took over the situation.” 14. On 04/24/2024 beginning at 1155, survey team review of multiple camera views of video-recordings, without audio capability, revealed the following timeline of events that occurred on 04/18/2024 when the vehicle Patient 1 was transported in from Douglas County Jail arrived to the OSH Sally Port 8. Regarding the video review there was no camera view provided in Sally Port 8 that showed directly into the back of the transport van used to transport Patient 1 so that the entirety of the inside of the van could be visualized. The camera that showed the view at the back of the van was mounted off to the side of the Sally Port so that a side view of the right rear of the van could be visualized. With both rear van doors opened only a small portion of the inside of the back compartment could be seen. In addition, the quality and clarity of some of the video footage was poor and details of some images were not clear. Further, there were occasions during video review where video skipped several seconds when there was activity occurring. Commonly video may skip seconds or minutes when there is no activity occurring. * Between ~ 1054:52 and 1056:23 two camera views inside Sally Port 8 showed: A DC Jail transport van drove into Sally Port 8 with two DC deputies seated in the front seats. The garage door closed after the van had fully entered the Sally Port. A DC deputy walked to the back of the van, opened one of the back doors, removed two bundles of items, and walked away towards the door to the admitting room. At ~ 1056:07 Patient 26 exited the van through the passenger right side doors and walked in front of the second DC deputy towards the door to the admitting room. * Between ~ 1058:18 and 1100:20 one camera view inside Sally Port 8 showed: A DC deputy walked back to the back of the van, opened one of the back doors and looked inside momentarily, then started to close the door, then reopened it and looked inside and left it open. They stood at the back of the van and periodically looked inside through the open door. * Between ~ 1100:21 and 1102:20 two camera views inside Sally Port 8 showed: The second DC deputy approached the back of the van and joined the first deputy, immediately followed by RN 4 who pushed a w/c towards the back of the van. The deputies opened the other door so that both back van doors were open. At ~ 1100:28 only a portion of Patient 1’s lower body was visualized up against the rear left side of the van. They were positioned on the floor so that their body was facing the interior of the left rear corner side panel of the van, their left buttocks could be seen on the van floor, the left side of their body was at the very end of the floor where the door closure was, their left leg was observed to be bent at the knee and had partially fallen outside of the van. The two deputies picked Patient 1 up off the van floor and in awkward and uncoordinated movements took the patient out of the van and rotated them to place them in the w/c. There was no indication that Patient 1 was assisting or resisting. The parts of their body that could be visualized were limp. Patient 1, who was Black, was positioned in the w/c with their shoulders at the level of the top of the w/c seat back, their head slumped fully forward towards their chest, and their eyes closed. RN 4 folded a blue blanket and place it around Patient 1’s chest and shoulders and wrapped the ends around the w/c handles. At 1101:38 as the RN began to pull the w/c backward towards the admitting room Patient 1’s upper body was observed to be positioned lower in the w/c and slumped toward the left. As their head was slumped forward, the lower part of their face, including mouth and nose, was covered by the blue blanket. At ~ 1102:01 as RN 4 pulled the w/c backwards along the side of the van towards the admitting room door, both deputies bent over the patient and made movements consistent with each having picked up one of the patient’s pants legs to lift the patient’s feet off the ground. * At ~ 1102:24 one camera view inside the admitting room attached to Sally Port 8 showed: RN 4 pulled the w/c with Patient 1 backward into the admitting room. One deputy had hold of the patient’s right pant leg near the hem with their right hand. The other deputy had hold of the patient’s left pant leg near the middle of the pant leg with their left hand. Both of the patient’s bare feet were dangling slightly above the floor. The patient’s hands were cuffed in their lap. Their head was slumped forward, their eyes were closed, and their face was covered by the blue blanket that was held in place by RN 4 around their chest and shoulders and the w/c handles. * Between ~ 1102:30 and 1105:50 one camera view inside the admitting room showed: RN 4 parked Patient 1 in the w/c near the middle of the room. The deputies’ positions around the patient’s body periodically block the camera view. At this time four other staff (not including RN 4 and the two deputies) arrived into the room. The RN can be seen to lean over towards the patient on the left side of the w/c and arms are extended toward the patient although the patient cannot be seen behind one of the deputies. At ~ 1103:02 the deputies stepped away and the patient was observed to be slumped further down in the w/c, however, the patient’s face was no longer covered by the blue blanket that remained around their chest and shoulders. It looked as though RN 4 had their right hand on or near the blanket below the patient’s face as if they moved the blanket to uncover the patient’s face. The patient was motionless and their eyes were closed. At that time there were at least six other staff in the room. RN 4 stepped away and back from the w/c and was observed to address the deputies and staff that had gathered in the room who all stood and faced the patient within a few feet of the patient. Two of those staff stepped towards and leaned towards the patient and took photographs of the patient with cell phones. Then there were eight other staff in the room. The 11 people in the room (excluding the patient) were observed to talk amongst themselves and to the group while Patient 1 remained motionless in the w/c with their wrists in law enforcement transport restraints, their chin laid on their chest, and their eyes closed. Patient 1 showed no signs of movement. At ~ 1104:18 RN 4 slightly leaned toward the patient, extended their arm, and may have touched the blue blanket, the patient’s clothing near their shoulder, or the w/c. It was not clear. At ~ 1104:24 one of the staff persons approached the patient, leaned toward them, and extended their arm towards the patient. There was no visible response or movement from Patient 1. At ~ 1104:29 a DC deputy removed the law enforcement transport restraints from the patient’s wrists. At ~ 1105:08 when their right hand was free from those restraints their right forearm, wrist, and hand slid down and across their right thigh. At that time the patient was observed to have slid further down in the w/c, the blue blanket was removed, their head remained slumped fully forward with their chin on their chest, their eyes were closed, and their legs were extended straight in front of them with their bare feet on the ground. At ~ 1105:27 a staff person took the blue blanket and with assistance from another staff person positioned it under and around both the patient’s legs at the knees and formed a handle of sorts to lift the patient’s legs up off the ground. At that time the patient’s buttocks were near to sliding off of the w/c and their arms had fallen off their thighs onto the w/c seat on either side of their body. At ~ 1105:44 one staff person pushed the w/c forward and another staff person held the blanket that was around the patient’s legs to keep them off the ground and the group moved towards the door out of the admitting room into a hallway towards the inpatient unit. At no time while in the admitting room did the patient assist or resist, nor did they open their eyes or demonstrate any observable movement. At no time was there any meaningful touch or other activity by any staff that could be construed as a patient assessment component. * Between ~ 1105:50 and 1108:30 four camera views showed: The two staff who pushed the w/c and held the patient’s legs up were joined by RN 13 and six other staff as they transported Patient 1 through hospital hallways to the inpatient unit. Patient 1 remained motionless with their eyes closed and slumped to the left with their arms laid limply on the w/c seat on either side of their body and their chin laid on their chest. Overhead camera views during the transport showed that the blanket around the patient’s knees used to hold the patient’s legs up during transport had been tied and knotted or twisted. At ~ 1108:30 staff pushed the patient in the w/c into the assigned patient room on the inpatient unit and that was last video observation of Patient 1. * Video recording beginning at 1108:30 captured staff activities in the hallway outside the room after Patient 1 entered the room, and after the Code Blue response had been initiated. Those video observations are described below under Finding 28 of this Tag. 15.a. On 05/02/2024 at ~ 1320 while in the AD the survey team observed that a Douglas County Jail transport van was parked in Sally Port 8. DC deputies agreed to show the survey team and hospital staff present the inside of the back of the van. A rear compartment that was fully separated from the rest of the van was observed. It was the entire width of the van and ~ 3 feet deep. It was divided into two unequal sections with a rigid divider from floor to ceiling comprised of metal on the bottom portion and metal screen on the top portion. The larger section comprised ~ two thirds of the width of the van. Each section contained a built-in black metal box that was covered with a silver metal top. Near the top and center of each black box there was a handle that protruded outward under which a padlock was dangling. The boxes were the entire width of each section and were ~ 2 feet high off the floor. The floor space that remained in each section between the box and the interior end of the van where the back doors closed was ~ one foot. 15.b. During the observation the DC deputies indicated that individuals in custody who had behavior problems were sometimes transported in that rear compartment and could sit on either side of the divider in the back of the van. 15.c. In an email received on 05/06/2024 at 1101 the DSC provided a photo from the security video of the 05/02/2024 observation. The photo showed the license plate number of the back of the van observed on 05/02/2024 was the same license plate number as the van observed in the video recordings of the 04/18/2024 Patient 1 transport. 16. Documentation in Patient 1’s medical record consisted of the following documents: * An “Oregon State Hospital Non-Medication Telephone Orders” form that contained a medication order for Narcan dated 04/18/2023 at 1120. * A Douglas County Circuit Court “Order of Commitment to Oregon State Hospital.” * A Pre Admit Note written by AD RN 4 and dated and timed 04/18/2024 at 1338 that reflected the RN’s encounter with Patient 1 that is also described under Finding 5.b. above in this Tag. * A Nursing Progress Note written by LH1 RN 13 and dated and timed 04/18/2024 at 1304 that reflected the RN’s encounter with Patient 1 that is also described under Finding 13 above in this Tag. * A Nursing Progress Note written by the LH1 NM and dated and timed 04/18/2024 at 1636 that reflected the NM’s encounter with Patient 1 from the time they were notified that a Code Blue was needed for Patient 1 who had arrived on LH1 and is also described under Finding 27 below in this Tag. * A Psychiatry General Note that was written by a psychiatrist, MD 30, and dated and timed 04/18/2024 at 1451. It reflected the MD’s encounter with Patient 1 from the time they responded to the Code Blue called on LH1. * A Psychiatry General Note that was written by a psychiatrist, MD 27, and dated and timed 04/18/2024 at 1838. It reflected the MD’s encounter with Patient 1 from the time they responded to the Code Blue called on LH1. There was no other documentation in the medical record. 17.a. As described under Finding 2.c. above in this Tag, the Interim OSHS, who was the CMO, issued a “CMO Directive” dated 04/19/2024 that contained three parts: 1. AD RNs would perform and document a brief assessment that included vital signs upon patient entry to AD and prior to transport to the inpatient unit. 2. If a patient was not responsive in AD the possibility of a medical emergency must be immediately assessed. 3. If a patient was combative to have vital signs taken while in the AD, that was to be communicated to the unit RN and documented. 17.b. Regarding the 1st and 3rd items on the CMO Directive, the medical records of all patients admitted to the hospital beginning the day of the CMO Directive, 04/19/2024, through 04/25/2024 were reviewed. The review reflected that 22 of those 24 patients had the brief assessment and vital signs required by the CMO Directive documented in their medical records. 17.c. In one record where a brief assessment and vital signs were not documented in the AD, Patient 2 on 04/19/2024, the inpatient note on that date reflected the patient arrived on the inpatient unit at 0945 and was ambulatory with crutches and communicative with staff. The CMO Directive was issued by email to AD staff on 04/19/2024 at 1007, after the two morning admissions on 04/19/2024. In the second record where vital signs were not taken in the AD, Patient 24 on 04/25/2024, the patient’s behavior was too combative and in accordance with the 3rd CMO Directive item the medical record contained the required AD RN note, and additionally an incident report had been filed by the AD RN. 17.d.. The 2nd item on the CMO Directive required that if a patient was not responsive in AD, the possibility of a medical emergency must be immediately assessed. Survey findings revealed that if a patient was observed or assessed to require a medical emergency response in the AD the disorganized and fragmented state of the medical emergency supplies and equipment in that area was such that a response would not likely be timely or efficient. The detailed findings are described under Findings 18 through 21.c. below and were the basis for identification of the IJ situation referred to under the Deficient Practice Statement above for this Tag, and under Tag A-0000. ****************************************************** 18. The findings that follow reflect the hospital’s failure to ensure medical emergency supplies and equipment were organized and managed to ensure availability of necessary items during a medical emergency response. 19. During tour of AD with DSC, PD and ADM on 04/24/2024 at 1020, observations included: * Upon entering AD hall, a secure door at the end of the hall led into the AR. From inside the AR, a secure door led into the Forensics Evaluation area. Another secure door from the AR led directly into Sally Port 8’s vehicle drive-in garage. A floor to ceiling garage door was observed between the drive-in garage and the outside of the building so that a vehicle could drive fully into the garage and have the doors closed and secured behind the vehicle. * From the AD hall, to the right of the AR entry door, a secure door lead into the AD office. A sliding window was observed between the AD office and drive-in garage so that AD staff could open the window and communicate with individuals in the garage. * From the AD hall, to the left of the entry AR door and across the hall from the AD office, a secure door led into room G04-117A. * A secure door leading to Sally Port 9 was observed near the Admissions office. Sally Port 9 had a secure door that led directly to the outside of the building and no drive-in garage. 20.a. During a second tour of AD on 04/24/2024 at 1610 with Interim DS, DSC, and RN 3, observations included: * In AD office, a portable oxygen tank and a blue duffle type Code Blue Bag. The bag had multiple zippered top and side pockets with red breakaway locks. The bag was opened and contained an Ambu bag, dressings, pulse oximeter, oxygen tubing, pen lights, and other emergency supplies. There was no inventory list observed that identified the contents of the Code Blue Bag. A clipboard with multiple copies of partially completed “Emergency Equipment Checklist” Attachment A was observed near the Code Blue Bag. * In Room G04-117A, a tackle box style Emergency Kit was observed with a green breakaway lock. The lid read “Emergency Box” in red professional type print. * An AED was observed mounted on the wall in the Forensics Evaluation area down a hall and around a corner from the AR. * Observation of the path from AR to outside AN1 nurse station involved leaving AD and going through 3 secure doors. 20.b. “Emergency Equipment Checklist” Attachment A observed in Admitting office near the Code Blue Bag was reviewed. There was no date that reflected when it had been created or revised. The top portion of the checklist had spaces for recording month and year and stated “Consult with Nursing Supervisor if any equipment problems. Every section must be completed.” The checklist had a “Date” column with rows numbered 1-31 for checking the following items each day in a month: - “Y N” for “AED Present” - “Y N” for “Code Blue Bag or Red Cart Lock Intact.” - “Y N” for “Emergency Med Box Lock Intact” - “Y N” for “Oxygen Tank = 1000 p.s.i.”F- “Y N” for “Suction Machine Charged, Clean & Operational” The checklist also had spaces for recording time, comments, and signature each day. 20.c. The “Emergency Equipment Checklist, Attachment A for January 2024 dated “Month/Year: 1/2024” was reviewed and was incomplete and did not provide assurance emergency supplies and equipment were checked and available when needed. Examples included: - The spaces for documenting the time was blank every day of the month. - For 01/01/2024, 01/15/2024, 01/16/2024, 01/17/2024, 01/19/2024 and 01/31/2024, “Y” and “N” were not circled or otherwise marked for “Code Blue Bag or Red Cart Lock Intact” and “Oxygen Tank = 1000 p.s.i.” checks. In addition, spaces for documenting signature were blank for those dates. - The columns for documenting “AED Present”, “Emergency Med Box Lock Intact”, and “Suction Machine Charged, Clean & Operational” had a squiggly line drawn through each and there was no documentation that reflected those had been checked. - The spaces for documenting comments were blank every day of the month. 20.d. The “Emergency Equipment Checklist, Attachment A for February 2024 dated “Month/Year: Feb 2024” was reviewed and was incomplete. Examples included: - The spaces for documenting the time was blank every day of the month. - For dates 02/02/2024, 02/09/2024, 02/16/2024, and 02/19/2024, “Y” and “N” were not circled or otherwise marked for “Code Blue Bag or Red Cart Lock Intact” and “Oxygen Tank = 1000 p.s.i.” checks. Spaces for documenting signature were blank for those dates. - The columns for documenting “AED Present”, “Emergency Med Box Lock Intact”, and “Suction Machine Charged, Clean & Operational” had a squiggly line drawn through each. - The spaces for documenting comments were all blank. 20.e. The “Emergency Equipment Checklist, Attachment A for March 2024 dated “Month/Year: March 2024” was reviewed: - The spaces for documenting “Time” was blank every day of the month. - For 03/01/2024, “Y” and “N” were not circled or otherwise marked for “Code Blue Bag or Red Cart Lock Intact” check and the signature space was blank. - For 03/01/2024, 03/18/2024, 03/19/2024, 03/20/2024, 03/21/2024 and 03/22/2024, “Y” and “N” were not circled or otherwise marked for “Oxygen Tank = 1000 p.s.i.” checks. - The columns for documenting “AED Present”, “Emergency Med Box Lock Intact”, and “Suction Machine Charged, Clean & Operational” had a squiggly line drawn through each and there was no documentation that reflected those had been checked. - The spaces for documenting comments were blank every day of the month. 20.f. The “Emergency Equipment Checklist, Attachment A for April 2024 dated “Month/Year: April” was reviewed: - The spaces for documenting the time was blank every day through the date of this survey. - For 04/10/2024, 04/11/2024, 04/12/2024, 04/15/2024, 04/16/2024, 04/22/2024, 04/23/2024 and 04/24/2024, “Y” and “N” were not circled or otherwise marked for “Code Blue Bag or Red Cart Lock Intact” and “Oxygen Tank = 1000 p.s.i.” checks. Spaces for documenting signature were blank for those dates. - The columns for documenting “AED Present”, “Emergency Med Box Lock Intact”, and “Suction Machine Charged, Clean & Operational” had a squiggly line drawn through each and there was no documentation that reflected those had been checked. - The spaces for documenting comments were blank every day of the month. 20.g. The checklist being used in OSH-Salem AD was not the same version as the “Emergency/Medical Equipment Checklist” Attachment A with revision date “10/2023” in the P&P titled “Emergency and Multi-Patient-Use Medical Equipment” in Findings 22.b. and 22.c. below. For example, the checklist being used in AD reflected “AED Present”. The checklist in the P&P reflected “AED shows green check”. The checklist being used in AD included “Code Blue Bag” and “Emergency Med Box Lock Intact.” The checklist in the P&P did not include those. The checklist in the P&P included “Medical Equipment Disinfected” and the checklist being used in AD did not include a medical equipment disinfection. In addition, observations of the Code Blue Bag in Findings 20.a. and 21.a. reflected it had multiple zippered pockets with breakaway locks. However, the checklist did not provide instructions or a system for tracking each of those to ensure the bag had not been opened and emergency supplies removed without staff awareness 20.h. During interview on 04/24/2024 at 1620, RN 3 stated: * If a patient was unresponsive in AD they would call a code blue and use the emergency supplies and medication observed in Finding 20.a. above or a “code cart might be brought from an inpatient unit.” * The Emergency Kit in Room G04-117A contained Narcan. * There was no suction equipment in AD and if a patient needed suction “a code cart would be brought from [AN1].” The closest code cart was inside the nurse’s station in AN1. * The Code Blue Bag with emergency supplies observed in Finding 20.a. should have a supplies list attached to the bag that identified the emergency supplies inside the bag. RN 3 looked for the supplies list and could not find it. * The “Emergency Equipment Checklist” observed near the Code Blue Bag should be completed “Monday through Friday”. 21.a. During tour of AD with DSC and PD on 04/25/2024 at 1230, observations included: * The door leading into AD office had an ~ 8.5 x 11 size, professional type sign on the door that read “Code Blue ... Emergency Equipment.” Handwritten entries added to the sign included “Blue bag + O2 are here AED by rm G04-121 (Forensic Eval [illegible marks] East Security hall)”. * Observation with RN 1 of a Code Blue Bag in the AD office revealed it was the same style observed during AD tour on 04/24/2024 at 1610. Four red breakaway locks were observed on the zippered top and side pockets. No inventory list was observed with the bag. The bag was opened with RN 1 and contents were observed and compared with an inventory list that had been received for the Code Blue Bag from hospital leadership earlier the same day. The inventory list was untitled, undated and had sections for “Center”, “Rt. Side” and “Lf. Side” pockets. Review of the inventory list and observation of the items in the Code Blue Bag reflected they were inconsistent and unclear. Examples included: - The inventory list reflected “Center [pocket] ... Pen Light (on lid with pens) & Steno Note Pad ... [quantity] ... 2 [and] 1” with a diagonal line crossed through “2 [and] 1”. Pen lights and steno note pad were observed in the bag. However, it was not clear how many or whether they should be in the bag as the quantities on the inventory sheet were lined out. -The inventory list reflected the “Rt. Side [pocket] ... Blood Pressure cuffs Lg/ExLg ... [quantity] ... 1 [and] 1” with a diagonal line crossed though “1 [and] 1”. Blood pressure cuffs were observed in the bag. Similarly, it was not clear whether they should be in the bag as the quantities on the inventory sheet were lined out. “Rt. Side [pocket]” also included “Stethoscope/oximeter ... [quantity] ... 1 [and] 1” with a diagonal line crossed through “1 [and] 1”. Similarly, those items were observed in the bag. - The inventory list reflected “Lf. Side [pocket] ... 3 [inch] roll gauze & 4 [inch] Coban ... [quantity] 2 and 1” with a diagonal line crossed through “2 and 1”. Similarly, those items were observed in the bag. - No protective eyewear was on the inventory list. Protective eyewear was observed in the bag. - The list included 3 oxygen tubing nasal cannulas. Two oxygen tubing nasal cannulas were observed in the bag. - The list included 2 oxygen non-rebreather face masks. One oxygen non-rebreather face mask was observed in the bag. * A Yankauer Suction tip with tubing was observed in the bag. No other suction items or equipment were observed in the bag. * No Narcan or other medications were observed in the bag. These findings were confirmed with RN 1 at the time of the observation. 21.b. During interview on 04/25/2024 at 1230, RN 1 provided the following information: * They started working in the AD about 6 months ago and AD was where they normally worked. * Most new admit patients and patients returning from medical appointments enter the hospital through Sally Port 8. Patients arriving in vehicles too large to enter Sally Port 8 and patients without behavior problems sometimes enter through Sally Port 9. * There is frequently a line of transport vehicles waiting to bring patients in through Sally Ports 8 and 9. The vehicles wait in parking spaces outside Sally Ports 8 and 9 “or wherever they can find a spot.” * Sometimes deputies call ahead and let AD staff know if a patient is “coming in hot”, meaning the patent was having behavioral issues. RN 1 stated while transport vehicles are waiting to bring patients into the hospital, they usually try to “touch bases” with the deputies by going outside and talking to them about how the patients are doing. They do not start evaluating patients until patients are getting out of the vehicle. If a patient had a medical problem while waiting in a transport vehicle, they would do a “formal assessment” of the patient and if the patient had a “serious issue” they would call a code blue. * If they needed Narcan for a patient, they would get it from the Code Blue Bag or from an Omnicell in AN1. RN 1 stated “We don’t have an Omnicell [in AD].” * If they needed suction equipment for a patient it would be in the Code Blue Bag in AD. * Regarding the red breakaway locks observed on the Code Blue Bag, RN 1 stated that after the Code Blue Bag was opened, the Code Blue Team was notified. The Code Blue Team checked the Code Blue Bag inventory, restocked the bag, and replaced the breakaway locks on the bag. * They confirmed there was no supplies inventory sheet with the Code Blue Bag. * They were not sure who checked the AED in Forensics Evaluation area to ensure it would be present and functioning if needed. 21.c. A second interview was conducted with RN 1 on 04/25/2024 at 1255 after they confirmed the Code Blue Bag in Finding 21.a. did not have all equipment necessary for patient suction, nor Narcan. Regarding obtaining suction equipment during a patient emergency, RN 1 stated “I’d have to go to [an inpatient] unit to get it or a code team person would get it.” Regarding obtaining Narcan during a patient emergency, RN 1 stated “I’d go to the Omnicell at [AN1] or ask a deputy. If it was my patient, I’d stay with the patient and have another nurse go get it.” 22.a. During interview on 04/25/2024 at 1200, DSC stated the P&P titled “Emergency and Multi-Patient-Use Medical Equipment” in Finding 22.b. was applicable hospital-wide including in AD. 22.b. The P&P titled “Emergency and Multi-Patient-Use Medical Equipment,” dated approved 03/01/2024 included: * “The purpose of this protocol is to describe the expectations and procedures for controlling, monitoring, and disinfecting emergency and multi-patient-use medical equipment available on patient living units at Oregon State Hospital (OSH) ...” * “All Oregon State Hospital living units must have a red emergency cart that is secured with a break-away lock, a suction machine, an automated external defibrillator (AED), and a portable oxygen tank, all of which are consistently controlled, secured, monitored, and ready to use ... Daily checks of the above items are performed by a nurse and are documented on the Emergency/Medical Checklist (Attachment A) ... The Lead Nurse is responsible for ensuring that the actions described in this protocol are performed ... The actions described in this protocol are generally performed on the Night Shift, although individual units may designate another shift for this purpose ...” * “The presence of the AED, and the green check is showing, must be verified each day ... The OSH Medical Equipment Coordinator must be immediately notified of defective equipment and related issues.” * “Red emergency carts must be stocked and locked at all times when not in use ... If the lock is found to be broken or missing, the contents must be checked against the Inventory Sheet ... The Inventory Sheet is taped to the top of the cart and also to the clipboard in the top drawer of the cart ... The Code Blue Team must be notified of the need for replacement items and a new break-away lock ... Contact information for the Code Blue Team is available ... on the Inventory Sheet, available in the red emergency cart ... and ... on a sticker on the top of the red emergency cart.” * “The status of the portable oxygen tank must be verified each day ... The oxygen tank must be replaced if the amount of oxygen is less than 1000 pounds per square inch (psi).” * “The availability of the suction machine machine, and related supplies, must be verified each day ... The suction machine must be ready for use with a package of suction tubing and a package containing oral suctioning want secured in the wide black plastic band on the front of the machine ...” * “Emergency medical equipment located in areas other than patient living units and treatment malls is maintained by the Code Blue Team.” 22.c. Attachment A, titled “Emergency/Medical Equipment Checklist” dated revised “10/2023” was reviewed. The top portion of the checklist had spaces for recording unit, month and year and stated “Every section MUST be completed. Notify unit nursing management (or designee) of equipment problems.” The checklist had a “Date” column with rows numbered 1-31 for checking the following items each day of the month: * “Y/N” for “AED shows green check” * “Y/N” for “Red Emergency Cart Lock Present” * “Y/N” for “Oxygen Tank = 1000 p.s.i.” * “Y/N” for “Suction Machine Plugged In, Tubing/Wand Present” * “Y/N” for “Medical Equipment Disinfected Complete WEEKLY” The checklist also had spaces for recording comments and RN/LPN signature each day. It was not clear how breakaway locks were tracked to ensure security and availability of emergency supplies and equipment. For example, it was not clear if those were to be numbered, unnumbered or a specific color considering numbered, unnumbered and different colored locks were observed on emergency carts and kits during the survey. The P&P did not include further process for management of emergency supplies and equipments in areas other than living units such as AD, including a system for tracking breakaway locks. 23.a. The P&P titled “Override Process for Medications in Emergency Situations” dated 05/05/2023 reflected: * “Purpose and Applicability ... To ensure medications are always readily and safely available for use at Oregon State Hospital (OSH), this policy ... This policy applies to all staff who order, dispense, or administer medications.” * “Staff must follow Procedures A to retrieve emergency medications from ADCs and from E-Kits when authorized in emergency situations ... Emergency medications are as listed in Attachment A and Attachment B.” 23.b. Procedures A included: * “Nurse ... Assess the patient ... Upon receipt of a verbal order from the practitioner to administer emergency medication ... Retrieve the medication(s) from the Automated Dispensing Cabinet (ADC) .... or from the Emergency Kit (E-Kit) ... Administer to the patient ... If medication from an E-Kit was used, complete the E-Lot requisition form attached to each kit and scan it to the pharmacy.” * “Pharmacy ... Upon receipt of an E-Kit requisition, deliver a replacement E-Kit and retrieve the opened E-Kit ... Prepare the opened E-Kit for redeployment ... Reconcile and replenish standard contents of E-Kits ... Review and record the expiration of all drug contents, and Stage the newly replenished E-Kit for deployment.” 