South Dakota Human Services Center

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 50715 Based on observation, interview, policy review, and manufacturer’s instructions for use (IFU) review, the provider failed to ensure: *Three of three Lifepak 20e defibrillators (life-saving device that sends an electrical shock to the heart) were checked daily per the manufacturer’s IFU. *An eyewash station located in the dental clinic was checked weekly and listed on the provider’s preventative maintenance list. *An Ultrasonic cleaner (automated cleaning device used to remove blood and tissue from dental instruments) performance test (procedure that verifies the machine’s ability to effectively clean) was tested on a regular basis according to the manufacturer’s IFU. *One of one return air vent was on the maintenance schedule to be checked and cleaned in the dishwashing area of the kitchen. Findings include: 1. Observation and interview conducted on 4/20/26 at 1:15 p.m. with nurse manager C on the adolescent acute unit revealed the presence of a code blue cart (emergency cart equipped with life-saving equipment and medications) equipped with a Lifepak 20e defibrillator. She stated that the night nurses were responsible for completing daily checks of both the defibrillator and the crash cart. Documentation reviewed included a daily Lifepak 20e defibrillator and code blue cart checklist, which verified that the auto-test printed, that the AC/DC power cord was plugged in with the green indicator light illuminated, and that all cables were attached and free of cracks, broken wires, or other visible signs of damage. Interview on 4/20/26 at 1:25 p.m. with nurse manager D regarding the defibrillator checks, she confirmed that the defibrillator completed a self-test daily at 3:00 a.m., with a corresponding test strip printed. She verified that the machine was not unplugged during daily checks and that the analyze function was not tested as part of the process. She was unaware of the manufacturer’s instructions for use (IFU) recommendations requiring daily completion of the operator’s checklist. Observations conducted on 4/20/26 at 3:30 p.m. in the birch adult unit and on 4/21/26 at 11:30 a.m. in the electroconvulsive therapy (ECT) procedure room revealed two Lifepak 20e defibrillators. Both units utilized the same checklist for staff completion as stated above. A review of the provider’s undated Code Blue Cart Maintenance policy revealed: “Code Blue carts shall be checked daily using the Code Blue Cart Checklists and forms.” Review of the manufacturer’s 2019 IFU for the Lifepak 20e Defibrillator/Monitor Operator’s Checklist revealed the defibrillator was to be disconnected from AC power, a two-second pause observed, and the device powered on to verify momentary SELF-TEST messages, illumination of LEDs, and an audible speaker beep. The IFU further indicated that the therapy cable was to be connected to the defibrillator to perform a cable check. “If a QUIK-COMBO therapy cable was in use, the test plug was to be connected to the therapy cable, the ANALYZE button pressed, and following the ANALYZING NOW message, the REMOVE TEST PLUG message was to be observed.” The IFU additionally directed that the defibrillator was to be reconnected to AC power and powered off after completion of the checks. 2. Observation and interview on 4/21/26 at 10:30 a.m. with nurse manager E in the dental clinic revealed the presence of an emergency eyewash station. A blank checklist was affixed to the paper towel dispenser above the unit to document weekly maintenance checks; however, no entries had been made. Nurse manager E stated she was unsure who was responsible for performing the weekly checks of the eyewash station. A follow-up interview with nurse manager E on 4/21/26 at 3:30 p.m. revealed that the eyewash station had not been checked since its installation in November 2025. She indicated that maintenance staff were responsible for conducting weekly checks, but this specific eyewash station had not been included in their routine weekly checks or preventive maintenance schedule. Further interview on 4/22/26 at 11:35 a.m. with physical plant manager B confirmed that all emergency eyewash stations were expected to be checked weekly and included in a preventive maintenance schedule according to the manufacturer’s IFU. He verified that the eyewash station located in the dental clinic had not been checked weekly and had not been listed on the preventive maintenance schedule for the previous six months. The provider did not have an emergency eyewash station policy. Review of the provider’s work order checklist for the eyewash stations revealed maintenance staff were to inspect the eyewash stations weekly, ensure saline solutions bottles and eye wash stations were accessible, “confirm operation of the plumbed system (caps pop and full flow of water), confirm saline bottles have not expired, confirm signature sheet is attached to