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Based on review of policy and procedure, record review, observation and interview, it was determined the facility:

A. Failed to ensure the patient's right to personal and physical privacy in that two of ten patient bathrooms observed had no door covering thereby denying the patients assigned to those rooms, personal and physical privacy while using the restroom.
B. Failed to maintain the buildings physical structure to ensure a safe environment, and that equipment was maintained in a state of good repair.
C. Failed to ensure patients received care in a safe setting and/or remained free from harm by failing to observe patients as ordered by the physician and utilize de-escalation procedures to prevent aggressive and/or violent acts towards other patients, staff and property.

The failed practices did not ensure the patient's right to be free from harm or receive care in a safe setting. See A-0143 and A-0144 for details.

Based on review of patient's rights document, observation, and interview, the facility failed to ensure the patient's right to personal and physical privacy in that two of ten patient bathrooms observed had no door covering thereby denying the patients assigned to those rooms, personal and physical privacy while using the restroom. The failed practice had the likelihood of affecting all patients who occupy a room with a missing bathroom door covering. Findings follow:

A. Review of document titled "Patient/Family Rights" no date, showed that patients' receive and acknowledge they have received a copy and that patients had the right "to be respected as an individual with dignity and unique value".
B. During a tour on 11/18/2024 between 5:00 PM and 6:45 PM, observation of two patient bathrooms showed no door covering which allowed for full view of the patient while showering, toileting, or other bathroom use.
C. During an interview with Nurse Manager on 11/18/2024 at 5:20 PM and with the Director of Physical Operations on 11/19/2024 at 9:30 AM, the findings in A-B were confirmed.

Based on observation of the patients rooms in Units 1, 2, 3A, 3B, Classrooms, Day Room, Intake Assessment Area, and Gym, and interview, it was determined the facility failed to maintain the buildings physical structure to ensure a safe environment, and that equipment was maintained in a state of good repair. The failed practice did not mitigate the risk of ligature, injury, or self-harm. The failed practice had the likelihood of affect all patients and staff in the facility. Findings follow:

A. During a tour of the facility on 11/18/2024 between 5:00 PM and 6:30 PM and again on 11/19/2024 between 9:00 AM and 10:45 AM, the following findings were observed:
1) The Gym showed the door leading into the gym was damaged in several places and needed to be replaced.
2) The Intake and Assessment Area leading into the assessment area showed to have a broken door that was not secure.
3) Assessment Rooms 204 through 206 showed to have broken or damaged information boards in each room with exposed screws.
4) Assessment Room 202 showed to have damaged walls.
5) Assessment Area sitting room showed to have screws that were not tamper resistant being used on the middle window column.
6) The Hallway leading into patient areas showed to have secured double doors that were damaged in multiple places and also had a one inch gap between the doors.
7) Day rooms and hallways in patient units 1, 2, 3A and 3B showed to have ceiling tiles that were not clipped which posed a ligature risk.
8) Room 604 showed to have paint hanging from the ceiling above a patient's bed.
9) All patient rooms in units 1, 2, 3A, and 3B showed the door frame leading into the bathrooms had the following:
a) The patient bathrooms had the solid doors removed and part of the the hinges in 3 areas on each frame were left behind exposing sharp edges that stuck out beyond the door frame which posed a self-harm or ligature risk.
b) Three screws were left in each hinge left behind for a total of nine screws on each door frame, which posed a self-harm or ligature risk.
10) The Anti Rooms (leading to the Isolation Room) for Units 1 and 2, showed to have closers that stuck out past the door frame that posed a ligature risk.
11) The Isolation Room (entered from the Anti-rooms from Unit 1 and 2), showed to have a metal door with a lever handle that posed ligature risk and a sliding latch lock that posed ligature risk.
12) The patient areas observed, showed to have door closers that stuck out past the door frame that posed a ligature on a door leading to the courtyard directly adjacent to the gym.
13) All patient areas observed, showed to have door closers that stuck out past the door frame that posed a ligature on the door leading to maintenance.
14) The double doors leading into Unit 3A, showed damaged doors and an astragal (strip of metal between the doors) that was cut in house was missing multiple screws causing it to become unattached posing a ligature risk.
15) The double doors leading into unit 3B, showed to have an astragal that was cut or modified in house that was damaged at the top posing ligature risks.
16) The patient hallway in unit 3B, showed to have double doors separating patient rooms that had a circular magnetic latching mechanism attached to the back side of the door and walls that posed ligature risks.
17) The double doors in the hallway on Unit 3B, which served as an overflow area and separated patient rooms, showed to have magnetic locks on the doors that didn't latch and remained closed.
18) All patient areas in units 1, 2, 3A, and 3B, showed to have multiple wall penetrations that needed to be patched and sealed.
19) All patient areas in units 1, 2, 3A, and 3B, showed to have multiple base boards that were missing.
20) The nurses' stations in Units 1 and 2, had doors that did not lock to prevent unauthorized personnel, including patients, from entering.
21) The nurses' station for Units 3A and 3B, adolescent units, showed to have a single curtain and two small book shelves separating the units which did not prevent unauthorized personnel, including patients, from gaining access to the other unit.
22) The Electrical Room, showed the door had a pad lock with a piece of metal sticking out from the door in two places that posed a ligature or self-harm risk.
B. During an interview with the Facilities Director on 11/18/2024 at 6:30 PM and again on 11/19/2024 at 10:45 AM the findings in a-v were confirmed.





