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Based on observations, interviews and record review, the facility failed to:

I. Ensure that patient treatment plan interventions were updated after episodes of seclusion and/or restraint for 6 of 6 non-sample patients who were reviewed for seclusion/restraint episodes that occurred after 6/6/11 (D3, D6, D9, D16, D17 and D18), and/or where seclusion/restraint episodes prior to 6/6/11were not addressed at treatment team meetings occurring on or after 6/6/11 (D16 and D17).The failure of the treatment team to develop alternative plans of treatment has resulted in continued episodes of seclusion/restraint for each of these patients, and has resulted in continuing violence on the unit and criminal charges being filed against patients for assault and lewd conduct. (Refer to B125-I)

II. Ensure that 18 of 18 patients on Unit D were provided active treatment during the time surveyed, starting 6/6/11 through the date of the survey 6/15/11. There was a loss of programming stemming from the unit's Activity Therapist being reassigned elsewhere without replacement, as well as a two week hiatus from unit schooling without structured programming provided for the patients. This failure of active treatment has led to more unstructured time for patients on the unit and may have contributed to increased incidents of violent behavior exhibited by patients over the days prior to the survey. (Refer to B125-II)

I. Based on observation, interview and record review, the facility failed to ensure that patient treatment plan interventions were updated after episodes of seclusion and/or restraint for 6 of 6 non-sample patients whose records were reviewed for treatment team responses on or after 6/6/11 to the patients' recent seclusion/restraint episodes (D3, D6, D9, D16, D17 and D18). For all six patients, no changes were made to treatment plans. The failure of the treatment team to develop alternative plans of treatment has resulted in continued episodes of seclusion/restraint for each of these patients and has resulted in continuing violence on the unit and criminal charges being filed against patients for assault and lewd conduct.

II. Based on observation, interview and document review, the facility failed to provide active treatment for 18 of 18 non sample patients on Unit D (D1 through D18) during the period of time starting 6/6/11 through the date of the survey 6/15/11. These failures were secondary to a loss of programming stemming from a reassignment of the unit's Activity Therapist elsewhere without replacement, as well as a current two week hiatus from unit schooling, without having structured programming provided for the patients. These failures of active treatment have led to more unstructured time for patients on the unit and may have contributed to increased incidents of violent behavior exhibited by patients over the month prior to the current survey.

I. Seclusion and Restraint Treatment Team Reviews

Findings include:

A. Observation

In an observation on June 14, 2011 between 1:45PM and 2:30PM, the surveyor witnessed escalating verbal arguing between two adolescent patients on unit D (D9 and D16). The two patients started yelling at each other with increasingly verbal threats of violence. There was one Mental Health Assistant (MHA) in the day room at the time, as well as 5 other non sample patients. The staff did not intervene until the two boys started fist fighting and wrestling. Another staff member (MHA) located in the nurse's station was unable to assist with stopping the fight because other patients blocked the exit door to the day room and would not let the staff member out. Both boys were separated after a few minutes by other staff coming to the unit in response to a panic button activation. Both patients had physical holds placed on them in order to control the fight and subsequent agitation that followed with de-escalation. Neither patient ended up with any other form of restraint or seclusion. The unit RN was not present at the time of the incident (off the grounds obtaining lunch); no other RN was present at the time on the unit. A Licensed Practical Nurse (LPN) was outside in a courtyard disarming another patient that had secreted rocks in his clothes with the intent to harm staff later that day as part of a riot attempt (per LPN staff report).

B. Interviews

1. In an interview on 6/13/11 at 1:30PM, the unit manager for unit D stated that "the kids here are troubled kids that have nowhere else to go. We do more criminal behavior management than mental health work here." In a second interview with the unit manager on 6/14/11 at 2:30PM, just after the observed incident noted above, the unit manager stated that "we talk about each episode of seclusion and restraint during treatment team meetings on Tuesdays and Fridays." She was then asked about changing the master treatment plans to address the behaviors that led to the seclusion or restraint; she stated "occasionally we make changes, but usually we wait until there are enough citations (criminal charges) that the probation officer takes them to juvenile hall for a few days; the kids are usually better when they return here from detention."

2. In an interview on 6/14/11 at 2:30PM with RN2 on unit D, s/he stated that "the two MHAs out on the unit are agency (outside agency) people and they don't know what to do for the patients,.... We can't keep these kids in control."

