G Werber Bryan Psych Hosp

“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: 28883 Based on record reviews, interviews, and policy review, the hospital staff failed to ensure appropriate supervision for 2 of 10 patients reviewed for elopement; Patients #1 and #5. Nursing Assistant (NA) #2 failed to provide appropriate supervision to Patient #1 while at the vending machines on campus. NA #2 was distracted, not continuously observing patients to prevent elopement or elopement attempts. Registered Nurse (RN) # 2 failed to check his/her surroundings and ensure Patient (Pt) #5 was not in the immediate vicinity when s/he opened the door to exit to the outside. This allowed Pt #5 to push past the nurse and elope. The findings included: Record review on 8/18/25 at 11:50 AM revealed the hospital admitted Patient #1 on 4/2/25 under an involuntary judicial order with diagnoses including Bipolar Disorder. The admission nursing documentation showed Patient (Pt) #1 had sustained a back and ankle injury after attempting to elope from a previous Behavioral Health hospital prior to transferring to this one. Review of the adverse event report provided by the hospital’s Risk Management revealed that on 7/18/25 at 10:36 AM, two staff members, Nursing Assistants (NAs) #1 and #2; had taken a group of patients (5 in total) outside the unit (still on hospital grounds); to the post office and adjacent canteen. One of the staff (NA #1) was in the post office assisting some of the patients to get money for the canteen; while NA #2 was monitoring patients at the vending machines. At 10:45 AM, Pt #1 was at a bench by the vending machine. When NA #2 looked for Pt #1, the patient was gone. The report indicated that the patient had been hiding in a briar patch and had made it to a gas station near the hospital. The patient was returned to the hospital on 7/18/25 at 6:59 PM. During an interview on 8/19/25 at 10:00 AM, Behavioral Health Assistant (BHA) #1 stated s/he had been working on the unit (Lodge H) that day; but wasn’t with the patients at the canteen and had stayed on the unit when Pt #1 had eloped. According to BHA #1, the patient probably was able to slip around the corner of the building near the vending machines and escape. When asked about the process used to take patients to the post office/canteen and back to the unit, BHA #1 stated that there is a ratio of one staff member for every 5 patients when going outside. One staff member stands at the door near the post office while another staff member is inside the post office assisting patients to obtain funds for the canteen. Once all patients have their money, they will all walk to the vending machines together to purchase drinks or snacks; then we all walk back to the lodge. The entire process takes about 10 minutes. BHA #1 stated they all stay together so the patients don’t wander off. During an interview on 8/19/25 at 10:17 AM, NA #1 stated s/he had been working at the hospital a year. When asked about the elopement incident for Pt #1, NA #1 stated s/he and NA #2 (who had not been routinely working on the Lodge H) had taken the patients to the canteen after having them sign out for the activity. NA #1 stated s/he had been in the post office with some of the patients; and NA #2 was outside with the rest. NA #1 stated that when s/he came out of the post office, NA #2 asked me where Pt 1 was. At first I didn’t know what (NA #2) was talking about, so I went back in (to the post office) to see if (Pt 1) was there, but didn’t see him/her. After checking in the library, NA #1 stated s/he had phoned the lodge to see if the patient had returned back there; and asked the lodge staff to call a Code Green (elopement). When asked about the process for taking patients to the post office/vending machines; NA #1 stated one staff member goes into the post office with patients, and the other staff is near the vending machines watching patients. When asked if this type of elopement had happened before, NA #1 stated it may have happened before; but could not give any specific details. NA #1 was asked if anything could have been done better and stated s/he wished s/he had been the one watching the patients since s/he was more experienced. During an interview on 8/19/25 at 10:55 AM, NA #2 stated s/he had been working at the hospital for 11 months on the adolescent unit; and only recently had been assigned to Lodge H. NA #2 verified taking Pt 1 along with about 5 others to the canteen on 7/18/25. NA #2 