HospitalInspections.org

Based on interview, record review, and observation the governing body failed to take responsibility for the conduct of the hospital when aware and having identified concerns for 8 of 8 pediatric patients, Patients #10, #11, #12, #13, #14, #15, #16, and #17 who presented to the hospital under involuntary status [Baker Act], or Ex Parte court order and not being medically assessed, not receiving mental health evaluations, not transferred to a facility that was able to meet the needs of the patients if unable to be met at the hospital, not providing nursing supervision, not providing training/education for staff, not providing a safe setting for the patients when residing in the facility, not communicating with patients' guardians, not receiving consent for treatment, not administering necessary medications, and not providing for a safe discharge. Without psychological and medical evaluations each minor that presents to the hospital is at an increased risk for the likelihood of medical harm when not evaluated for possible medical concerns that would require medical treatment, psychological harm without evaluation for an increased risk of self-injurious behaviors, homicide, suicide and/or death, not being psychologically evaluated prior to discharge to evaluate the safety of the discharge. Without being evaluated when presenting for care and services, while residing in the facility, and/or at the time of discharge by a physician, clinical psychologist, or psychiatric nurse, there is an increased likelihood of harm resulting from self-injurious behaviors, homicide, and/or suicide attempt(s).

Findings include:

1. Review of the medical record for Patient #16 documented the patient is a 14 year old male who presented to Springbrook Hospital on 2/2/2023 under a Law Enforcement Officer initiated Involuntary Examination [Baker Act] dated 2/2/2023 at 1:05 PM for suicide attempt/suicidal ideation.

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" for Patient #16 dated 2/2/2023 1:05 PM read, "On 02/02/2023 [Patient #16's name] walked off school campus. I observed [Patient #16's name] walking toward the Parkway and shouted to him to return to school. As I shouted, I observed a vehicle traveling westbound on Parkway which was going to make contact with [Patient #16's name] as he approached the road. I had to physically stop [Patient #16's name] from walking into traffic and harming himself. While he was restrained [Patient #16's name] advised it is now "easier to kill himself" due to his handcuffs. Additionally, [Patient #16's name] kicked me and attempted to bite me several times. During an interview with [Patient #16's name] he advised he wanted to kill himself and has thoughts of killing himself. [Patient #16's name] then confirmed him walking into traffic was an attempt on his own life. It is my belief as a law enforcement officer that [Patient #16's name] meets Baker Act criteria. Without treatment, [Patient #16's name] is a direct threat to himself and others."

Review of the Minor Nursing Screening dated 2/2/23 at 1802 [6:02 PM] documented the Summary which read, Pt. [Patient] come on BA 52 [Baker Act] by school RO [Resource Office]
[name of county school district], pt. was running into traffic stating he wanted to kill himself. Pt. refuses to talk. There was no additional information documented on this form.

Review of the medical record for Patient #16 did not provide documentation of nursing progress notes, patient flowsheets, a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge, and no patient rights or informed consent signed by the parent/guardian or nursing assessments/progress notes. The record did not provide documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit [discharge document] documented the form was for disposition was signed by Patient #16's Aunt on 2/5/2023 at 11:47 PM. Treatment administered read, "none." Reason not admitted to the hospital read, "minor." No referral information was provided.

2. Review of the medical record for Patient #11 documented the patient presented to the facility on 2/10/2023 at approximately 9:08 PM for an Involuntary Examination, due to threating harm to himself and others.

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" dated 2/10/2023 read, "On 2/10/2023 [Patient #11's name], AKA [also known as, name], got into a verbal confrontation with his guardian/grandfather due to restricted privileges. [Patient # 11's name] grandfather informed [Patient #11's name] suffers from ADHD [attention-deficit/hyperactivity disorder] and bipolar disorder [causes extreme mood swings to include emotional highs of mania and lows, depression], on the day of this incident he had a mental health episode. [Patient #11's name] does receive counseling through [Name of facility] per his grandfather. During his episode [Patient #11's name] was throwing things in the home, attempted to break household items, and did strike his grandfather with a screwdriver due to being angry. [Patient #11's name] was also alleged to push his grandmother as she did not give him her iPad to play with. [Patient #11's name] told his grandfather during this incident that he would hurt him."

Review of the Minor Nursing Screening dated 2/10/2023 at 2108 [9:08 PM] documented the minor was 10 years old. Reason for involuntary placement: depression, mood swings, anxiety, panic attacks, crying spells, racing thoughts. Medication/treatment: Is minor receiving treatment elsewhere, checked "yes", Social Worker [Social Worker's name], [Facility name and name of primary physician]. Medications: Prozac [used to decrease fear, anxiety, unwanted thoughts, and number of panic attacks] by mouth daily for depression last time and date medication taken is left blank, Omega fish oil, guanfacine [approved to treat ADHD, improve restlessness, impulsivity, and hyperactivity] at bedtime. Reason for taking ADHD. Last date and time taken was left blank. Sertraline [used to manage and treat major depressive disorder] daily. Last date and time taken was left blank. Summary of screening: 10 year old male presents to SBH [Springbrook Hospital] on a BA 52 for aggressive behavior toward grandfather. Trying to break things around the house. Patient is calm and cooperative at this time. Patient has history of bipolar and ADHD per BA 52.

Review of www.medicalnewstoday.com for Prozac read, "When a person decides that they are ready to discontinue Prozac, a doctor will likely recommend gradually reducing, or tapering their dosage. Tapering usually last 4 weeks, but a doctor may suggest tapering the medication over 6-8 weeks to reduce the risk of severity of symptoms."

Review of NAMI [National Alliance on Mental Illness for Prozac read, "Stopping flouoxetine [Prozac] abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, dizziness, vomiting, nightmares, headache, and/or paresthesias (prickling, tingling sensation on the skin)."

Review of www.healthline.com for guanfacine read, "Warning for stopping the drug: Don't stop taking guanfacine without talking to your doctor first. This medication needs to be stopped slowly. Your doctor may gradually decrease your dosage. If you stop taking it abruptly, it can cause your blood pressure to go too high."

Review of www.psycom.net read, "Withdrawal symptoms of intuniv [guanfacine] can include headaches, tremors, agitation, and nervousness. Abrupt discontinuation can also cause a rapid increase in blood pressure, so maintain contact with your doctor and seek medical attention if necessary when discontinuing the drug."

Review of www.medicalnewstoday.com read, "Common discontinuation symptoms of stopping sertraline may include nausea, headaches, and tingling skin. For this reason, when a person decides to discontinue sertraline, they should discuss this with their doctor. The doctor may recommend gradually lowering the dose to reduce or avoid symptoms."

Review of the medical record for Patient #11 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #11's guardian on 2/13/23 at 20:25 [8:25 PM] no referral information was provided.

During a telephone interview conducted on 2/28/2023 at 4:15 PM, Patient #11's guardian stated, "I was not aware that they don't get [Patient #11's name] evaluated by anyone before they let him go. I was not aware that he did get looked at by a doctor."

3. Review of the medical record for Patient #14 a 14 year old female who presented to Springbrook Hospital on 2/10/2023 under a Law Enforcement Officer Initiated Involuntary Examination dated 2/10/2023 at 10:23 PM for suicide attempt/suicidal ideation.

Review of the "Report of law Enforcement Officer Initiating Involuntary Examination" for Patient #14 dated 2/10/2023 at 10:23 PM read, "On 2/10/2023 at approximately 21:13 [9:13 PM] hours, I responded to [address of patient], in reference to a suicide attempt which was later reclassified to a Baker Act. Upon arrival, as I made entry into the residence, I observed a female juvenile identified as [Patient #14's name] sitting on the couch, crying hysterically. I did observe there to be superficial cut marks on her upper right leg. I then asked [Patient #14's name] how she cut her leg and she was unable to answer any questions at this time. It should be noted that I was attempting to ask questions, County Fire rescue was on scene and speaking with [Patient #14's name] as well. Fire Rescue did state that the cut marks were only superficial and did not require further medical attention. As Fire Rescue was attending to [Patient #14's name], I did then make contact with [Legal guardian's name] who is [Patient #14's name's] grandmother and legal guardian. [Guardian's name] stated that [Patient #14's name] was in a verbal argument with her grandfather when [Patient #14's name] did then run into the bathroom. Upon [Patient #14's name] leaving the bathroom [Guardian's name] stated she noticed her leg had cut marks on them and [Patient #14's name] was hysterically crying and refused to answer any more questions. After I made contact with [Guardian's name], I was able to make contact again with [Patient #14's name]. At this time [Patient #14's name] was much more calm and stopped crying. I asked [Patient #14's name] if she wanted to harm herself to which she stated she did not know why she cut her leg. I then asked [Patient #14's name] if she wanted to hurt herself to which she responded with, "I can't do it anymore I don't want to live anymore." [Patient #14's name] then stated to me that she tried to kill herself once before when she was approximately 8 years old and she believes that has to do with past trauma."

Review of the record did not provide documentation of the Minor Nursing Screening.

Review of the medical record for Patient #14 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #14's grandfather on 2/13/23 at 22:15 [10:15 PM] no referral information was provided.

4. Review of the medical record for Patient #12 documented the patient is a 15 year old male who presented to Springbrook Hospital on an Ex Parte Order for Involuntary Examination [When a person seeks such relief in Family Courts in absence of the other spouse or parent, it is called an "Ex Parte" hearing], dated 2/14/2023, due to a court determination of mental illness requiring treatment.

Review of the "Ex Parte Order for Involuntary Examination" for Patient #12 dated 2/14/2023 Case No. [number] read, "1. There is reason to believe the above named person has a mental illness as defined in section 394.455(18) F.S. [Florida Statute] and because of this mental illness said person (a). has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination: and/or (b). unable to determine for himself/ herself whether examination is necessary and, 2. Either (check a or b) (a). without care or treatment the above named person is likely to suffer from neglect or refuse care for himself/herself, and such neglect or refusal poses a real and present threat of substantial harm to his or her well-being and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services, or, (b). there is substantial likelihood that without care or treatment the above named person will cause serious bodily harm to himself or herself or another person in the near future as evidenced by recent behavior [both a. and b. were checked]. Additional information upon which this order is based, petitioner states respondent is defiant, exhibits aggressive behavior and abuses alcohol and drugs."

Review of the Minor Nursing Screening dated 2/14/2023 at 2207 [10:07 PM] documented the date of birth. Reason for involuntary placement was not completed. The form was not completed for Family dynamics is there a hx [history of] family violence or trauma, not documented for DCF notified, other agency involvement, or medications. Summary of screening read; 14 y/o male presents to SB [Springbrook] Hospital on an involuntary (ex parte) status for defiant behavior. Pt. is A+O x4 [alert and oriented for person, place, time, event]. He is calm and cooperative. No nursing signature or name of person who completed the form documented.

Review of documentation in the medical record for Patient #12 of emergency room documentation dated 2/15/2022 at 2204 [10:04 PM] read, "Time initially seen 2/15/2023 at 2159 [9:59 PM]. History of present illness: The patient presents with sent from Springbrook to be medicated for agitation anger. The onset was just prior to arrival. The course and duration of symptoms is improving. The degree at onset was moderate the degree at present is none, risk factors consist of none, therapy today none, associated symptoms none. 15 year old male from Springbrook reportedly became agitated and started to tear up the room. Patient states he was on the phone with his mom, and he became upset. Patient doesn't take any medication normally. Patient is calm now and cooperative no complaints. Reexamination and reevaluation 2/15/2023 at 22:08 [10:08 PM] note since patient is now calm and cooperative, we'll give a dose of Ativan and send him back to Springbrook. Impression and plan diagnosis aggressive outburst plan improved stable disposition discharged 2/15/2022 at 2220 [10:20 PM]."

Review of the medical record for Patient #12 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes to include the patient being sent to the hospital or the patient returning to the facility from the hospital, or effectiveness/side effects of the administration of Ativan. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #12's mother on 2/17/23 at 22:07 [10:07 PM] no referral information was provided.

5. Review of the medical record for Patient #10 documented the patient presented to the facility on 2/17/2023 at approximately 9:39 PM for an involuntary examination, due to depression, suicidal ideation, anxiety/panic attacks and history of Attention-Deficit/Hyperactivity Disorder (ADHD).

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" reads, "[Patient #10's name] advised she broke up with her boyfriend today after 6 months and is no longer wanting to live. [Patient #10's name] stated, "I'm gonna find a way to cut my wrists, no matter what you do" referring to her mother. [Patient #10's name] has a history of Baker Acts and mental illness. [Patient #10's name] has been diagnosed with major depressive disorder, anxiety, and ADHD. [Patient #10's name] mother advised [Patient #10's name] is on medication for these mental illnesses but [Patient #10's name] has not been taking them. [Patient #10's name] advised she did not cut herself today but wanted to. Due to these statements and [Patient #10's name] unable to determine for herself, being a juvenile, she was Baker Acted."

Review of the Minor Nursing Screening dated 2/17/2023 at 2139 [9:39 PM] date of birth, 15 y.o. female. Under the section titled, Arrival information, there was no information documented for where the minor was arriving from, no family dynamics, no living situation, no history documented related if there was or was not family violence or trauma, and if DCF [Department of Children and Families] was notified. Reason for involuntary placement: Depression, suicidal ideation, anxiety/panic attacks hx [history] of ADHD. Medication /treatments: Is minor receiving treatment elsewhere - left blank. Primary care physician name/telephone # not documented. Handwritten on the form documented "medical issues." Medications: Abilify [used to treat mental conditions such as bipolar I disorder (manic-depressive illness), major depressive disorder, and schizophrenia], at bed time last time date taken 2/17/2023 at 2030 [8:20 PM], Lexapro [used to treat depression and anxiety] at bed time, last taken 2/17/2023 at 2030, Jornay [central nervous system stimulant prescription medicine used for the treatment of attention deficit hyperactivity disorder] at bed time, last taken 2/17/2030. Summary of screening: female minor Baker Acted for verbalizing SI [suicidal ideations] to cut wrists after recent breakup c [with] boyfriend. Past dxs [diagnosis]: MDD [major depressive disorder], anxiety, ADHD. No behavior issues at this time.

Review of newchoicestc.com read, "Lexapro withdrawal symptoms can be severe, particularly if you attempt to stop abruptly. Instead, the dosage should be slowly tapered down over a period of time and under the guidance of medical professionals who can help prevent or mitigate any withdrawal symptoms."

Review of www.webmd.com for Jornay read, "If you suddenly stop using this medication, you may have withdrawal symptoms (such as depression, suicidal thoughts, or other mental/mood changes). To help prevent withdrawal, your doctor may lower your dose slowly."

Review of the medical record for Patient #10 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. There is no documentation of or nursing assessments and only on nursing progress note. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the nursing progress note dated 2/20/2023 at 1400 [2:00 PM] read, "Child has been calm and cooperative, no behavioral issues, interacting appropriately with peers, will continue to monitor."

Review of the Springbrook Non admit signed by Patient #10's parent, handwritten by the parent read, "I do not believe she should be d/ced [discharged] dated 2/20/23 no time. The form was signed by the RN dated 2/20/23 at 2123 [9:23 PM].

