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Based on review of hospital policies , medical records, and interviews with staff, the facility failed to provide safe restraint use by failing to provide a signed restraint order within 24 hours in 1 of 5 patients with restraint orders (Patient #5).

The findings include:

Review of policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" with review date of 3/9/2022 revealed "Definitions: Chemical (Medication) Restraint: The administration of a medication for the purpose of controlling an acute episodic behavior, with the intent or actual effect to restrict the patient's functioning or movement and/or to bring about sedation. Medical/Chemical restraint occurs when a patient is given a medication or combination of medications to control the patient's acute episodic behavior or restrict the patient's freedom of movement and/or which is not the standard treatment or dosage prescribed for the patient's condition...if the specific purpose of administering that medication, at that dose, via that route, and at that time, is to impact acute episodic behavior, it qualifies as a chemical restraint....3.0 Physician Order, Consultation, and Evaluation 3.1 Restraint or seclusion shall be used in emergency situations only and requires an order from a physician. 3.1.5 The physician shall authenticate the order within 24 hours..."

Review of the closed medical record for Patient #5 revealed a 63-year-old -male admitted as IVC (Involuntary commitment) on 01/25/2024 for schizoaffective disorder with Bipolar type (Mental disorder with feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania). Review of "Seclusion/Restraint Order" sheet dated 02/01/2024 at 1355 revealed "Medication/Chemical Restraint--Ativan (anti-anxiety medicine) 4 mg (Milligrams) IM (Intramuscular) x i (one time) agitation. Thorazine (treats mental health conditions. Helps with relaxation) 200 mg IM x i psychosis. Imminent Danger to Self. Imminent danger to Others....Arguing and very belligerent towards others, would not redirect, required IM injections to calm down s (without) a physical hold." Review revealed "Telephone order by (NP #33 /RN #34)." Review of the MAR (Medication Administration Record) revealed Thorazine 200 mg IM and Ativan 4 mg IM was administered by LPN #35. Review revealed MD #32 signed order on 02/08/2024 at 1100, 7 days after the verbal order was obtained.

Interview on 03/20/2024 at 1510 with RN #34, who has been an employee for 7 years, revealed no recollection of Patient #5. Interview revealed all restraint orders should be signed within 24 hours by the provider.

Interview on 03/20/2024 at 1340 with NP #33 revealed "the restraint order should have been signed before 2/8/2024." Interview revealed the order should have been signed within 24 hours.

Interview on 03/21/2024 at 1000 with MD #32 revealed the restraint order should have been signed within 24 hours after the original order. Interview with the Medical Provider for Patient #5 revealed the hospital policy was not followed.

Based on review of hospital policies, medical records, and interviews with staff, the facility failed to provide safe restraint use by failing to provide a face to face within 1 hour after a chemical intervention on 1 of 5 patients who were restrained. (Patient #5).

The findings include:

Review of hospital policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion" with review date of 3/9/2022, revealed "Definitions: Chemical (Medication) Restraint: ....5.0 Face to Face Evaluation by the Physician, LIP (Licensed Independent Practitioner), or trained RN: Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized LIP [(PA--Physician Assistant, NP (Nurse Practitioner)], or trained RN. The evaluation will be documented in the medical record to include the following: 5.1 The date and time of the evaluation 5.2 An assessment of the patient's immediate situation 5.3 An evaluation of the patient's reaction to the intervention 5.4 An assessment of the patient's medical and behavioral condition to include a complete review of systems assessment, behavioral assessment as a review and assessment of the patient's history, drugs and medications, most recent lab work, etc. 5.5 An assessment of the need to continue or terminate the restraint. ...If the evaluation is conducted by a trained RN, he/she must consult with the attending physician or other LIP responsible for the patient's care as soon as possible (within 30 minutes) after the evaluation. This consultation should include a discussion of the findings of the 1-hour evaluation, the need for other interventions or treatments, and the need continue or discontinue the use of restraint/seclusion...."

Review of the closed medical record for Patient #5 revealed a 63 year-old-male admitted as IVC (Involuntary commitment) on 01/25/2024 for schizoaffective disorder with Bipolar type (Mental disorder with feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania). Review of "Seclusion/Restraint Order" sheet dated 02/01/2024 at 1355 revealed "Medication/Chemical Restraint--Ativan (anti-anxiety medicine) 4 mg (Milligrams) IM (Intramuscular) x i (one time) agitation. Thorazine (treats mental health conditions. Helps with relaxation) 200 mg IM x i psychosis. Imminent Danger to Self. Imminent danger to Others....Arguing and very belligerent towards others, would not redirect, required IM injections to calm down s (without) a physical hold." Review revealed verbal "Telephone order by (NP #33/RN #34)." Review of the MAR (Medication Administration Record) revealed Thorazine 200 mg IM and Ativan 4 mg IM was administered by LPN #35. Review revealed no documentation of a face-to-face evaluation within an hour by the physician or NP.

Interview on 03/21/2024 at 1000 with MD #32 revealed Patient #5 did not have a face-to-face evaluation within an hour after the IM injections on 02/01/2024. Interview revealed Patient #5 should have had an evaluation by a MD within the hour. Interview revealed the policy was not followed.

Based on review of the elopement report log, medical record, incident reports, corrective action plan, facility floor plan, daily inspection log, and staff interviews, the hospital staff failed to accurately collect and analyze data for safety actions implemented for seven (7) of seven doors after a patient elopement.

Findings include:

Review of the elopement log from 10/01/2023 through 03/19/2024 revealed Patient # 20 eloped from the facility on 01/03/2024 and on 03/10/2024.