stated s/he was supposed to be watching patients get their snacks. NA #2 stated that one of the vending machines was not working, and s/he had been preoccupied for about 2 minutes trying to assist a patient to get a snack before noting that Pt #1 was missing. NA #2 was asked what his/her duties were when taking patients off the unit. NA #2 stated that s/he assists patients to get a snack, ensure they eat, and dispose of trash. When asked if there was anything related to safety that s/he was watching for; NA #2 stated “Yes, making sure they don’t hurt each other.” NA #2 stated the Assistant Director of Nursing (ADON) had gotten her/his witness statement (for the adverse event form); but other than that no one had spoken to her/him about the incident with the elopement for Pt #1. During an interview on 8/20/25 at 1:23 PM, the Assistant Director of Nursing (ADON) stated that staff used the policy “Off-Campus Therapeutic Activities” to govern how supervision is conducted during the trips made to the post office and canteen; any where off the lodge/unit. According to the ADON, there is no separate policy/procedure that addresses how to provide supervision to on campus activities that are off the unit/lodge. Review of the policy “Off-Campus Therapeutic Activities”, revised May 2023, revealed under “Escort Responsibilities”, that each staff escort will be assigned specific patients to monitor and keep in line of sight at all times...The maximum staff/patient ratio for off-campus therapeutic activities is 1:5...”. Record review on 8/19/25 at 11:00 AM revealed the hospital admitted Pt 5 on 4/23/25, on an involuntary judicial order with diagnoses including Schizoaffective Disorder, Bipolar, and Substance Abuse. Review of the hospital’s Adverse Incident Report revealed Pt 5 had eloped on 7/6/25 at 8:07 PM, after running out and exiting the lodge behind an employee who was taking out the trash. The patient was returned by a Public Safety Officer on 7/6/25 at 9:07 PM with a scratch noted on the right eyebrow. A Nurse’s note dated 7/7/25 at 4:37 AM revealed Pt 5 had pushed a nurse out of the way after s/he had opened the back door to throw trash out. The note stated the patient had run and jumped a fence; and was found on North Main Street close to Keenan High School. A review of the video footage of the elopement for Pt 5 was conducted on 8/19/25 at 2:00 PM with the Chief Nursing Officer (CNO). The video showed that on 7/6/25 at 8:06 PM, Pt 5 had been walking behind RN 2 as s/he was coming down the hallway. The patient was right behind the nurse. When RN 2 came to the door; s/he did not look around to check his/her surroundings before s/he unlocked the door. RN 2 had not looked to see that Pt 5 was behind him/her. Pt 5 pushed past the nurse, pushing the door open and had run away. RN 2 was on leave and not available for interview. The hospital provided an Incident Witness Statement by RN 2 for the incident with Pt 5. “I was going out back door to throw out trash from nurse’s station and I barely opened the back door when Pt 5 pushed me from behind and ran outside. I chased after patient keeping eyesight. Pt ran around to Lodge F then turned towards Morris Village fence then climbed over fence. I seen a PSO (Public Safety Officer) and directed him towards patient’s direction while keeping pt within eyesight. At the time I opened the back door pt was no where near exit at lodge”. The report indicated that at the time of the incident s/he was the charge nurse. Under “What information can you share about patient’s history and care?”, was documented “Pt has a history of constantly pacing hallway”. During an interview on 8/20/25 at 3:08 PM, the concerns with the elopements for Pts 1 and 5 were shared with administrative staff including the CNO, Medical Director, and Facility Director. They verified the concerns and stated they had reviewed the incidents and spoken with Risk Management. As part of their Performance Improvement they have identified concerns with staff being aware and planned on implementing education to raise elopement risk, had recommended revision of policies, and talked about developing specific processes for escorting patients; in addition to making sure cameras are working and the long term recommendation of building a fence. Review of the policy “Patient Rights and Responsibilities”, reviewed October 2024 revealed information that patients have a right to competent, considerate and respectful care in a safe setting.”

