HospitalInspections.org

Based on record review, observation, and interview, the facility failed to protect a patient's right to privacy when Patient #1 was allowed to sleep on a mattress, in the facility's dayroom; the patient was not afforded the privacy of a bedroom.

Findings:

Review of the facility provided policy Patient's Rights, (undated) reflected, "PURPOSE: ...shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times ...
BASIC RIGHTS FOR ALL PATIENTS ...B. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs and are treated with respect and dignity."
Incident report dated 11/14/24 at 7:45 pm reflected, Patient #1 reported a sexual incident between himself and his roommate, the incident took place on 11/13/24 between 9:00 pm and 10:00 pm.
Nurse's note dated 11/14/24 at 8:30 pm reflected," ...was struck multiple times before boys could be separated ...visually upset after altercation ..."

During an interview, on the morning of 11/18/24, Patient #1 stated in part, "After I got jumped, they (facility staff) said I had to get off of this unit. I told them I didn't feel safe being in the same room with patient #2. They put me to the other side of the unit, I slept on a mattress on the floor in the dayroom. I don't know why I had to move, why was I being punished?"

Observation made during a review of the facility provided video tape dated 11/14/24 at 8:35 pm, revealed Patient #1 being struck by patients #2 and #3. The boys are separated by staff. Staff are observed placing a mattress and bedding in a corner of the adjoining dayroom's floor. There is a locked door between the rooms, preventing patient #2 & #3 from going into this dayroom. Patient #1 is observed lying down with a blanket over his head; other patients are seen standing and walking around the dayroom. Patient #1 remains sleeping in the dayroom until the next day. Other patients are seen walking in the dayroom.

During an interview, on the morning of 11/18/24, when asked why Patient #1 was sleeping in the dayroom, Staff # stated in part, the unit was full. It happened in the evening; we would have had to wake other patients up to make a room change. We placed him in the dayroom at his request.

Based on record review, and interview the facility failed to ensure each patient had an individualized master treatment plan, developed and made available to the staff providing therapeutic care for (8) eight out of (8) eight patient's medical records reviewed. This failure places patients at risk of delayed, or inappropriate psychiatric treatment. (Patients #2,3,4,5,6, 11, 12, and 13)

Findings include:

Review of the facility provided Administrative Policy on "Treatment Plans", (reviewed on 1/02/2020) reflected,
"Purpose: 1. To provide guidelines for the documentation of the Master Treatment Plan (MTP) and treatment plan revisions.
2. The MTP is completed by the Unit therapist. The plan includes psychological problems and diagnosis as identified by the admitting psychiatrist's psychiatric evaluation, history and physical, intake assessment, psychosocial assessment, nursing assessment or other collaborative information.
3. The multidisciplinary treatment team consists of the unit therapist, psychiatrist, charge nurse. Other ancillary members may be included such as activity therapy utilization review but are not required.
Treatment Planning: The multidisciplinary treatment team will meet and formulate a comprehensive Master Treatment Plan (MTP) within three (3) day, after the patient's admission.
4. The therapist is responsible for documenting the decisions of the team in regards[sic] to:
a. Problem
b. Manifestations
c. Patient strengths and barriers to treatment
d. Long-term and short-term goals.
e. Therapeutic interventions to be used ...
12. The multidisciplinary treatment team will meet three times a week to review, update and/or revise the treatment plan for those patients that are due for an update according to their length of stay, or who have received a revision due to change in their status."

- Review of Patient #2's Master treatment plan cover sheet dated 11/13/24 reflected a problem list of Aggression with homicidal Ideation and Suicidal Ideation. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient's psychological needs, interventions, and goals. Patient #2's Restraint Debriefing dated 11/14/24 at 9:00 pm reflected a restraint hold to prevent Patient #2 from continuing to hit Patient #1. Patient #2 stated, "I will do it again." The incident occurred after patient #1 reported a previously unreported sexual encounter, that had reportedly taken place on 11/13/24 with Patient #2. The master treatment plan did not reflect an update for Patient #2's sexually acting out encounter and new risk.

- Review of Patient #3's Master treatment plan cover sheet, dated 11/15/24, reflected a problem list of Aggression, mood, and depression. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient's psychological needs, interventions, and goals.

- Review of Patient #4's Master treatment plan cover sheet, dated 10/25/24, reflected a problem list of depression with suicidal ideation, psychosis, and homicidal ideations. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient's psychological needs, interventions, and goals.

- Review of Patient #5's Master treatment plan cover sheet, dated 10/25/24, reflected a problem list of depression with suicidal ideation, and psychosis. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient's psychological needs, interventions, and goals.

- Review of Patient #6's Master treatment plan cover sheet, dated 10/2/24, reflected a problem list of depression with suicidal ideation. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient's psychological needs, interventions, and goals.

- Review of Patient #11's Master treatment plan cover sheet, dated 11/13/24, reflected a problem list of Aggression, mood with suicidal ideation, and Psychosis. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient's psychological needs, interventions, and goals.

- Review of Patient #12's Master treatment plan cover sheet, dated 11/10/24, reflected the nursing portion of the treatment plan was completed; the therapist had not addressed the patient's psychological needs, interventions, and goals.

- Review of Patient #13's Master treatment plan cover sheet, dated 10/20/24, reflected a problem list of depression and psychosis. The nursing portion of the treatment plan was completed; the therapist had not addressed the patient's psychological needs, interventions, and goals.

During an interview on the morning of 11/18/24 in an administrative office, when asked about the missing master treatment plans (the therapist's portion of the master treatment plan), Staff #5, Clinical Director pointed to the Master treatment plan coversheet and stated, "That is the Master Treatment Plan". When informed the sheet was titled Master Treatment Plan Coversheet, Staff #5 stated, "It hasn't been filed yet. We try to get them in the chart before the patient is discharged. Our treatment plans have to be created individually, it takes longer than the nursing treatment plan, we try to do our best, we do what we can." Staff #5 provided Patients 2's and 3's completed master treatment plans several hours later.

During an interview on the morning of 11/18/24 in an administrative office, Staff #3, Quality Director stated in part, "The initial Treatment plan, which included the multidisciplinary team, is completed within 8 hours of the admission. The Master treatment plan is completed and placed in the chart within 3 days of the admission. The master treatment plan should be in the chart at all times. There is no explanation, they should all have a master treatment plan, absolutely no reason."