Three Rivers Behavioral Health

“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: 28883 Based on record reviews, interviews, and policy review, the hospital failed to ensure nursing staff provided appropriate services to mitigate elopement risk for 11 of 11 patients reviewed for elopement; Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12. The findings included: Cross refer to A-398 Supervision of Contract Staff: Nursing staff failed to perform/document a nursing assessment/check for injury, and/or a contraband check upon return from elopement for Patients #3, #4, #5, #7, #10, and #11. Nursing staff failed to ensure adequate supervision/restrictions were in place to prevent elopement/re-elopement, and/or failed to ensure recommendations made to prevent elopement by the interdisciplinary team had been followed for Patients #1, #2, #4, #8, #9, #10, #11, and #12.”

“Special Medical Record Requirements CFR(s): Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals The medical records maintained by a psychiatric hospital must permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution. This Condition is not met as evidenced by: 28883 Based on record reviews, interviews, and policy review, the hospital failed to ensure the medical record for Patients #5, #7, #8, #10, and #11, 5 of 10 patients reviewed who had eloped from the hospital; included enough information to show that the facility had been aware of the status of the patient and had adequate plans and interventions placed to prevent elopement. The findings included: Cross refer to A-1640, Treatment Pan.”

“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 reviews, the hospital failed to ensure a safe environment for 10 of 11 patients reviewed for elopement, Patients #2, #3, #4, #5, #7, #8, #9, #10,#11, and #12. Hospital staff failed to ensure windows and doors had been properly secured with mechanisms in place to prevent elopement, allowing Patients #2, #3, #8, #9, #11, and #12 to leave the premises. Hospital staff failed to ensure contraband checks had been completed and documented upon return from elopement to ensure items would not be brought into the hospital that could be harmful to others; for Patients#2, #3, #4, #5, #7, #10, and #11. Hospital staff failed to ensure adequate supervision/restrictions were in place to prevent elopement/re-elopement and/or failed to ensure recommendations made to prevent elopement by the interdisciplinary team had been followed for Patients #8, #10, #11, and #12. The findings included: Record review on 8/5/25 at 12:28 PM revealed Pt 7 was involuntarily admitted to the hospital on 3/1/25 with diagnoses including Schizophrenia. Review on 8/5/25 at 1:33 PM of the hospital’s Incident Report revealed that on 3/5/25 at 6:06 PM, the patient had eloped and was gone for less than 30 minutes. Comments by the Risk Manager on the report included that a Code white had been called for the patient on the roof. The patient slid down off the side of the roof after staff told him/her to come down. Patient 7 slid off the side of the the roof and kept trying to get away. Patient was able to run away after staff attempted to return him/her to the building. The Nursing Supervisor called the police to bring the patient back to the unit. Review of the medical record revealed there had not been a contraband check completed for Pt 7 on his/her return to the facility after the elopement. During an interview on 8/7/25 at 3:20 PM, The Chief Nursing Officer (CNO) verfied the finding and stated that nursing staff should have completed and documented a contraband check after the elopement. Record review on 8/5/25 at 2:00 PM revealed Patient 8 had been involuntarily admitted on 3/11/25 with diagnoses including Severe Major Depression. Orders on admission were for every 15 minute observation. Review of the hospital’s Incident Report revealed that on 3/18/25 at 8:15 PM, Pt 8 had eloped out of room 203 with three other (youths). The window was not locked. They (the other youths) were found on the roof, but Pt 8 was still missing. Review of the camera footage by the Risk Manager revealed patients were performing hygiene and were able to slide a window open that was not properly installed by an outside vendor. A nursing note dated 3/18/25 (not timed) revealed the patient eloped from the unit along with 3 other (youths) out of a breached window in one of the rooms around 8:00 PM. Orders dated 3/18/25 at 5:00 PM revealed the patient had been restricted to his/her room at the time of the elopement, which per the medical record was room 300. Review of the observation sheet revealed documentation that Pt 8 was in her/his bedroom on 3/18/25 at 7:45 PM, but was in room 203 when s/he had eloped. Pt 8 had not been restricted to his/her room as ordered and was in the day room on 3/18/25 at 5:15 PM, 5:30 PM, 6:00 PM. 6:15 PM, and 7:15 PM. Review of the Master Treatment Plan Addendum dated 3/19/25 at 9:00 AM revealed the interdisciplinary team meeting was held due to the patient elopement. Recommendations included that the patient be placed on elopement precautions and unit restriction. However, review of the medical record revealed there had been no orders placed for the patient to be on unit restriction (the patient had current orders that had been placed prior to the elopement for room restriction). Patient 8 had orders placed for elopement precautions (an alert for staff to be on the lookout for attempts or behaviors that indicated elopement) upon return to the hospital on 3/19/25 at 4:00 AM. The interdisciplinary team did not implement new intervention or increased supervision for Pt 8 after the elopement. During an interview on 8/7/25 at 3:37 PM, the CNO verified Pt 8 had eloped from room 203 which was not his/her room; and that the patient was supposed to be on room restriction at the time of the elopement. After reviewing the physician orders for room restriction (dated 3/18/25 at 5:00 PM) and the observation record, the CNO verified that on 3/18/25, the nursing staff had documented the patient had been in other areas of the unit to include the dayroom and hallway after orders had been placed for Pt 8 to be on room restriction. Record review on 8/6/25 at 9:47AM revealed Pt 9 had been involuntarily admitted on 3/13/25 with diagnoses including Major Depression. Review of an Incident Report revealed Pt 9 had eloped on 3/18/25 at 8:15 PM through a window that had a faulty repair by an outside vendor. According to the report, Pt 9 along with 3 other youths escaped out of room 203 by sliding the window open. Found on roof. Pt 9 had been returned back to the unit on 3/18/25 at 9:30 PM. Camera footage revealed the patients had been performing hygiene and were able to slide a window open that was not properly installed by an outside vendor. Stacked two tables on top of each other and eloped off of the roof. During an interview on 8/7/25 at 10:40 AM, House Supervisor #5 stated that prior to the elopement, the window in room 203 had been busted, and an outside vendor had made a repair. However, when the repair had been made, apparently the window had not been installed correctly because the patients were able to get out. According to the House Supervisor, the windows normally don’t open. During an interview on 8/7/25 at 10:01 AM, the Maintenance Supervisor stated that the Director of Plant Operations had determined that the window in room 203 had not been properly installed by the glass vendor who had come to repair the window, thus allowing the adolescents to escape through the window. Record review on 8/6/25 at 11:20 AM revealed Pt 10 had been involuntarily admitted on 3/27/25 with diagnoses including Psychosis. Orders on admission were for every 15 minute observation. An Incident Report revealed that on 4/3/25 at 8:10 AM, Pt 10 had eloped after going into another patient’s room, hitting a window which quickly shattered, and exited out through the window. Apparently Pt 10 was able to scale the outside perimeter and eloped off facility grounds. Pt 10 was found at local gas station and returned to facility. A contraband search had not been documented for Pt 10 after returning to the facility from the gas station. During an interview on 8/6/25 at 3:30 PM, the CNO was asked what intervention(s) had been put into place as a result of the patient’s elopement. The CNO stated that they had ordered elopement precautions (an alert for staff to be on the lookout for elopement type behaviors or attempts), and that unit restriction had been recommended during the master treatment plan update on 4/4/25. The CNO verified there had been no orders placed for Pt 10 to be on unit restriction related to the elopement. The CNO verified that on 4/5/25, when the orders were put in for Pt 10 to be on unit restriction (for an hour and a half); it was due to Pt 10’s refusal to stop play fighting with a peer. During an interview on 8/7/25 at 9:38 AM, and after reviewing the record; Mental Health Technician (MHT) #7 verified the finding that a contraband check should have been documented but wasn’t. Record review on 8/6/25 at 1:05 PM revealed the hospital involuntarily admitted Pt 11 on 3/6/25 with Major Depressive Disorder. Orders on admission were for every 15 minute observation. An Incident report revealed that on 3/7/25 at 7:30 PM, Pt 11 was standing at the nurses desk and went down the hallway as they were waiting for the nurse to confirm a doctors order. The patient(s) noticed the door was unlocked and were standing outside of door. A nurse and another staff member attempted to get the patients to come back inside and patients ran. Code White was called and Registered Nurse and staff member went outside to look for patients. Review of the camera footage by the Risk Manager revealed the patients pushed the door open and eloped. The observation record revealed Pt 11 was back to the unit on 3/7/25 at 8:30 PM. There was nothing documented in the medical record about the patient’s return to the facility to include a time, how the patient had been returned; nor a nursing assessment for any injury or a contraband search upon return to the unit. No interventions to prevent re-elopement had been documented as a result of the elopement on 3/7/25. No orders had been placed for elopement precautions, nor had any additional