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Based on record review and interview, facility staff failed to actively involve legal guardians in the care planning and treatment for 1 of 5 minor patients reviewed (Patient #1); and failed to evaluate legal guardian expectations for involvement in care for 5 of 5 minor patients reviewed (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5).

Findings include:

Review of the facility's Patient Rights and Responsibilities brochure, dated 12/2014, revealed "You or your legally authorized representative have the right to: -Receive information about your care including diagnosis, treatment and outcomes, including outcomes that were not expected, in terms you can understand. -Make decisions about your care, including refusing care to the extent as permitted by law. -Ask questions and be listened to."

Review of the facility's Medical Staff Rules and Regulations dated 7/13/2017 revealed "Section 3. Contents: (a) A complete inpatient medical record shall include: (9) family's or legal representative's expectations for, and involvement in the assessment, treatment, and/or continuous care of a minor or otherwise incompetent patient."

Per medical record review, Patient #1 (a minor) was admitted to the facility on 12/22/2018 with a diagnosis of "adjustment disorder with mixed disturbances of emotion and conduct." Review of nursing progress notes on 12/26/2018 at 9:56 AM revealed "[Patient #1's parent] called and is requesting to have a family meeting, and a call from the MD." At 1:06 PM "Family meeting scheduled for Thursday 12/27/2018 at 11:00 AM. [Patient #1] is hoping that... will be able to go home after the family meeting tomorrow morning." Case management notes on 12/27/2018 at 9:32 AM revealed "Family meeting has been rescheduled from today at 11 AM to 12/28/2018 at 2:30 PM with option to discharge home following." Review of nursing notes on 12/27/2018 revealed Patient #1 was not participating in group activities and was refusing to talk with staff. Nursing progress notes on 12/27/2018 at 7:48 PM revealed "[Patient #1] is angry about not being able to leave. ...talks with [parent] on the phone but hangs up on [parent] because [parent] tells [#1] that the meeting tomorrow was canceled because [#1] is refusing to talk to staff and the psychiatrist." Case management notes on 12/28/2018 at 12:34 PM revealed "...team talked with patient about [behaviors] as [#1's] goal is to ho home--how behaviors are prohibiting discharge. Family meeting for today has been canceled as patient will not be discharged home." Per nursing notes on 12/29/2018 at 12:53 PM "[Parent] is wondering if [Patient #1] would be able to home soon. Writer assured [parent] that would let him/her know when the MD feels... ready for discharge." Patient #1 was discharged to home on 12/31/2018. There was no documentation of a family meeting during Patient #1's stay, or documentation that the reasons for delayed discharge were documented to Patient #1's parents.

Patient #1 was admitted on 12/22/2018 under an emergency detention. Per case management notes on 12/24/2018 at 9:49 AM "Probably cause hearing will not be scheduled with [county]." Per nursing notes on 12/27/2018 at 12:21 PM "Patient's [parent] made aware that patient is now here as a voluntary patient." During an interview on 2/19/2019 at 11:10 AM, Case Manager D stated when patient's are admitted under emergency detention "I talk with the parents and explain the court process." When asked if parents are notified if a patient's legal status changes, D stated "yes, I would notify the family." Review of Patient #1's medical record did not include documentation that Patient #1's admission was changed to voluntary until 12/27/2018, 3 days after noting that a probably cause hearing would not be scheduled. Case Manager D stated "I should" document that notification to families.

During an interview on 2/19/2019 at 10:25 AM, Director B stated "every situation is different, some families are more involved than others." When asked how the family or legal representative's expectations for involvement are evaluated and documented, B stated there should be "an evaluation to determine that, it should be in the medical record."

Review of medical records for Patient #2, Patient #3, Patient #4, and Patient #5 did not include documentation of an evaluation for the patient's legal guardian expectations for involvement in care and treatment planning.

During an interview on 2/19/2019 at 8:45 AM, Psychiatrist C stated C doesn't discuss treatment with patient's parents or guardians, "all the communication is done with the nursing staff and social worker" and family meetings are "not routine."

Review of the admission information sheet provided to minor parents and guardians upon admission did not include instruction or education about involvement in treatment planning or ongoing communication expectation with facility staff. During an interview on 2/19/2019 at 9:05 AM, Registered Nurse E stated "I tell parents to call for updates." Regarding involvement in goals for treatment, Nurse E stated "the case manager contacts the parents." During an interview on 2/19/2019 at 11:10 AM, Case Manager D stated "I call family for collateral information." When asked how family is usually involved in patient care and planning, D stated "the nurse usually talks with them when they are obtaining informed consent."

