HospitalInspections.org

Based on policy and procedure review, Medical Staff Bylaws, Rules and Regulations, medical contract, video camera review, staffing census sheets, credentialing file reviews, on-call schedule review, medical record review and staff interviews, the hospital's governing body failed to provide oversight and have systems in place to ensure medical staff provided quality care and practiced within their approved privileges; ensure the protection and promotion of patient's rights to provide a safe environment that was free from abuse and neglect for behavioral health patients; failed to have an organized nursing service to supervise and meet patient care and safety needs; and failed to demonstrate and document the degree and intensity of the individualized treatment provided to behavioral health patients.

The findings include:

1. The hospital failed to provide a medical consultation for a patient with a suspected injury in 1 of 14 sampled patients with medical consultation orders (Pt #30).

~cross refer to 482.12(a)(5) Governing Body - Medical Staff Accountability: tag A0049

2. Hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications for 7 patients involved in an incident on 12/22/2024 (Pt #5, 21, 3, 6, 20, 4 and 19).

~cross refer to 482.13(c)(2) Patients' Rights - Care in a Safe Setting: tag A0144

3. Hospital staff failed to prevent verbal abuse to patients by hospital staff for 1 of 1 sampled medical records ( Pt #52).

~cross refer to 482.13(c)(3) Patients' Rights - Free from Abuse/Harassment: tag A0145

4. Hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications for 7 patients involved in an incident on 12/22/2024 (Pt #5, 21, 3, 6, 20, 4 and 19).

~cross refer to 483.23(b)(3) Nursing Services - RN Supervision of Nursing Care: tag A0395

5. Hospital leadership failed to ensure Advanced Practice Providers (APPs) provided age-specific care and treatment based on their delineated privileges for 4 of 4 APP credentialing files reviewed (Staff #27, Staff #28, Staff #29, Staff #4).

~cross refer to 483.22 Medical Staff: tag A0339

6. The medical staff failed to conduct reappraisals of appointment and privileges granted for 2 of 6 sampled credentialing files reviewed (Staff #29, Staff #4).

~cross refer to 483.22 Medical Staff: tag A0340

7. The hospital failed to ensure that medications were kept in a secure area.

~cross refer to 483.?? Pharmaceutical Services: tag A0502

8. Hospital staff failed to ensure a Master Treatment Plan was completed and/or updated for 21 of 72 medical records reviewed (Pt #34, #35, #39, #52, #54, #59, #44, #46, #19, #40, #24, #26, #10, , #39, #12, #25, #28, #31, #14, #68 and #16).

~cross refer to 482.61(c)(1) Treatment Plan: Tag A1640

9. Hospital staff failed to ensure short-term and long-range goals were completed and/or updated for 8 of 72 medical records reviewed (Pt #12, #31, #32, #25, #29, #28, #14 and #38).

~cross refer to 482.61(c)(1)(ii) Treatment Plan - Goals: Tag A1642

10. Hospital staff failed to ensure a Master Treatment Plan with specific treatment modalities were completed and/or updated for 8 of 72 medical records reviewed (Pt #12, #31, #32, #25, #29, #28, #14 and #60).

~cross refer to 482.61(c)(1)(iii) Treatment Plan - Modalities: Tag A1643

11. Hospital failed to ensure treatment team responsibilities were completed for 11 of 72 medical records reviewed. (Pt #12, #31, #32, #25, #29, #28, #14, #59, #54, #38, and #9).

~cross refer to 482.61(c)(1)(iv) Treatment Plan - Team Responsibilities: Tag A1644

12. Hospital staff failed to document daily group therapy for 4 of 72 medical records reviewed (Pt #52, #35, #34, #33).

~cross refer to 482.61(c)(2) Document Therapeutic Efforts: Tag A1650

13. Hospital staff failed to ensure Social Services Progress Notes were completed for 11 of 72 medical records reviewed (Pt #34, #35, #54, #9, #10, #30, #39, #67, #25, #28, #16).

~cross refer to 482.61(d) Recording Progress Notes: Tag A1655

14. Hospital failed to ensure patients received follow up appointments and prescriptions prior to patients being discharged for 3 of 59 sampled closed medical records (Pt #60, #68, #36).

~cross refer to 482.61(e) Discharge Summary - Recommendations: Tag A1671

Based on review of Medical Staff Bylaws, Medical Staff Rules and Regulations, medical contract, hospital policy, medical record, and staff interviews, the hospital failed to provide a medical consultation for a patient with a suspected injury in 1 of 14 sampled patients with medical consultation orders (Pt #30).

The findings include:

Review on 01/28/2025 of Medical Staff Bylaws adopted 01/29/2024 revealed, " ...Basic Responsibilities of Medical Staff Membership... F. To work cooperatively with other medical staff members, nurses, and allied members of the professional staff, facility administration, and all others involved in the patient care, so as not to affect patient care adversely; and to assure that each patient is provided with the same level and quality of patient care... "

Review on 01/28/2025 of Medical Staff Rules and Regulations, revised on 04/2024, revealed, " ...10. Medical/Psychiatric Consultations...10.2 Progress notes must provide the reason for the consultation, a written opinion by the consultant, and recommendations for further care ... 10.6 A satisfactory consultation includes examination of the patient and the medical record. A progress note and formal report, signed by the consultant, must be included in the medical records ... "

Review on 01/28/2025 of "Collaborative Practice Agreement, Advanced Practice Provider" (APP) revealed, " ... 4. Medical Treatments, Tests, and Procedures ... a) Perform a comprehensive, age-appropriate examination of the patient based on the reason for the visit (to include gathering subjective and objective data related to chief complaint, history of present illness, past medical history, review of systems, family and social history, and current medications) ... d) Record progress notes as indicated ..."

Review on 01/28/2025 of hospital policy "Documentation Requirements In The Medical Record," last revised 11/2023, revealed, "... Medical Staff (Physicians) ... 10. Consultation reports should contain a written opinion by the consultant that reflects an actual examination of the patient and a review of the medical record and should be completed within twenty-four (24) hours... Physician Assistants/Family Nurse Practitioners... 4. Subsequent documentation regarding medical records and/or follow-up is to be documented in the progress notes... Progress Notes 1. The Progress Notes are integrated and each discipline documents in chronological order, events as they occur... Progress Note entries are to address the problem, evaluation, assessment/findings and therapeutic plan as appropriate..."

Closed medical record review on 01/14/2025 for Patient #30 (Pt) revealed a 14-year-old patient voluntarily admitted on 05/24/2024 for disruptive mood dysregulation (a disorder characterized with ongoing irritability, anger, and frequent, intense temper outbursts) and oppositional defiant disorder (a disorder characterized by uncooperative, defiant, and hostile behavior to authority figures). Pt #30 endorsed high risk behaviors including running away from home, was gone for eight days, and had been using marijuana. Nurse Progress Note on 07/06/2024 at 2300 revealed, Pt #30 became triggered by her peers and began to strike the wall of the day room with her right hand. Pt #30 complained of right hand pain but had good range of motion; no redness or bruising was noted. "Tylenol PO (oral) times two" (no dosage specified) was administered for pain. Nurse Progress Note on 07/07/2024 at 0745 revealed, Pt #30 complained of 7 out of 10 pain (0 being no pain and 10 being the highest level of pain) to her right hand with slight swelling noted to her fifth digit and palm of her hand but refused pain medications at that time. A medical consultation (consult) order was placed for right wrist/hand pain on 07/07/2024 at 0803 by Staff #27 and electronically signed by Staff #3 on 07/08/2024 at 0906. Pt #30 was discharged home on 07/18/2024. Record review failed to reveal documentation of a medical consult being completed or any progress notes related to a medical consult.

Interview on 01/27/2024 at 1313 with Staff #31 revealed there was no consult or notes that Staff #31 could locate regarding Pt #30's medical consult order.

Interview on 01/27/2025 at 1505 with Staff #18 revealed when a medical consult order was placed, a copy was automatically printed to the medical providers' office/copier. Staff #18 revealed they would then have 48 hours to complete the consult, but typically patients were seen within 24 hours. Staff #18 revealed Pt #30's order was "incorrectly" placed, as the medical Providers could not consult themselves; it would need to be ordered by Staff #3 instead. Staff #18 revealed Staff #27 should have contacted Staff #3 to follow-up on this medical consult, and if it was still needed, the consult would have to be re-ordered "correctly" and then the patient would be seen.

Telephone Interview on 01/28/2025 at 1000 with Staff #27 revealed Staff #27 worked part-time covering medical consults and would be on-site during the day when covering consults, including the weekends. Staff #27 covered all populations/campuses (adult and children) when on-call or on-site for medical consults. Staff #27 revealed an order would be placed for the patient who needed a consult, and the patient would typically be seen the same day. If Staff #27 was no longer on-site, the staff could call for a consult, and directives would be given to Nursing over the phone, or if it was urgent, Staff #27 would direct Nursing to send the patient to the ED (Emergency Department). Staff#27 did not recall Pt #30 and could not recall if a consult had been completed for Pt #30.

Based on policy and procedure review, video camera review, staffing census sheets, medical record review and staff interviews, the facility failed to protect and promote patients' rights by neglecting to ensure a safe environment for the delivery of care to adolescent behavioral health patients with a known history of aggression. Seven (7) adolescent female behavioral health patients were involved in an incident on December 22, 2024, which required police intervention and transfer of patients to an acute hospital. Hospital staff failed to honor patient's rights by not notifying patients legal guardians about treatment decisions, injuries and aggressive incidents; failing to ensure contraband was not accessible to patients; and failing to prevent verbal abuse from staff.

The findings include:

1. Hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications for 7 patients involved in an incident on 12/22/2024 (Pt #5, 21, 3, 6, 20, 4 and 19).

~cross refer to 482.13(c)(2) Patients' Rights - Care in a Safe Setting: tag A0144

2. Hospital staff failed to honor patient's rights by failing to establish legal guardianship identification, notify a patient's legal guardian of treatment decisions, patient injuries, altercations, and timely notification of an elopement for 5 of 72 sampled patient records reviewed (#9, 10, 35, 43, 11).

~cross refer to 482.13(b)(2) Patients' Rights - Informed Consent: tag A0131

3. Hospital staff failed to ensure safety requirements were met by failing to remove and prevent patient access to contraband items used to perform self harm in 2 of 2 sampled patients (Pt #30, #28).

~cross refer to 482.13(c) Patients' Rights - Privacy and Safety: tag A0142

4. Hospital staff failed to prevent verbal abuse to patients by hospital staff for 1 of 1 sampled medical records ( Pt #52).

~cross refer to 482.13(c)(3) Patients' Rights - Free from Abuse/Harassment: tag A0145

Based on review of hospital policies, medical records and staff interviews, hospital staff failed to honor patient's rights by failing to establish legal guardianship identification, notify patient's legal guardian of treatment decisions, patient injuries, altercations, and timely notification of an elopement for 5 of 72 sampled patient records reviewed (#9, 10, 35, 43, 11).

The findings include:

Review on 01/13/2025 of hospital policy, "Assessment and Admissions Process," last reviewed on 03/2022 revealed, "... An authorization for treatment is obtained by the patient or legal guardian at the time of admission...4.2.6 In the event a patient identifies that he/she has a legal guardian, the Admissions Specialist shall attempt to notify the legal guardian, notating the notification on the Admissions Assessment...5.0 The Admissions Specialist verbally reviews and completes all admission documents with the patient or guardian. 5.1 The patient or guardian acknowledges admission by signing the Consent for Treatment and Conditions of Admission..."

Review on 01/09/2025 of hospital policy, "Discharge Planning," last reviewed on 10/2022 revealed, "... 2. The Therapist/Case Manager discusses discharge options with the patient and legal guardian, if applicable...3. Reviews preliminary discharge plan and discharge criteria with patient and guardian (if applicable). 4. Obtains the patient's or legal guardian (if applicable) signature on a Release of Information for the provider who the patient will see after discharge... Discharge Process. Talk to patients and guardians about taking copies of the discharge plan to their first appointments. Safety Crisis Plan completed with patient and family/support person. A copy provided to the patient, support person, and for the medical record..."

Review on 01/23/2025 of hospital policy "UNTOWARD EVENTS - INFORMING FAMILIES," last reviewed 01/2020, revealed, "... If the patient (both adults and children) has a legal guardian, they will be notified of significant untoward events. Significant untoward events include:...2. Elopement...Procedure ... 3. The nurse will contact the family as quickly as possible. If unable to contact, repeated attempts will be made and so documented in the patient's medical record. 4. All attempted and actual contacts with the family will be documented in the patient's medical record."

1. Closed medical record review on 01/09/2025 for Pt #9 revealed a 32-year-old patient who was involuntarily committed on 05/11/2024 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave) and increased aggression (violent attacking behavior or attitude toward another person) with staff at his group home. Review of paperwork sent from Facility B revealed, Pt #9 had a legal guardian. Admissions High Risk Notification Alert on 05/11/2024 at 2113 revealed, "Adult with Legal Guardian: No." The Interdisciplinary Master Treatment Plan (MTP) was signed by the Treatment Team (Nurse, Therapist, and Nurse Practitioner) on 05/14/2024, and the patient and/or guardian signature was blank. Comprehensive Clinical Assessment at 1733 revealed the section titled, Patient is in the Custody of: with check boxes for self, parent, legal guardian, or other, was blank. Assessment of Family/Support Attitudes indicated Pt #9 did not provide permission for contact with family/support person. Social Services Progress Note at 1740 revealed Pt #9 had some social concerns and would need social resources post-discharge for housing and mental health. Review failed to reveal evidence of any follow-up, additional Social Services Progress Notes, or discussion with Pt #9's legal guardian. Discharge Safety Plan was initiated on 05/17/2024 at 1545 and revealed, "Were family, friends, or caregivers of the patient invited to participate?" with a yes or no checkbox, was blank. Pt #9 was discharged to a shelter on 05/20/2024. Record review failed to reveal evidence of verification of Pt #9's legal guardian.

Interview on 01/15/2025 at 1118 with Staff #34 revealed in May 2024, an outside source was reviewing paperwork from other facilities in admissions, and they should have notated on the High Risk Notification form if there was a legal guardian and then try to contact the guardian. Staff #34 revealed, "it's our due diligence to check and confirm legal guardians" as patients were not always reliable and could present as psychotic. Staff #34 revealed based off observation, Pt #9 had slight IDD (intellectual or developmental disability), but it was not documented, and Pt #9 needed social resources, such as housing and employment. Staff #34 acknowledged there was no documentation in Pt #9's medical record regarding the patient going back to his group home and no information regarding verification of a legal guardian.

Interview on 01/17/2025 at 0931 with Staff #39 revealed it was admissions' responsibility to verify a patient's legal guardian, especially if there was a discrepancy in paperwork from other facilities and their admissions paperwork. Staff #39 revealed a third party group was previously reviewing paperwork in May 2024, but there were a lot of discrepancies with them, and their contract was ended on 12/31/2024. Staff #39 revealed this group was primarily determining if a patient met criteria for admissions. Staff #39 revealed, with the previous process, it could have fallen through the cracks for determining Pt #9's legal guardian.

2. Closed medical record review on 01/09/2025 for Pt #10 revealed a 27-year-old patient who was involuntarily committed on 10/25/2024 with a diagnosis of schizophrenia with aggressive behaviors and homicidal ideations (HI - harming others). Admissions High Risk Notification Alert on 10/25/2024 at 1345 revealed, "Adult with Legal Guardian: Yes," with handwritten name and phone number listed. History & Psychiatric Evaluation completed on 10/25/2024 at 1400 revealed a voicemail was left with (name, phone number), they were unable to reach the legal guardian, and home medication would be continued at that time. Pt #10 was administered a chemical restraint (medications given to control a patient's behavior) on 10/26/2024 at 0958 for combative, threatening, aggressive, and destructive behaviors. Notification to family/guardian was marked as "No" on the restraint paperwork. A Nursing Note related to this incident revealed, Pt #10 "does not have legal guardian." Daily Nursing Progress Note at 1130 revealed, Staff #40 contacted (name, phone number) who from their documents was indicated as the legal document, but (named) stated they were not the legal guardian and provided the name and phone number of Pt #10's case manager. Comprehensive Clinical Assessment on 10/28/2024 at 1045 revealed Pt #10's case manager was contacted at 0947, but the Assessment of Family/Support Attitudes related to baseline, concerns, and goals was blank. Integrated Summary and Recommendations revealed Pt #10 reported having a social worker/case manager, and the tentative discharge plan was to discharge to his past residence or find another placement if he could not return. The Interdisciplinary Master Treatment Plan (MTP) was signed by the Psychiatrist, Therapist, Nurse, and Pt #10 on 10/28/2024, and the legal guardian phone review section was blank. A consent for psychotropic medications (medications used to treat mental health conditions) was signed by Staff #44 on 11/01/2024 and noted phone consent by a "new legal guardian." Discharge Summary: Disposition and After Care on 11/05/2024 revealed, no disposition or aftercare follow-up appointment was found in the chart. Pt #10 was discharged on 11/05/2024. Social Service Progress Note on 11/05/2024 at 1600 revealed Pt #10 was discharged around 1600 and prior to discharge, the group home was contacted for transportation, but they had not yet left to pick up Pt #10. Staff #35 offered to provide cab transportation to expedite discharge, which was approved by the (named) group home manager. At approximately 2100, (named) group home manager contacted Staff #35 that Pt #10 had not arrived at the group home. Staff #35 then spoke with the cab company who informed them that Pt #10 became threatening, aggressive, and exited the vehicle. Staff #35 contacted (named county) Sheriff and then contacted Pt #10's legal guardian and left a message. Record review failed to reveal evidence of discussion with Pt #10's legal guardian regarding treatment and discharge plans, including the change in transportation.

Interview on 01/10/2025 at 1014 with Staff #8 revealed the Therapists should contact patients' legal guardians and go over all the paperwork with them. Staff #8 revealed it might take a couple days to establish who the legal guardian was, and they should reach out to the House Supervisor if they were unable to contact a legal guardian. Staff f#8 was unsure when the legal guardian was correctly identified for Pt #10. Staff #8 revealed the legal guardian should have been contacted for Pt #10's chemical restraint. Staff #8 revealed Staff #35 had been in contact with Pt #10's legal guardian but acknowledged the discharge paperwork was not in the medical record to verify who was contacted.

Interview on 01/15/2025 at 1447 with Staff #46 revealed there was not a specific process in admissions to properly verify a patient's legal guardian. Admissions would request this information from the sending facility, but there were instances where it was not sent to them and they used what they had, such as the patient themselves. Staff #46 revealed, this could often be confusing, and admissions was not informed after the fact if there were any issues or changes with the legal guardian.

Staff #35 no longer worked at the facility.



50111

3. Closed medical record review on 01/15/2025 for Patient #35 (Pt) revealed a 44-year-old male admitted to the hospital on 09/25/2024 at 2308 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and a secondary diagnosis of autism (a lifelong developmental disability). Record review revealed Pt #35 had a legal guardian. Review of the Nurse Note on 09/26/2024 at 0530 revealed, "0445 AM patient was punched by the roommate ... The current patient sustained facial injuries: Bridge of the nose, a bruise in the upper side of the eye. Scratches were noted on the patient (sic) right nares. First Aid provided. Roommate was moved to a different room. Supervisor and attending were notified ..." Review of the Medicine Consult Note on 09/26/2024 at 1440 revealed, "... Blunt head trauma w/ (with) injuries appreciated w/ swelling of nasal bridge. XR (X-Ray - an imaging technique used to obtain pictures inside the body) facial ordered ..." Review of the Radiology Report on 09/27/2024 at 1307 revealed, "No acute fracture or dislocation." Medical record review failed to reveal documentation of legal guardian notification of Pt #35's injury. Pt #35 was discharged home on 10/10/2024 at 1420.

Interview on 01/17/2025 at 0900 with Staff #9 revealed there was no documentation in Pt #35's medical record that the legal guardian was notified of Pt #35's injury.

Interview on 01/21/2025 at 1506 with Staff #17 revealed Staff #17 did not recall notifying the legal guardian of Pt #35's injury. Interview revealed the legal guardian should have been notified immediately after the event occurred. Staff #17 revealed the nurse was responsible for notifying the legal guardian and the notification should have been documented in a progress note.

Interview on 01/24/2025 at 1300 with Staff #21 revealed Staff #21 did not notify the legal guardian of Pt #35's injury. Interview revealed nursing staff was responsible for legal guardian notification of injuries.

Staff #26 was not available for interview.



47421

4. Review of hospital policy titled "REPORTING AND INVESTIGATING PATIENT NEGLECT, ABUSE AND EXPLOITATION" last reviewed 03/31/2023 revealed, " ...Employee Reporting Procedure ...8. In the case of a minor or adult with legal guardian, the patient's parent or legal guardian should be notified of the incident by the appropriate personnel..."

Closed medical record review of Patient #43 revealed a 16-year-old male voluntarily committed to the 1 South unit on 09/13/2024 for suicidal ideation (SI). Record review revealed a past history of anxiety and autism. Review of Provider Orders revealed the patient was admitted with self-harm precautions, suicide precautions, and Q (every) 15-minute monitoring. Review of a nursing note on 09/14/2024 at 1100 revealed "(named patient) instigated fight with peer. He was punched in the face. No safety hold, emergency meds or injuries ... Consents needed for scheduled meds. Unable to reach guardian x2 (times 2). LMVM (left message voicemail) to return call." Review of the Discharge Summary on 09/15/2024 at 1228 revealed " ... (named patient) was involved in multiple altercations on his first and second day on the unit at which point, father requested that (named patient) be allowed to discharge on 09/15/2024 instead of 09/16/2024 as discussed with nurse practitioner ..." Review of Authorization To Contact Family Members And Disclose Information For Treatment Purposes form revealed the patients named father and phone number was listed. Record review revealed on 09/15/2024 the patient discharged home with family.

Interview on 01/15/2025 at 1100 with Staff #16 revealed that Staff #16 attempted to call the guardian but was unsuccessful and left a voicemail for the guardian to call back. Staff #16 did not recall if the patient's guardian called back or if the guardian was informed of the incident. Interview revealed there was no documentation of when or if the guardian was informed of the altercation.



51294

5. Review on 01/10/2025 of hospital policy "Elopements: Prevention and Response," last reviewed on 06/28/2021, revealed, "...Response to Elopement- In the event an elopement occurs, the following steps will be taken:...k. Family members/ significant others authorized by the patient's consent to access information regarding his/her admission may be notified about the patient's elopement and subsequent discharge."

Closed medical record review on 01/10/2025 for Patient #11 revealed a 16-year-old female admitted to the hospital on 06/24/2024 at 1124 as an IVC (Involuntary Commitment) with a diagnosis of mood lability (rapid and excessive changes in mood) with homicidal ideations (thoughts or plans to kill others). Patient #11 had a diagnosis of Disruptive Mood Dysregulation Disorder (Mood disorder characterized by anger and frequent, intense temper outbursts). Record review revealed Pt #11 had a legal guardian. Review of the Standardized Intake Assessment dated 06/24/2024 at 1200 revealed, "...Impulsive/aggressive tendencies...Patient's Risk Summary: Patient threatening family, to kill grandparents and harm others...Demanding to leave..." High Risk Notification Alert form dated 06/24/2024 at 1215 revealed "...Elopement Risk:...Active...Physician notified 1215." Initial nursing assessment dated 06/24/2024 at 1300 revealed, "...Arrived to unit belligerent- limited cooperation with admission process. Refused to answer many questions per report...Elopement/Aggression precautions in place. Unable to update parent at this time." According to the Social Services Progress Note, signed 06/26/2024 at 1440) "...06/24/2024- Therapist went to the code walker admission with MHT...when code was heard over the intercom. Therapist and MHT (Mental Health Tech) went on foot trying to see if they could find the patient but the therapist did find her blue scrub top. MHT and therapist seen (sic) (Patient #11) cross the street and the RN (Registered Nurse) picked them up and they all went across the street to make sure she was safe...therapist was able to speak with (patient # 11) to keep her calm and listen to her concerns ...(Patient #11) agreed to ride with therapist...in the van back to the facility...6/25/2024...Therapist spoke with mom regarding behaviors and functioning at home." According to Daily Nurse Progress Note dated 06/24/2024 at 1530, " ...Admitted to unit...Unit orientation complete. Unable to speak to parent at this time." Nursing note dated 06/24/2024 at 1930 revealed, "...Mother updated and gave consent for medication for duration of stay..." According to Daily Nurse Progress notes dated 06/26/2024 at 1132, the patient was on elopement precautions.

