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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13 PATIENT RIGHTS, was out of compliance.

A-0144 CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. Based on observations, interviews and document review, the facility failed to ensure a safe patient care environment in multiple areas of the children (patients under the age of 10) and adolescent unit (patients over the age of 11). Specifically, the facility failed to ensure patients were monitored in areas with known ligature and safety risks (items or objects which could be used to inflict self-harm or strangulation). Furthermore, facility staff failed to monitor and observe three of three patients with active physician orders for increased patient observations and precautions (Patient #1, #2 and #4).

A-0166 RESTRAINT OR SECLUSION The use of restraint or seclusion must be--(i) in accordance with a written modification to the patient's plan of care. Based on interviews and record review, the facility failed to ensure when a patient required physical restraint and/or seclusion there was a corresponding written modification to the patient's treatment plan. The failure was identified in one of one medical records reviewed for patients who required restraint and/or seclusion. (Patient #3)

A-0168 RESTRAINT OR SECLUSION The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. Based on interviews and record review, the facility failed to ensure a provider order was obtained for restraint and seclusion in one of one medical records reviewed for patients who required restraint and/or seclusion. (Patient #3)

A-0175 RESTRAINT OR SECLUSION The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. Based on interviews and record review, the facility failed to ensure patients who required physical restraint or seclusion were monitored according to physician orders and facility policy in one of one medical records reviewed for patients who required restraint and/or seclusion. (Patient #3)

Based on observations, interviews and document review, the facility failed to ensure a safe patient care environment in multiple areas of the children (patients under the age of 10) and adolescent unit (patients over the age of 11). Specifically, the facility failed to ensure patients were monitored in areas with known ligature (items or objects which could be used to inflict self-harm or strangulation) and safety risks. Furthermore, facility staff failed to monitor and observe three of three patients with active physician orders for increased patient observations and precautions (Patient #1, #2 and #4). (Cross-reference A-0286)

Findings include:

Facility policies:

The Patient Precautions policy read, at risk patients are assigned patient precautions based on patient behavior, history and clinical assessment. Staff will conduct patient monitors and observations to ensure patient safety and to provide patients with appropriate observation levels and interventions. Staff will be trained on how to monitor patients designated with high risk behaviors. Furthermore, staff will perform a competency once trained.

Patient precautions may only be discontinued per physician order and patient precautions will be recorded and updated on each Patient Observation Record sheet. Patient observations and monitors are required to be performed by staff to ensure patient precautions are implemented. The patient's face, neck, skin tone color, physical condition, emotional state, body language, tone of voice are visually observed by staff, during sleep hours the rise and fall of the patient's chest will also be observed. Staff will be vigilant with patient observations when patients are in the milieu to ensure the safety of all patients on the unit.

Sexual Aggression/Perpetration, Victim of Sexual Aggression and Boundary Violations patient precaution defined the following: A sexual aggressor is defined as a patient with a recent or current history of sexually aggressive behaviors and or perpetration. A victim of sexual aggression is defined as a patient with a recent or current history of sexual vulnerability due to sexually aggressive acts or attempts made towards them by another person. A boundary violation is defined as recent or current patient interactions which invaded another person's personal space.

Patients placed on Sexual Aggression/Perpetration, Victim of Sexual Aggression and Boundary Violations precautions are to be redirected when provocative behavior occurs. The patient's hands, feet and physical location are monitored while in the milieu, staff are to be vigilant with observations to ensure the safety of all patients. Additionally, an incident report is to be completed and the charge nurse and nursing supervisor are to be notified of all boundary issues, concerns and behaviors.

The Sexual Aggression and Sexual Victimization policy read, sexual aggression is defined as inappropriate sexual attempts, exchanges and touching. Sexually inappropriate interactions are defined as poor adherence to personal boundaries, lingering or sneaking into another patients room or bathroom and inappropriate touching or attempts at inappropriate touching, poor boundaries, lingering near or sneaking into patient bedrooms or bathrooms, sexually provocative statements, voyeurism (secretly viewing a person unclothed or while sexually engaged without consent), flashing (intentional exposure of one's genitals to cause a reaction of alarm or distress) and public masturbation (touching oneself in front of others for sexual pleasure).

Patients who have a history of sexually inappropriate behavior, sexual aggression, sexual assault and or have been determined to be a danger to other patients due to inappropriate sexual behaviors will be placed on sexually acting out (SAO) precautions. Additionally, patients known to have a history of prior sexual abuse and or sexual victimization are considered to be at an increased risk for sexual victimization and will be placed on Victim of Sexual Aggression precautions.

Nursing staff will conduct a sexual assault/victimization risk factor assessment for each patient and will subsequently place the patient on either SAO-Aggression or SAO-Victim precautions. The nursing staff member will advise the attending physician of which SAO precaution is needed for the patient and obtain the physician order for the specified precaution. Nursing staff will communicate each patient's precaution level to ensure appropriate documentation of all ordered precautions are accurate and reflect the precaution in place in addition to the level of monitoring provided for the patient. All precautions will remain in effect until the attending physician discontinues the specified precaution order.

Unit staff will observe patients placed on SAO-Aggression or SAO-Victim precautions to identify sexually inappropriate behaviors including but not limited to the following: boundary violations, sexual aggression, sexually inappropriate interactions and sexual victimization. The activities and interactions of patients on SAO-Aggression or SAO-Victim precautions are monitored to ensure adherence to social and physical boundaries and to prevent sexually provocative behavior. At all times staff are required to be aware of the physical location of patients on SAO-Aggression or SAO-Victim precautions and document their concerns. Patients identified as having SAO-Aggression or SAO-Victim precautions are at an increased risk of sexually inappropriate actions and behaviors and need to be kept separate from one another.

Staff interventions on the unit will include the following: Inspection of isolated areas within the unit to ensure patients are unattended in unoccupied rooms and locations on the unit. Staff will supervise patients who are unable to participate and or attend group sessions or designated structured activities.

The Patient Observation Guidelines policy read, the patient's observation level corresponds with the patient's direct safety needs and the safety needs of other patients. Staff will visually monitor each patient to ensure patient safety. Patient observation is defined as visual observation and documentation of patient behavior and physical location within the unit.

Patient observation levels will adhere to the following guidelines: Direct visual observation of the patient. Staff will acknowledge and recognize the patient's observation level and the specified precautions indicated for each patient on the unit in order to ensure patient safety. An increased level of observation may be initiated by a registered nurse (RN), however, a physician order is required to decrease the observation level.

Patients will be assigned one of three observation levels: green, yellow or red. Patients designated as green will have visual observations performed every 15 minutes. Observation level green requires staff to visually monitor and check-in with each patient and to ensure patient safety. Additionally. staff will document in a progress note once every 24 hours.

Patients assigned observation level yellow are required to remain in the milieu common area unless performing personal hygiene activities or while sleeping. Visual observation checks of patients are required to be documented by staff every 10 minutes on the patient tracking log. Additionally, the physical location and behavior of the patient are documented. A physician order is required to change patient observation status, additionally, the physician order is required to be placed within the patient medical record. Patients on observation level yellow will have a nursing progress note entered into their medical record once per shift for a total of two nursing progress notes performed daily.

