Patrick B Harris Psychiatric Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 28883 Based on observation, record review, interview, and policy review, Behavioral Health Assistant (BHA) #3, failed to be within arms length of Pt #6, one of three staff observed providing Individual Precautions (IP) to patients for safety. The findings included: The hospital admitted Pt #6 on 2/20/25 with diagnoses including, but not limited to, Schizoaffective Disorder, Bipolar Type. Observation on 11/5/25 at 2:05 PM revealed Behavioral Health Assistant (BHA) #3 sitting in a chair in the day room of lodge G, pod 1. Review of the assignment sheet revealed BHA #3 was providing Individual Precautions (IP) for Pt #6, for falls precautions and cheeking precautions. When asked what/she was doing, BHA #3 stated s/he was providing the 1:1 for Pt #6, and pointed to the patient who was seated at a table further than arms length away; (about 2 or 3 arms lengths). When questioned about the distance between the two; BHA #3 stated that s/he would only need to be within arms length if the patient was mobile or moving. Review on 11/6/25 at 9:57 AM revealed physician renewal orders dated 11/5/25 at 12:54 PM for Pt #6 to have Individual Precautions provided. The order did not specify a distance related to how far staff were to be from the patient. Review of the policy provided by the hospital entitled Medical/Behavioral Precautions, effective June 27, 2025, prepared by nursing services revealed the purpose of the policy was to provide guidelines to augment the hospital nursing staff’s clinical judgment in providing as safe an environment as possible, decreasing risks of patients with medical or behavioral problems and to improve the quality of the therapeutic millieu. Under Individual Precautions “...Patients on 1:1 Medical Observation will be observed by an assigned staff member that will remain within arm’s length of the patient unless otherwise ordered... The ordering LPP (Licensed Provider) may provide a specific order indicating “within six (6) feet” if required...It remains that a 1:1 observation will be the staff’s only assignment... Patient’s level will be determined by Treatment Team...”.”

“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: 28883 Based on record reviews, interview, and directive/policy review, the hospital failed to ensure a thorough investigation into allegations of verbal abuse for Patient #2 and #5, two of two Patients reviewed for abuse. Witness statements had not been obtained from all potential witnesses. There was no attempt by hospital staff to determine if the alleged abuse had occurred for Pt #5 on a different date than the morning of 8/24/25. The findings included: The hospital admitted Patient #2 on 4/19/22 with diagnoses including Schizoaffective Disorder, Bipolar Type. Review of an Incident Report dated 9/2/25 and a statement from Behavioral Health Assistant (BHA) #5, dated 8/27/25, revealed that BHA #5 had reported that Pt #2 had been verbally abused by BHA #4 the morning of 8/27/25. According to the statement from BHA #5, s/he had asked BHA #4 to assist in helping Pt #2 sit on the side of the bed. BHA #4 looked at Pt #2 and said this bitch can ger her/his fat ass up alone, let her/him sit there. They (Pt #2 and BHA #4 started bickering. Pt #2 told BHA #4 to shut up and then BHA #5 told BHA #4 s/he had it under control. BHA #5 had reported the incident to the Nurse Manager, who reported it to the Assistant Director of Nursing (ADON). The ADON reported it to Public Safety, and they interviewed the patient. Pt #2 stated s/he had been “disrespected”, but did not elaborate. The Nurse Manager spoke with the patient about the incident, and Pt #2 stated that s/he remembered being cursed at, but didn’t remember who it was because s/he had been half asleep. Public Safety reported the alleged abuse to the on-call investigator with the Columbia Public Safety and an agent with SLED (South Carolin Law Enforcement Division). The employee was suspended from work during the investigation. The hospital admitted Pt #5 on 12/20/2024 with diagnoses including Schizoaffective Disorder, Bipolar Type. Review of an Incident Report dated 9/2/25 and a statement from Behavioral Health Assistant (BHA) #5 dated 8/27/25 revealed that BHA #5 had reported that Pt #5 had been verbally abused by BHA #4 while getting dressed on the morning of 8/24/25. According to the Incident Report, BHA #4 made derogatory comments about the patient. The statement from BHA #5 was that BHA #4 and BHA #5 were waking patients and went into Pt #5’s room to tell her/him it was time for coffeee. Pt #5 did not get up. BHA #4 said I’m standing in your door until you are ready. Pt #5 responded that s/he needed privacy to change. BHA #4 then said that no one wanted to see what s/he had, it was nothing but saggy tits and stank ass pussy. The patient got upset. The report indicated BHA #5 had spoke with the Lodge Nurse Manager, who reported it to the Assistant Director of Nursing (ADON). The ADON reported it to public safety, and they interviewed the patient in his/her bedroom on the morning of 8/27/25. The patient stated s/he didn’t remember anything and doesn’t remember being mistreated. The Nurse Manager spoke with the patient about the incident, and Pt #2 stated s/he didn’t remember