HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The Hospital failed to develop policy and/or procedure to transport patients outside of the facility for appointments and/or therapy and to failed to appropriately monitor a patient while outside of the facility. (See A144A)

2. The Hospital failed to have appropriately qualified staff to transport a patient outside of the facility. (See A144B)

A. Based on observation, document review and interview, it was determined for 1 of 1 (Pt #1) patients who were transported outside of the facility, the Hospital failed to provide care in a safe setting by failing to develop policy and/or procedure to transport patients outside of the facility for appointments and/or therapy and failing to appropriately monitor a patient while outside of the facility.

Findings include:

1. The policy titled, "Patient Observation Level (effective 11/2024)" was reviewed. The policy indicated, " ... IV Procedure: A. Intervention/Observation a. General Patient Observations/15-minute Rounds - i. All patients are carefully monitored and assess a minimum of every 15 minutes upon arrival to intake. ii. In rare instances, when a patient on precautions must leave the unit, the patient will be accompanied and supervised by staff, who will continue to document 15-minute observations.

2. Pt #1's record was reviewed throughout the survey. Pt #1 was admitted on the youth psychiatric unit on 7/19/2023 with the diagnoses of ADHD (attention deficit/hyperactivity disorder, a disorder characterized by inattention, difficulty paying attention, keeping on task, or staying organized), PTSD (post-traumatic stress disorder, a condition that can develop after experiencing or witnessing a traumatic event), RAD (reactive attachment disorder, a rare condition affecting children who have experienced severe neglect or abuse early in life leading to an inability to form healthy emotional attachments with caregivers), and DMDD (major depressive disorder, a mental health condition characterized by persistent feelings of sadness, hopelessness, or a lack of interest and pleasure in activities for at least two weeks) and was hospitalized for homicidal ideation. DCFS (Department of Children and Family Services) is the patient's legal guardian.

Pt #1's 15-minute "Patient Observation Sheet" was found on the following dates to lack documentation of the 15 minutes checks:
3/27/2025 from 10:38 AM to 7:13 PM - logged out for "Appointment."
4/24/2025 - logged out for "Appointment" at 2:23 PM. Pt #1's observation log had monitoring at 2:30 PM and then no other monitoring documented for the rest of the day/night.
5/6/2025 from 07:52 AM to 7:18 PM - logged out for "Visitation Pass."
5/21/2025 from 3:08 PM to 5:29 PM - logged out for Appointment."
5/30/2025 from 3:18 PM to 4:58 PM- logged out for "Outings."
5/31/2025 from 3:26 PM to 7:17 PM - logged out for "Outings."
6/6/2025 from 11:56 AM to 1:45 PM and 2:05 PM to 4:18 PM - logged out for "Appointment."
6/10/2025 from 3:30 PM to 4:13 PM - logged out for "Appointment."
6/15/2025 from 3:29 PM to 8:12 PM - logged out for "Outings."
6/16/2025 from 3:42 PM to 6:31 PM - logged out for "Outings."
6/27/2025 from 4:24 PM to 7:57 PM - logged out for "Outings."
6/28/2025 from 1:40 PM to 8:23 PM - logged out for "Appointment."
6/30/2025 from 2:06 PM to 2:42 PM - logged out for "Outings."
7/2/2025 from 1:14 PM to 5:49 PM - logged out for "Outings."
7/6/2025 from 10:15 AM to 12:11 PM - logged out for "Outings."

Pt #1's monitor log indicated patient was taken outside of the facility 33 times between 2/13/2025 and 7/6/2025. On 15 of the dates, there was no appointment and/or therapy scheduled and no documentation of where the patient was transported to.

2. An interview was conducted on 9/3/2025 at approximately 1:00 PM with Chief Nursing Officer (CNO - E #2) and Director of Risk Management (E #9). E #2 and E #9 was asked for a policy or procedure related to taking patients outside of the facility for appointments, therapy, and/or outings. E #2 and E #9 stated "There is no policy for transfer of a patient outside the facility for appointments, therapy or outings." E #9 stated, "I realized there was a problem when I returned from medical leave."

3. An interview was conducted with E #2 on 9/3/25 at approximately 2:00 PM. E #2 stated, "(Pt #1) was taken offsite for medical appointments and equine therapy (treatment that utilizes horses to support mental health recovery and personal development) as authorized by DCFS. On other occasions, (Pt #1) was taken on other outings such as to a movie, a trampoline park and walks to the park. We do not have a policy to do that. There is no documentation completed while the patient was outside of the facility. We realize now there are areas of improvement needed for the process."


B. Based on document review and interview it was determined for 1 of 1 (Pt #1) DCFS (Department of Child and Family Services) patient's transported outside of the facility, the Hospital failed to ensure qualified staff transported a patient outside of the facility.

Findings include:

1. The Vehicle logs were reviewed and indicated Mental Health Technician (MHT - E #6), Education Coordinator (E #7). and MHT (E #10) transported Pt #1 outside of the facility.

2. Personnel files were reviewed. E #6 and E #7's personnel files included "Children and Family Services Licensing - Child Care Facility Driver Eligibility Check Results" which indicated "...approved to transport children..." E #10's personnel file did not include the Child Care Facility Driver Eligibility Form.

3. An interview was with the Chief Nursing Officer (E #2) conducted on 9/4/2025 at approximately 12:45 PM. E #2 stated, "All drivers who transport youth in DCFS custody must be certified by DCFS. (E #10) did transport (Pt #1) to a movie theater and the trampoline park. (E #10) does not have DCFS certification to drive patient outside the facility and should not have transported this patient as they were not certified to do so with DCFS."

Based on document review and interview, it was determined for 2 of 5 (Pt #2 and Pt #5) discharged patient records reviewed, the facility failed to ensure a discharge summary was completed.

Findings include:

1. The Hospital policy titled "Rules and Regulations of the Medical Staff " was reviewed. The policy indicated, "... A.8 Documentation... m. Discharge Summaries i. Service Types 1) Inpatient Psychiatric - all patient charts shall contain a discharge summary, which is dictated within thirty (30) days...."

2. Pt #2's record was reviewed on 9/3/25. Pt #2 was admitted on 4/29/25 with a diagnoses of "Disruptive mood dysregulation disorder, Attention deficit hyperactivity disorder, Posttraumatic stress disorder." Pt # 2 was discharged on 6/17/25. Pt #2's record lacked a discharge summary.

3. Pt #5's record was reviewed on 9/3/25. Pt #2 was admitted on 4/29/25 with a diagnoses of "Mood dysregulation disorder, Suicidal Ideation with plan to overdose on medications." Pt #5 was discharged on 7/29/25. Pt #5's record lacked a discharge summary.

4. On 9/3/25 at approximately 2:00 PM, an interview was conducted with CNO. E #2 reviewed the records and verbally agreed that the records lacked discharge summaries.