Patients placed on observation level of red are designated as a one to one observation (1:1 observation). 1:1 observations will have one staff member assigned to monitor and observe the patient. The patient will not be more than an arm's length away from the staff member at all times. A 1:1 observation level will be reviewed daily by the attending physician for the patient. The attending physician will document the continuation of a 1:1 observation order in the physician's daily progress note. Staff assigned to a patient to conduct 1:1 observations will not be assigned other duties or responsibilities while assigned the 1:1 observation. The charge RN will assess and document the patient's condition and response to the 1:1 observation every four hours in the nursing progress note section of the medical record.

Facility procedure:

The Treehouse Sensory Room Expectations read, patients on the Treehouse unit may use the sensory room when agitated, and responsive to re-direction in order to self-regulate and calm down. Only one child at a time may be in the sensory room.

1. The facility failed to ensure children and adolescents on the Treehouse unit were monitored and that patient safety was not compromised.

A. Observations and staff interviews revealed ligature and patient safety risks were not mitigated in the sensory room (a space designated for children or adolescents to engage and practice self-coping skills) located on the Treehouse unit.

a. On 12/9/21 at 12:54 p.m., an observation was conducted of the sensory room and revealed the sensory room had the following ligature and patient safety risks: an unsecured electrical power cord extended from within the sensory tunnel (a tunnel designed to soothe and relax a person when overstimulation from emotional and or physical interactions occur) to an unprotected electrical power outlet located on the wall adjacent to the tunnel.

i. On 12/9/21 at 1:25 p.m., an interview was conducted with Mental Health Specialist (MHS) #6. MHS #6 stated many of the children and adolescent patients on the Treehouse unit had suicide precautions in place. She stated patients could potentially self harm when unattended in the sensory room.

ii. On 12/13/21 at 2:29 p.m., an interview was conducted with Nursing Supervisor (Supervisor) #4. After reviewing findings of the observations conducted on 12/9/21, Supervisor #4 confirmed there were ligature and patient safety risks within the sensory room. Supervisor #4 stated electrical wires and cords were unsecured and physically accessible to a patient when in the room.

iii. On 12/15/21 at 12:09 p.m., the Risk Manager (Manager) #10 was interviewed. Manager #10 stated ligature and patient safety risk mitigation had not been performed within the sensory room.

B. Surveillance video between 9:15 a.m. to 9:45 a.m. on 12/4/21 was reviewed and revealed children and adolescent patients were provided unrestricted and unmonitored access to the sensory room.

a. A review of the video surveillance revealed multiple patients on the Treehouse unit were in the sensory room at the same time without staff supervision. Examples include:

i. From 9:15 a.m. to 9:19 a.m., Patient #2 and two adolescent patients were together in the sensory room.

ii. From 9:20 a.m. to 9:25 a.m., Patient #2 and an adolescent patient were in the sensory room.

iii. From 9:27 a.m. to 9:29 a.m., Patient #1, Patient #2 and two adolescent patients were inside the sensory room at the same time.

iv. From 9:29 a.m. to 9:33 a.m., Patient #1, Patient #2 and an adolescent patient were together in the sensory room.

v. From 9:34 a.m. to 9:44 a.m., Patient #1 and Patient #2 were in the sensory room together.

These examples were in contrast to the Treehouse Sensory Room procedure which read, no more than one patient was allowed to be in the sensory room.

b. Interviews with staff were conducted and revealed continuous patient monitoring was required for patients allowed to access and use the sensory room.

i. On 12/9/21 at 1:29 p.m., an interview was conducted with Mental Health Specialist (MHS) #6. MHS #6 stated MHSs were required to continuously monitor and observe the sensory room when a patient was in the room to ensure patient safety was not compromised. MHS #6 stated she had been assigned the duty of conducting patient observations on 12/4/21. MHS #6 explained she documented each patient observation she conducted on the patient tracking log. MHS #6 further stated because of her responsibility to document observations, she was not available to continuously monitor the sensory room.

MHS #6 stated she had instructed MHS #5 to monitor the sensory room while she performed patient observations on the unit.

ii. On 12/13/21 at 1:29 p.m., an interview was conducted with MHS #5, who stated she began working at the facility on 11/8/21. MHS #5 stated on 12/4/21 she worked on the Treehouse unit. MHS #5 stated on 12/4/21 she was assigned to shadow (on-the-job training by following and observing a more experienced colleague with the same position) MHS #6. She stated she had not completed new hire orientation and was not supposed be left alone to monitor patients on the unit.

MHS #5 stated she had not been provided training or education for the sensory room. MHS #5 further stated she was not provided information about procedures or processes related to the sensory room.

iii. On 12/14/21 at 11:10 a.m., an interview was conducted with Nursing Supervisor (Supervisor) #8. Supervisor #8 stated although there was no facility process or procedure in place for the sensory room, staff were required to continually monitor and observe patients while in the sensory room.

Supervisor #8 stated MHS #5 was shadowing MHS #6 while on the Treehouse unit on 12/4/21. He stated MHS #5 was still being oriented to the facility and had not been completely trained. Supervisor #8 stated MHS #6 was required to supervise MHS #5 and MHS #5 was not to be assigned patients to monitor or observe alone.

2. The facility failed to ensure physician orders for patient observations and precautions were implemented.

A. Document review and staff interviews revealed physician orders for a 1:1 observation for Patient #1 were not implemented.

a. According to the Patient Precautions policy, staff will ensure the safety of the patient and the safety of other patients in the milieu. The hands, feet, physical location, behavior, emotional state, body language and tone of voice of each patient will be observed and documented on the patients' observation record. Additionally, staff will ensure patient precautions were implemented and thoroughly monitored at all times.

b. According to the Patient Observation Guidelines policy, 1:1 observation was defined as one staff member assigned to monitor and observe only one patient. Staff members must not allow the patient to be more than an arm's length away during the duration of the 1:1 observation.

c. Patient #1 was a four year old male admitted to the facility on 11/30/21 with the following diagnosis: self-harming behaviors (deliberate infliction of pain or injury to one's body), aggression and inability to regulate emotions (poor ability to manage or regulate emotional responses).

i. On 12/2/21 at 7:00 a.m., Physician (Physician) #3 wrote an order for Patient #1 to be placed on a 1:1 observation.

ii. At 8:44 a.m., Registered Nurse (RN) #2 acknowledged and noted the 1:1 observation order placed by Physician #3. She stated, the RN who implemented the physician order will write noted in medical record below the physician order to verify the order was in place.

iii. Document review of Patient #1's patient tracking logs for 12/2/21, 12/3/21 and 12/4/21 were reviewed and revealed Physician #3's written order for a 1:1 observation was not implemented.

The facility was unable to provide evidence the 1:1 observation order written by Patient #1's physician had been implemented.

iv. On 12/13/21 at 2:29 p.m., an interview was conducted with Supervisor #4. Supervisor #4 stated she was informed Physician #3 wrote a 1:1 observation order for Patient #1. Supervisor #4 stated a hygiene tracker was implemented for Patient #1 in lieu of the 1:1 observation order. Supervisor #4 stated she assumed the 1:1 observation order written by Physician #3 was placed to ensure Patient #1 was routinely encouraged to perform personal hygiene activities such as hand washing, toileting and oral care.

Supervisor #4 stated she did not speak with Physician #3 directly about Patient #1 and was not informed Physician #3 wanted the 1:1 observation in place to ensure Patient #1's safety was not compromised.

v. On 12/9/21 at 2:44 p.m., an interview was conducted with RN #2. RN #2 stated Physician #3 wanted Patient #1 to be placed on 1:1 observations to ensure the patient's safety at all times while on the unit.

