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Based on observations, medical record review, and interviews, the hospital's governing body failed to provide effective oversight of the contract residential service.
This deficient practice resulted in one of fourteen current sampled inpatients (PI # 7) being injured on 2/10/2011, when three adolescents from the contract residential unit entered the acute care inpatient unit through an unlocked door, and placed all inpatients at risk for injury or harm.
Immediate jeopardy was identified and reported to hospital administration while surveyors were on site 2/24/2011. The hospital developed and implemented an immediate short term corrective action plan that removed the immediate jeopardy on 2/24/2011.
Findings Include:
PI # 7 was admitted to the hospital's acute care adolescent male unit on 2/8/2011, with a history of physical and verbal aggression and threats of suicide. On 2/10/2011, employee identifier (EI) # 9, Staff RN, documented that PI # 7 was involved in an altercation, fell and sustained a knee injury.
During an interview (2/24/2011 at 6:15 PM), EI # 9 stated she, and the other staff members assigned to the acute care inpatient adolescent unit, were occupied (with other inpatients) at the time of the incident involving PI# 7. EI # 9 stated this incident with PI # 7 occurred last week, when three adolescent male residential patients entered the inpatient adolescent male unit, through an unlocked door that separates the inpatient and residential units. EI # 9 reportedly observed three residential males attack inpatient PI # 7.

On 2/12/2011, the physician noted PI # 7 injured his knee during an altercation with "peers." The physician's note does not indicate the date of the incident, where the incident occurred, if the peers are acute care inpatients, or patients housed in the contract residential unit.

During the 2/22/2011 tour of the facility (beginning at 1:55 PM), EI # 1, Director of Clinical Services, said this hospital is certified as an acute care psychiatric hospital. This hospital also provides contract residential housing that is certified by another State Agency and Joint Commission. These residential units are community contract homes for children and adolescents (ages of 10 to 18 years). At the time of this survey, the designated contract residential units include a section on the hospital's third floor and the entire fourth floor.
Observations of the third floor acute care inpatients area revealed there are three doors separating the patient units. A locked door (reportedly installed on 2/18/2011) separates the acute care female inpatients from the acute care male inpatients. This door was observed unlocked and propped open on 2/24/2011 at 5:40 PM.
The double door that separates the acute care male inpatients from the residential male patients is not locked. Once the residential staff member or patients enter the acute care male inpatient side (of these double doors), they cannot exit the inpatient unit, unless staff unlock a second door, which the exit door used by acute inpatient and residential units.

On 2/24/2011 at 8:30 PM, VP Development JD, EI #11, stated this hospital is certified for a specific number of acute care hospital beds. The number of inpatient beds does not change. However, the acute care beds and assigned hall, units and patient care areas are relocated as needed. According to EI # 11, the State "CON" committee said the hospital may move the beds around as they (hospital) see fit.

This deficiency is written as result of Complaint Investigation AL00023937.

Based on observations, interviews, medical record review, and review of hospital policies, the hospital failed to provide a safe environment for inpatients admitted for acute psychiatric services.
Immediate jeopardy was identified by the surveyors while on site 2/24/2011.
The jeopardy concerns were described and reported to hospital administration (on 2/24/2011). The hospital developed and implemented short term immediate corrective action plan that removed the immediate jeopardy on 2/24/2011.

Refer to findings documented under A083 and A144.

This deficiency is written as result of Complaint Investigation AL00023937.

Based on observations, interviews, medical record, hospital policy reviews, the hospital failed to assure staff implementation of the hospital's Patient's Rights Policy, failed to provide a safe environment for Patient Identifier (PI) # 7, on 2/10/2011 when three adolescent residential males entered the inpatient male unit (through an unlocked residential door) and assaulted inpatient PI # 7, failed to monitor inpatients PI # 3 and # 6 (on 2/24/2011) to assure patient participation in their program and patient safety, and failed to monitor former inpatients PI # 9 and # 12 to identify and intervene, in the "choking out" activity reportedly being played by inpatients.
This deficient practice effected five of fourteen sampled patients (PI # 7, # 9, # 10, # 3, and # 6) and has the potential to effect all hospital inpatients.
On 2/24/2011, surveyors on site identified immediate jeopardy and reported these concerns to hospital administration. The hospital developed and implemented a short term immediate corrective action plan that removed the immediate jeopardy on 2/24/2011.

