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Based on record review, observation, and interview, the hospital failed to enforce patients' rights and to provide a safe care environment for hospital staff (Personnel #4) and for 4 of 11 patients (Patient #6, #8, #9, and #10).


1) Patient #6 attacked and seriously injured Personnel #4 on the evening of 03/06/16 who required medical intervention. Patient rounds/observation records dated 02/28/16 and 03/06/16 were left incomplete.


2) Patient #10 was hit by another patient. Patient #10 was observed with a bruise below his left eye.


3) Patient #9, a 17 year old adolescent, assaulted a 9 year old pediatric patient (Patient #8) choking him and pushing him into a wall. Patient rounds/observation records for Patient #9 dated 03/17/16 were left incomplete.


4) Items potentially usable in self-harm were accessible to patients in the hospital's dining room and male adolescent unit.


Cross refer to A 0144.

Based on observation, interview and record review, the hospital failed to ensure a safe environment was provided for hospital staff (Personnel #4) and for 4 of 11 patients (Patient #6, #8, #9, and #10). Items potentially hazardous and usable in self-harm were available to patients in the dining room and on the hospital's adolescent male unit.


1) Patient #6 attacked and seriously injured Personnel #4 on the evening of 03/06/16, who required medical intervention. Patient rounds/observation records dated 02/28/16 and 03/06/16 weres left incomplete.


2) Patient #10 was hit by another patient. Patient #10 was observed with a bruise below his left eye.


3) Patient #9, a 17 year old adolescent assaulted, a 9 year old pediatric patient (Patient #8) choking him and pushing him into a wall. Patient rounds/observation records for dated 03/17/16 were left incomplete.


4) Items potentially useable for self-harm were available to and in reach of patients. Patients had access to plastic ware with the potential for breaking into sharp edges and hygiene items with the potential for self-poisoning.


Findings included:

1) Patient #6's Intake to Unit Nurse Staff Hand-Off document dated 02/24/16 timed at 1142 reflected, "Risk Assessment suicidal moderate risk...past attempts...assaultive/homicidal...high, indications...aggressive...elopement risk...high..."


The Inpatient Admission Orders dated 02/24/16 timed at 2345 reflected, "Precautions...assaultive/aggression...level of observation Q15 minutes..."


The Patient Observation Record dated 02/28/16 timed at 2330 and 2345 was left blank for behavior, location and staff initials.


The 03/05/16 progress note (nursing) timed at 1500 reflected, "Patient became angry with another patient...making threats to fight...attempted to fight and staff intervened...given emergency medications... "


The 03/07/16 (03/06/16) progress note (nursing) timed at 2245
reflected, "Patient tore toilet seat off of toilet came out of room with it and attacked a staff member...hit her in the right eye, neck and back of head and back...client was taken to seclusion..."


The Patient Observation Record dated 03/06/16 timed at 2245 and 2300 was left blank for behavior, location and staff initials.


The 03/07/16 Psychiatric Progress Notes (physician) timed at 0755 reflected, "Patient attacked a nurse last night...aggressive irritable...nurse was taken to hospital with head injury..."


On 05/20/16 at 1153 Personnel #1 was interviewed. Personnel #1 was asked if the hospital had any events in regards to a patient hitting a nurse with a toilet seat. Personnel #1 stated "yes." Personnel #1 stated the patient removed the toilet seat and hit the nurse in the head/face. Personnel #1 stated the technician had left the unit to go on break.


