HospitalInspections.org

Based on observation, interview, record review and document review, the facility failed to:

1) Ensure consent was obtained for medication and admission (See Tag A 0131).

2) Ensure a patient was free from all forms of abuse or harassment (See Tag A 0145).

The cumulative effect of these systematic practices resulted in the failure of the facility to protect and promote patients' rights in the delivery of care to patients.

Based on record review, interview and policy review, the facility failed to ensure informed consent was obtained for medication administration for 3 of 31 sampled patients (Patient #14, #18, and #23), 2 unsampled patients (Patient #32 and #33), and 1 of 31 admission consents (Patient #20).

Findings include:

Patient #14 (P14)

P14 was admitted to the facility on 6/24/2020, with a diagnosis of major depressive disorder. P14's Physician ordered Vistaril on 6/24/2020. During a review of the patient's medical record, the Specific Authorization For Medications form was found to be blank.


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Patient #18 (P18)

P18 was admitted on 03/23/2020, with diagnoses of suicidal ideation with bipolar conduct disorder and major depressive disorder.

The physician's order dated 03/23/2020, documented Lamictal 100 milligrams by mouth at bedtime and Seroquel 200 milligrams by mouth at bedtime.

The Specific Authorization For Medications form for P18's medication did not have a signature for Witness #2 for the telephone consent obtained from the legal guardian.

Patient #23 (P23)

P23 was admitted on 05/11/2020, with diagnoses including oppositional defiant disorder, attention deficit hyperactivity disorder, bipolar and substance abuse.

The physician's order dated 06/04/2020, documented Abilify 5 milligrams by mouth twice daily.

The Specific Authorization For Medications form for P23's medication did not have a signature for Witness #2 for the telephone consent obtained from the mother.

Patient #20 (P20)

P20 was admitted on 6/28/12, with auditory hallucinations, oppositional defiance disorder and schizophrenia.

On 7/29/2020 in the morning, P20's Conditions of Admission/Admission Consent form lacked documented evidence of a parent/guardian signature and the date/time. Page 2 of the form was entirely blank.

On 7/31/20 at 11:30 AM, the Chief Executive Officer acknowledged a hospital staff member should have completed the form.


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Patient #32 (P32)

P32 was admitted on 07/29/2020, with a diagnosis of suicidal ideation.

The physician's order dated 07/29/2020, documented Lexapro 10 milligram (mg) by mouth daily and Trazodone 50 mg by mouth at bedtime as needed (PRN).

The Specific Authorization For Medications form was not completed. The following sections of the form were left blank:

- Signature of Patient/Legal Guardian and Date/Time
- Signature of Witness and Date/Time
- Telephone Consent Obtained From, Relationship, Phone #
- Telephone Consent, Witness #1, Witness #2, Date/Time

Patient #33 (P33)

P33 was admitted on 07/28/2020, with a diagnosis of suicidal ideations.

The physician's order dated 07/29/2020, documented Trazodone 50 mg by mouth at bedtime and Lexapro 10 mg by mouth daily.

The Specific Authorization For Medications form for P33's medications did not have signatures for Witness #1 and Witness #2 for the telephone consent obtained from the patient's mother.

On 07/30/2020 at 9:29 AM, a Registered Nurse (RN) confirmed the findings and explained there was no need to complete a Specific Authorization For Medications form for P32 and P33. The physician wrote in the physician's orders the patient's mother consented. The form would have been completed only if the nurse called the patient's guardian and obtained the consent. Two witnesses should have signed the form for consent obtained through telephone.

On 07/30/2020 at 9:45 AM, another RN indicated the nurses should have completed a Specific Authorization For Medications form even if the physicians obtained the consent and wrote "Mom consented" in the physician's order. The form should have been completed with the signatures of two witnesses for telephone consent.

On 07/30/2020 at 2:43 PM, the Nurse Manager revealed the nurses were expected to complete a Specific Authorization For Medications form prior to the administration of medications in the Adolescent Unit. The telephone consent should have been signed by two witnesses.