3. In an interview on 6/14/11 at 2:45PM with the Medical Director of the Adolescent Programs, who is also an attending physician on unit D, she was shown the master treatment plan for Patient D16, who had had 14 episodes of seclusion or restraint in the prior month, and was asked to compare the master treatment plan updates from 2/11 and 6/6/11. She stated, "the interventions haven't been changed." When asked if the interventions should have been changed to address the increase in aggressive behaviors, she stated, "I guess we should have done that." She was then asked if other patient's master treatment plans looked the same from month to month, she stated, "you'll find that to be true for most patients."

4. In an interview on 6/15/11 at 10:00AM, Patient D16 stated "I don't really get help with my behaviors here; there are fights every day and I don't feel safe here; staff isn't very nice to me and then don't stop fights before they happen."

5. In an interview on 6/15/11 at 10:15AM, Patient D9 stated, "I don't go to the treatment plan meetings, I don't care, nothing ever changes about my treatment here, and I'm just waiting until they tell me I'm going home."

C. Record Review

1. Patient D3: An Adolescent Master Treatment Plan updated 6/10/11 noted that Patient D3 had been secluded on 6/8/11 for "exposed [himself], swallowed a patient's pill, threw chairs, and while in seclusion smeared feces on the wall." The Master Treatment Plan (MTP) did not have any goals or interventions included that addressed these issues and was similar to a MTP dated 5/6/11. Patient D3 was charged with Assault and Lewd Conduct for this incident, noted in summonses left in the patient's medical record by police.

2. Patient D6: Physician's Order dated 6/7/11 at 2:50 PM noted "1. Physical Hold for 2 minutes to escort to seclusion. 2. Closed Door Seclusion for up to 2 hours for aggression." Treatment teams met on 6/10/11 and 6/14/11; Patient D6's MTP had not been updated after this episode of seclusion as of 6/15/11.

3. Patient D9: Patient was placed in closed door seclusion on 6/6/11 at 8:39AM for threatening peers; MTP update on 6/6/11 did not note the episode of seclusion earlier that day and remained unchanged compared to a MTP dated 2/14/11. Patient D9 was charged with two counts of assault for the 6/6/11 incident; Patient D9 also had two public sexual indecency charges pending from 6/4/11, noted from summonses left in the patient's medical record by police. There was no update in the patient's MTP related to these incidents.

4. Patient D16: In spite of the observed incident on 6/13/11 of the patient's aggression and subsequent hold by staff, there was no update to the Adolescent Master Treatment Plan. In the most recent Adolescent Master Treatment Plan update 6/6/11 the narrative section noted that "[Patient D16] required 2 chemical restraints, was placed on Shut Down once, 6 physical holds, 2 closed door seclusions and 2 open door seclusions" between the period of 5/13/11 and 6/5/11. Further review revealed that the MTP updated 6/6/11 was identical to the previous update of 4/15/11 with regard to aggressive and disruptive behaviors; there were no changes made to goals or interventions by 6/6/11 to address the patient's behavioral problems.

5. Patient D17: In an Adolescent Master Treatment Plan updated 6/6/11 the narrative section noted that "[Patient D17] required four chemical restraints for aggressive, disruptive, or assaultive behavior during this two week review period." The MTP dated 6/6/11 was exactly the same with regard to aggressive and disruptive behaviors as the update of 4/25/11; there had been no changes made to goals or interventions by 6/6/11 to address the patient's behavioral problems.

6. Patient D18: In an Adolescent Master Treatment Plan dated 6/13/11 the narrative section noted that "[Patient D18] required (between 5/13/11 and 6/12/11) 10 physical holds, 8 chemical restraints and 5 seclusions during this review period." The MTPs updated 5/13/11 and 6/13/11 were identical with regard to aggressive and disruptive behaviors; there had been no changes made to goals or interventions by 6/6/11 to address the patient's behavioral problems.

7. Incident Report reviews: Surveyors reviewed incident reports for Unit D. The unit averaged between 5 and 6 reports per day, several of which included physical holds, chemical restraint, open and closed door seclusion and mechanical restraint.

D. Policy Review

Arkansas State Hospital Policy and Procedure #ASH 11.12.01 titled "Treatment Planning" dated 3/3/03 and reviewed 5/7/04 under the section titled "Policy" stated: "In addition, a TPU (treatment plan update) meeting should be held whenever clinical circumstances have changed in a manner that requires revision of the MTP."

