HospitalInspections.org

The facility failed to protect and promote each patient's rights, as evidence by:

1. Based on a review of documentation, tour, and interviews, the facility failed to ensure the patients' right to receive care in a safe setting, as evidence by failing to adequately monitor patients, prevent abuse/neglect of patients, and not assessing patients with documented injuries and/or abuse allegations. Cross refer to A0144 Patient Rights.

2. Based on a review of documentation, tour, and interviews, the facility failed to ensure the patients' the right to be free from all forms of abuse or harassment, as evidence by failing to adequately monitor patients, prevent abuse/neglect of patients, and not assessing patients with documented injuries and/or abuse allegations. Cross refer to A0145 Patient Rights: Free From Abuse/Harassment.

Based on a review of documentation, tour, and interviews, the facility failed to ensure the patients' right to receive care in a safe setting, as evidence by failing to adequately monitor patients, prevent abuse/neglect of patients, and not assessing patients with documented injuries and/or abuse allegations.

Finding included:

Facility policy HR - 245 titled "Patient Abuse and Neglect" states, in part:

"Policy:
It is the policy of Acadia that no patient is to be mistreated or abused physically, verbally, psychologically or sexually while in our care. Patient neglect is also prohibited. Any employee who is found guilty of mistreating, abusing or neglecting a patient will be subject to disciplinary action up to and including termination. Acadia maintains a Zero Tolerance policy for patient abuse and or neglect.

Procedure:
Patient abuse is strictly prohibited and will not be tolerated. Examples of patient abuse include but are not limited to: striking a patient; using excessive force in restraining a patient; rough handling of the patient; teasing, taunting or ridiculing a patient; speaking inappropriately with a patient and threatening a patient.

Neglect would be failing to provide for the patient's basic emotional or physical needs or failing in any way that would endanger the patient's emotional or physical well-being. Failing to be fully engaged in promoting patient treatment plans would also be considered to be neglect.

All instances of witnessed or alleged patient abuse or neglect must be immediately reported to the Risk Manager, a department head or supervisor. Failure to report witnessed patient abuse may result in disciplinary action up to and including termination.


Upon investigation and after an assessment of the findings, a final determination should be made by the facility CEO or senior management. Findings of patient abuse will be considered a violation of the standards of conduct and subject to immediate termination. Upon the discretion of the facility and in accordance with applicable state or Federal requirements, such violations may be reported to the employee's state licensing agency and/or law enforcement agencies."

Facility based policy 900.2.3 titled, "Observation/Precaution Levels" stated in part,
"All patients are admitted, at a minimum, on Q.15 minute checks observation level.

Patients admitted or later placed on a higher observation level, i.e. Q.15 minute checks, Line-of-Sight (LOS) or 1 1 will be re-assessed by the physician/NP on a daily basis for appropriateness of observation level, and a Doctor's order to either continue or decrease in observation level will be entered in the patient's medical record.

OBSERVATION LEVELS ...
Q.15 minute checks

The unit staff observes the patient a minimum of every 15 minutes and documents the observation in the Patient Observation Monitoring Form ...

1:1
One (1) unit staff will provide constant visual observation and remain within arms-length of the patient. This continuous direct visual observation will continue even when patients shower, change clothes or use the bathroom. If/when the patient is asleep, the staff observes patient from a reasonable distance in order to closely observe patient and quickly intervene as necessary.

Staff will attempt to maintain the patient's privacy as much as possible. However, the safety of the patient must be the main consideration. The unit staff documents the observation every 15 minutes in the Patient Observation Monitoring Form."

Facility based policy 1000.23 titled, "Abuse Assessment and Reporting" stated in part,
"3. Any staff member who receives information on suspected or alleged abuse and/or neglect of a patient will complete an incident report and will report to RN, primary Clinical Services staff /physician."

Facility based policy "900.5" titled "Reassessment of Patient" stated in part,
"1. The patient is reassessed, at a minimum, at the end of each shift and the beginning of the next shift.

2 The Registered Nurse reassesses at a minimum in the following circumstances
2.1 Change in patient condition,
2.2 Physical complaint, ..."

Facility based policy 900.2.3 titled "Scope of Assessment by Discipline" stated in part,
"III CONTINUAL REASSESSMENT
A. It is the policy of Cedar Crest Hospital and RTC that each patient will be continually reassessed ...
3. Whenever a significant change occurs in the patient's condition ..."

Review of the medical record for Patient #1 revealed the following:
On 03/16/18 the following documentation was present:
* On the "Precaution/Observation Checklist" staff member #1 initialed/documented observation of this patient from 1530 through 1600.
* A staff note written at the bottom of the checklist stated "Pt [patient] became dysregulated several times throughout the shift. The pt was placed in the QR [quiet room] for overturning the entire hygiene cart. The pt regained her self control(sic) and was fine until a staff gave her directions; at which point she dumped a cup of orange juice in the hallway. There was a struggle between the pt and a staff when she was told to go to bed. The pt is currently in bed asleep Pt ate 75% of dinner and attended group."
* There was no documented nursing assessment of this patient for injuries on 03/16/18.

An incident report was filed on 03/16/18 regarding Patient #1 stating "Pt [patient] was in the hallway. Pt had dumped her orange juice on the floor after staff member #1 had given the pt redirection. Staff told the pt she could follow her to get towels. The pt said she would feel better if she cleaned it up herself. As the pt was attempting to return to the spill c[with] a towel, staff member #1 started threatening the pt. The pt became upset and started cursing and told the staff 'your(sic) to(sic) scared to do anything'. Staff member #1 left her 1:1 and chased the pt a few feet. She grabbed the pt's arm and spanked the patient. Staff step(sic) in redirected the staff member. The pt screamed curse words at the staff and staff member #1 shoved her 1:1 folder at the staff and said 'take my 1:1'. Staff member #1 was jerking the child/pt by her arm's(sic) as the pt screamed in pain, staff member #1 dragged the pt up the hall telling the pt she was going to the quiet room and getting shots. This staff went to the nurse. Pt has scratches and bruises on both L [left] and R [right] upper arms." The report contained no documentation that a nursing assessment of the patient and her alleged injuries had been performed.

Review of the medical record for Patient #2 revealed the following:
Physician orders included:
03/16/18 at 0820 "Continue 1:1"
03/16/18 at 1100 "[change symbol] 1:1 while awake"
03/17/18 at 0830 "Cont 1:1"
03/18/18 "Cont 1:1"

On 03/16/18 the following documentation was present:
* The Precaution/Observation Checklist" stated "See blue note". Staff member #1 initialed/documented observation of this patient from 1515 through 2230.
* A Multidisciplinary Progress Note by staff member #1 from "7p-8p" stated on part, "Pt talked with peer saying when she was on another unit a staff slapped her."
* A Multidisciplinary Progress Note by staff member #1 from "8p-9p" stated "Pt in activity room eating popcorn and watching TV with peers. Pt returned to pt room and showed staff she scratched her left wrist with a tiny piece of glass. Pt gave staff the glass. Staff took pt to RN. Wrist was cleaned up. Pt returned to her room."
* There was no nursing documentation of the abuse allegation/outcry made by the patient to the MHT.
* There was no nursing documentation of self-injurious behavior by the patient, injury, assessment or treatment of any injury.
* An incident report was completed regarding the patient scratching her wrist.
* There was no incident report or report to DFPS was made regarding the allegation a staff member on another unit slapped the patient.

