Kindred Hospitals-Dayton

“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: 29000 Based on record review, review of a sexual assault nurse examiner (SANE) report, review of the facility grievance and complaint log, staff interview, family interviews, SANE nurse interview, police detective interview, and policy review, the facility failed to conduct a thorough investigation into an allegation of sexual abuse in an attempt to identify the perpetrator and prevent other patients from sexual abuse. This affected one (Patient #2) out of one patient reviewed for sexual assault with the potential to affect all patients receiving care in the facility. The facility census was 18. Findings include: Review of the medical record revealed Patient #2 was admitted on 10/15/24. Review of the history and physical revealed the patient with a history of an aortic arch replacement on 08/06/24 which was complicated by bleeding. Patient #2 developed cardiogenic shock and was placed on extracorporeal membrane oxygenation (ECMO), developed increased intracranial pressure and had multiple cerebral vascular accidents (CVA). The patient had a history of seizures. A tracheostomy was placed for acute respiratory failure on 09/06/24. Patient #2 was on full ventilator support on admission with pulmonary consulted to help wean off the ventilator. Patient #2 was able to move her right arm and right leg, with the inability to move her left leg. The patient was not able to communicate, but did follow some simple commands. Upon admission Patient #2 required intermittent dialysis with the last treatment completed on 10/14/24. Review of the Speech therapy (ST) notes on 10/17/24 at 9:34 AM revealed Patient #2 had an evaluation for a Passy Muir Valve (PMV). Notes stated this patient was aroused with verbal and tactile stimulation, but only responded to yes/no questions regarding self. Notes from the ST on 10/23/24 at 11:51 AM stated the patient was alert with motor agitation. She was throwing her legs off the bed. Notes on 11/06/24 at 10:59 AM revealed an evaluation was completed for difficulty swallowing. The patient was alert and following commands greater than 50 % of the time. Motor agitation was present with left arm, trunk and right leg movements. The PMV was present. Review of pulmonary notes on 11/06/24 revealed Patient #2 was more alert, although not following commands consistently. Review of the complaint grievance log and incident reports revealed on 11/06/24 an incident was reported by Staff C stating Patient #2 reported she was sexually abused. Review of the 11/06/24 incident report revealed the facility investigation began on 11/06/24 at 5:15 PM after Patient #2 stated “They raped me.” The supervisor, Staff C, notified Patient #2’s mother and the Chief Clinical Officer (CCO) of Patient #2 ’ s allegations at 5:30 PM. The patient stated they do this when they clean her and stated the CCO was part of it. The local police arrived at 7:25 PM to interview the patient and her mother. One officer exited the room at 7:40 PM and spoke with the CCO informing them this patient stated the incidents happened 11/05/24 and 11/06/24 and it was a black cleaning guy. The facility investigation on 11/07/24 at 10:50 AM documented a police officer arrived and informed the CCO this patient was stating a black male in their mid 20’s from the cleaning department raped her on 11/05/24 and 11/06/24. The detective requested to have the names of the black males from the cleaning and clinical teams to be emailed to them. The facility investigation continued until 11/07/24 at 3:15 PM with the CCO reviewing the visitor log and then self reporting this allegation to the Ohio Department of Health. Review of the SANE report revealed an exam was performed on 11/07/24 at 1:25 AM for Patient #2. The assault history noted the exam was performed using direct visualization, alternative light source, magnification and photography with this patient unable to tolerate a speculum exam. The report listed injuries were noted and identified as a 2 centimeter (cm) by 0.5 cm tear to the posterior fourchette, a 2 to 3 cm tear to the fossa navicularis, and a 2 cm tear to the hymen at 6 o’clock. The report stated these injuries are consistent with forceful penetrating trauma. Interview on 11/12/24 at 11:00 AM, the Director of Quality (Staff A) stated the facility started the investigation into Patient #2’s allegation and had began interviews with staff. Patient #2’s mother came in and narrowed the perpetrator down to an african american environmental service (EVS) worker. The police detective told the facility to stop our investigation so they could interview people, so they stopped their investigation. Interview on 11/12/24 at 3:00 PM, the lead case Detective stated they saw the patient the next day at the transferring hospital. The patient stated she could not identify the person who raped her. The patient stated this happened four different times with four different