Medical record review failed to reveal documentation of timely legal guardian notification of patient #11's elopement. Pt #11 was discharged home on 06/27/2024.

Incident report dated 06/24/2024 at 1205 (but marked as date received 06/26/2024) revealed, "...On 6/24/2024 at approximately 12:00 PM an IVC adolescent who was waiting in the intake/assessment area asked to use the restroom. The staff member allowed the patient through the locked door to use the restroom in the lobby area. During her time at the restroom, the patient pushed a staff member who was exiting the building to the floor and ran out of the facility through the front door lobby. The patient ran through the parking lot and crossed the street. Staff called 911 for assistance per policy. Staff followed the patient to maintain her safety. The patient attempted to enter the car of a passerby and staff intervened to prevent her from entering the car of a stranger. The patient began hitting and kicking staff and was placed in a hold per CPI (Crisis Prevention Institute) standards to maintain safety. Staff were able to calm the patient and then released the hold. Staff were able to talk to the patient and she agreed to return to the facility via the hospital van. Patient was returned to safety within 15 minutes of the elopement. Police were called to cancel the assistance call. The patient was admitted directly to C1 North unit (female adolescent unit) and assessed for injury...The patient's mother was called subsequently to report the incident."

Interview on 01/13/2025 at 1700 with Staff #20 revealed that no video footage of the elopement of Patient #11 was available.

Interview on 01/14/2025 at 1202 with Staff #82, when asked about documentation in the chart with reference to notification of Patient #11's elopement they stated, "I could not find anything. I found references to talking to family but not a time."

Interview on 01/23/2025 at 1500 with Staff #47 revealed, "Two to three hours after they got her back, I asked if I needed to call the legal guardian. I was told my boss was going to handle it by the House Supervisor. I called my boss and was told they would call the parent...I don't know who and when they called the parent." When Staff #4 7 and the physician called the legal guardian the next day, Staff #47 explained what happened from their perspective. Staff #47 stated that the parent was "upset that they were not told, their issue was that they weren't told timely."

Interview on 01/23/2025 at 1750 with Staff #51 revealed, "I was at the front desk, it was a real busy day, I was working alone with nine patients in the waiting area...I was busy with a patient and she (Patient #11) started running to the front door, knocked a lady down and she was out the front door. It happened so fast." Staff #51 stated that changes have been made since the elopement and once patients come through the lobby they go back into the secured area and do not pass through the lobby to go to the bathroom. Staff #51 further stated that the sheriff will stay with them until the patient gets to the secure area in the back. Staff #51 further stated that the current practice is to have two staff members available instead of just one as had been the case on the day of the elopement.

Staff # 16 who completed the initial nursing assessment was not available for an interview.

Based on hospital policy review, medical record reviews, and staff interviews, the hospital staff failed to ensure safety requirements were met by failing to remove and prevent patient access to contraband items used to perform self harm in 2 of 2 sampled patients (Pt #30, #28).

The findings include:

Review on 01/16/2025 of hospital policy "Contraband Search Guidelines," last reviewed on 05/2022 revealed, " ... All patients will have their belongings searched for potentially hazardous items by facility staff upon arrival to their assigned unit ... I. Belongings Management and Search ... 10. Items considered hazardous/contraband include, but are not limited to: ... sharp objects including scissors, knives, metal nail files, knitting needles ... all jewelry except a wedding band and watch ... any other items deemed potentially dangerous by staff ... "

1. Closed medical record review on 01/14/2025 for Patient #30 (Pt) revealed a 14-year-old patient voluntarily admitted on 05/24/2024 for disruptive mood dysregulation (a disorder characterized with ongoing irritability, anger, and frequent, intense temper outbursts) and oppositional defiant disorder (a disorder characterized by uncooperative, defiant, and hostile behavior to authority figures). Pt #30 endorsed high risk behaviors including running away from home, was gone for eight days, and had been using marijuana. Admissions High Risk Notification Alert indicated self-harm risk with fresh cuts to Pt #30's arm. History of Present Illness on the Nursing Assessment at 2130 revealed Pt #30 started cutting her forearms the previous week with a steak knife. Patient Contraband Search form was completed on 05/24/2024 (no time specified); the section for jewelry was marked "Yes" for a nasal piercing, with the disposition listed as "???" Initial Nursing Treatment Plan was completed at 2130 for a problem of self-injurious behavior. Interventions were listed as monitor q15 (every 15) minutes, check pt room for contraband BID (twice a day), and provide education and monitor for warning signs, effectiveness and side effects. Review of Pt #30's orders revealed an order on 05/25/2024 for self-harm risk precautions, throughout the patient's hospitalization. Daily Nurse Progress Note completed by Staff #45 on 06/13/2024 at 1000 revealed Staff #45 removed Pt #30's nose piercing due to accusations by peers of Pt #30 taking it out; the septum piercing was placed in the front of the chart. Daily Nurse Progress Note completed by Staff #43 on 06/21/2024 at 1100 revealed Staff #47 saw Pt #30 exit the bathroom with fresh scratch marks that were bleeding and questioned how Pt #30 did that. Pt #30 gave Staff #47 a staple that she had taken from her phase packet. Pt #30 had bent the staple straight and was using it to self-harm. Staff #43 cleaned and bandaged the area and spoke with Pt #30 about other coping skills. Daily Nurse Progress Note on 07/02/2024 at 1000 revealed during environmental rounds, a piece of a comb was found, hidden under Pt #30's mattress. Pt #30 was discharged home on 07/18/2024.

Request for incident reports regarding Pt #30's contraband and self-harm on 01/17/2025 revealed no incident reports had been created.

Interview on 01/16/2025 at 1001 with Staff #31 revealed Pt #30's septum piercing was not initially removed, because Pt #30 told staff it was a permanent piercing. Staff #31 revealed further discussion with a Provider should have occurred regarding the piercing. When it was determined the piercing was not permanent, it was taken out. Staff #31 revealed all piercings should be removed for the children's campus. Staff #31 revealed the phase packet was a step program for the adolescents to work on, and in June 2024, it possibly had staples. Staff #31 revealed after this incident, they made sure there were no longer staples in the packet and only paper. Staff #31 revealed, there should be an incident report for Pt #30's self-harm on the unit.

Telephone Interview on 01/26/2025 at 1755 with Staff #43 revealed Staff #43 recalled Pt #30's self-harm incident with the staple. Staff #43 revealed the phase packet was stapled at that time. Staff #43 talked to Pt #30, tended to her arm, and noted the scratches were not very deep. Staff #43 reported this incident to Staff #41 but did not create an incident report. Staff #43 revealed the Registered Nurses would create incident reports.

Interview on 01/27/2025 at 1058 with Staff #41 revealed Staff #41 recalled Pt #30. Staff #41 confirmed the phase packets in June 2024 did have staples, and there had not been any concerns previously. Staff #41 revealed the patients were monitored with their packets in group therapy; the packets were returned at the end of the group, and the MHTs (mental health technicians) were responsible for going through the packets to ensure the packets and staples were still intact. Staff #41 revealed Pt #30's incident occurred during group time, and the missing staple would have been noticed when the packet was turned in at the end of group. Staff #41 revealed the phase packets were loose leaf paper now. Staff #41 revealed anyone could create an incident report, which should have been created for Pt #30's self-harm incident by the staff who found it or had the most information. Staff #41 spoke with Staff #3 and the House Supervisor but did not create an incident report for this. Staff #41 revealed the MHTs were responsible for the environmental checks, which occurred three times a day; the comb that was found most likely was from a hygiene bucket and had just been hidden as the MHTs also checked the patients' hygiene buckets twice a day.

Staff #45 no longer worked at the facility.



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2. Closed medical record review on 01/15/2025 for Pt #28 revealed a 15-year-old female admitted to the facility on 12/09/2024 as an IVC (Involuntary Commitment) for aggression and suicidal (thoughts to kill self) and homicidal (thoughts to hurt others) ideation with a plan. Review of the medical record revealed on "Patient Contraband Search" form that Patient #28 had a "belly ring and nose ring" that was "kept by patient". Patient #28 was discharged on 12/14/24.

Interview on 01/24/2025 at 1509 with Staff #50 in regard to piercings documented as kept by Patient #28 revealed, "It depends how fresh the piercing is, that would be a nurses decision not mine."

Based on policy and procedure review, video camera review, staffing census sheets, medical record review and staff interviews, hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications for 7 patients involved in an incident on 12/22/2024 (Pt #5, 21, 3, 6, 20, 4 and 19).

The findings include:

Review of hospital policy, "Medication Administration", revised 05/2022, revealed "Procedure ... 20. Staff will never leave the Medication Cart or Medication Room unlocked. ...".

Review of hospital policy, "Medication Management," revised 09/2020, revealed "Procedures for Children's Hospital ... 5.1 The intake staff will record home medications taken into custody at the time of admissions. ... 5.2 The intake staff will place patient home medications in a tamper-resistant security bag with a copy of the inventory form attached to the outside. The bag will be sealed and taken to the unit where the patient is admitted and given to the floor nurse ... 5.3 The nurse will secure the bag in the cabinets located in the medication rooms. These cabinets are kept locked when not in use. ..."

Review of hospital policy, "Medication Rooms Access and Key Control," revised 01/2020, revealed "Policy ... implement appropriate measures to ensure only authorized individuals have access to the unit medication room.

Review of hospital policy, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion," revised 11/2024, revealed "Policy ... 2.0 Use of Less-Restrictive Measures: The RN and unit staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preference and information from the initial assessment prior to seclusion/restraint, including: 2.1.1 Redirecting the patient's focus 2.1.2 Employing verbal de-escalation 2.1.3 Separating patient from group or community 2.1.4 Engaging the patient in 1:1 activity to promote safe expression of feelings 2.1.5 Offering the use of the quiet room to decrease stimuli and regain control ... 14.0 Staff Training and Competence Assessment: ... Direct care staff, NP's (nurse practitioners), and PA's (physician assistants) are required to attend a nationally recognized physical/aggression management training program and show evidence of competency related to participating in a code situation, application of restraints, or the monitoring, assessment and care of a patient in restraints or seclusion. As part of orientation ...14.1 ... all direct care staff ...receive ongoing training and demonstrate an understanding of: 14.1.1 The underlying causes of threatening behaviors ... 14.1.4 Alternative techniques to redirect a patient, engage the patient in constructive discussion or activity, or otherwise help the patient maintain self-control and avert escalation. Techniques may include de-escalation, mediation, self-protection, and other non-physical techniques such as time outs. ..."

Review of the hospital policy, "Code One Psychiatric Emergency" last reviewed 01/2021, revealed "Code Ones are paged to call additional staff to the area of need in order to aid in de-escalation or to assist with restrictive interventions as needed. ... Management of the Code One - Roles and Responsibilities ... The Code One Leader is the person who will oversee the crisis and give all instructions to the members of the team dealing with the out of control patient. ..."

Video review on 01/08/2025 at 1445 of the incident that occurred on the adolescent female unit on 12/22/2024 revealed there were six (6) adolescent female patients that breached the nurse's station and four (4) of the same females entered the unsecured medication room. Video review from 1830 through 2140 revealed that at 1830 Patient #5 reached over the nurse's station and grabbed a can of ginger ale and poured the liquid onto the floor in front of the nurse's station while Staff #10 was attempting to assist another patient with a phone call. Patient #5 gave the can to Patient #3 who drank remainder of liquids. Patient #5 reaches across nurse's station, grabbed and turned the computer monitor screen. Patient #3 was at the nursing station counter with the can held across counter. Staff #10 remained on the telephone inside the nursing station and appeared to verbalize to Patient #5 and #3. Patient #5 took the can from Patient #3. Patient #5 paced in front of the nurse's station with the can still in her possession. Patient #5 walked out of camera view with the can still in her hand. Staff #10 still on telephone, turned in nurse's station with the phone receiver still in hand. Patient #3 appeared to be talking with Patient #21 who was standing behind Patient #5 and #3 near the nurse's station. Patient #5 appeared to empty the remainder of the can and then slung the can content remainder at Staff #10 in the nurse's station. Staff #10 remained on the telephone. 1831 Unknown patient standing at nursing station counter waiting for Staff #10 to connect phone call. Patients #21, #5, #3 and an unknown patient stood at the nurse's station. Staff #10 gave the unknown Patient the telephone. Patient #5 continued to pace around nurse's station with the can still in her possession. 1832 Patient #6 walked up to the nurse's station. Staff #10 picked up cups from the floor that had been knocked off earlier by Patient #5 and placed the cups back in the same previous location between the wall and the computer at the nurse's station. Patient #5 continued to maintain possession of the can while pacing in front of the nurse's station. Patient #5 crushed the can and appeared to bite the can. Patient #6 appeared to get the can from Patient #5, Patient #5 shook her head as if to say no and pulled the can back. No staff were present in the nurse's station. 1833 Staff #12 entered the nurse's station and appeared to communicate with Patient #5. Patient #5 maintained possession of the soda can and ran towards the unit exit. Patient #5 appeared to slip in the liquid on the floor and fell. Staff #10 and Staff #11 walked to the back of the nurse's station near the medication room and met Staff #12. 1834 Staff #11 cleaned the liquid spill from the floor with towels. Patient #5 walked through playing with the can as staff dried the floor. 1835 Staff #10 walked out of the nurse's station but did not approach Patient #5 and then re-entered the nurse's station. Staff #12 remained inside the nurse's station. Patient #5 appeared at the nurse's station with the can torn into a couple of pieces and gave Patient #3 one of the can pieces. Staff #11 re-entered the nurse's station. Staff #10 came out of the nurse's station. Staff #12 came out of the nurse's station. Staff #12 opened the door to the nurse's station, then came back out. 1836 Two nurses and one technician were on the unit near the nurse's station. 1837 Staff #10 and Staff #12 re-entered the nurse's station. Staff #13 entered the nurse's station. Staff #11 re-entered the nurse's station and Patient #20 entered the camera view and walked in front of the nurse's station. Three nurses and two mental health technicians were in the nurse's station. One patient was standing in front of the nurse's station on the telephone. An unknown patient gets off the phone. Staff #14 entered from an adjoining unit. All staff were putting on gloves. Appeared a Code 1 (behavioral health emergency) was called. Staff #14 removed the walkie talkie and possibly keys and left at the nurse's station. Other staff arrived (7 total staff - 3 nurses and 4 MHT's) and one patient in camera view. Other patients walked down the hallway out of camera view. 1838 MHT's from other units arrived. Staff #12 exited the nurse's station. Two MHT's entered the nurse's station. MHT exits the nurse's station. Patient #4, Patient #6, Patient #20 and an unknown patient stood at the nurse's station. 1839 Patient #3, Patient #21, Staff #11 and Staff #13 re-entered the camera view. Patients were clapping at the return. 2 nurses and 3 mental health technicians re-entered the camera view. Patient #5 reappeared at the nurse's station and other MHT's gathered near the unit exit door/day room area. Staff #11 re-entered the nurse's station. Patient #3 jumped onto the nursing station counter, laid across the counter. Patient #5 and #21 were standing at the nurse's station. Patient #3 grabbed an I-pad from the nursing station while Staff #11 was in the nurse's station watching. Staff #11 turned and walked away towards the medication room. Patient #3 gave the I-pad to Patient #21 who then threw the I-pad back into the nurse's station. Patient #5 removed a medical record (patient chart) from the nurse's station desk. Staff #11 observed the patient. Patients #5, #3 and #21 were standing in front of the nurse's station with the medical record, then Patient #5 threw the medical record back into the nurse's station. Patient #3 reached across the nursing station, pulled the telephone out and threw it across the nurse's station. Staff #11 walked towards the patients, Staff #15 and Staff #10 entered the nursing station. Five other MHT's were outside the nursing station door. Three patients were inside the nursing station with two nurses inside the nursing station and four MHT's standing outside the nursing station. One MHT entered the nursing station. 1840 Staff #12 opened the door between the adolescent girls and children's (littles) units to remove Patient #21 who was escalating. Staff (nurse, MHT's) were attempting to de-escalate. The door between the units closed and Patient #21 was placed on the floor by staff. Patient #3 and #5 were pacing in front of the nurse's station near the location where staff had Patient #21 in a hold on the floor. Staff #10 re-entered from the dayroom. Patient #3 had her hands across the nurse's station as Patient #5 watched staff preparing to move Patient #21 to the Children's (littles) unit (which shared the same nurse's station). Patient #3 reached over the nurses station, picked up an I-pad and threw it at staff on the floor with Patient #21. Patient #5 was watching. Staff #16 was at the other end of the shared nurse's station (littles) and appeared to be on the telephone. Patient #5 threw a shoe at the staff on the floor with Patient #21. Patient #5 threw a second shoe at the staff on the floor with Patient #21. Patient #3 attempted to cross over the top of the nursing station counter. MHT entered and Patient #3 retreated. 1843 Patient #5 threw shoes at a nurse near the nurse's station. 1844 Patient #5 threw cups hitting a nurse in the head. 1846 Patient #3 threw water at a nurse. Patient #4 walked into the nurse's station, passed directly in front of the MHT that was holding the door open. The MHT did not attempt to stop Patient #4. Patient #4 attempted to enter the medication room through a door that was propped open. Patient #4 was placed in a hold and removed from the nurse's station. Patient #3 jumped over the nursing station counter and grabbed a telephone. Patient #20 laid across the nursing counter and attempted to grab an item from the nurse's station. Patient #3 threw the telephone. Patient #20 was pulled from the counter by a MHT. Patient #6 removed the computer monitor from the nurse's station and threw it to the floor. 1847 Patient #5 retrieved the phone from the nurse's station and gave it to Patient #20. Patients #3, #6 and #4 were stomping on the computer screen that was lying on the floor. Patient #20 threw the phone on the floor. Patient #5 reached for another computer monitor in the nurse's station. Patient #6 reached for the same computer monitor and was stopped by a nurse. Patient #4 attempted to jump over the nursing station counter, knocked an object off the desk to the floor and was stopped by the nurse and MHT. Patient #5 was slinging the phone base over the nurse's station. Patient #6 took the phone from Patient #5 and smashed it on the floor. Patient #5 was swinging the phone receiver over the nurse's station. Patient #3 attempted to grab the computer monitor from the nurse's station. Patient #5 continued to swing the phone receiver over the nurse's station. Patient #6 pulled the computer monitor from the nurse's station. 1848 Patient #6 threw the computer monitor on the floor, then stomped on it. Patient #5 tried to pull monitor base out of the nursing desk. A nurse pulled the monitor base from Patient #5. Patient #5 was throwing the phone receiver over the nurse's station like a lasso. Patient #3 grabbed a medical record chart from the nursing station and threw it. Patient #5 continued to twirl the phone receiver over her head. Patients #5 and #3 continued to destroy the medical record. A nurse appeared to speak with the patients in the nurse's station while on the phone possibly calling for more assistance. 1849 Patient #5 swung the phone receiver in and out of the nurse's station and over her head. Patient #6 threw the phone base over the nurse's station. 1850 Patient #3 climbed over the nurse's station, grabbed an I-pad and threw the I-pad and a walkie talkie over her shoulder. Patient #5 attempted to cross over the nurse's station twice. Patient #5 was stopped by an MHT on her second attempt. Patient #4 jumped up on the nurse's station counter. Patient #5 hit a MHT with the phone receiver and continued to swing the receiver over the nurse's station. An MHT removed Patient #4 from the counter. Patient #6 threw an object at the MHT in the nurse's station. An MHT blocked the object and then did a little dance/move. Patient #6 returned to the nurse's station and threw a chart hitting the MHT. Patient #5 continued to swing the phone receiver over the nurse's station at the MHT. Patients #3 and #4 jumped onto the nursing station and stood on the counter. Patient #6 swung the phone receiver and hit the MHT. Patient #5 threw an I-pad and hit the MHT. 1851 Patient #3 climbed onto the copy machine. Patient #5 climbed over the nurse's station counter and entered the nurse's station. Patient #4 threw a computer keyboard on the floor. Patient #6 grabbed a computer keyboard and smashed it against the nurse's station. Patient #3 knocked out ceiling tiles and pulled metal dividers from the ceiling. A nurse removed the metal divider from Patient #3. Patient #5 stood on the nurse's station counter. 1852 Patient #3 continued to knock out ceiling tiles. Patient #20 jumped onto the nursing station counter and sat down. Patient #21 climbed over the nurse's from the adjoining unit. Patient #4 jumped onto the nurse's station. Patient #3 swung from the ceiling. Patients #20, #5, and #4 sat on the counter and watched Patient #3's attempts to climb into the ceiling. 1853 Patient #3 climbed into the ceiling and continued to knock out ceiling tiles. Patient #20 threw a chair out of the nurse's station. An MHT stood behind the nurse's station. Patient #21 attempted to remove a computer monitor from the adjoining nurse's station. 1854 Patient #4 ran across the nurse's station to the adjoining unit to assist Patient #3 in removing the computer monitor. An MHT gave Patient #5 shoes. Patient #20 gave Patient #6 a metal divider. Patient #6 hit an MHT with the metal divider. Patient #5 threw a 3-hole puncher in the air. Patient #4 stood in a rolling chair. Patient #6 entered the nurse's station through the door (it did not appear to be locked) with a metal divider in her hand. Patient #20 threw a metal divider to Patient #5. Patient #4 threw a trashcan over the nurse's station. Patient #20 climbed over the counter, entered the nurse's station and tried to remove the metal monitor base. Patient #5 entered the medication room. Staff #11 appeared to try and redirect the patient. 1855 Staff #11 removed a cell phone, coat and purse and exited the medication room leaving Patient #5 in the room. Patient #21 removed a tray from a drawer in the adjoining nurse's station and threw it. Patient #6 and #4 ran into the medication room (door propped open). Patient #6 smashed an I-pad. 1856 An MHT entered the medication room, stood holding the door open and appeared to try and redirect the patients. Patient #6 used the I-Pad to destroy the Omnicell medication cabinet screen. Patient #4 handed a cup up to Patient #3 in the ceiling. Patient #20 served drinks to the other patients. Patients #4 and #20 exited the nursing station over the counter. 1857 Patient #21 opened another drawer and threw the tray with other items from the drawer. Patient #3 fell from the ceiling onto the nurse's station. Patient #5 attempted to break into the Omnicell with the metal divider. Patients #5 and #6 removed syringes with needles from the countertop in the medication room and opened them. Patient #6 appeared to locate a vial on the countertop and drew contents into a syringe. Patient #5 exited the medication room with two (2) syringes/needles. Patient #3 ran towards the medication room. 1858 Patient #6 walked across the medication room and withdrew water from a pitcher into the syringe. Patient #6 exited the medication room and nurse's station with a syringe/needle and metal divider in her hand. Patient #3 entered the medication room and went behind the door out of camera view. Patient #3 left the medication room holding what appeared to be a medication bag. Patient #21 continued to throw items from the nurse's station. 1859 Patients #20 and #3 opened the medication bag. An MHT's entered from the adjoining unit. Patient #6 attempted to stab the MHT in the neck with the syringe/needle. An MHT placed Patient #6 in a hold and removed the syringe/needle. An MHT exited to the adjoining unit. Patient #6 re-entered the nurse's station through the door (it did not appear to be locked). 1900 Patients #5, #21 and #20 continued to throw items from behind the nurse's station. Patient #6 re-entered the medication room and walked behind the door out of camera view. Patient #4 returned, jumped on the nurse's station and sat on the counter. Patient #3 came back in camera view and appeared to be holding an opened medication bottle. Patient #3 obtained a water bottle and exited the medication room. Patient #3 handed Patient #20 a water bottle and pills (unable to determine if pills were taken as back was to the camera but it did appear that the patient swallowed something). Patient #20 threw pills over the nursing station onto the unit floor in front of the nurse's station. An MHT grabbed the metal divider from Patient #20. Patient #6 exited the medication room holding two pill bottles. Patient #3 re-entered the medication room and walked behind the door out of camera view. 1901 Nurse (from main campus) entered from the adjoining unit. Patient #21 threw charts at the nurse. Patients #3 and #21 removed soda cans from the medication room. Patient #3 exited the medication room holding approximately 4 soda cans. The medication room door was closed. An MHT (from main campus) entered the nurse's station through the door (appeared to enter without use of a key fob/badge), Patient #21 spit soda at the MHT. The MHT removed Patients #3, #6 and #21 from the nurse's station. 1902 An MHT and nurse placed Patient #5 in a hold on the nurse's station counter and removed one of the two syringes/needles. Patient #3 threw an object and hit an MHT in the head. 1903 Staff continued to try and gain control over Patient #5. Patient #3 slung a phone receiver over the nurse's station counter hitting a nurse in the face (nose). MHT's escorted Patient #5 out of the nurse' s station through the door. Patient #6 threw a keyboard striking an MHT. Patient #21 threw an object over the nurse's station striking the nurse in the head. Patient #6 postured to strike an MHT with a metal divider and an MHT removed the metal divider from her hand. Patient #6 fell to the floor. An MHT attempted to redirect Patient #21 (went out of camera view). Patient #21 threw a chart and an MHT re-engaged the patient. 1905 Police arrived and placed Patients #6, #21, #5 and #4 in handcuffs. 1916 The administrator-on-call and chief nursing officer arrived. From 1920 to 2038 the police and emergency medical service were on the unit evaluating and preparing Patients #5, #21, #6, #19, #3, #20 and #4 to exit via stretcher to a local hospital for evaluation due to possible medication ingestion. 2024 The Medical Director arrived on the unit. 2140 The remaining patients were removed from the dayroom and sent to their bedrooms.
Review of the C1-North (adolescent girls) unit staffing census sheets for 12/22/2024 revealed there were two (2) registered nurses and two (2) mental health technicians scheduled to work 8am-8pm and one (1) mental health technician scheduled to work 1pm to 5pm, with a census of eighteen (18) patients. There was one (1) registered nurse, who was also working as the house supervisor and two (2) mental health technicians assigned to work on the adjoining C1-West-A unit (children/littles) with a census of eleven (11) patients.

