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Based upon review of 1 of 8 medical records, Healthcare Peer Review Reports, policies and procedures, and staff interviews, the hospital failed to ensure each patient received care in a safe setting as evidenced by failure to implement physical safety measures for patients in the Adolescent Youth Enhanced Unit when verbal threats of physical violence were made by patient #1 against another peer during the 7:00 a.m. to 3:00 p.m. shift on 7/10/13. During the 3:00 p.m. to 11:00 p.m. shift on 7/10/13, patient #1 carried out the physical violence threat and attacked another female peer. Findings:

Review of the Healthcare Peer Review Reports revealed on 7/10/13, patient #1 attacked another female peer on the Adolescent Youth Enhanced Unit. Interview with S3 Risk Manager on 8/2/13, 9:10 a.m. confirmed atient #1 and a female peer attacked another patient on 7/10/13.

1) Review of patient #1's medical record revealed according to the Nursing Progress Reports, on 7/10/13 during the 7:00 a.m. to 3:00 p.m. shift, the Registered Nurse (RN) documented the following "Angry, easily agitated, threatening to punch peer. Stated 'she gonna get hit. I'm about to punch her, she called me a hoe'. Required frequent redirection...Continue to monitor." Documentation by the RN for the 3:00 p.m. to 11:00 p.m. shift revealed "(Patient #1) anxious, agitated affect, loud, disruptive, impulsive, intrusive, disrespectful to staff and peers, needing constant redirection. (Patient #1) called a female peer into her room and attacked her, punching her in the head. Staff broke up and put patient in the time out for the night." Even though the staff documented patient #1 was making threats towards a peer which were carried out later in the day, there failed to be documented evidence the nursing staff implemented safety measures to ensure the threats of physical violence were not carried out.

Based upon review of 1 of 8 medical records (#1), observations, and staff interviews, the Registered Nurse failed to ensure each patient was supervised as evidenced by failing to supervise patient #1 in the cafeteria during lunch on 7/4/13 to ensure this adolescent patient did not received contraband (cigarettes) from an adult psychiatric patient. Findings:

Review of the Healthcare Peer Review Reports revealed on 7/4/13, patient #1 received two cigarettes from an adult psychiatric patient in the cafeteria during the lunch hour.

Review of the Nursing Progress Notes dated 7/4/13, completed by the Registered Nurse revealed "1:00 p.m. Peer came to nurse's station and said (patient #1) had gotten cigarettes from an adult male patient in cafeteria and that she and (patient #1) hid them in the bathroom on the unit. After searching (patient #1) person no cigarettes were found, but after search, (patient #1) went to bathroom and brought two Kool cigarettes to nurse's station and said 'here'. (Patient #1) states she and female peer asked adult male patient for cigarettes in the cafeteria and the adult male patient then dropped them on the floor but (patient #1) and female peer were called back to table before they could pick up cigarettes. States upon getting to table male peer asked what they were doing and was told 'getting cigarettes from that dude. He dropped them but we didn't get to pick them up'. States male peer then got up from table, walked over to cigarettes and picked them up and then brought them back to the table and she and female peer put them under their shirts and brought them back to the unit. States 'I gave her mine then she went and hid them in the bathroom'".

Observations of the cafeteria on 8/1/13, 11:30 a.m. revealed the adolescent patients were in the cafeteria eating lunch. The female patients were at tables on one side of the cafeteria with an RN and an MHT (Mental Health Technician) and the males were located at tables on the other side of the cafeteria with two staff members present. No adult patients were observed in the cafeteria.

Interview with S4 RN during the observations on 8/1/13 revealed when asked why the MHT had left the dining room for the dietary line, S4 RN replied the patients could no longer go to the food line and pick up their deserts, instead the MHT would go to the serving line and retrieve the patients deserts.

Based upon review of 1 of 8 medical records and staff interviews, the hospital failed to ensure patient #1's Treatment Plan Updates described specific treatment interventions and approaches related to verbal and physical aggression towards a female peer on the Adolescent Youth Enhanced Unit on 7/10/13. Findings:

Review of patient #1's medical record revealed according to the Nursing Progress Reports, on 7/10/13 during the 7:00 a.m. to 3:00 p.m. shift, the Registered Nurse (RN) documented the following "Angry, easily agitated, threatening to punch peer. Stated 'she gonna get hit. I'm about to punch her, she called me a hoe'. Required frequent redirection...Continue to monitor." Documentation by the RN for the 3:00 p.m. to 11:00 p.m. shift revealed "(Patient #1) anxious, agitated affect, loud, disruptive, impulsive, intrusive, disrespectful to staff and peers, needing constant redirection. (Patient #1) called a female peer into her room and attacked her, punching her in the head. Staff broke up and put patient in the time out for the night." Even though the staff documented patient #1 was making threats towards a peer which were carried out later in the day, there failed to be documented evidence the nursing staff implemented safety measures to ensure the threats of physical violence were not carried out.

Review of patient #1's Treatment Plan implemented on 6/3/13 revealed for the problem with aggressive behaviors, the staff was to provide one-on-one and group therapy. The interventions identified included "Staff will assist patient to identify triggers to aggressive behavior" and "Staff will assist patient in developing coping skills to manage aggressive behaviors". Review of the Treatment Plan Update dated 6/27/13 revealed the patients progress toward the goals were listed as "hyper-verbal, hyper-active, manipulative, name calling, hated by peers, messy, no insight, disruptive, and intrusive" The revised intervention was "go 3 days without being placed on Unit Restriction". Review of the Treatment Plan Update for 7/25/13 revealed the revised interventions were "go 7 days without fighting or threatening to harm self/others and she can shave again". Review of the Treatment Plan Update for 8/1/13 revealed the revised interventions were documented as "go 2 days without conflict with peers and staff and (patient #1) can have an outside meal or snack". The revised interventions identified on the Treatment Plan Updates failed to specifically describe treatment approaches the nursing staff were to implement for the identified verbal and aggressive behaviors.