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Based on facility policy reviews, grievance log, medical record reviews, observations and staff interviews, the facility staff failed to identify and respond to a grievance per policy for 2 of 7 grievances reviewed (Patients #7 and 34)

Findings included:

Review on 03/23/2023 of the facility policy titled "Patient and Family Grievances/ The Role of the Patient Advocate," reviewed date: 02/2022 revealed ...It is the responsibility of each staff member to respond in a timely manner to any concern or complaint voiced by patients and their families no matter how trivial the complaint may appear to be....7. The Patient Advocate responding to the grievance shall inform the patient or family the timeframe within which he/she shall expect follow-up. This time frame shall not exceed 7 days unless there are extenuating circumstances, at which point the patient shall be notified of the need for an extended time frame and an agreement made as to when follow up will occur, but no later than 30 days...."

1. Medical record review on 03/22/2023 of patient #7 revealed a 14-year-old male admitted on 01/24/2023 to the facility for suicidal and homicidal ideations. Review revealed no available documentation of the parents expressing concerns or grievances to the staff.

Review on 03/22/2023 of the facility`s grievance log revealed no grievances for patient #7.

Interview on 03/20/2023 with the NM #4 revealed she recalled the patient and parents. Interview revealed NM #4 met with the mom the day after an incident involving an altercation between patient #7 and a staff member. Interview revealed the parent asked for patient #7 to be discharged, and to receive a follow up response after the facility's investigation that included video review. Interview revealed she forwarded the parents' concerns that she received to administration via email, to include Risk Management, Chief Nursing Officer, and the Chief Operations Officer on 02/01/2023 at 1720. Interview revealed she "did not call the parents back, someone else would have ...Someone was supposed to follow up with her [patient`s mom]."

Interview on 03/16/2023 at 1340 with the Risk Manager revealed she did review a video regarding patient #7. Interview revealed the video was forwarded to the Chief Nursing Officer and NM #4 for review. Interview revealed "I don`t know if follow up was made to the family." Interview revealed "the Patient Advocate follows up on complaints and grievances."

Interview on 03/13/2023 at 1455 with the Patient Advocate revealed when he was not available an assigned supervisor was. Interview revealed he had an answering machine for any calls received when he was out of the office. Interview revealed no written response was provided to the complainant regarding the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. Interview revealed the hospital policy was not followed.

Interview on 03/22/2023 at 1435 with the Chief Operations Officer revealed any staff member can accept a grievance from patients or guardians. Interview revealed grievances were to be forwarded by email to Patient Advocate or Risk Manager. Interview confirmed the hospital policy was not followed.



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2. Review of medical record of Patient #34 revealed a 21 year old male admitted on 06/01/2022 for depressive disorder. Review of a grievance letter dated June 29, 2022 revealed "This letter is in response to the complaint you filed with (named facility) on 06/17/2022 regarding your son's hospitalization from 06/01/2022 to 06/24/2022...This investigation was opened on 06/17/2022 and concluded on 06/29/2022." (12 days after the grievance).

Interview on 03/15/2023 at 1515 with patient advocate #9 revealed the policy reads the grievance letter should be sent within 7 days. Interview revealed no reason for the delay in sending the grievance letter.

Interview on 03/22/2023 at 1435 with COO #10 revealed grievances should be resolved in 7 days or another letter is sent to the complainant explaining the delay. Interview revealed the policy was not followed.

Based on review of the medication room safety logs, medication dispense maintenance logs, and staff interviews, the hospital staff failed to accurately measure safety actions implemented after a medication room breech.

Findings include:

Review of the medication room event that occurred on 01/09/2023 at 2032 revealed Patient #20 opened the medication room window from the unit hallway, jumped through the window into the medication room, and removed fifteen (15) Thorazine 50 milligram tablets and thirty-four (34) Benadryl 50 milligram capsules from a drawer that was left partially opened on the medication dispense machine. Review of the facility action plan included placing plexi-glass inside the medication room windows and a convex mirror in front of the nurses' station to allow the staff to see the medication room window from the nurses' station. Action plan included the initiation of the Medication Room Safety Log to be completed by the nursing staff, twice daily at shift change and the Medication Dispense Maintenance Log to be completed every day by a pharmacist.