RN #2 stated she attempted to implement the 1:1 observation order written by Physician #3, but was informed by Supervisor #4 the facility did not have sufficient staff in place to implement the 1:1 observation ordered for Patient #1. RN #2 stated she was informed by Supervisor #4 other arrangements had been established for Patient #1. RN #2 stated a hygiene tracking sheet was created to monitor when Patient #1 used the restroom, washed his hands and brushed his teeth.

vi. On 12/13/21 at 4:01 p.m., an interview was conducted with Physician #3. Physician #3 stated she was concerned about Patient #1's safety. She stated Patient #1 was four years old and unable to maintain his own safety. Physician #3 stated she had concerns about Patient #1 being safe on a unit with older patients who were adolescents and teenagers (patients over the age of 13).

B. Document reviews and staff interviews revealed SAO (sexually acting out) precautions for Patient #2 and Patient #4 were not implemented.

According to the Sexual Aggression and Sexual Victimization policy, patients with a history of sexually inappropriate behavior, sexual aggression, sexual assault or display inappropriate sexual behavior will be placed on SAO precautions.

The policy defined a sexual aggressor was defined as any patient with a recent or current history of sexually aggressive behaviors and or perpetration. However, a victim of sexual aggression was defined as any patient with a recent or current history of sexual vulnerability due to sexually aggressive acts or attempts made or imposed upon them by another person.

Per facility policy, staff will implement the following interventions for patients with SAO precautions: Inspection of isolated areas on the unit will occur to ensure patients with SAO precautions do not occupy unattended or unoccupied locations on the unit. Nursing staff will be required to communicate to oncoming staff the specific patients placed on either SAO-Aggression, SAO-Victimization or both SAO-Aggression/SAO-Victimization precautions to ensure continued observations of precaution levels and documentation. Staff will be required to visualize patients placed on all forms of SAO precautions and be aware of the patient's physical location at all times. Patients who have been placed on an SAO precaution have an increased risk of sexually inappropriate actions and behaviors and need to be kept separate from other patients to ensure the safety of all patients at the facility.

a. Patient #2 was admitted to the facility on 11/8/21 with a diagnosis of suicidal ideation (thoughts or ideas of taking one's own life).

i. According to the medical record, on 11/20/21 at 8:15 p.m., a physician order was written for Patient #2 to be placed on SAO precautions.

ii. Document review of Patient #2's patient tracking logs from 11/20/21 to 11/27/21 were reviewed and revealed the physician order for SAO precautions had not been documented as implemented until 11/27/21.

Upon request, the facility was unable to provide evidence staff who conducted patient tracking and documentation implemented SAO precautions according to facility policy.

b. Patient #4 was admitted to the Treehouse Unit at the facility on 11/23/21. The intake for Patient #4 was reviewed and revealed Patient #4 had a history of sexually aggressive behavior and sexual victimization potentiality. Furthermore, the physician for Patient #4 wrote SAO-Aggression and SAO-Victimization precaution orders to be implemented for Patient #4 at the time of admission.

i. Patient tracking logs for Patient #4 were reviewed. Patient #4's patient tracking logs revealed from 11/24/21 through 12/7/21 facility staff had not implemented and or enacted the physician's order for SAO-Aggression precautions.

c. Interviews were conducted with staff who implemented physician orders, conducted patient observations and documented patient observations on the patient tracking logs.

i. On 12/9/21 at 4:01 p.m., an interview was conducted with RN #1. RN #1 stated she was not aware of what SAO precautions were. She stated she did not recall if she received training or education related to SAO precautions and what was needed to be implemented for a patient on SAO precautions. RN #1 stated she did not review SAO precautions with oncoming staff and was unsure staff correctly implemented SAO precautions for the patient.

ii. On 12/13/21 at 3:34 a.m., an interview was conducted with MHS #14. MHS #14 stated he did not know what SAO precautions were. He stated he was unaware of what was monitored and documented for patients placed on SAO precautions. MHS #14 stated he was not educated about SAO precautions and patients placed on SAO precautions were not specifically reviewed upon arrival to the unit at the beginning of a shift.

Based on interviews and record review, the facility failed to ensure when a patient required physical restraint and/or seclusion there was a corresponding written modification to the patient's treatment plan. The failure was identified in one of one medical records reviewed for patients who required restraint and/or seclusion. (Patient #3)

Findings include:

Facility policies:

The Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion read, it is the policy to support each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/herself or others. This facility is committed to preventing, reducing, and striving to eliminate the use of restraints and seclusion, as well as preventing emergencies that have the potential to lead to the use of these interventions.

Treatment Plan Review/Revision: When the patient has presented behavior that is dangerous to themselves or others so that restraint or seclusion were indicated, a review and modification of the treatment plan is indicated. Based upon the consultation with the attending physician or Licensed Independent Practitioner (LIP), information gathered from the debriefing with the patient, and the face-to-face evaluation, the Registered Nurse (RN) shall review and update the treatment plan within 8 hours. The updated treatment plan shall reflect: the identification of an assessed problem associated with the use of restraint/seclusion, if the problem has not been previously identified, goals related to prevention of the further use of restraint/seclusion, interventions which define alternative approaches to address the identified problem. Responsibility for each intervention is assigned. The plan is reviewed with the patient.

The use of restraint/seclusion will be thoroughly documented in the patient record. Documentation includes the treatment plan review and revision following the episode of restraint/seclusion which will include treatment interventions to prevent future use.

1. The facility failed to ensure a written modification to the treatment plan was completed in response to multiple episodes of restraint and/or seclusion which occurred during a patient's hospitalization.

a. Patient #3's medical record was reviewed. According to the medical record Patient #3 required physical restraint and/or seclusion on four occasions during his hospitalization. However, the medical record did not include a modification of Patient #3's master treatment plan to reflect the potential risk for use of seclusion or restraint or updated interventions to prevent future episodes.

i. On 11/29/21 at 4:36 p.m., Patient #3 required both physical restraint and seclusion due to assaultive behavior. According to the Seclusion and Restraint Packet in Patient #3's medical record, Patient #3 assaulted and punched staff and was unable to de-escalate.

The RN who performed the Post Intervention Face to Face Evaluation following the initiation of physical restraint and seclusion for Patient #3 documented a treatment plan modification was not indicated because it was "already on treatment plan." However, review of previous treatment plans completed on 11/18/21, 11/15/21 and 11/8/21 did not reflect the risk for restraint or seclusion as potential problem areas for Patient #3.

ii. On 12/2/21 at 4:36 p.m., Patient #3 required physical restraint because he climbed over the nurse's station, hit and bit an RN and attempted to attack other staff members.

The RN who completed the Post Intervention Face to Face Evaluation did not document whether a treatment plan modification was indicated or not.

iii. On 12/4/21 at 4:36 p.m., Patient #3 required physical restraint because he shoved multiple staff members, bit and hit a staff member, and refused to de-escalate.

The RN who completed the Post Intervention Face to Face evaluation documented a treatment plan modification was not indicated but did not document why it was not indicated.

iv. On 12/5/21 at 6:45 p.m., Patient #3 required physical restraint because he struck a peer, spit at and kicked staff.

