HospitalInspections.org

Based on observations, review of facility policies, review of facilty documents, review of medical records (MR), review of video surveillance, and interviews with staff (EMP), it was determined that the facility failed to protect and promote each patient's right to be free of abuse/harrassment, which had the potential to negatively impact all 20 patients on the adolescent unit. (A0145).

Cross Reference:
482.13(c)(3) Patient Rights: Free from abuse/harassment

On 5/23/24 at 12:02 PM, as a result of this failure, Immediate Jeopardy (IJ) was identified. The immediate interventions implemented by the facility included stopping adolescent admissions, increase leadership review and auditing, and provider notification of every incident of physical assault for adolescent patients within 30 minutes of the incident to consider new orders or interventions. These interventions were implemented and verified by the State Agency, and the IJ was removed on 5/24/24 at 11:09 AM.

Based on review of facility policies, review of facility documents, review of medical records (MR), review of video surveillance, and interviews with staff, it was determined that the hospital failed to keep patients free from physical abuse and harm on the adolescent unit. This failure had the potential to negatively impact all 20 out of 20 patients on the adolescent unit.

Findings include:

Review of facility document "Adolescent Welcome Handbook", no date, revealed, " ...The safety of all patients is the foremost staff concern and is the responsibility of everyone. All patients have the right to treatment in an environment that is safe and comfortable ..."

Review of facility policy "Patient Rights" origination date July 2018, effective date July 2023, revealed, "...Each patient shall have the right to be free from... Abuse, mistreatment, and neglect ..."

Review of facility policy "Levels of Observation and Precaution Levels" origination date January 2016, effective date May 2024, revealed, "...The physician shall order one of three levels of observation at time of admission... and may change level of observation if the patient's condition warrants a change... The physician will order a specific safety precaution... The RN may increase the level of observation if the patient's condition changes...Aggression Precautions...Special considerations will be given to room assignments and if possible the patient will have not have [sic] a roommate..."

Review of facility document "Incident Log" for March 2024 revealed a total of two (2) reported incidents occurring on the adolescent unit that were categorized as either assault to peer, or assault by peer.

Review of facility document "Incident Log" for April 2024 revealed a total of nine (9) reported incidents occurring on the adolescent unit that were categorized as either assault to peer, or assault by peer.

Review of facility document "Incident Log" for May 2024 (from May 1, 2024 to May 22, 2024) revealed a total of twenty-eight (28) reported incidents occurring on the adolescent unit that were categorized as either assault to peer, or assault by peer.

In an interview on May 22, 2024, between 10:45 AM and 11:23 AM, EMP1 stated this time of year has the highest volume of adolescent incidents. When asked what strategies were implemented to address this significant increase in peer to peer assaults, EMP1 stated that many of the kids are on 1:1 level of observation now, either the ones doing the violent behaviors, or the ones who are constantly on the receiving end. However, when asked about the current use of 1:1 level of observation on the adolescent unit, EMP1 stated that only one patient was currently on a 1:1 level of observation, and that was initiated within the last hour. EMP1 stated, "This is all new to us".



Patient #16

Review of MR16 "Face Sheet" revealed "...Admission Date 4/28/2024....Time 11:39 PM...Room 02144...Bed...A... Admitting Diagnosis... Major depressive disorder, recurrent, severe with psychotic symptoms..."

Review of MR16 "Psychiatric Evaluation" dated 4/29/24 at 11:29 AM revealed, "...sees and hears things... reports a history of anger outbursts...problems to be addressed... Aggressive behavior... Level of Observation: Q [every] 15 minutes... "

Facility provided a document, "Incident Report", that was submitted to State Incident Reporting Center. "Incident Report" revealed "... incident 5/10/24 at 9:36 PM... [Patient #16] got into a verbal altercation with [Patient #25] ...As staff were separating the two, [Patient #16] ran around staff and was able to assault [Patient #25] by punching him in the head... [Patient #25] had a raised reddened area to the posterior, lower side of the head..."

Review of MR16 "Nursing Notes" dated 5/11/24 at 6:50 AM revealed "Rough evening as [he/she] reacted to another peer causing commotion, extensive talk by staff and...states...does not know what happened, doesn't remember... "

Review of MR16 physician's orders revealed patient was placed on Assault/Aggression Precautions on 5/11/24 at 12:50 PM, however Patient #16 remained with a roommate (Patient #22).

Facility provided a document, "Incident Report", that was submitted to State Incident Reporting Center. This document revealed "... incident on 5/15/24 at 9:20 PM ... [Patient #16] was experiencing auditory hallucinations and banging head on the wall... roommate [Patient #22] tried to stop [Patient #16] from injuring self and [Patient #16] grabbed [Patient# 22] around the neck in an attempt to choke [Patient #22] .... [Patient #16] was...placed on suicide/self-harm precautions in addition to recently added assault and aggression precautions..."

Review of MR16 physician's orders revealed "...5/15/24 at 9:20 PM....Seclusion and Restraint order... Patient reportedly responded to voices, was in room with roommate who attempted to talk and calm patient. Patient turned on roommate [Patient #22] and attempted to choke, roommate, [Patient #22] yelled which alerted staff, staff able to separate... [Patient #16] went into hall and attempted charging door, staff needed to place patient in a hold to stop...aggressive behavior... Patient remain [sic] sad/depressed, expresses...does not understand, that [he/she] 'blacks out' and reacts...".

