HospitalInspections.org

.

Based on observation, interview, and document review, the hospital failed to ensure that staff provided patient care in a safe setting.

Failure to provide patient care in a safe setting, places patients at risk for serious harm, injury or death, and resulted in a serious adverse outcome involving a sexual incident between three adolescent patients.

Findings included:

1. Failure to include the patient in the formulation of an individualized treatment plan.

Cross Reference: A0130

2. Failure to provide care in a safe setting by identifying risks and monitoring roommates assignments with patients at increased risk for sexual aggression or sexual victimization.

3. Failure to develop and implement a system to identify patients at an increased risk for self-destructive or assaultive behavior and implement interventions, including a treatment plan to prevent adverse patient outcomes.

4. Failure to ensure a safe patient care environment by effectively conducting environmental rounds and patient observations.

5. Failure to ensure that staff follow policies and procedures to reassess patients for increased suicidal risks and notify provider when indicated.

Cross Reference: A0144

6. Failure to ensure the development and implementation of policies and procedures for the administration of involuntary compelled antipsychotic medications and the requirement to obtain a second medical opinion prior to medication administration.

7. Failure to ensure the development and implementation of policies and procedures for the administration of involuntary emergency antipsychotic medications and the requirement to obtain a review for a second medical opinion within 24 hours of medication administration.

Cross Reference: A0160

Due to the scope and severity of deficiencies cited under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET

.

.

Based on interview, medical record review, and review of policy and procedures, Investigator #19 found that the hospital failed to include the patient in the formulation of an individualized treatment plan for 8 of 15 patients reviewed (Patients #1901, #1902, #1903, #1904, #1905, #1911, #1912, and #1913).

Failure to ensure patient participation in their treatment care planning can result in inappropriate, inconsistent, or delayed treatment of patients' needs and may lead to patient harm and lack of appropriate treatment for a behavioral or medical condition.

Findings included:

1. Document review of facility policy titled, "Interdisciplinary Patient Centered Care Planning," policy number 1000.81, last approved 06/21, showed the following:

a. The patient or representative is to sign the Master Treatment Plan to indicate agreement with and participation in the development of the treatment plan.

b. A designated staff member is to discuss the Treatment Plan with the patient/representative if the patient is not present in the Treatment Team meeting.

c. If the patient refuses to sign the Treatment Plan, the refusal will be documented.

d. The Treatment Team, with the patient/representative, will update the Treatment Plan as clinically indicated, or at minimum every 7 days.

e. The patient/representative is to sign the Treatment Plan Update to indicate agreement and participation with review/modification of the treatment plan.

f. A designated staff member is to discuss the Treatment Plan Update with the patient/representative if the patient is not present in the Treatment Team meeting.

g. If the patient refuses to sign the Treatment Plan Update, the refusal will be documented.

Patient #1901

2. On 04/11/22, Investigator #19 reviewed the medical record for Patient #1901, a 13-year-old female patient admitted 12/03/21 for suicidal ideation with command hallucinations and history of sexual assault, and found the following:

a. The document titled, "Interdisciplinary Master Treatment Plan," completed on 12/09/21, showed that the patient did not sign the treatment plan confirming that the treatment plan had been reviewed with the patient or that the patient had the opportunity to ask questions.

b. Review of the treatment plan document showed that staff failed to document patient participation or the patient's refusal to sign.

c. Review of the treatment plan updates, dated 12/16/21, 12/22/21, 12/29/21, 01/05/22, 01/26/22, 02/01/22, 02/16/22, 02/23/22, 03/09/22, and 03/16/22, showed that the patient did not sign the updates confirming that the treatment plan had been reviewed with the patient or that the patient had the opportunity to ask questions.

d. Review of the treatment plan updates showed that staff failed to document patient participation or the patient's refusal to sign.

Patient #1902

3. On 04/11/22, Investigator #19 reviewed the medical record of patient #1902, a 13-year-old female admitted on 01/13/22 with depression, substance abuse, suicidal ideation, self-harm, and history of sexual assault, and found the following:

a. The document titled, "Interdisciplinary Master Treatment Plan," completed on 01/17/22, showed that the patient did not sign the treatment plan confirming that the treatment plan had been reviewed with the patient or that the patient had the opportunity to ask questions.

b. Review of the treatment plan document showed that staff failed to document patient participation or the patient's refusal to sign.

Patient #1903

4. On 04/11/22, Investigator #19 reviewed the medical record for Patient #1903, a 19-year-old female admitted on 02/09/22 for psychosis, aggression, mood instability, and history of sexual assault and sexual victimization, and found the following:

a. The document titled, "Interdisciplinary Master Treatment Plan," completed on 02/11/22, showed that the patient did not sign the treatment plan confirming that the treatment plan had been reviewed with the patient or that the patient had the opportunity to ask questions.

b. Review of the treatment plan document showed that staff failed to document patient participation or the patient's refusal to sign.

Patient #1904

5. On 04/11/22, Investigator #19 reviewed the medical record for Patient #1904, a 15-year-old female admitted on 01/26/22 with suicidal ideation and mood instability, and found the following:

a. The document titled, "Interdisciplinary Master Treatment Plan," completed on 01/28/22, showed that the patient did not sign the treatment plan confirming that the treatment plan had been reviewed with the patient or that the patient had the opportunity to ask questions.

b. Review of the treatment plan document showed that staff failed to document patient participation or the patient's refusal to sign.

Patient #1905

6. On 04/11/22, Investigator #19 reviewed the medical record for Patient #1905, a 13-year-old female admitted on 01/20/22 for suicidal ideation and mood instability, and found the following:

a. The document titled, "Interdisciplinary Master Treatment Plan," completed on 01/21/22, showed that the patient did not sign the treatment plan confirming that the treatment plan had been reviewed with the patient or that the patient had the opportunity to ask questions.

b. Review of the treatment plan document showed that staff failed to document patient participation or the patient's refusal to sign.

Patient #1911

7. On 04/29/22, Investigator #19 reviewed the medical record for Patient #1911, a 56-year-old male admitted on 04/08/22 for psychosis and aggression, and found the following:

a. The document titled, "Interdisciplinary Master Treatment Plan," completed on 04/09/22, showed that the patient did not sign the treatment plan confirming that the treatment plan had been reviewed with the patient or that the patient had the opportunity to ask questions.

b. Review of the treatment plan document showed that staff failed to document patient participation or the patient's refusal to sign.

c. Review of 2 of 2 documents titled, "Treatment Plan Updates," dated 04/18/22 and 04/26/22, showed that the patient did not sign the updates confirming that the update had been reviewed with the patient or that the patient had the opportunity to ask questions.

d. Review of the treatment plan updates showed that staff failed to document patient participation or the patient's refusal to sign.

Patient #1912

8. On 04/29/22, Investigator #19 reviewed the medical record for Patient #1912, a 28-year-old male admitted on 04/07/22 with psychosis, mood instability, and history of assault, and found the following:

a. The document titled, "Interdisciplinary Master Treatment Plan," completed on 04/08/22, showed that the patient did not sign the treatment plan confirming that the treatment plan had been reviewed with the patient or that the patient had the opportunity to ask questions.

b. Review of the treatment plan document showed that staff failed to document patient participation or the patient's refusal to sign.

Patient #1913

9. On 04/29/22, Investigator #19 reviewed the medical record for Patient #1913, a 15-year-old female admitted on 04/19/22 for psychosis, suicidal ideation, history of assault, and history of sexual assault, and found the following:

a. The document titled, "Interdisciplinary Master Treatment Plan," completed on 04/21/22, showed that the patient did not sign the treatment plan confirming that the treatment plan had been reviewed with the patient or that the patient had the opportunity to ask questions.

b. Review of the treatment plan document showed that staff failed to document patient participation or the patient's refusal to sign.

10. On 04/20/22 at 12:45 PM, during an interview with Investigator #19 and Investigator #15, the Assistant Director of Nursing (ADON) (Staff #1501) confirmed that medical records reviewed failed to include documentation of the patient's participation in the treatment planning process, patient signatures and documentation of the patient's participation or refusal to sign. Staff #1501 stated that the Case Managers are responsible for meeting with the patients to review their Master Treatment Plans and Treatment Plan Updates. The ADON reported that when the Case Manager meets with the patients to review their treatment plans, staff should be obtaining a signature from the patient. If the patient refuses, or is unable to sign, the Case Manager would document the reason for the refusal.

