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Based on record review and interview the hospital failed to ensure a written response to grievances was provided in a reasonable time frame for 2 patients (Patient # R7 and Patient # R8) with grievances out of a total 3 written grievance responses reviewed.
Findings:
Review of the hospital policy titled, "Patient Grievance Procedures", policy number RI.012, reviewed/revised date of 03/14 revealed in part the following: ....All complaints of abuse or neglect will be considered a grievance. When a report of sexual or physical abuse or neglect, whether directly or by referral is received the Department of Health and Hospitals will be notified within 24 hours from the time the facility was notified of the complaint.....The Patient Advocate will continue with the investigation of the grievance until a resolution is achieved.....5.0 All allegations of abuse or neglect are considered grievances and cannot be resolved at the unit level. Investigation should be initiated immediately as directed by the nursing supervisor or previously outlined administrative representatives.....7.0 When a prompt resolution is possible, the hospital will provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. 8.0 If a prompt resolution is not possible, a written response will be forwarded to the person filing the grievance within seven days of receipt stating that the issue is being investigated. A second/final response will be sent when the investigation is completed, indicating the hospital's decision, the name of the hospitals contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. This notice will be sent after the investigation is completed....
Patient #R7
Review of the Hospital Abuse/Neglect Initial Report revealed on 9/25/14 Patient #R7 stated S17Social Worker hit him. Patient #R7 reported that S17Social Worker hit him in the hand because he accidentally touched S17Social Worker on the buttock. Patient #R7 reported he had nerve damage in his hand and he was in pain.
The first written response to the grievance was dated on October 9, 2014 (15 days after the grievance was filed). The findings were confirmed by S4Patient Advocate on 10/10/14 at 8:45 a.m.

Patient #R8
Review of the Hospital Abuse/Neglect Initial Report revealed Patient #R8 reported to a staff member on 9/25/14 that her roommate Patient #R9 had performed oral sex on her while she was asleep.
Review of the response to the grievance revealed the letter was dated 10/10/14 (16 days after the grievance was reported). The findings were confirmed by S4Patient Advocate on 10/10/14 at 8:45 a.m.











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Based on record review and interviews, the hospital failed to ensure that a patient who filed a grievance was provided a written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. The hospital failed to provide a written response to the patient for 2 (Patient #3 and Patient #R5) patients' grievances from a total of 5 grievances reviewed.
Findings:

Review of the hospital policy titled, "Patient Grievance Procedures", policy number RI.012, reviewed/revised date of 03/14 revealed in part the following: ....All complaints of abuse or neglect will be considered a grievance. When a report of sexual or physical abuse or neglect, whether directly or by referral is received the Department of Health and Hospitals will be notified within 24 hours from the time the facility was notified of the complaint.....The Patient Advocate will continue with the investigation of the grievance until a resolution is achieved.....5.0 All allegations of abuse or neglect are considered grievances and cannot be resolved at the unit level. Investigation should be initiated immediately as directed by the nursing supervisor or previously outlined administrative representatives.....7.0 When a prompt resolution is possible, the hospital will provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. 8.0 If a prompt resolution is not possible, a written response will be forwarded to the person filing the grievance within seven days of receipt stating that the issue is being investigated. A second/final response will be sent when the investigation is completed, indicating the hospital's decision, the name of the hospitals contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. This notice will be sent after the investigation is completed....

Patient #2 and #3 incident:
Review of the medical record for Patient #2 revealed the patient was a 13 year old female admitted to the hospital on 9/17/14 on a PEC (Physician Emergency Certificate) secondary to Suicidal Ideation with a plan and increased depression. Her Psychiatric Evaluation listed her diagnosis as Bipolar with a history of psychosis. Her observation status was Line of Sight (CVO) with Suicide Ideations and Sexually Predator Precaution on 9/22/14.