“Treatment Plan CFR(s): Standard Treatment Plan Each patient must have an individualized, comprehensive treatment plan based on an inventory of the patient’s strengths and disabilities. This Standard is not met as evidenced by: 28883 Based on record review, interviews, and policy review, the hospital failed to ensure 1 of 2 patients reviewed who had eloped, Patient #1, had an individualized treatment plan on admission that included his/her risk for elopement and information later that the goal had been met with the end of elopement precautions being needed. The initial treatment plan for Patient #1 did not include the concern of elopement risk nor intervention(s) placed to mitigate the risk. The Master Treatment Plan had not been updated to include that Pt #1 was no longer an elopement risk; and that the goal for not having eloped had been met. The interdisciplinary team had met on 7/21/25 to discuss Pt 1’s elopement on 7/18/25. During the next treatment team meeting on 8/14/25, the concern for elopement was no longer noted/had fallen off with no documentation of discussion or determination that Pt 1 was no longer an elopement risk. The findings included: Record review on 8/18/25 at 11:50 AM revealed the hospital admitted Patient #1 on 4/2/25 under an involuntary judicial order with diagnoses including Bipolar Disorder. The admission nursing assessment dated 4/2/25 at 4:04 PM revealed (Pt) #1 had sustained a back and ankle injury after attempting to elope from a previous Behavioral Health hospital prior to transferring to this one. Record review on 8/19/25 at 9:30 AM of the Master Treatment Plan dated 4/4/25 revealed elopement risk had not been documented as a problem; though Pt #1 had orders on admission dated 4/2/25, for Elopement from Facility (EFF) Precautions (an alert for staff that patient is at risk and to keep a close eye out for attempts). There had been nothing documented on the treatment plan about a previous elopement attempt prior to coming to the hospital; nor about the decision to put Pt #1 on EFF Precautions on admission. The finding was verified during an interview with the Assistant Director of Nursing (ADON) on 8/19/25 at 12:21 PM. Review of physician orders revealed EFF precautions were initiated again on 7/18/25 at 7:06 PM after an elopement from the facility to a gas station. On 7/21/25, a treatment plan update/team meeting had been held to address the patient’s elopement on 7/18/25. The short term goal was that Pt #1 would have zero attempts of elopement in the next 30 days, with a target date of 8/21/25. The treatment team noted the patient was placed on EFF precautions and started on nicotine patches. The order for EFF Precautions expired on 7/30/25 at 8:38 AM. During an interview on 8/19/25 at 12:21 PM, the Assistant Director of Nursing (ADON) verified the finding and stated the order had timed out, due to the orders for EFF being good for 3 days and requiring renewal. Further review of updates to the Master Treatment Plan along with a review of Psychiatric, Medical, Social Work, Counselor, and Nursing notes in the medical record revealed no discussion or documentation about ending EFF precautions for Pt #1; though the order EFF precautions had expired/fallen off. A Psychiatry note dated 7/21/25 at 10:37 AM revealed information about Pt 1’s elopement on 7/18/25, with the plan to continue EFF precautions. A Psychiatry note dated 7/27/25 at 8:41 AM revealed Pt #1 was on EFF precautions due to an elopement risk, and “Will continue EFF precautions”. A nursing progress note dated 7/29/25 at 8:50 AM revealed “Pt remains on EFF and made no attempts to leave the lodge”. A note by Behavioral Health Assistant (BHA) #2 dated 7/30/25 documented “Pt status for being on EFF was discontinued at 8:38 AM today...”. A monthly medical Provider note dated 7/31/25 at 3:44 PM documented that the patient’s CT (Computerized Tomography) scan had been canceled and would be rescheduled when the patient was no longer an elopement risk. There was nothing in the medical record to indicate that Psychiatry (the responsible service) or the interdisciplinary team had decided to end the EFF precautions. The Master Treatment Plan had not been updated to include the goals had been met or that the patient was no longer a risk for elopement. The concern for elopement had fallen off the 8/14/25 treatment plan and was no longer included after the order had expired; though there was a notation by the psychiatrist that the patient had made no attempts to leave the facility. There had been no interdisciplinary team meeting documented between 7/21/25 and 8/14/25. The finding that the treatment plan and interdisciplinary team notes did not include a discussion about ending the EFF precautions was verified by the Assistant Director of Nursing (ADON) during an interview on 8/19/25 at 12:46 PM. Review of the policy “Special Treatment Modalities/Observation Levels”, reviewed 5/14/24, revealed the policy defined the process for administering care to patient populations who, because of their behavior/condition, require more intensive monitoring. Under EFF (Elopement From Facility) Precautions was documented, “Any patient who may be at significant risk of leaving the unit/lodge or grounds without permission is restricted to the unit/lodge and placed on EFF precautions until the treatment team or appropriate LPP reassesses the patient’s elopement risk potential and determines the patient is no longer an escape risk...”. Review of the policy “Treatment Team and Treatment Planning”, reviewed 4/28/25, revealed it is the policy of the hospital that each patient admitted has a written individualized plan based on assessed needs. “Treatment planning requires an understanding that each patient is unique and each treatment plan must be based on the individual strengths and needs of the patient. Treatment planning begins on the day of admission and ends when the individual is discharged. Treatment planning is interdisciplinary team collaboration, including the patient. The treatment team is led by the Licensed Prescribing Practitioner (LPP) and at minimum consists of the LPP, the Registered Nurse (RN) and the Social Worker...The Initial Treatment Plan (ITP) is completed within 24 hours of the patient’s admission to the hospital and serves as the guide for care, treatment, and services until the MTP is formulated. The ITP is not intended to be a comprehensive document; however, it should reflect the information that is gathered during initial assessment by the LPP and RN. Identified needs, overall goals, and initial interventions are addressed...”.”