1. Review of the medication room safety logs documented by the nursing staff from January 11, 2023 through March 20, 2023 revealed the logs were incomplete and failed to consistently have the documented medication window closed and locked, medication room door closed and locked, medication dispense drawers closed and locked and two (2) nurse's signatures. Review of the medication safety logs for the Campus A 1E unit revealed the logs were not completed twice a day at nursing shift change on January 11, 14, 15, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27,28, 29, 30, and 31, 2023 (17 of 21 days), on February 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 28, 2023 (28 of 28 days) and on March 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19, 2023 (18 of 19 days). Review of the medication safety logs for the Campus A 1NA unit revealed the logs were not completed twice a day at nursing shift change on January 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 25, 27, 28, 29, and 30, 2023 (15 of 21 days), on February 3, 4, 5, 6, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 23, 26, and 27, 2023 (17 of 28 days) and on March 5, 6, 7, 10, 11, 12, 13, 18, and 19, 2023 (9 of 19 days). Review of the medication safety logs for the Campus A 1NB unit revealed the logs were not completed twice a day at nursing shift change on January 11, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, and 28, 2023 (12 of 21 days), on February 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 16, 17, 20, and 28, 2023 (14 of 28 days) and March 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, and 19, 2023 (18 of 19 days). Review of the medication safety logs for the Campus A 2NB unit revealed the logs were not completed twice a day at nursing shift change on January 11, 12, 13, 14, 17, 18, 19, 20, 24, 25, 26, 27, 28, 29, 30, and 31, 2023 (16 of 21 days), on February 1, 2, 8, 9, 10, 14, 15, 16, 21, 22, 23, 25, and 28, 2023 (13 of 28 days) and March 1, 2, 3, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19, 2023 (16 of 19 days). Review of the medication safety logs for the Campus A 1W unit revealed the logs were not completed twice a day at nursing shift change on January 16, 19, 20, 21, 22, 23, 25, 27,28, 29, 30, and 31, 2023 (12 of 21 days), on February 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 27, and 28, 2023 (27 of 28 days) and on March 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19, 2023 (19 of 19 days). Review of the medication safety logs for the Campus A 2W unit revealed the logs were not completed twice a day at nursing shift change on January 17, 20, 21, 28, 29, 30, and 31, 2023 (7 of 21 days), on February 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, and 28, 2023 (24 of 28 days) and on March 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, and 19, 2023 (18 of 19 days). Review of the medication safety logs for the Campus B C1WA unit revealed the logs were not completed twice a day at nursing shift change on January 17, 23, and 31, 2023 (3 of 21 days), and on February 14, 2023 (1 of 28 days). Review of the medication safety logs for the Campus B C1N unit revealed the logs were not completed twice a day at nursing shift change on February 1, 2, 4, 7, 15, 23, and 27, 2023 (7 of 28 days) and on March 2, 4, 6, 13, and 14, 2023 (5 of 19 days). Further review of the medication safety logs for the Campus B C1N unit revealed no log provided by the facility for January 10-31, 2023 (21 of 21 days). Review of the medication safety logs for the Campus B C1S unit revealed the logs were not completed twice a day at nursing shift change on February 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 18, 19, 21, 22, 23, 25, 26, 27, and 28, 2023 (21 of 28 days) and on March 1, 2, 4, 5, 6, 7, 9, 11, 12, 13, 14, and 18, 2023 (12 of 19 days). Further review of the medication safety logs for the Campus B C1S unit revealed no log provided by the facility for January 10-31, 2023 (21 of 21 days). Review of the medication safety logs for the Campus C 2SE unit revealed the logs were not completed twice a day at nursing shift change on January 15, 16, 20, 21, 22, 23, 25, and 26, 2023 (8 of 21 days), on February 1, 3, 5, 6, 7, 13, 14, 15, 16, 20, 21, 22, 26, and 27, 2023 (14 of 28 days) and on March 1, 2, 3, 4, 6, 8, 9, 12, 13, 15, 16, 17, and 18, 2023 (13 of 19 days). Review of the medication safety logs for the Campus C 3SE unit revealed the logs were not completed twice a day at nursing shift change on January 11, and 23, 2023 (2 of 21 days), on February 6, 10, 13, 25, and 27, 2023 (5 of 28 days) and on March 19, 2023 (1 of 19 days). Review of the medication safety logs for the Campus C 3SW unit revealed the logs were not completed twice a day at nursing shift change on January 16, 23, 28, 29, 30 and 31, 2023 (6 of 21 days), on February 2, 6, 7, 10, 19, 21, 24, 25, 26, 27, and 28, 2023 (11 of 28 days) and on March 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 18, and 19, 2023 (16 of 19 days).