being cursed at. Public Safety reported the alleged abuse to the on-call investigator with Columbia Public Safety and with SLED (the South Carolina Law Enforcement Division). SLED took the report as information only. The employee was suspended from work during the investigation. The investigation concluded there was not enough evidence of Patient abuse. Review of witness statements revealed BHA #5 had written his/her statement on 8/27/25 accusing BHA #4 of verbal abuse against Pts #2 occurring on 8/27/25, and against Pt #5 on 8/24/25. BHA #4 had writen a statement on 8/27/25 at 10:06 PM stating that on the 24th s/he had awakened the patients giving verbal cues the first round, using a soft reassuring voice. On the 2nd round I used a louder voice. For the 27th, BHA #4 had written that s/he had entered pods and woke up residents using a soft and reassuring voice, the 2nd time around used a louder voice. A second statement from BHA #4, by e-mail, dated 8/28/25 at 9:42 AM to the ADON revealed information from BHA #4 that s/he hadn’t woked on the 24th and 27th, and had been sitting with an “IP” (person on individual precautions one to one) and the patient had slept all night. No derogatory statements were made. A note handwritten on the bottom of the e-mail by the ADON stated that BHA #4 had not worked the night of 8/23/25 into the morning of 8/24/25, and had not worked on the night of 8/24/25. Review of the timecard for BHA #4 revealed this was correct; s/he had worked the nights of 8/22/25, 8/25/25, and 8/26/25. Review of witness statements obtained by the hospital related to the allegations made against BHA #4 for Pts #2 and #5 revealed they had obtained a statement from BHA#2 and BHA #7 who worked nights on lodge H. BHA #2 wrote a statement 9/1/25 at 5:00 AM stating that BHA #4 was great, always putting patients first and making sure a smile in on their faces. S/he is a very bright and optimistic and makes every shift more delightful with her/his positive spirit and optimistic mindset. A pleasure to be around and a great addition. There was nothing documented to show whether BHA #2 was aware of any verbal abuse/derogatory statements made by BHA #4 to Patients #2 or #5. BHA #7 wrote a statement on 8/31/25 that stated s/he believed BHA #4 was being falsely accused of something s/he didn’t do, having sat with BHA #4 and never heard her/him say anything bad or derogatory about the patients. There were no witness statements from some of the staff that had worked the night of 8/26/25 into the morning of 8/27/25 related to the allegation for Pt #2, to include Registered Nurse (RN) #3, Licensed Practical Nurse (LPN) #1, and BHA #7; to see if they had overheard or witnessed anything related to the alleged abuse. During an interview on 11/6/25 at 11:30 AM, the ADON stated that based on the allegation by BHA #5 for Pt #5 for the morning of 8/24/25, and review of when BHA #4 had worked, the dates didn’t match. The ADON was asked and stated s/he had not looked into this timeline related to the abuse alleged by BHA #5 to have occurred on the morning of 8/24/25 and other dates when BHA #5 may have workded; to see whether it may have occurred but on a different date. The ADON stated that Pt #5 had been interviewed and did not recall any verbal abuse. According to the ADON, Pt #5 was alert and oriented and would have let us know. According to the ADON, it depends who s/he will interview; and whether the patient is delusional or not. The ADON reviewed BHA #4’s time card and stated that BHA #4 had worked on the night of 8/22/25 into the morning of 8/23/25. The ADON stated I do not go back to other dates unless something is there. When asked if s/he had specifically asked BHA #4 if the allegations against her/him for Pts #2 and #5 were true, the ADON stated BHA #4 denied every bit of it; and stated that s/he had talked to BHA #5 personally. When asked about Pt #2 and why no statements had been obtained from other staff (that had worked the night of 8/26/25 into 8/27/25), besides BHA #2 and BHA #7, the ADON stated s/he would not normally seek out interviews with other staff that might have been working. Review of the directive provided by the hospital entitled Abuse Neglect, or Exploitation of Patients and Clients Prohibited,dated January 18, 2007, revealed that employees must repot suspected abuse, neglect or exploitation of clients and patients as required by law and departmental policy. Following investigation, if improper conduct by an employee is found to have occurred, appropriate disciplinary action shall be taken. The following type of improper conduct are strictly prohibited, and included psychological abuse. “Psychological abuse” means deliberately subjecting a patient or client to threats or harrassment or other forms of intimidating behavior causing or likely to cause fear, humiliation, degradation, agitation, confusion, or other forms of serious emotional distress. Psychological abuse included but is not limited to, abusive language or gesures, use of profane language, calling names....teasing or ridiculing....All employees shall cooperate with the investigating personnel and answer questions concerning the incident asked by their supervisor, SLED, Public Safety and/or other officials authorized to conduct a review or investigation...”.”