During a telephone interview on 2/22/2023 at 10:10 AM Patient #10's mother stated, "[Patient #10's name] has been Baker Acted again, she was out less than 48 hours. She did not attempt suicide when she left but was at school and expressed that desire. We felt that she was not stabilized while she was at Springbrook. She had not received any medications while there and no examination for her mental health. They need to understand that she was not stabilized at all. A nurse called us and told us to come and get her. We tried to tell them she was not stabilized and not safe to go home, but they just shrugged their shoulders. I did sign that I didn't feel she should be discharged. She was not safe to go home. I had to take her home, so I did."

6. Review of the medical record for Patient #15 documented the patient is a 15-year-old female who presented to Springbrook Hospital on 2/17/2023 under a Law Enforcement Officer initiated Involuntary Examination" dated 2/17/2023 at 9:41 PM with suicidal ideation.

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" for Patient #15 dated 2/17/2023 at 9:41 PM read, "Subject has been having problems at school and more recently a video was posted on social media of her in a fight. Subject sent a message to her sister via Instagram stating, "I want to end my life I can't take it anymore. "Subject stated the comment was not made for attention but will not explain anything further."

Review of the Minor Nursing Screening dated 2/17/2023 at 2158 [9:58 PM] read, Summary of screening, "According to Baker Act female minor has been having problems at school and recently posted on social media that she wanted to end her life. No behavioral issues at this time." Reason for involuntary placement not documented, Arrival information not documented, DCF notification not documented.

Review of the medical record for Patient #15 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.


Review of the Springbrook Non admit the disposition - was blank. The form was signed by Patient #15's guardian. Patient #15 was discharged on 2/5/2023 at 11:47 PM. Treatment administered read, "none." Reason not admitted to the hospital read, "minor." No referral information was provided.

7. Review of the medical record for Patient #17 documented the patient is a 13 year old female who presented to Springbrook Hospital under a Ex Parte Order for Involuntary Examination dated 2/17/2023.

Review of the "Ex Parte Order for Involuntary Examination" for Patient #17 dated 2/17/2023 at 10:00 AM Case No. [number] read, "1. There is reason to believe the above named person has a mental illness as defined in section 394.455(18) F.S. and because of this mental illness said person (a). has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination: and/or (b). unable to determine for himself/ herself whether examination is necessary and, 2. Either (check a or b) (a). without care or treatment the above named person is likely to suffer from neglect or refuse care for himself/herself, and such neglect or refusal poses a real and present threat of substantial harm to his or her well-being and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services, or, (b). there is substantial likelihood that without care or treatment the above named person will cause serious bodily harm to himself or herself or another person in the near future as evidenced by recent behavior [both a. and b. were checked]. Additional information upon which this order is based, Petitioner states respondent has behavioral outbursts, theft, and threats of suicide. She recently attempted to jump out of a moving car."

Review of the Minor Nursing Screening dated 2/18/2023 at 1325 [1:25 PM] read, Demographic information Guardian preferred language - not documented, arrival information where arriving from - not documented, Family dynamics Hx of family violence or trauma - not documented, reason for involuntary placement - not documented, Medications treatment if minor receiving RX [medications] elsewhere primary care physicians name - not documented. Medications documented: Concerta [used to treat attention deficit hyperactivity disorder] daily last taken 2/17/23 at 0830, Intuniv at bedtime last taken 2/17/23 at 2000, clonidine [decreases anxiety attacks and psychiatric symptoms] no frequency or when last taken documented. No screening summary documented.

Review of www.addictioncenter.com read, "Concerta withdrawal produces very uncomfortable symptoms, such as headaches and anxiety. Depression can be severe during withdrawal."

Review of novarecoverycenter.com read, "Common clonidine withdrawal symptoms include: nervousness, agitation, anxiety, depression, tremors, chronic headaches, insomnia, nausea or vomiting."

Review of the medical record for Patient #17 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments and one progress note dated 2/20/2023. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the nursing progress note dated 2/20/2023 at 1705 [5:05 PM] read, "Child ate chicken and then c/o [complaint of] throat itching and throat pain, difficulty breathing, child was transported to [hospital name] ER [emergency room] at 1700 [5:00 PM] There is no documentation in the record of when the patient return from the hospital. There are no vital signs or additional nursing assessments documented after the patient returned from the hospital.

Review of emergency department documentation dated 2/19/2023 at 1747 [5:47 PM] allergic reaction, dysphagia. Discharged back to facility 2/19/2023 at 1843 [6:43 PM].

During an interview on 2/27/2023 at 1:00 PM, Patient #17's mother stated, "I was not aware that my daughter did not receive a psychiatric evaluation because they discharged her and that evening, we had to bring her to [Name of the facility] due to her suicidal behavior and she is now in a facility and getting the treatment she needs. She did attempt suicide again after discharge, attempting to jump out of a car in oncoming traffic. They are terrible. They sent her to the hospital and didn't call me. Initially when they discharged her, they did not provide any referrals. They, simply put, did nothing for her mental health. They were a babysitter, but they wouldn't even provide her medications and did nothing to help her. I told them that she was not safe to go home all they said is, sorry, but we can't keep her the Baker Act is up. The nurse told me that when I went to get her."

Review of the Springbrook Non admit documented the form was for disposition was signed by Patient #17's parent on 2/21/2023 at 10:06 AM.

8. Review of the medical record for Patient #13 documented the patient is a 17 year old female who presented to Springbrook Hospital on 2/18/2023 under a Law Enforcement Officer Initiated Involuntary Examination" dated 2/18/2023 at 12:20 AM with suicidal ideation.

Review of the "Report of the Law Enforcement Office Initiating Involuntary Examination" for Patient #13 dated 2/18/2023 at 12:20 AM read, "Subject stated she wants to commit suicide because she is overwhelmed in life."

Review of the Minor Nursing Screening dated 2/18/2022 at 0039 [12:39 AM] summary of screening read, "Female minor Baker Acted for suicidal ideation and states at this time, "I just don't want to live anymore" No behavioral issues noted at this time. Demographic information, placement type and preferred language, arrival information where is minor arriving from, family dynamics, living situation, is there a history of family violence or trauma, DCF notified is there another agency involved, Reason for involuntary placement - none of this information is documented.

Review of the medical record for Patient #13 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit documented, Reason not admitted: Patient is a minor, Disposition: Home. Dated 2/20/2023 at 12:00 [midnight] Numerous calls placed to mother prior to pick up. Mother signed 2/21/23 0106 [1:06 AM] for discharge. No referral information was provided.

During an interview on 2/24/2024 at 12:15 PM with Patient #13's mother she stated, "My daughter has had several concerns with wanting to end her life. I was only called on the day she was going to be discharged and told her Baker Act was due to end at about 1 AM and I needed to come and get her. I was not called and explained her patient rights. I was not given any referral information to get her assistance and she is still struggling with her mental health. They did not assist her at all, she [the patient] explained that she sat in a room with a tech and never saw anyone while she was there."

During an interview on 2/22/2023 at 9:55 AM the DON stated, "I was aware that the adolescents were being sent home with their parents. I have not been called and instructed nurses to let any pediatric patients go at the end of the Baker Act hours. I was aware that they have not been evaluated by a psychiatrist or psychologist. I can't tell you whether they were safe discharges, I did not discharge them. I would think if they were still having suicidal thoughts the nurses would call the sheriff and have them Baker Acted again. We don't do anything but hold these kids for observation, we don't provide them medications if they take them regularly, we have no physician that provi

The Immediate Jeopardy began on February 2, 2023, the facility failed to ensure patient rights were honored for care in a safe setting for 8 of 8 pediatric patients, Patient #10, #11, #12, #13, #14, #15, #16 and #17 who presented to the hospital under involuntary examination [Baker Act] or Ex Parte court order; the patients' guardians were not informed of the patient rights for care in a safe setting to include but not limited to medical and mental assessments, nursing supervision, providing a safe setting for the patients when residing in the facility, necessary medications, and a safe discharge. This systemic failure constitutes an immediate jeopardy.

Springbrook Hospital was not in compliance with Conditions of Participation for 42 CFR 482.13 Patient Rights, Requirements for Hospitals and Code of Federal Regulations (CFR) 42, Part 482 Conditions of Participation for Hospitals.

Refer to A0117 Patient Rights - Notice of Rights and A0144 Patient Rights-Care in a Safe Setting.

Based on record review and interview the facility failed to inform the patient representative of patient rights for 8 of 8 pediatric patients, Patients #10, #11, #12, #13, #14, #15, #16, and #17 who presented to the hospital for an involuntary examination [Baker Act] or under an Ex Parte court order.

Findings include:

1. Review of the medical record for Patient #16 documented the patient is a 14 year old male who presented to Springbrook Hospital on 2/2/2023 under a "Law Enforcement Officer initiating Involuntary Examination" [Baker Act] dated 2/2/2023 at 1:05 PM for suicide attempt/suicidal ideation.

Review of the medical record for Patient #16 did not contain documentation in the record of the patient's representative having been informed of the patient's rights. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

2. Review of the medical record for Patient #11 documented the patient presented to the facility on 2/10/2023 at approximately 9:08 PM for an Involuntary Examination.

Review of the medical record for Patient #11 did not contain documentation in the record of the patient's representative having been informed of the patient's rights. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

3. Review of the medical record for Patient #14 documented the patient #14 is a 14 year old female who presented to Springbrook Hospital on 2/10/2023 under a "Law Enforcement Officer Initiating Involuntary Examination" dated 2/10/2023 at 10:23 PM for suicide attempt/suicidal ideation.

Review of the medical record for Patient #14 did not contain documentation in the record of the patient's representative having been informed of the patient's rights. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

4. Review of the medical record for Patient #12 documented the patient is a 15 year old male who presented to Springbrook Hospital on an Ex Parte Order for Involuntary Examination [When a person seeks such relief in Family Courts in absence of the other spouse or parent, it is called an "Ex Parte" hearing], dated 2/14/2023.

Review of the medical record for Patient #12 did not contain documentation in the record of the patient's representative having been informed of the patient's rights. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

5. Review of the medical record for Patient #10 documented the patient presented to the facility on 2/17/2023 at approximately 9:39 PM for an involuntary examination.

Review of the medical record for Patient #10 did not contain documentation in the record of the patient's representative having been informed of the patient's rights. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

6. Review of the medical record for Patient #15 documented the patient is a 15-year-old female who presented to Springbrook Hospital on 2/17/2023 under a "Law Enforcement Officer initiating Involuntary Examination" dated 2/17/2023 at 9:41 PM with suicidal ideation.

Review of the medical record for Patient #15 did not contain documentation in the record of the patient's representative having been informed of the patient's rights. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

7. Review of the medical record for Patient #17 documented the patient is a 13 year old female who presented to Springbrook Hospital under a Ex Parte Order for Involuntary Examination dated 2/17/2023.

Review of the medical record for Patient #17 did not contain documentation in the record of the patient's representative having been informed of the patient's rights. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

8. Review of the medical record for Patient #13 documented the patient is a 17 year old female who presented to Springbrook Hospital on 2/18/2023 under a "Law Enforcement Officer Initiating Involuntary Examination" dated 2/18/2023 at 12:20 AM with suicidal ideation.

Review of the medical record for Patient #13 did not contain documentation in the record of the patient's representative having been informed of the patient's rights. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

During an interview on 2/24/2024 at 12:15 PM with Patient #13's mother she stated, "I was not called and explained her patient rights."

During an interview on 2/23/2023 at 3:00 PM Staff G, RN stated, "I have not provided their parents or guardians informed consent and patient rights information, we don't do that. I can't tell you why we don't do that."

During an interview conducted on 2/23/2023 at 3:16 PM Staff C, RN stated, "We do not give the parents or guardians patient rights and have them sign informed consent. I don't know why it's always been done this way."

During a telephone interview conducted on 2/23/2023 at 10:30 AM Staff H, RN stated, "We do not give them patient rights information or get their guardians to do an informed consent."

During an interview conducted on 2/23/2023 at 3:30 PM Staff D, RN, stated, "We do not provide any patient's rights or informed consent."

During an interview on 2/23/2022 at 3:45 PM Staff F, RN stated, "I do not call parents or guardians and get informed consent or provide them patient rights information."

During an interview on 2/22/2023 at 9:55 AM the Director of Nursing (DON) stated, "We do not provide patient rights and informed consent to the parents or guardians."

During an Interview on 2/23/2023 at 2:00 PM with the Director of Admissions stated, "I do not see that we provided the parents any patient information or consents. I didn't really think about this. I would not be getting any consents; the nurses do this."

During an interview on 2/24/2023 at 9:15 the Risk Manager (RM) stated, " I have not provided the child or parent with the patient rights forms, they are no admitted. They are here just for observation until we find placement."

During an interview on 2/24/2023 at 11:00 AM the Clinical Director of Social Services stated, " I do not know if they [the parents] understand that they can ask for an evaluation."

Review of the form titled, "Your Rights While Receiving Mental Health Services" last reviewed 1/8/23 read, "Rights of persons: The following rights are guaranteed you under Florida law. These will be fully explained to you at the time of admission to this facility. A copy of this form will be given to you to keep. You have the right to read the Baker Act law and rules at any time. Your signature on the form if you choose to sign, only acknowledges that you have had the rights explained and that a copy of this form was provided to you. Treatment: you have the right to receive the least restrictive, available, appropriate treatment in this facility. You will get a physical examination within 24 hours of arrival, and you will be asked to help develop a treatment plan to meet your individual needs. The criteria, procedures, and required staff training used by this facility for restraints, seclusion, isolation, emergency treatment orders, close levels of supervision, or physical management are available for your review. Such interventions may never be used for punishment, convenience of staff, or to compensate for inadequate staffing."

Based on observation, interview, and record review the facility failed to ensure patient rights were honored for care in a safe setting for 8 of 8 pediatric patients, Patients #10, #11, #12, #13, #14, #15, #16, and #17 who presented to the hospital under involuntary status [Baker Act], or Ex Parte court order and were not medically assessed, did not receive a mental health evaluation, no attempts were made to transfer to a facility that was able to meet the needs of the patient if unable to be met at the hospital, did not provide nursing supervision, did not provide training/education for staff, did not provide a safe setting for the patients when residing in the facility, did not communicate with patients' guardians, did not receive information for patient rights, did not provide necessary medications, and did not provide for a safe discharge. Without being evaluated when presenting for care and services, while residing in the facility, and/or at the time of discharge by a physician, clinical psychologist, or psychiatric nurse, there is an increased likelihood of harm resulting from self-injurious behaviors, homicide, and/or suicide attempt(s).

Findings include:

1. Review of the medical record for Patient #16 documented the patient is a 14 year old male who presented to Springbrook Hospital on 2/2/2023 under a Law Enforcement Officer initiating Involuntary Examination [Baker Act] dated 2/2/2023 at 1:05 PM for suicide attempt/suicidal ideation.

