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Based on observation, interview and record review, the facility failed to appropriately assess a patient with a change in condition for 1 of 3 sampled patients, Patient #1, as evidenced by failing to assess and evaluate the status of Patient #1 after sustaining a visible head injury.

The findings included:

Review of the clinical record revealed Patient #1 was transported to the hospital Pediatric Emergency Department (ED) via rescue. She arrived under a Baker Act initiated by police for attempting to violently harm a family member in the home. Review of the hospital Visit Encounter list revealed since July 2020, Patient #1 had 14 ED visits, 8 of which resulted in inpatient admissions to the adolescent Behavioral Health Unit.

Patient #1 was admitted to the adolescent Behavioral Health Unit on 02/10/21 at 9:00 PM. Safety measures included a one to one sitter 24 hours a day stationed at the patient's doorway to monitor for behaviors and self-infliction of injury, in addition to the standard every 15 minute patient room checks.

Review of the History and Physical Physician Note, dated 02/11/21 at 9:39 AM, documents in part, 'Chief complaint - presents with Baker Act; police responded to her (family members) house, she became combative and tried to choke her (family member). Adolescent (age documented) with known psychiatric history including psychosis, mood disorder, schizophrenia, aggressive behavior, multiple Baker Acts in past, admitted to inpatient psychiatry secondary to having aggressive behavior at home. Per ED chart, patient attempted to choke her (family member). In ED required (4 different medications) to help control her behavior.'

Review of the Restraint/Seclusion log for February 2021 revealed Patient #1 had 4-point restraints applied 25 times from 02/10/21 through 02/19/21: 18 of these incidences occurred on the day shift and 7 occurred on the night shift.
Review of the clinical record revealed documentation of Patient #1's behaviors requiring the use of 4-point restraints.

A Nursing Note, dated 02/14/21 at 7:30 PM, documents 'Patient placed herself on the floor and was banging her head on the wall of her room. Medical Doctor (MD) was called and order was obtained. Patient was put in 4-point restraints for her own safety, will continue to assess, one to one remains in effect, sitter is with patient.'

A Nursing Note, dated 02/17/21 at 7:30 AM, documents 'Combative, pulling door, pushing and grabbing staff, on floor, trying to bang head.'

A Nursing Note, dated 02/19/21 at 1:36 PM, by RN Staff B, documents, 'Patient was observed in the room by this writer defiant, limit testing, attention seeking, laying on the floor banging head continuously after several verbal redirection attempts. As the writer placed pillows and blankets on the floor to prevent patient from self-harmful behavior patient removed blankets and pillows away from her and continued to bang head on the floor with no regard, as result an abrasion and bleeding from mid forehead occurred. MD was notified and patient was placed in 4-point restraints for safety. Patient offered ice pack for swelling and a band aid but refused treatment.'

Review of the Physician Order, dated 02/19/21 at 1:41 PM, documented the indication for the 4-point restraints to be 'Banging head on the floor, attempting to bite staff's leg when attempted to stop her, spitting.'

A Nursing Note, dated 02/19/21 at 2:30 PM, by Unit Manager Staff A documents, 'Patient was banging her head against the floor. Staff placed padding as less restrictive means, the patient removed padding and continued to bang head on floor. Fighting with staff to try and continue banging her head against the floor. Redness and swelling noted to patient's forehead.'

Review of a Physician Order, dated 02/19/21 at 2:39 PM, revealed a CAT (computerized tomography) scan of the brain was ordered for Patient #1. The indication for the CAT scan is documented as - 'Injury. Patient intentionally banged head on the floor.'

Review of the clinical record revealed the 4-point restraints applied on Patient #1 at 1:30 PM on 02/19/21 were discontinued at 3:30 PM on 02/19/21.

Further review of the clinical record revealed no documentation of any assessment of Patient #1 by a Physician after she sustained a visible head injury, notably the swelling and redness to her forehead. This was confirmed by the Manager of Clinical Effectiveness, Staff E, on 04/05/21 at 11:00 AM after review of the electronic medical record.

Review of the facility policy, titled, Assessment-Inpatient, states in part, 'Reassessment is completed by the Registered Nurse. All patients are fully reassessed (head to toe) at a minimum of every day to determine the patient's response to treatment. Patients are also assessed PRN (as needed) as warranted by their condition such as a significant change in the patient's condition and/or when a significant change occurs in the patient's diagnosis.... Recommended time frames for reassessment are as follows: Behavioral Health - once daily and PRN. Patients on precautions such as suicidal, elopement, assaultive behavior - 1 time per shift.'

