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Based on review of policy, observation, clinical record review, interview, and video review it was determined the facility:
A. Failed to provide a safe environment in which children were free from physical and sexual harm.
B. Failed to maintain a structurally safe and secure environment, free of defects, ligature risk, and pests.
C. Facility failed to maintain an adequate number of staff to patients to ensure a safe environment was maintained.
See A-0144

Based on review of policy, observation, clinical record review, interview, and video review it was determined the facility failed to provide a safe environment in which children were free from physical harm. The failed practice allowed children to experience physical harm by other patients and/or staff members. The failed practice had the likelihood of affecting all patients receiving care in the facility.
A. Review of policy "Special Precautions Policy and Procedure - MBH" last reviewed 08/25/21, showed the patients ordered to have line of sight (LOS) observation level "The patient must always remain in the line of sight of a staff member..."also the patient "remains on every fifteen (Q15) minute" monitoring.
B. Review of policy "Safety and Supervision" last revised 08/15/18, showed "patients are never together without staff maintaining visual contact". Additionally, when patients are in a classroom "direct care staff shall ensure that patients are monitored at all times" and that "staff should be seated in a location that will allow full view of patients at all times."
C. During a review of videos on 07/24/25 at 10:30 AM and review of clinical records, the following was found:
a) Review of video dated 06/12/25 time stamp viewed 2:05 PM to 2:17 PM, showed 3 male children aged 8 to 10 years old, (Patient #3 and two unidentified patients) in the dayroom of unit #2. A very large male, Behavioral Instructor (BI) #1, was observed entering the room and sitting on the back wall of chairs while talking on a cell phone throughout most of the video. The three children were observed pacing in the dayroom and appeared to be anxious and/or bored. At 2:12 PM all three children were observed walking around a corner out of camera sight. After a few seconds Patient #3 is observed running back into the dayroom area where he picked up two plastic chairs, which were unsecured, threw them and broke them into multiple pieces. Licensed Practical Nurse #1 was observed running into the dayroom and removing the broken chairs pieces while BI #1 re-entered the dayroom and is seen putting Patient #3 in a "basket hold" and pinning the child against the wall with his full weight. After a few seconds BI #1turns to face the dayroom and is observed "twisting" Patient #3's wrist in an upward angle, while maintaining the hold. After approximately two minutes BI #1 was observed forcibly thrusting Patient #3 forward, causing the child to stumble as he ran to get distance from BI #1.
b) Evidence was requested on 07/24/25 at 11:00 AM, which showed the incident observed in the video dated 06/12/25 between 2:05 PM and 2:17 PM had been documented in the patient's chart and that it had been reported to his legal representatives, none was provided.
c) Review of the "Report to Quality Assurance" dated 06/12/25, at 2:33 PM, showed Patient #3 "became dysregulated and punched wall. Bruising and swelling noted to right hand". Additionally, a witness statement sent to the Director of Nursing on 06/16/25 at 12:57 PM, showed staff placed patient in "incorrect Crisis Prevention Intervention (CPI) hold". The report stated, the guardian had not been notified.
d) Evidence was requested on 07/24/25 at 11:00 AM, which showed the facility had investigated the incident and/or implemented interventions or training to prevent recurrence of these types of incidents, none was provided.
e) During an interview with the Administrator on 07/24/25 at 2:30 PM, she stated, The employee who performed the improper hold was terminated and a police report was filed, however, there was no evidence provided which showed the other staff observed in the video or on the unit had been re-educated.