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" for Patient #16 dated 2/2/2023 1:05 PM read, "On 02/02/2023 [Patient #16's name] walked off school campus. I observed [Patient #16's name] walking toward the Parkway and shouted to him to return to school. As I shouted, I observed a vehicle traveling westbound on Parkway which was going to make contact with [Patient #16's name] as he approached the road. I had to physically stop [Patient #16's name] from walking into traffic and harming himself. While he was restrained [Patient #16's name] advised it is now "easier to kill himself" due to his handcuffs. Additionally, [Patient #16's name] kicked me and attempted to bite me several times. During an interview with [Patient #16's name] he advised he wanted to kill himself and has thoughts of killing himself. [Patient #16's name] then confirmed him walking into traffic was an attempt on his own life. It is my belief as a law enforcement officer that [Patient #16's name] meets Baker Act criteria. Without treatment, [Patient #16's name] is a direct threat to himself and others."

Review of the Minor Nursing Screening dated 2/2/23 at 1802 [6:02 PM] documented the Summary which read, Pt. [Patient] come on BA 52 [Baker Act] by school RO [Resource Office]
HCSd, pt. was running into traffic stating he wanted to kill himself. Pt. refuses to talk. There was no additional information documented on this form.

Review of the medical record for Patient #16 did not provide documentation of nursing progress notes, patient flowsheets, a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge, or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit [discharge document] documented the form was for disposition was signed by Patient #16's Aunt on 2/5/2023 at 11:47 PM. Treatment administered read, "none." Reason not admitted to the hospital read, "minor." No referral information was provided.

2. Review of the medical record for Patient #11 documented the patient presented to the facility on 2/10/2023 at approximately 9:08 PM for an Involuntary Examination, due to threating harm to himself and others..

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" dated 2/10/2023 read, "On 2/10/2023 [Patient #11's name], AKA [also known as, name], got into a verbal confrontation with his guardian/grandfather due to restricted privileges. [Patient # 11's name] grandfather informed [Patient #11's name] suffers from ADHD [attention-deficit/hyperactivity disorder] and bipolar disorder [causes extreme mood swings to include emotional highs of mania and lows, depression], on the day of this incident he had a mental health episode. [Patient #11's name] does receive counseling through [Name of facility] per his grandfather. During his episode [Patient #11's name] was throwing things in the home, attempted to break household items, and did strike his grandfather with a screwdriver due to being angry. [Patient #11's name] was also alleged to push his grandmother as she did not give him her iPad to play with. [Patient #11's name] told his grandfather during this incident that he would hurt him."

Review of the Minor Nursing Screening dated 2/10/2023 at 2108 [9:08 PM] documented the minor was 10 years old. Reason for involuntary placement: depression, mood swings, anxiety, panic attacks, crying spells, racing thoughts. Medication/treatment: Is minor receiving treatment elsewhere, checked "yes", Social Worker [Social Worker's name], [Facility name and name of primary physician]. Medications: Prozac [used to decrease fear, anxiety, unwanted thoughts, and number of panic attacks] by mouth daily for depression last time and date medication taken is left blank, Omega fish oil, guanfacine [approved to treat ADHD, improve restlessness, impulsivity, and hyperactivity] at bedtime. Reason for taking ADHD. Last date and time taken was left blank, sertraline [used to manage and treat major depressive disorder] daily. Last date and time taken was left blank. Summary of screening: 10 year old male presents to SBH [Springbrook Hospital] on a BA 52 for aggressive behavior toward grandfather. Trying to break things around the house. Patient is calm and cooperative at this time. Patient has history of bipolar and ADHD per BA 52.

Review of www.medicalnewstoday.com for Prozac read, "When a person decides that they are ready to discontinue Prozac, a doctor will likely recommend gradually reducing, or tapering their dosage. Tapering usually last 4 weeks, but a doctor may suggest tapering the medication over 6-8 weeks to reduce the risk of severity of symptoms."

Review of NAMI [National Alliance on Mental Illness for Prozac read, "Stopping flouoxetine [Prozac] abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, dizziness, vomiting, nightmares, headache, and/or paresthesias (prickling, tingling sensation on the skin)."

Review of www.healthline.com for guanfacine read, "Warning for stopping the drug: Don't stop taking guanfacine without talking to your doctor first. This medication needs to be stopped slowly. Your doctor may gradually decrease your dosage. If you stop taking it abruptly, it can cause your blood pressure to go too high."

Review of www.psycom.net read, "Withdrawal symptoms of intuniv [guanfacine] can include headaches, tremors, agitation, and nervousness. Abrupt discontinuation can also cause a rapid increase in blood pressure, so maintain contact with your doctor and seek medical attention if necessary when discontinuing the drug."

Review of www.medicalnewstoday.com read, "Common discontinuation symptoms of stopping sertraline may include nausea, headaches, and tingling skin. For this reason, when a person decides to discontinue sertraline, they should discuss this with their doctor. The doctor may recommend gradually lowering the dose to reduce or avoid symptoms."

Review of the medical record for Patient #11 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #11's guardian on 2/13/23 at 20:25 [8:25 PM] no referral information was provided.

During a telephone interview conducted on 2/28/2023 at 4:15 PM, Patient #11's guardian stated, "I was not aware that they don't get [Patient #11's name] evaluated by anyone before they let him go. I was not aware that he did get looked at by a doctor."

3. Review of the medical record for Patient #14 documented the patient #14 is a 14 year old female who presented to Springbrook Hospital on 2/10/2023 under a Law Enforcement Officer Initiated Involuntary Examination dated 2/10/2023 at 10:23 PM for suicide attempt/suicidal ideation.

Review of the "Report of law Enforcement Officer Initiating Involuntary Examination" for Patient #14 dated 2/10/2023 at 10:23 PM read, "On 2/10/2023 at approximately 21:13 [9:13 PM] hours, I responded to [address of patient], in reference to a suicide attempt which was later reclassified to a Baker Act. Upon arrival, as I made entry into the residence, I observed a female juvenile identified as [Patient #14's name] sitting on the couch, crying hysterically. I did observe there to be superficial cut marks on her upper right leg. I then asked [Patient #14's name] how she cut her leg and she was unable to answer any questions at this time. It should be noted that I was attempting to ask questions, County Fire rescue was on scene and speaking with [Patient #14's name] as well. Fire Rescue did state that the cut marks were only superficial and did not require further medical attention. As Fire Rescue was attending to [Patient #14's name], I did then make contact with [Legal guardian's name] who is [Patient #14's name's] grandmother and legal guardian. [Guardian's name] stated that [Patient #14's name] was in a verbal argument with her grandfather when [Patient #14's name] did then run into the bathroom. Upon [Patient #14's name] leaving the bathroom [Guardian's name] stated she noticed her leg had cut marks on them and [Patient #14's name] was hysterically crying and refused to answer any more questions. After I made contact with [Guardian's name], I was able to make contact again with [Patient #14's name]. At this time [Patient #14's name] was much more calm and stopped crying. I asked [Patient #14's name] if she wanted to harm herself to which she stated she did not know why she cut her leg. I then asked [Patient #14's name] if she wanted to hurt herself to which she responded with, "I can't do it anymore I don't want to live anymore." [Patient #14's name] then stated to me that she tried to kill herself once before when she was approximately 8 years old and she believes that has to do with past trauma."

Review of the record did not provide documentation of the Minor Nursing Screening.

Review of the medical record for Patient #14 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #14's grandfather on 2/13/23 at 22:15 [10:15 PM] no referral information was provided.

4. Review of the medical record for Patient #12 documented the patient is a 15 year old male who presented to Springbrook Hospital on an Ex Parte Order for Involuntary Examination [When a person seeks such relief in Family Courts in absence of the other spouse or parent, it is called an "Ex Parte" hearing], dated 2/14/2023, due to a court determination of mental illness requiring treatment..

Review of the "Ex Parte Order for Involuntary Examination" for Patient #12 dated 2/14/2023 Case No. [documented] read, "1. There is reason to believe the above named person has a mental illness as defined in section 394.455(18) F.S. [Florida Statute] and because of this mental illness said person (a). has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination: and/or (b). unable to determine for himself/ herself whether examination is necessary and, 2. Either (check a or b) (a). without care or treatment the above named person is likely to suffer from neglect or refuse care for himself/herself, and such neglect or refusal poses a real and present threat of substantial harm to his or her well-being and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services, or, (b). There is substantial likelihood that without care or treatment the above named person will cause serious bodily harm to himself or herself or another person in the near future as evidenced by recent behavior [both a. and b. were checked]. Additional information upon which this order is based, petitioner states respondent is defiant, exhibits aggressive behavior and abuses alcohol and drugs."

Review of the Minor Nursing Screening dated 2/14/2023 at 2207 [10:07 PM] documented the date of birth. Reason for involuntary placement was not completed. The form was not completed for Family dynamics is there a hx [history of] family violence or trauma, not documented for DCF notified, other agency involvement, or medications. Summary of screening read; 14 y/o male presents to SB [Springbrook] Hospital on an involuntary (ex parte) status for defiant behavior. Pt. is A+O x4 [alert and oriented for person, place, time, event]. He is calm and cooperative. No nursing signature or name of person who completed the form documented.

Review of documentation in the medical record for Patient #12 of emergency room documentation dated 2/15/2022 at 2204 [10:04 PM] read, "Time initially seen 2/15/2023 at 2159 [9:59 PM]. History of present illness: The patient presents with sent from Springbrook to be medicated for agitation anger. The onset was just prior to arrival. The course and duration of symptoms is improving. The degree at onset was moderate the degree at present is none, risk factors consist of none, therapy today none, associated symptoms none. 15 year old male from Springbrook reportedly became agitated and started to tear up the room. Patient states he was on the phone with his mom, and he became upset. Patient doesn't take any medication normally. Patient is calm now and cooperative no complaints. Reexamination and reevaluation 2/15/2023 at 22:08 [10:08 PM] note since patient is now calm and cooperative, we'll give a dose of Ativan and send him back to Springbrook. Impression and plan diagnosis aggressive outburst plan improved stable disposition discharged 2/15/2022 at 2220 [10:20 PM]."

Review of the medical record for Patient #12 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes to include the patient being sent to the hospital or the patient returning to the facility from the hospital, or effectiveness/side effects of the administration of Ativan. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #12's mother on 2/17/23 at 22:07 [10:07 PM] no referral information was provided.

5. Review of the medical record for Patient #10 documented the patient presented to the facility on 2/17/2023 at approximately 9:39 PM for an involuntary examination, due to depression, suicidal ideation, anxiety/panic attacks and history of Attention-Deficit/Hyperactivity Disorder (ADHD).

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" reads, "[Patient #10's name] advised she broke up with her boyfriend today after 6 months and is no longer wanting to live. [Patient #10's name] stated, "I'm gonna find a way to cut my wrists, no matter what you do" referring to her mother. [Patient #10's name] has a history of Baker Acts and mental illness. [Patient #10's name] has been diagnosed with major depressive disorder, anxiety, and ADHD. [Patient #10's name] mother advised [Patient #10's name] is on medication for these mental illnesses but [Patient #10's name] has not been taking them. [Patient #10's name] advised she did not cut herself today but wanted to. Due to these statements and [Patient #10's name] unable to determine for herself, being a juvenile, she was Baker Acted."

Review of the Minor Nursing Screening dated 2/17/2023 at 2139 [9:39 PM] date of birth, 15 y.o. female. Under the section titled, Arrival information, there was no information documented for where the minor was arriving from, no family dynamics, no living situation, no history documented related if there was or was not family violence or trauma, and if DCF [Department of Children and Families] was notified. Reason for involuntary placement: Depression, suicidal ideation, anxiety/panic attacks hx [history] of ADHD. Medication /treatments: Is minor receiving treatment elsewhere - left blank. Primary care physician name/telephone # not documented. Handwritten on the form documented "medical issues." Medications: Abilify [used to treat mental conditions such as bipolar I disorder (manic-depressive illness), major depressive disorder, and schizophrenia], at bed time last time date taken 2/17/2023 at 2030 [8:20 PM], Lexapro [used to treat depression and anxiety] at bed time, last taken 2/17/2023 at 2030, Jornay [central nervous system stimulant prescription medicine used for the treatment of attention deficit hyperactivity disorder] at bed time, last taken 2/17/2030. Summary of screening: female minor Baker Acted for verbalizing SI [suicidal ideations] to cut wrists after recent breakup c [with] boyfriend. Past dxs [diagnosis]: MDD [major depressive disorder], anxiety, ADHD. No behavior issues at this time.

Review of newchoicestc.com read, "Lexapro withdrawal symptoms can be severe, particularly if you attempt to stop abruptly. Instead, the dosage should be slowly tapered down over a period of time and under the guidance of medical professionals who can help prevent or mitigate any withdrawal symptoms."

Review of www.webmd.com for Jornay read, "If you suddenly stop using this medication, you may have withdrawal symptoms (such as depression, suicidal thoughts, or other mental/mood changes). To help prevent withdrawal, your doctor may lower your dose slowly."

Review of the medical record for Patient #10 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. There is no documentation of or nursing assessments and only on nursing progress note. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the nursing progress note dated 2/20/2023 at 1400 [2:00 PM] read, "Child has been calm and cooperative, no behavioral issues, interacting appropriately with peers, will continue to monitor."

Review of the Springbrook Non admit signed by Patient #10's parent, handwritten by the parent read, "I do not believe she should be d/ced [discharged] dated 2/20/23 no time." The form was signed by the RN dated 2/20/23 at 2123 [9:23 PM].

During a telephone interview on 2/22/2023 at 10:10 AM Patient #10's mother stated, "[Patient #10's name] has been Baker Acted again, she was out less than 48 hours. She did not attempt suicide when she left but was at school and expressed that desire. We felt that she was not stabilized while she was at Springbrook. She had not received any medications while there and no examination for her mental health. They need to understand that she was not stabilized at all. A nurse called us and told us to come and get her. We tried to tell them she was not stabilized and not safe to go home, but they just shrugged their shoulders. I did sign that I didn't feel she should be discharged. She was not safe to go home. I had to take her home, so I did."

6. Review of the medical record for Patient #15 documented the patient is a 15-year-old female who presented to Springbrook Hospital on 2/17/2023 under a Law Enforcement Officer initiatied Involuntary Examination dated 2/17/2023 at 9:41 PM with suicidal ideation.

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" for Patient #15 dated 2/17/2023 at 9:41 PM read, "Subject has been having problems at school and more recently a video was posted on social media of her in a fight. Subject sent a message to her sister via Instagram stating, "I want to end my life I can't take it anymore. "Subject stated the comment was not made for attention but will not explain anything further."

Review of the Minor Nursing Screening dated 2/17/2023 at 2158 [9:58 PM] read, Summary of screening, "According to Baker Act female minor has been having problems at school and recently posted on social media that she wanted to end her life. No behavioral issues at this time. Reason for involuntary placement not documented, Arrival information not documented, DCF notified not documented."

Review of the medical record for Patient #15 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit did not document on the form for disposition. The form was signed by Patient #15's guardian. Patient #15 was discharged on 2/5/2023 at 11:47 PM. Treatment administered read, "none." Reason not admitted to the hospital read, "minor." No referral information was provided.

The record did not provide the Springbrook Non-Admit for discharge. No discharge information was provided according to the patient's record.

