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The facility failed to safeguard and uphold the rights of each patient. This failure resulted in:

A. 10 of 10 patients were admitted to an inpatient psychiatric unit with contraband in their possession that was not confiscated in the Intake Department. The contraband, in the form of a weapon, drugs, and cigarette lighters, created an environmental safety risk and had the potential to cause serious harm to patients and staff, as well as, extensive damage to property.

B. 7 of 7 patients were admitted to the unit with contraband in their possession that was not confiscated in the Intake Department. This negligence by staff could have resulted in serious injury to numerous patients and extensive damage to property. Items confiscated from patients on the unit included a pocket knife with a four-inch blade, numerous medications including Xanax, Viibryd, and Lithium Carbonate, three cigarette lighters, two packs of cigarettes, and a transport/gait belt. In addition, there were two instances of patients caught smoking in their bedrooms, one being an adolescent.


Cross reference:
CFR 483.13 A0144 Patient Rights: Care in Safe Setting
CFR 483.13 A0145 Patient Rights: Free from Abuse/Harassment

Based on interview and record review, the facility failed to ensure patients received care in a safe setting. This failure resulted in 10 of 10 patients (Patient #26, #27, #28, #29, #30, #31, #32, #33, #34, and #35) being admitted to an inpatient psychiatric unit with contraband in their possession. The contraband, in the form of a weapon, drugs, and cigarette lighters, created an environmental safety risk and had the potential to cause serious harm to patients and staff, as well as, extensive damage to property.


Findings:

Record review of policy 6553820, "Contraband and Restricted Articles," approved 6/2019, showed:

"Purpose: ... To provide a monitoring system for patients who present with sharps or items designated as contraband ...

Policy: Items, which are considered a danger or potential danger to patients and others, will be locked in the secure location ...

Procedure: On admission, patient will have his/her belongings checked in his/her presence ... [Some] items are not allowed during the hospital stay ... Items considered to be restricted: ...

3. Anything that may jeopardize patient mental, emotional, or physical safety ...

5. ... hair clamps/clips ... safety pins ...

7. ... belts ...

8. Drugs ...

15. Lighters ...

22. Weapons ... knives ...

Special Points: Medications will be sent to the unit (unless a family member is present who will be requested to take them home)."


Patient #27.
Record review of an Incident Report by Staff Q dated 7/16/2019 at 8:35 PM for Patient #27 showed: "Knife taken away from patient after it was found during skin/body search." The knife had a four (4) inch blade.

Record review of written statement by Staff R dated 7/16/2019 at 8:25 PM showed: Staff R escorted Patient #27 from the Intake Department to the Bridges unit. "When unit skin assessment was done by Staff Q, patient was found to have a pocket knife with him in his pocket ... It was a scary incident that put everyone in danger."


Patient #28.
Record review of an Incident Report by Staff S dated 6/7/2019 at 1:30 AM showed: "Patient was found with packet containing 25 full Zanex [sic] (Xanax) and 5 broken Zanex [sic] (Xanax) ... wallet. Patient wearing chain. Patient had lighter."


Patient #29.
Record review of an Incident Report by Staff T dated 6/7/2019 at 9:15 PM showed two (2) bottles of medications in Patient #29's bedroom: 30 Viibryd 20 mg tablets [antidepressant] and 5 Lithium Carbonate 150 mg capsules [mood stabilizer]. Staff T also found a pack of Marlboro cigarettes.


Patient #30.
Record review of an Incident Report by Staff U dated 5/22/2019 at 7:30 AM showed: Patient found with a lighter. Patient #30 was admitted two (2) days earlier on 5/20/2019.

Record review of the Daily 7p to 7a Nursing Assessment Note by Staff U dated 5/22/2019 at 8:26 AM showed: MHT found lighter in Patient #30's pocket while doing laundry.


Patient #31.
Record review of an Incident Report by Staff V dated 5/21/2019 at 4:50 PM for Patient #31 showed: Patient found with a lighter. Patient #31 was admitted five (5) days earlier on 5/16/2019.

Record review of the Daily 7a to 7p Nursing Assessment Note by Staff V dated Tuesday, 5/21/2019 at 4:40 PM, showed: There was a smell of cigarette smoke in Patient #31's room. Patient #31 stated he had been smoking in his room since Saturday [5/18/2019].