II. Lack of Active Treatment

Findings include:

A. Observations

1. In an observation on 6/13/11 at 3:00PM on unit D, the surveyors observed 4 female non- sample patients in a day room either watching television or coloring pictures; these activities continued for approximately 70 minutes. In a second day room there were 7 male non-sample patients similarly engaged in diversional activities like coloring, playing with paper dashboards or watching television; two non-sample patients were sleeping on the floor of the dayroom during most of the observation period. Half of the unit patient population was supposed to be in school (per the schedule; however, school was on hiatus) and the other half was scheduled for "Problem Solving and Stress Management" group which did not occur.

2. In an observation on 6/14/11 at 2:30PM on unit D, 5 male non- sample patients were in the day room either watching television, coloring or sleeping on the floor. There were two staff members (MHAs) in the room, neither of whom was engaged with the patients. On the female side of the unit, there were 4 non-sample patients in the day room; 1 was engaged with her interpreter, the other 3 patients were watching cartoons on television. Half of the patients were scheduled for school at this time and the other half were scheduled for "Expressive Art" group; neither activity occurred that day.

3. In an observation on 6/15/11 at 10:00AM on unit D, approximately 9 of the 14 male non-sample patients were in the dayroom at one time or another, again watching television, playing with paper dashboards or sleeping on the floor. On the female side of the unit, the four non-sample patients were coloring or watching television. There were four non-sample male patients attending "Survivor's Group" that morning (5 non-sample patients did not attend) and 9 non-sample patients were scheduled to attend school, which was on hiatus.

B. Interviews

1. In an interview on 6/13/11 at 1:00PM the Adolescent unit manager stated that "when school is out we don't have a lot of activities on the unit for the kids; we just go outside in the mornings and try to keep the kids out of trouble the rest of the day. We haven't had much activity in treatment since our activities therapist was transferred to an adult unit earlier this year. We just try to keep them busy to keep them out of trouble; we've had too many riots here lately."

2. In an interview on 6/14/11 at 2:30PM with RN2 on unit D, s/he stated that "the two MHAs out on the unit are agency (outside agency) people and they don't know what to do for the patients.... We can't keep these kids in control."

3. In an interview on 6/15/11 at 9:30AM, Patient D16 stated that "there aren't many groups during the day; I just play with my car (paper dashboard) and use my imagination. I like the gym and the art room, but I don't get to go because my level is always too low."

4. In an interview on 6/15/11 at 10:00AM, Patient D17 stated, "I go to school from 1 to 4; in the mornings I lay on the floor and sleep because I don't have the level to go to art, RT (recreation therapy), or gym (all off unit activities). On the unit, I watch TV, play cards or dominoes or sleep."

5. In an interview on 6/15/11 at 10:30 AM the supervisor of Activities Therapy stated that "Unit D hasn't had a lot of structured activity since the therapist transferred to another unit." She agreed that without school being in session there was more unstructured time on the unit.

C. Document Review

1. Review of the "Adolescent Unit D" schedule dated 4/7/10 noted that without the 3 hour daily school activity in session the patients on unit D were scheduled to receive up to 3 hours per day of structured therapeutic activities/groups either in a morning block or an afternoon block. There were no structured activities after 4 PM on weekdays and only 4 hours of structured activities on the weekends (Recreation, Explorers, Role Model, and Home Economics).

2. Incident Report reviews: Surveyors reviewed incident reports for Unit D. The unit averaged between 5 and 6 reports per day, several of which included physical holds, chemical restraint, open and closed door seclusion and mechanical restraint.

Based on observations, interviews and record review, the Medical Director failed to:

I. Ensure that patient treatment plan interventions were updated after episodes of seclusion and/or restraint for 6 of 6 non-sample patients whose records were reviewed for treatment team responses on or after 6/6/11 to the patients' recent seclusion/restraint episodes (D3, D6, D9, D16, D17 and D18). For all six patients, no changes were made to treatment plans. The failure to ensure that the treatment team developed alternative plans of treatment resulted in continued episodes of seclusion/restraint for each of these patients and has resulted in continuing violence on the unit and criminal charges being filed against patients for assault and lewd conduct. (Refer to B125-I.)