Interview on 03/23/2023 at 1220 with NM #4 revealed the nursing staff were expected to complete the medication room safety logs twice a day during nursing shift changes. Interview revealed the house supervisors were expected to review the medication room safety logs daily and to discuss any issues/concerns with the staff. Interview revealed "I check once in a while." Interview revealed there had been no tracking, aggregation, analyzing or monitoring of the data collected on the medication room safety log tool since initiation in January 2023. Interview revealed the nursing staff were expected to check the medication dispense drawers prior to leaving the medication room.

Interview on 03/21/2023 at 1415 with the CNO (Chief Nursing Officer) revealed the facility had not tracked, aggregated, analyzed, or monitored the data collected on the medication room safety log tool since initiation in January 2023.

2. Review of the medication dispense maintenance logs documented by the pharmacist revealed that all the medication dispensing machines were serviced on 02/09/2023. Review of the medication dispense maintenance logs revealed the pharmacist initiated the daily log checks on 02/10/2023. Review of the medication dispense maintenance logs for Campus A, from February 10, 2023 through March 21, 2023, revealed documentation in February 2023 of four (3) machine dispense drawers not working on the 2W unit and documentation in March 2023 of two (2) medication dispense machines that the drawer open alarm was not working in the Admissions unit. Review of the medication dispense maintenance logs for Campus B, from February 10, 2023 through March 21, 2023, revealed no medication dispense machine issues/concerns documented in February 2023 and documentation in March 2023 of one (1) medication dispense machine that the drawer open alarm was not working in the Childrens unit. Review of the medication dispense maintenance logs for Campus C, from February 10, 2023 through March 21, 2023, revealed no medication dispense machine issues/concerns documented in February 2023 and March 2023.

Interview on 03/23/2023 at 1240 with the Pharmacist at Campus B revealed the pharmacists completed the medication dispense maintenance logs daily and reported any issues/concerns to the administrative staff during the morning administration huddle. Interview revealed there had been no tracking, aggregation or analyzing of the data collected on the medication dispense maintenance logs since initiation in February 2023.

Based on medical record review, observations, and staff and patient interviews, the nursing staff failed to communicate food allergies to the dietary department for 2 of 3 food allergies reviewed. (Patient #22 and Patient #5)

Findings include:

1. Review on 03/17/2023 of the medical record for Patient #22 revealed a 74-year-old male admitted involuntarily to the facility on 03/06/2023 at 1428 with a chief complaint of Suicidal Ideations with a plan to overdose on Fentanyl. Review of the medical record for Patient #22 revealed a SBAR (situation, background, assessment, recommendation) intake report form was completed by RN #1 on 03/06/2023 at 1210 with documentation of food allergies as squash, eggplant (hives), shellfish and containing products. Record review revealed a second SBAR intake report form was completed by RN #1 on 03/06/2023 at 1350 with documentation of food allergies as squash, eggplant (hives), shellfish and containing products, with the addition of egg derivatives. Review of the SBAR forms revealed no documented allergy reaction for squash, shellfish and containing products and egg derivatives. Review on 03/17/2023 of the dietary order for Patient #22 revealed food allergies documented as squash, eggplant (hives), shellfish and containing products. The dietary order included special diet for Diabetic and Low Sodium with comments "food allergy." Review of the record and dietary reports failed to reveal documentation of the egg derivative allergy included in a dietary order.

Interview on 03/13/2023 at 1500 with Patient #22 revealed the Patient state he had an egg allergy with the reaction of airway distress. Patient #22 said "I got eggs every day on my breakfast tray. I let the staff know about it."

Interview on 03/14/2023 at 1615 with Registered Nurse (RN #1) revealed she had worked at the facility for 4 years and more than 26 years total as an RN. Interview revealed RN #1 recalled the documentation for Patient #22 to include allergy of "egg derivative" on the Nursing Admission Assessment form which was information relayed from the admission's intake unit to the unit where patient was admitted on 03/06/2023.

Interview on 03/16/2023 at 1100 with the Food Service Director revealed the kitchen staff used liquid eggs in a carton for the adult units and liquid eggs in a bag for the children's units. Interview revealed the dietary staff received a daily summary report of the patient allergies, diets and diet modifications. Interview revealed that when the Mental Health Technicians (MHT) brought the patients to the cafeteria to eat, the MHT placed the patients with allergies at the front of the line and the MHT stood at the front/head of the patient/tray line and shared with the dietary aid the patient's allergies or special diets. Interview revealed that with the recent change at Campus A, the dietary staff received a report with the patient diets, allergies and modifications, then the dietary staff prepared the food trays based on the information provided in the report. Interview revealed the dietary aid pre-marked the patient trays with any allergies, diet modifications and type of diet. Interview revealed the pre-marked special trays were placed on the cart and separated from the generic trays by the MHT when the trays were picked up from the cafeteria. Interview revealed that if the dietary staff identified the food allergies based on the diet order and allergies placed in the electronic system by the nursing staff.