23.c. Attachment A reflected “Emergency Medications Stocked in Automated Dispensing Cabinets (ADC)” and included: * “Stocked in all unit, treatment mall, and Medical Clinic ADCs on both campuses with the noted minimum quantities” followed by a list of medications: “Aspirin (Uncoated) 325 mg - 2 tablets ...” “Charcoal, Activated Suspension (Acti-Dose) 50 grams - 1 tube/bottle ...” “Dextrose/Glucose ... 40% (15 grams) - 2 tubes ...” “Diphenhydramine (Benadryl) a. 50 mg/mL - 2 vials b. 25 mg - 10 capsules c. 50 mg - 10 capsules ...” “Epinephrine (Epi-Pen) 0.3 mg/0.3 mL - 1 auto-injector syringe ...” “Glucagon 1 mg - 2 kits ...” “Haloperidol (Haldol) a. 5 mg/mL - 2 vials b. 5 mg - 10 tablets c. 10 mg - 10 tablets ...” “Lorazepam (Ativan) ... a. 2 mg/mL - 2 vials b. 1 mg - 10 tablets c. 2 mg - 10 tablets ...” “Naloxone (Narcan) 4 mg/spray - 2 devices ...” “Nitroglycerin (Nitrostat) 0.4 mg - 1 bottle ...” “Olanzapine (Zyprexa) a. 10 mg/2 mL - 2 vials ... b. 5 mg - 10 tablets c. 10 mg - 10 tablets.” * “Additionally stocked in all treatment mall and Medical Clinic ADCs on both campuses with the noted minimum quantities ... Albuterol (Proair/Proventil) a. 90 mcg (HFA) - 1 inhaler b. 3 mL nebulizer solution - 5 vials.” 23.d. Attachment B reflected “Emergency Medications Stocked in Emergency Kits (E-Kits) ... Admissions Emergency Kit ... Naloxone (Narcan) 4 mg/spray - 2 devices”. Attachment B did not include Epi Pen in Admissions Emergency Kits. Refer to Findings 24.a. and 25.a. that reflected Epi Pen was in Emergency Kits in OSH-Salem AD and OSH-JC Admissions area. The P&P did not include further information about how breakaway locks on E-Kits were managed and tracked. The P&P reflected additional emergency medications were stocked and available in inpatient units and other areas that were not available in Salem campus AD and JC admissions areas. P&Ps were not clear how staff in Salem campus AD and JC admissions area were to obtain those additional emergency medications should they be needed for a patient emergency. 24.a. The OSH-Salem AD was toured during the IJ verification visit with Interim DS, DSC, and ADM on 05/02/2024 at 1300. Observations inside room G04-117A with ADM included: * A 6 drawer Red Emergency Cart with one blue breakaway lock on the outside. The lock had no number or other information for tracking to ensure cart security. This created the possibility that contents could be tampered, removed and lock replaced without staff being alerted. The outside of Drawers 1, 2, 3, 4 and 6 were labeled with the contents of the drawers. Drawer 5 was not labeled and no items were observed inside the drawer. * An “Admissions Code Blue Equipment Check Sheet” inventory list dated “Updated 4/30/2024” was observed. The inventory list was separated into 6 sections for Drawers 1 through 6, with supplies/equipment in each drawer. Observation and of cart labels, cart contents, and the inventory list revealed inconsistencies between those. For example: - Sterile tongue depressors, roll gauze and Coban were observed inside Drawer 3 and were on the check sheet for Drawer 3, but were not observed on any of the drawer labels. - A label on Drawer 3 reflected “EMT scissors” and EMT type scissors were observed in Drawer 3. The check list reflected only “scissors” which could be confused with regular office type scissors. * A tackle box style Emergency Kit with breakaway lock was observed in Drawer 6. The top of the kit had a white label that read “Earliest Expiration 2/25” with a signature and a title. It was not clear whether the expiration date was intended to be February 25 or February 2025. A 2-page, front/back document titled “Admissions Emergency Kit” was observed in a plastic sleeve with the kit. Page 1 was a list that reflected two medications were in the kit, Narcan and Epi Pen. It included: - Naloxone (Narcan) 2 mg/mL syringe, quantity “2” with the following unclear expiration dates “4/24” with 3 lines marked through and no indication regarding when or why it was marked through, and below that “2/25”. The “Dosage & Administration” reflected “Adult 1 mg/1mL in each nostril” and “Indications” reflected “Suspected opiate overdose.” - “Epi pen”, quantity “1” with unclear expiration date “3/25” and no dosage, administration or indication information. The top of page 2 reflected it was a “Record of Inspection for Intact Seal and Expiration Date (Required Monthly).” The document had multiple spaces for recording signature, title, date and lock #. Review of the document reflected it was unclear and lacked evidence of seal and expiration inspections that were “required monthly”. - The first entry dated 11/10/2022 included signature, title and lock # 10572981. - The next entry dated 03/16/ 2023 included a signature, title and lock # 10572989. There was no documentation that reflected the lock (seal) and expiration date had been checked between 11/10/2022 and 03/16/2023. It was additionally not clear why the lock # had changed. - The next entry dated 04/11/2023 included a signature, title, “(inspection)” handwritten and no lock #. It was not clear what had been “inspected.” - The next entry dated 05/10/2023 included a signature, no title and lock # 10572996. It was not clear why the lock # had changed. - The next entry dated 09/12/2023 included a signature, title, and the word “date” followed by a check mark, and no lock #. It was not clear what “date” had been checked. - The next entry dated 09/15/2023 included a signature, no title and lock # 10285209. The documentation lacked evidence that reflected the lock and expiration date had been checked between 05/10/2023 and 09/15/2023. It was not clear why the lock # had changed. - The next entry dated 03/05/2024 included a signature, title and lock # 10285209. The documentation lacked evidence that reflected the lock and expiration had been checked between 09/15/2023 and 03/05/2024. * The “Emergency/Medical Equipment Checklist” dated revised “10/2023” in Finding 22.c. was observed with the cart. 24.b. During interview on 05/02/2024 at the time of the OSH-Salem IJ verification visit, ADM confirmed there was no number on the blue breakaway lock on the Red Emergency Cart. ADM stated that if the blue breakaway lock was broken, the Code Blue Team had replacement blue breakaway locks and would restock the cart and replace the lock. 25.a. During the OSH-JC IJ verification visit on 05/02/2024 beginning at 1410, the area “where admits come in” was observed by virtual remote monitoring with Interim DS, JCA, JC nursing staff and other hospital leadership. Observations included: * A 6 drawer Red Emergency Cart. The outside of Drawers 1, 2, 3, 4 and 6 were labeled indicating the contents of the drawers. Drawer 5 was not labeled and no items were observed inside the drawer. The cart had red breakaway lock # 3842072 on the outside. This was inconsistent with observations of the AD Red Emergency Cart in Finding 24.a. above which had an unnumbered blue breakaway lock. * The same “Admissions Code Blue Equipment Check Sheet” inventory list used for the AD Red Emergency Cart in Finding 24.a. above was observed. Observation of cart labels, cart contents, and inventory list revealed inconsistencies between those. For example: - A package of stethoscope ear pieces and diaphragms were observed in Drawer 2 and were not on the checklist or any of the drawer labels. - Sterile tongue depressors, roll gauze and Coban were observed in Drawer 3 and were on the check sheet for Drawer 3, but were not observed on any of the drawer labels. - A label on Drawer 3 reflected “Trauma sheers”. Similar to AD, the check list reflected only “scissors” which could be confused with regular office type scissors. - A pulse oximeter inside Drawer 3 was labeled “Tx Mall 3” which could create confusion as to where that piece of equipment should be kept. * An Emergency Medication Kit with breakaway lock # 3842071 was observed in Drawer 6. A document titled “JC Admissions Emergency Kit” was observed in a plastic sleeve with the kit and indicated Narcan and Epi pen were inside the kit. The document was similar to the document titled “Admissions Emergency Kit” observed with the Emergency Medication Kit during tour of AD during the IJ verification visit on 05/02/2024. However, there was no “Record of Inspection for Intact Seal and Expiration Date”. The document included no evidence the Emergency Kit breakaway lock # was checked to ensure the lock had not been removed, contents tampered with, and medications readily available when needed. * An “Emergency/Medical Equipment Checklist” for May 2024 dated revised “07/2021” was observed with the Red Emergency Cart. This was not the same version observed during tour of AD during the IJ verification visit on 05/02/2024 in Finding 24.a. above, nor the version in the P&P titled “Emergency and Multi-Patient-Use Medical Equipment” in Findings 22.b and 22.c. above. 25.b. During interview on 05/02/2024 with OSH-JC nursing staff and other hospital staff at the time of the remote OSH-JC IJ verification visit, the following information was provided: * The hospital had a designated Code Blue Team that consisted of 2 staff. The same 2 staff covered JC and Salem campuses. * The Code Blue Team had replacement breakaway locks for the Red Emergency Carts. * The Code Blue Team tracked breakaway lock #s on Red Emergency Carts “whenever we call them”. * They confirmed “Emergency/Medical Equipment Checklist” dated “07/2021” was observed with the Red Emergency Cart. ****************************************************** 26. The findings that follow reflect the hospital’s failure to ensure an organized and coordinated medical emergency response: 27. Incident documentation recorded by LH1 NM, dated 04/18/2024 and untimed, reflected that “Staff came to my office inside the nurses station to advise me that a code blue (medical emergency) was needed for this patient as the code blue was being called over the radio. I responded, running down the south hall to the patient’s room at 1115 as the code blue was being called via overhead page. When I entered the patient bedroom the patient was non-responsive, eyes closed, without respirations, without pulse (as assessed by another RN present). I advised that staff begin chest compressions and then I ran to obtain the crash cart/code blue cart. When I returned to the patient bedroom I opened the code cart, gave the code blue sheet and clipboard to unit [OS2 24] and assigned [them] to the recorder role. I then entered the patient bedroom and advised that staff move the patient from the patient bed onto the floor after the current set of chest compressions were complete. Staff used the patient’s blanket to lower this patient from [their] bed onto the floor and resumed chest compressions. More staff entered the scene and the automatic external defibrillator was brought to the scene. A nurse took a position at the patient’s head and administered 2 rescue breaths using the ambu-bag between each set of 30 compressions. I took the role of code lead and asked staff to switch out with the person administering chest compressions to prevent physical exhaustion while counting chest compressions out loud. Staff continued to administer chest compressions and rescue breaths and the AED was attached to the patient. The AED analyzed and advised no shock, chest compressions and rescue breaths continued. Medical doctors and other staff continued to arrive and rescue attempts continued. This patient was pronounced deceased by our physicians at 1156 and at that time EMTs were present. It was later reported to me that the unit nurse assigned to the admission called for the code blue as this patient was being moved from the wheelchair to the patient bed by security and admissions office staff. Per staff report, the patient was slumped down in the wheelchair unable to maintain an upright posture while [they were] being transported to the unit.” 28. Video recordings of the Code Blue medical emergency response for Patient 1 on 04/18/2024 revealed a disorganized and uncoordinated response as follows: ~ 1108:29 - Patient 1 was transported into the inpatient room in a w/c. RN 13 and other staff entered the room. Multiple staff entered and exited the room and others milled around outside the room with no demonstration of urgency. Another patient exited the patient room across the hall from Patient 1’s room. ~ 1110:34 - MHST 14 walked at a leisurely pace and without urgency down the hall from the NS toward the patient room, pushed a mobile vital signs machine on wheels, and entered the patient room ~ 14 seconds later at ~ 1110:48. ~ 1111:56 - LH1 NM and Agency LPN 21 walked down the hallway from the NS towards the patient room at a quicker pace than previous staff, however, with minimal urgency. (The video observation is contrary to medical record documentation referenced under Finding 16 above, and incident documentation under Finding 27 above, that described the response of LH1 NM as “I responded, running down the south hall to the patient’s room ...”) ~ 1112:14 - LH1 NM ran down the hall away from the patient room toward the NS. More staff, some at a quicker pace, began to arrive and gather in the hallway outside of the patient room while some entered the room. ~ 1112:33 - Staff were observed to push a Red Emergency Cart down the hall from the NS toward the patient room. It arrived at the patient room at 1112:45 and was positioned outside the doorway of that room where it remained until it was pushed further down the hall away from the room after EMS arrived. ~ 1112:45 until the arrival of EMS at ~ 1124:01 video recording showed: More staff arrived and continued to enter the patient’s room and gather in the hall. The number of staff gathered in the hallway between the patient’s room and the NS, particularly in the vicinity of the patient’s room, created increased congestion that presented an obstacle for navigation through the hall, including for other patients whose rooms were between Patient 1’s room and the NS. At times there were 20 or more staff, and may have included patients, in the space outside the room and there was no way to determine how many were in the room as staff continued to enter and exit. The crowd that had gathered did not leave a clear pathway for EMS who arrived at ~ 1124:01 with ~ eight EMT and Fire responders, a gurney, and EMS equipment. Additionally, during the scene described above, multiple staff in the hallway were observed to do nothing, staff lined up against the hallway walls, some staff stood on their tiptoes or crowded the doorway of the room to try to see in the room, others engaged in various discussions and activities. Agency RN 26 and Agency LPN 25 were observed to open and look in, or retrieve items from drawers on the Red Emergency Cart, and then they would leave the drawers partially open. (There was no incident or medical record documentation by either Agency RN 26 or Agency LPN 25 regarding their activities and tasks during the Code Blue.) ~ 1112:46 - OS2 24 was observed to stand immediately next to the Red Emergency Cart at the patient room doorway with a clipboard to which a form was attached, looked at their left wrist, and recorded something on the form. During the video the form was discerned to be the Code Blue Flow Sheet. During the duration of this code activity captured on the video recordings until ~ 1125:17 OS2 24 never entered Patient 1’s room, and they were not positioned during much of that time to be able to observe the code activities that were being carried out in the room. For example: They were observed to wander in the hallway outside the room, they stood to the left of the doorway without a view into the room, they stood in the hallway approaching the opposite wall, they sometimes leaned forward to look into the room and sometimes that was through a number of other staff that crowded the doorway, they crouched down on their knees in the hallway to the left of the door, they sat down on the floor on their knees and lower legs in the hallway, they talked with other staff. Up until ~ 1124:39 OS2 24 had the clipboard in their possession. The video skipped ~ 10 seconds at that time. The next time recorded was ~ 1124:51 and OS2 24 was observed to walk down the hall away from the patient’s room and further from the NS without the clipboard in their possession. (On 05/09/2024 at ~ 1500 staff that included the DNS, LH1 NM, CBC, PD, DQM, and DSC confirmed that the form OS2 24 could be seen writing on in the video was a Code Blue Flow Sheet, and that it was the same Code Blue Flow Sheet provided during the survey for Patient 1.) ~ 1124:33 - Staff present demonstrated a lack of situational awareness in relation to the placement of the Red Emergency Cart. When staff began to exit the scene and hallway a staff person pushed the Red Emergency Cart further away from the patient’s room, further down the hallway from where staff were gathered, and further away from the NS. At ~ 1124:57 the only staff near the cart walked away from it and no staff looked in the cart’s direction until 1125:16. The Red Emergency Cart had a suction machine placed on the top and at least two of the cart doors were partially open. The video recording provided ended at 1125:17. 29.a. While there were medical record entries by various staff about the Code Blue response, the Code Blue Flow Sheet for the 04/18/2024 response for Patient 1 was not complete. There were only three entries made on the form in the multitude of required boxes and spaces. Those were the Date, Time, Time of Code Blue, and a checkmark on the “Yes” box for AED utilization. Otherwise, there were several short unclear entries, some with associated times, written in the margins of the form. For example, “11:26 EMS” and “gray sweatshirt” and “8th.” Nor was the form authenticated by whoever made the entries, including in the required space for “Recorder”. 29.b. Incident documentation recorded by LH1 NM, dated 04/18/2024 and untimed, reflected they “ ... gave the code blue sheet and clipboard to unit [OS2 24] and assigned [them] to the recorder role ... I took the role of code lead ... “ However, review of the Code Blue Flow Sheet reflected the following spaces on the form were blank: *”Team Captain:” and Team Captain “Title:” *”Recorder printed name:” and “Signature:” and “Date:” and “Time:” 29.c. The “Medications administered” table on the “Code Blue Flow Sheet” had columns for “Time,” “Medication,” “Dose,” “Route,” and “Effect.” Those spaces were completely blank. There was no documentation on the flow sheet related to the administration of the Narcan that was identified as given in incident and medical record documentation. Nor was the dose given found in any of that documentation. Further, the incident and medical record documentation related to the Narcan order and administration was unclear and inconsistent as follows: * A Nursing Progress Note written by LH1 RN 13 and dated and timed 04/18/2024 at 1304 reflected in regard to Narcan administration that “Narcan was requested and administered by [PMHNP 23].” * A Psychiatry General Note written by psychiatrist MD 30 and dated and timed 04/18/2024 at 1451 reflected in regard to Narcan administration that they “gave telephone order to [Agency LPN 21] RN [sic] for Narcan to be administered to the patient. [PMHNP 23] administered the intranasal Narcan prior to EMS arrival (at approx. 1125-1126). Intranasal Narcan was the only formulation we had on hand on the unit at this time, per staff report.” * A Psychiatry General Note written by psychiatrist MD 27 and dated and timed 04/18/2024 at 1838 reflected in regard to Narcan administration that “When I was informed that [Patient 1] had not received Narcan yet, I ordered the Narcan be given, presuming that both it would be safe in the absence of potential intoxication/overdose and also that it would be potentially extremely beneficial if [the patient] were intoxicated/obtunded from opioids. Nursing staff went to obtain this and it was given via intranasal route several minutes later.” * Incident documentation by Agency LPN 21, dated 04/18/2024 and untimed, reflected that “[MD 30] and [PMHNP 22] gave TO for narcan, I ran to grab the narcan and handed it to nurse that was by patient side.” * Incident documentation by Agency RN 12, dated 04/18/2024 and untimed, reflected that “Nasal Narcan administered as ordered without effectiveness result.” * An “Oregon State Hospital Non-Medication Telephone Orders” form that contained a medication order dated 04/18/2023 at 1120. The order was written as “Give Narcan 4 mg intranasal x1 now for unresponsiveness.” The handwritten entry in the “Nurse Printed Name” was barely legible [Agency LPN 21]. The handwritten entry on the “Nurse Signature” space was illegible and was followed by what may have been written as “LPN” although it was difficult to discern. The “Date” and “Time” of the nurse signature was 04/18/2024 at 1130 and there was an initial in the “Nurse ‘Readback’ Initials” space. The print and signature name of an [PMHNP 22] followed the nurse’s information and was dated and timed 04/24/2024 at 1102, six days after the event. There were no other LIP orders in the medical record. * There were no medical record or incident notes related to Patient 1 by PMHNP 22 who was identified in documentation as having ordered Narcan and who signed the Telephone Order for it. * There were no medical record or incident notes related to Patient 1 by PMHNP 23 who was identified in documentation as having ordered Narcan and as having administered it. . * Each of the medical record and incident notes written by the two MDs, an RN, and an LPN reflected that Narcan was ordered by different LIPs. * In the incident documentation by Agency LPN 21 they wrote they “grabbed” the Narcan and then handed it to another “nurse.” There was no documentation by Agency LPN 21 or the other “nurse” to reflect who that “nurse” was and what that “nurse” did with the medication. * In the incident documentation by Agency RN 12 their note was written consistent with the way a nurse who administered the medication would document and as if RN 12 had administered the Narcan. * There was no documentation of Narcan administration by the person that administered the medication in the medical record or on the Code Blue Flow Sheet. 29.d. Incident documentation recorded by [TM 34], dated 04/18/2024 and untimed, reflected that “As compressions continued, I was tasked with gathering staff’s names that were involved or present for the medical emergency ... I provided the list of staff members involved to LH1 Unit Administrator [UA 35].” It was unclear whether the names and roles of all staff who presented and gathered as observed in the video recording had been identified. There was no documentation included on or with the Code Blue Flow Sheet that identified all staff who presented or participated. 29.e. Further, the following spaces on the Code Blue Flow Sheet were blank: * “Time of onset:” * “Location:” * “Chief Complaint:” * A table with seven columns for “[time, blood pressure, pulse, respirations, temperature, pulse oximetry on room air or supplemental O2, blood glucose]” * “Pertinent physical findings:” * “Defibrillation: __No __Yes” and “How many times:” and “Successful: __No __Yes” * “EMS called at:” and “EMS arrived at:” *”Physician/nurse practitioner called hospital at:” *”Patient transported by: __N/A __OSH transport __EMS Time:” *”Disposition of patient:” *”Emergency contact called: __No __Yes Name: Relationship: Phone number:” *”Provide copies of the following to the EMS Team: __ Medication administration record __Vital signs flow sheet __ Laboratory data __Emergency medical transfer report __ Diagnostic (e.g., EKG) __ Medical H&P” 30.a. The P&P titled “Code Blue Medical Emergency” dated 01/21/2020 was reviewed. It stated that “[OSH] will provide immediate response to any medical emergency that presents anywhere on campus and requires a coordinated team effort ...” The P&P attachment, “Procedures A,” consisted of a table with two columns for “Responsible Person/Group” and “Procedures.” Those persons were listed as: - “First responder” - “Second responder” - “Security” - “Team Captain” - “Physician/NP/RN” - “Equipment Monitor” - “Airway Rescuer” - “Recorder” - “Communicator” - “Crowd Control Monitor” - “Photocopy” 30.b. Duties delineated for each role/title were vague and unclear. For example: * The “Team Captain” duties included: “Assign roles and responsibilities ... Assist with completing the Code Blue Flowsheet ...” * The “Equipment Monitor” duties included: “Verify all of the emergency equipment arrives to the scene ... Prepare and hand out equipment as needed or directed by the Team Captain ... Monitor emergency equipment throughout the incident.” * The “Recorder” duties included: “Complete the Code Blue Flowsheet.” * The “Crowd Control Monitor” duties included: “Maintain safety of the scene and milieu as necessary ... Verify essential personnel have access to the scene, person, and emergency equipment ... Request the Communicator cancel responders when sufficient responders have arrived at the scene ...” 30.c. The procedures were not clearly written to ensure staff were trained and knowledgeable to be able to competently carry out the required duties/tasks in an organized and coordinated manner. For example: * It was not clear how roles were to be assigned and how and where those were to be recorded. * It was not clear what “assist with” completing the Flowsheet meant. * It was not clear what “emergency equipment” was to arrive to the scene and what was meant by “monitor emergency equipment ...” The equipment was not specified, nor was there reference to other applicable P&Ps. * There was no direction r/t where the Recorder needed to locate themselves, and otherwise obtain the necessary information, to ensure they could clearly and completely “Complete the Code Blue Flowsheet.” * It was not clear how the “safety of the scene and milieu” was determined, who “essential personnel” were, or who and how many persons were considered “sufficient responders.” * It was not clear who was responsible to monitor and manage the presence of other patients at or near the scene to ensure safety of those patients and others. * There were no mentions of emergency medications or reference to other applicable P&Ps. It was not clear which role was to obtain and prepare Code Blue medications, from where those were to be obtained, and who was to administer them. 30.d. The review of the Code Blue video recording and the Code Blue documentation for Patient 1 failed to demonstrate that roles and responsibilities for all Code Blue positions had been assigned and that duties/tasks had been carried out. Further, the Code Blue Flowsheet used during Patient 1’s Code Blue did not align with the procedure requirements in Procedures A. 31.a. During interview with staff that included the DSC, DLD, and OBC on 05/06/2024 beginning at 1235 they confirmed the Code Blue training dates for the AD RNs 1 through 4 and stated there were no drills or hands-on practice, return demonstrations, or competency evaluations associated with those trainings, including during annual “refreshers.” They further stated that hospital-wide Code Blue drills had not been conducted since the Covid-19 pandemic. They stated those were recently resumed on 04/23/2024 and that on that date on the OSH-Salem campus 54 staff participated in Code Blue drills, and on 04/26/2024 on the OSH-JC campus 13 staff participated in Code Blue drills. They further confirmed that none of the four AD RNs had been present or participated in the Code Blue drills conducted on 04/23/2024 and 04/26/2024. 31.b. Review of AD RN Code Blue training records reflected the following: * For RN 1 the documentation showed that since 2020 they had a 20-minute online Code Blue training on 03/26/2020, an online Code Blue training on 04/24/2021, and a 30-minute Code Blue “refresher” on 02/27/2023 during 2023 Annual Training. * For RN 2 the documentation showed that since 2020 they had a 30 minute Code Blue “refresher” on 04/02/2024 during 2024 Annual Training. * For RN 3 the documentation showed that since 2020 they had a 20-minute online Code Blue training on 05/07/2020, an online Code Blue training on 03/12/2021, and none since. * For RN 4 the documentation showed that since 2020 they had a 20-minute online Code Blue training on 04/18/2020, an online Code Blue training on 05/08/2021, and none since. ****************************************************** 32.a. The findings that follow reflect the hospital’s failure to ensure there were formal, written, and approved P&Ps and other resources for AD patient care operations, and that AD staff were knowledgeable and competent to perform their duties. 32.b. Review of the “Oregon State Hospital - Salem Organizational Structure” chart that was “Last Updated 4/1/24” showed that the AD, the ADM, and the RNs who worked in the AD, reported to the OSH Deputy Superintendent in hospital administration and were not part of the Nursing Department. 32.c. Review of the AD Staff List provided reflected that the ADM’s title was “Business Operations Manager.” There was no indication in information gathered during the survey that the ADM who was assigned oversight and responsibility for the AD RNs and the nursing and patient care services provided in the AD was an RN themselves. Further confirmation was provided by the DSC in an email on 05/16/2024 at 1503 that the ADM was not an RN. 32.d. During interviews on 04/24/2024 beginning at 1030, on 04/25/2024 at 1230, on 04/25/2024 beginning at 1340, and on 05/02/2024 beginning at ~ 1300 the following information was provided or confirmed. Staff that were included in one or more of those sessions included the ADM, AD RN 1, DSC, DQM, Interim DS, DLD, OBC, and other nursing, education and S&C staff: * The hours of operation of the AD were Monday through Friday business hours. There were four AD RNs who worked eight-hour shifts with slightly staggered start times. * The AD RNs were not part of the Nursing Department and did not fall under the direction of the CNO. Rather, the oversight of the AD operations was the responsibility of hospital administration. * Nursing Department P&Ps did not apply to the AD RNs. * There were no formalized, written, and approved P&Ps for AD patient care operations and procedures. * There were no provisions for direct observation of patients at the time the transport van entered the Sally Port, nor direct observation of patients who waited in transport vehicles upon their arrival to the hospital’s premises prior to the transport van entry into the Sally Port. * Systems and processes for Nursing Department staff orientation, onboarding, and annual training did not apply to the AD RNs. * There was no formal and organized AD orientation and onboarding program, and that there was no documentation of AD orientation and onboarding for the two most recent AD RNs who started in 08/2023, and no documentation of competency evaluations. * The onboarding process for AD RNs was described as “shadowing” one of the other two AD RNs on “how to get people into the door with the deputies” for “usually about two weeks before they’re turned loose.” There were no * Two manuals were presented as the only written resource documents for AD patient care operations and procedures. They were not current or approved, and contained unclear and inconsistent information related to patient care operations. 