station and up to date.” A review of the provider’s undated Equipment and Machinery Records policy revealed that records were to be kept for all equipment. The purpose is “to facilitate preventive maintenance, to ensure accurate inventory, and to assist in maintenance schedules.” Maintenance staff were responsible for maintaining records daily, weekly, monthly, or quarterly “relative to the description and function of the machinery or equipment,” and for inspecting and documenting the equipment assigned to them. 3. Observation and interview on 4/22/26 at 8:21 a.m. with dental assistant H in the dental clinic revealed an Ultrasonic cleaning system used to clean dental instruments. Dental assistant H confirmed that after daily use, the Ultrasonic machine was drained and sprayed down with Cavacide (disinfectant cleaner). Dental assistant H had not consulted the manufacturer’s IFU for additional operating or maintenance instructions. Review of the undated Ultrasonic Cleaner Performance Test insert included in the manufacturer’s IFU, the ultrasonic cleaning system’s performance was to be tested regularly using strips of standard-weight (household) aluminum foil. The aluminum foil strips used for testing should have been dated and retained until the next performance test was completed. Further review of the Ultrasonic manufacturer’s IFU indicated the cleaning tank was prepared with the cleaning solution in accordance with the manufacturer’s IFU and operated for 15 minutes to de-gas the solution by eliminating trapped air. After degassing, the unit should be turned off, and three pieces of aluminum foil should be suspended in the solution for 5 minutes. The foils were then reviewed to assess the effectiveness of the ultrasonic cleaning system. On 4/22/26 at 8:30 a.m., dental assistant H and nurse manager E confirmed that the performance test had never been performed on the Ultrasonic cleaning system. Both confirmed that no records or documentation had been maintained to demonstrate that the staff was following the manufacturer’s IFU. The provider did not have a policy or process for operating and maintaining the Ultrasonic cleaning system. 18559 4. Observation and interview on 4/22/26 with the food service account manager A of the dishwashing area of the kitchen revealed a dirty return air vent in the ceiling above the dishwasher. The vent had a yellow-colored, grease-like substance on the slats. She agreed the vent was dirty and she had reported the vent to maintenance to be cleaned. Interview on 4/22/26 with physical plant manager B revealed the vent was dirty and needed to be replaced. The vent was not on a weekly or monthly schedule to be checked for cleanliness. The last time the vent was checked had been five years ago when it was replaced. The provider did not have a policy for checking vents for cleanliness.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 50715 Based on observation, interview, manufacturer’s instructions for use (IFU) review, policy review, and Association for the Advancement of Medical Instrumentation (AAMI), the provider failed to ensure: *Four of seventy observed surgical instruments were free of rust and corrosion. *Eighteen of seventy observed surgical instruments were not etched with lettering. *Four of seventy peel packs (disposable packages used to hold instruments during sterilization) containing surgical instruments were free of rust and brown discoloration within the sterilized package. Findings include: 1. Observation and interview on 4/21/26 at 8:50 a.m. in the central store room (CSR) with CSR assistant G revealed a standing bin with four drawers containing sterilized scissors, hemostats, and towel clamps in peel packs. Of the fifty observed peel packs, two showed brown discoloration, and the instruments in those packages had rust on the hinges. She agreed that the instruments and packaging contained rust. They do not use the instruments often, but their previous medical director wanted the provider to keep all the instrumentation. Further review of the surgical instruments in the peel packs revealed that 16 surgical scissors were etched with lettering not done by the manufacturer. CSR assistant G was unaware that the surgical instruments contained personal etching. She agreed that etched instruments would not have complied with the manufacturer’s IFU and could have harbored bacteria. 2. Interview on 4/21/26 at 9:20 a.m. with infection prevention F regarding the above findings revealed she had not realized you could not etch instruments, but agreed bacteria could have settled into the grooves of the lettering. Infection prevention F agreed that the observed instruments contained rust and should not be used on patients. 