suspects. The Detective stated the only issue the police have is the SANE nurse informed them of blunt trauma identified on the SANE exam. The Decective stated they were still investigating, but it is difficult do to this when the patient is unable to identify a perpetrator. The Detective stated they asked the facility not to interview the housekeeper who works 4:00 PM-11:00 PM. The Detective stated they had not yet spoken to the EVS worker identified by the mother and currently had nothing to prove or say this staff member shouldn’t be working. A second interview on 11/13/24 at 10:15 AM with the Detective revealed the Detective had spoken with the EVS worker and believed he was much older than who the patient described. The Detective stated they felt the only evidence they had for this case was the evidence the SANE nurse obtained. The Detective stated they had no problem with they facility conducting interviews with staff and patients, they just didn’t want them speaking to the identified EVS worker. Interview on 11/13/24 at 3:00 PM, Staff A stated the facility did not suspend anyone since they did not have a suspect that matched the description provided by Patient #2 and they cannot suspend everyone with the broad description of a black male. Interview via telephone on 11/13/24 at 5:30 PM, the SANE nurse stated she believes something happened to Patient #2. She had injuries to the posterior focia and hymen at 6 o’clock, which came at an anterior approach. The SANE nurse stated when she irrigated these areas they bled which is concerning for trauma. The patient was very adamant it was a black male who caused her injuries. The SANE nurse staed sometimes it may take two months to get the test results and with the vaginal bleeding Patient #2’s tests most likely won’t show anything. Interview per telephone on 11/14/24 at 11:24 AM, Patient #2’s mother stated her daughter was transferred to this facility on 10/15/24 and things were going well. Her good friend was visiting on 10/25/24 and said there was a janitor peeking in her room, so the mother asked for a curtain. On 11/06/24 Patient #2 said someone raped her so the mother had her sent to the hospital for a rape kit. Her vaginal bleeding has stopped since she was moved to a different facility after the hospital assessment. Interiew on 11/18/24 at 9:12 AM, Staff C stated on 11/06/24 she assisted the patient care technician (PCT) to provide care for Patient #2. Patient #2 had been on her period since she was admitted. The patient had her sheet and chux pushed up her back. Staff C and the PCT cleaned her up and placed new sheets underneath her, leaving the room around 4:15 PM. Patient #2 commonly kicked her leg and bats her arms towards staff when receiving care, unless she is sedated. At approximately 5:15 PM another nurse observed Patient #2 had had scooted down in the bed and was lying crooked with the sheets again up by her neck. Patient #2 was again fighting the staff providing care. Staff C and the PCT saw a respiratory therapist (RT) walk by and called for her to help. Shortly after this the patient stated “They raped me.” Staff C asked her to clarify her comment. Patient #2 stated to call her mom and her grandma. Staff C kept asking who had raped her, but she wouldn’t respond. Staff C then called the Director of Quality who said to call her mother, which was done. When her mother arrived and asked Patient #2 who did this to her she kept repeating “Cleaning me, cleaning me.” When the patient was asked when does this happen? Patient #2 stated at five or six at night. Staff C stated she never saw anyone but the PCT, the RT, and Staff C go into the room. Staff C stated when the police arrived they went to the room and spoke with the patient and her mother. They then came out and spoke with the Chief Clinical Officer (CCO). Staff C was working the next day and a police officer came back and eluded the patient’s bleeding was new per the SANE nurse. The day supervisor called the hospital to see if the patient would be returning and was informed evidence of penetration was found during the SANE exam. Staff C stated one day her mother said one of the housekeepers was standing at the door looking in and requested a portable curtain. A second interview on 11/18/24 at 12:04 PM with the SANE nurse revealed the injuries could be acute, but it is difficult to narrow down, but within a few days. The SANE nurse stated observations revealed the bleeding was coming from inside the vaginal vault as menstrual and other bleeding was from a laceration. Interview on 11/20/24 at 8:05 AM, the Chief Operating Officer, Staff B, stated stated they started the investigation immediately when Patient #2 reported the allegations. The next day the facility heard from the hospital they had found evidence of abuse. Staff B stated they met with the detective and discussed the situation. The detective stated the perpetrator was a black male in their mid 20’s who worked in