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Based on interview and record review, the facility failed to ensure:

1. A Plan of Care was developed, implemented, and maintained when restraints were applied (A166);

2. A physician's order was obtained when bilateral wrist restraints were applied (A168); and

3. An order for the continued use of restraints was obtained (A173).

The cumulative effect of these systemic problems resulted in failure to ensure patients were cared for in a safe manner, and their rights were protected and promoted at all times.

Based on interview and record review, the facility failed to ensure a plan of care was developed, implemented and maintained when restraints were applied and restraint use continued for the medical safety of one sampled patient (Patient 43). This resulted in Patient 43 not having a plan of care developed and maintained while restraints were used for 12 days.

Findings:

On March 29, 2016, the record for Patient 43 was reviewed. Patient 43 was admitted to the facility on March 16, 2016, with diagnoses of acute respiratory failure and a severe infection.

The physician's, "History and Physical," dated March 16, 2016, at 9:15 p.m., indicated Patient 43 had been intubated (the placement of of tube through the mouth and into the airway to assist with breathing).

The, "Monitoring Flowsheet RN (Registered Nurse)," dated March 17, 2016, at 2 a.m., indicated bilateral soft wrist restraints were being used due to Patient 43's attempts to pull out tubes and/or lines, and the patient's inability to follow safety instructions.

There was no documentation that indicated when the restraints were initially applied.

There was no documentation that indicated the physician was notified of the restraints being applied.

Orders dated March 17, 2016, at 7:04 a.m., indicated an order was written by the physician for, "Restraint monitoring, documentation & assessment per policy Q24H (every 24 hours) until 3/18/2016 (March 18, 2016) 7:04 AM."

The, "Monitoring Flowsheet RN (Registered Nurse)," indicated usage of bilateral wrist restraints were continued until March 19, 2016, at 6 p.m., when a, "trial out of restraints," was done.

The, "Restraint Assessment & Physician Order Non-Violent/Non-Self Destructive (Medical Safety)," form dated March 22, 2016, at 6:30 a.m., indicated the RN applied soft limb restraints because Patient 43 was attempting to pull out tubes and/or lines and was unable to follow safety instructions.

There was no indication the physician was contacted or an order was obtained for the application of restraints.

Orders dated March 22, 2016, at 8:38 a.m., indicated an order was written by the physician for, "Restraint monitoring, documentation & assessment per policy Q24H (every 24 hours) until 3/23/2016 (March 23, 2016) 8:38 AM."

The record indicated the restraint use continued through March 28, 2016.

There was no documentation that indicated a plan of care was developed and implemented for the use of restraints until March 29, 2016, at 3:13 a.m. (12 days after the implementation of restraints for the patient's safety).

During an interview with Registered Nurse (RN) 5, on March 29, 2016, at 10 a.m., she reviewed the record and was unable to find documentation of a plan of care being developed and implemented for the use of restraints until March 29, 2016, at 3:13 a.m. RN 5 stated a plan of care for the use of restraints should have been initiated at the time restraints were applied and updated at least every 24 hours.

During an interview with the Intensive Care Unit Nurse Manager (ICUNM), on March 30, 2016, at 11:15 a.m., she reviewed the record for Patient 43 and stated a Plan of Care should have been implemented at the time restraints were applied and the Plan of Care should have been reviewed/updated at least every 24 hours.

The facility policy and procedure titled "Interdisciplinary Plan of Care" dated December 28, 2015, revealed " ... A Registered Nurse, following assessment of the patient, formulates the Plan of Care ... Care Plan revision or additional documentation may occur with a change in the Level of Care, changes in treatments or procedures and as necessary. ... Registered nurses will update all Outcomes and mark the inpatient Care Plan "reviewed" a minimum of every 24 hours. ..."

Based on interview and record review, the facility failed to ensure the physician was immediately notified/consulted, and an order was obtained, when bilateral wrist restraints were applied for one sampled patient (Patient 43). This resulted in restraints being applied without a provider's order and had the potential to result in the inappropriate use of restraints.