“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: 22198 Based on observation, interviews, review of incident reports, and Governing Body meeting minutes, the Governing Body (GB) failed to ensure legal responsibility for the conduct of the hospital when the hospital failed to ensure that it protected and promoted all Patient’s Rights, kept patients safe from a known impulsive and unpredictable patient (P) 9 admitted under emergency court order for two counts of assault and battery 3rd degree charges following the assault of peers while hospitalized at Medical University of South Carolina (MUSC) Institute of Psychiatry (IOP), and allowed 48 of 48 incidents of assault to staff, patients, and self, from 11/17/24 through 02/11/25 without implementing changes and safety measures. Subsequently assault number 44 occurred on 02/04/25 when flanked by two staff, P9 punched P4 in the face multiple times resulting in P4 seeking emergency medical care and was diagnosed with a nasal bone fracture. The Immediate Jeopardy was identified starting on 12/17/24 when the hospital knew about P9’s history and reason for the admission (assault and battery and under court order).The first unprovoked assault occurred on 12/21/24 and a total of 43 documented reports of P9 assaulting peers, staff, and self on the Lodge and resulted in P4’s being harmed on 02/04/25. The hospital leadership had been notified of the first 43 reported assaults and failed to implement safety measures to protect all patients in the Lodge. On 04/25/25 at 1:16 PM the Chief Executive Officer (CEO), the Medical and Clinical Service Director, and the Chief Nurse Executive (CNE) were notified of Immediate Jeopardy and a copy of the Immediate Jeopardy Template was sent to the CEO at 1:20 PM. An approved Removal Plan was obtained on 04/28/25 at 10:34 AM and the processes put in place by the hospital to remove the immediacy were verified on 04/28/25 at 3:00 PM. The citation remained at Condition level. Findings include: Cross Reference A0049 - The Governing Body did not ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. Cross Reference A0115 Patient’s Rights-The hospital did not protect and promote each patient’s rights. Cross Reference A00145 Patient’s Rights The patients including P4 were not free from all forms of abuse or harassment. Cross Reference A0309 - 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 did not ensure the hospital-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety and that all improvement actions were evaluated.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 22198 Based on video footage observation, interviews, reviews of incident reports, review of personnel files, and policy review, the hospital failed to ensure that all patient’s rights were protected when: 1.The hospital failed to protect patients and staff from 43 incidents of physical abuse by one of twenty-four patients reviewed (Patient (P) 9) and 2. The hospital failed to ensure four of five direct care staff (Registered Nurse (RN) 5 and RN9 and Behavioral Health Assistant (BHA) 6 and BHA 7) had updated training on patient rights; elopement, abuse, neglect, and exploitation. These systemic failures prevented the hospital from having a successful Patient’s Rights program that protected and promoted the Rights of all patients treated at the facility. Findings include: 1.The failure of the hospital to prevent and protect patients from abuse resulted in an Immediate Jeopardy at A0115: Patient Rights. The Immediate Jeopardy was identified as starting on 12/17/24 when the hospital knew about P9’s history and reason for the admission was assault and battery and under court order. The first unprovoked assault occurred on 12/21/24. There were 43 documented reports of P9 assaulting peers, staff, and self on the Lodge with no interventions, resulted in P4 being harmed on 02/04/25. On 04/25/25 at 1:16 PM the Chief Executive Officer (CEO), the Medical and Clinical Service Director, and the Chief Nurse Executive (CNE) were notified of the Immediate Jeopardy and a copy of the Immediate Jeopardy Template was sent to the CEO at 1:20 PM. An approved Removal Plan was obtained on 04/28/25 at 10:34 AM and the processes put in place by the hospital to remove the immediacy were verified on 04/28/25 at 3:00 PM. The citation remained at Condition level. Cross Reference: A0145. 2.The hospital failed to ensure four of five direct care staff (Registered Nurse (RN) 5 and RN9 and Behavioral Health Assistant (BHA) 6 and BHA 7) had updated training on patient rights; elopement, abuse, neglect, and exploitation. Cross Reference: A0144.