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Based on document review, video review, observation, and interview, it was determined that the hospital failed to comply with the Condition for Coverage 42 CFR 482.13, Patient Rights.

Findings include:

1. The Hospital failed to ensure that patient observational rounds included visualizing the patient's face; noting the patient's active precautions; and documenting the completion of rounds, including patient's behavior and location at least every 15 minutes to ensure patient safety. (A-144 A).

2. The Hospital failed to ensure that routine room and unit inspections for contraband were completed as required. (A-144 B).

A. Based on observation, document review, and interview, it was determined that for 3 of 8 patients (Pt. #2, Pt. #4, and Pt. #11) reviewed for monitoring, the hospital failed to ensure that patient observational rounds included visualizing the patient's face; the patients' ordered precautions were marked accurately on the rounding/observation sheets; and the patients' behavior and location were documented at least every 15 minutes to ensure patient safety.

Findings include:

1. A tour of the Adolescent Boys Behavioral Health Unit (2 North) was conducted on 7/2/2024, at approximately 9:00 AM. There were 9 patients on census, of which 6 were on suicide precautions. The following was observed:
- Every 15 minute (Q15) patient rounds were being done by Mental Health Specialist (MHS/E#9) at start of the tour. E#9 was in progress of documenting the 9:00 AM rounds. The round sheets were reviewed and one patient's (Pt. #2) rounding sheet did not have any precautions marked.
- At approximately 9:50 AM, Pt. #2 was noted to go into Pt. #2's room, laid in the bed, and covered Pt. #2's entire body (including head/face) with a blanket. At approximately 9:55 AM, a Nurse (E#4) was rounding on patients and went into Pt. #2's room to check on Pt. #2 but did not uncover Pt. #2's face.

2. The hospital's policy titled, "Patient Observation Rounds Process" (revised 8/2022), was reviewed and required, " ...Action Steps: 1. Charge Nurse: ...Conducts a review of the Observation Rounds sheets/process and signs each patient's Observation Round Sheet twice per shift ... Makes all changes to the patient observation forms regarding precautions ... MHS: Review and update patient observation form and reflect any room or bed changes, new admissions and/or discharges as they occur ...Observe each patient, a minimum of every 15 minutes and/or according to precaution level and document observation of the patient observation form ... Verify correct patient by: ID band, patient photo, asking the patient to tell you his/her first and last name and/or birth date. Document patient location and behavior when the observation occurs on the patient observation form ... Observe patients on bed rest or when sleeping by: Staff must enter bedrooms to verify patient identity and confirm presence of respirations from a close proximity to ensure that the patient is not in distress ..."

3. The clinical record of Pt. #2 indicated that Pt. #2 was admitted on 7/1/2024, at 8:34 PM, with a diagnosis of disruptive mood dysregulation disorder. Admission orders, dated 7/1/2024 at 10:51 PM, included precautions for elopement (EP) and self-injurious behaviors (SIB) and indicated that Pt. #2 was on routine Q15 minute monitoring. The patient observation form, dated 7/1/2024, was not marked for SIB precautions as one of the precautions ordered. The patient observation form, dated 7/2/2024, did not have any precaution types marked.

4. The clinical record of Pt. #4 indicated that Pt. #4 was admitted on 6/27/2024 at 6:31 PM, with a diagnosis of disruptive mood dysregulation disorder. Admission orders, dated 6/27/2024 at 6:35 PM, indicated that Pt. #4 was on routine Q15 minute monitoring for suicide, sexual victimization, assault/homicide, and elopement. Patient observation forms from 6/27/2024 to 7/2/2024 did not have suicide precautions marked as one of the precaution types ordered for Pt. #4.

5. The clinical record of Pt. #11 indicated that Pt. #11 was admitted on 6/28/2024 at 11:28 AM, with a diagnosis of major depressive disorder. Provider orders, dated 6/28/2024 at 12:00 PM, indicated that Pt. #11 was on routine Q15 minute monitoring for Suicide Precautions (SP), Self-Harm Risk (SIB), and Fire Setting (FS). The patient observation form, dated 6/28/2024, lacked documentation that Pt. #11 was rounded on every 15 minutes between 5:30 PM and 6:00 PM. The patient observation form, dated 7/2/2024, lacked documentation of Pt. #11's location and the initials of the rounder at 5:45 AM and Pt. #11's behavior at 11:45 AM.