Findings:

On March 29, 2016, the record for Patient 43 was reviewed. Patient 43 was admitted to the facility on March 16, 2016, with diagnoses of acute respiratory failure and a severe infection.

The physician's, "History and Physical," dated March 16, 2016, at 9:15 p.m., indicated Patient 43 had been intubated (the placement of a tube through the mouth and into the airway to assist with breathing).

The "Monitoring Flowsheet RN (Registered Nurse)" dated March 17, 2016, at 2 a.m., indicated bilateral soft wrist restraints were being continued due to Patient 43's attempts to pull out tubes and/or lines and the patient's inability to follow safety instructions.

There was no documentation that indicated when the restraints were initially applied.

There was no documentation that indicated the physician was notified of the restraints being applied.

The "Orders" dated March 17, 2016, at 7:04 a.m., indicated an order was written by the physician for "Restraint monitoring, documentation & assessment per policy Q24H (every 24 hours) until 3/18/2016 (March 18, 2016) 7:04 AM (5 hours after the restraints were applied by nursing)."

The "Restraint Assessment & Physician Order Non-Violent/Non-Self Destructive (Medical Safety)" dated March 22, 2016, at 6:30 a.m., indicated the RN applied "soft limb" restraints because Patient 43 was attempting to pull out tubes and/or lines and was unable to follow safety instructions.

There was no indication the physician was contacted for the "emergent application" of restraints.

Orders dated March 22, 2016, at 8:38 a.m., indicated an order was written by the physician for "Restraint monitoring, documentation & assessment per policy Q24H (every 24 hours) until 3/23/2016 (March 23, 2016) 8:38 AM (2 hours after the restraints were applied by nursing)."

During an interview with the Intensive Care Unit Nurse Manager (ICUNM), on March 30, 2016, at 11:15 a.m., she reviewed the record for Patient 43 and stated an order for the application of restraints was needed. The ICUNM stated the nurse should have notified the physician and obtained the physician's order for restraints as soon as possible after the restraints were applied.

The facility policy and procedure titled "Restraint Use for the Non-Violent, Non-Self-Destructive Patient" revised August 8, 2007 (eight and a half years ago), revealed "... If a licensed physician or qualified NP/PA (Nurse Practitioner/Physician Assistant) is not available to issue such an order, a medical/surgical restraint-qualified registered nurse (RN) can initiate restraint use based on an appropriate assessment of the patient. ... If the initiation of restraint is based on a significant change in the patient's condition, the RN will immediately notify the attending physician or delegated NP/PA. ..."

Based on interview and record review, the facility failed to ensure an order for the continued use of restraints was obtained for one sampled patient (Patient 43). This resulted in restraints being applied without a physician's order and restraints being continued after the physician's order had expired. This had the potential to result in restraints being applied for longer than necessary.

Findings:

On March 29, 2016, the record for Patient 43 was reviewed. Patient 43 was admitted to the facility on March 16, 2016, with diagnoses of acute respiratory failure and a severe infection.

The physician's, "History and Physical," dated March 16, 2016, at 9:15 p.m., indicated Patient 43 had been intubated (the placement of a tube through the mouth and into the airway to assist with breathing).

Orders dated March 17, 2016, at 7:04 a.m., indicated an order was written by the physician for, "Restraint monitoring, documentation & assessment per policy Q24H (every 24 hours) until 3/18/2016 (March 18, 2016) 7:04 AM."

The "Monitoring Flowsheet RN (Registered Nurse)" indicated usage of bilateral wrist restraints were continued until March 19, 2016, at 6 p.m., when a "trial out of restraints" was done.

There was no documentation that indicated an order for bilateral wrist restraints was written when the initial order expired on March 18, 2016, at 7:04 a.m., and the use of restraints continued for an additional 34 hours.

During an interview with Registered Nurse (RN) 5, on March 29, 2016, at 10 a.m., she reviewed the record and was unable to find documentation of a physician's order for restraints from March 18, 2016, at 7: 04 a.m., until the restraints were discontinued on March 19, 2016, at 6 p.m. (34 hours later). RN 5 stated a physician's order should be obtained when restraints were applied and then every 24 hours if continued use of restraints was needed.