Open medical record review on 03/19/2024 revealed Patient #20 was a 15-year-old-male who presented to the hospital under involuntary commitment with suicidal ideations (SI) and aggression on 12/23/2023 and was admitted on 1C South - the adolescent boys' unit. The patient endorsed SI with an attempt to hang himself with a bedsheet and an ongoing plan to cut his wrist. The patient had a history of seven (7) suicide attempts and numerous psychiatric admissions since the age of eleven (11). The patient diagnoses included Post Traumatic Stress Disorder (PTSD), Oppositional Defiant Disorder (ODD), and Attention Deficit Hyperactivity Disorder (ADHD). Review of the Standardized Intake Assessment on 12/23/2023 revealed that involuntary legal status was checked as the elopement risk factors and the initial nursing assessment on 12/23/2023 revealed no indications for elopement risk. Review of admission orders on 12/23/2023 revealed the patient's level of observation was for every 15 minutes, and the Precautions/Interventions was unit restrictions (UR) until face-to-face evaluation with provider. The unit restrictions was discontinued after the physician assessment on 12/24/2023 at 1015. On 12/25/2023 at 1800 the patient was placed on elopement precautions after an incident where the patient kicked through the entrance door of the unit in pursuit of a staff member. A behavior management plan was initiated on 12/26/2023 at 1200 following the incident of agitation, aggression and kicking of the unit door by patient #20 identified coping skills to help de-escalate future situations, with plans for identifying coping skills, following the unit rules, and accepting direction from the staff. The plan included a 1:1 meeting at the end of each shift with staff to discuss behavior, progress that has been made, and feedback to the patient. Review of the Psychiatric Progress Note on 12/28/2023 revealed that the patient stated that he did not want to leave the hospital or run away and was just "frustrated". The review revealed the elopement precautions were discontinued on 12/28/2023 at 1213 after the provider's assessment. Review revealed on 01/03/2024 the patients on the unit were instructed to their rooms at approximately 1745 due to the unit being "out of control" and two staff were posted in the hallway. Patient #20 ran into another patient's room. As staff approached the room, Patient #20 ran from the room towards the end of the hall, kicked the door open and eloped from the hospital. Review of the Patient Observation Sheet on 01/03/2023 revealed the patient was logged out to elopement at 1746 and logged in from elopement at 2136 (3hours and 50 minutes). Review revealed Patient #20 was located by named police department at the CVS pharmacy and was taken to an outside hospital for a medical screening and returned to the facility. A behavior management plan was initiated on 01/04/2024 at 0800 following the incident of elopement by patient #20. Patient #20 was then placed on elopement precautions and 1:1 (one-to-one observation) per doctor's order but the orders were discontinued on 01/08/2024 based on physician clinical judgement. On 03/10/2024 at approximately 1400, Patient #20 kicked the exit door and eloped from the facility. RN #28 noted at 1400, Patient #20 "ran through hallway, pushing exit door and forced door to open (same door as in 01/03/2024 elopement). Two more patients [Patients #3 and #15] followed him. Supervisor notified." At 1430 RN #28 noted that "legal guardian was called, giving information and voiced understanding. We will follow up later". RN #4 update at 1935 stated: "patient returned to unit via police department. ...skin assessment completed. Patient has scratch on left arm..." A behavior management plan was initiated on 03/11/2024 at 0800 following the incident of elopement by patient #20 along with two other patients. Review of physician order revealed Patient #20 was placed on elopement precautions on 03/10/2024 at 2200. MD #3 progress note on 03/09/2023 at 1251 stated "...continues to wait on news from placements. Pt [patient] has ongoing high-risk behaviors and concerns for safety that require long-term referrals." On 03/11/2024 at 1104 MD #3 noted "pt kicked open the door at the end of the hallway and eloped from the hospital. Pt returned sometime later. Pt has ongoing mood lability (rapid mood changes) and frequent behavioral issues. Pt is looking for placement at this time and is waiting on news for long-term care."

Review on 03/20/2024 of the incident report following the elopement of Patient #20 on 01/03/2024 indicated the time of the elopement/AWOL (absent without leave) was 1730. The comments indicated: "... down the hall, there were two members of staff. This patient was near his room when he ran into another patient's room. The patient was seen running down the hall towards the exit door as staff intervened. The staff heard a loud bang, and the patient was out the door. Staff searched the grounds for this patient, but he was not found. Supervisor was notified, a code walker was called, RPD (police department) was called, and a report was taken, the provider was notified, and the AOC [guardian] was notified..." Addendum from Director #10 on 01/18/2024 stated: "patient was located approximately 1.5 hours later one mile down the road at a local CVS. Patient had injury on arm from cutting himself with scissors. Patient was transported by EMS [emergency medical services] to local ED (emergency department) to determine the need for any medical treatment. Patient was returned that evening with no medical treatment necessary." Incident report on 03/10/2024 indicated the time of the elopement was 1400. The comments indicated: "named patient running with other two patients pushing the exit door at the end of the hallway and eloped from the facility." Addendum from Director #13 on 03/12/2024 at 0844 stated: "patient returned to named facility by PD, no injuries noted upon assessment, no crimes committed during elopement. Elopement precautions are in place and patient has been placed on unit restriction, patient will remain in gown and socks per policy."

Review on 3/20/2024 of the facility's corrective action plan regarding the 03/10/2024 incident that involved Patients #20, #3, and #15 revealed, Director #11 removed operational function of exterior door used in elopement (boarded up door) and fire safety protocol was established and training was provided for the inoperable door on 03/10/2023. The action plan revealed a contractor was obtained and presented to the campus for fencing upgrade design on 03/11/2023.

Review on 03/20/2024 of the Children Hospital building floor plan revealed seven (7) exit doors located in different hallways. The review revealed that the exit doors were not identified on the plan.

A review on 03/20/2024 of the Children's Hospital Unit Exit Door Mag [magnet] Lock Daily Inspection revealed that the daily inspection was initiated on 01/29/2024. The daily inspection log failed to reveal any documentation on February 3, 4, 10, 11, 17, 18, 24, 25 of 2024 March 2, 3, 9, 10, 16, and 17 of 2024 (14 of 51 days). The review revealed magnets were "tightened" on January 31, 2024, February 5, 6, 15, and 22 of 2024, and March 5, and 7 of 2024. The review revealed no indication of which door and which magnet needed to be tightened.

Interview on 3/20/2024 at 1330 with CEO - Chief Executive Officer, Directors # 10, 11, 12, and 13 revealed, that the exit doors had a magnetic lock at the top and bottom with a large piece of safety glass in the middle. Interview revealed Patient #20 "whaled on the door and the force against the door caused the door to bend and became compromised. Interview revealed the door was temporarily out of order and new doors were ordered. The plan also consisted of building a foyer outside of the exit doors to deter further elopements. The interview revealed that the plant operation was conducting daily environment of care rounding to ensure that the doors were not compromised.

