Butler Hospital

“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: 32374 Based on observation, clinical record review and staff interviews, the hospital failed to ensure a patient who was on 5 minute safety checks for known self-injurious behaviors receive care in a safe setting after they were able to obtain a plastic utensil from an unknown source and ingest it on three separate occasions during their admission, which resulted in three hospital transfers and the need for endoscopic surgical removal for 1 of 3 patients reviewed, (Patient ID 1). Findings are as follows: According to the hospital’s “Patient Rights and Responsibilities,” patients have “the right to receive care in a safe setting.” Review of the hospital’s policy titled “Categories of Observation” effective as of 2/2024. ...Special Precautions include the following: a. Removal of belts, drawstrings, shoelaces and jewelry, no belongings are to be kept in the patient’s room unless stored in a locked closet or drawer. b. Supervision of the patient in the use of restricted items as per nursing procedure c. Access to some areas of the unit may be limited at the discretion of the nursing staff on duty ... During unit observation on 4/2/2026, the unit environment revealed that all patients had the ability to reach over the nurses’ station desk, which was located next to Patient ID #1’s room. Hazardous items, including pens and markers, were observed to be within a patient’s reach at the desk which was observed to be unattended for several minutes. Clinical record review revealed that Patient ID #1 was admitted to the hospital due to increased depression and worsening severity of intrusive thoughts to harm his/herself. The patient was initially placed on 5 minute checks with special precautions. Clinical notes reveal on day 12 of the admission, the patient self-reported that he/she had broken off a piece of a plastic utensil and swallowed the handle (approximately 3 inches). The patient was transferred to an acute care hospital for evaluation and returned after the object was removed via endoscopy. The patient was again placed on 5 minute checks with special precautions. Clinical notes reveal on day 18 of the admission, the patient self-reported that he/she had swallowed the handle of a plastic utensil and she/he could feel it stuck in their throat. The patient was evaluated and transferred to an acute care hospital. The patient returned to the facility after an endoscopy was completed to remove the object, and the patient was again placed on 5 minute checks with special precautions. Clinical notes reveal on day 20 of the admission, the patient self-reported that he/she had swallowed the handle of a plastic utensil and the patient was evaluated and transferred to an acute care hospital and was admitted for observation after the endoscopic removal of a foreign object. He/she returned to the facility two days later and was placed on constant observation. During a surveyor interview with Attending Physician, Staff B on 4/6/2026 at 10:15 AM he revealed that Patient ID #1 reported to him that he/she was able to obtain the plastic utensils while they were on the unit. Staff B stated that the patient had been in good control of their urges and was using activities such as coloring and crocheting and the team had adjusted his/her medications. He stated that placing the patient on one-to-one observation has caused the patient to regress in the past. The Physician, Staff B, acknowledged that the patient had 3 separate episodes of ingesting the handle of a plastic utensil while he/she was being monitored every 5 minutes on special precautions. The hospital failed to protect a patient with known self-injurious behaviors from accessing and ingesting hazardous items on three separate occasions resulting in multiple transfers to an acute care hospital and the need for endoscopic intervention.”