During an interview with the Intensive Care Unit Nurse Manager (ICUNM), on March 30, 2016, at 11:15 a.m., she reviewed the record for Patient 43 and stated, if the nurse applied a restraint, an order for restraints was needed immediately after application, and the physician should be called to obtain that order as soon as possible after the restraint was applied. In addition, the ICUNM stated a physician's order for restraints must be obtained every 24 hours when a patient was restrained.

The facility policy and procedure titled "Restraint Use for the Non-Violent, Non-Self-Destructive Patient" revised August 8, 2007 (eight and a half years ago), revealed "... Continued use of restraints beyond the first 24 hours will be authorized by the licensed physician or qualified delegate (NP/PA) renewing the original order or issuing a new order if restraint continues to be clinically justified. ..."

Based on observation, interview, and record review, the facility failed to ensure, in the psychiatric hospital emergency treatment services unit (ETS):

1. A suicide risk assessment/treatment plan for safety was completed on one patient (Patient 18) according to accepted standards of practice, when she arrived to the ETS unit after two recent suicide attempts by hanging herself. No, "Triage Level," risk identification was completed by the triage nurse, no risk determination was made by the primary nurse in the ETS unit, no psychiatric evaluation was completed by a psychiatrist/provider, and no treatment plan was initiated to prevent her from harming herself, resulting in a third suicide attempt in the bathroom of the ETS unit;

2. The nursing staff communicated patient information to the staff monitoring minors when a minor child was placed in the, "minor room," to be monitored. This resulted in one 15 year old patient (Patient 18), going into the bathroom across the hall and locking the door, where she wrapped her shirt around her neck, and attempted to strangle herself;

3. Communication and collaboration with the General Acute Care Hospital (GACH) Emergency Department (ED) medical staff, resulting in the potential for missed opportunities to improve processes and care to psychiatric patients;

4. Adequate numbers of psychiatric physicians/providers were available to provide initial assessments and treatment plans for seven patients who were admitted into the locked area of the ETS (Patients 18, 5, 20, 21, 22, 23, and 24) resulting in a delay in determining the level of monitoring required and the potential for harm or death in patients in the locked area (A 1112); and,

5. Adequate numbers of staff were available to monitor minor patients, resulting in one 15 year old (Patient 18), going into the bathroom across the hall and locking the door, wrapping her shirt around her neck, and attempting to strangle herself (A 1112).

The cumulative effect of these systemic practices resulted in failure to meet the emergency needs of patients in a safe and effective manner.

Findings:

During an interview with the ETS Nurse Manager (NM) on March 22, 2016, at 9:55 a.m., the NM stated Patient 18 was brought to the facility on March 19, 2016, on a 5150 (a psychiatric hold due to her being a danger to herself after two attempts to hang herself). The NM stated Patient 18 was placed in a room, "with the kids," and was being watched by the, "minor monitor." The NM stated Patient 18 had to go to the bathroom, so she was allowed to go into the bathroom directly across the hall from the minor room and lock the door. According to the NM, the staff checked her every five minutes while she was in the bathroom, and when they knocked on the door, they got no response, so they used a key to get in. The NM stated Patient 18 was found with her own shirt wrapped around her neck, she was unresponsive, and she was having seizures. According to the NM, Patient 18 was sent to a local hospital for emergency treatment, and when she returned she was put on a one to one (one staff member with her at all times to prevent her from doing anything to harm herself).

1. According to the American Psychiatric Association (APA), "Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors," a suicide risk assessment is done to identify risk factors that may increase or decrease a patient's level of suicide risk, to estimate an overall level of suicide risk, and to develop a treatment plan that addresses patient safety and modifiable contributors to suicide risk.

The record for Patient 18 was reviewed. Patient 18, a 15 year old female, was admitted involuntarily to the psychiatric hospital after two recent attempts to hang herself.