Interview on 03/25/2024 at 1225 with Tech #16 revealed the doors in the children's building were previously labeled but the labels were removed during painting, cleaning, and repairs. The Technicians were expected to inspect the magnets on each door daily and repair or tighten the magnets as needed. The interview revealed the Maintenance Technicians were also expected to document which door needed to be tightened, but Tech #16 stated "we usually don't because we communicate with each other". The interview revealed that the maintenance staff only work Monday through Friday, and the Mental Health Technicians were expected to conduct the inspection of the doors on weekends, but Tech #16 did not know where they (the staff) documented their inspections.

A request was made to hospital management about the weekend log for the daily inspection of the doors in the children's hospital. The hospital management failed to provide a weekend inspection log.

Based on policy review, medical record review, incident report review, corrective action plan review, personnel file review, and staff interviews, the facility staff failed to develop an effective corrective action plan by not monitoring to ensure two staff members were present in the courtyard after 1 of 3 elopements at the facility involving the same patient (Patient #3).

Findings included:

Review on 03/20/2024 of the facility's policy, "Elopements: Prevention and Response" effective 06/98, with facility review on 06/28/21, revealed, "Universal prevention of elopements require the following: two staff members must be present for all off-unit group activities. When outdoors, one staff member will position themselves closest to the fence line or wall, while the other staff member stands at the opposite end of the courtyard to ensure full line of sight. Redirect patients to stand away from unit doors, fence lines and walls."

Closed medical record review on 03/19/2024 revealed, Patient #3 was admitted to the facility on 02/09/2024 as an IVC (involuntary commitment) due to SI (suicidal ideations) and HI (homicidal ideations) and was housed on the adolescent boys' unit. The patient was initially ordered elopement precautions (EP) due to IVC and being a new admit until MD #3 conducted initial psychiatric evaluation the following day. On 02/10/2024 at 1000, MD #3 conducted the initial psychiatric evaluation of the patient which revealed, the patient presented with SI/HI, was combative in the home and was running away frequently. The patient endorsed SI with no current plan but was self-harming per cutting with plastic on arms and has a history of suicide attempt by jumping off of a parking deck. At 1217, the patient had orders to discontinuation of EP. Review revealed, the master treatment plan addressed SI/HI with goals focused on coping skills and regulating emotions. The patient was noted to be calm/content and involved during group therapy/activities from 02/10/2024 to 02/13/2024 (4-days). However, on 02/14/2024, group notes revealed, the patient was continuously redirected and refused to complete the group activity. On 02/15/2024 at 1500, nurse's note revealed patient #3 with another peer attacked and had an altercation with a peer who was disruptive during group, resulting in staff intervening and separating the patients. After the peer-to-peer incident, Patient #3 was anxious and pacing. MD #3 was notified, and the patient was administered Zyprexa (for mental/mood conditions) 20 milligrams orally and Benadryl 50milligrams orally, and the legal guardian was notified. A behavior management plan was initiated on 02/16/2024 at 0850 following the peer-to-peer incident with patient #3 identifying coping skills to help de-escalate future situations, with plans to have a 1:1 at the end of each shift with staff to discuss behavior and what progress has been made. On 02/16/2024, during morning and evening group therapy/activities, patient #3 was noted to be focused, involved, and calm. On 02/17/2024, per patient observation sheet, patient #3 was in the patio/yard area at approximately 1015 during fresh air time. At approximately 1030, patient #3 scaled the fence and jumped over to the other side. RN #6 noted at 1130, patient #3 "jumped the fence during outside time and eloped. Police have been called and are looking. Parents aware and are understanding. Will f/u [follow-up] with any updates". RN #6 update at 1258 stated: "Police unable to locate; patient placed on missing person list. Parents aware and understanding". RN #6 update at 1305 stated "[Case number]" with officer's last name. MD #3 progress note at 1210 stated "pt [patient] eloped from the hospital this morning and has not returned to the hospital as of the time the doctor came around the unit to see patients. Pt was reported missing, and police and family were informed". Review revealed, the patient had not returned to the facility within 48 hours and was noted to be "discharged" from the facility on 02/19/2024.

Review on 03/17/2024 of the incident report for Patient #3 revealed, the incident time noted as 1030 for elopement/AWOL (absent without leave). Comments stated: "Patient climbed and jumped over the fence during fresh air time. Police were unable to find him. He was placed on missing person list. Parents are aware and understanding. [Case number]". Review revealed, an addendum from Director #13 on 02/19/2024 stated: "To date, patient has not been found and no updates have been provided by family or police; will continue to follow up."

Review on 03/20/2024 of the facility's corrective action plan regarding the 02/17/2024 incident that involved Patient #3 revealed, Director #11 examined the fence, and determined it was not compromised. However, a contractor was secured to fabricate a metal side rail to the fencing to decrease the ability to scale the fence. A review of the Elopement policy and procedure was conducted on 02/18/2024, and one staff member was identified as having been non-compliant with Elopement policy and procedure. The staff member went out on leave, unrelated to the incident. Review of staff positioning in the outdoor area was conducted and revealed that the staff member was not standing in the appropriate position for fence monitoring, which is covered in the elopement policy training and attestation in the New Hire Orientation. Medical record review was conducted and revealed that the patient observation rounds were compliant per policy; also, the patient was placed on elopement precautions at admission, but these were lifted based on physician clinical judgment and order. Review revealed, the corrective actions did not include monitoring of fresh air time to ensure two staff members were present in the courtyard with patients.

Interview on 03/20/2024 at 1330 with CEO, Directors # 10, 11, 12, and 13 revealed, the fence was not compromised, was considered an "anti-climb fence" with a slanted section of fence at the top, and there was a "tiny gap" (less than 1/2 inch) between the fence and the building. A metal fabricator was constructing an additional stainless steel side panel to cover said gap between the fence and the building for an additional resource to prevent this from occurring again, with an estimate of 30 days of completion. Interview revealed, MHT #7 did not follow protocol for positioning, with only MHT #7 present outside at that time with a group of about 14 of 18 adolescents while the second staff member was at lunch.

