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Based on record review, interview, and observation, the hospital failed to ensure the patients' right to receive care in a safe setting for three of eleven patients (Patients #11, #7, #3).

1) Patient #11, an adolescent patient admitted on 01/13/20, had a history of four suicide attempts involving firearms. The patient had the intention to die and was noted on admission with poor insight and judgement. Nine days into his treatment, Patient #11 was irritable, angry, depressed, suicidal, and again evidenced poor judgement and insight. In the afternoon, at a time when the patients got delayed going to the gym activity and one mental health technician was on break, Patient #11 challenged Hospital Personnel #8 to a race competition. In disregard of current hospital policy, Hospital Personnel #8 ran alongside Patient #11 down the hall. At the end of the hallway, Patient #11 tripped, fell against the door and to the ground where his head hit the concrete. The patient bled from his mouth and nose and required emergent transport to a medical hospital. He was diagnosed with a frontal skull fracture, a broken nasal bone, and a concussion. Upon his return to the hospital, Patient #11 missed and/or was only minimally able to participate in fourteen therapeutic groups essential to the patient's treatment plan.

2) Patient #7, a six-year old patient, was allowed to run in the dayroom, hit a chair, fell and hurt his knee on 10/15/19.

3) Adolescent Patient #3 fell outside on 01/27/20. There was evidence of a nurse documented assessment of the patient's potential injuries.

4) The adolescent unit at the time of the survey was observed with a dusty floor, a pool of water in the quiet room's bathroom, and racial graffiti in an occupied patient room which had the potential to physical or emotional harm for patients.

Findings included:

1) Record review of Patient #11's Admission Sheet (Face Sheet) reflected the patient's admission on 01/13/20 at 1818. Admission diagnoses included Major Depressive Disorder. The patient was discharged on 01/27/20 at 1710 with diagnoses that included Major Depressive Disorder, and Unspecified Fracture of Facial Bones.

Patient #11's Psychosocial Assessment dated 01/13/20 at1740 reflected that patient had attempted suicide four times by trying to shoot himself, had a history of self-harm and had experienced the trauma of emotional abuse. The patient was noted to have poor judgement and insight.

Patient #11's Psychiatric Evaluation dated 01/14/20 at 1500 reflected the patient was admitted for threat of self-harm. The patient stated he had "put a gun to his head" a few weeks prior to his admission and told his counselor he heard voices and wanted to die.

Patient #11's Physician Daily Progress Note dated 01/22/20 at 1125 reflected the patient's statement that he was angry. The physician assessed the patient to be irritable, angry, anxious, depressed, suicidal and with poor judgement and insight.

Patient #11's Nursing Progress Notes dated 01/22/20 at 1748 reflected the at 1637 the patient "was running down [the] hall with much force and speed against others ...unable to stop due to ...speed and tripped over shoes and fell into door ...bleeding from ...nose and mouth ...grape-size knot to the center of forehead with bruising ...due to amount of blood and pt [the patient's] position and condition, staff was not able to obtain vitals before EMS [emergency medical services] arrived."

Medical Hospital Emergency Department (ED) Report dated 01/22/20 at 1733 reflected that Patient #11 had been admitted to the ED after he "was running down a hall when he ran into a door, causing him to fall and hit his head on a concrete floor ...brief LOC [loss of consciousness] and does not remember events after fall ...reports epistaxis [nose bleed], wounds to lips, pain to left clavicle [collar bone], and neck pain ..."

Medical Hospital ED Provider notes dated 01/22/20 at 1733 reflected that Patient #11 had a right frontal skull fracture and a bilateral nasal bone fracture.

Patient #11's Physician Daily Progress Note dated 01/23/20 at 1123 reflected that the patient "broke his nose and injured other periorbital areas ...anxious ... depressed ... suicidal ..."