Interview on 03/16/2023 at 1130 with the dietary aid that was preparing the food trays revealed she reviewed the dietary summary report and documented the special dietary instructions and allergies on the top of the Styrofoam food box with a black permanent marker.



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2. Closed medical record on 03/14/2023 revealed, on 11/24/2022 at 1146 Patient #5 was a 7-year-old male, IVC'd (Involuntary Commitment) due to severe aggression toward parents, SI (Suicidal Ideation) and delusions. Patient #5 reported " ...having a voice called '"Dakota"' telling him to hurt himself." Patient #5 exhibited self-harm by throwing himself into the bathtub, banging his head and biting himself. Patient #5 was admitted to the Children's Hospital campus "B", C1 West A (Co-ed) unit room 307A. Medical record review revealed, a handwritten note that documented "NURSING ADMISSION ASSESSMENT ...ALLERGIES ...gluten, dairy, lactose ...NUTRITIONAL SCREEN: ...Special Diet: Describe: dairy, gluten, added sugars" with an arrow pointed to the "Food Allergies? Describe:" section of the document. Continued medical record review revealed, the nursing admission assessment was completed by HS #16 on 11/24/2022 at 1438. Review of the daily checklist for 11/24/2023 - 11/30/2023 noted pt had allergies to gluten and dairy (missing added sugars).

Interview on 03/16/2023 at 1440 with HS #16 revealed HS # 16 worked in admissions as a Registered Nurse when Patient #5 arrived at the facility. HS #16 stated allergies were noted in admissions and the nurse or clinician completed the nursing assessment in admissions. HS #16 reviewed Patient #5's chart, confirmed HS #16's signature and confirmed HS #16 completed the admission assessment packet. HS #16 confirmed the allergies for Patient #5 were dairy, gluten and added sugars. HS #16 reviewed the daily checklist and noted that the allergies listed were gluten, dairy but not added sugar. Interview revealed HS #16 obtained Patient #5's allergies from Patient #5's mom or a previous chart. HS #16 stated the allergies were entered into the HCS (facilities electronic record for paper orders). HS #16 stated that HS #16 may have included the added sugars under the special diet tab which automatically populates over to the dietitian for patients menus. HS #16 stated the clinician SW (Social Worker) completed the yellow alert page which was used when calling report to the unit. HS #16 reviewed the yellow page and noted Patient #5's allergies were not on the yellow page. Review of the closed medical record on 03/16/2023 of orders entered by HS #16 on 11/24/2022 at 1539 for Patient #5 revealed, Patient #5 was admitted to inpatient " ...CHILDREN'S 1 WEST A ...Dietary ...Special Diets Gluten Free gluten and dairy free ..." Added sugar was not included in Patient #5's allergies.

Review of the "Kid's Menu 2022 - 2 week Cycle" on 03/16/2023 revealed " ...Tuesday ...Nov-15, Nov-29 ...Wednesday ...Nov-16, Nov-30 ... Breakfast ..." included "Orange Juice ...Syrup ...Cold Cereal of Choice ..."

Interview on 03/17/2023 at 1232 with NM #4 revealed, the unit nurse received a verbal report from admissions per the high risk notification (yellow page). NM #4 stated once allergies were placed in the HCS (electronic record system for orders) all nurses checked HCS for orders. The unit nurse checked orders and placed stickers on the front of the patient's chart if any allergies were noted. NM #4 stated "all MHTs (Mental Health Technician) and Nurses should be aware of all allergies. NM #4 reviewed the "Kid's Menu 2022 - 2 week Cycle" and confirmed Orange Juice, Syrup and Cold Cereal was part of the breakfast menu during Patient #5's admission. NM #4 stated the dietitian was not aware of Patient #5's added sugar allergies. Interview revealed the breakfast that was served to Patient #5 that included orange juice, syrup and cereal would not have been a correct diet for a patient with no added sugars.

Based on facility policy review, observations, and staff interviews, the facility staff failed to ensure medications were secured for 2 of 2 observations at Campus B.