Findings Include:

On 2/8/2011, PI # 7 was admitted to the facility with diagnosis that include Bipolar Disorder, Impulse Control Disorder, Suicidal Ideation, and a History of physical and verbal aggression.

On 2/10/2011, Employee Identifier (EI) # 9, a Staff Nurse documented that PI # 7 was involved in an altercation. During an interview (on 2/24/2011 at 6:15 PM), EI # 9 recalled the incident and stated three residential males entered the inpatient unit, through the unlocked door that separates the inpatient adolescent male unit from the residential adolescent male unit, and attached PI # 7. According to EI # 9, she and the other staff members on the unit were occupied (with other inpatients) when the incident initially started.

On 2/12/2010, the physician's progress notes record that PI # 7 was involved in an altercation with his "peers." The physician did not indicate who the peers were or their location (i.e. the unlocked residential unit).

On 2/22/2011 at 2:35 PM, the surveyor observed PI # 7 enter the educational classroom, singing in a low tone, mumbling words that included mixing...it up...the boys.
When asked his name, PI# 7 laughed and provided a fictitious name and age. When directed by EI # 1, Director Clinical Services, to give his correct name, PI # 7 laughed and spelled his name. PI # 7 was not wearing an identification bracelet. When questioned (by EI # 1) about his missing bracelet, PI # 7 said he tore the identification bracelet off because it was itching.

On 2/23/2011 at 9:45 AM, PI # 7 was interviewed. The patient reported that he was attacked on the inpatient hall last week (unable to recall exact date). PI # 7 states that he was in the hall, outside his room, when three residential patients entered the inpatient unit, through the unlocked residential door (this door separates the inpatient male adolescent unit from the residential adolescent male unit). According to PI # 7, the three residential males pushed him (PI # 7) up against the wall. He (PI # 7) pushed them off, trying to get away, slipped, fell and twisted his knee, before staff arrived to intervene.

The hospital's patient hand book includes a copy of the "Patient's Rights" policy that informs patients of their right to "...Proper, safe and sanitary shelter...the right to be free from verbal and / or physical abuse..."

On 2/24/2011 at 6:15 PM, Staff Nurse EI # 9, recalled she was on the female side of the adolescent hall when she heard a code for behavior control, this was the incident involving the residential males and inpatient PI # 7 (on 2/10/2011). EI # 9 states she had to stay with the females of the female side of the unit, to prevent female inpatients from mixing with the male inpatients. EI# 9 states at the time of the incident involving PI# 7, no barrier or door separated the male and female adolescent halls (on 2/10/11), so she (EI # 9) stood in front of the group of female adolescents, to keep them (female inpatients) away from the altercation
EI # 9 states she observed PI # 7 shoving the three residential males off, before he (PI # 7) stumbled, fell backward, hit his head, and twisted his (PI # 7) knee.
EI # 9 said the hospital had problems with the residential patients taunting the inpatients, through the unlocked door, and had prior altercations involving the mixing of inpatients and residential patients.
When questioned about staff numbers, EI # 9 stated staff to inpatient ratios change, but the average is ten patients to one staff member.
When asked about the reported "choke out" activity, EI # 9 says she heard that some of the residential patients play the "choke out...a game to try to pass out..." EI # 9 denied observing this activity / game being played by patients.
During the interview, EI # 9 stated the staff on the residential hall on the third floor do not always have access to a telephone. According to EI #9, residential staff have at times, called out from the unlocked door and asked for help, or asked an inpatient to tell staff to call for assistance on the residential unit.
When asked about the locked door that separated the female and male inpatient units, EI # 9 states this locked door was installed last week (on 2/18/20110 because staff were having problems with PI # 6 (an adolescent female) repeatedly running off the female inpatient hall and into the room of a former adolescent male inpatient (on the male inpatient unit).