.

.

Item #1 - Roommate assignments for prevention of sexual aggression or sexual victimization

Based on observation, interview, and document review, the hospital failed to provide care in a safe setting by failing to ensure that staff followed policies and procedures that identified patients at increased risk for sexual aggression or sexual victimization and implemented a plan to monitor the room assignments of patients on enhanced precautions to prevent incidents of sexual aggression or sexual victimization.

Failure to identify patients at increased risk for harm and to implement a plan for the prevention of sexual aggression or sexual victimization by ensuring that patients identified with sexual aggression precautions will not be roomed with a patient identied with sexual victimization precautions places patients at risk for serious physical and psychological harm.

Findings included:

1. Review of the hospital document titled, "Sexual Aggression/Victimization Precautions," policy number 1000.80, last reviewed 06/21, showed that nursing staff determines if a roommate assignment is appropriate and makes adjustments as needed based on identifiable risk factors.

2. Document review of the hospital's adolescent unit daily census sheet dated 04/23/22, showed 1 patient with sexual aggression precautions (SAP) and 7 patients with sexual victimization precautions (SVP). The document showed that the patient with SAP (Patient #1201) was assigned a roommate with SVP (Patient #1202).

3. On 04/23/22 at 11:30 AM, Investigator #12 Interviewed the charge nurse on the hospital's adolescent unit (Staff #1219). Staff #1219 stated that patients with SAP cannot share rooms with patients who are on sexual victimization precautions. When asked to review the roommate assignment for Patients #1201 and #1202, Staff #1219 stated, "they should not be in the same room."


Item #2 - Failure to identify patients at increased risk for self-destructive, assaultive behavior and implement interventions to prevent adverse outcomes

Based on interview, record review, and review of hospital policies and procedures, the hospital failed to provide care in a safe setting by developing and implementing policies and procedures that identified patients at increased risk for sexual aggression/victimization, suicidal behaviors/self-harm behaviors, and assaultive/aggressive behaviors and to implement interventions, such as treatment planning, to prevent incidents related to these increased safety risks, as demonstrated by 8 of 8 records reviewed (Patient #1501, #1502, #1503, #1504, #1507, #1511, #1515, and #1516).

Failure of the hospital staff's ability to identify patients at increased risk for harm and to implement a plan of care for the prevention of sexual aggression/victimization, suicidal behaviors/self-harm behaviors, and assaultive/aggressive behaviors to ensure patient care in a safe setting, places the patients at risk for serious physical and psychological harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Suicide Precautions," policy number 1000.24, last revised 06/21, found that the purpose of the policy is to provide a safe environment for all patients by providing guidelines for addressing the immediate safety needs of patients identified as high risk for suicide. All suicide threats, gestures, and attempts are considered serious and are to be responded to immediately. The policy and procedure failed to provide guidelines for staff to implement a consistent process to establish specific goals and targets, document preventative measures and interventions, or record the patient's progress and readiness for discharge, such as a Master Treatment Plan (MTP) and Individual Treatment Plan (ITP), for patients placed on suicide precautions, or that had been identified at an increased risk for suicidal/self-harm behaviors.

2. Document review of the hospital's policy and procedure titled, "Assault Precautions," policy number 1000.43, last revised 06/21, found that the purpose of the policy is to provide a safe environment for all patients by providing guidelines for addressing the immediate safety needs of patients identified as high risk for assaultive behavior. All verbal and physical threats, and attempts are considered serious and are to be responded to immediately. The policy and procedure failed to provide guidelines for staff to implement a consistent process to establish specific goals and targets, document preventative measures and interventions, or record the patient's progress and readiness for discharge, such as a Master Treatment Plan (MTP) and Individual Treatment Plan (ITP), for patients placed on assault precautions, or that had been identified at an increased risk for aggressive/assaultive behaviors.

3. Document review of the hospital's policy and procedure titled, "Sexual Aggression(SAP)/Victimization Precautions (SVP)," policy number 1000.80, last revised 06/21, found that the purpose of the policy is to provide a safe, therapeutic environment of care for all patients by providing a plan for the prevention of sexually inappropriate behavior, including aggression and the potential for victimization by identifying early warning signs for sexual behavior, monitoring the patient with a suspected potential for sexual aggression/victimization, and implementing intervention steps to minimize the risk of inappropriate sexual behavior. The policy indicated that when nursing staff identifies a patient with risk factors for Sexual Aggression/Victimization, the patient will be placed on Sexual Aggression Precautions (SAP) or Sexual Victimization Precautions (SVP) and the provider will be notified. When a patient is identified with increased risk factors and SVP and/or SAP precautions are initiated, staff will then develop a Sexually Inappropriate Treatment Plan and update the Master Treatment Plan Problem List.

4. Document review of the hospital's policy and procedure titled, "Suspected or Confirmed Cases of Patient Sexual Activity," policy number 1000.30, last revised 06/21, showed that for cases of suspected or confirmed patient sexual activity the treatment team will initiate a sexually inappropriate behavior treatment plan.

5. On an Incident Report dated 02/11/22, staff reported an incident categorized as "Sexual Intercourse - Patient to Patient." The incident took place on 02/11/22 at approximately 7:00 PM, on the adolescent unit, in the outside courtyard area. A group of adolescent patients were escorted to the outside courtyard area by a nursing staff member. While in the darkened courtyard, two female patients (Patient #1501 and #1504), who had both reported a history of sexual abuse, engaged in sexual intercourse (oral sex) with a male patient (Patient #1507). At the time of the incident, the male patient (Patient #1507) was on Unit Restrictions (UR), which restricted him to the unit only and did not allow access to the outside courtyard area (Unit Restriction-Outside URO). The Investigator's review of the incident's video footage showed that the staff member conducting the observations failed to respond when several adolescent patients were not visible in the blind spot of the darkened courtyard or openly displayed boundary violations, such as hugging and sexual touch. The staff member was observed sitting on a bench in the middle of the courtyard with his back to the patients hidden in the darkened back corner of the courtyard looking at an electronic device. The following patients were involved in the reported incident:

Patient #1501

6. On 04/06/22, Investigator #15 reviewed the medical record of Patient #1501, a 13-year-old non-binary born female involuntary patient admitted on 02/03/22, with a psychiatric diagnosis of Major Depressive Disorder (MDD), Anxiety, Post Traumatic Stress Disorder (PTSD), and Borderline Personality Disorder. Patient #1501 reported a significant history of abuse, including sexual abuse by a family member (grandfather) from age 2 until recently. Review of the medical records showed the following:

a. Patient #1501 was placed on SVP upon admission; however, no plan of care was developed at that time to address her significant history of sexual abuse or to prevent sexual incidents during hospitalization. On 02/18/22, staff added "sexual precautions" to the MTP Problem list and initiated a Sexual Precautions Individual Treatment Plan, 15 days after the Patient's admission.

b. Prior to the incident on 02/11/22, the psychiatric provider documented Patient #1501 exhibited inappropriate sexual behavior on 3 days, 02/08/22, 02/09/22 and 02/11/22. In addition, the nursing staff documented that the Patient exhibited inappropriate sexual behavior or boundaries on 2 days, 02/03/22 and 02/07/22. Staff failed to document the development of a plan of care in response to the identified sexually inappropriate behaviors to prevent and minimize the risk of sexually inappropriate incidents.

c. After the incident on 02/11/22, the psychiatric provider documented Patient #1501 exhibited inappropriate sexual behavior on 3 days, 02/19/22, 02/20/22, and 02/21/22. In addition, the nursing staff documented that the Patient exhibited inappropriate sexual behavior or boundaries on 5 days, 02/14/22, 02/17/22, 02/19/22, 02/20/22, and 02/21/22. In response to the continued incidents of reported sexually inappropriate behavior, staff failed to document or implement revisions to the plan of care (initiated on 02/18/22) to prevent and minimize the risk of additional sexually inappropriate incidents.