51070

Based on review of Policy and Procedure, record review, observation, and interview, the facility failed to ensure patients received care in a safe setting and/or remained free from harm by failing to observe patients as ordered by the physician and utilize de-escalation procedures to prevent aggressive and/or violent acts towards other patients, staff and property. The failed practice did not preserve each patient's right to receive care in a safe setting through mitigation of psychological and physical risk. The failed practice had the likelihood of affecting all patients receiving care in the facility. Findings follow:

A. A review of Policy titled "Admission Criteria" last reviewed 06/2024, showed patients who pose a "significant verbal threat, assaultive behavior or homicidal ideation that potentially threatens the safety of others within 3 days prior to admission" may be admitted for services. Additionally, under "Exclusionary Criteria" patients may not be admitted but with exception if they have "a history of violent behavior beyond the capabilities of the staff and physical environment to contain and safely manage the patient with the current population". During an interview with the Director of Admissions on 11/19/2024 at 11:00 AM and the Director of Clinical Services on 11/20/2024 at 10:00 AM, showed that referrals for admission were sent to the Acadia Corporate office for review and acceptance and that Admissions Staff were not empowered to decline an admission once the patient has presented to the facility if deemed inappropriate.

B. Review of the "Patient Handbook", with no date, showed that patients "are responsible for being considerate of all personnel, property, and other clients". In an interview with the Risk Manager on 11/18/2024 at 6:45 PM, confirmed that each patient reviews the Patient Handbook during the admission process and signs that they have done so.

C. Review of the "Incident Log" dated 01/01/2024 through 10/30/2024, showed multiple incidents of patients attacking patients and staff (some with injury), property destruction which allowed adolescents to gain access to unauthorized areas, "riot like" group aggression which on several occasions required police assistance up to and including arrest, unprotected sexual activity, and suicide attempts. The findings in the "Incident Log" were confirmed during an interview with the Risk Manger on 11/19/2024 at 9:30 AM.