On 03/17/18 the following documentation was present.
* The Precaution/Observation Checklist" stated "Pt went to the bathroom at 1720 after 2 minutes, I knocked at the door and she said yes I am here. After another 2 minutes I knocked and opened the door. She was at the sink, she got mad saying I am not supposed to open the door. I told her I have to do that due to her doctor's order stating one on one ...". The monitoring was complete for this date.
* A Multidisciplinary Progress Note by the MHT at 933 PM stated in part, "Pt went to the bathroom and was standing door way [sic] of bathroom. Pt scratched arm acting as if it was itching and pt pulled sleeve back down as pt finished going to bathroom ... Pt then stated I did something wrong. Staff asked pt what. Pt stated I cut myself and lifted up left forearm sleeve. Staff asked pt what pt cut with. Pt pulled a piece of glass from mouth. Staff asked pt where pt got the glass from. Pt stated from mirror earlier in the day. First aid was completed ...Will RN was notified also. Will cont to monitor."

On 03/19/18 the following documentation was present.
* The Precaution/Observation Checklist" stated "See blue note". The monitoring was not completed on the form for this date from 1645 until 2245.
* A nursing note at 1814 stated, "Staff saw patient with a piece of her underwear on her neck, wanted to kill self...."
* A nursing note at 1845 stated in part, "Pt agitated and angry at staff after she attempted to hang self and is being closely monitored. At the nurse's station ...Cont 1:1 observation status ..."

Review of the Precaution/Observation Checklist for Patient #19 on 03/16/18 who was on q 15 minute checks revealed the following:
* Monitoring of this patient was not documented from 1300 through 1500.
* Staff member #1 initialed/documented monitoring this patient from 1515 through 1600.
* According to the assignment sheet and observation documentation staff member #1 was assigned to monitor a 1:1 patient (Patient #2) at that time.

A tour of the unit was conducted on the evening of 03/26/18 at approximately 7pm. The unit walls contained multiple holes, fist-sized and larger. Insulation was visible and accessible in several of the holes. Gum was stuck to the floor in several places and the unit walls were visibly soiled. Formica edging was missing from the nursing station countertop, creating a sharp surface.

Staff member # 2 was assigned the male children and they stated to the surveyor they were in charge of 8 children. When asked where all the children were located, staff member #2 was explaining that some children were in the activity room and some were in the courtyard. The surveyor asked staff member #2 if it was difficult to watch 8 children at one time and make sure everyone was safe. Before staff member #2 could answer, a patient (later identified as Patient #21) ran up to the surveyor and stated "some of the big kids try to help her, too".

Several children were playing basketball in an enclosed courtyard, the door to which (from the activity room) was propped open by a table measuring approximately 3 ' x3 '. A child sat at the table, coloring. Upon examination, one edge of the table held a sharp, thick piece of dark-brown plastic, half of which was peeling back from the table edge. The table was accessible to all children in the courtyard and the activity room and presented a safety hazard.

Summary of Findings:
On 03/16/18, according to the assignment sheet and observation documentation staff member #1 was assigned to monitor a 1:1 patient (Patient #2). This staff member initialed/documented observation of the 1:1 (Patient #2) from 1515 through 2230. This staff member also initialed/documented monitoring Patient #1 from 1530 through 1600 and patient #19 (on q 15 minute checks) from 1300 through 1500. Staff member #1 should have only monitored patient #2 per physician 1:1 order. Staff member would not have been able to monitor two other patients (#1 and 19) simultaneously while assigned a 1:1 patient. This indicates that Patient # 2 who was on 1:1 observation was not adequately monitored from 1515 through 1600, increasing the potential risk of this patient engaging in self-injurious behavior.

On 03/16/18 according to facility based incident report and investigation at 2045 staff member #1 stated the following occurred with Patient #1.
Per staff member #1 interview "That patient (#1) broke my glasses the other day ...did you hear about that?' When Staff member #1 was asked about their interactions with Patient #1 after Patient #1 had poured orange juice on the floor, Staff member #1 replied, 'I told her to go ahead and hit me ...you will get the punishment for hitting.' When staff member #5 asked them what that punishment is, they replied, 'The quiet room or her room.' Staff member #1 also told the patient 'If you keep hitting me, I'll tell the nurse that you need shots.' When staff member #1 was asked if there was any physical contact with the patient they replied 'I just stood there and held her wrist ...I got a hold of her wrist.' Then she states she 'chased her to her room.'

During an interview with Patient #1 on 03/26/17, they showed the surveyors several small bruises (approximately the same size as fingerprints) under their left arm near the arm pit area. And small bruises on their right upper arm. The patient was asked what are those are and replied, "me". Patient #1 was asked if their arm was grabbed and they replied, "yeah". Patient #1 was asked by who and responded "staff". They were asked, do you know their name and replied, "I don't want to say it." Then she added a "a lady".

The above interactions meet the facility definition of abuse of a patient (verbal and physical). Patient #1 was not protected from abuse by staff member #1 while at the facility. Staff member #1 continued to work at the facility with children and adolescents after a brief one-day suspension during the investigation, placing this population at risk of further abuse.

At the time of above incident, staff member #1 was assigned to and documented monitoring Patient #2 on 1:1 status. The fact this patient was engaged in the above incident with Patient #1 indicated that the 1:1 Patient (#2) was not adequately monitored at that time. Subsequent documentation indicated that the 1:1 Patient (#2) engaged in self injurious behavior between 8 and 9 PM (when the incident with Patient #1 also occurred) a note by staff member #1 stated ". Pt returned to pt room and showed staff she scratched her left wrist with a tiny piece of glass. Pt gave staff the glass. Staff took pt to RN. Wrist was cleaned up. Pt returned to her room." With appropriate 1:1 monitoring, Patient #2 might have been prevented from or verbally re-directed from injuring themselves. The lack of appropriate monitoring/observation may have contributed to this patient being able to engage in self harm/injury. This meets the facility based definition of neglect due to Patient #2 not being appropriately monitored and sustaining an injury. Staff member #1 continued to work at the facility with children and adolescents after a brief one-day suspension during the investigation, placing this population at risk of further neglect.