3. Observation and interview conducted on 4/22/26 at 8:21 a.m. in the dental clinic with dental assistant H and nurse manager E revealed that, of twenty observed peel packs, two orthodontic instruments reprocessed in 2023 and 2024 contained rust within the hinges and box lock (hinge mechanism where the two halves are joined), and two instruments were etched with lettering. Dental assistant H stated that many of the instruments were old, and she had been reviewing and discarding them. She confirmed that the instruments were re-sterilized if they were greater than one year old. She further stated, “I only allowed the peel packages with the red lettering on the back to be used because I had inspected them.” Observation of the peel packs revealed that not all packages had red lettering on the back, and that some had been reprocessed two to three years ago. Dental assistant H and nurse manager E confirmed the presence of rust and stated they were unaware that the instruments were etched with personal lettering. Both staff acknowledged that the instruments should not be used on patients. 4. Review of the provider’s undated Packaging, Sterilization, and Storage of Reusable Instruments policy revealed all reusable items should have been cleaned and inspected before reuse. “Inspect packaging materials for defects and extraneous material [blood, tissue] before using. Do not use packaging materials with defects or foreign materials that cannot be removed. Inspect every package removed from storage to ensure integrity and items will not be used if: wrapping has been exposed to moisture (water stains); item is opened, damaged (hold, tear, or abraded area).” 5. Review of the provider’s undated Transporting, Manual Cleaning, and Inspection of Instruments policy revealed under the inspecting cleaning instruments section, all instruments prior to packaging will be checked for the following: “All instruments for corrosion, cracks, pits, nicks, rust, burrs, or worn spots. Any instruments with defects will be removed from service.” 6. Review of the 2017 AAMI-ST 79 guidelines, pg. 40 revealed, “Instruments should be carefully inspected for flaws, damage, debris, detergent residue, and completeness, then dried.””

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 27198 Based on observation and interview, the provider failed to ensure portable space heaters used in two randomly observed staff areas (rooms B109 and B136) had heating elements that did not exceed 212 degrees Fahrenheit (100 degrees Celsius) as required. Findings Include: 1. Observation on 4/21/26 at 11:04 a.m. revealed a portable space heater was in use in room B136 (marked “Housekeeping”). That space heater was not used in a prohibited area; however, for portable space heaters to be used in nonsleeping staff and employee areas, they are required to have heating elements that do not exceed 212 degrees Fahrenheit (100 degrees Celsius). Interview with the director of operations at the same time as the observation revealed he was unaware that space heater was in use in that location. Further interview at that same time revealed the provider did not have documentation indicating that portable space heater’s heating elements did not exceed 212 degrees Fahrenheit (100 degrees Celsius). 2. Observation on 4/21/26 at 11:17 a.m. revealed a portable space heater was in use in office B109. That space heater was not used in a prohibited area; however, for portable space heaters to be used in nonsleeping staff and employee areas, they are required to have heating elements that do not exceed 212 degrees Fahrenheit (100 degrees Celsius). Interview with the director of operations at the same time as the observation revealed he was unaware that space heater was in use in that location. Further interview at that same time revealed the provider did not have documentation indicating that portable space heater’s heating elements did not exceed 212 degrees Fahrenheit (100 degrees Celsius).”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 26632 Based on a review of the South Dakota Department of Health (SD DOH) complaint intake information, SD DOH facility reported incidents (FRI), observations, interviews, record review, and policy review, the provider failed to ensure safety mechanisms were in place to support five of five sampled patients (2, 3, 4, 5, and 6) and staff were safe from physical abuse and harassment by one of one sampled patient (1) who frequently displayed verbal, physical, aggressive, and sexually inappropriate behaviors. Findings include: This failure has the potential to cause harm to other patients who reside in the same unit from serious injury or harm from his unpredictable and inappropriate behaviors. Notice: On 5/30/24 at 4:30 p.m. administrator A was informed of an Immediate Jeopardy (IJ) for failure to have had a plan in place to prevent patients from serious injury or harm. Plan: The facility provided the following acceptable removal plan on 5/31/24 at 11:03 a.m. for patient rights: 1. “Multi program collaboration review of the treatment plan and daily rounds. a. Weekly treatment team, consisting of attending psychiatrist or designee, charge nurse (or designee) from both