7. Review of the medical record for Patient #17 documented the patient is a 13 year old female who presented to Springbrook Hospital under an Ex Parte Order for Involuntary Examination dated 2/17/2023.

Review of the "Ex Parte Order for Involuntary Examination" for Patient #17 dated 2/17/2023 at 10:00 AM Case No. [number] read, "1. There is reason to believe the above named person has a mental illness as defined in section 394.455(18) F.S. and because of this mental illness said person (a). has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination: and/or (b). unable to determine for himself/ herself whether examination is necessary and, 2. Either (check a or b) (a). without care or treatment the above named person is likely to suffer from neglect or refuse care for himself/herself, and such neglect or refusal poses a real and present threat of substantial harm to his or her well-being and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services, or, (b). There is substantial likelihood that without care or treatment the above named person will cause serious bodily harm to himself or herself or another person in the near future as evidenced by recent behavior [both a. and b. were checked]. Additional information upon which this order is based, Petitioner states respondent has behavioral outbursts, theft, and threats of suicide. She recently attempted to jump out of a moving car."

Review of the Minor Nursing Screening dated 2/18/2023 at 1325 [1:25 PM] read, Demographic information Guardian preferred language - not documented, arrival information where arriving from - not documented, Family dynamics Hx of family violence or trauma - not documented, reason for involuntary placement - not documented, Medications treatment if minor receiving RX [medications] elsewhere primary care physicians name - not documented. Medications documented: Concerta [used to treat attention deficit hyperactivity disorder] daily last taken 2/17/23 at 0830, Intuniv at bedtime last taken 2/17/23 at 2000, clonidine [decreases anxiety attacks and psychiatric symptoms] no frequency or when last taken documented. No screening summary documented.

Review of www.addictioncenter.com read, "Concerta withdrawal produces very uncomfortable symptoms, such as headaches and anxiety. Depression can be severe during withdrawal."

Review of novarecoverycenter.com read, "Common clonidine withdrawal symptoms include: nervousness, agitation, anxiety, depression, tremors, chronic headaches, insomnia, nausea or vomiting."

Review of the medical record for Patient #17 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments and only one progress note. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. There is no documentation of nursing assessments and only one nursing progress note. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the nursing progress note dated 2/20/2023 at 1705 [5:05 PM] read, "Child ate chicken and then c/o [complaint of] throat itching and throat pain, difficulty breathing, child was transported to [hospital name] ER [emergency room] at 1700 [5:00 PM]." There is no documentation in the record of when the patient return from the hospital. There are no vital signs or additional nursing assessments documented after the patient returned from the hospital.

Review of emergency department documentation dated 2/19/2023 at 1747 [5:47 PM] allergic reaction, dysphagia. Discharged back to facility 2/19/2023 at 1843 [6:43 PM].

During an interview on 2/27/2023 at 1:00 PM, Patient #17's mother stated, "I was not aware that my daughter did not receive a psychiatric evaluation because they discharged her and that evening, we had to bring her to [Name of the facility] due to her suicidal behavior and she is now in a facility and getting the treatment she needs. She did attempt suicide again after discharge, attempting to jump out of a car in oncoming traffic. They are terrible. They sent her to the hospital and didn't call me. Initially when they discharged her, they did not provide any referrals. They, simply put, did nothing for her mental health. They were a babysitter, but they wouldn't even provide her medications and did nothing to help her. I told them that she was not safe to go home all they said is, sorry, but we can't keep her the Baker Act is up. The nurse told me that when I went to get her."

Review of the Springbrook Non admit documented the form was for disposition was signed by Patient #17's parent on 2/21/2023 at 10:06 AM.

8. Review of the medical record for Patient #13 documented the patient is a 17 year old female who presented to Springbrook Hospital on 2/18/2023 under a Law Enforcement Officer Initiated Involuntary Examination dated 2/18/2023 at 12:20 AM with suicidal ideation.

Review of the "Report of the Law Enforcement Office Initiating Involuntary Examination" for Patient #13 dated 2/18/2023 at 12:20 AM read, "Subject stated she wants to commit suicide because she is overwhelmed in life."

Review of the Minor Nursing Screening dated 2/18/2022 at 0039 [12:39 AM] summary of screening read, "Female minor Baker Acted for suicidal ideation and states at this time, "I just don't want to live anymore" No behavioral issues noted at this time. Demographic information, placement type and preferred language, arrival information where is minor arriving from, family dynamics, living situation, is there a history of family violence or trauma, DCF notified is there another agency involved, Reason for involuntary placement - none of this information is documented.

Review of the medical record for Patient #13 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit documented, Reason not admitted: Patient is a minor, Disposition: Home. Dated 2/20/2023 at 12:00 [midnight] Numerous calls placed to mother prior to pick up. Mother signed 2/21/23 0106 [1:06 AM] for discharge. No referral information was provided.

During an interview on 2/24/2024 at 12:15 PM with Patient #13's mother she stated, "My daughter has had several concerns with wanting to end her life. I was only called on the day she was going to be discharged and told her Baker Act was due to end at about 1 AM and I needed to come and get her. I was not called and explained her patient rights. I was not given any referral information to get her assistance and she is still struggling with her mental health. They did not assist her at all, she [the patient] explained that she sat in a room with a tech and never saw anyone while she was there."

During an interview on 2/22/2023 at 9:55 AM the DON stated, "I was aware that the adolescents were being sent home with their parents. I have not been called and instructed nurses to let any pediatric patients go at the end of the Baker Act hours. I was aware that they have not been evaluated by a psychiatrist or psychologist. I can't tell you whether they were safe discharges, I did not discharge them. I would think if they were still having suicidal thoughts the nurses would call the sheriff and have them Baker Acted again. We don't do anything but hold these kids for observation, we don't provide them medications if they take them regularly, we have no physician that provides those orders. I don't see any assessments done by the nurses except the initial minor assessments. Sometimes I see a progress note in the charts, but there are no notes done regularly on the kids."

During an interview on 2/23/2023 at 10:15 AM, the Executive Director (ED) stated, "We do not have a pediatric psychologist in house or contracted for our pediatric Baker Act patients. I was not aware that the patients were being discharged without any follow

The facility failed to develop and implement a plan of correction when aware of an identified concern for 8 of 8 pediatric patients, Patients #10, #11, #12, #13, #14, #15, #16, and #17, presenting to the hospital for psychiatric evaluation under involuntary examination [Baker Act] or Ex Parte court order, the patients were not provided a medical assessment, mental health evaluations, were not transferred to a facility able to meet the needs of the patient if unable to be met at the hospital, did not provide nursing supervision, did not provide training/education for staff, did not provide a safe setting for the patient when residing in the facility, did not communicate with patient's guardians, did not receive consent for treatment, did not provide necessary medications, and did not provide a safe discharge. This systemic failure constitutes an immediate jeopardy.

Springbrook Hospital was not in compliance with Conditions of Participation for 42 CFR 482.21 Quality Assessment and Program Improvement, Requirements for Hospitals and Code of Federal Regulations (CFR) 42, Part 482 Conditions of Participation for Hospitals.

Refer to A0283 Quality Improvement Activities.

Based on interview, record review, and observation the facility failed to develop and implement quality improvement activities for identified concerns for improvement and changes for 8 of 8 pediatric patients, Patients #10, #11,#12,#13, #14, #15, #16 and #17, who presented to the hospital under involuntary examination [Baker Act], or Ex Parte court order who were not medically assessed, did not receive a mental health evaluation, were not transferred to a facility able to meet the needs of the patient if unable to be met at the hospital, did not provide nursing supervision, did not provide training/education for staff, did not provide a safe setting for the patient when residing in the facility, did not communicate with the patient's guardian, did not receive consent for treatment, did not provide necessary medications, and did not provide for a safe discharge. Without being evaluated by a physician, clinical psychologist, or psychiatric nurse, the likelihood of harm to self or others resulting from suicide attempt(s) or other life threatening complications/conditions and or death could occur.

Findings include:

1. Review of the medical record for Patient #16 documented the patient is a 14 year old male who presented to Springbrook Hospital on 2/2/2023 under a "Law Enforcement Officer Initiating Involuntary Examination" [Baker Act] dated 2/2/2023 at 1:05 PM for suicide attempt/suicidal ideation.

Review of the Minor Nursing Screening dated 2/2/23 at 1802 [6:02 PM] documented the Summary which read, Pt. [Patient] come on BA 52 [Baker Act] by school RO [Resource Office]
HCSd, pt. was running into traffic stating he wanted to kill himself. Pt. refuses to talk. There was no additional information documented on this form.

Review of the medical record for Patient #16 did not provide documentation of nursing progress notes, patient flowsheets, a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge, and no patient rights or informed consent signed by the parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit [discharge document] documented the form was for disposition was signed by Patient #16's Aunt on 2/5/2023 at 11:47 PM. Treatment administered read, "none." Reason not admitted to the hospital read, "minor." No referral information was provided.

2. Review of the medical record for Patient #11 documented the patient presented to the facility on 2/10/2023 at approximately 9:08 PM for an Involuntary Examination, due to threating harm to himself and others.

Review of the Minor Nursing Screening dated 2/10/2023 at 2108 [9:08 PM] documented the minor was 10 years old. Reason for involuntary placement: depression, mood swings, anxiety, panic attacks, crying spells, racing thoughts. Medication/treatment: Is minor receiving treatment elsewhere, checked "yes", Social Worker [Social Worker's name], [Facility name and name of primary physician]. Medications: Prozac [used to decrease fear, anxiety, unwanted thoughts, and number of panic attacks] by mouth daily for depression last time and date medication taken is left blank, Omega fish oil, guanfacine [approved to treat ADHD, improve restlessness, impulsivity, and hyperactivity] at bedtime. Reason for taking ADHD. Last date and time taken was left blank, sertraline [used to manage and treat major depressive disorder] daily. Last date and time taken was left blank. Summary of screening: 10 year old male presents to SBH [Springbrook Hospital] on a BA 52 for aggressive behavior toward grandfather. Trying to break things around the house. Patient is calm and cooperative at this time. Patient has history of bipolar and ADHD per BA 52.

Review of www.medicalnewstoday.com for Prozac read, "When a person decides that they are ready to discontinue Prozac, a doctor will likely recommend gradually reducing, or tapering their dosage. Tapering usually last 4 weeks, but a doctor may suggest tapering the medication over 6-8 weeks to reduce the risk of severity of symptoms."

Review of NAMI [National Alliance on Mental Illness for Prozac read, "Stopping flouoxetine [Prozac] abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, dizziness, vomiting, nightmares, headache, and/or paresthesias (prickling, tingling sensation on the skin)."

Review of www.healthline.com for guanfacine read, "Warning for stopping the drug: Don't stop taking guanfacine without talking to your doctor first. This medication needs to be stopped slowly. Your doctor may gradually decrease your dosage. If you stop taking it abruptly, it can cause your blood pressure to go too high."

Review of www.psycom.net read, "Withdrawal symptoms of intuniv [guanfacine] can include headaches, tremors, agitation, and nervousness. Abrupt discontinuation can also cause a rapid increase in blood pressure, so maintain contact with your doctor and seek medical attention if necessary when discontinuing the drug.

Review of www.medicalnewstoday.com read, "Common discontinuation symptoms of stopping sertraline may include nausea, headaches, and tingling skin. For this reason, when a person decides to discontinue sertraline, they should discuss this with their doctor. The doctor may recommend gradually lowering the dose to reduce or avoid symptoms."

Review of the medical record for Patient #11 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #11's guardian on 2/13/23 at 20:25 [8:25 PM] no referral information was provided.

During a telephone interview conducted on 2/28/2023 at 4:15 PM, Patient #11's guardian stated, "I was not aware that they don't get [Patient #11's name] evaluated by anyone before they let him go. I was not aware that he did get looked at by a doctor."

3. Review of the medical record for Patient #14 documented the patient #14 is a 14 year old female who presented to Springbrook Hospital on 2/10/2023 under a Law Enforcement Officer Initiated Involuntary Examination" dated 2/10/2023 at 10:23 PM for suicide attempt/suicidal ideation.

Review of the record did not provide documentation of the Minor Nursing Screening.

Review of the medical record for Patient #14 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #14's grandfather on 2/13/23 at 22:15 [10:15 PM] no referral information was provided.

4. Review of the medical record for Patient #12 documented the patient is a 15 year old male who presented to Springbrook Hospital on an Ex Parte Order for Involuntary Examination [When a person seeks such relief in Family Courts in absence of the other spouse or parent, it is called an "Ex Parte" hearing], dated 2/14/2023, due to a court determination of mental illness requiring treatment.

Review of the Minor Nursing Screening dated 2/14/2023 at 2207 [10:07 PM] documented the date of birth. Reason for involuntary placement was not completed. The form was not completed for Family dynamics is there a hx [history of] family violence or trauma, not documented for DCF notified, other agency involvement, or medications. Summary of screening read; 14 y/o male presents to SB [Springbrook] Hospital on an involuntary (ex parte) status for defiant behavior. Pt. is A+O x4 [alert and oriented for person, place, time, event]. He is calm and cooperative. No nursing signature or name of person who completed the form documented.

Review of documentation in the medical record for Patient #12 of emergency room documentation dated 2/15/2022 at 2204 [10:04 PM] read, "Time initially seen 2/15/2023 at 2159 [9:59 PM]. History of present illness: The patient presents with sent from Springbrook to be medicated for agitation anger. The onset was just prior to arrival. The course and duration of symptoms is improving. The degree at onset was moderate the degree at present is none, risk factors consist of none, therapy today none, associated symptoms none. 15 year old male from Springbrook reportedly became agitated and started to tear up the room. Patient states he was on the phone with his mom, and he became upset. Patient doesn't take any medication normally. Patient is calm now and cooperative no complaints. Reexamination and reevaluation 2/15/2023 at 22:08 [10:08 PM] note since patient is now calm and cooperative, we'll give a dose of Ativan and send him back to Springbrook. Impression and plan diagnosis aggressive outburst plan improved stable disposition discharged 2/15/2022 at 2220 [10:20 PM].

Review of the medical record for Patient #12 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes to include the patient being sent to the hospital or the patient returning to the facility from the hospital, or effectiveness/side effects of the administration of Ativan. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #12's mother on 2/17/23 at 22:07 [10:07 PM] no referral information was provided.

5. Review of the medical record for Patient #10 documented the patient presented to the facility on 2/17/2023 at approximately 9:39 PM for an involuntary examination, due to depression, suicidal ideation, anxiety/panic attacks and history of Attention-Deficit/Hyperactivity Disorder (ADHD).