On 06/01/16 from 1336 to 1415 Personnel #4 was interviewed. Personnel #4 stated, she had about 14 adolescents on the evening of 03/06/16 with one technician. Personnel #4 stated, towards the end of the shift the technician left to go on his lunch break which left her alone. Personnel #4 was asked if she asked for someone to come to the unit and cover while the technician was off the unit. Personnel #4 stated, she did not call anyone because there was no additional staff to cover for lunch breaks. Personnel #4 stated, she thought it would be ok for the technician to take a break as the boys were already in bed. Personnel #4 stated, Personnel #5 unexpectedly came to see her on the unit. Personnel #4 stated, Patient #6 kept coming up to the desk asking who was working that night. Personnel #4 stated, the patient was sent to his room. Personnel #4 said, she went into Patient #6's room while Personnel #5 went in the next room and attempted to come through the bathroom. Personnel #4 stated, Patient #6 hit her across the head and face with a toilet seat which he had apparently pulled off the toilet when she entered the room. A code was called and she (Personnel #4) was sent to the medical hospital. Personnel #4 stated, she had blood coming from her face during the event and she is still having some eye problems and anxiety over the assault which includes nightmares. Personnel #4 stated, generally there are two people assigned to the unit. Personnel #4 stated she did not feel it was safe on the unit.


On 05/27/16 at 1427 Personnel #6 was interviewed by telephone. Personnel #6 was asked to provide details and/or information regarding the above event. Personnel #6 stated, he had left for his lunch break around 2200 or 2230. Personnel #6 stated, he was the only assigned technician for the unit and thought there may have been between twelve to fourteen adolescents. Personnel #6 stated one person doing rounds for fourteen patients is almost impossible.


On 06/17/16 from 1039 to 1050 Personnel #1 was interviewed. Personnel #1 was asked to review Patient #6's medical record. Personnel #1 verified the Q15 observation rounds records for 03/06/16 and 02/28/16 were left blank.


The policy and procedure entitled, "Rounds for Patient Observation" with an effective date of 01/10/14 reflected, "Every patient must be seen by a staff member at a minimum of every fifteen minutes...record of the whereabouts of all patients will be maintained during each shift by each unit... "



2) Patient #10's Nursing Admission Assessment dated 05/20/16 at 1100 did not reflect a facial bruise.


Record review of nursing progress notes dated 05/26/16 at 1754 reflected Patient #10 "...was smacked..."


Patient #10 was observed by a surveyor on 05/28/16 at 1715 with a greenish fading bruise below his left eye. Patient #10 stated he was hit by Patient #11.


During an interview on 05/28/16 at 1755 Personnel #2 acknowledged the incident.



3) Patient #8's Inpatient Admission Orders dated 03/17/16 timed at 1703 reflected, "Mood (affective) disorder, unspecified, Attention-Deficit/Hyperactivity Disorder ...precautions ...elopement, assaultive/aggression...level of observation...Q (every) 15 minutes..."


The 03/17/16 progress note (nursing) timed at 2245 reflected, "Presents to hospital with aggression...patient was earlier reported to have an incident with another adolescent patient who grabbed Patient #8 by his neck and pushed him against the wall as reported by Mental Health Technician..."


On 06/17/16 Personnel #1 was interviewed from 0918 to 1002. Personnel #1 was asked to review the medical record for Patient #8. Personnel #1 stated when Patient #8 was admitted he was placed on the wrong unit by the intake department. The nurse allowed Patient #8 to go to the Gym with adolescent boys.


Patient #9's medical record document entitled, "Form, Screening" dated 03/14/16 under the section "Presenting Problem" reflected, "I'm not suicidal...I'm homicidal...says he has thought of wanting to kill...with a knife...attempted to jump out of a moving car on the highway after being upset about his prescription being sent to the wrong pharmacy...wrapped blind chords around his neck...put fingers in an outlet to electrocute himself...jumped his mother...beat her up...assaulting others with desk, chairs, his hands...fears he might hurt a child."


The 03/14/16 progress note (nursing) timed at 2025 reflected, "Presented back to hospital having been discharged 03/11/16 for aggressive behavior and running away...unable to answer questions...Q15 minutes...monitored...safety..."


The 03/17/16 progress note (nursing) timed at 0940 reflected, "Woke up irritable loud, cursing...verbalized he was fighting in his dreams...wants to kill...and stab him in the chest with a knife...threatening to hit...Dr. notified..."