orders been placed for increased supervision. Review of nursing documentation revealed Pt 11 eloped again on 3/10/25 out a door. An “Updated Incident report” revealed that on 3/10/25 at 12:35 AM, Pt 11 eloped while waiting on an ambulance for pickup to go back to the emergency department. The report documented, “Patient eloped previously in similar manner”. Patient was found near a hotel. Escorted back to the unit in handcuffs via law enforcement personnel at 12:50 AM. According to the nursing documentation in the “Updated Incident report”, interventions for this episode included elopement precautions had been added. However, a review of physician orders revealed no orders had been documented for elopement precautions. A contraband search had not been documented on return to the unit on 3/10/25. Review of the Master Treatment Plan dated 3/7/25 at 11:00 AM (prior to the first elopement), revealed the patient as an elopement risk; but no interventions had been documented. There was no update to the master treatment plan documented after the elopement on 3/7/25. During an interview on 8/7/25 at 2:48 PM, the CNO verified the above findings. When asked, the CNO verified there had not been any interventions added related to the elopement on 3/7/25; to include orders for for elopement precuations. The CNO verified that the initial master treatment plan signed before the elopement included the patient was an elopement risk, but no recommendations for interventions had been given. There had been no update to the master treatment plan after the elopement on 3/7/25. The hospital had not added precautions or increased the patient’s observation level after the elopement. The CNO verified nursing had documented on 3/10/25, after the 2nd elopement; that elopement precautions would be added but no order for this had been placed. The CNO verified that a contraband search had not been documented after the elopements on 3/7/25 and 3/10/25. Record review on 8/7/25 at 1:00 PM revealed Pt 12 had been involuntrily admitted on 3/5/25 with Major Depressive Disorder and Post Traumatic Stress Disorder. Orders on admission were for every 15 minute observation. Review of the “Updated Incident Assessment” revealed that on 3/7/25 at 7:30 PM, Pt 12 and (Pt 11) were standing at the desk and went down the hallway as they were waiting for the nurse to confirm a doctors order. The patients noticed the door was unlocked and were standing outside of the door. When staff tried to get them back inside they ran and eloped. Review of the Standardized Intake Assessment dated 3/5/25 (on admission), revealed Pt 12 had a history of elopements. The nursing admission assessment documented that the patient was not an elopement risk. Review of the Master Treatment Plan signed prior to the elopement on 3/7/25 at 11:00 AM; revealed elopement risk had been added to the master treatment plan, but no interventions listed. A physician’s Daily progress note dated 3/8/25 at 3:05 PM revealed “Patient states that (she/he) ran off last night “because (she/he) saw an open door.” Review of a Daily Nurse Progress Note dated 3/7/25 at 10:57 PM revealed “Pt transferred to adolescent unit from flex after elopement from facility shortly after 7:00 PM. Pt was escorted back in police custody”. According to the observation record, the patient was back on the unit at 8:32 PM. There were no orders documented that placed the patient on elopement precautions upon return to the facility. During an interview on 8/7/25 at 2:39 PM, the CNO stated that on admission during the initial nursing assessment they ask patients if they want to elope or are at risk, and if they say they aren’t, they wouldn’t put her/him on elopement precautions. Upon reviewing the master treatment plan and noting that the interdisciplinary team (IDT) had identified the patient as an elopement risk on 3/7/25 at 11:00 AM, the CNO was asked what would have happened during that IDT meeting. According to the CNO, the doctor was there at the meeting. They wouldn’t have needed to call the doctor for orders. If the team had determined the need for elopement precautions, the doctor would give the order for it and and the nurse would put it in for elopement precautions. The CNO verified s/he didn’t see an order in the medical record for elopement risk or precautions on 3/7/25 after the meeting or prior to elopement. The CNO verified they did not put in an order for elopement precautions (EP) after Pt 12 eloped and stated they should have. According to the CNO, once they do put in an order for EP, it depends on the patient; but what it could possibly mean is for that patient, socks are worn instead of shoes. Interventions for elopement precautions vary from patient to patient; and the staff decides what you could do to stop the elopement risk. When EP is put in as an order, it is a warning for staff to watch out. When asked about the door the patients escaped through; the CNO stated the door was supposed to be locked. During an interview on 8/8/25 at 10:30 AM, the Chief Executive Officer (CEO) stated the magnetic mechanism on the door had not been working correctly and did not cause the door to close and lock allowing the patients to elope. 52713 Medical record review on 8/6/25 at 10:35 AM revealed Patient (P)2 was admitted to the facility on 3/1/25 as an involuntary admission. The facility’s incident report indicated that P2 and P3 both eloped on 3/4/25 at 12:30 PM from a side door that was not properly latched. There is no documentation showing that a contraband search was conducted for P2 once he/she returned to the facility. Medical record review on 8/6/25 at 12:50 PM revealed P3 was admitted to the facility on 2/25/25 as an involuntary admission. Further review of the medical record did not reveal any documentation of a contraband search conducted for P3 once he/she returned to the facility after the elopement. Medical record review on 8/6/25 at 11:14 AM revealed P4 was admitted to the facility on 4/28/25 as an involuntary admission. Review of the facility’s incident report revealed P4 was ouside on 5/9/25 at 4:05 PM, when s/he climbed a tree and gained access to the rootop and eloped. P4 was brought back by the police. Review of the medical record did not display any documentation showing that a contraband search was conducted on P4 once he/she returned to the facility. Medical record review on 8/6/25 at 2:47 PM revealed P5 was admitted to the facility on 3/12/25 as an involuntary admission. Review of the facility’s incident report revealed P5 was outside on the patio on 3/15/25 at 10:45 AM when s/he jumped the fence and eloped before staff could get to her/him. Review of the medical record did not display any documentation showing that a contraband search was conducted or documented for P5 once he/she returned to the facility. While conducting a separate record review with the Chief Nursing Officer (CNO) on 8/7/25, starting at 9:39AM, he/she confirmed that there was no documentation of contraband search located in the medical records of P2, P3, P4, and P5. During an interview with Mental Health Technician (MHT) 3 on 8/6/25 at 3:58 PM, he/she stated that contraband checks are to be performed at the time of admission and anytime that a patient leaves the facility for any reason. MHT3 identified that any member of the facility staff can do these checks. During an interview with MHT4 on 8/6/25 at 3:37 PM, he/she identified that contraband searches are to be done when the patients return to the facility after eloping. He/she further elaborated by mentioning that licensed staff or a MHT are allowed to conduct the contraband searches. During an interview with Behavioral Interventionist (BI) on 8/8/25 at 10:07AM, it was revealed that some of BI’s responsibilities include Crisis Prevention Intervention (CPI) and trainings regarding contraband searches. He/she verified that a patient has a contraband search performed during an admission and anytime a patient leaves the facility for any reason. Review of the hospital policy, “Contraband Search Guidelines”, reviewed October 2024, identified that all patients should have a noninvasive body search conducted by facility staff on admission and upon return from therapeutic passes or other trips outside the facility unsupervised by staff. Document the search in the patient’s medical record to include the date and time of the search, persons conducting the search, the reasons for the search, the extent of the search and the results. Review of the hospital policy, “Elopement Response Risk Management”, reviewed October 2024, revealed that risks of elopements are minimized by conducting thorough assessments, maintaining a secure facility, and conducting monitoring and observation. Responses to elopements that do occur emphasize safety of the patient and staff, attentiveness to the mental and legal status of the patient, and appropriate notifications. Information included that if the patient returns to the unit, a search should be made of the patient and belongings and should be documented in the medical record. A registered nurse should assess and document the patient’s mental status and condition upon arrival to the unit. Upon the patient’s return, a registered nurse should implement elopement precautions as ordered by the physician or initiated by nursing order as per facility policy. Review of the hospital policy, “Special Precautions-Heightened Level of Observation”, revised April 2025, revealed information that it is the policy of the hospital to provide a safe and secure environment for patients during their hospitalization. All patients will be routinely observed in compliance with physicians’ orders and prescribed protocols. Patients who need an increased level of observation and precaution for other reasons, such as an elopement risk will be followed per related policies and procedures. A Special Precaution is defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation ...An order for the appropriate level of precautions should be documented in the physician’s order section of the medical record, and the Precaution should be initiated by the charge nurse or designee. When special precautions are initiated by nursing order, the nurse should contact the physician as soon as possible to notify the need for precautions.”