Review on 01/13/2025 of the medical record for Patient #5 revealed a 15-year-old female presented via law enforcement on involuntary commitment on 12/17/2024 at 1436 with a diagnosis of suicidal ideations (plan to lay in the road to get hit by a car) and self-harm behaviors (cutting wrist with glass). Physician orders on 12/17/2024 at 1641 revealed every 15 minute observations, common area observation, self-harm risk and suicide precautions. Patient #5 had a chemical restraint documented on 12/17/2024 at 2000 for throwing items at staff, pulling the phone and computers at the nursing station and threatening staff. Physician orders on 12/18/2024 at 1052 revealed placement in a room close to the nursing station, reinforce to patient to maintain four (4) foot distance from other patients, re-education with patient on maintaining boundaries, unit restrictions and sexual aggression risk. The patient had a chemical restraint on 12/18/2024 at 1605 for altercations with peer and staff. Additional orders on 12/18/2024 at 2331 revealed elopement risk and unit restrictions. Patient #5 had a chemical restraint documented on 12/20/2024 at 1335 for attacking, yelling and spitting at staff and grabbing items in the nursing station. Physician orders on 12/20/2024 at 2342 revealed block patient room and aggression/homicide precautions. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1815 that Patient #5 was in the dayroom and calm. Further review revealed no 15 minute observation checks documented from 1815 through 2100. At 2106 documentation revealed that Patient #5 had been transported to the Emergency Room. Patient #5 had a physical restraint documented on 12/22/2024 at 1900 for aggression and self-harm with a syringe/needle. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #5 to an outside facility for evaluation of suspected overdose. A behavior management plan was initiated on 12/24/2024 at 1400. Patient #5 had chemical restraints for aggression, destroying property and threatening staff on 12/28/2024 at 2100, on 01/04/2025 at 1912 and on 01/05/2025 at 1520. Review of a Psychiatric Progress note documented on 01/06/2025 revealed "Pt (patient) ongoing aggression and constant conflict with peers. Pt was agitated and assaultive yesterday and required IM (intramuscular) PRN (as needed medications) due to aggression. Pt shows no improvement in mood or insight. Pt was attempting to follow staff through doors this morning. Mood ROS (Review of Systems) severe anxiety Psychosis/Mania ROS aggressive behavior required prn injection, inappropriate with peers, impulsivity. Assessment and Plan: is dangerous to self or others Patient has required or demonstrated: PRN meds in the last 24H (hours) for psychosis or aggression Self-Injury, assault, active SI/HI (suicidal/homicidal ideations) in the last 24 H." Patient #5 was discharged to legal guardian custody on 01/06/2025. Review of incident reports for Patient #5 revealed documentation of aggression on 12/17, 12/18,12/20 (times 2), 12/21, 12/22,12/26, 12/28, 12/31/2024, 01/04 and 01/05/2025. (Total of 11 incidents between 12/17/2024 and 01/05/2025)

Review on 01/23/2025 of the medical record for Patient #21 revealed a 12-year-old female presented via law enforcement on involuntary commitment on 09/27/2024 at 1850 with a diagnosis of Major Depressive disorder. Physician orders on 09/27/2024 at 2046 revealed every 15 minute observations. Physician orders written 09/27/2024 at 2207 revealed placement in room close to the nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries, aggression/homicide precaution, self-harm risk, sexual victimization risk, elopement risk and unit restriction. Review of the History and Physical documented on 09/28/2024 at 0900 revealed that Patient #21 presented with severely aggressive and assaultive behaviors. Patient #21 was transferred from the adolescent girls unit to the children's unit on 10/08/2024 for sexual aggression. Patient #21 had a chemical restraint documented on 10/12/2024 at 1436 for assaulting peers. Physician order on 10/20/2024 at 2231 to block patient room. Review of physician orders dated 12/05/2024 at 0254 revealed place in room close to the nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries and sexual aggression risk. Review of Psychiatric Progress note documented on 12/20/2024 at 0929 revealed "Pt with ongoing mood instability and agitation and is often out of group. Pt has ongoing concerns with poor boundaries but has not had any recent aggressive incidents. Review of Psychiatric Progress note documented on 12/21/2024 at 1111 revealed "Pt states she has been feeling suicidal recently and presents depressive and anxious. Pt with active SI (suicidal ideations) this morning and states she does not want to be alive. Pt with ongoing mood instability and was self-harming per banding her head." Patient #21 had a physical restraint documented on 12/22/2024 at 1840 for aggression/property destruction. Patient #21 had a physical restraint documented on 12/22/2024 at 1850 for aggression/property destruction. Patient #21 had a physical restraint documented on 12/22/2024 at 1902 for aggression/property destruction. Review of a Psychiatric Progress note documented on12/23/2024 at 0959 revealed documentation of Patient #21 involved in riot on the unit on 12/22/2024 and was sent out to the Emergency Department and had not returned. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #21 to an outside facility for evaluation of suspected overdose. Review of Psychiatric Progress note documented on 12/24/2024 at 0948 revealed "Pt with severe aggressive and assaultive behaviors and riotous behaviors. Pt is refusing to leave her room and is threatening to assault staff and act out again. Pt shows no improvement and has severe behavioral issues." Patient #21 had a chemical restraint on 12/24/2024 at 1415 for self-injurious behaviors. A behavior management plan was initiated on 12/24/2024 at 1500. Physician orders documented on 12/24/2024 at 1601 revealed common area observation, suicide precautions, elopement risk and unit restriction. Review of Psychiatric Progress note documented on 12/26/2024 at 0918 revealed "Pt with severe aggressive ideations and threats towards others. Pt presents severe anxiety and suicidal ideations. Pt has no update at this time and is waiting on news for placement." Review of Psychiatric Progress note documented on 12/27/2024 at 0938 revealed "Pt with severe aggressive ideations and threats towards others. Pt shows no improvements in mood or behaviors and is an ongoing danger towards others and self. Pt with frequent outbursts and threats towards staff." Review of Psychiatric Progress note documented on 12/28/2024 at 0949 revealed case management reached out to group home to determine if admission arrival date was still anticipated for 01/02/2025. Review of Psychiatric Progress note documented from 12/30/2024 through 01/06/2025 revealed no change in Patient #21's mood or behaviors. Patient #21 had a chemical restraint on 12/31/2024 at 1825 for self-injurious behaviors. Review of physician order dated 01/02/2025 revealed room monitor. Review of Psychiatric Progress note documented on 01/08/2025 revealed " ... Pt was agitated and threatening staff yesterday and was attempting to jump the nurse's station, throw paper, and attempts to damage property. Pt was briefly taken off the unit to seclusion and was able to calm down." Patient #21 had a chemical restraint and seclusion on 01/10/2025 at 0935 for aggression. Patient #21 had a physical and chemical restraint on 01/14/2025 at 1245 for aggression. Patient #21 had a physical and chemical restraint on 01/14/2025 at 1316 for aggression and property damage. Patient #21 had a physical restraint on 01/16/2025 at 1430 for aggression and property damage. Review of incident reports for Patient #21 revealed documentation of aggression/self-harm on 10/09,10/12, 10/19,10/29,11/13, 11/15, 12/22,12/24/2024, 01/07 and 01/10/2025. (Total of 10 incidents between 10/09/2024 and 01/10/2025)

Review on 01/14/2025 of the medical record for Patient #3 revealed a 17-year-old female presented via law enforcement on involuntary commitment on 11/16/2024 at 1926 with a diagnosis of Major Depressive Disorder, recurrent. Patient #3 was re-admitted to Hospital A on 12/24/2024 at 1505 after returning from observation admission on 12/22/2024 at Hospital B. Physician orders on 11/17/2024 at 1605 revealed every 15 minute observations ,common area observation, aggression/homicide precautions and suicide precautions. Nursing notes dated 11/27/2024 revealed that Patient #3 was agitated and aggressive to peer and staff. Patient #3 was administered Thorazine and Benadryl. Physician orders on 11/28/2024 at 0204 revealed block patient room. Physician orders dated 12/03/2024 at 1330 revealed place in room close to nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries, sexual aggression risk and sexual victimization risk. A behavior management plan was initiated on 12/03/2024 at 1200. Nursing note documented on 12/03/2024 at 2240 revealed Patient #3 was involved in altercation with another peer and that staff attempted to remove Patient #3, the patient refused. Patient #3 was involved in a physical altercation with peer on 12/15/2024. Physician orders on 12/16/2024 at 0031 revealed cheeking precautions. Patient #3 was involved in verbal and physical altercation with staff and peer on 12/16/2024. Nursing note dated 12/16/2024 at 2130 revealed that Patient #3 had obtained ink pen caps and placed in pocket. Patient #3 pulled ink pen cap out of pocket and cut her arm. Patient #3 moved to hallway, pulled a 2nd ink pen cap from her pocket making verbal threats of "stabbing" a staff member and then cut self on the neck multiple times. Staff were able to take both ink pen caps from the patient. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1815 that Patient #3 was in the group room and calm. Further review revealed no 15 minute observation checks documented from 1815 through 2100. At 2103 documentation revealed that Patient #3 had been transported to the Emergency Room. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. Patient #3 had chemical restraint on 12/26/2024 at 2045 for attempted elopement and aggression. Patient #3 had a chemical restraint documented on 12/29/2024 at 2025 for aggression. Patient #3 was involved in a verbal altercation on 12/30/2024 and on 12/31/2024 Patient #3 removed signs from the unit wall and was not re-directable. Late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #3 to an outside facility for evaluation of suspected overdose. Review of a Psychiatric Progress note documented on 01/02/2025 revealed "Pt (patient) is expecting to discharge today with DSS placement. Pt's DSS and insurance are resistant to discharge due to conce

Based on review of hospital policy, medical records and staff interviews, the hospital staff failed to prevent verbal abuse to patients by hospital staff for 1 of 1 sampled medical records ( Pt #52).

The findings include:

Review on 01/24/2025 of hospital policy "Reporting and Investigating Patient Neglect, Abuse and Exploitation," last revised 03/31/2023, revealed, "... Patients ... are treated with dignity and respect, and have a right to be free from abuse ... 1. Abuse ... b. Engaging in unprofessional behavior (verbal or physical) that is degrading to the patient. These may include, but are not limited to, cursing, malicious teasing, baiting or humiliating the patient, obscene language or gestures, threatening remarks or gestures ..."

1. Closed medical record review on 1/21/2025 for Patient #52 (Pt) revealed a 26-year-old male admitted to the hospital on 01/05/2025 at 1649 with a diagnosis of bipolar disorder (a condition that causes extreme mood swings). Record review revealed Pt #52 was given the following medications on 01/07/2025 as a chemical restraint (medications given to control a patient's behavior) for aggression toward peers: Ativan (a medication used to treat anxiety) 2 mg (milligrams) IM (intramuscular) at 1321, Thorazine (a medication used to treat psychosis and mental illness) 100 mg IM at 1322, and Benadryl (an antihistamine medication) 100 mg IM at 1323. Review revealed Pt #52 received further treatment and was discharged home on 01/15/2025 at 1016.

Interview on 01/23/2025 at 1031 with Staff #7 revealed Pt #52 had reported to Staff #7 that hospital staff were speaking to him in a disrespectful manner. Interview revealed Staff #7 encouraged Pt #52 to report the behavior to the patient advocate or the attending physician. Interview revealed Staff #7 was not present when Pt #52 received the chemical restraint but witnessed a staff member laughing afterwards because Pt #52 was crying after receiving the IM medications. Interview revealed Staff #7 had witnessed multiple staff members cursing at patients, using a disrespectful tone toward patients, and mocking or laughing at patients. Interview revealed Staff #7 had not reported this behavior because Staff #7 feared retaliation from staff.

Interview on 01/21/2025 with Staff #55 revealed Staff #55 witnessed a nurse giving medications to a patient and refusing to tell the patient what medications were being given. Staff #55 revealed that the nurse stated to the patient that "(the nurse) was the one giving the meds (medications) and the patient wouldn't know what was given." Staff #55 stated the behavior "evoked paranoia (distrust and suspicion of others)."

Interview on 01/28/2025 at 0937 with Patient #72 revealed some of the staff talk "(expletive)" to patients. Pt #72 reported hearing "staff tell patients I don't give a (expletive) about this job. Call the Patient Advocate. They are not going to do anything." Interview revealed staff "argues" with the patients. Pt #72 heard staff tell patients while arguing with them, "you put your hands on me, I am going to (expletive) you up." Pt #72 verbalized he had been hospitalized before, the current unit was the worst he had ever been on, and that no one cared how the patients were treated. Pt #72 stated there were a lot of incidents on the unit and nothing had happened.



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2. Interview on 01/14/2025 at 1215 with staff #56 when asked if she noticed staff disrespecting patients. Staff #56 stated "yes" and identified staff #80 as being disrespectful to patients all the time. Staff #56 witnessed staff #80 tell patients they could not have their medications because "I am on my break, don't' bother me" Staff #56 stated staff #80 was mean to patients.

Interview on 01/14/2025 at 1237 with staff #80 revealed staff #80 worked at the facility for the last 4 years. Interview revealed that staff #80 often worked in the medication room and administered medications to patients. This surveyor asked staff #80 if staff #80 witnessed staff disrespecting patients. Staff #80 stated "I am guilty. Sometimes I am a little short with patients. I am trying to get things done."

Based on review of policy, incident reports, and interviews with staff, hospital leadership failed to ensure adequate follow-up of adverse incidents for patient safety in 2 of 8 incidents reports reviewed (Pt #38, Pt #47).

The findings include:

Review of a policy on 01/27/2025 titled "Occurrence Reporting" with a revision date of 07/23, revealed "Policy: The responsibility for completing a Healthcare Peer Review (HPR) report rests with any hospital staff member who witnesses, discovers, or has direct knowledge of an occurrence. Occurrences are defined as any happening not consistent with the routine care and/or operation of the facility which may place the facility at increased risk for liability. Purpose: The Healthcare Peer Review Report is a risk management tool that notifies the hospital of potential areas of loss. It enables the hospital to take corrective action, reducing the losses and improving the quality of healthcare provided in the hospital. The HPR Report is also a reporting vehicle by which to notify Risk Management of potential liability claims. The HPR report can help the various hospital committees and administration in identifying potential areas of risk and implementing measures to reduce and prevent future claims. the overall effect is an increase in the quality of patient care provided by the hospital....11. The Risk Manager, PI Director or designee shall review the form for completeness and conduct a follow -up if appropirate....Corporate Office:...The Risk Manager will maintain summary reports of events/occurrences on a monthly basis. On a monthly basis summary reports will be forwarded to the Assistant Corporate Risk Manager no later than 10th of the following month...."

1. Review on 01/14/2025 of Patient #38 revealed a 28-year-old male admitted on 08/07/2024 under IVC for paranoia (irrational and persistent belief that others are intentionally harming, deceiving, or persecuting you) and delusions (strong, false belief someone holds onto even when there's clear evidence showing it's not true). Patient #38 was discharged home on 08/16/2024.

Review of the incident report dated 08/10/2024 at 2045 revealed " ... B. INCIDENT TYPE: Found in unauthorized area ..." Review revealed Staff #79 reviewed the incident report on 08/16/2024 at 0933.

Interview on 01/21/2025 at 1150 with Staff #79 revealed the incident was reviewed for accuracy. Incidents at this magnitude typically only require the incident form review to ensure it was filled out correctly and if something was missing put an addendum with that information, otherwise the investigation was complete. The magnitude of the incident was based off injury and harm, and what harm was caused by the incident. Interview revealed all incidents are investigated by the Risk Manager for facts which were documented in the Midas system (incident reporting system) by the front line staff. The tabs in the Midas system gave a thorough investigation and information needed to determine incident level including level of care, day of the event, and history or intervention outcome. Interview revealed Staff #79 did not perform a video review and did not question how long Patient #38 was off the unit. Interview revealed Patient #38 was returned to the unit and was safe and was what Staff #79 was concerned with for this investigation.

Interview on 01/17/2025 with Staff #22 revealed there was no video review of the incident. The only notes regarding the incident were what were provided. Interview revealed the expectation would be the staff working and involved in the incident should have been interviewed and a video review should have been conducted at the time of the investigaton.

Interview on 01/21/2025 at 1707 with Staff #20 revealed the investigator did not do the expected investigation.



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2. Review of a closed medical record on 01/17/2025 for Patient #47 revealed a 50-year-old female admitted on 11/22/2024 via IVC (Involuntary Commitment) for SI (Suicidal Ideation). Review of the intake "High Risk Notification Alert" form dated 11/22/2024 at 1112 revealed Patient #47 had a medical diagnosis of diabetes and an allergy to Lantus Insulin (medication used to control blood sugars).

Review of "Physician Medication Orders"per staff #19 revealed an order for "Insulin glargine (Lantus Insulin) Subcutaneous 100 units/ml (milliliter) SOLN (Solution) 15 units to be administered on 11/22/2024. Review of a MAR (Medication Administration Record) dated 11/22/2024 revealed the Lantus Insulin was not administered on 11/22/2024.

Review of an Omnicell (medication dispenser) report for 11/22/204 revealed the Lantus Insulin was pulled out of the Omnicell but was not administered to the patient. Per investigation this surveyor was not able to confirm the Lantus Insulin was administered to Patient #47.

Interview on 01/13/2025 at 1438 with Patient #47 revealed the patient alleged the patient was administered Lantus Insulin and it was documented that she had an allergy to the Insulin.

Interview on 01/23/2025 at 1434 with staff #54 (Patient Advocate) revealed staff #54 was responsible for receiving and resolving patient complaints. She remembered Patient #47 made a complaint regarding an allegation that she received Lantus Insulin which she was allergic to. Staff #54 stated she "did not investigate the complaint because the complaint was turned over to Nursing and Pharmacy leadership. Staff #54 confirmed that there was not an incident report in the facility's reporting system.

Interview on 01/23/2025 at 1600 with staff #49 (Nursing Leadership) revealed staff #49 was not aware of the allegation regarding Patient #47 having received Lantus Insulin which was documented as an allergy in the patient's medical record. Staff #49 was not aware that the medication had been removed from the Omnicell until this surveyor made staff #49 aware of the occurrence. Staff #49 confirmed there was not an investigation nor an incident report entered into the facilities incident reporting system. Staff #49 confirmed there should have been an incident report entered into the system for potential medication error.

Interview with staff #88 (Pharmacist) on 01/24/2025 at 1345 revealed he made a call to staff #19 and explained the patient was allergic to Lantus Insulin and the facility did not carry Levemir Insulin that the patient stated she took at home.

Interview with staff #19 on 01/25/2025 at 1052 revealed he was not aware Patient #47 had an allergy to Lantus Insulin and would not have ordered the medication for a patient with a known allergy.

This surveyor requested interviews with two nurses who documented in Patient #47's medical record regarding Lantus Insulin. Per leadership both nurses no longer worked at the facility.

Based on review of hospital medical staff bylaws, medical contract, credentialing file reviews, on-call schedules, and staff interviews, hospital leadership failed to ensure Advanced Practice Providers (APPs) provided age-specific care and treatment based on their delineated privileges for 4 of 4 APP credentialing files reviewed (Staff #27, Staff #28, Staff #29, Staff #4).

The findings include:

Review on 01/28/2025 of Medical Staff Bylaws adopted 01/29/2024 revealed, " ... 2. To ensure the high level of professional performance of all practitioners authorized to practice in the facility, through appropriate delineation of clinical privileges that each practitioner may exercise ... Section III. Conditions and Duration of Appointment ... C. Appointment to the medical staff shall confer on the appointee only such clinical privileges as have been granted by the Governing Body in accordance with these Bylaws, and shall indicate limitations, if any, on an individual's privileges to admit and treat patients ... Application for Appointment. A. No person shall exercise clinical privileges in the facility unless and until they apply for and receives appointment to the Medical Staff as set forth in these Bylaws ... "

Review on 01/28/2025 of Collaborative Practice Agreement, Advanced Practice Provider (APP) revealed, " ... 3. Patient Population. The (consultation company) APP manages medical care for adults age 18 and older with a wide range of medical issues for patients requiring hospitalization for mental health conditions ..."

1. Review on 01/27/2025 of Staff #27's credentialing file revealed, Staff #27, who was a medical Advanced Practice Provider, was initially appointed on 11/22/2022 with history and physical examination and general medical management privileges with supervision for the adult population. Staff #27 was reappointed on 11/22/2024 with full privileges for admission, history and physical examination, and general medical management for the adult population. Review revealed no privileges were granted for the adolescent or child populations.

Review on 01/27/2025 of the on-call schedule from July 2024 revealed that Staff #27 was scheduled for medical consultation (consult) coverage for the adult and children's campuses on Thursday, July 4, 2024, Saturday and Sunday, July 6 and 7, 2024, and Saturday and Sunday, July 20 and 21, 2024. Review of the on-call schedule from December 2024 revealed that Staff #27 was scheduled for medical consult coverage for the adult and children's campuses on Sunday, December 1, 2024, and Thursday through Sunday, December 5-8, 2024. Review of the on-call schedule from January 2025 revealed that Staff #27 was scheduled for medical consult coverage for the adult and children's campuses on Saturday and Sunday, January 11 and 12, 2025, and Saturday and Sunday, January 18 and 19, 2025.

Telephone interview on 01/28/2025 at 1000 with Staff #27 revealed Staff #27 worked part-time covering medical consults and would be on-site during the day when covering consults, including the weekends. Staff #27 covered 2 weekends a month and would sometimes cover another Provider during the week. Staff #27 revealed an order would be placed for the patient who needed a consult, and the patient would typically be seen the same day. Staff #27 covered all populations/campuses (adult and children) when on-call or on-site for medical consults. Staff #27 was unsure what privileges were requested for the last reappointment and thought the privileges included adolescents, not just adults.