On 07/31/2020 at 8:30 AM, an RN indicated the nurse should have obtained the consent from the patient/guardian even if the physician wrote in the order the patient/guardian consented. Telephone consent should have been signed by two witnesses.

The facility's policy titled Medication Administration and Records dated November 2015, documented patients who were able to provide expressed and informed consent would have done so; otherwise consent would have been obtained from the guardian/parent/guardian advocate; or an Emergency Treatment Order by the attending licensed practitioner would have been necessary.

Documentation of expressed and informed consent should have been verified by the Nursing Staff and recorded on the Specific Authorization for Psychotropic Medications.

Based on observation, interview, record review, and document review the facility failed to ensure 1) a patient's sexual assault was prevented; 2) staff reported an allegation of sexual abuse; 3) the allegation of sexual assault was reported to authorities in a timely manner per the facility's policy; 4) a timeline of events and facts related to the investigation of an allegation of sexual assault was accurately formulated; 5) documentation of the training for all staff in response to the allegation of sexual assault and to prevent further occurrence of similar incident was provided; and 6) an allegation of physical abuse was reported and investigated for 1 of 31 sampled patients (Patient #1).

Findings include:

Patient #1 (P1)

P1 (victim) was admitted on 10/13/19, discharged on 10/22/19, readmitted on 05/13/2020, and discharged on 05/18/2020, with diagnoses including major depressive disorder, suicidal ideations, and post-traumatic stress disorder. P1 stayed in the Adolescent Unit (West Unit) while at the facility. The patient was under the age of 14 years during the May admission.

Patient #23 (P23)

P23 (alleged perpetrator) was admitted on 05/11/2020 and discharged on 05/18/2020, with diagnoses including bipolar disorder, suicide attempt, oppositional defiant disorder, and cannabis abuse. P23 stayed in the Adolescent Unit while at the facility.

1) Failure to prevent a patient's sexual assault:

Patient #1

P1's Admission Order dated 05/13/2020, indicated suicide precautions including patient observation every 15 minutes.

The physician's order dated 05/18/2020 at 4:30 PM, documented to send P1 to Emergency Room (ER) for rape kit.

A Child/Adolescent Sexual Abuse/Assault Forensic Medical Examination Report dated 05/18/2020, documented probable abuse. The child (P1) had given a spontaneous, clear, detailed description to a neutral fact-finder, with or without positive examination findings.

P1's Discharge Summary dated 05/25/2020, documented on 05/18/2020 P1 was scared in the Day Room (Recreational Room) because one of the boys (a patient) from the Day Room came into P1's room two nights ago, closed the door, and took off P1's clothes. The other patient (one of the boys) took off his clothes. P1 told him to stop, he did not stop initially. They showed their private parts and touched. When P1 said no again, he then stopped and walked out of P1's room. P1 spoke to staff about the incident. Later, P1 told a family member over the phone that P1 was raped.

Patient #23

P23's Admission Order dated 05/11/2020, indicated suicide precautions including patient observation every 15 minutes.

The Discharge Care Plan and Home Medications form dated 05/19/2020, documented P23 was discharged into the custody of a police department and taken to juvenile detention.

On 07/30/2020 at 8:15 AM, a tour of the Adolescent Unit revealed the following:

- There was a nurse's station, a Recreational Room (Day Room), and ten double occupancy patient rooms on one straight hallway with five patient rooms on each side of the hallway.
- The hallway was situated perpendicular to the nurse's station which made the entire hallway visible from the nurse's station. The hall was about 50 feet long and had an exit door at the end.
- A patient telephone was mounted to the wall in front of the nurse's station and just to the left of the entrance to the patient room hallway as seen from the inside of the nurse's station.
- The Recreational Room was situated about 15 feet to the left of the nurse's station and was accessed through a single door.