“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: 28883 Based on record reviews, interviews, and policy reviews, nursing staff failed to provide nursing services to ensure patient needs were met for 11 of 11 patients reviewed for elopement, Patients #1, #2, #3, #4, #5, #7, #8, #9, #10, #11 and #12. Nursing staff failed to perform/document a nursing assessment/check for injury, and/or a contraband check upon return from elopement for Patients #3, #4, #5, #7, #10, and #11. Nursing staff failed to ensure adequate supervision/restrictions were in place to prevent elopement/re-elopement, and/or failed to ensure recommendations made to prevent elopement by the interdisciplinary team had been followed for Patients #1, #2, #4, #8, #9, #10, #11, and #12. The findings included: Record review on 8/5/25 at 12:28 PM revealed Pt 7 was involuntarily admitted to the hospital on 3/1/25 with diagnoses including Schizophrenia. Orders on admission were for every 15 minute observation. A nursing/physician order dated 3/5/25 at 7:00 PM revealed a Code White (Elopement) had been called due to the patient on the roof. Review of nursing documentation in the medical record revealed there had been nothing documented about the elopement in the nursing notes. There was nothing documented about the events surrounding the elopement, or timeframes of what had happened to include when or how Pt 7 had been returned to the facility. Nursing staff failed to document an assessment of the patient for any injury upon return, nor a contraband search to show the patient had not returned with any items that could be harmful to him/herself or others. Review on 8/5/25 at 1:33 PM of the hospital’s Incident Report (not part of the medical record) revealed that on 3/5/25 at 6:06 PM, the patient had eloped and was gone for less than 30 minutes. Comments by the Risk Manager on the report included that the patient slid down off the side of the roof after staff told him/her to come down. Patient 7 slid off the side of the the roof and kept trying to get away. Patient was able to run away towards an adjacent hospital after staff attempted to return him/her to the building. The Nursing supervisor called the police to bring the patient back to the unit. Review of camera footage by the Risk Manager revealed the patient had jumped on the covering in the main courtyard area and eloped. During an interview on 8/7/25 at 3:20 PM, the Chief Nursing Officer (CNO) was asked if there was any nursing documentation of what happened with the elopement for Pt 7 in the medical record. Review of the record with the CNO revealed no nursing documentation nor an “updated incident report” (nursing documentation that would include incidents and actions taken) which included information about the events of the elopement on 3/5/25. The CNO verifed there was no documentation of an assessment of the patient on return from elopement nor of a contraband search. The CNO verified these were supposed to have been documented by nursing. . Record review on 8/5/25 at 2:00 PM revealed Patient 8 had been admitted on 3/11/25 with diagnoses including Severe Major Depression. Orders on admission were for every 15 minute observation. Review of the hospital’s Incident Report revealed that on 3/18/25 at 8:15 PM, Pt 8 had eloped out of room 203 with three other boys/girls. Pt is still missing at this time. Review of the camera footage by the Risk Manager revealed patients were performing hygiene and were able to slide a window open that was not properly installed by an outside vendor. They had stacked two tables on top of each other and eloped off of the roof. Nursing documentation in the medical record revealed an Updated Incident Assessment dated 3/18/25 at 8:15 PM. It included information that Patient 8 went to room 203 with a plan to escape with three other boys/girls. They were discovered on the roof top and managed to escape the building. Nursing documentation included that the patient had been found later at a boy/girlfriend’s house and was on the way back to the unit. Pt 8 was returned to the unit on 3/19/25 at 12:15 AM by police. A physician’s order dated 3/18/25 at 5:00 PM revealed the patient had been restricted to her/his room at the time of the elopement; with the patient observation record indicating s/he had been in the bedroom on 3/18/25 at 7:45 PM; but the patient was in a different room when s/he had eloped at 8:00 PM. Pt 8 had not been restricted to her room as ordered and was in the day room on 3/18/25 at 5:15 PM, 5:30 PM, 6:00 PM. 6:15 PM, and 7:15 PM. There had been no new or additional interventions implemented for Pt 8 as a result of the elopement. During an interview on 8/7/25 at 3:37 PM, the CNO verified Pt 8 had eloped from room 203 which was not his/her room. After reviewing the physician orders for room restriction (dated 3/18/25 at 5:00 PM) and the observation record, the CNO verified that on 3/18/25, the nursing staff had documented the patient had been in other areas of the unit to include the dayroom and hallway while having orders for room restriction. During an interview on 8/6/25 at 4:22 PM, reviewed the incident report and stated s/he had worked on 3/18/25, from 11:00 PM to 7:00 AM and was there when Pt 8 returned to the unit on 3/19/25 at 12:15 AM. The nurse verified the patient should have been in his/her own room, 300 and not in another patient’s room when s/he escaped. When asked how staff enforced room restrictions, Registered Nurse (RN) #7 stated the patient could have been noncompliant; and added there is no way for us to enforce room restriction. Record review on 8/6/25 at 9:47AM revealed Pt 9 had been involuntarily admitted on 3/13/25 with diagnoses including Major Depression. Orders on admission were for every 15 minute observation. Review of an Incident Report revealed Pt 9 had eloped on 3/18/25 at 8:15 PM through a window that had a faulty repair by an outside vendor. According to the report, Pt 9 along with 3 other girls/boys escaped out of room 203 by sliding the window open. Found on roof. Pt 9 had been returned back to the unit on 3/18/25 at 9:30 PM. Review by the Risk Manager of camera footage revealed the patients had been performing hygiene and were able to slide a window open that was not properly installed by an outside vendor. Stacked two tables on top of each other and eloped off of the roof. Nursing documentation on an “Updated Incident Assessment” revealed that on 3/18/25 at 8:00 PM, Pt 9 and 3 others decided to escape out the window when they realized it was unlocked. Intervention(s) used to de-escalate the patient- 1:1 processing, increased observation and patient moved to the flex unit. An order was documented for 3/18/25 at 11:00 PM for the patient to be transferred to the flex unit, which did happen. A Master Treatment Plan addendum dated 3/19/25 at 9:00 AM for elopement included interventions of Time Out, verbal de-escalation, unit restriction, and elopement precautions. Review of physician’s orders revealed an order had not been placed for increased supervision (as noted on the Updated Incident Assessment) or for unit restriction (as noted on the Master Treatment Plan addendum). During an interview on 8/7/25 at 4:00 PM, the CNO verified the above findings and that no orders for increased supervision/restriction had been included on return from elopement. The CNO verified the flex unit the patient had been transferred to was also a locked unit. The CNO stated they were trying to break up the girls with the move. Record review on 8/6/25 at 11:20 AM revealed Pt 10 had been involuntarily admitted on 3/27/25 with diagnoses including Psychosis. Orders on admission were for every 15 minute observation. An Incident Report revealed that on 4/3/25 at 8:10 AM, Pt 10 had eloped after going into another patient’s room, hitting a window which quickly shattered, and exited out through the window. Apparently s/he was able to scale the outside perimeter and eloped off facility grounds. Pt 10 was found at local gas station and returned to facility. Review of camera footage by the Risk Manager revealed the patient was on the phone and then went into a patient room, kicked out the window and eloped. An admission nursing assessment dated 3/28/25 at 2:00 AM revealed the patient was an elopement risk due to his/her involuntary legal status and being actively psychotic. However, orders for elopement precautions had not been put in place on admisison. A Nurses note dated 4/3/25 at 1:22 PM revealed that the patient had eloped that morning and had been placed on elopement precautions. However, orders for elopement precautions had not been put in place until the next day, 4/4/25 at 12:00 Noon. There had been no orders for elopement precautions placed on admission or immediately after the elopement to notify staff that this was a concern for the patient. During an interview on 8/6/25 at 3:30 PM, the CNO verified the finding. When asked what intervention had been put into place as a result of the patient’s elopement, the