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Based on interview and record review the facility failed to ensure the right to receive care in a safe setting for six (#2, #8, #9, #11, #12, #13) of 13 patients reviewed resulting in the potential for less than optimal outcomes. See specific tag:

A 0144: Based on interview and record review the facility failed to ensure that one (#8) patient was protected from intimidation and misappropriation of belongings, and five (#2, #9, #11, #12, #13) patients out of a total sample of 13 were protected from physical assault from a physically aggressive patient (#1), resulting in patients feeling unsafe, and in lacerations and bruising.

Based on interview and record review the facility failed to ensure that one (#8) patient was protected from misappropriation of belongings and intimidation, and that five (#2, #9, #11, #12, #13) patients out of a total sample of 13 reviewed for safety were protected from physical assault from a physically aggressive patient (#1), resulting in feeling unsafe, lacerations and bruising affecting six patients with the potential to effect all patients in the adolescent unit during Patient #1's admission. Findings include:

On 10/27/20 at approximately 0950 Charge Nurse Staff C was overheard telling the Admission Intake Department that Patient #1 was not a good fit for readmission to the facility because he was one of the most difficult and aggressive patients they had ever had, and the facility had a difficult time keeping staff and other patients safe from him. Staff C was interviewed at that time and said
that Patient #1 "stole from patients" and, "threats were constant".

On 10/27/20 at 1330 Patient #1's clinical record and Adverse Event Reports were reviewed with Staff B. The following was revealed:

Patient #1 was a 16 year old male who was admitted to the facility on 9/17/20 at 1515 by ambulance from an Emergency Department after he physically assaulted his brother, threw a brick through his mother's window and allegedly threatened to cut his throat with a glass shard. Admission diagnoses included Obesity and Major Depressive Disorder - Single Episode Unspecified Type.

A Psychiatrist Admission History and Physical exam (H&P) dated 9/18/20 at 0820 noted that Patient #1 was 5 foot 10 inches tall and weighed 200.6 pounds (lb). Patient #1 reported that he was sexually abused by his godfather when he was eight years old and had assaultive behaviors ever since that time. The H&P noted that Patient #1 had been in multiple juvenile detention centers. The Psychiatrist documented in the 9/18/20 H&P that Patient #1 was a homicide risk due to unpredictable behaviors and ordered routine every 15 minute (q15) monitoring for Patient #1 and a blocked (private) room, but no other safety interventions to protect others.

An Integrated Assessment for Patient #1 dated 9/17/20 at 1630 documented that Patient #1 had a history of assaulting family members and staff at detention facilities, was currently facing legal charges for assault, and was currently on probation for assault. The Integrated Assessment noted that Patient #1 's Assault Risk was "high risk".

A Social Work Note for Patient #1 dated 9/21/20 at 1214 documented that Patient #1 had a history of multiple admissions to juvenile detention facilities and was very violent towards his family. The Social Worker noted that Patient #1's mother did not want him to return home as, "she feels unsafe."

On 10/27/20 at approximately 1400 Patient #1's Social Worker Staff I and the Adolescent Unit Social Work Lead Staff J were interviewed during review of Patient #1's Social Work Notes and Interdisciplinary Team (IDT) Care Plan. Staff I and Staff J said that the IDT team's focused on discharge planning and a Child Protective Services (CPS) follow-up for Patient #1 as the Psychiatrist felt that Patient #1 was not benefiting from treatment and his mother was refusing to take him home. Review of Patient #1's face sheet at this time revealed Patient #1 remained in the facility for five weeks (9/17/20 - 10/22/20).

