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Based on record review and interview, the facility failed to follow policies and procedures for obtaining informed consent in minor patients. The facility failed to ensure informed consent for treatment of minor patients was obtained from the parent or guardian in 6 of 10 minor patients admitted (Patient #3, #4, #5, #7, #8 and #10) and failed to ensure informed consent for psychotropic medication was obtained from the parent/guardian in 7 of 10 minor patients receiving psychotropic medications (Patient #2, #3, #4, #5, #7, #8, and #10) in a total of 10 minors medical records reviewed.

Findings include:

Review of policy titled "211.10 Informed Consent for Treatment" # 5024136 last reviewed 12/2018 under definitions #3 revealed: "Informed Consent: Written or documented witnessed verbal consent voluntarily provided by a patient who is competent ... or by the patient's legal guardian or parent of a minor." Under Policy revealed "Informed consent is necessary... At the time of admission,.. obtained through the Admission Information Acknowledgement document... B. Specific informed consent and consent to treatment shall be obtained for participation in... Scheduled psychotropic medications... used for treatment of psychiatric conditions that are prescribed for the purpose of ameliorating (to make better) the condition for which the patient was admitted... C. An informed consent document shall declare that the patient or the person acting on the patient's behalf has been provided with specific information... concerning... 1. The benefits of the proposed treatment... 3. The expected side effects or risks...alternative treatment... probable consequences of not receiving the proposed treatment. 6. The time period for which the consent is effective; and 7. The right to withdraw informed consent to treatment at any time in writing... E. In the case of minors age 14 or over, the written informed consent of the minor and the minor's parent or guardian is required. Under III Treatment in the absence of written informed consent #1 revealed "informed consent for treatment may be temporarily obtained by telephone from the parent of a minor patient or the guardian of a patient. Oral consent shall be documented in the patient's record, along with details of the information verbally explained to the patient or guardian about the proposed treatment."

Review of policy titled "212.10 Medication Guidelines, Laboratory Monitoring" #6724712, Page 3 a. Revealed "Medications shall not be administered unless i. The patient or his/her legal guardian authorizes the treatment through signing an informed consent."

Review of policy titled "Medication Administration" #7589818 last reviewed 2/2020, page 8 under General Principles #5 b revealed "The nurse is responsible to ensure the Informed Consent for Medication is current and prior to administration of psychotropic medication orders."

Review of Patient #2's medical record revealed Patient #2 was a 14-year-old admitted 5/11/20 6:55 PM under an involuntary hold due to aggression and suicidal gestures, discharged 5/15/20. Note dated 5/15/20 at 10:21 AM by RN (4 days after admission) revealed "Mother gave verbal consent for program & meds" (medications). The medications were not listed in the nursing note. Discharge Summary 5/15/20 at 11:12 AM written by MD revealed psychotropic medications were given "Patient was restarted on fluoxetine..., guanfacine..., which he took with good compliance." There was no written documentation indicating informed consent was obtained from the guardian/parent on the psychotropic medications: fluoxetine or guanfacine.

Review of Patient #3's medical record revealed Patient #3 was a 14-year-old admitted 5/20/30 at 3:55 AM under an involuntary hold for suicidal ideation's and plans to hurt self due to aggression and suicidal gestures, discharged home on 5/28/20. Admission Information Acknowledgement consent checked involuntary was signed by Patient #3 5/20/20 at 3:36 AM. Space labeled Parent/Guardian signature was blank. Discharge Summary 5/28/20 at 12:51 PM by MD revealed "She was restarted on her psychotropic medications of Abilify, trazodone, Lexapro and gabapentin". There was no written or verbal documentation of informed consent being obtained from the guardian/parent for treatment or for the psychotropic medications Abilify, trazodone, Lexapro and gabapentin.

Review of Patient #4's medical record revealed Patient #4 was a 15-year-old with a history of asthma admitted 5/28/20 at 7:16 PM under an involuntary hold due to disorganized and threatening behavior, discharged home on 6/16/20. Psychiatric Admission Note 5/28/20 at 7:14 PM by Physician Assistant revealed "Information was obtained through collateral sources" which did not include parent or guardian. Social Service Progress Note dated 6/03/20 at 3:53 PM revealed social worker had talked to Patient #4's parent "on 5/29, 6/1, and 6/3... demanded to see [Patient #4].. explained ... he is currently a 1:1, who is actively psychotic... and she thinks we are not taking care of him." There is no Admission Information Acknowledgement consent in the medical record for this hospitalization. Physician ordered psychotropic medications: Zyprexa, Lorazepam, Cogentin, Trazodone and Haldol. There was no written documentation indicating informed consent was obtained from the guardian/parent on the psychotropic medications: Zyprexa, Lorazepam, Cogentin, trazodone and Haldol.