“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: 43881 Based on clinical record review and staff interviews, the hospital failed to ensure a patient who was restrained received care in a safe setting after an injury was identified following application of restraints for 1 of 2 patients reviewed, (Patient ID #2). Findings are as follows: According to the hospital’s “Patient Rights and Responsibilities,” patients have “the right to receive care in a safe setting.” Clinical record review revealed that Patient ID #2 was admitted to the hospital due to erratic behaviors and concerns for mania or psychosis. On 2/12/2026 at approximately 12:35 PM, Patient ID #2 began yelling at staff and posturing which resulted in staff initiating “hands on” and subsequently restraining the patient to a transport chair and administering injectable medications for agitation. Record review of a nursing progress note authored by Employee C, RN, on 2/12/2026 at 2:35 PM, states in part that the patient had a “bruised area” on his/her left wrist “secondary from initial hands on/placement into the chair.” Record review revealed that staff photographed the patient’s left wrist the following day, 2/13/2026. Upon review, the photograph demonstrated an irregularly shaped oval area of red and purple discoloration with scattered pinpoint red markings, which were more concentrated on one side of the oval. Faint purple/blue discoloration was also noted extending beyond the outer border of the affected area. During a surveyor interview on 3/17/2025 at 1:59 PM with Employee C, she stated that she thought the injury occurred while the patient was being restrained. She explained that the patient was “struggling” when she/he was being restrained and when she/he was placed in the transport chair, “the restraint strap was underneath the patient’s wrist” and indicated that the injury likely occurred “when they pulled the strap tight.” She further indicated that “it looked like a burn” and when staff noticed this, they “loosened the strap.” During a surveyor interview on 3/18/2026 at approximately 1:30 PM with the Director of Risk Management, she was unable to provide evidence that Patient ID #2 received care in a setting determined to be safe following an injury sustained during the application of restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 43881 Based on clinical record review and staff interviews, the hospital failed to ensure that a physician’s order for restraint was obtained immediately (within minutes) following the initiation of restraint, as required by 42 CFR §482.13(e)(5), evidenced by a delay of 1 hour and 9 minutes, and lack of supporting documentation for 1 of 5 patients reviewed, (Patient ID # 3). Findings are as follows: The hospital’s policy titled, “Restraint and Seclusion” states in part, “The purpose of this Restraint and Seclusion policy (this “Policy) is to assure the safety of patients and staff, and to ensure compliance with all applicable regulations, when restraint and seclusion become necessary during patient care.” Record review revealed that Patient ID #3 was restrained to a transport chair on 1/29/2026 at 7:45 PM after charging at another patient “brandishing a plastic fork.” The patient was subsequently released from the restraint at 8:15 PM. Further record review revealed that a physician’s order for the application of this restraint was obtained by the nurse at 8:54 PM, 1-hour and 9-minutes after the restraint was applied, not immediately following the application of the restraint in accordance with federal regulations. During a surveyor interview on 3/18/2026 at 12:10 PM, with the Nurse Educator, she was unable to provide evidence that a physician’s order for the application of the above-mentioned restraint was obtained during the application of the restraint or immediately following application in accordance with federal regulations.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 43881 Based on clinical record review and staff interview, the hospital failed to ensure that a patient’s condition relative to pain was assessed and reassessed in accordance with hospital policy or that interventions were implemented for 1 of 4 patients reviewed, (Patient ID #1). Findings are as follows: The Hospital’s policy titled, “Pain Management” states in part, “The patient’s right to pain management will be respected and supported by all members of the Butler health care team... ...If a patient has a new report of pain during their hospitalization, the nurse will assess the patient using the appropriate scale and document the level of pain...” Further, the hospital’s policy titled, “Restraint and Seclusion” states in part, “Every hour the RN [Registered Nurse] assesses the patient’s respiratory and circulatory status, skin integrity...This is documented in the medical record.” Clinical record review revealed that Patient ID #1 was admitted to the hospital due to increased delusions and agitation. On 2/11/2026 at approximately 6:45 PM, Patient ID #1 became physically aggressive toward a Registered Nurse. Staff intervened and restrained the patient. During the event, staff assisted “by taking a limb on each side” and “all staff and the patient then fell to the floor.” The patient was subsequently placed in a transport chair with restraints for approximately 2 hours and 15 minutes. The record indicated that Employee A, a Psychiatry Resident Physician, performed a face-to-face assessment of the patient at 6:49 PM. The assessment stated in part that the patient reported “sharp left-sided rib pain with slight difficulty breathing” and she/he had “pinpoint tenderness to palpation.” The assessment further indicated that at that time, the patient indicated that his/her pain was improving. Record review revealed that the hospitalist, Employee B, was called at 7:37 PM by nursing staff after the patient’s oxygen saturation level reportedly decreased to 87%. The hospitalist indicated that according to staff’s report, the patient had slowed respirations after she/he was restrained to the transport chair and receiving injectable medications for agitation. The patient’s oxygen saturation level reportedly improved after staff removed the restraint straps from the chest per the patient’s request. The record indicated that the hospitalist evaluated the patient’s respiratory condition and noted that the patient did not appear to be in acute distress but to monitor the patient “closely.” However, the record failed to reveal evidence that the patient’s previously reported pain was addressed. Nursing staff failed to assess the patient’s pain using the appropriate scale, failed to document the pain level, and failed to implement interventions to address the patient’s pain during the remainder of the restraint episode or thereafter. Additionally, the clinical record failed to reveal evidence that hourly nursing assessments that included the patient’s respiratory and circulatory status, and skin integrity, were documented in accordance with hospital policy until the end of the restraint episode, approximately 2 hours and 15 minutes. Further record review indicated that on 2/12/2026 at approximately 6:30 AM, the patient “woke up screaming” and complained of severe pain that increased with deep breathing. The physician who evaluated the patient indicated that the patient was lying in bed in “moderate distress.” The patient was subsequently transferred to an acute care hospital for a medical evaluation. Clinical records from the receiving hospital revealed that the patient had fractures in the left anterior 8th, 9th, and 10th ribs. During a surveyor interview on 3/18/2026 at approximately 12:00 PM with the Director of Risk Management, she was unable to provide evidence that nursing staff assessed and documented Patient ID #1’s pain in accordance with hospital policy after the initial complaint of pain, or that the patient’s pain was reassessed and managed prior to the onset of severe pain the following morning.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 43881 Based on record review, staff interviews and personnel file reviews, the hospital failed to ensure that patients received care in an environment that a reasonable person would consider to be safe relative to unlicensed personnel performing tasks outside of their scope of practice. Findings are as follows: 1. The hospital allowed unlicensed personnel (a Certified Medical Assistant with a phlebotomy certificate) to insert intravenous (IV) catheters outside of their scope of practice in the state of Rhode Island, (Refer to A-0144).”

