HospitalInspections.org

Based on observations, staff interview and review of documentation, the Hospital failed to have an effective governing body who is legally responsible for the conduct of the hospital. Finding include:


The Governing Body failed to effectively ensure the hospital:

1. Had an effective Quality Assessment and Performance Improvement Program which was clearly defined, implemented and maintained.

See A-0263

2. Maintained adequate medical records that addressed treatment modalities, updated treatment plans with short and long term goals and treatment plans that addressed all treatment needs.

See A-1645

3. Had adequate staff to provide care in a safe setting.

See A-0144
See A-1680

During the Survey from 5/28/21 - 6/2/21, the Hospital was unable to provide Governing Body Meeting Minutes that identified any of the concerns brought forward by the Survey team.

Based on observations, interviews and record review, the Hospital failed to ensure safety of their patients on 1 (Childrens Psychiatric Unit) of 5 units when a Mental Health Technician was seen utilizing inappropriate restraint techniques, resulting in abuse, while supervising out door fresh air space.

Based on observations, record review and interviews the Hospital failed to provide care in a safe setting in one (Children's Psychiatric Unit) of five inpatient psychiatric units. While the patients of the Children's Psychiatric Unit were outside for a fresh air break Mental Health Technician #1 grabbed Patient #4 by the wrist/arm when attempting to de-escalate an argument between Patient #4 and other pediatric patients.

Findings include:

Review of the Hospital's Patient Abuse and Neglect Policy dated, 1/2019, indicated that the Hospital promotes respect, dignity and safety for all patients.

1. All allegations of patient abuse or neglect will be thoroughly investigated.
2. Actions are taken in order to protect the Patient, prevent incidents, investigate allegations and respond to the incidents of abuse or neglect.
3. Efforts to prevent neglect/abuse include but are not limited to:
a. Adequate staffing to meet the needs of the Patient
b. Pre-employment screening of employees for records of abuse/neglect
c. Protecting the Patients during an investigation of abuse/neglect
d. Educating all staff about the requirement for identifying, reporting and intervention in incidents of abuse and/or neglect.
e. Investigations will be completed timely and thoroughly with corrective actions to occur as appropriate.

Definition of Class II abuse:
A. Any act or failure to act, performed knowingly, recklessly, or intentionally, including incitement to act, which cause or may have caused non-serious physical injury to a person served.
B. Any act of force or corporal punishment, including striking or pushing a person served, regardless of whether the act results in non-serious injury to a person served.
C. Exploitation


Review of the Hospital's Restraint and/or Seclusion Policy, dated 2/2019, indicated that The Hospital is committed to preventing, reducing and eliminating the use of physical and chemical restraint and seclusion in the care of every patient. At the same time, the Hospital recognizes that restraint/seclusion may be required in emergent situations in which there is imminent risk of a patient physically harming him/herself or others.

When such emergencies appear imminent, therapeutic, non-physical interventions are always preferred.

If a restraint/seclusion is deemed clinically necessary and all therapeutic interventions have been exhausted, these procedures will be carried out in a way that respects the dignity, privacy, and safety of each patient.

Upon admission each patient is assessed for the risk of harming themselves or others and identification of techniques that would assist the patient to control his/her behavior is discussed and documented.

The Hospital will develop an individual Crisis Prevention Plan for each patient. The plan must be appropriate to the biological age and developmental stage. The Plan must include:
-a list of triggers that might cause the patient to feel agitated or distressed
-strategies to help calm down and de-escalate the situation
-patient preferences, such as the type of restraint and positioning
-the gender of the staff person restraining you
-ways in which each patient would like to be calmed
-the least restrictive for m of restraint that protects the physical safety of the patient, staff or others is used.

Restraints/seclusion will be used only upon the authorization of a Licensed Independent Practitioner (LIP) or registered nurse and who has personally observed and examined the patient and is clinically satisfied with the use of the restraint/seclusion is justified to prevent the patient from causing physical harm to him/herself or others.

-A child under the age of thirteen years old who requires a mechanical restraint must have prior authorization of the Medical Director or designee.
-Parents or legal guardian must be notified of every incident.


Review of the Hospital's Code Yellow Policy, dated 1/2019, indicated that the Hospital has a procedure for active psychiatric crisis situations. Examples may include but not be limited to suicidal gesture, aggressive acting out toward self or others, self-injury and threatening behavior.