Two patients were not appropriately monitored per facility based policy.
* On 03/16/18 Patient #19's (on q 15 minute checks) Precaution/Observation Checklist did not have documented monitoring from 1300 through 1500.
* On 03/17/18 Patient #2 (on 1:1 observation) was not continuously monitored in the bathroom per facility policy, later that day the patient was able to scratch their arm with a piece of glass obtained from a mirror "earlier in the day" this may have occurred when staff was maintaining visualization of the patient while in the bathroom.
*On 03/19/18 Patient #2's (1:1 observation) Precaution/Observation Checklist did not have documented monitoring from 1645 until 2245. On that date this patient attempted to strangle themselves at 1814, "Staff saw patient with a piece of her underwear on her neck, wanted to kill self...." This patient was potentially neglected due to being able to attempt self-harm and documentation did not reflect appropriate monitoring per policy.

Patient #2 alleged abused on 03/16/18, The MHT documented, "Pt talked with peer saying when she was on another unit a staff slapped her." There was no nursing follow up or documentation of the abuse allegation/outcry made by the patient to the MHT. There was no incident report or report to DFPS, per policy, made regarding the allegation a staff member on another unit slapped the patient. Patient #2 also sustained an injury on 03/16/18, a "scratched her left wrist", the MHT documented taking the patient to the nurse. There was no nursing documentation of this self-injurious behavior by the patient, injury, assessment or treatment of any injury.

The above findings indicate the facility failed to ensure patient rights to care in a safe setting. The vulnerable patient population of children and adolescents were at risk of abuse and neglect due to improper monitoring and the continued employment of a staff member who engaged in abusive action (verbal and physical) and neglect of patients while working. The nursing staff also failed to properly assess patients for alleged abuse, reported injuries, or follow up on allegations of abuse. The above findings were confirmed in an interview with staff members #4., 5, and 6 on 03/26/18.

Based on a review of documentation, tour, and interviews, the facility failed to ensure the patients' the right to be free from all forms of abuse or harassment, as evidence by failing to adequately monitor patients, prevent abuse/neglect of patients, and not assessing patients with documented injuries and/or abuse allegations.

Findings included:

Facility policy HR - 245 titled "Patient Abuse and Neglect" states, in part:

"Policy:
It is the policy of Acadia that no patient is to be mistreated or abused physically, verbally, psychologically or sexually while in our care. Patient neglect is also prohibited. Any employee who is found guilty of mistreating, abusing or neglecting a patient will be subject to disciplinary action up to and including termination. Acadia maintains a Zero Tolerance policy for patient abuse and or neglect.

Procedure:
Patient abuse is strictly prohibited and will not be tolerated. Examples of patient abuse include but are not limited to: striking a patient; using excessive force in restraining a patient; rough handling of the patient; teasing, taunting or ridiculing a patient; speaking inappropriately with a patient and threatening a patient.

Neglect would be failing to provide for the patient's basic emotional or physical needs or failing in any way that would endanger the patient's emotional or physical well-being. Failing to be fully engaged in promoting patient treatment plans would also be considered to be neglect.

All instances of witnessed or alleged patient abuse or neglect must be immediately reported to the Risk Manager, a department head or supervisor. Failure to report witnessed patient abuse may result in disciplinary action up to and including termination.


Upon investigation and after an assessment of the findings, a final determination should be made by the facility CEO or senior management. Findings of patient abuse will be considered a violation of the standards of conduct and subject to immediate termination. Upon the discretion of the facility and in accordance with applicable state or Federal requirements, such violations may be reported to the employee's state licensing agency and/or law enforcement agencies."

Facility based policy 900.2.3 titled, "Observation/Precaution Levels" stated in part,
"All patients are admitted, at a minimum, on Q.15 minute checks observation level.

Patients admitted or later placed on a higher observation level, i.e. Q.15 minute checks, Line-of-Sight (LOS) or 1 1 will be re-assessed by the physician/NP on a daily basis for appropriateness of observation level, and a Doctor's order to either continue or decrease in observation level will be entered in the patient's medical record.

OBSERVATION LEVELS ...
Q.15 minute checks

The unit staff observes the patient a minimum of every 15 minutes and documents the observation in the Patient Observation Monitoring Form ...

1:1
One (1) unit staff will provide constant visual observation and remain within arms-length of the patient. This continuous direct visual observation will continue even when patients shower, change clothes or use the bathroom. If/when the patient is asleep, the staff observes patient from a reasonable distance in order to closely observe patient and quickly intervene as necessary.

Staff will attempt to maintain the patient's privacy as much as possible. However, the safety of the patient must be the main consideration. The unit staff documents the observation every 15 minutes in the Patient Observation Monitoring Form."

Facility based policy 1000.23 titled, "Abuse Assessment and Reporting" stated in part,
"3. Any staff member who receives information on suspected or alleged abuse and/or neglect of a patient will complete an incident report and will report to RN, primary Clinical Services staff /physician."

Facility based policy "900.5" titled "Reassessment of Patient" stated in part,
"1. The patient is reassessed, at a minimum, at the end of each shift and the beginning of the next shift.

2 The Registered Nurse reassesses at a minimum in the following circumstances
2.1 Change in patient condition,
2.2 Physical complaint, ..."

Facility based policy 900.2.3 titled "Scope of Assessment by Discipline" stated in part,
"III CONTINUAL REASSESSMENT
A. It is the policy of Cedar Crest Hospital and RTC that each patient will be continually reassessed ...
3. Whenever a significant change occurs in the patient's condition ..."

Review of the medical record for Patient #1 revealed the following:
On 03/16/18 the following documentation was present:
* On the "Precaution/Observation Checklist" staff member #1 initialed/documented observation of this patient from 1530 through 1600.
* A staff note written at the bottom of the checklist stated "Pt [patient] became dysregulated several times throughout the shift. The pt was placed in the QR [quiet room] for overturning the entire hygiene cart. The pt regained her self control(sic) and was fine until a staff gave her directions; at which point she dumped a cup of orange juice in the hallway. There was a struggle between the pt and a staff when she was told to go to bed. The pt is currently in bed asleep Pt ate 75% of dinner and attended group."
* There was no documented nursing assessment of this patient for injuries on 03/16/18.

An incident report was filed on 03/16/18 regarding Patient #1 stating "Pt [patient] was in the hallway. Pt had dumped her orange juice on the floor after staff member #1 had given the pt redirection. Staff told the pt she could follow her to get towels. The pt said she would feel better if she cleaned it up herself. As the pt was attempting to return to the spill c[with] a towel, staff member #1 started threatening the pt. The pt became upset and started cursing and told the staff 'your(sic) to(sic) scared to do anything'. Staff member #1 left her 1:1 and chased the pt a few feet. She grabbed the pt's arm and spanked the patient. Staff step(sic) in redirected the staff member. The pt screamed curse words at the staff and staff member #1 shoved her 1:1 folder at the staff and said 'take my 1:1'. Staff member #1 was jerking the child/pt by her arm's(sic) as the pt screamed in pain, staff member #1 dragged the pt up the hall telling the pt she was going to the quiet room and getting shots. This staff went to the nurse. Pt has scratches and bruises on both L [left] and R [right] upper arms." The report contained no documentation that a nursing assessment of the patient and her alleged injuries had been performed.