The ETS triage risk assessment, dated March 19, 2016, at 6:19 p.m., indicated Patient 18 was brought to the facility because she was a danger to herself, she had a history of suicide attempts, and she had attempted to hurt herself in the past 24 hours, with a note by the nurse that indicated, "kill self and plan." The, "Triage Level," indicated choice of five different categories, with appropriate responses listed for each category as follows:

a. Level 1 - Current behavior endangering self or others and/or medical emergency, as evidenced by a suicide attempt or self-harm in progress: emergency services response needed;

b. Level 2 - Very high risk of imminent harm to self or others, as evidenced by acute suicidal ideation with a clear plan and/or history of self harm or aggression: very urgent mental health response needed;

c. Level 3 - High risk of harm to self or others and/or high distress, especially in absence of support system, as evidenced by suicidal ideation with no plan and/or history of suicidal ideation: urgent mental health response needed;

d. Level 4 - Moderate risk of harm and/or significant distress, as evidenced by significant distress associated with serious mental illness: semi-urgent mental health response needed; and,

e. Level 5 - Low risk of harm and/or distress, as evidenced by no acute distress associated with serious mental illness: non-urgent mental health response needed.

The triage nurse did not assign a triage level to Patient 18, and did not determine which type of mental health response was needed for her.

Record review of Patient 18's risk assessment indicated Patient 18 met the criteria for a triage level 2 requiring a "very urgent mental health response".

There was no evidence Patient 18 was seen by a psychiatrist after triage. There was no evidence of a treatment plan to prevent the patient from injuring herself.

The ETS nursing assessment, completed at 7:45 p.m. (one hour and 26 minutes after the triage assessment was completed), indicated Patient 18 was there because, "I tried to hang myself but I'm OK now." The assessment indicated the patient suffered from auditory hallucinations (hearing voices) and was taking antipsychotic medications. According to the record, Patient 18 had no desire to hurt others, but had attempted to commit suicide. The nurse's notes indicated Patient 18 was being, "monitored with other minors."

There was no evidence Patient 18 was seen by a psychiatrist after the ETS nursing assessment. There was no evidence of a treatment plan to prevent the patient from injuring herself.

The next medical record entry, ETS progress notes written by the ETS registered nurse (RN) at 8:50 p.m., indicated at 8:30 p.m. (two hours and 11 minutes after arrival), Patient 18 went to the bathroom and was found unconscious on the floor with her shirt tied around her neck. She was hypoxic (lacking oxygen) and started seizing. 911 was called, and she was taken by ambulance to a local emergency department for medical treatment.

There was no evidence Patient 18 was seen by a psychiatrist prior to her suicide attempt (the second in 24 hours and third attempt within a week).

According to the record, the psychiatrist first had contact with Patient 18 after she attempted to strangle herself in the bathroom.

2. According to the American Psychiatric Association (APA), "Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors," providing optimal treatment for patients with suicidal behaviors involves a multidisciplinary treatment team approach. Useful strategies for coordination in any treatment setting include clear role definitions, regular communication among team members, and advance planning for management of crises. The psychiatrist should encourage open communication among the staff members regarding treatment of the patient.

During a tour of the ETS unit on March 22, 2016, at 10 a.m., the minor room was observed with two children sitting inside on recliners. A staff member was seated at the doorway, and had a clipboard with a paper for each child where he was documenting their location and demeanor/behavior every 15 minutes.

During an interview with the minor monitor, a certified nursing assistant (CNA), on March 22, 2016, at 10:05 a.m., the CNA stated he was assigned to monitor the patients in the, "minor room." He stated he was responsible for making sure their needs were met, and keeping them safe from the adult patients in the ETS unit. The monitor stated he did not know anything about why the minors were there, he did not know if they were at risk for being a danger to themselves or to others, and the nurses did not give him any kind of a report on the patients when they put a new one in there. He stated he was just told to, "watch them."

The monitor stated if one of the minors had to go to the bathroom, he would walk them across the hall (observed to be located approximately eight feet from the minor room) and let them go into the bathroom. He stated he did not go in with them, and he allowed them to lock the door. The monitor stated while the minor was in the bathroom, he waited for them to come out, but it was, "kind of hard," because he was still responsible for the minors in the minor room at the same time. The monitor stated he was never told how often to check on the minors when they were in the bathroom, but if they were in there, "for a long time," he would knock on the door to see if they were alright. The monitor defined, "a long time," as comparing it to the length of time it took for him to go to the bathroom. He stated if it took longer than he normally took, he would check on them.