Patient #1504

7. On 04/07/22, Investigator #15 reviewed the medical record of Patient #1504, a 15-year-old female voluntary patient admitted on 02/02/22, with a psychiatric diagnosis of Major Depressive Disorder (MDD), Anxiety, Bipolar Disorder, and Post Traumatic Stress Disorder (PTSD). Patient #1504 reported a history of sexual abuse, including sexual abuse by a family member. Patient #1504's father reported that she was currently engaging in risk-taking sexually inappropriate behaviors. Review of the Patient's medical record showed the following:

a. Patient #1504 was not placed on SVP upon admission. On the Psychiatric Evaluation the provider documented that the Patient would be placed on SVP based on the Patient's history of sexual abuse. The Patient was not placed on SVP until after the incident on 02/11/22. The MTP was not updated to add Sexually Inappropriate Behavior to the Problem List and an Individual Treatment Plan was not initiated throughout the Patient's admission.

b. Prior to the incident on 02/11/22, the psychiatric provider documented Patient #1504 exhibited inappropriate sexual behavior on 4 days, 02/05/22, 02/06/22, 02/08/22 and 02/11/22. In addition, the nursing staff documented that the Patient exhibited inappropriate sexual behavior or boundaries on 9 days, 02/03/22, 02/04/22, 02/05/22, 02/07/22 (two incidents), 02/09/22 and 02/11/22 (two incidents prior to the reported sexual intercourse incident). Staff failed to document the development of a plan of care in response to the identified sexually inappropriate behaviors to prevent and minimize the risk of sexually inappropriate incidents.

c. After the incident on 02/11/22, the psychiatric provider documented Patient #1504 exhibited inappropriate sexual behavior on 3 days, 02/16/22, 02/17/22, and 02/20/22. In addition, the nursing staff documented that the Patient exhibited inappropriate sexual behavior or boundaries on 6 days, 02/13/22, 02/14/22, 02/17/22, 02/18/22, 02/19/22, and 02/20/22. In response to the continued incidents of reported sexually inappropriate behavior, staff failed to initiate and implement a plan of care to prevent and minimize the risk of additional sexually inappropriate incidents.

Patient #1507

8. On 04/20/22, Investigator #15 reviewed the medical record of Patient #1507, a 16-year-old male involuntarily detained patient admitted on 12/23/21, with a psychiatric diagnosis of Major Depressive Disorder (MDD), Anxiety Disorder, and Mood Disorder, unspecified. Patient #1507 reported homicidal thoughts, with a plan to stab 3 random students at school. Patient #1507 denied a history of sexual abuse or aggression. The Patient reported that he had a restraining order against him after he had written a story about a female classmate in 7th grade. Review of the Patient's medical record showed the following:

a. Upon admission, Patient #1507 was not identified with an increased risk for SVP or SAP based on clinical information provided and admission assessments. On 02/07/22, nursing staff documented that Patient #1507 would be placed on SVP and SAP. Review of the medical records found that the Patient was placed on SAP on 02/12/22 (5 days later). The MTP was not updated to add Sexually Inappropriate Behavior to the Problem List and an Individual Treatment Plan was not initiated throughout the Patient's admission.

b. Prior to the incident on 02/11/22, the psychiatric provider documented Patient #1507 exhibited inappropriate sexual behavior on 3 days, 01/14/22, 02/09/22 and 02/10/22. In addition, the nursing staff documented that the Patient exhibited inappropriate sexual behavior or boundaries on 5 days, 12/24/21, 01/21/22, 02/07,22, 02/08/22 and 02/09/22. Staff failed to document the development of a plan of care in response to the identified sexually inappropriate behaviors to prevent and minimize the risk of sexually inappropriate incidents.

c. After to the incident on 02/11/22, the psychiatric provider documented Patient #1507 exhibited inappropriate sexual behavior on 1 day, 02/15/22. In addition, the nursing staff documented that the Patient exhibited inappropriate sexual behavior or boundaries on 8 days, 02/14/22, 02/15/22, 02/16,22, 02/19/22, 02/22/22, 02/24/22, 02/26/22, and 02/28/22. In response to the continued incidents of reported sexually inappropriate behavior, staff failed to initiate and implement a plan of care to prevent and minimize the risk of additional sexually inappropriate incidents.

9. On 04/07/22 at 11:00 AM, during an interview with Investigator #15, the Nurse Manager (Staff #1503) stated that when a patient is observed displaying sexually inappropriate behavior, the patient is placed on enhanced precautions (SVP and/or SAP) and the treatment team is notified.

10. On 04/20/22 at 10:10 AM, during an interview with Investigator #15 and Investigator #19, the Risk Manager (Staff #1504) stated that when a patient is placed on enhanced precautions, such as SAP or SVP, staff will initiate a supporting treatment plan.

11. On 04/07/22 at 11:15 AM, during an interview with Investigator #15, Nurse Manager (RN) (Staff #1503) stated that during the admission process, patients are assessed for an increased risk for sexual aggression or sexual victimization, based on reports of a history of sexual trauma or abuse or reported incidents of sexual aggression or assault. Once the patients are identified with the need for increased safety precautions (SVP and/or SAP), the treatment team should add this to the MTP and initiate an Individual Treatment Plan.

12. Investigator #15's review of additional medical records for Patients #1502, #1503, #1511, #1515, and #1516 showed evidence of similar findings, including the identification of increased risks and the failure of staff to initiate a plan of care documented in the MTP and ITP, providing a process to identify interventions, establish goals, track the patients progress during admission and prevent adverse outcomes.

13. On 04/20/22 at 12:55 PM, during an interview with Staff #1501, Investigator #15 asked about the missing behavioral treatment plans and the inconsistencies that were found during the medical record review when staff identified the need for enhanced safety precautions and the initiation of treatment plans and individualized interventions to address those increased risks. Staff #1501 stated that the inclusion to the MTP/ITP would depend on the circumstances. Staff #1501 reported that the treatment team and the provider would review the clinical data, incident, or reported behavior and decide whether to add to the MTP and create an ITP.


ITEM #3 Effectively conducting patient observations and ensuring a safe patient care environment

Based on observation, interview, record review, and review of hospital policies and procedures, the hospital failed to provide care in a safe setting by developing and implementing policies and procedures that guide staff to effectively conduct environmental safety rounds and patient observations.

Failure to develop policies and procedures that provide a safe patient care environment and protect patients from self-harm or harm from others, places the patients at risk for serious physical and psychological harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Patient Observation Policy," policy number 1000.5, last revised 06/21, showed the following:

a. The Charge Nurse ensures that Patient Observations Rounds are occurring as ordered, 24 hours a day, seven days a week.

b. Twice per shift, the Charge Nurse reviews all patient observational rounds and initials the supervisor verification.

c. The Mental Health Technician (MHT), Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA) are responsible for reviewing and updating the patient observations records. Any changes in the individual precaution levels, room or bed changes, new admissions and/or discharges will be reflected, as they occur.

d. Clearly print employee name and initials in the appropriate section of the patient observations record.

e. Observe each patient a minimum of every 15 minutes and/or according to the precaution level and document observation on the patient observation form.

f. Document the patient location and behavior when the observation occurs on the patient observation form.

g. Visually observe patients when behind closed doors or curtains.

h. Staff that is accompanying the patient off Fairfax grounds (Emergency Department, Social Security or housing appointments) must document observations on the Patient Observation Form.

2. Document review of the hospital's policy and procedure titled, "Level of Observation Orders Policy," policy number 1000.21, last revised 06/21, showed the following:

a. Staff will complete the patient observation record as rounds are made, using the coding system described on the record for patient activities.

b. Staff will observe the patient and note their behavior, whereabouts, and any other pertinent behavior.

c. Staff will initial appropriate documentation in the designated areas. Documentation should occur concurrently with the actual process of performing the physical rounds.

d. Staff will be vigilant for potential risk factors identified for specific patients (level of precautions).

3. Document review of the hospital's digital training slides titled, "Rounds and Observation Levels," no policy number, no date of last revision, showed the following:

a. You must visually observe the patient's face on each round (even if the patient is in the bathroom).

b. If patient is leaving the unit, rounds sheets should go with the staff accompanying the patient.

c. Check environment for safety.

Incident #1 - 02/11/22 Patient Observations

4. On an Incident Report dated 02/11/22, staff reported an incident categorized as "Sexual Intercourse - Patient to Patient."