Review of Patient #5's medical record revealed Patient #5 was a 14-year-old admitted 5/23/20 at 10:51 PM under an involuntary hold for suicidal behavior, discharged home 5/29/20 at 12:13 PM. Admission Information Acknowledgement marked involuntary was signed by Patient #5 5/23/20 at 10:46 PM and box titled "Parent or Guardian" was blank. Psychotropic medications for duloxetine and trazodone were ordered. Nursing note 5/24/20 at 10:17 PM revealed "MEDS RESTARTED, WRITTENS SENT OUT." Nursing note 5/24/20 at 2:08 pm revealed "[parent] gave verbal consent for meds and program." Medications were not identified. There were on signed informed consents for psychotropic medications for duloxetine and trazodone.

Review of Patient #7's medical record revealed Patient #7 was a 17-year-old admitted 5/25/20 at 12 PM under an involuntary 72 hours emergency detention after becoming aggressive and breaking down the door of siblings bedroom, discharged home 6/05/20 at 8:12 PM. There was no informed consent for treatment in the medical record or verbal informed consent for treatment documented in Patient #7's medical record. Physician orders revealed patient was on Abilify, trazodone, geodon, buspirone, benztropine, aripiprazole, benztropine (Cogentin) and haloperidol and ziprasidone (Geodon). There were no signed informed consents or documentation of obtaining verbal consent from parent/guardian for psychotropic medications.

Review of Patient #8's medical record revealed Patient #8 was a 12-year-old admitted 6/28/20 at 2:15 AM under an involuntary 72 hour hold for increased aggression towards staff at group home, discharged to another acute behavioral health hospital 7/01/20 at 5:51 PM. There was no signed or documented verbal discussion with guardian to obtain informed consent for treatment.
Physician orders revealed orders for psychotrophic medication for fluoxetine, guanfacine, trazodone and risperidone. There were no signed informed consents or documentation of obtaining verbal consent with guardian for the psychotropic medications.

Review of Patient #10's medical record revealed Patient #10 was a 11-year-old admitted 6/19/20 at 11:12 AM with a history of cyclothymia, oppositional defiant disorder, adjustment disorder and ADHD, under an involuntary hold for missing her court date and violation of her commitment and was discharge home 6/22/20 at 10:07 PM. There was no signed informed consent for treatment or documentation that one was sent. Admission note by MD under Initial Treatment Plan revealed "Psychotropic medications... I will continue guanfacine ER" and also listed fluoxetine. There was no written informed consent documentation that informed consent were sent for the psychotropic medications (fluoxetine and guanfacine).

On 7/29/20 at 10:36 AM during interview with Nurse Clinician 3/Electronic Health Record (NC3) F and Registered Health Information Technician (RHIT) G, NC3 F stated when verbal informed consent for treatment and verbal informed consent for psychotropic medications is obtained from a parent or guardian, there should be documentation of what was discussed to include what they were giving consent for, and each medication informed consent was being given for, documented in the nursing note.

On 7/29/20 at 4:48 PM during interview while reviewing medical records with Registered Health Information Technician (RHIT) G, RHIT G stated there were no other informed consents in the medical records of Patient #1, #2, #3, #4, #5, #7, #8 and #10.

Based on record review and interview the facility failed to assess, evaluate and care for patient needs by failing to obtain an order for use of a straight catheter and evaluating their needs in accordance with accepted standards of nursing practice in 1 of 1 patient admitted requiring self-cath (Patient #1) in a sample of 10 medical records reviewed.

Findings include:

Record review of Policy titled "Indwelling Urinary Catheter Guidelines" #5597826, last revised 11/2018 revealed "The Center of Disease Control (CDC) strongly recommends that the use and duration of urinary catheters be minimized and completely avoided when able...and ... agree with these recommendations, but also realize tht there are certain medical conditions in which... urinary catheterization is needed... Documentation should be completed upon insertion... and/or removal... When a physician determines appropriate use for and orders... References: CDC-Center of Disease Control, Perry & Potter, 2014."