Review of the Minor Nursing Screening dated 2/17/2023 at 2139 [9:39 PM] date of birth, 15 y.o. female. Under the section titled, Arrival information, there was no information documented for where the minor was arriving from, no family dynamics, no living situation, no history documented related if there was or was not family violence or trauma, and if DCF [Department of Children and Families] was notified. Reason for involuntary placement: Depression, suicidal ideation, anxiety/panic attacks hx [history] of ADHD. Medication /treatments: Is minor receiving treatment elsewhere - left blank. Primary care physician name/telephone # not documented. Handwritten on the form documented "medical issues." Medications: Abilify [used to treat mental conditions such as bipolar I disorder (manic-depressive illness), major depressive disorder, and schizophrenia], at bed time last time date taken 2/17/2023 at 2030 [8:20 PM], Lexapro [used to treat depression and anxiety] at bed time, last taken 2/17/2023 at 2030, Jornay [central nervous system stimulant prescription medicine used for the treatment of attention deficit hyperactivity disorder] at bed time, last taken 2/17/2030. Summary of screening: female minor Baker Acted for verbalizing SI [suicidal ideations] to cut wrists after recent breakup c [with] boyfriend. Past dxs [diagnosis]: MDD [major depressive disorder], anxiety, ADHD. No behavior issues at this time.

Review of newchoicestc.com read, "Lexapro withdrawal symptoms can be severe, particularly if you attempt to stop abruptly. Instead, the dosage should be slowly tapered down over a period of time and under the guidance of medical professionals who can help prevent or mitigate any withdrawal symptoms]."

Review of www.webmd.com for Jornay read, "If you suddenly stop using this medication, you may have withdrawal symptoms (such as depression, suicidal thoughts, or other mental/mood changes). To help prevent withdrawal, your doctor may lower your dose slowly."

Review of the medical record for Patient #10 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. There is no documentation of or nursing assessments and only on nursing progress note. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the nursing progress note dated 2/20/2023 at 1400 [2:00 PM] read, "Child has been calm and cooperative, no behavioral issues, interacting appropriately with peers, will continue to monitor."

Review of the Springbrook Non admit signed by Patient #10's parent, handwritten by the parent read, "I do not believe she should be d/ced [discharged] dated 2/20/23 no time. The form was signed by the RN dated 2/20/23 at 2123 [9:23 PM].

During a telephone interview on 2/22/2023 at 10:10 AM Patient #10's mother stated, "[Patient #10's name] has been Baker Acted again, she was out less than 48 hours. She did not attempt suicide when she left but was at school and expressed that desire. We felt that she was not stabilized while she was at Springbrook. She had not received any medications while there and no examination for her mental health. They need to understand that she was not stabilized at all. A nurse called us and told us to come and get her. We tried to tell them she was not stabilized and not safe to go home, but they just shrugged their shoulders. I did sign that I didn't feel she should be discharged. She was not safe to go home. I had to take her home, so I did."

6. Review of the medical record for Patient #15 documented the patient is a 15-year-old female who presented to Springbrook Hospital on 2/17/2023 under a "Law Enforcement Officer initiating Involuntary Examination" dated 2/17/2023 at 9:41 PM with suicidal ideations.

Review of the Minor Nursing Screening dated 2/17/2023 at 2158 [9:58 PM] read, Summary of screening, "According to Baker Act female minor has been having problems at school and recently posted on social media that she wanted to end her life. No behavioral issues at this time. Reason for involuntary placement not documented, Arrival information not documented, DCF notified not documented.

Review of the medical record for Patient #15 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit did not document on the form for disposition. The form was signed by Patient #15's guardian. Patient #15 was discharged on 2/5/2023 at 11:47 PM. Treatment administered read, "none." Reason not admitted to the hospital read, "minor." No referral information was provided.

The record did not provide the Springbrook Non-Admit for discharge. No discharge information was provided according to the patient's record.

7. Review of the medical record for Patient #17 documented the patient is a 13 year old female who presented to Springbrook Hospital under a Ex Parte Order for Involuntary Examination dated 2/17/2023.

Review of the Minor Nursing Screening dated 2/18/2023 at 1325 [1:25 PM] read, Demographic information Guardian preferred language - not documented, arrival information where arriving from - not documented, Family dynamics Hx of family violence or trauma - not documented, reason for involuntary placement - not documented, Medications treatment if minor receiving RX [medications] elsewhere primary care physicians name - not documented. Medications documented: Concerta [used to treat attention deficit hyperactivity disorder] daily last taken 2/17/23 at 0830, Intuniv at bedtime last taken 2/17/23 at 2000, clonidine [decreases anxiety attacks and psychiatric symptoms] no frequency or when last taken documented. No screening summary documented.

Review of www.addictioncenter.com read, "Concerta withdrawal produces very uncomfortable symptoms, such as headaches and anxiety. Depression can be severe during withdrawal."

Review of novarecoverycenter.com read, "Common clonidine withdrawal symptoms include: nervousness, agitation, anxiety, depression, tremors, chronic headaches, insomnia, nausea or vomiting."

Review of the medical record for Patient #17 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments and only one progress note. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. There is no documentation of nursing assessments and only one nursing progress note. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the nursing progress note dated 2/20/2023 at 1705 [5:05 PM] read, "Child ate chicken and then c/o [complaint of] throat itching and throat pain, difficulty breathing, child was transported to [hospital name] ER [emergency room] at 1700 [5:00 PM]" There is no documentation in the record of when the patient return from the hospital. There are no vital signs or additional nursing assessments documented after the patient returned from the hospital.

Review of emergency department documentation dated 2/19/2023 at 1747 [5:47 PM] allergic reaction, dysphagia. Discharged back to facility 2/19/2023 at 1843 [6:43 PM].

During an interview on 2/27/2023 at 1:00 PM, Patient #17's mother stated, "I was not aware that my daughter did not receive a psychiatric evaluation because they discharged her and that evening, we had to bring her to [Name of the facility] due to her suicidal behavior and she is now in a facility and getting the treatment she needs. She did attempt suicide again after discharge, attempting to jump out of a car in oncoming traffic. They are terrible. They sent her to the hospital and didn't call me. Initially when they discharged her, they did not provide any referrals. They, simply put, did nothing for her mental health. They were a babysitter, but they wouldn't even provide her medications and did nothing to help her. I told them that she was not safe to go home all they said is, sorry, but we can't keep her the Baker Act is up. The nurse told me that when I went to get her."

Review of the Springbrook Non admit documented the form was for disposition was signed by Patient #17's parent on 2/21/2023 at 10:06 AM.

8. Review of the medical record for Patient #13 documented the patient is a 17 year old female who presented to Springbrook Hospital on 2/18/2023 under a "Law Enforcement Officer Initiating Involuntary Examination" dated 2/18/2023 at 12:20 AM with suicidal ideation.

Review of the Minor Nursing Screening dated 2/18/2022 at 0039 [12:39 AM] summary of screening read, "Female minor Baker Acted for suicidal ideation and states at this time, "I just don't want to live anymore" No behavioral issues noted at this time. Demographic information, placement type and preferred language, arrival information where is minor arriving from, family dynamics, living situation, is there a history of family violence or trauma, DCF notified is there another agency involved, Reason for involuntary placement - none of this information is documented.

Review of the medical record for Patient #13 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.
Review of the Springbrook Non admit documented, Reason not admitted: Patient is a minor, Disposition: Home. Dated 2/20/2023 at 12:00 [midnight] Numerous calls placed to mother prior to pick up. Mother signed 2/21/23 0106 [1:06 AM] for discharge. No referral information was provided.

During an interview on 2/24/2024 at 12:15 PM with Patient #13's mother she stated, "My daughter has had several concerns with wanting to end her life. I was only called on the day she was going to be discharged and told her Baker Act was due to end at about 1 AM and I needed to come and get her. I was not called and explained her patient rights. I was not given any referral information to get her assistance and she is still struggling with her mental health. They did not assist her at all, she [the patient] explained that she sat in a room with a tech and never saw anyone while she was there."

During an interview on 2/23/2023 at 3:00 PM Staff G, RN stated, "There are patients that get released after 72 hours and haven't been seen by a doctor. I am not able to make the determination that they need to be Baker Acted, that is outside of my scope of practice to do that. I have not provided their parents or guardians informed consent and patient rights information, We don't do that. I can't tell you why we don't do that. "

During an interview on 2/22/2023 at 9:55 AM the DON stated, "I was aware that the adolescents were being sent home with their parents. I have not been called and instructed nurses to let any pediatric patients go at the end of the Baker Act hours. I was aware that they have not been evaluated by a psychiatrist or psychologist. I can't tell you whether they were safe discharges, I did not discharge them. I would think if they were still having suicidal thoughts the nurses would call the sheriff and have them Baker Acted again. We don't do anything but hold these kids for observation, we don't provide them medications if they take them regularly, we have no physician that provides those orders. I don't see any assessments done by the nurses except the initial minor assessments. Sometimes I see a progress note in the charts, but there are no notes done regularly on the kids." The DON remarked, This wasn't brought to QAPI because the adolescents are not admitted into the hospital. They are here until they can be transferred or are sent home. They aren't admitted, we only observe them, we are not set up to take care of adolescents. This has not been discussed in QAPI. This wasn't brought to QAPI because the adolescents are not admitted into the hospital they are here until they are transferred or sent home. They aren't admitted, we only observe them, we are not set up to take care of adolescents."

During an interview on 2/23/2023 at 10:15 AM, the Executive Director (ED) stated, "We do not have a pediatric psychologist in house or contracted for our pediatric Baker Act patients. I was not aware that the patients were being discharged without any follow up. I thought it was being done. No one told me this was happening. Well, the nurses are seeing them, so they are being assessed. Nurses are not able to do the psychological assessment, but we have not had anyone to deal with the children in a long time. No doctor here wants to treat them. So, we observe them and try to get them to a pediatric receiving facility. No one is assessing them except the nurses. Nurses cannot provide a psychological or mental health examination. We are not providing any discharge instructions; we are not providing any medications they might regularly take. If they need medical attention or any ETO [emergency treatment orders] we send them to the hospital because there is no doctor here that will take responsibility for them. We do have a problem with placing the children sometimes, but many times we get them placed within a few hours. We have not tried to get any telemedicine providers. I didn't think we could do that. This has been happening for a very long time that we have been receiving children and adolescents. We have been given no assistance from the county or [Name of an agency] related to our inability to provide the care or services they need. I really wasn't aware that this was happening. No nurses have ever called me and asked me what they should do when the Baker Acts were expiring. I have never instructed the nurses to just let them go. I suppose it is not a safe discharge if they are being sent home without an evaluation, but we have no other choices, it is the law that they must be released after 72 hours. This was not brought to QAPI because we don't do not treat the pediatric patients, we transfer them to a facility that provides that care or they go home."

During a telephone interview conducted on 2/23/2023 at 10:30 AM, Staff H, RN stated, "Usually after 72 hours we call parents and tell them to come and get their child. We are not allowed to give medications or do any kind of assessments on them. We get them and they are awaiting placement at a facility that takes children. It is not safe to discharge them without them being seen by a psychologist or doctor. I was told by the DON [Director of Nursing] and others that once the Baker Act is up we need to call the parents and send them home."

During an interview on 2/23/2023 at 3:00 PM, Staff G, RN stated, "There are patients [minors] that get released after 72 hours and haven't been seen by a doctor. I am not able to make the determination that they need to be Baker Acted, that is outside of my scope of practice to do that. I'm not sure why we are releasing the children if they haven't had a doctor examine them. I guess it would not be a safe discharge."

During an interview conducted on 2/23/2023 at 3:16 PM, Staff C, RN stated, "Pediatric patients have been released without being evaluated by a psychiatrist or a psychologist after their Baker Acts have expired, after the 72 hours hold for the Baker Act. They have not been evaluated because we don't have a physician on staff who deals with the pediatric population. I am not able to determine that a patient is no longer suicidal, it is not within my scope of practice to determine this. I guess maybe they should not be let go if they are not evaluated by someone who can make that call. I guess it would not be a safe discharge if they have not been evaluated by a doctor or nurse practitioner. I have been instructed by management to release them when their Baker Act has expired if they don't have any bed available anywhere else."

During an interview conducted on 2/23/2023 at 3:30 PM, Staff D, RN, stated, "I have discharged pediatric Baker Acted patients from here. They were not seen by a mental health professional; they were not evaluated by psychiatry at all. Their Baker Act reached the 72-hour mark, and we sent them home with their parents. I wouldn't say they were provided a safe discharge. It was what we have been instructed to do by the Administrator on call. That would be [Administrator's name] or the DON or Risk Manager. I am not able to determine if the patient can be cleared from the Baker Act. It is not within my scope of practice to determine if a patient is no longer at risk for suicide and no longer meets the Baker Act criteria. I would say that really isn't very safe."

During an interview on 2/23/2022 at 3:45 PM, Staff F, RN stated, "I did and have discharged pediatric patients when their Baker Act was up after 72 hours, usually because they haven't been accepted anywhere. They are not seen by any mental health providers; they are not given an examination by anyone but a nurse at intake. I did let [Patient #16's name] go home with his parents. He was not seen by a physician; he was not cleared by a physician. We have been told that we let them leave with their parents when their Baker Act time is up, and we haven't found a bed. The Administrator, [Administrator's name], the DON, Risk Manager have all told us that."

During an interview on 2/24/2023 at 9:15 the Risk Manager (RM) stated, "I was aware that patients were released when the Baker Acts expired, usually to their parents. I did see some of the pediatric patients and did not document suicide risk assessments in any of my notes. We cannot administer medications or assess the children without physician orders. We should be documenting when they transfer to the hospital and why they have gone. It is a standard of practice to perform an assessment on a patient if they are attempting to injure themselves. I do not get consent to treat from parents when they come. I have not provided the child or parent with the patient rights forms. They are not admitted. They are just here for observation until we find placement. Many times, we can get them placed quickly so it's not a problem. I have never told anyone to let a child go at the end of the Baker Act, when it expires. I don't know why they let them go, but I know we can't keep them longer than 72 hours. As a nurse I am not conducting a psychological assessment to determine the need for a Baker Act."

During an interview on 2/24/2023 at 9:32 AM, the Medical Director stated, "I have been the Medical Director for five to six years. I have been aware that we have pediatric patients, that we have no one to treat them. At one time we had [Physician's name]. We have been, the way we understood, we were holding these kids until transfer could be arranged, treating did not occur. We have not had a psychiatrist or psychologist evaluating these kids. I am not certified to care for the pediatric population, have not had the additional training needed to safely assess them. It is not safe to discharge a patient who has suicidal intent without being seen. I was not aware that any pediatric Baker Acts were leaving at the end of their 72 hours. They just informed me this week. We have not provided any type of treatment to these kids. We don't have the ability to do so. We are not adequately trained to take care of their specialized needs. We have been aware of this problem for years now. We have tried to get this resolved. We went to the community, the sheriff's office, and [Name of a facility] with no results, at least that is what I have been told by [Administrator's name]. I have not had discussions with the board about this issue. I don't believe this was brought up in ou

The facility failed to provide nursing services for 8 of 8 pediatric patients, Patients #10, #11, #12, #13, #14, #15, #16, and #17, presenting to the hospital for psychiatric evaluation under involuntary examination [Baker Act] or Ex Parte court order. The patients were not provided a medical assessment, were not transferred to a facility able to meet the needs of the patient if unable to be met at the hospital, did not provide nursing supervision, did not provide training/education for staff, did not provide a safe setting for the patient when residing in the facility, did not communicate with the patient's guardian, did not receive consent for treatment, did not provide necessary medications, and did not provide a safe discharge.