Review of the medical record for Patient #3 revealed he was a 13 year old male admitted on a PEC on 9/20/14 for fighting with mother and threatening to kill her and having a gun. His psychiatric evaluation on 9/21/14 revealed diagnoses of Bipolar Disorder, Cannabis Dependence and Conduct Disorder. Review of his admission orders revealed he was placed on Elopement, Behavioral, Suicidal and Violence/Assaultive Precautions and his observation level was every 15 minutes on 9/22/14.
Review of the Hospital Abuse/Neglect Initial Report submitted to Department of Health and Hospitals revealed in part: "... On video at 1910 on 9/22/14 in Patient #2 and Patient #3 were in the dayroom with other patients. Patient #2 was crawling on the floor, and appeared to be seeking attention from peers. Patient #2 put her hand in Patient #3's lap. Another patient pulled Patient #2 away, while Patient #3 guarded his lap. Patient #2 attempted to touch Patient #3 again, Patient #3 got up and walked around room. Patient #2 walked over to the other side of the room, and sat down. S15LPN was standing in nursing station doorway, and appeared to be giving out medications at the time..."
An observation was made on 10/9/14 at 4 p.m. of the video on 9/22/14 at 1910. Numerous patients were in the dayroom running around the dayroom. Patient #2 was crawling on the floor in front of Patient #3 while he was sitting in a chair. Patient #2 did attempt to grab Patient #3's groin area, but it was unclear if Patient #2 actually touched Patient #3.

Review of the Interdisciplinary Notes dated 9/22/14 revealed the following in part: "...1940 Patient #3 reports that a female peer grabbed his butt and tried to grab the front of his groin; female peer became loud and defiant, cursing staff and escorted to dayroom away from Patient #3. 1955- Nursing Supervisor notified of situation. 2015- Spoke with M (Mother) of situation, understanding..."

An interview was conducted with S4Patient Advocate on 10/10/14 at 9 a.m. She reported a letter notifying the mother and the patient of the results of the investigation was not sent to the family.

Incident with R5 and R6

Review of the Alleged Sexual Abuse and Alleged Physical Abuse submitted to Department of Health and Hospitals revealed in part, "....Date of Discovery 8/17/14 at 15:30, Patient R5 stated Patient R6, her roommate threatened to choke her if she didn't have sex with her. Patient R5 stated Patient R6 took Patient R5's hand and place in R6's crotch. Patient R5 stated R6 was only wearing a shirt and wasn't wearing any underwear. Patient R5 stated a staff member walked in and R6 let go of her hand and asked "what is going on?" Patient R5 stated they both said nothing. R5 waited until R6 was discharged before reporting it to staff. R5 stated "I was scared to report it sooner because R6 was bigger than me." Patient R5 stated "I don't want to press charges; I just wanted the staff to know."

An interview was conducted with S4Patient Advocate on 10/10/14 at 9 a.m. When questioned if a letter was provided to Patient R5 when the investigation was completed, she reported she wasn't the Patient Advocate at that time, but she was unable to locate a letter to Patient R5.

Based on observation, record review, and staff interview, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) failing to ensure patients on the Youth Enhanced Unit (YEU) with the patient census consisting of patients on Aggressive/Assaultive/Violent precautions were not allowed to possess contraband as evidenced by Patient #7 having a hair pick in his hair during group therapy; and
2) failing to ensure the environment of care was free of ligature risks and safety hazards as evidenced by A) the presence of loose vent covers (measuring approximately 2 foot X 2 foot) on the ceiling in the patient care rooms and B) failing to ensure patients on the Tweens Units were free of ligature risks and safety hazards as evidenced by 2 rotating black fans mounted half way up the wall in the Tween's day room with the approximately 5 feet length of electrical cords plugged into the electrical outlets at the bottom of the wall and a metal vent with sharp edges only secured in 2 corners in the hall shower room, which could easily be removed from the wall.

Findings:

1) Contraband on YEU:

Review of the hospital's policy titled, "Valuable - Patient's Personal Belongings/Contraband", policy number TXOP.012, current date of 03/14 revealed in part the following: Policy: ....Contraband is not permitted in the patient area at any time....Contraband is strictly prohibited in the program. Contraband is defined as such items as: knives, weapons of any kind, drugs (prescription or non-prescription), alcohol or any item that can pose a threat of physical harm to the patient or another person in the program.

Review of the hospital's policy titled, "Contraband", policy number TX.002, current date of 03/14 revealed in part the following: Policy: To provide a safe and therapeutic environment for patients and staff, contraband is defined and procedures regarding contraband found are delineated. Procedure: When contraband is brought onto any unit, it will be confiscated from the patient or visitors by the unit staff....The DON (Director of Nursing)/Supervisor will be informed of the presence of contraband....Specific items considered contraband: ....Hair picks or rakes....

