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Based on record review and interview, the facility failed to timely notify the legal guardian of significant change in patient condition in 1 of 10 records (Patient #14) reviewed, in a total sample of 27 patients. This deficiency potentially affects all in-patients at this facility.

Findings include:

In interview with Patient #14's legal guardian (N) on 5/13/14 at 8:55 AM, N stated that the hospital failed to inform N about Patient #14's "attempt to kill self " while in hospital. N stated that N "did not know about it until the next day", which meant that N could give not give input or approval of care that followed change of condition.

The 5/14/14 at 11 AM record review of Patient #14's (age 14), "all flowsheet data (3/15/14-3/20/14 2359)" documents at 10:41 PM on 3/18/14 that "patient drank 2 bottles of soap and 1 bottle of mouthwash" in suicide attempt. The 3/18/14 at 10:59 PM " Plan of Care-encounter notes" documents that Patient #14 scratched self on arm (location not documented) in a self-mutilation attempt.

Continued review of this medical record, at date and time above, documents no evidence that contact with legal guardians (parents) was made to tell them of patient's significant change in condition until the next day (3/19/14) at 1:35 PM. At that time, Psychiatrist J called family to "discuss ongoing treatment...need to start Lithium (anti-psychotic medication)".

In interview with Unit manager C on 5/15/14 at 4:30 PM, C stated that no documentation of timely notification could be found.

Based on record review and interview, the facility failed to ensure patients with suicide ingestion ideation were protected from ingesting liquids not meant for drinking, in 1 of 3 records reviewed (Patient #14), in a total sample of 10 patients. This had the potential to affect all patients with suicide ingestion ideation at this facility.

Findings include:

Medical record review of Patient #14 on 5/14/14 at 10:30 AM shows the following:
Patient #14 was admitted on 3/16/14 at 12:04 AM with severe Major Depression with Psychosis, due to suicide attempt with self-inflicted poisoning by drug or medicinal substance. On admission, patient was determined to have poor insight and judgment, with Patient #14's parents stating that patient is impulsive with behaviors of self harm, per "mental status evaluation" by RN M at 12:15 AM on 3/16/14.

Per The "Plan of Care-Encounter Notes" on 3/18/2014 at 9:25 PM, Patient #14 "drank 2 bottles of soap and 1 bottle of mouthwash in room" before coming to nurses station to report ingestion.

Review of the "BH (Behavioral Health) Team Treatment Plan-encounter notes, Multidisciplinary Problems (active)" documents no evidence that this patient had care planned interventions for removal of substances from room that could be ingested for the benefit of self harm, before the 3/18/2014 incident.

In interview with unit manager C on 5/13/2014 at approximately 2 PM, C states that patients on the children and adolescent unit receive 2 ounce plastic bottles of non-toxic soap and mouthwash. C states that the quantity of these substances are not monitored in patient rooms. C, on 5/15/14 at 4:30 PM, stated that the patient's care plan did not have interventions for removal of substances that could be ingested.

Based on record review and interview, the facility failed to conduct and document a thorough investigation of patient allegations of caregiver abuse, in 2 of 7 total patient complaints/grievances reviewed (Patient's # 2 and #8). This has the potential to affect all patients receiving care at this facility.

Findings include:

1) The 5/14/14 at 10: 30 AM review of hospital complaint/ grievance file for the past 12 month period documents that Patient #2's parent filed a complaint with the hospital on 4/20/14, alleging "staff told patient that if patient returned to the hospital, (staff) was going to punch (patient #2) in the nose". The complaint response information shows no documentation of an investigation into the allegations of threats of physical abuse made against Patient #2. There was no interview with patient/patient's parent to determine circumstances/ details of when/ where/ how or why alleged threat was made. There was no interview with the staff member alleged to make the threat of physical violence to identify the details of patient contact.

In interview with Unit manager C on 5/14/14 at 10:36 AM, C stated that Behavioral Therapist G was identified, and did "work with Patient #2 on the date of the allegation (4/16/14)". C stated that there was no documentation of interview with parent /Patient #2, or the identified staff G. C stated that a thorough investigation was not done nor documented to rule out caregiver abuse. (Reference Z 0053)

2) Patient #7 was interviewed by phone on 5/21/14 at 11 AM, and stated that on or around 5/5/14, Patient #7 was "humiliated and embarrassed" when Unit Manager D addressed patient in "loud and angry voice" in a group therapy sessions revealing private medical information. Patient #7 stated that Staff Therapist E stated "you better get your shit together", and when that was reported to Unit manager D, D raised her voice and scolded Patient #7, stating " I heard you have a problem with the staff". Patient # 7 stated that nothing was ever done to address staff behavior when the hospital staff was told.