Springbrook Hospital was not in compliance with Conditions of Participation for 42 CFR 482.23 Nursing Services, Requirements for Hospitals and Code of Federal Regulations (CFR) 42, Part 482 Conditions of Participation for Hospitals.

Refer to A 0395 RN Supervision of Nursing Care.

Based on interview, record review, and observation the facility failed to ensure nursing services for patient care for 8 of 8 pediatric patients, Patient #10, #11, #12, #13, #14, #15, #16 and #17 who presented to the hospital under involuntary examination [Baker Act] or Ex Parte court order and were not provided nursing care and services of assessing to determine the nursing needs of the patients, were provided nursing supervision, were not assessed for side effects/withdrawal symptoms of medications when abruptly stopped, and did not provide for a safe discharge resulting in patients being discharged and not being assessed for possible medical concerns requiring the need for a physician, and when aware the patient was not psychologically evaluated. Without proper assessment and supervision it can increase the likelihood of harm, injury, and/or death to self or others.

Findings include:

1. Review of the medical record for Patient #16 documented the patient is a 14 year old male who presented to Springbrook Hospital on 2/2/2023 under a Law Enforcement Officer Initiated Involuntary Examination [Baker Act] dated 2/2/2023 at 1:05 PM for suicide attempt/suicidal ideation.

Review of the Minor Nursing Screening dated 2/2/23 at 1802 [6:02 PM] documented the Summary which read, Pt. [Patient] come on BA 52 [Baker Act] by school RO [Resource Office]. [Name of a local school district], pt. was running into traffic stating he wanted to kill himself. Pt. refuses to talk. There was no additional information documented on this form.

Review of the medical record for Patient #16 did not provide documentation of nursing progress notes, patient flowsheets, a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge, and no patient rights or informed consent signed by the parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit [discharge document] documented the form was for disposition was signed by Patient #16's Aunt on 2/5/2023 at 11:47 PM. Treatment administered read, "none." Reason not admitted to the hospital read, "minor." No referral information was provided.

2. Review of the medical record for Patient #11 documented the patient presented to the facility on 2/10/2023 at approximately 9:08 PM for an Involuntary Examination due to threating harm to himself and others.

Review of the Minor Nursing Screening dated 2/10/2023 at 2108 [9:08 PM] documented the minor was 10 years old. Reason for involuntary placement: depression, mood swings, anxiety, panic attacks, crying spells, racing thoughts. Medication/treatment: Is minor receiving treatment elsewhere, checked "yes", Social Worker [Social Worker's name], [Facility name and name of primary physician]. Medications: Prozac [used to decrease fear, anxiety, unwanted thoughts, and number of panic attacks] by mouth daily for depression last time and date medication taken is left blank, Omega fish oil, guanfacine [approved to treat ADHD, improve restlessness, impulsivity, and hyperactivity] at bedtime. Reason for taking ADHD. Last date and time taken was left blank, sertraline [used to manage and treat major depressive disorder] daily. Last date and time taken was left blank. Summary of screening: 10 year old male presents to SBH [Springbrook Hospital] on a BA 52 for aggressive behavior toward grandfather. Trying to break things around the house. Patient is calm and cooperative at this time. Patient has history of bipolar and ADHD per BA 52.

Review of www.medicalnewstoday.com for Prozac read, "When a person decides that they are ready to discontinue Prozac, a doctor will likely recommend gradually reducing, or tapering their dosage. Tapering usually last 4 weeks, but a doctor may suggest tapering the medication over 6-8 weeks to reduce the risk of severity of symptoms."

Review of NAMI [National Alliance on Mental Illness for Prozac read, "Stopping flouoxetine [Prozac] abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, dizziness, vomiting, nightmares, headache, and/or paresthesias (prickling, tingling sensation on the skin)."

Review of www.healthline.com for guanfacine read, "Warning for stopping the drug: Don't stop taking guanfacine without talking to your doctor first. This medication needs to be stopped slowly. Your doctor may gradually decrease your dosage. If you stop taking it abruptly, it can cause your blood pressure to go too high."

Review of www.psycom.net read, "Withdrawal symptoms of intuniv [guanfacine] can include headaches, tremors, agitation, and nervousness. Abrupt discontinuation can also cause a rapid increase in blood pressure, so maintain contact with your doctor and seek medical attention if necessary when discontinuing the drug."

Review of www.medicalnewstoday.com read, "Common discontinuation symptoms of stopping sertraline may include nausea, headaches, and tingling skin. For this reason, when a person decides to discontinue sertraline, they should discuss this with their doctor. The doctor may recommend gradually lowering the dose to reduce or avoid symptoms."

Review of the medical record for Patient #11 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #11's guardian on 2/13/23 at 20:25 [8:25 PM] no referral information was provided.

During a telephone interview conducted on 2/28/2023 at 4:15 PM, Patient #11's guardian stated, "I was not aware that they don't get [Patient #11's name] evaluated by anyone before they let him go. I was not aware that he did get looked at by a doctor."

3. Review of the medical record for Patient #14 documented the patient #14 is a 14 year old female who presented to Springbrook Hospital on 2/10/2023 under a Law Enforcement Officer Initiated Involuntary Examination dated 2/10/2023 at 10:23 PM for suicide attempt/suicidal ideation.

Review of the record did not provide documentation of the Minor Nursing Screening.

Review of the medical record for Patient #14 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #14's grandfather on 2/13/23 at 22:15 [10:15 PM] no referral information was provided.

4. Review of the medical record for Patient #12 documented the patient is a 15 year old male who presented to Springbrook Hospital on an Ex Parte Order for Involuntary Examination [When a person seeks such relief in Family Courts in absence of the other spouse or parent, it is called an "Ex Parte" hearing], dated 2/14/2023, due to a court determiniation of mental illness requiring treatment.

Review of the Minor Nursing Screening dated 2/14/2023 at 2207 [10:07 PM] documented the date of birth. Reason for involuntary placement was not completed. The form was not completed for Family dynamics is there a hx [history of] family violence or trauma, not documented for DCF notified, other agency involvement, or medications. Summary of screening read; 14 y/o male presents to SB [Springbrook] Hospital on an involuntary (ex parte) status for defiant behavior. Pt. is A+O x4 [alert and oriented for person, place, time, event]. He is calm and cooperative. No nursing signature or name of person who completed the form documented.

Review of documentation in the medical record for Patient #12 of emergency room documentation dated 2/15/2022 at 2204 [10:04 PM] read, "Time initially seen 2/15/2023 at 2159 [9:59 PM]. History of present illness: The patient presents with sent from Springbrook to be medicated for agitation anger. The onset was just prior to arrival. The course and duration of symptoms is improving. The degree at onset was moderate the degree at present is none, risk factors consist of none, therapy today none, associated symptoms none. 15 year old male from Springbrook reportedly became agitated and started to tear up the room. Patient states he was on the phone with his mom, and he became upset. Patient doesn't take any medication normally. Patient is calm now and cooperative no complaints. Reexamination and reevaluation 2/15/2023 at 22:08 [10:08 PM] note since patient is now calm and cooperative, we'll give a dose of Ativan and send him back to Springbrook. Impression and plan diagnosis aggressive outburst plan improved stable disposition discharged 2/15/2022 at 2220 [10:20 PM]."

Review of the medical record for Patient #12 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes to include the patient being sent to the hospital or the patient returning to the facility from the hospital, or effectiveness/side effects of the administration of Ativan. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #12's mother on 2/17/23 at 22:07 [10:07 PM] no referral information was provided.

5. Review of the medical record for Patient #10 documented the patient presented to the facility on 2/17/2023 at approximately 9:39 PM for an involuntary examination due to depression, suicidal ideation, anxiety/panic attacks and history of Attention-Deficit/Hyperactivity Disorder (ADHD).

Review of the Minor Nursing Screening dated 2/17/2023 at 2139 [9:39 PM] date of birth, 15 y.o. female. Under the section titled, Arrival information, there was no information documented for where the minor was arriving from, no family dynamics, no living situation, no history documented related if there was or was not family violence or trauma, and if DCF [Department of Children and Families] was notified. Reason for involuntary placement: Depression, suicidal ideation, anxiety/panic attacks hx [history] of ADHD. Medication /treatments: Is minor receiving treatment elsewhere - left blank. Primary care physician name/telephone # not documented. Handwritten on the form documented "medical issues." Medications: Abilify [used to treat mental conditions such as bipolar I disorder (manic-depressive illness), major depressive disorder, and schizophrenia], at bed time last time date taken 2/17/2023 at 2030 [8:20 PM], Lexapro [used to treat depression and anxiety] at bed time, last taken 2/17/2023 at 2030, Jornay [central nervous system stimulant prescription medicine used for the treatment of attention deficit hyperactivity disorder] at bed time, last taken 2/17/2030. Summary of screening: female minor Baker Acted for verbalizing SI [suicidal ideations] to cut wrists after recent breakup c [with] boyfriend. Past dxs [diagnosis]: MDD [major depressive disorder], anxiety, ADHD. No behavior issues at this time.

Review of newchoicestc.com read, "Lexapro withdrawal symptoms can be severe, particularly if you attempt to stop abruptly. Instead, the dosage should be slowly tapered down over a period of time and under the guidance of medical professionals who can help prevent or mitigate any withdrawal symptoms."

Review of www.webmd.com for Jornay read, "If you suddenly stop using this medication, you may have withdrawal symptoms (such as depression, suicidal thoughts, or other mental/mood changes). To help prevent withdrawal, your doctor may lower your dose slowly."

Review of the medical record for Patient #10 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. There is no documentation of or nursing assessments and only on nursing progress note. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the nursing progress note dated 2/20/2023 at 1400 [2:00 PM] read, "Child has been calm and cooperative, no behavioral issues, interacting appropriately with peers, will continue to monitor."

Review of the Springbrook Non admit signed by Patient #10's parent, handwritten by the parent read, "I do not believe she should be d/ced [discharged] dated 2/20/23 no time. The form was signed by the RN dated 2/20/23 at 2123 [9:23 PM].

During a telephone interview on 2/22/2023 at 10:10 AM Patient #10's mother stated, "[Patient #10's name] has been Baker Acted again, she was out less than 48 hours. She did not attempt suicide when she left but was at school and expressed that desire. We felt that she was not stabilized while she was at Springbrook. She had not received any medications while there and no examination for her mental health. They need to understand that she was not stabilized at all. A nurse called us and told us to come and get her. We tried to tell them she was not stabilized and not safe to go home, but they just shrugged their shoulders. I did sign that I didn't feel she should be discharged. She was not safe to go home. I had to take her home, so I did."

6. Review of the medical record for Patient #15 documented the patient is a 15-year-old female who presented to Springbrook Hospital on 2/17/2023 under a Law Enforcement Officer Initiated Involuntary Examination dated 2/17/2023 at 9:41 PM with suicidal ideation.

Review of the Minor Nursing Screening dated 2/17/2023 at 2158 [9:58 PM] read, Summary of screening, "According to Baker Act female minor has been having problems at school and recently posted on social media that she wanted to end her life. No behavioral issues at this time. Reason for involuntary placement not documented, Arrival information not documented, DCF notified not documented.

Review of the medical record for Patient #15 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit did not document on the form for disposition. The form was signed by Patient #15's guardian. Patient #15 was discharged on 2/5/2023 at 11:47 PM. Treatment administered read, "none." Reason not admitted to the hospital read, "minor." No referral information was provided.

The record did not provide the Springbrook Non-Admit for discharge. No discharge information was provided according to the patient's record.

7. Review of the medical record for Patient #17 documented the patient is a 13 year old female who presented to Springbrook Hospital under a Ex Parte Order for Involuntary Examination dated 2/17/2023, due to threats and attempt of suicide.

Review of the Minor Nursing Screening dated 2/18/2023 at 1325 [1:25 PM] read, Demographic information Guardian preferred language - not documented, arrival information where arriving from - not documented, Family dynamics Hx of family violence or trauma - not documented, reason for involuntary placement - not documented, Medications treatment if minor receiving RX [medications] elsewhere primary care physicians name - not documented. Medications documented: Concerta [used to treat attention deficit hyperactivity disorder] daily last taken 2/17/23 at 0830, Intuniv at bedtime last taken 2/17/23 at 2000, clonidine [decreases anxiety attacks and psychiatric symptoms] no frequency or when last taken documented. No screening summary documented.

Review of www.addictioncenter.com read, "Concerta withdrawal produces very uncomfortable symptoms, such as headaches and anxiety. Depression can be severe during withdrawal."

Review of novarecoverycenter.com read, "Common clonidine withdrawal symptoms include: nervousness, agitation, anxiety, depression, tremors, chronic headaches, insomnia, nausea or vomiting."

Review of the medical record for Patient #17 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments and only one progress note. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. There is no documentation of nursing assessments and only one nursing progress note. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the nursing progress note dated 2/20/2023 at 1705 [5:05 PM] read, "Child ate chicken and then c/o [complaint of] throat itching and throat pain, difficulty breathing, child was transported to [hospital name] ER [emergency room] at 1700 [5:00 PM] There is no documentation in the record of when the patient return from the hospital. There are no vital signs or additional nursing assessments documented after the patient returned from the hospital.

Review of emergency department documentation dated 2/19/2023 at 1747 [5:47 PM] allergic reaction, dysphagia. Discharged back to facility 2/19/2023 at 1843 [6:43 PM].

During an interview on 2/27/2023 at 1:00 PM, Patient #17's mother stated, "I was not aware that my daughter did not receive a psychiatric evaluation because they discharged her and that evening, we had to bring her to [Name of the facility] due to her suicidal behavior and she is now in a facility and getting the treatment she needs. She did attempt suicide again after discharge, attempting to jump out of a car in oncoming traffic. They are terrible. They sent her to the hospital and didn't call me. Initially when they discharged her, they did not provide any referrals. They, simply put, did nothing for her mental health. They were a babysitter, but they wouldn't even provide her medications and did nothing to help her. I told them that she was not safe to go home all they said is, sorry, but we can't keep her the Baker Act is up. The nurse told me that when I went to get her."

Review of the Springbrook Non admit documented the form was for disposition was signed by Patient #17's parent on 2/21/2023 at 10:06 AM.

8. Review of the medical record for Patient #13 documented the patient is a 17 year old female who presented to Springbrook Hospital on 2/18/2023 under a Law Enforcement Officer Initiated Involuntary Examination dated 2/18/2023 at 12:20 AM with suicidal ideation.

Review of the Minor Nursing Screening dated 2/18/2022 at 0039 [12:39 AM] summary of screening read, "Female minor Baker Acted for suicidal ideation and states at this time, "I just don't want to live anymore" No behavioral issues noted at this time. Demographic information, placement type and preferred language, arrival information where is minor arriving from, family dynamics, living situation, is there a history of family violence or trauma, DCF notified is there another agency involved, Reason for involuntary placement - none of this information is documented.

Review of the medical record for Patient #13 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.
Review of the Springbrook Non admit documented, Reason not admitted: Patient is a minor, Disposition: Home. Dated 2/20/2023 at 12:00 [midnight] Numerous calls placed to mother prior to pick up. Mother signed 2/21/23 0106 [1:06 AM] for discharge. No referral information was provided.