Review of the medical record for Patient #2 revealed the following:
Physician orders included:
03/16/18 at 0820 "Continue 1:1"
03/16/18 at 1100 "[change symbol] 1:1 while awake"
03/17/18 at 0830 "Cont 1:1"
03/18/18 "Cont 1:1"

On 03/16/18 the following documentation was present:
* The Precaution/Observation Checklist" stated "See blue note". Staff member #1 initialed/documented observation of this patient from 1515 through 2230.
* A Multidisciplinary Progress Note by staff member #1 from "7p-8p" stated on part, "Pt talked with peer saying when she was on another unit a staff slapped her."
* A Multidisciplinary Progress Note by staff member #1 from "8p-9p" stated "Pt in activity room eating popcorn and watching TV with peers. Pt returned to pt room and showed staff she scratched her left wrist with a tiny piece of glass. Pt gave staff the glass. Staff took pt to RN. Wrist was cleaned up. Pt returned to her room."
* There was no nursing documentation of the abuse allegation/outcry made by the patient to the MHT.
* There was no nursing documentation of self-injurious behavior by the patient, injury, assessment or treatment of any injury.
* An incident report was completed regarding the patient scratching her wrist.
* There was no incident report or report to DFPS was made regarding the allegation a staff member on another unit slapped the patient.

On 03/17/18 the following documentation was present.
* The Precaution/Observation Checklist" stated "Pt went to the bathroom at 1720 after 2 mins, I knocked at the door and she said yes I am here. After another 2 mins I knocked and opened the door. She was at the sink, she got mad saying I am not supposed to open the door. I told her I have to do that due to her doctor's order stating one on one ...". The monitoring was complete for this date.
* A Multidisciplinary Progress Note by the MHT at 933 PM stated in part, "Pt went to the bathroom and was standing door way [sic] of bathroom. Pt scratched arm acting as if it was itching and pt pulled sleeve back down as pt finished going to bathroom ... Pt then stated I did something wrong. Staff asked pt what. Pt stated I cut myself and lifted up left forearm sleeve. Staff asked pt what pt cut with. Pt pulled a piece of glass from mouth. Staff asked pt where pt got the glass from. Pt stated from mirror earlier in the day. First aid was completed ...Will RN was notified also. Will cont to monitor."

On 03/19/18 the following documentation was present.
* The Precaution/Observation Checklist" stated "See blue note". The monitoring was not completed on the form for this date from 1645 until 2245.
* A nursing note at 1814 stated, "Staff saw patient with a piece of her underwear on her neck, wanted to kill self...."
* A nursing note at 1845 stated in part, "Pt agitated and angry at staff after she attempted to hang self and is being closely monitored. At the nurse's station ...Cont 1:1 observation status ..."

Review of the Precaution/Observation Checklist for Patient #19 on 03/16/18 who was on q 15 minute checks revealed the following:
* Monitoring of this patient was not documented from 1300 through 1500.
* Staff member #1 initialed/documented monitoring this patient from 1515 through 1600.
* According to the assignment sheet and observation documentation staff member #1 was assigned to monitor a 1:1 patient (Patient #2) at that time.

A tour of the unit was conducted on the evening of 03/26/18 at approximately 7pm. The unit walls contained multiple holes, fist-sized and larger. Insulation was visible and accessible in several of the holes. Gum was stuck to the floor in several places and the unit walls were visibly soiled. Formica edging was missing from the nursing station countertop, creating a sharp surface.

Staff member # 2 was assigned the male children and they stated to the surveyor they were in charge of 8 children. When asked where all the children were located, staff member #2 was explaining that some children were in the activity room and some were in the courtyard. The surveyor asked staff member #2 if it was difficult to watch 8 children at one time and make sure everyone was safe. Before staff member #2 could answer, a patient (later identified as Patient #21) ran up to the surveyor and stated "some of the big kids try to help her, too".

Several children were playing basketball in an enclosed courtyard, the door to which (from the activity room) was propped open by a table measuring approximately 3 ' x3 ' . A child sat at the table, coloring. Upon examination, one edge of the table held a sharp, thick piece of dark-brown plastic, half of which was peeling back from the table edge. The table was accessible to all children in the courtyard and the activity room and presented a safety hazard.

Summary of Findings:
On 03/16/18, according to the assignment sheet and observation documentation staff member #1 was assigned to monitor a 1:1 patient (Patient #2). This staff member initialed/documented observation of the 1:1 (Patient #2) from 1515 through 2230. This staff member also initialed/documented monitoring Patient #1 from 1530 through 1600 and patient #19 (on q 15 minute checks) from 1300 through 1500. Staff member #1 should have only monitored patient #2 per physician 1:1 order. Staff member would not have been able to monitor two other patients (#1 and 19) simultaneously while assigned a 1:1 patient. This indicates that Patient # 2 who was on 1:1 observation was not adequately monitored from 1515 through 1600, increasing the potential risk of this patient engaging in self-injurious behavior.

On 03/16/18 according to facility based incident report and investigation at 2045 staff member #1 stated the following occurred with Patient #1.
Per staff member #1 interview "That patient (#1) broke my glasses the other day ...did you hear about that?' When Staff member #1 was asked about their interactions with Patient #1 after Patient #1 had poured orange juice on the floor, Staff member #1 replied, 'I told her to go ahead and hit me ...you will get the punishment for hitting.' When staff member #5 asked them what that punishment is, they replied, 'The quiet room or her room.' Staff member #1 also told the patient 'If you keep hitting me, I'll tell the nurse that you need shots.' When staff member #1 was asked if there was any physical contact with the patient they replied 'I just stood there and held her wrist ...I got a hold of her wrist.' Then she states she 'chased her to her room.'

During an interview with Patient #1 on 03/26/17, they showed the surveyors several small bruises (approximately the same size as fingerprints) under their left arm near the arm pit area. And small bruises on their right upper arm. The patient was asked what are those are and replied, "me". Patient #1 was asked if their arm was grabbed and they replied, "yeah". Patient #1 was asked by who and responded "staff". They were asked, do you know their name and replied, "I don't want to say it." Then she added a "a lady".

The above interactions meet the facility definition of abuse of a patient (verbal and physical). Patient #1 was not protected from abuse by staff member #1 while at the facility. Staff member #1 continued to work at the facility with children and adolescents after a brief one-day suspension during the investigation, placing this population at risk of further abuse.

