HospitalInspections.org

Based on review of facility policies, review of medical records and staff interview, the facility failed to ensure patients received care in a safe setting.

Findings included:

Facility policy titled "Patient Rights and Responsibilities" stated in part, "List of Rights
1. Without limitation patients shall be entitled to:
...e. Care in a safe and sanitary setting."

Facility policy titled "High Risk Behavior Precautions" stated in part, "Purpose: To establish guidelines for supervision of patients and interventions of patients who exhibit high risk behaviors.
Policy: It is the policy of the Pavilion that patients who exhibit high risk behaviors will be placed on appropriate precautions ...
Procedures: Patients are assessed ... and reassessed throughout hospitalization by the interdisciplinary treatment team for any behavior or behavioral history that demonstrates need for high risk precautions ...
Nursing/Clinical Services-
...2. A physicians [sic] order will be obtained for each high risk behavior precaution identified upon admission or for any change to the high risk precautions during the course of treatment (an RN may initiate) *modifications to the interventions must be included in the physician order and must be reflected on the patients [sic] treatment plan
...High risk behavior precaution interventions-
The interdisciplinary team will implement specific behavioral interventions based on the high risk behaviors identified and will monitor and update the treatment plan as needed including but not limited to the following:
...Sexually Acting Out (SAO) Aggressor/victimization
...d. Staff must be aware of and monitor the patients during high risk times such as late at night or early morning or during shower time, change of shift, meal times, visiting hours, unit crisis or during any acting out episodes
...f. Staff will document all incidents of sexually acting out in the patient medical record ...
i. Response notification-
i. Unit staff will notify Charge Nurse, Nurse Supervisor, and/or physician of any patient behaviors indicating a change in the patients' status and document this in the electronic medical record ...
iii. Obtain orders from physician as necessary."

Review of the incident reports and the medical record for patient #2 revealed patient #2 was involved in a sexual incident but was not placed on SAO precautions. This information would not be readily available if the patient were to be readmitted to the facility.

The above was confirmed in an interview with staff #8 on the afternoon of 7/24/18.

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure nursing staff kept a current nursing/interdisciplinary care plan for each patient.

Findings included:

Facility policy titled "Interdisciplinary Treatment Planning" stated in part, "In essence, the treatment plan serves as an organizational tool whereby the care rendered each patient is designed, implemented, assessed, and updated in an orderly and clinically sound manner.
Procedure:
...3. The treatment plan shall contain specific interventions that relate to goals, are written in behavioral and measurable terms, and include expected achievement dates as well as person responsible for implementation ...
11. ...More frequent treatment plan reviews/revisions will be based on changes in the patient's condition such as:
a) A new impairment or significant information about an existing impairment is identified.
b) A major change occurs in the patient's clinical condition ...
12. Treatment plan reviews and updates shall include the following steps:
a. Review of progress toward goals and effectiveness of interventions for each open problem ..."

Facility policy titled "High Risk Behavior Precautions" stated in part, "Purpose: To establish guidelines for supervision of patients and interventions of patients who exhibit high risk behaviors.
...High risk behavior precaution interventions-
The interdisciplinary team will implement specific behavioral interventions based on the high risk behaviors identified and will monitor and update the treatment plan as needed including but not limited to the following:
...Sexually Acting Out (SAO) Aggressor/victimization
...f. Staff will document all incidents of sexually acting out in the patient medical record
g. Behavior will be monitored closely for any identified 'triggers' of sexually acting out included in the treatment plan
h. The treatment plan will include specific coping mechanisms to reduce the potential for sexually acting out
i. Response notification-
i. Unit staff will notify Charge Nurse, Nurse Supervisor, and/or physician of any patient behaviors indicating a change in the patients' status and document this in the electronic medical record and the treatment plan will be updated to indicate the change in condition ..."

Review of the medical record for patient #1 revealed patient #1 was involved in a sexually inappropriate incident with patient #1. Patient #1's master treatment plan did not address this incident.
Patient #2's master treatment plan dated 4/6/18 stated in part, "4/5/18 pt reported 'me and - did it' pt stated we 'had sex' ... pt shared a room with another adolescent whom [they] said [they] had sex with." Patient #2's treatment plan did not contain specific interventions that relate to goals, was written in behavioral and measurable terms, and did not include expected achievement dates as well as person responsible for implementation."

The above was confirmed in an interview with staff #8 on the afternoon of 7/24/18.

Based on review of facility policy, review of medical records and staff interview, the facility failed to ensure medical records were accurately written.

Findings included:

Facility policy titled "High Risk Behavior Precautions" stated in part, "Purpose: To establish guidelines for supervision of patients and interventions of patients who exhibit high risk behaviors.
...High risk behavior precaution interventions-
...Sexually Acting Out (SAO) Aggressor/victimization
...f. Staff will document all incidents of sexually acting out in the patient medical record
i. Response notification-
i. Unit staff will notify Charge Nurse, Nurse Supervisor, and/or physician of any patient behaviors indicating a change in the patients' status and document this in the electronic medical record ..."

Review of the incident reports and medical records for patients #1 and #2 revealed they were involved in a sexually inappropriate incident on 4/5/18. There was no documentation stating what happened.

In an interview with staff #8 on the afternoon of 7/24/18, when discussing the lack of charting, staff #8 stated, "Yes and the doctor said 'sex.' Anything could have happened."

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure discharge summaries accurately documented the outcome of hospitalization.

Findings included:

Review of the incident reports and medical records for patients #1 and #2 revealed they were involved in a sexually inappropriate incident on 4/5/18.

Patient #1's discharge summary dated 4/20/18 stated in part, "Patient was active in the unit, had improved sleep and appetite, interacting with staff and peers appropriately ..."

Patient #2's discharge summary dated 4/6/18 stated in part, "[Patient #2] was active in the unit, had improved sleep and appetite, interacting with staff and peers appropriately ..."

The discharge summary for patients #1 and #2 did not document the outcome of their hospitalizations accurately.

Review of facility incident report dated 5/29/18 at 5:55 pm stated in part, "This patient [patient #3] wrapped left hand into other pateints [sic] hair while punching her multiple times in the right side of the head and face, then throwing her down to the floor ..." Patient #3 was discharged on 5/29/18 after the incident. The discharge summary for patient #3 dated 6/1/18 stated in part, " ...by the time the patient was discharged, the patient was stable with no overt psychiatric signs that would constitute a danger to self or others.
Patient was active in the unit, had improved sleep and appetite, interacting with staff and peers appropriately.
Upon discharge, patient was not in any acute distress; patient denied any endangering ideation of harm to self or others ..."

Patient #3 was discharged after the incident to a juvenile detention facility and attacked another patient immediately prior to discharge. The discharge summary did not reflect patient #3's inpatient stay accurately.

The above was verified by staff #8 on the afternoon of 7/24/18.