5. Review of the hospital's video of the incident with the hospital's Risk Manager (Staff #1504) confirmed that incident took place on 02/11/22, on the adolescent unit in the outside courtyard area. The video showed that one staff member and approximately 9 patients entered the outside courtyard area at 6:52 PM. At 6:57 PM, all the patients were out of the view of the camera in the darkened corner of the courtyard. While in the darkened courtyard, two female patients (Patient #1501 and #1504) who both had a reported history of sexual abuse, engaged in sexual intercourse (oral sex) with a male patient (Patient #1507). The staff member sat in a chair facing out to the darkened courtyard and appeared to be looking at an electronic device. At 7:01 PM, the staff member moved to a bench in the middle of the courtyard, facing away from the darkened back corner where several of the patients were still out of the view of the video camera and still appeared to be looking at an electronic device. Throughout the review of the video, from 6:52 PM to 7:30 PM, the patients intermittently moved around the courtyard, sometimes visible on the camera, and sometimes moving to the darkened corners of the courtyard out of view.

6. During the investigation of the incident, Investigator #15 found discrepancies in the patient observations/rounding forms for the three patients involved in the incident. Review of the observation round forms for Patients #1501, #1504, and #1507 showed that staff failed to document that the patients were located in the courtyard between 6:52 PM and 7:30 PM.

a. On 02/11/22, staff documented that Patient #1501 was on Suicide Precautions, Unit Restriction Outside Privileges (URO) which meant that the Patient could go to the outside courtyard (with staff supervision). On Patient #1501's Observation Record for Q15 (observations every 15 minutes) Rounds, dated 02/11/22, staff documented the following:

6:45 PM - Location: Day Room
7:00 PM - Location: Hallway
7:15 PM - Location: Hallway
7:30 PM - Location: Bathroom

Review of the Observation Records found that the MHT performing rounds inside on the unit was documenting the Patient's location and behavior. Review of the video showed that Patient #1501 entered the outside courtyard at 6:52 PM and returned inside to the unit at 7:30 PM.

b. On 02/11/22, staff documented that Patient #1504 was on Suicide Precautions, Unit Restriction Therapy Privileges (URT) which meant that the Patient could go to the outside courtyard and the gym (with staff supervision). On Patient #1504's Observation Record for Q15 (observations every 15 minutes) Rounds, dated 02/11/22, staff documented the following:

6:45 PM - Location: Day Room
7:00 PM - Location: Day Room
7:15 PM - Location: Day Room
7:30 PM - Location: Day Room
7:45 PM - Location: Day Room

Review of the Observation Records found that the MHT performing rounds inside on the unit was documenting the Patient's location and behavior. Review of the video showed that Patient #1501 entered the outside courtyard at 6:52 PM and returned inside to the unit at 7:30 PM.

c. On 02/11/22, staff documented that Patient #1507 was on Assault Precautions, Unit Restriction (UR) which meant that the Patient could not leave the unit or go to the outside courtyard. On Patient #1507's Observation Record for Q15 (observations every 15 minutes) Rounds, dated 02/11/22, staff documented the following:

6:45 PM - Location: Hallway
7:00 PM - Location: Illegible documentation
7:15 PM - Location: Patients' Room
7:30 PM - Location: Hallway
7:45 PM - Location: Hallway

Review of the Observation Records found that the MHT performing rounds inside on the unit was documenting the Patient's location and behavior. Review of the video showed that Patient #1507 entered the outside courtyard at 6:52 PM and returned inside to the unit at 7:30 PM.
The investigators failed to observe the staff member documenting observation rounds for the patient in the courtyard.

7. On 04/20/22 at 10:10 AM, during an interview with Investigator #15 and Investigator #19, Staff #1504 verified that on 02/11/22, the staff doing the observation rounds inside on the unit, was also performing observation rounds for the patients in the courtyard. Staff #1504 verified that review of the video showed that the patients were not visible in the back corner of the darkened courtyard. Staff #1504 stated that the discrepancies in the documentation of the patient's observations is due to the patients coming in and out from the courtyard to the unit. However, Investigator #19's review of the video failed to find evidence to substantiate that the observation rounds documented for Patient #1501, #1504, and #1507 during the times between 6:52 PM and 7:30 PM on 02/11/22 were accurate.

Incident #2 - 01/30/22 Environmental Safety-Blind Spots

8. On an Incident Report dated 01/30/22, staff reported an incident categorized as "Sexual Misconduct - Patient to Patient" involving two adolescent patients, Patient # 1506 and Patient #1515. Patient #1506, a 15-year-old female, reported to the psychiatric provider that she had been sexually molested by a peer (Patient #1515).

9. On a Nursing Progress Addendum, dated 02/01/22, nursing staff documented that Patient #1506 reported to the psychiatric provider that Patient #1515, a 13-year-old transgender, female to male patient, pinned her to the wall in the hallway leading to the dayroom and forced kisses on her several times. Patient #1506 reported that Patient #1515 told her that there are no cameras facing that hallway.

10. During a tour of the South Adolescent unit on 04/07/22 at 1:15 PM, with Nursing Manager (Staff #1503), Investigator #15 observed that the chair positioned facing the hallway leading to the dayroom was empty. The short hallway leading to the dayroom had previously been identified as a blind spot, due to the lack of video monitoring capabilities and no sight lines when staff was conducting observations in the main hallway. Staff #1503 stated that the blind spot should always be monitored, however sometimes their staff is called away respond to a Code called on a different unit. Staff #1503 stated that was why the hallway was not being monitored on 04/07/22.

11. On 04/20/22 at 6:45 AM, during an interview with Investigator #15, Mental Health Technician (MHT) (Staff #1507) stated that sometimes at night, the team will leave the nurses station door open to ensure that the blind spot located near the double doors entering the unit is always monitored.

12. Investigator #15 found that hospital staff reported inconsistencies in the process for performing patient observations off-unit and monitoring identified blind spots within the hospital. Review of the hospital's policies and procedures showed that the hospital failed to develop a policy and procedure to clarify guidelines for staff when performing environmental safety rounds in the exterior courtyard areas or a policy and procedure to safely and effectively monitor identified blind spots within the hospital.


Item #4 Reassess patients for increased suicidal risks and notify provider when indicated.

Based on policy review and document review, the hospital failed to ensure staff followed policies and procedures to reassess patients for increased risk of suicidal behaviors and, based on the risk formulation, notified the provider of increased risk when indicated, as demonstrated by 6 of 7 records reviewed (Patients #1902, #1904, #1905, #1906, #1909, #1914, and #1916).

Failure to complete the suicide risk reassessment and notify the provider of any identified increased suicide risk puts the patient at risk for an unsafe environment for care, psychological harm, and serious injury or death.

Findings included:

1. Document review of facility policy titled, "Suicide Risk Assessment and Management," policy number 1000.26, last reviewed 06/21, showed the following:

a. All patients admitted to Fairfax Behavioral Health will be assessed for suicidality by the admitting Registered Nurse (RN) using the RN-Columbia Suicide Severity Rating Screen (RN-CSSRS).

b. Reassessment of suicidality will occur every waking shift (twice per day) for any patient on suicide precautions or who exhibit a significant change in mental status; these are documented on the nursing progress note.

c. This assessment shall contain, at a minimum:

i. Current or past thoughts of suicide

ii. Recent or past history of suicide attempts

iii. Evidence of suicidal planning or intent

iv. Risk Formulation including categorization of risk as compared to the general patient population on the inpatient unit (lower, similar, or higher).

v. Individualized actions (interventions) initiated to prevent suicide and/or self-destructive behavior.

Patient #1902

2. On 04/11/22, Investigator #19 reviewed the medical record of Patient #1902 for the dates of 01/14/22 through 01/27/22. Patient #1902 is a 13-year-old female admitted for suicidal ideation, cutting, and alcohol intoxication. Patient #1902 had a history of a recent suicidal gesture that resulted in an emergency department visit, where she was referred to the facility. She also had a history of sexual assault by a family member.

a. Investigator #19 reviewed the Daily Nursing Progress Notes and found that nursing staff assessed the patient using the RN-CSSRS twice per day as directed by hospital policy. In 9 of 34 notes for Patient #1902, nursing documented that the patient answered "yes" to the following 2 questions: #1-Have you ever wished you were dead or wished you could go to sleep and not wake up? #2-Have you ever actually had any thoughts of killing yourself? Nursing staff documented the patient's level of suicide risk as "low" and failed to notify the provider, as is directed by the screening tool and hospital policy. The RN-CSSRS Risk Formulation shows that a "yes" answer to any 2 or more questions on the CSSRS indicates that the nurse must notify the provider and document the provider's response.