Request on 03/21/2024 of security camera review for when patient #2 scaled the fence revealed, the video was unavailable for review.

Review on 03/26/2024 of MHT #7 personnel file revealed that MHT signed off on the elopement policy during new hire orientation on 01/07/2021, and a performance improvement plan was initiated on 02/28/2023 regarding every 15 minute checks not being conducted on patients, and the MHT met with the lead trainer on 03/06/2023 for re-education.

Based on policy review, contract agreement, medical record review and staff interview, the facility staff failed to identify, report and implement preventive measures after the prescribing provider was not notified of a critical lab value for 1 of 2 sampled patients with new orders for lithium (Patient # 4).

The findings included:

Review on 03/25/2024 of policy "OCCURRENCE REPORTING" reviewed dated 07/2023 revealed "The responsibility for completing a Healthcare Peer Review (HPR) report rests with any hospital staff member who witnesses, discovers, or has direct knowledge of an occurrence. Occurrence are defined as any happening not consistent with the routine care and/or operation of the facility which may place the facility at increased risk for liability."

Review on 03/25/2024 of policy "CRITICAL VALUES TEST RESULTS" reviewed 01/2020 revealed "It is the policy of (Hospital A) to notify the physician immediately of any critical value test results ..."

Review on 03/21/2024 of the policy "LABORATORY SERVICES" reviewed 02/2020 revealed "It is the policy of (Hospital A) to provide laboratory services through contractual agreements. Specimens will be collected by (Company C) Phlebotomist or authorized (Hospital A) staff ... Results Laboratory results are processed and available per (Company C) and (Hospital B) policy. 1. All lab results are available in HCS, on the (Company C) Web Site, or by calling the (Hospital B) Laboratory. 2. Critical value results are called into the unit by the laboratory with a concurrent faxed copy. b. The RN receiving the critical value will notify the physician immediately ..."

Review on 03/21/2024 of the "Outsourced Laboratory Testing Services Agreement" signed 07/02/2019 revealed "... This Laboratory Testing Services Agreement (the 'Agreement') is entered into as of the effective date of the 1st (first) day of July, 2019, by and between (Company C) ... and (Hospital A's Corporate Name) ... EXHIBIT A - PERFORMANCE METRICS ... 6. Corrected and Amended Results, Critical Value, and State Reportables Notification ... B. Notification. Vender shall notify the applicable Affiliate by phone or Critical Values ...Notification of Critical Values will be in accordance with the standard ranges ... In addition to notifying Affiliate of Corrected and Amended Results, Critical Values and State Reportables, Affiliate (Company C) representative must provide to Affiliate Laboratory Director or other representative with a cause analysis and corrective action plan for all failures to communicate and document Corrected and Amended Results, Critical Values and State Reportables ..."

Closed medical record review on 03/20/2024 revealed Patient #4 was a 15-year-old female admitted to the facility on 01/24/2024 at 1319 under IVC (involuntary commitment) for suicidal ideations. Review of the Medication Administration Record (MAR) revealed Patient #4 was started on Lithium ER (extended release) tablet 300 mg (milligrams) twice a day on 01/25/2024 at 2012. The patient was administered the Lithium ER twice a day on 01/26/2024, 01/27/2024, 01/28/2024, 01/29/2024, 01/30/2024, 01/31/2024 and one time in the morning on 02/01/2024. Provider Orders revealed an order on 01/30/2024 at 0600 for Lithium Serum with Start time of 01/30/2024 at 0600 and Stop time of 01/30/2024 at 0810. Review of the Lithium Serum result dated 02/02/2024 at 1157 revealed a result of 2.4 (reference range was 0.5-1.2). Review of the medical record did not reveal documentation the critical result was called to facility. Review of the medical record revealed Patient #4 was discharged home on 02/01/2024 at 1231.

Interview on 03/21/2024 at 1345 with MD #3 revealed Patient #4 "had a negative outcome." MD #3 spoke with multiple people including Patient #4's Cardiologist and the Pharmacist #42 here prior to starting Lithium. Patient #4 was taking the medication enalapril and it will increase the blood levels of lithium which can lead to lithium toxicity. Monitoring the patient for signs of lithium toxicity and monitoring the lithium level with lab draws was the plan and agreeance to start the lithium. MD #3 ordered the Lithium level however Patient #4 discharged prior to MD #3 getting the result back. MD #3 received a telephone call from Patient #4's family letting him know Patient #4 was in the emergency department (ED) with a critical lithium level. MD #3 shared the information from the telephone call with Pharmacist #42 and requested she contact Company C to get the lithium result at discharge. Interview revealed a pending lithium level is not a reason to keep a patient in the hospital when they are ready for discharge. MD #3 revealed lithium levels are usually back the next morning after it is drawn. Interview revealed had he (MD #3) received a call with the critical lab value of the lithium he would have stopped the Lithium and sent Patient #4 to the ED instead of discharging her.

Interview on 03/22/2024 at 1240 with Pharmacist #42 revealed MD #3 wanted to order Lithium for Patient #4 who was already taking Enalapril for her heart valve. Lithium is contraindicated as the ace inhibitor would increase the lithium level. It was discussed and felt if would be safe as long as got a lithium level prior to discharge. Pharmacist #42 revealed she heard Patient #4 had discharged before the Lithium level was back from the lab. Interview revealed MD #3 notified Pharmacist #42 Patient #4 was in the ED with an elevated lithium level. Pharmacist #42 called Company C three times before she was able to get the lithium result. Patient #4 discharged on 02/01/2024 and Pharmacist #42 contacted Company C on 02/02/2024. The lithium level was drawn on 01/30/2024 and the result should have been returned prior to Patient #4 discharging. Interview revealed it is ultimately up to the Provider to get the results of labs that are ordered. There is no policy that speaks to this practice and who is responsible for retrieving lab results. Interview revealed Pharmacist #42 did not enter an incident report nor did she report it to anyone to enter in the reporting system. Interview revealed Pharmacist #42 "cannot enter incident reports."

Based on policy review, observation, and staff interview the facility staff failed to monitor nourishment storage equipment to ensure safety and quality for 6 of 6 nourishment refrigerators observed on the adult campus.