During an interview on 2/24/2024 at 12:15 PM with Patient #13's mother she stated, "My daughter has had several concerns with wanting to end her life. I was only called on the day she was going to be discharged and told her Baker Act was due to end at about 1 AM and I needed to come and get her. I was not called and explained her patient rights. I was not given any referral information to get her assistance and she is still struggling with her mental health. They did not assist her at all, she [the patient] explained that she sat in a room with a tech and never saw anyone while she was there."

During an interview on 2/22/2023 at 9:55 the Director of Nursing (DON) stated, "I was aware that the adolescents were being sent home with their parents. The nurses are capable of completing suicide risk assessments and if they feel the patient is safe to discharge with parents, they will let them go. I have not been called and instructed nurses to let any pediatric patients go at the end of the Baker Act hours. I was aware that they have not been evaluated by a psychiatrist or psychologist. I can't tell you whether they were safe discharges, I did not discharge them. I would think if they were still having suicidal thoughts the nurses would call the sheriff and have them Baker Acted again. We don't do anything but hold these kids for observation, we don't provide them medications if they take them regularly, we have no physician that provides those orders. I don't see any assessments done by the nurses except the initial minor assessments. Sometimes I see a progress note in the charts, but there are no notes done regularly on the kids. We do have the techs documenting the every 15 minute checks. I don't see any patient rights documentation in their charts. There is no consistent documentation or evidence that we have assessed the patient when they went to the emergency room. I don't see documentation that their parent or guardian was notified that they went to the emergency room. We should notify the parent or guardian when they leave and go to the hospital. I would say that these patients are not admitted but are under observation during the time of the Baker Act. Nurses should see and document on them daily and with any changes in their conditions. I do not see any type of a suicide assessment completed on the patients. I don't see daily assessments for behaviors. There is not documentation in the record that there should be. This has not been discussed in QAPI. This wasn't brought to QAPI because the adolescents are not admitted into the hospital they are here until they are transferred or sent home. They aren't admitted, we only observe them, we are not set up to take care of adolescents."

During an interview on 2/23/2023 at 10:15 AM, the Executive Director (ED) stated, "We do not have a pediatric psychologist in house or contracted for our pediatric Baker Act patients. I was not aware that the patients were being discharged without any follow up. I thought it was being done. No one told me this was happening. Well, the nurses are seeing them, so they are being assessed. Nurses are not able to do the psychological assessment, but we have not had anyone to deal with the children in a long time, no doctor here wants to treat them. So, we observe them and try to get them to a pediatric receiving facility. No one is assessing them except the nurses. Nurses cannot provide a psychological or mental health examination. We are not providing any discharge instructions; we are not providing any medications they might regularly take. If they need medical attention or any ETO [emergency treatment orders] we send them to the hospital because there is no doctor here that will take responsibility for them. We do have a problem with placing the children sometimes, but many times we get them placed within a few hours. We have not tried to get any telemedicine providers. I didn't think we could do that. This has been happening for a very long time that we have been receiving children and adolescents, we have been given no assistance from the county or [name of an Agency] related to our inability to provide the care or services they need. I really wasn't aware that this was happening. No nurses have ever called me and asked me what they should do when the Baker Acts were expiring. I have never instructed the nurses to just let them go. I suppose it is not a safe discharge if they are being sent home without an evaluation, but we have no other choices, it is the law that they must be released after 72 hours."

During a telephone interview conducted on 2/23/2023 at 10:30 AM Staff H, RN stated, "Usually after 72 hours we call parents and tell them to come and get their child. We are not allowed to give medications or do any kind of assessments on them. We get them and they are awaiting placement at a facility that takes children. It is not safe to discharge them without them being seen. I was told by the DON [Director of Nursing] and others that once the Baker Act is up we need to call the parents and send them home. We do send the pediatric patients out for medical clearance if we see something wrong. They do not get seen by a doctor at all when they are here. I want to do more to help them, but I'm told I can't. I do not do any type of suicide risk assessments on them. We have been told all we do is hold them here until a bed can be found and that we must take them because we are a receiving facility. I don't chart daily on them; I don't do an assessment."

During an interview on 2/23/2023 at 3:00 PM Staff G, RN stated, "I do house supervision not with any pediatric patient, we cannot admit them. So, I make sure that the minor assessment is completed, all the necessary paperwork is correct and contact their parents and get additional information if needed. If they get sent out to the hospital for medical clearance or because they need medications, we should be documenting that, but usually I'm only seeing children to get the minor completed. I don't get vital signs or do any kind of physical assessment. I have never been told that I needed to do that. I don't do any other assessments. There are patients [pediatric] that get released after 72 hours and haven't been seen by a doctor. I am not able to make the determination that they need to be Baker Acted, that is outside of my scope of practice to do that. I'm not sure why we are releasing the children if they haven't had a doctor examine them. I guess it would not be a safe discharge. I did not perform another suicide risk assessment on the children when they discharged. We don't perform them on the children."

During an interview conducted on 2/23/2023 at 3:16 PM Staff C, RN stated, "Pediatric patients have been released without being evaluated by a psychiatrist or a psychologist after their Baker Acts have expired, after the 72 hours hold for the Baker Act. They have not been evaluated because we don't have a physician on staff who deals with the pediatric population. I am not able to determine that a patient is no longer suicidal, it is not within my scope of practice to determine this. I guess maybe they should not be let go if they are not evaluated by someone who can make that call. I guess it would not be a safe discharge if they have not been evaluated by a doctor or nurse practitioner. We do not complete suicide risk assessments on the pediatric patients, we do not complete nursing assessments or do vital signs on the children who are here for Baker Acts. Sometimes they are not accepted anywhere, and their Baker Act expires. I have not completed suicide risk assessments on the kids before they have been released to their parents. I have been instructed by management to release them when their Baker Act has expired if they don't have any bed available anywhere else."

During an interview conducted on 2/23/2023 at 3:30 PM Staff D, RN, stated, "I have discharged pediatric Baker Acted patients from here. They were not seen by a mental health professional; they were not evaluated by psychiatry at all. Their Baker Act reached the 72-hour mark, and we sent them home with their parents. I wouldn't say they were provided a safe discharge. I have not provided them or their parents with any community resources. It was what we have been instructed to do by the administrator on call. That would be the DON or Risk Manager. I am not able to determine if the patient can be cleared from the Baker Act. It is not within my scope of practice to determine if a patient is no longer at risk for suicide and no longer meets the Baker Act criteria. I did not complete a suicide risk assessment before they were discharged. When they are here, they are brought in by law enforcement. We do an intake for minors, but that does not include a suicide risk assessment. We don't do any other nursing assessments. I do not take vital signs and I don't do a physical assessment on them. I really can't tell you why we don't. We do not administer any medications they normally take because they don't have a doctor so there are no orders. If they have any type of a medical problem, we just call 911 and send them to the hospital. We cannot follow the emergency room recommendations for medications because they don't have anyone looking after them. I would say that really isn't very safe."

During an interview on 2/23/2022 at 3:45 PM Staff F, RN stated, "I did and have discharged pediatric patients when their Baker Act was up after 72 hours, usually because they haven't been accepted anywhere. They are not seen by any mental health providers; they are not given an examination by anyone but a nurse at intake. We complete the minor assessment. That does not include a suicide risk assessment, it is fairly simple, and it does not include any type of a nursing physical assessment. They do not get vital signs completed, they do not get any medications, we have no orders to give medications, so the kids are without their normal medications if they take any. I do see them throughout the day and if the MHT's [Mental Health Tech] alerts me to a problem. I have no documentation in the chart about seeing them, so I have no way to prove I have seen them. I did let [Pati

The facility failed to ensure adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning for 8 of 8 pediatric patients, Patients #10, #11, #12, #13, #14, #15, #16, and #17 who presented to the hospital under involuntary examination (Baker Act) or Ex Parte court order.

Springbrook Hospital was not in compliance with Conditions of Participation for 42 CFR 482.62 Special Staff Requirements, Requirements for Hospitals and Code of Federal Regulations (CFR) 42, Part 482 Conditions of Participation for Hospitals.

Refer to A1710 Psychological Services

Based on interview and record review the facility failed to provide psychological services to meet the needs for 8 of 8 pediatric patients, Patients #10, #11, #12, #13, #14, #15, #16 and #17, who presented to the facility under involuntary examination (Baker Act) or Ex Parte court order. The patients were not seen or evaluated to determine the existence for a possible serious psychiatric condition. Without a psychological evaluation for each minor that presents to the hospital on an involuntary basis or on an Ex Parte court order and prior to discharge increases the risk of the likelihood of harm physically and psychologically while residing in the hospital and after discharge which could result in suicidal attempt(s) or serious harm to self or others.

Findings include:

1. Review of the medical record for Patient #16 documented the patient is a 14 year old male who presented to Springbrook Hospital on 2/2/2023 under a Law Enforcement Officer Initiated Involuntary Examination [Baker Act] dated 2/2/2023 at 1:05 PM for suicide attempt/suicidal ideation.

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" for Patient #16 dated 2/2/2023 1:05 PM read, "On 02/02/2023 [Patient #16's name] walked off school campus. I observed [Patient #16's name] walking toward the Parkway and shouted to him to return to school. As I shouted, I observed a vehicle traveling westbound on Parkway which was going to make contact with [Patient #16's name] as he approached the road. I had to physically stop [Patient #16's name] from walking into traffic and harming himself. While he was restrained [Patient #16's name] advised it is now "easier to kill himself" due to his handcuffs. Additionally, [Patient #16's name] kicked me and attempted to bite me several times. During an interview with [Patient #16's name] he advised he wanted to kill himself and has thoughts of killing himself. [Patient #16's name] then confirmed him walking into traffic was an attempt on his own life. It is my belief as a law enforcement officer that [Patient #16's name] meets Baker Act criteria. Without treatment, [Patient #16's name] is a direct threat to himself and others."

Review of the medical record for Patient #16 did not provide documentation of nursing progress notes, patient flowsheets, a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge, and no patient rights or informed consent signed by the parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit [discharge document] documented the form was for disposition was signed by Patient #16's Aunt on 2/5/2023 at 11:47 PM. Treatment administered read, "none." Reason not admitted to the hospital read, "minor." No referral information was provided.

2. Review of the medical record for Patient #11 documented the patient presented to the facility on 2/10/2023 at approximately 9:08 PM for an Involuntary Examination, due to threating harm to himself and others.

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" dated 2/10/2023 read, "On 2/10/2023 [Patient #11's name], AKA [also known as, name], got into a verbal confrontation with his guardian/grandfather due to restricted privileges. [Patient # 11's name] grandfather informed [Patient #11's name] suffers from ADHD [attention-deficit/hyperactivity disorder] and bipolar disorder [causes extreme mood swings to include emotional highs of mania and lows, depression], on the day of this incident he had a mental health episode. [Patient #11's name] does receive counseling through [Name of facility] per his grandfather. During his episode [Patient #11's name] was throwing things in the home, attempted to break household items, and did strike his grandfather with a screwdriver due to being angry. [Patient #11's name] was also alleged to push his grandmother as she did not give him her iPad to play with. [Patient #11's name] told his grandfather during this incident that he would hurt him."

Review of the medical record for Patient #11 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #11's guardian on 2/13/23 at 20:25 [8:25 PM] no referral information was provided.

During a telephone interview conducted on 2/28/2023 at 4:15 PM, Patient #11's guardian stated, "I was not aware that they don't get [Patient #11's name] evaluated by anyone before they let him go. I was not aware that he did get looked at by a doctor."

3. Review of the medical record for Patient #14 documented the patient #14 is a 14 year old female who presented to Springbrook Hospital on 2/10/2023 under a Law Enforcement Officer Initiated Involuntary Examination dated 2/10/2023 at 10:23 PM for suicide attempt/suicidal ideation.

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" for Patient #14 dated 2/10/2023 at 10:23 PM read, "On 2/10/2023 at approximately 21:13 [9:13 PM] hours, I responded to [address of patient], in reference to a suicide attempt which was later reclassified to a Baker Act. Upon arrival, as I made entry into the residence, I observed a female juvenile identified as [Patient #14's name] sitting on the couch, crying hysterically. I did observe there to be superficial cut marks on her upper right leg. I then asked [Patient #14's name] how she cut her leg and she was unable to answer any questions at this time. It should be noted that I was attempting to ask questions, County Fire rescue was on scene and speaking with [Patient #14's name] as well. Fire Rescue did state that the cut marks were only superficial and did not require further medical attention. As Fire Rescue was attending to [Patient #14's name], I did then make contact with [Legal guardian's name] who is [Patient #14's name's] grandmother and legal guardian. [Guardian's name] stated that [Patient #14's name] was in a verbal argument with her grandfather when [Patient #14's name] did then run into the bathroom. Upon [Patient #14's name] leaving the bathroom [Guardian's name] stated she noticed her leg had cut marks on them and [Patient #14's name] was hysterically crying and refused to answer any more questions. After I made contact with [Guardian's name], I was able to make contact again with [Patient #14's name]. At this time [Patient #14's name] was much more calm and stopped crying. I asked [Patient #14's name] if she wanted to harm herself to which she stated she did not know why she cut her leg. I then asked [Patient #14's name] if she wanted to hurt herself to which she responded with, "I can't do it anymore I don't want to live anymore." [Patient #14's name] then stated to me that she tried to kill herself once before when she was approximately 8 years old and she believes that has to do with past trauma."

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #14's grandfather on 2/13/23 at 22:15 [10:15 PM] no referral information was provided.

4. Review of the medical record for Patient #12 documented the patient is a 15 year old male who presented to Springbrook Hospital on an Ex Parte Order for Involuntary Examination [When a person seeks such relief in Family Courts in absence of the other spouse or parent, it is called an "Ex Parte" hearing], dated 2/14/2023, due to a court determination of mental illness requiring treatment.

Review of the "Ex Parte Order for Involuntary Examination" for Patient #12 dated 2/14/2023 Case No. [documented] read, "1. There is reason to believe the above named person has a mental illness as defined in section 394.455(18) F.S. [Florida Statute] and because of this mental illness said person (a). has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination: and/or (b). unable to determine for himself/ herself whether examination is necessary and, 2. Either (check a or b) (a). without care or treatment the above named person is likely to suffer from neglect or refuse care for himself/herself, and such neglect or refusal poses a real and present threat of substantial harm to his or her well-being and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services, or, (b). there is substantial likelihood that without care or treatment the above named person will cause serious bodily harm to himself or herself or another person in the near future as evidenced by recent behavior [both a. and b. were checked]. Additional information upon which this order is based, petitioner states respondent is defiant, exhibits aggressive behavior and abuses alcohol and drugs."

Review of the medical record for Patient #12 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes to include the patient being sent to the hospital or the patient returning to the facility from the hospital, or effectiveness/side effects of the administration of Ativan. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit paperwork was documented it was signed by Patient #12's mother on 2/17/23 at 22:07 [10:07 PM] no referral information was provided.