b. Investigator #19 reviewed the Daily Nursing Progress Notes and found that nursing staff assessed the patient using the RN-CSSRS twice per day as directed by hospital policy. In 2 of 34 notes for Patient #1902, nursing documented that the patient answered "yes" to the following 3 questions: #1-Have you ever wished you were dead or wished you could go to sleep and not wake up? #2-Have you ever actually had any thoughts of killing yourself? #3-Have you been thinking about how you might do this? Nursing staff documented the patient's level of suicide risk as "moderate" and did not notify the provider as directed by the screening tool and hospital policy.

c. On 01/24/22, in a Daily Nursing Progress Note during day shift, nursing staff documented that Patient #1902 had gone to the staff earlier that day after scratching her arm with broken glass and was tearful and upset throughout the day. No report to the provider was documented. No room search or confiscation of contraband (glass) was documented. No additional CSSRS was completed, as is directed by hospital policy.

d. On 01/25/22, in an Addendum Progress Note during evening shift, nursing staff documented that Patient #1902 was found in a male patient's room and ran out of the room to her bathroom in tears. Staff wrote that they went to speak with her and, after they left her room and then returned, the patient was found in their bathroom cutting her wrist and neck with a piece of broken glass from a broken nail polish bottle. Staff wrote that the patient was tearful and said she was cutting because she wanted to die. Staff documented that this was reported to the charge nurse and the provider. An additional CSSRS was not completed, as is directed by hospital policy.

e. On 01/26/22, in a Daily Progress Note during day shift, nursing staff documented that Patient # 1902 endorsed suicidal ideation with no intent or plan. The nurse documented that the patient self-harmed yesterday by cutting her neck and wrists and that the patient stated that she tried to kill herself. An additional CSSRS was not completed, as is directed by hospital policy.

f. On 01/27/22, in a Daily Progress Note during day shift, nursing staff documented that Patient #1902 endorsed suicidal ideation and verbalized that she wants to kill herself. The provider and case manager were informed. An additional CSSRS was not completed, as is directed by hospital policy.

Patient #1904

3. On 04/11/22, Investigator #19 reviewed the medical record of Patient #1904 for the dates of 01/27/22 through 02/04/22. Patient #1904 is a 15-year-old female referred from the emergency department for depression and suicidal ideation after attempting to hang herself. She reports the presence of guns in her home.

a. Investigator #19 reviewed the Daily Nursing Progress Notes and found that nursing staff assessed Patient #1904 using the RN-CSSRS twice per day as directed by hospital policy. In 4 of 18 notes for Patient #1904, nursing documented that the patient answered "yes" to the following 2 questions: #1-Have you ever wished you were dead or wished you could go to sleep and not wake up? #2-Have

.

Item #1 Compelled Medication - Refusal of Prescribed Antipsychotic Medication and Obtaining Second Opinion

Based on interview, record review, and review of hospital policies and procedures, the hospital failed to develop and implement policies and procedures for the administration of chemical restraints, to ensure that patient's rights are protected when the patient refuses their scheduled antipsychotic medication that a second concurring medical opinion is obtained prior to compelling the medication administration, as demonstrated by 3 of 3 records reviewed (Patient #1510, #1518, and #1519).

Failure to develop and implement policies and procedures for the administration of compelled involuntary antipsychotic medications that includes the requirement to obtain an additional second medical opinion prior to administration of the compelled medication, puts patients at risk for violation of their right to refuse antipsychotic medications, risk of psychological harm, and loss of personal dignity.

Reference:

Revised Code of Washington (RCW) 71.05.215 Right to refuse antipsychotic medicine - Rules.

(1) A person found to be gravely disabled or to present a likelihood of serious harm as a result of a behavioral health disorder has a right to refuse antipsychotic medication unless it is determined that the failure to medicate may result in a likelihood of serious harm or substantial deterioration or substantially prolong the length of involuntary commitment and there is no less intrusive course of treatment than medication in the best interest of that person.

(2) The authority shall adopt rules to carry out the purpose of this chapter. These rules shall include:

(b) For short-term treatment up to thirty days, the right to refuse antipsychotic medications unless there is an additional concurring medical opinion approving medication by a psychiatrist, physicians assistant working with a supervising psychiatrist, psychiatric advanced practice registered nurse practitioner, or physician or physician assistant in consultation with a mental health professional with prescriptive authority.

(c) For continued treatment beyond thirty days through the hearing on any petition filed under RCW 71.05.217, the right to periodic review of the decision to medicate by the medical director or designee.

(e) Documentation in the medical record of the attempt by the physician, physician assistant, or psychiatric advanced registered nurse practitioner to obtain informed consent and the reasons why antipsychotic medication is being administered over the person's objection or lack of consent.

Findings included:

1. Document review of the hospital's policy titled, "Administration of Medication without Formal Consent," policy number 1000.52, last revised 06/21, showed the following:

a. Involuntary antipsychotic medications may be administered to a detained/committed patient when it is determined that the failure to medicate may result in a likelihood of serious harm or substantial deterioration or substantially prolong the length of involuntary commitment and there is no less intrusive course of treatment that medication in the best interest of that person.

b. Only the treating physician or psychiatric advanced registered nurse practitioner may order involuntary medication.

c. An attempt must be made to obtain informed consent from the patient prior to administration of the antipsychotic medication.

d. The treating provider shall document reason for involuntary medication and request a concurring medical review, within 24 hours, by a psychiatrist, psychiatric advanced practice nurse practitioner, of physician in consultation with a mental health professional with prescriptive authority.

e. The provider completing the second opinion shall document in detail the reasons for concurring or not concurring with the treating physicians' opinion.

f. Involuntary medication may be administered only if the second opinion concurs with the treatment provider's order for involuntary medication.

g. Staff will attempt to administer the medication without the need for physical restraint. If physical restraint is necessary to safely administer the medication(s), staff shall follow the procedures outlined in Policy PC 1000.53 "Proper Use and Monitoring of Physical-Chemical Restraints and Seclusion."

2. Investigator #15's review of the hospital's policy failed to find evidence guiding clinical staff on a clear process for compelled antipsychotic medications, including clarifying the form used to initiate the provider's order, how to document the request for a consult to obtain a second opinion prior to medication administration, what form is used by the provider completing the second opinion to document their findings, and clarification between the different requirements for compelled antipsychotic medication administration and emergency antipsychotic medication administration.

Patient #1510

3. On 04/21/22 at 3:45 PM, Investigator #15 and the Assistant Director of Nursing (ADON) (Staff #1501) reviewed the medical record for Patient #1510, a 17-year-old female admitted on 04/01/22, on an involuntary detainment with a psychiatric diagnosis of Major Depressive Disorder (MDD). Patient #1510 endorsed Suicidal Ideation with a plan to overdose or cut herself. Patient #1510 had recently attempted suicide by overdosing, which led to the Patient's current admission. Review of the medical record showed the following:

a. On 04/02/22 at 9:48 PM, nursing staff documented on Seclusion and Restraint documents that Patient was banging her head on the wall and cutting herself with her fingernails. Patient #1501 refused to take the oral medications offered by nursing staff.

b. Nursing Staff initiated a Restraint Medical Doctor (MD) Order, dated 04/02/22. Based on the Patient's imminent danger to self and the refusal to take oral medications, nursing staff contacted the psychiatric provider and obtained a verbal order for a chemical restraint of Haldol (antipsychotic) 10 mg, Ativan (benzodiazepine) 1 mg and Benadryl (anticholinergic) 50 mg. The medications were administered at 10:10 PM via intermuscular injection (IM).

c. Investigator #15 found no evidence in Patient #1510's medical record documenting an attempt to obtain a second medical opinion or documentation from a provider detailing the concurring second opinion medical review prior to administration of the antipsychotic medication. Review of the medical record found that the intervention was not clearly identified as the administration of a compelled antipsychotic medication, which would require a request for, and documentation of, a second concurring opinion prior to medication administration.

4. On 04/21/22 at 3:45 PM, during an interview with Investigator #15, Staff #1501 verified that the medication administered on 04/02/22 at 10:10 PM was considered a compelled antipsychotic medication administration. When asked how to determine if the order was for an emergency medication or a compelled medication, Staff #1501 reviewed the medical record and stated that the Medication Administration Records (MAR) showed the patient's refusal to take their scheduled 9:00 PM antipsychotic medication. Additionally, nursing staff documented the Patient's refusal to take their medications on the Restraint MD Order. Staff #1501 verified that Patient #1510 was given compelled IM antipsychotic medications without ensuring that a second opinion was obtained. Staff #1501 verified that the medical record for Patient #1510 did not contain a request for a second opinion or documentation for a second concurring opinion prior to the administration of the medications given on 04/02/22.