Findings include:

Review of the facility policy titled "Medication Administration" revised May 2022 revealed "... Procedure ... 18. The nurse will not double-pour or pre-pour medicines ... ... 20. Staff will never leave the Medication Cart or Medication Room unlocked. ..."

1. Observation on 03/22/2023 at 1555 of the Campus B (C1-North) unit medication room revealed five (5) medication cups left unattended on the top of the medication dispensing machine. Observation of the cups revealed the patient names and room numbers were handwritten by RN #5 on the outside of the cups. Observation of the cup contents revealed one cup contained Metformin (diabetic medication), two cups contained Buspirone (anxiety medication), one cup contained Thorazine (medication used to treat psychotic disorders) and Oxcarbazepine (medication used to treat seizures) and one cup with Omeprazole (medication used to treat acid reflux, etc.).

Interview on 03/22/2023 at 1555 with NM #4 revealed patient medications should not be pulled prior to administration. Interview revealed medications should be secured at all times. Interview revealed the staff failed to follow the facility policy.

Interview on 03/22/2023 at 1600 with RN #6 revealed RN #7 "pulled the medications approximately 10-15 minutes ago." Interview revealed RN #6 was trained to pull medications prior to administration (1-hour before or 1-hour after due). Interview revealed RN #7 was off the unit and not available to interview.

2. Observation on 03/15/2023 at 1440 of the Campus B (C1-West A) unit medication room revealed a medication drawer on the medication dispensing cart was left opened. Observation revealed the opened drawer contained 15 oral pills of Ritalin 10 milligrams. Observation revealed RN #5 and NM #4 tested the medication dispensing machine and found the open drawer alert appears on the machine monitor, however the machine alarm was not audible.

Interview with RN #5 on 03/15/2023 at 1445 revealed "I usually hear an alarm but did not hear the alarm today."

Interview on 03/22/2023 at 1450 with NM #4 revealed the staff were expected to close all medication drawers prior to leaving the medication room. Interview revealed medications should be secured at all times. Interview revealed the staff failed to follow the facility policy.

Based on review of the policy, observations during tours, medical record review and staff interviews, facility staff failed to provide a clean and sanitary environment in 2 of 3 campuses observed (Campus A and Campus B).

The findings include:

Review of procedure titled "(Named Hospital) Environmental Services--7 Step Cleaning and Sanitizing Procedure" with date of 04/23/2021 revealed "The seven-step cleaning process includes emptying the trash; high dusting; sanitizing and spot cleaning; restocking supplies; cleaning the bathrooms; mopping the floors; hand hygiene and inspection. 7 Step Cleaning Process: 1. Pull Trash--Daily. Remove liners and reline all waste containers. Change the bag when 3/4 full or at the end of your shift. Clean waste receptacles. 2. High Dust--Twice weekly. High dust everything above shoulder level. Never high dust around people. 3. Damp wipe--daily. Wipe everything you are able to reach. Use germicide for all surfaces except glass. Use a dry cloth to polish interior and low-level glass. Start with the door and work around the room in a circular pattern. Be sure to include: wall spotting, light switches, windowsills, and furniture. 4. Clean/Sanitize Bathroom--Daily. Start at the door and end with the toilet. Use a bowl mop inside the bowl and wipe the outside with a disinfectant damp wiper. Sanitize shower and clean shower pain from hair and debris. Do not use the cleaning wipes on any other surface after cleaning the toilet. 5. Ice Machines--Daily. Remove drain pain cover and wipe out pan. Be sure water drains properly. Sanitizes and clean the dispensing heads both water and ice. Wipe down exterior sides and top. 6. Floor care daily. Place Wet Floor sign at the entrance before you begin. Start with corner farthest from the door and work your way out. Mop out corners to prevent build up. 7. Inspect the room daily. Report any needed repairs. Correct any deficiencies. Is the room ready for another patient?"

Campus A:
1. Observation on 03/13/2023 at 1445-1530 of a patient care floor on Campus A revealed a community bathroom with dirty dark buildup in each corner of the room extending approximately one-half inch from each corner. Observation revealed a rust colored stain line on the wall under the sink extending from the sink basin to the floor. Observation of the community bathroom under the sink on the wall revealed a red colored splatter measured 1/2 inch in diameter. Observation of the door frame in the bathroom in a patient room near the dayroom revealed brown rust like material. The rust like material resembling pencil shavings was seen on the floor and in the door frame near the shower. Observation of the ceiling in the patient room revealed brown splatter extending approximately 2 feet on the ceiling tiles. Observation behind the door of the corner of the patient room revealed a dark buildup extending approximately one-half inch from the wall. Observation in the quiet room revealed a stained brown area resembling a water stain on the tile on the ceiling measuring approximately 5 inches by 5 inches.