5. Review of the medical record for Patient #10 documented the patient presented to the facility on 2/17/2023 at approximately 9:39 PM for an involuntary examination, due to depression, suicidal ideation, anxiety/panic attacks and history of Attention-Deficit/Hyperactivity Disorder (ADHD).

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" reads, "[Patient #10's name] advised she broke up with her boyfriend today after 6 months and is no longer wanting to live. [Patient #10's name] stated, "I'm gonna find a way to cut my wrists, no matter what you do" referring to her mother. [Patient #10's name] has a history of Baker Acts and mental illness. [Patient #10's name] has been diagnosed with major depressive disorder, anxiety, and ADHD. [Patient #10's name] mother advised [Patient #10's name] is on medication for these mental illnesses but [Patient #10's name] has not been taking them. [Patient #10's name] advised she did not cut herself today but wanted to. Due to these statements and [Patient #10's name] unable to determine for herself, being a juvenile, she was Baker Acted."

Review of the medical record for Patient #10 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. There is no documentation of or nursing assessments and only on nursing progress note. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

During a telephone interview on 2/22/2023 at 10:10 AM Patient #10's mother stated, "[Patient #10's name] has been Baker Acted again, she was out less than 48 hours. She did not attempt suicide when she left but was at school and expressed that desire. We felt that she was not stabilized while she was at Springbrook. She had not received any medications while there and no examination for her mental health. They need to understand that she was not stabilized at all. A nurse called us and told us to come and get her. We tried to tell them she was not stabilized and not safe to go home, but they just shrugged their shoulders. I did sign that I didn't feel she should be discharged. She was not safe to go home. I had to take her home, so I did."

6. Review of the medical record for Patient #15 documented the patient is a 15-year-old female who presented to Springbrook Hospital on 2/17/2023 under a Law Enforcement Officer Initiated Involuntary Examination dated 2/17/2023 at 9:41 PM with suicidal ideation.

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" for Patient #15 dated 2/17/2023 at 9:41 PM read, "Subject has been having problems at school and more recently a video was posted on social media of her in a fight. Subject sent a message to her sister via Instagram stating, "I want to end my life I can't take it anymore. "Subject stated the comment was not made for attention but will not explain anything further."

Review of the medical record for Patient #15 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit did not document on the form for disposition. The form was signed by Patient #15's guardian. Patient #15 was discharged on 2/5/2023 at 11:47 PM. Treatment administered read, "none." Reason not admitted to the hospital read, "minor." No referral information was provided.

The record did not provide the Springbrook Non-Admit for discharge. No discharge information was provided according to the patient's record.

7. Review of the medical record for Patient #17 documented the patient is a 13 year old female who presented to Springbrook Hospital under a Ex Parte Order for Involuntary Examination dated 2/17/2023, due to threats and attempt of suicide.

Review of the "Ex Parte Order for Involuntary Examination" for Patient #17 dated 2/17/2023 at 10:00 AM Case No. [number] read, "1. There is reason to believe the above named person has a mental illness as defined in section 394.455(18) F.S. and because of this mental illness said person (a). has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination: and/or (b). unable to determine for himself/ herself whether examination is necessary and, 2. Either (check a or b) (a). without care or treatment the above named person is likely to suffer from neglect or refuse care for himself/herself, and such neglect or refusal poses a real and present threat of substantial harm to his or her well-being and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services, or, (b). there is substantial likelihood that without care or treatment the above named person will cause serious bodily harm to himself or herself or another person in the near future as evidenced by recent behavior [both a. and b. were checked]. Additional information upon which this order is based, Petitioner states respondent has behavioral outbursts, theft, and threats of suicide. She recently attempted to jump out of a moving car."

Review of the medical record for Patient #17 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments and only one progress note. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. There is no documentation of nursing assessments and only one nursing progress note. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

During an interview on 2/27/2023 at 1:00 PM, Patient #17's mother stated, "I was not aware that my daughter did not receive a psychiatric evaluation because they discharged her and that evening, we had to bring her to [Name of the facility] due to her suicidal behavior and she is now in a facility and getting the treatment she needs. She did attempt suicide again after discharge, attempting to jump out of a car in oncoming traffic. They are terrible. They sent her to the hospital and didn't call me. Initially when they discharged her, they did not provide any referrals. They, simply put, did nothing for her mental health. They were a babysitter, but they wouldn't even provide her medications and did nothing to help her. I told them that she was not safe to go home all they said is, sorry, but we can't keep her the Baker Act is up. The nurse told me that when I went to get her."

Review of the Springbrook Non admit documented the form was for disposition was signed by Patient #17's parent on 2/21/2023 at 10:06 AM.

8. Review of the medical record for Patient #13 documented the patient is a 17 year old female who presented to Springbrook Hospital on 2/18/2023 under a Law Enforcement Officer Initiated Involuntary Examination dated 2/18/2023 at 12:20 AM with suicidal ideation.

Review of the "Report of Law Enforcement Officer Initiating Involuntary Examination" for Patient #13 dated 2/18/2023 at 12:20 AM read, "Subject stated she wants to commit suicide because she is overwhelmed in life."

Review of the medical record for Patient #13 did not provide documentation of a medical examination or a psychological or psychiatric screening being completed at the time of presentation or discharge. There is no documentation of medication administration. There is no acknowledgement of patient rights and informed consent signed by parent/guardian or nursing assessments/progress notes. The record did not provide for documentation of the facility having made attempts to transfer the minor to a facility that could meet the minor's needs. The documentation was requested during an interview with the DON on 2/22/2023 at 9:55 AM and the Executive Director on 2/23/2023 at 10:15 AM. No documentation was provided.

Review of the Springbrook Non admit documented, Reason not admitted: Patient is a minor, Disposition: Home. Dated 2/20/2023 at 12:00 [midnight] Numerous calls placed to mother prior to pick up. Mother signed 2/21/23 0106 [1:06 AM] for discharge. No referral information was provided.

During an interview on 2/24/2024 at 12:15 PM with Patient #13's mother she stated, "My daughter has had several concerns with wanting to end her life. I was only called on the day she was going to be discharged and told her Baker Act was due to end at about 1 AM and I needed to come and get her. I was not called and explained her patient rights. I was not given any referral information to get her assistance and she is still struggling with her mental health. They did not assist her at all, she [the patient] explained that she sat in a room with a tech and never saw anyone while she was there."

During an interview on 2/22/2023 at 9:55 AM the DON stated, "I was aware that the adolescents were being sent home with their parents. I have not been called and instructed nurses to let any pediatric patients go at the end of the Baker Act hours. I was aware that they have not been evaluated by a psychiatrist or psychologist. I can't tell you whether they were safe discharges, I did not discharge them. I would think if they were still having suicidal thoughts the nurses would call the sheriff and have them Baker Acted again. We don't do anything but hold these kids for observation, we don't provide them medications if they take them regularly, we have no physician that provides those orders. I don't see any assessments done by the nurses except the initial minor assessments. Sometimes I see a progress note in the charts, but there are no notes done regularly on the kids."

During an interview on 2/23/2023 at 10:15 AM, the Executive Director (ED) stated, "We do not have a pediatric psychologist in house or contracted for our pediatric Baker Act patients. I was not aware that the patients were being discharged without any follow up. I thought it was being done. No one told me this was happening. Well, the nurses are seeing them, so they are being assessed. Nurses are not able to do the psychological assessment, but we have not had anyone to deal with the children in a long time. No doctor here wants to treat them. So, we observe them and try to get them to a pediatric receiving facility. No one is assessing them except the nurses. Nurses cannot provide a psychological or mental health examination. We are not providing any discharge instructions; we are not providing any medications they might regularly take. If they need medical attention or any ETO [emergency treatment orders] we send them to the hospital because there is no doctor here that will take responsibility for them. We do have a problem with placing the children sometimes, but many times we get them placed within a few hours. We have not tried to get any telemedicine providers. I didn't think we could do that. This has been happening for a very long time that we have been receiving children and adolescents. We have been given no assistance from the county or [Name of an agency] related to our inability to provide the care or services they need. I really wasn't aware that this was happening. No nurses have ever called me and asked me what they should do when the Baker Acts were expiring. I have never instructed the nurses to just let them go. I suppose it is not a safe discharge if they are being sent home without an evaluation, but we have no other choices, it is the law that they must be released after 72 hours."

During a telephone interview conducted on 2/23/2023 at 10:30 AM, Staff H, RN stated, "Usually after 72 hours we call parents and tell them to come and get their child. We are not allowed to give medications or do any kind of assessments on them. We get them and they are awaiting placement at a facility that takes children. It is not safe to discharge them without them being seen by a psychologist or doctor. I was told by the DON [Director of Nursing] and others that once the Baker Act is up we need to call the parents and send them home."

During an interview on 2/23/2023 at 3:00 PM, Staff G, RN stated, "There are patients [minors] that get released after 72 hours and haven't been seen by a doctor. I am not able to make the determination that they need to be Baker Acted, that is outside of my scope of practice to do that. I'm not sure why we are releasing the children if they haven't had a doctor examine them. I guess it would not be a safe discharge."

During an interview conducted on 2/23/2023 at 3:16 PM, Staff C, RN stated, "Pediatric patients have been released without being evaluated by a psychiatrist or a psychologist after their Baker Acts have expired, after the 72 hours hold for the Baker Act. They have not been evaluated because we don't have a physician on staff who deals with the pediatric population. I am not able to determine that a patient is no longer suicidal, it is not within my scope of practice to determine this. I guess maybe they should not be let go if they are not evaluated by someone who can make that call. I guess it would not be a safe discharge if they have not been evaluated by a doctor or nurse practitioner. I have been instructed by management to release them when their Baker Act has expired if they don't have any bed available anywhere else."

During a telephone interview conducted on 2/23/2023 at 10:30 AM Staff H, RN stated, "Usually after 72 hours we call parents and tell them to come and get their child. We are not allowed to give medications or do any kind of assessments on them. We get them and they are awaiting placement at a facility that takes children. It is not safe to discharge them without them being seen by a psychologist or doctor. I was told my DON [Director of Nursing] and others that once the Baker Act is up we need to call the parents and send them home."

During an interview conducted on 2/23/2023 at 3:30 PM, Staff D, RN, stated, "I have discharged pediatric Baker Acted patients from here. They were not seen by a mental health professional; they were not evaluated by psychiatry at all. Their Baker Act reached the 72-hour mark, and we sent them home with their parents. I wouldn't say they were provided a safe discharge. It was what we have been instructed to do by the Administrator on call. That would be [Administrator's name] or the DON or Risk Manager. I am not able to determine if the patient can be cleared from the Baker Act. It is not within my scope of practice to determine if a patient is no longer at risk for suicide and no longer meets the Baker Act criteria. I would say that really isn't very safe."

During an interview on 2/23/2022 at 3:45 PM, Staff F, RN stated, "I did and have discharged pediatric patients when their Baker Act was up after 72 hours, usually because they haven't been accepted anywhere. They are not seen by any mental health providers; they are not given an examination by anyone but a nurse at intake. I did let [Patient #16's name] go home with his parents. He was not seen by a physician; he was not cleared by a physician. We have been told that we let them leave with their parents when their Baker Act time is up, and we haven't found a bed. The Administrator, [Administrator's name], the DON, Risk Manager have all told us that."

During an interview on 2/24/2023 at 9:15 the Risk Manager (RM) stated, "I was aware that patients were released when the Baker Acts expired, usually to their parents. I did see some of the pediatric patients and did not document suicide risk assessments in any of my notes. We cannot administer medications or assess the children without physician orders. We should be documenting when they transfer to the hospital and why they have gone. It is a standard of practice to perform an assessment on a patient if they are attempting to injure themselves. I do not get consent to treat from parents when they come. I have not provided the child or parent with the patient rights forms. They are not admitted. Thay are just here for observation until we find placement. Many times, we can get them placed quickly so it's not a problem. I have never told anyone to let a child go at the end of the Baker Act, when it expires. I don't know why they let them go, but I know we can't keep them longer than 72 hours. As a nurse I am not conducting a psychological assessment to determine the need for a Baker Act."

During an interview on 2/24/2023 at 9:32 AM, the Medical Director stated, "I have been the Medical Director for five to six years. I have been aware that we have pediatric patients, that we have no one to treat them. At one time we had [Physician's name]. We have been, the way we understood, we were holding these kids until transfer could be arranged, treating did not occur. We have not had a psychiatrist or psychologist evaluating these kids. I am not certified to care for the pediatric population, have not had the additional training needed to safely assess them. It is not safe to discharge a patient who has suicidal intent without being seen. I was not aware that any pediatric Baker Acts were leaving at the end of their 72 hours. They just informed me this week. We have not provided any type of treatment to these kids. We don't have the ability to do so. We are not adequately trained to take care of their specialized needs. We have been aware of this problem for years now. We have tried to get this resolved. We went to the community, the sheriff's office, and [Name of a facility] with no results, at least that is what I have been told by [Administrator's name]. I have not had discussions with the board about this issue. I don't believe this was brought up in our quality meetings. We should be having the children evaluated before they are discharged to make sure they are no longer suicidal. It would not be a safe discharge to allow them to leave without determining if they continue to be suicidal or have a plan. These concerns have not been brought up in QAPI and no staff have brought any concerns to me."

During a telephone interview on 2/27/2023 at 10:00 AM the Chief Operating Officer/Vice President stated, "Yes, I was aware that we were providing adolescent holding for Baker Acts and that we have no one to provide this service. At one time we did have a psychologist. We have not attempted to find another or to get telemedicine coverage. We have been concerned about this and failed in our responsibility, but the facility is not equipped to care for adolescents and children. We do not have the capacity to do this or the trained staff. We have brought this up to [Name of an agency], [Name of a service], [Name of a facility], and [local county sheriff's office] who will not transport these kids to the proper facility, to the appropriate facilities with the capacity to treat them. It is not a safe environment, all other counties we have, have transportation plans that cover transporting Baker Act patients to the appropriate facilities. We are stuck, dumped on by [Name of an agency]. We had a physician who used to be with JACHO [Joint Commission on Accreditation of Healthcare Organizations] and he advised us that we were not to treat them, so we were just taking his advice. I don't know if he was a Baker Act expert, but we did take his advice. I don't know if we asked anyone one else for any other advice. I don't know when we last spoke to [Name of an agency], [Name of a service] or [Name of a facility]. It has not been on the agenda of the Governing Board meetings for the last year at least. I don't know what the answer is maybe we just don't accept pediatric patients. As the governing body we are responsible for the overall function of the hospital and the care it provides. We should know who is on staff and the services that we are providing are at practice standards for patient safety. I don't think this is a safe environment for them, but this was not and is not our problem. We have been told what we have to do by the county, [Name of an agency], [Name of a service] and [Name of a facility], and we must do that. We should be providing the appropriate level of care."

Review of the policy and procedure titled, "Procedure For Initiating Involuntary Psychiatric Examination Under the Baker Act" Policy number SS 014 NUR 4:046 effective date 3/1/2018 last review date 1/8/2023 read, "Purpose: The purpose of this policy is to provide guidelines for involuntary psychiatric examination under the Baker Act. Responsibility: It is the responsibility of the administrator, medical director and/or designee to implement this policy and procedure. It is the responsibility of the nu