On 07/30/2020 at 1:22 PM, the Chief Executive Officer (CEO) revealed on 05/18/2020 Patient #6 reported to the Child/Adolescent Therapist about P1 and P23 possibly had interacted sexually on the night of 05/16/2020. The CEO reviewed the video from the surveillance system. The CEO confirmed P23 went inside P1's room on 05/16/2020 at 7:45 PM and left the room at 7:49 PM.

The CEO indicated the Behavioral Health Associate (BHA) unlocked the doors of the patient rooms then went to the Day Room to gather the patients. P1 and P23 snuck behind the BHA unnoticed. The CEO acknowledged the BHA should not have left the doors unlocked and unattended. The BHA should have maintained the line of sight in the hallway when the doors were unlocked.

On 07/31/2020 at 8:30 AM, a Registered Nurse (RN) explained the patient rooms in the West Unit were locked when the patients were not inside the room. When a patient requested to use the bathroom, a nurse or a BHA would unlock the door of the patient's room and remain outside the room or in the hallway to maintain the line of sight of the patient. The staff should not have left the hallway unattended when the patient rooms were unlocked to ensure patient's safety. The entire hallway in the unit where the patient rooms were located was visible from the nurse's station. A patient should not have been allowed to enter another patient's room.

On 07/31/2020 at 8:58 AM, a BHA revealed the patients in the West Unit were observed and monitored every five or 15 minutes per the physician's order. The unit usually had two BHAs and a nurse per shift. The BHAs or the nurse should have been aware of the location of each patient.

On 07/31/2020 at 9:06 AM, another BHA indicated the patients usually stayed in the Day Room or the gym during the day shift. The patient rooms were locked when the patients were not inside their room. Patients should have been escorted by the staff whenever the patients requested to go to their room. Either the BHA or the nurse should have stayed with the patients while the patients were in the Day Room or the gym. Another staff member would have monitored the hallway to ensure patient's safety.

On 07/31/2020 at 9:41 AM, an Attending Physician explained the BHAs and nurses were expected to observe and monitor the patients every five or 15 minutes as ordered. Either the BHAs or the nurse should have been with the patients when the patients transitioned from activities to their rooms.

On 07/31/2020 at 10:05 AM, the Medical Director indicated the staff were expected to maintain the line of sight of the patients to ensure patient's safety. The Medical Director was notified of the allegation of sexual assault which involved P1 and P23. The Medical Director acknowledged the sexual assault could have been prevented if the staff did not lose sight of the patients and did not leave the door unlocked and unattended.

On 07/31/2020 at 10:35 AM, a copy of the recorded video from the surveillance system was viewed with the Risk Coordinator. The video was recorded on 05/16/2020 from 8:10 PM to 8:18 PM in front of P1's room. The video revealed P1 entered the room at 8:10 PM and P23 followed afterwards. P23 left P1's room at 8:18 PM and entered a patient's room across from P1's room.

The Risk Coordinator confirmed the observations from the video and explained the time in the surveillance system camera was 45 minutes ahead of actual time. The events recorded in the video occurred on 05/16/2020 from 7:25 PM to 7:33 PM in real time. P23 was inside P1's room for eight minutes. P1's room was the patient's room near the nurse's station. There were no staff visible in the hallway as seen in the video. The room across from P1's room was P23's room.

On 07/31/2020 at 11:34 AM, another BHA explained a patient could have entered another patient's room if the staff was not watching the hallway. The incident could have been prevented if the staff member had maintained the line of sight of the patients and the hallway.

On 07/31/2020 at 12:40 PM, the CEO explained the BHA assigned to P1 and P23 on 05/16/2020 during night shift, did the patient safety rounds as scheduled every 15 minutes for both patients after P23 left P1's room. The CEO explained there was not enough video copied to the data storage device shown to the Inspectors.