Patient #1518

5. On 04/29/22, Investigator #15 reviewed the medical record for Patient #1518, a 34-year-old male voluntarily admitted on 04/22/22, with a psychiatric diagnosis of Major Depressive Disorder (MDD) and Suicidal Ideation (SI). Patient #1510 had recently attempted suicide by attempting to shoot himself, which led to the Patient's current admission. Review of the Patient's medical record showed the following:

a. On an Incident Report dated 04/23/22, staff documented an incident categorized as "Patient Out of Control."

b. On 04/23/22 at 5:30 PM, nursing staff documented that Patient #1518 was attempting to assault other patients and staff.

c. On 04/23/22, nursing staff initiated a Restraint MD Order based on evidence of imminent danger to self (patient) and the Patient's attempt to assault peers and staff. Nursing staff contacted the psychiatric provider and obtained a one-time NOW verbal order for a chemical restraint of Haldol (antipsychotic) 10 mg, Ativan (benzodiazepine) 2 mg and Benadryl (anticholinergic) 50 mg. The medications were administered at 5:40 PM via intermuscular injection (IM).

d. Review of the MAR showed that on 04/23/22 at 9:23 PM, Patient #1518 refused their scheduled 9:00 PM dose of olanzapine (antipsychotic). Investigator #15's review found that the IM medications were given at 5:40 PM, approximately 3 ½ hours prior to the scheduled 9:00 PM olanzapine and the Patient's refusal at 9:23 PM.

e. Investigator #15 found no evidence in Patient #1518's medical record documenting an attempt to obtain a second medical opinion or documentation from a provider detailing the concurring second opinion medical review prior to administration of the antipsychotic medication. Investigator #15's review of the medical record found that the intervention was not clearly identified as the administration of a compelled antipsychotic medication and the process and requirements were not followed, as directed by hospital policy and state regulations.

6. On 04/29/22 at 12:15 PM, during an interview with Investigator #15, Staff #1501 verified that the medication administered on 04/23/22 at 5:40 PM was considered a compelled antipsychotic medication administration based on documentation in the MAR noting the Patient's refusal of his olanzapine. Staff #1501 was unable to address the time difference between the compelled medication administration at 5:40 PM and the refusal of the scheduled antipsychotic medication documented at 9:23 PM. Staff #1501 verified that the medical record for Patient #1518 did not contain a request for a second opinion, documentation for a second concurring opinion prior to the administration of the medications given on 04/23/22.

Patient #1519

7. On 04/29/22, Investigator #15 reviewed the medical record for Patient #1519, a 42-year-old male admitted on 03/25/22, on an involuntary detainment with a psychiatric diagnosis of Psychosis, unspecified. Upon admission, Patient #1519 presented with aggression and confusion. Review of the Patient's medical record showed the following:

a. On a Physician's Order Form, dated 03/27/22 at 9:30 AM, the psychiatric provider wrote the following order:

i. Patient can receive IM antipsychotics if refuses oral antipsychotics.

ii. Thorazine 100 mg oral three times daily. Give first dose now.

iii. Please obtain 2nd Opinion to obtain order to compel IM antipsychotics if patient refuses oral antipsychotics.

b. On a Psychiatric Progress Note - 2nd Opinion Consultation, dated 03/27/22 at 1:00 PM. The second opinion provider documented their agreement with the initial psychiatric providers request.

c. During the Patient's admission, staff initiated Incident Reports dated 04/02/22, 04/04/22, 04/05/22, and 04/07/22. Staff categorized each of these incidents as "Patient Out of Control."

d. Review of Patient #1519's Seclusion and Restraint documents showed the following:

i. On 04/02/22 at 9:05 PM, nursing staff documented that the Patient "tried to punch staff" by swinging his hand during "second opinion." The psychiatric provider gave a telephone order for physical restraint, which was sustained from 9:03 PM to 9:12 PM. Additionally, the psychiatric provider ordered the administration of Ativan 2 mg IM NOW, which the nursing staff administered at 9:03 PM.

ii. Investigator #15's review of the incident on 04/02/22 failed to find evidence that clearly defined the incident as a compelled medication administration or an emergency medication administration. There is an existing order dated 03/27/22 for compelled medications for refusal of antipsychotic medications, with a concurring second opinion, however if the one time IM NOW order was an intervention for an emergency situation, the requirement for a medical review second opinion within 24 hours of the medication administration was not met.

iii. On 04/04/22, nursing staff documented that Patient #1519 had court on 04/04/22 and had refused to take his antipsychotic medications prior to the court hearing. (Beginning 24 hours prior to a hearing, the individual may refuse all psychiatric medications. Reference: RCW 71.05.21).

iv. On 04/04/22 at 1:50 PM, nursing staff documented that the Patient presented an imminent danger to others. The Patient disrobed and became agitated and assaultive, hitting staff while they attempted to administer IM medications. The psychiatric provider gave a telephone order for physical restraint, which was sustained from 1:50 PM to 2:11 PM, seclusion, which was sustained from 2:11 PM to 2:45 PM, and chemical restraint. The psychiatric provider ordered the administration of Thorazine 100 mg IM and Ativan 1 mg IM, which the nursing staff administered at 1:50 PM.

v. Investigator #15's review of the incident on 04/04/22 failed to find evidence that clearly defined the incident as a compelled medication administration or an emergency medication administration. There is an existing order dated 03/27/22 for compelled medications for refusal of antipsychotic medications, with a concurring second opinion, however staff failed to document that Patient's refusal of his scheduled antipsychotic medications lead to this incident.

vi. On 04/07/22 at 6:45 AM, nursing staff documented that the Patient presented an imminent danger to others. The Patient attacked and punched staff. The psychiatric provider gave a telephone order for physical restraint, which was sustained from 6:45 AM to 6:50 AM, seclusion, which was sustained from 6:50 AM to 7:50 AM, and chemical restraint. At 6:40 AM, the psychiatric provider wrote a one-time NOW order for the administration of Thorazine 100 mg IM and Ativan 2 mg IM, for aggressive behavior, the nursing staff administered at 6:45 AM.

vii. Investigator #15's review of the incident on 04/07/22 failed to find evidence that clearly defined the incident as a compelled medication administration or an emergency medication administration. There is an existing order dated 03/27/22 for compelled medications for refusal of antipsychotic medications, with a concurring second opinion, however staff failed to document that Patient's refusal of his scheduled antipsychotic medications lead to this incident. If the one-time IM NOW order was an intervention for an emergency, the requirement for a medical review second opinion within 24 hours of the medication administration was not met.

8. On 04/29/22 at 1:30 PM, during an interview with Investigator #15, Staff #1501 verified that Patient #1519's medical record did include a second concurring opinion consultation dated 03/27/22. Staff #1501 verified that nursing staff failed to document if the IM medications administered on 04/02/22, 04/04/22 and 04/07/22 were compelled medications based on the Patient's refusal of scheduled psychotropic medication or one-time emergency medications. Staff #1501 stated that the second opinion obtained on 03/27/22 should cover the IM medications during the Patient's admission.


Item #2 Emergency Medications and obtaining Second Opinion Review within 24 hours

Based on interview, record review, and review of hospital policies and procedures, the hospital failed to develop and implement policies and procedures for the administration of chemical restraints, to ensure that patient's rights are protected during the administration of emergency involuntary antipsychotic medications, including a review of the decision and documentation of the second medical opinion review within 24 hours after the administration, as demonstrated by 6 of 6 records reviewed (Patient #1501, #1502, #1503, #1510, #1517, and #1518).

Failure to develop and implement policies and procedures for the administration of emergency involuntary antipsychotic medications that includes the second medical opinion review of the decision within 24 hours, puts patients at risk for violation of their right to refuse antipsychotic medications, risk of psychological harm, and loss of personal dignity.

Reference:

Revised Code of Washington (RCW) 71.05.215 Right to refuse antipsychotic medicine - Rules.

(1) A person found to be gravely disabled or to present a likelihood of serious harm as a result of a behavioral health disorder has a right to refuse antipsychotic medication unless it is determined that the failure to medicate may result in a likelihood of serious harm or substantial deterioration or substantially prolong the length of involuntary commitment and there is no less intrusive course of treatment than medication in the best interest of that person.