CNO stated that they had ordered elopement precautions (an alert for staff to be on the lookout for elopement type behaviors or attempts), and that unit restriction had been recommended during the master treatment plan update on 4/4/25. The CNO stated an intervention they could use when a patient is placed on elopement precautions if to give the patients socks to wear and make sure they don’t have shoes. The CNO verified there had been no orders placed for Pt 10 to be on unit restriction until 4/5/25, when the orders were put in briefly for refusing to stop play fighting with a peer. There was no nursing documentation that the patient had been placed on unit restriction after the master treatment plan update recommendation on 4/4/25. When asked if nursing staff had completed a search of the patient’s belongings on return to the unit for contraband, the CNO verified the contraband search had not been documented and should have been. According to the CNO, the patient had gone to a gas station and police brought him back. Record review on 8/6/25 at 1:05 PM revealed the hospital involuntarily admitted Pt 11 on 3/6/25 with Major Depressive Disorder. Orders on admission were for every 15 minute observation. An Incident report revealed that on 3/7/25 at 7:30 PM, Pt 11 and (Pt 12) were standing at the nurses desk and went down the hallway as they were waiting for the nurse to confirm a doctors order. The patient(s) noticed the door was unlocked and were standing outside of door. A nurse and a technician attempted to get the patients to come back inside and patients ran. Code White was called and RN and technician went outside to look for patients. Review of the camera footage by the Risk Manager revealed the patients pushed the door open and eloped. The observation record revealed Pt 11 was back on the unit at 3/7/25 at 8:30 PM. There was nothing documented in the medical record about the patient’s return to the facility to include a time, or how the patient had been returned; nor a nursing assessment for any injury or a contraband search upon return to the unit. No interventions had been documented as a result of the elopement. Review of nursing documentation revealed an “Updated Incident Assessment” revealed a 2nd elopement for Pt 11 on 3/10/25 at 12:35 AM. The note stated that Pt 11 eloped again while waiting on an ambulance for pickup and return back to the emergency department. Patient eloped previously in similar manner. Patient was found near a hotel. Escorted back to the unit in handcuffs via law enforcement personnel at 12:50 AM. According to the nursing documentation in the “Updated Incident Assessment”, orders for elopement precautions had been added. However, a review of physician orders revealed no orders had been documented for elopement precautions. A contraband search had not been documented on return to the unit. During an interview on 8/7/25 at 2:48 PM, the CNO verified the above findings. When asked, the CNO verified there had not been any interventions added related to the elopement on 3/7/25; to include orders for for elopement precuations. The hospital had not added precautions or increased the patient’s observation level. The CNO verified nursing documented on 3/10/25, after the 2nd elopement that elopement precautions would be added; but no order for this had been placed. The CNO verified that a contraband search had not been documented after the elopements on 3/7/25 and 3/10/25. Record review on 8/7/25 at 1:00 PM revealed Pt 12 had been involuntrily admitted on 3/5/25 with Major Depressive Disorder and Post Traumatic Stress Disorder. Orders on admission were for every 15 minute observation. Review of the “Updated Incident Assessment” revealed that on 3/7/25 at 7:30 PM, Pt 12 and (Pt 11) were standing at the desk and went down the hallway as they were waiting for the nurse to confirm a doctors order. The patients noticed the door was unlocked and were standing outside of the door. The nurse and technician attempted to get the patients to come back inside and they ran. Code White was called and the nurse and technician went outside to look for the patients. Review of the Standardized Intake Assessment dated 3/5/25, revealed Pt 12 had a history of elopements. The nursing admission assessment documented that the patient was not an elopement risk. Review of the Master Treatment Plan signed 3/7/25 at 11:00 AM revealed elopement risk had been added to the master treatment plan, but no interventions listed. A physician’s Daily progress note dated 3/8/25 at 3:05 PM revealed “Patient states that (she/he) ran off last night “because (she/he) saw an open door.” Review of a Daily Nurse Progress Note dated 3/7/25 at 10:57 PM revealed “Pt transferred to adolescent unit from flex after elopement from facility shortly after 7:00 PM. Pt was escorted back in police custody. According to the observation record, the patient was back on the unit at 8:32 PM. There were no orders documented that placed the patient on elopement precautions. During an interview on 8/7/25 at 2:39 PM, the CNO stated during the initial nursing assessment they ask patients if they want to elope or are at risk, and if they say they aren’t, we wouldn’t put her/him on elopement precautions. When asked on admission the patient said no, so we wouldn’t put her/him on elopement precautions. Upon reviewing the master treatment plan and noting that the interdisciplinary team identified the patient as an elopement risk on 4/7/25 at 11:00 AM, the CNO was asked what would happen at that time. According to the CNO, the doctor was there, so they wouldn’t need to call the physician for orders. When it was determined that the patient had a need for elopement precautions, the doctor would give the order and the nurse would put it in for elopement precautions. The CNO verified s/he didn’t see an order for elopement risk or precautions on 3/7/25; prior to elopement or after the treatment plan meeting. The CNO verified they did not put in an order for elopement precautions (EP) after Pt 12 eloped and stated they should have. According to the CNO, once they do put in an order for EP it depends on the patient; but what it could possibly mean is socks instead of shoes. Interventions vary from patient to patient; what you could do to stop the elopement risk. When EP is put in as an order, it is a warning for staff to watch out. When asked about the door the patient eloped from; the CNO stated the door was supposed to be locked. During an interview on 8/8/25 at 10:30 AM, the Chief Executive Officer (CEO) stated the magnetic mechanism on the door had not been working correctly and did not cause the door to close and lock allowing the patients to elope. Medical record review on 8/5/25 at 1:47 PM revealed Patient (P)1 was admitted to the facility on 2/20/25 as an involuntary admission. A nursing progress note, dated 2/20/25, revealed that P1 attempted to elope off of the unit three times. In the updated treatment plan, dated 2/24/25, it documented P1 was on assault and elopement precautions. However, there was no documentation showing that elopement precaution orders were implemented. Medical record review on 8/6/25 at 10:35 AM revealed P2 was admitted to the facility on 3/1/25 as an involuntary admission. P2 eloped from the facility on 3/4/25 at 12:30 PM according to the facility’s incident report. After P2 eloped from the facility, per facility’s policy, a registered nurse should implement elopement precautions as ordered by the physician or initiated by nursing order. There was no documentation showing that nursing staff implemented elopement precaution orders for P2 upon his return to the facility. Medical record review on 8/6/25 at 11:14 AM revealed P4 was admitted to the facility on 4/28/25 as an involuntary admission. According to the standardized intake assessment, P4 attempted to elope through the facility’s double doors upon admission. A notification form, dated 4/28/25, revealed that P4 was a high risk for elopement. P4 was placed on elopement precautions (EP) and unit restriction (UR) on the same day as admission. An updated incident assessment revealed that on 5/9/25 at 4:05 PM, P4 was outside the unit during group activities when he/she scaled and climbed a tree to gain the access to the roof top. Reviewing the daily assignment for 5/9/25, P4 is identified to be on elopement precautions and unit restriction. Review of ancillary orders revealed P4 had orders for elopement precautions and unit restriction when P4 was outside the unit and eloped on 5/9/25. Medical record review on 8/6/25 at 12:50 PM revealed P3 was admitted to the facility on 2/25/25 as an involuntary admission. Review of the facility’s incident report revealed P3 had eloped on 3/4/25 at 12:30 PM. Review of the medical record did not display documentation of an updated nursing assessment performed for P3 once he/she returned to the facility. Medical record review on 8/6/25 at 2:47 PM revealed P5 was admitted to the facility on 3/12/25 as an involuntary