The 03/17/16 progress note (nursing) timed at 2135 reflected, "Patient was at the gym and was reported he grabbed...9 year old patient by the neck and pushed him against the wall..."


The Patient Observation Record dated 03/17/16 timed at 1930, 1945, and 2000 were left blank for behavior, location and staff initials.


On 05/28/16 at 1907 Personnel #7 was interviewed. Personnel #7 stated Patient #8 (9 year old) and Patient #9 (17 year old) were taken to the Gym. Personnel #7 stated, Patient #8 was sent by accident with the older boys. Personnel #7 stated, Patient #9 threw Patient #8 against the wall and grabbed him around his neck. Personnel #7 stated, the 17 year old should not have been with the 9 year old as the 17 year old did not like little kids.


On 06/17/16 Personnel #1 was interviewed from 0918 to 1002. Personnel #1 was asked to review the medical record for Patient #9. Personnel #1 verified Patient #9's close observation record for 03/17/16 should not have been left blank from 1930 to 2000.



4) On 05/28/16 at between 16:30 and 1647, thirty-nine male and female pediatric and adolescent patients were observed in the hospital's dining room. After receiving their food from the serving line, all patients walked by a dispenser with plastic eating utensils and retrieved their eating utensils. Two plastic forks were observed unattended on the floor.

On 05/28/16 at 1755 Personnel #2 acknowledged the plastic ware dispenser in the dining room.

Hygiene items including shampoo/body wash and deodorant labeled "for external use only" and "call poison control or contact physician" were observed in patient rooms 215, 217, and 222 on 05/28/16 between 1710 and 1712. Personnel #13 acknowledged the items at that time and stated they were "not supposed to be there."

Based on record review, interview, and observation, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for 4 of 11 patients (Patient #3, #6, #8, and #10).


1) Patient #3 was admitted with no altered skin integrity but developed skin injury to his scrotum and buttocks. Hospital personnel failed to measure, describe, and accurately document and monitor Patient #3's altered skin integrity.


2) Patient #10 was observed by the surveyor with a fading bruise below his left eye and had an altercation with another patient. Nursing staff failed to assess and document the skin change.


3) Patient #8 (9 year old) was assaulted by a 17 year old adolescent (Patient #9) who choked and threw Patient #8 against a wall. No follow-up assessment was found for Patient #8.


4) Patient #6's care plan did not address Patient #6's laceration sustained while in seclusion.



Cross Refer to A395 and A396

Based on record review, interview, and observation, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for 3 of 11 patients (Patient #3, #8 and #10).


1) Patient #3 was admitted with no altered skin integrity but developed skin injury to his scrotum and buttocks. Hospital personnel failed to measure, describe and accurately document and monitor Patient #3's altered skin integrity.


2) Patient #10 was observed by a surveyor with a fading bruise below his left eye, and had an altercation with another patient. Nursing staff failed to assess and document the skin change.


3) Patient #8 (9 year old) was assaulted by a 17 year old adolescent (Patient #9) who choked and threw Patient #8 against a wall. No follow-up assessment was found for Patient #8.


Findings included:


1) Patient #3's Inpatient Admission Orders dated 04/14/16 timed at 2120 reflected, "Affective Disorder...level of observation Q 15 minutes...skin assessment..."


The Nursing Assessment dated 04/14/16 reflected, "Skin normal, turgor adequate..." No altered skin integrity was documented on the skin assessment for Patient #3.


The 04/15/16 Multidisciplinary Progress Notes timed at 1445 reflected, "Patient observed to have wound to scrotum about the size of a dime...patient was changed...order received for zinc oxide to open area TID..."


The 04/15/16 Physician's Orders timed at 1450 reflected, "Apply Barrier Creme to open areas to scrotum TID (three times a day)...apply zinc oxide to open area to scrotum TID..."


The 04/16/16 Patient Data and Assessment Record reflected, "Skin section...lesions." No notes or comments on turgor, color, measurements of altered skin integrity.