Review of the facility policy, titled, Behavioral Health General Unit Guidelines, states in part, 'Vital Signs - Vital signs are checked on admission and once daily on all patients, unless otherwise ordered by the physician or deemed necessary by medications or the treatment the patient is receiving. Clinical Observation Notes - Careful and accurate recording of clinical observation notes is one of the most important functions of the psychiatric staff member. Charting on a Behavioral Health patient may include some of the following observations, to include, Personal appearance; Somatic complaints and objective symptoms.'

Review of the clinical record revealed no evidence of any neurological checks to include eye pupil assessment, hand grips or extremity strength to assess for any neurological deficits or changes post Patient #1 banging her head forcefully against the floor causing redness and swelling to her forehead.
Further, the last evidence of vital sign assessment is documented as of 02/17/21 at 9:39 AM with further documentation that vital signs were refused or no documentation at all to explain why vital signs were not done. Additionally, documentation on 02/19/21 at 1:30 PM to 3:30 PM, during the time Patient #1 was in 4-point restraints documents under vital sign assessment 'Patient refused'; however, Patient #1 was immobilized in 4-point restraints and unable to move her extremities.

Review of the clinical record nursing documentation from 3:30 PM on 02/19/21 to nursing change of shift at 7:00 PM on 02/19/21, revealed no documentation of the status of the swelling and abrasion to Patient #1's forehead post the head banging incident, no neurological checks and no vital sign assessment.

Review of a Nursing Note by the night shift RN (Registered Nurse) Staff H, dated 02/19/21 at 8:00 PM, documents 'Patient seen in bedroom, dozing off and on. 1:1 sitter at bedside. Patient noted sad, depressed, and withdrawn, not verbally responding to staff. No noted distress. Will continue to monitor.' There is no evidence of documentation of the status of the patient's swelling and abrasion to her forehead, no neurological checks conducted and no vital sign assessment during the entire 12-hour shift ending at 7:00 AM on 02/20/21.

Review of the Medication Administration Records (MAR) revealed an entry, dated 02/20/21 at 5:50 AM, Patient #1 was administered Tylenol 650 milligrams. Further review of the MAR and Nursing Notes revealed no documentation for the indication for the Tylenol and no follow up documentation the Tylenol was effective or ineffective in treating the pain at the undisclosed location.

On 03/31/21 at 3:50 PM, the MARs were reviewed with the Manager of Clinical Effectiveness Staff E, who confirmed there was no documentation of an indication for the Tylenol that was administered to Patient #1 at 5:50 AM on 02/20/21. The Manager of Clinical Effectiveness Staff E stated maybe the reason was for a headache or generalized aches and pains. She stated the nurse should have documented the reason for the PRN (as needed) medication.

Review of the facility policy, titled, Medication Monitoring, states in part, 'It is the policy of (Hospital name) Health System to monitor the effects of medication (routine and PRN) on the patient.... Each patient's response to his or her medication is monitored according to the clinical needs of the patient and addresses the patient's response to the prescribed medication and actual or potential medication related problems.'

Review of a Nursing Note by night shift RN Staff H, dated 02/20/21 at 7:05 AM, documents, 'Patient on rounds in bed resting with eyes closed in no physical distress. No complaints verbalized and safety precautions in progress. Continue close observation.' No assessment of the patient's forehead swelling or abrasion was documented. No neurological assessment or vital signs assessment to include respirations was documented.

Review of a Nursing Note by RN Staff A, dated 02/20/21 at 11:39 AM, documents, 'At 1000 as this writer was working in the nursing station was notified by safety observer Staff D that something was wrong with (patient's name). As this writer approached (patients name) she was observed lying in prone (on her stomach) position, unresponsive, no pulse with aspiration on bed sheets. 2nd nurse alerted rapid response at 1009, a blue alert at 1014, and brought crash cart into the room. Staff D performed vitals showing no reading, this writer started an accucheck (blood sugar test) while MD initiated chest compressions until rapid response team arrived.'

Review of the Physician Discharge Summary Expiration Note, dated 02/20/21 at 11:09 AM, documents the staffs' unsuccessful efforts to revive Patient #1 with the time of death documented as 10:45 AM on 02/20/21.