Review of Patient #1's medical record revealed Patient #1 was a 14-year-old with a history of Tourette's, OCD and autism spectrum disorder admitted 05/24/2020 11:56 PM under a 72 hour emergency detention after having an angry outburst, with homicidal threats towards his parents. Admission History & Physical dated 5/25/20 at 12:46 AM by Physician Assistant (Kenneth Gillespie) under History of Present Illness revealed "The patient has a bladder stoma... he does self cath multiple times per day." Under Assessment/Plan revealed "May continue to self cath with his personal catheters he brought from home." There was no order for straight cath, use of catheter was not assessed or evaluated, and use of the straight cath was not indicated in patient's treatment plan.

On 7/29/29 at 9:55 AM during interview with Physician Assistant (PA) H, PA H stated if a new patient would require a urinary catheter, the physician on call would be contacted to address the concern prior to accepting the patient, it would be discussed with the staff on the floor, and documented in the patient's medical record.

On 7/29/20 at 10:12 AM during interview with Nurse Manager Sherman South I, I stated it is unusual to have a patient who requires any type of urinary catheter stating the physician "should have been contacted" on admission for an order, if he was using straight caths (flexible tubes that are used to empty urine from the bladder intermittently).

On 7/29/20 at 10:36 AM during interview while reviewing Patient #1's medical record with Nurse Clinician 3/Electronic Health Record (NC3) F, NC3 F stated the Registered Nurse who completed the intake assessment should have discussed this with the patient and family to determine the needs of the patient, and called the physician for an order, as needed. NC3 F confirmed there was no physician order for a straight cath in Patient #1's medical record.

Based on record review and interview, the Social Services Workers failed to provide timely assessments of their patient's needs to formulate interventions and discharge plans according to their policies and procedures in 6 of 10 patients admitted for care (Patient #1, #2, #4, #6, #7 and #8) out of a total of 10 inpatient medical records reviewed.

Findings include:

Record review of policy titled "Documentation Guidelines" #7816511, last revised 4/2020, under Social Service Initial Assessment revealed "A Social Service Initial Assessment (Part 1) must be completed on every patient within 72 hours of admission."

Review of Patient #1's medical record revealed Patient #1 was a 14-year-old with a history of Tourette's, OCD and autism spectrum disorder admitted 05/24/2020 11:56 PM under a 72 hour emergency detention after having an angry outburst, with homicidal threats towards his parents, discharged 5/31/20 at 6:59 PM. Social Service Initial Assessment Part 1 & 2 with the last entry dated 6/09/2020, 16 days after admission.

Review of Patient #2's medical record revealed Patient #2 was a 14-year-old was admitted 5/11/20 6:55 PM under an involuntary hold due to aggression and suicidal gestures, discharged 5/15/20. Social Service Initial Assessment Part 1 with the last entry dated 5/27/20 at 1:17 PM, 16 days after admission.

Review of Patient #4's medical record revealed Patient #4 was a 15-year-old with a history of asthma, admitted 5/28/20 at 7:16 PM under an involuntary hold due to disorganized and threatening behavior, discharged home on 6/16/20 at 2:23 PM. Social Service Initial Assessment Part 1 & 2 with last entry dated 6/05/20 at 5:11 PM, 8 days after admission.

Review of Patient #6's medical record revealed Patient #6 was a 15-year-old admitted 5/22/20 at 4:51 PM under an involuntary 14 day evaluation hold, transferred from another acute behavioral health facility for being sexually inappropriate, and discharged home 5/30/20 at 11:24 AM. Social Service Initial Assessment Part 1 & 2 with last entry dated 6/12/20 at 7:56 PM, 21 days after admission.

Review of Patient #7's medical record revealed Patient #7 was a 17-year-old admitted 5/25/20 at 12 PM under an involuntary 72 hours emergency detention after becoming aggressive and breaking down the door of siblings bedroom, discharged home 6/05/20 at 8:12 PM. Social Service Initial Assessment Part 1 & 2 with last entry dated 6/02/20 at 2:26 PM, 8 days after admission.

Review of Patient #8's medical record revealed Patient #8 was a 12-year-old admitted 6/28/20 at 2:15 AM under an involuntary 72 hour hold for increased aggression towards staff at group home, discharged to another acute behavioral health hospital 7/01/20 at 5:51 PM. Social Service Initial Assessment Part 1 & 2 with last entry dated 7/02/20 at 2:25 PM, greater than 3 business days (86-1/4 hours) after admission.

On 7/29/20 at 8:32 AM during interview with Director of Social Services (SSD) E, SSD E stated it is the expectation that the initial assessment is completed by the Social Worker within 72 hours of admission stating, "sometimes they don't get all the information collected."

Based on record review and interviews, the facility failed to provide a complete discharge planning evaluation and treatment plan per the facilities policy and procedures in 7 of 10 patients discharged (Patient #1, #2, #4, #6, #7, #8 and #10) in a total of 10 medical records reviewed.

