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Based on observation, interview, and record review, the facility failed to ensure a safe patient environment was provided for 3 of 15 patients (Patients #3, #14, and #12).

1. Patients #3 and #14, on suicide precautionary staff observation levels, were able to gain access to and barricade themselves in a patient area laundry room where they drank liquid laundry detergent in a self-harm attempt
2. Patient #12, physician assessed to be unpredictable and impulsive, had a history of a suicide attempt by swallowing batteries prior to hospital admission. Three weeks into her hospital stay, Patient #12 had access to and swallowed a battery and retained a crayon that she inserted into her ear, necessitating the services of specialty medical physicians.


Findings included:

1. Observations of the Hospital Adolescent Resilience Unit on 06/17/22 at 1108 reflected a laundry room close to the nurses' station. A large container of liquid Tide laundry detergent was noticeable on one of the washing machines. On 06/17/22 at 1111, Hospital Personnel J confirmed a recent incident where two female patients had barricaded themselves in the laundry room and "staff didn't lock the door."


a) Record Review of Patient #3's Patient Information Sheet reflected the 16-year-old patient had been admitted on 04/12/22 with diagnoses that included Disruptive Mood Dysregulation, Attention Deficit Hyperactivity, and Oppositional Defiant Disorder.

Patient #3's Psychiatric Evaluation dated 04/13/22 at 0730 reflected she had been admitted due to a suicide attempt and auditory hallucinations to hurt self. The patient was suicidal with a plan and was noted to have poor coping skills. She was placed on suicide and aggression precautionary staff-observation levels.

Patient #3's Medical Consult dated 06/07/22 at 1645 reflected Patient#3 "got into laundry room yesterday with another patient and drank some Tide detergent ...not sure exactly how much ...did throw up once last night ...does complain of mild nausea today ..."

Patient #3's Physician Daily Progress Note dated 06/06/22 at 0930 reflected the patient was angry, "aggressive, easily agitated, defiant, unpredictable, labile." She intended "self-harm" and had "poor insight ..." The patient drank detergent because "she like[d] it ..."


b) Patient #14's Patient Information Sheet reflected the patient's admission on the evening of 04/29/22. Admitting diagnoses included Disruptive Mood Dysregulation, Major Depressive Disorder, and Attention Deficit Hyperactivity.

Admission Orders dated 04/29/22 at 2325 reflected Patient #14 had been admitted after she ran away from home and told police she wanted to "kill herself."

Nursing Flow Sheet dated 06/05/22 at 1030 reflected Patient #14 was "out of control ...Thorazine 25mg IM ...patient kick[ed] staff ...put patient in seclusion..."

Physician Orders dated 06/06/22 at 0400 reflected the patient was on 15-minute staff observation level for suicide, self-harm, aggression, and elopement precautions.

Physician Orders dated 06/06/22 at 0900 reflected the order for the patient to have a medical consult because she " ...drank detergent ..."

Multidisciplinary Progress Notes dated 06/06/22 at 1705 reflected "Pt reported that she consumed a little bit of laundry detergent. She was observed attempting to grab hand sanitizer while stating that she wanted to drink it. Pt reported that she wanted to die."

Restraint/Seclusion/Emergency Medication Debriefing Form dated 06/06/22 at 0930 reflected the patient "was trying to jump onto the nurses' station ...need additional MHT [mental health technician] ..."

Hospital Personnel F was interviewed regarding the incident on 06/17/22 at 1355 and stated Hospital Personnel K had entered the laundry room to place an object there. Upon leaving, the door did not lock properly, and Hospital Personnel K stepped away to "notify maintenance." During that time, Patient #3 and Patient #14 went into the laundry room and "strongly" pushed against the door. Patient #3 admitted to drinking laundry detergent. Patient #14 "was not sure." The medical physician was notified and conducted a physical examination.




2. Patient #12's Patient Information Sheet reflected the 17-year-old patient was admitted on 05/06/22 with diagnoses that included Major Depressive Disorder.

Patient #12's Physician Comprehensive Psychiatric Evaluation dated 05/07/22 at 1530 reflected the patient had been admitted for a suicide attempt by swallowing two batteries. The patient was assessed to be "unpredictable, unreliable, impulsive, isolative, withdrawn." The patient's chief complaint was "anger."

Multidisciplinary Progress Notes dated 06/03/22 at 2347 reflected Patient #12 "at the early part of the shift" grabbed "a battery from behind the nursing station ...quickly escaped to her room ...reported she has swallowed it ...room search ...nothing found ...order given for abdominal x-ray ..."

Nursing Shift Progress Notes dated 06/04/22 at 0730 reflected staff received "report from RN that x-ray has been taken on pt [Patient #12] d/t report of swallowing batteries."

Nursing Progress Notes dated 06/04/22 at 1333 reflected nursing reviewed the x-ray report that noted that "a battery-shaped radiodensity overlies the gastric region presumed ingested ..."

Nursing Progress Notes dated 06/04/22 at 1522 reflected the medical physician "was notified to discuss x-ray results of location of battery in gastric region ...will call [Children's Hospital] Emergency Department for recommendation of care ...pt [Patient #12] swallowed batteries before ...last weekend, pt was sent to hospital for sticking crayon in her ear ..."

Nursing Progress Notes dated 06/04/22 at 1202 reflected the patient complained of "stomach and ear pain."

Hospital Employee F acknowledged the above findings during an interview on 06/17/22 at 1545 and stated Patient #12 required the services of an Ear-Nose-Throat specialist to get the crayon out of the ear.


Record review of the Hospital Patient Bill of Rights provided to the surveyor on 06/17/22 reflected the patient had the "right to a clean and humane environment...protected from harm..."