Interview with Unit manager D on 5/21/14 at 2:25 PM, D stated that she "might remember a conversation with Patient #7 about what Therapist E said", stated "I know it was not meant in a derogatory manner". D stated that no interview with E had been conducted or documented about the allegation to determine in what context the statement was made. Unit Manager D denied allegations of talking to patient in a "loud/ rude manner" or revealing private medical information in front of a group therapy session with other patients on the in-patient unit. D stated that no investigation was done or documented to rule out caregiver abuse.

In interview with Risk Manager B on 5/21/14 at 3:30 PM, B stated that a voice message was left on the hospital's patient complaint phone line stating that patient "had a complaint". B stated that B and Psychologist F called parent multiple times, without reaching parent or patient to identify the issues, but was unaware that Unit Manager D knew of the allegations. Risk manager B and Psychologist F stated they did not interview Unit manager D to determine if complaints had been voiced on the care unit.

Based on record review and interview, the facility failed to ensure that patient care plans were individualized with measurable goals in order to evaluate reductions in unwanted/harmful behaviors, in 4 of 10 careplans reviewed (Patient #'s 12, 13, 14 and 15), and has the potential to affect all in-patiients at this facility.

Findings include:

1) Patient #14- The 5/14/2014 at 10:50 AM review documents the following:
The "BH team treatment plan- encounter notes" documented by RN M on 3/16/2014 at 12:57 AM, and cosigned by Psychiatrist J on 3/16/2014 at 10:14 AM documents "Problem: Danger to self/other/property". The care plan has 4 goals:
1) Demonstrates decreased or appropriate substitute for self injurious behavior
2) Demonstrates behavior control
3) Denies intent to self harm to harm self/others
4) Maintain personal safety.
Review of this documentation shows that goals are not measurable nor individualized to this patient.

In interview with Unit Managers A and C, and Psychologist F on 5/15/14 at approx. 4PM, they were asked to identify at discharge whether the care planned behaviors were reduced, and if so by how much. They stated that with care plans written like this, they could not tell. Unit manager A stated that the care planned "goals could give more information about what is meant by behavioral control and personal safety".

2) Patient #13- The 5/15/2014 at 1 PM review documents the following: The "BH team treatment plan- encounter notes" documented by RN S on 3/14/2014 at 5:41 PM, and cosigned by Psychiatrist J on 3/15/2014 at 9:32 AM documents:
"Problem: danger to self/other/property, with the following "goals": able to care for self, demonstrates decreased or appropriate substitute for self injurious behavior, demonstrates behavioral control, denies intent to harm self/others, improve mental status, maintain personal safety, stabilization of mood." Review of this documentation shows that goals are not measurable nor individualized to this patient.
3) Patient #12- The 5/15/2014 at 1 PM review documents the following: The "BH team treatment plan- encounter notes" documented by RN L on 3/7/2014 at 6:13 PM, and cosigned by Psychiatrist T on 3/8/2014 at 12:16 PM documents:
"Problem: danger to self/others/property", with "goals" of: able to care for self, demonstrates decreased or appropriate substitute for self injurious behavior, demonstrates behavior control, denies intent to harm self/others, improve mental status, maintain personal safety". Review of this documentation shows that goals are not measurable nor individualized to this patient.
4) Patient #15- The 5/15/2014 at 1 PM review documents the following: The "BH team treatment plan- encounter notes" documented by RN U on 3/15/2014 at 2:48 PM, and cosigned by Psychiatrist V on 3/17/2014 at 9:06 AM documents:
"Problem: danger to self/other/property" with "goals" of: able to care for self, demonstrates appropriate reality testing, demonstrates behavioral control, denies intent to harm self/others, improve mental status, maintain personal safety, stabilization of mood". Review of this documentation shows that goals are not measurable nor individualized to this patient.
In interview with Unit Managers A and C, and Psychologist F on 5/15/14 at approx. 5PM, they stated that they were aware that all care planned goal were not measurable nor individulaized.