Interview on 01/28/2025 at 1245 with Staff #32 revealed, Staff #27 was not privileged for the adolescent and child population. Staff #32 revealed, the APPs would be privileged if they continued to cover medical consults for the children's campus.

2. Review on 01/28/2025 of Staff #28's credentialing file revealed, Staff #28 who was an Advanced Practice Provider, was initially appointed on 05/21/2021 for history and physical examination and general medical management privileges for the adult and adolescent populations. Staff #28 was reappointed on 05/25/2023 with full privileges for history and physical examination, and general medical management for the adult and adolescent populations. Review revealed no privileges were granted for the child population.

Review on 01/27/2025 of the on-call schedule from July 2024 revealed that Staff #28 was scheduled for medical consult coverage for the adult and children's campuses on Saturday and Sunday, July 13 and 14, 2024, and Saturday and Sunday, July 27 and 28, 2024. Review of the on-call schedule from December 2024 revealed that Staff #28 was scheduled for medical consult coverage for the adult and children's campuses on the remaining weekends in December: 14 -15, 21 -22, and 28 -29, 2024. Review of the on-call schedule from January 2025 revealed that Staff #28 was scheduled for medical consult coverage for the adult and children's campuses on Saturday and Sunday, January 4 and 5, 2025, and Saturday and Sunday, January 25 and 26, 2025.

Interview on 01/28/2025 at 1245 with Staff #32 revealed, Staff #28 was not privileged for the child population. Staff #32 revealed, they would be privileged if the APPs continued to cover medical consults for the children's campus.



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3. Review on 01/27/2025 of Staff #29's credentialing file revealed, Staff #29 who was a medical Advanced Practice Provider, was initially appointed on 05/25/2021 and granted privileges for history and physical examination and general medical management for the adult population. Staff #29 was reappointed on 05/26/2023 with full privileges for history and physical examination, and general medical management for the adult population. Review revealed no privileges were granted for the adolescent and child population.

Review on 01/27/2025 of the on-call schedule from July 2024 revealed that Staff #29 was scheduled for medical consult coverage for the adult and children's campuses on July 4, 10, 17,, 24, and 31, 2024.

Interview on 01/28/2025 at 1245 with Staff #32 revealed, Staff #29 was not privileged for the adolescent and child population. Staff #32 revealed, the APPs would be privileged if they continued to cover medical consults for the children's campus.



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4. Closed medical record review of Patient #43 revealed a 16-year-old male voluntarily committed to the 1 South unit on 09/13/2024 for suicidal ideation (SI). Review of Provider Orders revealed the patient was admitted under the care of Staff #4 (an APP) with self-harm precautions, suicide precautions, and Q (every) 15-minute monitoring. Review of the Discharge Summary documented by Staff #4 on 09/15/2024 at 1228 revealed " ... (named patient) was involved in multiple altercations on his first and second day on the unit at which point, father requested that (named patient) be allowed to discharge on 09/15/2024 instead of 09/16/2024 as discussed with nurse practitioner (NP) ..." Review of the History and Physical Exam/Psychiatric Evaluation form on 09/13/2024, all medication and ancillary orders, psychiatric progress note on 09/15/2024, and Discharge Summary on 09/15/2024 revealed all were completed and signed by the Nurse Practitioner (Staff #4). Record review revealed the NP admitted and discharged the patient for psychiatric care and treatment. Record review did not reveal the patient was evaluated by a Physician during hospitalization.

Interview on 01/14/2025 at 1230 with Staff #4 revealed the staff member recalled the patient. Interview revealed Staff #4 admitted the patient for psychiatric care. Interview revealed that the patient's father was upset the patient had not been seen by a physician. Staff #4 informed the patient's father that the patient was being seen by an NP provider.

Review of a Credential file for Staff #4 revealed an approved appointment to the active medical professional staff at Facility A, effective 12/12/2023. Review of an appointment letter dated 12/12/2023 stated, "The privileges granted and maintained in your credentialing file include history and physical examination, as well as general medical management for the adult, adolescent, and children population...." Further review of Staff #4 credential file revealed a Delineation of Clinical Privileges for Facility A. Staff #4 was granted privileges by the MEC (medical executive committee) and the Board of Governors for history and physical exam and general medical management. Review did not reveal Staff #4 had psychiatric privileges.

Interview on 01/28/2025 at 1245 with Staff #32 revealed, Staff #4 was privileged for history and physical examination, as well as general medical management for the adult, adolescent, and children population. Interview revelaed Staff #32 did not request and was not approved for psychiatric care and treatment for adults, adolescent and children. Interview confirmed Staff #4 had provided psychiatric care and treatment to Pt #43.

Based on review of Medical Stall Bylaws, credentialing files and staff interviews, the medical staff failed to conduct reappraisals of appointment and privileges granted for 2 of 6 sampled credentialing files reviewed (Staff #29, Staff #4).

The findings include:

Review of Medical Staff Bylaws adopted 01/29/2024 revealed, " ... 2. To ensure the high level of professional performance of all practitioners authorized to practice in the facility, through appropriate delineation of clinical privileges that each practitioner may exercise ... Section III. Conditions and Duration of Appointment ... B. Initial medical practitioner and allied appointments shall be for a period of two (2) years which will include a provisional period of one year. Reappointments shall be for a period of two years. Any person receiving provisional appointment shall have their credentials presented to the medical staff for review prior to the end of such provisional appointment with action taken by the medical staff and Governing /body to advance the appointment to full appointment to the appropriate category, to terminate the member's appointment at the end of the term of provisional appointment, or to extend the provisional status for purposes of obtaining other specific information. ... Application for Appointment. A. No person shall exercise clinical privileges in the facility unless and until they apply for and receives appointment to the Medical Staff as set forth in these Bylaws ... "

1. Review on 01/27/2025 of Staff #29's credentialing file revealed, Staff #29 who was a medical Advanced Practice Provider, was initially appointed on 05/25/2021 and granted privileges for history and physical examination and general medical management for the adult population. Review of the letter notifying Staff #29 of the appointment was dated 05/25/2021 and stated, "At the time of initial appointment, medical staff members are place on provisional status for a period of at least one year. Prior to the end of the provisional period, an evaluation of performance and recommendation for advancement to full privileges, extension of provisional status, or denial of some of or all privileges will be determined, per the Bylaws of the Medical Staff. ..." Review of the credentialing file revealed no evidence that the performance or recommendation to advance to full privileges was conducted until NP #29 was reappointed for full privileges to the adult population on May 26, 2023 (2 years after the initial appointment with provisional status).

Interview on 01/29/2025 at 1125 with Staff #20 revealed there was no evidence of staff reappraisal of the provisional status for Staff #29 from 2022 through 2023. Interview revealed NP #29 had continued to work as a medical staff APP with no lapse in coverage during this time. Interview revealed Medical Staff Bylaws were not followed.

2. Review of Staff #4's credentialing file revealed, Staff #4 who was a medical Advanced Practice Provider, was initially appointed on 12/12/2023 and granted privileges for history and physical examination and general medical management for the adult, adolescent and children population. Review of the letter notifying Staff #4 of the appointment was dated 12/12/2023 and stated, "At the time of initial appointment, medical staff members are place on provisional status for a period of at least one year. Prior to the end of the provisional period, an evaluation of performance and recommendation for advancement to full privileges, extension of provisional status, or denial of some of or all privileges will be determined, per the Bylaws of the Medical Staff. ..." Review of the credentialing file revealed no evidence that the performance or recommendation to advance to full privileges was conducted.

Interview on 01/29/2025 at 1125 with Staff #20 revealed there was no evidence of staff reappraisal of the provisional status for Staff #4. Interview revealed NP #4 had continued to work as a medical staff APP with no lapse in coverage during this time. Interview revealed Medical Staff Bylaws were not followed.

Based on policy and procedure review, video camera review, staffing census sheets, medical record review and staff interviews, the facility's nursing staff failed to have an effective nursing service providing oversight of day-to-day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to behavioral health patients.

The findings include:

1. Hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications for 7 patients involved in an incident on 12/22/2024 (Pt #5, 21, 3, 6, 20, 4 and 19).

~cross refer to 483.23(b)(3) Nursing Services - RN Supervision of Nursing Care: tag A0395

2. Hospital staff failed to provide and/or assist with hygiene needs for 1 of 1 patients observed with lack of proper hygiene; and failed to evaluate a patient for falls risk in 1 of 1 patients observed with unsteady gait. (Patient #40).

~cross refer to 483.23(b)(6) Nursing Services - Supervision of Contract Staff: tag A0398

Based on policy and procedure review, video camera review, staffing census sheets, medical record review and staff interviews, the hospital leadership failed to ensure a medication room was secured; failed to provide adequate staff to ensure de-escalation techniques were used with patients exhibiting aggressive and threatening behaviors; and failed to prevent patient access to unauthorized areas, contraband, and medications for 7 patients involved in an incident on 12/22/2024 (Pt #5, 21, 3, 6, 20, 4 and 19).

The findings include:

Review of hospital policy, "Medication Administration", revised 05/2022, revealed "Procedure ... 20. Staff will never leave the Medication Cart or Medication Room unlocked. ...".

Review of hospital policy, "Medication Management," revised 09/2020, revealed "Procedures for Children's Hospital ... 5.1 The intake staff will record home medications taken into custody at the time of admissions. ... 5.2 The intake staff will place patient home medications in a tamper-resistant security bag with a copy of the inventory form attached to the outside. The bag will be sealed and taken to the unit where the patient is admitted and given to the floor nurse ... 5.3 The nurse will secure the bag in the cabinets located in the medication rooms. These cabinets are kept locked when not in use. ..."

Review of hospital policy, "Medication Rooms Access and Key Control," revised 01/2020, revealed "Policy ... implement appropriate measures to ensure only authorized individuals have access to the unit medication room.

Review of hospital policy, "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion," revised 11/2024, revealed "Policy ... 2.0 Use of Less-Restrictive Measures: The RN and unit staff implement the least restrictive, non-physical interventions, utilizing patient identified preferred de-escalation preference and information from the initial assessment prior to seclusion/restraint, including: 2.1.1 Redirecting the patient's focus 2.1.2 Employing verbal de-escalation 2.1.3 Separating patient from group or community 2.1.4 Engaging the patient in 1:1 activity to promote safe expression of feelings 2.1.5 Offering the use of the quiet room to decrease stimuli and regain control ... 14.0 Staff Training and Competence Assessment: ... Direct care staff, NP's (nurse practitioners), and PA's (physician assistants) are required to attend a nationally recognized physical/aggression management training program and show evidence of competency related to participating in a code situation, application of restraints, or the monitoring, assessment and care of a patient in restraints or seclusion. As part of orientation ...14.1 ... all direct care staff ...receive ongoing training and demonstrate an understanding of: 14.1.1 The underlying causes of threatening behaviors ... 14.1.4 Alternative techniques to redirect a patient, engage the patient in constructive discussion or activity, or otherwise help the patient maintain self-control and avert escalation. Techniques may include de-escalation, mediation, self-protection, and other non-physical techniques such as time outs. ..."

Review of the hospital policy, "Code One Psychiatric Emergency" last reviewed 01/2021, revealed "Code Ones are paged to call additional staff to the area of need in order to aid in de-escalation or to assist with restrictive interventions as needed. ... Management of the Code One - Roles and Responsibilities ... The Code One Leader is the person who will oversee the crisis and give all instructions to the members of the team dealing with the out of control patient. ..."

Video review on 01/08/2025 at 1445 of the incident that occurred on the adolescent female unit on 12/22/2024 revealed there were six (6) adolescent female patients that breached the nurse's station and four (4) of the same females entered the unsecured medication room. Video review from 1830 through 2140 revealed that at 1830 Patient #5 reached over the nurse's station and grabbed a can of ginger ale and poured the liquid onto the floor in front of the nurse's station while Staff #10 was attempting to assist another patient with a phone call. Patient #5 gave the can to Patient #3 who drank remainder of liquids. Patient #5 reaches across nurse's station, grabbed and turned the computer monitor screen. Patient #3 was at the nursing station counter with the can held across counter. Staff #10 remained on the telephone inside the nursing station and appeared to verbalize to Patient #5 and #3. Patient #5 took the can from Patient #3. Patient #5 paced in front of the nurse's station with the can still in her possession. Patient #5 walked out of camera view with the can still in her hand. Staff #10 still on telephone, turned in nurse's station with the phone receiver still in hand. Patient #3 appeared to be talking with Patient #21 who was standing behind Patient #5 and #3 near the nurse's station. Patient #5 appeared to empty the remainder of the can and then slung the can content remainder at Staff #10 in the nurse's station. Staff #10 remained on the telephone. 1831 Unknown patient standing at nursing station counter waiting for Staff #10 to connect phone call. Patients #21, #5, #3 and an unknown patient stood at the nurse's station. Staff #10 gave the unknown Patient the telephone. Patient #5 continued to pace around nurse's station with the can still in her possession. 1832 Patient #6 walked up to the nurse's station. Staff #10 picked up cups from the floor that had been knocked off earlier by Patient #5 and placed the cups back in the same previous location between the wall and the computer at the nurse's station. Patient #5 continued to maintain possession of the can while pacing in front of the nurse's station. Patient #5 crushed the can and appeared to bite the can. Patient #6 appeared to get the can from Patient #5, Patient #5 shook her head as if to say no and pulled the can back. No staff were present in the nurse's station. 1833 Staff #12 entered the nurse's station and appeared to communicate with Patient #5. Patient #5 maintained possession of the soda can and ran towards the unit exit. Patient #5 appeared to slip in the liquid on the floor and fell. Staff #10 and Staff #11 walked to the back of the nurse's station near the medication room and met Staff #12. 1834 Staff #11 cleaned the liquid spill from the floor with towels. Patient #5 walked through playing with the can as staff dried the floor. 1835 Staff #10 walked out of the nurse's station but did not approach Patient #5 and then re-entered the nurse's station. Staff #12 remained inside the nurse's station. Patient #5 appeared at the nurse's station with the can torn into a couple of pieces and gave Patient #3 one of the can pieces. Staff #11 re-entered the nurse's station. Staff #10 came out of the nurse's station. Staff #12 came out of the nurse's station. Staff #12 opened the door to the nurse's station, then came back out. 1836 Two nurses and one technician were on the unit near the nurse's station. 1837 Staff #10 and Staff #12 re-entered the nurse's station. Staff #13 entered the nurse's station. Staff #11 re-entered the nurse's station and Patient #20 entered the camera view and walked in front of the nurse's station. Three nurses and two mental health technicians were in the nurse's station. One patient was standing in front of the nurse's station on the telephone. An unknown patient gets off the phone. Staff #14 entered from an adjoining unit. All staff were putting on gloves. Appeared a Code 1 (behavioral health emergency) was called. Staff #14 removed the walkie talkie and possibly keys and left at the nurse's station. Other staff arrived (7 total staff - 3 nurses and 4 MHT's) and one patient in camera view. Other patients walked down the hallway out of camera view. 1838 MHT's from other units arrived. Staff #12 exited the nurse's station. Two MHT's entered the nurse's station. MHT exits the nurse's station. Patient #4, Patient #6, Patient #20 and an unknown patient stood at the nurse's station. 1839 Patient #3, Patient #21, Staff #11 and Staff #13 re-entered the camera view. Patients were clapping at the return. 2 nurses and 3 mental health technicians re-entered the camera view. Patient #5 reappeared at the nurse's station and other MHT's gathered near the unit exit door/day room area. Staff #11 re-entered the nurse's station. Patient #3 jumped onto the nursing station counter, laid across the counter. Patient #5 and #21 were standing at the nurse's station. Patient #3 grabbed an I-pad from the nursing station while Staff #11 was in the nurse's station watching. Staff #11 turned and walked away towards the medication room. Patient #3 gave the I-pad to Patient #21 who then threw the I-pad back into the nurse's station. Patient #5 removed a medical record (patient chart) from the nurse's station desk. Staff #11 observed the patient. Patients #5, #3 and #21 were standing in front of the nurse's station with the medical record, then Patient #5 threw the medical record back into the nurse's station. Patient #3 reached across the nursing station, pulled the telephone out and threw it across the nurse's station. Staff #11 walked towards the patients, Staff #15 and Staff #10 entered the nursing station. Five other MHT's were outside the nursing station door. Three patients were inside the nursing station with two nurses inside the nursing station and four MHT's standing outside the nursing station. One MHT entered the nursing station. 1840 Staff #12 opened the door between the adolescent girls and children's (littles) units to remove Patient #21 who was escalating. Staff (nurse, MHT's) were attempting to de-escalate. The door between the units closed and Patient #21 was placed on the floor by staff. Patient #3 and #5 were pacing in front of the nurse's station near the location where staff had Patient #21 in a hold on the floor. Staff #10 re-entered from the dayroom. Patient #3 had her hands across the nurse's station as Patient #5 watched staff preparing to move Patient #21 to the Children's (littles) unit (which shared the same nurse's station). Patient #3 reached over the nurses station, picked up an I-pad and threw it at staff on the floor with Patient #21. Patient #5 was watching. Staff #16 was at the other end of the shared nurse's station (littles) and appeared to be on the telephone. Patient #5 threw a shoe at the staff on the floor with Patient #21. Patient #5 threw a second shoe at the staff on the floor with Patient #21. Patient #3 attempted to cross over the top of the nursing station counter. MHT entered and Patient #3 retreated. 1843 Patient #5 threw shoes at a nurse near the nurse's station. 1844 Patient #5 threw cups hitting a nurse in the head. 1846 Patient #3 threw water at a nurse. Patient #4 walked into the nurse's station, passed directly in front of the MHT that was holding the door open. The MHT did not attempt to stop Patient #4. Patient #4 attempted to enter the medication room through a door that was propped open. Patient #4 was placed in a hold and removed from the nurse's station. Patient #3 jumped over the nursing station counter and grabbed a telephone. Patient #20 laid across the nursing counter and attempted to grab an item from the nurse's station. Patient #3 threw the telephone. Patient #20 was pulled from the counter by a MHT. Patient #6 removed the computer monitor from the nurse's station and threw it to the floor. 1847 Patient #5 retrieved the phone from the nurse's station and gave it to Patient #20. Patients #3, #6 and #4 were stomping on the computer screen that was lying on the floor. Patient #20 threw the phone on the floor. Patient #5 reached for another computer monitor in the nurse's station. Patient #6 reached for the same computer monitor and was stopped by a nurse. Patient #4 attempted to jump over the nursing station counter, knocked an object off the desk to the floor and was stopped by the nurse and MHT. Patient #5 was slinging the phone base over the nurse's station. Patient #6 took the phone from Patient #5 and smashed it on the floor. Patient #5 was swinging the phone receiver over the nurse's station. Patient #3 attempted to grab the computer monitor from the nurse's station. Patient #5 continued to swing the phone receiver over the nurse's station. Patient #6 pulled the computer monitor from the nurse's station. 1848 Patient #6 threw the computer monitor on the floor, then stomped on it. Patient #5 tried to pull monitor base out of the nursing desk. A nurse pulled the monitor base from Patient #5. Patient #5 was throwing the phone receiver over the nurse's station like a lasso. Patient #3 grabbed a medical record chart from the nursing station and threw it. Patient #5 continued to twirl the phone receiver over her head. Patients #5 and #3 continued to destroy the medical record. A nurse appeared to speak with the patients in the nurse's station while on the phone possibly calling for more assistance. 1849 Patient #5 swung the phone receiver in and out of the nurse's station and over her head. Patient #6 threw the phone base over the nurse's station. 1850 Patient #3 climbed over the nurse's station, grabbed an I-pad and threw the I-pad and a walkie talkie over her shoulder. Patient #5 attempted to cross over the nurse's station twice. Patient #5 was stopped by an MHT on her second attempt. Patient #4 jumped up on the nurse's station counter. Patient #5 hit a MHT with the phone receiver and continued to swing the receiver over the nurse's station. An MHT removed Patient #4 from the counter. Patient #6 threw an object at the MHT in the nurse's station. An MHT blocked the object and then did a little dance/move. Patient #6 returned to the nurse's station and threw a chart hitting the MHT. Patient #5 continued to swing the phone receiver over the nurse's station at the MHT. Patients #3 and #4 jumped onto the nursing station and stood on the counter. Patient #6 swung the phone receiver and hit the MHT. Patient #5 threw an I-pad and hit the MHT. 1851 Patient #3 climbed onto the copy machine. Patient #5 climbed over the nurse's station counter and entered the nurse's station. Patient #4 threw a computer keyboard on the floor. Patient #6 grabbed a computer keyboard and smashed it against the nurse's station. Patient #3 knocked out ceiling tiles and pulled metal dividers from the ceiling. A nurse removed the metal divider from Patient #3. Patient #5 stood on the nurse's station counter. 1852 Patient #3 continued to knock out ceiling tiles. Patient #20 jumped onto the nursing station counter and sat down. Patient #21 climbed over the nurse's from the adjoining unit. Patient #4 jumped onto the nurse's station. Patient #3 swung from the ceiling. Patients #20, #5, and #4 sat on the counter and watched Patient #3's attempts to climb into the ceiling. 1853 Patient #3 climbed into the ceiling and continued to knock out ceiling tiles. Patient #20 threw a chair out of the nurse's station. An MHT stood behind the nurse's station. Patient #21 attempted to remove a computer monitor from the adjoining nurse's station. 1854 Patient #4 ran across the nurse's station to the adjoining unit to assist Patient #3 in removing the computer monitor. An MHT gave Patient #5 shoes. Patient #20 gave Patient #6 a metal divider. Patient #6 hit an MHT with the metal divider. Patient #5 threw a 3-hole puncher in the air. Patient #4 stood in a rolling chair. Patient #6 entered the nurse's station through the door (it did not appear to be locked) with a metal divider in her hand. Patient #20 threw a metal divider to Patient #5. Patient #4 threw a trashcan over the nurse's station. Patient #20 climbed over the counter, entered the nurse's station and tried to remove the metal monitor base. Patient #5 entered the medication room. Staff #11 appeared to try and redirect the patient. 1855 Staff #11 removed a cell phone, coat and purse and exited the medication room leaving Patient #5 in the room. Patient #21 removed a tray from a drawer in the adjoining nurse's station and threw it. Patient #6 and #4 ran into the medication room (door propped open). Patient #6 smashed an I-pad. 1856 An MHT entered the medication room, stood holding the door open and appeared to try and redirect the patients. Patient #6 used the I-Pad to destroy the Omnicell medication cabinet screen. Patient #4 handed a cup up to Patient #3 in the ceiling. Patient #20 served drinks to the other patients. Patients #4 and #20 exited the nursing station over the counter. 1857 Patient #21 opened another drawer and threw the tray with other items from the drawer. Patient #3 fell from the ceiling onto the nurse's station. Patient #5 attempted to break into the Omnicell with the metal divider. Patients #5 and #6 removed syringes with needles from the countertop in the medication room and opened them. Patient #6 appeared to locate a vial on the countertop and drew contents into a syringe. Patient #5 exited the medication room with two (2) syringes/needles. Patient #3 ran towards the medication room. 1858 Patient #6 walked across the medication room and withdrew water from a pitcher into the syringe. Patient #6 exited the medication room and nurse's station with a syringe/needle and metal divider in her hand. Patient #3 entered the medication room and went behind the door out of camera view. Patient #3 left the medication room holding what appeared to be a medication bag. Patient #21 continued to throw items from the nurse's station. 1859 Patients #20 and #3 opened the medication bag. An MHT's entered from the adjoining unit. Patient #6 attempted to stab the MHT in the neck with the syringe/needle. An MHT placed Patient #6 in a hold and removed the syringe/needle. An MHT exited to the adjoining unit. Patient #6 re-entered the nurse's station through the door (it did not appear to be locked). 1900 Patients #5, #21 and #20 continued to throw items from behind the nurse's station. Patient #6 re-entered the medication room and walked behind the door out of camera view. Patient #4 returned, jumped on the nurse's station and sat on the counter. Patient #3 came back in camera view and appeared to be holding an opened medication bottle. Patient #3 obtained a water bottle and exited the medication room. Patient #3 handed Patient #20 a water bottle and pills (unable to determine if pills were taken as back was to the camera but it did appear that the patient swallowed something). Patient #20 threw pills over the nursing station onto the unit floor in front of the nurse's station. An MHT grabbed the metal divider from Patient #20. Patient #6 exited the medication room holding two pill bottles. Patient #3 re-entered the medication room and walked behind the door out of camera view. 1901 Nurse (from main campus) entered from the adjoining unit. Patient #21 threw charts at the nurse. Patients #3 and #21 removed soda cans from the medication room. Patient #3 exited the medication room holding approximately 4 soda cans. The medication room door was closed. An MHT (from main campus) entered the nurse's station through the door (appeared to enter without use of a key fob/badge), Patient #21 spit soda at the MHT. The MHT removed Patients #3, #6 and #21 from the nurse's station. 1902 An MHT and nurse placed Patient #5 in a hold on the nurse's station counter and removed one of the two syringes/needles. Patient #3 threw an object and hit an MHT in the head. 1903 Staff continued to try and gain control over Patient #5. Patient #3 slung a phone receiver over the nurse's station counter hitting a nurse in the face (nose). MHT's escorted Patient #5 out of the nurse' s station through the door. Patient #6 threw a keyboard striking an MHT. Patient #21 threw an object over the nurse's station striking the nurse in the head. Patient #6 postured to strike an MHT with a metal divider and an MHT removed the metal divider from her hand. Patient #6 fell to the floor. An MHT attempted to redirect Patient #21 (went out of camera view). Patient #21 threw a chart and an MHT re-engaged the patient. 1905 Police arrived and placed Patients #6, #21, #5 and #4 in handcuffs. 1916 The administrator-on-call and chief nursing officer arrived. From 1920 to 2038 the police and emergency medical service were on the unit evaluating and preparing Patients #5, #21, #6, #19, #3, #20 and #4 to exit via stretcher to a local hospital for evaluation due to possible medication ingestion. 2024 The Medical Director arrived on the unit. 2140 The remaining patients were removed from the dayroom and sent to their bedrooms.
Review of the C1-North (adolescent girls) unit staffing census sheets for 12/22/2024 revealed there were two (2) registered nurses and two (2) mental health technicians scheduled to work 8am-8pm and one (1) mental health technician scheduled to work 1pm to 5pm, with a census of eighteen (18) patients. There was one (1) registered nurse, who was also working as the house supervisor and two (2) mental health technicians assigned to work on the adjoining C1-West-A unit (children/littles) with a census of eleven (11) patients.

