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Based on review of medical records (MR), and staff interviews (EMP), it was determined the facility failed to provide a safe setting for one of one patients. (MR1)

1) Review of MR2 revealed the patient associated with the medical record was found in the bed of the patient associated with MR1, rubbing their back. Continued review of documentation in MR2 revealed a physician's progress note dictated January 31, 2012, 1553, which stated "... [The patient] actually got into bed of another patient who is afraid [of the patient] ... ."

2) Telephone interview with EMP4 on February 7, 2012, at approximately 8:45 AM, revealed that it was witnessed that the patient associated with MR2 was found sitting on the bed of the patient associated with MR1. Stated this patient was rubbing the other patient's back. EMP4 stated that the patient associated with MR1 did wake up and that this patient was very scared. EMP4 stated that they tried to calm this patient while trying to redirect the other patient.

Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to follow adopted policies related to documentation of responsibilities for patient care, in three of four medical records reviewed. (MR1, MR2, MR3)

Findings include:

Review of the policy entitled "Special Precautions/Patient Observations", revealed "I. Purpose: A Special Precaution is defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiative of specific protocols and supplemental documentation ... One of the tools used to ensure patient safety is a special precaution or an intensified level of staff awareness and observation ... The level of precautions required for a patient is a matter of clinical judgment, but the basis for that clinical judgment must be well documented. Special Precaution procedures can be initiated by physician or nursing staff when a patient may be considered to be an increased risk for harm to self, others or property, for those patients who are identified as an elopement risk or for those who need and (sic) increased level of observation and precaution for other reasons, such as fall prevention. Clinical staff should assess the patient's risk factors and initiate the following procedures to help protect the patient and others ... III. Procedure: ... 2. An order for the appropriate level of precautions shall be documented in the physician's order section of the medical record, and the charge nurse or designee shall initiate the observations ... Initiation of precautions should be documented in the physician's orders, Kardex, on the Special Precaution/Observational Level Form and as part of the Treatment Plan ... 12 ... N. Self-Harm, Boundary Precautions and Elopement/AWOL Risk. Guidelines for implementation on this level of precautions include: 1. Level of observation-every 15 minutes around the clock. 2. Determined by clinical assessment, patient comments and behavior. 3. May be initiated by RN as a nursing measure. 4. A physician is notified within 1 hour and an order for the level of observation obtained. 5. For boundary precautions, the physician determines if it is appropriate for the patient to have a roommate. 6. If on checks for self harm, a safety search of the patients' room and person is completed. Search roommates belongings also, for patients placed on self harm checks, staff will adhere to contraband list ... O. One to One (1:1) for Suicide Self Harm. Guidelines for implementation on this level of precaution include: 1. Level of Observation - constant, includes bathroom use and bathing, around the clock, shall always be in line of vision and at arms length. 2. Determined by clinical assessment, patient comments and behavior. 3. Assigned staff member is within arms length and within staff sight at all times. Staff shall have radio communication. 4. A physician is notified within 1 hour and an order for the level of observation obtained. 5. A safety search of the patients' room, roommates' belongings and person is completed. Staff will adhere to the contraband list ... ."

Attached to this policy was form entitled "Suicide Attempt/Gesture Protocol. The Form stated "1. Assess situation/call for help (Code Blue or Medical Back-Up as needed). 2. Maintain 1:1 observation. 3. Provide emergency treatment as needed ... 4. RN to evaluate/assess for further intervention. 5. Notify physician/Nursing Supervisor. 6. Obtain order for PA consult or ER transfer as appropriate. 7. Obtain order for increased precaution level as appropriate. 8. Notify family/guardian if applicable. 9. Update treatment plan. 10. Document incident in Medical Record. 11. Complete HPR."

Review of the policy entitled "Health Care Peer Review (HPR) Occurrence Reporting System", revealed "... Definitions ... B. Serious Injuries/Events constitute any of the following outcomes as a result of healthcare intervention but may not be limited to this list ... Suicidal gestures or attempt ... Sexual involvement ... Possession and/or the use of drugs/alcohol or other contraband on or off campus ... Procedure: A. Any facility employee or staff member who discovers, is directly involved in or is responding to an event/occurrence is to complete or direct the completion of a Healthcare Peer Review (HPR) form. This form is referred to directly to the facility Risk Manager within 72 hours of completion ... C. Completing the HPR: a. The HPR is to be completed at the time of event. b. Healthcare Peer Review (HPR) Reports are to be signed by the individual preparing the report. c. The Charge Nurse on duty at time of event is notified of any HPR incident, reviews HPR for completeness, making suggestions or additions as necessary from nursing perspective ... e. The event is documented in the medical record by the person most closely associated with the event and includes: A concise statement of the facts of the event, statements are non-judgmental and objective. Clinical condition of patient ... Names, times of notifications of physician, supervisory personnel, family members as necessary ... g. The Charge Nurse ensures the following information is obtained prior to forwarding completed HPR to the Risk Manager: Information on form is complete. Appropriate persons were notified ... Patient was examined and received immediate medical attention as needed. Medical record documentation is appropriate. Intervention and appropriate actions taken for prevention or protection of patient/facility. h. The completed form is forwarded to the Risk Manager within 72 hours ... ."