On 2/24/2011 at 5:30 and 5:45 PM, the surveyor interviewed two former inpatients, PI # 9 and PI # 10. These former adolescent males stated, while inpatients on the adolescent male unit, they engaged in "choking out" with other inpatients. These patients described this activity as a kind of game and that patients call the "...choking out" or the "...pass out" game.
PI # 9 and PI # 10, stated this game (described below) is played by inpatients, when the staff are occupied, off the unit and out of site of their patients.
These former inpatients explained how this game is played by saying that one patient is designated as a "look out." This look out patient stands at, or near the entrance door to the room where patients are gathered to play the game. The look out patient stands and watches for staff.
The patient being "choked out" stands in front of the patient doing the "choked out." The patient being "choked out" starts huffing and puffing rapidly and when this patient feels dizzy, they give a thumbs up sign, to the patient standing behind (who is doing the choke out). The thumbs up sign indicates readiness to be "choked out."
The look out patient at the door looks for staff and gives a thumbs up sign to indicate that no staff near or headed to the area (where patients are gathered).
Once the look out gives a thumbs up sign, the patient doing the "choke out" (standing behind the patient being "choked out"), puts their arm around the "choke out" patient's neck and begins choking the patient.
When the patient in front feels like they are going to pass out, that patient "taps out" (this is when the patient being choked out pats or taps the person doing the choking on the arm). When the patient doing the choking feels the "tap out" pat, they stop choking the patient. The patient being "choked out" will pass out just after the "tap out," however, the patients report that sometimes the patient passes out before they tap out.
PI # 9 and PI # 10 explained that they have to have two thumbs up signs before they can do the choke out, and it takes about 1 to 2 minutes to "choke out" a person.
According to one of the patients, a former employee used to participate in the "choking out" but this employee is no longer working at the hospital.
When asked who engaged in this activity, these patients responded, "everybody." The patients stated they (patients) have had to slow down "choking out" because last week one of the patient was "choked out," fell on his face, and went to the hospital. The patients stated that after this incident, staff began keeping a closer eye on them (patients).

Observations of the inpatient adolescent unit (on 2/22-24/2011) revealed inpatient adolescent females, inpatient adolescent males, and residential adolescent males are housed on the same floor/unit.
The female inpatient area is separated from the inpatient males by a locked door (installed 2/18/2011 before the survey). The inpatient adolescent male and residential adolescent male units are separated by unlocked double doors.

On 2/24/2011 at 10:45 AM, the surveyor observed residential staff member EI# 17 escorting female inpatients PI # 3 and PI # 6 back to the adolescent female unit. EI # 17 reported that PI # 3 and PI # 6 entered the residential classroom, laughing, yelling, banging on the doors, and disrupting the residential class.

On 2/24/2011 at 5:40 PM, a surveyor observed the door, between the female and male inpatient adolescent halls, unlocked and open. The surveyor observed EI # 12, a psychiatric technician, standing with her back to the male inpatients. When questioned about the door being open, EI # 12 said she had to search a patient. EI # 12 stated the doors between the adolescent inpatient female and male units cannot be shut if there is no staff member on the male side of the hall. EI # 6, a staff RN stated she was in the process of admitting two patients (at the time the surveyor observed the open door).


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During a tour of the Child Unit, on 2/22/11 at 2:10 PM, room number 112 was observed to have bare, beige colored walls without pictures, calendars
or any type of visual decoration. Three beds were in the room and linens were observed on two of the beds. The middle bed was covered with a faded rose colored blanket that was riddled with holes. One bed had a thin, bare mattress on top of a wooden base and there were no linens on the bed.

On 2/24/11 at 10:10 AM, the following observations were made on the Adult Unit:
- Room 208: There were no pictures on the walls. The windows were opaque and nothing on the outside was visible.

- Room 202: There were no pictures on the walls. The windows were opaque. Nothing outside was visible.

On 2/24/2011 at 7:30 PM , immediate jeopardy was identified and reported to hospital administration.

At 8:30 PM, Hospital Administration documented and implemented the following immediate short term corrective actions that relieved the immediate jeopardy.

The Hospital's "Immediate Solution to Residential and Acute Care Patient Safety on the 3rd Floor:
- Effective 8:30 PM on 24 February 2011, a staff person will be placed on the acute side of the door that separates the residential program from the acute care.
- This position will be staffed (24) hours per days (7) days a week to prevent residential patients from unescorted access to the acute care program.
- This position will be a direct relief post where the staff will not leave this position unless directly relieved by another staff member. This staffing is in addition to and not inclusive of the required staffing for the residential and acute care programs.
- Residential patients are not to be permitted access to the acute care program without staff escort from the residential program. While residential program patients are in the acute care program corridor, acute care patients will remain off the hall until the residential patients are off the hall."