On 08/04/2020 at 7:31 AM, an interview with the BHA assigned to P1 and P23 on 05/16/2020, night shift, was conducted. The BHA indicated night shift started at 7:00 PM. Patients took shower between 7:30 PM to 8:30 PM. Patients could make telephone calls between 7:30 PM to 9:00 PM using the telephone mounted to the wall in front of the nurse's station. Patient's bedtime was at 9:00 PM. The BHA explained a staff member should have monitored each patient during these activities.

The BHA revealed on 05/16/2020, night shift, the BHA unlocked the patient rooms and went to the Day Room. The BHA heard somebody crying in the Day Room. The BHA confirmed there was no staff member who monitored the hallway after the patient rooms were unlocked. The BHA indicated the nurse was pulling-out medications and the other BHA was with the patients who were making telephone calls.

The BHA acknowledged P23 could have been prevented from entering P1's room if the patient rooms were not left unlocked and the staff member did not lose the line of sight in the hallway. The BHA should have asked the other staff to monitor the hallway so the BHA could disengage and attend to the other patients in the Day Room.

On 08/04/2020 at 8:10 AM, the CEO confirmed P1 was sexually assaulted on 05/16/2020. P23 was discharged into the custody of a police department on 05/18/2020 and taken to a juvenile detention unit. The CEO acknowledged the staff could have intervened by maintaining the line of sight of patient's location. The BHA should not have left the patient rooms unlocked when the BHA went to the Day Room. The CEO confirmed the sexual assault could have been prevented.

The facility's policy titled Patient Abuse and Neglect dated 09/01/15, documented no patient was to be mistreated or abused physically, verbally, psychologically or sexually while in the care of the facility.

The facility's policy titled Abuse or Neglect Reporting last reviewed on 01/17/2020, indicated the facility had the responsibility to ensure all patients were free from all types of abuse, neglect, and harassment.

2) Failure of the staff to report an allegation of sexual abuse:

On 07/30/2020 at 1:22 PM, the CEO revealed on 05/18/2020 a patient told the Child/Adolescent Therapist about a possible sexual encounter between P1 and P23 over the weekend. The patients who attended the group therapy session informed the Child/Adolescent Therapist a staff member had told the patients to let it go and forget it, referring to the alleged incident. There were about eight to ten patients who usually attended the group therapy session.

The CEO had watched the video in the surveillance system during the investigation of the allegation of sexual assault. On the 05/17/2020 recorded video, the CEO had observed a BHA talking to a group of patients (P1, P6, P23, and P34) in the gym. The BHA was assigned to the Adolescent Unit on 05/17/2020, day shift.

During the patient and staff interviews, the CEO revealed it was reported that on 5/17/2020, P34 had yelled at P23 upon learning of the alleged incident. The BHA allegedly told the patients, P1 should have said no to the alleged sexual encounter. The BHA told the patients to forget it.

The CEO interviewed the BHA on 05/20/2020. The BHA denied having knowledge of the alleged sexual assault.

The CEO revealed the patients confirmed to the police who were assigned to the case, the BHA told the patients not to talk about the alleged incident. The BHA told the patients to forget about the incident, let it go, and people would not get fired.

The CEO indicated the BHA was suspended on 05/20/2020 pending investigation. The BHA's employment was terminated on 06/01/2020 for failure to report an allegation of sexual abuse. The CEO explained the staff were expected to report an allegation of abuse to their supervisor, Patient Advocate, and CEO immediately.

On 07/31/2020, three BHAs were interviewed regarding abuse reporting.
- At 8:58 AM, the first BHA explained the patients were advised they could express or share anything they wanted to the BHA and not to be scared. The BHA would have reported immediately to the nurse and House Supervisor any allegation of abuse.
- At 9:06 AM, the second BHA indicated any allegation of abuse should have been reported immediately to the nurse, House Supervisor, and Patient Advocate. Patients should have not been discouraged to report an allegation of abuse.
- At 11:34 AM, the third BHA verbalized the patients should have been allowed to express their thoughts. The BHA would have listened to the patients and allowed the patients to report an allegation of abuse. An abuse allegation should have been reported immediately to the nurse, House Supervisor, and Patient Advocate or CEO.