Review of the policy entitled "Progress Notes", revealed "... A Progress Note will be completed every shift on the inpatient units to document mood/affect, interactions, appetite, patient verbalizations and thought content, staff observations, interventions and responses, behavioral management and changes in patient's condition, status or treatment. The Progress Note must reflect the status of problem areas identified on the Treatment Plan ... Procedure: A. When to Chart: ... 3. After any unusual incident. 4. When care is given regarding a problem. 5. When the status of a problem changes. 6. When there is a response to treatment. 7. When a problem is resolved ... ."

1) Review of MR2 revealed the patient associated with the medical record was found in the bed of the patient associated with MR1, rubbing their back. There was no documentation present in MR1 indicating that this event occurred.

2) Review of MR3 revealed the patient had ripped open a pillow and put the plastic covering over their head. There was no documentation noted in the medical record that the physician was notified of this incident.

A request was made for the HPR report associated with this incident.

Interview with EMP2 on February 6, 2012, revealed that there should have been an HPR report associated with this incident. EMP2 confirmed that there was not an incident report filed.

Telephone interview with EMP2 on February 17, 2012, at approximately 2:40 PM, confirmed that the medical record did not contain clear documentation that the incident was reported to the physician.

3) Continued review of MR3 revealed forms entitled "Suicide Risk Assessment Tool."

The tool stated "RN to complete for patients on self harm precautions and/or patients with suicidality. (checkbox) Days. (checkbox) Evenings. (checkbox) Nights." The form contains items numbered one through five, which stated "1. Suicidal Ideations (checkbox) Yes. (checkbox) Denies. If yes, note frequency, intensity, duration. 2. Suicidal Behaviors (checkbox) Yes. (checkbox) No. 3. Suicide Plan (checkbox) Yes. (checkbox) Denies. 4. Intent (checkbox) Yes. (checkbox) Denies. 5. Any recent psychosocial stressor (phone call, visit, etc.) If yes, please describe. Intervention. If nay answer to questions 1-4 is yes, contact physician. Physician Name ... Date & Time of Call ... Action. (checkbox) Current Precaution Level maintained. (checkbox) Other, describe ... ."

It was noted that there were instances on the forms when the physician and/or intervention was not documented when a "yes" answer was noted.

Telephone interview with EMP2, on February 17, 2012, at approximately 2:40 PM, confirmed the findings related to the Suicide Risk Assessment Tools.

Based on review of facility documents, closed medical records (MR), and staff interviews, it was determined that the facility failed to ensure that the patient's treatment plan, was current for one of four medical records reviewed. (MR2)

Findings include:

Review of the policy entitled "Boundary Precautions (Aggressor or Victim), revealed "I. Purpose: To provide guidelines for the observation of patients with a history of poor boundaries, sexual acting out, sexual perpetration, those patients who have a probability of demonstrating such behavior, potential for sexual victimization, and/or any patient who demonstrates any such behavior while hospitalized at The Meadows ... IV. Procedure: ... D. The patients identified to need these special precautions will remain on checks every 15 minutes or less for structure and supervision throughout the entire hospitalization, unless discontinued by treatment team with a physician's order. E. Patients on these precautions may sleep in a room without a roommate. The Physician will determine the sleeping arrangements of patients on precautions ... H. Patients on Boundary Precautions will be observed every 15 minutes as well as random checks at unannounced intervals ... General Safety Procedures to be enforced: 1. Report and record all aggressive and sexual remarks and gestures in the progress notes. 2. Report and record all behaviors that may indicate inappropriate boundaries. 3. Report and record all behaviors that may indicate patient has the potential to be victimized ... Documentation: 1. Document use of boundary precautions as an intervention on the treatment plan ... ."

1) Review of MR2 revealed that the patient was found rubbing the back of room mate on January 31, 2012, at 0300. Continued review of the medical record revealed a physician's order for for boundary precautions on January 31, 2012, which was untimed. The order was noted by nursing at 0830. Review of the patient's Treatment Plan reviewed no updates related to Boundary Precautions.

2) Telephone interview with EMP2 on February 17, 2012, at approximately 2:40 PM, confirmed the findings.