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 17281 Based on “Performance Improvement Committee Meeting” minutes review, “Governing Body Committee” minutes review, policy review, and interview, the Governing Body failed to ensure the medical staff was accountable to the Governing Body for the quality of care and safety of patients. Specifically, the medical staff failed to report the number of patient-to-patient altercations and collaborate with the Governing Body to decrease altercations. This failure had the potential to affect all patients receiving services at the hospital. Findings include: Review of the undated facility policy titled, “Governing Body Committee” revealed, “ ...The Governing Body Committee shall conduct governing body responsibilities for the Department’s G Werber Bryan Hospital ...and is responsible for implementation of the commitment of the Department of Mental Health to set the framework for supporting safety and quality of patient care, treatment, and services. The Committee promotes performance improvement and provides for organizational management and planning. ...” Review of the facility “Performance Improvement Committee Meeting” minutes dated 02/19/25 under the “Risk Manager Report” for BPH [Bryan Psych Hospital] Adult Civil data revealed, “ ...there were 103 incidents reported in January [2025] for BPH Adult. This is up from the previous month. Out of 103 incidents ...Patient/Patient Altercations (Increased from 21 in December to 34) ...Out of the 103 incidents: 3 required minor first aid ....” Review of the “Governing Body Committee” minutes dated 04/15/25 under the Performance Data revealed, “ ...BPH Adult Civil - 1 patient injury; 1 patient injury the previous quarter ...” Review of the “Governing Body Committee” minutes did not reveal the medical staff reported the number of patient-to-patient altercations to the Governing Body. In an interview on 04/28/25 at 11:00 AM, with Chief Executive Officer (CEO) 38 stated the Governing Body Committee did not receive the number of patient-to-patient altercations data reported at the Performance Improvement Committee meetings. CEO 38 stated members of the medical staff attend the Performance Improvement Committee meetings, but did not provide the patient-to-patient altercation data to the Governing Body Committee. In an interview on 04/28/25 at 11:00 AM, Medical and Clinical Service Director (MCSD) 37 stated members of the medical staff were aware of patient-to-patient altercations because the incidents were discussed during morning huddles. MCSD 37 stated the patient-to-patient altercation data was not discussed during Governing Body Committee meetings. In an interview on 04/28/25 at 11:15 AM, Chief Nursing Executive (CNE) 3 stated patient to patient altercations are discussed during morning huddles which include nursing staff and members of the medical staff. CNE 3 stated the discussions are not documented and the information is not included in the Governing Body Committee meetings.”

“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: 22198 Based on reviews of personnel files, interviews and review of hospital policies, the hospital failed to ensure four of five direct care staff (Registered Nurse (RN) 5, RN9, Behavioral Health Assistant (BHA) 6, and BHA 7) had updated annual training on patient rights; elopement, abuse neglect and exploitation. This failure to ensure that staff are trained and competent to perform their duties to protect and promote each Patient’s rights, places all patients receiving care in this hospital at risk for not receiving care in a safety setting. Findings include: During a personnel file review for the direct care staff the following was identified: RN5 was hired on 09/17/2000; review of RN5’s training and competency for the 2024/2025 training year, revealed RN5 did not have training in 2024/2025 for MAPS [Managing Agitation in the Psychiatric & Long-Term Care Setting], Patient’ Rights. The last recorded training and competency was in 2023. The training and competency for Restraint/Seclusion and Elopement was last completed in 2022. There was no documented evidence in RN5’s personnel file of receiving training and competency on Abuse/Neglect/Exploitation. RN9 was hired on 10/02/2022; review of RN9’s personnel file did not reveal training and competency testing for Elopement, Patient’s Rights’ Code of Conduct and Abuse/Neglect/Exploitation. BHA6 was hired on 05/02/2022; review of BHA6’s personnel file failed to reveal training and competentency for Elopement training, and Restraint/Seclusion training was last completed 01/2024. BHA7 was hired on 03/04/2024; review of BHA7’s personnel file failed to reveal training and competencies for Restraint/Seclusion, Patient’s Rights, and Elopement. The MAPs annual training and competency was due in March of 2025 but was not completed. During an interview on 04/22/24 at 3:10 PM, the Primary Source Verification Coordinator 23 confirmed RN5, RN9, BHA6, and BHA7’s personnel files training and competencies were missing or were outdated. At the end of the interview, Primary Source Verification Coordinator 