On 10/08/14 at 9:25 a.m., an observation was made of group therapy on the YEU. Patient #7 was observed sitting in the group of patients with a hard, plastic hair pick protruding from his hair. S16RN who was present at the time of the observation confirmed the patient should not have the hair pick in his hair during the group session, and stated the pick should have been locked up after the patient's shower.

Review of the medical record for Patient #7 revealed the patient was a 15 year old male admitted to the hospital on 10/03/14 under a PEC (Physician Emergency Certificate) for suicidal ideations. Review of the record revealed the patient had a history of self-injurious behaviors.



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2. Ligature Risk and Safety Hazards

A) Observations on 10/08/14 between 9:10 a.m. and 10:30 a.m. revealed the presence of loose vent covers (measuring approximately 2 foot X 2 foot) on the ceiling in the patient care rooms. The vent covers in several Patient Rooms (including but not limited to Patient Room #336, #367, and #369) were noted to be unsecured and/or loose. The vent covers could have been removed from the ceiling by a patient with minimal to moderate force resulting in the patient having access to the sections of the hospital immediately above the ceiling. The Director of Nursing was present at the time of these observations. The Director of Nursing verified that the vent covers were unsecured and/or loose and could pose a safety hazard should they be removed by a patient.

B) A tour was made of the Tween Dayroom on 10/8/14 at 9:30 a.m. Two black rotating fans were observed secured half way up the wall with approximately 5 feet of electrical cords hanging underneath the fan and plugged into an electrical outlet at the bottom of the wall. S6Intake Coordinator confirmed the observation.

An observation was made at 9:35 a.m. on 10/8/14 of the hall shower room at the end Tween unit of a metal vent on the wall (at about 5 feet up the wall). The metal vent had sharp edges and was only secured on two corners. The vent was easily pulled out from the wall. S6Intake Coordinator confirmed the observation.

Based on record review and staff interview, the hospital failed to ensure the QAPI program included an evaluation of the preventative actions for adverse events for 3 of 3 adverse events reviewed. Findings:

On 10/09/14 at 4:00 p.m., S3Risk Management provided a Root Cause Analysis Report of an adverse event dated 06/08/14 related to a patient's death after the patient was transferred to an acute care hospital. Review of the Root Cause Analysis revealed an investigation of the incident with Risk Reduction Actions Taken and Prevention Strategies documented. The Root Cause Analysis revealed no documented evidence of any evaluation of the impact of the preventative actions implemented by the hospital.

On 10/10/14 at 8:50 a.m., S3Risk Management provided two more Root Cause Analysis Reports of an adverse event involving inappropriate sexual behavior between 2 patients on 06/25/14. Review of the Root Cause Analysis revealed an investigation of the incident with Risk Reduction Actions Taken and Prevention Strategies documented. The Root Cause Analysis revealed no documented evidence of any evaluation of the impact of the preventative actions implemented by the hospital.

In an interview on 10/10/14 at 8:50 a.m., S3Risk Management reviewed the above 3 Root Cause Analyses and confirmed there was no evaluation done of the preventative actions that were implemented by the hospital for these 3 adverse events, other than the absence of any further incidents.

Based on observations, record reviews, and interviews, the hospital failed to ensure the nursing service had adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Mental Health Technicians (MHTs) to provide adequate supervision of high risk patients according to physician's orders and hospital policy as evidenced by:

1. On 9/22/14 on the Tweens Unit a RN (Registered Nurse) was attempting to provide nursing care to (3) Constant Visual Observation patients and (1) 1:1 observation patient with 1RN, 1 LPN (Licensed Practical Nurse), and 1 MHT (Mental Health Tech) providing care for the other 12 acute care psychiatric patients. An incident of neglect occurred during this time period involving Patient #2 and Patient #3.
2. On 9/25/14 on the 11 p.m. to 7 a.m. shift on the Tweens Unit a RN and a LPN were providing care to 19 acute care psychiatric patients.
3. On 9/27/14 on the 11 p.m. to 7 a.m. shift on the Tweens Unit a RN and 2 MHTs were providing care for (1) 1:1 patient, and (1) Constant Visual Observation patient and 17 other acute care psychiatric patients.