f) Review of video dated 07/09/25 time stamp reviewed 8:40: AM to 9:00 AM, showed two Behavioral Instructors (#2 and #3) with 8 young male children (Patients #6, #8-#9, and #12-#19) enter a classroom. The children were seated and placed their heads on the table. BI #3 was seated at a large desk and BI #2 stood in the corner. After approximately a minute BI #2 left the room, leaving BI #3 with 1:8 staffing. After another minute or two BI #2 returned to the classroom with another young child who sat at a desk and put his head down. BI #2 again left the classroom leaving BI #3 with 1:9 staffing. During the review two more adult males, BI #4 and the Pastoral Care Director, entered spoke to BI #3 and then left the room. During this time a patient was observed banging his head on the table and the other young patients lifted their heads to look around. Again, BI #2 entered the classroom with 2 more young male patients, bringing the total number up to 11 children. BI #2 exited the classroom again and right after BI #3 was observed leaving the desk and stepping outside the door. At this time 11 children (Patients #6, #8-#9, and #12-#19) were alone for approximately 30-40 seconds. BI #2 and #3 stepped back into the classroom at which time one young male was observed walking across the classroom and attacking and punching another child multiple times in the face and head area. BI #3 slowly walked over and intervened. Another set of young males on the other side of the classroom also began attacking and punching each other. BI #2 appears to call for help at which time the Director of Nursing, the Pastoral Care Director, and the Nutritional Director entered the room and helped regain control of the children. The event lasted from 8:40 AM to 8:59 AM.
g) Review of the "Report to Quality Assurance" dated 07/09/25 at 9:14 AM, showed a leadership review was performed of the classroom incident. It states Patient #9 "returned from class, mouth bleeding. Peer hit him with closed fist on left side of face". Review of Patient #9's observation record showed, patient "did fight other peer and got jumped by other peers in classroom."
h) Review of Patient #9's clinical record, showed a physician order was placed on 07/09/25 at 11:42 AM, for an x-ray of the "left jaw/check". An x-ray report dated 07/09/25 at 4:17 PM showed "no acute fractures".
i) Evidence was requested which showed the facility had investigated the incident and/or implemented interventions to prevent recurrence of these types of incidents on 07/24/25 at 11:00 AM, none was provided.
D. Review of clinical records for six Patients (#2, #4, #6, #8-#10) of ten (#1-#10) reviewed, showed gaps in Q15 minute monitoring as ordered by the physician. The gaps extended from 15 mins to more than 14 hours with no documented reason for the missing observations in the record.
a) Patient #2, showed no evidence of monitoring as ordered on:
06/11/25 from 11:00 AM to 2:00 PM (3 hours)
06/16/25 from 11:15 PM to 11:45 PM (30 minutes)
06/21/25 from 3:30 PM to 11:45 PM (8 hours 15 minutes)
07/04/25 from 8:45 PM to 9:00 PM (15 minutes)
07/14/25 from 3:15 PM to 10:45 PM (8 hours 30 minutes)
07/17/25 from 12:00 AM to 6:45 AM (6 hours 45 minutes)
b) Patient #4, showed no evidence of monitoring as ordered on:
06/27/25 from 4:00 PM to 4:45 PM (45 minutes)
07/04/25 from 8:45 PM to 9:00 PM (15 minutes)
07/14/25 from 3:15 PM to 10:45 PM (7 hours 30 minutes)
07/16/25 from 4:15 PM to 10:45 PM (6 hours 30 minutes)
07/17/25 from 12:00 AM to 6:45 AM (6 hours 45 minutes)
07/19/25 from 6:00 PM to 6:45 PM (45 minutes)
07/23/25 from 9:00 PM to 10:45 PM (1 hour 45 minutes)
c) Patient #6, showed no evidence of monitoring as ordered on:
05/02/25 from 12:00 AM to 2:45 PM (14 hours 45 minutes)
05/05/25 from 11:15 PM to 11:45 PM (30 minutes)
05/08/25 from 1:30 PM to 2:45 PM (1 hour 15 minutes)
07/02/25 from 9:15 PM to 10:45 PM (1 hour 30 minutes)
07/09/25 from 12:00 AM to 6:45 AM (6 hours 45 minutes)
d) Patient #8, showed no evidence of monitoring as ordered on:
06/26/25 from 8:45 PM to 10:45 PM (2 hours)
07/07/25 from 9:45 PM to 10:45 PM (1 hour)
07/09/25 from 12:00 AM to 6:45 AM (6 hours 45 minutes)
e) Patient #9, showed no evidence of monitoring as ordered on:
05/02/25 from 11:15 PM to 11:45 PM (30 minutes)
05/05/25 from 3:15 PM and 11:15 PM to 11:45 PM (45 minutes)
06/24/25 from 11:15 PM to 11:45 PM (30 minutes)
07/02/25 from 9:15 PM to 10:45 (1 hour 30 minutes)
07/07/25 from 9:45 PM to 10:45 PM (1 hour)
07/09/25 from 12:00 AM to 6:45 AM (6 hours 45 minutes)
f) Patient #10, showed no evidence of monitoring as ordered on:
06/04/25 from 2:00 PM to 2:15 PM (15 minutes)
07/04/25 from 8:45 PM to 9:00 PM (15 minutes)
07/14/25 from 9:00 PM to 9:15 PM (15 minutes)
07/17/25 from 12:00 AM to 6:45 AM (6 hours 45 minutes)
E) During an interview on 07/24/25 at 2:30 PM, the Administrator and the Director of Nursing confirmed the findings in A-D.