Review on 01/13/2025 of the medical record for Patient #5 revealed a 15-year-old female presented via law enforcement on involuntary commitment on 12/17/2024 at 1436 with a diagnosis of suicidal ideations (plan to lay in the road to get hit by a car) and self-harm behaviors (cutting wrist with glass). Physician orders on 12/17/2024 at 1641 revealed every 15 minute observations, common area observation, self-harm risk and suicide precautions. Patient #5 had a chemical restraint documented on 12/17/2024 at 2000 for throwing items at staff, pulling the phone and computers at the nursing station and threatening staff. Physician orders on 12/18/2024 at 1052 revealed placement in a room close to the nursing station, reinforce to patient to maintain four (4) foot distance from other patients, re-education with patient on maintaining boundaries, unit restrictions and sexual aggression risk. The patient had a chemical restraint on 12/18/2024 at 1605 for altercations with peer and staff. Additional orders on 12/18/2024 at 2331 revealed elopement risk and unit restrictions. Patient #5 had a chemical restraint documented on 12/20/2024 at 1335 for attacking, yelling and spitting at staff and grabbing items in the nursing station. Physician orders on 12/20/2024 at 2342 revealed block patient room and aggression/homicide precautions. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1815 that Patient #5 was in the dayroom and calm. Further review revealed no 15 minute observation checks documented from 1815 through 2100. At 2106 documentation revealed that Patient #5 had been transported to the Emergency Room. Patient #5 had a physical restraint documented on 12/22/2024 at 1900 for aggression and self-harm with a syringe/needle. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #5 to an outside facility for evaluation of suspected overdose. A behavior management plan was initiated on 12/24/2024 at 1400. Patient #5 had chemical restraints for aggression, destroying property and threatening staff on 12/28/2024 at 2100, on 01/04/2025 at 1912 and on 01/05/2025 at 1520. Review of a Psychiatric Progress note documented on 01/06/2025 revealed "Pt (patient) ongoing aggression and constant conflict with peers. Pt was agitated and assaultive yesterday and required IM (intramuscular) PRN (as needed medications) due to aggression. Pt shows no improvement in mood or insight. Pt was attempting to follow staff through doors this morning. Mood ROS (Review of Systems) severe anxiety Psychosis/Mania ROS aggressive behavior required prn injection, inappropriate with peers, impulsivity. Assessment and Plan: is dangerous to self or others Patient has required or demonstrated: PRN meds in the last 24H (hours) for psychosis or aggression Self-Injury, assault, active SI/HI (suicidal/homicidal ideations) in the last 24 H." Patient #5 was discharged to legal guardian custody on 01/06/2025. Review of incident reports for Patient #5 revealed documentation of aggression on 12/17, 12/18,12/20 (times 2), 12/21, 12/22,12/26, 12/28, 12/31/2024, 01/04 and 01/05/2025. (Total of 11 incidents between 12/17/2024 and 01/05/2025)

Review on 01/23/2025 of the medical record for Patient #21 revealed a 12-year-old female presented via law enforcement on involuntary commitment on 09/27/2024 at 1850 with a diagnosis of Major Depressive disorder. Physician orders on 09/27/2024 at 2046 revealed every 15 minute observations. Physician orders written 09/27/2024 at 2207 revealed placement in room close to the nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries, aggression/homicide precaution, self-harm risk, sexual victimization risk, elopement risk and unit restriction. Review of the History and Physical documented on 09/28/2024 at 0900 revealed that Patient #21 presented with severely aggressive and assaultive behaviors. Patient #21 was transferred from the adolescent girls unit to the children's unit on 10/08/2024 for sexual aggression. Patient #21 had a chemical restraint documented on 10/12/2024 at 1436 for assaulting peers. Physician order on 10/20/2024 at 2231 to block patient room. Review of physician orders dated 12/05/2024 at 0254 revealed place in room close to the nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries and sexual aggression risk. Review of Psychiatric Progress note documented on 12/20/2024 at 0929 revealed "Pt with ongoing mood instability and agitation and is often out of group. Pt has ongoing concerns with poor boundaries but has not had any recent aggressive incidents. Review of Psychiatric Progress note documented on 12/21/2024 at 1111 revealed "Pt states she has been feeling suicidal recently and presents depressive and anxious. Pt with active SI (suicidal ideations) this morning and states she does not want to be alive. Pt with ongoing mood instability and was self-harming per banding her head." Patient #21 had a physical restraint documented on 12/22/2024 at 1840 for aggression/property destruction. Patient #21 had a physical restraint documented on 12/22/2024 at 1850 for aggression/property destruction. Patient #21 had a physical restraint documented on 12/22/2024 at 1902 for aggression/property destruction. Review of a Psychiatric Progress note documented on12/23/2024 at 0959 revealed documentation of Patient #21 involved in riot on the unit on 12/22/2024 and was sent out to the Emergency Department and had not returned. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. A late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #21 to an outside facility for evaluation of suspected overdose. Review of Psychiatric Progress note documented on 12/24/2024 at 0948 revealed "Pt with severe aggressive and assaultive behaviors and riotous behaviors. Pt is refusing to leave her room and is threatening to assault staff and act out again. Pt shows no improvement and has severe behavioral issues." Patient #21 had a chemical restraint on 12/24/2024 at 1415 for self-injurious behaviors. A behavior management plan was initiated on 12/24/2024 at 1500. Physician orders documented on 12/24/2024 at 1601 revealed common area observation, suicide precautions, elopement risk and unit restriction. Review of Psychiatric Progress note documented on 12/26/2024 at 0918 revealed "Pt with severe aggressive ideations and threats towards others. Pt presents severe anxiety and suicidal ideations. Pt has no update at this time and is waiting on news for placement." Review of Psychiatric Progress note documented on 12/27/2024 at 0938 revealed "Pt with severe aggressive ideations and threats towards others. Pt shows no improvements in mood or behaviors and is an ongoing danger towards others and self. Pt with frequent outbursts and threats towards staff." Review of Psychiatric Progress note documented on 12/28/2024 at 0949 revealed case management reached out to group home to determine if admission arrival date was still anticipated for 01/02/2025. Review of Psychiatric Progress note documented from 12/30/2024 through 01/06/2025 revealed no change in Patient #21's mood or behaviors. Patient #21 had a chemical restraint on 12/31/2024 at 1825 for self-injurious behaviors. Review of physician order dated 01/02/2025 revealed room monitor. Review of Psychiatric Progress note documented on 01/08/2025 revealed " ... Pt was agitated and threatening staff yesterday and was attempting to jump the nurse's station, throw paper, and attempts to damage property. Pt was briefly taken off the unit to seclusion and was able to calm down." Patient #21 had a chemical restraint and seclusion on 01/10/2025 at 0935 for aggression. Patient #21 had a physical and chemical restraint on 01/14/2025 at 1245 for aggression. Patient #21 had a physical and chemical restraint on 01/14/2025 at 1316 for aggression and property damage. Patient #21 had a physical restraint on 01/16/2025 at 1430 for aggression and property damage. Review of incident reports for Patient #21 revealed documentation of aggression/self-harm on 10/09,10/12, 10/19,10/29,11/13, 11/15, 12/22,12/24/2024, 01/07 and 01/10/2025. (Total of 10 incidents between 10/09/2024 and 01/10/2025)

Review on 01/14/2025 of the medical record for Patient #3 revealed a 17-year-old female presented via law enforcement on involuntary commitment on 11/16/2024 at 1926 with a diagnosis of Major Depressive Disorder, recurrent. Patient #3 was re-admitted to Hospital A on 12/24/2024 at 1505 after returning from observation admission on 12/22/2024 at Hospital B. Physician orders on 11/17/2024 at 1605 revealed every 15 minute observations ,common area observation, aggression/homicide precautions and suicide precautions. Nursing notes dated 11/27/2024 revealed that Patient #3 was agitated and aggressive to peer and staff. Patient #3 was administered Thorazine and Benadryl. Physician orders on 11/28/2024 at 0204 revealed block patient room. Physician orders dated 12/03/2024 at 1330 revealed place in room close to nursing station, reinforce to patient to maintain 4 foot distance from other patients, re-education with patient on maintaining boundaries, sexual aggression risk and sexual victimization risk. A behavior management plan was initiated on 12/03/2024 at 1200. Nursing note documented on 12/03/2024 at 2240 revealed Patient #3 was involved in altercation with another peer and that staff attempted to remove Patient #3, the patient refused. Patient #3 was involved in a physical altercation with peer on 12/15/2024. Physician orders on 12/16/2024 at 0031 revealed cheeking precautions. Patient #3 was involved in verbal and physical altercation with staff and peer on 12/16/2024. Nursing note dated 12/16/2024 at 2130 revealed that Patient #3 had obtained ink pen caps and placed in pocket. Patient #3 pulled ink pen cap out of pocket and cut her arm. Patient #3 moved to hallway, pulled a 2nd ink pen cap from her pocket making verbal threats of "stabbing" a staff member and then cut self on the neck multiple times. Staff were able to take both ink pen caps from the patient. Review of the 15 minute observation sheet dated 12/22/2024 revealed documentation at 1815 that Patient #3 was in the group room and calm. Further review revealed no 15 minute observation checks documented from 1815 through 2100. At 2103 documentation revealed that Patient #3 had been transported to the Emergency Room. A late entry nursing note was documented on 12/23/2024 referencing the incident that occurred on 12/22/2024. Patient #3 had chemical restraint on 12/26/2024 at 2045 for attempted elopement and aggression. Patient #3 had a chemical restraint documented on 12/29/2024 at 2025 for aggression. Patient #3 was involved in a verbal altercation on 12/30/2024 and on 12/31/2024 Patient #3 removed signs from the unit wall and was not re-directable. Late entry physician order was written on 01/02/2025 for 12/22/2024 to transport Patient #3 to an outside facility for evaluation of suspected overdose. Review of a Psychiatric Progress note documented on 01/02/2025 revealed "Pt (patient) is expecting to discharge today with DSS placement. Pt's DSS and insurance are resistant to discharge due to c

Based on observations, review of policy, and interviews of staff, the hospital staff failed to provide and/or assist with hygiene needs for 1 of 1 patients observed with lack of proper hygiene; and failed to evaluate a patient for falls risk in 1 of 1 patients observed with unsteady gait. (Patient #40).

The findings include:

Observation on 01/13/2025 at 1200 during a tour of a patient care floor revealed Patient #40, drooling and with shaking hands, sitting at a table in the dayroom attempting unsuccessfully to open an orange juice container. Observation revealed Patient #40's medium length brown hair was oily and unbrushed and the front of her shirt had dried stains extending down to her pants. Observation revealed Patient #40 had dried food residue on her mouth and cheeks. Observation revealed Patient #40 was unsteady while walking around the unit.

Review of a policy on 01/13/2025 titled "Nursing Standards of Care" with revision date of 01/20, revealed "POLICY: It is the policy that all patients admitted to (Facility A) will have their nursing care delivered in accordance with established standards of care and practice. It is also policy that these standards be written, objective and used in the measurement of quality care. Assessment: Standard of Care: The patient is assessed by the nurse in a timely, comprehensive, accurate and systematic manner. Standard of Nursing Practice: The nurse continuously and systematically collects, records and analyzes data that are comprehensive and accurate....a. The assessment will include a review of the patient biopsychosocial status, environment self-care abilities deficits....Activities of Daily Living: Standard of Care: The patient can expect direction, assistance and supervision of his/her activities of daily living in supporting and promoting patient independent function in this area."

Review of a policy on 01/13/2025 titled "Fall Prevention" with revision date of 05/22, revealed "(Facility A) assesses all patients' falls risk and implements individuals measures designed to prevent falls and reduce potential injuries. General environmental risks should also be reduced to prevent falls...A fall is defined as an unintentional event that results in a person coming to rest on the ground or other lower level. An unsteady patient who is fully assisted by staff members is not considered a fall...PROCEDURE: Assess all patients Upon Admission. A falls risk assessment is completed to evaluate and identify those patients who may be at risk of falling. The falls risk assessment process provides the nurse with an opportunity to evaluate the patient's potential for falls and allows the nurse to instruct the patient as to his/her responsibilities for preventing falls. All patients will be assessed for fall potential during the Admission process."

Review of a policy on 01/13/2025 titled "Patient's Bill of Rights" with revision date of 06/2016, revealed "As a Patient, you have the right: 1. To considerate and respectful care in a safe environment with respect to personal dignity, values, beliefs, privacy, humane care, freedom from mental and physical abuse, neglect and exploitation, and to live as normally as possible while receiving treatment."

Review of an open medical record on 01/15/2025 revealed Patient #40 was a 41 year old female who was transferred from an outside facility with IVC (involuntary commitment) orders for admission on 01/02/2025. Patient #40 had not slept in 4 days and was noted to be paranoid (suspicious), anxious (worried), and disorganized at the time of her presentation to the facility. Review of the daily nurse progress notes revealed Patient #40 was "independent" of ADL's (Activities of Daily Living: Bathing). Review of the medical record from 01/02/2025 through 01/13/2025 revealed no documentation of a shower/bath or hygiene. Review revealed no documentation of a falls risk.

Interview on 01/13/2025 at 1205 with Staff #49 revealed Patient #40's hair looked "unwashed" and needed attention. Interview revealed patients were evaluated for falls risk upon admission. Interview revealed no falls evaluation on Patient #40 was documented in the medical record.

Interview on 01/13/2025 at 1500 with Staff #9 revealed Patient #40 should have been evaluated for a falls risk upon admission and a shower chair should have been ordered for safety in the shower.

Based on review of hospital policies, medical records and staff interviews, the hospital failed to ensure an accurate medical record by failing to document a change in physical status and procedures performed during an emergency medical situation for 1 of 2 patient deaths reviewed (Pt #1).

The findings include:

Review on 01/15/2025 of hospital policy "Code Blue (a life-threatening medical emergency) Procedure," last reviewed 01/2020, revealed, "... The nurse will complete the Code Blue Record including the names of those who participated in the code ... The 'Change in Physical Status' form will be completed by the nurse documenting events occurring up to the initiation of the Code Blue Procedure and placed in the patient's chart ..."

Review on 01/15/2025 of hospital policy "Change in Physical Status," last reviewed/revised 03/01/2021, revealed, "... 2. The Licensed Practical Nurse (LPN) shall: ... a. Observe individuals for any changes in physical status ... c. Document observations and communications to the RN (Registered Nurse) or physician in a progress note ... 3. The RN (Registered Nurse) shall: ... Document an initial nursing progress note briefly describing the individual's change in physical status ..."

Closed medical record review on 01/08/2025 for Patient #1 (Pt) revealed a 39-year-old male who arrived to the hospital on 06/06/2024 at 0248. Review of the Intake Assessment at 0321 revealed the patient presented for a suicide attempt by overdose on Keppra (a seizure medication) and other unnamed psychotropic medications (medications used to treat mental health conditions). Review of the Intake Assessment revealed the On-Call Provider was notified at 0340. Record review revealed Pt #1 was admitted at 0410 with a diagnosis of major depressive disorder and alcohol use. Review of the Vital Signs at 0530 revealed a blood pressure of 117/77 (below 120/80 is considered normal blood pressure), a respiratory rate of 19 (normal range is 12 to 20), a heart rate of 69 (normal range is 60 to 100), and an oxygen saturation (level of oxygen in the blood) of 98 percent (normal range is 95 to 100 percent). Review of the Nurse Note on 06/06/2024 at 1630 revealed, "... Responded to call by the unit LPN of patient being unresponsive in the room at around 1020 hrs (hours). Code blue called. Found patient partially face down tilted to the left side, called on patient, unresponsive to touch & (and) shake. Checked for pulse but unpalpable. Turned patient supine (onto back) and initiated chest compression (sic). As help arrives including code cart connected the pads and the AED machine (Automated External Defibrillator- used to treat a person whose heart has stopped) as compression was ongoing. Called for ambubag (a mask and bag used to deliver oxygen or air to a person) & (and) yankauer (suction tip) for suction as foam was coming out of his mouth and nostril. (Staff #18) managing airway, (Staff #19) assisting with chest compression. (Staff #18) obtained pulse during CPR (Cardiopulmonary Resuscitation) unable to obtain blood pressure. Oxygen saturation 69 % (percent) on machine. EMS (Emergency Medical Services) arrived and took over the CPR. The EMS continued with CPR and later pronounced time of death as 1052 hours." Review of the Medicine Consult Note, no date or time documented, revealed, "I heard the code called at 10:33am ... Pt was unresponsive and cynotic (sic) with extremities purple blue and face blue ... he was unresponsive, not breathing and does not have a pulse. I assisted with three person CPR ... Eyes were dilated with minimal reaction to light ... I continued to open the patient's airway with minimal success due to patient's jaw being locked due to rigor (stiffening of the joints and muscles after death). 1x (One time) narcan (a medication that can reverse the effects of narcotics in an emergency situation) 0.4mg (milligrams) provided at appx (approximately) 1042am. EMS arrived appx 1045 and handoff was performed and my care of the patient ended." Review of the Discharge Summary on 06/17/2024 at 0428 revealed, "... the patient was pronounced dead at approximately 10:50 ... Upon approach, he was found to be lying in bed, face down. As writer entered the room, staff did turn the patient over and noted him to be stiff and purple/blue in his extremities. He was nonverbal. His eyes were not reactive to light. He remained unresponsive throughout CPR ..." Medical record review failed to reveal a Code Blue Form, a Change in Physical Status Form or a Progress Note at the time of the Code Blue.

Interview on 01/09/2025 at 1200 with Staff #20 revealed there was no additional Code Blue documentation for Pt #1. Interview revealed all Code Blue documentation should have been placed in the patient's medical record.

Interview on 01/14/2025 at 1021 with Staff #49 revealed hospital staff were expected to document Code Blue information on the Code Blue Form. Interview revealed Code Blue documentation should have been reviewed by the unit manager and placed in the patient's medical record.

Based on review of hospital policy, medical records, and staff interviews, the hospital failed to ensure a discharge summary was completed within 30 days following discharge for 4 of 59 sampled closed medical records reviewed (Pt #9, #35, #10, #34).

The findings include:

Review on 01/24/2025 of hospital policy "Medical Records Completion," last revised 11/2023, revealed, "... Discharge Summaries must be dictated within thirty days from the date of discharge ..."

Review of the Medical Staff Rules and Regulations adopted 01/29/2024 revealed, "... 5.3.2 Member and Provider Responsibility for Medical Record Providers are responsible for ensuring that the following are dated, documented legibly, and in chronological order in each patient's medical record: ... diagnoses at the time of discharge. Members must complete the discharge summary within 30 days of discharge. ..."

1. Closed medical record review on 01/09/2025 for Pt #9 revealed a 32-year-old patient who was involuntarily committed on 05/11/2024 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave) and increased aggression (violent attacking behavior or attitude toward another person) with staff at his group home. Pt #9 was discharged to a shelter on 05/20/2024. Record review failed to reveal a Discharge Summary for Pt #9.

Interview on 01/14/2025 at 1612 with Staff #53 revealed the Discharge Summary for Pt #9 had been dictated but had not yet been sent to the facility to be printed. Staff #53 was unable to provide evidence of what had been dictated.

Interview on 01/24/2025 at 1130 with Staff #9 revealed Discharge Summaries should be completed within 30 days of discharge for all inpatients.

2. Closed medical record review on 01/09/2025 for Pt #10 revealed a 27-year-old patient who was involuntarily committed on 10/25/2024 with a diagnosis of schizophrenia with aggressive behaviors and homicidal ideations (HI - harming others). Discharge Summary: Disposition and After Care revealed, "no disposition or aftercare follow-up appointment was found in the chart." Pt #10 was discharged on 11/05/2024. Record review revealed the Discharge Summary was dictated on 12/27/2024 (52 days after discharge).

Interview on 01/09/2025 at 1014 with Staff #8 revealed the discharge paperwork regarding Pt #10's disposition and aftercare should be in the chart, but it was not. Staff #8 was able to locate an appointment that had been made for Pt#10 at an outpatient clinic but was unsure of the date or time.

Interview on 01/24/2025 at 1130 with Staff #9 revealed Discharge Summaries should be completed within 30 days of discharge for all inpatients.

Staff #35, who assisted with Pt #10's discharge, no longer worked at the facility.



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3. Closed medical record review on 01/15/2025 for Patient #35 (Pt) revealed a 44-year-old male admitted to the hospital on 09/25/2024 at 2308 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Pt #35 was discharged home on 10/10/2024 at 1420. Record review failed to reveal a Discharge Summary for Pt #35.

Interview on 01/24/2025 at 1130 with Staff #9 revealed Discharge Summaries should be completed within 30 days of discharge for all inpatients.

4. Closed medical record review on 01/15/2025 for Patient #34 (Pt) revealed a 27-year-old male admitted to the hospital on 09/28/2024 at 1235 with a diagnosis of substance abuse and major depressive disorder. Pt #34 was discharged home on 10/04/2024 at 1117. Record review revealed the Discharge Summary was dictated on 11/17/2024 (44 days after discharge).

Interview on 01/24/2025 at 1130 with Staff #9 revealed Discharge Summaries should be completed within 30 days of discharge for all inpatients.

Based on review of hospital policy, video review and staff interviews, the hospital failed to ensure that medications were kept in a secure area.

The findings include:

Review of hospital policy, "Medication Administration", revised 05/2022, revealed "Procedure ... 20. Staff will never leave the Medication Cart or Medication Room unlocked. ...".