Based on observation, interview, and record review, the facility failed to ensure the condition of the physical hospital and overall hospital environment was maintained in such a manner that the safety and well-being of patients were assured. Multiple observed large holes in three out of four patient care areas provided access to potentially harmful dry-wall material, expletive graffiti on walls contributed to a non-therapeutic environment, and a malfunctioning unit-access door allowed patient exit.

1. The hospital's Optimism Unit had holes in the wall which exposed building material to at least 24 patients including Patient #12 who had ingested harmful objects in prior suicide attempts and Patient #13 who, despite of her precautionary staff-observation for self-harm and suicide, was surveyor observed taking building material out of a hole in the wall. The day prior to the survey, a malfunctioning badge-activated unit access door allowed Patient #11 to elope from the patient care area.

2. The hospital's Confidence Unit, housing 18 male (pre)adolescent patients at the day of survey, had a hole in the wall and a lose-hanging floorboard on at least one wall, and offensive graffiti on the wall next to at least four patient rooms.

3. The hospital's patient Gym had paint peeling off the wall in least five patches; contraband was observed to be easily accessible and potentially usable for patient harm.

4. The hospital's female adolescent patient Unit (Resilience) had two large holes in the day area, potentially providing access to in-wall building material for 7 adolescent female patients housed on that unit. Paint on the walls and floorboards were missing.





Findings included:


1. A tour of the Hospital Optimism Unit on 06/17/22 at 1045 was conducted with Hospital Personnel D and Hospital Personnel J.

The unit consisted of a long and a shorter hallway, separated by a door. At the end of the shorter hallway by the exit door, a large hole in the wall, approximately two feet by one foot, was observed. Patient #13 sat in front of the hole and removed pieces of drywall material through the hole. Hospital Personnel J stated at that time that the hole was "at least two feet."

Hospital Personnel H stated on 06/17/22 at 1305 that Patient #13 was on self-harm and suicide precautions.

A second hole in the wall, slightly smaller in dimensions, was observed on the same hallway and provided patient access to drywall material.

Missing base boards of several feet were observed on at least three locations on the Optimism unit.

Throughout the Optimism hallway, multiple offensive-expletive writings were observed on the wall in at least four places, graffiti covered at least additional four wall spaces.

The yellow paint on Room 212's door frame and the black paint on one of the walls was peeled off in at least two places.

Hospital Personnel J accompanied the surveyor and acknowledged the above findings at that time, stating that the expletive wall writings were a "daily" occurrence.

Record Review of the hospital census dated 06/17/22 reflected the Optimism Unit had 24 adolescent patients and included Patient #12, Patient #13, and Patient #11.

Record Review of Patient #12's Multidisciplinary Progress Notes dated 06/03/22 at 2347 reflected Patient #12 retrieved "a battery from behind the nursing station ...quickly escaped to her room ...reported she has swallowed it ...order given for abdominal x-ray ..."

Record Review of Patient #13's Patient Information Sheet reflected she was admitted the evening of 06/13/22 with admitting diagnoses that included Unspecified Mood Disorder.
Patient #13's Physician Orders dated 06/13/22 at 1553 reflected the patient wanted to hurt herself at that time.
Physician Daily Progress Notes dated 06/17/22 reflected the patient was irritable and had poor insight and judgement.
Patient #13's Observation Form dated 06/16/22 reflected suicide and self-harm precautions.


Record review of Patient #11's Information Sheet reflected the patient was admitted the early morning hours of 06/02/22. Admitting diagnoses included Post-Traumatic Stress Disorder and Bipolar disorder.
Patient #11's Physician Psychiatric Evaluation dated 06/02/22 at 0950 reflected the patient was admitted due to plans for self-harm. The patient was assessed to be labile, anxious, and depressed.
Physician Orders dated 06/16/22 at 2020 reflected Patient #11's specific behaviors included imminent risk of self-injury and imminent risk of injury to others.
Multidisciplinary Progress Notes dated 06/16/22 at 2012 reflected Patient #11 "had walked out of the unit from Optimism due to door malfunction..."

2. The hospital's Confidence Unit was toured on 06/17/22 at approximately 1050. The surveyor was accompanied by Hospital Personnel J. Observations on the unit included offensive-expletive writing on the walls next to Rooms 109, 111, 112, 114, the laundry room, and a room labeled "storage." Hospital Personnel J stated at that time that patients were provided crayons for unit activities and then continued the writings on the wall.

A hole in the wall and lose-hanging floorboard were observed on at least one wall in one of the hallways on the Confidence Unit.

Record review of the hospital census dated 06/17/22 reflected the unit had 18 (pre)adolescent male patients.

3. The Gym was toured on 06/17/22 at 1105. The blue wall paint was peeled off in large pieces in at least five places, a large patch of paint was observed on the floor.

A paper waste bag was observed on the floor. Visibly sticking out of the bag was a plastic zip-lock bag with residues from its earlier, brown-colored contents. Hospital Personnel J acknowledged the contraband finding at the time of observation and denied that plastic was allowed in the hospital at that time.
Hospital Personnel F stated during an interview on 06/17/22 at 1445 that the plastic bag was "from an employee."

4. Upon entry to the Resilience Unit on 06/17/22 at 1108, two large holes in the wall were immediately visible. They were approximately two feet by two feet in size and located in the area across the main unit door. Two walls in that area were bare of paint on at least three places and the floorboards were missing.

Multiple feet of floorboard were folded up and placed in front of the dryer in the unit's laundry room.

On 06/17/22 at 1111, Hospital Personnel J acknowledged the above findings while accompanying the surveyor.

Record review of the patient census dated 06/17/22 reflected the unit had 7 adolescent female patients.