32.e. A manual titled “Admissions Department” had the date 04/05/2024 at the bottom of each page. It contained unclear information and was incomplete. For example: * It contained sections and paragraphs that had language written in red ink and some written in purple ink. It was unclear what those denoted. During interviews referenced above the ADM stated that the purple was the “nursing” section, and the red was language that needed to be updated. * On Page 5 of the manual it described that AD personnel included four MH Triage RNs. It further stated that “Each position with the [AD] plays a pivotal role ... Each staff in these positions have a duty to perform their positions ... in accordance to [sic] all policies and procedures set by OSH and the Admissions Director for all department functions.” However, during interviews referenced above there were no AD P&Ps. * A yellow highlighted excerpt on Page 20 of the manual was written was “The [MH] Triage RN will document in a closing note, at minimum, how the patient presented upon arrival ... check vitals (O2), Temp, and BP, when possible ...” The date on the bottom of that page was 04/05/2024, prior to the 04/18/2024 admission of Patient 1. However, during interviews referenced above the ADM stated that that although the manual reflected last revisions were made on 04/05/2024, the excerpt had been added to the manual after the Patient 1’s 04/18/2024 admission and after the 04/19/2024 CMO Directive. In a written response from the ADM received on 05/02/2024 they wrote in regard to confirmation of the date and time that the edit had been “This is not possible.” * In addition, the added excerpt was unclear about the extent of vitals to be taken as it said to check vitals, but specified only Temp, and BP, when possible. * The Admissions Department manual contained no reference to medical emergency response, or maintenance of emergency supplies or equipment in the AD. 32.f. A manual titled “Mental Health Admissions Triage Nurse” contained unclear information and was incomplete. For example: * Written at the bottom of various pages of the manual were dates of 06/13/2021, 06/25/2021 and 07/13/2022. It was unclear what date the manual was last determined to be current. * In the manual on a page titled “Day of Admission” with the date 06/13/2021 at the bottom of the page there were three paragraphs. One included direction for the MH Triage RN to obtain a temperature on patients upon arrival. That was not done for Patient 1 on 04/18/2024 and staff confirmed during the interviews referenced above that there was no written AD P&P for that practice. * Although the AD operated M-F day shift hours and was only staffed with AD RNs at those times, the manual reflected that “Evening, Nights, and Weekends Admissions” could occur. It was unclear how those would be managed, including whether patients would be assessed and vitals taken. During the interviews referenced above the ADM indicated there were no P&Ps for that at this time and that they needed to develop a process to include PNMs for after hours admissions. * The manual contained a copy of a seven-page “Sentinel Event Alert” published by The Joint Commission dated 09/12/2017. It was unclear what it’s purpose was as there was no explanation for that elsewhere in the manual. * The manual included a P&P for restraints with a date of 12/21/2020. It was confirmed that was not the current version of that P&P. * The manual contained a copy of the P&P for “Admission of Patients with Medical Problems” dated 10/03/2018 that directed that “If a newly admitted patient experiences an emergency medical condition. OSH will provide emergency care as indicated in OSH Policy 8.002 ...” However, there was no other information in the manual for medical emergency response in the AD, including for maintenance of emergency supplies or equipment. ****************************************************** 29708”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals, it was determined that the hospital’s failures to fully develop and implement P&Ps that ensured nursing services were under the supervision of an RN, and that nursing personnel were knowledgeable and competent to provide appropriate and timely patient assessment and response to the nursing and emergency care needs of the patient population of each department included: * Failure to ensure AD RN and inpatient RN staff relied upon independent nursing judgement to provide appropriate and timely assessment of patient condition and identification of the need for medical emergency response. * Failure to ensure RN staff requested the immediate presence of a physician when the patient’s unresponsive physical condition was believed to be behavioral versus medical. * Failure to ensure that an RN supervised the nursing services in the AD and that AD RN practices for patient care were in accordance with, and supported by, written and approved P&Ps, and that they completed organized and documented AD orientation and onboarding that ensured clinical and procedural competency for patient care operations in that department. Findings include: 1. The findings that follow reflect that RN staff failed to conduct appropriate and timely assessment and vital signs for Patient 1 who arrived at the hospital from jail. When AD RN first observed the patient in the transport vehicle they stated they saw the patient’s eyes open briefly. That was the only detectable movement the patient made between the time they were transferred from the back of the transport vehicle until another RN who had accompanied the patient for transport from the AD through the hospital to the inpatient unit checked for a pulse after the transport and entry into the patient’s assigned inpatient room. Neither of those RNs made independent decisions using their own nursing judgement that would call for an immediate assessment and emergency response to an unresponsive and motionless person. Instead those RNs inappropriately deferred to, believed without reasoning or questioning, and acted upon DC deputies’ characterizations of the patient’s unresponsive condition as being purposeful as in “choosing not to walk,” “won’t stand up,” and “refusal to respond,” “normal” and “usual,” and “catatonic.” Those RNs failed to request the immediate presence of a physician to evaluate whether the patient’s unresponsive physical condition was behavioral versus medical. Refer to Tag A-144 for additional information regarding Patient 1’s encounter. 2. A document titled “OSH Office of Quality Management” was reviewed. It included the following information: * “Incident Nature: Sentinel Event - Unexpected Patient Death” * “Date/Time of Incident: 04/18/2024 1115hrs” * “At approx. 1047 hrs. access control informed admissions Douglas County jail transport were waiting with [Patient 1] for admission to OSH. Staff arrived and the country [sic] transport vehicle entered a Sally Port, at approximately 1054 hrs. Deputies told [RN 4] [that Patient 1] would need a wheelchair because [they were] ‘catatonic’ and at times ‘flops around like a fish’. This was reported to have been described to nursing staff as normal behavior by [Patient 1]. As [Patient 1] was transferred from the transport van to the wheelchair, at approximately 1101 hrs, the admission [RN 4] reported [they] observed [Patient 1’s] eyes open and close, possibly in response to light hitting [Patient 1’s] eyes. [Patient 1] was wheeled into OSH admissions at approximately 1102 hrs. Additional staff were called to the admissions area and assisted in photographing [Patient 1] for identification. Douglas County transport restraints were removed from [Patient 1] and [they were] taken, via wheelchair, to Lighthouse 1 by OSH Staff. During this process [Patient 1] was noted as not moving on [their] own accord and staff held the patients [sic] legs up with a blanket so [their] feet would not drag on the floor. Staff and the patient arrived on the unit at approx. 1107hrs. where the patient was taken directly to a patient room. As [Patient 1] was being transferred to the bed an RN decided to check the patient for a pulse and found none. Sternal rubs were done with no response and additional checks found no pulse. A Code Blue was initiated and additional staff arrived and life saving procedures were performed including the use of CPR and an AED. Narcan and epinephrine were administered and were ineffective. Paramedics arrived at approx. 1121hrs and took over life saving efforts. [Patient 1] was pronounced dead at 1156 hrs.” 3.a. During review of incident documentation and hospital response with staff that included the Interim DS, DQM, DSC, COP, COM, DOS, PD, BOM1, and AAG on 04/24/2024 beginning at 1440 staff described the hospital’s investigation and actions taken to date. A document titled “Investigative Memo,” dated 04/24/2024 provided a summary of the information given by staff during the incident and response review on 04/24/2024 and included the following: * “Date of incident: 4/18/2024” * “Incident Nature: Unexpected patient death” * “The purpose of this memo is to document the investigative process and immediate actions associated with the unexpected patient death on 4/18/2024, [Patient 1].” * “Actions in response to preliminary investigative findings: Video review and policy evaluation identified no policy requirement for vitals check on new admissions. On 4/19/2024 OSH Interim Superintendent [and CMO] memorialized ‘CMO Directive - Admission vitals 4-19-24’ based on initial investigative findings that vitals were not taken of the patient upon admission.” 3.b. Review of the document on OSH letterhead, signed by the CMO/Interim OSHS and dated 04/19/2024, reflected the following: “To all OSH staff, This CMO Directive modifies and adds to OSH policy 6.058, ‘Admissions.’ To ensure that patients who may be medically unstable on arrival are promptly assessed and receive necessary medical care as soon as possible, it is my directive, effective April 19, 2024, that: * An Admissions RN must perform a brief assessment for every patient admitted to OSH, including - at minimum - vital signs and visual observation to identify any medical needs requiring immediate attention, before the patient leaves the Admissions area. This assessment must be documented in the patient’s medical record. * If a patient is not responsive to staff in the Admissions area, the possibility of a medical emergency must be immediately assessed. * If a patient is too combative to safely obtain vital signs, this must be communicated to the unit RN and documented in the medical record, along with the nature of the patient’s behavior. This directive will remain in effect until policy 6.058 is updated.” 4.a. During interview on 04/24/2024 at 1105 with RN 4, they stated they had worked in AD since August 2023. RN 4 provided the following information regarding Patient 1: * A “Douglas County” transport van pulled into Sally Port 8 drive-in garage. The deputies said the patient would need a wheelchair because they had not been able to get into the van themselves and had been “flopping around like a fish.” The deputies stated that was the patient’s baseline. * RN 4 stated they got a wheelchair for the patient and went to the back of the van with a security staff. The patient, who was in the back of the van, “opened their eyes and moved a little”. RN 4 introduced themselves to the patient. The deputies told the patient, “We’ll get you out [of the van]” and the patient closed their eyes. RN 4 stated “I thought [the patient was] not being cooperative” and asked for more security staff. RN 4 stated 5-6 security staff came. The deputies gave the patient a few minutes to get out of the van and when they did not, the deputies lifted the patient to the wheelchair. RN 4 stated the deputies held the patient’s legs up while they wheeled the patient backwards from the van into the AR. * RN 4 stated in the AR “we got a photo of the patient for [their] ID” and the deputies said it would be OK to remove the patient’s cuffs because they had never been aggressive. The deputies removed the cuffs. The patient was not able to hold their head up and “kept [their] eyes closed.” RN 4 stated the patient was slouched with their head to one side, and “not holding it up like a normal person holds their head.” * RN 4 stated “typically we take a temperature and ask about a cough” in the AR. RN 4 stated they did not check the patient’s temperature or any other vital signs and did not ask the patient if they had a cough. When RN 4 was asked if the patient was breathing, they stated, “I didn’t observe any chest rise and fall.” In response to the surveyor’s follow-up question in regard to indications of oxygenation such as the patient’s skin color and appearance, RN 4 additionally stated that the patient “was African American, had dry skin, and I didn’t notice anything abnormal.” * RN 4, a unit nurse, and security staff pushed the patient in the wheelchair from the AR to LH1. One of the security staff lifted the patient’s legs with a blanket so their legs wouldn’t drag. When they got to the patient’s room on the unit, the unit RN and 2 security staff laid the patient supine on the bed. RN 4 stated, “At that point, I knew something was off because there was no response from the patient, so I checked for a pulse. Nothing. I checked a sternal rub and nothing.” The patient had no pulse and was not breathing, and they called a code blue. 4.b. Incident documentation recorded by AD RN 4, dated 04/18/2024 and untimed, reflected that “Access control called the main admissions office phone at around 10:47 to report that Douglas County was waiting to get into Sally port 8 for an admission. Douglas County was scheduled to drop off two admits to OSH today on 4/18. [Patient 26] who was scheduled to admit to FW1, and [Patient 1] was scheduled to admit to LH1. The Douglas county transport van was waiting in the circle outside of OSH for roughly 5-10 minutes, due to there being a secure transport van in Sally Port 8. [RN 3] admissions RN, went outside Sally port 9 to talk to the Douglas county officers to find out how the pts were doing. When [RN 3] came back through Sally port 9, [they] reported to me ([RN 4] Admissions RN) that the officers said [Patient 1] will need a ‘wheelchair’ because [the patient] ‘flops around like a fish’ and is ‘catatonic’. After secure transport left Sally port 8. Douglas county pulled into Sally port 8. FW3 unit staff showed up first, and [RN 3] who was assigned to admit [Patient 26] brought in [Patient 26] and introduced them to the FW3 staff and that pt was taken to FW3. [Patient 1’s] unit staff from LH1 ([RN 13] along with unit MHT) showed up next. I was assigned to admit [Patient 1] as I had done [their] pre-admit note in avatar as well as a nurse to nurse with the jail RN. The deputy standing in the admissions area adjacent to Sally port 8 then reported to me, ’[Patient 1] won’t stand up, [they’re] catatonic. [They’ll] need a wheelchair’. RN asked the deputy ’[They] won’t stand at all?’, and deputy responded ‘No’. Wheelchair and a blanket was obtained by this RN. [MHST 18] was the security assigned to help with admissions for 4/18. As Sally port 8 doors were opened by access control, [MHST 18] held open the doors while this RN followed deputies to the back of the van with the wheelchair. The deputies opened up both doors to the back of the van. [Patient 1] was seen sitting in a slumped position with [their] back against van partition. As soon as the van doors opened, there was sunlight that came streaming into the back of the van, and this RN could see [Patient 1’s] eye open and close. Deputies said to [Patient 1] that they needed [them] to get into the wheelchair and gave [the patient] a few seconds but pt did not make any movements or indication that [they were] going to get up. Deputies then assisted pt on either side and lifted the pt into the wheelchair. RN introduced [themselves] to [Patient 1] and explained [they were] at the hospital but pt did not respond. RN asked for pt to lift [their] legs, so [they] could be wheeled, but [Patient 1] did not lift [their] legs. Both deputies each lifted one of the pt’s legs by the pant leg so [the patient’s] heels would not be dragging, and this RN wheeled [Patient 1] backwards into the adjacent admitting room connected to Sally port 8. [MHST 18] had called for additional security at the request of this RN, who were also present in the admitting area. A photo was obtained of [the patient] for [their] ID badge for security, but [they] did not open [their] eyes. This RN was assessing whether or not the cuffs should be removed in the admitting area, or on the unit for safety, when officers reported that they did not see [the patient] as a threat, and [they] had ‘never been physically violent’. This RN gave the directive for officers to remove the cuffs as pt was not exhibiting any signs of aggressive behaviors. Cuffs were removed by officers. Pt was wheeled by security to LH1, with one security wrapping a blanket underneath pt’s legs and lifting them up so they did not drag on the floor. Admissions RN and unit staff followed as well. Pt was taken onto LH1 unit, and down one of the first hallways on the right hand side as you enter the unit, where the pt’s assigned bedroom was. Pt was wheeled into [their] room, and staff informed [the patient] that it was [their] bedroom and [they] could get up. One staff member said ’[Patient] won’t get up, [they’re] catatonic’. Security and unit RN and another staff lifted the pt onto the bed. Pt was now in a supine position on the bed. Unit RN, [RN 13], then began doing [their] assessment. [RN 13] tried verbal stimuli, yelling pt’s name, checking radial and pedal pulse, checked for breathing. This RN checked for radial pulse on the right side, and there was no pulse felt. This RN confirmed with [RN 13] there was no pulse. Compressions were started, and a code blue was called on the radio by security. Crash cart was obtained with AED. Pt was moved to the floor in supine position for compressions and ambu bag was used for breath. 911 was called. Two OSH medical doctors arrived. AED advised no shock. EMS arrived and took over care.” 5. Incident documentation recorded by LH1 RN 13, dated 04/18/2024 and untimed, reflected that “I was the RN assigned to [Patient 1’s] admission along with [MHT2 8]. We were called to the admission Sally Port around 1100 and waited in line as the county had two patients and the first was going to a different unit. [MHT2 8] and I remained outside the Sally Port per protocol, waiting for report from [AD RN 4]. It was reported that the pt was not cooperating, would not walk, and [AD RN 4] retrieved a wheelchair. Security arrived at the Sally Port, evidently having been paged by admissions. The pt was retrieved from the transport vehicle utilizing the wheelchair and brought into the Sally Port; I was not able to observe the pt from my vantage point outside the Sally Port. It was reported to us that the pt was continuing to be uncooperative and not responding. Two security staff wheeled the pt out of the Sally Port, one pushing [TMHA 19], the other holding the pt’s legs up with a blanket draped under [the patient’s] ankles ([MHST 20], switched with [MHST 17] at some point). We quickly made our way to LH1; I walked alongside the wheelchair, attempting to engage the pt, explain the plan. We passed the bubble on LH1 at 1111. We had decided to take [Patient 1] directly to [their] room and transfer [them] to [their] bed. On arrival to [patient’s] room, security [TMHA 19] and I immediately lifted the pt out of the wheelchair and onto the bed. During that transfer, I noted the pt was more limp than would have been expected from a simply unresponsive pt. I immediately began checking for a pulse on [their] R wrist and began calling [their] name loudly. I performed sternal rubs when I could not elicit a response verbally. When there continued to be no response I requested staff call a code blue (code was called @ 1114). I then attempted to find a pulse under [the patient’s] upper arm, carotid, pedal while continuing to attempt to rouse [them] verbally and with sternal rubs and watch for chest rise (this was difficult to assess as [the patient] was in loose fitting jail clothing). I pulled open [the patient’s] eye lid and noted a dilated pupil; I used my flashlight to test reactivity and no reactivity was seen. Staff arrived quickly and we began chest compressions (@ 1115). Staff arrived with the AED and crash cart. After applying the AED pads, we transferred the pt to the floor to have a more firm surface and continued compressions alternating with AMBU bag respirations following CPR protocol. Narcan was requested and administered by [PMHNP 23]. Various staff and medical personnel rotated through administering compressions and AMBU respirations. CPR was continued per protocol, following prompts from AED (no shock ever advised) until paramedics arrived and took over the situation.” 6.a. The incident documentation described under Findings 6.b. through 6.g. below include further indications that Patient 1’s unresponsive and concerning condition was evident yet RN 4 failed to assess and respond and allowed staff to remove the patient’s motionless body from the AD and transport them throughout the hospital, and RN 13 failed to assess and respond at the time they assumed care of the patient outside of the AD. 6.b. Incident documentation recorded by MHST 18, dated 04/18/2024 and untimed, reflected that “I, [MHST 18], was the admissions security staff to assist during the admit with the new patient [Patient 1]. There were two patients from Douglas County admitting today and [Patient 1] was the second one to come in at approximately 1105. When the Deputies arrived, they had let us know that this patient was not talking or moving but that this was usual for [them]. They recommended that we bring a wheelchair due to [the patient] choosing not to walk but that it was “[their] normal” per the deputy. They mentioned that they had to help place [Patient 1] into the vehicle to bring [them] here to OSH. [AD RN 4] took a wheelchair to the van where the patient was sitting. The officers asked the patient to exit the vehicle a couple times to which the patient did not move. I am unsure as to who helped the patient exit the vehicle and place [them] into the wheelchair. I stood holding the door at sallyport 8 open and called for additional security. Additional security responded. [AD RN 4] introduced [themself] when [they] entered the building, then I introduced myself and let [the patient] know I would be taking [their] photo for [their] OSH ID badge. I took [the patient’s] photo. [AD RN 4] asked [the patient] to contract for safety and there was no response. The deputies assured us that the patient would be safe and that this is just how [they were]. So [AD RN 4] gave them the go ahead to remove the cuffs. Another security staff asked, “is [the patient] catatonic?” and the deputies responded saying “pretty much.” 6.c. Incident documentation recorded by TMHA 19, dated 04/18/2024 and untimed, reflected that “The admissions [RN 4] made the decision to have the deputies remove the restraints before we moved the patient to Lighthouse 1, after the restraints where removed I grabbed the wheelchair handles while [MHST 20] held up the patients’ legs with the assistance of a blanket while we moved the patient to Lighthouse 1. On arrival to the unit, we moved [the patient] into [their] assigned room (unknown number), the unit nurse who accompanied us from admission to the unit [RN 13] asked that we move [the patient] on the bed. [MHST 14] grabbed the patients left shoulder while I grabbed the right shoulder and [RN 13] grabbed [the patient’s] legs and we move [sic] the patient from the wheelchair on to the bed. The patient was still [sic] appeared to be in [sic] catatonic at that time. After assisting with the movement, I left as I was already late for my assigned lunch period.” 6.d. Incident documentation recorded by MHST 16, dated 04/18/2024 and untimed, reflected that “... a call came over the radio for additional security assistance at Sallyport 8 with a new admit at 11:03. As I got closer to Sallyport 8 I could see security staff and two sheriff deputies standing in a semicircle around [Patient 1], who was still out of view to me in the admissions room attached to sallyport 8. There were two unit staff, [RN 13] and [MHT2 8], standing outside the room waiting for the admit per protocol, as I tried to quietly enter the room to not disrupt anything. I could see the admissions [RN 4], standing next to [Patient 1] attempting to get [them] to respond and open [their] eyes, but [they] just sat slumped in the wheelchair, in full cuffs, and unresponsive. Someone leaned over to me to let me know that this was a behavior, and I took that to mean that this situation was going to be unpredictable due to this being a new admission with no prior hospitalization. It is protocol to hear the patient agree to safety before we can release [them] from [their] cuffs. The deputies mentioned that [the patient] hadn’t been violent, that all their assistance was because [they were] ‘catatonic’ and refused to respond. I saw that the unit staff had propped open the door to listen, so I stepped out to fill them in on what the deputies had said. When I came back into the room, they started to remove the cuffs, so I left the room again to open doors ahead of them to ease the transportation process. [TMHA 19] was pushing the wheelchair while [MHST 20] was holding [the patient’s] legs up with a blanket, so [their] feet didn’t drag on the ground. Halfway there, [MHST 17] swapped out with [MHST 20] and carried the patient’s legs in a blanket. Once we got to the patient’s new unit, LH1, [RN 13] wanted to assess the patient in [their] room (Room# G02-143) so [RN 13] and security staff lifted the patient from the chair to the bed. [RN 13] sent someone to grab the vitals machine while [they] continued to rub on the patient’s chest, tap [their] shoulders, and shout [their] name. I stood out in the hallway due to patients walking by the room, redirecting them as they came near.” 6.e. Incident documentation recorded by MHST 17, dated 04/18/2024 and untimed, reflected that “When I arrived at Sally Port 8, I saw the admission, [Patient 1] slouched down in a wheelchair unresponsive with closed eyes. Admission [RN 4] asked the two deputies from Douglas County how [Patient 1] has [sic] been on the way over from Douglas County? One of the deputies stated, ‘This is how [the patient] always, [sic] is unresponsive and is catatonic.’ [RN 4] was attempting to get a response from [the patient]. One of the deputies stated, ’[the patient] is not violent we just needed to get [them] out of the truck by force because [they were] not cooperating with us.’ [RN 4] stated [they] did not want to transport [Patient 1] in the wheelchair with [their] feet being dragged. [TMHA 19] stated we can use a blanket to hold [the patient’s] feet up and have someone hold the blanket while escorting the patient. [MHST 20] began to assist with holding the blanket while [TMHA 19] was pushing the wheelchair to Lighthouse 1. I relived [sic] [MHST 20] due to [them] needing a break. Once we arrived on Lighthouse 1 in the main entry hall, [the patient] continued to slide down in the wheelchair I asked security to assist me in helping move up [Patient 1] in the wheelchair. Staff then entered the south hall and went into room G02-143. [RN 13] and [TMHA 19] and I assisted [the patient] to [their] bed. [RN 13] began to do an assessment on [the patient] and began to check [their] pulse on [their] right wrist, [RN 13] stated [they were] not feeling any pulse.” 6.f. Incident documentation recorded by MHST 20, dated 04/18/2024 and untimed, reflected that “I responded to a call for security assistance at Sally Port 8. When I arrived, I saw Douglas County Deputies and OSH staff were standing around a patient, later identified as [Patient 1], that was in a wheelchair. The Deputies described [the patient] as being catatonic. I asked the Deputies if [the patient] had been responsive at all during the trip, they said that [the patient] was moving up and down in the back of the van. I then turned towards [the patient] and addressed [them] loudly and there was no response. I observed that there was abnormally thick but clear saliva around [their] mouth, I addressed [the patient] again and there was no response. [MHST 18], who was assigned new admissions processing then took a picture of [Patient 1], as part of the admissions process. It was then decided that since [the patient] appeared not to be cooperative with us that we would use a blanket to lift [their] legs so that we could easily transport [them] to Lighthouse 1 via the use of a wheelchair.” 6.g. Incident documentation recorded by LH1 NM, dated 04/18/2024 and untimed, reflected that “[LH1 NM] is writing this incident report on behalf of [MHT 33]: I was doing the RCM/SSM checks - I saw [Patient 1] being taken to [their] room via wheelchair and [they] looked lifeless - security pushing [them] in a wheelchair - [the patient’s] hands were hanging out to the sides and staff were holding [their] legs to keep [them] in the wheelchair.” 