The monitor stated at times the minor room had up to nine juveniles. He stated at times they would move to a different room (further away from the bathroom) so they could hold more. According to the monitor, no matter how many minors were in the room being monitored, there was always one staff member to monitor them and take them to the bathroom.

The monitor stated it would, "absolutely" be helpful if he knew they (the patients) had a history of suicide attempts, or if they were a danger to others with violent tendencies. He stated he would not let them close and lock the bathroom door, but instead he would keep the door opened slightly while they were in there, or get another staff member to go with them.

3. During an interview with the Associate Medical Director (AMD 2) of ETS on March 28, 2016, at 9:15 a.m., the AMD stated he did not meet with the medical director of the GACH ED, or attend the ED medical staff meetings.

The agendas for the GACH ED Medical Staff meetings for March 2015 through February 2016 were reviewed. The agendas did not include any presentations, discussions, membership, or attendees from ETS.

Based on observation, interview, and record review, the facility failed to ensure, in the psychiatric hospital emergency treatment services (ETS):

1. Adequate numbers of psychiatric physicians/providers were available to provide initial assessments and treatment plans for seven patients who were admitted into the locked area of the ETS (Patients 18, 5, 20, 21, 22, 23, and 24) without a determination of the level of monitoring required; and,

2. Adequate numbers of staff were available to monitor minor patients. Monitors were responsible for watching/monitoring the patients in the minor room, as well as taking them to the bathroom and monitoring them there.

These failed practices resulted in Patient 18, prior to being seen by a physician, going into the bathroom in ETS, locking the door, wrapping her shirt around her neck and attempting to strangle herself, becoming hypoxic (lack of oxygen to the brain) and having a seizure when she was located by the staff. In addition, these failed practices resulted in the potential for harm or death for other patients in the ETS area.

Findings:

1 a. The record for Patient 18 was reviewed. Patient 18, a 15 year old female, was admitted involuntarily to the psychiatric ETS unit on March 19, 2016, after two recent attempts to hang herself.

The ETS triage risk assessment, dated March 19, 2016, at 6:19 p.m., indicated Patient 18 was brought to the facility because she was a danger to herself, she had a history of suicide attempts, and she had attempted to hurt herself in the past 24 hours, with a note by the nurse that indicated, "kill self and plan." According to the record, Patient 18 met the triage criteria for level two, requiring a very urgent mental health response.

There was no evidence Patient 18 was seen by a psychiatrist after triage. There was no evidence of a treatment plan to prevent the patient from injuring herself.

The ETS nursing assessment, completed at 7:45 p.m. (one hour and 26 minutes after the triage assessment was completed), indicated Patient 18 was there because, "I tried to hang myself but I'm OK now." The assessment indicated the patient suffered from auditory hallucinations (hearing voices) and was taking antipsychotic medications. According to the record, Patient 18 had no desire to hurt others, but had attempted to commit suicide. The nurse's notes indicated Patient 18 was being, "monitored with other minors."

There was no evidence Patient 18 was seen by a psychiatrist after the ETS nursing assessment. There was no evidence of a treatment plan to prevent the patient from injuring herself.

The next medical record entry, ETS progress notes written by the ETS registered nurse (RN) at 8:50 p.m., indicated at 8:30 p.m. (two hours and 11 minutes after arrival), Patient 18 went to the bathroom and was found unconscious on the floor with her shirt tied around her neck. She was hypoxic (lacking oxygen) and started seizing. 911 was called, and she was taken by ambulance to a local emergency department for medical treatment.

There was no evidence Patient 18 was seen by a psychiatrist prior to her suicide attempt (the second in 24 hours and the third attempt in a week).

According to the record, the psychiatrist first had contact with Patient 18 after she attempted to strangle herself in the bathroom (two hours and 11 minutes after she arrived at the ETS unit meeting criteria for a very urgent mental health response).

b. The record for Patient 5 was reviewed. Patient 5, presented to the facility's ETS area, on February 9, 2016, at 6:35 p.m., with complaints that he was insane and, "I can't function anymore."