Nursing Progress Notes reflected Patient #11's complaints of pain required medication intervention at least eleven times over the three days following the incident (01/23/20 at 0340, 01/23/20 at 0905, 01/24/20 at 1020, 01/24/20 at 1145, 01/25/20 at 0045, 01/25/20 at 0750, 01/25/20 at 2033, 01/26/20 at 0235, 01/26/20 at 0305, 01/26/20 at 1627, and 01/26/20 at 1800). On 01/24/20 at 1145, Patient #11 told the nurse he was in "too much pain" to attend nursing group. On 01/27/20, the day of discharge, Patient complained of a pain level of 5 out of 10 (the highest level) at 0820.

Clinical Services Group Notes dated 01/23/20, 01/24/20, 01/25/20, 01/26/20 reflected Patient #11 was unable to attend and/or was only minimally able to participate in fourteen therapeutic groups focused on promoting healthy coping skills, suicide prevention strategies, and problem solving (on 01/23/20 at 0900, 1015, 1115, 1330, 1445, and 1900; on 01/24/20 at 0900, 1015, 1115, 1330; on 01/25/20 at 0900, 1015, 1115, and 1330).

During an interview on 01/29/20 at 1025, Hospital Personnel #5 stated an incident on 01/22/20, where a patient "raced the nurse down the hallway, it was a game, tripped, and fell against the door." The patient returned to the hospital after emergently treated at a local medical hospital Emergency Department (ED).

Hospital Personnel #12 was interviewed on 01/29/20 at 1130. She stated that at the time of incident, the patients were delayed going to the gym activity before dinner. One of the staff members, a Mental Health Technician, was on break at that time and " ...if the Tech had been on the floor instead of on break, the kids wouldn't have been so bored ...[Hospital Personnel #8] told me ...[Patient #11] said, 'Come, race me' ...encouraged by other patients ...tripped over himself, flew into the door and hit his face ..." During an interview on 01/29/20 at 1401, Hospital Personnel #12 was surveyor asked whether hospital policy in place on the day of the incident allowed running on the unit's hallway and responded that it "was not discouraged."

Hospital Policy #1022 dated 07/17/19 was titled "Sports/Recreation Participation: Employees" and reflected that "it is the policy ...that physical participation is not considered in the course and scope of employment and is prohibited."

2) Patient #7's Admission sheet reflected the 10/05/19 admission date. Admission diagnoses included Bipolar Disorder.

Patient #7's Nursing Shift Progress and Assessment Note dated 10/15/19 at 2015 reflected the patient "was running and hit his right knee on the chair and fell."

Patient #7's Nursing Progress Note dated 10/15/19 at 2030 reflected Patient #7 "was running in the day room, chasing other patients ...hit his right knee on the chair ...began crying ...holding his right knee, stating that it hurt." Nursing documented the patient had a history of falls in the previous three months.

Hospital Personnel #5 acknowledged the finding during an interview on 01/29/20 at 1301.

3) Patient #3's Admission Sheet reflected an admission date of 01/23/20 at 2000. Diagnoses included Major Depressive Disorder. Patient #3's Patient Observation Form dated 01/27/20 reflected that the patient "fell outside around 3:37 pm ...nurse checked patient out ..."

Patient #3's Nursing Day Shift Progress and Assessment Note dated 01/27/20 did not reflect a patient post-fall assessment.

Hospital Personnel #5 acknowledged the finding during an interview on 01/29/20 at 1301 and stated, "I can't find an assessment or post-fall report."


4) Observation on the adolescent patient unit 01/29/20 between 1025 and 1035 reflected patients attended school in a room visible to observers from the hallway. One male patient wore socks only and slid across the floor into his seat.

The unit's quiet room ("pause place") was located immediately upon entry to the unit; its antechamber was observed with multiple clusters of dust on the floor. The adjacent bathroom had a pool of water approximately the size of two feet by one foot between the toilet and the sink.

A paper bag in that area was observed soaked on the bottom. The quiet room was observed with a quarter-sized hole in the wall and at least three dark discolored spots on the East wall.

Hospital Personnel acknowledged the above findings on 01/29/20 during the unit tour.

Room 104, a semiprivate room, had one bed placed close to the window. It had a blue colored mattress without a sheet. The surveyor lifted the mattress up. The wood bed framed top displayed racial graffiti.

Hospital Personnel #6 denied knowledge of the graffiti during an interview on 01/29/20 at approximately 1050.