7. On 04/24/2024 beginning at 1155, survey team review of multiple camera views of video-recordings, without audio capability, revealed the following timeline of events that occurred on 04/18/2024 when the vehicle Patient 1 was transported in from Douglas County Jail arrived to the OSH Sally Port 8. Regarding the video review there was no camera view provided in Sally Port 8 that showed directly into the back of the transport van used to transport Patient 1 so that the entirety of the inside of the van could be visualized. The camera that showed the view at the back of the van was mounted off to the side of the Sally Port so that a side view of the right rear of the van could be visualized. With both rear van doors opened only a small portion of the inside of the back compartment could be seen. In addition, the quality and clarity of some of the video footage was poor and details of some images were not clear. Further, there were occasions during video review where video skipped several seconds when there was activity occurring. Commonly video may skip seconds or minutes when there is no activity occurring. * Between ~ 1054:52 and 1056:23 two camera views inside Sally Port 8 showed: A DC Jail transport van drove into Sally Port 8 with two DC deputies seated in the front seats. The garage door closed after the van had fully entered the Sally Port. A DC deputy walked to the back of the van, opened one of the back doors, removed two bundles of items, and walked away towards the door to the admitting room. At ~ 1056:07 Patient 26 exited the van through the passenger right side doors and walked in front of the second DC deputy towards the door to the admitting room. * Between ~ 1058:18 and 1100:20 one camera view inside Sally Port 8 showed: A DC deputy walked back to the back of the van, opened one of the back doors and looked inside momentarily, then started to close the door, then reopened it and looked inside and left it open. They stood at the back of the van and periodically looked inside through the open door. * Between ~ 1100:21 and 1102:20 two camera views inside Sally Port 8 showed: The second DC deputy approached the back of the van and joined the first deputy, immediately followed by RN 4 who pushed a w/c towards the back of the van. The deputies opened the other door so that both back van doors were open. At ~ 1100:28 only a portion of Patient 1’s lower body was visualized up against the rear left side of the van. They were positioned on the floor so that their body was facing the interior of the left rear corner side panel of the van, their left buttocks could be seen on the van floor, the left side of their body was at the very end of the floor where the door closure was, their left leg was observed to be bent at the knee and had partially fallen outside of the van. The two deputies picked Patient 1 up off the van floor and in awkward and uncoordinated movements took the patient out of the van and rotated them to place them in the w/c. There was no indication that Patient 1 was assisting or resisting. The parts of their body that could be visualized were limp. Patient 1, who was Black, was positioned in the w/c with their shoulders at the level of the top of the w/c seat back, their head slumped fully forward towards their chest, and their eyes closed. RN 4 folded a blue blanket and place it around Patient 1’s chest and shoulders and wrapped the ends around the w/c handles. At 1101:38 as the RN began to pull the w/c backward towards the admitting room Patient 1’s upper body was observed to be positioned lower in the w/c and slumped toward the left. As their head was slumped forward, the lower part of their face, including mouth and nose, was covered by the blue blanket. At ~ 1102:01 as RN 4 pulled the w/c backwards along the side of the van towards the admitting room door, both deputies bent over the patient and made movements consistent with each having picked up one of the patient’s pants legs to lift the patient’s feet off the ground. * At ~ 1102:24 one camera view inside the admitting room attached to Sally Port 8 showed: RN 4 pulled the w/c with Patient 1 backward into the admitting room. One deputy had hold of the patient’s right pant leg near the hem with their right hand. The other deputy had hold of the patient’s left pant leg near the middle of the pant leg with their left hand. Both of the patient’s bare feet were dangling slightly above the floor. The patient’s hands were cuffed in their lap. Their head was slumped forward, their eyes were closed, and their face was covered by the blue blanket that was held in place by RN 4 around their chest and shoulders and the w/c handles. * Between ~ 1102:30 and 1105:50 one camera view inside the admitting room showed: RN 4 parked Patient 1 in the w/c near the middle of the room. The deputies’ positions around the patient’s body periodically block the camera view. At this time four other staff (not including RN 4 and the two deputies) arrived into the room. The RN can be seen to lean over towards the patient on the left side of the w/c and arms are extended toward the patient although the patient cannot be seen behind one of the deputies. At ~ 1103:02 the deputies stepped away and the patient was observed to be slumped further down in the w/c, however, the patient’s face was no longer covered by the blue blanket that remained around their chest and shoulders. It looked as though RN 4 had their right hand on or near the blanket below the patient’s face as if they moved the blanket to uncover the patient’s face. The patient was motionless and their eyes were closed. At that time there were at least six other staff in the room. RN 4 stepped away and back from the w/c and was observed to address the deputies and staff that had gathered in the room who all stood and faced the patient within a few feet of the patient. Two of those staff stepped towards and leaned towards the patient and took photographs of the patient with cell phones. Then there were eight other staff in the room. The 11 people in the room (excluding the patient) were observed to talk amongst themselves and to the group while Patient 1 remained motionless in the w/c with their wrists in law enforcement transport restraints, their chin laid on their chest, and their eyes closed. Patient 1 showed no signs of movement. At ~ 1104:18 RN 4 slightly leaned toward the patient, extended their arm, and may have touched the blue blanket, the patient’s clothing near their shoulder, or the w/c. It was not clear. At ~ 1104:24 one of the staff persons approached the patient, leaned toward them, and extended their arm towards the patient. There was no visible response or movement from Patient 1. At ~ 1104:29 a DC deputy removed the law enforcement transport restraints from the patient’s wrists. At ~ 1105:08 when their right hand was free from those restraints their right forearm, wrist, and hand slid down and across their right thigh. At that time the patient was observed to have slid further down in the w/c, the blue blanket was removed, their head remained slumped fully forward with their chin on their chest, their eyes were closed, and their legs were extended straight in front of them with their bare feet on the ground. At ~ 1105:27 a staff person took the blue blanket and with assistance from another staff person positioned it under and around both the patient’s legs at the knees and formed a handle of sorts to lift the patient’s legs up off the ground. At that time the patient’s buttocks were near to sliding off of the w/c and their arms had fallen off their thighs onto the w/c seat on either side of their body. At ~ 1105:44 one staff person pushed the w/c forward and another staff person held the blanket that was around the patient’s legs to keep them off the ground and they moved towards the door out of the admitting room into a hallway towards the inpatient unit. At no time while in the admitting room did the patient assist or resist, nor did they open their eyes or demonstrate any observable movement. At no time was there any meaningful touch or other activity by any staff that could be construed as a patient assessment component. * Between ~ 1105:50 and 1108:30 four camera views showed: The two staff who pushed the w/c and held the patient’s legs up were joined by RN 13 and six other staff as they transported Patient 1 through hospital hallways to the inpatient unit. Patient 1 remained motionless with their eyes closed and slumped to the left with their arms laid limply on the w/c seat on either side of their body and their chin laid on their chest. Overhead camera views during the transport showed that the blanket around the patient’s knees used to hold the patient’s legs up during transport had been tied and knotted or twisted. At ~ 1108:30 staff pushed the patient in the w/c into the assigned patient room on the inpatient unit and that was last video observation of Patient 1. 8.a. During interview with staff that included the DSC, DLD, and OBC on 05/06/2024 beginning at 1235 they confirmed the Code Blue training dates for the AD RNs 1 through 4 and stated there were no drills or hands-on practice, return demonstrations, or competency evaluations associated with those trainings, including during annual “refreshers.” They further stated that hospital-wide Code Blue drills had not been conducted since the Covid-19 pandemic. They stated those were recently resumed on 04/23/2024 and that on that date on the OSH-Salem campus 54 staff participated in Code Blue drills, and on 04/26/2024 on the OSH-JC campus 13 staff participated in Code Blue drills. They further confirmed that none of the four AD RNs had been present or participated in the Code Blue drills conducted on 04/23/2024 and 04/26/2024. 8.b. Review of AD RN Code Blue training records reflected the following: * For RN 1 the documentation showed that since 2020 they had a 20-minute online Code Blue training on 03/26/2020, an online Code Blue training on 04/24/2021, and a 30-minute Code Blue “refresher” on 02/27/2023 during 2023 Annual Training. * For RN 2 the documentation showed that since 2020 they had a 30 minute Code Blue “refresher” on 04/02/2024 during 2024 Annual Training. * For RN 3 the documentation showed that since 2020 they had a 20-minute online Code Blue training on 05/07/2020, an online Code Blue training on 03/12/2021, and none since. * For RN 4 the documentation showed that since 2020 they had a 20-minute online Code Blue training on 04/18/2020, an online Code Blue training on 05/08/2021, and none since. 9.a. Review of the “Oregon State Hospital - Salem Organizational Structure” chart that was “Last Updated 4/1/24” showed that the AD, the ADM, and the RNs who worked in the AD, reported to the OSH Deputy Superintendent in hospital administration and were not part of the Nursing Department. 9.b. Review of the AD Staff List provided reflected that the ADM’s title was “Business Operations Manager.” There was no indication in information gathered during the survey that the ADM who was assigned oversight and responsiblity for the AD RNs and the nursing and patient care services provided in the AD was an RN themself. Further confirmation was provided by the DSC in an email on 05/16/2024 at 1503 that the ADM was not an RN. 9.c. During interviews on 04/24/2024 beginning at 1030, on 04/25/2024 at 1230, on 04/25/2024 beginning at 1340, and on 05/02/2024 beginning at ~ 1300 the following information was provided or confirmed. Staff that were included in one or more of those sessions included the ADM, AD RN 1, DSC, DQM, Interim DS, DLD, OBC, and other nursing, education and S&C staff: * The hours of operation of the AD were Monday through Friday business hours. There were four AD RNs who worked eight-hour shifts with slightly staggered start times. * The AD RNs were not part of the Nursing Department and did not fall under the direction of the CNO. Rather, the oversight of the AD operations was the responsibility of hospital administration. * Nursing Department P&Ps did not apply to the AD RNs. * There were no formalized, written, and approved P&Ps for AD patient care operations and procedures. * There were no provisions for direct observation of patients at the time the transport van entered the Sally port, nor direct observation of patients who waited in transport vehicles upon their arrival to the hospital’s premises prior to the transport van entry into the Sally port. * Systems and processes for Nursing Department staff orientation, onboarding, and annual training did not apply to the AD RNs. * There was no formal and organized AD orientation and onboarding program, and that there was no documentation of AD orientation and onboarding for the two most recent AD RNs who started in 08/2023, and no documentation of competency evaluations. * The onboarding process for AD RNs was described as “shadowing” one of the other two AD RNs on “how to get people into the door with the deputies” for “usually about two weeks before they’re turned loose.” There were no * Two manuals were presented as the only written resource documents for AD patient care operations and procedures. They were not current or approved, and contained unclear and inconsistent information related to patient care operations. 9.d. A manual titled “Admissions Department” had the date 04/05/2024 at the bottom of each page. It contained unclear information and was incomplete. For example: * It contained sections and paragraphs that had language written in red ink and some written in purple ink. It was unclear what those denoted. During interviews referenced above the ADM stated that the purple was the “nursing” section, and the red was language that needed to be updated. * On Page 5 of the manual it described that AD personnel included four MH Triage RNs. It further stated that “Each position with the [AD] plays a pivotal role ... Each staff in these positions have a duty to perform their positions ... in accordance to [sic] all policies and procedures set by OSH and the Admissions Director for all department functions.” However, during interviews referenced above there were no AD P&Ps. * A yellow highlighted excerpt on Page 20 of the manual was written was “The [MH] Triage RN will document in a closing note, at minimum, how the patient presented upon arrival ... check vitals (O2), Temp, and BP, when possible ...” The date on the bottom of that page was 04/05/2024, prior to the 04/18/2024 admission of Patient 1. However, during interviews referenced above the ADM stated that that although the manual reflected last revisions were made on 04/05/2024, the excerpt had been added to the manual after the Patient 1’s 04/18/2024 admission and after the 04/19/2024 CMO Directive. In a written response from the ADM received on 05/02/2024 they wrote in regard to confirmation of the date and time that the edit had been “This is not possible.” * In addition, the added excerpt was unclear about the extent of vitals to be taken as it said to check vitals, but specified only Temp, and BP, when possible. * The Admissions Department manual contained no reference to medical emergency response, or maintenance of emergency supplies or equipment in the AD. 9.e. A manual titled “Mental Health Admissions Triage Nurse” contained unclear information and was incomplete. For example: * Written at the bottom of various pages of the manual were dates of 06/13/2021, 06/25/2021 and 07/13/2022. It was unclear what date the manual was last determined to be current. * In the manual on a page titled “Day of Admission” with the date 06/13/2021 at the bottom of the page there were three paragraphs. One included direction for the MH Triage RN to obtain a temperature on patients upon arrival. That was not done for Patient 1 on 04/18/2024 and staff confirmed during the interviews referenced above that there was no written AD P&P for that practice. * Although the AD operated M-F day shift hours and was only staffed with AD RNs at those times, the manual reflected that “Evening, Nights, and Weekends Admissions” could occur. It was unclear how those would be managed, including whether patients would be assessed and vitals taken. During the interviews referenced above the ADM indicated there were no P&Ps for that at this time and that they needed to develop a process to include PNMs for after hours admissions. * The manual contained a copy of a seven-page “Sentinel Event Alert” published by The Joint Commission dated 09/12/2017. It was unclear what it’s purpose was as there was no explanation for that elsewhere in the manual. * The manual included a P&P for restraints with a date of 12/21/2020. It was confirmed that was not the current version of that P&P. * The manual contained a copy of the P&P for “Admission of Patients with Medical Problems” dated 10/03/2018 that directed that “If a newly admitted patient experiences an emergency medical condition. OSH will provide emergency care as indicated in OSH Policy 8.002 ...” However, there was no other information in the manual for medical emergency response in the AD, including for maintenance of emergency supplies or equipment. ****************************************************** 29708”

“Meet Hospital CoPs CFR(s): [Psychiatric hospitals must] Meet the Conditions of Participation specified in§§482.1 through 482.23 and §§482.25 through 482.57; This Standard is not met as evidenced by: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals it was determined that the hospital failed to comply with all CoPs specified in CFRs 482.1 through 482.23 and CFRs 482.25 through 482.57 as the following CoPs were determined to be out of compliance: * CFR 482.12 - CoP: Governing Body * CFR 482.13 - CoP: Patient’s Rights * CFR 482.23 - CoP: Nursing Services 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 at Tag A-043, CFR 482.12 - CoP: Governing Body, that reflects the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all CoPs. Those findings included for this hospital that did not have a dedicated Emergency Department, failure to ensure appropriate assessment and initial treatment of individuals anywhere on the hospital’s campus who exhibited a need for a medical emergency response (Tag A-093). 2. Refer to the findings cited at Tag A-115, CFR 482.13 - CoP: Patient’s Rights, that reflects the hospital failed to fully develop and implement P&Ps that ensured each patient’s right to receive care in a safe setting. The hospital’s failures to ensure appropriate patient assessment and provisions for response to medical emergencies created an unsafe EOC that potentially contributed to harm and death of one patient and created the likelihood of harm to other patients (Tag A-144). 3. Refer to the findings cited at Tag A-385, CFR 482.23 - CoP: Nursing Services, that reflects the hospital failed to fully develop and implement P&Ps that ensured that the nursing services were under the supervision of an RN, that patient needs were met by ongoing nursing assessment, and that nursing personnel responded to the nursing and emergency care needs of the patient population of each department (Tag A-392). ****************************************************** 29708”

“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: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation it was determined that the governing body 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. 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 at Condition Tag A-115 under CFR 482.13 - CoP: Patient’s Rights that reflects that policies, procedures, and systems for the provision of safe care were not clear, complete, or implemented (Tag A-144); that identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur (Tag A-145); and that response to, investigation of, and follow-up to patient grievances related to safe care were not clear, complete or timely (Tag A-118). 2. Refer to the findings cited at Condition Tag A-263 under CFR 482.21 - CoP: Quality Assessment and Performance Improvement that reflects additionally that the hospital failed to ensure that incidents and adverse patient events were clearly identified, tracked, investigated and analyzed, and that corrective actions were planned and implemented to prevent recurrence of those, to promote learning throughout the hospital, and to establish clear expectations for patient safety. Further, there was no process for systematic identification and tracking of negative outcomes to patients that involved patient injuries, ED visits, and hospitalizations in relation to incidents (Tag A-286). 3. Refer to the findings cited at Condition Tag A-385 under CFR 482.23 - CoP: Nursing Services that reflects additionally that the RN failed to supervise the nursing care for each patient to ensure the provision of safe and appropriate care that included prevention of patient to patient altercations and injuries, and sexual contact. RN failures included, but were not limited to: failure to ensure nursing staff appropriately supervised and observed patients to prevent incidents, failure to ensure investigations of incidents were complete and corrective actions were taken that prevented recurrence, and failure to ensure that response to grievances regarding patient safety were timely and appropriate (Tag A-395). ******************************************************”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation, it was determined that the hospital failed to ensure each patient’s right to provision of care in a safe setting, the right to freedom from all forms of abuse and neglect, and the right to prompt and appropriate response to grievances. Those failures resulted in actual and potential physical and psychological harm to patients. 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 at Tag A-144 under CFR 482.13(c)(2) - Standard: Privacy and Safety that reflects that policies, procedures, and systems for the provision of safe care were not clear, complete, or implemented and resulted in the following: * Failure to prevent patient to patient physical altercations and injuries. * Failure to prevent patient to patient sexual contact and sexual assault. * Failure to ensure staff carried out assigned duties related to all aspects of observation and supervision of patients. * Failure to ensure TCPs and ES orders were followed. * Failure to ensure door security and situational awareness practices that ensured patient safety. * Failure to ensure all high risk patient care areas monitored by 24/7 security staff video monitoring were fully observable and did not include blind spots. * Failure to ensure staff practices were in accordance with, and supported by, written and approved P&Ps for the following: - Condom distribution to patients. - Processing and tracking police reports filed on behalf of patients who had been assaulted by other patients. - Security staff “access control” video monitoring * Failure to ensure Code Blue responses were organized, appropriate, and documented. * Failure to ensure staff training related to patient safety was current. 2. Refer to the findings cited at Tag A-145 under CFR 482.13(c)(3) - Standard: Privacy and Safety that reflects that identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur. 3. Refer to the findings cited at Tag A-118 under CFR 482.13(a)(2) - Standard: Patient Grievances that reflects that response to, investigation of, and follow-up to patient grievances related to safe care were not clear, complete or timely. ******************************************************”

“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: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of 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 patients in the hospital. 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 at Condition Tag A-115 under CFR 482.13 - CoP: Patient’s Rights that reflects that policies, procedures, and systems for the provision of safe care were not clear, complete, or implemented (Tag A-144); that identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur (Tag A-145); and that response to, investigation of, and follow-up to patient grievances related to safe care were not clear, complete or timely (Tag A-118). 2. Refer to the findings cited at Tag A-286 under CFR 482.21(a), (c)(2), (e)(3) - Standard: Patient Safety that reflects the hospital failed to ensure that incidents and adverse patient events were clearly identified, tracked, investigated and analyzed, and that corrective actions were planned and implemented to prevent recurrence of those, to promote learning throughout the hospital, and to establish clear expectations for patient safety. Further, there was no process for systematic identification and tracking of negative outcomes to patients that involved patient injuries, ED visits, and hospitalizations in relation to incidents. ******************************************************”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation it was determined that the hospital failed to ensure that nursing services were organized and managed to ensure the provision of safe and appropriate care to each patient in the hospital. 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 at Condition Tag A-115 under CFR 482.13 - CoP: Patient’s Rights that reflects that policies, procedures, and systems for the provision of safe care were not clear, complete, or implemented (Tag A-144); that identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur (Tag A-145); and that response to, investigation of, and follow-up to patient grievances related to safe care were not clear, complete or timely (Tag A-118). 2. Refer to the findings cited at Tag A-395 under CFR 482.23(b)(3) - Standard: RN Supervision of Nursing Care that reflects an RN failed to supervise the nursing care for each patient to ensure the provision of safe and appropriate care that included prevention of patient to patient altercations and injuries, and sexual contact. RN failures included, but were not limited to: failure to ensure nursing staff appropriately supervised and observed patients to prevent incidents, failure to ensure investigations of incidents were complete and corrective actions were taken that prevented recurrence, and failure to ensure that response to grievances regarding patient safety were timely and appropriate. ******************************************************”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 08621 ****************************************************** Based on review of grievance documentation for 1 of 1 patient reviewed for grievances (Patient 11) it was determined that the hospital failed to ensure patients’ rights were recognized, protected, and promoted in regards to patient grievances. Response to, investigation of, and follow-up to patient grievances were not clear, complete or timely. Findings include: 1. Review of patient grievance documentation filed by Patient 11 revealed the following: 1.a. A “Patient Grievance” form was signed and dated by Patient 11 on 08/13/2023 at 1932. At the top of the form Patient 11 had written in large letters “*Emergent*.” The grievance was described as “[Patient 10] is continuing to provoke and instigate myself and other patients. [MHT] witnessed [Patient 10] provoking me as I walked back onto the unit at approx. 6:02 pm. Just now [Patient 10] lunged at [another patient] with a raised fist attempting to intiate [sic] a violent interaction. Staff unwillingness to address this issue is putting staff and patient [sic] in harm’s way ... emergency transfer [Patient 10] to another unit.” The “For Staff use only” box reflected the “Date Received” was 08/14/2023. The “Grievance Committee Response” reflected the “Date of Grievance Review” was 08/21/2023 and the response was “attached” to the form. The undated attachment contained one paragraph that reflected “IDT is aware of the issues that are happening between you and the described peer and have taken the necessary follow up. All follow up will be confidential to protect patient privacy. In the future please encourage peers who are having issues to reach out to staff or complete their own grievances so that we may follow up with them.” 1.b. A second “Patient Grievance” form was signed and dated by Patient 11 on 08/13/2023 with no time. The grievance was described as “[Patient 10] has been increasing [their] aggressive behavior toward me and other patients. Flicking [another patient] and pushing through people. Just now in East TV Room I was grabbing a spoon after receiving my meal and [Patient 10] walked in from the air court and threw [their] shoulder into me ... Move [Patient 10] to another ward, My safety and the safety of the other patients is at risk.” The “For Staff use only” box reflected the “Date Received” was 08/14/2023. The “Grievance Committee Response” reflected the “Date of Grievance Review” was 08/21/2023 and the response was “attached” to the form. The undated attachment was identical to the one described in the grievance above. 1.c. A third “Patient Grievance” form was signed and dated by Patient 11 on 08/16/2023 at 0950. The grievance was described as “I filed 2 grievances within the last 72 hours about [Patent 10’s] continual aggressive behavior and [on 08/15/2023] in the milieu of Tree 1 [Patient 10] violently assaulted me by close fist strike to the left temple of my head. When I returned from the E.R. at approx 7 pm [Patient 10] was already out of seclusion. This morning in East Plaza at approx 9:15 [Patient 10] came out and began to attempt an altercation from afar telling staff ’[Patient 11] can’t be within 10 feet of me.’ This is systemic supported abuse and violence.” The “For Staff use only” box reflected the “Date Received” was 08/17/2023. The “Grievance Committee Response” reflected the “Date of Grievance Review” was 08/29/2023 and the response was “The treatment team has reviewed the issues and resolved it. The two patients currently do not reside on the same unit. The IDT may not discuss patient treatment with you.” 1.d. The fourth related “Patient Grievance” form was signed and dated by Patient 11 on 08/22/2023 at 1555. The grievance was described as “On, or about, August 15th at approximately 3:30PM I was assaulted by [Patient 10]. I do not believe the report has been forwarded to law enforcement and/or the Marion County DA for prosecution. The the [sic] documentation and proper reporting of this crime needs to be done immediately. If this violent assault is not reported, investigated, and charges are not filed I will hold each, and every, member of the Treatment Team, P.E.T, and all other relevant parties accountable both personally and professionally to the harm inflicted by this neglect. This will include each, and every licensee, who is charged with my care and treatment as a public servant of Oregon ... I still have not spoken with a detective, OSH security, or even been approached by a therapist to talk about, decompress, or process this attack for which I am the victim.” The “For Staff use only” box reflected the “Date Received” was 08/23/2023. The “Grievance Committee Response” reflected the “Date of Grievance Review” was 08/29/2023 and the response was “On 8/29 management called security to inquire about the police report regarding the assault. The police report was submitted by the unit on 8/15/23. Security stated that it had not yet been sent out to OSP for review. The detective who usually picks them up missed a week due to other obligations. It was stated the [detective] should return this week and will receive it by end of week sometime. Management asked if security was planning to follow up and they stated they don’t typically check in after each report unless a patient requests it specifically as there are too many to keep up with at times according to security. Management has reach out to the IDT and the therapist that you are currently working with on 8/29 and let them know you would appreciate meeting to help you process/decompress regarding the incident.” 2. In response to surveyor request for tracking information related to the police report that was filed, an internal OSH email, with an attachment, sent from the DOS dated 03/13/2024 at 0807 was provided. It included the following information: “Like most of our stuff we don’t have a written protocol but the process is described below ... This was closed out by [detective name] without being assigned a case number due to not meeting prosecutorial guidelines. At the time the case was received, the unofficial protocol we were using was ... Incident occurs prompting a report made to OSP ... [unit staff] fills out an OSP reporting form and submits it to the Security Management email box. Form is received by Security and printed ... Printed form is maintained by Security Investigator until OSP makes a visit to OSH to collect these forms ... When OSP detectives come to OSH, the printed forms are handed over to the detectives ...” 3.a. The document attached to the 03/13/2024 email from the DOS was titled “Oregon State Hospital - Security Department Reporting of a crime” was reviewed. It included the following information: * “Date of Incident: 08/15/2023” * “Reported by: [NM identified in the incident report]” * “Date/Time: 08/15/2023 at 1530” * “Victim of Crime: [Patient 11]” * “Suspect of Crime: [Patient 10]” * “Summary of Incident: [Patient 11] was speaking to the Unit Administrator ... [Patient 10] walked up ... swung around the staff and punched [Patient 11] in the left eye ... eye immediately began to swell, become bruised ...” * “Signature of person completing this report” that was followed by a signature. The lower part of the form had two sections, one of which was for “Security Use Only” which contained the following: * “Date Submitted:” * “Submitting Manager:” * “Reporting Manager Signature:” Those fields were blank and contained no entries. The last section of the form for “Dispatch Use Only” contained the following: * “Date Received:” * “Case Number:” Those fields were blank and contained no entries. 3.b. As of the date of the survey there was no documentation to reflect when that report had been received by the Security Department and whether or when it had been submitted to OSP. Nor was there evidence that Patient 11 had been updated as to the status of the report to OSP after the 08/29/2023 “Grievance Committee Response” for the 08/22/2023 grievance Patient 11 had filed. 4. Refer also to Finding 3 for Patient 11 cited at Tag A-144 under CFR 482.13(c)(2) - Standard: Privacy and Safety that reflects Patient 11 was assaulted and injured by Patient 10 on 08/15/2023 after submission of their grievances related to concerns about safety for themselves and others. ******************************************************”