D. Review of Patient #1-#18's patient records showed the following:
a. Adolescent Patients #1- #8, #10 and #15 were involved in "riot like" behavior on 10/13/2024, that caused extensive property damage which allowed adolescent patients to gain access into unauthorized areas and used threatening behaviors towards other patients and staff. Police were called to assist and Patients #1, #3, and #4, were pepper sprayed and handcuffed by local police. Patients #3 and #4 were arrested into police custody and discharged from the facility.
b. Review of "Seclusion/Restraint Packet" for Patients #1 and #3, dated 10/13/2024, showed that "staff retreated to nurses station during incident until police took control" and that there was "not enough staff" given as a reason for not using de-escalation techniques or removing patients from the area.
c. Adolescent Patients #1-#4 were reported to have had unprotected sexual activity on 10/13/2024, in an unlocked hallway bathroom on Unit 3A. Patient #3 and #4 were arrested and discharged from the facility. Record review of Patients #1 and #2, showed a physician order dated 10/14/2024 for a Sexual Assault Nurse Exam (SANE). Both patients were transferred to a local hospital to receive a SANE exam and orders for laboratory testing was ordered for pregnancy test, sexual transmitted diseases (STDs) and hepatitis.
d. Medication orders for Patients #1 & #2, dated 10/15/2024 showed orders for the Plan B pill to prevent pregnancy. Patient #1 received Plan B pill on 10/15/2024 at 9:51 AM and Patient #2 refused the medication.
e. Review of Patient #5 showed the patient was admitted on 07/31/2024 and an order dated 08/27/2024 for STD laboratory testing. Evidence was requested as to why STD testing was ordered and evidence as to which test had been performed as ordered and any required treatment had been given, none was provided.
f. Review of Patient #2 showed the patient gained entry into an unauthorized area, the Nurses Station, and damaged building property and electronics on 10/22/2024 at 10:51.
g. Review of Patient #5 showed multiple aggressive acts that included property damage on seven reported occasions, threatening behaviors towards peers and staff, and a self-harm event on 10/12/2024 utilizing a broken piece of wall, and four events which required local police assistance to control the patient and allow for chemical restraint on 8/26/2024, 09/23/2024, 10/13/2024 and 10/22/2024. Further record review showed on 10/31/2024, Patient #5 touched several patients inappropriately and reached into another patient's pants touching and exposing the patients private parts in a public area.
h. Review of Patient #7 showed on 06/18/2024 at 5:15 PM, the patient gained entry into an unlocked office and took a phone cord which was then used to tie around the patients neck in an attempt to self-harm. In a separate note dated 6/18/2024, no time, Registered Nurse (RN) noted a code was called and patient was found lying on floor with decreased level of consciousness after tying clothing around neck, the incident did not require emergency care. It was unclear from record review and incident reporting if the phone cord event and clothing event were the same with poor documentation or two separate self-harm events occurred on the same day.
i. Review of Patient #8 showed on 05/05/2024 at 7:45 PM, patient was discovered by staff during rounds in another patient room, with a sheet tied around the neck and the other end knotted and hung over a door in a self-harm attempt.
j. Review of Patient #15 showed on 10/12/2024 at 8:56 PM, patient was banging on Nurses station door and windows, de-escalation attempts did not work, and police were called to control patient, allowing for staff to administer physician ordered chemical restraint.
k. During an interview with the Director of Quality and the Director of Risk Management on 11/20/2024, findings in D were confirmed.

E. Review of Patients #1-#18 showed that all patients had a physician order for frequent observation every 15 minutes or every 5 minutes if on suicide/elopement precautions. All records reviewed showed gaps in observation of 15 minutes to 2 and half hours. There was no indication as to why there were gaps in observations or if the patients were being observed during the gaps in documentation.

F. Review of the New Hire/Annual Orientation skills list on 11/20/2024, showed that "Precautions/Observations" were reviewed with all RNs, Licensed Practical Nurses (LPNs), and Behavioral Health Aids (BHAs) during orientation and annually. During an interview on 11/20/2024 at 1:30 PM, the Director of Quality confirmed the findings and stated that the electronic observation system has technical issues and occasionally goes down, however staff were supposed to be using downtime procedures which included documenting observations on paper. During the interview it was confirmed that paper documentation was not found to support missing observations.

Based on review of policy and procedure, observation and interview, it was determined the facility failed to ensure a Registered Nurse (RN) was always available on Unit 3B, an adolescent unit, in that the medication room did not have a refrigerator to store medications required to be kept under refrigeration until use, requiring the RN to leave the unit and retrieve refrigerated medications from Unit 3A. The failed practice did not ensure the adolescent patients on Unit 3B always had an RN available for patient care. The failed practice had the likelihood of affecting all patients admitted to Unit 3B. Findings follow:

A. Review of policy titled "Assignment of Nursing Staff" last revision 01/2024, showed that an RN was assigned to each patient unit.
B. Review of staffing sheets dated 07/28/2024 through 10/18/2024, showed Unit 3B had the capacity for 12 patients and frequently staffed with only one RN unless acuity was high.
C. Observation on 11/18/2024 at 5:40 PM of adolescent Unit 3B's medication room showed there was no refrigerator available for refrigerated medications.
D. During an interview with the Nurse Manager on 11/18/2024 at 5:40 PM and on 11/19/2024 at 9:30 AM with RN #1, both confirmed that Nurses were required to leave Unit 3B and retrieve refrigerated medications from unit 3A thereby leaving Unit 3B temporarily without a RN.