The RN who completed the Post Intervention Face to Face evaluation documented a treatment plan modification was indicated because Patient #3 was placed on a 1:1. However there were no changes specific to Patient #3's need for restraints noted in an updated treatment plan.

b. An Update to the Master Treatment Plan was completed on 11/30/21. The update identified Suicidal Ideation as the problem area. Goals documented for the patient included: to participate in school; to talk to a staff member about his anger before an outburst; and to identify three coping skills he had learned.

The problem area and goals were similar to those identified on Patient #3's treatment plan completed on 11/18/21, which read the problem area was suicidal ideation and the identified goals were to participate in school, talk to staff about emotions, and reporting five new coping skills he had learned. The update to the treatment plan completed on 11/30/21 did not specify the risk for use of restraint or seclusion as a problem area and did not identify new or modified interventions to prevent future need for restraint or seclusion.

c. On 12/8/21 an Acute Interdisciplinary Treatment Plan Update was completed. The update again identified Patient #3's problem area as suicidal ideation, and the identified goals included use of coping skills, participation in school, and talking to a staff member at least once a day about his feelings. The updated treatment plan did not specify the use of restraint or seclusion as a problem area and did not identify updated interventions to prevent additional episodes of restraint and seclusion.

d. On 12/15/21 at 10:15 a.m., the Director of Nursing (DON) #12 was interviewed. DON #12 stated when a patient required physical restraint or seclusion a Master Treatment Plan Modification was completed as part of the Seclusion and Restraint Packet. She stated the treatment plan modification was to include the type of intervention required, the reason for the intervention, and short-term and long-term objectives for the patient to be able to regain self-control and prevent future need for the intervention. She stated the intent for the modification was to ensure staff and the treatment team were aware of interventions to help the patient avoid future use of seclusion or restraint.

DON #12 stated the Master Treatment Plan modification was reviewed and signed by the treatment team and included in the patient's medical record. She stated if Patient #3's medical record did not include treatment plan modifications for his four episodes of restraint and seclusion they likely were never completed.

e. On 12/15/21 at 12:09 p.m., the Risk Manager (Manager) #10 was interviewed. Manager #10 stated on review of Patient #3's record there was only one update to the patient's treatment plan following an episode of seclusion and restraint and referred to the update completed on 11/30/21. She stated she considered this update sufficient to satisfy the requirement for a treatment plan modification as it included anger and coping skills as continued goals for Patient #3.

However, this was in conflict to the facility's policy which read the updated treatment plan was to include the identification of an assessed problem associated with use of restraint or seclusion and interventions which define alternative approaches to address the identified problem. The problem identified in Patient #3's updated treatment plan remained suicidal ideation, and the interventions and goals specified were the same as those identified in previous treatment plans and did not address how the interventions would prevent future need for restraint or seclusion.

Manager #10 stated according to facility policy a treatment plan modification should have been completed after each of Patient #3's episodes of restraint and/or seclusion. She stated a treatment plan modification was not completed after Patient #3 required physical restraint on 12/2/21, 12/4/21 or 12/5/21.

Based on interviews and record review, the facility failed to ensure a provider order was obtained for restraint and seclusion in one of one medical records reviewed for patients who required restraint and/or seclusion. (Patient #3)

Findings include:

Facility policies:

The Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion policy read, physician orders, consultation and evaluation: restraint or seclusion shall be used in emergency situations only and requires an order from a physician. The physician or licensed independent practitioner (LIP) must be contacted for an order either during the emergency initiation of the restraint or seclusion or immediately after the restraint or seclusion has been initiated. Telephone and verbal orders for restraint and seclusion may be received and recorded by an RN. The physician shall authenticate the telephone order within 24 hours. The physician's order for use of restraint or seclusion will be recorded in the medical record and include the nurse receiving the order and the physician giving the order with appropriate dates and times.

1. The facility failed to ensure a provider's order for restraint and seclusion was completed and authenticated according to facility policy.

a. Patient #2's medical record was reviewed. The medical record revealed on 11/29/21 at 4:36 p.m. Patient #2 required physical restraint and seclusion for assaultive behavior.

The Seclusion/Restraint Order form, which was included in the Seclusion and Restraint Packet in the medical record, revealed both physical restraint and seclusion were ordered for the Patient #2. According to the order form a telephone order was obtained from Provider #3 by Registered Nurse (RN) #9. The order included RN #9's signature, however the area for the provider's signature was not signed or dated.

A separate section of the Seclusion and Restraint packet, titled Staff/Administrative/Supervisory Debriefing, included a section which read, Administrative Review Completed By. This section was left blank.

On review of the general physician orders for Patient #2, there was no documentation of an order for restraint and seclusion on 11/29/21.

This was in contrast to facility policy, which read when a telephone order for restraint or seclusion was obtained by an RN, the provider was to authenticate the telephone order within 24 hours.

b. On 12/13/21 at 3:22 p.m., RN #11 was interviewed. RN #11 stated when a patient was aggressive or assaultive and the staff believed physical restraint or seclusion was warranted, staff was required to contact either the attending or on-call provider to obtain an order. She stated if the provider was not available at the facility to write an order then staff obtained a telephone order and transcribed the order into the patient's medical record.

RN #11 stated an order for restraint and/or seclusion included the date and time the order was given, any verbal information the provider gave to the receiving staff, and documentation to reflect the order was read back to the provider. She stated if the order was given via telephone the transcribing staff member signed the order and the provider was required to sign the order within 24 hours.

RN #11 stated it was important for the provider to sign an order for restraint or seclusion to verify the provider gave the order and to ensure the nurse or staff member did not write the order without the provider's knowledge.

c. On 12/15/21 at 10:15 a.m., the Director of Nursing (DON) #12 was interviewed. DON #12 stated both seclusion and physical restraint required an order from a provider. She stated the order was documented in the medical record as part of the Seclusion and Restraint Packet. She stated the order included the type of intervention initiated, the allowable duration of the order, the criteria for the patient to be released from restraint or seclusion, and the less restrictive interventions attempted prior to restraint or seclusion. DON #12 stated if a telephone order was given all of these items were to be discussed with the provider when the order was obtained.

DON #12 stated providers were to sign and authenticate a telephone order for restraint or seclusion within 24 hours of giving the order. She stated she, the Assistant Director of Nursing, or another member of the facility's leadership reviewed each Seclusion and Restraint Packet to ensure complete documentation of the episode was present, to include a complete provider order.

DON #12's interview was in conflict to the medical record for Patient #3, in which the telephone order for physical restraint and seclusion was not signed by the ordering provider, and there was no evidence the administrative review occurred to ensure complete documentation of the episode.

DON #12 stated it was important for the provider's order for seclusion or restraint to be signed because seclusion and restraint were highly restrictive interventions which involved risk to the patient, and it was necessary for the provider to be aware each time a patient required restraint or seclusion.

d. On 12/13/21 at 2:13 p.m., the Risk Manager (Manager) #10 was interviewed. Manager #10 stated when a patient required seclusion or restraint staff were to complete the Seclusion and Restraint Packet to document the entirety of the episode. She stated the provider's order was to be completed as part of the packet. Manager #10 stated the order required the signature of the provider who ordered the seclusion or restraint.

Manager #10 reviewed the Seclusion and Restraint packet in Patient #3's medical record and confirmed the order for restraint and seclusion documented on 11/29/21 was not signed by the provider.