The findings include:

Review on 03/26/2024 of the hospital policy "TEMPERATURE LOGS- Policy No.: 024" last revised 01/09/2023, states "PROCEDURE: To record temperatures of all refrigerator/freezer/cooler equipment as well as dish machines on a daily basis ... ACTION: ... 2. Logs are to be completed daily as assigned. 3. Logs are to be kept on file for one year in the Food Service Directors office. 4. If a piece of equipment is not in use, either out of service or not needed for that day's duties, "Not In Use" should be noted in the comments section of the log."

Observation on 03/26/2024 at 1020 of nourishment refrigerator (#3), located on unit 1 South, failed to reveal any nourishment refrigerator temperature logs on the unit. Request for temperature logs failed to reveal any temperature logs located on the unit during observation.

Review on 03/26/2024 at 1220 of the refrigerator temperature logs for the nourishment refrigerator (#3), located on unit 1 South, failed to reveal log completion for the months of January 2024 (31 of 31 days) and February 2024 (29 of 29 days). Review revealed temperatures for the month of March 2024 were completed for one day, on 03/26/2024. Review failed to reveal temperature documentation in March 2024 for 25 of 26 days.

Observation on 03/26/2024 at 1025 of nourishment refrigerator (#4), located on unit 1 West, revealed nourishment refrigerator temperature logs for October 2023 through December 2023. Observation failed to reveal refrigerator temperature logs for January 2024 through March 2024.

Review on 03/26/2024 at 1220 of the refrigerator temperature logs for the nourishment refrigerator (#4), located on unit 1 West, failed to reveal documented temperatures for the month of January 2024 on the following dates: 01/01/2024, 01/03/2024, 01/06/2024 through 01/09/2024, 01/14/2024 through 01/16/2024, 01/20/2024, 01/21/2024, 01/29/2024, and 01/31/2024 (13 of 31 days). Review failed to reveal documented temperatures for the month of February 2024 on the following dates: 02/02/2024 through 02/04/2024, 02/09/2024 through 02/11/2024, 02/16/2024 through 02/19/2024, and 02/23/2024 through 02/26/2024 (14 of 29 days). Further review failed to reveal a log was completed for the month of March 2024 (25 of 25 days).

Observation on 03/21/2024 at 1232 of nourishment refrigerator (#1), located on unit 1 East, revealed storage of patient snacks. Observation failed to reveal a refrigerator temperature log for the month of March 2024.

Review on 03/26/2024 at 1220 of the refrigerator temperature logs for the nourishment refrigerator (#1), located on unit 1 East, revealed temperatures for the month of January 2024 were completed for all dates. Review failed to reveal documented temperatures for the month of February 2024 on the following dates: 02/03/2024, 02/09/2024, 02/16/2024 through 02/18/2024, 02/20/2024, 2/21/2024, and 02/23/2024 through 02/27/2024 (12 of 29 days). Review failed to reveal a temperature log for the month of March 2024 (25 of 25 days).

Interview during observation on 03/22/2024 at 1245 with RN#23 revealed there was no March 2024 nourishment refrigerator temperature log on the unit. When asked about the March 2024 log she stated, "It is not here." RN#23 revealed the log was normally completed by night shift staff.

Observation on 03/26/2024 at 1038 of nourishment refrigerator (#6), shared by units 2 East and 2 West, failed to reveal any nourishment refrigerator temperature logs on the unit. Nurse Manager #17 was unable to locate refrigerator temperature logs.

Review on 03/26/2024 at 1220 of the refrigerator temperature logs for the nourishment refrigerator (#6), shared by units 2 East and 2 West, failed to reveal a log was completed for the month of January 2024 (31 of 31 days). Review failed to reveal documented temperatures for the month of February 2024 on the following dates: 02/02/2024 through 02/06/2024, 02/09/2024 through 02/11/2024, 02/13/2024 through 02/19/2024, and 02/23/2024 through 02/25/2024 (18 of 29 days). Review failed to reveal documented temperatures for the month of March 2024 on the following dates: 03/01/2024, 03/08/2024, 03/15/2024, and 03/21/2024 through 03/25/2024 (8 of 25 days).

Observation on 03/26/2024 at 1030 of nourishment refrigerator (#5), shared by units 2 North A and 2 North B, revealed a nourishment refrigerator temperature log for March 2024. Review of the March 2024 log failed to reveal temperature documented on 03/20/2024 and 03/25/2024. Observation failed to reveal refrigerator temperature logs for January 2024 and February 2024.

Review on 03/26/2024 at at 1220 of the refrigerator temperature logs for the nourishment refrigerator (#5), shared by units 2 North A and 2 North B, failed to reveal documented temperatures for the month of January 2024 on 01/09/2024, 01/11/2024, and 01/23/2024 (3 of 31 days). Review failed to reveal temperature documentation on 02/14/2024 for the month of February 2024 (1 of 29 days). Review failed to reveal documented temperatures for the month of March 2024 on 03/20/2024 and 03/25/2024 (2 of 25 days).

Observation on 03/26/2024 at 0955 of nourishment refrigerator (#2), shared by units 1 North A and 1 North B, revealed storage patient snacks. Observation of the March 2024 temperature log failed to reveal temperatures documented for several dates. Observation failed to reveal refrigerator temperature logs for January 2024 or February 2024.

Review on 03/26/2024 at 1220 of the refrigerator temperature logs for the nourishment refrigerator (#2), shared by units 1 North A and 1 North B, failed to reveal documented temperatures for the month of January 2024 on 01/09/2024, 01/11/2024, and 01/23/2024 (3 of 31 days). Review revealed documented temperatures for the month of February 2024 for all dates. Review failed to reveal documented temperatures for the month of March 2024 on 03/23/2024, 03/24/2024, and 03/25/2024 (3 of 25 days).

Interview on 03/26/2024 at 1140 with Director #9 revealed nourishment refrigerator temperature logs were to be completed daily by night shift staff. Director #9 acknowledged there was missing documentation and stated that there were "gaps in the logs" and "some units may not have logs."

Based on observation, policy review, observation, medical record review, patient advocate complaint worksheet review and staff interviews the facility failed to coordinate an orderly discharge by failing to provide a medication prescription at discharge for 1 of 15 discharged patients (Patient #24) and failing to provide an aftercare appointment for 1 of 15 discharged patients (Patient #5).