Findings:

Review of the hospital policy titled, "Assignment of Patients to Staff", policy number TX.001, reviewed/revised June 2014, revealed in part the following: ....The purpose of this policy and procedure is to ensure that every patient is assigned a staff member who has the responsibility for monitoring the patient for safety, behavior and location....4.4 Staffing ratios on the Youth Enhanced, Adult Enhanced and Children's Enhanced Units will be 1:4 on days and evening. All other units will follow a 1:5 staffing ratio on days and evenings and 1:9 staffing ratio on nights. Patients placed on Constant Visual Observation (CVO) will be monitored by one staff member who may be assigned up to two patients placed on CVO. Staffing for CVOs and 1:1 will be excluded from the unit staffing ratios.

Review of the hospital policy titled, "Acuity Staffing Plan", policy number NR.003, reviewed/revised June 2014, revealed in part the following: Policy: This hospital maintains a nursing staffing level that supports safe and efficient care for each patient on the unit....
Procedure:....2.0 The acuity level of each unit will be formally rated prior to every 8 hour shift. These determinations are made by the Charge Nurse, Manager or the Nursing Shift Supervisor in consultation with the patients' treatment team and with particular attention to special supervision orders of the patients' treating psychiatrists.
3.0 Staffing needs for each unit are reassessed at least once per shift by the Manager, Supervisor or Charge Nurse based on the following information sources: Milieu Dynamics, Admissions scheduled, Discharges scheduled, Transportation needs/outside consults, Programming needs, Administrative meetings requiring staff time, Individualized treatment plans and individual patient needs, Current family needs, Use of special procedures as seclusion/restraint, Sentinel events, Volume of patients.
5.0 The Charge Nurse or Staff Nurse on the unit is to notify the Nursing Supervisor, when un unusual and exceptional situations, the acuity needs of the individual patients or the milieu dynamics change to exceed previously projected staffing needs.... The Supervisor will assess the situation and prioritize actions for resolution of the situation. Resolution plans may include: re-assignment of staff on unit, re-assignment of staff from other units, deployment of acquisition of additional staff if indicated, suspension of non-critical duties/activities, deployment of management staff who are nurses to cover units, deployment of other management staff who have appropriate experience and training to fulfill patient supervision responsibilities of Mental Health Technicians.
Patient Monitoring System
Constant Visual Observation (CVO)....
The patient must be maintained within the visual contact of the staff at all times. Patients on CVO will be monitored on a 1:2 staffing ratio. The assigned staff to a CVO will not be assigned additional unit responsibilities. The assigned staff will monitor no more than two patients on CVO on all shifts.....
One-to-one (1:1)....
The patient must be maintained within the visual contact/arm's reach of the staff at all times.... At any given time, the staff assigned to provide visual contact/arm's reach must insure that another staff member will assume this responsibility if he/she must leave the presence of the patient (i.e. lunch breaks, etc.)