Based on record review and interview, facility staff failed to document denial of rights for 2 of 2 patients reviewed on camera monitoring precautions (Patient #1, Patient #6).

Findings include:

Review of facility policy "Suicide Precautions/Behavior Monitoring/Safety Rounding" revealed "D. Camera monitoring may be initiated by nurse and or physician based on behaviors and/or other medical concerns to mitigate safety risk. Patients are not video recorded. Patient denial of rights will be documented in their medical record."

Per medical record review, nursing progress notes on 12/27/2018 at 11:53 PM revealed Patient #1 was put in a therapeutic violent restraint and "Doctor and parent notified. Parent gives permission for camera monitoring. Will continue to closely monitor..." Patient #1's "Client Rights Limitation or Denial Documentation" form, dated 12/30/2018, revealed "Client right to be affected: Privacy. Date limitation/denial begins: 12/30/2018. Describe specific, individualized limitation/denial: camera monitoring. This limitation shall be reviewed: Daily." The form documented that camera monitoring was discontinued on 12/30/2018 at 9:10 AM. Review of Patient #1's medical record did not include denial of rights documentation on 12/28/2018 or 12/29/2018.

Per medical record review, Patient #6 was admitted to the facility on 12/19/2018 for depression. Per nursing notes on 12/23/2018 at 1:01 PM "Will continue to provide camera monitoring for safety." Review of Patient #6's "Client Rights Limitation or Denial Documentation" form, dated 12/23/2018, did not include a description of the specific limitation/denial or documentation that the denial was reviewed daily as indicated.

During an interview on 2/19/2019 at 9:30 AM, Director B stated "the [client denial of rights] form should be filled out when [camera monitoring] is initiated."

Based on record review and interview, facility staff failed to modify patient care plans to include the use of restraints for 2 of 3 restrained patients reviewed (Patient #1, Patient #7).

Findings include:

Review of facility policy "Restraint and Seclusion Policy" dated 6/7/2018 revealed "A. Violent of Self-Destructive Behavioral Restraints/Seclusion: 3. The patient's plan of care is modified to include restraint management."

Per medical record review, Patient #1 had a violent behavior episode on 12/27/2018 that resulted in a therapeutic hold restraint. Patient #1's care plan was not updated to include restraint management.

Per medical record review, Patient #6 was placed in a temporary physical hold restraint on 1/28/2019 and again on 1/29/2019. Patient #6's care plan was not updated to include restraint management.

During an interview on 2/19/2019 at 9:05 AM, Registered Nurse E stated if a patient is put in restraints "it would be on the care plan." Per E, "we have a restraint care plan, I can't remember if it's on paper or on the computer." During an interview on 2/19/2019 at 9:35 AM, Manager A stated "it looks like [Patient #6's] care plan for restraints was deactivated. We will have to look into that."

Based on record review and interview, facility staff failed to document a face to face evaluation for 1 of 3 restrained patients reviewed (Patient #6).

Findings include:

Review of facility policy "Restraint and Seclusion Policy" dated 6/7/2018 revealed "A. Violent of Self-Destructive Behavioral Restraints/Seclusion: 1. A face-to-face evaluation of the patien tmust be performed within one hour of the restraint initiation..."

Per medical record review, Patient #6 was placed in a physical hold followed by restraint chair on 12/23/2018 at 10:25 AM. Patient #6's record did not include documentation of face-to-face evaluation.

During an interview on 2/19/2019 at 9:40 AM, Manager A stated "it's typically documented in the [restraint] flowsheet, but it's not there."

Based on record review and interview, facility staff failed to document less restrictive interventions for 1 of 3 restrained patients reviewed (Patient #6).

Findings include:

Review of facility policy "Restraint and Seclusion Policy" dated 6/7/2018 revealed "C. Documentation shall include the following: 2. Alternatives or other less restrictive interventions attempted (as applicable)."

Per medical record review, Patient #6 was placed in a physical hold followed by restraint chair on 12/23/2018 at 10:25 AM. Patient #6's record did not include documentation of less restrictive interventions that were attempted prior to the initiation of restraints.

During an interview on 2/19/2019 at 9:40 AM, Manager A stated "they usually try to deescalate, those attempts should be detailed [in the medical record]."

Based on record review and interview, facility staff failed to develop individualized and measurable care plan goals and interventions for 5 of 5 patient care plans reviewed (Patient #1, Patient #2, Patient #3, Patient #4, ); and failed to identify timely and relevant problems for 2 of 5 patients (Patient #1, Patient #4).