(2) The authority shall adopt rules to carry out the purpose of this chapter. These rules shall include:

(d) Administration of antipsychotic medication in an emergency and review of this decision within twenty-four hours. An emergency exists if the person presents an imminent likelihood of serious harm and medically acceptable alternatives to administration of antipsychotic medications are not available or are unlikely to be successful; and in the opinion of the physician, physician assistant, or psychiatric advanced nurse practitioner, the person's condition constitutes an emergency requiring the treatment be instituted prior to obtaining a second medical opinion.

(e) Documentation in the medical record of the attempt by the physician, physician assistant, or psychiatric advanced registered nurse practitioner to obtain informed consent and the reasons why antipsychotic medication is being administered over the person's objection or lack of consent.

Findings included:

1. Document review of the hospital's policy titled, "Administration of Medication without Formal Consent," policy number 1000.52, last revised 06/21, showed the following:

a. Involuntary antipsychotic medications may be administered to a detained/committed patient in an emergency (RCW 71.05.215).

b. Definition of an emergency: An emergency exists if the person presents an imminent likelihood of serious harm, and medically acceptable alternatives to administration of antipsychotic medications are not available or unlikely to be successful; and in the opinion of the physician, the person's condition constitutes an emergency requiring the treatment be instituted prior to obtaining a second medical opinion.

c. Only a physician or psychiatric advanced registered nurse practitioner may order emergency involuntary medications.

d. The format for medication order shall be a one-time NOW order, not an as needed (PRN) order.

e. Staff will attempt to administer the medication without the need for physical restraint. If physical restraint is necessary to safely administer the medication(s), staff shall follow the procedures outlined in Policy PC 1000.53 "Proper Use and Monitoring of Physical-Chemical Restraints and Seclusion."

f. The physician will review the decision to administer the emergency medication within twenty-four hours. The review will be documented as part of the authentication of the order.

g. If a second medical opinion has not been obtained prior to the use of the emergency medications, the treatment provider will request a concurring medical review within twenty-four hours, by a psychiatrist, psychiatric advanced registered nurse practitioner, or physician.

h. The provider completing the second opinion shall document in detail the reasons for concurring or not concurring with the treating physicians' opinion.

2. Investigator #15's review of the hospital's policy failed to evidence guiding clinical staff on a clear process for emergency antipsychotic medications, including clarifying the form used to initiate the provider's order, how to document the request for a consult to obtain a second opinion within 24 hours of medication administration, what form is used by the provider completing the second opinion to document their findings, and clarification between the different requirements for emergency antipsychotic medication administration and compelled antipsychotic medication administration.

Patient #1501

3. On 04/06/22, Investigator #15 reviewed the medical record for Patient #1501, a 13-year-old nonbinary born female admitted on an involuntary detention on 02/03/22, with a psychiatric diagnosis of Major Depressive Disorder (MDD), Anxiety, and Post Traumatic Stress Disorder (PTSD). Patient #1501 endorsed suicidal ideation with an undisclosed plan. Review of the Patient's medical record showed the following:

a. On the Psychiatric Progress Note dated 02/09/22, the psychiatric provider documented that due to restrictions to the entire unit related to inappropriate behaviors, Patient #1501 became agitated and began self-harming by head banging, attempting to elope by running at the exit doors. The Patient was not able to redirect. The psychiatric provider wrote a one-time NOW order for 10 mg Zyprexa (antipsychotic) for agitation.

b. Review of the Medication Administration Record (MAR) showed that the medication was administered via intramuscular injection (IM) at 1:45 PM on 02/09/22.

c. Investigator #15's review of the medical record for Patient #1501 found that staff failed to document a request for a second medical opinion or document that the concurring second medical opinion was obtained within 24 hours of the emergency medication administration.

Patient #1502

4. On 04/06/22, Investigator #15 reviewed the medical record for Patient #1502, a 16-year-old female admitted voluntarily on 01/09/22, with a psychiatric diagnosis of Major Depressive Disorder (MDD), Tourette's Disorder (nervous system disorder involving repetitive movements or unwanted sounds), and Post Traumatic Stress Disorder (PTSD). Patient #1502 endorsed Suicidal Ideation triggered by an upcoming court hearing related to the sexual molestation by her biological father between ages 3-14. Patient #1502 had recently attempted suicide by overdosing on Gabapentin, which led to the Patient's current admission. Review of the Patient's medical record showed the following:

a. On a Nursing Progress Note dated 02/05/22, staff documented that that Patient began choking themselves with strings from their mask. The Mental Health Technician (MHT) documented that the Patient was given IM medication.

b. Review of the Psychiatric Progress Note dated 02/05/22 at 10:25 PM, showed that the psychiatric provider documented that Patient #1502 continued to endorse suicidal ideation and would not disclose her plan. Investigator #15 found that the psychiatric provider failed to document the Patient's self-harm/suicide attempt or the order for emergency IM medications.

c. On 02/05/22 at 7:20 PM, nursing staff obtained a telephone order from the psychiatric provider for Olanzapine (antipsychotic) 10 mg IM NOW and Benadryl 25 mg IM NOW.

d. Review of the Medication Administration Record (MAR) showed that the medication was administered via IM at 7:20 PM on 02/05/22.

e. Investigator #15's review of the medical record for Patient #1502 found that staff failed to document a request for a second medical opinion or document that the concurring second medical opinion was obtained within 24 hours of the emergency medication administration.

Patient #1503

5. On 04/21/22, Investigator #15 reviewed the medical record for Patient #1503, a 14-year-old female admitted voluntarily on 01/04/22, with a psychiatric diagnosis of Mood Disorder, unspecified, Major Depressive Disorder (MDD), and Post Traumatic Stress Disorder (PTSD). Patient #1503 had a reported history of sexual abuse by her biological father, trauma, and neglect. Patient #1503 had recently assaulted her grandmother and endorsed Suicidal Ideation with a plan to overdose, which led to the Patient's current admission. Review of the Patient's medical record showed the following:

a. On 01/18/22 at 3:00 PM, the Medication Administration Record (MAR) showed that the psychiatric provider initiated an order for Olanzapine (antipsychotic) 10 mg IM NOW and Benadryl 50 mg IM NOW for psychosis. The medications were administered at 1:27 PM via IM.

b. On 01/19/22 at 11:00 AM, the Medication Administration Record (MAR) showed that the psychiatric provider initiated on order for Olanzapine (antipsychotic) 10 mg IM NOW and Benadryl 50 mg IM NOW for agitation. The medications were administered at 10:53 AM via IM.

c. Investigator #15's review of the medical record for Patient #1503 found that staff failed to document a request for a second medical opinion or document that the concurring second medical opinion was obtained within 24 hours of the emergency medication administration.

Patient #1510

6. On 04/21/22 at 3:45 PM, Investigator #15 and the Assistant Director of Nursing (ADON) (Staff #1501) reviewed the medical record for Patient #1510, a 17-year-old female admitted on 04/01/22, on an involuntary detainment with a psychiatric diagnosis of Major Depressive Disorder (MDD). Patient #1510 endorsed Suicidal Ideation with a plan to overdose or cut herself. Patient #1510 had recently attempted suicide by overdosing, which led to the Patient's current admission. Review of the medical record showed the following:

a. Nursing Staff initiated a Restraint Medical Doctor (MD) Order, dated 04/12/22 at 9:46 PM. Patient #1510 had attempted to break into the nurses' station with the intent to find an object to end her own life. Based on the Patient's imminent danger to self, nursing staff contacted the psychiatric provider and obtained a verbal order for physical restraint, which was sustained for one minute at 9:43 PM, seclusion, which was sustained from 9:43 PM to 10:17 PM, and chemical restraint. The psychiatric provider ordered the administration of Olanzapine (antipsychotic) 10 mg IM NOW and Benadryl 50 mg IM NOW, which the nursing staff administered at 9:55 PM.

b. Nursing Staff initiated a Restraint Medical Doctor (MD) Order, dated 04/14/22 at 11:30 AM. Patient #1510 had become agitated and punched a staff member. Based on the Patient's imminent danger to others, nursing staff contacted the psychiatric provider and obtained a verbal order for physical restraint, which was sustained from 11:26 AM to 11:46 AM, and chemical restraint. The psychiatric provider ordered the administration of Olanzapine (antipsychotic) 10 mg IM NOW and Benadryl 50 mg IM NOW, which the nursing staff administered at 11:26 AM.

c. Nursing Staff initiated a Restraint Medical Doctor (MD) Order, dated 04/16/22 at 8:15 PM. Patient #1510 had become assaultive, punching and kicking staff members. Based on the Patient's imminent danger to others, nursing staff contacted the psychiatric provider and obtained a verbal order for physical restraint, which was sustained from 8:08 PM to 8:28 PM, and chemical restraint. The psychiatric provider ordered the administration of Olanzapine (antipsychotic) 10 mg IM NOW and Benadryl 50 mg IM NOW, which the nursing staff administered at 8:08 PM.

d. Investigator #15's review of the medical record for Patient #1510 found that staff failed to document a request for a second medical opinion or document that the concurring second medical opinion was obtained within 24 hours of the emergency medication administrations on 04/12/22, 04/14/22 and 04/16/22.