Based on review of staffing schedules, observation, and interview, it was determined the facility failed to maintain a staff to patient ratio to ensure a safe environment was maintained. The failed practice increased the risk for adverse events and led to an unsafe environment. The failed practice had the likelihood of affecting all patients admitted to the facility.
A. Review of policy "Staffing Policy" last revised 05/2023, showed that "during the day and evening the minimum number is one staff ...to every four to five (4-5) patients."
B. Review of video dated 06/10/25 time stamp viewed from 3:30 PM to 3:50 PM, showed two Patients #1 (a seven-year-old male) and #2 (a ten-year-old female), in the dayroom of psychiatric unit #3 alone with no adult presence for more 20 minutes at which time an incident occurred between the children. Review of the staffing schedule dated 06/10/25 for 3:00 PM to 11:00 PM, showed a Nursing Supervisor, one Registered Nurse and two Behavioral Instructors had been scheduled to provide patient care on unit #3.
C. Review of video dated 07/09/25 time stamp reviewed 8:40: AM to 9:00 AM, showed one adult staff member with eleven (11) children in a classroom with intermittent entrance and exit of a second adult. At one point during the video observation no adult was present in the classroom for approximately 30-40 seconds. Immediately following the adults return several incidents could be seen occurring in which additional staff had to respond to help control.
D. During an interview on 07/24/25 at 10:30 AM, the Director of Nursing confirmed the findings in A-C.


Based on review of policy, observation, and interview it was determined the facility failed to maintain a structurally safe and secure environment, free of defects, ligature risk, and pests. The failed practice allowed for an environment in which patients had the potential for injury and/or harm. The failed practice had the likelihood of affecting all patients, staff, and visitors in the facility.
A. Review of policy "Suicide Risk Assessment and Prevention Policy" effective 2019, showed one purpose of the policy is to "ensure a safe hospital environment that is free of ligature and self-harm risk ..."
B. During a tour of the facility on 07/23/25 between 9:00 AM and 10:00 AM, showed the following safety hazards and/or defects:
a) Patient care units, one through four (1-4), had three (3) offices on each unit. Each office had hinges that extended outside the door frame posing a ligature risk.
b) The double doors leading to the "Priv Crib" hallway used by patients to enter classrooms and other activity areas had two hinges that extended outside of the door frame and a U-shaped doorknob that was not ligature free.
c) Ceiling tiles throughout all patient care areas in the facility showed stains, bulging/bowing, holes, bent mental holding strips, and/or missing tiles.
d) The back doors on unit 1 and unit 4 showed gaps to the outside which allowed pests to enter. Pests were observed entering the facility during the tour through these gaps.
e) The seclusion room on unit 3 showed large areas of chipped paint on the floor.
C. During the tour findings in A and B were confirmed with the Administrator on 07/23/25 between 9:00 AM and 10:00 AM.


Based on review of policy, nursing employee records and interview, it was determined the facility failed to follow federal and state guidelines in that three of ten employee records reviewed showed no evidence of a baseline tuberculosis (TB) assessment. The failed practice put patients at risk of exposure to individual staff members who had the potential of be infected with TB. The failed practice had the likelihood of affecting all patients, staff, and visitors in the facility.
A. Review of policy "Tuberculosis Prevention and Control Plan, last revised 08/23, showed the facility "will enforce the latest recommendation of the Center for Disease Control and Prevention (CDC) regarding prevention of occupational transmission of TB." Also, for new employees ..."are required to present proof of baseline TB skin test within the last 6 years upon hire, if the employee cannot provide proof they will undergo a TB screening process that includes a baseline risk assessment, TB symptom evaluation, TB skin test, and additional evaluation for TB as needed." If an individual has a positive skin test, they will be "referred to their private physician or to the County Health Department for follow up and/or treatment."
B. Review of employee records on 07/25/25 at 9:00 AM, showed three employees, two registered nurses (RN) and one behavioral instructor (BI) of ten records reviewed, showed no evidence that initial TB screening and/or testing had been completed upon hire. One of the RNs employee file had note dated in 2022 that stated the employee had reported having a previous positive TB test and showed the employee had been referred to the County Health Department for further evaluation. No evidence was provided which showed the employee followed up with the County Health Department or evidence of a negative TB result.
C. During an interview on 07/25/25 at 10:30 AM, the Administrator confirmed all three employees still worked in the facility and were currently scheduled in patient care areas and confirmed the findings in A and B.