II. Ensure that 18 of 18 non-sample patients on Unit D (D1 through D18) were provided active treatment during the time reviewed, starting 6/6/11 through the time of the survey 6/15/11. This failure was in part secondary to a loss of programming stemming from a reassignment of the unit's activity therapist without replacement, as well as a two week hiatus from unit schooling without structured programming provided for the patients. These failures of active treatment have led to more unstructured time for patients on the unit and may have contributed to increased incidents of violent behavior exhibited by patients over the month prior to the survey. (Refer to B125-II)

Based on observation, document review and interviews, it was determined that the facility has failed to plan and implement structured programming of therapeutic activities for the needs of 18 of 18 non-sample patients (D1 through D18) on adolescent unit (Unit D). Seven of the male patients and 2 of the female patients did not have off unit privileges in order to participate in gym, art, recreation therapy or outings; the only substitute activities were diversional, such as viewing commercial television or coloring, without active engagement by facility staff. The lack of structured therapeutic activities has contributed to a chaotic milieu. The unit has not had an activities therapist since February 2011 and does not provide evening activities, and provides only 4 hours of programmed activities on the weekends. These failures to provide increased structure for this population has led to an inability to deliver an important mode of treatment that may lead to more comprehensive inpatient care and more timely discharge.

Findings include:

A. Observations

1. In an observation on 6/13/11 at 3:00PM on unit D, the surveyors observed 4 female non- sample patients in a day room, either watching television or coloring pictures; these activities continued on for approximately 70 minutes. In a second day room there were 7 male non-sample patients similarly engaged in diversional activities like coloring, playing with paper dashboards or watching television; two non-sample patients were sleeping on the floor of the dayroom during most of the observation period. Half of the unit patient population was scheduled to be in school during that time (school was on hiatus and there was no indication that a substitute program had been developed) and the other half were scheduled for "Problem Solving and Stress Management," group which did not occur.

2. In an observation on 6/14/11 at 2:30PM on unit D, 5 male non-sample patients were in the day room watching television, coloring or sleeping on the floor. There were two staff members (MHAs) in the room, neither of whom was engaged with the patients. On the female side of the unit, there were 4 non-sample patients in the day room; 1 was engaged with her interpreter, the other 3 patients were watching cartoons on television. Half of all the patients on the unit were scheduled for school at this time and the other half were scheduled for "Expressive Art" group; neither activity occurred that day.

3. In an observation on 6/15/11 at 10:00AM on unit D, nine of the male non-sample patients were in the dayroom at one time or another, again watching television, playing with paper dashboards or sleeping on the floor. On the female side of the unit, the four non-sample patients were coloring or watching television. There were four non-sample male patients attending "Survivor's Group" that morning (5 non-sample patients who were scheduled to attend did not) and 9 non-sample patients were scheduled to attend school (the 9 patients included the four female patients in another dayroom watching television), which was on hiatus.

B. Interviews

1. In an interview on 6/13/11 at 1:00PM the Adolescent unit manager stated that "when school is out we don't have a lot of activities on the unit for the kids; we just go outside in the mornings and try to keep the kids out of trouble the rest of the day. We haven't had much activity in treatment since our activities therapist was transferred to an adult unit earlier this year. We just try to keep them busy to keep them out of trouble; we've had too many riots here lately."

2. In an interview on 6/14/11 at 2:30PM with RN2 on unit D, s/he stated that "the two MHAs out on the unit are agency (outside agency) people and they don't know what to do for the patients.... We can't keep these kids in control."

3. In an interview on 6/15/11 at 9:30AM with Patient D16, he stated that "there aren't many groups during the day, I just play with my car (paper dashboard) and use my imagination. I like the gym and the art room, but I don't get to go because my level is always too low."

4. In an interview on 6/15/11 at 10:00AM, Patient D17 stated, "I go to school from 1 to 4; in the mornings I lay on the floor and sleep because I don't have the level to go to art, RT (recreation therapy), or gym (all off unit activities). On the unit, I watch TV, play cards or dominoes or sleep."

5. In an interview on 6/15/11 at 10:30AM the supervisor of Activities Therapy stated that "Unit D hasn't had a lot of structured activity since the therapist transferred to another unit." She agreed that without school being in session there was more unstructured time on the unit.

C. Document Review

Review of the "Adolescent Unit D" schedule dated 4/7/10 noted that without the 3 hour daily school activity in session the patients on unit D were scheduled to receive up to 3 hours per day of structured therapeutic activities/groups either in a morning block or an afternoon block. There are no structured activities after 4PM on weekdays and only 4 hours of structured activities on the weekends (Recreation, Explorers, Role Model and Home Economics).