housekeeping. Staff B stated they have no staff who met this description. Staff B stated they provided the detectie a list of all EVS employees. Staff B asked the detecgtive how the facility should proceed and the detective stated he wanted to interview patients prior to the facility. The detective called back later to ask if anyone wears purple sweatshirt or scrubs, which no department does. Staff B stated the facility has restarted their investigation once they were informed of there were issues with the facility not investigating Patient #2’s concern. Review of the facility policy titled “Abuse of Patient, Elder, Child by Staff Identification Response and Reporting,” dated October 2022, defined a dependent adult as one between the ages of 18 and 64 who has physical or mental limitations which restrict his or her ability to carry out normal activities or to protect his or her rights. This policy defines patient abuse, neglect and/or mistreatment any incident of physical, sexual or verbal abuse, neglect and or mistreatment that is reported by the patient or family or is witnessed, reported or suspected by an employee. This policy lists the procedure if a suspected abuse occurs with an employee immediate action measures should include, but not limited to, suspension of the employee involved, reassignment of other staff not involved in an allegation, review of patient’s care plan and restriction of visitors and to notify the attending physician, Chief Clinical Officer and nursing supervisor immediately. This policy further instructs staff to assess the patient’s mental state in order to judge the accuracy of the report, assess charged employees work records and note any history of similar incidents or related behaviors, investigate all other possible sources of information relation to the incident and/or persons involved. Interview on on 11/14/24 at 11:00 AM, Staff A verified the facility failed to complete an investigation of sexual assault to prevent further abuse towards other patients.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 29000 Based on medical record review, policy review, and staff interview, the facility failed to ensure patients were turned every two hours to prevent the occurance of new skin breakdown. This affected four (#2, #3, #4 and #6) patients with the potential to affect all patients cared for in this facility. The facility census was 18. Findings include: 1. Review of the medical record revealed Patient #2 was admitted on 10/15/24. Review of the history and physical revealed the patient with a history of an aortic arch replacement on 08/06/24 which was complicated by bleeding. Patient #2 developed cardiogenic shock and was placed on extracorporeal membrane oxygenation (ECMO), developed increased intracranial pressure and had multiple cerebral vascular accidents (CVA). The patient had a history of seizures. A tracheostomy was placed for acute respiratory failure on 09/06/24. Patient #2 was on full ventilator support on admission with pulmonary consulted to help wean off the ventilator. Patient #2 was able to move her right arm and right leg, with the inability to move her left leg. The patient was not able to communicate, but did follow some simple commands. Review of the a skin care assessment dated 10/17/24 at 7:56 PM by the wound care nurse revealed wounds to the right heel measuring 2.5 centimeters (cm) by 1.5 cm with no depth. The left heel had a Stage 3 ulcers with measurements of 3 cm by 2.6 cm by 0.2 cm. Review of physician orders revealed to turn the patient every two hours arouund the clock due to history and unable to turn and re-position self. The medical revealed repositioning was completed but lacked evidence it was completed every two hours. Review of nursing notes on 10/25/24 at 11:49 PM documented Patient #2 was turned to the right side. The next documentation of repositioning be completed was not until at 4:10 AM. Notes by patient care technicians on on 10/26/24 and 10/29/24 from 7:00 PM through 7:00 AM on docuemented Patient #2 repositioned themselve. There was no documentation of repositioning occurring every two hours as ordered. Notes on 10/27/24 at 4:00 AM revealed this patient was turned with the next turn not completed until 8:00 AM. Notes from patient care technicians, Staff D, on 10/30/24 at 12:23 AM revealed this patient turned themselves. Turning was not documented again until 4:10 AM with no documentation of what position the patient was in. On 11/04/24 Staff D documented Patient #2 repositioned themselves at 12:26 AM with the next documentation completed at 7:00 AM. Documentation by Staff D on 11/05/24 at 1:00 AM noted Patient #2 repositioned themselves. The next documentation was at 6:00 AM stating the patient re-positioned themselves. Notes on 11/06/24 at 1:32 PM stated the patient re-positioned self with the next documentation of repositioning occurring at at 8:00 PM when the patient was on the left side. On 11/01/24 documentation revealed the presence of a sacral wound measuring 6 cm x 8 cm. This note further stated this wound was a deep tissue pressure injury acquired after admission. Review of the facility policy titled “Clinical Guidelines for Pressure Injury,” dated June 2022, revealed the policy instructed staff to complete a skin assessment upon admission, then every shift. Staff must re-position patients a minimum of every two hours. Interview on 11/18/24 at 4:20 PM, Staff C verified the findings of not repositioning Patient #2 every two hours as ordered with this patient developing a sacral wound. 