The Physician Medical Consult Form dated 04/18/16 timed at 1245 reflected, "Skin warm, dry and normal..."


The 04/19/16 patient Data and Assessment Record reflected, "Skin section...within normal limits..."


The 04/25/16 Multidisciplinary Progress Note dated 04/25/16 timed at 0625 reflected, "Pericare provided with multiple (4) small excoriated spots note with no odor."


The 04/25/16 Physician Medical Consultation Form timed at 0850 reflected, "Skin section...dry, normal..."


The 04/25/16 Patient Data and Assessment reflected, "Skin section...within normal limits..."


The Physician's Orders dated 04/25/16 timed at 2100 reflected, "Cleanse wounds (scrotum) with soap and water then pat dry with gauze followed by application of bacitracin ointment...then dress with non adherent pad..."


The Physician's Orders dated 05/03/16 timed at 1030 reflected, "Triple antibiotic ointment apply to excoriations on bilateral testicles BID (twice daily) till resolved..."


The Physician's Orders dated 05/03/16 reflected, "Monistat 2% cream apply to bilateral testicles BID till resolved..."


The Patient Data and Assessment dated 05/03/16 reflected, "Skin section...within normal limits..."


The Multidisciplinary Progress Notes dated 05/06/16 timed at 1805 reflected, "Sitting in dayroom...did not eat much...has a Stage II Ulcer to scrotum...wound care done..." No documentation on the size, measurements and description of the wound was documented.


The Multidisciplinary Progress Notes dated 05/15/16 at 0820 reflected, "Patient complains of pain on his bottom...at 1450 two Stage II pressure ulcers located on right buttock...at 2302...has to be spoon fed...confused..."


The Patient Data and Assessment document dated 05/15/16 reflected, "Skin section...within normal limits..."


The Physician's Orders dated 05/15/16 timed at 1442 reflected, "Stage II Pressure Ulcer (Skin Injury) to right buttock...apply Zinc Oxide to area TID..."


The Medical Consultation Form dated 05/15/16 timed at 0830 reflected, "Skin section...dry and normal..." No reference to altered skin integrity.


The Multidisciplinary Progress Notes dated 05/16/16 timed at 2125 reflected, "Made comfortable in bed...Stage 2 wound to bottom, scrotum and right buttock...wound care done..."


The Multidisciplinary Progress Notes dated 05/17/16 timed at 1030 reflected, "Stage 2 to scrotum and right buttock..."


On 06/17/16 at approximately 1109 Personnel #1 was asked to review Patient #3's medical record. Personnel #1 verified Patient #3's altered skin integrity and wounds was not assessed accurately and documented by hospital personnel.



2) Patient #10's Nursing Admission Assessment dated 05/20/16 at 1100 did not reflect a facial bruise. Daily nursing assessments of Patient #10's skin dated 05/21/16 through 05/28/16 reflected no bruising.


Nursing Progress Notes dated 05/26/16 at 1754 reflected Patient #10 "...was smacked...no bruising or swelling...will continue to monitor."


Patient #10 was observed by a surveyor on 05/28/16 at 1715 with a greenish fading bruise below his left eye. Patient #10 stated he was hit by Patient #11.


Personnel #1 was asked about nursing care and evaluation of Patient #10's bruise on 05/28/16 at 1930. Personnel #1 reviewed Patient #10's chart and denied documentation of a bruise on Patient #10.



3) Patient #8's Intake Assessment dated 03/12/16 (03/17/16) timed at 1358 reflected, "Bipolar Disorder...9 year old...per mother patient is becoming highly aggressive at home and school...had a two hour restraint at school...ran away...yesterday upset with teacher...threw chairs, desk across room...punched the Vice Principle...weekend head banging..."


The Inpatient Admission Orders dated 03/17/16 timed at 1703 reflected, "Mood (affective) disorder, unspecified, Attention-Deficit/Hyperactivity Disorder...precautions...elopement, assaultive/aggression...level of observation...Q (every) 15 minutes..."