On 07/31/2020 at 9:13 AM, a House Supervisor indicated the staff were expected to report any allegation of abuse to their Supervisor, Patient Advocate, and CEO immediately. A prompt response to the allegation such as making the alleged victim safe and initiating the investigation could have been done, if the abuse allegation was reported immediately.

On 07/31/2020 at 12:00 PM, the Child/Adolescent Therapist revealed during a group therapy session on 05/18/2020 at 9:00 AM, the patients verbalized a lot happened during the weekend. The therapist encouraged the patients to write them in their free-write. All of the patients indicated a staff member told the patients to "let it go, forget it, and not talk about it". There were about eight to ten patients who attended the group therapy. None of the patients wrote about it in their free-write.

On 08/04/2020 at 9:55 AM, the Child/Adolescent Therapist confirmed on 05/18/2020 around 10:00 AM Patient #6 (P6) reported P23 went into P1's room on 05/16/2020 at night and the two patients "made out" and "saw each other's genitals". P6 indicated P1 claimed of being raped. P6 was very fearful to tell the Child/Adolescent Therapist anything and fearful of getting "anyone" in trouble.

The facility's policy titled Abuse or Neglect Reporting last reviewed on 01/17/2020, documented any suspicion of an alleged incident of patient abuse or neglect would have been reported immediately to the charge nurse or immediate supervisor.

3) Failure to report an allegation of sexual assault to authorities in a timely manner per the facility's policy:

Patient #1 (P1)

The physician's order dated 05/18/2020 at 11:00 AM, documented to place P1 on unit restriction. The indication/rationale was sexual aggression related to 05/16/2020 incident.

The physician's order dated 05/18/2020 at 4:30 PM, documented to send P1 to Emergency Room (ER) for rape kit.

The Nursing Reassessment Progress Note dated 05/18/2020, revealed the RN received an order to send patient out for rape kit test. The RN was informed by the Charge Nurse of the receiving hospital, the police should have been notified first prior to transfer. The police department was called at 5:25 PM on 5/18/2020.

A Child/Adolescent Sexual Abuse/Assault Forensic Medical Examination Report dated 05/18/2020, documented probable abuse. The child (P1) had given a spontaneous, clear, detailed description to a neutral fact-finder, with or without positive examination findings.

P1's Discharge Summary dated 05/25/2020, documented on 05/18/2020 P1 was scared in the Day Room (Recreational Room) because one of the boys (a patient) from the Day Room came into P1's room two nights ago, closed the door, and took off P1's clothes. The other patient (one of the boys) took off his clothes. P1 told him to stop, he did not stop initially. They showed their private parts and touched. When P1 said no again, he then stopped and walked out of P1's room. P1 spoke to staff about the incident. Later, P1 told a family member over the phone that P1 was raped.

On 07/31/2020 at 8:30 AM, an RN revealed an allegation of sexual assault should have been reported to the police immediately. The RN should have documented in the Nurse's Notes the date and time the police was notified.

On 07/31/2020 at 9:13 AM, a House Supervisor explained the police should have been notified immediately if there was an allegation of sexual assault.

On 07/31/2020 at 12:40 PM, the CEO indicated the police were notified on 05/18/2020 in the afternoon, prior to sending P1 to ER for rape kit and per the advice of the receiving hospital. The CEO expected the Patient Advocate to call the police immediately when the allegation of sexual assault which involved P1 was reported. The CEO acknowledged there was no documented evidence the police was called immediately after the allegation of assault was reported.

On 08/04/2020 at 8:10 AM, the CEO clarified the nurse should have called the police on 05/18/2020 around 11:00 AM or immediately after the Child/Adolescent Therapist informed the nurse of the allegation of sexual assault. The nurse should have documented in the Nurse's Notes the date and time the police was notified.