2. Review of the medical record revealed Patient #3 was admitted on 10/13/24 after having their aortic valve replaced. The patient developed osteomyelitis in the sternum with the sternum removed. This patient was admitted to continue with intravenous (IV) antibiotics and wound vacuum dressing changes to the sternum. Wound care nursing notes on 10/13/24 revealed wounds to the mid upper abdomen measuring 0.5 cm by 0.5 cm by 0.1 depth with no tunneling. There wounds included a right upper quadrant wound measuring 1.2 cm by 1.5 cm by 0.1 cm., a right distal breast wound measuring 2.4 cm by 6 cm with the depth unable to determined, a left upper quadrant wound measuring 1 cm by 1 cm, and a sternum wound measuring 8 cm by 1.5 cm with the unable to be determined. Physician orders at admission included to turn every two hours and to give pressure relieving interventions to prevent skin breakdown. Medical record review revealed Patient #3 was not turned every two hours per physician order. On 11/03/24 the patient was turned to her right side at 12:32 AM and not repositioned until 6:00 AM. Notes on 11/03/24 at 8:35 PM documented the patient was turned to the right side and remained there until 11/04/24 at 8:06 AM. The patient was assisted to a sitting position on 11/04/24 at 12:10 PM and not repostioned until 4:48 PM. The documentation revealed the patient was on their right side from 11/04/24 at 8:41 PM until 11/05/24 at 6:02 AM. Patient #3 was repositioned to her left side on 11/05/24 from 10:00 PM until 2:00 AM on 11/06/24. This patient was in a sitting up position on 11/06/24 from 10:20 AM until 3:59 PM. Review of wound care notes dated 11/04/24 listed a new wound was noted to the sacrum measuring 8 cm by 7 cm. Interview on 11/18/24 at 4:25 PM, Staff C verified Patient #3 was not turned every two hours and developed a pressure ulcer to the sacrum after admission. 3. Review of the medical record revealed Patient #4 was admitted to this hospital on 10/30/23 from a local hospital after suffering a cardiac arrest on 10/11/23. Additional diagnoses included an anoxic/hypoxemic brain injury. Patient #4 was admitted to this hospital with a tracheostomy, on a ventilator, and with a percutaneous endoscopic gastrostomy (PEG) tube. Reviw of notes from the wound care nurse on 10/31/23 listed wounds on the anterior portion of the neck, left medial wrist, and hard dark skin between thumb and first finger linear from palm to dorsal hand and linear between fifth finger and wrist. The medical record revealed Patient #4 was on their right side on 11/04/23 from 2:00 PM until 7:09 PM. The patient was on their right side on 11/06/23 from 10:42 AM until 4:01 PM. On 11/17/24 documentation revealed the patient was on their right side from 9:00 AM until 1:00 PM. On 11/18/23 the patient was on the right side from 6:00 AM to 10:00 AM and again from 8:00 PM until 11/19/23 at 2:00 AM. Docuementation revealed Patient #4 was on their right side on 11/23/23 from 10:49 PM until 11/24/24 at 4:05 AM. Notes on 12/02/23 revealed the patient was on their right side from 4:00 AM until 10:26 AM. Notes on on 12/10/23 revealed the patient was turned to the left side at 5:49 PM and remained there until 12/11/23 at 1:57 AM, when the patient was turned the right and remained in this position until 6:15 AM. Notes documented this patient was on his right side frequently for greater than four hours and was not able to reposition themselves. The record documented on 12/07/23 a new wound to the right buttock measuring 8 cm by 6 cm, with depth unable to determined. A new wound was noted to the right lateral foot measuring 2.6 cm by 3 cm, with depth unable to determined. Patient #4 was transferred to a skilled nursing facility on 12/11/23 with new wounds to the right buttock and right ankle. Patient #4 returned to this facility on 12/22/23 from an outside hospital at 2:00 AM. Review of the record revealed notes on 12/23/23 at 6:25 PM documenting the patient was turned to the right side and remained there until 12/24/23 at 2:34 AM. The patient was on their left side on 12/24/23 from 12:34 PM until 8:00 PM. Documentation on 12/26/23 showed this patient was turned to the left side from 7:00 AM until 11:00 AM, then to the right side until 4:15 PM. Patient #4 was transferred to a skilled nursing faciity on 01/22/24. Patient #4 returned to this facility on 03/23/24 at 6:00 PM. Review