Patient #1517

7. On 05/05/22, Investigator #15 reviewed the medical record for Patient #1517, a 19-year-old female admitted on 02/09/22, on an involuntary detainment with a psychiatric diagnosis of Bipolar Disorder and Post Traumatic Stress Disorder (PTSD). Upon admission, Patient #1517 presented with mania, tangential, pressured speech, sexually inappropriate behavior, and endorsed auditory hallucinations, due to medication noncompliance. Review of the medical record showed the following:

a. Nursing Staff initiated a Restraint Medical Doctor (MD) Order, dated 02/09/22 at 7:58 PM. Patient #1517 had attempted to choke a staff member. Based on the Patient's imminent danger to others, nursing staff contacted the psychiatric provider and obtained a verbal order for physical restraint, seclusion, and chemical restraint. The psychiatric provider ordered the administration of Haldol (antipsychotic) 10 mg IM NOW, Benadryl 50 mg IM NOW, and Ativan 2 mg IM NOW, which the nursing staff administered at 7:58 PM.

b. Nursing Staff initiated a Restraint Medical Doctor (MD) Order, dated 02/22/22 at 12:20 AM. Patient #1517 attempted to attack another patient. Based on the Patient's imminent danger to others and danger to self, nursing staff contacted the psychiatric provider and obtained a verbal order for physical restraint, seclusion, and chemical restraint. The psychiatric provider ordered the administration of Haldol (antipsychotic) 5 mg IM NOW, Benadryl 50 mg IM NOW, and Ativan 2 mg IM NOW, which the nursing staff administered at 12:18 AM.

c. Nursing Staff initiated a Restraint Medical Doctor (MD) Order, dated 02/22/22 at 11:24 AM. Patient #1517 had become verbally threatening to other patients and staff members and physically assaulted another patient. Based on the Patient's imminent danger to others, nursing staff contacted the psychiatric provider and obtained a verbal order for seclusion and chemical restraint. The psychiatric provider ordered the administration of Olanzapine (antipsychotic) 10 mg IM NOW, which the nursing staff administered at 11:24 AM.

d. Nursing Staff initiated a Restraint Medical Doctor (MD) Order, dated 02/22/22 at 3:40 PM. Patient #1517 had become aggressive, spitting, kicking and attempting to scratch staff members. Based on the Patient's imminent danger to others, nursing staff contacted the psychiatric provider and obtained a verbal order for physical restraint and chemical restraint. The psychiatric provider ordered the administration of Haldol (antipsychotic) 10 mg IM NOW, Benadryl 50 mg IM NOW, and Ativan 2 mg IM NOW, which the nursing staff administered at 3:40 PM.

e. Investigator #15's review of the medical record for Patient #1517 showed that on 02/10/22 at 11:55 AM, the psychiatric provider initiated the request for a second concurring medical opinion to compel antipsychotic medication administration when the Patient refused their scheduled antipsychotic medication. A second concurring opinion was received and documented on a written order dated 02/10/22 at 12:00 PM.

f. Investigator #15's review of the medical record for Patient #1517 found that staff failed to document a request for a second medical opinion or document that the concurring second medical opinion was obtained within 24 hours of the emergency medication administrations 02/09/22, 02/22/22 at 12:18 AM, 02/22/22 at 11:24 AM, and 02/22/22 at 3:40 PM.

Patient #1518

8. On 04/29/22, Investigator #15 reviewed the medical record for Patient #1518, a 34-year-old male voluntarily admitted on 04/22/22, with a psychiatric diagnosis of Major Depressive Disorder (MDD) and Suicidal Ideation (SI). Patient #1510 had recently attempted suicide by attempting to shoot himself, which led to the Patient's current admission. Review of the Patient's medical record showed the following:

a. Nursing Staff initiated a Restraint Medical Doctor (MD) Order, dated 04/25/22 at 9:58 PM. Patient #1518 had attempted to attack a peer. Based on the Patient's imminent danger to others, nursing staff contacted the psychiatric provider and obtained a verbal order for physical restraint and chemical restraint. The psychiatric provider ordered the administration of Haldol (antipsychotic) 5 mg IM NOW and Benadryl (anticholinergic) 50 mg IM NOW and Ativan 2 MG IM NOW, which the nursing staff administered at 9:57 PM.

b. Investigator #15's review of the medical record for Patient #1518 failed to find evidence of a request for a second medical opinion or evidence documenting the concurring second medical opinion was obtained within 24 hours of the emergency medication administration.

9. On 04/29/22 at 1:45 PM, during an interview with Investigator #15, Staff #1501 verified that only one of the medical records reviewed had a 2nd Opinion Consultation for Compelled Medication (Patient #1517) and none of the me

.

Based on interview and document review, the hospital failed to adopt and implement policies and procedures that ensure unvaccinated staff receive weekly COVID-19 testing (Item #1) and that ensure unvaccinated staff wear appropriate personal protective equipment (PPE) (Item #2).

Failure to adopt and implement policies and procedures for ensuring that unvaccinated staff receive weekly COVID-19 testing and wear appropriate PPE places patients, visitors, staff, and the community at risk for harm, including death.

Findings included:

Item #1 Weekly Testing for Unvaccinated Staff

1. Review of the hospital document titled, "COVID-19 Mandatory Vaccination, Washington," no policy number, effective 08/21, showed that healthcare workers who have met the requirements for exemption must be tested once weekly for COVID-19.

2. On 04/28/22 between 11:20 AM and 11:55 AM, Investigator #12 interviewed 5 staff members with approved COVID-19 vaccine exemptions. The interviews showed that 1 of 5 staff was not receiving weekly testing for COVID-19 (Staff #1201).

3. On 04/28/22 at 12:30 PM, Investigator #12 interviewed the Chief Operating Officer (Staff #1206), the Human Resources generalist (Staff #1207), and the Regional Director of Risk Management (Staff #1208) about the weekly COVID-19 testing process for unvaccinated staff. Staff #1207 stated that unvaccinated staff were supposed to submit their test to the lab by Tuesday of each week, and unvaccinated staff who did not submit weekly tests would be suspended. The interview showed that 4 of 14 staff worked without receiving weekly testing (Staff #1201, #1202, #1203, and #1204). Staff #1206 stated that they had identified "gaps in their hiring process," and 3 staff had not been set up for weekly testing since they were hired (Staff #1201, #1203, and #1204). Staff #1207 confirmed that Staff #1202 was set up for weekly testing but had not submitted a test since 03/25/22.


Item #2 Personal Protective Equipment (PPE)

1. Review of the hospital document titled, "COVID-19 Mandatory Vaccination, Washington," no policy number, effective 08/21, showed that healthcare workers who have met the requirements for exemption must wear an N95 respirator or higher-level respirator approved by the National Institute of Occupational Safety and Health (NIOSH) at all times while in the building unless actively drinking or eating or within their own private office space.

2. On 04/28/22 between 11:20 AM and 11:55 AM, Investigator #12 interviewed 5 staff members with approved COVID-19 vaccine exemptions. During the interviews, the investigator observed that 1 of 5 staff was not wearing an N95 respirator (Staff #1205) as required by hospital policy. When asked about the hospital's policy for wearing N95 respirators, Staff #1205 stated that the hospital only requires that the unvaccinated staff wear the N95 masks and goggles when they go to the patient care units.

3. On 04/28/22 at 1:37 PM, during an interview with the Regional Director of Risk Management (Staff #1208), Staff #1208 confirmed the investigator's finding that Staff #1205 was not following hospital policy and should have been wearing an N95 respirator.
.