The CEO confirmed the findings on the investigation of the allegation of sexual assault was not reported to the Governing Body. The CEO acknowledged the findings should have been presented to the Governing Body during its meeting on 07/02/2020. The Governing Body could have discussed the findings and initiated corrective actions in accordance with the policy.

On 08/04/2020 at 9:40 AM, an RN revealed on 05/18/2020 around 10:45 AM, the Child/Adolescent Therapist informed the RN of an allegation of sexual assault which involved P1. The RN notified the Attending Physician and the House Supervisor. The House Supervisor informed the Patient Advocate who took over the investigation.

The RN explained on 05/18/2020 at 11:00 AM, the physician ordered to place P1 on unit restriction. The indication/rationale was sexual aggression related to the allegation of sexual assault which occurred on 05/16/2020. The RN did not call the police immediately after the Child/Adolescent Therapist informed the RN of the allegation of sexual assault. The RN expected the Patient Advocate to call the police. The RN acknowledged the police should have been called immediately or around 11:00 AM on 05/18/2020 for an allegation of sexual assault.

On 08/04/2020 at 9:55 AM, the Child/Adolescent Therapist confirmed on 05/18/2020 around 10:00 AM, Patient #6 reported P23 went into P1's room on 05/16/2020 at night and the two patients "made out" and "saw each other's genitals". Patient #6 indicated P1 claimed of being raped. The Child/Adolescent Therapist notified the RN about the allegation.

On 08/04/2020 at 10:17 AM, another House Supervisor explained the police should have been notified immediately for an allegation of sexual assault.

The facility's policy titled Examination for Alleged Sexual Assault/Encounter Guidelines last reviewed on 01/10/17, documented after notification of an alleged rape or sexual assault, the RN in charge would immediately notify the following:

- The local police department
- Attending psychiatrist
- The Director of Nursing
- Chief Operating Officer.

The facility's policy titled Abuse or Neglect Reporting last reviewed on 01/17/2020, documented examples of abuse which included rape, sexual assault, or other criminal sexual behavior. The CEO/Designee should have reported the findings of the investigation to the Governing Body who should have initiated any actions required to prevent further future occurrence.

The Minutes of the Board of Governors Meeting on 07/02/2020 did not include the discussion of the findings on the investigation of the allegation of sexual assault which involved P1 and occurred on 05/16/2020.

4) Failure to accurately formulate a timeline of events and facts related to the investigation of an allegation of sexual assault:

On 07/31/2020 at 1:00 PM, the CEO provided a copy of the timeline of events related to the investigation of an allegation of sexual assault. The copy documented 05/18/2020 incident timeline included:

- Peer (patient) advised Child and Adolescent Therapist of incident which occurred on 05/16 between an adolescent and a child.
- Patient Advocate advised CEO of incident reporting around 2:00 PM.
- CEO initiated investigation and notifications.
- Notification to both parents occurred at that time.
- Initiated obtaining statements from patients and employees.

The Incident Investigation Report dated 06/10/2020, documented the incident was reported to a therapist on 5/18, after therapy group at 3:51 PM, by a peer.

On 08/04/2020 at 8:10 AM, the CEO explained a timeline of events and facts should have documented the dates and times the events occurred and should have been accurate and more specific. The timeline should have contained a very good log of every detail which occurred in the conduct of the investigation.

The CEO acknowledged the copy of the timeline provided related to the investigation of an allegation of sexual assault was not accurate nor complete. Per the Incident Report, the Child/Adolescent Therapist reported the incident to the Patient Advocate on 05/18/2020 at 3:51 PM and not at 2:00 PM as indicated in the timeline. The time when a patient reported the allegation of sexual assault to the Child/Adolescent Therapist was not specified. The time when the RN was informed of the allegation of sexual assault on 05/18/2020 around 11:00 AM was not indicated in the timeline. The time of police notification was also not included in the timeline. The CEO provided an amended timeline on 08/04/2020 at 12:30 PM.

