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Based on review of medical records, video surveillance, policy and procedures, and staff interviews, it was determined that the facility failed to ensure that the rights of patients were protected and promoted for three patients (P) (P#1, P#2, P#4) of four patients reviewed.

Findings included:

Cross- refer to A0144 as it relates to the facility's failure to provide care for in a safe environment for P#1 and P#2.

Cross -refer to A0385 as it relates to the facility's failure to ensure that nursing services adhered to the facility's policy and procedures related to restraints and seclusion for P#1 and P#4.

Based on a review of medical records, video surveillance, facility policies and procedures, and staff interviews it was determined that the facility failed to ensure the following:
1. Patient observation/monitoring was conducted as ordered and per facility policies for two (P#1 and P#2) of four sampled patients (P#1, P#2, P#3, P#4).

2. Signed physician's order for seclusion and physical restraint was documented for two patients (P#1 and P#4) of four (P#1, P#2, P#3, and P#4) sampled patients.

Findings included:

Cross -refer to A 0144 as it relates to the facility's failure to provide care to the patient in a safe setting when P#1 and P#2 were not visually observed as ordered.

Cross -refer to A 0398 as it relates to staff failure to adhere to policy and procedures related to restraints and seclusion for P#1 and P#4.

Based on review of medical records, video surveillance, policy and procedures, and staff interviews, it was determined that the facility failed to ensure that patients received care in a safe setting for two patients (P) (P#1, P#2) of four patients reviewed.
Specifically, video surveillance revealed that P#1 and P#2 were in a patient room with the door closed for approximately 46 minutes without a staff member opening the door to conduct visual observation. Further, P#1 had an active order for peer restriction and a blocked room (restricted from having a roommate), both patients (P#1 and P#2) were ordered to be observed at a minimum of every 15 minutes.

Findings included:

1. A review of P#1's medical record revealed that he was admitted to the facility on 4/29/25 with a diagnosis of disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outburst) and oppositional defiant disorder (a behavioral condition characterized by a pattern of uncooperative, defiant, and hostile behavior toward authority figures). A review of a "Progress Notes ," dated 4/30/25, a Registered Nurse (RN) note revealed that staff received complaints from patients about inappropriate behavior exhibited by P#1 including telling a female patient on the unit that he would "come to her room at night and do things to her". "Progress note" additionally revealed that P#1 also made "inappropriate comments."
A review of "Physician Orders" revealed that a peer restriction order and sexually acting out (SAO) precaution order was entered on 4/30/25, and signed 5/1/25 at 8:11 p.m.
A review of "Physician Orders," dated 5/1/25, revealed an order for observations to be conducted every 15 minutes.
A review of "Physician Orders," dated 5/2/25 at 10:30 a.m., revealed an order for P#1 to be on a blocked room (cannot have roommates).
A review of "Progress Notes," dated 5/2/25 at 11:33 p.m., revealed that during reflection time, a patient stated that P#1 sexually assaulted him. The nurse called the Medical Director (MD) AA who gave an order for a blocked room and sexual abuse precautions. P#1 was asked if he wanted to speak with a counselor, to which he replied, 'no'.

A review of "Progress Notes," dated 5/3/25 at 11:44 p.m., revealed that that a house supervisor contacted Registered Nurse (RN) BB that P#1 was alleging that he was sexually abused by P#2. The supervisor advised RN BB to call and get a transfer order to have P#1 transferred for a medical evaluation . A review of the "EMTALA Memorandum of Transfer-[Facility]," dated 5/3/25, revealed that on 5/4/25, at 4:00 a.m., P#1 was transferred by Emergency Medical Services (EMS) to a local facility for a medical assessment.

2. A review of P#2's medical record revealed a "Progress Note" dated 5/2/25 at 9:49 p.m. by RN DD that during reflection time, P#2 came out of his room and reported that his roommate (P#1) sexually assaulted him. RN DD notified Medical Doctor (MD) AA, who gave the order to block P#2's room and to place P#2 on a precaution for sexually acting out (SAO). RN DD offered, and P#2 accepted to speak with a counselor. RN DD notified the Chief Nursing Officer (CNO) and the Administrator On-Call (AOC). An order was given to transfer P#2 to an emergency room (ER) for an assessment. RN DD notified P#2's case manager (CM).
A review of an "Emergency Medical Treatment and Labor Act (EMTALA) Memorandum of Transfer," dated 5/2/25 at 11:18 p.m., revealed that P#2 was transferred via Emergency Medical Services (EMS) to an outside hospital for rectal bleeding.