Patient #32.
Record review of the Daily 7a to 7p Nursing Assessment Note by Staff X dated 3/12/2019 at 7:20 AM showed: Smelled smoke in room of Patient #32. Patient admitted to smoking cigarettes, adding that he had cigarettes in his pocket in the Intake Department. No contraband was found in his room. He stated he flushed the lighter and cigarettes. Staff X documented that Patient #32's mother stated she gave her son cigarettes the day prior to his admission into the hospital.

Record review of an Incident Report by Staff W dated 3/17/2019 at 9:15 AM for Patient #32 showed: Lighter and cigarettes found in towel in patient's room. The Incident Report further identified Patient #32 as a 16-year-old male. Patient #32 was admitted six (6) days earlier on 3/11/2019.


Patient #34.
Record review of an Incident Report by Staff Y dated 2/20/2019 at 8:40 AM for Patient #34 showed: Patient #34, an 84-year-old female had a transport (gait) belt around her waist. Patient #34 was admitted the previous day, 2/19/2019.


Patient #26.
Record review of an Incident Report by Staff D dated 7/31/2019 at 1:30 PM for Patient #26 showed: "Patient found with an empty bottle of nicotine lozenges in her hand." Patient #26 was admitted five (5) days earlier on 7/25/2019.


Patient #33.
Record review of an Incident Report by Staff Q dated 2/27/2019 at 5:45 AM for Patient #33 showed: Hair clips in bedroom.


Patient #35.
Record review of an Incident Report by Staff Z dated 1/28/2019 at 9:45 AM for Patient #35 showed: Two (2) safety pins attached to the patient's bra. The Incident Report further identified Patient #35 as a 16-year-old female. Patient #35 was admitted seven (7) days earlier on 1/21/2019.



In an interview with Staff AA on 8/30/2019 at 12:05 PM, she stated:

a) Patients are asked to empty their pockets in the triage room.

b) Patients pockets are not "patted down."

c) Handheld electronic wands are used to detect metal objects in the patient's pockets.

d) Intake staff asks about belongings.

e) Intake "may not" go through all of a patient's suitcases.

f) The skin check is conducted on the unit, not in the intake area.


In an interview with Staff B on 8/30/2019 at 12:00 PM, she stated, she was aware of the contraband that is outlined in the Incident Reports, adding that there has been a problem with contraband making it to the units. She also stated, she is going to get a privacy screen and gowns to assess for contraband in the intake area.


In an interview with Staff L on 8/30/2019 at 12:00 PM, she stated patients are asked to empty their pockets. She also stated that a handheld electron wand is used on the patient's pockets.


In an interview with Staff M on 8/30/2019 at 12:00 PM, she stated the skin assessments were done in the Intake Department at one time, but this is not the current practice.


Observation of the Intake Department on 8/30/2019 at 12:30 PM revealed a handheld electronic wand for detecting metal objects.

Based on interview and record review, the facility failed to ensure the patients right to be free from neglect. This failure resulted in 7 of 7 patients (Patient #27, #28, #29, #30, #31, #32, and #34) being admitted to the unit with contraband that was not confiscated in the Intake Department. These items that could have resulted in serious injury to numerous patients and extensive damage to property. Those items included:

A. A pocket knife with a four-inch blade (Patient #27);

B. Numerous medications, including Xanax, Viibryd, and Lithium Carbonate (Patient #28 and Patient #29);

C. Three cigarette lighters (Patient #30, #31, and Patient #32);

D. Two packs of cigarettes (Patient #29 and Patient #32), and

E. A transport/gait belt (Patient #34).

F. There were two instances of patients caught smoking in their bedrooms (Patient #31 and Patient #32).


Findings:

A. A pocket knife with a four-inch blade - Patient #27.

Record review of an Incident Report by Staff Q dated 7/16/2019 at 8:35 PM for Patient #27 showed: "Knife taken away from patient after it was found during skin/body search." The knife had a four (4) inch blade.