The facility's policy titled Abuse or Neglect Reporting last reviewed on 01/17/2020, documented the investigation would have involved confidential interviews with all individuals related to the alleged incident of abuse or neglect. Upon conclusion of interviews, a timeline of events and facts would have been formulated to help identify any factors which have supported the alleged abuse or neglect.

5) Failure to provide documentation of the training for all staff in response to the allegation of sexual assault and to prevent further occurrence of similar incident:

The Incident Investigation Report dated 06/10/2020, documented the corrective action taken as a result of the investigation of the allegation of sexual assault which occurred on 05/16/2020. The corrective action included staff re-education to occur immediately regarding transition time with the House Supervisor on 05/18/2020 during safety huddles. All staff who worked in the unit (Adolescent Unit) on 05/16/2020 were to be counseled and re-educated regarding locking doors and vigilance when transitioning patients from activity areas to rooms.

The Supervisory and Educational Feedback Form which contained the re-education provided to two BHAs and an RN who worked in the unit on 05/16/2020, night shift, were signed by the staff on the dates indicated:

- RN signed on 06/06/2020.
- a BHA signed on 06/06/2020.
- a BHA who was assigned to P1 and P23 signed the form on 06/08/2020.

On 08/04/2020 at 8:10 AM, the CEO explained the re-education regarding locking doors and remaining vigilant when transitioning patients from activity to patient rooms should have been provided to all staff immediately. The re-education was given to prevent further occurrence of similar incident.

The CEO confirmed there was no documentation of the training provided or sign-in sheet of the attendees for the 05/18/2020 staff re-education. The CEO acknowledged all staff should have signed the Supervisory and Educational Feedback Form and not only the three staff who worked in the unit on 05/16/2020, night shift. The CEO indicated the BHA who was assigned to P1 and P23 on 05/16/2020, night shift, should have been counseled on 05/18/2020 instead of 06/08/2020. The CEO revealed the BHA worked in the unit on 05/18/2020, night shift. The re-education and counseling of the BHA should have been immediate.

6) Failure to report and investigate an allegation of physical abuse:

Patient #1 (P1)

A Nurse's Progress Note dated 10/20/19, documented P1's family members visited the patient. A family member reported P1 told them the staff was abusing the patient and putting their hands on P1.

A Nursing Reassessment Progress Note dated 05/14/2020, documented P1 was choked by another patient due to the patient playing truth and dare. P1 gave a love bite (hickey) to another patient. Another patient also gave P1 a love bite. RN discovered this during the assessment of P1's neck while checking for marks from choking.

Review of the Incident Log from July 2019 to July 2020, revealed there was no documented evidence the above-mentioned two incidents were reported and investigated.

On 07/30/2020 at 12:32 PM, the Director of Risk and Performance Improvement confirmed the findings and explained the two incidents should have been reported and investigated. The nurses who had knowledge of the incidents should have completed an Incident Report. The House Supervisor or Risk Manager should have been notified. The Risk Manager could have initiated the investigation once the nurses completed the Incident Report. The incident would have been entered in the Incident Log.

The Director of Risk and Performance Improvement indicated the documentation in the Nurse's Progress Notes on 10/20/19 as described above, was an allegation of abuse and should have been reported and investigated immediately.

On 07/30/2020 at 1:22 PM, the CEO revealed the nurses should have completed an Incident Report for the two incidents mentioned above. The report should have been completed within the shift. The Risk Manager or Patient Advocate could have initiated an investigation when the Incident Report was completed. Incident reporting and investigation were essential to identify the cause and prevent further occurrence of similar incidents. The CEO acknowledged there was no investigation completed for the two incidents.

On 07/31/2020 at 8:30 AM, an RN explained the incident identified on 10/20/19 was an allegation of physical abuse, while the 05/14/2020 documentation was a physical confrontation. The RN explained both incidents should have been reported and investigated. The nurses who had knowledge of the incidents should have completed an Incident Report within the shift. The physician, family, House Supervisor, and Patient Advocate should have been notified.