of wound nurse notes on 03/25/24 documented the sacrum wound was 9 cm by 7.5 cm by 1.3 cm deep. The coccyx wound was 9.6 cm by 9 cm by 1.6 cm deep. Review of the record revealed notes on 03/25/24 revealed the patient was on their left side from 4:00 AM until 10:00 AM. Notes on 03/26/24 at 5:40 PM documented the patient was turned to their right side and wasn’t turned to the left side until 03/27/24 at 4:00 AM. Notes on 03/29/24 at 2:00 AM noted the patient was on their left side and remained there until 1:10 PM when he was turned to the right side. Interview on 11/19/24 at 9:35 AM, the wound care nurse, Staff W, stated Patient #4 had no wound to the right buttock and right food when he was admitted on 10/30/23. The first documentation and measurements of the areas were completed on 12/07/23. Staff W stated they felt the right foot wound was from the foot resting against the foot rail. Interview on 11/19/24 at 11:25 AM, Staff C verified the findings of not turning Patient #4 every two hours. 4. Review of the medical record revealed Patient #6 was admitted on 01/09/24 after having a cerebral vascular accident (stroke) and acute respiratory failure. The patient had a tracheostomy and PEG tube procedures completed on 1/04/24. Review of the skin assessment dated 01/11/24, completed by the wound care nurse, revealed a right medial ankle wound measuring 2 cm by 2 cm by 0.2 cm, a left hand wound measuring 1 cm by 1 cm by 0.5 cm, a left elbow wound measuring 4 cm by 3 cm with no depth, the left lower leg had scattered abrasions, the left lateral forearm had a wound measuring 2 cm by 2 cm by 0.1 cm deep, and a right lateral knee wound measuring 1 cm by 1 cm. Review of the orders revealed repositioning was ordered every two hours due to this patient being unable to reposition themselves. The medical record revealed notes on 01/14/24 at 12:14 PM stating Patient #6 was turned to the left side and remained there until 6:13 PM. On 01/15/24 the patient was placed on their back at 8:45 PM until 1:37 AM. The record revealed on 01/19/24 a deep tissue sacrococcygeal wound was identified measuring 9 cm by 6 cm by 0.2 cm . Orders were received to treat the wound. Review of the record revealed notes on 1/20/24 at 3:00 PM documenting Patient #6 was positioned onto their right side and not repositioned until 9:44 PM. The patient was turned to their left side on 01/23/24 at 12:52 PM and remained there until 5:36 PM. On 01/25/24 the patient was turned to the left side at 4:00 AM and remained there until 9:54 AM. On 01/25/24 at 8:52 AM the patient was turned to the left side and not repositioned until 2:36 PM. Documentation from 01/27/24 at 4:05 PM until 01/27/24 at 4:00 AM revealed no evidence repostioning was completed. Notes documented the patient was on their left side on 01/27/24 from 6:00 AM until 2:25 PM. Patient #6 was discharged to an extended care facility on 02/05/24 with orders to complete dressing changes to the sacrococcygeal area. Interview on 11/20/24 at 11:00 AM, Staff C verified the findings of not turning Patient #2, #3, #4, and #6 every two hours with the development of pressure wounds.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 28999 Based on record review, interview, and policy review, the facility failed to ensure the physician was notified of a change in condition. This affected one (Patient #4) of ten patients reviewed. Findings include: Record review revealed Patient #4 was transferred from an outside hospital on 08/21/24 at 4:10 PM with a diagnosis of respiratory failure. The patient’s code status was a full code. An attending physician’s history and physical noted the patient had a past medical history of Parkinson’s disease. The patient had an out-of-hospital pulseless electrical activity arrest. Return of spontaneous circulation was achieved with 15 minutes of resuscitative efforts. An MRI was suggestive of anoxic brain injury, however, the patient’s family requested the hospital insert a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube on 08/15/24. The patient was transferred to the facility for long-term acute care including ventilator management. Telemetry was ordered every four hours. The patient’s vital signs on admission included a blood pressure of 144/77 millimeters of mercury (mm/hg), heart rate of 91 beats per minute, respiratory rate of 30, and temperature of 97.4 degrees Fahrenheit (F). By 08/22/24 at 9:10 AM, the patient’s blood pressure was low at 94/55 mm/Hg. At 9:31 PM, the patient’s temperature was elevated 101.4 degrees F. There was no documentation the physician was notified of Patient #4’s elevated temperature or low blood pressure. On 08/23/24 at 12:33 AM, Patient #4’s temperature remained elevated at 101.4 degrees F. At 12:47 PM, the patient’s temperature was 100.5 degrees F and his blood pressure was 84/56 mm/hg. A nursing note revealed the physician was notified and the patient’s responsible party was notified, as he was at the bedside of the patient. The