Record review of written statement by Staff R dated 7/16/2019 at 8:25 PM showed: Staff R escorted Patient #27 from Intake Department to the Bridges unit. "When unit skin assessment was done by Staff Q, patient was found to have a pocket knife with him in his pocket ... It was a scary incident that put everyone in danger."


B. Numerous medications, including Xanax, Viibryd, and Lithium Carbonate - Patient #28 and Patient #29.

Patient #28.
Record review of an Incident Report by Staff S dated 6/7/2019 at 1:30 AM showed: "Patient was found with packet containing 25 full Zanex [sic] (Xanax) and 5 broken Zanex [sic] (Xanax) ... wallet. Patient wearing chain. Patient had lighter."

Patient #29.
Record review of an Incident Report by Staff T dated 6/7/2019 at 9:15 PM showed two (2) bottles of medications in Patient #29's bedroom: 30 Viibryd 20 mg tablets [antidepressant] and 5 Lithium Carbonate 150 mg capsules [mood stabilizer].


C. Three cigarette lighters (Patient #30, #31, and #32).

Patient #30.
Record review of an Incident Report by Staff U dated 5/22/2019 at 7:30 AM showed: Patient found with a lighter. Patient #30 was admitted two (2) days earlier on 5/20/2019.

Patient #31.
Record review of an Incident Report by Staff V dated 5/21/2019 at 4:50 PM for Patient #31 showed: Patient found with a lighter. Patient #31 was admitted five (5) days earlier on 5/16/2019.

Patient #32.
Record review of an Incident Report by Staff W dated 3/17/2019 at 9:15 AM for Patient #32 showed: Lighter and cigarettes found in towel in patient's room. The Incident Report further identified Patient #32 as a 16-year-old male. Patient #32 was admitted six (6) days earlier on 3/11/2019.



D. Two packs of cigarettes (Patient #29 and Patient #32).

Patient #29.
Record review of an Incident Report by Staff T dated 6/7/2019 at 9:15 PM showed two (2) bottles of medications in Patient #29's bedroom: 30 Viibryd 20 mg tablets [antidepressant] and 5 Lithium Carbonate 150 mg capsules [mood stabilizer]. Staff T also found a pack of Marlboro cigarettes.

Patient #32.
Record review of an Incident Report by Staff W dated 3/17/2019 at 9:15 AM for Patient #32 showed: Lighter and cigarettes found in towel in patient's room. The Incident Report further identified Patient #32 as a 16-year-old male. Patient #32 was admitted six (6) days earlier on 3/11/2019.



E. A transport/gait belt (Patient #34).

Patient #34.
Record review of an Incident Report by Staff Y dated 2/20/2019 at 8:40 AM for Patient #34 showed: Patient #34, an 84-year-old female had a transport (gait) belt around her waist. Patient #34 was admitted the previous day, 2/19/2019.



F. Two instances of patients smoking in their bedrooms (Patient #31 and Patient #32).

Patient #31.
Record review of an Incident Report by Staff V dated 5/21/2019 at 4:50 PM for Patient #31 showed: Patient found with a lighter. Patient #31 was admitted five (5) days earlier on 5/16/2019.

Record review of the Daily 7a to 7p Nursing Assessment Note by Staff V dated Tuesday, 5/21/2019 at 4:40 PM, showed: There was a smell of cigarette smoke in Patient #31's room. Patient #31 stated he had been smoking in his room since Saturday [5/18/2019].

Patient #32.
Record review of the Daily 7a to 7p Nursing Assessment Note by Staff X dated 3/12/2019 at 7:20 AM showed: Smelled smoke in room of Patient #32. Patient admitted to smoking cigarettes, adding that he had cigarettes in his pocket in the Intake Department. No contraband was found in his room. He stated he flushed the lighter and cigarettes. Staff X documented that Patient #32's mother stated she gave her son cigarettes the day prior to his admission into the hospital.

Record review of an Incident Report by Staff W dated 3/17/2019 at 9:15 AM for Patient #32 showed: Lighter and cigarettes found in towel in patient's room. The Incident Report further identified Patient #32 as a 16-year-old male. Patient #32 was admitted six (6) days earlier on 3/11/2019.