Based on interviews and record review, the facility failed to ensure patients who required physical restraint or seclusion were monitored according to physician orders and facility policy in one of one medical records reviewed for patients who required restraint and/or seclusion. (Patient #3)

Findings include:

Facility policies:

The Proper Use and Monitoring of Physical/Chemical Restraint and Seclusion policy read, the use of restraint and seclusion will be thoroughly documented in the patient's medical record. If physical restraint is indicated the Registered Nurse (RN) will assign a staff member, trained and deemed competent in the monitoring of seclusion and restraints, to conduct continuous in-person monitoring for the duration of the seclusion/ restraint episodes. Any patient in a physical restraint will have a staff person who is not participating in the hold observing him/her for any signs of distress or incorrect holding procedures. Documentation related to restraint or seclusion includes 15 minute assessments of the patient's status, continuous monitoring of patient and care provided.

The Patient Observation Guidelines policy read, for patients on Enhanced Observations (Yellow Level): documentation of the Observation Check Log is to be completed 6 times per hour at staggered intervals but no more than 10 minutes between documented checks. Each check will document the patient's location and behavior. Changes in the observation status are to be entered in the physician's order section.

1. The facility failed to ensure patients who required physical restraint and/or seclusion were monitored and their condition assessed according to the frequency specified in the physician orders and facility policy.

a. Patient #3's medical record was reviewed. According to the medical record Patient #3 required physical restraint and/or seclusion on four occasions during his hospitalization. On three of the four occasions staff did not complete timely and accurate documentation of Patient #3's condition during the restraint or seclusion in accordance with the facility policy, which required documentation of monitoring every 15 minutes, or the physician's order, which specified monitoring every 10 minutes.

i. On 11/8/21 when Patient #3 was admitted, the provider's admission orders for Patient #3 specified observation level Yellow (monitoring the patient every 10 minutes). There was no additional physician order to specify a change in the observation level. Subsequent observation check logs completed for Patient #3 between 11/8/21 and 12/4/21 documented Patient #3 remained on Yellow observation level.

ii. On 11/29/21 at 4:36 p.m., Patient #3 required both physical restraint and seclusion due to assaultive behavior. According to the Seclusion and Restraint Packet in Patient #3's medical record, Patient #3 assaulted and punched staff and was unable to de-escalate.

The Seclusion and Restraint Packet read Patient #3 was in a physical restraint from 4:36 p.m. to 5:03 p.m. The patient was then in seclusion from 5:03 p.m. to 5:52 p.m.

The Observation Check Log/Seclusion and Restraint Log for 11/29/21 was reviewed. According to the log a Mental Health Specialist (MHS) documented at 4:40 p.m. the patient's condition was coded "O," which meant the patient was in a physical hold, and "M", which meant the patient was striking out. The next documented observation of the patient's condition occurred at 5:00 p.m., which was 20 minutes later. This was in contrast to the physician's ordered observation level for observation every 10 minutes, and the facility policy which required the patient to be monitored every 15 minutes.

The log revealed MHS #13 documented monitoring of Patient #3 during the patient's time in seclusion. MHS #13 completed monitoring of the patient at 5:15 p.m., 5:30 p.m., and 5:45 p.m. This was in conflict to the observation level ordered for Patient #3 which was every 10 minutes.

iii. On 12/2/21 at 4:36 p.m., Patient #3 required physical restraint because he climbed over the nurse's station, hit and bit an RN and attempted to attack other staff members. According to the Seclusion and Restraint Packet, Patient #3 was in physical restraint from 4:36 p.m. to 4:53 p.m.

There was no evidence in the Observation Check Log/Seclusion and Restraint Log for 12/2/21 to identify when Patient #3 was in a physical restraint or his condition while in restraint. At 4:40 p.m. staff documented he was both "A," which meant the patient was quiet or calm, and "H," which meant the patient was agitated. At 4:50 p.m. staff documented he was "A" for quiet or calm. Neither observation reflected the patient was in a physical restraint during this time period.

iv. On 12/4/21 at 4:36 p.m., Patient #3 required physical restraint because he shoved multiple staff members, bit and hit a staff member, and refused to de-escalate. Patient #3 was in a physical restraint from 4:36 p.m. to 4:37 p.m.

There was no evidence in the Observation Check Log/Seclusion and Restraint Log for 12/4/21 to identify when Patient #3 was in a physical restraint or his condition while in restraint. At 4:30 p.m. staff documented the patient was "EFJI," which meant overactive, uncooperative, verbal outburst and assaultive. At 4:40 p.m. the patient was "FGHJ," which meant uncooperative, crying, agitated and verbal outburst. Neither observation reflected the patient was in a physical restraint during this time period, and an observation of the patient's status and condition was not recorded for 4:36 p.m., when the patient was in a physical restraint.

b. On 12/14/21 at 2:38 p.m., MHS #13 was interviewed. MHS #13 stated when a patient was in physical restraint it was necessary to monitor the patient for any signs of pain and changes in behavior. He stated the staff member who was assigned to monitor the patient during a physical hold documented the monitoring on the daily observation log, and used a specific code "O" to specify the time the patient was in the restraint. MHS #13 stated similarly when a patient was in seclusion the staff member monitored the patient continually and was to record the observations of the patient's condition in the observation log.

MHS #13 stated if a patient was on a specific observation level the frequency of documented observations would not change solely because the patient was in seclusion. He stated if the patient was to be monitored every 10 minutes this would be maintained while the patient was in seclusion. He stated this was important because only the physician could approve a change in the patient's observation level, and patients were often anxious or attempted to self-harm during seclusion and needed close monitoring.

MHS #13 reviewed the Observation Check Log/Seclusion and Restraint Log completed on 11/29/21 for Patient #3. He stated when he monitored Patient #3 in seclusion he overlooked the specified observation level for observations every 10 minutes. He stated he only documented observations every 15 minutes because he was accustomed to the observation frequency on the facility's residential unit, which was every 15 minutes. He stated he should have documented Patient #3's condition every 10 minutes while the patient was in seclusion according to the ordered observation level.

c. On 12/15/21 at 10:15 a.m., the Director of Nursing (DON) #12 was interviewed. DON #12 stated when a patient was in physical restraint or seclusion, staff were to document their monitoring and assessment of the patient on the daily observation log. She stated when a patient was in a physical restraint or seclusion staff were to document the patient's condition every 15 minutes on the observation log.

DON #12 stated if a patient was in restraint or seclusion, the required frequency for monitoring was every 15 minutes however she was unsure whether the policy required staff to continue monitoring the patient at the observation level ordered by the physician. She stated if a patient was ordered to be on checks every 10 minutes staff should maintain this frequency of observation and continue to document the monitoring at those intervals.

DON #12 stated when a patient was in physical restraint staff were expected to document when the patient was in restraint by using the "O" code on the observation log. She stated the correct codes on the observation log should be used to document the patient's behavior and status while in a restraint, in order to ensure the patient was physically okay during the restraint.

DON #12's interview was in contrast to Patient #3's medical record, which revealed monitoring during an episode of restraint and seclusion was not completed every 10 minutes according to the physician's order or every 15 minutes according to facility policy, and the patient's condition and physical status during two episodes of physical restraint was not recorded in the observation check logs.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QAPI was out of compliance.