sepsis protocol was initiated. At 8:51 PM, Patient #4’s temperature was 101.6 degrees F, his blood pressure was 88/53 mm/hg, and respirations were 36 breaths per minute. There was no documentation the physician was notified of Patient #4’s elevated temperature or low blood pressure. On 08/24/24 at 8:38 AM, an order changed the patient’s code status to a Do Not Resuscitate (DNR) Comfort Care-Arrest. At 12:37 PM, the patient’s blood pressure was 89/57 mm/Hg. By 5:03 PM, Patient #4’s temperature was 101.6 degrees F and his blood pressure was 82/48 mm/hg. The patient’s blood pressure remained low. The patient experienced cardiac arrest and according to the expiration summary was pronounced deceased at 10:03 PM. During an interview on 10/31/24 at 2:30 PM, Staff A and Staff B confirmed that the medical record lacked documentation the physician was notified when Patient #4 experienced an elevated temperature and low blood pressure. The facility policy titled “Interdisciplinary Assessment and Re-Assessment”, effective June 2023 stated an acute change of condition is a clinically important change from a patient’s established and documented baseline in physical, cognitive, behavioral, or functional domains. An acute change in condition may occur abruptly or over several hours or several days, presenting as physical changes or as changes in function, mood, cognition, or behavior. In the long-term acute care hospital setting a primary goal of identifying acute changes of conditions is to enable staff to evaluate and manage a patient and avoid transfer to a hospital emergency room. To achieve this goal, nurses as well as physicians must recognize a change in condition. Changes in the condition of the patient are determined by assessments using clinical parameters, current and past documented medical condition, medical orders, and/or by patient safety factors. The nurse assigned to the patient is responsible for notification of and communication to the patient’s primary physician. The nurse is instructed to notify the nursing supervisor of patient change in condition. The patient’s family/significant other should also be notified. Any change in condition, notification, and interventions should be documented in the medical record.”

“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: 18665 Based on interview, record review and policy review, the facility failed to ensure a patient was monitored as planned for patient safety management resulting in a near miss event and a potential for significant harm; and failed to record the event in the facility reporting system. This affected one (Patient #1) of ten patient record reviewed. The hospital census was two. Findings include: Review of Patient #1’s medical record revealed an admission date of 07/25/24 from an acute care hospital due to suicidal ideations. There was an emergency hold order mandating admission to the psychiatric facility, due to unsafe behaviors and patient report of intent to harm themselves as manifested by a self-inflicted injury of a laceration on Patient #1’s left arm which had been sutured. Review of a history and physical report revealed Patient #1 had diagnoses including bipolar, schizophrenia, anxiety, major depressive disorder, hypothyroid disorder, gastroesophageal reflux disease, borderline personality disorder, post-traumatic stress disorder, and history of suicide attempts by overdose, hanging and self-harm cutting. Review of the admission assessment dated 07/25/24 revealed Patient #1 had been admitted for a status post suicide/ self-harm action of cutting her left arm to an extent that required sutures at the emergency department and safety management required one to one staff monitoring, with constant supervision of her activities and location for safety. Patient #1 was identified as a risk for self-harm, high risk for adverse behaviors. Review of Patient #1’s plan of care and physician orders revealed that she had a level of monitoring for safety that included two staff to one patient ratio during waking hours and one to one staff to patient ratio during sleeping activity since admission. Review of the nursing notes dated 08/31/24 for day shift (7 AM to 7 PM) revealed the level of safety observation was two Behavioral Health Technicians (BHT) with the Patient #1. The Patient #1 was in her room seated on her bathroom floor which was a common preference. The two BHT were in the room and supposed to be within line of sight to monitor the Patient #1. Review of a nursing note dated 08/31/24 at 11:01 AM revealed that the nurse was alerted by a BHT that Patient #1 required assistance and assessment in the patient’s room. Review of the documentation revealed that the nurse, Staff C, entered Patient #1’s bathroom to find that Patient #1 was seated on the floor of the shower area with the shower curtain pulled to hide her. She was positioned with her head bowed down to her chest. When the nurse raised Patient #1’s head, there was