23 was provided with an opportunity to bring any additional training and competencies forward that may have been misfiled. Primary Source Verification Coordinator 23 confirmed the personnel files were up to date and did not include additional information. On 04/24/25 1:31 PM during an interview with Assistant Director of Nursing (ADON) 1 after providing the Employee Education policy, ADON1 confirmed per hospital policy, the identified employees had not completed their annual/updated training and competencies per policy and the nursing leadership was aware of it. ADON1 stated “we have some work to do.” Review of the hospital policy titled, “Employee Education” dated 04/05/23 revealed, “This directive provides educators/trainers and individual employees with information that will assist them in achieving expected standards of performance related to orientation and training. ... Each newly employed staff member (includes but not limited to regular staff, contracted staff, agency staff, volunteers, students) is provided orientation ... Ongoing education is provided to meet annual mandatory training and continuing education needs. ... Annual Mandatory Training is accomplished in the individual’s hire month. Staff participate in ongoing education and training to maintain or increase their competency. This will be accomplished by computerized online learning modules (staff competence is assessed and documented electronically, classes and newsletters. These topics include but are not limited to: ... Patient Rights (direct care staff) ... Abuse/Neglect (direct care staff) ... Restraint and seclusion policy/procedures (direct care staff) Patient Safety (direct care staff and clinical support staff) Reporting unanticipated adverse events (direct care staff and clinical support ... Early Recognition intervention Criteria (ERIC).””

“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: 22198 Based on review of medical record and incident reports, observation of video footage, interviews, and review of policies, the hospital failed to ensure it kept all patients (P) safe when it allowed P9, admitted under emergency order for two counts of assault and battery 3rd degree charges following the assault of peers while hospitalized previously at Medical University of South Carolina( MUSC) Institute of Psychiatry (IOP), to continually assault patients, staff, and self at this hospital from 12/21/24 through 02/09/25. After 43 of the 48 reported assaults by P9, while flanked by two staff, P9 punched P4 in the face with a closed fist multiple times resulting P4 requiring emergency medical care at the emergency department for a fractured nasal bone. Cross Reference: A0043 Governing Body and A0115 Patient Rights. Findings include: During the entrance conference on 04/22/25 at 9:06 AM with the hospital leadership all incidents reports to include all incidents including all forms of abuse, neglect, and misappropriation were requested. Review of P9’s medical record revealed under the “Psychosocial Assessment” dated 12/20/24 at 1:06 PM revealed, “[P9] was admitted to BPH [Bryan Psychiatric Hospital] Adult from Sheriff Al Cannon Detention Center on 12/17/24 by emergency order. ... The admission interview was ended after 17 minutes due to [P9’s] unwillingness to engage in a conversation with any staff members. [P9] was escorted to Lodge by LPP and Public Safety.” Chief Complaint was documented as “Mania/Hypomania, Psychosis.” Under the “Reason for Admission: ...by emergency order for acute psychiatric stabilization. [He/she] has been detained at the detention center since 11/22/24 on two counts of assault and battery 3rd degree charges following the assault of peers while hospitalized at MUSC [Medical University of South Carolina] IOP [Institute of Psychiatry]. ...exhibited acute symptoms of psychosis, prompting emergency papers and transportation to MUSC on 11/07/24 for psychiatric care. While at MUSC, [P9] assaulted nursing staff, resulting in [him/her] returning to Al Cannon. Mental Health providers at the detention center have reported that the patient has demonstrated a cycle of being jailed, transported to MUSC, discharged to the community, and then re-jailed within a matter of days due to noncompliance and homelessness. This cycle has reportedly persisted for the past six months, ...” The Initial Treatment/Care Plan dated 12/20/2024 included medications but did not include safety considerations to address P9’s impulsive and unpredictable assaults. During an interview on 04/24/25 at 1:31 PM, Assistant Director of Nursing (ADON) 1 confirmed that from P9’s admission on 12/17/24 the hospital was aware of P9’s impulsive and unpredictable attacks but it was not included in P9’s initial Interdisciplinary Treatment Plan (IDT). During an interview and review of the incidents related to P9 on 04/24/25 at 1:41 PM, the ADON 2 reviewed the full timeline of P9’s incidents from admission on 12/17/24 through discharge on 02/11/25 and verified that 43 of the 48 incidents occurred prior to 02/04/25 when P9 assaulted P4 that resulted in injury. The assault incidents towards other patients related to P9 as follows: “1. On 12/21/24 (not timed) Attacked [unidentified] peer unprovoked in the day area on Lodge. 