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Based on one (1) out of two (2) medical records (Medical Record #1) reviewed for complaints and grievances, review of facility documents, and staff interview, it was determined that the facility failed to implement its grievance policy and document a grievance from a patient or a patient's representative.

Findings include:

Reference: Facility policy titled, Grievances: Patient, Family; Role of the Patient Advocate, states, " ... PURPOSE: Definition: For the purpose of this policy, a "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489. ... If a patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is considered resolved when the patient is satisfied with the actions taken on their behalf. ... PROCEDURES: ... 6. The grievance will be logged into the Grievance Log by the Patient Advocate or designee. ..."

1. On 10/18/21 beginning at 1:00 PM, Medical Record #1 was reviewed, and the following was revealed:

a. The RN - Nursing Note dated and timed for 9/21/21 at 10:20 PM states, "... Nursing assessment 3-11 ... He/she stated he/she felt uncomfortable because his/her roommate put a pillow on his/her face last night. His/her roommate was placed on 1:1 at bedtime and his/her roommate will also be sleeping in the lounge. Pt [patient] stated, "I don't feel comfortable, I just want to leave." Pt's mother sent the police here this evening for a wellness check, and it was determined that the pt is in a safe environment. Pt told his/her mother on the phone he wants to leave. Mother stated she wanted to sign the pt out tonight, she was offered a 48 [hour] notice several x's [times] but declined. She spoke [with] RN, RN supervisor, and APN (attending) on the phone. [Staff #1] and [Physician] were also notified. ..."

b. The "Patient Request to Terminate Inpatient Treatment" document signed by the patient and dated 9/22/2021 indicated the reason for the request was, "Don't feel safe with other patient." The document also contained a hand-written checkmark that indicated, "I feel that I am no longer in a crisis situation and wish to leave treatment."

c. The patient was discharged from the facility on 9/22/2021. The "Leaving Against Medical Advice" form, dated 9/22/21 and timed 1:45 PM included the Social Worker's signature and an indication that the "patient refused" to sign.

2. The complaint and grievance log for July 1, 2021 through October 18, 2021 was reviewed and Patient #1's grievance was not documented. During an interview at 2:45 PM, Staff #1 confirmed that there was no grievance documented and stated that it was decided to keep it at the treatment team level. Staff #1 stated that introducing a third party would have created more confusion. Staff #1 stated that he/she documented it as an incident report.

A. Based on medical record review, review of facility documents and staff interview, it was determined that the facility failed to ensure that policies and procedures for incident reporting were implemented by all staff.

Findings include:

Reference: Facility policy titled, Healthcare Peer Review (HPR) / Incident Reporting Process, states, "... B. Definitions: 1. Incident: An event, outcome, or situation that is not consistent with routine care of patients and/or the desired operations of the facility and results in or could have resulted in (near miss) unexpected medical intervention, unexpected intensity of care, or unexpected physical or mental impairment. ... PROCEDURES: ... B. Healthcare Facility Staff: 1. Any healthcare facility employee who discovers, is directly involved in or responds to an incident is to complete or direct completion of a HPR/Incident Report as soon after the event as possible, but not later than the end of the shift. ..."

1. During an interview on 12/20/21 at 10:20 AM, Staff #14 stated that during his/her evaluation of Patient #1 on 9/21/21, Patient #1 informed Staff #14 that his/her roommate (Patient #2) had told Patient #1 that he/she had tried to smother Patient #1 with a pillow during the night.

2. A review of Medical Record #1 revealed an "RN- Nursing note" dated 9/21/21 at 10:20 PM, which states, "... [He/she] stated [he/she] felt uncomfortable because [his/her] roommate put a pillow on [his/her] face last night. ..."

3. A review of a facility incident report for the alleged event occurring overnight on 9/20-9/21/21 revealed that the incident report was completed on 9/23/21 by Staff #1. Staff #1 was not the clinical staff who discovered the incident.

a. The report was not completed at the time the incident was discovered by the staff members involved. This was not in accordance with facility policy.

4. The above finding was confirmed with Staff #1 on 12/20/21 at 12:59 PM.

B. Based on review of facility policy, and staff interview, it was determined that the facility failed to ensure that policy and procedures for 1:1 patient monitoring were clarified and implemented in accordance with provider orders to ensure patient safety.

Findings include:

Reference: Facility policy titled, Special Precautions Patient Classification, states, "... B. One-to-One Observation Status - ... The patient will be maintained on constant visual observation by a staff member at a distance no greater than three (3) feet to ensure patient safety. ... 1. The patient on this level of observation must be with the assigned staff member at all times. ..."

1. A review of Medical Record #2 revealed a provider's order dated 9/21/21 at 9:30 AM, which states, "... 1:1 @ HS [bedtime] for safety". The medical record lacks evidence that staff clarified the intended start and end time of this order.

a. A "RN- Nursing Note" dated 9/21/21 at 1315 states, "... Pt [patient] denies HI/SI [homicidal ideation/suicidal ideation] but attempted to smother his roommate last night. Pt will be placed on a 1:1 from the hours of 11P-7A. ..." Documented evidence revealed that the 1:1 was initiated at 9:30 PM. The medical record lacked evidence that staff clarified the intended start time of the 1:1.