Findings include:

Review of facility policy "Admission Assessment, Reassessment, Care Planning and Documentation" dated 5/23/2018 revealed "Assessment: 1. Assessment is the systematic and continual collection and analysis of data about the status of a patient culminating in the formation of a nursing diagnosis and/or identification of patient care needs. Planning: 1. Planning is the developing includes goals derived from the nursing assessment, reassessment and patient preferences. 3. The plan of care must be individualized to maximize nursing efforts to assist the patient to meet the outcome(s) of the plan. Intervention: 3. Interventions that pre-populate in the care plan should be modified as needed, or deleted to match the patient's individual needs. 4. Interventions should include frequency and other specific information that will guide all nursing care providers to a consistent plan for the patient. Evaluation: 1. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis or plan of care. 2. Evaluation of patient outcomes is the responsibility of the RN. The patient's plan of care is to be reviewed and updated as the patient's condition indicates."

Per medical record review, Patient #1 was admitted to the facility on 12/22/2018 with adjustment disorder and suicidal ideation. The initial nursing assessment on 12/22/2018 at 5:40 AM revealed "Skin integrity: Right forearm cutting, superficial." The initial nursing screening for at risk behavior revealed "Self-Harm/Abuse: Yes; Recent. Comment: Right forearm on this past Monday with random object." Patient #1's nursing plan identified the following problems and goals: "Problem: Mood - Altered. Goal: Mood stable; Problem: Coping - Ineffective, Individual. Goal: Effective coping; Problem: Discharge Planning. Goal: Knowledge of discharge instructions." The goals were not measurable or individualized. There was no problem or goals specific to Patient #1's self-harm behaviors. During an interview on 2/19/2019 at 9:05 AM, Registered Nurse E stated "yes" cutting would be expected to be included on the care plan.

Per medical record review, Patient #2 was admitted to the facility on 2/6/2019 with suicidal ideation. Patient #2's nursing plan included the following problems and goals: "Problem: Coping - Ineffective, Individual. Goal: Effective coping; Problem: Discharge Planning. Goal: Knowledge of discharge instructions." The goals were not measurable or individualized, progress toward goals was unable to be objectively measured. Interventions listed in nursing progress notes include "Active listening; Direct observation; Emotional support; Encourage expression; Encourage verbalization." Interventions were not individualized.

Per medical record review, Patient #3 was admitted to the facility on 2/13/2019 with suicidal ideation. Patient #3's nursing plan included the following problems and goals: "Problem: Coping - Ineffective, Individual. Goal: Effective coping; Problem: Discharge Planning. Goal: Knowledge of discharge instructions." The goals were not measurable or individualized, progress toward goals was unable to be objectively measured. Interventions listed in nursing progress notes include "Active listening; De-escalation; Emotional support; Encourage expression; Encourage verbalization." Interventions were not individualized.

Per medical record review, Patient #4 was admitted to the facility on 2/13/2019 for self-harm behaviors and violent outbursts. Patient #4's nursing plan, initiated on 2/13/2019, included "Problem: Discharge Planning. Goal: Knowledge of discharge instructions." On 2/16/2019, 3 days after admission, a problem for "Risk of self-harm" with a goal of "absence of self-harm" was initiated. Interventions listed in nursing progress notes include "Active listening; Direct Observation; Emotional support; Encourage expression; Encourage verbalization." Interventions were not individualized to help Patient #4 progress toward goals. During an interview on 2/18/2019 at 3:35 PM, Director B stated "I would consider self-harm to be the primary problem." Per B, problems "should be initiated within the first 24 hours of admission."

Per medical record review, Patient #5 was admitted to the facility on 12/7/2018 with depression and suicidal ideation. Patient #5's nursing plan included the following problems and goals: "Problem: Coping - Ineffective, Individual. Goal: Effective coping; Problem: Discharge Planning. Goal: Knowledge of discharge instructions." The goals were not measurable or individualized, progress toward goals was unable to be objectively measured. Interventions listed in nursing progress notes include "Active listening; Direct observation; Emotional support; Encourage expression; Encourage verbalization." Interventions were not individualized to help Patient #5 progress toward goals.

During an interview on 2/18/2019 at 2:00 PM, Manager A stated progress toward goals is documented in the progress notes. When asked how progress toward a goal of "effective coping" is objectively measured, Manager A did not respond.

Based on record review and interview, facility staff failed to document and reconcile home medications upon admission for 1 of 5 patients reviewed (Patient #1). Failure to reconcile home medications has potentially contributed to delayed treatment of Patient #1's depression.