The 03/17/16 progress note (nursing) timed at 2245 reflected, "Presents to hospital with aggression...patient was earlier reported to have an incident with another adolescent patient who grabbed (Patient #8) by his neck and pushed him against the wall as reported by Mental Health Technician..."


The 03/18/16 progress note (nursing) timed at 0100, 1413, and 1750 revealed no follow-up nurse assessment for Patient #8 after he was thrown up against the wall and choked by Patient #9, a 17 year old adolescent on 03/17/16.


On 06/17/16 Personnel #1 was interviewed from 0918 to 1002. Personnel #1 was asked to review the medical record for Patient #8. Personnel #1 verified Patient #8 did not receive a follow-up assessment after being choked by Patient #9.


The policy and procedure entitled, "Nursing Documentation" with an effective date of 03/27/16 reflected, "The nursing process...serves as the basis for the nursing documentation of care...multi-disciplinary progress notes are indicator for transfer...discharge, change in patient condition, medical, behavioral, seclusion, restraints, patient incidents, unusual issues..."

Based on interview and record review the hospital failed to ensure 2 of 11 patients (Patient #3's and #6's) care plan addressed Patient #3's altered skin integrity and a laceration Patient #6 sustained while in seclusion.


Findings included:


1) Patient #3's Inpatient Admission Orders dated 04/14/16 timed at 2120 reflected, "Affective Disorder...level of observation Q 15 minutes...skin assessment..."


The Nursing Assessment dated 04/14/16 reflected, "Skin normal, turgor adequate..." No altered skin integrity was documented on the skin assessment for Patient #3.


The 04/15/16 Multidisciplinary Progress Notes timed at 1445 reflected, "Patient observed to have wound to scrotum about the size of a dime...patient was changed...order received for zinc oxide to open area TID..."


The Multidisciplinary Progress Notes dated 05/15/16 at 0820 reflected, "Patient complains of pain on his bottom...at 1450 two Stage II pressure ulcers located on right buttock...at 2302...has to be spoon fed...confused..."


The Physician's Orders dated 05/15/16 timed at 1442 reflected, "Stage II Pressure Ulcer (Skin Injury) to right buttock...apply Zinc Oxide to area TID..."


The Multidisciplinary Progress Notes dated 05/16/16 timed at 2125 reflected, "Made comfortable in bed...Stage 2 wound to bottom, scrotum and right buttock...wound care done..."


The Master Treatment Plan dated 04/18/16 revealed no documentation which addressed Patient #3's altered skin integrity and skin injury.


On 06/17/16 at approximately 1109 Personnel #1 was asked to review Patient #3's medical record. Personnel #1 verified Patient #3's treatment plan was incomplete and did not address altered skin integrity.



2) Patient #6's Intake Assessment dated 02/24/16 timed at 2246 reflected, "14 year old...has anger issues and becomes aggressive with family members...running away, impulsive...hit brother in the nose and tried to smash his head against the sidewalk...history of fire starting and is aggressive towards animals...hostile towards parents in assessment room...patient found with screwdriver and lighter...moderate/high risk of suicide due to impulsive behavior unable to contract for safety...high assaultive behavior..."


The 03/07/16 (03/06/16) progress note (nursing) timed at 2245 reflected, "Patient tore toilet seat off of toilet came out of room with it and attacked a staff member...hit her in the right eye, neck and back of head and back...client was taken to seclusion where he hit glass in door with his fist...when staff placed hand on glass the glass shattered and hit client in the face cutting him just above the nose...sent to ER (emergency room)..."


The 03/07/16 progress note (nursing) timed at 0200 reflected, "Patient returned to unit from ER...cut cleaned applied triple antibiotic ointment...stated he blacked out and does not remember what he did...placed on 1:1 and returned to bed..."


The Master Treatment Plan dated 02/24/16 and updated 03/15/16 revealed no documentation which indicated the patient sustained a laceration to the nose during an aggressive episode.