1. Staff should first attempt to utilize verbal intervention skills initially when attempting to de-escalate patients. Offers of coping skills and alternative ways to resolve the situation and even oral medication may be offered. If it is unsuccessful a Code Yellow will be called.

2. During Shift Report, the Nursing Supervisor or designee will designate a Mental Health Technician (MHT) from each unit who will respond to a Code Yellow.

Patient #4 was admitted to the Hospital in 4/2021 for treatment of post-traumatic stress disorder, attention deficit disorder and oppositional defiant disorder.

Review of Patient #4's Crisis Prevention Plan, undated, does not include a list of triggers that might cause the patient to feel agitated or distressed. The Crisis Prevention plan also does not include any signs that the patient or others might notice if the patient becomes frightened or upset.

The list of things that can make Patient #4 feel better when he/she is having a difficult time are: voluntary time out in room. voluntary time out in quiet room, calling sponsor, talking with staff, deep breathing exercises, listening to quiet music in room, pacing the halls, exercise, calling a friend or family, talking to therapist or psychiatrist if available, sensory interventions that utilize sight, touch, taste, smell, sound (No further description of the patients sensory needs are listed) and requesting PRN (as needed) medication.

The Crisis Prevention Plan was signed only by the Patient's parent, and not by any members of the Hospital staff to confirm receipt or discussion of Patient #4's needs.

During a tour of the Hospital on 5/28/21 at 9:00 A.M., Surveyor's witnessed Mental Health Technician (MHT) #1 and MHT #2 supervising 10 Pediatric Patient's in the outdoor fresh air space. During the observation, Patient #4 became agitated and began posturing towards another pediatric patient in the outdoor space. MHT #1 and MHT #2 tried to step in between Patient #4 and the other patients. When Patient #4 continued to move aggressively towards the other patient, MHT #1 grabbed Patient #4 and pulled him/her by the wrist/forearm to separate Patient #4 from the other pediatric patients.

During an interview on 5/28/21 at 9:00 A.M. MHT #2 said that he is trained in Crisis Prevention Institute (CPI) restraint training and that staff should never put hands on a pediatric patient to de-escalate a situation.

During an interview on 5/28/21 at 10:30 A.M. the Interim Chief Nursing Officer CNO) said that the Hospital will have to complete retraining of CPI (Restraint Technique) with MHT #1 and MHT#2 because putting hands on a child was abuse.

During an interview on 6/1/21 at 9:20 A.M. the Director of Human Resources said that staffing is based on acuity. She further stated that the acuity is based on the Chief Nursing Officer and nursing supervisor's reports.

During an interview on 6/1/21 at 10:00 A.M., MHT #1 said that he was trained in CPI restraint training 3 months ago. He said that another patient was provoking Patient #4 outside on 5/28/21 during the morning fresh air break. MHT #1 said that he should have called a code yellow. The situation was heading towards an issue and he was just trying to de-escalate the situation when he pulled Patient #4 by the wrist/forearm to get him/her away from the other patients.

During an interview on 6/1/21 at 10:10 A.M., MHT #2 said that there were too many kids outside for two staff members. MHT #2 said that staffing is a problem at the Hospital. MHT #2 said that there should have been a nurse outside to support the MHT's when Patients require restraints or de-escalation. MHT #2 said that in hind sight, he should have called for help with the situation on 5/28/21 between Patient #4 and the other patients.

During an interview on 6/1/21 at 9:50 A.M., The interim CNO said that she called in both MHT #1 and MHT #2 to re-educate on CPI and proper de-escalation technique. She said that training has been inadequate and they are trying to "bump" it up as of 6/1/21.

The Hospital failed to follow their own policies to prevent abuse and ensure proper restraint techniques be used in the setting of the Pediatric Unit Patients.

Based on observations, record review and interviews, the Hospital failed to implement a corrective action plan after it was observed by Department of Public Health (DPH) surveyors that an inappropriate restraint occurred to Patient #4 during child recreational/outdoor time resulting in abuse. The failure to implement timely, corrective actions indicated a failure in the hospital's ability to maintain an effective quality performance improvement program, and potentially compromised the safety of other patients currently at the facility.

See tags 273, 286 and 309.

Based on interviews and document review, the hospital failed to collect data to monitor the effectiveness and safety of services and quality of care.