At the time of above incident, staff member #1 was assigned to and documented monitoring Patient #2 on 1:1 status. The fact this patient was engaged in the above incident with Patient #1 indicated that the 1:1 Patient (#2) was not adequately monitored at that time. Subsequent documentation indicated that the 1:1 Patient (#2) engaged in self injurious behavior between 8 and 9 PM (when the incident with Patient #1 also occurred) a note by staff member #1 stated ". Pt returned to pt room and showed staff she scratched her left wrist with a tiny piece of glass. Pt gave staff the glass. Staff took pt to RN. Wrist was cleaned up. Pt returned to her room." With appropriate 1:1 monitoring, Patient #2 might have been prevented from or verbally re-directed from injuring themselves. The lack of appropriate monitoring/observation may have contributed to this patient being able to engage in self harm/injury. This meets the facility based definition of neglect due to Patient #2 not being appropriately monitored and sustaining an injury. Staff member #1 continued to work at the facility with children and adolescents after a brief one-day suspension during the investigation, placing this population at risk of further neglect.

Two patients were not appropriately monitored per facility based policy.
* On 03/16/18 Patient #19's (on q 15 minute checks) Precaution/Observation Checklist did not have documented monitoring from 1300 through 1500.
* On 03/17/18 Patient #2 (on 1:1 observation) was not continuously monitored in the bathroom per facility policy, later that day the patient was able to scratch their arm with a piece of glass obtained from a mirror "earlier in the day" this may have occurred when staff was maintaining visualization of the patient while in the bathroom.
*On 03/19/18 Patient #2's (1:1 observation) Precaution/Observation Checklist did not have documented monitoring from 1645 until 2245. On that date this patient attempted to strangle themselves at 1814, "Staff saw patient with a piece of her underwear on her neck, wanted to kill self...." This patient was potentially neglected due to being able to attempt self-harm and documentation did not reflect appropriate monitoring per policy.

Patient #2 alleged abused on 03/16/18, The MHT documented, "Pt talked with peer saying when she was on another unit a staff slapped her." There was no nursing follow up or documentation of the abuse allegation/outcry made by the patient to the MHT. There was no incident report or report to DFPS, per policy, made regarding the allegation a staff member on another unit slapped the patient. Patient #2 also sustained an injury on 03/16/18, a "scratched her left wrist", the MHT documented taking the patient to the nurse. There was no nursing documentation of this self-injurious behavior by the patient, injury, assessment or treatment of any injury.

The above findings indicate the facility failed to ensure the patients' the right to be free from all forms of abuse or harassment. The vulnerable patient population of children and adolescents were at risk of abuse and neglect due to improper monitoring and the continued employment of a staff member who engaged in abusive action (verbal and physical) and neglect of patients while working. The nursing staff also failed to properly assess patients for alleged abuse, reported injuries, or follow up on allegations of abuse. The above findings were confirmed in an interview with staff members #4., 5, and 6 on 03/26/18.

The facility failed to ensure that the hospital had an organized nursing service that provided 24-hour nursing services as evidence by:

1. Based on review of documentation and interview the facility failed to ensure that a registered nurse must supervise and evaluate the nursing care for each patient, as evidence by the nursing staff failed to properly assess patients for alleged abuse, reported injuries, or follow up on allegations of abuse. Cross refer to A0395 RN Supervision of Nursing.

2. The facility registered nurse failed to assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. This was evident by assigning patient monitoring to staff that were already monitoring patient's on 1:1 status, failing to ensure staff assigned to monitor staff could adequately monitor them to prevent injury or harm to patients, and failing to ensure that monitoring was maintained an documented on all patient's including 1:1 and q 15 minute checks. Cross refer to 0397 Patient Care Assignments.

Based on review of documentation and interview the facility failed to ensure that a registered nurse must supervise and evaluate the nursing care for each patient, as evidence by the nursing staff failed to properly assess patients for alleged abuse, reported injuries, or follow up on allegations of abuse.

Findings included:

Facility policy HR - 245 titled "Patient Abuse and Neglect" states, in part:

"Policy:
It is the policy of Acadia that no patient is to be mistreated or abused physically, verbally, psychologically or sexually while in our care. Patient neglect is also prohibited. Any employee who is found guilty of mistreating, abusing or neglecting a patient will be subject to disciplinary action up to and including termination. Acadia maintains a Zero Tolerance policy for patient abuse and or neglect.

Procedure:
Patient abuse is strictly prohibited and will not be tolerated. Examples of patient abuse include but are not limited to: striking a patient; using excessive force in restraining a patient; rough handling of the patient; teasing, taunting or ridiculing a patient; speaking inappropriately with a patient and threatening a patient.

Neglect would be failing to provide for the patient's basic emotional or physical needs or failing in any way that would endanger the patient's emotional or physical well-being. Failing to be fully engaged in promoting patient treatment plans would also be considered to be neglect.

All instances of witnessed or alleged patient abuse or neglect must be immediately reported to the Risk Manager, a department head or supervisor. Failure to report witnessed patient abuse may result in disciplinary action up to and including termination.


Upon investigation and after an assessment of the findings, a final determination should be made by the facility CEO or senior management. Findings of patient abuse will be considered a violation of the standards of conduct and subject to immediate termination. Upon the discretion of the facility and in accordance with applicable state or Federal requirements, such violations may be reported to the employee's state licensing agency and/or law enforcement agencies."

Facility based policy 1000.23 titled, "Abuse Assessment and Reporting" stated in part,
"3. Any staff member who receives information on suspected or alleged abuse and/or neglect of a patient will complete an incident report and will report to RN, primary Clinical Services staff /physician."

Facility based policy "900.5" titled "Reassessment of Patient" stated in part,
"1. The patient is reassessed, at a minimum, at the end of each shift and the beginning of the next shift.

2 The Registered Nurse reassesses at a minimum in the following circumstances
2.1 Change in patient condition,
2.2 Physical complaint, ..."

Facility based policy 900.2.3 titled "Scope of Assessment by Discipline" stated in part,
"III CONTINUAL REASSESSMENT
A. It is the policy of Cedar Crest Hospital and RTC that each patient will be continually reassessed ...
3. Whenever a significant change occurs in the patient's condition ..."