The facility's policy titled Incident Reporting and Severity last reviewed on 02/01/18, documented an incident was an unanticipated happening which was not consistent with the routine care and/or operation of the facility and may have occurred due to a violation of policy and procedure. Any facility staff member who witnessed, discovered, or had direct knowledge of an incident should complete an Incident Report as soon as practical after the incident was witnessed or discovered, before the end of the shift/work day.

Complaint #NV00061115

Based on observation and interview, the facility failed to ensure the physical environment was maintained in such a manner as to ensure the safety of patients in 2 of 3 buildings (Buildings A & B).

Findings include:

On 7/30/2020 at 2:45 PM, a tour of Buildings A, B, and C was conducted in the presence of the Chief Executive Officer. The following door opener assemblies on the employee-locked doors were observed to be of the lever type, that when in a locked position, could be used as an anchor point and presented a ligature risk.

Building A- Rooms:

-105A
-105B
-113
-114
-127
-128
-130
-144
-145
-162
-165
-166
-170
-The unlabeled door across from the Pharmacy

Building B- Rooms:

-015
-026
-052
-053
-048
-049
-1035
-1038
-1013
-1014
-1041
-1042
-1043
-The two restrooms on the Geriatric Psychiatric Unit

The Chief Executive Officer acknowledged the ligature risk of the door levers.

Based on interview, record review, and policy review, the facility failed to ensure the Public Guardian's Office was informed when a patient under the authority of the Office was discharged.

Findings include:

Patient #9 (P9):

P9 was admitted to the facility on 4/14/2020 with diagnosis of bipolar disorder, after being placed on a Legal 2000 (Involuntary Mental Health hold) for suicidal ideations.

On 7/29/2020, P9's medical record was reviewed including a document titled Clark County Public Guardian's Office Hospital Cover Sheet. The document stated in part, "Please update your records to reflect this office as the legal guardian and to NOTIFY CCPG of any change in medical condition(s), to obtain consent for all invasive treatment(s) and obtain consent for discharge".

The facility was aware P9 was client of the Public Guardian. The following documents indicated the staff members who provided care for P9 were aware of the Public Guardian status.

-The court document dated 2/21/2020, which documented the Clark County Public Guardian was awarded General Guardianship over P9's Person & Estate was faxed to the facility on 4/14/2020 at 11:53 AM.

-On 4/15/2020 at 10:20 AM, the Psychosocial Assessment indicated patient information was discussed with a representative of the Clark County Public Guardian's office.

-On 4/15/2020, a Progress Note signed by the Physician indicated P9 told him she had a Public Guardian.

-The Medication Consent for Psychotropics indicated the Clark County Guardian's Office gave phone consent on 4/16/2020.

-On 4/21/2020 at 10:06 AM, a Case Manager (Employee #18) documented P9 would be taking the shuttle at 12:00 PM to the confirmed address, however, there was no documentation the Public Guardian was notified.

On 7/30/2020, at 9:30 AM, P9's medical record was reviewed with the Lead Case Manager and the Director of Clinical Services in the presence of the CEO. The Manager indicated the facility was aware the patient had a Public Guardian and acknowledged the last entry by a Case Manager (Employee #18), did not include that the Public Guardian was informed of the discharge. The Director explained it was the Case Manager's responsibility to inform the Public Guardian of the discharge, and indicated The Public Guardian was not notified, but should have been.

On 7/31/2020, the facility provided the document Employee Corrective Action Notice, dated 7/31/2020, concerning Employee #18, indicating the employee was expected to review the contents of a patient chart to determine whether a patient had a Public Guardian and include that entity in the discharge planning process.

The facility policy titled Case Management Discharge Planning, revised 2/6/17, indicated Case Management was responsible (with input from the patient's treatment team) for the capacity of the patient to care for himself/herself. The policy stated "Any and all contacts must be communicated with. This may include family, friends or community providers".

Complaint #NV00060949