Findings include:

Review of the Hosptial's Performance Improvement Plan for 2019 (no updated plan provided when asked) indicated that the Hospital has a Performance Improvement Plan established to ensure objective and systematic monitoring and evaluation of the appropriateness and quality of patient care.

Objectives in the Performance Improvement Plan (2019) are:
A. Establish an organiational culture that encourages and supports continued improvement of efficiency and effectiveness in patient care delivery.
B. Use aggregate and statistical analyses to identify known, suspected or potential problems in pateint care delivery, as well as opportunities for further improvement in currently acceptable care.
C. Prioritize investigation and resolution of problems by focusing on those with the greatest impact on patient outcome.
D. Assure that the program's methods and systems are comprehensive and integrated to permit improvement in or resolution of identified problems.

Review of the Hospital's Patient Abuse and Neglect Policy dated, 1/2019, indicated that the Hospital promotes respect, dignity and safety for all patients.

1. All allegations of patient abuse or neglect will be thoroughly investigated.
2. Actions are taken in order to protect the Patient, prevent incidents, investigate allegations and respond to the incidents of abuse or neglect.
3. Efforts to prevent neglect/abuse include but are not limited to:
a. Adequate staffing to meet the needs of the Patient
b. Pre-employment screening of employees for records of abuse/neglect
c. Protecting the Patients during an investigation of abuse/neglect
d. Educating all staff about the requirement for identifying, reporting and intervention in incidents of abuse and/or neglect.
e. Investigations will be completed timely and thoroughly with corrective actions to occur as appropriate.

During an interview on 06/01/2021 at 11:30 A.M. Mental Health Technician (MHT) #2 stated that he does not have access to the incident reporting system.

During an interview on 06/01/2021 at 10:00 A.M the Chief Executive Officer (CEO) could not provide evidence that the facility had a current, functional quality improvement and patient safety program. The CEO said that the previous staff member who was responsible for conducting investigations had a data collection process that was not streamlined, had investigations that were in different locations and could not be analyzed by others. The CEO also stated that certain incident reports were discovered on a staff member's desk and as a result, were not being reported to the Performance Improvement Committee.

The CEO said that she has gathered information to propose a restructuring of the Performance Improvement Plan. She plans to contract with an outside source to build a robust Performance Improvement Program, but this has not occured as of the date of the survey.

Based on interviews and record reviews, the Hospital failed to create a policy for investigation of adverse events.

Review of the Hospital's Patient Abuse and Neglect Policy dated, 1/2019, indicated that the Hospital promotes respect, dignity and safety for all patients.

1. All allegations of patient abuse or neglect will be thoroughly investigated.
2. Actions are taken in order to protect the Patient, prevent incidents, investigate allegations and respond to the incidents of abuse or neglect.
3. Efforts to prevent neglect/abuse include but are not limited to:
a. Adequate staffing to meet the needs of the Patient
b. Pre-employment screening of employees for records of abuse/neglect
c. Protecting the Patients during an investigation of abuse/neglect
d. Educating all staff about the requirement for identifying, reporting and intervention in incidents of abuse and/or neglect.
e. Investigations will be completed timely and thoroughly with corrective actions to occur as appropriate.

During an interview on 6/1/21 at 8:45 A.M., the Interim Chief Nursing Officer said that on the morning of 6/1/21, she reviewed the events that took place in the outdoor space on 5/28/21 in which the Mental Health Technitian grabbed a pediatric patient by the wrist/forearm. She said then she submitted a safety report.

During an interview on 6/1/21 at 10:15 A.M., Mental Health Technician #2 said that he was unsure of how to submit an safety/incident report after an adverse event. He said that throughout his time at the Hospital, there have been events in which he has been hit and or spit on and has never filed an incident report. He said he may tell the nurse what happens, but does not participate in any follow-up.

During an interview on 6/1/21 at 2:00 P.M. the Interim Children's Unit Program Director said that only nurses do safety/incident reports.

During an interveiw on 6/1/21 at 9:00 A.M. with the Chief Executive Officer and the Interim Performance Improvement Director, the CEO was unable to identify or answer questions in relation to the Hospital's policy for investigation of adverse events. She said that they follow the DMH regulations. She was unable to provide the Survey team with a Hosptial Policy that addresses safety/incident reports and investigation of adverse events.

Based on interviews and observations, the hospital executive leadership failed to have an effective, ongoing, quality improvement program that addresses priorities for improved quality of care and patient safety.