The findings included:

Review of policy titled "Discharge Planning" with revision date of 10/22 revealed "Discharge planning begins the day of admission for all patients served by (named facility). Discharge planning is discussed daily and at each Treatment Team Meeting for a patient. 2. The Therapist/Case Manager discusses discharge options with the patient and legal guardian...3. Reviews preliminary discharge plan and discharge criteria with patient and guardian....8. Patients are expected to attend an aftercare appointment within 7 days from their discharge date, typically with a therapist."

1. Observation on 03/26/2024 at 1000, on unit 1 North B, revealed a patient was in the process of receiving the patient discharge paperwork and review of the instructions. Review of the discharge paperwork with Nurse Manager #18 and RN#20 revealed the medication prescription was electronically prescribed according to documentation on the "DISCHARGE MEDICATION SUMMARY FOR PATIENT." The form contained the name, address, and telephone number for the pharmacy under the "THESE DISCHARGE PRESCRIPTIONS e-PRESCRIBED TO:" section of the form.

Closed medical record review for Patient #24 (Pt#24) revealed an 18 year old male patient that presented to the facility on 08/31/2023 with Involuntary Commitment documents (a legal process through which an individual is deemed by a qualified person to have symptoms of severe mental disorder and is detained in a psychiatric facility involuntarily) for depression and suicidal ideation with plans to harm himself. Review revealed Pt #24 was discharged home on 09/06/2023. Review of the "DISCHARGE MEDICATION SUMMARY FOR PATIENT" revealed a list of discharge medications. Review of the discharge medication list included LamoTRIgine 200 milligrams (mg) once a day, FluvoxaMINE 150 mg at bedtime, Brexpiprazole 2 mg at bedtime, and Gabapentin 100 mg three times a day. Review failed to reveal documentation that disharge medications were prescribed for Pt#24.

Review of the Patient Relations Worksheet on 03/21/2024, completed by a Patient Care Advocate (PCA#24) on 09/06/2023 (no time documented), revealed a complaint was received by phone. The description stated Pt#24's (family member) requested the medication prescription be called in to the pharmacy to avoid a delay in receiving the medications. The worksheet stated the complaint was resolved on 09/06/2023 with an action of "PA [Patient Advocate] provided request to treatment team."

Interview during 1 North B observation on 03/26/2024 at 1000, with a Nurse Manager (Nurse Manager #18) and a Registered Nurse (RN#20), revealed the process for reviewing discharge paperwork and verification of medication prescriptions. RN#20 revealed the pharmacy name, location and phone number must be documented under the "THESE DISCHARGE PRESCRIPTIONS e-PRESCRIBED TO:" section of the form to verify that the prescription was electronically sent by the physician. Interview revealed if a paper prescription was provided, a copy of the paper prescription would be placed in the patient's chart. Interview revealed prescriptions were sometimes called into the pharmacy.

Interview with RN#20 on 03/22/2024 at 1145 revealed RN#20 did not recall Pt#24. RN#20 reviewed the discharge paperwork in the medical record and revealed the prescription medications were not electronically prescribed. RN#20 confirmed there was no paper prescription located in Pt#24's medical record. RN#20 stated MD#21, Pt#24's doctor, preferred to call in medication prescriptions to the pharmacy. Interview revealed if the medication prescription was not electronically prescribed and a paper prescription was not provided, RN#20 would normally follow up with the provider to ensure that the medication prescription had been called in to the pharmacy prior to discharge. RN#20 did not recall following up the MD#21 about the medication prescription for Pt#24.

Interview with a Patient Care Advocate (PCA#24) on 03/22/2024 at 1040 revealed PCA#24 contacted the treatment team after receiving a phone call complaint that Pt#24's medication prescription was not called in to the pharmacy. Interview revealed that PCA#24 would typically receive confirmation from someone in the treatment team that the request had been completed. PCA#24 did not recall if the treatment team had followed up with notification that the medication prescription was called in to the pharmacy.

Interview with a Licensed Clinical Social Worker (Therapist #25) on 03/22/2024 at 1100 revealed Therapist #25 recalled PCA#24 emailed a request for Pt#24's prescription to be sent to the pharmacy. Interview revealed Therapist #25 notified MD#21.

MD#21 was unavailable for interview.



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2. Review of the closed medical record for Patient #5 revealed a 63 year old male admitted as IVC (Involuntary commitment) on 01/25/2024 for schizoaffective disorder with Bipolar type (Mental disorder with feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania). Review of Patient #5's After Care/Discharge Plan dated 02/08/24 at 3:30 PM revealed Therapist #1 documented in "Appointment Date/Time" slot: "Unable to schedule apt (appointment) LG (Legal Guardian) did (sic) not provide an apt..." Review revealed the facility failed to arrange an appointment for discharge follow up for Patient #5.

Interview on 03/20/2024 at 1430 with Therapist #1 revealed the aftercare appointment was not made for Patient #5.

Interview on 03/20/2024 at 1530 with ACDS #8 revealed the after care appointment was not made for Patient #5. Interview revealed the discharge packet contained the information for the aftercare facility. Interview revealed the discharge disposition was appropriate but aftercare appointment was not arranged. Interview revealed the policy was not followed for arranging an aftercare appointment.

Based on review of facility policy, medical records and staff interviews, the facility staff failed to ensure a Master Treatment Plan was completed and/or updated in 4 of 11 medical records reviewed (Patient #11, Patient #2, Patient #5 and Patient #25); and legal guardian signature on Treatment plan on 1 of 11 medical records reviewed (Patient #5).

The findings include:

A. Review on 03/22/2024 of the policy titled "Interdisciplinary Patient-Centered Care Planning" revised 05/2023, revealed "..Procedure...4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan. ...The treatment team will complete the MTP (Master Treatment Plan)... ...b. Completion of an individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheet will include the problem, specific patient behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention. ... Interdisciplinary Treatment Plan Update 1. ...A treatment plan revision can be completed any time the treatment team decides to alter the proposed strategies based upon the patient's needs. Reviews of the treatment plan are documented on the appropriate treatment plan forms in the medical record. The following would be cause for conducting a review of the plan and developing a revision: ... A major change occurs in the patient's clinical condition, such as the need for the use of restraint or seclusion. ... The patient fails to reach treatment goals despite reasonable clinical care. ... The treatment team determines the patient's current treatment plan would more appropriately be delivered on an individual basis rather than group interventions."