Review of the medical record for Patient #1 revealed the following:
On 03/16/18 the following documentation was present:
* A staff note written at the bottom of the checklist stated "Pt [patient] became dysregulated several times throughout the shift. The pt was placed in the QR [quiet room] for overturning the entire hygiene cart. The pt regained her self control(sic) and was fine until a staff gave her directions; at which point she dumped a cup of orange juice in the hallway. There was a struggle between the pt and a staff when she was told to go to bed. The pt is currently in bed asleep Pt ate 75% of dinner and attended group."
* An incident report was filed on 03/16/18 regarding Patient #1 stating "Pt [patient] was in the hallway. Pt had dumped her orange juice on the floor after staff member #1 had given the pt redirection. Staff told the pt she could follow her to get towels. The pt said she would feel better if she cleaned it up herself. As the pt was attempting to return to the spill c[with] a towel, staff member #1 started threatening the pt. The pt became upset and started cursing and told the staff 'your(sic) to(sic) scared to do anything'. Staff member #1 left her 1:1 and chased the pt a few feet. She grabbed the pt's arm and spanked the patient. Staff step(sic) in redirected the staff member. The pt screamed curse words at the staff and staff member #1 shoved her 1:1 folder at the staff and said 'take my 1:1'. Staff member #1 was jerking the child/pt by her arm's(sic) as the pt screamed in pain, staff member #1 dragged the pt up the hall telling the pt she was going to the quiet room and getting shots. This staff went to the nurse. Pt has scratches and bruises on both L [left] and R [right] upper arms." The report contained no documentation that a nursing assessment of the patient and her alleged injuries had been performed.
* There was no documented nursing assessment of this patient for injuries on 03/16/18.

Review of the medical record for Patient #2 revealed the following:
On 03/16/18 the following documentation was present:
* A Multidisciplinary Progress Note by staff member #1 from "7p-8p" stated on part, "Pt talked with peer saying when she was on another unit a staff slapped her."
* A Multidisciplinary Progress Note by staff member #1 from "8p-9p" stated "Pt in activity room eating popcorn and watching TV with peers. Pt returned to pt room and showed staff she scratched her left wrist with a tiny piece of glass. Pt gave staff the glass. Staff took pt to RN. Wrist was cleaned up. Pt returned to her room."
* There was no nursing documentation of the abuse allegation/outcry made by the patient to the MHT.
* There was no nursing documentation of self-injurious behavior by the patient, injury, assessment or treatment of any injury.
* An incident report was completed regarding the patient scratching her wrist.
* There was no incident report or report to DFPS was made regarding the allegation a staff member on another unit slapped the patient.

Summary of Findings:
On 03/16/18 according to facility based incident report and investigation at 2045 staff member #1 stated the following occurred with Patient #1. Per staff member #1 interview "That patient (#1) broke my glasses the other day ...did you hear about that?' When Staff member #1 was asked about their interactions with Patient #1 after Patient #1 had poured orange juice on the floor, Staff member #1 replied, 'I told her to go ahead and hit me ...you will get the punishment for hitting.' When staff member #5 asked them what that punishment is, they replied, 'The quiet room or her room.' Staff member #1 also told the patient 'If you keep hitting me, I'll tell the nurse that you need shots.' When staff member #1 was asked if there was any physical contact with the patient they replied 'I just stood there and held her wrist ...I got a hold of her wrist.' Then she states she 'chased her to her room'."There was no documented nursing assessment of this patient for injuries on 03/16/18.

Patient #2 alleged abused on 03/16/18, The MHT documented, "Pt talked with peer saying when she was on another unit a staff slapped her." There was no nursing follow up or documentation of the abuse allegation/outcry made by the patient to the MHT. There was no incident report or report to DFPS, per policy, made regarding the allegation a staff member on another unit slapped the patient. Patient #2 also sustained an injury on 03/16/18, a "scratched her left wrist", the MHT documented taking the patient to the nurse. There was no nursing documentation of this self-injurious behavior by the patient, injury, assessment or treatment of any injury.

The above findings indicate the nursing staff failed to properly assess patients for alleged abuse, reported injuries, or follow up on allegations of abuse. The above findings were confirmed in an interview with staff members #4., 5, and 6 on 03/26/18.

Based on a review of documentation, the facility registered nurse failed to assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. This was evident by assigning patient monitoring to staff that were already monitoring patient's on 1:1 status, failing to ensure staff assigned to monitor staff could adequately monitor them to prevent injury or harm to patients, and failing to ensure that monitoring was maintained an documented on all patient's including 1:1 and q 15 minute checks.

Findings included:

Findings included:

Facility based policy 900.2.3 titled, "Observation/Precaution Levels" stated in part,
"All patients are admitted, at a minimum, on Q.15 minute checks observation level.

Patients admitted or later placed on a higher observation level, i.e. Q.15 minute checks, Line-of-Sight (LOS) or 1 1 will be re-assessed by the physician/NP on a daily basis for appropriateness of observation level, and a Doctor's order to either continue or decrease in observation level will be entered in the patient's medical record.

OBSERVATION LEVELS ...
Q.15 minute checks

The unit staff observes the patient a minimum of every 15 minutes and documents the observation in the Patient Observation Monitoring Form ...

1:1
One (1) unit staff will provide constant visual observation and remain within arms-length of the patient. This continuous direct visual observation will continue even when patients shower, change clothes or use the bathroom. If/when the patient is asleep, the staff observes patient from a reasonable distance in order to closely observe patient and quickly intervene as necessary.

Staff will attempt to maintain the patient's privacy as much as possible. However, the safety of the patient must be the main consideration. The unit staff documents the observation every 15 minutes in the Patient Observation Monitoring Form."

Review of the medical record for Patient #1 revealed the following:
On 03/16/17 the following documentation was present:
* On the "Precaution/Observation Checklist" staff member #1 initialed/documented observation of this patient from 1530 through 1600.

Review of the medical record for Patient #2 revealed the following:
On 03/16/17 the following documentation was present:
* The Precaution/Observation Checklist" stated "See blue note". Staff member #1 initialed/documented observation of this patient from 1515 through 2230.
* A Multidisciplinary Progress Note by staff member #1 from "7p-8p" stated on part, "Pt talked with peer saying when she was on another unit a staff slapped her."
* A Multidisciplinary Progress Note by staff member #1 from "8p-9p" stated "Pt in activity room eating popcorn and watching TV with peers. Pt returned to pt room and showed staff she scratched her left wrist with a tiny piece of glass. Pt gave staff the glass. Staff took pt to RN. Wrist was cleaned up. Pt returned to her room."
* There was no nursing documentation of the abuse allegation/outcry made by the patient to the MHT.
* There was no nursing documentation of self-injurious behavior by the patient, injury, assessment or treatment of any injury.
* An incident report was completed regarding the patient scratching her wrist.
* There was no incident report or report to DFPS was made regarding the allegation a staff member on another unit slapped the patient.

On 03/17/17 the following documentation was present.
* The Precaution/Observation Checklist" stated "Pt went to the bathroom at 1720 after 2 mins, I knocked at the door and she said yes I am here. After another 2 mins I knocked and opened the door. She was at the sink, she got mad saying I am not supposed to open the door. I told her I have to do that due to her doctor's order stating one on one ...". The monitoring was complete for this date.
* A Multidisciplinary Progress Note by the MHT at 933 PM stated in part, "Pt went to the bathroom and was standing door way [sic] of bathroom. Pt scratched arm acting as if it was itching and pt pulled sleeve back down as pt finished going to bathroom ... Pt then stated I did something wrong. Staff asked pt what. Pt stated I cut myself and lifted up left forearm sleeve. Staff asked pt what pt cut with. Pt pulled a piece of glass from mouth. Staff asked pt where pt got the glass from. Pt stated from mirror earlier in the day. First aid was completed ...Will RN was notified also. Will cont to monitor."