Findings include:

According to the policy titled "Restraint and/or Seclusion" dated 3/2021, indicates that a physical restraint is a physical hold that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.
Restraint will only be used only when there is an imminent risk of a patient causing physical harm to him/herself or others, and only after attempting non-physical interventions to control a patient's behavior, unless safety issues demand an immediate physical response.

On 05/28/2021, at 9:00 A.M., during recreational/outdoor time, the surveyors observed an inappropriate restraint, where Patient #4 was grabbed by the forearm/wrist and pulled away from the rest of the patients. Patient #4 was not an imminent risk of causing physical harm to his/herself or others. .

The Mental Health Technicians (MHTs) directly involved with the inappropriate restraint were taken off the unit and no longer working the day of the incident.

During an interview on 06/01/2021 at 12:45 P.M, The Interim CNO said the two MHT's directly involved in the 05/28/2021 restraint incident were re-trained. The Interim CNO acknowledged that no other staff members were re-trained since the 05/28/2021 incident. The Interim CNO acknowledged that the facility failed to evaluate the rest of the MHT staff to determine whether or not the other MHTs were appropriately trained in child restraint practices and that there was no retraining offered to all Mental Health Technician staff, which provided care for the patients throughout the hospital.



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The Hospital failed to meet the requirements for special medical records and meet the staff requirements to provide care in Psychiatric Hospitals.

See A-1610
See A-1640

Based on record reviews and interviews, the Hospital failed to provide accurate and complete medical records, comprehensive treatment plans and failed to allow CMS the opportunity to determine the degree and intensity of treatment furnished to the patients for 5 (Patient #1, Patient #4, Patient #6, Patient #9 and Patient #10) of 10 medical records reviewed.

Findings include:

Review of the Hospital's Restraint and/or Seclusion Policy, dated 2/2019, indicated that the Hospital is committed to preventing, reducing and eliminating the use of physical and chemical restraint and seclusion in the care of every patient. At the same time, the Hospital recognizes that restraint/seclusion may be required in emergent situations in which there is imminent risk of a patient physically harming him/herself or others.

When such emergencies appear imminent, therapeutic, non-physical interventions are always preferred.

If a restraint/seclusion is deemed clinically necessary and all therapeutic interventions have been exhausted, these procedures will be carried out in a way that respects the dignity, privacy, and safety of each patient.

Upon admission each patient is assessed for the risk of harming themselves or others and identification of techniques that would assist the patient to control his/her behavior is discussed and documented.

The Hospital will develop an individual Crisis Prevention Plan for each patient. The plan must be appropriate to the biological age and developmental stage. The Plan must include:
-a list of triggers that might cause the patient to feel agitated or distressed
-strategies to help calm down and de-escalate the situation
-patient preferences, such as the type of restraint and positioning
-the gender of the staff person restraining you
-ways in which each patient would like to be calmed
-the least restrictive form of restraint that protects the physical safety of the patient, staff or others is used.

1. Patient #1 was admitted to the Hospital in 4/2021 for inpatient psychiatric level of care. The Hospital failed to create and update individualized treatment plans for patient #1. The Treatment Plan in his/her record was left blank with only a signature of an occupational therapist. The treatment plans in the record did not have any short or long term goals and the treatment modality was not addressed.

2. Patient #4 was admitted to the Hospital in 4/2021 for treatment of post-traumatic stress disorder, attention deficit disorder and oppositional defiant disorder. The Hospital failed to have a complete medical record and individualized, comprehensive treatment plans to determine the intensity of Patient #4's treatment.

Review of Patient #4's Crisis Prevention Plan, undated, does not include a list of triggers that might cause the patient to feel agitated or distressed. The Crisis Prevention plan also does not include any signs that the patient or others might notice if the patient becomes frightened or upset.

The list of things that can make Patient #4 feel better when he/she is having a difficult time are: voluntary time out in room. voluntary time out in quiet room, calling sponsor, talking with staff, deep breathing exercises, listening to quiet music in room, pacing the halls, exercise, calling a friend or family, talking to therapist or psychiatrist if available, sensory interventions that utilize sight, touch, taste, smell, sound (No further description of the patients sensory needs are listed) and requesting PRN (as needed) medication.

The Crisis Prevention Plan was signed only by the Patient's parent, and not by any members of the Hospital staff to confirm receipt or discussion of Patient #4's needs.