1. Closed medical record review on 03/20/2024 for Patient #11 revealed a 15-year-old male admitted to the facility on 09/23/2023 with a diagnosis of psychosis and disruptive mood dysregulation disorder. Review of the medical record revealed no documentation of a Master Treatment Plan completed from 09/23/2023 through 02/29/2024. Patient #11 was discharged to a Residential Treatment Facility on 02/29/2024.

Interview on 03/21/2024 at 1635 with ADCS #8 revealed that a Master Treatment Plan should have been completed for Patient #11. ADCS #8 reviewed Patient #11's medical record and was unable to locate documentation of a Master Treatment Plan.



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2. Closed medical record review on 03/20/2024 revealed, patient #2 was admitted to the facility on 02/06/2024, voluntary status, due to SI (suicidal ideations) and was housed on C1 South - adolescent boys' unit. On 02/06/2024 at 2200, nurse's note revealed that MHT (mental health technician) #28 was doing observation checks, and when MHT got to patient #2's room, patient #2 started hitting the MHT and attempted to put the MHT in a chokehold. MHT did not fight back and attempted to get out of the situation. Code one (psychiatric emergency) was called and staff helped remove MHT from the situation. MHT #28 sustained a "bleeding nose and swelling in left eye"; patient #2 did not sustain any injuries. Legal guardian was informed, as well as the provider on call, and patient was placed on aggression precautions. MD initial psychiatric evaluation was conducted on 02/07/2024 at 1100 with MD #3. The evaluation revealed, the 16-year-old patient presented with SI, walked into the road in effort to be hit by a car, with history of at least three prior suicide attempts, including one in January 2024 with an overdose of anti-depressants. The evaluation also revealed, "prior to being seen by psychiatrist, pt [patient] was assaultive towards staff that entered room to do 15 minute checks and gave MHT [#28] a bloody nose". Clinical assessment conducted by therapist #29 on 02/07/2024 revealed, a history of arrests in 2019-2020, 2023 for battery & assault, and attempted murder. Therapist #29, along with patient #2, identified a short-term goal of "staying calm and work on aggression" with a long-term goal of stop using illicit substances. The master treatment plan and interdisciplinary master treatment plan was initiated on 02/07/2024 and addressed SI and substance use with goals focused on coping skills. MD #3 psychiatric progress note on 02/08/2024 at 1137 revealed, "pt [patient] presents severely aggressive behaviors including assaulting a staff member upon admission and severe mood instability. Pt shows poor insight but states he was doing better". A behavior management plan was initiated on 02/09/2024 at 0900 following the patient-to-staff altercation on 02/06/2024, which noted patient #2 displayed little remorse nor provided a response for his actions; patient identified coping skills to help de-escalate future situations, with plans to have a 1:1 at the end of each shift with staff to discuss behavior and what progress has been made. Behavior plan also stated the expected behavior was for patient #2 to be in better control of impulse behaviors, and refrain from any display of aggressive or assaultive behaviors towards staff or peers; if patient's behavior becomes disruptive, patient #2 will program in an area away from peer designated by the charge nurse or house supervisor. MD #3 psychiatric progress note on 02/09/2024 at 1125 revealed, "pt [patient] has been severely aggressive towards peers and staff and assaulted a peer this morning per hitting him. Pt has been arguing and instigating with peers, threatening peers and staff, and has ongoing assaultive behaviors. Pt is a danger towards others and has severe mood instability". On 02/09/2024 at 1215 a chemical restraint was ordered for patient #2, as patient #2 walked on the countertop at the nurse's station and across the printer to the other side of the nurse's station; 1:1 verbal interaction was attempted prior to restraint but patient #2 was not re-directable. Patient #2 was administered Thorazine (for mental/mood conditions) 50 milligrams (mg) injection and Benadryl 50mg injection, and legal guardian was notified. Patient #2 had a master treatment plan problem sheet update for "restraint/seclusion/hold" following this incident, which noted "aggressive acting-out behavior requiring the use of a chemical restraint"; patient #2 was noted to be climbing over the nurse's station and had a verbal altercation with another patient. MD #3 psychiatric progress note on 02/10/2024 at 1230 revealed, "Pt [patient] has been severely aggressive still and was in another altercation with a peer this morning. Per report pt was not the initiator of altercation but was yelling, arguing, and peer ran up on him. Pt presents severe anxiety and aggressive behaviors. Pt shows no improvement and is a danger towards others". Therapist group note on 02/11/2024 at 1200, revealed that patient #2 was unfocused, needed additional learning, and was "fighting peer". An update to the behavior management plan on 02/11/2024 [no time listed] revealed, patient #2 "was involved in several physical altercations with a peer due to patients continuous antagonizing of the individual". On 02/11/2024 at 1450 a chemical restraint was ordered for patient #2, as patient #2 was involved in a physical altercation with a peer; 1:1 verbal interaction and reduced stimuli was attempted prior to restraint but patient #2 was noted to be "an imminent danger to others". Patient #2 was administered Thorazine (for mental/mood conditions) 50mg injection and Benadryl 50mg injection at 1500, and legal guardian was notified. Patient #2 had a second master treatment plan problem sheet update for "restraint/seclusion/hold" following this incident, which noted "aggressive acting-out behavior requiring the use of a PRN [as needed] medication". MD #3 psychiatric progress note on 02/12/2024 at 1111 revealed, "Pt [patient] has severe ongoing aggression and was in multiple altercations over the weekend. Pt shows little insight into mood or behaviors and has severe aggressive behaviors. Pt presents severe agitation". MD #3 psychiatric progress note on 02/13/2024 at 1041 revealed, "Pt [patient] is expecting to discharge today and is safe to do so. Pt is not an acute danger towards self but has ongoing issues with behavior and conflict with peers. Greater than 30 minutes was spent planning and organizing this patient's discharge". Patient #2 was discharged home on 02/13/2024 at 1200 with legal guardian. Review failed to reveal the treatment plan was updated and failed to clearly indicate that 1:1 discussions occurred at the end of each shift.