Review of Patient #1's Physician's orders, Interdisciplinary Team (IDT) Care Plan, and Nursing Daily Assessment Flowsheets revealed Patient #1 was placed in a blocked (private) room since the first day of admission and that his level of supervision throughout his admission remained routine q 15 (every 15 minutes) monitoring. No enhanced supervision was documented despite five documented physical assaults on other patients, one episode of bullying, two near misses for physical assaults on staff and one restraint/seclusion notation on 10/22/20 which documented that Patient #1 attacked staff and was not redirectable (there was no Adverse Event Report for this incident). The debriefing for Patient #1's restraint episode on 10/22/20 dated 10/22/20 at 1600 noted that Staff attempted to deescalate Patient #1 without success and noted, "Patient has repeatedly been physically aggressive towards staff, and staff's attempts to be therapeutic were unsuccessful."

Psychiatry Progress Notes and Daily Nursing Assessment Flow Sheets from 9/17/20 through 10/22/20 consistently documented that Patient #1 was agitated, angry, unpredictable, with poor impulse control, at risk for injury to others, and a "homicidal risk".

A Psychiatry Progress Note dated 9/30/20 at 0807 noted, "continues to display potentially dangerous behavior. He is easily escalated." A Psychiatry Progress Noted dated 10/1/20 at 0800 documented, "has been displaying threatening behavior in the unit. Staff reports that he is very difficult to redirect. Admits to wanting to hurt people." A Psychiatry Progress Note dated 10/4/20 at 1213 noted, "becomes rude, threatening and combative when redirected." A Psychiatry Progress Note dated 10/12/20 at 0900 noted, "continues to display dangerous behaviors in the unit. Behavior is difficult to redirect at times and PRN (as needed) medications have been used fairly regularly along with his scheduled medications." A Psychiatry Progress Note dated 10/18/20 at 1010 noted, "his behavior is escalating. Staff reports PRN medications are often used and he is difficult to redirect when he becomes aggressive. He admits to increased anger outbursts which lead to physical aggression." There were no physician's orders for enhanced supervision for Patient #1 or any additional safety interventions to protect other patients.

On 10/27/20 at approximately 1500 seven Adverse Event Reports (I&A) for Patient #1, an Office of Recipient Rights complaint/grievance investigation, and additional Nursing Notes documented physical assaults on others by Patient #1 during his (five weeks) admission and were reviewed as follows:

1. An I&A dated 9/17/20 at 2100 (six hours after admission) documented that Patient #1, "attacked another Patient" in the gym. The I&A documented that Patient #1 punched Patient #12 in the face. There was no root cause analysis (RCA) of the event. The only corrective measures documented were to put Patient #1 in a blocked room and give him a PRN (as needed) dose of 50 milligrams (mg) of Thorazine (an antipsychotic medication with strong sedative properties). Patient #12 's clinical record was reviewed at this time and revealed that Patient #12 was a 17 year old male who was admitted into the facility on 9/12/20 and discharged on 9/19/20. Diagnoses included Major Depression, Generalized Anxiety and Suicidal Ideation. A Nursing Note for Patient #12 dated 9/17/20 at 2100 noted, "patient was attacked by another patient in the gym. Patient was pounded in the face leaving a small laceration over the right eyebrow. Bleeding was stopped with first aide. Guardian was notified and was upset. Guardian expressed interest in signing an intent to terminate treatment." A Medical Doctor Consultation report dated 9/17/20 at 1159 documented, "laceration to right eyebrow - altercation."

2. A Nursing Note dated 9/23/20 at 1500 noted, "he is also threatening to hurt a peer over a folder." There was no Adverse Event Report documented for this, and no notation on the Patient's care plan, and no additional supervision or safety measures implemented for Patient #1.