6. An interview was conducted with MHS (E#9) on 7/2/2024, at approximately 9:05 AM. E#9 stated that E#9 did not know for certain what precautions Pt. #2 was on, but thought Pt. #2 was on assault precautions. E#9 stated that E#9 was off over the weekend, and Pt. #2 was recently admitted to the unit. E#9 stated that it's important to know what precautions a patient is on so that they can identify behaviors to watch for, and the precaution types should be marked on the rounding sheet. E#9 stated that rounding is done to ensure the safety of the patients and is done continuously. E#9 stated that patient observations need to be documented at least every 15 minutes and should include the patient's behavior, location, and the initials of the person performing the rounds.

7. On 7/2/2024, at approximately 1:25 PM, an interview was conducted with Nurse (E#4). E#4 stated that staff will round at least every 15 minutes. E#4 stated that part of their rounding is to check that no patient is in a room behind closed doors and there is no patient in the wrong room. E#4 stated that at night when patients are sleeping, staff will utilize a flashlight to visualize that patient is breathing by observing for chest rise and fall. E#4 stated that if the patient's head is covered by a blanket, E#4 will not uncover the patient's head. E#4 stated that the requirement to uncover a patient's head is only for patients on 1:1 monitoring.

8. On 7/2/2024, at approximately 2:45 PM, an interview was conducted with the Nurse Educator (E#5). E#5 stated that during patient rounding, staff are doing a quick survey of the room and ensuring sure that patients are not harming themselves. E#5 stated that staff should make note of any ligature risks and items that may be used to harm patient self, staff and other patients. E#5 stated that staff should visualize the patient's face to verify the identity of the patient and ensure the patient is in the correct room and ensure the patient is not harming self. E#5 stated that this is an expectation for all patients, not just 1:1 patients. E#5 stated that at night time, staff are expected to use a flashlight to check on the patient.


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B. Based on document review and interview, it was determined that for 2 of 2 Patient Care Units (2 North and 3 North) reviewed for Environmental and Contraband Rounding, the hospital failed to ensure that routine room and unit inspections for contraband were completed as required. This had the potential to affect all patients on census on these units.

Findings include:

1. The hospital's policy titled, "Contraband Room Searches and Contraband List" (Effective 12/2023), was reviewed and required, "...10. The RN [Registered Nurse] ensures that routine room and unit inspections are completed every shift to screen for contraband and restricted use items..."

2. The Unit Environment Rounding logs for 2 North were reviewed from June 1 to July 1, 2024 and lacked environmental rounds for the following dates and shifts:
6/1/2024 to 6/2/2024 (AM (morning) and PM (evening) Shift); 6/3/2024 (PM Shift); 6/5/2024 to 6/6/2024 (AM and PM Shift); 6/8/2024 (PM Shift); 6/9/2024 (PM Shift); 6/10/2024 (AM Shift); 6/11/2024 to 6/12/2024 (AM and PM Shift); 6/13/2024 (PM Shift); 6/14/2024 (AM and PM Shift); 6/15/2024 (AM Shift); 6/16/2024 to 6/18/2024 (AM and PM Shift); 6/19/2024 (AM Shift); 6/20/2024 (AM Shift); 6/21/2024 (AM and PM Shift); 6/22/2024 (PM Shift); 6/23/2024 to 7/1/2024 (AM and PM Shift).

3. The Unit Environment Rounding log for 3 North was reviewed from June 1 to July 1, 2024 and lacked environmental rounds for the following dates and shifts:
6/1/2024 to 6/2/2024 (AM and PM Shift); 6/3/2024 (AM Shift); 6/4/2024 to 6/11/2024 (AM and PM Shift); 6/12/2024 (PM Shift); 6/13/2024 to 6/18/2024 (AM and PM Shift); 6/19/2024 (PM Shift); 6/20/2024 (AM Shift); 6/21/2024 to 6/23/2024 (AM and PM Shift); 6/24/2024 (AM Shift); 6/25/2024 to 6/26/2024 (AM and PM Shift); 6/27/2024 (AM Shift); 6/28/2024 to 6/29/2024 (AM and PM Shift); 6/30/2024 (PM Shift); and 7/1/2024 (AM and PM Shift).

4. On 7/2/2024 at approximately 9:40 AM, an interview was conducted with MHS (Mental Health Specialist) E#9. E#9 stated that Environmental and Contraband rounding is done twice a day. One for AM (morning shift) and another for PM (evening shift).