“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: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of P&Ps and review of other documentation it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient’s right to receive care in a safe setting. The hospital’s failures to provide adequate observation, supervision and other preventive measures and precautions created an unsafe EOC that resulted in actual and potential physical, mental or emotional harm to patients. Deficient practices included: * Failure to prevent patient to patient physical altercations and injuries. * Failure to prevent patient to patient sexual contact and sexual assault. * Failure to ensure staff carried out assigned duties related to all aspects of observation and supervision of patients. * Failure to ensure TCPs and ES orders were followed. * Failure to ensure door security and situational awareness practices that ensured patient safety. * Failure to ensure all high risk patient care areas monitored by 24/7 security staff video monitoring were fully observable and did not include blind spots. * Failure to ensure staff practices were in accordance with, and supported by, written and approved P&Ps for the following: - Condom distribution to patients. - Processing and tracking police reports filed on behalf of patients who had been assaulted by other patients. - Security staff “access control” video monitoring * Failure to ensure Code Blue responses were organized, appropriate, and documented. * Failure to ensure staff training related to patient safety was current. * Failure to ensure incident investigations were clear and complete to identify causes and to plan and implement corrective actions to prevent recurrence for the affected patient and other patients. Findings include: 1.a. The P&P titled “Continuous Rounds, Census, and Milieu (RCM) Management” dated as 05/01/2023 was reviewed and included the following: * “Nursing staff must perform continuous rounds focused on census and milieu management (RCM) at all times on each unit when patients are present.” * “RCM rounds and related verifications and observations are documented on the Unit Patient Census and Status Flowsheet, also known as the ‘RCM Flowsheet.’” * “The oncoming RN (or Lead LPN) must note each patient’s status next to the patient’s name on the RCM Flowsheet using the ‘Daily Clinical Screening Status’ codes found on the flowsheet.” * “For patients on Enhanced Supervision, both the type and level of supervision must be noted.” * The RN (or Lead LPN) must verify that RCM duties are being continuously and accurately performed and documented by observing the RCM’s actions and reviewing the RCM Flowsheet at least twice per shift.” * “RCM staff must maintain a continuous presence in the milieu, walking each hall and varying their routes and times in order to prevent any identifiable patterns. This activity must occur on all shifts.” * “RCM staff must not station themselves in the Bubble, at the Hub, or other unit location and must only access these areas for short periods of time (less than 5 minutes) to complete specific RCM-related tasks.” * “When not actively completing RCM-related observation rounds, RCM staff must remain in the milieu, therapeutically interacting with patients, facilitating positive social interactions, providing assistance to patients and co-workers, and intervening early to defuse tense or potentially dangerous situations.” * “RCM staff must verify that patients are not engaging in unsafe or unlawful behavior and must intervene if such behavior is noted. This includes but is not limited to: monitoring for potentially aggressive behaviors to staff or peers and intervening ... monitoring for potential sexual contact between patients and intervening ...” * “RCM staff must verify the presence and viability of each patient on the unit at least once per hour, at random intervals (within 10 minutes before or after the top of each hour).” * “RCM staff must maintain continuous possession of the RCM clipboard, flowsheet(s), and a two-way radio ... 1.b. The P&P titled “Procedure B: Environment Checks” dated as 06/07/2023 was reviewed and included the following: * “To protect the safety of patients and staff, OSH staff are responsible to maintain the cleanliness and sanitation of patient care areas, including patient rooms. Environment checks may be conducted as often as necessary, and frequency may change depending on patient, unit, or treatment mall need ... Staff are encouraged to involve patients in maintaining cleanliness and sanitation of their rooms whenever possible ...” * “OSH staff designated in these procedures are authorized to: Enter a patient’s room to remove food and fluids (excluding water) ... Enter a patient’s room to remove and dispose of garbage; Check to ensure state-issued bedding is clean ... Ensure dirty clothing is in a covered laundry basket ... During rounding or other environmental monitoring, dispose of patient sundry items which are unlabeled or past the listed expiration date ...” * “Designated staff include; Nurses, including contracted nurse staff; Mental Health Technicians (MHT); Interdisciplinary team members (IDT); Clinical support staff ... Environmental Services staff.” 1.c. The P&P titled “Enhanced Supervision” dated as 11/09/2017 was reviewed and included the following: * “Oregon State Hospital (OSH) strives to promote and maintain the safety, health, and wellbeing of patients, in part by minimizing the occurrence of aggressive, suicidal, or self-destructive behavior. While persons who engage in such behavior often require a targeted increase in therapeutic interventions, which may include the increased presence of staff, this need must be weighed against the intrusion and isolation that such interventions may create. The least intrusive means of providing effective treatment must be used, with the goal of helping patients regain the ability to maintain safety toward self and others without the need for an increased staff presence.” * “The psychiatrist or psychiatric mental health nurse practitioner (PMHNP), using clinical input from other members of the interdisciplinary treatment team (IDT), must determine the type and level of enhanced supervision necessary to safeguard patients and staff. The IDT must collaboratively plan and implement therapeutic interventions to address dangerous, self-destructive, and/or suicidal behavior, or needs associated with medical illness.” * “The type of enhanced supervision indicates the primary behavior or condition that warrants more careful monitoring and/or intervention ... ‘Behavior supervision’ may be ordered to provide enhanced monitoring and intervention for patients who are at risk of engaging in dangerous behaviors. These behaviors may include harming others, elopement, sexual contact with peers, etc.” * “The level of enhanced supervision describes the frequency with which staff make contact with the patient being supervised. 1. “Unobtrusive supervision” means a staff member must be assigned to be aware of a patient’s location and activities at all times, and have visual and, if the patient is awake and able, verbal contact with the patient at least three (3) times per hour, at irregular intervals, never more than 30 minutes apart. 2. “Close supervision” means a staff member must be assigned to be aware of a patient ’ s location and activities at all times, and to have visual and, if the patient is awake and able, verbal contact with the patient at least five (5) times per hour, at irregular intervals, never more than 15 minutes apart. 3. “1:1 supervision” means a staff member must be assigned to monitor a patient’s location and activities at all times. The assigned staff member must maintain constant visual contact and consistent physical proximity, as well as verbal contact while the patient is awake, within parameters specified by the physician/PMHNP order and as described on the Intervention Card. The psychiatrist or PMHNP must specify additional parameters, as appropriate, in the order. Supervision at staff ratios greater than 1:1 (2:1, etc.) means the same as 1:1 except that more than one staff person is assigned to monitor the patient. * “’Intervention card’ means the document which assists staff working with any patient on 1:1 supervision and some patients on lower-level supervision. The Intervention Card includes the supervision order, the behavior(s) of concern, the hypothesis about the underlying reason for the behavior(s), and recommended interventions.” * “Patient education handout means the document that is prepared for a patient who is placed on enhanced supervision. It provides information about the behavior of concern, any limitations on patient movement or property, and how often the patient can expect to interact with staff.” * “Initial Response to Acute Safety Concern, Any HCP who becomes aware of a patient’s unsafe, unpredictable, or suicidal behavior or deterioration in medical condition must immediately take measures to verify the safety of patients and others, and notify the registered nurse or licensed practical nurse (nurse). The nurse must: 1. Immediately assess the patient and implement necessary safety and security measures. 2. If there is a need to assess for enhanced supervision, immediately contact the psychiatrist or PMHNP responsible for the patient’s care, or the Psychiatrist On Duty (POD). 3. When necessary, authorize temporary supervision and implement required documentation until the psychiatrist or PMHNP is available. 4. Document in a progress note the assessment of the patient, the specific behavior(s) and/or medical condition(s) that prompted intervention, the method of intervention, the patient’s response to the intervention, and the reason this specific intervention was used. 5. Determine if a search of the patient’s person or property may be necessary ...” * “Initiation of enhanced supervision ... Behavioral or suicide/self-harm supervision must be ordered only following face-to-face assessment by a psychiatrist or PMHNP. When a behavioral or suicide/self-harm supervision is needed, the psychiatrist or PMHNP must determine the primary type of supervision, the level of supervision, and any other relevant therapeutic interventions to be utilized. Findings must be documented in a progress note.” * “Reassessment of enhanced supervision a. If any patient is started on enhanced supervision by a covering psychiatrist or PMHNP, the patient must be reassessed by the attending psychiatrist or PMHNP the next business day, with the assessment documented in a progress note. b. If a patient remains on 1:1 or greater supervision for seven (7) consecutive days following the previous face-to-face assessment, the attending or covering psychiatrist or PMHNP or medical physician (in the case of medical supervision) must personally reassess the patient. This assessment must be documented in a progress note. If supervision continues to be deemed appropriate, a rationale for ongoing supervision and interventions to help the patient become safe must be documented. c. If a patient is on 1:1 or greater supervision for 14 consecutive days, the attending or covering psychiatrist or PMHNP or medical physician (in the case of medical supervision) must inform the supervisor, Chief Medical Officer (CMO), or designee. This discussion must include review of the treatment provided to the patient, and the patient ’ s progress toward safety. The practitioner must document this discussion (including rationale for ongoing supervision, alternatives considered, and any change in interventions provided based on supervisor review) in a progress note. This must be repeated at each consecutive 14 days the patient remains on 1:1 or greater supervision.” * “Discontinuation or change of enhanced supervision a. Only a psychiatrist or PMHNP may discontinue behavioral or suicide/selfharm supervision, and only following a face-to-face examination. This applies also to temporary supervision implemented by the nurse. b. Only a psychiatrist or PMHNP may change an order for behavioral or suicide/self-harm supervision. For significant changes (increase or decrease in level, change of type, or significant changes in parameters - for example, discontinuation of restriction to unit), a personal examination is required. For minor changes (for example, small modifications to allowed property), personal examination shall be at the discretion of the ordering practitioner.” * “Enhanced Supervision Orders 1. All orders for enhanced supervision must be entered into the electronic medical record, and must contain the following required elements: a. Type of supervision b. Level of supervision c. Primary behavior(s) of concern d. Time of day that supervision is required e. Distance staff should remain from the patient while supervising f. Allowed patient movement, particularly off unit g. Allowed patient property” * “The psychiatrist or PMHNP order may modify the default parameters for enhanced supervision. a. Default parameters include: i. Enhanced supervision level and type is around the clock (24 hours per day) ii. Enhanced supervision is applicable in all areas, both on and off the unit iii. A patient on enhanced supervision may attend and participate in most treatment mall classes and activities, cafeteria meals, quad time, visits, and religious services. iv. Continuous visualization of the head, neck and hands of any patient on 1:1 or greater suicide/self-harm supervision is required, including during patient use of bathroom and shower. v. For a patient on 1:1 or greater supervision, staff must remain approximately 2 arms’ length from the patient (in the doorway, if the patient is in their bedroom).” 1.d. The P&P titled “Enhanced Supervision” dated as 02/28/2024 was reviewed and included the following: * “This policy establishes guidelines for enhanced supervision at Oregon State Hospital (OSH). OSH strives to promote and maintain the safety, health, and wellbeing of patients by minimizing the occurrence of aggressive, suicidal, or self destructive behavior. This policy applies to all OSH staff.” * “The need for targeted increase in therapeutic intervention must be weighed against the intrusion and isolation that such interventions may create. The least intrusive means of providing effective treatment must be used, with the goal of helping patients regain the ability to maintain safety toward self and others without the need for an increased staff presence.” * “The psychiatrist or psychiatric mental health nurse practitioner (PMHNP), using clinical input from other members of the interdisciplinary treatment team (IDT), must determine the type and level of enhanced supervision necessary to safeguard patients and staff. The IDT must collaboratively plan and implement therapeutic interventions to address dangerous, self-destructive, and/or suicidal behavior, or needs associated with medical illness.” * “’Enhanced supervision’ is careful monitoring and/or intervention characterized by types that indicate the primary behavior or condition and levels that describe the frequency with which staff contact the supervised patient ... ‘Behavioral supervision’ provides enhanced monitoring and intervention for patients who are at risk of engaging in dangerous behaviors including harming others, elopement, sexual contact with peers, etc. ... Level: ‘Unobtrusive supervision’ means a staff member must be assigned to be aware of a patient’s location and activities at all times. Staff must have visual contact at least three (3) times per hour and, if the patient is awake and able, verbal contact with the patient at irregular intervals, never more than 30 minutes apart ... ‘Close supervision’ means a staff member must be assigned to be aware of a patient’s location and activities at all times. Staff must have visual contact at least five (5) times per hour and, if the patient is awake able, verbal contact with the patient, at irregular intervals, never more than 15 minutes apart ... ‘1:1 supervision’ means a staff member must be assigned to monitor a patient’s location and activities at all times. The assigned staff member must maintain constant visual contact and consistent physical proximity, as well as verbal contact while the patient is awake, within parameters specified by the physician/PMHNP order and as described on the Intervention Card. The psychiatrist or PMHNP must specify additional parameters, as appropriate, in the order.” * “’Intervention card’ is the document which assists staff working with any patient on supervision. The Intervention Card includes the supervision order, the behavior(s) of concern, the hypothesis about the underlying reason for the behavior(s), and recommended interventions.” * “’Patient education handout’ is the document prepared for a patient who is placed on enhanced supervision, providing information about the behavior of concern, any limitations on patient movement or property, and how often the patient can expect to interact with staff.” 1.e. The P&P titled “Use of Personal Portable Electronic Devices” dated as 09/30/2022 was reviewed and included the following: * “The purpose of this protocol is to define expectations relative to the use of personal portable electronic devices by nursing staff, as well as by other staff when working in the capacity of nursing staff or under the supervision of unit nursing management, while on duty at Oregon State Hospital (OSH). The goal of this protocol is patient and staff safety.” * “Personal portable electronic devices (PPED)” means any personal, self-contained, easily carried by an individual electronic device that has the capacity to receive, record, collect, store, or transmit data or images. Types of devices include, but are not limited to: cellular phones, hand-held computers, book viewers, music players, games, watches, fitness trackers, headphones (including earbuds), and speakers.” * “Primary patient care area” means all on-ground areas in which patients may normally be expected to be present. Primary patient care areas, such as clinic and treatment mall rooms and dining halls, become secondary patient care areas outside of normal hours of operation.” * “Staff may not access or interact with PPED while on assignment in a patient care role or while working on a patient living unit. (Questions regarding the applicability of this protocol to a specific person or role must be directed to unit nursing management.) 1. All non-hospital issued PPED must be turned off or set on silent mode and safely stored, preferably in the employee’s locker, during the work shift. Watches and fitness trackers may be worn but must be silenced. 2. Employees are encouraged to utilize the central staff phone in their assigned work area for emergency contacts. 3. If the employee chooses to carry their PPED on their person, the following rules apply. a. The device (exclusive of fitness trackers and watches), must not be visible to a patient, regardless of the actual or anticipated position or posture of the staff. For example, a phone that extends above a pants’ pocket, even if covered by a shirt or other garment, is not allowed. b. The staff member must not answer, or otherwise interact with, the device in a primary patient care area or in the presence of patients. c. The staff member must not leave a patient care assignment to answer, or otherwise interact with, the device without insuring adequate coverage during the staff ‘s absence. * “Except as noted above, staff may only access and interact with PPED while on rest and meal breaks. This access and use must not occur in primary patient care areas (even when no patients are visible) or where it could cause disruption or distraction to other staff (such as unit chart rooms, medication rooms, etc.).” 1.f. A document titled “Attachment C Staff Prohibited Items” dated 07/06/2022 was reviewed and included the following: * “The following items may be transported through patient care areas under secure possession of health care personnel (HCP), and must be stored in a secure, non-patient-care area (such as a break room or staff locker) as indicated in OSH Policy and Procedure 8.044, “Contraband and Prohibited Items”. These items may not be used in patient-care areas, even under the secure possession of HCP: glass, mirror or ceramic items; plastic bags or plastic wrap; personal toiletries (e.g., hair brushes, soaps, perfumes, deodorant, toothpaste, toothbrush, Aerosolized products); personal electronic devices not issued by OSH (e.g., cellphones, radios, MP3 players, cameras, or recording devices of any kind).” 1.g. The P&P titled “Sexual Activity Involving Patients” dated as 12/08/2022 was reviewed and included the following: * “Oregon State Hospital (OSH) has the responsibility to take reasonable steps to discourage sexual contact between patients and to direct appropriate follow-up actions if sexual contact or sexual assault occurs. This policy establishes definitions of appropriate touch and inappropriate sexual behaviors for patients and expectations for staff response in the event of such behaviors.” * “Staff and patients are authorized to use appropriate touch; however, staff and patients must receive permission before touching another person. Even if permission is received, the other party may change their mind at any time, and the appropriate touch must stop immediately ... Staff must follow Procedures A if staff witness or receive reported allegations of a patient engaging in inappropriate sexual behaviors (other than sexual contact) with another person ... Staff must follow Procedures B if staff witness or receive reported allegations of a patient engaging in sexual contact with another person. Patient sexual contact is considered a reportable incident ...” * “’Appropriate touch’ includes, but is not limited to: Handshakes, Fist bumps, Touching a person’s shoulder, Side hugs, and Any behavior normally associated with friendship or emotional support. ‘Inappropriate sexual behaviors’ include: Sexual contact, Intimate/inappropriate touching, Kissing, Extended hand holding, Full body hugs, Hugs from behind, Sexual conversations/statements, Going off alone with another patient to be more intimate, Other behaviors normally associated with sexual interactions or relationships, and/or Any sexual or dating behavior the interdisciplinary treatment team deems as contraindicated for recovery.” * “’Sexual assault’ means an incident of sexual contact between patients where criminal activity is alleged to have occurred as defined by Oregon Criminal Code, including, but not limited to, non-consensual sexual intercourse or penetration, and those acts involving an alleged victim who lacks capacity to consent to sexual contact.” 1.h. The P&P titled “Sexual Activity Involving Patients” dated as 02/16/2024 was reviewed and included the following: * “’Appropriate touch’ includes, but is not limited to: 1. Handshakes, 2. Fist bumps, 3. Touching a person’s shoulder, 4. Side hugs, and 5. Any behavior normally associated with friendship or emotional support. B. ‘Inappropriate sexual behaviors’ include: 1. Sexual contact, 2. Intimate/inappropriate touching, 3. Kissing, 4. Extended hand holding, 5. Full body hugs, 6. Hugs from behind, 7. Sexual conversations/statements, 8. Going off alone with another patient to be more intimate, 9. Other behaviors normally associated with sexual interactions or relationships, and/or 10. Any sexual or dating behavior the interdisciplinary treatment team deems as contraindicated for recovery 1.i. The “Procedure B: Staff Response to Sexual Contact Involving Patients” dated as 02/16/2024 was reviewed and included the following: * “For witnessed sexual contact or upon receiving a report of alleged sexual contact: 1. Staff must notify the lead RN ... and a manager on site ... The lead RN or PNM must notify: a. The patient’s psychiatrist/psychiatric mental health nurse practitioner (PMHNP) or Psychiatrist on Duty ... The unit Nurse Manager or program nurse manager (PNM) if after hours, OSH Security department, The Infection Prevention and Employee Health Department. Psychiatry staff must meet with all involved patients individually to assess immediate medical and psychological needs ... Psychiatry and nursing staff must collaborate to determine what environmental interventions are needed to limit contact between involved patients. This may include transfer ... Staff must report the incident ... Staff must document the incident and intervention in every involved patient’s electronic medical record ...” 1.j. The “Procedure A: Staff Response to Inappropriate Sexual Behaviors Involving Patients” dated as 12/08/2022 was reviewed and included the following: * “For witnessed inappropriate sexual behaviors, staff must intervene to stop the inappropriate sexual behaviors. Appropriate interventions include, but are not limited to: 1. Instructing the individuals to stop and separate, 2. Call for additional staff for assistance ...” * “For witnessed inappropriate sexual behaviors or alleged inappropriate sexual behaviors: 1. Staff must notify the lead RN of the incident (PNM if the incident occurs on an SRTF unit). 2. The lead RN may consult with the interdisciplinary team (IDT) and/or PNM to determine if room changes or other environmental interventions are needed to limit contact between the involved patients. 3. Staff must document the incident and intervention in every involved patient’s electronic medical record ... 4. The IDT must meet to determine if further assessment of any involved patient to identify additional treatment needs is appropriate, or if treatment care plan updates are necessary ... Inappropriate sexual behaviors between a patient and staff must be reported.” 1.k. The Procedure B: Staff Response to Inappropriate Sexual Behaviors Involving Patients” dated as 12/08/2022 was reviewed and included the following: * “Following an incident of patient sexual contact, the IDT must: 1. Meet no later than the next business day, excluding weekends and holidays, to review and address the incident. Treatment care plan updates that may result from the IDT meeting must be made per OSH policy 6.011, “Treatment Care Planning.” 2. Meet with all involved patients to assess any further psychological or medical needs and coordinate any recommended follow-up services ... If sexual contact occurs between patients that all involved patients describe as consensual, Psychology or Psychiatry staff will assess each involved patient for capacity to give consent and document the assessment in the electronic medical record ... If one or more involved patient does not describe the sexual contact as consensual, no assessment will occur. Instead, staff must follow OSH policy 8.019, ‘Staff Response to Alleged Criminal Acts’ ... Staff must follow OSH policy 8.019 if it is determined that a patient does not have capacity to consent, or a suspected sexual assault has occurred.” 1.l. During interview with staff that included the DSC, the QMD and others on 02/28/2024 beginning at 1615 they stated that the policy definitions of sexual contact had been changed on 02/05/2024 to include what had been previously categorized as “intimate touching.” Those “intimate touching” encounters between patients had not previously required that an incident report and an investigation be completed. As of the 02/05/2024 policy change those behaviors were considered to be “sexual contact” and would require an incident report and investigatory next steps. ****************************************************** 2. The following is regarding an incident involving Patient 22 and Patient 23. 2.a. During interview with staff that included the Superintendent, CNO, QMD, DSC, COM, CMO, DNS, and PD on 02/28/2024 beginning at ~ 1630 staff stated that on 02/10/2024 at ~ 1030 Patient 22 physically attacked Patient 23. They stated that the unwitnessed assault occurred without provocation in the AN1 air court and resulted in physical harm to Patient 23 that included LOC and a head laceration. When Patient 23 was found a Code Blue was called, 911 was called, and the patient was transported to the local acute care hospital for ED services. The following information was provided during the interview: * Upon return from the ED later the day of the incident, Patient 23 was transferred to the OSH medical unit for care and monitoring. * Security staff initiated video review immediately after the incident to determine what happened and who had assaulted Patient 23. * When it was shown on video that Patient 22 was the aggressor, orders for 1:1 observation and for placement in seclusion were initiated for Patient 22 until they could be transferred to another unit. * An Everbridge email notification was sent to hospital leadership staff on the day of the incident at 1117 to inform them that Patient 23 had been transported to the acute care hospital secondary to LOC and “contusion” over the left eye. * On 02/12/2024 hospital leadership met to continue follow-up actions and initiate the formal investigation that was underway at the time of this survey. * Video recordings of unit, patient, and staff activities prior to the event had been reviewed. * Staff adherence to unit shift assignments had been evaluated. * Medical records for Patient 22 and Patient 23 had been reviewed. * Initial investigation findings included that RN and MHT staff assigned to be continually present in the milieu were not in the milieu at the time of the incident, that observation orders in place for Patient 23 had not been followed, and there was a lack of staff supervision to ensure assignments were followed. * Initial actions taken included communications to all staff regarding their responsibilities to comply with unit assignments and to maintain continual presence on the milieu. * Staff changes were made that included placement of employee staff on AL during the investigation, and termination of some agency staff contracts. 2.b. Review of Patient 23’s medical record reflected that they sustained injuries and had subsequent hospitalizations that included: * A “Patient Progress Note” written by an OSH MD on 02/10/2024 at 1250 included the following: “Writer got called about the code blue in AN-1 at around I 0:50 AM this morning. When I went to the unit, [Patient 23] was lying down in the air court area, with [their] face towards ground bleeding profusely from a laceration on the forehead. Pt was conscious and able to talk with staff but could not recollect what happened. Staff were able to reposition [the patient] with [their] face facing side ways and apply pressure on the lacerated wound to prevent further bleeding. Pt later stated that someone choked [them] from behind and [they were] unconscious for a moment. I’ve noticed a deep lacerated wound on the right side of [their] forehead approximately 8 cm x 4 cm. EMS arrived and applied pressure dressing on [the patient’s] head ... sent to Salem Hospital ER for further evaluation and treatment.” * A local hospital ED encounter note for 02/10/2024 included the following: “The patient ... presents to the Salem Health Emergency Department with head, face and neck pain after being assaulted. Patient states that [they were] assaulted ... at the Oregon State Hospital states that [they were] choked and then thrown to the ground and [they] landed on the edge of concrete brick. [They state] that [they were] getting choked and then [they] felt like [they were] going to pass out and was thrown to the ground and does not remember what happened after that. Staff at the bedside were able to get video of this and did state that it was caught on camera and [Patient 21] was choked and thrown to the ground and [they] did have a loss of consciousness ... Patient has a large gaping X shaped laceration across [their] forehead extending over the bridge of the nose and down towards the right eye but does not involve the globe or the lid ... does have some swelling of the eyelid on the left that progressed throughout [their] stay here. Neck: ... does have tenderness over the anterior neck ... evaluated for facial laceration, head injury, choking episode with neck pain. Ddx includes, but is not limited to: I have concerns for intracranial hemorrhage, skull fracture, facial bone fractures, airway or vascular injury of the neck secondary to choking episode ... ADMIT TO OBSERVATION: Yes, Time starts 1130 AM Disposition of the patient will be determined by the results of the ED workup as well as re-evaluation of the patient to determine adequate response to treatment ... PROCEDURE NOTE: LACERATION REPAIR Site: Forehead Length: 15 cm Laceration Type based on exam: complex Anesthesia was obtained with several cc of 1 % lidocaine with epinephrine. Prior to repair the laceration was thoroughly cleansed and irrigated per nursing protocol. The wound was examined prior to repair and no significant arterial, nerve or underlying tendon injury was noted. Foreign bodies were not appreciated. The area was prepped and draped in the usual sterile fashion. The site was then repaired with 4-0 gut utilizing several simple interrupted sutures and several short running sutures. Deep sutures were needed for good wound approximation. 