Review of hospital policy, "Medication Management", revised 09/2020, revealed "Procedures for Children's Hospital ... 5.1 The intake staff will record home medications taken into custody at the time of admissions. ... 5.2 The intake staff will place patient home medications in a tamper-resistant security bag with a copy of the inventory form attached to the outside. The bag will be sealed and taken to the unit where the patient is admitted and given to the floor nurse ... 5.3 The nurse will secure the bag in the cabinets located in the medication rooms. These cabinets are kept locked when not in use. ..."

Review of hospital policy, "Medication Rooms Access and Key Control", revised 01/2020, revealed "Policy ... implement appropriate measures to ensure only authorized individuals have access to the unit medication room.

Video review on 01/08/2025 at 1445 of an incident that occurred on 12/22/2024 at 1830 revealed the medication room door was propped open. Review of the video revealed syringes with needles and an unknown medication vial were left unsecured on the medication room countertop.

Interview on 01/10/2025 at 1120 with Staff #1 revealed that the pharmacy was not notified of the medication room breach until Monday 12/23/2024. Staff #1 assessed the C1-North/C1-West-A medication room on 12/23/2024 and retrieved a plastic tray that had home medication bottles that had been picked up from the unit/unit floor after the incident. The pharmacist identified a bottle of Concerta (medication used to treat attention deficit disorder) that should have had 12 pills, only had 8 (4 pills missing) and Clozapine (antipsychotic medication used to treat schizophrenia that should have had 21 pills (21 pills missing). Staff #1 indicated that the pharmacist working on 12/22/2024 made rounds on the unit and saw the medication room door propped open, shut the door and told the staff that the door could not be propped open. Interview revealed the medications, syringes and needles should have been locked in the cabinets in the medication room and not accessible to patients.

Interview on 02/04/2025 at 1115 with Staff #78 revealed that during pharmacy rounding on 12/22/2024, the medication room door on C1-North Adolescent female unit/C1-West-A was propped open with a trashcan. Staff #78 removed the trashcan and closed the medication room door. Interview revealed there were no unit staff present to tell to keep the door closed at all times. Interview revealed that the medication room door should be locked and closed at all times.

Based on observations, review of policy and procedures, medical record review patient and staff interviews facility failed to maintain a clean and sanitary environment by not ensuring patient group dayrooms were free of pest (1 East); failing to ensure a Patient's room was free of ants (patient #7 -1 West); and failing to provide an environment that was free of dirt, dust, stains, paper trash, and holes in the dry wall for 3 of 9 units toured (1 East, 1 West and 2NB - main campus).

The findings include:

1. Observation on 01/13/2025 at 1340 during tour of the 1 East Unit revealed upon arrival to the unit there were patients in the hallway and patients in the group dayroom. This surveyor entered the dayroom. Patient #47 stepped inside the dayroom from the hallway and stated, "there are roaches crawling all behind there" and pointed to the coffee machine on the counter. An unnamed female patient spoke up and stated, "yeah they are always crawling along down there" and pointed to the floor base of the cabinet and the floor. After this surveyor moved the coffee machine forward, observation revealed large and small roaches crawling on the back of the countertop. Observation to the counter base at floor level revealed dirt and a sticky floor. Observation revealed 2 large bowls of fruit (oranges) at the end of the countertop.

Interview on 01/13/2025 at 1345 with Staff #22 revealed when this surveyor asked if staff #22 saw the roaches behind the coffee machine, staff #22 stated "they're there."

Interview on 01/13/2025 at 1347 with patient #47 revealed the patient was admitted to 1 East on 01/10/2025. Interview revealed the patient observed roaches when the patient first arrived in the unit. The patient stated "I spoke to the staff RN (Registered Nurse) about it. I killed it and showed it to her. I was told to throw it away." Interview revealed patient #47 identified the RN as staff #25. Interview revealed roaches were everywhere in the fruit bowls on the counter, on the sugar packs and ice machine.

Interview on 01/13/2025 at 1510 with staff #25 revealed, when asked by surveyor regarding a patient showing staff #25 a dead roach, staff #25 instructed the patient to throw the roach away. Staff #25 replied "she told me but I don't remember seeing one. There were several staff around and someone said '"throw it away."' Interview revealed staff #25 stated "I did not say that."

Review of a hospital policy titled "DAILY CLEANING PROCEDURES ...DISTRIBUTION: HOUSEKEEPING DEPARTMENT with the latest revised date of 06/2020 revealed, " POLICY In order to maintain the hospital facilities in a clean, sanitary, orderly and attractive condition and to provide a suitable environment for the care of patients ...the following procedures have been identified .....CLEANING PROCEDURES ...4. Cabinets and Cupboards: Clean on the outside with Neutral Disinfectant Cleaner ...Clean tops underside and knobs, ...."

Review of hospital policy titled "FUNCTION OF HOUSEKEEPING with a reviewed date of 01/2023 revealed, "...POLICY ...to maintain a clean and comfortable environment for patients, employees, medical staff and general public ....PROCEDURE ...The responsibilities of Environmental Services Manager and Lead Housekeeper are: 1. To establish a current, written organizational plan outlining the care and cleaning of the facility ....5. To regularly review the performance of housekeeping personnel through evaluations of quality and quantity ....6. To maintain adequate communication with all other departments and personnel in the facility through inspections and meetings."

Review of documentation titled "ENVIRONMENTAL SERVICES SUPERVISORY INSPECTION FORM" for the 1 East Unit was reviewed for the sampled months 06/2024 - 12/2024. Review revealed inspections were to be conducted daily on the 1 East Unit and any issues or concerns were to be reported to the attention of the supervisor. Review revealed staff documented concerns with check marks in the "No" column, written comments in the comment column and comments at the bottom of the form for the following dates: June and July, 2024 "EATING IN DAY ROOM (MEALS) ...MEALS ATE IN DAY ROOM; August 2024 patients were eating meals in the dayroom; September 2024 staff documented at bottom of form "StAff still Allowing pAtients to EAt in Rooms. Ants in Room 105" Review of a second inspection form for September and October, 2024 revealed all the meals were eaten in the dayroom/ unit; October 2024 revealed staff document at the bottom of the form the patient continue to eat in "Rooms" Review revealed for November 2024 staff documented on inspection form staff "has a hard time cleaning the day room. Patients do not leave ... (staff #49) ...is aware) ...Eating in rooms causing Ants" Review of December 2024 inspection form revealed staff documented "How can we stop patients from eating in rooms ....How can we get the dayroom for at least 45 mins to clean ....How can we get staff to help with after meals clean up" Review of a second December inspection form revealed staff documented for the dayroom/patient chairs, tables ...Roaches, Food Eating All meals ...Patient do not leave Day room."

2. Medical record review on 01/11/2025 revealed Patient #7 a 35 year old male was IVC'd and admitted to the hospital on 08/12/2024 at 1949. Review of the "HISTORY AND PSYCHIATRIC EVALUATION" by staff #66 dated 08/13/2024 at 1200 revealed Patient #7 was non-compliant with medication and was IVC'd because he threatened family with a knife. Further record review revealed Patient #7 was admitted to the 1 West Unit. Review of "Psychiatric Progress Note by staff #72 dated 08/17/2024 at 1400 revealed 5 days after admission Patient #7 complained of itching to his left arm and patient stated, "felt like an insect bite." Review revealed Patient #7's "L (Left) arm appeared red." Review of a Psychiatric Progress note by staff #72 dated 08/20/2024 at 1535 revealed Patient #7 reported something was biting him on his L arm and it makes him upset." Continued review revealed staff #72 placed an order for a Medical Consult. Review of a "Medicine Consult Note" by staff #18 dated 08/21/204 at 1600 under the HPI (History of Present Illness) section revealed Patient #7 reported " ...a spreading vesicular (small fluid filled blister) rash over his abdomen that started 3d (days) ago. 2d ago it came on his arm. Yesterday it spread to his leg. sx (symptom) include pruritic (itching) ...has not tried anything" "Physical Exam" revealed "Several viscous in a linear fashion on umbilical region several viscous grouped on the back of R (right) leg open superficial abrasion on L forearm ....Impressions/Recommendations ...Arthropod (insect) bites: -acute, no s/s (signs and symptoms) infectious. Add hydrocortisone (itching relief medication) TID (three time a day) prn (as needed) for sx (symptom) relief"

Interview on 01/14/2025 at 1249 with staff #73 revealed Patient #7 was admitted to the unit in room 117 near the nursing station. Interview revealed the patient complained he was bitten by ants in his room. A medical consult was done for staff #18 and the results was a red rash. Interview reveal staff #73 called in a work order for maintenance and notified staff #23. Interview revealed maintenance arrived immediately and sprayed the patient's room.

Interview on 01/15/2025 at 1125 with staff #72 revealed staff #72 observed patient #7's arm was swollen and had a rash. Interview revealed staff #18 observed patient #7's arm, stomach and legs regarding the rash. Interview revealed staff #73 called maintenance regarding bugs in patient's room.



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3. Observations on 01/13/2025 at 1145 through 1245 during a tour of a patient care floor (2NB Main campus) revealed dried splatter stains on the wall near the phone in the day room. Observation revealed 3 (three) spots of drywall missing exposing the inside of the wall. The areas of the wall were various sizes with the dust of the damaged walls observed on the floor beneath the damaged wall. Observation of the chairs in the day room revealed trash beside the cushions of the chairs. Observation of the nurses desk revealed a wood like board under the nurses desk on the floor with protrusions of 4 nails on the board. Observation revealed multiple wires exposed on the wooden box attached under the desk. Observation revealed when the board was removed, a layer of dust was found under the board with a penny and a bead.

Review on 1/16/2025 of the procedure titled "...Environmental Services: Daily 7 step Cleaning & Sanitizing Procedure" with revision date of 08/13/2024 revealed "The seven-step cleaning process includes emptying the trash; high dusting; sanitizing and spot cleaning; restocking supplies; cleaning the bathrooms; mopping the floors; hand hygiene and inspection. 1. Pull trash--daily. 2. High Dust--Twice weekly. 3. Damp wipe--daily. 4. Clean/sanitize bathroom--daily. 5. Ice Machines--Daily. 6. Floor Care---daily. 7. Inspect the room--daily. Report any needed repairs. Correct any deficiencies...."

Interview on 01/16/2025 at 1615 with Staff #23 revealed "painters arrive every 2.5 weeks per the contract for repairs." Interview added more employees are needed to cover the facility. "There is only one supervisor and not enough of us to get around for inspections. It is a challenge to get around for inspections."

Interview on 01/16/2025 at 1145 with Staff #49 revealed the concerns should have been reported when found. Interview revealed the repairs were needed soon for safety.

Based on observations and staff interviews facility failed to prevent and control the transmission of infection by failing to remove chairs with torn seat coverings from patient use for 2 of 3 patient group dayrooms (2 West, 1 East) on the main campus and 2 of 3 units toured on the Childrens campus (C1 West adolescent female unit and C1 North children's unit).

The findings include:

1. Observation on 01/08/2025 at 1130 during tour of the 2 West Unit revealed male and female behavioral health patients in the group dayroom. Observations revealed 20 patients gathered in the dayroom for a Recreational Therapy session and later patients exited the dayroom. This surveyor asked the staff to move the chairs away from the wall and windows. Observation revealed the seat coverings were cracked and peeling. Further observation revealed 4 of 26 chairs had large tears to the seat cushions. Observation revealed the floor was black, dirty with grit and was sticky.

Interview with staff #23 and staff #24 on 01/09/2025 at 1413 revealed per staff #23 housekeeping staff had a difficult time cleaning the dayrooms because the unit staff does not always take the patients off the unit to the cafeteria. Review revealed the cleaning staff had a difficult time cleaning the dayrooms Review reveal per staff #24 the dayroom not being clean is a infection cross-contamination problem.



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2. Observation of C1 West (adolescent female unit) on 01/09/2025 at 1545 revealed 3 chairs with large areas of outer covering exposed to reveal fabric underneath in the activity room.

3. Observation of C1 North (children's unit) on 01/09/2025 at 1510 revealed 5 chairs with holes with fabric underneath exposed, red dried substance on a wall and floor and sink area with exposed pegs under the sink in the large activity room.

Interview on 01/09/2025 at 1545 with leadership staff during the tour confirmed the chair covers were torn and had holes in them making it difficult to clean the chairs.

Based on review of hospital policies, medical records and staff interviews, hospital staff failed to demonstrate and document the degree and intensity of the individualized treatment provided to behavioral health patients.

The findings include:

1. Hospital staff failed to ensure a Master Treatment Plan was completed and/or updated for 21 of 72 medical records reviewed (Pt #34, #35, #39, #52, #54, #59, #44, #46, #19, #40, #24, #26, #10, , #39, #12, #25, #28, #31, #14, #68 and #16).

~cross refer to 482.61(c)(1) Treatment Plan: Tag A1640

2. Hospital staff failed to ensure short-term and long-range goals were completed and/or updated for 8 of 72 medical records reviewed (Pt #12, #31, #32, #25, #29, #28, #14 and #38).

~cross refer to 482.61(c)(1)(ii) Treatment Plan - Goals: Tag A1642

3. Hospital staff failed to ensure a Master Treatment Plan with specific treatment modalities were completed and/or updated for 8 of 72 medical records reviewed (Pt #12, #31, #32, #25, #29, #28, #14 and #60).

~cross refer to 482.61(c)(1)(iii) Treatment Plan - Modalities: Tag A1643

4. Hospital failed to ensure treatment team responsibilities were completed for 11 of 72 medical records reviewed. (Pt #12, #31, #32, #25, #29, #28, #14, #59, #54, #38, and #9).

~cross refer to 482.61(c)(1)(iv) Treatment Plan - Team Responsibilities: Tag A1644

5. Hospital staff failed to document daily group therapy for 4 of 72 medical records reviewed (Pt #52, #35, #34, #33).

~cross refer to 482.61(c)(2) Document Therapeutic Efforts: Tag A1650

6. Hospital staff failed to ensure Social Services Progress Notes were completed for 11 of 72 medical records reviewed (Pt #34, #35, #54, #9, #10, #30, #39, #67, #25, #28, #16).

~cross refer to 482.61(d) Recording Progress Notes: Tag A1655

7. Hospital failed to ensure patients received follow up appointments and prescriptions prior to patients being discharged for 3 of 59 sampled closed medical records (Pt #60, #68, #36).

~cross refer to 482.61(e) Discharge Summary - Recommendations: Tag A1671

Based on review of hospital policies, medical records and staff interviews, hospital staff failed to ensure a Master Treatment Plan was completed and/or updated for 21 of 72 medical records reviewed (Pt #34, #35, #39, #52, #54, #59, #44, #46, #19, #40, #24, #26, #10, , #39, #12, #25, #28, #31, #14, #68 and #16).

The findings include:

Review on 01/23/2025 of hospital policy "Interdisciplinary Patient-Centered Care Planning," last reviewed on 04/2024, revealed, "... Developing the Treatment Plan ... 4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan ... The treatment team will complete the MTP (Master Treatment Plan) including: ... b. Completion of Individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem, specific behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention ... Interdisciplinary Treatment Plan Update ... 1. ... The treatment team, including the patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum of every (7) seven days after the completion of the Master Treatment Plan ... The following would be cause for conducting a review of the plan and developing a revision: ... A new impairment/problem ... 2. ... a. ... Once a goal has been resolved, the date will be identified on the treatment plan ... c. Staff members, upon discharge, shall either document on remaining goals the date if resolved or 'ongoing' meaning that the problem has not yet been resolved ..."

Review on 01/24/2025 of hospital policy "Documentation Requirements In The Medical Record," last revised 11/2023, revealed, "... Treatment Plan ... 14. Behavior management plans shall be written as part of the Treatment Plan ..."

1. Closed medical record review on 01/15/2025 for Patient #34 (Pt) revealed a 27-year-old male admitted to the hospital on 09/28/2024 at 1235 with a diagnosis of substance abuse and major depressive disorder. Review of the Nurse Note on 09/29/2024 at 2000 revealed, "Pt. was transferred today ... because of inappropriate sexual contact with a female pt ..." Review of the medical record revealed a blank Interdisciplinary MTP. Record review failed to reveal documentation of a MTP, a Behavior Management Plan or Individual Problem Sheets during Pt #34's admission (6 days). Pt #34 was discharged home on 10/04/2024 at 1117.

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should have been completed within 72 hours of admission and signed by the Therapist, RN (Registered Nurse), and the Provider.

Interview on 01/24/2025 at 1340 with Staff #9 revealed there was no MTP, Individual Problem Sheets, or a Behavior Management Plan completed for Pt #34. Interview revealed the MTP should have been initially developed and then updated after an event occurred if the problem was not previously included in the MTP. Interview revealed a Behavior Management Plan should have been completed within 24 hours the event as part of the treatment plan.

2. Closed medical record review on 01/15/2025 for Patient #35 (Pt) revealed a 44-year-old male admitted to the hospital on 09/25/2024 at 2308 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Review of the MTP on 09/26/2024 revealed, "Problem #1: Psychosis (loss of contact with reality) ... Problem A: HTN (hypertension- high blood pressure) ... Problem B: Diabetes (when the body doesn't produce insulin properly) ..." Review of the Medical Problem Sheet failed to reveal a target date for the problem of diabetes. Review of the Medical Problem Sheet failed to reveal if Pt #35's goals were achieved for the problems of diabetes and HTN. Record review failed to reveal documentation of an Individual Problem Sheet for Psychosis during Pt #35's admission (14 days after the MTP was initiated). Review failed to reveal evidence of a MTP update during Pt #35's admission (14 days after the MTP was initiated). Pt #35 was discharged home on 10/10/2024 at 1420.

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be updated every 7 days and signed by the Therapist, RN, and the Provider.

Interview on 01/24/2025 at 1340 with Staff #9 revealed there was no Psychiatric Problem Sheet and no MTP update completed for Pt #35. Interview revealed that each short term goal on the Problem Sheets should have documentation of the date the goal was achieved or the goal should be documented as discontinued on the date of discharge.

3. Closed medical record review on 01/15/2025 for Patient #33 (Pt) revealed a 47-year-old female admitted to the hospital on 09/26/2024 at 2209 with a diagnosis of schizophrenia. Review of the Nurse Note on 09/29/2024 at 1800 revealed, "This patient came to the Nurses station about 1800 ... told Charge RN (Registered Nurse) and LPN (Licensed Practical Nurse) that the male patient that she was sitting by on Sat (Saturday) 9/28/2024 in the day room ... made sexual advances towards her ..." Review of the MTP, initiated on 09/27/2024 revealed, "Problem #1: SI (Suicidal Ideation- thoughts of suicide) ... Problem #2: AVH (auditory and visual hallucinations) ... Problem A: Asthma ..." Review of the Medical Problem Sheet failed to reveal a target date or if Pt #33's goals were achieved for the problem of asthma. Review of the medical record failed to reveal documentation of a Behavior Management Plan or Individual Problem Sheets for SI and AVH during Pt #33's admission (5 days after the MTP was initiated). Pt #33 was discharged home on 10/02/2024 at 2254.

Interview on 01/24/2025 at 1340 with Staff #9 revealed there were no Psychiatric Problem Sheets completed for Pt #33. Interview revealed the MTP should have been updated after an event occurred if the problem was not previously included in the MTP. Interview revealed a Behavior Management Plan should have been completed within 24 hours of the event as part of the treatment plan. Interview revealed that each short term goal on the Problem Sheets should have documentation of the date the goal was achieved or the goal should be documented as discontinued on the date of discharge.

4. Closed medical record review on 01/21/2025 for Patient #52 (Pt) revealed a 26-year-old male admitted to the hospital on 01/05/2025 at 1649 with a diagnosis of bipolar disorder (a condition that causes extreme mood swings). Review of the Individual Problem Sheet failed to reveal documentation of the date Pt #52's goals were achieved or discontinued. Pt #52 was discharged home on 01/15/2025 at 1016.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that each short term goal on the Problem Sheets should have documentation of the date the goal was achieved or the goal should be documented as discontinued on the date of discharge.



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5. Open medical record review of Patient #54 revealed a 36-year-old female involuntarily committed on 01/01/2025 for suicidal ideation. Review of the Master Treatment Plan (MTP) revealed a completion date of 01/05/2025 (4 days after admission). Review of the updated MTP revealed it was updated and signed 01/17/2025 (12 days after initial MTP). Record review revealed the patient was discharged 01/17/2025. Record review revealed the MTP was not completed within 72 hours and the updated MTP was not updated every 7 days per the facility policy.

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be completed within 72 hours and updated at a minimum of every 7 days after initial completion.

6. Closed medical record review of Patient #59 revealed a 39-year-old male involuntarily committed on 10/03/2024 for suicidal ideation. Review of the Master Treatment Plan (MTP) revealed a completion date of 10/07/2024 (4 days after admission). Record review revealed the patient was discharged 10/10/2024. Record review revealed the MTP was not completed within 72 hours per the facility policy.

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be completed within 72 hours.

7. Closed medical record review of Patient #44 revealed a 27-year-old female involuntarily committed on 10/04/2024 for suicidal ideation. Review of the Master Treatment Plan (MTP) revealed a completion date of 10/08/2024 (4 days after admission). Record review revealed the patient was discharged 10/09/2024. Record review revealed the MTP was not completed within 72 hours per the facility policy.

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be completed within 72 hours.

8. Closed medical record review of Patient #46 revealed a 22-year-old male involuntarily committed on 09/30/2024 for psychosis. Review of the Master Treatment Plan (MTP) revealed a completion date of 10/03/2024. Record review revealed the patient was discharged 10/16/2024. Record review did not reveal an updated MTP (due 10/10/2024). Record review revealed the MTP was not updated every 7 days per the facility policy.

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be updated at a minimum of every 7 days after initial completion.



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9. Closed medical record review on 01/09/2025 for Patient #19 revealed a 14-year-old female voluntary admitted to the facility on 12/17/2024 at 1813 with a diagnosis of Major Depressive Disorder and suicidal ideations. Review of the medical record revealed no evidence of an initial Master Treatment Plan (MTP) documented by the facility staff. Patient #19 was discharged to home with family on 12/23/2024 at 2000.

Interview on 01/23/2025 at 1150 with Staff #8 revealed that the initial master treatment plan should be completed within 72 hours of admission and updated every seven days.



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10. Open medical record review on 01/15/2025 of Patient #40 revealed a 42-year-old female admitted on 01/02/2025 at 1410 with a diagnosis of Bipolar disorder (a condition that causes extreme mood swings) and unspecified psychosis not due to substance abuse. Review revealed Patient #40 had not slept in 4 days and had paranoid (suspicious), anxious (worried) and disorganized thoughts. Review of the medical record revealed a blank Interdisciplinary MTP (Master Treatment Plan). Patient #40 remained as an inpatient at the facility on 01/17/2025.

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should have been completed within 72 hours of admission and signed by the Therapist, RN (Registered Nurse), and the Provider.

11. Closed medical record review on 01/13/2025 of Patient #24 revealed a 44 year-old female involuntarily committed on 09/30/2024 for psychosis. Review of the MTP revealed only facility signatures on 10/2/2024 and 10/4/2024 with the remaining portions of the MTP blank. Record review revealed the patient was discharged 10/11/2024. Record review did not reveal a completed MTP.

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be initiated within 72 hours and updated at a minimum of every 7 days after initial completion.

12. Closed medical record review on 01/14/2025 of Patient #26 revealed a 60 year old male voluntarily admitted on 07/08/2024 for Bipolar disorder with suicidal ideations (thoughts) with a plan to electrocute himself. Review revealed no MTP in Patient #26's medical record. Patient #26 was discharged on 07/14/2025.

Interview on 01/16/2025 at 1200 with Staff #9 revealed Patient #26 MTP could not be located. Interview revealed policy was not followed for a MTP to be initiated within 72 hours.