A0286- Patient Safety. The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will identify and reduce medical errors. The hospital must measure, analyze, and track adverse patient events. Program Activities: Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. Executive Responsibilities. The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: That clear expectations for safety are established. Based on interviews and document review, the facility's quality and performance improvement (QAPI) program failed to analyze adverse patient events in order to identify contributing factors and implement preventive actions in one of one adverse patient events reviewed.

Based on interviews and document review, the facility's quality and performance improvement (QAPI) program failed to analyze adverse patient events in order to identify contributing factors and implement preventive actions in one of one adverse patient events reviewed. (Cross-reference A-0144)

Findings include:

Facility policies:

The Protection of Patients from Abuse and Neglect policy read, through its Performance Improvement Program the facility strives to proactively identify high risk or error prone processes that may present risks to patient safety, including those that may contribute to or cause abuse or neglect. As described in the facility Performance Improvement Plan, this is accomplished through review of such data as: single occurrences or patterns and trends in serious incidents and allegations; performance monitoring of important patient care processes. The goal of such review is the identification of opportunities to decrease potential risks to patient safety, and the development of plans or recommendations for remediation of the identified concern.

Should issues of abuse or harassment present themselves, precautions are taken to ensure the safety of the patient. All allegations of abuse or harassment are reported to the Risk Manager and internally investigated and appropriate actions taken. The policy referenced the Incident Data Gathering and Reporting, and the Investigating Serious Incident, Allegations and Near Misses policies.

Individual patient needs for intensified staffing may be accomplished through the ordering of one to one supervision or other levels of intensified supervision, as described in the Special Precautions Guidelines. In response to allegations or suspicions of abuse or neglect the facility will conduct an investigation as described in the policy titled Investigation Serious Incidents, Allegations and Near Misses. Investigations are carried out by the facility's Risk Manager or designee and may include but are not limited to: interviews with all individuals who have direct knowledge of the event or allegation under review; interviews with individuals knowledgeable of any facility process or system associated with the allegation; review of documents related to the event or allegation.

The QAPI Program/Plan read, Objectives are to enhance, maintain and improve the quality and safety of patient care through service measurement and assessment of patient care, resolution of problems and on-going pursuit of opportunities to improve patient care. To facilitate a proactive approach toward continuous improvement and evaluate action taken to assure that desired results are achieved and maintained. The QAPI program provides a mechanism for measurement and assessment of important processes or outcomes related to patient care and safety. Assessment findings are used to study and improve the processes that affect patient care outcomes, identify education needs and evaluate competence of staff.

The Performance Improvement Committee includes the CEO, Medical staff member, Director of Performance Improvement and Risk Management, Director of Nursing and Director of Clinical Services. The committee is responsible to oversee and accomplish the following: ensure that comprehensive assessment and root cause analysis is initiated when data analysis indicates undesirable variations in performance; assure appropriate actions are implemented to effectively resolve identified problems or improve existing processes. Data is collected for assessment of processes and outcomes, particularly high risk processes, and the findings are analyzed to identify significant variances and opportunities to improve patient outcomes.

The Investigating Serious Incidents, Allegations and Near Misses policy read, the purpose of this policy is to provide for a structured response to serious patient related incidents and to those occurrences defined by the organization as near misses. Sentinel Events comprise a special class of serious incidents with extreme consequences, as involving any of the following: the report of a sexual assault of patients either by other patients or by staff, on or off grounds while in our care.

Upon being notified of patient abuse or neglect allegations, the facility's designated Risk Manager will initiate an internal investigation of the occurrence. Investigations may include but are not limited to: interviews with all individuals who have direct knowledge of the event under review; interviews with individuals knowledgeable of any facility process or system associated with the incident; review of documents related to the incident. Upon gathering available data related to the event the Risk Manager will analyze the and consult with other management or clinical personnel as needed. The analysis should focus on identifying not only the direct causes of the incident, but also on identifying any underlying causes that may reflect process issues in need of further review.

The Processing Sexual Contact/ Incident policy read, consider a sexual act between a patient and another person abuse or assault if the patient is a minor and the partner is at least two years older.

The Sexual Aggression and Sexual Victimization policy read, discovery of a non-consensual sexual allegation can occur either as witnessed by staff or reported to staff by a third party or one of the patients allegedly involved. Upon report of an allegation of non-consensual sexual behavior between patient and patient the Charge Nurse and facility leadership take the following actions. Initiates investigation including interviews of all patients involved, conducted separately, any witnesses, and staff directly responsible for the observation rounds at the time of the event. Sexual allegations are investigated for reasons including, most importantly, the protection of patient rights, to find causes, and to prevent similar occurrence.

The Patient Precautions policy read, patient precautions are implemented to assure observation, intervention and response to at risk patient issues and to provide protection of patients. precautions are initiated by a physician order. Physician orders are obtained to initiate, increase, decrease or discontinue an observation monitoring level. Patient care staff will receive training in high risk patient behaviors and will assess patients throughout their hospital stay to assure precautions are updated as indicated.

Sexual Aggression/ Perpetration, Victim of Sexual Aggression, Boundary Violation precautions: interventions include to communicate with the treatment team to determine actions or changes in treatment plan interventions; when around peers during activities monitor hands and feet and where patient is seated; milieu presence and vigilant observations are essential to patient safety.

The Patient Observation Guidelines policy read, one to one (1:1) observation entailed a specific and dedicated staff member was assigned to the patient, remaining in arm's length of patient at all times. The clinical justification for the one to one observation must be included in the physician's order. This level of observation must be reviewed daily by the attending physician or designee and a new order written by the physician continuing, discontinuing or adjusting the one to one observation.

1. The facility failed to investigate and analyze an adverse patient event involving an allegation of sexual abuse between two minor patients in order to identify causes and contributing factors and implement preventive action. (Cross-reference A-0144)

A. Medical Records

Medical record review revealed an adverse patient event which occurred on the facility's Child and Adolescent Unit. The event involved an allegation of sexual touching between Patient #1 and Patient #2.

a. Patient #2's medical record was reviewed. On 11/30/21 at 7:00 a.m., Patient #1's attending psychiatrist (Provider #3) entered a psychiatric evaluation which read, Patient #1 was four years old and was admitted for self-harming behaviors, aggression and history of trauma and neglect.

i. On 12/2/21 at 8:44 a.m., Provider #3 entered a physician order which read, complete patient bathroom checks every 1.5 hours; have patient wash hands before meals and bathroom; have patient brush his teeth. The order further read, place patient on 1:1 (a specific and dedicated staff member was to be assigned to the patient, remaining in arm's length of patient at all times).

Provider #3 entered a psychiatric progress note the following day, 12/3/21, which read, Formulation of Risk: Continue 1:1.

ii. A psychiatric progress note was entered on 12/4/21 at 3:47 p.m. The note read, the physician was notified at approximately 10:00 a.m. Patient #1 was involved in sexually inappropriate activity where privates were touched by a peer. The attending physician was notified of the report of inappropriate touching and stated to place the other patient involved on a separate unit. Police and parents were notified, and Patient #1's parents removed the patient from the hospital and brought him to the emergency room for evaluation.

b. Patient #2's medical record was reviewed. On 11/9/21 at 7:00 a.m., Patient #2's attending psychiatrist (Provider #3) entered a psychiatric evaluation which read, Patient #2 was nine years old and was admitted for aggression, suicidal ideation and significant history of trauma. According to the evaluation Patient #2's psychiatric history included aggression toward other children, including harming a two year old sibling.

i. On 11/20/21 at 8:15 p.m., a physician order was entered which read, Patient to be blocked (meaning the patient was not to have a roommate) for SAO (sexually acting out) precautions. The order read the recommendation was to continue to block until further evaluation. On 12/3/21 at 1:00 p.m., a physician order was entered which read, continue to block room for aggression and SAO.

ii. Review of the Observation Check Logs completed for Patient #2 revealed on 11/27/21, seven days after the order for SAO precautions was entered, the check logs were amended to include SAO as an identified precaution for the patient. Subsequent check logs including the check log completed on 12/4/21 included SAO precautions.

iii. On 12/4/21 at 10:10 p.m., a psychiatric progress note was entered which read, the physician was notified at 10:15 a.m. Patient #2 was alleged to have touched another patient inappropriately. The note read, the event was to be investigated fully to determine what actually happened.