2 deep sutures were placed. A dressing was placed over the site ... Extensive suture repair of the forehead laceration with good approximation and hemostasis.” The ED note reflected that the patient had blood drawn for lab testing and underwent CT testing of the head, facial bones, and angio of the neck. The patient was discharged back to OSH on 02/10/2024. * A “Patient Progress Note” written by an OSH MD on 02/10/2024 at 2240 included the following: “Pt was evaluated after [they] came back from Salem Hospital ... had the laceration sutured on the forehead. Pt had wound dressing in place. Pt was awake, alert and oriented ... calm and mentioned that a peer came from behind and strangulated [them]. Reports having pain while trying to open [their] mouth and difficulty chewing the food. Reports having moderate pain in [their] forehead ... left eye shut due to swelling. Speech was fluent with regular rate and volume. Fair insight and judgement per test situation.” * A “Patient Progress Note” written by an OSH MD on 02/11/2024 at 1657 included the following: “[Patient 23] ... earlier [today] ... had xl vomiting, received Zofran. No further vomiting. Reports head and neck pain, vision problems and stress related to the event ... reports [they] felt sudden neck pain (staff reported [the patient] was grabbed from the back and [their] neck was put in a choke hold), and [they] lost consciousness, fell on [their] face; [they have] no memories of the event ... Facial swelling, anxiety ... both eyelids are swollen and bruised, and bruises below the orbits. Left eye hard to ope, [sic] right eye is also somewhat shut but less severe ... TMJs are tender, only able to open [their] mouth about 4-5cm wide ... is a large, X-shaped suture on the forehead that extends to the glabella. Nasal base is swollen and tender, but air flows through both nostrils. Neck is anterior swollen somewhat. Decreased lateral rotation, only 30 deg to left and right ... There is a scant bruise on the right side of the neck ... Choking event, LOC, fall on face, facial contusion with sutures, orbital and neck soft tissue injuries. Anxiety related to the event. Suspected concussion ...” * Patient 23 was transferred from the medical unit to TR3 unit on 02/13/2024. * A “Patient Progress Note” written by an OSH NP on 02/14/2024 at 2144 included the following: “Pt said that [they are] still having nausea and is having some trouble eating ... waking up in pain ... vision is still blurry.” * A “Patient Progress Note” written by an OSH MD on 02/19/2024 at 1722 included the following: “Called by nursing staff due to patient showing worsening distress with frequent vomiting and severe persisting headache over the last hour without relief by various when necessary medications. Patient seen in [their] room ... appears to be in mild distress but notes that [their] vomiting has subsided for the moment. Given recent severe head injury and episode of choking after strangulation from peer last weekend, I discussed with nursing staff and we agreed that having [the patient] assessed in the emergency department was appropriate. Prepared paperwork and discussed with nursing staff ... patient was agreeable with the plan.” * A “Patient Progress Note” written by an OSH MD on 02/20/2024 at 1633 included the following: “ ER follow up, a. Urinary retention, could not urinate for them in ER. [Patient] was straight cathed for 800 ml. b. Still having significant HA. Now associated with nausea and vomiting. Loud noises make [their] head hurt more ... 1.Post concussion headache. Now with some associated nausea and vomiting. Zofran is controlling the nausea and decreasing the vomiting. But still has severe HA. CT did not show any hemorrhage intra and extra cranial ... 2.Laceration: seems to be healing well. No indication of infection. 3.Urine retention. Straight cathed for 800 ml in the ER. Still having issues today. Will need to have [patient] scanned and possible repeat scan. Also need to find out how much [they are] drinking -what [they are] vomiting. [Patient] may not be making as much urine if [they are] slightly dehydrated.” * A “Patient Progress Note” written by an OSH MD on 02/21/2024 at 1243 included the following: “1. Patient continuing to have urinary retention, feels like [they need] to urinate, but cannot make urine flow. When [they bear] down in [sic] push it out, [their] headache increases significantly ... NECK: Tenderness to palpation and rotation C2-4 on the right ... Assessment/Plan 1.Urinary retention since assault 2/10/24. Initially was able to urinate small amounts but required straining. Now cannot urinate even with straining. 2.Headaches: suspect post-concussion HA, but it definitely gets worse when [patient] strains. Craning CTs have been negative x2. Transfer to [Salem Hospital ED]. Spoke with [physician] in the ER. Requested evaluation of [the patient’s] cervical spine and other evaluations if indicated.” * A “Patient Progress Note” written by an OSH NP on 02/21/2024 at 1734 included the following: “On 2/20/24, ... met with pt following AM report. Pt was transported to ... ED on 2/19/24 ... Pt continues to report difficulty urinating, along with continued headache, N/V. Pt stated that [they are] currently experiencing 8/10 pain and that [they are] ‘starting to feel really agitated’ due to pain and continued external stimuli (routinely loud volume on unit, bright lights in hallway). Pt went on, ‘I feel like I should be on [the medical unit]. I need a quiet place. I don’t know why they didn’t keep me there longer. It was a lot quieter.’ PMHNP informed pt that [they] will complete an urgent transfer request to a medical unit and pt indicated understanding. Assessment/Plan: Consulted with clinic MD regarding pt status pre and post ED transport, noting continued urinary retention and post-concussive pain, dizziness, N/V. MD met with pt that afternoon for assessment (see MD note for details). PMHNP completed emergency transfer request for [medical unit].” * A “Patient Progress Note” written by an OSH NP on 02/23/2024 at 1941 included the following: “On 2/21/24, PMHNP reassessed pt ... Pt reported continued urinary retention and after a bladder scan in clinic revealed approx 805 ml, unit NM assisted pt with straight cath which yielded approx 1050 ml. Clinic MD was immediately notified who subsequently sent pt back to Salem ED for imaging. Pt was sent back with indwelling catheter and notation of urinary retention without identifiable cause. Pt was referred to urology and neurology for flu. Transfer to [medical unit] was subsequently accepted ... Prior to transfer, around 1650 on 2/22/24, pt reported visualizing a blood clot in [their] catheter tube. PMHNP visualized an approx 0.5 mm size blood clot ... no further clots were observed, no change in output that might indicate a blockage ... Pt was transferred [to medical unit] following lunchtime on 2/23/24.” * A “Patient Progress Note” written by an OSH MD on 02/26/2024 at 1047 included the following: “[Patient] vomited this AM ... post concussion- improving, but has ongoing NV and HA ... Urinary retention- pulled out Foley this AM, start PRN bladder scanning and PRN straight cath, urology consult on 2/28. retention is likely related of stress because symptoms started about 10 days after [their] initial injury, [Patient] says [they feels] more relaxed now that [they’re] back [on medical unit].” * A “Patient Progress Note” written by an OSH MD on 02/28/2024 at 1452 included the following: “[Patient] returned from Urology eval ... had urinary retention temporarily last week, Foley was removed 2 days ago and bladder scan and straight cath PRN were ordered, but [patient] had normal urine since, no straight cath needed. The retention was likely situational, as [patient] admits, teh [sic] previous unit [they were] at was too stressful, and being on medical 1 : 1 watch caused more stress so [they] couldn’t urinate.” * A “Patient Progress Note” written by an OSH MD on 03/02/2024 at 1616 included the following: “[Patient] was seen and evaluated on the unit after [they] requested to be seen for [their] headache. [Patient] reports experiencing ‘the worst headache of [their] life’ and nausea since waking up this morning. Symptoms did not resolve or improve after taking imitrex and pain medication. Denied experiencing shortness of breath, chest or abdominal pain, dizziness or sensation of the room spinning ... Given [patient’s] recent history of head trauma and intensity of headache pain, new nausea and unsteady gait, ordered that [they] be transferred to Salem ED for head CT to rule out intracranial bleed. Spoke to Salem Health triage nurse ...” * During interview with staff that included the CMO, DSC, QMD, and Deputy CNO on 03/04/2024 at 1100 they reported that Patient 23 had been transported to the Salem Hospital ED on 03/02/2024 and had been admitted as an inpatient to neurology with a fever of ~ 103 degrees and a possible diagnosis of “viral meningitis.” 2.c.i. During tour of three Salem-campus hospital units (AN1, AN3, and TR1) on 02/28/2024 beginning at ~1515 observations were made: * On AN1 the unit’s NS, hallways, common areas, and air court were observed to be configured as follows: The main entry door onto the unit led into the West Hallway. Near the end of the West Hallway on the left was the Med Room window and after that the door into the Med Room. That was followed by a door into the main NS and “bubble.” The “bubble” was a NS counter and area that was fully enclosed with see through material from the counter to the ceiling in the front and on both sides. The windows on each side of the “bubble” had a round area through which patients and staff could converse. Behind it, the bubble was connected to the rest of the NS and Med Room. Extending out from the NS at the end of the West Hallway were three other hallways, South, East, and North. In front of the NS was the “commons” space in which television and seating was provided for patients. There was an entry door into the commons from the East Hallway and an entry door into the commons from the South Hallway. Extending outward from the commons spaces toward the exterior of the building was the air court space. There was an entry into the air court from the East commons space and an entry into the air court from the South commons space. A description of the air court follows below. * During the tours of AN1, AN3, and TR1 there were numerous staff observed in the milieu hallways and common areas. Staff were observed to interact with patients. Some staff were observed actively walking through the halls with clipboards. Other staff who were identified as 1:1 constant observers were observed to sit outside of patient rooms with clipboards. 2.c.ii. An undated “Video Timeline” document completed by hospital staff included the following “Scene description” that described the air court space in which Patient 23 was attacked: “The AN1 air-court is a 30’ x 20’ screened patio area, which faces east, along the east side of the unit. At either end of the air-court are entry doors, with one from the east commons room and one from the south commons room. Along the interior wall of the air-court are large windows which span approximately 3’ off the floor to near the ceiling of both common rooms. The outer, mesh screen material, is heavy fencing spanning from approximately 1’ from the floor to the ceiling. Along the base of the meshed screen was is a concrete curb-line. At the south wall line of the air-court is a mesh door to Quad [secured, walled outdoor space] ... Inside the air-court is plastic patio furniture which consists of plastic chairs and at times tables. The air-court and each commons room contain (1) surveillance camera each, which do have some blind spots areas.” 2.d. Survey team review of video-recordings, without audio capability, revealed the following timeline of events on 02/10/2024 beginning at 1033:49 when Patient 23 entered the air court space where they were attacked: ~ 1033:49 Patient 23 entered the air court through the East Hall door with a beverage cup in one hand and a banana in the other hand. ~ 1034:15 Patient 23 positioned a chair and seated themselves to face south toward the outside of the air court. They sipped on beverage and ate the banana. ~ 1036:41 Patient 23 exited air court briefly through south commons door with banana peel in hand. ~ 1036:55 Patient 23 reentered air court without the banana peel in hand, sat down in south facing chair, resumed sipping beverage. ~ 1037:22 Patient 22 entered air court through south door, Patient 23 turned head toward Patient 22 momentarily then back to face south. Patient 22 walked around and periodically stood still in the space for the next ~ 52 seconds, then moved directly behind Patient 23. ~ 1038:14 Patient 22 lunged toward Patient 23 from behind, placed their arm around Patient 23’s neck in a “chokehold” manner, and lifted Patient 23 to a standing position. Patient 23 initially struggled, reached both their arms up and behind their head and neck to attempt to release the grip of Patient 22. Patient 23’s arms fell to their sides after 12 seconds and they stopped moving. Over the next 16 seconds Patient 23 maintained the “chokehold” while they also shook Patient 23’s limp body which was lifted off the ground. ~ 1038:42 Patient 22 released the “chokehold” and threw Patient 23 toward the southwest corner of the air court onto the ground. Patient 23’s motionless body was not clearly visible in the video recordings of the air court. Only a small portion of their body could be seen but not clearly. ~ 1038:47 Patient 22 calmly and without expression walked out of the air court through the South Hall door. ~ 1039:17 30 seconds after Patient 23 was thrown to the ground a third patient entered the air court through the East Hall door and eventually saw Patient 23 who continued to lie motionless on the ground in the corner of the air court. ~ 1039:23 That third patient exited the air court. (Seen on other camera views at that time the patient waved their arms in the air and appeared to yell for help, after which eight staff emerged from the West Hall side of the NS and hurried toward the air court.) ~ 1039:30 Multiple staff enter the air court and upon observation of Patient 23 on the ground some ran back out, after which numerous staff begin to rapidly respond to the air court, many of whom were observed on other camera views entering the unit through the unit’s secure doors from other parts of the hospital. ~ 1041:47 Staff pushed the Code Cart into the air court. ~ 1042:21 By this time there were at least 16 individuals, if not more, in the air court. It was a crowded, disorganized, and chaotic scene and it was unclear what roles and tasks the various staff were carrying out. ~ 1054:08 EMS staff entered the air court with a gurney and equipment and assumed care of Patient 23. It was shown on other camera views that after Patient 22 left the air court at 1038:47 they walked across the South Hallway into the activities room, then to the NS where they stood until staff were seen to rush from the NS toward the air court. After that they walked down East Hall and entered the East Hall door towards the air court. At 1040:22 they exited that space, reentered the East Hall corridor and walked toward their room. 2.e.i. Survey team review of video-recordings that began on 02/10/2024 at ~ 1000, prior to the time of the air court incident, revealed the times when staff left the fully enclosed NS. This excluded the staff persons assigned to constant 1:1 observation of a patient located on the North Hall. During interview with staff that included the CFO/COO, QMD, DSC, and IRSI at the time of the video review on 02/29/2024 beginning at 1030, they stated that staff assigned to constant 1:1 are not considered to be present on the milieu as their role and responsibility is to observe and focus all attention on the 1:1 patient. The video recordings showed that from ~ 1000 until ~ 1039:30, the time the third patient called for help upon finding Patient 23 on the ground, there was not a continual presence of any staff in the milieu. During the times below multiple patients were observed to wander throughout the halls, pace around the NS and Med Room, stand against the walls, sit on the floor, lay on the floor, talk on the patient phone, enter and exit common areas. 2.e.ii. Review of the “Day Shift” functional assignment sheet for 02/10/2024 reflected that from 1000 to 1100 MHT B was assigned to the “Environmentals” role/task. Video recordings showed the time MHT B was out of NS from 1000 to the time the third patient called for help in the air court was ~ 16 minutes, 26 seconds: ~ 1000:00 visible inside NS. ~ 1005:05 left NS, walked down South Hall, then onto East Hall, then back in front of NS, reentered NS at 1021:00, ~ 16 minutes later. ~ 1027:14 left NS through West Hall door, walked into room with closed door on West Hall ~ 16 seconds later. ~ 1030:15 exited West Hall room, reentered NS across the hall at 1030:25, 10 seconds later. ~ 1039:32 left NS hurriedly toward air court. 2.e.iii. Review of the “Day Shift” functional assignment sheet for 02/10/2024 reflected that from 1000 to 1100 MHT C was assigned to the “RCM” role/task. Video recordings showed the time MHT C was out of NS from 1000 to the time the third patient called for help in the air court was ~ 10 minutes, 11 seconds: ~ 1000 appeared from East Hall, walked down South Hall, reentered NS ~ two minutes, 10 seconds later. ~ 1007:25 left NS, walked down South Hall, reentered NS ~ one minute, 11 seconds later. ~ 1010:07 left NS, walked down South Hall then East Hall, then approached MHT F and MHT H who were seated in chairs in the hall outside of the NS, reentered NS ~ three minutes, 14 seconds later. ~ 1014:04 left NS, walked down West Hall and entered through door into fourth room on left of hallway at 1014:13. ~ 1015:05 left West Hall room, walked across the hall into the NS, 14 seconds later. ~ 1015:30 left NS, walked down South Hall, reentered NS ~ one minute, 38 seconds later. ~ 1027:13 left NS, walked down South Hall then East Hall, returned NS at 1028:45, ~ one minute, 32 seconds later. ~ 1039:35 left NS hurriedly toward air court. 2.e.iv. Review of the “Day Shift” functional assignment sheet for 02/10/2024 reflected that from 1000 to 1100 MHT D was assigned to the “Bubble” role/task. Video recordings showed the time MHT D was out of NS from 1000 to the time the third patient called for help in the air court was ~ four minutes, 22 seconds: ~ 1000:00 appeared from South Hall, walked into first room on the left on East Hall, stood outside of room with door open, reentered NS at 10:02:38. ~ 1011:45 left NS, stood directly outside of NS, reentered NS ~ 17 seconds later. ~ 1016:11 left NS, walked down South Hall, reentered NS ~ 38 seconds later. ~ 1017:37 left NS, walked down South Hall, reentered NS ~ 23 seconds later. ~ 1027:32 left NS, approached MHT F and MHT H who were seated outside of the NS, reentered NS ~ 17 seconds later at 1027:49. ~ 1039:30 left NS hurriedly toward air court. 2.e.v. Review of the “Day Shift” functional assignment sheet for 02/10/2024 reflected that from 1000 to 1100 LPN FF was assigned to the “”Meds” role/task. Video recordings showed the time LPN FF was out of NS from 1000 to the time the third patient called for help in the air court was ~ 1 minute, 32 seconds: ~ 0959:00 on North Hall stood near MHT H, who was seated in a chair outside of the NS. ~ 0959:54 entered NS after MHT F exited the NS and sat in a chair beside MHT H outside of the NS. ~ 1000:03 left NS, handed something to MHT C who was outside of NS, reentered NS at 1000:14, 11 seconds later. ~ 1001:53 left NS, walked down West Hall and entered through door into fourth room on left of hallway 15 seconds later. ~ 1017:45 left West Hall room, walked across the hall into the NS, 12 seconds later. ~ 1039:35 left NS hurriedly toward air court 2.e.vi. Review of the “Day Shift” functional assignment sheet for 02/10/2024 reflected that from 1000 to 1100 LPN GG was assigned to the “SSM” role/task. Video recordings showed the time LPN GG was out of NS from 1000 to time the third patient called for help in the air court was ~ five minutes, 40 seconds: ~ 1000:45 appeared from South Hall, walked down West Hall corridor and back, entered NS at 1001:46. ~ 1027:18 left NS, walked down West Hall observed to be checking room door handles, then walked down South Hall, then down East Hall, then approached MHT F and MHT H both seated in chairs near the NS on North Hall across from closed double doors. The three staff walked through the closed double doors further into the North Hall, then shortly thereafter reemerged back through the closed double doors to the location of the chairs. ~ 1031:12 reentered NS ~ three minutes, 54 seconds after leaving NS. ~ 1039:35 left NS hurriedly toward air court. 2.e.vii. Review of the “Day Shift” functional assignment sheet for 02/10/2024 reflected that from 1000 to 1100 MHT HH was assigned to the “Environmentals” role/task. Video recordings showed the time MHT HH was out of NS from 1000 to time the third patient called for help in the air court was ~ 17 minutes: ~ 1005:05 left NS, walked down South Hall, then onto East Hall, then back in front of NS, around the corner into the West Hall corridor, then reentered NS at 1022:00 ~ 17 minutes later. ~ 1039:32 left NS hurriedly toward air court. 2.e.viii. Review of the video recordings as identified earlier in this Tag reflected that at 1039:29 eight individuals emerged from the West Hall side of the nurses’ station and hurried toward South Hall. The eight staff included those already described above in this finding and the following: - RN A assigned to the role/task of “Lead ... RN Duties” on the “Day Shift” functional assignment sheet for 02/10/2024 from 0800 until 1400. - RN K assigned to the role/task of “Milieu RN” on the “Day Shift” functional assignment sheet for 02/10/2024 from 0800 until 1100. 2.e.ix. Neither RN A nor RN K were observed on video to have been outside of the NS from 1000 until the time they responded to the call for help at 1039:29. 2.e.x. In addition, staff were observed to not practice door security and situational awareness. For example: ~ 1015:27 MHT C exited the West NS door and walked away with their back to the door while the door was partially open and a patient stood next to the door. ~ 1016:11 MHT D exited the West NS door and walked away with their back to the door while the door was fully open. They had walked onto the South hallway before the NS and closed. ~ 1027:13 MHT B exited the West NS door and walked away with their back to the door while the door was partially open and a patient walked behind them toward the door. ~ 1039:35 LPN GG was the last staff to exit the West NS door, they walked away with their back to the door while the door was partially open. A patient was seated immediately across the hall from the open door. ~ 1039:36 RN K exited the West NS/Med Room door into the hallway and walked away with their back to the door while the door was partially open. Two patients walked immediately behind RN K past the open NS/Med Room door ~ 1041:22 two staff exited the West NS door and hurriedly walk away in opposite directions with their backs to the nearly fully open door while two patients were across the hall and faced the open NS door. For two seconds their are no staff on that side of the NS between the two patients and the door as it closed. 2.e.xi. The video-recordings reflected there was lack of continual staff presence on the milieu for the purpose of continuous observation, monitoring, and supervision of patient behaviors and activities from 1000 until after Patient 23 was found on the ground by another patient. That included that all eight RN, LPN, and MHT staff assigned to be on the unit and who were not assigned to a 1:1 role were inside the NS from ~ 1031:12 until 1039:30, after the third patient called for help when they found Patient 23 on the ground. During the video review with staff that included the CFO/COO, QMD, DSC, and the IRSI on 12/29/2024 beginning at 1030 they confirmed that unit staff were not continually present in the milieu prior to the incident as required by the “functional” shift assignments and policies and procedures for staff assigned to Milieu RN, RCM, and SSM roles/tasks. 2.e.xii. Review of an undated “Dispositioned Staff information” summary included the following information about disposition of some staff present on the AN1 unit on the day of Patient 23’s attack: “The following staff were put on administrative leave because they were not following their assignment per the functional. All were assigned to be in the milieu at the time, but after camera review were in the chart room ... [RN A assigned to Lead RN Duties], [MHT B assigned to Environmentals], and [MHT C assigned to RCM] ...” “[RN K assigned to Milieu RN] - continues to work. Was visible in medication room for the hour, covering the medication room.” “[MHT HH assigned to E] ... has been restricted from working patient care units.” 2.f.i. During interview with the DOS on 02/29/2024 beginning at 1430 they stated there were ~ 1,083 cameras in use on the OSH-Salem campus. They indicated that there were three security staff positioned at three security monitoring stations in the hospital’s “access control” office on a 24/7 basis. The responsibility of those staff was to continually monitor the live video camera feed from those ~ 1,083 cameras. The DOS stated that not all of those ~ 1,083 camera views could be observed at the same time. They stated that the monitor staff were “not omnipresent” but tended to focus on the milieus and activities of units or groups that were high acuity or high concern and as requested by specific units for particular reasons. They further stated that monitor staff watched for “visual cues” and “behaviors of staff and patients” that were unusual or unexpected. The DOS stated that there were times when monitor staff had observed a situation develop and called the unit to advise them and sometimes that had been before unit staff were aware of the situation. The DOS did not know whether the AN1 air court camera view had been monitored by “access control” monitor staff at the time Patient 22 attacked Patient 23. At ~ 1455 the DOS stated that there was no written procedure or protocol for how monitor staff were to decide which of the ~ 1,083 camera views to monitor and what they were to look for. They stated that all monitor staff were “legacy trained” by other staff. 2.f.ii. Additional review of video recording and still photo images of the air court was conducted on 03/14/2024 beginning at 1135 with the DSC and IRSI. During the review it was confirmed by those staff that the video camera view of the air court had a blind spot in the southwest corner where Patient 23 had been thrown and laid. A significant section of the air court where the southwest exterior air court wall met the brick building wall and formed a corner was not observable on video camera views. In the video recording, a very small portion of Patient 23’s body could be discerned, however, was not clear. 2.f.iii. “Access control” monitor staff may have observed the attack had the air court camera been monitored at the time of the incident. However, had the air court camera been monitored after the attack while Patient 23 laid on the ground, there would have been no clear image to observe as the patient laid in the camera blind spot. Based on staff performance on that day as described, and on the blind spot in the camera view where Patient 23 was on the ground, it was unclear how long Patient 23 might have remained undetected in the corner of the air court. 2.g.i. During review of video recordings of staff presence and activity on the unit prior to Patient 23’s attack from ~ 1000 until after staff responded to Patient 23 who had been found on the ground in the air court, observations were made related to a 1:1 constant supervision situation on the North Hall. During that previous review with hospital staff an individual seated in a chair outside of the NS was identified to be the patient who was the subject of 1:1 constant supervision as identified on the 02/10/2024 functional shift assignment sheet. The staff person assigned to provide the 1:1 constant supervision was identified as seated next to the patient. However, during interview with staff that included the PD, DSC, NM, DNS and others on 04/01/2024 beginning at 1105, to clarify discrepancies related to staff shift assignments, staff present stated that the individual previously identified by other staff as a patient, was in fact an employee, MHT H. Staff stated that Patient 27 who required 1:1 constant supervision was roomed in a patient room on the section of the North Hall behind closed double doors. The North Hall closed double doors were across the hallway and several feet away from the NS door. The two individuals seated in chairs outside the NS door were MHT F and MHT H. Review of the “Day Shift” functional assignment sheet for 02/10/2024 reflected that from 1000 to 1100 MHT F was assigned to the “Constant 1” role/task and MHT H was assigned to the “North Hall Assist” role/task. The shift assignment sheet reflected there was one patient, Patient 27, identified to require 1:1 constant supervision. Video recording captured the following: ~ 0959:52 MHT F left NS, seated self on chair on the left side of MHT H who was focused, head and shoulders and back fully slumped over toward their lap, on a reading or writing or drawing activity. Further, MHT H was wearing a “hoody” sweatshirt with the hood pulled over their head. The two sat in chairs on the North Hall outside the NS several feet away from closed double doors that led further into the North Hall where a patient was roomed. Each of the double doors had a narrow (few inches wide) rectangular window embedded into the top half of the door that was above the height of the chairs the two staff were seated in. In the seated position in the chairs, staff would not have been able to see through the narrow door windows several feet away into the North Hall to the patient’s room on the left side of the corridor. ~ 1002:56 MHT F appeared to take item out of their sweatshirt pocket with left hand and began to focus on that item they held in their hands. ~ 1003:11 MHT F moved position so that the lighted face of a cell phone in their hand became clearly visible, they turned to their left away from MHT H so that their back was to MHT H, head and shoulders were slumped downward, and faced the wall that was to their immediate left. ~ 1008:06 MHT F slumped head, shoulders, back further downward with their back toward MHT H, their head was only partially visible above their back. ~ 1013:00 MHT F lifted head, turned slightly toward MHT H as MHT C approached the two. ~ 1013:17 MHT F turned back away from MHT H into previous position after MHT C reentered NS three seconds later. ~ 1030:11 MHT F had brief interaction with LPN GG who had approached, still turned with back to MHT H, MHT F held cell phone up with left hand so that the lighted face of the cell phone was clearly seen. There were ~ nine brief instances from 1000 to 1030 when MHT F moved their head or looked up toward the direction of MHT H, although their body position did not change. During that time period there were no occasions where MHT F stood up, approached the North Hall closed double doors, opened the doors, or looked through the narrow windows into that hall. MHT H’s position with their head, shoulders, and back slumped fully over, almost as if folded in half, focused on activity in their lap, was primarily unchanged throughout the video. Periodically they would lift their head and shoulders up or turn toward MHT F for a moment. To that point there were no occasions where MHT H stood up, approached the North Hall closed double doors, opened the doors, or looked through the narrow windows into that hall. ~ 1030:15 MHT F rose from the chair during interaction with LPN GG who had approached. ~ 1030:41 MHT H rose from chair, then MHT F, MHT H, and LPN GG walked away from the space where they were seated and through the closed double doors further into the North Hall. ~ 1031:10 MHT F and LPN GG reentered the North Hall back through the closed double doors where MHT F and MHT H had been seated. ~ 1031:13 MHT H reentered the North Hall space. ~ 1031:20 MHT F resumed their previous position in the North Hall chair, slumped over, head down and toward the wall, back turned to MHT H. ~ 1034:58 MHT F lifted arm and lighted face of cell phone was visible. ~ 1036:14 MHT F momentarily lifted and turned head to the right. ~ 1039:27 MHT F momentarily lifted and turned head at which time a portion of the lighted face of cell phone was again visible. ~ 1039:30 Eight staff exited the NS and hurried toward the air court. ~ 1039:32 MHT F and MHT H stood up from their chairs, the entire lighted face of a cell phone was clearly visible in MHT F’s right hand. ~ 1039:34 MHT F and MHT H walked away from the chairs they were seated in, with their backs toward the North Hall closed double doors. MHT was seen to place a cell phone with a fully lighted screen in their sweatshirt pocket, proceeded to walk around corner of NS and out of proximity and view of MHT H and the North Hall closed double doors. ~ 1039:47 MHT H turned head for a moment toward the North Hall closed double doors. ~ 1039:51 MHT F returned back to hallway where MHT H was located and neither of those staff looked toward the North Hall closed double doors. ~ 1040:17 MHT F entered NS and left MHT H in hallway. ~ 1040:24 MHT H faced back toward the North Hall closed double doors for a moment. ~ 1040:33 LPN GG left NS and stood next to MHT H in the hallway, both of them with their backs turned toward the North Hall closed double doors. ~ 1040:53 LPN GG turned briefly to face the North Hall closed double doors, then turned their back toward those again. ~ 1041:30 LPN GG turned briefly toward the closed double doors. ~ 1043:01 MHT H opened the NS door and partially entered the NS with their back toward the closed double doors and stood in the doorway for 20 seconds. ~ 1043:54 MHT H turned briefly toward the closed double doors. ~ 1044:34 LPN GG reentered NS and left MHT H in hallway. ~ 1044:57 MHT H approached the closed double doors and looked through one of the narrow door windows for seven seconds, then proceeded to pace the hallway in front of those doors and appeared to periodically look through one of the door windows. MHT F, the assigned constant staff with 1:1 supervision responsibilities had not returned nor was any other staff present with MHT H at that time. ~ 1046:10 Another staff person not previously visible during the video review left NS and stood outside the NS door near MHT H in the hall, both of them had their backs toward the North Hall closed double doors, and were in those positions until 1050, the end of this video review. 