On 03/31/21 11:30 AM, an interview was conducted with the Director of Behavioral Health and Patient #1's Neuropsychologist who stated they were very familiar with Patient #1 and had been working with her for a while now over her multiple admissions. The Neuropsychologist stated Patient #1 was well known to staff and had a history of banging her head on the floor. An inquiry was made if neuro checks were performed after the visible head injury to which the Director of Behavioral Health stated they did neuro checks. No evidence of neuro checks was forthcoming. Review of notes in Patient #1's clinical record from 2:00 PM on 02/19/21 through 10:00 AM on 02/20/21 revealed no evidence of documentation of any neuro checks or vital sign assessments conducted for Patient #1.

On 03/31/21 at 12:05 PM, an interview was conducted with Psychiatric Assistant Staff D, who's role was Patient #1's one to one sitter, stated on 02/20/21 at 7:00 AM shift change, Patient #1 was not awake. He stated he received report from the night shift outside of the patient's room and at 8:00 AM the patient was observed laying on her stomach with the covers over her. An inquiry was made if he noticed if the patient was changing position or breathing and he stated he did not notice if she was breathing or not and did not pay any attention to if she was changing positions. He stated on the weekends the kids are allowed to sleep in until 9 AM and at 9 AM they are woken up and go to breakfast. He stated Patient #1 was not allowed in the dining room or with the other kids because of her aggressive behaviors. He stated after the other kids had their breakfast he went to wake Patient #1 up. He went inside the room to wake her up, she did not move, he called her name and gave her a little poke but she did not move. He stepped out of the room to call the nurse and the nurse came right away and then a code was called and they turned her over. An in-house psychiatric physician was on the unit at the time and responded to the code. He stated he did not think much about her not getting up. She was quiet and sleeping. He stated he 'did not want to poke the bear'.

Review of the Hourly Safety Observer flow sheets revealed hourly documentation by the Psychiatric Assistants, to include Staff D initialing the form at 7:00 AM, 8:00 AM and 9:00 AM on 02/20/21. Further review of the flow sheet revealed the documentation included patient behaviors, interventions and safety/observer actions, however it does not document if the patient is observed changing position, breathing or rising and falling chest movement.

On 03/31/21 at 2:30 PM and 04/02/21 at 9:50 AM, security video footage from 5:00 AM to 10:00 AM on 02/20/21 of the one to one sitters stationed at Patient #1's bedroom door was reviewed. The one to one sitters were observed to be stationed at the patient's door with Patient #1 in view at all times. The night shift sitter and day shift sitter, Psychiatric Assistant Staff D's personnel records were reviewed revealing they are not medically licensed staff and assessing for respirations on a patient is not in their scope of practice.

On 03/31/21 at 12:30 PM, an interview was conducted with the Director of the Pediatric ED who stated on 02/10/21 they received a call Patient #1 was coming in via rescue and police under a Baker Act. She stated on arrival Patient #1 was intentionally trying to fall off the stretcher and it took 3 security guards, the physician and nurses in addition to medications to settle the patient down. She further stated Patient #1 is well known to the ED staff and she has a history of attempting to jump out of a moving car and she would frequently bang her head against the floor and walls. Patient #1 required one to one supervision to prevent harm to others and self-inflicted harm to herself.

On 03/31/21 at 12:50 PM, a tour was conducted of the Adolescent Behavioral Health Unit accompanied by the Director of Behavioral Health and Manager of Clinical Effectiveness. Joining in on the tour was the Adolescent Behavioral Health Unit, Unit Manager Staff A. Patient #1's room was observed and the floor was noted to be a very hard concrete like surface. Unit Manager Staff A stated he and the staff were very familiar with Patient #1 as she had numerous admissions to the unit. He further stated Patient #1 could be very volatile with her behaviors changing rapidly from calm to violent, attempting to inflict harm on staff, other patients and herself. He stated Patient #1 had a history of banging her head on the floor and in doing so required the use of 4-point restraints to calm her down and prevent her from hurting herself further. He stated they attempt to limit the number of hours in restraints however Patient #1 required them frequently due to her violent tendencies. He stated the staff were very familiar with the patient's head banging and approached her cautiously as you would not know if you were going to get punched or kicked. An inquiry was made to the Unit Manager Staff A to explain the circumstances surrounding Patient #1 on the morning of 02/20/21, when she was discovered unresponsive in her bed around 10:00 AM, to which he stated on weekends they allow the kids to sleep in until 9:00 AM, then get them up for breakfast. He stated Patient #1 did not join the others for breakfast as she did not participate in any group activities for fear of her hurting someone, therefore when she was still sleeping at 9:00 AM, she was not woken up with the rest of the kids. He further stated if she was sleeping, if you woke her up you might get punched.