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13. Closed medical record review on 01/09/2025 for Pt #10 revealed a 27-year-old patient who was involuntarily committed on 10/25/2024 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave) with aggressive behaviors and homicidal ideations (HI - harming others). The Interdisciplinary Master Treatment Plan (MTP) was signed by the Psychiatrist, Therapist, Nurse, and Pt #10 on 10/28/2024. MTP Problem #1 was listed as HI with an update due on 11/04/2024. Pt #10 was discharged on 11/05/2024. Review failed to reveal an update to the MTP or a Behavior Management Plan (BMP). Review also failed to reveal evidence of a discussion with Pt #10's legal guardian regarding the MTP.

Interview on 01/10/2025 at 1014 with Staff #8 revealed Pt #10's MTP should have been updated on 11/04/2024 even if he was discharged the next day. Staff #8 revealed Staff #35 was in touch with Pt #10's legal guardian and might not have gone back in the medical record to sign the guardian's acknowledgment of the MTP. Staff #8 acknowledged the MTP should have been updated for aggression due to Pt #10's behavior while at the facility, and Staff #8 would have expected to see a BMP as well.

14. Closed medical record review on 01/14/2025 for Pt #39 revealed a 43-year-old patient who was involuntarily committed on 10/05/2024 with a diagnosis of schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave) and antisocial personality disorder (a disorder characterized by impulsive and irresponsible behavior). The MTP was signed by the Psychiatrist, Therapist, Nurse, and Pt #39 on 10/08/2024. MTP Problem #1 was listed as AH/VH (auditory/visual hallucinations), and MTP Problem #2 was listed as substance use, with an update due on 10/13/2024. MTP Psychiatric Problem Sheets initially listed 10/13/2024 as the target date for weekly updates, but this date was marked out and handwritten as 10/20/2024 instead. A MTP update was signed by the Psychiatrist on 10/17/2024, the Nurse on 10/18/2024, and the Therapist, with no date listed for the Therapist's signature (9 days after the MTP was initiated); the next update due was listed as 10/20/2024. An additional problem sheet for aggression requiring use of chemical restraint was created on 10/28/2024. Pt #39 was discharged to a shelter on 11/02/2024 at 1100. Record review failed to reveal evidence of a MTP update following the 10/17/2024 update during Pt #39's admission (16 days after the first update) and failed to reveal evidence of a BMP.

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be updated at a minimum of every 7 days after initial completion.

Interview on 01/24/2024 at 1419 with Staff #70 revealed MTPs are based off what the issue was from admission or the Provider's History and Psychiatric Evaluation of the patient. Staff #70 revealed the MTP updates would focus on these problems and would not add anything else to the problem sheet(s). Staff #70 was not aware of a BMP being completed.



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15. Open medical record review on 01/08/2025 for Patient #12 revealed a 15-year-old female admitted to the facility on 08/09/2024 with severe psychosis (disconnection with reality) and selective mutism (inability or unwillingness to speak) refractory (resistant) to medication treatment. Review of the medical record revealed that there was no Master Treatment Plan (MTP) found in the medical record. Patient #12 was discharged on 01/10/2025.

Interview on 01/24/2025 at 0905 with Staff #53 revealed that in regard to Pt #12, "I checked and there is no Master Treatment Plan or problem sheets". She further stated that all six charts (belonging to Patient #12) were reviewed and no MTP was found.

16. Closed medical record review on 01/14/2025 for Pt #25 revealed a 27-year-old male admitted to the facility on 09/13/2024 for psychosis and suicidal ideation (thoughts to hurt self) with a plan. Review of the medical record revealed there was no MTP or MTP updates found in the medical record. Patient #25 was discharged on 10/03/24.

Interview on 01/23/2025 at 1235 with Staff #52 revealed that in regard to Pt #25, in regard to absence of MTP in the medical record, "It wouldn't surprise me if it's not there, we are extremely short staffed". Staff #52 further stated that for Patient #52, MTP "should have been done by 09/16/2024, it was 4 days out of compliance." The chart was reviewed by Staff #52 were reviewed and no MTP was found.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no MTP was found in the medical records for Patient #25.

17. Closed medical record review on 01/15/2025 for Pt #28 revealed a 15-year-old female admitted to the facility on 12/09/2024 as an IVC (Involunary Commitment) for aggression and suicidal and homicidal (thoughts to hurt others) ideation with a plan. Review of the medical record revealed there was no MTP found in the medical record. Patient #28 was discharged on 12/14/24.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no MTP was found in the medical records for Patient #28.

18. Closed medical record review on 01/21/2025 for Pt #31 revealed a 31-year-old male admitted to the facility on 08/14/2024 as an IVC for hallucinations (sensory experiences in the absence of an external stimuli) and suicidal ideation. Review of the medical record revealed there was no MTP found in the medical record. Patient #31 was discharged on 08/20/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no MTP was found in the medical records for Patient #31.

19. Closed medical record review on 01/14/2025 for Pt #14 revealed an 11-year-old male admitted to the facility on 12/19/2024 with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed there was no MTP were found in the medical record. Patient #14 was discharged on 12/24/2024 and would not have required a MTP update per policy.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no MTP was found in the medical records for Patient #14.



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20.. Open medical record review on 01/23/2025 for Patient #68 revealed a 46-year-old female involuntarily admitted to the facility on 01/18/2025 at 1813 with a diagnosis of bipolar disorder, manic and suicidal ideations with a plan. Review of the medical record revealed no evidence of an initial Master Treatment Plan (MTP) documented by the facility staff. Patient #68 was discharged home with family on 01/24/2025.

Interview on 01/23/2025 at 1150 with Staff #8 revealed that the initial master treatment plan should be completed within 72 hours of admission and updated every seven days.

Interview on 01/27/2025 at 1615 with Staff #84 revealed the therapist had started working at the hospital three weeks ago and just picked up a case load last week. Thee staff member confirmed there was no MTP found for Patient #68.

21. Closed medical record review on 01/10/2025 for Patient #16 revealed a 67-year-old male involuntarily admitted to the facility on 06/18/2024 with a diagnosis of schizophrenia, paranoid type and depression. Review of the medical record revealed no evidence of an initial Master Treatment Plan (MTP) documented by the facility staff. Patient #16 was discharged to an assisted living facility on 08/16/2024 (28 days after admission). Review revealed no MTP updates were found in the medical record.

Interview on 01/10/2024 at 1315 with Staff #8 revealed that she thought a MTP had been completed, but no documentation could be found of a MTP for Patient #16.

Interview on 01/23/2025 at 1150 with Staff #8 revealed that the initial master treatment plan should be completed within 72 hours of admission and updated every seven days.

Interview on 01/20/2024 at 0900 with Staff #20 revealed there was no MTP available for Patient #16.

Based on review of hospital policies, medical records and staff interviews, hospital staff failed to ensure short-term and long-range goals were completed and/or updated for 8 of 72 medical records reviewed (Pt #12, #31, #32, #25, #29, #28, #14 and #38).

The findings include:

Review on 01/23/2025 of hospital policy "Interdisciplinary Patient-Centered Care Planning," last reviewed on 04/2024, revealed, "...Developing the Treatment Plan...4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan...The treatment team will complete the MTP (Master Treatment Plan) including:...b. Completion of Individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem, specific behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention...Interdisciplinary Treatment Plan Update...1....The treatment team, including the patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum of every (7) seven days after the completion of the Master Treatment Plan...The following would be cause for conducting a review of the plan and developing a revision:...A new impairment/problem...2.... a. ...Once a goal has been resolved, the date will be identified on the treatment plan...c. Staff members, upon discharge, shall either document on remaining goals the date if resolved or 'ongoing' meaning that the problem has not yet been resolved..."

1. Open medical record review on 01/08/2025 for Patient #12 revealed a 15-year-old female admitted to the facility on 08/09/2024 with severe psychosis (disconnection with reality) and selective mutism (inability or unwillingness to speak) refractory (resistant) to medication treatment. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #12 was discharged on 01/10/2025.

Interview on 01/24/2025 at 0905 with Staff #53 revealed that in regard to Pt #12, "I checked and there is no Master Treatment Plan or problem sheets". She further stated that all six charts were reviewed and no MTP was found.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #12.

2. Closed medical record review on 01/21/2025 for Pt #31 revealed a 31-year-old male admitted to the facility on 08/14/2024 under Involuntary Commitment (IVC) for hallucinations (sensory experiences in the absence of an external stimuli) and suicidal (thoughts to harm self) ideation. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #31 was discharged on 08/20/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #31.

3. Closed medical record review on 01/2/2025 for Pt #32 revealed a 42-year-old male admitted to the facility on 06/29/2024 under IVC for psychosis and suicidal and homicidal (thoughts to harm others) ideation. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #32 was discharged on 07/25/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #32.

4. Closed medical record review on 01/14/2025 for Pt #25 revealed a 27-year-old male admitted to the facility on 09/13/2024 for psychosis and suicidal ideation with a plan. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #25 was discharged on 10/03/2024.

Interview on 01/23/2025 at 1235 with Staff #52 revealed that in regard to Pt #25, in regard to absence of MTP and problem sheet in the medical record, "It wouldn't surprise me if it's not there, we are extremely short staffed". Staff #52 further stated that for Patient #52, MTP (and problem sheet) "should have been done by 09/16/2024, it was 4 days out of compliance." The chart was reviewed by Staff #52 were reviewed and no MTP or problem sheet was found.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #25.

5. Closed medical record review on 01/15/2025 for Patient #29 revealed a 17-year-old female admitted to the facility on 12/09/2024 as an IVC for depression, self-harm and suicidal ideation without a plan. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #29 was discharged on 12/24/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #29.

6. Closed medical record review on 01/15/2025 for Pt #28 revealed a 15-year-old female admitted to the facility on 12/09/2024 with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #28 was discharged on 12/14/24.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #28.

7. Closed medical record review on 01/15/2025 for Pt #14 revealed a 15-year-old male admitted to the facility on 12/19/2024 under IVC with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that there were no short-term and long-range goals found in the medical record. Patient #14 was discharged on 12/24/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included patient short-term and long-range goals related to the MTP was found in the medical records for Patient #14.



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8. Closed medical record review on 01/14/2025 for Pt #38 revealed a 28-year-old male admitted to the facility on 08/07/2024 under IVC for paranoia (irrational and persistent belief that others are intentionally harming, deceiving, or persecuting you) and delusions (strong, false belief someone holds onto even when there's clear evidence showing it's not true). Review of the medical record revealed the MTP was developed on 08/09/2024 (day of admission). Pt was #38 discharged home on 08/16/2024. Review of the treatment plan problem sheets revealed no documentation of the date Pt#38's goals were achieved or discontinued.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that each short term goal on the Problem Sheets should have documentation of the date the goal was achieved or the goal should be documented as discontinued on the date of discharge.

Based on review of hospital policies, medical records and staff interviews, hospital staff failed to ensure a Master Treatment Plan with specific treatment modalities were completed and/or updated for 8 of 72 medical records reviewed (Pt #12, #31, #32, #25, #29, #28, #14 and #60).

The findings include:

Review on 01/23/2025 of hospital policy "Interdisciplinary Patient-Centered Care Planning," last reviewed on 04/2024, revealed, "...Developing the Treatment Plan...4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan...The treatment team will complete the MTP (Master Treatment Plan) including:...b. Completion of Individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem, specific behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention...Interdisciplinary Treatment Plan Update...1....The treatment team, including the patient/family/representative will complete a review of the treatment plan as clinically indicated, or at a minimum of every (7) seven days after the completion of the Master Treatment Plan...The following would be cause for conducting a review of the plan and developing a revision:...A new impairment/problem...2.... a. ...Once a goal has been resolved, the date will be identified on the treatment plan...c. Staff members, upon discharge, shall either document on remaining goals the date if resolved or 'ongoing' meaning that the problem has not yet been resolved..."

Review on 01/24/2025 of hospital policy "Documentation Requirements In The Medical Record," last revised 11/2023, revealed, "...Treatment Plan...14. Behavior management plans shall be written as part of the Treatment Plan ..."

1. Open medical record review on 01/14/2025 for Patient #12 revealed a 15-year-old female admitted to the facility on 08/09/2024 with severe psychosis (disconnection with reality) and selective mutism (inability or unwillingness to speak) refractory (resistant) to medication treatment. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #12 was discharged on 01/10/2025.

Interview on 01/24/2025 at 0905 with Staff #53 revealed that in regard to Pt #12, "I checked and there is no Master Treatment Plan or problem sheets". She further stated that all six charts were reviewed and no MTP was found.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included specific treatment modalities related to the MTP were found in the medical records for Patient #12.

2. Closed medical record review on 01/21/2025 for Pt #31 revealed a 31-year-old male admitted to the facility on 08/14/2024 under Involuntary Commitment (IVC) for hallucinations (sensory experiences in the absence of an external stimuli) and suicidal (thoughts to harm self) ideation. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #31 was discharged on 08/20/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included specific treatment modalities related to the MTP were found in the medical records for Patient #31.

3. Closed medical record review on 01/2/2025 for Pt #32 revealed a 42-year-old male admitted to the facility on 06/29/2024 under IVC for psychosis and suicidal and homicidal ideation. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #32 was discharged on 07/25/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included specific treatment modalities related to the MTP were found in the medical records for Patient #32.

4. Closed medical record review on 01/14/2025 for Pt #25 revealed a 27-year-old male admitted to the facility on 09/13/2024 for psychosis and suicidal ideation with a plan. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #25 was discharged on 10/03/2024.

Interview on 01/23/2025 at 1235 with Staff #52 revealed that in regard to Pt #25, in regard to absence of MTP and problem sheet in the medical record, "It wouldn't surprise me if it's not there, we are extremely short staffed". Staff #52 further stated that for Patient #52, MTP (and problem sheet) "should have been done by 09/16/2024, it was 4 days out of compliance." The chart was reviewed by Staff #52 were reviewed and no MTP or problem sheet was found.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included specific treatment modalities related to the MTP were found in the medical records for the following patients: Pt #12, Pt #31, Pt #32, Pt #25, Pt #29, Pt #28 and Pt #14).

5. Closed medical record review on 01/15/2025 for Pt #29 revealed a 17-year-old female admitted to the facility on 12/09/2024 as an IVC for depression, self-harm and suicidal ideation without a plan. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #29 was discharged on 12/24/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included specific treatment modalities related to the MTP were found in the medical records for the following patients: Pt #12, Pt #31, Pt #32, Pt #25, Pt #29, Pt #28 and Pt #14).

6. Closed medical record review on 01/15/2025 for Pt #28 revealed a 15-year-old female admitted to the facility on 12/09/2024 with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #28 was discharged on 12/14/24.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included specific treatment modalities related to the MTP were found in the medical records for Patient #28.

7. Closed medical record review on 01/15/2025 for Pt #14 revealed a 15-year-old male admitted to the facility on 12/19/2024 under IVC with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #14 was discharged on 12/24/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included specific treatment modalities related to the MTP were found in the medical records for Patient #14.



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8. Closed medical record review on 01/22/2025 for Pt #60 revealed a 43-year-old male admitted to the facility on 10/10/2024 under IVC (involuntary commitment) with schizophrenia and assaultive behavior. Record review revealed the patient was admitted due to setting a homeless person's tent on fire and breaking into a business prior to arrival. Review of the Discharge Summary signed 12/05/2024 by a psychiatrist revealed the patient was disruptive on the unit causing him to receive medication for assaultive behaviors on 10/14/2024. Review of the MTP signed and dated by a therapist on 10/17/2024 recorded three problem areas identified that included psychosis, aggression and homelessness. Review of the medical record revealed that there were no specific treatment modalities listed for the MTP found in the medical record. Patient #60 was discharged on 10/15/2024.

Interview on 01/24/2025 at 1205 with Staff #9 revealed no modalities were found. The staff member stated there was no evidence that the specific treatment modalities related to the MTP were documented for Patient #60.

Based on hospital policy review, medical record reviews, and staff interviews, the hospital failed to ensure treatment team responsibilities were completed for 11 of 72 medical records reviewed. (Pt #12, #31, #32, #25, #29, #28, #14, #59, #54, #38, and #9).

The findings include:

Review of hospital policy titled "Interdisciplinary Patient-Centered Care Planning" last reviewed 04/2024, revealed " ...4. Within 72 hours of admission, the multidisciplinary team shall meet to develop the treatment plan including:...b. Completion of Individual Problem Sheet for each active psychiatric or medical problem. The Problem Sheets will include the problem, specific behavioral manifestations, long and short term goals with target dates, and interventions for each appropriate discipline. Interventions will include the action/task, patient-specific focus, and the name/credentials of the individual responsible for the intervention ...
5. The patient/family and/or guardian is to sign the treatment plan to indicate their agreement with and participation in development of the plan ..."

1. Open medical record review on 01/08/2025 for Patient #12 revealed a 15-year-old female admitted to the facility on 08/09/2024 with severe psychosis (disconnection with reality) and selective mutism (inability or unwillingness to speak) refractory (resistant) to medication treatment. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #12 was discharged on 01/10/2025.

Interview on 01/24/2025 at 0905 with Staff #53 revealed that in regard to Pt #12, "I checked and there is no Master Treatment Plan or problem sheets". She further stated that all six charts were reviewed and no MTP or problem sheets were found.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included team responsibilities related to the MTP were found in the medical records for Patient #12.

2. Closed medical record review on 01/21/2025 for Pt #31 revealed a 31-year-old male admitted to the facility on 08/14/2024 under Involuntary commitment (IVC) for hallucinations (sensory experiences in the absence of an external stimuli) and suicidal (thoughts to harm self) ideation. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #31 was discharged on 08/20/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included team responsibilities related to the MTP were found in the medical records for Patient #31.

3. Closed medical record review on 01/2/2025 for Pt #32 revealed a 42-year-old male admitted to the facility on 06/29/2024 under IVC for psychosis and suicidal and homicidal ideation. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #32 was discharged on 07/25/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included team responsibilities related to the MTP were found in the medical records for Patient #32.

4. Closed medical record review on 01/14/2025 for Pt #25 revealed a 27-year-old male admitted to the facility on 09/13/2024 for psychosis and suicidal ideation with a plan. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #25 was discharged on 10/03/2024.

Interview on 01/23/2025 at 1235 with Staff #52 revealed that in regard to Pt #25, in regard to absence of MTP and problem sheet in the medical record, "It wouldn't surprise me if it's not there, we are extremely short staffed". Staff #52 further stated that for Patient #52, MTP (and problem sheet) "should have been done by 09/16/2024, it was 4 days out of compliance." The chart was reviewed by Staff #52 were reviewed and no MTP or problem sheet was found.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included team responsibilities related to the MTP were found in the medical records for Patient #25.

5. Closed medical record review on 01/15/2025 for Pt #29 revealed a 17-year-old female admitted to the facility on 12/09/2024 as an IVC for depression, self-harm and suicidal ideation without a plan. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #29 was discharged on 12/24/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included team responsibilities related to the MTP were found in the medical records for Patient #29.

6. Closed medical record review on 01/15/2025 for Pt #28 revealed a 15-year-old female admitted to the facility on 12/09/2024 with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #28 was discharged on 12/14/24.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included team responsibilities related to the MTP were found in the medical records for Patient #28.

7. Closed medical record review on 01/15/2025 for Pt #14 revealed a 15-year-old male admitted to the facility on 12/19/2024 under IVC with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that team responsibilities related to the MTP were not documented in the medical record. Patient #14 was discharged on 12/24/2024.

Interview on 01/24/2025 at 1340 with Staff #9 revealed that no "problem sheet" that would have included team responsibilities related to the MTP were found in the medical records for Patient #14.



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8. Closed medical record review of Patient #59 revealed a 39-year-old male involuntarily committed on 10/03/2024 for suicidal ideation. Review of the Master Treatment Plan (MTP) revealed a completion date of 10/07/2024. Record review revealed the patient was discharged 10/10/2024. Review of the MTP revealed no printed name or signature of the treatment team nurse and no patient signature was documented.

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be completed and signed within 72 hours by the treatment team and patient. Interview revealed the MTP should be signed by the Physician, Nurse, and Social Worker.

9. Open medical record review of Patient #54 revealed a 36-year-old female involuntarily committed on 01/01/2025 for suicidal ideation. Review of the Master Treatment Plan (MTP) revealed a completion date of 01/05/2025. Review of the updated MTP revealed it was updated and signed 01/17/2025. Record review revealed the patient was discharged 01/17/2025. Review of the MTP revealed the nurse signed and dated the MTP on 01/17/2025 (12 days after initial MTP).

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should be completed and signed within 72 hours by the treatment team.



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10. Closed medical record review on 01/14/2025 for Pt #38 revealed a 28-year-old male admitted to the facility on 08/07/2024 under IVC for paranoia (irrational and persistent belief that others are intentionally harming, deceiving, or persecuting you) and delusions (strong, false belief someone holds onto even when there's clear evidence showing its not true) and discharged on 08/16/2024. The Interdisciplinary Master Treatment Plan (MTP) revealed it was signed by the Therapist and the Nurse Practitioner on 08/09/2024. The MTP failed to include documentation of the Psychiatrist and Nurse signatures/involvement.

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP should have been completed within 72 hours of admission and signed by the Therapist, Registered Nurse (RN), and the Provider.



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11. Closed medical record review on 01/09/2025 for Pt #9 revealed a 32-year-old patient who was involuntarily committed on 05/11/2024 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave) and increased aggression (violent attacking behavior or attitude toward another person) with staff at his group home. The Interdisciplinary Master Treatment Plan (MTP) was signed by the Therapist, Nurse, and the Nurse Practitioner on 05/14/2024. Pt #9 was discharged to a shelter on 05/20/2024. Review of the MTP revealed no patient or guardian signature was documented. Review failed to reveal a psychiatric problem sheet with the team responsibilities related to the MTP.

Interview on 01/14/2025 at 1612 with Staff #53 revealed there was no MTP problem sheet with responsibilities for Pt #9.

Interview on 01/23/2025 at 1145 with Staff #8 revealed the MTP, including the problem sheet, should be completed and signed within 72 hours by the treatment team and the patient.

Based on review of hospital policies, medical records and staff interviews, hospital staff failed to document daily group therapy for 4 of 72 medical records reviewed (Pt #52, #35, #34, #33).

The findings include:

Review on 01/28/2025 of hospital policy "Active and Individualized Treatment," last reviewed 04/2024, revealed, "... Active treatment services provided must be: ... Provided 7 days a week ... Each group leader assigned to conduct a group session identified in the treatment plan is responsible for ... documenting the group per facility policy in each patient's medical record ..."

Review on 01/24/2025 of hospital policy "Documentation Requirements In The Medical Record," last revised 11/2023, revealed, "... Group Notes ... 1. Group notes shall be documented in the Progress Note section within eight (8) hours of the group session ... "

1. Closed medical record review on 01/21/2025 for Patient #52 (Pt) revealed a 26-year-old male admitted to the hospital on 01/05/2025 at 1649 with a diagnosis of bipolar disorder (a condition that causes extreme mood swings). Record review failed to reveal notes for Psychoeducation and Nurse Group on 01/06/2025, 01/07/2025, and 01/08/2025, 01/10/2025, and 01/14/2025. Record review failed to reveal notes for Activity Therapy, Psychoeducation and Nurse Group on 01/09/2025. Review failed to reveal notes for Activity Therapy, Psychoeducation and Process Group on 01/12/2025. Record review failed to reveal notes for Activity Therapy, Psychoeducation and Nurse Group on 01/13/2025. Pt #52 was discharged home on 01/15/2025 at 1016.

Interview on 01/21/2025 at 1506 with Staff #17 revealed group therapy was sometimes not completed as scheduled depending on what was occurring on the unit at that time. Interview revealed Nurse Group was sometimes not completed if there were admissions during the time Nurse Group was scheduled. Interview revealed there should be a Group Therapy Note in the patients' medical records for all completed group therapies.

Interview on 01/24/2025 at 1437 with Staff #25 revealed it was difficult to get group therapy done at times because more staff was needed.

Interview on 01/24/2025 at 1130 with Staff #9 revealed there should be Group Therapy Notes for Activity Therapy, Process Group, Psychoeducation, and Nurse Group in each patient's medical record daily.