Review of MR16 "Nursing Note" revealed..."5/15/2024 at 9:39 PM... Per roommate report, patient talked about increasing voices...is known to have auditory hallucinations, agitation increased to [Patient #16] placing hands around roommates [sic] neck, roommate alert and staff responded to break hold and attempt to de-escalate... agitation increased and patient needed to be placed in a hold @ approximately 2120 [9:20 PM]..."

Review of MR16 revealed no evidence that a change in patient's level of observation was considered or that Patient #16 was evaluated for a private room after the aggression/assault incidents on 5/10/24 and 5/15/24.

These findings were confirmed with EMP10 on 5/22/24 at 3:30 PM.

Inpatient census obtained on 5/20/24 revealed Patient #16 and Patient #22 were still roommates, five (5) days after Patient #16 assaulted Patient #22. Patient #16 was not assigned to a new room after the 5/15/24 incident when this patient attempted to harm his roommate.

This finding was confirmed with EMP1 on 5/24/24 at 10:51 AM.



Patient #17

Review of MR17 revealed that this patient was the victim of three (3) physical assaults and one (1) attempted physical assault by two different peers on May 20, 2024, from 12:35 PM to 3:30 PM.

Review of MR17 "Face Sheet" revealed "...Admission Date: 5/12/2024 at 0119 [1:19 AM]..."

Review of MR17 physician's orders revealed "...5/12/2024 at 0543 [5:43 AM]... Observation Status: 15 Minute Observation Each Shift..."

Assault #1

Review of MR17 "Nursing Note" dated 5/20/2024 at 12:35 PM revealed "...Pt was attacked by peer [Patient #20] on unit, patients were quickly separated. No hold for patient or medications administered..."

Video surveillance of above incident, reviewed on 5/24/2024 at 11:27 AM, revealed Patient #17 sitting in a chair on the unit and is suddenly attacked by a peer (Patient #20) that enters the area.

Assault #2
Review of MR 17 "Nursing Note" dated 5/20/2024 at 1:22 PM revealed "...Patient was attacked again at 1322 [1:22 PM] by a different peer [Patient #21] in the milieu, hit multiple times before staff was able to separate. No holds or medication administered. Guardian called, no answer, voicemail left. Supervisor...made aware..."

Video surveillance of above incident, reviewed on 5/24/2024 at 11:27 AM, revealed Patient #17 is sitting on the floor talking to a peer. Patient #21 observed running fast towards the Patient #17 and hitting her/him.

Attempted Assault #3
Review of MR17 "Nursing Note" dated 5/20/2024 at 1:45 PM revealed "...Pt was attacked by peer [Patient #21] on milieu, unprovoked, separated by staff quickly, no holds or medication administered. Pt states she has no injuries and no complaints at this time. Supervisor...made aware. MD... made aware. Father called and made aware..."

Review of MR21 physician's orders revealed Patient #21 was previously placed on Close Visual Observation (CVO) every shift on 5/20/2024 at 8:17 AM. However, Patient #21 was still able to assault or attempt assault of Patient #17. Assault/Aggression Precautions were then ordered on 5/20/2024 at 1:49 PM for Patient #21.

Review of MR17 revealed Patient #17 was evaluated by a medical provider on 5/20/2024 at 2:07 PM. No additional orders were added to MR17.

Video surveillance of above incident, reviewed on 5/24/2024 at 11:30 AM, revealed Patient #17 standing near the nurses' station when Patient #21 runs fast towards Patient #17, but is stopped by a staff member. No physical contact occurs.

Assault #4
Review of MR17 "Nursing Note" dated 5/20/2024 at 3:30 PM revealed "...Pt was attacked by the same peer [Patient #21] as earlier, unprovoked, pts were quickly separated, no holds or medications administered. Supervisor...made aware. MD... made aware. Father called, no answer, voicemail left..."

Video surveillance of above incident, reviewed on 5/24/2024 at 11:44 AM, revealed Patient #17 sitting in a chair with a group of kids in the milieu. Patient #21, who is not sitting in the group of kids, runs quickly toward Patient #17, grabs Patient #17 by the hair, pulls Patient #17 out of the chair and onto the floor, and hit him/her approximately 4 times before staff intervenes and separates the patients.

A review of MR17 revealed no evidence, after four (4) incidents of aggression/physical assault by peers, that additional interventions were considered to protect Patient #17's safety.

This finding was confirmed with EMP10 on 5/22/2024 at 3:01 PM.



Patient #18

Review of MR18 "Face Sheet" revealed that patient was admitted to the hospital on May 8, 2024.

Facility provided a document, "Incident Report", that was submitted to State Incident Reporting Center. "Incident Report" from May 12, 2024, revealed that, at 6:49 PM, Patient #18 was punched in the head multiple times without warning by another adolescent patient (Patient # 26).