On 04/02/21 at 10:55 AM, an interview was conducted with RN Staff B who worked with Patient #1 on the day shift of 02/19 and 02/20/21. He stated on 02/19 Patient #1 was observed sitting on the ground hitting her head harder than usual on the floor. He stated he attempted to intervene and deescalate the situation by placing pillows and blankets on the floor but the patient just moved them out of the way and kept banging her head hard on the floor. He stated she was out of control and banging her head on the floor harder than usual. An inquiry was made about the swelling and abrasion she sustained while banging her head on the floor to which he stated she was bleeding a bit from the forehead and there may have been some minor swelling but the patient refused an ice pack. He stated they had to restrain her for 2 hours and after that she was calm again and by 7 PM she was fine. An inquiry was made why the physician ordered a CAT scan of the brain to which he stated he ordered the scan to take precautions if you bang your head you have to make sure everything is ok.
A further inquiry was made if he did any neuro checks on Patient #1 after she sustained the visible head injury to which he confirmed he did not, stating she was alert and awake with no confusion. An inquiry was made when he started his shift at 7:00 AM on 02/20/21, did he receive report from the night RN Staff H she had administered Tylenol to Patient #1 at 5:50 AM, to which he stated he was told by the nurse she gave the Tylenol because the patient said she had a headache. A further inquiry was made, when he did his initial assessment when his shift started, what was Patient #1's status to which he stated 'I did not eyeball her when I came on. I had a discharge to complete. I did not eyeball her until I was alerted at 10 AM by the one to one sitter that (patient's name) did not look good.' He stated they work as a team on this unit so if he is busy with something else they all get report together in the morning and another nurse will take on his assignment to help out. He stated RN Staff C would have been the nurse who looked at Patient #1.

On 04/02/21 at 11:20 AM, an interview was conducted with RN Staff C who stated she has worked with Patient #1 many times and knows she has a history of banging her head on the walls and floor. She stated they all get report together and work as a team and split their patients, so if one nurse is busy doing a discharge or medications the other nurse would do the assessments, whatever needs to get done it gets done. She stated she remembers in report they were told Patient #1 received Tylenol around 5:55 AM for complaints of a headache or pain. She stated during shift change rounds Patient #1 was sleeping and the one to one sitter was seated at the patient's door. On the weekends the kids get to sleep in so she she was setting up her computer work and felt comfortable that everything was in place before she started to pass medications. She stated if she worked that day she would have done the assessment however stating she does not recall, whatever I put in my notes. She stated she recollects on rounds the patient was sleeping. An inquiry was made if she was aware Patient #1 had swelling and an abrasion to her forehead from the injury sustained the day before, to which she stated she does not remember anything about swelling or abrasion but recalled they ordered a CAT scan. She stated she did not walk into the room and look at the patient's eyes and did not do any neuro checks on the patient that morning. RN Staff C stated she does not recollect if she did any assessment on Patient #1 that morning because the patient was still sleeping, and stated when she was doing medications for everybody, that is when she heard RN Staff B (Patient #1's assigned nurse) call a rapid response because the sitter could not wake (patient's name) up. She stated at that point she grabbed the crash cart and took it into the room.

Review of Nursing Note documentation by night shift RN Staff H on 02/20/21 at 7:04 AM documents under Safe Environment - sitter at bedside; patient asleep. There is no documentation Patient #1 was breathing and alive.

Review of Nursing Note documentation by day shift RN Staff C on 02/20/21 at 8:20 AM documents under Mental Status Exam - Level of eye contact minimal; motor lethargic, mood depressed, sad; interaction during interview apathetic; Appetite good, all of meal taken (Breakfast was not served until after 9 AM and the breakfast tray was never brought into Patient #1's room on 02/20/21 as observed in the video footage observed from 5 AM to 10 AM on 02/20/21); Documentation under Pain Screening - Patient currently in pain? - No. (Patient #1 was not woken up to assess for pain); Documentation entered at 8:20 AM states 'respiratory even, unlabored'. During the interview conducted with RN Staff C on 04/02/21 at 11:20 AM, she stated she did not do a hands on face to face assessment of Patient #1 because the patient was sleeping and was left to sleep. During the interview with RN Staff C on 04/02/21 at 11:20 AM, she stated she did not assess Patient #1's breathing.