A review of a "Progress Note," dated 5/3/25 at 4:03 p.m., revealed that a Registered Nurse (RN) contacted the receiving facility for P#2 and was informed that P#2 would not be returning to the facility. The receiving facility representative confirmed that a rape kit had been collected. The RN updated the Chief Nursing Officer (CNO), Risk Management, and Medical Doctor (MD) AA.
A review of a Discharge Summary dated 5/6/25 at 7:20 a.m. revealed that P#2 was transferred from the facility to an outside facility emergency room (ER) on 5/2/25 for complaints of rectal bleeding. Continued review revealed that on 5/4/25 at 2:00 p.m., P#2 was discharged from the facility due to being transferred and that P#2 would be sent to different facility for continuation of treatment.

A review of the facility's security video footage dated 5/2/25, beginning at time-stamped 5:44 p.m., revealed a hallway with P#1 and P#2's room #312 on the left side and the nurses' station across the right side of the hallway. P#1 and P#2 were identified and observed to be walking together back and forth from their room to the hallway and the nurse's station. P#1 and P#2 were observed interacting with staff and other patients in the hallway.
At 5:49:08 p.m., P#1 and P#2 were observed entering room #312, and closing the door.
At 5:50:44 p.m., P#1 and P#2 were observed peaking their heads out of the door, which remained ajar.
At 5:55:30 p.m., a patient wearing a blue shirt and long leggings was observed approaching room #312. She peaked her head inside the room but remained in the hallway.
At 5:56:13 p.m., the same patient was observed moving away from room #312's door and walking to the nurses' station. The door had been closed at this time.
At 5:56:37 p.m., the same patient returned to room #312 and was observed knocking on the door. No one opened the door, and the patient left.
At 6:03:16 p.m., BHA EE was observed walking with a tablet conducting observation rounds. P#1 and P#2 remained in room #312 with the door closed. BHA EE appeared to be documenting on the tablet. BHA EE was observed near the door to room #312 but not opening it.
At 6:19:13 p.m., BHA EE was observed walking with a tablet conducting observation rounds. P#1 and P#2 remained in room #312 with the door closed. BHA EE appeared to be documenting on the tablet. BHA EE was observed near the door to room #312 but not opening it.
At 6:30:38 p.m., BHA EE was observed walking with a tablet conducting observation rounds. P#1 and P#2 remained in room #312 with the door closed. BHA EE appeared to be documenting on the tablet. BHA EE was observed near the door to room #312 but not opening it.
At 6:42:09 p.m., the door to Room #312 was observed opening a couple of inches from the inside, and BHA EE was observed entering the doorway. BHA EE and P#1 and P#2 were observed leaving the room.
At 6:45:08 p.m., BHA EE was observed taking vital signs on patients in the unit. P#2 was observed speaking to Registered Nurse (RN) DD in the hallway. BHA EE soon joined them. During that time, P#1 was observed returning to room #312 and lingering in the doorway.
At 6:45:38 p.m., RN DD, BHA EE, and P#2 are seen walking down the hall and out of the camera's view.
At 6:52:00 p.m., RN DD, BHA EE, and P#2 return in view of the camera, and P#2 sat in a chair near the nurse's station. P#1 was observed speaking from the doorway #312 when RN DD points her finger at him. P#1 left the doorway and returned to room #312.


A review of the facility's policy titled "Rights and Responsibilities of Individuals," revealed that the purpose of the policy was to detail that the facility protects and promotes patient's rights that are extended to all patients.
Continued review revealed, Procedure, Patient Rights:
1. The following rights shall be afforded to all patients and are not subject to modification:
a. Patients have the right to be protected by the Hospital from neglect; from physical, verbal, and emotional abuse; and from all forms of misappropriation and/or exploitation.

During an interview on 5/14/25 at 11:00 a.m. in the conference room, Medical Doctor (MD) AA recalled a sexual assault allegation incident that happened on 5/2/25 in the evening and the on-call provider was contacted.
MD AA recalled that he was contacted due to the nature of the allegations. MD AA recalled that P#1 was supposed to be in a block room with precautions for sexually acting out (SAO) and peer restrictions. MD AA recalled that after learning about the incident, MD AA told staff to separate P#1 and P#2 and block their rooms, ensure both P#1 and P#2 are on SAO precautions, and alert the administrator on-call. MD AA said that P#1 was placed on peer restrictions and SAO precautions prior to the current incident due to making inappropriate sexual comments to a peer. MD AA recalled that the blocked room order was active for P#1, meaning that P#1 was not allowed to have a roommate and was unsure why P#1 was moved in with P#2.