Incident report created on 02/06/2024 for patient #2, with incident time noted as 2100 for "Aggression Patient towards staff". The comments revealed, MHT #28 was doing observation checks and when MHT got to patient's room, patient started hitting MHT in the face and attempted to put MHT in a chokehold. MHT did not fight back and attempted to leave situation. Code one was called and staffed helped remove MHT from the situation. MHT sustained a bleeding nose and swelling in left eye. Patient did not sustain any injuries. Patient guardian was called and informed of this occurrence. Provider on call notified and patient placed on aggression. Incident report created on 02/09/2024 for patient #2, with incident time noted as 1135 for "Aggression Patient towards patient". The comments revealed, patient in verbal altercation with another patient, belligerent attempting to fight but was held off from being in contact with the other patient. Patient separated and placed in a comfort room". Incident report created on 02/09/2024 for patient #2, with incident time noted as 1215 for "patient out of control". The comments revealed, "Pt [patient] out of control and aggressive towards staff and peers. Pt jumped on top of the nurse's station and walked across the printer to the other side. Pt was not directable. Pt administered 100mg Thorazine IM [injection] and 50mg Benadryl per doctors order". Incident report created on 02/10/2024 for patient #2, with incident time noted as 1020 for "Aggression patient towards patient". The comments revealed, "patient was attacked by another patient following a verbal altercation". Incident report created on 02/11/2024 for patient #2, with incident time noted as 1450 for "Physical confrontation with other patients". The comments revealed, "Patient involved in physical altercation with peer. Patients separated for safety and de-escalation. Patient assessed for injury. Patient received PRN [as needed] medication per doctors order. Guardian notified".

Interview on 03/21/2024 at 1027 with ADCS (Associate Director of Clinical Services) #8 revealed, the ADCS did not recall patient #2, but reviewed patient #2's chart and noted that the master treatment plan should have been updated to include aggression. The master treatment plan and interdisciplinary master treatment plan was initiated on 02/07/2024 and addressed SI and substance use with goals focused on coping skills; record review revealed that these plans were not updated to include aggression. ADCS revealed, the therapist should have based their goals off the patient's history of chronic aggressive behavior. ADCS revealed, a behavior management plan was initiated on 02/09/2024 at 0900 following the patient-to-staff altercation on 02/06/2024, and should get updated with an action plan if continued aggression is noted. Record review revealed an update to the behavior management plan on 02/11/2024 [no time listed], which stated: patient #2 "was involved in several physical altercations with a peer due to patients continuous antagonizing of the individual". Record review failed to provide clear indication of an updated action plan.

Interview on 03/22/2024 at 1140 with therapist #2 revealed, the therapist recalled patient #2 but had limited interactions with this patient. Therapist revealed, the patient's "behavior seemed worse than a previous visit [in January 2024] and always wanted to fight", and previously, the staff could redirect the patient's behavior. Therapist revealed, the patient was removed from group therapy on 02/09/2024, and the patient jumped over the nurse's station.

Telephone interview on 03/22/2024 at 1218 with RN #5 revealed, RN works PRN, typically on the adolescent girl's unit, but recalled patient #2. RN revealed, patient #2 did not want to be separated after an argument with another patient on 02/09/2024; patient #2 was moved to C1 West B and did not want to stay there, and the patient jumped over the counter, and walked across the printer to the other side of the nurse's station. RN revealed, patient #2 "was adamant" to be on C1 South instead. RN revealed, the staff attempted to "call him down", and patient #2 "may have hit or slapped the glasses off a nurse" at that time. RN performed the 15 minute checks, following patient #2's chemical restraint, and patient #2 went into another day room by himself and took a nap. RN revealed, patient #2 caused disruptions with groups/therapy and "was a problem the whole time, picking with a particular patient". RN revealed, patient #2 was "very aggressive and adamant of what he was going to do and what he wasn't going to do" during the patient's hospitalization.



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3. Review of the closed medical record for Patient #5 revealed a 63 year old male admitted as IVC (Involuntary commitment) on 01/25/2024 for schizoaffective disorder with Bipolar type (Mental disorder with feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania). Review revealed the Master Treatment Plan was created on 01/26/2024, one day after admission. Review revealed no further documentation on the Master Treatment Plan. Patient #5 was discharged on 02/09/2024 at 1345, 14 days after admission.

Interview on 03/20/2024 at 1430 with Therapist #1 revealed the MTP (Master Treatment Plan) should be reviewed every 7 days. Interview revealed "unsure why it was not done." Interview revealed an entry for February 1, 2024 and February 8, 2024 was missing.

4. Review of the closed medical record for Patient #25 revealed a 24 year old female admitted on 01/14/2024 under IVC for paranoid thoughts, sleep difficulty and medication noncompliant. Review of the MTP revealed an initial date of 01/15/2024. Review revealed no further dates of review were documented. Patient #25 was discharged on 01/23/2024, 9 days after admission.

Interview on 03/20/2024 at 1430 with Therapist #1 revealed the MTP should be reviewed every 7 days. Interview revealed "unsure why it was not done." Interview revealed an entry for 01/22/2024 was missing.

B. Review of the policy titled "Interdisciplinary Patient-Centered Care Planning" with revision date of 05/2023, revealed "...5. The patient/family and/or guardian is to sign the treatment plan to indicate their agreement with and participation in development of the plan. A designated staff member is responsible for discussing the treatment plan with the patient and family/representative/guardian if they are not present at the treatment team meeting...."

Review of the closed medical record for Patient #5 revealed a 63 year old male admitted under IVC on 01/25/2024 with schizoaffective disorder with Bipolar type. Review revealed Patient #5 had a legal guardian. Review of the Master Treatment Plan revealed the guardian's signature was not documented. Review revealed the facility policy was not followed.

Interview on 03/22/2023 at 1535 with Therapist #1 revealed the legal guardian should have been notified of the MTP. The interview revealed a guardian signature or phone review from the guardian should have been present on the MTP.

NC00214633; NC00214587; NC00214617; NC00214015; NC00214473; NC00212832; NC00211897; NC00214669; NC00213517; NC00213988; NC00204978; NC00207535; NC00203154; NC00206218; NC00207224