“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: 43881 Based on record review, staff interviews and personnel file reviews, the hospital failed to ensure that patients received care in an environment that a reasonable person would consider to be safe by allowing unlicensed personnel (a Certified Medical Assistant with a phlebotomy certificate) to insert intravenous (IV) catheters, a flexible tube inserted into a vein to deliver medications, fluids, or nutrition directly into the bloodstream, for 3 of 3 patients reviewed, (Patient ID #s 1, 2, and 3). Findings are as follows: On 6/13/2025, the Rhode Island Department of Health received an anonymous complaint alleging that Employee A, a phlebotomist, was observed inserting an intravenous catheter into a male patient in the Electroconvulsive Therapy (ECT) Department, a location in which ECT treatment is provided that involves electrical stimulation of the brain to treat severe mental health conditions. The hospital’s policy titled, “ECT Policies and Procedures” effective 5/3/2023 states in part, “ ...a. Anesthetics and medications are administered during treatment via intravenous (IV) line inserted by a registered nurse ...” Record review of Employee A’s personnel file revealed the employee obtained certification from the National Healthcareer Association as a Phlebotomy Technician, a healthcare professional responsible for collecting blood samples from patients, and a Clinical Medical Assistant, a healthcare worker who performs routine administrative, clerical, and clinical duties in various healthcare settings. According to the Rhode Island Department of Health website, Medical Assistants are unlicensed healthcare workers and “must not” insert an intravenous catheter. During a surveyor interview on 6/17/2025 at 11:15 AM with Employee A, she confirmed that she has inserted IV catheters into patients while working in the ECT Department. She revealed that if there were many patients scheduled to receive ECT, she was asked by the nurses to assist in inserting IV catheters. She revealed that since working in the ECT Department, Patient ID #s 1, 2, and 3 specifically asked for her to insert their IV catheters. When asked if she had reviewed her scope of practice on the state of Rhode Island website, she stated she did not. During a surveyor interview on 6/16/2025 at 9:18 AM and at 2:25 PM with the Director of Nursing Education, she confirmed that Employee A has been inserting IV catheters while in the ECT Department and has personally observed her performing this task approximately 10 times. She informed the surveyor that according to an article published by an accredited Medical Assistant certification program, Medical Assistants can place IV catheters in the state of Rhode Island. When asked if she confirmed this with the Rhode Island Department of Health website, she indicated she had not. When asked if the procedure record for Patient ID #s 1, 2, and 3, indicated whether Employee A or any other staff inserted an IV catheter into the patient, she confirmed that it did not and only the site where the IV was placed is documented.”