A telephone interview was conducted on 5/13/25 at 3:17 p.m. with Registered Nurse (RN) DD RN DD recalled that on 5/2/25, she was the charge nurse on the Three South Unit. She recalled that Behavioral Health Assistant (BHA) EE approached her and explained that he wanted to change some patient rooms around because a patient sharing a room with P#2 wanted out of the room because of something P#2, said that was sexual in nature. She said she instructed BHA EE to make the changes he wanted, but to let her know who he moved when he was finished so she could update the bed board.
RN DD recalled that the unit was very busy that day, and BH EE was very busy, so after some time had passed, she had not asked for an update. RN DD said she recalled that P#1 was on a blocked room order and SAO precautions for a previous incident, but that BHA EE did not say he was going to move P#1. She continued to say that after the incident, she asked BHA EE why he moved P#1 into P#2's room when P#1 was on a blocked room order. BHA EE told her that he was not aware P#1 was on a blocked bed order because it was not on the tablet. RN DD explained that P#1 should not have been assigned a roommate because he was on a blocked room order.

RN DD recalled that that evening, P#2 came to speak with her regarding an incident in his room. She said P#2 explained that P#1 had put his penis into P#2's rectum and mouth and forced a pillow in his face and added that he was bleeding from his rectum.
BHA EE accompanied RN DD and P#2 to the bathroom so that she (RN DD) could physically assess P#2's injuries. RN DD explained that when she assessed P#2's rectum, she did not see any visible trauma or blood. She asked P#2 to wipe his bottom and saw no blood on the tissue paper. She then instructed P#2 to wipe again, and this time she and BHA EE would step out of the bathroom and allow him some privacy because he felt uncomfortable. She said when P#2 came out of the bathroom, there was a tiny spot of blood on the tissue. RN DD recalled P#2's initial history and physical (H&P), noting lacerations on his arm and his buttocks from an incident that had occurred at his previous facility. RN DD said she was unsure whether the blood on the tissue had come from those previous wounds or had come from his rectum. Nonetheless, she called the doctors, the AOC and the Director of Nursing and notified them of the incident. An order was placed to have P#2 transferred to a local hospital for a medical evaluation and treatment.
RN DD added that when staff spoke to P#1 about the incident, he began shouting that he was innocent, and that P#2 was a liar. She said P#1 maintained that nothing had occurred between the two boys until the next day, when the police questioned him about the incident. RN DD said both patients were separated until P#2 was sent to the local hospital.

RN DD said that the doors to patient rooms were to remain open while patients were in their rooms. The patients were all in their rooms because it was reflection time. During the day, patients were not allowed in their rooms, and the doors remained closed and locked. She added that when the BHAs conduct their observation rounds, they should observe the patient face to face because some questions require the BHA to see the patient to answer. Even when the patients are sleeping, BHAs must go into the room and stand close enough to observe three breaths to ensure that the patient is breathing.
RN DD acknowledged that nursing staff manage and supervise BHAs.

During a telephone interview on 5/14/25 at 12:30 p.m., BHA EE recalled the incident involving P#1 and P#2 on 5/2/25 because it occurred shortly before shift change. In addition, the shift had been hectic because one of the BHA's working on the unit had been re-assigned to another unit which left him alone with a lot of high acuity patients.
BHA EE stated that he knew P#1 and #2 were behind closed doors. BHA EE explained that because earlier, they had been fighting, arguing with another patient, throwing water at one another and shouting, he did not want to excite them further by going into their room to conduct observation rounds.

BHA EE explained that on 5/2/25, P#2 had been roomed with another patient. Throughout the day, his roommate complained that P#2 was making homosexual comments towards him and making him uncomfortable. The other patient wanted to be moved out of the room. BHA EE recalled that he moved P#2's former roommate to a different room further down the hallway. BHA EE continued to explain that during that time, P#1 requested to be moved into P#2's room, and BHA EE granted P#1 permission to move into P#2's room. He added that at the time, he was unaware that P#1 was on blocked bed orders, which meant that that patient cannot be roomed with another patient. He added that the charge nurse would tell which patients were on these orders during the shift huddle. Sometimes that information was also shown on the bed board On 5/2/25, BHA EE was unaware of the order because the blocked bed did not appear on the tablet for P#1. So, unless it was discussed, he could not know if a patient had a blocked bed order.
BHA EE said the assistants can make patient room changes without permission, and the charge nurse usually updated the bed board to reflect the changes.