admission. Review of the facility’s incident report revealed P5 had eloped on 3/15/25 at 10:45 AM. Review of the medical record did not show documentation of an updated nursing assessment performed for P5 once he/she returned to the facility. While conducting a separate record review with the Chief Nursing Officer (CNO) on 8/7/25, starting at 9:39AM, he/she confirmed that there were no nursing assessments documented in the medical records for P3 and P5. The CNO also confirmed that elopement precautions orders should have been placed for P1. The CNO was asked if a patient is allowed outside the unit if placed on orders for unit restriction. The CNO confirmed that a patient is not allowed to go outside. The CNO stated that P4 should not have been outside when he/she was on unit restriction. CNO confirmed that there was no documentation showing that a contraband search was conducted for P4 once he/she returned to the facility. During an interview with Mental Health Technician (MHT) 4 on 8/6/25 at 3:37 PM, it was identified that he/she was in orientation during the day of the incident involving P4. Regarding unit restriction and elopement precautions, MHT4 stated that a patient should not be allowed to go outside at any time when a patient is on unit precautions. During an interview with the CNO on 8/8/25 at 9:26 AM, it was identified that special observation orders, such as 1:1 (one to one), unit restriction, and elopement precautions, are to be reviewed every 24 hours by a physician to determine if the observation status should be continued or discontinued. The CNO revealed that a nurse can determine if an order should be implemented for a patient. Subsequently, the nurse should contact the physician to notify him/her of the need for these type of orders. Once the physician verified that the special level of observation is sufficient, that order is open ending until the physician determines otherwise. Review of the hospital policy, “Elopement Response Risk Management”, reviewed October 2024, revealed that risks of elopements are minimized by conducting thorough assessments, maintaining a secure facility, and conducting monitoring and observation. Responses to elopements that do occur emphasize safety of the patient and staff, attentiveness to the mental and legal status of the patient, and appropriate notifications. If the patient returns to the unit, a search should be made of the patient and belongings and should be documented in the medical record. A registered nurse should assess and document the patient’s mental status and condition upon arrival to the unit. Upon the patient’s return, a registered nurse should implement elopement precautions as ordered by the physician or initiated by nursing order as per facility policy. Review of the hospital policy, “Special Precautions-Heightened Level of Observation”, revised April 2025, revealed information that it is the policy of the hospital to provide a safe and secure environment for patients during their hospitalization. All patients will be routinely observed in compliance with physicians’ orders and prescribed protocols. Patients who need an increased level of observation and precaution for other reasons, such as an elopement risk will be followed per related policies and procedures. A Special Precaution is defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation ...An order for the appropriate level of precautions should be documented in the physician’s order section of the medical record, and the Precaution should be initiated by the charge nurse or designee. When special precautions are initiated by nursing order, the nurse should contact the physician as soon as possible to notify the need for precautions.”

“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 reviews, interviews, and policy review, the multi-disciplinary team failed to ensure each patient had an individualized, comprehensive treatment plan that addressed the problem/behavior of elopement for 5 of 10 patients reviewed who had eloped from the hospital, Patients #5, #7, #8, #10, and #11. Multidisciplinary staff failed to identify the problem of elopement risk/elopement and/or failed to update the treatment plan to include interventions to mitigate possible future elopement for Patients #5, #7, and #11. The multi-disciplinary team failed to follow through and implement recommendations to prevent elopement for Patients #8 and #10. The findings included: Record review on 8/5/25 at 12:28 PM revealed Pt 7 was involuntarily admitted to the hospital on 3/1/25 with diagnoses including Schizophrenia. Review on 8/5/25 at 1:33 PM of the hospital’s Incident Report revealed that on 3/5/25 at 6:06 PM, the patient had eloped from the hospital and was gone for less than 30 minutes. Comments by the Risk Manager on the report included that a Code White had been called for the patient on the roof; patient slid down off side of the roof after staff told him/her to come down. Patient slid off side of the roof and kept trying to get away, patient was able to run away towards Lexington Medical Center after staff attempted to return him to the building. Nursing supervisor called the police to bring patient back to the unit. Physician notified, patient placed on restriction. Review of camera footage revealed the patient had jumped on the covering in the main courtyard area and eloped. During an interview on 8/7/25 at 3:20 PM, a review of the Master Treatment Plan for Pt 7 revealed it had not been updated to include that an elopement had occurred or that the interdisciplinary team had identified interventions to put into place to prevent future elopements. The CNO stated that the Master Treatment Plan should have been updated. Further review of physician orders revealed Pt 7 had been placed on unit restriction for 24 hours after the elopement and this had not been included on the master treatment plan. . Record review on 8/5/25 at 2:00 PM revealed Patient 8 had been involuntarily admitted on 3/11/25 with diagnoses including Severe Major Depression. Review of the hospital’s Incident Report revealed that on 3/18/25 at 8:15 PM, the patient had eloped out of room 203 with three other youths. The window was not locked. They were found on the roof. Pt is still missing at this time. Review of the camera footage by the Risk Manager revealed patients were performing hygiene and were able to slide a window open that was not properly installed by an outside vendor. They had stacked two tables on top of each other and eloped off of the roof. Pt 8 was returned to the unit on 3/19/25 at 12:15 AM by police. Review of the Master Treatment Plan Addendum dated 3/19/25 at 9:00 AM revealed the interdisciplinary team meeting was held due to the patient elopement. Recommendations included that the patient be placed on elopement precautions and unit restriction. An order for elopement precautions had already been placed by the nurse on 3/19/25 at 4:00 AM. There had been no orders placed for the patient to be on unit restriction (the patient had current orders that had been in place prior to the elopement for room restriction). No new or additional interventions had been implemented for Pt 8 as a result of the elopement. During an interview on 8/7/25 at 3:37 PM, the CNO verified the findings. Record review on 8/6/25 at 11:20 AM revealed Pt 10 had been involuntarily admitted on 3/27/25 with diagnoses including Psychosis. An Incident Report revealed documented that on 4/3/25 at 8:10 AM, Pt 10 had eloped after going into another patient’s room, hitting a window which quickly shattered, and exited out through the window. Apparently s/he was able to scale the outside perimeter and eloped off facility grounds. Pt 10 was found at local gas station and returned to facility. Camera footage revealed the patient was on the phone and then wento into patient room, kicked out the window and eloped. A Master Treatment Plan Addendum for elopement dated 4/4/25 at 9:00 AM included an intervention for unit restriction. However, no orders had been placed for the intervention of unit restriction on 4/4/25 as recommended by the interdisciplinary team. A nurses note dated 4/5/25 at 10:48 AM documented that the patient was placed on UR (unit restriction) for one day not not being able to be redirected. Review of physician orders revealed orders for unit restriction dated 4/5/25 to start at 10:00 AM and end on 4/5/25 at 11:33 AM, which was only for 1 1/2 hours for refusing to stop play fighting with a peer. During an interview on 8/6/25 at 3:30 PM, the CNO verified there was no order for unit restriction due to the elopement attempt. The CNO verified the master treatment plan had not been updated on 4/3/25 after the elopement attempt and stated that the interdisciplinary team would normally have completed the update on 4/3/25. Record review on 8/6/25 at 1:05 PM revealed the hospital involuntarily admitted Pt 11 on 3/6/25 with Major Depressive Disorder. An Incident report revealed that on 3/7/25 at 7:30 PM, Pt 11 was standing at the nurses desk and went down the hallway as they were waiting for the nurse to confirm a doctors order. The patient(s) noticed the door was unlocked and were standing outside of door. A nurse and a technician attempted to get the patients to come back inside and patients ran. Code White was called and RN and technician went outside to look for patients. Review of the camera footage by the Risk Manager revealed the patients pushed the door open and eloped. The observation record revealed Pt 11 was back on 3/7/25 at 8:30 PM. Review of the Master Treatment Plan dated 3/7/25 at 11:00 AM revealed the patient had been identified as an elopement risk, but no interventions had been documented. There was no update to the master treatment plan documented after the elopement on 3/7/25. During an interview on 8/7/25 at 2:48 PM, the CNO verified the above findings. 