“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: 32374 Based on record review and staff interviews, it was determined that the hospital failed to ensure housekeeping personnel followed standard patient safety practices relative to patients leaving a unit unattended which resulted in a patient eloping from the hospital against medical advice for 1 of 4 patients reviewed for elopement, (Patient ID #1). Findings are as follows: On 11/12/2024, the Rhode Island Department of Health received a report from the hospital which indicated that on 11/7/2024, a patient eloped from the hospital after a housekeeper opened the unit door and allowed the patient to leave the unit. Record review revealed that Patient ID #1 presented to hospital in November of 2024 seeking detox and was subsequently admitted on a voluntary basis. His/her diagnoses include, but are not limited to, alcohol use disorder, methamphetamine use disorder and marijuana use. On 11/7/2024, the patient’s record indicated she/he was on 15-minute safety checks with physician orders indicating she/he was restricted from leaving the unit. Record review of nursing progress notes from 11/7/2024 revealed that the patient was agitated and wanted to leave. Additionally, the note indicated that the patient had been pacing on the unit and was observed by staff near a doorway telling staff to let him/her out. Further review of nursing progress notes from 11/7/2024 revealed that the Charge Nurse was informed by staff at 11:16 AM that Patient ID #1 could not be located on the unit during the 11:15 AM observation checks and that a housekeeper had allowed the patient to leave the unit when she opened the door to the unit. During a surveyor interview on 11/19/2024 at 11:42 AM with Employee A, Mental Health Worker, she revealed that on 11/7/2024 at around 11:00 AM, she was conducting observation checks when she noticed that Patient ID #1 was gathering his/her belongings. Employee A then stated that at 11:08 AM, she asked the nurse if the patient was being discharged to which the nurse replied that the patient was not. Employee A indicated that she then was unable to locate the patient during the 11:15 AM observation checks after checking all areas of the unit. Employee A stated that she had seen the Housekeeper “come in and out of the unit” multiple times and asked the Housekeeper if she had seen the patient to which the Housekeeper replied that the patient left the unit as “[she/he] was all set to go.” During a surveyor interview on 11/19/2024 at 10:38 AM with Employee B, Housekeeper, she revealed that on 11/7/2024 she entered the unit through the main double doors and heard the patient say, “bye” as she/he exited through the doors. Employee B indicated that she did not say anything to the patient as she/he exited because she thought she/he had been discharged. When asked if it is routine for nursing staff not to walk out of the unit with patients upon discharge, she stated that nursing staff only do this “sometimes.” During a surveyor interview on 11/19/2024 at approximately 11:15 AM with the Nurse Director of D3, Employee C, she stated that upon discharge, patients are always escorted out of the unit by nursing staff since they have to open the door for the patient to exit. During a surveyor interview on 11/19/2024 at 11:15 AM with Employee D, Housekeeper, outside of the D3 unit, she revealed she heard about the patient elopement from other staff and indicated that her managers did not personally talk to her about what to do or what not to do upon entering a patient unit. When asked what precautions she is taking specific to ensuring no patients elope form the unit, she stated that the day after the elopement occurred, her and other Housekeeping staff would follow behind one another when entering the unit, but they do not do this anymore. Following the above-mentioned interview, another Housekeeper, Employee E, was observed entering the D3 unit through the main double doors at 11:18 AM using his own fob key, to electronically unlock the doors. During a surveyor interview with Employee E on 11/19/2024 at approximately 11:35 AM, he indicated that he has been instructed to ring the doorbell upon entering the unit via the main double doors and acknowledged that earlier, he did not ring the doorbell to enter the unit via the double doors as expected. During a surveyor interview on 11/19/2024 at approximately 1:20 PM with Employee F, Environmental Services Manager, he revealed that Housekeeping staff have been told numerous times not to let anyone out of the unit as they are entering the unit unless that person has a hospital badge and stated that this has been their usual practice. In addition, Employee F indicated that Housekeeping staff have been instructed to always use the employee entrance, not the main double doors, to enter the units unless they have a cart or big equipment for which they would have to ring the doorbell and wait for staff to let them in.”

“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: 32374 Based on record review, video surveillance, and staff interview, it has been determined that the hospital failed to provide nursing services which ensures all observation safety protocols were followed and implemented, and that patient care plans were reviewed and revised as required for 1 of 1 patient who engages in intentional swallowing of foreign objects, (Patient ID #1). Findings are as follows: 1. The hospital failed to ensure staff who were assigned to a patient for constant observation, ensured the safety of the patient, and adhered to the “Categories of Observation” policy (Refer to A-0398). 2. The hospital failed to follow their policy “Interdisciplinary Treatment Plans”, regarding the failure to update Patient ID #1’s plan of care upon return from the medical hospital on 10/13/2023, following an episode of intentional swallowing of a foreign object.”