“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 and interviews, the hospital failed to update the treatment plans for Patients #1 and #2, 2 of 4 patients reviewed for special medical record requirements. Patient #1’s treatment plan had not been updated relative to being roomed in a dayroom for safety. Patient #2’s treatment plan had not been updated to reflect the episode of aggression toward Pt #1 and a move to another pod. The findings included: Record review on 11/3/25 at 1:16 PM revealed Pt #1 had been admitted to the hospital on May 5, 2025, with diagnoses including Schizophrenia. Further review revealed Pt #1 had been seen in the Emergency Department (ED) of an area acute care hospital for seizures and inability to walk on 7/31/25. Pt #1 was discharged from the ED on 8/1/25. Pt #1 was being followed with neurology for seizures and physical therapy for walking strength/endurance. Pt #1 was currently on Individual Precautions (IP); which is the medical equivalent of 1:1 and was assigned one person to observe her/him and assist within arm’s length. Review of nursing notes revealed a note dated 8/28/25 documenting that Pt. #2 had attacked Pt #1 with a pillowcase filled with shoes and crayons after Pt #1 got into the shared bathroom before Pt #2. The note documented that on 8/28/25 at 9:16 PM, the nurse spoke with Psychiatrist #1 and discussed a possible room change to pod 2 or pod 3 for Pt #1, but all rooms were currently occupied at the time. Further review of observation records and interviews of staff revealed Pt #1 had been roomed in the pod 2 dayroom from 8/30/25 through the morning of 9/2/25 for safety to remove him/her from potential aggression and access by Pt #2. Review of the Treatment Plans for Pt #1 dated 8/26/25, 9/2/25, and 9/10/25 revealed no information that Pt #1 had been moved to the dayroom for safety or other reasons. During an interview on 11/4/25 at 2:27 PM, Psychiatrist #1 reviewed the treatment plans for Pt #1 from 9/2/25, and verified there had been nothing documented related to the discussion and determination that the bed placement for Patient #1 was to be the pod 2 dayroom; or that other possible options had been discussed. When asked if s/he would have expected the people involved in the treatment team to document something about the bed move related to the altercation between Patients #1 and #2, Psychiatrist #1 agreed that this should have been documented. During an interview on 11/5/25 at 9:58 AM, the Medical Director and Quality Manager #1 reviewed the treatment plan and updates for Pt #1, and verified there had been nothing documented related to the move to the day room for Pt #1’s safety. The Medical Director stated they would have needed to make a notation that Pt #1 was more vulnerable and that s/he had been moved to the dayroom for safety. Record review on 11/5/25 at 10:04 AM with Quality Manager #1 revealed Pt #2 had been admitted to the hospital on 4/19/22 with diagnoses including Schizoaffective Disorder. Review of the progress notes and 24 Hour Patient Observation Record for Pt #2 revealed there had been an altercation on 8/28/25 where Pt #2 hit Pt #1 and had been moved to pod 4, lodge H on 8/29/25 at 3:00 PM. A psychiatric note dated 9/2/25 documented that on 8/28/25, Pt #2 had hit another patient using the shared bathroom with a pillow full of shoes and crayons and had been moved to pod 4 with another peer. Pt #2 had been moved back to pod 1 on lodge H on 8/30/25 at 10:00 AM. Review of the treatment plan, updated 9/2/25, revealed there had been nothing documented related to an incident of aggression where Pt #2 hit Pt #1 and had been moved; and then had been moved back. An entry in the treatment plan for Potential for violence had been opened on 3/10/25. There had been no interventions added related to the incident of aggression on 8/28/25. The Quality Manager verified there should have been an intervention documented. Pt #2 had been moved, but they didn’t document the discussion/intervention. There also had not been a treatment team meeting conducted and documented for Pt #2 the day after the aggression, on 8/29/25 to show the incident had been reviewed. During an interview on 11/6/25 at 3:52 PM, the Medical Director stated that although audits of the treatment plans had been conducted and trends were being shared with quality, a performance improvement plan had not been developed. They also noted that no narriatives or specific dates had been established to indicate progress.”