programs (Psych Rehab and Intensive Treatment Unit), Social Work, Psychologist, and other disciplines as assigned will meet weekly and update the treatment plan. Documenting updates to goals, interventions, and objectives. b. Meet Friday May 31, 2024 and weekly thereafter until patient is stable and returns to his home program. c. Psych Rehab treatment team will round each business day with Intensive Treatment Unit team for updates to the active treatment for patients. d. Chart reviews completed nightly by assigned night shift staff to monitor completion of the treatment plan documentation each business day. Night shifts staff will report to Adult Acute Hospital Nurse Manager or designee compliance or lack of compliance. Acute Hospital Nurse Manager or designee will compile audits and report to Quality Council beginning in June and monthly until patient returns to home program.” 2. “Create behavior plan if assessed by the treatment team as appropriate based on patient ability to engage and follow a plan. a. Complete by end of day 5/31/2024 if treatment team deems clinically appropriate. b. Will include patient strengths, likes and dislikes and guidance to staff on how to interact safely. c. Will give outline of positive reinforcement, not negative reinforcement that would be indicative of a punitive response. d. Behavior plan will be reviewed weekly or sooner as clinically appropriate during the treatment team meeting to review the treatment plan. e. Every two weeks chart reviews will be completed by assigned night shift staff to ensure behavior plan is updated. Assigned night shift staff will report to Adult Acute Hospital Nurse Manager or designee compliance or lack of compliance. Adult Acute Hospital Nurse Manager or designee will compile audits and report to Quality Council beginning in June and monthly until patient returns to home program. f. C2 Staff will be required to document they have read the behavior plan. g. Adult Acute Program Nurse Manager or designee will monitor log to ensure all staff working have signed acknowledgement of understanding behavior plan (if behavioral plan is deemed applicable).” 3. “Physical Therapeutic Environment. a. Patient will remain on C2 Adult side with no other patients for reduced stimulation for patient and safety of other patients until medication affecting behaviors has cleared and behaviors and aggression has diminished. b. Other adult patients will be house on the C2 Adolescent side of the unit until patient on adult side is stable once again free from aggression behaviors. c. All patients will be given individualized treatment and assessed for appropriateness of level of care on intensive treatment unit based on their individual needs and their ability to handle the stimulus of other patients. d. This will be audited through regular clinical assessment.” 4. “Staff education and support with interacting with patient. a. SDHSC [South Dakota Human Services Center] will have Employee Assistance Program services available on campus weekly beginning week of June 3, 2024. Staff will be encouraged to utilize these services to process any concerns, fears, and barriers to interacting therapeutically with patients. b. Staff will be directed that all interactions with patient will be with no less than two staff. c. SDHSC Nonviolent Crisis Intervention Coordinator created a guide with de-escalation techniques and suggestions on how to safely interact with patient utilizing Nonviolent Crisis Intervention skills. This guide has been developed and will be distributed beginning with PM on 5/30/24. d. C2 Staff will be required to document they have read the de-escalation guide. e. Adult Acute Program Nurse Manager or designee will monitor log to ensure all staff working have signed acknowledgement they read the de-escalation guide.” 5. “All nursing staff working on C2 will read nursing documentation required reading on day published (May 31). Nursing staff not working on C2 on 5/31/2024 will read the documentation changes prior to working their next shift on C2. a. Nursing documentation required reading will be distributed via Policy tech reiterating all patients on C2 will have a nursing note documented for each patient each shift on C2. b. Adult Acute Nurse Manager or Designee will monitor completion of required reading and report to Quality Council in June 2024.” The removal plan for the IJ was received and accepted on 5/31/24 at 11:03 a.m. The implementation of their plan was verified and their IJ status was removed on 6/3/24 at 11:00 a.m. Review of the provider’s SD DOH FRIs on 5/2/24, 5/7/24, 5/12/24, and 5/22/24 reports, observation, interview, record review, and policy review, the provider failed to ensure the safety of: *Five of five sampled patients (2, 3, 4, 5, and 6) from physical and verbal abuse by one of one sampled patient (1). *One of one mental health associate (I) from verbal and sexual abuse by one of one sampled patient (1). Refer to A145.”