Interview on 03/13/2023 at approximately 1505 with EVS #7 (housekeeping supervisor) revealed environmental rounds are done daily. Interview revealed the ceiling splatter, bathroom rust like material, ceiling stain, buildup in the corners and bathroom wall stains had not been noted prior to the tour. Interview revealed the items did not appear to be new or recent. Interview revealed no work orders had been generated for the items prior to this survey.



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2. Review on 03/14/2023 of a closed medical record for Patient #17 revealed a 40-year-old male admitted involuntarily to Campus A on 05/05/2022 with a chief complaint of suicidal ideation with a plan to cut himself or walk into traffic. Review of the History and Psyche Evaluation on 05/06/2022 at 1015 by MD #18 revealed "...PMH (past medical history) Hepatitis B & C (serious liver infections caused by virus), variceal bleeding,(bleeding in the esophagus) s/p (status post) banding (treatment for esaphageal varices [abnormal veins in the lower part of the throat], DVT (deep vein thrombosis), PE (pulmonary embolus [blood clot in the lung])...small bowell obstruction 2020 and SVT (supraventricular tachycardia)..." Observation Sheet review for 05/16/2022 revealed Patient #17 was assigned to room 502-A, and on 05/17/2022 was reassigned to room 508-A. Observation Sheet review dated 05/17/2022 from 0000 to 0715 revealed Patient #17 had access to his room. Observation Sheet dated 05/17/2022 from 0730-0745 until 2245 revealed Patient #17 was located in the hallway, dayroom, outside and bathroom; and was not observed in his room for 12 hours and 15 minutes. Patient #17 was transferred to an acute care hospital on 05/25/2022 at 1251 for possible blood product transfusion.

Interview on 03/14/2023 at 1208 with the Director of EVS #21 revealed " ...the expectation was all patient rooms are mopped and cleaned once daily. We follow a 7-step process, rooms don't get cleaned on Saturdays or Sundays, and staff that work weekend days are off another day during the week to prevent overtime. So, when the assigned EVS worker was off work to make up for working the weekend the unit they were assigned did not get cleaned. We are short staffed. For Covid positive patients, nursing had placed a sign on the door for droplet precautions, that stated STOP & DO NOT ENTER until all linen was removed from the room by nursing staff, and EVS staff would then fog the room, and after a 45 minute waiting period the room could be cleaned before another patient could occupy the room ..." Interview revealed there were delays in cleaning patient rooms during summer months of 2022 with higher than usual Covid positive patients due to staffing shortages. Interview revealed currently EVS remained short staffed and were unable to mop and clean patient rooms daily per the 7-Step Cleaning and Sanitizing procedure. Interview revealed there were delays for patients who were reassigned a new room due to a Covid positive roommate due to staffing shortages and cleaning protocols.

Telephone interview on 03/16/2023 at 1510 with RN #20 who cared for Patient #17 on 05/17/2022 revealed she did not recall the patient. Interview revealed " ...EVS is challenging, if we have discharges on the weekends, we can't always count on EVS. Nursing had to step up on weekends to assist with cleaning. It was possible a patient who was moved due to a Covid positive roommate would have to wait for EVS to fog the room ..." Interview revealed there were no couches in the dayroom for a patient to lie down on, only chairs. Interview revealed it was possible a patient would have to wait to access their bed if they were reassigned a new room due to a Covid positive roommate.



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3. Tour and observations on 03/13/2023 at 1515 of the General Psychiatric floor on Campus A revealed the quiet room was unusable due to a broken window with plyboard over it. RN #11 stated that she was unsure when the window had been broken. Dried urine streams were noted on the toilet in the quiet room. While at the nurse's station, a patient walked up and stated "This place is nasty! I'm going to take my meds [medications] so that I don't have to come back. Y'all need to clean better." Observation of that patient's bathroom revealed baby powder on the floor around the sink, dried toothpaste in the sink, and the toilet was noted to be soiled with urine around the basin. The shower was noted to have 3 bundles of patient's dried hair in the floor of the shower. A patient stated that EVS (Environmental Services) "had done been here this morning but my room still looks like this. I asked the EVS guy if he would clean my bathroom and he said 'Don't talk to me!' " Observation revealed multiple corners in patient rooms, in the dayroom, at the nurse's station and in the hallways that were filled with packed dust and dirt. Observation revealed stains and handprints on the walls surrounding the patient telephones and dirt noted on the floor.