B. Adverse Event Report

Review of the adverse event report entered in response to the alleged sexual touching which occurred between Patients #1 and #2 on 12/4/21 revealed further details regarding the event.

a. The Acute Reporting Packet for the adverse event, completed by Nursing Supervisor (Supervisor) #8, was reviewed. The description of the occurrence read, at approximately 9:45 a.m. Patient #1 approached staff and reported Patient #2 touched his penis while in the sensory room (a separate room on the Child and Adolescent Unit).

i. The Acute Reporting Packet included information gathered from Patient #1, the alleged victim, and read Patient #1 was interviewed as part of the initial investigation of the event. There was no evidence in the Acute Reporting Packet Patient #2 was interviewed as part of the initial investigation of the alleged event.

ii. The Acute Reporting Packet also included Staff Interviews regarding any other incidents involving Patient #1 and #2 and whether observation procedures were followed for both clients. However, the Staff Interview portion did not identify which staff were interviewed and there was no evidence staff were interviewed to identify the causes or contributing factors to the event.

According to facility policy, on discovery of an allegation of sexual abuse staff were to initiate investigation including interviews of all patients involved and interviews with all individuals who have direct knowledge of the event under review in order to identify underlying causes and prevent reoccurrence.

iii. The Acute Reporting Packet further read, were observation procedures being followed for both clients? Supervisor #8 documented "Yes."

This was in conflict to review of surveillance video from 12/4/21 for the Child and Adolescent Treatment Unit, which revealed observation procedures were not followed for Patients #1 and #2 according to facility policy, the ordered level of precautions for Patient #2, and the facility's guidelines for use of the sensory room. Video review revealed the patients were allowed unmonitored and unrestricted access to the sensory room on multiple occasions, and Patient #2 was allowed to be in the sensory room alone with Patient #1 despite being on SAO precautions. (Cross Reference A-0144)

C. Adverse Event Investigation

Review of the investigation and follow-up actions performed in response to the adverse event involving Patients #1 and #2 revealed investigation of the event was not completed according to facility policy and failed to identify contributing factors and necessary preventive actions.

a. Staff interviews revealed facility leadership responsible to investigate adverse patient events did not complete the steps described by facility policy to investigate the event involving Patients #1 and #2 and thus did not identify multiple contributing factors to the event, including: lack of staff awareness and understanding of the SAO precautions; discontinuation of a physician order for 1:1 monitoring without the input of the ordering provider; and assignment of a staff member who lacked complete training to monitor patient safety on the Child and Adolescent Unit.

i. On 12/13/21 at 1:29 p.m., Mental Health Specialist (MHS) #5 was interviewed. MHS #5 stated on 12/4/21 she was still completing her orientation as a new hire and was shadowing (on-the-job training by following and observing a more experienced colleague with the same position). She stated she was brought to the Child and Adolescent Unit sometime in the morning and was assigned to shadow MHS #6. She stated she had not previously worked on the Child and Adolescent Unit and had only worked with older adults in the facility.

MHS #5 stated MHS #6 asked her to monitor the patients in the sensory room, which included Patients #1 and #2, and stated MHS #6 then walked away from the sensory room to complete observations of other patients. MHS #5 stated she was not informed of guidelines for monitoring patients in the sensory room and was not oriented to any specific patient precautions or safety needs. She stated it was her understanding that as she was still completing her training shifts she was not permitted to monitor patients independently. MHS #5 stated after MHS #6 left the sensory room to complete observations of other patients, MHS #5 remained briefly at the door of the sensory room but then walked away and rejoined MHS #6 in a different area of the unit. She stated shortly after she left the sensory room Patient #1 approached her and MHS #6 and reported Patient #2 had touched him on the penis in the sensory room.

MHS #5 stated since the event occurred she had not spoken with a supervisor about the event and was not interviewed or invited to any discussion of the event. She stated she had not received additional education related to monitoring patient safety in the sensory room. MHS #5 stated when she worked on the Child and Adolescent Unit on 12/4/21 she was not aware of the precautions in place for Patients #1 and #2, and she stated she did not know what SAO precautions were.

There was no evidence the facility identified the assignment of a staff member who lacked training to monitor patients as a potential contributing factor to the event involving Patients #1 and #2. The facility provided coaching to MHS #6 and MHS #15 on 12/4/21 in response to the event; however the coaching did not address whether it was permitted for MHS #6 to task an untrained staff member who was shadowing to supervise patients so that MHS #6 could perform other job duties.

ii. Additional interviews revealed staff members who were routinely assigned to care for and monitor patients on the Child and Adolescent Units lacked knowledge of the SAO precautions and the level of monitoring which was required for a patient on SAO precautions. As example:

On 12/9/21 at 10:27 a.m., an interview was conducted with MHS #15 on the Child and Adolescent Unit. MHS #15 was assigned on 12/9/21 to be the 1:1 for Patient #2. The unit census, which listed SAO precautions for Patient #2, was reviewed with MHS #15. MHS #15 stated he did not know what SAO stood for and he would have to ask another staff member to find out.

Video review for 12/4/21 revealed MHS #15 was working on the Child and Adolescent Unit on the date of the event involving Patients #1 and #2. MHS #15 was observed on video surveillance monitoring patients on the unit, including Patient #2 who was on SAO precautions. However, according to the interview conducted five days later on 12/9/21, MHS #15 was unaware of what SAO precautions entailed.

On 12/9/21 at 4:01 p.m., an interview was conducted with RN #1. RN #1 stated she was the charge RN on the Child and Adolescent Unit on the date of the event involving Patients #1 and #2. RN #1 stated she was not aware of what SAO precautions were. She stated she did not recall if she received training or education related to SAO precautions and what needed to be implemented for a patient on SAO precautions. RN #1 stated she did not review SAO precautions with oncoming staff and was unsure staff correctly implemented SAO precautions for the patient.

Similar lack of knowledge regarding SAO precautions was identified during interviews conducted on 12/13/21 with MHS #14 and RN #16. This was in contrast to facility policy which read patient precautions were implemented with the purpose to assure observation, intervention and response to at risk patient issues and staff were to be trained regarding precautions and high risk behaviors.