On 06/17/16 from 1039 to 1050 Personnel #1 was interviewed. Personnel #1 was asked to review Patient #6's medical record. Personnel #1 was asked to review the treatment plan. Personnel #1 verified the treatment plan did not address the laceration Patient #6 sustained while in seclusion.


The policy and procedure entitled, "Treatment Plans" with a revision date of 01/13/14 reflected, "The master treatment plan will consist of short and long term goals and identify...problem identification...measurable and attainable goals...discharge planning needs..."

Based on interview and record review, the hospital failed to ensure 2 of 11 patients (Patient #3's and #6's) Treatment Plan addressed Patient #3's altered skin integrity and a laceration Patient #6 sustained while in seclusion.


Findings included:


1) Patient #3's Inpatient Admission Orders dated 04/14/16 timed at 2120 reflected, "Affective Disorder...level of observation Q 15 minutes...skin assessment..."


The Nursing Assessment dated 04/14/16 reflected, "Skin normal, turgor adequate..." No altered skin integrity was documented on the skin assessment for Patient #3.


The 04/15/16 Multidisciplinary Progress Notes timed at 1445 reflected, "Patient observed to have wound to scrotum about the size of a dime...patient was changed...order received for zinc oxide to open area TID..."


The Multidisciplinary Progress Notes dated 05/15/16 at 0820 reflected, "Patient complains of pain on his bottom...at 1450 two Stage II pressure ulcers located on right buttock...at 2302...has to be spoon fed...confused..."


The Physician's Orders dated 05/15/16 timed at 1442 reflected, "Stage II Pressure Ulcer (Skin Injury) to right buttock...apply Zinc Oxide to area TID..."


The Multidisciplinary Progress Notes dated 05/16/16 timed at 2125 reflected, "Made comfortable in bed...Stage 2 wound to bottom, scrotum and right buttock...wound care done..."


The Master Treatment Plan dated 04/18/16 revealed no documentation which addressed Patient #3's altered skin integrity and skin injury.

On 06/17/16 at approximately 1109 Personnel #1 was asked to review Patient #3's medical record. Personnel #1 verified Patient #3's treatment plan was incomplete and did not address altered skin integrity.



2)Patient #6's Intake Assessment dated 02/24/16 timed at 2246 reflected, "14 year old...has anger issues and becomes aggressive with family members...running away, impulsive...hit brother in the nose and tried to smash his head against the sidewalk...history of fire starting and is aggressive towards animals...hostile towards parents in assessment room...patient found with screwdriver and lighter...moderate/high risk of suicide due to impulsive behavior unable to contract for safety...high assaultive behavior..."


The 03/07/16 (03/06/16) progress note (nursing) timed at 2245 reflected, "Patient tore toilet seat off of toilet came out of room with it and attacked a staff member...hit her in the right eye, neck and back of head and back...client was taken to seclusion where he hit glass in door with his fist...when staff placed hand on glass the glass shattered and hit client in the face cutting him just above the nose...sent to ER (emergency room)...".


The 03/07/16 progress note (nursing) timed at 0200 reflected, "Patient returned to unit from ER...cut cleaned applied triple antibiotic ointment...stated he blacked out and does not remember what he did...placed on 1:1 and returned to bed..."


The Master Treatment Plan dated 02/24/16 and updated 03/15/16 revealed no documentation which indicated the patient sustained a laceration to the nose during an aggressive episode.


On 06/17/16 from 1039 to 1050 Personnel #1 was interviewed. Personnel #1 was asked to review Patient #6's medical record. Personnel #1 was asked to review the treatment plan. Personnel #1 verified the treatment plan did not address the laceration Patient #6 sustained while in seclusion.


The policy and procedure entitled, "Treatment Plans" with a revision date of 01/13/14 reflected, "The master treatment plan will consist of short and long term goals and identify...problem identification...measurable and attainable goals...discharge planning needs..."