3. An I&A dated 9/24/20 at 1545 documented that Patient #1 had a physical confrontation with Patient #9. The I&A documented that Patient #1 grabbed Patient #9 by the hair and slapped him several times and then punched him in the eye. A Nursing Note for Patient #1 dated 9/24/20 at 1820 noted, "had an argument with a peer around 1545. Patient punched peer in back of head and was given PRN medicine per order and attacked peer again 10 minutes later. Patient given another PRN per order." There was no documentation in the I&A about the second attack on Patient #9 and there was no root cause analysis (RCA) of the incident. Patient #1's level of supervision remained at q 15 minute checks. There was no update to Patient #1's care plan after the incident. The only corrective measure documented was Patient #9 was moved to a different hallway on the adolescent unit. Review of Patient #9's clinical record at that time revealed that he was a 16 year old male who was admitted from 8/18/19 to 9/24/20 for diagnoses of Major Depression and Suicidal Ideation. Patient #9's Care Plan noted that he was at risk for physical victimization.

4. Nursing Note dated 9/25/20 at 1500 noted, "intimidating peers. Threatening."

5. A Nursing Note dated 9/27/20 at 1500 noted, "Patient tried fighting with peer twice today." There was no notation of this on Patient #1's Care Plan and no I&A for this event. Supervision and/or safety measures were not increased.

6. A Nursing Note dated 9/27/20 at 1630 noted, "Patient became agitated with peer for second time this afternoon following previous incident. Patient was allowed back in the dayroom but once again began threatening and posturing peer and staff. PRN given." There was no I&A for this and no notation of this on the patient's care plan.

7. An Office of Recipient Rights (ORR) grievance/complaint by Patient #8 dated 9/27/20 that Patient #1 misappropriated some of his clothing and then damaged the items when Nursing Staff asked him to return them. A Nursing Note for Patient #8 dated 9/27/20 at 1630 documented, "Patient was separated from peer this afternoon after peer became focused on him. Peer (#1) stated that he believed patient (#8) had stolen his clothing and began threatening him and posturing towards him. Staff spoke with patient (#8) following incident at which time the patient stated that he did not feel safe being around peer (#1) going forward." There was no I&A for this, and no updated interventions or supervision noted on Patient #1's Care Plan after this incident. Patient #8's clinical record was reviewed at this time and revealed that Patient #8 was a 17 year old male who was admitted into the facility from 9/23/20 to 9/28/20 for diagnoses which included Major Depressive disorder - Recurrent/Severe, and Anxiety Disorder.

8. An I&A dated 10/5/20 at 1630 noted that Patient #1 was "out of control" and was aggressively threatening staff. The Patient was given a PRN. There were no added safety interventions or supervision noted after this and no update to the patient Care Plan. There was no RCA for this event.

9. An I&A dated 10/11/20 at 2040 documented that Patient #1 attacked Patient #13. The I&A noted, " Patient (#)1 was observed punched (Patient #13) in the head and face area three times. Patient was agitated and not responding to staff's attempt at redirection to stop aggressing other patients as well. Patient remained agitated after event PRN given." Review of Patient #13's clinical record revealed he was a 17 year old male who was admitted from 10/7/20 to 10/13/20 for a diagnosis of Major Depressive Disorder - Recurrent/Severe, and Suicidal Ideation. A Care Plan noted that he was at risk of victimization due to a history of childhood sexual and physical abuse. A Medical doctor consultation dated 10/12/20 at 1210 noted, "punched in the head. Upper lip cut." There were no additional safety interventions or enhanced supervision for Patient #1 after this incident and no update to his Care Plan. There was no RCA for this event.

10. An I&A dated 10/17/20 at 1100 documented that Patient #1 "attacked" Patient #11. The I&A documented, "Patient observed extremely agitated following phone call with mother. Patient began aggressively posturing towards staff and peers. Patient focused on peer whom he believed was smiling at him. Patient charged at peer and punched peer in right side of face." Patient #1 was given PRN Thorazine. Review of Patient #11's clinical record revealed Patient #11 was a 17 year old male who was admitted from 10/9/20 to 10/20/20 for diagnoses of Depression and Suicidal Ideation. Patient #11's Care Plan noted that he was at risk for victimization. A Nursing Note for Patient #11 dated 10/17/20 at 1210 noted, "hit in the face by peer. Not provoked." There were no added safety interventions or supervision noted after this and no update to Patient #1's Care Plan. There was no RCA for this event.