There was no evidence that prior to the survey facility leadership identified staff's lack of understanding of SAO precautions, which were ordered for Patient #2 at the time of the event, as a potential contributing factor to the adverse patient event involving Patients #1 and #2.

iii. On 12/13/21 at 4:10 p.m., Provider #3 was interviewed. Provider #3 stated she ordered 1:1 monitoring for a patient when she felt it was necessary for the patient's safety. She stated on 12/2/21 she ordered a 1:1 for Patient #1 because she was concerned that due to his young age his basic needs were not being met by staff. Provider #3 stated her concerns for Patient #1 which prompted her to order 1:1 monitoring included his mood and difficulty with transitions, increased agitation and behaviors after a family session at the facility, and the possibility his previous self-harming behaviors would recur. She stated Patient #1 was four years old and unable to maintain his own safety. Provider #3 stated she had concerns about Patient #1 being safe on a unit with older patients.

Provider #3 stated staff did not inform her a 1:1 was not implemented for Patient #1, and she stated on the following day on 12/3/21 she wrote in her progress note the plan was to continue the 1:1. Provider #3 stated after the event on 12/4/21 involving Patients #1 and #2 she inquired where the 1:1 was and was told Patient #1 did not have 1:1 monitoring in place.

Provider #3 stated she believed it was unacceptable the level of monitoring she ordered for Patient #1 was not implemented. She stated she had discussed 1:1 monitoring with the patient's family as part of his treatment plan and she expected the order to be followed. She stated if the 1:1 monitoring had been implemented as ordered, the event involving Patients #1 and #2 would not have occurred.

Provider #3 stated she had not been contacted or interviewed by facility leadership as part of an investigation of the event. She stated she had expressed concerns regarding the event to the facility's medical director but had no further communication regarding the event. This was in contrast to facility policy, which read investigation of adverse events and allegations of sexual abuse included interviews with all individuals with knowledge of the event under review and individuals knowledgeable of facility processes associated with the event, with a focus on identifying underlying causes the may reflect process issues in need of further review.

There was no evidence that prior to the survey facility leadership identified the 1:1 for Patient #1 was discontinued without knowledge of the intended purpose for the order and without the input of the attending physician who ordered the 1:1. The facility did not implement preventive action or education to ensure staff did not routinely discontinue physician orders for a higher level of monitoring without the knowledge of the ordering provider.

b. Leadership interviews confirmed investigation of the adverse event involving Patients #1 and #2 lacked elements required by the facility's policies and failed to identify and analyze contributing factors.

i. On 12/14/21 at 3:31 p.m., the Risk Manager (Manager) #10 was interviewed. Risk Manager #10 stated when an adverse event occurred, the Acute Reporting Packet was completed if the adverse event was potentially required to be reported to outside entities. She stated she was notified on 12/4/21 of the event involving Patients #1 and #2 and she requested the Acute Reporting Packet to be completed immediately.

Risk Manager #10 stated when she reviewed the packet on 12/6/21, she identified Patient #1 had been interviewed as part of the investigation however there was no evidence Patient #2 was interviewed. She stated she then completed an interview with Patient #2 and the patient denied the alleged event occurred; she stated she kept notes of this interview but she did not enter the interview into the documented investigation of the event. Risk Manager #10 stated Patient #2 should have been interviewed immediately as part of the initial investigation because it was important to obtain the alleged assailant's account of the event.

Risk Manager #10 stated she had reviewed video footage from the Child and Adolescent Unit on the date of the alleged event. She stated two staff members who were present and responsible for monitoring patients at the time the event occurred, Mental Health Specialist (MHS) #6 and MHS #15, were interviewed and provided coaching in response to the event. She stated on review of video footage she saw a third staff member who was also present on the unit at the time of the event, however she was unsure who this staff member was and stated she did not interview the staff member as part of her investigation. Risk Manager #10 stated she did not know of any other staff members who were interviewed as part of the investigation because this was not documented in the Acute Reporting Packet.

Manager #10 stated when she reviewed the medical records for Patients #1 and #2 she noted there was an order for a 1:1 in Patient #1's physician orders. However, she stated staff had informed her the 1:1 was not implemented because the 1:1 was specifically intended to ensure Patient #1's hygiene and toileting needs were attended to and staff had developed an alternative process to address Patient #1's hygiene.

Risk Manager #10 stated she had not interviewed Provider #3, who wrote the order for the 1:1, as part of the investigation of the event. She stated she did not know who had spoken with Provider #3 regarding the plan to discontinue the 1:1, or whether staff had confirmed with Provider #3 the intended purpose for the 1:1 order before determining it was appropriate to implement an alternative plan. Risk Manager #10 stated it was her understanding the order for a 1:1 was purely related to Patient #1's hygiene needs, and if the order had been intended for a different purpose or if it was related to safety precautions that information would have changed the way the event was investigated and responded to.

Risk Manager #10 stated once she had interviewed Patient #2 and determined the sensory room on the unit was closed down and education was to be provided to staff regarding the use of the sensory room, she believed there were no further actions needed for the investigation. She stated although the adverse event report had not yet been closed in the reporting system she considered the investigation essentially complete because the event was related specifically to the use of the sensory room. She stated she had reviewed the Acute Reporting Packet twice and determined the packet was satisfactory. Risk Manager #10 stated when an adverse patient event was investigated the primary goal was to determine whether the allegation was substantiated and the second goal was to identify lapses in staff compliance to policies.

This was in contrast to the facility QAPI program and facility policies to review adverse patient events, which read, analysis should focus on identifying not only direct causes of the incident but also any underlying causes that may reflect process issues in need of review. Comprehensive assessment is initiated when data indicates undesirable variations in performance and appropriate actions are implemented to effectively resolve identified problems or improve existing processes.

ii. On 12/15/21 at 10:15 a.m., the Director of Nursing (DON) #12 was interviewed. DON #12 stated she was aware of the event involving Patient #1 and #2 and was involved in the investigation of the event. She stated in response to the event the sensory room was closed and staff were re-educated on how to use and monitor the sensory room.

DON #12 stated as part of the investigation of the event facility leadership interviewed MHS #6 and MHS #15 as they were present when the alleged event occurred. However, she stated she did not know if anybody interviewed the other MHS who was present on the unit when the event occurred. DON #12 stated all staff present and observing the unit when an adverse patient event occurred should be interviewed in order to gather accurate information about the event. She stated this information was necessary to determine if there were flaws or weaknesses in facility processes and to accurately report the event to outside entities.

DON #12 stated she was aware a 1:1 had been ordered for Patient #1 two days prior to the event, however she stated she was informed by staff the treatment team had determined the intent of the 1:1 was specifically to monitor the patient's hygiene issues and toileting, and because staff had implemented an alternative plan to address the patient's hygiene staff felt the 1:1 was not needed. However, she stated staff should have consulted the attending physician who wrote the order because the attending physician directed the patient's care and there may have been a different intent or purpose to the 1:1 order.

DON #12 stated she did not know if the patients' attending physician was interviewed as part of the investigation. She stated if the 1:1 monitoring which was ordered for Patient #1 was intended for reasons other than hygiene, the facility would need to review processes for ordering and evaluating the necessity for 1:1 monitoring.

iii. On 12/15/21 at 1:03 p.m., a second interview was conducted with Manager #10. Manager #10 stated the investigation of the event involving Patients #1 and #2 was not formally closed yet because the event was reported to the Department of Human Services (DHS) and DHS still needed to conduct their investigation. However, she stated there were no more actions which would help to substantiate the allegation as it was not witnessed by staff and Patient #2 denied the alleged event occurred; therefore, she stated there was not much more the facility would do to investigate the event. Manager #10 stated she would keep the investigation open due to the surveyors' visit, however she did not elaborate on any further actions which would be taken in response to the event.