The Hospital filled out partial and standardized treatment plans without identifying individualized treatment modalities, short and long-term goals, as well as identifying how the Hospital is providing treatment to meet any short or long-term goals.

Patient #4 had treatment plans created on 4/9/21 for Danger to Self and Danger to Others. The treatment plans were not individualized and not updated to reflect progress, treatment modality and goals. Further, there were no new care plans created after admission to address Patient #4's increased anger and aggression exhibited towards other pediatric patients on the inpatient psychiatric unit.

Review of the interdisciplinary Treatment Plan Review Update for Patient #4 does not reflect progress in Patient #4's treatment or strategies to decrease the Patient's behaviors.

3. Patient #6 was admitted to the Hospital in 5/2021 for treatment of suicidal ideation with a plan to commit suicide. The Hospital failed to complete documentation for the Crisis Prevention Plan in order to develop strategies to utilize to decrease distress and incorporate them into the treatment plans. The Hospital had Patient #6 sign the paperwork, but there were no interventions put in place.

Patient #6 did not have any individualized interdisciplinary treatment plans that addressed individual treatment modalities used to provide assisstacet with progress towards short and long term goals.

4. Patient #9 was admitted to the Hospital in 2/2021 for the treatment of post-traumatic stress disorder, schizophrenia, and adjustment disorder with disturbance of conduct. The Hospital failed to have a complete medical record and individualized, comprehensive treatment plans to determine the intensity of Patient #9's treatment.

Review of Patient #9's treatment plans indicated that target goal dates were not updated to reflect Patient #9's progress or lack of progress. The Master Treatment Plan dated 2/14/21 indicated that Patient #9 had suicidal ideation, psychosis, increased anxiety and mood instability. The Master Comprehensive Treatment Plan dated 2/14/21 indicated that Patient #9 had psychosis as evidence by delusions. The long term dispositional goal was for the Patient to demonstrate stable mood and be free of hallucinations and delusions. The treatment plan does not indicate specific individualized goals and treatment modalities to address the needs of the patient to progress towards goals.

Review of Patient #9's weekly Interdisciplinary Treatment Plan Updates indicate that the patient is making some progress, but does not indicate how progress has been made or what they are doing to promote progress in treatment.

Review of the medical record on n 6/2/21, there was no documentation from the therapist to update Patient's current clinical status. The last clinical note was written on 3/5/21. The Patient Staffing and Interdisciplinary Treatment Plan/Reviews were incomplete and inconsistent with providing updated information regarding patient's current psychiatric needs and treatment modalities provided.

5. Patient #10 was admitted to the Hospital in 5/2021 for treatment of bipolar disorder and delusions. The Hospital failed to create any individualized interdisciplinary treatment plans for the patient. There was nothing in the medical record to reflect any treatment plan was created or that there were any short or long term goals for Patient #10. Further, there was no individualized treatment modality identified to address the patients psychiatric needs.

During an interview on 5/28/21 at 8:30 A.M., the Chief Executive Officer said that she will be addressing the treatment modalities used for the patients as she hasn't seen that the Hospital's plan for treatment modality is individualized for each patient.

During an interview 6/1/21 at 8:30 A.M., the Senior Vice President of Clinical Services said that when the Hospital opened two years ago, everyone was trained on "trauma focused cognitive behavioral therapy". She said that there has been a lot of turn over. When asked for updated/current training documentation for staff, the Senior Vice President of Clinical Services said that she believes that the education is unit based and was unable to provide documentation. There was no identified reason to the lack of documentation in the medical records.

During an interview on 6/1/21 at 9:15 A.M., the Chief Executive officer said that she has identified a need for an immediate Children's Unit Program Director and has enlisted the Director of Assessment and Intake to be the interim Children's Unit Program Director until the new hire starts. The CEO said that she has identified the Interim Children's Unit Program Director has the skill set and training to address the current needs on the Unit.

During an interview on 6/1/21 at 2:00 P.M. the Interim Children's Unit Program Director said that there has been a lack of programming on the Children's Unit. She will focus on organizing the programming and staffing to be sure that treatment is more consistent.

The Hospital failed to have adequate numbers of qualified professional and supportive staff to provide safety and observation of patients while admitted to the Hospital on 1 (The Children's Psychiatric Unit) of 5 units while providing supervision during in the fresh air space. .