Review of a closed medical record on 03/15/2023 of Patient #15 (Visit #2) revealed a 33-year-old female admitted on 11/26/2022. Review of "Daily Patient Inventory Monitoring" (a daily patient survey sheet), revealed that Patient #15 answered "yes" to "clean " on 11/27/2022 and 12/02/2022, and answered "no" to "clean " on 12/02/2022, 12/04/2022 and 12/06/2022 . Review failed to reveal any staff response or interventions on each Daily Patient Inventory Monitoring sheets. Review revealed Patient #15 was discharged on 01/02/2023.

A request for past daily cleaning logs found that none were available.



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Campus B:
4. Observation on 03/14/2023 at 1030 of Children's Hospital Campus B (NM #4 present), patient's rooms and bathrooms revealed, the following: room 301 shower handle coating was peeled, off; room 302 bathroom had odors of a sewer and had urine in the toilet. The observation revealed room 304 the paint coating was peeling away on the door frame; room 305 had two brown bags used for trash that were overflowing; and room 307 the bed spread was noted with multiple black stains of different shapes and sizes. Observation revealed room 308 the sink and toilet was not clean. Continued observation revealed, room 309 shower had rust around the back of the shower basin, the toilet seat was loose and what looked to be blood was over the top of the bathroom door. Room 312 shower had 3 shampoo wrappers in the basin and the toilet was not clean. Room 314 toilet was not clean; and room 315 shower had rust or mold to the backside of the shower basin. Observation on 1 South hallway smelled of sewer. NM #4 opened the locked room labeled "Anter Room" there was an immediate strong, pungent smell of sewer. Continued observation of room 100 and 101 revealed rust or mold to the backside of the shower basin. Rooms 103 and 104 bathroom toilet bowls had brown stains on the sides of entire bowls. Observation revealed room 107 had dust hanging from the ceiling vent and the bathroom toilet was not clean and had a sewer smell. Room 108 bedroom floor was not clean and had dust and dirt in the corners. Room 111 bedroom floor was dirty with trash and dried water, or blood stains dripping down the walls.

Interview during the observation with NM #4 revealed during the morning routine one of two MHTs (Mental Health Technician) gather the patients off the hall and the other MHT performed environmental rounds/checks. Environmental checks ensure beds are made, rooms and bathrooms are cleaned. NM #4 acknowledged many rooms and bathrooms had not been cleaned for 03/14/23. NM #4 stated the Ante Room was the restriction/seclusion rooms but were never used. NM #4 stated the units were often spot checked for repairs and cleanliness. NM #4 stated that NM #4 was not aware of the housekeeping schedule and would put in a work order on 03/14/23 for repairs. NM #4 confirmed that NM #4 was not aware of the extent of the units prior to the tour.



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5. Observations during tour of Campus B on 03/22/2023 revealed large areas of sheetrock ripped/pulled off of the wall in the large dayroom on the Adolescent boy's unit (1C-South). Observations during tour of Campus B on 03/22/2023 revealed eight (8) chairs in the large dayroom on the Adolescent boy's unit (1C-South) with tears in the upholstery. Observations during tour of Campus B on 03/23/2023 revealed six (6) chairs in the small dayroom on the 1C-West A unit with tears in the upholstery.

Review of a purchase order dated 01/20/2023 revealed documentation of 45 chairs ordered for the Children's Campus (Campus B) with a proposed delivery date of 03/24/2023.

Interview on 03/23/2023 at 1220 with the Campus B Nurse Manager revealed the new chairs for the dayrooms had been ordered with an expected delivery/installation date of April 9, 2023.

Based on review of facility policy, medical records and staff interviews, the facility staff failed to ensure a Master Treatment Plan included the medical diagnosis were completed in 3 of 16 medical records reviewed (Patients #53, #54 and #55); timely patient signature of the Master Treatment plan in 1 of 16 medical records reviewed (Patient #34); and legal guardian signature on Treatment plan on 1 of 16 medical records reviewed (Patient #55).

The findings include:

Review of the policy titled "Interdisciplinary Patient-Centered Care Planning" with revision date of 01/2021, revealed "...a. Any medical problems or diagnoses that are not receiving treatment will be listed on the Treatment Plan cover sheet/problem list as deferred with justification provided. If the medical problem requires active treatment, it will either be included in the plan as a 'Chronic/Stable' medical problem if only routine care is provided....4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan. 5. The patient/family and/or guardian is to sign the treatment plan to indicate their agreement with and participation in development of the plan. A designated staff member is responsible for discussing the treatment plan with the patient and family/representative/guardian if they are not present at the treatment team meeting. If the patient refuses to sign or is unwilling to sign, that will be documented...."