1. Review of the medical record for Patient #2 revealed the patient was a 13 year old female admitted to the hospital on 9/17/14 on a PEC (Physician Emergency Certificate) secondary to Suicidal Ideation with a plan and increased depression. Her Psychiatric Evaluation listed her diagnosis as Bipolar with a history of psychosis. Her observation status was Line of Sight (CVO) with Suicide Ideations and Sexually Predator Precautions on 9/22/14.
Review of the medical record for Patient #3 revealed he was a 13 year old male admitted on a PEC on 9/20/14 for fighting with mother and threatening to kill her and having a gun. His psychiatric evaluation on 9/21/14 revealed diagnoses of Bipolar Disorder, Cannabis Dependence and Conduct Disorder. Review of his admission orders revealed he was placed on Elopement, Behavioral, Suicidal and Violence/Assaultive Precautions and his observation level was every 15 minutes on 9/22/14.
Review of the Hospital Abuse/Neglect Initial Report submitted to Department of Health and Hospitals revealed in part: "... On video at 1910 on 9/22/14 in Patient #2 and Patient #3 were in the dayroom with other patients. Patient #2 was crawling on the floor, and appeared to be seeking attention from peers. Patient #2 put her hand in Patient #3's lap. Another patient pulled Patient #2 away, while Patient #3 guarded his lap. Patient #2 attempted to touch Patient #3 again, Patient #3 got up and walked around room. Patient #2 walked over to the other side of the room, and sat down. S15LPN was standing in nursing station doorway, and appeared to be giving out medications at the time..."
An observation was made on 10/9/14 at 4 p.m. of the video from 9/22/14 at 1910. Numerous patients were in the dayroom running around the dayroom. Patient #2 was crawling on the floor in front of Patient #3 while he was sitting in a chair. Patient #2 did attempt to grab Patient #3's groin area, but it was unclear if Patient #2 actually touched Patient #3. Three staff members where in the nursing station room adjacent from the dayroom at the time of the occurrence. Prior to, during, and after the incident there was no evidence of staff monitoring a patient on 1:1 observation level or 3 patients on CVO observation level.
A phone interview was conducted on 10/8/14 at 12:45 p.m. with S5RN. She reported she was the RN assigned to Patient #2 on the evening shift of 9/22/14. She further reported her assignment consisted of providing care to 3 patients on CVO (line of sight) and 1 patient on 1:1 observation. The patient on 1:1 observation had a recent suicide attempt on the unit with attempting to twist a T-shirt around his/her neck. The nurse could not remember the patient's name. She went on to report the unit was not staffed according to policy and she had let the nursing supervisor know a couple of times that shift they were understaffed. S5RN reported the suicidal patient was made a 1:1 patient at the last minute and really messed up staffing. She went on to report she placed all the patients in the dayroom so she could monitor them better. She reported at the time of the incident she was speaking to 2 different physicians because one patient was having uncontrollable EPS (Extrapyramidal Symptoms) and she was trying to get a prn (as needed) medication order for Patient #2 because she was having behavior issues.
An interview was conducted with S4Patient Advocate on 10/9/14 at 10:00 a.m. She reported she investigated the incident and reported the incident to Department of Health and Hospitals. S4Patient Advocate reported the hospital became aware of the incident due to Patient #3 reporting the occurrence of the incident to S5RN on 9/22/14 after the incident occurred. She went on to report S5RN didn't witness the event, but when asked if she should have due to the CVO observation level, she stated yes. S4Patient Advocate further reported the nurse was assigned 3 CVO patients at the time the incident occurred. S5Patient Advocate reported it was found on review of the incident S8MHT escalated Patient #2's behavior instead of deescalating her behavior. When asked about more specific details, it was reported their personalities did not mesh. With review of the video no interaction was noted between S8MHT and Patient #2 at the time of the incident.
Review of the Interdisciplinary Notes dated 9/22/14 revealed the following in part: "...1940 Patient #3 reports that a female peer grabbed his butt and tried to grab the front of his groin; female peer became loud and defiant, cursing staff and escorted to dayroom away from Patient #3. 1955- Nursing Supervisor notified of situation. 2015- Spoke with M (Mother) of situation, understanding..."
An interview was conducted with S2DON (Director of Nurses) on 10/8/14 at 10:10 a.m. He reported on the Tweens unit the hospital tries to staff on day and evening shift 1 staff member to 5 patients. If a patient is on 1:1 observation that is the only patient a staff member can have and at the maximum one staff member can have 2 patients on CVO (Line of sight) observation level. If there is only 1 patient on CVO observation level that is the only patient that staff member will have. S2DON reported S5RN did not observe the incident happen with Patient #2 and Patient #3 because she was on the phone with a physician when the incident occurred. S2DON confirmed the patient assignments were not in accordance with hospital policy.

2. Review of the Staffing Pattern completed by S2DON for Thursday, 9/25/14 on the 11 p.m. to 7 a.m. shift revealed one RN and one LPN was assigned 19 acute care psychiatric patients on the Tweens Unit. An interview was conducted with S2DON on 10/8/14 at 12:30 p.m. With review of the staffing level for the 11 p.m. and 7 a.m. shift on 9/25/14 he verified the staffing was not ideal.

3. Review of the Staffing Pattern completed by S2DON for Saturday, 9/27/14 on the 11 p.m. to the 7 a.m. shift revealed there was 1 RN and 2 MHTs assigned 19 acute care psychiatric patients with one patient being on 1:1 observation level and 1 patient being on CVO (line of sight). This would have left 17 patients with one staff member. An interview was conducted with S2DON on 10/8/14 at 12:30 p.m. He verified the unit was short staffed on 9/27/14 on the 11 p.m. and 7 a.m. shift.



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