2.g.ii. It was unclear how MHT F’s activities would be considered as “1:1 constant” supervision, and how MHT H’s activities would be considered “North Hall Assist” in any way. Both of those staff were intently focused on activities other than direct observation and supervision of Patient 27 who was behind closed doors in their room which was behind another set of closed doors several feet away from where the two MHTs sat. There were very few occasions where those two staff even looked momentarily in the direction of the closed double doors, and when seated it was unclear how much they could see through those double doors. 2.g.iii. An internal OSH email dated 02/14/2024 at 1057 had a “Subject” of “AN1: Staff Follow Up.” It included the following information about disposition of some staff present on the AN1 unit on the day of Patient 23’s attack: “Below are the names of the staff who were actively engaged in their functional assignment and feel there is no need for follow up. - MHT D - MHT F - MHT H.” 2.h.i. Review of the hospital’s internal investigation and follow-up documentation revealed a CADM report. The report had multiple dates that included a “CADM Meeting Date” of 02/15/2024 and a “CAT CADM Report Review Session” of 02/21/2024. Information on the report included:. * “On Saturday, 2/10/24, at approximately 10:37 (according to the clock on the video review), [Patient 22] entered the air court on ANl. Prior to entering the air court, [they were] walking thought [sic] the milieu and looked down the halls and towards the bubble. [Patient 23] was sitting in the air court in a chair by the south hall entrance, with [their] back to the main space, looking out towards the quad towards the south, sipping a cup of hot beverage and acknowledged [Patient 22] entry to the air court. [Patient 22] was standing in the air court, to the back left behind [Patient 23] for approximately a minute. During this time, [Patient 22] was looking out of the air court towards the quad to the east, before slowing walking up behind [Patient 23] ... [Patient 22] was noticed to be looking through the windows of the air court towards the dayrooms and unit. At this time, it was noted that no staff were present in the milieu/dayroom area. [Patient 22] put [their] arm around [Patient 23’s] neck in a “sleeper hold” at 10:38 ... applying pressure to the sides of [Patient 23’s] neck. While holding [Patient 23] around the neck, [Patient 22] lifted [Patient 23] out of the chair and suspended [them] in the air, until it appears [they went] limp and [lost] consciousness ... continuing to hold [their] arm around [Patient 23’s] neck, [Patient 22] proceeded to harshly shake [Patient 23] multiple times side to side. As [Patient 22] released the hold from around [Patient 23’s] neck, [Patient 22] tossed [them] to the side towards the fencing of the air court. Total time of [Patient 23’s] arm around [Patient 23’s] neck, was 27 seconds (12 seconds until loss of consciousness and 15 seconds of continued carotid compression). [Patient 23] was laying on the ground of the air court for 34 seconds before another patient entered the air court from the east hall entrance. Upon finding [Patient 23] on the ground unconscious and bleeding, the other patient immediately called for assistance ... Code blue called ... EMS arrived ... [Patient 23] was sent to Salem hospital to receive medical care ... had a significant X-shaped stellate laceration for which [they] received multiple sutures at the hospital; approximately 7x7 cm laceration, with right eye closed and not able to be opened. During the code blue medical response by OSH staff, [Patient 23] was conscious and able to respond to questions by staff ... did not appear to recall specifics of the incident ... was sent to Salem Hospital for medical treatment. Upon [their] return, AP was [placed on the medical unit] for continued medical monitoring and to also provide separation from aggressor ... was transferred to TR3 on Monday, 2/12/24.” * “With video review at approximately 11:15, it was determined that [Patient 22] was the aggressor to [Patient 23]; due to lack of direct observation of the event, the aggressor was not known until video was reviewed ... was placed in seclusion at approximately 11:45. During the process of going to the seclusion room, [Patient 22] was noted to make statements [that they were] going to murder staff. Transfer request was submitted to have [Patient 22] moved to a gender specific unit because of concerns of potentially targeting additional [opposite gender] patients; ... transfer request approved 2/14/24. * “Chart review indicates that [Patient 22] was previously in seclusion for making threats towards murdering staff (2212 on 2/7/24) and released 2/9/24; no indication from documentation around threats towards other patients. 2/7/24 documentation does indicate making statements of ‘I’m homicidal’ and ‘I feel like killing someone again, grab someone around the neck and strangle the fuck out of them’, but does not indicate being towards other patients; following documentation indicates HI towards staff.” * “During video review, it was noted that from approximately 10:30 to 10:38 (when patient who found [Patient 23] and they yelled for help) there were no staff in the east or south halls, in the activity rooms, or day rooms. Staff assigned to RCM, SSM and milieu RN were not present in the milieu. Three additional staff had assignments that have the expectation of having milieu presence.” 2.h.ii. An undated document titled “Communication Timeline” reflected: “2/13/24: DNS/PD, communicated during AM Huddle 2/13/24: DNS/PD, had a bigger discussion at leadership meeting; team was asked to communicate to staff via huddles and newsletters 2/14/24 Debrief with An1 leadership during leadership meeting and discussed importance of presence in the milieu 2/14/24 talked during PET meeting about importance of staff being in the milieu and for all managers to help when on units and able 2/15/24: LH1 unit newsletter disseminated to unit staff 2/16/24: LH3 unit newsletter disseminated to unit staff AN1, AN2, AN3, LH1, LH2, LH3: Communicated in multiple huddles for all shifts following the incident regarding staff, bubble, and RCM/SSM expectations and being in the milieu. Continuing discussions regarding the email sent by program DNS outlining these expectations. This information was also collected into the unit newsletters and disseminated.” 2.i. Survey team review of Patient 22’s medical record, who was admitted to OSH on 11/09/2023, revealed that the TCP was not consistent with Patient 22 incident documentation related to aggressive behaviors nor LIP orders for ES. For example: * 11/12/2023 incident documentation and an “Incident Review Form” signed and dated by unit leadership staff on 11/17/2023 reflected that Patient 22 had reportedly touched the buttocks and breast of an opposite gender staff person. Under “Safety and Risk Mitigation” was recorded “Enhanced Supervision” and “Staff were informed about event & to keep [opposite gender] staff/patients safe.” However, there was no instruction as to how opposite gender patients were to be kept safe. * The “Client Profile - Order Details” for “Order Type: Enhanced Supervision” specified: - From 11/13/2023 at 1653 to 11/27/2023 at 1711 ES orders were in place for “Unobtrusive Suicide/Self Harm.” * The “10 Day TCP” post-admission dated 11/15/2023 included: - “Since [admission] [Patient 22] has engaged in disorganized and intrusive behavior; e.g., smacking a staffs [sic] bottom and grabbing [their] breast - “[Patient 22] will maintain safety toward self and others as evidenced by no documented incidents of self-harm, aggression, intrusiveness, touching others inappropriately, or unit disruption for 30 days ... Status: New [goal].” - “If [Patient 22] is intrusive to [their] peers / staff or engages in sexualized touching of others, staff will redirect [them] to [their] room, the sensory room, or different area of the unit to help maintain safety.” - “Staff will maintain Enhanced Precautions on [Patient 22] to monitor for any aggression or intrusive behavior. Please refer to the Behavior Card for additional information.” * The “30 Day IDT Meeting” TCP dated 12/05/2023 included: - “ ... [Patient 22] has engaged in disorganized, intrusive, and unsanitary behavior; e.g., smacking a staffs [sic] bottom and grabbing [their] breast, playing with feces, ejaculate, etc., which has led to a seclusion even to maintain safety.” - “[Patient 22] has engaged in disorganized behavior. [They have] been medication adherent and reports they are useful. [They have] not expressed any SI or gestures thus precautions was discontinued on 11/27.” - “[Patient 22] will maintain safety toward self and others as evidenced by no documented incidents of self-harm, aggression, intrusiveness, touching others inappropriately, or unit disruption for 30 days ... Status: New [goal].” - “If [Patient 22] is intrusive to [their] peers / staff or engages in sexualized touching of others, staff will redirect [them] to [their] room, the sensory room, or different area of the unit to help maintain safety.” * ES orders and implementation was not consistent with the TCP. The “Client Profile - Order Details” for “Order Type: Enhanced Supervision” specified: - From 12/12/2023 at 0213 to 12/14/2023 at 1343 ES orders were in place for “Close Suicide.” * The “Add Enhanced Supervision” TCP dated 12/14/2023 included: - “ ...[Patient 22] has engaged in disorganized, intrusive, and unsanitary behavior; e.g., smacking a staffs [sic] bottom and grabbing [their] breast, playing with feces / ejaculate, etc., which has led to a seclusion even to maintain safety. [They have] engage [sic] in suicidal gestures; e.g., tying ripped up clothing around [their] neck.” - “Added intervention around Enhanced Supervision.” - “[Patient 22] will maintain safety toward self and others as evidenced by no documented incidents of self-harm, aggression, intrusiveness, touching others inappropriately, or unit disruption for 30 days ... Status: New [goal].” - “If [Patient 22] is intrusive to [their] peers / staff or engages in sexualized touching of others, staff will redirect [them] to [their] room, the sensory room, or different area of the unit to help maintain safety.” - “Staff will maintain Enhanced Supervision on [Patient 22] to monitor for any self-harm comments or actions. Start Date: 12.14.2023” * The “30 Day TCP Review” TCP dated 01/02/2024 included: - “... [Patient 22] has engaged in disorganized, intrusive, and unsanitary behavior; e.g., smacking a staffs [sic] bottom, grabbing [their] breast, and playing with feces which has led to a seclusion events to maintain safety.” - “[Patient 22] will maintain safety toward self and others as evidenced by no documented incidents of self-harm, aggression, intrusiveness, touching others inappropriately, or unit disruption for 30 days ... Status: Not Met, Continue.” - “If [Patient 22] is intrusive to [their] peers / staff or engages in sexualized touching of others, staff will redirect [them] to [their] room, the sensory room, or different area of the unit to help maintain safety.” * 01/03/2024 incident documentation, an “Incident Review Form” signed and dated by unit leadership staff on 01/12/2024, and a second “Incident Review Form” signed and dated by unit leadership staff on 02/09/2024 reflected that Patient 23 began to throw feces and urine out of their patient room, some of which was directed at staff. The incident resulted in time in a seclusion room for Patient 22. * The “30 Day TCP Review” TCP dated 01/31/2024 included: - “Since admission [Patient 22] has engaged in disorganized, intrusive, and unsanitary behavior ...” - “[Patient 22] will maintain safety toward self and others as evidenced by no documented incidents of self-harm, aggression, intrusiveness, touching others inappropriately, or unit disruption for 30 days ... Status: Not Met, Continue.” - “If [Patient 22] is intrusive to [their] peers / staff or engages in sexualized touching of others, staff will redirect [them] to [their] room, the sensory room, or different area of the unit to help maintain safety.” * (The CADM Report referenced in the Finding above indicated that staff review of the patient’s medical record revealed that on 02/07/2024, three days before they attacked and choked Patient 23, Patient 22 made “... statements of ‘I’m homicidal’ and ‘I feel like killing someone again, grab someone around the neck and strangle the fuck out of them.’”) * The “Client Profile - Order Details” for “Order Type: Enhanced Supervision” reflected there were no other ES orders until after Patient 22 attacked Patient 23 on 02/10/2024, on which date Patient 22 was placed on “1:1 Behavioral” ES. * The “Unscheduled Update” TCP dated 02/15/2024 included: - “On 2-10-24 [Patient 22] very significantly assaulted a peer. [They were] placed on 1:1 Behavioral Precautions and is being transferred to a [gender specific] exclusive unit.” - “[Patient 22] will maintain safety toward self and others as evidenced by no documented incidents of self-harm, aggression, intrusiveness, touching others inappropriately, or unit disruption for 30 days ... Status: Not Met, Continue.” - “If [Patient 22] is becoming intrusive, agitated, or making threats towards others staff will attempt to provide distractions such as offering them space in a less stimulating area (their room, sensory room, or a different area of the unit) to maintain safety. - “Staff will maintain Enhanced Precautions to monitor for any aggression and to promote safety, redirection, and attempts at regulation. Please refer to the Behavior Card and enhanced supervision sheet for additional information. Start Date: 02/15/2024.” ****************************************************** 3. The following is regarding an incident involving Patient 10 and Patient 11. 3.a. Review of grievance and incident documentation revealed that Patient 11 was physically assaulted and injured by Patient 10 on 08/15/2023 after having conveyed to staff safety concerns and fear of Patient 10. The findings that follow reflect that: *Investigation of the incident was not clear or complete. *Patient 11 requested that criminal charges be filed against Patient 10, however there was no documentation to reflect when or whether that had been completed. *Responses to Patient 11’s four related grievances pre- and post-incident were not timely or complete. 3.b. Incident documentation reflected that on 08/15/2023 at 1520 Patient 11 “ ... was standing at the hub having a conversation with [the NM] when [Patient 10] walked behind [Patient 11] ... numerous times before [Patient 11] verbalized [their] concern of [Patient 10] being behind [them]. [Patient 10] responded and punched [Patient 11] in the eye/nose. [MHT] put [themselves] between [Patient 10] and [Patient 11] and then [Patient 10] walked off towards [their] room. [Patient 11] did not retaliate to this assault physically but exclaimed verbally that [they were] upset. From the nursing station, I called a code green over the walkie talkie and brought paper towels for [Patient 11] to catch the blood from [their] nose while [a staff person] helped redirect nearby patients. [RN] and [NM] walked [Patient 10] to the [seclusion room] where [they] spent nearly two hours deescalating while [Patient 11] was helped with getting ice for [their] injury. [Patient 11] then went to the emergency room to have [their] injury looked at per [their] request.” 3.c. Review of patient grievance documentation filed by Patient 11 revealed the following: *A “Patient Grievance” form was signed and dated by Patient 11 on 08/13/2023 at 1932. At the top of the form Patient 11 had written in large letters “*Emergent*.” The grievance was described as “[Patient 10] is continuing to provoke and instigate myself and other patients. [MHT] witnessed [Patient 10] provoking me as I walked back onto the unit at approx. 6:02 pm. Just now [Patient 10] lunged at [another patient] with a raised fist attempting to intiate [sic] a violent interaction. Staff unwillingness to address this issue is putting staff and patient [sic] in harm’s way ... emergency transfer [Patient 10] to another unit.” The “For Staff use only” box reflected the “Date Received” was 08/14/2023, the day prior to the assault. The “Grievance Committee Response” reflected the “Date of Grievance Review” was 08/21/2023 and the response was “attached” to the form. The undated attachment contained one paragraph that reflected “IDT is aware of the issues that are happening between you and the described peer and have taken the necessary follow up. All follow up will be confidential to protect patient privacy. In the future please encourage peers who are having issues to reach out to staff or complete their own grievances so that we may follow up with them.” *A second “Patient Grievance” form was signed and dated by Patient 11 on 08/13/2023 with no time. The grievance was described as “[Patient 10] has been increasing [their] aggressive behavior toward me and other patients. Flicking [another patient] and pushing through people. Just now in East TV Room I was grabbing a spoon after receiving my meal and [Patient 10] walked in from the air court and threw [their] shoulder into me ... Move [Patient 10] to another ward, My safety and the safety of the other patients is at risk.” The “For Staff use only” box reflected the “Date Received” was 08/14/2023, the day prior to the assault. The “Grievance Committee Response” reflected the “Date of Grievance Review” was 08/21/2023 and the response was “attached” to the form. The undated attachment was identical to the one described in the grievance above. *A third “Patient Grievance” form was signed and dated by Patient 11 on 08/16/2023 at 0950. The grievance was described as “I filed 2 grievances within the last 72 hours about [Patent 10’s] continual aggressive behavior and [on 08/15/2023] in the milieu of Tree 1 [Patient 10] violently assaulted me by close fist strike to the left temple of my head. When I returned from the E.R. at approx 7 pm [Patient 10] was already out of seclusion. This morning in East Plaza at approx 9:15 [Patient 10] came out and began to attempt an altercation from afar telling staff ’[Patient 11] can’t be within 10 feet of me.’ This is systemic supported abuse and violence.” The “For Staff use only” box reflected the “Date Received” was 08/17/2023. The “Grievance Committee Response” reflected the “Date of Grievance Review” was 08/29/2023 and the response was “The treatment team has reviewed the issues and resolved it. The two patients currently do not reside on the same unit. The IDT may not discuss patient treatment with you.” *The fourth related “Patient Grievance” form was signed and dated by Patient 11 on 08/22/2023 at 1555. The grievance was described as “On, or about, August 15th at approximately 3:30PM I was assaulted by [Patient 10]. I do not believe the report has been forwarded to law enforcement and/or the Marion County DA for prosecution. The the [sic] documentation and proper reporting of this crime needs to be done immediately. If this violent assault is not reported, investigated, and charges are not filed I will hold each, and every, member of the Treatment Team, P.E.T, and all other relevant parties accountable both personally and professionally to the harm inflicted by this neglect. This will include each, and every licensee, who is charged with my care and treatment as a public servant of Oregon ... I still have not spoken with a detective, OSH security, or even been approached by a therapist to talk about, decompress, or process this attack for which I am the victim.” The “For Staff use only” box reflected the “Date Received” was 08/23/2023. The “Grievance Committee Response” reflected the “Date of Grievance Review” was 08/29/2023 and the response was “On 8/29 management called security to inquire about the police report regarding the assault. The police report was submitted by the unit on 8/15/23. Security stated that it had not yet been sent out to OSP for review. The detective who usually picks them up missed a week due to other obligations. It was stated the [detective] should return this week and will receive it by end of week sometime. Management asked if security was planning to follow up and they stated they don’t typically check in after each report unless a patient requests it specifically as there are too many to keep up with at times according to security. Management has reach out to the IDT and the therapist that you are currently working with on 8/29 and let them know you would appreciate meeting to help you process/decompress regarding the incident.” 3.d.i. In response to surveyor request for tracking information related to the police report that was filed, an internal OSH email, with an attachment, sent from the DOS dated 03/13/2024 at 0807 was provided. It included the following information: “Like most of our stuff we don’t have a written protocol but the process is described below ... This was closed out by [detective name] without being assigned a case number due to not meeting prosecutorial guidelines. At the time the case was received, the unofficial protocol we were using was ... Incident occurs prompting a report made to OSP ... [unit staff] fills out an OSP reporting form and submits it to the Security Management email box. Form is received by Security and printed ... Printed form is maintained by Security Investigator until OSP makes a visit to OSH to collect these forms ... When OSP detectives come to OSH, the printed forms are handed over to the detectives ...” 3.d.ii. The document attached to the 03/13/2024 email from the DOS was titled “Oregon State Hospital - Security Department Reporting of a crime” was reviewed. It included the following information: * “Date of Incident: 08/15/2023” * “Reported by: [NM identified in the incident report]” * “Date/Time: 08/15/2023 at 1530” * “Victim of Crime: [Patient 11]” * “Suspect of Crime: [Patient 10]” * “Summary of Incident: [Patient 11] was speaking to the Unit Administrator ... [Patient 10] walked up ... swung around the staff and punched [Patient 11] in the left eye ... eye immediately began to swell, become bruised ...” * “Signature of person completing this report” that was followed by a signature. The lower part of the form had two sections, one of which was for “Security Use Only” which contained the following: * “Date Submitted:” * “Submitting Manager:” * “Reporting Manager Signature:” Those fields were blank and contained no entries. The last section of the form for “Dispatch Use Only” contained the following: * “Date Received:” * “Case Number:” Those fields were blank and contained no entries. 3.d.iii. As of the date of the survey there was no documentation to reflect when that report had been received by the Security Department and whether or when it had been submitted to OSP. 3.e. An incident investigation form titled “Incident Review Form” was signed and dated by unit leadership staff on 08/21/2023. It summarized the incident, and under “Safety and Risk Mitigation” was recorded “Follow-up with Victims(s),” “Incident Debrief,” “Security/OSP Contacted,” and “After the provider met with [Patient 10] [they] agreed to maintain 10 ft distance between [them] and [Patient 11]. [Patient 10] also agreed to remain in [their] hallway and avoid [Patient 11’s] hall. A police report was filed on [Patient 11’s] behalf. On 08/17/2023 [Patient 10] was moved to another unit due to the incident.” The “Incident Review Form” completed six days after the incident did not reflect an investigation of the incident. For example, under the sections “What factors contributed to the incident and how did you investigate those factors?” and “Assessment” and “Clinical Interventions” there was no indication of medical record or document review for the following: * Identification and evaluation of Patient 11’s injuries. * Relevant TCP goals and interventions for both patients in place and implemented. * Evaluation of any enhanced supervision orders for either patient. * History of aggression for either patient. * History of conflict between those two patients. * Lack of response to the three related grievances Patient 11 had filed on 08/13/2023 and 08/16/2023. * Status of the “police report was filed on [Patient 11’s behalf].” As of the date unit leadership staff signed the form that had not been processed. 3.f. During interview at the time of the review with staff that included the DNS, PD, and QMD on 03/07/2024 beginning at 1220 no additional information was provided. ****************************************************** 4. The following is regarding an incident involving Patient 3. 4.a. An “Office of Quality Management” investigation document was signed by an OQM investigator and reflected an “END REPORT” date of 06/24/2022 at 1133. The report reflected that “On 6/3/2022 [Patient 3] had taken a urine analysis (UA) at the Oregon State Hospital (OSH) clinic. The clinician relayed to nursing staff that [Patient 3] had spermatozoon identified in the UA. Nursing staff notified the program director who relayed the finding to the OSH Superintended [sic] along with information [Patient 3] was on 1: 1 constant supervision for more than a week leading up to the UA ... [Patient 3] was at OSH starting 5-20-2022 and was placed in 1:1 supervision with directions to maintain line of sight visual of [Patient 3] when [they were] out of [their] room.” The 15-page report concluded that “The findings of this investigation did not identify a staff or patient having the opportunity to engage in sex with [Patient 3]. There have been no allegations made by [Patient 3] of a sexual encounter at OSH and this investigation concluded the origination of the spermatozoon was not isolated to the time of [Patient 3’s admission to OSH.” However, it was unclear how the investigation conclusion that no sexual contact between Patient 3 (who themself could not be the source of the sperm) and another individual had occurred between Patient 3’s admission on 05/20/2022 and 06/03/2022, the date the urine specimen had been obtained. 4.b. The OQM report reflected the following findings related to Patient 3’s impaired cognition, confusion, and lack of reliability to provide credible information on their own behalf. Patient 3’s behaviors and mental state reflected they were a vulnerable person. For example: “I was informed the clinician had told nursing staff they attempted to speak with [Patient 3] and [they were] extremely dysregulated and difficult to comprehend ... I [reviewed] patient progress notes which showed the patient was highly dysregulated upon [their] initial entry to the hospital on 5-20-2022. [They were] placed on 1:1 at 1551 on that date. Per [OQM Investigator’s] supplement a Psychiatry Admission Assessment stated: Patient was put on close observation 1:1 (behavioral) at 1551 by unit attending [PMHNP] who noted in the order that the patient ‘is attempting to enter peer’s [sic] rooms, grabbing staff’s [sic] badges, combative, disorganized.’ In review of Psychiatry General Note dated 6/3/2022 I found: ... [Patient 3] reports feeling confused, ‘I want to go home’, and when asked if [they] knew where [they were they] stated ‘This is confusing to me why did the floors change?’. When told that [they were] at Oregon state [sic] Hospital, [they] responded ‘No, no, no’. [They] stated ‘One minute I’m supposed to be running out of here, next walking, but ... ’ and didn’t finish [their] statement, [they] stared off. I received a lab report from [their] urine that was collected this morning which showed Spermatazoa [sic] positive. I asked [Patient 3] if [they] could recall anyone having any type of sexual contact with [them] while [they were] either here or at jail prior to coming here. [They] stated “Not that I’ve known”. When asked if [they] remembered coming into the hospital or being in jail, [they] responded ‘bits and pieces’. [Patient 3] remains disorganized and confused. ‘This is a joke, right? Tell me this is a joke’ when questions asked of [them] ... 6/3/22- [Patient 3] remains grossly disorganized and confused, however there is noted improvement in [their] speech, responding to questions a little better this week. [They continue] to report feeling confused and unaware of their surroundings, denying that [they are] at OSH. When discussing [their] urine sample with positive spermatazoa [sic], [they report] that [they are] unaware of anyone having any type of sexual encounter with [them] while here at OSH or at jail. [They] stated ‘Not that I’ve known’ ... [Patient 3] also believes that I am related to [their] fiance’s [relative] (I am not).[They] did not believe me when I told [them] otherwise.” 4.c. The OQM report reflected that “This investigation revealed the age of the spermatozoon was not limited to 72-hours ... An approximate origination date or time was not able to be concluded by the laboratory staff. The laboratory staff confirmed the single cell was the only one [they] observed in the sample. [They] also stated the cell could have been many days, or even weeks old ... I was informed this collection was one where [Patient 3] did not have the area cleaned around the urinary tract exit prior to collection ... I contacted [OSH Lab Director] with some clarifying questions ... I was informed the spermatozoon was detected during magnification on a slide. I was advised [they] only saw one and it was non-viable. I was advised the lack of viability presented indications the cell single spermatozoon was not from a recent encounter. The window of time was 72 hours to possible 12 or more days old. I asked how the spermatozoon would get into a ... urine collection. I was advised [sic] would have been washed from the body into the urine at the time of collection. I asked if the presence of a single cell provided any information. I was advised that [Lab Director] suspected [they] would have seen more if the encounter was recent, but [they] could not provide a professional opinion on that matter.” Review of the UA report reflected it was “Collected” on 06/03/2022 at 0931 and “Received” in the lab on 06/03/2022 at 0955. The “Urine Source” was “Clean Catch, Mid-Stream.” The report identified “A” or abnormal results that included the “Urine Appearance ... WBC ... Epithelial Cells ... and Bacteria.” An abnormal result was also identified for “Spermatozoa” as “Observed.” There was no information on the report that identified the quantity or quality of the observed sperm. The report also included a statement “Contamination present. Reorder and submit clean catch specimen if clinically indicated.” The OQM report stated that OSH staff were “not able” to conclude the origination date of the sperm, they stated the age “could have been” days or weeks, referred to “possible” time frames, and stated they “could not” provide a professional opinion. There was no indication in the OQM report that an evaluation of the sperm was conducted by a pathologist or other forensic or subject matter professional who had expertise to date the sperm age more conclusively. 