“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: 32374 Based on record review and staff interviews, it has been determined that the hospital failed to ensure nursing staff develop and keep current the 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 for 1 of 1 patient care plan reviewed regarding the intentional swallowing of foreign objects (Patient ID #1). Findings are as follows: The Hospital’s policy titled, “Interdisciplinary Treatment Plans” effective 3/9/2021 states in part, “I. Purpose: The purpose of this Interdisciplinary Treatment Plans policy is to establish an interdisciplinary team care planning process to ensure that patient care and treatment is planned appropriately for the patient’s needs and severity of condition, impairment, illness or disability. ...III. Policy: It is the policy of Butler Hospital to ensure that an interdisciplinary care plan is developed for each patient and that each discipline involved in the care of the patient must participate in patient assessment and propose a joint approach toward achieving the goals and interventions set for the patient. V. Procedure: 1) Treatment planning and patient care are performed by a clinical team which is headed by a physician and includes members of the nursing staff, social service clinicians, occupational therapists, psychologists, dietitians, and various medical and other consultants”. Record review for Patient ID #1 revealed s/he presented to the hospital in June of 2022. Diagnoses include, but are not limited to developmental delay, borderline personality disorder, pseudotumor cerebral s/p shunt, psychogenic non -epileptic seizure and epilepsy. The patient has a history of swallowing foreign objects. S/he also has had multiple admissions to this hospital. Record review revealed that Patient ID #1 had swallowed a battery on 8/28/2023 and was sent to Rhode Island Hospital. The patient returned to Butler hospital on 9/1/2023. On 10/3/2023 a physician progress note revealed that Patient ID #1 reported to staff that s/he again had swallowed a battery. The patient was again sent to the Rhode Island Hospital where it was confirmed that s/he had swallowed a battery. Patient ID #1 returned to Butler Hospital, however, after failing to pass the battery naturally s/he was sent back to Rhode Island Hospital on 10/11/2023 for removal of the battery and was discharged back to Butler Hospital on 10/13/2023. On 11/27/2023, the State Health Department received an incident report identifying that Patient ID #1, who was on constant observation had again swallowed a battery. A federal incident investigation was initiated. Review of Patient ID #1’s current care plan dated 10/13/2023, when the patient was previously seen at Rhode Island Hospital for swallowing a battery, failed to reveal a care plan relative to the patient’s known history of intentional swallowing of foreign objects. During an interview with the Risk Manager regarding the current care plan and the lack of identifying the patient’s intentional swallowing behaviors, she was unable to produce evidence that the plan of care had been updated after the patients last incident of swallowing a foreign object.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 32374 Based on record review and staff interviews, it has been determined that the hospital failed to ensure nursing personnel follow hospital policies relative to ensuring the safety for 1 of 1 patient with intentional swallowing of foreign objects who was on constant observation and swallowed a battery resulting in an unintended medical procedure. (Patient ID #1) Findings are as follows: The hospital’s policy titled, “Categories of Observation” effective 8/10/2021 states in part, “...1) Constant Observation shall be ordered for any patient who needs to have a staff member with him/her at all times ... a. An assigned staff member must be with the patient at all times, including in the bathroom. b. The staff member must be able to visually observe the patient at all times and be able to quickly intercede should it become necessary ...” Record review revealed that Patient ID #1, who presented to the hospital in June of 2022. Diagnoses include, but are not limited to developmental delay, borderline personality disorder, pseudotumor cerebral s/p shunt, psychogenic non-epileptic seizure and epilepsy. Patient ID #1 also has a history of intentional swallowing of foreign objects. Record review revealed that the patient had swallowed a battery on 8/28/2023 and was sent to Rhode Island Hospital, then returned to the Butler hospital on 9/1/2023. On 10/3/2023 a physician progress note states that patient reported to staff that s/he had swallowed a AAA battery from the TV remote control around 6:30 AM, during which time she was on constant observation. The patient was sent to the Rhode Island Hospital, and it was confirmed that s/he swallowed a battery. The patient was sent back to Butler Hospital, however after failing to pass the battery naturally, s/he was sent back to Rhode Island Hospital on 10/11/2023 for the removal of the battery. Record review completed on 11/29/2023 revealed Patient ID #1, had intentionally swallowed a battery from a TV remote control. It was identified that