Based on review of policy, observation, and clinical records, it was determined the facility failed to provide an environment free from sexual harm and/or abuse. The failed practice allowed children to experience sexual abuse from other peers. The failed practice had the likelihood of affecting all patients receiving care within the facility.

A. Review of policy "Special Precautions Policy and Procedure - MBH" last reviewed 08/25/21, showed the patients with who have physician orders for line of sight (LOS) observation level "The patient must always remain in the line of sight of a staff member..." also the patient "remains on every fifteen (Q15) minute" monitoring.
B. Review of policy "Safety and Supervision" last revised 08/15/18, showed "patients are never together without staff maintaining visual contact". Additionally, when patients are in a classroom "direct care staff shall ensure that patients are monitored at all times" and that "staff should be seated in a location that will allow full view of patients at all times."
C. During a review of videos on 07/24/25 at 10:30 AM and review of clinical records, the following was found:
a) Review of video dated 06/10/25 time stamp viewed from 3:30 PM to 3:50 PM, showed Patient #1 (a seven-year-old male) and Patient #2 (a ten-year-old female), in the dayroom of psychiatric unit #3, without an adult physically present within view. Review of Patients (#1 and #2) clinical record showed they were on unit restriction and were to be observed via line of sight (LOS). Video review showed Patient #1 and #2 hide below the nurses station windows out of view next to the solid wall at 3:43 PM at which time Patient #2 performed oral sex on Patient #1. Both children got up and checked to make sure no one had seen them and again went under the windows at 3:45 PM and repeated the act. The children again stood up walked around the dayroom appearing to make sure no one had seen them. At 3:47 PM, Patient #1 laid down behind a row of plastic chairs in the dayroom and Patient #2 repeated the sex act a third time. Both children stood up and Patient #2 was seen knocking on the nurses station widow at 3:49 and an adult was observed coming out of the nurses' station. At 3:50 PM a male is seen coming out of an office door and talking with Patient #1.
b) During an interview on 07/24/25 at 1:30 PM, the Director of Nursing (DON) stated, The nurses station windows were considered LOS observation as the nurses could see the children through the glass.
c) Review of Patient #1s clinical record showed physician orders for strict unit restrictions, LOS 24/7, elopement precautions, building restriction, and sexually acting out precautions on 06/10/25 from 12:00 AM to 12:00 AM.
d) Review of Patient #2's clinical record showed physician orders for strict unit restrictions, LOS 24/7, suicide and assault precautions, no sharps, spork watch, and sexually acting out precautions on 06/10/25 from 12:00 AM to 12:00 AM. The observation record showed no gaps in staff observations on 06/10/25.
e) Review of "Report to Quality Assurance" dated 06/10/25, at 10:03 AM, showed leadership reviewed of the incident and that it had been reported to the child abuse hotline. Evidence was requested which showed the facility had performed a full investigation of the incident and/or implemented interventions to prevent recurrence of these types of incidents. None was provided.
D. During an interview on 07/24/25 at 2:30 PM, the Administrator and the Director of Nursing confirmed the findings in A-C.

Based on review of pyxis reports, clinical record review, and interview it was determined that one (#10) of ten (#1-#10) patients reviewed received the incorrect dose of medication on three (3) separate occasions. The failed practice had the likelihood to cause patient harm from the patients receiving the incorrect medications. The failure had the likelihood of affecting all patients receiving medications. Findings follow:

A. Review of the Medication Administration Record (MAR) dated 05/30/25, 05/31/25, and 06/01/25, showed Patient #10 had a Physician order for Acetaminophen 325 milligrams (MG), one (1) tablet every four (4) hours as needed for fever or pain.
B. Review of the "Additional Nurse's Notes" section on the MAR, showed Acetaminophen 650 MG had been administered on 05/30/25 at 7:40 PM, 05/31/25 at 12:55 PM, and 06/01/25 at 2:15 PM, each time for a headache.
C. Review of the "Patient Usage" report dated 05/3025, 05/31/25, and 06/01/25, showed two Acetaminophen 325 milligram (MG) tabs were removed from the Pyxis machine indicating that two tablets had been given as documented on all three occurrences.
D. During an interview on 07/25/25 at 10:15 AM, the Director of Nursing verified the findings in A-C.