BHA EE continued to say that the facility's policy was that patient doors remained open except for bedtime, when patients are in the room. Some patients cannot sleep when the door was open request that the door be closed. In this case, staff placed a towel on the top corner of the door to prevent it from closing all the way and latching, was mostly closed. BHA EE explained that with a peer restriction order patients were not allowed to be in a room with other patients but can remain interacting with their peers in the unit. He could not recall if P#1 had been on a peer restriction order. BHA EE explained that when conducting observation rounds, the tablet used interacts with a Bluetooth beacon in the patient's armband and automatically populates the information into the tablet. The questions he must answer require him to see the patient face-to-face unless they are in a restroom. In this case, allowing the Bluetooth beacon to document the observation without conducting the face-to-face portion would be acceptable.

Based on a review of medical records, facility policy and procedures, and staff interviews, it was determined that the facility failed to ensure that nursing services adhered to established policies and procedures for two (P#1, P#4) of four patients reviewed when:

1. P#1's medical record failed to reveal a physician's order, patient monitoring, and post-seclusion debriefs per facility policy for a seclusion incident that occurred 5/3/25.

2. P#4's medical record failed to reveal a physician's order for a physical restraint on 3/19/25.

Findings included:

1. A review of P#1's medical record revealed that he was admitted to the facility on 4/29/25 with a diagnosis of disruptive mood disorder (a condition in which children or adolescents experience ongoing irritability, anger, and frequent, intense temper outburst) and oppositional defiant disorder (a behavioral condition characterized by a pattern of uncooperative, defiant, and hostile behavior toward authority figures). A review of P#1's "Seclusion/Restraint One Hour Face to Face Assessment," dated 5/3/25, revealed that physical, chemical, and seclusion restraints were initiated for P#1 for aggressive behavior from 12:25 p.m. until 12:35 p.m. A review of the "Behavioral Health-Patient Observation Sheet," dated 5/3/24 from 12:25 p.m. through 1:25 p.m., failed to reveal documented observations of P#1 while he was in the seclusion room. Further review failed to reveal evidence of a post seclusion debriefing documentation related to P#1's seclusion intervention.

A review of P#1's "Discharge Summary," dated 5/3/25, noted that at approximately 12:20 p.m., P#1 was heard yelling from the group room and was brought out by staff for being combative, aggressive, and physically and verbally abusive. The provider was notified, and P#1 was placed in a seclusion/restraint at 12:25 p.m. The provider ordered an intramuscular injection at 12:31 p.m., and P#1 tolerated it well. P#1 was taken out of the seclusion room at 1:10 p.m. Further review of P#1's medical record failed to reveal a physician's order for seclusion on 5/3/25.

2. A review P#4's "Seclusion/Restraint One Hour Face to Face Assessment", dated 3/19/25 at 7:56 a.m., a Registered Nurse (RN) noted that P#4 was in a restraint hold due to being verbally and physically aggressive at 3:35 a.m., a face-to-face assessment was conducted at 3:50 a.m. A continued review revealed that the restraint had been discontinued prior to the face-to-face assessment. A review of P#4's medical record failed to reveal a provider's order for restraints on 3/19/25.


A review of the facility's policy titled, "Seclusion and Restraint", #CTS-031, last reviewed 11/2024, revealed that the purpose of the policy was to provide guidelines for the use of seclusion or restraints in emergency situations to ensure the patient's and/or other's safety. Seclusion or restraint shall be considered and emergency management intervention when a patient demonstrates an overt and immediate threat of harm to self or others, and when less restrictive interventions have been attempted and proven unsuccessful.
Continued review revealed, F, The Use of Seclusion:
1. Document the use of seclusion in the medical record including observable behavior and least restrictive methods employed.