Based on record review and interview, the facility failed to maintain original/legally reproduced copies of the "safety/prevention plan" developed for the management of negative behaviors during admission and post-discharge, in 5 of 10 records reviewed (Patient #'s 12, 13, 14, 15 and 16), and has the potential to affect all facility in-patients.

Findings include:

Record review on 5/15/14 at 1:30 through 3:30 PM shows the following:

Review of Patient #'s 12, 13, 14, 15 and 16's care plans in the "BH (Behavioral Health) Team Treatment Plan-Encounter Notes-Multidisciplinary Problems (active)" indicated under "Interventions: Assist Patient in developing a Safety Plan".

In interview with Unit Manager C on 5/15/14 at 3 PM, C states that each patient is discharged with a "safety plan" that is developed by patients and their assigned behavioral staff while their here (in hospital)". C states that this is used as part of the behavioral plan of care while in the hospital, and is used by the patient and patient's family to assist in managing adverse behaviors after discharge as part of discharge planning. When asked to view these safety plans for Patient #'s 12, 13, 14, 15 and 16, C stated that the safety plan is not part of the permanent medical record, and is given to the patient/patient legal guardian upon discharge. C states the hospital does not keep the original nor copies of this document.

Review of a blank form titled "MY safety/prevention plan"show that patients and staff fill in the following information:
1) "My signs and symptoms of ___"
2) "Identify possible triggers that increase your symptoms___"
3) Identify and be aware of early warning signs (physical and emotional changes)___"
4) "Name coping skills for each early sign___"
5) "Review coping skills and tell parents, therapist, and psychiatrist___"
6) "Identify and be aware of late warning signs -Ask for help/ Use safety plan!!!"
7) "Name coping skills for each late warning sign"
8) Call parents, therapist, doctor, crisis line, hospital, and increase therapy sessions.
8) Write down one positive coping statement, and post it and view it daily!!"
9) Safety plan: if you are having thoughts, which create painful feelings or urges to hurt yourself in any way, you will tell the following people. (name and number should be listed for family, school, therapist, doctor, responsible friend, crisis line 911 / 211"
10) Use a daily scaling question to improve family communication about (depression, suicidal thoughts, urges to hurt self, anger, anxiety, cravings)
Example 0= not depressed, 1=depressed, 2= more depression without suicidal thoughts, 3=increased depression with few suicidal thoughts,
4=increased depression and frequent suicidal thoughts without a plan to hurt self, 5=overwhelming depression and suicidal thoughts with a plan to hurt self".

This safety plan has individualized care planned behavioral interventions that are used to direct and manage care for Patient #'s 12, 13, 14, 15, 16 which were used by the hospital staff and the patient. This document was not kept as part of these patient's permanent medical records, even though it is given to patients upon discharge to assist in guiding their behavioral self-care as part of the discharge education and planning process.

Based on record review and interview, the facility failed to develop an ongoing audit system to review discharge plans in closed medical records to determine if patient needs were met, in 1 of 2 interviews (Staff O) regarding the discharge planning quality improvement process. This potentially affects all hospital in-patients.

Findings include:

Review of hospital policy "Discharge Planning #2052", it states under "4.4.16. The hospital QAPI (Quality Assessment Performance Improvement) program tracks re-admissions to their hospitals, at least quarterly. Once the QAPI program has identified potentially preventable readmissions, it is expected to reassess its discharge planning process. Discharge planning processes may be revised to address particular problems that are identified. Reassessment includes: ...b. A review of discharge plans in closed medical records to determine whether they were responsive to the patient's post hospital needs...".

In interview on 5/12/14 at 1:45 PM, with UR (Utilitization Review)/ Director of Business Operations O, O stated that in April of 2014, the hospital developed a utilization management plan to look at the high rate of hospital re-admissions, and was in the process of collecting data for analysis of potential causation. O stated that this was the only UR/ QAPI project the hospital was working on at present that dealt with patient discharge information.

In interview with Risk manager B on 5/12/14 at 2:15 PM, B stated that no system of patient record audits had been used by the hospital to ensure compliance with discharge planning regulations under 42 CFR 482, or to ensure that patient needs were met per hospital policy.