52713 Medical record review on 8/6/25 at 2:47 PM revealed P5 was admitted to the facility on 3/12/25 as an involuntary admission. According to the incident report, on 3/15/25 P5 was asked to come inside. P5 started jumping on the fence and ran away from the facility. A code white, for elopement, was called. Emergency services were called, and P5 was returned to the facility within 30 minutes. The updated treatment plan, dated 3/20/25 revealed the update to the treatment plan had not been conducted due to the patient’s elopement. The entry on the treatment plan indicated the review was due to a physical altercation P5 had with a peer that included antagonism/bullying. Elopement was not identified as a problem, and goals to prevent elopement/re-elopement were not documented. There was no indication this concern of elopement had been discussed during the treatment team meeting. Nursing staff followed their policy and placed P5 on elopement precautions and unit restriction orders on 3/15/25. During record review with the Chief Nursing Officer (CNO) on 8/7/25 at 9:39 AM, it was mentioned that he/she was not part of P5’s treatment plan on this date. The CNO did state the the elopement incident (from 3/15/25) and any/all elopement incidents should be discussed in the treatment team meeting with the patients. Review of the hospital policy, “Interdisciplinary Patient-Centered Care Planning”, revised December 2024, revealed it is the policy of the hospital to provide therapeutic services based upon a patient centered individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient’s assessed needs to be addressed during treatment and develop appropriate goals and interventions. All therapeutic services that are beyond routine tasks to be provided to the patient are included in the plan and the treatment plans are routinely reviewed to assess the patient’s progress and determine if any modifications are needed. The policy included that a treatment plan revision can be completed any time the treatment team decides to alter the proposed strategies based upon the patient’s needs. Review of the treatment plan are documented on the appropriate treatment plan forms in the medical record. The following would be cause for conducting a review of the plan and developing a revision: A new impairment/problem or significant information about an existing impairment is identified.”

“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: 25065 Based on governing body bylaws review, governing body meeting minutes, patient medical record reviews, personnel education reviews, and interviews, the hospital’s governing body failed to implement measures to protect patients from sexual abuse. Findings include: Cross Reference A0049/ 482.12(a)(5) - The Governing Body -Ensure that the medical staff is accountable to the governing body for the quality of care provided to patients Cross Reference A0115/ 482.13 Patient’s Rights Cross Reference A00145/ 482.13(c)(3) Patient’s Rights- The patient has a right to be free from all forms of abuse or harassment. Review of the hospital’s “Board of Governors Meeting 4th Quarter 2024 January 14, 2025,” provided by the hospital revealed “...Culture of Safety/Workplace Violence Prevention 2024 and analysis: ...During 2024, there were a total of 45 sexual incidents. There were 36 sexual misconduct, 6 sexual intercourse, and 3 sexual assaults reported. Twenty-eight occurred on the adolescent unit, 11 on the adult units, and 6 on Flex. ln [November] 2024, the facility implemented Get SMART training to provide additional support and guidance for staff on preventing sexual incidents from occurring. This is included in the annual nursing skills fair. Additionally, the facility moved to Observe-smart proximity rounding, which provides for improved patient observation rounding to assist in decreasing sexual incidents...” P1 on 01/17/2025 and P4 on 04/05/2025 were both transferred to the emergency department (ED) for treatment after they were sexually assaulted by other patients in separate incidents. Both patients received an ED discharge diagnosis of sexual assault. During an interview on 04/24/2025 at 11:34 AM, Human Resource Director (HRD) presented documentation of the completion of staff education as follows: 46.39% of staff completed the course on “Precautions and Prevention of High Risk Behaviors,” 72.22% of staff completed the course on “Abuse and neglect,” 50.46% of staff completed the course on “Patient Observation Rounds and Attestation,” and 45.50% of staff completed the course on “Stop & [and] Think ... Serious Conversations At Work Preventing Sexual Allegations.” The HRD stated the staff were supposed to complete all of the courses by 04/30/25 (Based on the available documentation, 28%- 54% of staff had not completed the assigned courses). There was no documentation that further action was taken by the governing body to prevent further sexual abuse incidents.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 25065 Based on medical record reviews, incident report reviews, and interviews, the hospital failed to protect each patient’s right to be free from sexual abuse for two of four patients reviewed for allegations of sexual abuse (Patient (P) 1 and P4) out of seven sampled patients. This deficient practice had the potential to affect all patients receiving behavioral health services in the hospital. Findings include: P1 on 01/17/2025 and P4 on 04/05/2025 were both transferred to the emergency deparment (ED) after separate incidents of alleged sexual assault by other patients. Both patients received an ED discharge diagnosis of sexual assault. (Cross reference to A0145/ 482.13(c)(3))”

“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: 25065 Based on governing body bylaws review, patient medical record reviews, and interviews, the governing body failed to ensure the medical staff was accountable for the quality of care provided to two of four patients reviewed for abuse (Patient (P) 1 and P4). After two separate sexual abuse incidents, the hospital’s governing body and medical staff failed to implement sufficient actions to prevent further sexual abuse from occurring. This deficient practice had the potential to affect all patients receiving behavioral health services at the hospital. Findings include: Review of the “Three Rivers Behavioral Health Bylaws of the Board of Governors, “effective 04/01/2020, indicated “. . .The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital. . .Duties and Responsibilities. . .Ensure continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professionals and other health care providers who provide services at the Hospital . . .” Review of an incident report dated 01/17/25 at 3:23 PM, provided by the facility, indicated P1 reported that his/her roommate had oral and digital sex with him/her and complained “[his/her] vagina hurts.” Review of P1’s Emergency Department Visit Note, dated 01/17/25 at 4:41 PM, provided by the facility, indicated the chief complaint was alleged assault. Further review indicated P1’s final diagnosis was “Sexual assault of child (Primary).” Review of P4’s incident report documented on 04/05/25 at 1:59 PM, provided by the facility, indicated P4 reported that P3 had forced P4 to perform fellatio (oral sex) on him/her on 04/04/25 at 10:00 PM. Further review indicated the physician sent P4 to the children’s hospital for evaluation. Review of P4’s “ED Visit Note,” dated 04/05/25 indicated the final diagnosis was “sexual assault of child.” During an interview on 04/23/25 at 2:15 PM, Psychiatrist (Pysch) 2 was asked by the surveyor what could have been done to protect all patients from hypersexual behaviors by other patients. Psych2 stated “That’s a good question. When you have a co-ed facility or having a roommate, that’s difficult.” Psych2 stated he/she was not aware of anything being done related to the number of hypersexual inpatients. During an interview on 04/24/25 at 12:55 PM, the Administrator confirmed he/she was on the governing board. The Administrator stated the governing board was made aware of the incidents of sexual assaults and during the governing body meetings. The Administrator stated the biggest change the governing body had made was to get the tablets for the Mental Health Technicians (MHTs) to use to document rounding observations and to begin “Get Smart” education that addressed boundaries of having staff get closer to patients when doing observations and not do it from a distance. There was no documentation the governing body ensured that further action had been taken by the medical staff to prevent further patient sexual abuse.