bandage gauze wrapped around Patient #1’s neck with a knotted tie that could not be manually removed. Patient #1 was not unconscious, but her skin was abnormal in color, with a pale or bluish tinge, and the nurse used a scissors to cut the gauze allowing Patient #1’s facial skin color to return to natural hue. An immediate assessment of Patient #1 after the removal of the ligature found her alert and oriented, breathing without difficulty, denying pain, verbalizing angrily and telling staff to leave her alone. Review of the written nursing assessment of Patient #1’s vital signs on 08/31/24 immediately post-event revealed that measurements were within normal limits including oxygenation values. Patient #1 was ambulatory and at 1:40 PM was tipping over chairs, pacing in the hallway and striking her head on the walls. Despite staff interventions to redirect her, Patient #1 continued with self-destructive actions and the staffing ratio continued to be two to one for safety monitoring. Review of the nursing notes revealed Patient #1’s self-harm behavior continued with her head strikes causing bruising, redness with swelling and Patient #1 was evaluated by the facility’s hospitalist physician at 6:50 PM who recommended evaluation at an acute care hospital to rule out acute injury of her head and neck. Review of a hospital report dated 08/31/24 revealed Patient #1’s head and neck imaging revealed no acute injury and she returned to the facility that evening. Review of facility incident reports provided on 09/09/24 revealed there was no written report of the event for Patient #1 on 08/31/24. During an interview on 09/09/24 at 4:35 PM, Staff G stated Patient #1 was positioned on the floor of the shower within the bathroom of her room and staff allowed her to close the curtain for a moment of privacy thinking that they were allowing her peace due to her constant insistence that she did not want to be closely supervised. Patient #1 used the opportunity that she gained out of sight of the two staff members to wrap a length of gauze around her neck and knot it before staff intervened to free her. Patient #1 did not experience an injury, had not lost consciousness and was fighting staff when they intervened to remove the gauze. Patient #1 was being monitored by two to one ratio, staff to patient safety supervision, prior to, during and after the event and should not have been allowed a moment out of direct sign of staff assigned to monitor her. During an interview on 09/12/24 at 8:06 AM, Staff A stated the event with Patient #1 on 08/31/24 had not been recorded as an adverse event, had not been documented in the incident reporting system despite two nurses being on duty and aware of the facility’s system for event reporting and having been involved in the event. Staff A confirmed that there were two staff supervising Patient #1 at the time of the event and that they misjudged the situation by allowing Patient #1 to have a moment of privacy behind the curtain, leaving her out of the direct line of sight that was planned for patient safety management. Staff A confirmed that the incident met the definition of the facility’s Event Reporting policy, but no report was filed at the time of the event or within 24 hours post-event. Staff A said there was no written educational direction for staff post-event despite the patient’s potential for harm in being out of direct sight for supervision. Staff A said the level of two to one safety monitoring had continued for Patient #1 and Patient #1 was sent out for evaluation on the evening of 08/31/24 after she engaged in additional self-destructive behavior of head banging, which was a result of her decompensated, agitated state of being that day. Staff A said there was no report of incident, no investigation regarding the near miss event nor any inquiry regarding the use of a length of gauze for a patient with high risk for self-harm behavior. During an interview on 09/17/24 at 9:22 AM , Staff A stated Patient #1 remained on the unit awaiting placement at a state psychiatric hospital, which had a waiting list due to bed availability. Review of the facility’s policies titled “Responsibilities in Event Reporting”, number H-PC 07-007, revealed the policy of the facility was to ensure that personnel were responsible for reporting in a timely and efficient manner, patient and visitor events through the Event Reporting System that were separate from the patient’s medical records, in a confidential file. The definition of an Event was “any occurrence or situation not consistent with the routine operation of the facility and which may have caused or may have the potential for causing injury to patients, visitors, or loss or damage to property. Events include any threat to patient safety; can include physical injury, patient dissatisfaction, and near misses.” A report was to be completed within 24 hours and nursing staff was responsible for the documentation and reporting process.”