Findings include:

Review of facility policy "Medication Reconciliation" revealed "A. Sources of the patient's medications prior to arrival include patient/caregiver's verbal report, patient/caregiver-owned medication lists, pill bottles, clinic or facility medication list, pharmacy prescription refill information, and discharge medication list from a recent hospitalization. B. The medication list obtained for the patient will be entered in the EMR [electronic medical record] by the pharmacist, certified pharmacy technician, or RN. ...D. The provider will utilize the completed list of medications the patient is taking prior to admission to order correct hospital admission medication orders. Reasons for purposeful discrepancies (i.e., for clinical reasons) should be documented."

Per medical record review, Patient #1 was admitted to the facility on 12/22/2018 with a diagnosis of "adjustment disorder with mixed disturbances of emotion and conduct." Per the initial nursing screening "Prior to Admission Medications," Patient #1 had escitalopram (antidepressant medication) 10 mg tablet and guanfacine (attention deficit and hyperactivity disorder medication) 2 mg tablet documented as reviewed on 12/22/2018 at 4:52 AM. Per the initial psychiatric evaluation on 12/22/2018 at 4:39 PM, Patient #1 "was placed on guaifenesin [cough medicine]" during a previous psychiatric hospitalization. There was no review of home medications as part of the psychiatric evaluation. Review of the psychiatrist plan for hospitalization revealed "At this time, the patient does not need medications. We will observe [#1's] behavior to see if [#1] remains safe." There was no documentation that Patient #1's home medication list was reviewed by the admitting physician or documentation to support the decision to hold or discontinue Patient #1's home medication at the time of admission.

Review of nursing progress notes on 12/23/2018 at 11:10 AM revealed "Later in the day almost hyper active, fast paced speech patterns, placing self on floor and rolling around, rather dramatic and attention seeking at these times." Review of nursing progress notes on 12/23/2018 at 4:06 PM revealed "rates depression 10/10." The physician progress note dated 12/23/2018 at 8:44 PM revealed "The patient will be restarted on guanfacine at 2 mg at bedtime."

Review of physician progress notes on 12/24/2018 at 12:48 PM revealed "I asked [Patient #1] if [#1] would like to try Wellbutrin [antidepressant] to further improve [#1's] attention deficit activity disorder. ...does not want to start another drug." Nursing notes on 12/24/2018 at 9:00 PM revealed Patient #1 "states that [#1] is depressed and rates depression a 6/10." Physician progress notes on 12/25/2018 at 1:36 PM revealed "...currently on Zyprexa [antipsychotic medication]." Review of Patient #1's medication administration record revealed Zyprexa was ordered on 12/22/2018 at 4:25 AM every 4 hours as needed, but there was no documentation that Patient #1 had received the medication at any time during Patient #1 hospitalization. Nursing progress notes on 12/25/2018 at 4:41 PM revealed "Admits to feeling depressed... Stated 'I don't care about anything.'" Case management notes on 12/26/2018 at 11:19 AM revealed "Complains of depression." Nursing notes on 12/26/2018 at 6:54 PM revealed "Rates depression 7/10."

Review of physician progress notes on 12/27/2018 at 4:03 PM revealed "[Patient #1's parent] was contacted... reports that the patient did well on the Lexapro [escitalopram]. ...said [Patient #1] was depressed and the Lexapro seemed to take [#1] out of [#1's] depression. I agreed to restart Lexapro for depression." Review of Patient #1's medication administration record revealed escitalopram 10 mg was ordered on 12/27/2018 and administered on 12/27/2018 at 5:27 PM. Escitalopram 20 mg was ordered and administered daily on 12/28/2018, 12/29/2018 and 12/30/2018.

There was no documentation in the medical record that Psychiatrist C purposefully held Lexipro upon admission or considered it as part of Patient #1 treatment plan prior to the telephone conversation with Patient #1's parent on 12/27/2018. During an interview on 2/19/2019 at 8:45 AM, Psychiatrist C stated Patient #1 was admitted with suicidal ideation "after starting Lexipro [escitalopram]... there's a black box warning for patients under 24 years old so I stopped the medication, and [Patient #1] didn't have any signs of depression so I thought [#1] was better off without it." When asked why C wanted to start Patient #1 on Wellbutrin on 12/24/2018 if Patient #1 was not exhibiting signs of depression, C stated "that works by a different mechanism [than Lexipro]." Regarding the admission medication process, Psychiatrist C stated "the nurses get [home medications], the meds are in the computer. If [patients] come in on meds, I tweak them and prescribe them as an outpatient at discharge." Regarding the lack of documentation of home medications upon admission, Psychiatrist C stated "I was well aware" that Patient #1 was on escitalopram at admission. When asked if decisions to stop medications are discussed with parents, C stated "no, that is a flaw."