Facility provided a document, "Incident Report", that was submitted to State Incident Reporting Center. "Incident Report" from May 13, 2024, revealed that, at 7:51 PM, Patient #18 was sitting alone in the gym when another patient (Patient #27) began to hit them. The assailant was removed by staff. During this time, a total of three other adolescent patients (Patient #'s 28, #29, and #32) also punched Patient #18.

Facility provided a document, "Incident Report", that was submitted to State Incident Reporting Center. "Incident Report" from May 14, 2024, revealed that, at 8:39 AM, Patient #18 was attacked from behind by another adolescent patient (Patient #30). Before staff could intervene, two other adolescent patients (Patient #29 and Patient #31) also punched Patient # 18 multiple times.

Review of MR18 physician's orders revealed that the patient was previously ordered a 1:1 level of observation on May 12, 2024 at 11:34 AM, before the first incident. The order for 1:1 level of observation was discontinued on May 13, 2024 at 5:45 PM (about 2 hours prior to the second assault). No evidence of reason for discontinuation was located in MR18. 1:1 level of observation was next ordered on May 14, 2024 at 10:03 AM, after the third assault, with a reason listed as "Observation for Safety purpose".

Interview on May 23, 2024 at 3:00 PM with EMP11 confirmed that Patient #18 was only on a 1:1 level of observation during the first assault by peers. A review of MR18 revealed no evidence of additional interventions to maintain the safety of Patient #18.

Based on review of facility policy, review of medical record (MR), and interview with staff, it was determined that for 2 out of 21 patients (Patient #23 and Patient #24) in the sample, hospital staff failed to document elopement attempts in the medical record per hospital policy. Findings include:

Review of facility policy "Nursing Documentation" origination date January 2016, effective date September 2023, revealed, "...Daily Nursing Shift Note/Assessment ...provides continuity of care on a 24-hour basis and is a valuable tool for all clinicians involved in the care of the patient ...Any significant findings and subsequent interventions in nursing re-assessment, including ...change in patient condition, medical or behavioral ...patient incidents ...elopements and returns shall be documented in the narrative section of the Daily Nursing Assessment. Notes shall state observed patient behaviors in simple descriptive terms ..."


Review of MR23 "Daily RN Assessment note 7a-7p" dated May 22, 2024, indicated precaution orders for AWOL/Elopement. Order stated "AWOL/Elopement Precautions QSHIFT [every shift] ...pt [patient] pushed through unit door in attempt to exit unit".

No documentation to include the patient's behavior, details of the elopement attempt, or subsequent nursing interventions was located in MR23.

Review of MR24 "Daily RN Assessment note 7a-7p" dated May 22, 2024, indicated precaution orders for AWOL/Elopement. Order stated "AWOL/Elopement Precautions QSHIFT [every shift] ...pt [patient] pushed through door in attempt to exit unit".

No documentation to include the patient's behavior, details of the elopement attempt, or subsequent nursing interventions was located in MR24.

During an interview with EMP1, EMP2, and EMP3 on May 24, 2024 between 9:00 AM and 11:00 AM, it was confirmed there was no evidence of nursing documentation regarding the attempted elopements of Patient # 23 and Patient # 24 on May 22, 2024.

Based on medical record review (MR), facility policy review, and staff interview, it was determined that for 1 of 21 patients (Patient #20) in the sample, the Hospital failed to have a psychiatric evaluation completed within 60 hours of admission. Findings include:

Review of facility policy "Psychiatric Evaluation", origination date December 2015, last revised May 2024, revealed "Each patient admitted...receives a psychiatric evaluation that must: Be completed and available to staff within 24 hours of admission.... contain a record of mental status. The mental status describes the appearance and behavior, emotional response, verbalization, thought content and cognition of the patient as reported by the patient and observed by the examiner at the time of the examination...Describe attitudes and behavior...Estimate intellectual functioning, memory functioning and orientation as well as how each were tested/assessed. Include an inventory of the patient's assets in descriptive, not interpretive fashion..."

MR20

Review of "Face Sheet" revealed "...Admitted on 5/16/24 at 11:07 PM... Admitting Diagnosis: Major depressive disorder, recurrent severe without psychotic features..."

Review of "Psychiatric Evaluation" dated 5/17/24 at 3:43PM revealed, pages # 5, #6, #7 and part of #8 were not completed and were left blank.
On Page 5, the following areas were blank, "...Appearance...Attitude...Motor Activity...Neuromuscular Integration...Speech...".
On Page 6, the following areas were blank, "Speech: (Continued)...Speech Other/Comments...Mood...Affect...Thought Process...Thought Content...Attention/Concentration...Orientation...Immediate Memory...Immediate Memory how tested...Remote Memory...Remote Memory how tested...Recent memory...Recent Memory how tested..."
On Page 7, the following areas were blank, "Judgment...Judgment how tested...Insight...Insight how tested...Intellectual Functioning...Intellectual Functioning how tested...Assets/Strengths...Willingness to Participate in Treatment...Liabilities/Deficits..."
On Page 8, the following areas were blank, "Liabilities/Deficits (Continued)...Psychiatric diagnosis..."

This finding was confirmed with EMP10 on 5/22/24 at 2:41 PM.