11. An I&A dated 10/21/20 at 1330 documented that Patient #1 "attacked" Patient #2. The I&A noted, "peer was grabbed by neck and slammed to the ground. A Nursing Note for Patient #1 dated 10/21/at 1700 describing the event added additional details, "Patient (#1) was pacing around unit and became agitated by another patient (#2) for no apparent reason observed sitting by himself engaged in conversation with others. Patient #1 walked by Patient #2 saying negative remarks, "shut up you little white boy." Patient #2 responded with, "you can't make me." Staff called for assistance and moved towards patients because Patient #1 lunged towards Patient #2, put hands around his neck lifted him from his seat and slammed him into cubes." A Medical Physician consultation dated 10/21/20 (time not legible) noted, " altercation with peer. Held up by neck. Erythemia both sides of neck. Subjective complaints." Review of Patient #2's clinical record revealed he was a 12 year old male who was admitted on 10/12/20 for Suicidal Ideation, Homicidal Ideation and Auditory and Visual Hallucinations. His medical admission assessment noted that he was small for his age at 4 foot 10 inches tall weighing 77 pounds. His Care Plan noted that he was at risk for victimization due to a history of physical abuse by a stepfather that resulted in termination of parental rights. There were no added safety interventions, enhanced supervision, or updates to Patient #1's Care Plan after this event.. There was no RCA for this event.

12. An I&A dated 10/22/20 at 1520 documented that Patient #1 was, "out of control" and attempted to attack staff and was put in a physical hold, put into seclusion and given a PRN.

On 10/28 at 1200 Patient #1's psychiatrist Staff Q was interviewed by phone. Staff Q said that he felt that Patient #1's threats and aggressive behaviors were, "deliberate", and "manipulative", and said that there was no way to treat "deliberate behaviors" therapeutically. Staff Q said that he would have written an order for enhanced supervision of Patient #1 if staff had asked him, but no one did. Staff Q said that he contacted the police regarding Patient #1 but they refused to get involved because Patient #1 was in a mental health facility.

On 10/28/20 at approximately 1330 the Assistant Director of Nursing Staff B was interviewed. Staff B said that communication needed to be improved between the Interdisciplinary Team (IDT) and the Psychiatrist. Staff B said that ideally the IDT Care Plan should be updated after each adverse event documenting physical assault or aggression and this was not done. Staff B stated that usually a violent and physically aggressive patient received enhanced supervision and noted that this was not done for Patient #1. Staff B was unable to explain why Patient #1's supervision was not enhanced or why individualized interventions that worked to calm Patient #1 down were not added to the IDT Care Plan so that all facility staff had access to them. Staff B said that every time she rounded on the Adolescent unit she saw staff watching Patient #1 so she assumed that he was on an enhanced supervision program and did not realize that it was not ordered or implemented.

The facility policy entitled, "Assault Precautions and Use of Code DR. White", revised 3/2012 was reviewed and revealed the following statements:

"Purpose: to provide a plan for monitoring potentially aggressive/violent patients via Assault Precautions (AP) ...and to minimize disruption of the therapeutic milieu as well as ensure the safety of all patients and staff",

"Early identification: Risk for assault is assessed of all patients upon intake and admission. Any "yes" response could indicate a risk for assault and the patient may require heightened precautions:
1. Is there a prior history of assault? ... such as in the home, workplace, or Emergency Room?
2. Is the patient verbalizing the desire or intent to assault?
3. Is the patient agitated?
4. Has the patient demonstrated aggression or violence upon admission?
Reassessment during hospitalization should occur if specific behaviors are noted."

"Patients who are considered at risk for acting out with aggression or violence may be placed on Assault Precautions (AP) by order of the physician. The physician will also indicate the level of monitoring required: 15 minute checks, Line of Sight, or Arms' Length."