On 03/19/17 the following documentation was present.
* The Precaution/Observation Checklist" stated "See blue note". The monitoring was not completed on the form for this date from 1645 until 2245.
* A nursing note at 1814 stated, "Staff saw patient with a piece of her underwear on her neck, wanted to kill self...."
* A nursing note at 1845 stated in part, "Pt agitated and angry at staff after she attempted to hang self and is being closely monitored. At the nurse's station ...Cont 1:1 observation status ..."

Review of the Precaution/Observation Checklist for Patient #19 on 03/16/18 who was on q 15 minute checks revealed the following:
* Monitoring of this patient was not documented from 1300 through 1500.
* Staff member #1 initialed/documented monitoring this patient from 1515 through 1600.
* According to the assignment sheet and observation documentation staff member #1 was assigned to monitor a 1:1 patient (Patient #2) at that time.

Summary of Findings:
On 03/16/18, according to the assignment sheet and observation documentation staff member #1 was assigned to monitor a 1:1 patient (Patient #2). This staff member initialed/documented observation of the 1:1 (Patient #2) from 1515 through 2230. This staff member also initialed/documented monitoring Patient #1 from 1530 through 1600 and patient #19 (on q 15 minute checks) from 1300 through 1500. Staff member #1 should have only monitored patient #2 per physician 1:1 order. Staff member would not have been able to monitor two other patients (#1 and 19) simultaneously while assigned a 1:1 patient. This indicates that Patient # 2 who was on 1:1 observation was not adequately monitored from 1515 through 1600, increasing the potential risk of this patient engaging in self-injurious behavior.

Staff member was involved in an verbal and physical incident with Patient #1 at 2045, at this time they were assigned to and documented monitoring Patient #2 on 1:1 status. The fact this patient was engaged in an incident with Patient #1 indicated that the 1:1 Patient (#2) was not adequately monitored at that time. Subsequent documentation indicated that the 1:1 Patient (#2) engaged in self injurious behavior between 8 and 9 PM (when the incident with Patient #1 also occurred) a note by staff member #1 stated ". Pt returned to pt room and showed staff she scratched her left wrist with a tiny piece of glass. Pt gave staff the glass. Staff took pt to RN. Wrist was cleaned up. Pt returned to her room." With appropriate 1:1 monitoring, Patient #2 might have been prevented from or verbally re-directed from injuring themselves. The lack of appropriate monitoring/observation may have contributed to this patient being able to engage in self harm/injury. This meets the facility based definition of neglect due to Patient #2 not being appropriately monitored and sustaining an injury.

Two patients also were not appropriately monitored per facility based policy.
* On 03/16/18 Patient #19's (on q 15 minute checks) Precaution/Observation Checklist did not have documented monitoring from 1300 through 1500.
* On 03/17/18 Patient #2 (on 1:1 observation) was not continuously monitored in the bathroom per facility policy, later that day the patient was able to scratch their arm with a piece of glass obtained from a mirror "earlier in the day" this may have occurred when staff was maintaining visualization of the patient while in the bathroom.
*On 03/19/18 Patient #2's (1:1 observation) Precaution/Observation Checklist did not have documented monitoring from 1645 until 2245. On that date this patient attempted to strangle themselves at 1814, "Staff saw patient with a piece of her underwear on her neck, wanted to kill self...." This patient was potentially neglected due to being able to attempt self-harm and documentation did not reflect appropriate monitoring per policy.

The above findings indicate the facility failed to ensure the nursing care of each patient was assigned to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. The above findings were confirmed in an interview with staff members #4., 5, and 6 on 03/26/18.

Based on a review of documentation and clinical records, the hospital failed to meet all special provisions applying to psychiatric hospitals, as evidenced by:

Non-compliance with
482.62 Special Staff Requirements for Psychiatric Hospitals

* The Nursing Director failed to direct, monitor and evaluate the nursing care furnished (cross refer to B0148).
* The facility failed to provide an adequate number of registered nurses, licensed vocational nurses and mental health workers to provide the treatment necessary under each patient's active treatment plan (cross refer to B0150).

The hospital failed to provide adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning.

* The Nursing Director failed to direct, monitor and evaluate the nursing care furnished, resulting in neglect of and injury to patients (cross refer to B0148).
* The facility failed to provide an adequate number of registered nurses, licensed vocational nurses and mental health workers to provide the treatment necessary under each patient's active treatment plan, resulting in neglect of and injury to patients (cross refer to B0150).

Based on a review of documentation, the nursing director failed to direct, monitor and evaluate the nursing care furnished.

Findings were:

Review of the medical record for patient #1 revealed that on the evening of 3-16-18, patient #1 and staff #1 were involved in an altercation, during which staff #1 grabbed the wrists/arms of patient #1. Staff #3 (a registered nurse) was notified of the altercation. Nursing assessment/notes for patient #1 on 3-16-18 contained no indication that patient #1's alleged injuries had been assessed by staff #3.

Review of the medical record for patient #2 revealed that on the evening of 3-16-18, patient #2 purposefully scratched her own wrist with a piece of glass and reported that she did so to staff #1. Staff #1 documented that patient #2 was taken to staff #3 (a registered nurse) so her injuries could be assessed. Nursing assessment notes for patient #2 on 3-16-18 contained no indication that patient #2's injuries had been assessed by staff #3.

Facility based policy "900.5" titled "Reassessment of Patient" stated in part,
"1. The patient is reassessed, at a minimum, at the end of each shift and the beginning of the next shift.

2 The Registered Nurse reassesses at a minimum in the following circumstances
2.1 Change in patient condition,
2.2 Physical complaint, ..."

Facility based policy 900.2.3 titled "Scope of Assessment by Discipline" stated in part,
"III CONTINUAL REASSESSMENT
A. It is the policy of Cedar Crest Hospital and RTC that each patient will be continually reassessed ...
3. Whenever a significant change occurs in the patient's condition ..."

The above was confirmed in an interview with the CEO and other administrative staff on the evening of 3-26-18.

Based on a review of clinical records and facility documentation, the facility failed to ensure that there was an adequate number of registered nurses, licensed practical nurses and mental health workers to provide the nursing care necessary under each patient's active treatment program.

Findings were:

Facility based policy 900.2.3 titled, "Observation/Precaution Levels" stated in part,
"All patients are admitted, at a minimum, on Q.15 minute checks observation level.