The ETS nursing triage assessment, completed on February 9, 2016, at 6:40 p.m., indicated Patient 5's legal status was voluntary and the patient was placed in ETS.

There was no evidence Patient 5 was seen by a psychiatrist until 7:40 p.m., when the psychiatrist documented the patient was, "unable to function," and was a voluntary patient. There was no documentation of examination findings, physician's orders, or treatment plan, at this time.

According to the record, the psychiatrist completed the psychiatric evaluation on February 10, 2016, at 1 a.m., (six hours and 20 minutes after Patient 5 arrived). The psychiatrist documented Patient 5 was a, "danger to self," and gravely disabled, and required inpatient hospitalization.

Patient 5's discharge summary indicated on admission, Patient 5 was severely depressed and was hearing demonic voices. Patient 5 remained hospitalized an additional nineteen days.

c. The record for Patient 20 was reviewed. Patient 20, a 14 year old female, was admitted involuntarily to the psychiatric ETS unit on March 21, 2016, after attempting to choke herself.

The ETS nursing assessment, completed March 22, 2016, at 55 minutes after midnight, indicated Patient 20 was there because she was found trying to choke herself and refusing to take her antipsychotic medications. The patient was uncooperative and refused to be interviewed. The record indicated she was placed on minor monitoring in the ETS unit.

There was no evidence Patient 20 was seen by a psychiatrist after the ETS nursing assessment. There was no evidence of a treatment plan to prevent the patient from injuring herself.

According to the record, the psychiatrist's first contact with Patient 20 was at 5:30 a.m. (five hours and 31 minutes after she arrived), and completed the psychiatric evaluation at 6 a.m.

d. The record for Patient 21 was reviewed. Patient 21, a nine year old male, was admitted involuntarily to the psychiatric ETS unit on March 22, 2016, after threatening to kill himself.

The ETS nursing assessment, completed at 5 a.m. (two hours and 13 minutes after arrival), indicated the child was there because he was a danger to himself and a danger to others. According to the record, he was placed on minor monitoring in the ETS unit.

There was no evidence Patient 21 was seen by a psychiatrist after the ETS nursing assessment. There was no evidence of a treatment plan to prevent the patient from injuring himself or others.

According to the record, the psychiatrist's first contact with Patient 21 (completed the psychiatric evaluation) was at 10:10 a.m. (seven hours and 23 minutes after he arrived).

e. The record for Patient 22 was reviewed. Patient 22, a 20 year old male, arrived at the ETS unit involuntarily on March 28, 2016, at 3:58 a.m., after demonstrating behavior that made him a danger to himself and to others.

The triage assessment, completed on arrival, indicated Patient 22 was a moderate risk for danger to himself or others, and was sent into the locked area of the ETS unit.

There was no evidence Patient 22 was seen by a psychiatrist after the triage assessment. There was no evidence of a treatment plan to prevent the patient from injuring himself or others.

According to the record, the psychiatrist's first contact with Patient 22 was at 6:30 a.m. (two hours and 32 minutes after he arrived), and completed the psychiatric evaluation.

f. The record for Patient 23 was reviewed. Patient 23, a 53 year old male, arrived at the ETS unit involuntarily on March 27, 2016, at 3:15 p.m., after demonstrating behavior that made him a danger to others.

The triage assessment, completed on arrival, indicated Patient 23 was a high risk for danger to himself or others, and was sent into the locked area of the ETS unit.

There was no evidence Patient 23 was seen by a psychiatrist after the triage assessment. There was no evidence of a treatment plan to prevent the patient from injuring himself or others.

According to the record, the psychiatrist's first contact with Patient 23 was at 6:50 p.m. (three hours and 35 minutes after he arrived), and completed the psychiatric evaluation.

g. The record for Patient 24 was reviewed. Patient 24, a 27 year old male, arrived at the ETS unit involuntarily on March 28, 2016, at 3:10 a.m. Patient 24, with no psychiatric history, was verbalizing fears of wanting to kill himself.