Continued review revealed, G, The Use of Restraints:
1. Document the use of restraints in the medical record including observable behavior and the least restrictive methods employed.
2. Restraints are used upon the written or verbal order of a physician. A registered nurse, after personally observing the patient may initiate restraint if he/she is clinically satisfied and the use of restraint is justified. A physician shall confirm orders written by a registered nurse within one hour. When the order for seclusion expires, the patient is re-evaluated by a physician, Licensed Independent Practitioner (LIP), or registered nurse via direct observation.
3. The restraint order should specify:
a. The length of time is authorized for up to two hours for adolescents ages nine to 17 years.
b. Purpose of restraint.
c. Precipitating events leading to need for restraint/clinical justification.
d. Close observation will be by continuous in-person monitoring.
e. Criteria for discontinuing seclusion.

Continued review revealed K, following every seclusion or restraint episode, the staff will have two debriefings. The patient and family, if possible and appropriate, participate in one meeting. The staff will also debrief separately. The purpose of the debriefing is to: identify what led to the incident and what could have been handled differently, ascertain that the patients' physical and well-being, psychological comfort, and the right to privacy were addressed; and counsel the patient from any trauma that may have resulted from the incident.

Continued review revealed, Procedure, B, Restraint, Assigned Staff:
6. If the patient is an adolescent notify the parent/guardian of the initiation of restraint.
7. Monitor the patient through in-person, continuous observation and document every fifteen minutes.
11. After the patient is released from restraints, staff will debrief with the patient.
12. Staff debriefing may take place prior to or after debriefing with the patient.
14. All restraint episodes must be logged into the Restraint/Seclusion Log.

A telephone interview was conducted on 5/13/25 at 3:17 p.m. with Registered Nurse (RN) DD. RN DD. She said that a Behavioral Health Assistant (BHA) will stand at the seclusion door for the duration of the seclusion to ensure continuous face-to-face observation of the patient and that observations should be documented every 10 to 15 minutes while the patient is in seclusion. RN DD said that when a patient was placed in a physical restraint or seclusion, an order must be in the electronic medical record (EMR).

During an interview on 5/14/25 at 11:00 a.m. with Medical Doctor (MD) AA in a conference room, MD AA stated that he is the facility's Medical Director. He added that when a patient is placed in seclusion, an initial assessment of the patient should be documented, and a debriefing should be documented when the patient is removed from seclusion. MD AA continued to explain that a BHA is assigned at the seclusion room door when a patient is in seclusion. They must apply pressure to the door handle while the patient is in the room to maintain continuous face-to-face observation until the patient is released from seclusion. The individual observing the patient is supposed to document the observations. He was unsure of the frequency with which observations are to be documented.

A telephone interview was conducted on 5/14/25 at 12:30 p.m. with Behavioral Health Assistant (BHA) EE.BHA EE stated that when a patient is placed in seclusion, a technician will stand at the door and apply pressure to the handle to ensure that the door remains locked, and that continuous face-to-face observation of the patient is conducted. He explained that he believes he is supposed to document his observations of a patient in seclusion but was unsure of the frequency. He explained that he's heard it's every 15 minutes, but he's not sure because he's also heard that it's every hour, but he thinks he should document seclusion observations hourly.

A telephone interview was conducted on 5/14/25 at 12:41 p.m. with Registered Nurse (RN) FF. RN FF could recall hearing yelling coming from the group room, and staff were unsuccessful in de-escalating the situation with P#1 and had to remove him from the group room. A code purple was called, and when RN FF responded to the code, she recalled seeing that a BHA and the supervisor had placed P#1 in a physical hold by holding his arms, and the provider, who was present, gave RN FF verbal orders for a chemical restraint. RN FF said she went to the medication room, drew the medication, and put the orders in the electronic medical record (EMR).
When she came back to where the patient was, he had already been moved to the seclusion room, and the supervisor took the medications and went down to the seclusion room to administer them to P#1.
RN FF recalled that when she conducted the one-hour face-to-face assessment, P#1 would not speak and eventually fell asleep, and she could not debrief him when he was taken out of seclusion. She could not recall if she documented any information related to the debriefing in the EMR. She explained that when patients come out of seclusion, they are supposed to be debriefed twice. The first debriefing includes asking the patient about the incident and the intervention. The second debriefing does not involve questioning the patient but observing them in the environment after they have been removed from seclusion. She added that the debriefings are supposed to be documented in the EMR. RN FF explained that when a patient is in seclusion, a BHA is always present, providing continuous face-to-face observation, and the BHA should document these observations every five minutes.