“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: 26632 Based on the provider’s submitted South Dakota Department of Health (SD DOH) facility reported incidents (FRI), observation, interview, record review, and policy review, the provider failed to ensure the safety of: *Five of five sampled patients (2, 3, 4, 5, and 6) from physical and verbal abuse by one of one sampled patient (1). *One of one mental health associate (MHS) (I) had been safe from verbal and sexual abuse by one of one sampled patient (1). Findings include: 1. Review of the provider’s SD DOH FRIs regarding patient 1 revealed: *FRI 1 on 5/2/24 at 6:00 p.m. revealed: -Patients 1 and 2 had been seated at the dining table watching television in the intensive treatment unit (ITU). -Patient 1 left where he was seated and went to his room for several minutes. After patient 1 had left, patient 2 got up, moved to where patient 1 had been seated and sat in that spot. Patient 1 came back and stated to patient 2 “I was sitting [in] that spot, you need to move.” Patient 1 slapped patient 2 across his head with an open hand. The interventions put in place after the altercation were “increased staffing was added to the adult side of the intensive treatment unit in order to keep the patients physically separated or intervene when they get within arm’s reach of each other.” *FRI 2 on 5/7/24 at 4:20 p.m. revealed: -Patient 3 was seated at the table with his head down listening to music on his headphones. Patient 1 had been seated in the day hall watching television. He stood up and approached patient 3 in a threatening manner. He yelled at patient 3 and then knocked his headphones off and slapped patient 3’s head at that time. -Patient 1 continued to be very agitated and was making threatening statements to patient 3 and the staff. Patient 3 was transferred from the ITU to the adult acute unit. The provider initiated new interventions to keep other patients safe by keeping patient 1 and other patients separated as much as possible. Every attempt was being made to not have other adult patients with him when possible. *FRI 3 on 5/12/24 at 2:15 p.m. revealed: -Patient 1 was in the ITU and was watching other patients from the adult acute unit through the windows of the shared courtyard. He and patient 4 had been observed as making hand signs at each other which the staff interpreted as “gang” signs. -Patient 1 suddenly and forcefully pushed a door open to the courtyard. He and patient 4 ran towards each other and started to have a fist fight. They went to the ground and rolled around and continued to strike each other. MHA Q yelled for them to separate. Patients 1 and 4 stood up and briefly separated. MHA Q was able to get patient 1 to go back to the ITU. Patient 4 continued to attempt to hit patient 1 as he was going into the ITU. MHA Q secured the door between patient 1 and 4. Patient 1 was assessed for injuries and had several cuts and scratches on his hands. He was given an as needed anti-anxiety medication and then went to his room. There were no other interventions implemented. *FRI 4 on 5/22/24 patient 5 was walking up and down the hallway past patient 1’s room. Patient 5 was talking and laughing out loud, which was his typical behavior. Patient 5 entered his bedroom and was standing just inside his doorway when patient 1 opened his bedroom door. Patient 5 then entered his room and shut the door. Patient 1 started to swear and asked patient 5 what he had said. Patient stopped outside patient 5’s bedroom door, opened it, and then pushed patient 5 down onto a mat. -On 5/24/24 a difficult case conference was held with department head staff. Interventions put in place related to patient 1’s continued aggression towards other patients from that meeting included: --“Make medication adjustments based on recommendations from a couple of the more seasoned psychiatrists.” --“Remove the adolescents from one side of the ITU and put all the other adults on that side so that patient 1 would be by himself.” Review of four MHA incident reports revealed patient 1 had aggression towards MHA H, registered nurse (RN) M, and maintenance staff S. 2. Review of patient 1’s medical record revealed: *He had been admitted on 8/17/23 and was discharged to be transferred on 10/26/23 to the psych rehab program. *His medications had been changed in the psych rehab (PR) and was re-admitted to the ITU at the hospital on 5/2/24. *His diagnoses included schizophrenia and anti-social personality disorder. *Review of patient 1’s physician/psychiatrist progress notes revealed: *A note on 5/6/24 at 10:45 a.m. by medical director/psychologist stated due to the medication changes. -His medication had been changed from Risperdal to Abilify (mood stabilizing medications) and after approximately one week he had become agitated and irritable. *Review of patient 1’s behavioral event documentation from 5/2/24 through 5/29/24 indicated he had: -Three episodes of hitting other patients. -Two episodes of destruction of property. -Forty-three episodes of intimidation, physical aggression, refusals, and questioning. -Eleven episodes of sexual harassment. -One episode of making physical threats. Review of patient 1’s treatment plan report for 5/2/24 revealed:*Multidisciplinary summary: “[Patient 1] was transferred to C2 on 5/2/24 due to increase paranoia, “ *He had two new problems with short-term goals and interventions. Those included: -Long term goal was “Within 7 days [patient 1’s name] will be able to transfer back to his home after a decrease of paranoia is observed.” -Short Term Goal: “Patient will have 2 instances of paranoia within 7 days.” -Interventions-Mental health staff will offer low-stimulus activities to [patient 1] to monitor for paranoia and offer coping skills when he appears upset.” *Patient 1’s multidisciplinary summary 5/23/24 revealed his long and short-term goals included: -“get money and save money.’ -“Discharge to sisters home in [name of town].” -“Patient’s treatment plan was updated due to a recent seclusion event. Treatment plan content wording was adjusted to reflect verbal and physical aggression. Seclusion event details were documented under the treatment plan objective. An intervention was added for staff to offer supportive 1:1 conversation to the patient. Treatment plan will continue to be reviewed and updated as needed.” 3. Observation and interview on 5/29/24 at 9:37 a.m. with RN/nurse manager N revealed: *RN/nurse manager N was the adolescent nurse manager. *RN/nurse manager E was adult nurse manager. *One staff person was assigned to watch the cameras. The cameras were in each patient room, the seclusion rooms, the day room, and the dining area for each side of Cedar 2. *The staff would rotate to be responsible for two-to-three hours of monitoring the cameras. *During the tour of the Cedar 2 unit it was revealed the unit was divided in half by a wall. One side was the ITU for adults and the other side was the ITU for adolescents. *Patient 1 was the only patient in the adult ITU. *There were three adult patients in the adolescent ITU. *The adolescent patients had been moved to another unit due to the need for patient 1 to be alone in a unit. *If an adolescent patient required the adolescent ITU they would have grouped the adults back together. *Increased staffing would have been needed if the adults on the adolescent side would have to moved back to the adult side. 4 .Video review on 5/29/24 at 11:06 a.m. with assistant administrator D revealed: *On 5/2/24 patient 1 and 2 were in the adult ITU on Cedar 2. -At 5:53 p.m. patient 1 was seated in a chair watching television, got up, and went to the nurses’ window, then sat down at a picnic-type table. -At 5:54 p.m. patient 2 stood up and sat at the other end of the table away from patient 1. -At 5:56 p.m. patient 1 went up to the nurses’ window and then went down the hall to his room. -At 5:57 p.m. patient 2 moved to where patient 1 had been seated. Patient 1 then came immediately back and started to yell at patient 2. Three staff came to the area to intervene and he reached out and hit patient 2 on the left side of his head. Staff assisted patient 1 in walking down the hall to his room. He was cooperative with the staff. -At 5:59 p.m. patient 1 was out walking in the hallway. *On 5/7/24 patient 1 and 3 were in the adult ITU on Cedar 2. -At 4:20 p.m. patient 1 was sitting in the day area. -At 4:23 p.m. patient 3 was sitting at the table with headphones on, then patient 1 walked over to patient 3 and pulled his headphones off. -At 4:25 p.m. patient 1 walked down the hall to his room. -At 4:26 p.m. multiple staff arrived on to the adult ITU. -At 4:27 p.m. RN R was in patient 1’s room with him. A code green [all available staff to report to the unit] was initiated. -At 4:30 p.m. RN R was in the hall by patient 1’s door looking into his room. She then entered his room. RN M then came down the hall and also entered his room. She was holding a syringe and stated she was giving him Ativan (a sedating medication) intramuscularly. -At 4:37 p.m. RN M left his room and told staff who had reported for the code green they could return to their assigned areas. *On 5/22/24 patient 1 and patient 5 were in the adult ITU in Cedar 2. -At 3:58 p.m. patient 5 was walking around the cedar 2 unit with headphones on and talking to himself, then patient 5 was standing in the doorway of his room, when patient 1 went to the doorway of patient 5’s room and pushed patient 5 down onto a mat on the floor. -At 4:01 patient 5 went to his room. -At 4:02 p.m. patient 5 came out of his room, took his headphones off, and returned them to the nurses’ desk. -At 4:03 p.m. patient 1 went back to his room. Staff had to redirect other patients out of the hallway. Interview on 5/29/24 at 2:42 p.m. with HA G revealed she: *Provided direct care of the patients, and