this is the third time in approximately 3 months that the patient had obtained and swallowed a battery while under the supervision of the Butler Hospital staff. During a surveyor interview on 11/29/2023 at 2:40 PM with the unit Nurse Director, she informed the surveyor that the patient had just been transferred to her unit and that all staff were made aware that the TV remote controls are to only be used by the staff and not given to patients. Additionally, she stated that the Mental Health Workers are assigned to cover the constant observation for one hour at a time, on a rotating basis for any patient on constant observation. The Nurse Director provided a copy of the schedule for the incident date of 11/27/2023. This schedule identified Staff C, a Mental Health Worker as having Patient ID #1 as her constant observation assignment. The 11/27/2023 second shift schedule, revealed the following constant observation coverage for Patient ID #1: -Staff C was assigned the 1-1 coverage from 3:30-4:30 PM, 5:30-6:30 PM and 7:30-8:30 PM. -Staff F was assigned the 1-1 from 4:30-5:30 PM and from 8:30-9:30 PM. -Staff E was assigned the 1-1 from 6:30 -7:30, however she had to leave, and Staff D was assigned from 6:30-7:30 per the unit director. A review of the surveillance video with the Risk Manager on 11/30/2023 revealed the patient and the constant observer on the unit. -Staff D, a Mental Health Worker was observed with the patient between 6:30 - 7:30 PM. Staff D is seen taking the TV remote from behind the nurse’s station, holding it in his hand and walking with the patient to the Sensory room around 7:10 PM where they remained. -At approximately 7:30 PM Staff C is observed going into the Sensory Room where the patient and Staff D were watching TV. -Staff D is observed leaving the Sensory Room without the TV remote control. -8:05 PM, Staff C is observed exiting the Sensory Room with the patient who has the TV Remote Control, and they go into the kitchen for a short time. -Upon leaving the kitchen the patient is seen handing the TV remote control to Staff C. -7:45 PM, Staff F is observed with the patient check board to document the 5-minute checks. Staff F is observed standing in front of the Sensory Room looking into the room to complete the check for Patient ID # 1. During an interview with Staff D, a per diem Mental Health Worker, on 11/30/2023 via phone, he stated that when he came to work on 11/27/2023, he was on R-3 unit, until approximately 4:30 PM, then moved to the L-2 unit to replace a worker who had gone home. He states he assigned to cover the constant observation for Patient ID # 1 from 6:30-7:30 PM. He stated that the patient wanted to go into the sensory room to watch TV, so when the room was available, he went to the nurses station and took the TV remote control and went to the Sensory room with the patient. He stated the TV remote had tape on it covering the area to the battery compartment. He stated once the patient chose a channel, he placed the remote control on the arm of the chair that he was sitting in. At 7:30 when Staff C arrived to take over the constant observation coverage, he reported to her and left the TV remote on the arm of the chair. During an interview with Staff C on 11/30/2023 at 1:10 PM, via phone in the presence of the Risk Manager and Unit Director, she informed the surveyor that she presented to work at 3:00 and was assigned to constant observe Patient ID #1. She stated she covered the constant observation as scheduled from 3:30-4:30 and again from 5:30-6:30. Upon her return from dinner to the patient at 7:30 PM she noted the patient and Staff D were in the sensory room watching TV. She stated that the patient had the TV Remote which was “taped up”. She stated they remained in the Sensory Room for approximately another half hour and then went to the kitchen. The patient asked to go to her room, she stated she returned the TV remote to the nurse’s desk. Staff C stated the patient then told her s/he had swallowed the battery from the remote. She stated that she did not give the TV remote to the patient and did not see him/her remove the battery or swallow the battery. During an interview with Staff F, a Mental Health Worker, on 11/30/2023 at approximately 11:35 AM, she stated that she was assigned to complete the 5-minute checks between 7:30-8:30 PM. She stated that while doing the 5-minute checks, she saw Patient ID #1 with the TV remote in her hand while in the Sensory Room with Staff C. She acknowledged that she knew that only staff was to have the TV remote, however she didn’t say anything because Staff C was with the patient. During surveyor interview with the Risk Manager and the Unit Director on 11/30/2023 at approximately 3:10 PM after viewing the video and completing staff interviews, both were unable to explain how Patient ID #1 who was on constant observation was able to obtain and swallow the TV remote battery without staff knowledge. The Unit Director informed the surveyor that per policy, staff assigned to constant observation need to be able to observe the patient visually at all times and quickly intercede if necessary. She stated that the staff have all been educated about patients not having the TV remote controls.”