Findings include:

Review of the Hospital's Fresh Air Daily Outdoor Access Plan, undated, indicated that There will be a minimum of 2 staff, and will include the same ratio of staff to patients as is utilized on the unit. Staff assigned to supervise patients during outside access must be trained in de-escalation techniques and will be sreponsible to:

1. Confirm any unit restriction orders with assigned patient's RN before leaving the unit.
2. Confirm the walkie-talkie is fully charged and functioning before leaving the unit.
3. Carry a walkie-talkie on their person at all times.
4. Staff is responsible to perform a head count of patients leaving the unit, enterine outside enclosure, entering elevators and upon arrival to unit.
5. Ensure the safety and security of all pateitns during outside access by continuous visual monitoring of all patients.

For Patient #4, the Hospital failed to provide adequate staff to provide a safe environment when outdoors for fresh air time.

On 5/28/21 at 9:00 A.M. the Mental Health Technician (MHT) #1 and MHT#2 were observed to be supervising fresh air time with 10 Children's Unit Patients. During that time, Patient #4 became aggressive and combative towards other pediatric patients. Patient #4 was yelling and posturing towards other patients in an aggressive manner. MHT #1 and MHT #2 were observed trying to keep Patient #4 away from the other 9 children in the outdoor space. Patient #4 continued to run towards the other patients attempting to strike them. MHT #1 grabbed Patient #4 by the wrist and started pulling him/her to the other side of the fresh air space. MHT #2 observed. At no time did MHT #1 or MHT #2 attempt to call for additional help from other staff members to help with appropriate de-escalation of the situation.

The Chief Executive Officer, who was observing with the Survey Team, went to the Nursing Station and requested help for MHT #1 and MHT #2. Upon arriving outside to the outdoor space, MHT #1 was bringing 2 patients back up to the Children's Unit, leaving MHT#2 alone with 8 pediatric patients in the fresh air space.

During an interview on 6/1/21 at 10:00 A.M., MHT #1 said that he should have called a code for support with the increasing behaviors that were taking place during the fresh air time. He said that another pediatric patient was provoking Patient #4 and he tried to get them apart.

During an interview on 6/1/21 at 10:10 A.M. MHT #2 said that staffing is a problem at the Hospital. MHT #2 said that there should have been a nurse outside to support the MHT's when Patients require restraints or de-escalation.

During an interview on 6/1/21 at 11:30 A.M. the Interim Chief Nursing Officer said that there should have been more staff outside to assist with 10 children.

The Hospital failed to follow their own Policy for providing care and supervision during outdoor fresh air time on the Children's Psychiatric Unit.

The Hospital failed to maintain adequate medical records to reflect treatment modalities, failed to have updated treatment plans with short and long term goals, updated clinical notes and failed to identify individualized care needs.

See A-1642 and A-1643

Based on record reviews and interviews, the Hospital failed to maintain adequate medical records that addressed short and long term goals for patient care and did not have updated and appropriate treatment plans in 5 (Patient #1, Patient #4, Patient #6, Patient #9 and Patient #10) of 10 medical records reviewed on 2 (Children's Unit and Adult Intesive Unit) of 5 psychiatric units.

Findings include:

1. Patient #1 was admitted to the Hospital in 4/2021 for inpatient psychiatric level of care. The Hospital failed to create and update individualized treatment plans for patient #1 with any short or long term goals. The Treatment Plan in his/her record was left blank with only a signature of an occupational therapist.

2. Patient #4 is a pediatric patient admitted to the Hospital in 4/2021 for treatment of post-traumatic stress disorder, attention deficit disorder and oppositional defiant disorder.

Patient #4 had treatment plans created on 4/9/21 for Danger to Self and Danger to Others. The treatment plans were not individualized and did not have short or long term goals. Further, there were no new care plans created after admission to address Patient #4's increased anger and aggression exhibited towards other pediatric patients on the inpatient psychiatric unit.

3. Patient #6 was admitted to the Hospital in 5/2021 for treatment of suicidal ideation with a plan to commit suicide. The Hospital failed to complete documentation to develop strategies to utilize to decrease distress and incorporate them into the treatment plans. The Hospital had Patient #6 sign the paperwork, but there were no interventions put in place with short or long term goals..

4. Patient #9 was admitted to the Hospital in 2/2021 for the treatment of post-traumatic stress disorder, schizophrenia, and adjustment disorder with disturbance of conduct. The Hospital failed to have a complete medical record and individualized, comprehensive treatment plans to determine the intensity of Patient #9's treatment with short and long term goals.