4.d. The OQM report also reflected: *”More than 48-hours of video was reviewed during this investigation. Video showed staff performed the enhanced supervision as required in the orders and each time [Patient 3] entered another patient’s room staff were directly responsive and prevented any chance of a sexual encounter. There was not an observed window of opportunity for a sexual encounter between [Patient 3] and [opposite-gender] staff or peers.” * “[OQM Director at that time] requested we focus the review of video surrounding the time that would be 72-hours prior to the collection of the UA. Specifically, we were to cover 24-hours prior through 24-hours after that time. This placed the review window from 5-30-22 at 0900 hours through 6-1-22 at 0900 hours (48-hours).” * “[Patient 3] had entered peers’ rooms 5-21-22 at about 1326 hrs, 5-22-22 at about 2110 hrs, and 5-24-22 at about 0755 hrs. I requested additional video authorization from [OSH Superintendent] for these three events ... reviewed ... each time the patient entered another patient’s room staff were quick to redirect the patient and there was no realistic change [sic] that sexual activity happened between [Patient 3] and other [sic] individual during the three events.” It was unclear why video for only the specified 48 hours and three other short time periods were reviewed. 4.e. The OQM report lacked identification or reference to the fact that Patient 3 had two occurrences of seclusion since their admission on 05/20/2022. Those occurrences were not identified or evaluated as part of the investigation. Review of seclusion documentation reflected the following: *Review of an “Emergency Seclusion or Restraint Review” form reflected that Patient 3 was placed in seclusion on 05/20/2022 with a start time at 1105 and seclusion end time was 1208. The “Emergency Seclusion or Restraint Flowsheet” form reflected that four same-gender staff conducted and documented all seclusion observations and tasks recorded on 05/20/2022 at 1105, 1120, 1135, 1150, 1200, 1206, and 1208. Additional tasks were recorded at 1215 and 1225 as Patient 3 declined to leave the seclusion room at 1208 and remained in the room with the door unlocked at until 1225. *Review of an “Emergency Seclusion or Restraint Review” form reflected that Patient 3 was placed in seclusion on 05/25/2022 with a start time at 0940 and seclusion end time was 1340. The “Emergency Seclusion or Restraint Flowsheet” form reflected that three opposite-gender staff conducted and documentation the seclusion observations and tasks recorded on 05/25/2022 from 0955 through 1330 as follows: -Staff JJ recorded seclusion observation entries at 0955, 1010, 1025 1040, and 1055. -Staff KK recorded seclusion observation entries at 1110, 1125, and 1140. -Staff LL recorded seclusion observation entries at 1200, 1215, 1230, and 1245. -Staff JJ recorded seclusion observation entries at 1300, 1315, and 1330. “Comments” written by those staff included “hitting floor ... mumbling ... tearful ... sitting by door ... confused demeanor ... unpredictable ... praying or talking to unseen others ... standing in the restroom ... trembling hands” 4.f. During interview at the time of the review with staff that included the NM, IRSI, PD, and QMD on 03/07/2024 beginning at 1045 no additional information was provided. ****************************************************** 5. The following is regarding an incident involving Patient 1 and Patient 2. 5.a. Incident documentation reflected that on 05/20/2021 at 1915 there was a physical altercation between two patients on Mountain 3 at JC. The document reflected, “I was in the personal belongings room at 1915, getting a water for a client. I heard a loud thud near me and then a client shouting ‘staff.’ I ran over to the activity room and saw [Patient 1] on top of [Patient 2] punching [them] in the face. [Staff] approached the two, yelling ‘hey’ while pushing [Patient 1] off of [Patient 2] ... [Patient 2] was bleeding from the nose and tried sitting up ... Two nurses asked [Patient 2] if [they were] ok, and [they] responded with ‘what happened?’ and ‘where am I?’ ... [Staff] then was asked to take [Patient 2] to the emergency room where we found out that [their] nose was broken.” 5.b. There was no documentation of an investigation of this incident to prevent recurrence. 5.c. During interview on 03/07/2024 at 1311 with DNS-JC, PD-JC and other staff, they confirmed there was no investigation documentation for this incident. ****************************************************** 6. The following is regarding an incident involving Patient 4 and Patient 9. 6.a. Review of incident documentation for Patient 4 reflected that on 02/20/2024 “While on 1:1, [Patient 4] was seen exiting room at 1417 ... nurse asked pt ‘want to go to the air court since you’re covered up, for some fresh air.’ Pt responded ‘yeah.’ Pt came near doorway leading into TV room as [they] took [their] glasses off [their] face, nurse asked staff to notify RN in chartroom as this is a known pre-curser, [Patient] started to stare at [Patient 9], once nurse noted the tense moments between peers, nurse attempted to verbally de-escalate situation by suggesting ‘everyone get going’ to there [sic] own space ... [Patient 4] then proceeded to follow [Patient 9] into the TV room an [sic] initiate a physical altercation by posturing and putting [their] hands up, both [Patient 9] and [Patient 4] began to exchange punches ...” The report did not reflect whether [Patient 4] sustained any injuries. 6.b. Incident documentation for Patient 9 reflected that on 02/20/2024 at 1419 “[Patient 9] was the victim ... [Patient 4] ... initiated the physical aggression.” The report did not reflect whether [Patient 9] sustained any injuries. 6.c. Review of an “Enhanced Supervision Intervention Card” for Patient 4 dated 01/24/2024 reflected the following orders and direction in place at the time of the 02/20/2024 incident: *”Patient is on a 1:1 [Behavioral Precautions]: Hx of assaults peers and staff unprovoked due to Paranoia, AH, PTSD, with hyperarousal and hypervigilance. Be within hearing distance when out of room to hear conversation [they have] with other peers. Pt historically has assaulted more peers between 1500 and 0700.” *”There is concern for occurrence of assaults after restrictions are lifted, so while [Patient 4] is progressing currently, it is important to still be very vigilant and monitoring for any precursors - paranoia, darting glares with repeated return stares to a person, dissociating/zoning out/not aware of environment.” *”Primary Behavior(s) of concern: Primary Behavior(s) of concern: paranoid delusions, significant physical aggression and assault. There is concern that when restrictions are lifted, assaults follow shortly after, so still very important to be vigilant.” *”Significant history of aggression and assaults on peers and staff. History of assaults typically occurring in afternoons and evenings. Can be triggered/ can target new people on unit, patients and staff. When paranoia is worsened, there is an increased risk of assaults ... It is important to be vigilant ...” *”Hallucinations/Delusions warning signs: Ask for support from other staff in the area. Reality check pt when intensely staring or preoccupied with individuals or a situation. Narrate the situation actually occurring. Example, “[Patient 4], this is [insert name], they are doing rounds to make sure that everyone is doing ok.”, “That patient is just walking down the hall for exercise, is there something you’re worried about with that person?” 6.d. “Incident Review Form” investigation documentation signed and dated 03/11/2024 was not clear. For example, it did not reflect that the incident had been thoroughly reviewed to determine whether staff had been “vigilant,” repeated multiple times as a priority on the ES Card. It did not reflect evaluation of whether staff had carried out all interventions as directed timely and appropriately. Further, the form reflected in conclusion that “Is this a recurring incident for individual ...? Yes,” and “What (if any) additional actions were needed?” to which the response was “None needed.” It was not clear how that determination was made. 6.e. Documentation of incidents that occurred prior to the 02/20/2024 incident reflected that Patient 4 was the aggressor on those occurrences: *On 08/07/2023 at 2128 Patient 4 entered Patient 5’s room and pushed Patient 5 who sustained a “bump on the back of [their] head” as result of hitting the ground during the assault. On the way to the seclusion room after that Patient 4 “turned into the TV room and punched [Patient 6] causing [them] to have a “bleeding nose.” The “Incident Review Form” investigation signed and dated on 08/18/2023 only described injuries to the patient’s involved and did not describe an investigation to identify whether, for example, TCP interventions in place had been carried out or were effective, nor did it describe actions planned to prevent recurrence. *On 09/14/2023 at 1810 Patient 4 “entered [Patient 7’s] room, started punching [them] twice hitting [Patient 7] on the head x 1 and torso x 1. [Patient 7] sustained a small bump and redness to [their] left temple but refused further assessment ... When [Patient 4] went into locked seclusion [they] ... told staff in the ante room, ‘why are you putting me in here, I only punched a black kid that’s all and started giggling’ ...” The “Incident Review Form” investigation signed and dated 09/22/2023 did not reflect, for example, that the patient’s TCP interventions or history with people of color had been reviewed, nor did it describe what actions were planned to prevent recurrence. There was no reference on the ES orders described above related to patients of color. *On 10/01/2023 at 2030 in the hall Patient 4 “hit [Patient 8] in the face with a closed fist.” 6.f. During interview with staff that included the DSC and PD on 03/13/2024 at ~ 1030 they confirmed the findings related to Patient 4 and stated that the hospital was “actively working on investigation gaps.” ****************************************************** 7. The following is regarding an incident involving Patient 24 and Patient 25. 7.a. Review of incident documentation reflected that on 02/21/2024 at 1930 on FW1 unit Patient 25 “approached the hub where I was sitting and without being prompted stated, ‘I hope there isn’t [sic] any cameras in the sensory room’. I asked [them] why and [they] replied, ‘Because I don’t want anyone to talk to me about what happened’. I asked [them] what happened, and [they replied, ‘Sex.’. I asked with who [sic], and [they] responded, ’[Patient 24]’, referring to another patient on the unit.” Incident documentation also reflected that video review was conducted and showed that Patient 24 was in the sensory room, that Patient 25 entered the sensory room, that Patient 24 turned out the lights, and that at 1854 the patients engaged in sexual intercourse, and that they then left the room. The report reflected that security staff found an open condom wrapper in the sensory room and although Patient 24’s room was searched security staff, Patient 24 reported to them that they had flushed the condom. In addition, “Patient 25 was placed on a 1:1 when out of room for [their] safety. Since [they] had reported to another staff member that [they were] coerced into sex ... both [patients’] clothing was collected by security and [Patient 25] was sent to Salem Health ED for a sexual assault exam. Infection prevention was notified of sexual contact, per protocol ... Security later reported to this [NM] that on the way to the ED [Patient 25] was remarkig [sic] that [they] hoped this would get [their] charges dismissed. It was also reported that once [Patient 25] realized [they] could not submit to a sexual assault exam anonymously, [they] declined the exam and was subsequently transferred back to OSH.” 7.b. Review of Patient 25’s “Transfer TCP Review” TCP dated 01/26/2024, in place at the time of the 02/21/2024 sexual incident reflected the following: * “RN/Staff will ... redirect any unsafe and/or inappropriate behaviors (specifically being victimized by peers).” * Patient 25 had been transferred to FW1 unit on 01/25/2024. * Since transfer to that unit on 01/25/2024 Patient 25 “appeared to be a victim of [an opposite-gender patient’s] hypersexual behaviors ...” 7.c. A CADM investigation report with a “CADM Meeting Date” of 02/28/2024 included the following information: * The CADM concluded that “No significant gaps in care or treatment identified.” * “Video review: Video showed [Patient 25] and [Patient 24] engaged in conversations from 1700 until the incident ... Throughout the video that was reviewed they were very close in conversation in both the hall, activity room, and aircourt.” *”Per [physician] there was an exchange of $2 and [Patient 24] gave a card to [Patient 25] ‘I (heart shape) you’.” * It reflected that “There are 2 chart notes indicating that [Patient 25] saw condoms being handed out to [opposite-gender] patients and [Patient 25] asked staff, ‘Why are you handing out condoms. Does this mean we should be getting busy?’ and another time, ‘Because you give out condoms here, it makes people think about sex.’ On 2/18 condoms were given to [another patient] ... [they] showed them to [Patient 25] who then came to the property room to ask the above question. Staff educated both of them that these were not for peer to peer use and that we do not permit sexual contact.” *It reflected that “Neither patient needed capacity assessment based on clinical opine/consult between [OSH physicians]. [Patient 25] continues to be easily influenced by [other patients] and demonstrates ambivalence as part of [their] psychotic disorder. If a capacity evaluation were to be performed, [Patient 25] would not meet criteria for informed consent based on [their] inability to clearly and consistently make a rational decision.” The CADM did not reflect that Patient 25’s TCP had been reviewed. It didn’t identify as part of the investigation that the TCP referenced that Patient 25 had “appeared to be a victim” of another patient’s sexual behaviors the month prior, nor did it reflect review of incident documentation for that event. The CADM reflected that Patient 25 was a vulnerable person who was easily influenced, would not meet criteria for informed consent, and was unable to consistently make rational decisions. It also identified that Patient 25 had interpreted the distribution of condoms to patients as permissive of sexual intercourse. However, it reflected that Patient 24 and Patient 25 were in close proximity and conversation during the ~ two hours prior to the occurrence and there was no indication that the TCP instruction to “redirect any unsafe and/or inappropriate behaviors (specifically being victimized by peers)” had been followed. 7.d. During interview with staff that included the DSC, PD, and NM on 03/13/2024 beginning at 1145 the NM stated that condoms were made available to patients for “self care” and provided at the NS to anyone who asked regardless of gender. The NM stated the RNs and LPNs were supposed to inform the patients that the condoms were for self-care use. 7.e. In response to a request for the hospital’s policies and procedures related to condom distribution, in an email from the DSC received on 03/14/2024 at 1217 they wrote that “We do not have a policy/procedure/protocol for the distribution of condoms.” It was unclear why the hospital would engage in the practice of condom distribution to any patient who asked without a written policy and procedure that ensured the protection and safety of all patients. There was no evidence in the CADM that review of relevant policies and procedures had been conducted. 7.f. It was unclear how the CADM investigation concluded for this incident that “there were no significant gaps in care or treatment.” ****************************************************** 8. The following is regarding an incident involving Patient 25 and Patient 26. 8.a. Incident documentation reflected that on 02/22/2024 at 0830 while staff were speaking with Patient 24 about the sexual encounter with Patient 25, described in the finding above, that occurred on 02/21/2024 Patient 24 stated that Patient 25 “also had sex with a patient who was previously on FW1, [Patient 26].” 8.b. Review of Patient 25’s “Transfer TCP Review” TCP dated 01/26/2024, in place at the time of the 02/21/2024 sexual incident reflected the following: * “RN/Staff will ... redirect any unsafe and/or inappropriate behaviors (specifically being victimized by peers).” * Patient 25 had been transferred to a new unit, FW1, on 01/25/2024. * That since transfer to that unit on 01/25/2024 Patient 25 “appeared to be a victim of [an opposite-gender patient’s] hypersexual behaviors ...” 8.c. There was no indication that prior to 02/22/2024 an incident report had been initiated or an investigation conducted into the reported sexual contact incident between Patient 25 and Patient 26 that occurred on either 01/25/2024 or 01/26/2024 on FW1 unit. ****************************************************** 9. Similar findings related to patient to patient incidents that resulted in injuries to patients and for which investigations were unclear and incomplete were identified for the following incidents reviewed: * Incidents for which Patient 14 was the aggressor on 12/25/2023 that involved Patient 11, on 12/29/2023 that involved Patient 15, and on 12/31/2023 that involved Patient 16. * Incidents for which Patient 17 was the aggressor on 12/27/2023 that involved Patient 19, and on 02/04/2024 that involved Patient 18. * An Incident for which Patient 12 was the aggressor on 08/17/2023 that involved Patient 13. ****************************************************** 10.a. Review of the incident log revealed no Pt2Pt incidents on AN1 from 02/11/2024 through the date of the survey. Review of the log reflected that hospital-wide the number of Pt2Pt incidents had declined from 55 in August 2023 to 29 in February 2024. 10.b. Review of the incident log reflected that from 08/01/2024 through 01/31/2024 there were one or two “sexual contact” incidents per month hospital-wide at both the OSH-Salem and OSH-JC. For the month of February 2024 the number of “sexual contact” incidents increased to seven. For the first part of the month of March 2024, from 03/01/2023 through 03/10/2023, the number was four. 10.c. During interview with staff that included the CMO, DSC, QMD, and Deputy CNO on Monday 03/04/2024 at 1100 they reported that over the weekend on 03/02/2024 there had been a patient to patient altercation on MTN3 that resulted in transfer of one of those patients to the ED, and on 03/03/2024 on LF2 a patient to patient altercation that involved multiple patients resulted in injury to one of those patients. ****************************************************** 40575 11.a. The P&P titled “Code Blue Medical Emergency” dated as 07/01/2020 was reviewed and reflected the following: * “A physician, nurse practitioner (NP), or registered nurse (RN) must assess the person to determine whether an emergency medical condition exists ...” * “Team Captain ... Assign roles and responsibilities ... Unless the physician, NP or RN has determined the person cannot be safely moved, direct moving them to the nearest medical staging area. When the person experiencing a medical emergency is a patient, document in the electronic health record (EHR).” * “Physician/NP/RN ... Assess the person to determine whether they are experiencing an emergency medical condition ... Determine whether an ambulance is needed to transport the person to the nearest acute-care facility ... Communicate essential information to responding EMTs ... If the Code Blue is for a patient, a. Notify the receiving emergency department of the patient’s clinical history. b. Complete a summary of the Code Blue event in the EHR. c. Contact authorized primary contacts via telephone.” * “Recorder ... Complete the Code Blue Flowsheet.” * “Crowd Control Monitor ... Maintain safety of the scene and milieu as necessary ... Verify essential personnel have access to the scene, person, and emergency equipment ... Request the Communicator cancel responders when sufficient responders have arrived at the scene ... Assist with transporting the person ...” 11.b. During video review of the assault on Patient 23 that occurred on 02/10/2024, the footage revealed that at one time, there were approximately 16 people that responded to the code blue and it is unclear what roles or involvement each person had since the “Code Blue Flowsheet” only has the space for “Team captain” and “Recorder.” The form lacked information on who performed an assessment on Patient 23 and what physician/NP or RN were present to fill this role. The form also lacked information regarding Patient 23’s emergency contact being notified. ****************************************************** 12.a. The P&P titled “Training and Competency Requirements” dated as 09/01/2023 was reviewed and reflected “RN, LPN, and MHT position requirements ... Current Cardiopulmonary Resuscitation (CPR) certification ... Current ‘Anaphylaxis Education and Epinephrine Auto-Injector Pen Training’ Competency ... Annual requirements for all nursing staff ... In addition to all applicable training requirements listed previously, all nursing staff assigned to patient care units must also participate in Code Green Drills at a frequency of once every two months.” 12.b. Staff training related to nursing staff requirements was not complete for all staff. Review of employee training documentation reflected the following: - RN W with hire date 01/27/2019 reflected no evidence of current Code Green Drill training as required by hospital policy. - MHT Z with hire date 07/09/2023 reflected no evidence of current Code Green Drill training as required by hospital policy. - MHTT DD with hire date 12/05/2022 reflected no evidence of current Code Green Drill training as required by hospital policy - RN A with hire date 01/14/2024 reflected no evidence of current Anaphylaxis Education and Epinephrine Auto-Injector Pen Training competency as required by hospital policy. - MHT B with hire date 03/03/2024 reflected no evidence of current Anaphylaxis/Epinephrine Pen training competency. There was no evidence of current Anaphylaxis/Epinephrine Pen training competency for several employees including but not limited to: - MHT C with hire date 03/10/2024 - MHT D with hire date 12/26/2021 - MHT2 E with hire date 12/08/2019 - MHT F with hire date 09/11/2022 - MHT H with hire date 02/28/2022 - RN L with hire date 01/27/2019 - RN M with hire date 01/27/2019 - MHT N with hire date 01/27/2019 - MHT O with hire date 01/27/2019 - LPN S with hire date 06/27/2021 - MHT2 T with hire date 08/25/2019 . 12.c. During interview on 03/07/2024 starting at 1030 with the QM, DSE, SC, CS and other staff members, they confirmed the records lacked “Anaphylaxis Education and Epinephrine Auto-Injector Pen Training” competency and “Code Green Drill” training for the above staff. 12.d. An email dated 03/18/2024 at 0624 from the QM reflected “I did find the training for one staff member in column J. I plan to verify the remaining today as well.” No additional documentation was received. ******************************************************”

“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: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation it was determined that the hospital failed to fully develop and implement clear P&Ps that ensured each patient’s right to be free from all forms of abuse and neglect. Identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur. The CMS Interpretive Guidelines 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 Guidelines reflect those 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 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 include: 40575 1.a. The P&P titled “Incident Reporting” dated as revised 02/05/2024 was reviewed and included the following: * “OSH staff must accurately report incidents in accordance with this policy. In response, OSH must conduct thorough investigations, prepare reports showing the tracking and trending of data, and implement and monitor corrective or preventative actions.” * “Any of the following reportable incidents must be reported ... Code Blue ... ER visit or admission of a patient ... Physical aggression toward patients, staff, or visitors resulting in any degree of injury ... Sexual contact and inappropriate sexual behaviors between patients or with a patient ... Sexual crimes or an inappropriate sexual behavior ...” 1.b. The P&P titled “Procedure A: Reporting an Incident” dated as 02/05/2024 was reviewed and included the following: * “Unless otherwise noted in this policy, every staff who witnesses a reportable incident must complete a separate incident report for each person involved in the reportable incident within one business day of the reportable event. For example, in a patient-to-patient aggression incident where a staff member is injured, three incident reports would be required to be submitted by each person that witnessed the reportable incident - one for each patient involved and one for the injured staff.” * “For reportable incidents involving patients (i.e. incident reports with patients listed as “subject”) an RN must assess the involved patient(s), when it is safe to do so, and document in the Progress Note. This assessment should consider elements appropriate to the nature of the incident, such as physical and psychological safety, access to prohibited items, and risk for recurrence.” * “Each incident report must identify the reporting staff ’ s location at the time of the incident.” * “If the incident report includes information from another source, the reporting staff must provide the name of the outside source and indicate if they were a witness or an involved party.” 1.c. The P&P titled “Procedure B: Incident Report Response” dated as 02/05/2024 was reviewed and included the following: * “The Incident Review Form must include: a. A brief summary of the incident (reference all incident reports describing the incident); b. A description of factors which contributed to the incident; and c. Actions taken or planned to respond to the incident, including but not limited to patient assessment and documentation in the patient medical record. d. Description of how OSH will prevent the event from reoccurring.” 2. Refer to the incident investigation findings cited at Tag A-144 under CFR 482.13(c)(2), Standard: Privacy and Safety. Those findings reflect the hospital’s failure to ensure investigations of incidents/events that reflected potential neglect were clear, complete, and accurate to prevent recurrence for those patients who experienced actual and potential harm, and for 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: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation it was determined that the hospital failed to ensure that incidents and adverse patient events were clearly identified, tracked, investigated and analyzed. Further, the hospital failed to plan and implement corrective actions to prevent recurrence of those, to promote learning throughout the hospital, and to establish clear expectations for patient safety. Findings include: 1. Refer to the findings cited at Tag A-144 under CFR 482.13(c)(2) - Standard: Privacy and Safety that reflects that policies, procedures, and systems for the provision of safe care were not clear, complete, or implemented and resulted in the following: * Failure to prevent patient to patient physical altercations and injuries. * Failure to prevent patient to patient sexual contact and sexual assault. * Failure to ensure staff carried out assigned duties related to all aspects of observation and supervision of patients. * Failure to ensure TCPs and ES orders were followed. * Failure to ensure door security and situational awareness practices that ensured patient safety. * Failure to ensure all high risk patient care areas monitored by 24/7 security staff video monitoring were fully observable and did not include blind spots. * Failure to ensure staff practices were in accordance with, and supported by, written and approved P&Ps for the following: - Condom distribution to patients. - Processing and tracking police reports filed on behalf of patients who had been assaulted by other patients. - Security staff “access control” video monitoring * Failure to ensure Code Blue responses were organized, appropriate, and documented. * Failure to ensure staff training related to patient safety was current. 2. Refer to the findings cited at Tag A-145 under CFR 482.13(c)(3) - Standard: Privacy and Safety that reflects that identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur. 3. Refer to the findings cited at Tag A-118 under CFR 482.13(a)(2) - Standard: Patient Grievances that reflects that response to, investigation of, and follow-up to patient grievances related to safe care were not clear, complete or timely. 4. During interviews with staff that included the DSC, QMD, and CMO about the patient incident log on 02/28/2024 and 03/04/2024 they indicated that the hospital had no process for systematic identification and tracking of outcomes to patients that involved patient injuries, ED visits, and hospitalizations in relation to incidents. They stated that information about patient injuries sustained and ED/hospital visits was only identifiable in individual patient incident reports or individual patient medical records. ******************************************************”

“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: 08621 ****************************************************** Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 24 of 26 patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 ,19, 22, 23, 24, 25, and 26), review of investigation documentation, review of grievance documentation, review of P&Ps and review of other documentation it was determined that the RN failed to supervise the nursing care for each patient to ensure the provision of safe and appropriate care. Findings include: 1. Refer to the findings cited at Tag A-144 under CFR 482.13(c)(2) - Standard: Privacy and Safety that reflects that policies, procedures, and systems for the provision of safe care were not clear, complete, or implemented and resulted in the following: * Failure to prevent patient to patient physical altercations and injuries. * Failure to prevent patient to patient sexual contact and sexual assault. * Failure to ensure staff carried out assigned duties related to all aspects of observation and supervision of patients. * Failure to ensure TCPs and ES orders were followed. * Failure to ensure door security and situational awareness practices that ensured patient safety. * Failure to ensure all high risk patient care areas monitored by 24/7 security staff video monitoring were fully observable and did not include blind spots. * Failure to ensure staff practices were in accordance with, and supported by, written and approved P&Ps for the following: - Condom distribution to patients. - Processing and tracking police reports filed on behalf of patients who had been assaulted by other patients. - Security staff “access control” video monitoring * Failure to ensure Code Blue responses were organized, appropriate, and documented. * Failure to ensure staff training related to patient safety was current. 2. Refer to the findings cited at Tag A-145 under CFR 482.13(c)(3) - Standard: Privacy and Safety that reflects that identification of, investigations of, and response to, allegations of abuse, and incidents that reflected potential neglect that resulted in actual and potential patient harm, were not clear, complete, and accurate to ensure those incidents and events did not recur. Investigations of the majority of incidents were conducted primarily by hospital nursing and other clinical staff. Exceptions included investigations of incidents that resulted in significant or serious harm. 3. Refer to the findings cited at Tag A-118 under CFR 482.13(a)(2) - Standard: Patient Grievances that reflects that response to, investigation of, and follow-up to patient grievances related to safe care were not clear, complete or timely. Patient grievance response and follow-up was conducted primarily by hospital nursing and other clinical staff. ******************************************************”