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 25065 Based on policy review, record reviews, incident report reviews, hospital self-reports review, observation, and interviews, the hospital failed to ensure each patient had the right to be free from all forms of abuse for two of four patients reviewed for allegations of sexual abuse (Patient (P) 1and P4) from a sample of seven patients. This deficient practice had the potential to affect all patients receiving behavioral health services in the hospital. Findings include: Review of the hospital’s policy titled “Alleged Patient Abuse, Neglect, Exploitation Clinical Services,” with review date December 2024, indicated abuse was defined as “Any act or failure to act by an employee of a hospital which was performed or which failed to be performed knowingly, recklessly or intentionally and which caused or may have caused, injury or death to a patient, and includes such acts as: (1) rape or sexual assault of a patient; ...” There was no documentation in the definition related to patient-to-patient sexual abuse. Review of the hospital’s abuse policy titled “Sexual Aggression & [and] Victimization Prevention Guidelines & Response Notification Plan Risk Management and Clinical Services,” with review date December 2024, indicated “. . . It is the policy of Three Rivers Behavioral Health to provide a safe and secure environment that discourages the development of intimate relationships with fellow patients during or after hospitalization. . .Patients should not be allowed to be in their rooms with the doors closed for an extended length of time. During quiet times and bedtimes, the door should remain open. Monitor for patients trying [sic] enter other patients rooms. . .” Review of the hospital’s “Patient Bill of Rights And Responsibilities,” indicated the printed patient rights did not address the patient’s right to be free from abuse, neglect, and exploitation. 1. Review of P1’s medical record indicated P1 was admitted on 01/12/25. Review of P1’s “Nursing Admission Assessment - Youth” dated 01/12/25 indicated P1 had “sexual victimization in the last 6 [six] months” and over a “lifetime.” Review of P1’s “Physician Orders,” dated 01/17/25 indicated P1 had “sexual victimization risk.” Review of an incident report dated 01/17/25 at 3:23 PM indicated P1 reported that his/her roommate P2 had oral and digital sex with him/her and complained of “her vagina hurts.” The incident report also indicated P2 was the roommate of P1. Review of the “Hospital’s Investigational Summary,” (undated) of the incident documented by Director of Quality and Risk (DQR) indicated P1 was seen at the emergency department (ED) and tested for HIV (human immunodeficiency virus), chlamydia, and syphilis. P1 returned to the facility with no new diagnosis. Review of P1’s “Emergency Department Visit Note,” dated 01/17/25 at 4:41 PM indicated the chief complaint was alleged assault. Further review indicated P1’s final diagnosis was “Sexual assault of child (Primary).” Review of P2’s medical record indicated P2 was admitted on 01/13/25. Review of P2’s “Nursing Admission Assessment - Youth,” dated 01/14/25 indicated P2 had no history of sexual aggression or sexual victimization risk. Observation on 04/23/25 at 9:30 AM of a hospital-provided video recording of the adolescent unit on the night shift on 01/16/25 to 01/17/25 (7:00 PM on 01/16/25 to 7:00 AM on 01/17/25) navigated by DQR indicated the doors of patient rooms other than the door to P1’s and P2’s room were open, while P1’s and P2’s door had a crack in it. During an interview on 04/22/25 at 2:57 PM, DQR stated since it happened (P1 and P2 sexual incident) in a patient’s room where there was no camera, DQR can say a sexual occurrence was substantiated, but he/she cannot say it was assault. DQR stated one patient said it was assault, and another patient said it was consensual. DQR stated they don’t always get the emergency department (ED) visit note when a patient is sent to the ED. DQR confirmed he/she did not obtain P1’s ED visit note and went by the nurse’s documentation of the tests that were performed and there was no new diagnosis. 2. Review of P3’s medical record indicated P3 was admitted on 04/03/25. Review of P3’s “Standardized Intake Assessment,” dated 04/03/25 indicated P3 had no history of sexual aggression. Review of P3’s “Nursing Admission Assessment - Youth, dated 04/03/25 at 12:00 PM indicated P3 had no documentation of sexually aggressive behavior or potential for sexual victimization. Review of an incident report dated 04/05/25 at 1:20 PM indicated P3’s roommate (P4) accused P3 on 04/04/25 at 10:00 PM of forcing P3 to perform fellatio (oral sex). Further review indicated when P3’s mother was notified, P3’s mother reported that P3 had been “accused of inappropriate sexual behavior once on the school bus and once in the boy’s bathroom at school.” Review of P4’s medical record indicated P4 was admitted on 04/03/25. Review of P4’s “Standardized Intake Assessment, “dated 04/03/25 indicated P4 had sexual victimization in the last six months. Review of P4’s “Initial Psychiatric Evaluation,” dated 04/04/25 had no documentation of P4’s past history of sexual victimization. Review of P4’s “Nursing Admission Assessment - Youth,” dated 04/05/25 indicated P4 had no sexually aggressive behavior and no potential for sexual victimization. Review of P4’s incident report, dated 04/05/25 at 1:59 PM, indicated P4 reported that on 04/04/25 at 10:00 PM P3 had forced him/her to perform fellatio on him/her (P3) Further review indicated P4 reported “while [he/she] was DSS [Department of Social Services] custody, an adult had forced P4 to perform fellatio on [him/her].” Further review indicated the physician sent P4 to the children’s hospital for evaluation. Review of P4’s “ED Visit Note,” dated 04/05/25, indicated the final diagnosis was “sexual assault of child.” During an interview on 04/23/25 at 3:30 PM, DQR confirmed P4’s ED visit note had a final diagnosis of sexual assault. The Administrator was notified of an Immediate Jeopardy situation related to Patient Rights on 04/25/25 at 3:50 PM. (Cross Reference tag A0115/482.13 and A1640/ 482.61(C)(1))”

“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: 25065 Based on hospital policy review, patient medical record review, and interviews, the hospital failed to ensure each patient had a current individualized comprehensive treatment plan to meet the needs of the patient for five patients (Patient (P) 1, P2, P5, P6, and P7) of seven sampled patient records reviewed. This deficient practice had the potential to prevent each patient from receiving therapeutic services based on the identification of the patient’s assessed needs to be addressed during treatment. Findings include: Review of the hospital policy titled, “Interdisciplinary Patient-Centered Care Planning,” reviewed/revised in December 2024, indicated “. . .It is the policy of Three Rivers Behavioral Health to provide therapeutic services based upon a patient-centered individualized treatment plan. . .Each patient’s written Treatment Plan must include: [bulleted list] -Substantial diagnosis(es) -Identification of problems to be treated and the specific behavioral manifestations of those problems in the patient -Short-term and long term goals for each active problem, developed with patient input -The specific treatment modalities with individualized patient focus -The responsibilities of each member of the treatment team ...The Nurse completing the Nursing Assessment or designee shall develop the Initial Treatment Plan within eight (8) hours of admission. . .At the time of the development of the Interdisciplinary Master Treatment Plan (MTP), the Initial Treatment Plan will be considered resolved, with psychiatric problems either moved to the MTP or fully resolved and medical problems moved to the MTP . . .Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan. . .The treatment team will complete the MTP including: a. Completion of diagnosis, problem list, and patient assets on the Treatment Plan Cover Sheet b. Completion of an individual Problem Sheet for each active psychiatric or medical problem. . .The treatment team. . .will complete a review of the treatment plan as clinically indicated, or at a minimum every seven (7) days. . .A treatment plan revision can be completed any time the treatment team decides to alter the proposed strategies based upon the patient’s needs. . .The following would be cause for conducting a review of the plan and developing a revision: A new impairment/problem or significant information about an existing impairment is identified. . .” 