Review of Patient #9's treatment plans indicated that target goal dates were not updated to reflect Patient #9's progress or lack of progress. There was no documentation from the therapist to update Patient's current clinical status. The last clinical note was written on 3/5/21. The Patient Staffing and Interdisciplinary Treatment Plan/Reviews were incomplete and inconsistent with providing updated information regarding patient's current psychiatric needs and treatments provided. There was no documentation as to short and long term goals and the treatment used to acheive the goals as desired.

5. Patient #10 was admitted to the Hospital in 5/2021 for treatment of bipolar disorder and delusions. The Hospital failed to create any individualized interdisciplinary treatment plans for the patient. There was nothing in the medical record to reflect any treatment plan was created or that there were any short or long term goals for Patient #10.

During an interview on 6/1/21 at 8:30 A.M., the Senior Vice President of Clinical Services said that when the Hospital opened two years ago, everyone was trained on "trauma focused cognitive behavioral therapy". She said that there has been a lot of turn over with their employees. When asked for updated/current training documentation for staff members, the Senior Vice President of Clinical Services said that she believe the education is unit based and was unable to provide documention. There was no identified reason for the lack of documentation of treatment goals in the medical records.

During an interview on 6/1/21 at 9:15 A.M., the Chief Executive officer said that she has identified a need for an immediate Children's Unit Program Director and has enlisted the Director of Assessment and Intake to be the interim Children's Unit Program Director until the new hire starts.

During an interview on 6/1/21 at 2:00 P.M. the Children's Unit Program Director said that there has been a lack of programming on the Children's Unit. She will focus on organizing the programming and staffing to be sure that treatment is more consistent.

During an interview on 6/2/21 at 10:15 A.M. the Director of Utilization Review said that treatment plans are not strong at the Hospital and they are hoping to add managers to oversee treatment planning in the future.

During an interview on 6/2/21 at 11:30, Program Therapist #1 said that he does document clinical notes and doesn't know where they are if they are not in the medical record.

Based on record reviews and interviews, the Hospital failed to maintain adequate medical records that addressed individualized treatment modalities for patient care in 5 (Patient #1, Patient #4, Patient #6, Patient #9 and Patient #10) of 10 medical records reviewed on 2 (Children's Unit and Adult Intesive Unit) of 5 psychiatric units.

Findings include:

1. Patient #1 was admitted to the Hospital in 4/2021 for inpatient psychiatric level of care. The Hospital failed to create and update individualized treatment plans for patient #1. The Treatment Plan in his/her record was left blank with only a signature of an occupational therapist. The treatment plans did not identify which treatment modality was to be utilized to provide adequate psychiatric care.

2. Patient #4 was admitted to the Hospital in 4/2021 for treatment of post-traumatic stress disorder, attention deficit disorder and oppositional defiant disorder. The Hospital failed to have a complete medical record and individualized, comprehensive treatment plans to determine the intensity of Patient #4's treatment.

The Hospital filled out partial and standardized treatment plans without identifying individualized treatment modalities.

Patient #4 had treatment plans created on 4/9/21 for Danger to Self and Danger to Others. The treatment plans were not individualized and not updated to reflect progress, treatment modality and goals. Further, there were no new care plans created after admission to address Patient #4's increased anger and aggression exhibited towards other pediatric patients on the inpatient psychiatric unit.

Review of the Interdisciplinary Treatment Plan Review Update for Patient #4 does not reflect progress in Patient #4's treatment or strategies to decrease the Patient's behaviors.

3. Patient #6 was admitted to the Hospital in 5/2021 for treatment of suicidal ideation with a plan to commit suicide.

Patient #6 did not have any individualized interdisciplinary treatment plans that addressed individual treatment modalities used to provide adequate care.

4. Patient #9 was admitted to the Hospital in 2/2021 for the treatment of post-traumatic stress disorder, schizophrenia, and adjustment disorder with disturbance of conduct. .

Review of Patient #9's treatment plans indicated that target goal dates were not updated to reflect Patient #9's progress or lack of progress. The Master Treatment Plan dated 2/14/21 indicated that Patient #9 had suicidal ideation, psychosis, increased anxiety and mood instability. The Master Comprehensive Treatment Plan dated 2/14/21 indicated that Patient #9 had psychosis as evidence by delusions. The long term dispositional goal was for the Patient to demonstrate stable mood and be free of hallucinations and delusions. The treatment plan does not indicate specific individualized treatment modalities to address the needs of the patient to progress in his/her treatment.