Patients admitted or later placed on a higher observation level, i.e. Q.15 minute checks, Line-of-Sight (LOS) or 1 1 will be re-assessed by the physician/NP on a daily basis for appropriateness of observation level, and a Doctor's order to either continue or decrease in observation level will be entered in the patient's medical record.

OBSERVATION LEVELS ...
Q.15 minute checks

The unit staff observes the patient a minimum of every 15 minutes and documents the observation in the Patient Observation Monitoring Form ...

1:1
One (1) unit staff will provide constant visual observation and remain within arms-length of the patient. This continuous direct visual observation will continue even when patients shower, change clothes or use the bathroom. If/when the patient is asleep, the staff observes patient from a reasonable distance in order to closely observe patient and quickly intervene as necessary.

Staff will attempt to maintain the patient's privacy as much as possible. However, the safety of the patient must be the main consideration. The unit staff documents the observation every 15 minutes in the Patient Observation Monitoring Form."

Review of the medical record for Patient #1 revealed the following:
On 03/16/17 the following documentation was present:
* On the "Precaution/Observation Checklist" staff member #1 initialed/documented observation of this patient from 1530 through 1600.

Review of the medical record for Patient #2 revealed the following:
On 03/16/17 the following documentation was present:
* The Precaution/Observation Checklist" stated "See blue note". Staff member #1 initialed/documented observation of this patient from 1515 through 2230.
* A Multidisciplinary Progress Note by staff member #1 from "8p-9p" stated "Pt in activity room eating popcorn and watching TV with peers. Pt returned to pt room and showed staff she scratched her left wrist with a tiny piece of glass. Pt gave staff the glass. Staff took pt to RN. Wrist was cleaned up. Pt returned to her room."

On 03/17/17 the following documentation was present.
* The Precaution/Observation Checklist" stated "Pt went to the bathroom at 1720 after 2 mins, I knocked at the door and she said yes I am here. After another 2 mins I knocked and opened the door. She was at the sink, she got mad saying I am not supposed to open the door. I told her I have to do that due to her doctor's order stating one on one ...". The monitoring was complete for this date.
* A Multidisciplinary Progress Note by the MHT at 933 PM stated in part, "Pt went to the bathroom and was standing door way [sic] of bathroom. Pt scratched arm acting as if it was itching and pt pulled sleeve back down as pt finished going to bathroom ... Pt then stated I did something wrong. Staff asked pt what. Pt stated I cut myself and lifted up left forearm sleeve. Staff asked pt what pt cut with. Pt pulled a piece of glass from mouth. Staff asked pt where pt got the glass from. Pt stated from mirror earlier in the day. First aid was completed ...Will RN was notified also. Will cont to monitor."

On 03/19/17 the following documentation was present.
* The Precaution/Observation Checklist" stated "See blue note". The monitoring was not completed on the form for this date from 1645 until 2245.
* A nursing note at 1814 stated, "Staff saw patient with a piece of her underwear on her neck, wanted to kill self...."
* A nursing note at 1845 stated in part, "Pt agitated and angry at staff after she attempted to hang self and is being closely monitored. At the nurse's station ...Cont 1:1 observation status ..."

Review of the Precaution/Observation Checklist for Patient #19 on 03/16/18 who was on q 15 minute checks revealed the following:
* Monitoring of this patient was not documented from 1300 through 1500.
* Staff member #1 initialed/documented monitoring this patient from 1515 through 1600.
* According to the assignment sheet and observation documentation staff member #1 was assigned to monitor a 1:1 patient (Patient #2) at that time.

Summary of Findings:
On 03/16/18, according to the assignment sheet and observation documentation staff member #1 was assigned to monitor a 1:1 patient (Patient #2). This staff member initialed/documented observation of the 1:1 (Patient #2) from 1515 through 2230. This staff member also initialed/documented monitoring Patient #1 from 1530 through 1600 and patient #19 (on q 15 minute checks) from 1300 through 1500. Staff member #1 should have only monitored patient #2 per physician 1:1 order. Staff #1 would not have been able to monitor two other patients (#1 and 19) simultaneously while assigned a 1:1 patient. This indicates that Patient # 2 who was on 1:1 observation was not adequately monitored from 1515 through 1600, increasing the potential risk of this patient engaging in self-injurious behavior.

Staff member was involved in an verbal and physical incident with Patient #1 at 2045, at this time they were assigned to and documented monitoring Patient #2 on 1:1 status. The fact this patient was engaged in an incident with Patient #1 indicated that the 1:1 Patient (#2) was not adequately monitored at that time. Subsequent documentation indicated that the 1:1 Patient (#2) engaged in self injurious behavior between 8 and 9 PM (when the incident with Patient #1 also occurred) a note by staff member #1 stated ". Pt returned to pt room and showed staff she scratched her left wrist with a tiny piece of glass. Pt gave staff the glass. Staff took pt to RN. Wrist was cleaned up. Pt returned to her room." With appropriate 1:1 monitoring, Patient #2 might have been prevented from or verbally re-directed from injuring themselves. The lack of appropriate monitoring/observation may have contributed to this patient being able to engage in self harm/injury.

Two patients also were not appropriately monitored per facility based policy.
* On 03/16/18 Patient #19's (on q 15 minute checks) Precaution/Observation Checklist did not have documented monitoring from 1300 through 1500.
* On 03/17/18 Patient #2 (on 1:1 observation) was not continuously monitored in the bathroom per facility policy, later that day the patient was able to scratch their arm with a piece of glass obtained from a mirror "earlier in the day" this may have occurred when staff was maintaining visualization of the patient while in the bathroom.
*On 03/19/18 Patient #2's (1:1 observation) Precaution/Observation Checklist did not have documented monitoring from 1645 until 2245. On that date this patient attempted to strangle themselves at 1814, "Staff saw patient with a piece of her underwear on her neck, wanted to kill self...." This patient was potentially neglected due to being able to attempt self-harm and documentation did not reflect appropriate monitoring per policy.

A tour of the child/adolescent unit was conducted on the evening of 3-26-18 at approximately 7pm. Staff #2 was assigned the male children and staff #2 stated to me that [staff #2] was in charge of 8 children. When asked where all the children were, staff #2 was explaining that some children were in the activity room and some were in the courtyard. The surveyor asked staff #2 if it was difficult to watch 8 children at one time and make sure everyone was safe. Before staff #2 could answer, patient #21 ran up to the surveyor and stated "some of the big kids try to help her, too". Although anecdotal, an unsolicited response such as this from a child could indicate that staffing on the child/adolescent unit is not an isolated occurrence.

The above findings indicate the facility failed to provide an adequate number of mental health workers to provide the nursing care necessary according to each patient's active treatment program and in accordance with physician's orders.

The above was confirmed in an interview with the CEO and other administrative staff on the evening of 3-26-18.