1. Review of P1’s medical record indicated P1 was admitted on 01/12/25. Review of P1’s “Initial Treatment Plan,” dated 01/12/25 indicated the problems identified were danger to self and danger to others. Review of P1’s Interdisciplinary Master Treatment Plan dated 01/14/25 indicated P1’s psychiatric diagnoses included disruptive mood dysregulation disorder (DMDD), oppositional defiant disorder (ODD), and rule out attention deficit hyperactive disorder (ADHD). Review indicated the problems identified on the MTP included homicidal ideations and suicidal ideations with self-harm, both identified on 01/14/25. Review indicated an individual problem sheet was completed for each of the two identified problems. Review of P1’s “Physician Daily Progress Note,” dated 01/17/25 at 1:45 PM by Psychiatrist (Psych) 2 indicated “. . .patient seen today case discussed with staff reports that [he/she] is upset today haven’t reported that [he/she] was sexually assaulted by appear [sic] on the unit last evening. Patient apparently did not disclose this at the time however this morning indicates that [he/she] was sexually assaulted. . .” Review of P1’s “Emergency Department Visit Note,” dated 01/17/25 at 4:41 PM indicated the chief complaint was alleged assault. Further review indicated P1’s final diagnosis was “Sexual assault of child (Primary).” Review of P1’s medical record indicated P1’s MTP was not revised with the new diagnosis of sexual assault on 01/17/25. During an interview on 04/22/25 at 2:57 PM, Director of Quality and Risk (DQR) stated the analysis he/she completed indicated P1’s treatment plan was updated with sexual victimization after the allegation of sexual assault was received on 01/17/25. When told by the surveyor that a revision of the MTP was not found in P1’s medical record, DQR reviewed P1’s medical record and confirmed a revision was not documented. 2. Review of P2’s medical record indicated P2 was admitted on 01/13/25 at 6:52 PM and discharged on 01/21/25 at 7:55 PM. Further review indicated P2’s admission diagnosis was “other persistent mood (affective) disorder.” Review of P2’s “Initial Treatment Plan,” signed by Registered Nurse (RN) 1 on 01/13/25 at 10:45 PM indicated the reason for hospitalization was aggression, destruction of property, and suicidal ideations. The problems identified included danger to self and danger to others. Review of P2’s “Interdisciplinary Master Treatment Plan,” signed by RN1, Psych1, and Medical Social Worker (MSW) 1 on 01/16/25 at 10:00 AM and P2 on 01/16/25 at 10:35 AM, indicated P2’s psychiatric problems identified on 01/13/25 included “Aggression / Destruction of Property.” Review indicated an individual problem list was documented for aggression. There was no documentation of an individual problem list for destruction of property. Review of P2’s “Master Treatment Plan Addendum,” signed by RN1 on 01/16/25 at 10:00 AM indicated the reason for review was “physical altercation” with recommendations of special precautions of “assault” and interventions of verbal de-escalation, unit restriction, and behavioral reward system. Review indicated additional goals to be addressed in treatment included aggression and sexual boundary violations. The addendum had the names of Psych1 and MSW1 with a date of 01/16/25 at 10:00 AM with no signature documented by Psych1 and MSW1. Review of P2’s “Master Treatment Plan Addendum,” dated 01/17/25 and signed by RN1, MSW1, P2, and Director of Clinical Services - BH (Behavioral Health) (DCS) on 01/17/25 at 2:30 PM, indicated the reason for review was “sexual acting out incident” with recommendation of sexual special precautions and interventions of no roommate, verbal de-escalation, and transferred unit. Review indicated the problem identified was “peer antagonism /bullying.” Review of an incident report documented on 01/17/25 at 7:30 AM indicated P1 alleged P2 had sexually abused P1. Review indicated additional goals to be addressed in treatment included sexually inappropriate behaviors. There was no documentation that aggression and sexual boundary violations were included as written on the addendum documented on 01/16/25 at 10:00 AM. During an interview on 04/23/25 at 1:35 PM, Chief Nursing Officer (CNO) and Chief operating Officer (COO) confirmed P1’s allegation of P2 sexually abusing P1 was not documented in the Master Treatment Plan on 01/17/25 but rather “peer antagonism / bullying” was documented. 3. Review of P5’s medical record indicated P5 was admitted on 04/17/25 at 3:33 PM with an admission diagnosis of major depressive disorder, recurrent. Review of P5’s “Nursing Admission Assessment - Youth” indicated P5 had a history of sexual abuse and indicators for sexual victimization risk. Review of P5’s physician orders indicated an order on 04/17/25 at 7:00 PM for sexual victimization risk precautions. Review of P5’s “Initial Nursing Treatment Plan” indicated risk of sexual victimization with interventions of “Discuss with patient fears related to past trauma(s) and current triggers possible in hospital environment.” Review of P5’s “Interdisciplinary Master Treatment Plan” indicated the problem identified was suicide ideations. There was no documentation related to sexual victimization risk or a history of sexual abuse. During an interview on 04/23/25 at 2:15 PM, Psych2 stated any problem identified on the psychiatric evaluation or the nursing admission assessment should be included in the Master Treatment Plan. 4. Review of P6’s medical record indicated P6 was admitted on 04/16/25 at 8:53 PM with an admission diagnosis of major depressive disorder, single episode. Review of P6’s “Nursing Admission Assessment - Youth” (not signed, dated, and timed) indicated a history of sexual victimization and sexual abuse. Review of P6’s “Initial Psychiatric Evaluation” conducted on 04/17/25 at 5:55 PM indicated initial treatment plan included suicide precautions. Review of P6’s physician orders indicated an order on 04/17/25 at 12:00 AM for sexual victimization risk and suicide precautions by Physician Assistant (PA) 1. Review of P6’s “Initial Nursing Treatment Plan” created on 04/16/25 indicated risk of sexual victimization with interventions of “Discuss with patient fears related to past trauma(s) and current triggers possible in hospital environment. (specify) upon admission” and “Encourage patient to seek out staff if [he/she is] feeling unsafe as needed.” Review of P6’s “Interdisciplinary Master Treatment Plan” created on 04/18/25 indicated the problem was “suicide ideations with plan.” There was no documentation that sexual victimization risk was planned for on the Master Treatment Plan. During an interview on 04/23/25 at 2:15 PM, Psych2 stated any problem identified on the psychiatric evaluation or the nursing admission assessment should be included in the Master Treatment Plan. 5. Review of P7’s medical record indicated P7 was admitted on 04/19/25 at 6:01 PM with an admission diagnosis of major depressive disorder, single episode. Review of P7’s “Initial Psychiatric Evaluation” conducted on 04/20/25 indicated P7 had a history of sexually inappropriate behavior toward a six-year-old female. Review of P7’s initial treatment plan indicated suicide precautions. There was no documentation of precautions related to sexual aggression. Review of P7’s “Nursing Admission Assessment - Youth” dated 04/19/25 at 9:10 PM indicated history of “sexually provocative/hypersexual behaviors” was not checked and “History of sexual aggression (over time) was answered “No.” Review of P7’s physician orders indicated an order on 04/19/25 at 9:32 PM by Psych1 for sexual aggression risk and suicide precautions. Further review indicated a physician order by Psych2 on 04/22/25 at 3:46 PM for “one on one” observation and “restricted to unit.” Review of P7’s “Initial Nursing Treatment Plan,” created on 04/19/25 indicated “Assaultive/Aggressive” was checked as “None” and “Inappropriate Sexual behavior” was checked as “Patient will display appropriate boundaries with others” with the intervention of “Observe patient interactions with others to ensure appropriate boundaries.” Review of P7’s “Interdisciplinary Master Treatment Plan” created on 04/22/25 indicated the problem identified was “Suicidal ideations with self-harm.” There was no care plan created for sexual aggression. During an interview on 04/23/25 at 1:35 PM, both the CNO and COO stated P7 had been on the flex Adolescent unit since admission with the roommate’s bed blocked, because he/she had sexual aggression. CNO confirmed sexual aggression should have been included in P7’s multidisciplinary treatment plan. During an interview on 04/23/25 at 2:15 PM, Psych2 stated any problem identified on the psychiatric evaluation or the nursing admission assessment should be included in the Master Treatment Plan and have a care plan created.”