Based on observation, interview, and record review, the facility failed to ensure the Compass Boys Unit and the Foundations (children's) Unit were staff with an adequate number of licensed registered nurses. This failure resulted in one RN covering both units for 3 of 3 shifts (July 4, 2019, July 6, 2019, and July 7, 2019).


Findings:

Observation of the Compass Boys Unit and the Foundations Unit on 8/29/2019 at 9:00 AM showed two units separated by a set of double doors. The nurse's station was elongated with half of it looking into the Compass Boys Unit and the other half overlooking the Foundations Unit. The set of double doors was the line of demarcation between the two units. The two units were each staffed with an RN: Staff P was on the Compass Boys Unit and Staff K was on the Foundations Unit. The bed boards showed nine (9) patients on the Compass Boys Unit and six (6) patients on the Foundations Unit. The Pathways Unit and the Women's Unit are two units separated by a set of double doors. The nurse's station is juxtaposed to the two units in the same fashion as the Compass Boys and the Foundations units.


Record review of assignment sheets showed:

July 4, 2019 - Staff BB was assigned to cover the Compass Boys Unit and the Foundations Unit for the 7P to 7A shift.

July 6, 2019 - Staff BB was assigned to cover the Compass Boys Unit and the Foundations Unit for the 7P to 7A shift.

July 7, 2019 - Staff CC was assigned to cover the Compass Boys Unit and the Foundations Unit for the 7P to 7A shift.


In an interview with Staff P on 8/29/2019 at 9:10 AM, he stated:

a) The door between the Compass Boys Unit and the Foundations Unit is always kept locked;

b) He has three (3) years of behavioral health experience in youth services;

c) He started to work at SUN Behavioral in February 2019;

d) He has been asked to work both the Compass Boys Unit and the Foundations Unit at the same time;

e) He has safety concerns when one Mental Health Technician (MHT) is "handling" 9-10 children;

f) Staff is always an issue;

g) Staffing is determined by a grid; and

h) He doesn't think the acuity is taken into account when determining adequate staffing.


In an interview with Staff K on 8/29/2019 at 9:20 AM, she stated:

a) The door between the Compass Boys Unit and the Foundations Unit is always kept locked;

b) She has been an RN for four (4) years, working in the operating room;

c) She started to work at SUN Behavioral in January 2019;

d) She has no behavioral health experience; and

e) The same RN may be over the Compass Boys Unit and the Foundations Unit, adding, she has questioned this practice.


In an interview with Staff B on 8/30/2019 at 10 AM, she stated:

a) The Compass Boys Unit and the Foundations Unit are two separate units;

b) One RN may cover both the Compass Boys Unit and the Foundations Unit at the same time;

c) The Pathways Unit and the Women's Unit are two separate units;

d) One RN may cover both the Pathways Unit and the Women's Unit at the same time; and

e) She uses a grid and tries to have nurses on each unit.

Based on record review and interview, the registered nurse failed to ensure that the Mental Health Technicians (MHT) followed through with his assignment to conduct and document observation rounds on each patient every 15-minutes on the Compass Boys Unit. This failure resulted in 6 of 8 adolescent patients (Patient #12, #13, #14, #15, #16, and #17) not having observation rounds conducted and documented for 30 minutes.


Findings:

Observation of the Compass Boys Unit on 8/29/2019 at 9:35 AM showed Staff H on the unit with a clip board in hand. The surveyor asked Staff H to see the Observation Sheets. He was observed documenting the Q15 minute observation rounds at 9:35 AM for 9:15 AM and 9:30 AM on two (2) patients (Patient #17 and Patient #36).

Record review of the Observation Sheets on 8/29/2019 at 9:35 AM showed no documentation of rounds for 8/29/2019 at 9:15 AM and 9:30 AM for six (6) patients: Patient #12, #13, #14, #15, #16, and Patient #17.

In an interview with Staff H on 8/29/2019 at 9:35 AM, he stated he knew he was behind on the Q15 minute observation rounds.

In an interview with Staff B on 8/29/2019 at 9:45 AM, she stated Staff H (MHT) was going to be suspended that day. She also stated that on Tuesday, 8/26/2019, Staff H did not document observation rounds from 9 AM until 11 AM and then falsified the observation rounds by filling in the missing information.