2. During interviews conducted with staff members on 12/20/21, the following was revealed:

a. At 10:15 AM, Staff #12 and Staff #13 were interviewed about the unit schedule. Staff #12 stated that he/she does not work evening shifts and deferred to Staff #13. Staff #13 stated that doors to patient rooms are locked during the day for patient safety and are unlocked by staff between 8-8:30 PM. Staff #13 stated that patients can then go back and forth to their rooms until bedtime which is between 9:30PM-10:00 PM, dependant on the patient's assigned level of care.

b. At 10:20 AM, Staff #14 stated that he/she evaluated Patient #1 and Patient #2 the morning after they were both admitted (9/21/21). Staff #14 stated that during his/her evaluation of Patient #1, the patient stated, "Just so you know, my roommate [Patient #2] told me he tried to smother me". Staff #14 stated that no one saw or heard any disturbance from the patient room. Staff #14 ordered a 1:1 sitter for Patient #2 at bedtime for safety. Staff #14 stated that at bedtime meant beginning at 9:30 PM. When asked for clarification, Staff #14 stated that the 1:1 monitoring should begin at the time the patient rooms are unlocked for the night. Staff #14 confirmed any time the patients are out of sight of staff there should be a 1:1 sitter in accordance with his/her order for 1:1 at bedtime.

(i) Staff #14 stated that when he/she arrived on the unit the next morning (9/22/21), he/she saw Patient #2 walking down the hallway with Patient #1 following. Staff #14 stated that it did not make sense that if Patient #1 feared Patient #2, that he/she would follow him/her alone. Staff #14 then made the decision to place Patient #2 on a continuous 1:1 as much for his/her own safety due to the patient's current mental state.

c. At 10:50 AM a follow-up interview was conducted with Staff #13. Staff #13 stated that he/she does work evening (3PM-11PM) shifts on the Adolescent Unit "occasionally". Staff #13 confirmed his/her earlier statement that staff unlock the patient room doors between 8-8:30 PM. Staff #13 stated that 1:1's begin at whatever time the provider ordered the 1:1 to start.

d. Staff #15 was also interviewed regarding the daily patient schedule. Staff #15 stated that the bedtime for Level 1 patients was at 9:30 PM and for Level 2 and 3 patients the bedtime was at 10 PM. Staff #15 stated the bedroom doors are unlocked at 9:30 PM. This was inconsistent with Staff #13's statement that doors are unlocked between 8-8:30 PM.

(i) Staff #15 stated that the 1:1 typically ends after the night shift at 7 AM. When asked who is watching the patient after that time and before the doors are locked for the day, Staff #15 explained that the 1:1 observer will wake the patient prior to leaving and the patient will be moved to the lounge so that staff can see the patient.


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3. During an interview on 10/19/21 at 12:10 PM, Staff #1 confirmed that on the morning of 9/22/21, Patient #2 entered the patient room without a 1:1 observer while Patient #1 was alone in the room. Staff #1 stated that this occurred because Patient #2's order for 1:1 had expired at 7:00 AM on 9/22/21. Patient #2 was not being observed by staff to prevent interaction with other patients before the patient rooms were locked for the day.

4. During an interview on 12/20/21 at 11:16 AM, Staff #1 confirmed that the facility policy for 1:1 patient monitoring is not clear for a start time when ordered for "at bedtime".

C. Based on one (1) of two (2) medical records (Medical Record #1) reviewed, review of facility documents, and staff interview, it was determined that the facility failed to ensure that staff notify the necessary agencies when allegations of assault are reported.

Findings include:

Reference #1: Facility policy titled, Assault Precautions, states, "PROCEDURES: ... In the event that a patient attacks another patient (provoked/unprovoked) and regardless of precaution, the following procedure is to be followed: ... 3. Notify the local police of patient to patient assault and provide police with patient demographics. 4. Notify the Risk Manager and the Department of Health of patient to patient assault. ..."

Reference #2: Facility policy titled, Child Abuse, states, "... D. DCP&P Institutional Abuse must be notified immediately of the abuse allegation ... In cases involving allegations made by a patient against another patient, information on all parties involved may be shared with DCP&P specific to the present allegation and investigation. ..."

1. A review of Medical Record #1 revealed an "RN- Nursing note" dated 9/21/21 at 10:20 PM, which states, "... [He/she] stated [he/she] felt uncomfortable because [his/her] roommate put a pillow on [his/her] face last night. ..." The medical record lacked evidence that this event was reported to the police, DCP&P, or institutional abuse per facility policy.

2. During an interview on 12/20/21 at 10:20 AM, Staff #14 was interviewed. Staff #14 stated that during his/her evaluation of Patient #1 on 9/21/21, the patient stated, "Just so you know, my roommate [Patient #2] told me he tried to smother me". Staff #14 stated that no one saw or heard any disturbance from the patient room.

3. During an interview on 10/19/21 at 3:07 PM, Staff #3 stated that he/she was made aware of Patient #1's allegations by the patient's mother on 9/21/21 at 3:50 PM and passed this information on to the Charge RN. Staff #3 stated that when a patient makes an accusation of a crime, potential crime, or abuse, that he/she needs to call Institutional Abuse and inform them of the allegations. Staff #3 stated that he/she did not report Patient #1's allegations because he/she did not believe the allegations occurred. This was not in accordance with facility policy referenced above.

4. During an interview on 12/20/21 at 11:30 AM, Staff #1 confirmed that the police were not notified of the potential criminal activity. This event was also not reported to the New Jersey Department of Health. This was not in accordance with the above referenced facility policy.