A. 1. Review of the open medical record for Patient #53 revealed a 42 year old male admitted on 03/17/2023 for schizoaffective disorder with hyper religious behavior. Review revealed medical diagnosis of Hypothyroidism (under active thyroid) and asthma. Review revealed no documentation of the medical conditions on the Master Treatment Plan.

Interview on 03/22/2023 at 1535 with RN #27 (Chief Nurse) revealed a medical diagnosis should have been written on the Master Treatment Plan, to include whether the diagnosis was active or deferred. Interview revealed the policy was not followed.

2. Review of the open medical record for Patient #54 revealed a 33 year old female admitted on 03/18/2023 for increased symptoms of depression with a plan to overdose. Review revealed medical diagnosis of Hypothyroidism, Fibromyalgia (extreme fatigue and aches) and Pre-diabetic (blood glucose elevated). Review revealed no documentation of the medical conditions on the Master Treatment Plan.

Interview on 03/22/2023 at 1535 with RN #27 (Chief Nurse) revealed a medical diagnosis should have been written on the Master Treatment Plan, to include whether the diagnosis was active or deferred. Interview revealed the policy was not followed.

3. Review of an open medical record for Patient #55 revealed a 33 year old male admitted on 03/15/2023 with suicidal attempt. Review revealed medical diagnosis of Hypertension (high blood pressure) and Diabetes 2 (chronic condition of irregular control of glucose). Review revealed no documentation of the medical conditions on the Master Treatment Plan.

Interview on 03/22/2023 at 1535 with RN #27 (Chief Nurse) revealed a medical diagnosis should have been written on the Master Treatment Plan, adding the diagnosis should be checked as active or deferred. Interview revealed the policy was not followed.

B. Review of the closed medical record for Patient #34 revealed a 21 year old male admitted on 06/01/2022 for Major depressive disorder. Review of the Master Treatment Plan revealed the patient`s signature was dated 06/24/2022 (23 days after the Master Treatment Plan meeting). Review revealed no documentation for the late signature. Review revealed the facility policy was not followed.

Interview on 03/22/2023 at 1535 with RN #27 (Chief Nurse) revealed the Master Treatment Plan should have been signed during the hospital stay instead of on day of discharge. Interview confirmed there was no documentation explaining the lack of the patient`s signature on the day of the Master Treatment Plan meeting. Interview revealed the policy was not followed.

C. Review of the open medical record for Patient #55 revealed a 33 year old male admitted on 03/15/2023 with suicidal attempt. Review revealed Patient #55 had a legal guardian. Review of the Master Treatment Plan revealed the guardian's signature was dated 03/20/2023 (5 days after the Master Treatment Plan meeting) . Review revealed no documentation for the delayed signature. Review revealed the facility policy was not followed.

Interview on 03/22/2023 at 1535 with RN #27 (Chief Nurse) revealed the legal guardian should have been contacted within 72 hours after admission or a note should have been written of the attempts to reach the guardian. Interview revealed no documentation was found of an attempt to reach the guardian prior to the signature. Interview revealed the facility policy was not followed. Interview revealed the guardian should have been contacted or attempts made and documented the day of the Master Treatment plan meeting. Interview confirmed there was no documentation explaining the late signature of the guardian. Interview revealed the policy was not followed.

D. Review of the open medical record for Patient #23 revealed a 27 year old male admitted on 06/12/2023 for Schizoaffective disorder (a disorder that affects a person's ability to think, feel and behave clearly). Review revealed the Master Treatment plan was completed on 06/22/2023 (11 days after admission).

NC00199266; NC00198640; NC00198044; NC00198067; NC00198628; NC00197622; NC0017835; NC00197113; NC00197142; NC00196985; NC00195515; NC00195046; NC00195575; NC00195545; NC00196137; NC00195130; NC00194154; NC00194937; NC00194292; NC00193692; NC00193636; NC00192751; NC00192808; NC00192136; NC00191906; NC00191994; NC00191648; NC00191623; NC00191152; NC00191349; NC00191339; NC00191385; NC00190686; NC00190827; NC00190591; NC00190369; NC00190090; NC00189635; NC00189524; NC00189197; NC00189136