2. On 12/27/24 (not timed) Attacked two peers hitting peers in the head in the Day area on Lodge. 3. On 01/01/25 at 10:30 AM Patient hit peer unprovoked in the face in Day area on Lodge. 4. On 01/01/25 at 9:20 PM Patient struck multiple peers unprovoked [four unidentified Patients were struck] on Lodge. 5. On 01/02/25 at 12:03 AM, Patient slapped [unidentified] peer on the left side of the face in POD on Lodge. 6. On 01/02/25 at 8:08 AM Pt [patient] attacked peer [unidentified] and several staff members unprovoked outside break room on Lodge F. 7. On 01/02/25 at 1:35 PM Pt attacked peer [unidentified] unprovoked in the Day room area. 8. On 01/02/25 at 2:04 PM Pt struck peer unprovoked in Day area. 9. On 01/02/25 at 2:05 PM Pt struck peer in POD Atrium hallway. 10. On 01/02/25 at 2:08 PM Pt struck peer unprovoked in Day area on Lodge. 11. On 01/03/25 at 6:55 AM Pt assaulted 6 patients [not identified], 3 Behavioral Health Assistants [BHAs] and a Public Safety Officer [PSO] on Lodge. 12. On 01/03/25 at 10:45 PM Pt. assaulted 3-patients [not identified] in the Day area on Lodge. 13. On 01/04/25 at 7:41 AM Pt assaulted 3-patients [unidentified] on Lodge. 14. On 01/04/25 at 12:32 AM Pt. assaulted 4-Patients on Lodge Bedside and Day area. 15. On 01/05/25 at 10:18 PM Pt assaulted peer [not identified] while sleeping in POD 16. On 01/05/25 at 2:13 PM Pt Physically aggressive towards several staff and one patient [not identified] in POD. 17. On 01/07/25 at 6:10 AM Pt Physically aggressive towards peers [not identified] and staff 18. On 01/11/25 at 2:15 PM Pt attacked one peer [not identified] unprovoked in the Day area. 19. On 01/14/25 at 9:40 AM Pt attacked 2-patients [not identified] in the Day area. 20. On 01/17/25 at 3:25 PM Pt struck peer [not identified] with closed fist on Lodge. 21. On 01/25/25 at 4:28 PM, after being released from seclusion, Pt attempted to hit another peer [not identified] in POD. 22. On 01/25/25 at 12:30 PM Pt attacked a staff member and a peer [not identified] hitting peer on the head in the seclusion area. 23. On 01/27/25 at 6:00 PM Pt ran out of quiet room into Atrium and hit peer. Peer hit back. 24. On 01/29/25 at 1:55 PM POD 1 Pt hit peer [not named] in the head with a closed fist. Peer hit back. 25. On 02/04/25 at 10:10 AM Pt hit peer [identified as P4] in the face several times near Atrium on Lodge . After P4 was identified to have a nasal fracture from an Emergency Department [ED] on 04/05/25, there were additional incidents before P9 was transferred to a Forensic unit: 26. On 02/07/25 at 1:43 PM Pt punched peer [P3] in the head and attacked 2-Social Workers in the seclusion room hall. 27. On 02/08/25 at 4:00 PM Pt abuse to self 28.On 02/09/25 at 4:12 PM blue discoloration around Pt finger from punching wall with fist.” Review of the video footage from 02/04/25 on Lodge of the incident between P9 and P4 with Chief Nursing Executive (CNE) 3 and ADON1 and ADON 2 revealed, visualization of two staff Program Manager License Professional Counselor (LPC) 24 and Activity Director 34 flanking each side of P9 while walking down the Atrium hallway. P4 is barely visible on the video footage because P4 was standing behind a Social Worker who was talking with a seated patient. Without provocation P9 lunged at P4 and punched P4 in the face more than once until staff were able to stand between P4 and P9. Once P9 could not get to P4, P9 just walked off down the hallway (to P9’s room identified in a staff interview). During an interview on 04/25/25 at 11:00 AM, CNE3 stated that the hospital tried protecting the other patients by placing P9 in Ambulatory restraints but P9 could get out of the adult ambulatory restraints because he/she was so small. CNE3 stated the IDT recommended adolescent Ambulatory restraints for P9 that the physician ordered, however those did not work either. Review of the hospital’s policy titled, “Patient Rights and Responsibilities” dated 12/21, revealed “This directive establishes policies for the support and protection of the fundamental human, civil, constitutional, and statutory rights of the individual patient receiving treatment within the Division of Inpatient Services (DIS). ... Care and individualized treatment are conducted in a courteous, professional manner consistent with accepted standards of clinical practice and with respect for human dignity and the health and safety of the patient. ... Notifications with primary care practitioners and entities are in accordance with all applicable federal and