5. Patient #10 was admitted to the Hospital in 5/2021 for treatment of bipolar disorder and delusions. The Hospital failed to create any individualized interdisciplinary treatment plans for the patient and there was no individualized treatment modality identified to address the patients psychiatric needs.

During an interview on 5/28/21 at 8:30 A.M., the Chief Executive Officer said that she will be addressing the treatment modalities used for the patients as she hasn't seen that the Hospital's plan for treatment modality is individualized for each patient.

During an interview on 6/1/21 at 8:30 A.M., the Senior Vice Presidnet of Clinical Services said that when the Hospital opened two years ago, everyone was trained on "trauma focused cognitive behavioral therapy". She said that there has been a lot of turn over with their employees. When asked for updated/current training documentation for staff members, the Senior Vice President of Clinical Services said that she believed the education is unit based and was unable to provide documention. There was no identified reason for the lack of documentation of treatment modalities in the medical records.

During an interview on 6/1/21 at 2:00 P.M., the Interim Children's Unit Program Director said that there has been a lack of programming on the Children's Unit. She will focus on organizing programming and staffing to be sure that treatment is more consistent.

The Hospital failed to provide adequate numbers of supportive staff to provide safe observation levels to Patient's on 1 (Children's Psychiatric Unit) of 5 Units while admitted to the Hospital

See A-1687

The Hospital failed to have adequate numbers of supportive staff to provide a safe environment and observation of patients while admitted to one (the Children's Psychiatric Unit) of five units of the Hospital when the Hospital failed to provide adequate staff to provide a safe environment when outdoors for fresh air time on the Children's Psychiatric Unit.

Findings include:

Review of the Hospital's Fresh Air Daily Outdoor Access Plan, undated, indicated that There will be a minimum of 2 staff, and will include the same ratio of staff to patients as is utilized on the unit. Staff assigned to supervise patients during outside access must be trained in de-escalation techniques and will be sreponsible to:

1. Confirm any unit restriction orders with assigned patient's RN before leaving the unit.
2. Confirm the walkie-talkie is fully charged and functioning before leaving the unit.
3. Carry a walkie-talkie on their person at all times.
4. Staff is responsible to perform a head count of patients leaving the unit, enterine outside enclosure, entering elevators and upon arrival to unit.
5. Ensure the safety and security of all patients during outside access by continuous visual monitoring of all patients.

On 5/28/21 at 9:00 A.M. the Mental Health Technician (MHT) #1 and MHT#2 were observed to be supervising fresh air time with 10 Children's Unit Patients. During that time, Patient #4 became aggressive and combative towards other pediatric patients. Patient #4 was yelling and posturing towards other patients in an aggressive manner. MHT #1 and MHT #2 were observed trying to keep Patient #4 away from the other 9 children in the outdoor space. Patient #4 continued to run towards the other patients attempting to strike them. MHT #1 grabbed Patient #4 by the wrist and started pulling him/her to the other side of the fresh air space. MHT #2 observed. At no time did MHT #1 or MHT #2 attempt to call for additional help from other staff members to help with appropriate de-escalation of the situation.

The Chief Executive Officer, who was observing with the Survey Team, went to the Nursing Station and requested help for MHT #1 and MHT #2. When the Surveyors arrived to the outdoor space, MHT #1 was bringing 2 patients back up to the Children's Unit, leaving MHT#2 alone with 8 pediatric patients in the fresh air space.

During an interview on 6/1/21 at 9:20 A.M. the Director of Human Resources said that staffing is based on acuity. She further stated that the acuity is based on the Chief Nursing Officer and nursing supervisor's reports.

During an interview on 6/1/21 at 10:00 A.M., MHT #1 said that he should have called a code for support with the increasing behaviors that were taking place during the fresh air time.

During an interview on 6/1/21 at 10:10 A.M. MHT #2 said that staffing is a problem at the Hospital. MHT #2 said that there should have been a nurse outside to support the MHT's when Patients require restraints or de-escalation.

During and interview on 6/1/21 at 11:30 A.M. the Interim Chief Nursing Officer said that there should have been more staff outside to assist with 10 children.