helped with everyday activities. *Watched the adult and adolescent ITUs through the cameras. The task of watching the cameras was rotated between staff to avoid fatigue. *Had other duties while watching the cameras that included: assisting patients with making phone calls, and observing the day hall and the courtyard. Agreed there were distractions while staff watched the cameras so there were times the cameras were not monitored. *Had worked with patient 1 since his admission and during his previous admissions. *Felt he used his size as intimidation to get what he wanted. *Observed he was less aggressive with women, but did touch them in an unwanted way. *Charted his behaviors in his electronic medical record. *Knew he had been in PR prior to his admission to the ITU and that he had a medication change and increased behaviors due to the medication change. *Explained patient 1 had been doing “pretty good”, and was not aware of any need for seclusion. He was very paranoid, he had heard PR did not want him back, and started to be more aggressive. *Stated he had become more fidgety and watched her because she was assigned to monitor the cameras. He had asked to go outside on 5/12/24 and was told no because there were patients outside from another unit. He had watched and waited until the area was clear and then broke the door open to the courtyard and “went after” patient 4. *Explained how patients were monitored in seclusion as: -The cameras were watched by staff, in addition to other duties. -All of the corners of the rooms were not able to be seen with the current camera system. -If the person had been placed on suicide precautions staff would go to the patient’s room if the patient was unable to be seen on the cameras. The staff could look through the patient’s door and see all areas of the room. Interview on 5/29/24 at 3:19 p.m. with HA HO regarding patient 1 revealed:. *He felt patient 1 was paranoid, used intimidation, and used aggression against staff. *Patient 1 had been there for over a month and he had not seen any changes. He was aware patient 1’s medications had been changed while in PR when he was at PR he was doing well and working towards discharge. *He felt if patient 1 did not get what he wanted he would become more aggressive. *He stated people are scared of patient 1, some staff “walk on eggshells” around him and he is inappropriate with the female staff. *He felt patient 1 manipulated situations and understood what he was doing. *He stated there needed to be more interventions for patient’s behaviors. He did not feel any changes had been made regarding patient 1 to keep patient 6 safe. Interview on 5/29/24 at 3:47 p.m. with HA IP regarding patient 1 revealed: *He primarily worked in PR and would frequently pick up shifts in the SITU in Cedar 2. *When patient 1 was in PR he had done very well. He would use his headphones and walk around outside, had a job in the unit, and all interactions he observed of him were good. *After patient 1 moved to the adult SITU in Cedar 2 and his mood would “Go from 0 to 100 very quickly.” Interview on 5/29/24 at 4:11 p.m. with RN AM regarding patient 1 revealed:*Patient 1 had been in the adult SITU in Cedar 2 for about a month. *Staff were scared of him. They feared what he would do when the redirected him or tried to do any of the interventions for his behaviors. *There had been multiple incidents of him being threatening and aggressive. She felt there were no consequences for his actions. Telephone interview on 5/30/24 at 9:00 a.m. with HA I regarding patient 1 revealed:*Patient 1 was hypersexual (compulsive sexual behavior), paranoid, and had threatening behaviors. *He had inappropriately touched multiple female staff. *She felt he knew what he was doing. *He would slap her butt, rub her back up and down, and squeeze her buttocks. *She would tell him to stop but he was not redirected unless someone else had witnessed and stepped in. *She felt violated and targeted by his sexual behaviors. *She would try to not put herself in a position to allow him to be close to her. *She stated he appeared to run the unit. Interview on 5/30/24 at 10:38 a.m. with RN/Nurse Manager E regarding patient 1 revealed:*He is the nurse manager for the adult SITU. *The SITU team had not been involved in patient 1’s treatment. The PR team still provided all the interventions regarding patient 1 for staff. *The teams were aware of his behaviors. The PR team decided on 5/23/24 to have patient 1 in the adult SITU by himself for the safety of others. *A lot of the staff were scared of patient 1. *Agreed patient 1 “ran the SITU because he was very scary.” Review of the provider’s 1/30/23 Patient Abuse, Neglect, or Exploitation policy revealed the provider was: *”To ensure that the patients at SDHSC are protected from abuse, neglect or exploitation.” *”To identify a process that shall address allegations of abuse, neglect or exploitation.””