Findings include:

Record review of policy titled "Documentation Guidelines" #7816511 last revised 4/2020 under Social Service Discharge Assessment revealed "The Social Service Discharge Assessment will be completed within one (1) workday following discharge."

Review of Patient #1's medical record revealed Patient #1 was a 14-year-old with a history of Tourette's, OCD, and autism spectrum disorder admitted 05/24/2020 11:56 PM under a 72 hour emergency detention after having an angry outburst, with homicidal threats towards his parents, discharged 5/31/20 at 6:59 PM. Discharge Social Service Assessment with last entry dated 6/12/20 at 12:11 PM, 12 days after discharge, revealed "The outpatient success of (Name) will depend heavily on his adherence to continuing to take his medications as prescribed and continued follow up with his outpatient providers." Under Discharge Planning revealed Follow-Up appointments needed." Discharge Summary dated 5/31/20 at 9:06 PM revealed "The discharge... is premature... Prescriptions were written, but a three day supply of medications... could not be provided on a Sunday." There was no further follow-up documented.

Review of Patient #2's medical record revealed Patient #2 was a 14-year-old was admitted 5/11/20 6:55 PM under an involuntary hold due to aggression and suicidal gestures, discharged 5/15/20 at 6:16 PM. Discharge Social Service Assessment with last entry dated 6/01/20 at 9 AM, 17 days after discharge, revealed "[Patient #2] indicated that she would participate in outpatient treatment services... Discharge Planning... Follow-Up appointments needed." There were no follow-up appointments listed.

Review of Patient #4's medical record revealed Patient #4 was a 15-year-old with a history of asthma admitted 5/28/20 at 7:16 PM under an involuntary hold due to disorganized and threatening behavior, discharged home on 6/16/20 at 2:23 PM. Discharge Social Service Assessment 6/15/20 at 1:55 PM revealed "An AODA (alcohol or other drug abuse) assessment was also completed and the recommendation is for intensive outpatient treatment." There were no follow-up appointments listed.

Review of Patient #6's medical record revealed Patient #6 was a 15-year-old admitted 5/22/20 at 4:51 PM under an involuntary 14 day evaluation hold, transferred from another acute behavioral health facility for being sexually inappropriate, and discharged home 5/30/20 at 11:24 AM. Discharge Social Service Assessment was completed 6/12/20 at 10:26 AM, 13 days after discharge.

Review of Patient #7's medical record revealed Patient #7 was a 17-year-old admitted 5/25/20 at 12 PM under an involuntary 72 hours emergency detention after becoming aggressive and breaking down the door of siblings bedroom, discharged home 6/05/20 at 8:12 PM. Discharge Social Service Assessment was dated 6/05/20 at 5:17 PM, 2 hours and 55 minutes before discharge. Discharge Summary 6/11/20 at 5:31 PM, under recommendations for aftercare revealed, "within 1 month." There were no follow-up appointments listed.

Review of Patient #8's medical record revealed Patient #8 was a 12-year-old admitted 6/28/20 at 2:15 AM under an involuntary 72 hour hold for increased aggression towards staff at group home, transferred to another acute behavioral health hospital 7/01/20 at 5:51 PM. Social Service Initial Assessment, last entry dated 7/02/20 at 2:25 PM, which indicate the key components needed to develop a treatment plan and formulate discharge needs, was not completed prior to Patient #8 being discharged.

Review of Patient #10's medical record revealed Patient #10 was a 11-year-old admitted 6/19/20 at 11:12 AM with a history of cyclothymia, oppositional defiant disorder, adjustment disorder, and ADHD (Attention Deficit Hyperactivity Disorder) , was under an involuntary hold for missing her court date and violation of her commitment, and was discharged home 6/22/20 at 10:07 PM. Discharge Social Service Assessment last entry dated 6/22/20 at 12:09 PM under Discharge Needs, Post-Acute Services Needed revealed "Community support programs, Psychiatric services, Psychotherapy, Transportation services." There was no documented follow-up of continued treatment needs being met.

On 7/29/20 at 8:32 AM during interview with Director of Social Services (SSD) E,SSD E stated it is the expectation that the discharge summary is completed within 24 hours of discharge. SSD E stated the Social Workers discharge summary should list any needed follow-up, including dates and times of follow-up appointments.

On 7/29/20 at 3:14 PM during interview with Psychiatrist J, MD J confirmed follow-up and follow-up appointments were not documented in the discharge summary stating "I recently started to do that in my note," the "medical clinic should be involved."