On 04/5/21 at 11:27 AM, an interview was conducted with UM Staff A who reconfirmed Patient #1 had a long history of banging her head on the floor and an inquiry was made to him regarding his documentation in Patient #1's clinical record about the swelling to her forehead and abrasion. UM Staff A stated there was an abrasion, and he reached out to the doctor to get orders and the doctor ordered a CAT scan of the brain following the incident. He further stated there may have been some edema but he thought it was more of an abrasion and not swelling. He stated he would have to check the notes. UM Staff A was apprised he documented redness and swelling to Patient #1's forehead and was provided with a copy of his nursing documentation. After reviewing the note, he stated 'I guess if I documented it then there must have been swelling'. An inquiry was made if Patient #1 was assessed by a physician after the head banging incident resulting in a visible head injury, to which he stated he was not sure if the doctor did rounds that afternoon or not. He stated he did a face to face assessment of the patient and she was fine. A further inquiry was made, if she had a visible head injury would they have conducted neuro checks to which he confirmed neuro checks or vital signs were not done but she looked fine.

Review of Nursing Note documentation from 2:00 PM on 02/19/21 through 8:20 AM on 02/20/21, there is no assessment of Patient #1's forehead swelling or abrasion.

On 04/08/21 at 8:35 AM, a telephone interview was conducted with RN Staff H who stated she does not remember much about the incident and it was a traumatic event. She stated Patient #1 did not require restraints on the night of 02/19/21 through the morning of 02/20/21, however she did have to restrain her in the past due to her uncontrolled behaviors with potential for harm to herself or others. RN Staff H confirmed Patient #1 had a history of banging her head on the floor. She stated in change of shift report she received report that Patient #1 had banged her head on the floor during the day and required 4-point restraints. An inquiry was made about the status of the redness, swelling and abrasion to Patient #1's forehead, to which she stated she did not observe her forehead because her hair was covering her forehead. An inquiry was made about Patient #1 receiving Tylenol at 5:50 AM and the indication for it, to which she stated Patient #1 would not take pills so medications had to be in liquid form and the other nurse on the unit brought her the liquid Tylenol and she administered it to Patient #1. An inquiry was made why Patient #1 received the Tylenol as she did not document any indication, to which she stated she believed the patient asked for the Tylenol because she had a headache and she remembered telling Patient #1 she has to stop throwing herself on the ground. RN Staff H stated it is their protocol to document the reason for administering PRN medications. She further stated it was the other night nurse on the unit that documented Tylenol was administered, even though RN Staff H was the one who actually gave it to the patient. A further inquiry was made if she did any neuro checks or vital sign assessment to which RN Staff H confirmed she did not and further stated at the end of her shift, Patient #1 was sleeping in her bed.
Review of a Nursing Note dated 02/20/21 at 7:05 AM by RN Staff H documents, 'Patient on rounds in bed resting with eyes closed in no physical distress. No complaints verbalized and safety precautions in progress. Continue close observation.' The Nursing Note documentation does not document if Patient #1 was observed breathing.

Observation of the video footage showed RN Staff H exiting Patient #1's room at approximately 5:51 AM on 02/20/21, potentially making this time the last time Patient #1 was assessed as still breathing.

On 04/07/21 at 2:07 PM, a telephone interview was conducted with Patient #1's Psychiatrist who stated none of them was prepared for Patient #1's tragic death. He confirmed Patient #1 had a long history of head banging and self-harm. An inquiry was made if he was informed she had sustained a swollen forehead after she was aggressively banging her head on the floor, to which he stated he was not sure, they called him a lot, she was very difficult to control. An inquiry was made if she had sustained a swollen forehead as a result of the banging on the floor, would the protocol be to do neuro checks, to which he stated even with a minor fall you would definitely do vital signs and neuro checks. He further stated if there is any injury you would send the child to the ED or have a medical doctor in to assess. An inquiry was made since Patient #1 was banging her head on the floor harder than she usually did that day, could she have sustained a concussion, to which he stated "Oh yea, definitely".

As of 04/08/21, the County Medical Examiner autopsy report for the cause of death of Patient #1 was still pending.