state laws and regulations ... following instructions, policies, rules, and regulations in place that support quality care and a safe environment for all.” Review of the hospital policy titled “Identifying and Reporting Suspected Abuse/Neglect/Exploitation” dated 11/23, revealed, “ ... Physical Abuse: the intentional inflicting of or allowing to be inflicted, physical injury on a person by an act or failure to act. Physical abuse includes, but is not limited to slapping, hitting, kicking, biting, choking, pinching, ... Any physical injury that results in substantial harm to the patient or the genuine threat of substantial physical harm is also considered physical abuse. ... DIS [Division of Inpatient Services] employees who witness, discover, or are notified of abuse, neglect or exploitation are expected to: 1, report the incident as outlined above 2. take action to protect, comfort and assure treatment of the patient 3. initiate the Unusual Occurrence Report The Nurse Manager in charge is expected to: 1. assess the patient and assist in providing immediate care and follow-up 2. obtain any additional pertinent information 3. document observations in the clinical record ... The treatment team develops a treatment plan for the patient identified as a victim of abuse or neglect that includes appropriate interventions to assist the patient to cope with abuse episodes.””

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) 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: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 17281 Based on facility policy review, “Performance Improvement Committee Meeting” minutes review, and interview, the Governing Body failed to assume responsibility and collaborate with the Performance Improvement Committee to ensure performance improvement efforts for patient safety were implemented. Specifically, the Governing Body failed to review facility performance improvement patient to patient altercation reports and provide guidance to the Performance Improvement Committee to improve patient safety. This failure had the potential to affect all patients receiving services at the hospital. Findings include: Review of the facility policy titled, “Performance Management and Improvement Plan” dated 10/2024 revealed, “ ...At specific intervals, reviews facility performance reports, addressing opportunities for improvement, and offering suggestions and/or support as indicated ...Establishes performance improvement priorities in collaboration with appropriate staff and Governing Body Committee ...Allocates resources to improve organization performance ...” Review of the facility “Performance Improvement Committee Meeting” minutes dated 02/19/2025 under the “Risk Manager Report” for BPH [Bryan Psych Hospital] Adult Civil data revealed, “ ...there were 103 incidents reported in January [2025] for BPH Adult. This is up from the previous month. Out of 103 incidents ...Patient/Patient Altercations (Increased from 21 in December to 34) ...Out of the 103 incidents: 3 required minor first aid ....” Review of the “Governing Body Committee” minutes dated 04/15/2025 under the Performance Data revealed, “ ...BPH Adult Civil - 1 patient injury; 1 patient injury the previous quarter ...” Review of the “Governing Body Committee” minutes did not reveal the patient-to-patient data reported in the “Performance Improvement Committee Meeting” on 02/19/2025 was reported to the Governing Body or that the Governing Body collaborated with the Performance Improvement Committee to decrease the number of patient-to-patient altercations. In an interview on 04/28/2025 at 11:00 AM, Chief Executive Officer (CEO) 38 stated the Governing Body Committee receives data on the number of patient injuries resulting from patient-to-patient altercations from the Performance Improvement Committee, but the number of patient-to-patient altercations that occur each month was not included for Governing Body Committee discussion. In an interview on 04/28/2025 at 11:30 AM, Performance Improvement Liaison (PIL) 43 stated patient to patient altercation data was an active initiative and was reviewed every month by the Performance Improvement Committee. PIL 43 stated the Performance Improvement Committee received patient to patient altercation data during their monthly meetings and the committee discussed what action was currently being done to decrease altercations and if new actions needed to be initiated if established benchmarks were not met. PIL 43 stated the Governing Body Committee received data on the number of patient injuries that result from patient-to-patient altercations, but not the number of patient-to-patient altercations that occurred each month. PIL 43 stated the Performance Improvement Committee had not received guidance and had not collaborated with the Governing Body to decrease patient to patient altercations.”