2. Closed medical record review on 01/15/2025 for Patient #35 (Pt) revealed a 44-year-old male admitted to the hospital on 09/25/2024 at 2308 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review failed to reveal notes for Process Group, Psychoeducation, and Nurse Group on 09/26/2024, 09/28/2024, 09/30/2024, 10/02/2024, 10/03/2024, 10,04/2024, 10/05/2024, 10/08/2024, and 10/09/2024. Review failed to reveal notes for Activity Therapy, Process Group, and Nurse Group on 10/07/2024. Review failed to reveal any Group Therapy Notes on 09/27/2024, 09/29/2024, 10/01/2024, and on 10/06/2024. Pt #35 was discharged home on 10/10/2024 at 1420.

Interview on 01/21/2025 at 1506 with Staff #17 revealed group therapy was sometimes not completed as scheduled depending on what was occurring on the unit at that time. Interview revealed Nurse Group was sometimes not completed if there were admissions during the time Nurse Group was scheduled. Interview revealed there should be a Group Therapy Note in the patients' medical records for all completed group therapies.

Interview on 01/24/2025 at 1437 with Staff #25 revealed it was difficult to get group therapy done at times because more staff was needed.

Interview on 01/24/2025 at 1130 with Staff #9 revealed there should be Group Therapy Notes for Activity Therapy, Process Group, Psychoeducation, and Nurse Group in each patient's medical record daily.

3. Closed medical record review on 01/15/2025 for Patient #34 (Pt) revealed a 27-year-old male admitted to the hospital on Saturday, 09/28/2024 at 1235 with a diagnosis of substance abuse and major depressive disorder. Record review failed to reveal any Group Therapy Notes for Pt #34 on 09/28/2024 and 09/29/2024. Review failed to reveal notes for Psychoeducation Group and Nurse Group on 09/30/2024. Review failed to reveal any Group Therapy Notes on 10/01/2024. Review failed to reveal notes for Activity Therapy, Psychoeducation Group and Nurse Group on 10/02/2024. Review failed to reveal any Group Therapy Notes on 10/03/2024. Pt #34 was discharged home on 10/04/2024 at 1117.

Interview on 01/21/2025 at 1506 with Staff #17 revealed group therapy was sometimes not completed as scheduled depending on what was occurring on the unit at that time. Interview revealed Nurse Group was sometimes not completed if there were admissions during the time Nurse Group was scheduled. Interview revealed there should be a Group Therapy Note in the patients' medical records for all completed group therapies.

Interview on 01/24/2025 at 1437 with Staff #25 revealed it was difficult to get group therapy done at times because more staff was needed.

Interview on 01/24/2025 at 1130 with Staff #9 revealed there should be Group Therapy Notes for Activity Therapy, Process Group, Psychoeducation, and Nurse Group in each patient's medical record daily.

4. Closed medical record review on 01/15/2025 for Patient #33 (Pt) revealed a 47-year-old female admitted to the hospital on 09/26/2024 at 2209 with a diagnosis of schizophrenia. Record review failed to reveal notes for Process Group, Psychoeducation, and Nurse Group on 09/27/2024, 09/28/2024, and on 09/30/2024. Review failed to reveal any Group Therapy Notes on 09/29/2024. On 10/01/2024, review failed to reveal notes for Process Group and Nurse Group. On 10/02/2024, review failed to reveal notes for Activity Therapy, Process Group, and Psychoeducation. Pt #33 was discharged home on 10/02/2024 at 2254.

Interview on 01/21/2025 at 1506 with Staff #17 revealed group therapy was sometimes not completed as scheduled depending on what was occurring on the unit at that time. Interview revealed Nurse Group was sometimes not completed if there were admissions during the time Nurse Group was scheduled. Interview revealed there should be a Group Therapy Note in the patients' medical records for all completed group therapies.

Interview on 01/24/2025 at 1437 with Staff #25 revealed it was difficult to get group therapy done at times because more staff was needed.

Interview on 01/24/2025 at 1130 with Staff #9 revealed there should be Group Therapy Notes for Activity Therapy, Process Group, Psychoeducation, and Nurse Group in each patient's medical record daily.

Based on review of hospital policy, medical records and staff interviews, hospital staff failed to ensure Social Services Progress Notes were completed for 11 of 72 medical records reviewed (Pt #34, #35, #54, #9, #10, #30, #39, #67, #25, #28, #16).

The findings include:

Review on 01/24/2025 of hospital policy "Documentation Requirements In The Medical Record," last revised 11/2023, revealed, "... Social Services .... 2. The initial Social Services note shall be made within seventy-two hours (72) of admission ... 4. Each problem addressed by Social Services staff on the Master Treatment Plan shall be addressed in the progress note at least weekly ..."

1. Closed medical record review on 01/15/2025 for Patient #34 (Pt) revealed a 27-year-old male admitted to the hospital on 09/28/2024 at 1235 with a diagnosis of substance abuse and major depressive disorder. Record review failed to reveal Social Services Progress Notes during Pt #34's admission (6 days). Pt #34 was discharged home on 10/04/2024 at 1117.

Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days.

2. Closed medical record review on 01/15/2025 for Patient #35 (Pt) revealed a 44-year-old male admitted to the hospital on 09/25/2024 at 2308 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review revealed a Social Services Progress Note was completed on 09/26/2024. Review failed to reveal Social Services Progress Notes after 09/26/2024 until discharge (14 days). Pt #35 was discharged home on 10/10/2024 at 1420.

Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days.



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3. Open medical record review of Patient #54 revealed a 36-year-old female involuntarily committed on 01/01/2025 for suicidal ideation. Review of the Master Treatment Plan (MTP) revealed a completion date of 01/05/2025. Review of the updated MTP revealed it was updated and signed 01/17/2025. Record review revealed the patient was discharged 01/17/2025. Record review revealed no Social Services progress notes were documented.

Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed at a minimum of every 7 days and as needed.



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4. Closed medical record review on 01/09/2025 for Pt #9 revealed a 32-year-old patient who was involuntarily committed on 05/11/2024 with a diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave) and increased aggression (violent attacking behavior or attitude toward another person) with staff at his group home. Record review revealed a Social Services Progress Note was completed on 05/14/2024 at 1740, which noted Pt #9 would need social resources post-discharge for "housing and mental health." Review failed to reveal Social Services Progress Notes after 05/14/2024 until discharge (6 days). Pt #9 was discharged to a shelter on 05/20/2024 (time not specified) with an outpatient follow-up appointment on 05/21/2024.

Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days.

5. Closed medical record review on 01/09/2025 for Pt #10 revealed a 27-year-old patient who was involuntarily committed on 10/25/2024 with a diagnosis of schizophrenia, with aggressive behaviors and homicidal ideations (HI - harming others). Record review failed to reveal Social Services Progress Notes during Pt#10's admission (11 days). Pt #10 was discharged on 11/05/2024.

Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days.

6. Closed medical record review on 01/14/2025 for Pt #30 revealed a 14-year-old patient voluntarily admitted on 05/24/2024 for disruptive mood dysregulation (a disorder characterized with ongoing irritability, anger, and frequent, intense temper outbursts) and oppositional defiant disorder (a disorder characterized by uncooperative, defiant, and hostile behavior to authority figures). Record review revealed a Social Services Progress Note was completed on 05/27/2024. A second Social Services Progress Note was completed on 06/07/2024 (11 days later). Review failed to reveal Social Services Progress Notes after 06/07/2024 until discharge (41 days). Pt #30 was discharged home on 07/18/2024 at 1100 with a psychological evaluation scheduled at Facility C at 1300.

Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days.

7. Closed medical record review on 01/14/2025 for Pt #39 revealed a 43-year-old patient who was involuntarily committed on 10/05/2024 with a diagnosis of schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave) and antisocial personality disorder (a disorder characterized by impulsive and irresponsible behavior). Record review revealed a Social Services Progress Note was completed on 10/08/2024. A second Social Services Progress Note was completed on 10/15/2024. Two Social Services Progress Notes were completed on 10/22/2024. Review failed to reveal Social Services Progress Notes after 10/22/2024 until discharge (11 days). Pt #39 was discharged to a shelter on 11/02/2024 at 1100 with an outpatient follow-up appointment on 11/04/2024 at 1000.

Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days.

8. Closed medical record review on 01/24/2025 for Pt #67 revealed a 43-year-old patient who was involuntarily committed on 10/29/2024 for severe, recurrent major depressive disorder (MDD - mental health disorder characterized by two or more weeks of feeling sad, low self-esteem, and loss of interest in normal activities), anxiety (tension and/or worried thoughts), suicidal ideations (SI - cause harm or death to one self), and HI. Record review failed to reveal Social Services Progress Notes during Pt #67's admission (15 days). Pt #67 was discharged home on 11/13/2024.

Interview on 01/10/2025 at 1014 with Staff #8 revealed Therapists should be writing a note for each therapy session and did not know why the Social Service Progress Notes were missing from Pt #10's medical record.

Follow-up Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed at a minimum of every 7 days and as needed.



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9. Closed medical record review on 01/14/2025 for Pt #25 revealed a 27-year-old male admitted to the facility on 09/13/2024 for psychosis and suicidal ideation with a plan. Review of the medical record revealed that the comprehensive clinical assessment was completed on 09/21/2024 (8 days after admission). There were no social work progress notes found in the medical record. Pt # 25 was discharged on 10/03/2025.

Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days.

10. Closed medical record review on 01/15/2025 for Pt #28 revealed a 15-year-old female admitted to the facility on 12/09/2024 with aggression with suicidal and homicidal ideations with a plan. Review of the medical record revealed that the comprehensive clinical assessment was found in the chart completely blank. There were no social work progress notes found in the medical record. Pt # 28 was discharged on 12/14/2024.

Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days.



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11. Closed medical record review on 01/10/2025 for Patient #16 revealed a 67-year-old male involuntarily admitted to the facility on 06/18/2024 with a diagnosis of schizophrenia, paranoid type and depression. Review of the medical record revealed one Social Services Progress Note documented on 07/06/2024 documenting an attempt to gain collateral information regarding the patient's legal guardian. Review of the record revealed no further Social Services Progress Notes were documented during the patient's admission (28 days). Patient #16 was discharged to an assisted living facility on 08/16/2024 (28 days after admission).

Interview on 01/23/2025 at 1145 with Staff #8 revealed Social Services Progress Notes should be completed with each MTP update, as needed, and at a minimum of every 7 days.

Based on review of hospital policy, medical records, and staff interviews, the hospital failed to ensure patients received follow up appointments and prescriptions prior to patients being discharged for 3 of 59 sampled closed medical records (Pt #60, #68, #36).

The findings include:

Review of the "Duties of Social Services Staff" policy reviewed 10, 2022 revealed, "... Social services staff coordinates discharge planning with internal and external staff and with patients. Social services staff implement discharge planning that includes facilitating placement of patients based on recommended level of care and making appointments for patients with providers.

Review of a "Discharge Planning" policy last reviewed 10/2022 revealed, "Discharge planning begins the day of admission for all patients served by (hospital name). Discharge planning is discussed daily and at each Treatment Team Meeting for a patient. ... The Therapist/Case Manager is the responsible party for initiating, planning and working with the patient, the family, the Treatment Team members, and outside providers/agencies to develop the Discharge Plan. The Therapist/Case Manager discusses after care with the patient and guardian(s), in collaboration with community supports. The Therapist/Case Manager schedules after care appointments for patients ... Patients are expected to attend an aftercare appointment within 7 days from their discharge date, typically with a therapist. Patients who are prescribed psychotropic medications are expected to see a psychiatrist and/or primary care physician or therapist within 30 days from their discharge date. ... If an adult patient does not want the therapist to make the appointments, document it in a progress note. Tell the patient that he/she will need to have appointments before discharge. Talk to the attending psychiatrist about the issue. If no appointments have been made the day of discharge, tell the attending psychiatrist and follow any instructions. ..."

1. Closed medical record review on 01/22/2025 for Pt #60 revealed a 43-year-old male admitted to the facility on 10/10/2024 under IVC (involuntary commitment) with schizophrenia and assaultive behavior. Record review revealed the patient was admitted due to setting a homeless person's tent on fire and breaking into a business prior to arrival. Patient #60 was discharged via taxi to a shelter located in Raleigh, NC on 10/15/2024. Review of the Discharge Summary signed by a psychiatrist on 12/01/2024 revealed discharge medications included Synthroid (medication for thyroid hormone replacement), lithium (mood stabilizer), Prilosec (medication for acid reflux), and Invega (antipsychotic medication). Review of the Discharge Medication Summary revealed Synthroid, lithium and Invega were e-prescribed to a pharmacy in Carroboro, NC (approximately 30 miles away from the patient's shelter location).

Interview on 01/24/2025 with Staff #85 revealed the patient had come from a shelter in Hillsboro, NC prior to arrival at the hospital and was working with an ACTT team. The staff member reported talking with the ACTT team who reported they had been trying to find the patient without success. The staff member stated that the ACTT team's role was to help the patient with resources, finding medications, transport and appointments. The staff member reported that they discussed discharge plans and ACTT was going to pick up the patient at the time of discharge and take him to the shelter. The staff member reported the patient's case was transferred to another therapist due to a change in units. The staff member stated a transfer sheet that included the patient's discharge plan should have been completed when he was moved to another unit, but the staff member was unable to locate the transfer sheet in the patient's medical record.

Interview on 01/24/2025 at 1500 with Staff #86 revealed she was a Case Manager that reviewed the discharge information with the patient prior to discharge. The staff member stated she "helps the therapist" by getting information from the patient and reviews the discharge plans with the patient. She said she reviewed the placement and arranged a cab voucher and outpatient care plans with the patient. She stated the patient told her he had no outpatient provider so she chose a provider (different from the ACTT team that was involved with his care previously). The staff member stated the therapist would usually provide that information but "that unit (2 East) didn't have a therapist for awhile." The staff member stated she didn't get any information that the patient came from a shelter in Chapel Hill and that he had ACTT team involved with his care.

Telephone interview on 11/24/2025 at 1500 with Staff #87 revealed he didn't remember the patient. The nurse revealed his role was to talk with the Nurse Practitioner (NP) and tell her where the patient got his prescriptions. He stated he would explain to the patient what his prescriptions are and where they were sent.

Telephone interview on 01/27/2025 at 1055 with Staff #42 revealed she was the NP that e-prescribed the patient's medication to a pharmacy in Carroboro, NC. Interview revealed the NP did not remember Patient #60. The NP stated she would normally ask the patient where he wanted his medication sent to. She stated that that information was usually discussed in treatment team meetings if there was a change in location. Staff #88 stated she didn't know how the patient who was housing at a shelter in Raleigh, NC would be able to get his medication from a pharmacy in Carroboro, NC. The NP stated it was possibly a "communication missed."

2. Open medical record review on 01/23/2025 for Patient #68 revealed a 46-year-old female involuntarily admitted to the facility on 01/18/2025 at 1813 with a diagnosis of bipolar disorder, manic and suicidal ideations with a plan. Patient #68 was discharged home via sheriff on 01/24/2025. Review of discharge paperwork signed by the patient and a therapist on 01/23/2025 at 1630 revealed no aftercare appointments arranged for therapy or psychiatric follow up care. Review of a therapy note dated 01/23/2025 at 1630 recorded, "Patient stated during d/c (discharge planning) she will find her own outpatient therapy services. ..."

Interview on 01/27/2025 at 1615 with Staff #84 revealed the therapist had started working at the hospital three weeks ago and just picked up a case load last week. The staff member stated the patient wanted to get her own provider. The staff member stated the patient didn't have any prior contacts and didn't report having a psychiatrist. She stated the normal process is that she would call someone in her area and set up an appointment. The staff member stated, "That was the first time it happened (wanting to get her one appointment). I didn't notify the provider. I didn't contact her spouse. She transported via sheriff to (named) county." Interview revealed the hospital policy was not followed.



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3. Closed medical record review on 01/23/2025 for Patient #36 revealed a 23-year-old male admitted to the hospital on 11/15/2024 at 1535 under IVC (involuntary commitment) for evaluation of suicide ideation, paranoid ideations and delusions. Patient #36 was discharged home on 11/26/2024. Review of the Discharge Medication Summary revealed Patient #36 was to continue taking Depakote (medication to treat bipolar disorder/mental health disorder), Invega Sustenna (medication to treat schizoaffective disorder/mental health disorder), Vistaril (medication to treat anxiety) and Inderal (medication to treat anxiety). Review revealed the Vistaril, Depakote, Inderal and Invega Sustenna were e-prescribed to Patient #36's pharmacy on 11/26/2024 at 0859. The Discharge Medication Summary was signed Patient #36 and a Nurse on 11/26/2024 at 1600. Review of the Nurse note dated 11/26/2024 (not timed) revealed "Pt (patient) A&O x 3 (alert and oriented times three), stable at D/C (discharge). Escorted to reception for transport ..."

Review of the e-prescription documentation revealed the Invega Sustenna, the Inderal, and the Vistaril was e-prescribed to Patient #36's pharmacy on 11/27/2024 at 1531 and accepted by the pharmacy at 1532. The Depakote was e-prescribed on 11/27/2024 however there was an error and the pharmacy did not receive the e-prescription. The Depakote was e-prescribed an additional time and was not received due to an error. The Depakote was e-prescribed for the third time on 11/29/2024 at 1132 and accepted by the pharmacy at 1353.

Review of the Service Desk tickets and communication provided on 01/16/2025 revealed there was a problem with e-prescription of Depakote DR 500 mg (milligrams) identified and a service ticket sent to the Service Desk on 07/26/2024 at 0957. There was a correction made on 08/08/2024 at 1039. There was email communication from the Director of Pharmacy to the Providers on 01/02/2025 at 1621 notifying of a problem discovered and requesting the Providers check all Depakote e-scripts for an error message as the e-scripts may not be sent properly to the pharmacy. There was a second ticket provided for the Depakote e-scripts submitted on 01/03/2025 at 0948 and corrected at 1142.

Interview on 01/16/2025 at 1435 with Staff #67 revealed she had e-prescribed the medication Patient #36 was to continue taking at discharge to Patient #36's pharmacy. Interview revealed there was a problem with the Depakote going through to the pharmacy. Staff #67 could not remember if someone had contacted the facility about the prescription or if she had noticed it had not going through and continued to try to send the e-prescription. Interview revealed the facility was aware there was a problem previously and thought it had been fixed, so when this e-prescription did not go through, Staff #67 felt it was the same problem already identified and continued to send the e-prescription. Interview revealed when a discharged patient or legal guardian calls back to the facility after the patient has been discharged, there is no documentation of this call nor what it was about. The interview revealed Staff #67 felt the problem with e-scribing of Depakote got fixed however it appears to have happened again. Interview revealed the facility was working to have a permanent fix for the problem with e-prescribing Depakote.

Based on review of the facility's psychologist contract, personnel file, medical record review, and staff interviews, the facility failed to provide psychological services for 1 of 1 sampled patients needing psychological testing and evaluation (Patient #30).

The findings include:

Review on 01/24/2025 of the Psychologist Service Agreement, effective April 2018, revealed, "... I. Obligations of Psychologist. A. Psychologist shall provide psychological evaluation and on-call services for Facility's IVC (involuntarily committed) patients as needed and requested by Facility pursuant to a schedule agreed to by the parties ... D. Psychologist shall actively participate in Facility's overall patient care evaluation program..."

Review on 01/27/2025 of Staff #30's personnel file revealed Staff #30 was initially appointed on 06/09/2003 with most recent reappointment on 06/26/2023. Staff #30 was privileged for adult, adolescent, and child psychological assessments.

Closed medical record review on 01/14/2025 for Patient #30 (Pt) revealed a 14-year-old patient voluntarily admitted on 05/24/2024 for disruptive mood dysregulation (a disorder characterized with ongoing irritability, anger, and frequent, intense temper outbursts) and oppositional defiant disorder (a disorder characterized by uncooperative, defiant, and hostile behavior to authority figures). Pt #30 endorsed high risk behaviors including running away from home, was gone for eight days, and had been using marijuana. Comprehensive Clinical Assessment on 05/27/2024 revealed Pt #30's family would like the Pt to go to a residential facility to assist with substance use and making the right decisions. Master Treatment Plan (MTP) completed on 05/27/2024 with verbal consent from Pt #30's family noted the initial discharge disposition as alternative living arrangements. MTP update (MTPU) on 06/03/2024 revealed Pt #30's family was involved with referrals, and the recommended discharge plan was PRTF (Psychiatric Residential Treatment Facility, a non-acute inpatient facility for patients with mental illness or substance abuse). Psychiatric Progress Note on 06/21/2024 revealed Pt #30 was not discharged as planned due to the bed being given away; the family did not sign the required papers and forms for placement, and Pt # 30 was unable to go to the facility. MTPU on 06/24/2024 listed barriers to discharge planning as pending placement, and the family did not feel safe for Pt #30 to return home. Psychiatric Progress Note on 06/24/2024 revealed Pt #30 stated her family found a place (out of state) for long-term placement, and Pt #30 was ready to go to placement when possible. MTPU on 07/01/2024 listed barriers to discharge planning as pending placement, and the family continued to believe Pt #30 would run away if the patient returned home. MTPU on 07/08/2024 listed barriers to discharge planning as referrals were denied, but the family was still concerned about Pt #30 returning home. Aftercare and Discharge Plan on 07/17/2024 revealed Pt #30 was to be discharged home with family on 07/18/2024. An aftercare appointment was made at Facility C for 07/18/2024 at 1300 for an additional evaluation the family had requested, with transportation designated as the (named) family. Discharge Summary on 07/18/2024 revealed Pt #30's family requested residential referrals, but Pt #30 did not get accepted right away and two places were pending at the time of dictation. Pt #30 was discharged home on 07/18/2024 with the pending referrals to residential treatment. Record review revealed no psychological evaluation or testing was performed.

Interview on 01/15/2025 at 0958 with Staff #47 revealed Staff #47 recalled Pt #30, who had been accepted to a PRTF out of state. Staff #47 revealed patients were kept inpatient as close to the time of admission to a residential facility; sometimes the patients would go home first, and then the family would transport them to the PRTF. Staff #47 revealed Pt #30's family wanted a psychological evaluation for the Pt, but it was not offered at the facility anymore. Staff #47 made an appointment on their behalf for a psychological evaluation at Facility C with the day and time noted on the discharge sheet.

Telephone Interview on 01/27/2025 at 1535 with Staff #30 revealed Staff #30 was the on-call admissions psychologist, who assisted admissions with determining if a patient met the criteria for IVC (involuntary commitment). Staff #30 covered all populations at the hospital (adult, adolescent, and child). Staff #30 was only responsible for IVC evaluations for patients and did not perform any other psychological testing or evaluations. Staff #30 revealed at one point, the facility had a psychologist who performed psychological, cognitive testing but was unsure if there was anyone currently.

Interview on 01/28/2025 at 0910 with Staff #20 revealed the facility previously had a psychologist who performed evaluation and testing, but after they left in April 2024, they were not replaced due to the low volume of testing. Staff #20 had discussed this with Staff #3, who agreed that testing was infrequently needed. Staff #20 revealed Staff #30 preferred to do IVC evaluations but could also perform other assessments and evaluations if needed/requested. Staff #30 acknowledged the facility's job descriptions had inadequate descriptions of job duties, and the facility was in the process of reviewing and updating these but had not updated Staff #30's job description yet.

NC00217667; NC00217755; NC00218498; NC00218743; NC00218789; NC00219198; NC00219332; NC00219796; NC00219847; NC00219896; NC00219970; NC00220111; NC00220706; NC00220914; NC00221039; NC00221233; NC00221241; NC00221299; NC00221389; NC00221413; NC00221425; NC00221895; NC00222154; NC00222168; NC00222408; NC00222848; NC00222906; NC00222927; NC00223079; NC00223169; NC00223368; NC00223421; NC00223815; NC00224145; NC00224147; NC00224494; NC00225763; NC00224785; NC00225195; NC00225261; NC00225541; NC00225678; NC00225819; NC00226240; NC00225942; NC00226152; NC00225873; NC00226254; NC00226287; NC00226540