The triage assessment, completed on arrival, indicated Patient 24 was a high risk for danger to himself, and he was sent into the locked area of the ETS unit.

There was no evidence Patient 24 was seen by a psychiatrist after the triage assessment. There was no evidence of a treatment plan to prevent the patient from injuring himself.

According to the record, the psychiatrist's first contact with Patient 24 was at 5:45 a.m. (two hours and 35 minutes after he arrived), and completed the psychiatric evaluation.

During a concurrent interview at the psychiatric hospital with the Manager of Quality and Education (MQE), the Associate Medical Director of the Adolescent Inpatient Unit (AMD 1), the Associate Medical Director of ETS (AMD 2), the Associate Chief Nursing Officer (ACNO), and the Inpatient Unit Nurse Managers (NM 1 and 2), they stated quality indicators were in place to determine the time it took for a patient to receive an evaluation by a psychiatrist/provider. The ACNO stated the, "door to physician times," for patients going into the locked area of ETS were, "long." They stated patients who came to the psychiatric facility voluntarily seeking assistance were seen by the triage nurse, and a physician/provider was called to see them, "immediately." They stated patients who came involuntarily or agreed to go into the ETS locked area waited longer to see a physician/provider. They stated they were aware of the delays, and were working on increasing the physician staffing to improve the times, but they had not yet accomplished the improvement.

During an interview with Psychiatrist 1 on March 28, 2016, at 3 p.m., the psychiatrist stated patients in the ETS unit should be seen within one hour. He stated that was not always possible, depending on the physician staffing. According to the psychiatrist, he was the only one scheduled for that evening and night, and he would be responsible for all of the new patients who came in needing an initial psychiatric evaluation (voluntary and involuntary - usually about 15 to 17 patients), responding to all, "codes," (patients who needed intervention for behaviors), and all inpatient needs in all of the inpatient units (Units A, B, C, and D). He stated there was no way he would be able to complete initial psychiatric evaluations on all new patients within one hour.

The quality data was reviewed with the Quality Management Nurse (QMN) on March 29, 2016. According to the data, the goal for the door to evaluation time for a patient in ETS was 27 minutes. The actual times were reported as follows:

- First quarter 2015 - 103 minutes;
- Second quarter 2015 - 235 minutes;
- Third quarter 2015 - 98 minutes; and,
- Fourth quarter 2015 - 102 minutes.

During a concurrent interview, the QMN stated she attended the quality management meetings for the entire organization, and reported the psychiatric hospital data quarterly. She stated the quality management committee was aware of the data and the delays.

2. During a tour of the ETS unit on March 22, 2016, at 10 a.m., the minor room was observed with two children sitting inside on recliners. A staff member was seated at the doorway, and had a clipboard with a paper for each child where he was documenting their location and demeanor/behavior every 15 minutes.

During an interview with the minor monitor, a certified nursing assistant (CNA), on March 22, 2016, at 10:05 a.m., the CNA stated he was assigned to monitor the patients in the, "minor room." He stated he was responsible for making sure their needs were met, and keeping them safe from the adult patients in the ETS unit. The monitor stated he did not know anything about why the minors were there, he did not know if they were at risk for being a danger to themselves or to others, and the nurses did not give him any kind of a report on the patients when they put a new one in there. He stated he was just told to, "watch them."

The monitor stated if one of the minors had to go to the bathroom, he would walk them across the hall (observed to be approximately eight feet) and let them go into the bathroom. He stated he did not go in with them, and he allowed them to lock the door. The monitor stated while the minor was in the bathroom, he waited for them to come out, but it was, "kind of hard," because he was still responsible for the minors in the minor room at the same time. The monitor stated he was never told how often to check on the minors when they were in the bathroom, but if they were in there, "for a long time," he would knock on the door to see if they were alright. The monitor defined, "a long time," as comparing it to the length of time it took for him to go to the bathroom. He stated if it took longer than he normally took, he would check on them.

The monitor stated at times the minor room had up to nine juveniles. He stated at times, they would move to a different room (further away from the bathroom) so they could hold more patients. According to the monitor, no matter how many minors were in the room being monitored, there was always one staff member to monitor them and take them to the bathroom.