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Based on observation, interview, and record review, the hospital failed to ensure that patient rights were protected and promoted for at least 11 of 11 patients (Patients #8, #11, #43, #45, #46, #47, #48, #4, #51, #53, #56).

1. The hospital failed to ensure the right to a specific time frame for review of patient grievances and provision of a response for two of two patients (Patients #8 and #11) whose filed grievances included allegations of a sexual assault and patient injury. Altogether, 188 complaints logged in 2024 did not evidence a response outcome letter to the complainants.
Refer to A 122

2. The hospital failed to ensure the right to receive care in a safe setting for nine of nine patients including
a) all five patients on the hospital's preadolescent girls' unit (Patients #43, #45, #46, #47, #48) who had been admitted with command hallucinations to kill or hurt self, poor impulse control, physician-assessed poorly controlled response to behavior modifying treatment, and/or severe mental deterioration that required close observation for self-harm and suicide attempts. The patients had access to non-food items including in-wall insulation material, plasterboard and paint peelings, potentially ingestible during a self-injury attempt, for at least 24 hours during the survey,
b) four adolescent patients (Patients #4, #51, #53, #56), admitted for depression, self-harm, with increased suicidality and plans and/or previous attempts of suicide by shooting, stabbing, or hanging. During their inpatient hospitalization, the patients had access to plastic spoons, a piece of glass, a screw and screwdriver, and a nail from a broken wall and used these objects in self-harming attempts. In addition, one patient retained a charger cord for future self-harm in the hospital, and another patient drank the Nitric Acid Ammonium Salt solution of the hospital-provided ice-pack and required emergency medical evaluation and poison control guidance.
c) no fire drills and/or fire inspections had been conducted.
Refer to A 144.

3) The hospital initiated a restraint on one of one patient (Patient #4) without obtaining a physician order. At the time of survey, the adolescent patient refused to be discharged to the designated care giver, got upset, grabbed two plastic spoons out of a trash can and cut herself, jumped over the barrier that separated the nurses' station from the milieu, banging her head on the wall in self-harm attempts. Unable to calm down with continued physical and verbal aggression, Patient #4 was staff restrained and escorted off the unit where she sat on the floor in a small area between two locked exit doors for more than an hour awaiting arrival of police and emergency services for continued self-harming behavior.
Refer to A 168

4) No verified emergency behavior management competency was provided for one of one staff member who physically picked up Patient #11, age 6, from a bed; the patient struggled and resisted, and the staff member dropped him to the floor.
Refer to A 208.

Based on record review and interview, the facility failed to ensure the provision of a response to a grievance, in that 2 of 2 patients (Patient #8 and Patient #11) did not receive a response to a grievance within the specific time frames.

Findings Include:

Patient #8's mother filed a grievance on 03/08/2024 for allegations of sexual assault and never received a response outcome letter from the facility.

Patient #11's mother filed a grievance on 05/06/204 for allegations of patient injury and never received a response outcome letter from the facility.

Record review of the Complaint and Grievance log on 05/20/2024 at 2:00 PM reflected that 188 complaints had been logged from 02/01/2024-5/20/2024. The outcome response for all 188 entries did not evidence a response outcome letter was sent to any of the complaints listed.

During an interview with Personnel #8 in a 1st floor office on 05/15/2024 at 9:00 AM stated the following, "I have worked here since 2/19/24. I remember the incident with [Patient #11] ...She let me know about everything that had happened ...She asked me if I knew anything about her son being dropped by an employee and I told her no, but I did tell her that I would address it. I always write up my complaints and then move them up for resolution. I submitted it to [Personnel #10], and he told me that it was already on their radar. The mom also called me for an update which I usually do within 48 hours of receiving a complaint. I updated mom by phone of the status of where we were in the investigation ...she did request that there be additional investigation regarding this incident because she felt the facility failed her son. I forwarded that email on to [Personnel #10] per the mom's request. Once I forward an email to quality/risk then I do not follow up with families. [Personnel #10] will follow up with the families regarding the outcome of an investigation ...

I have not sent out a single grievance outcome letter since I started last February ...I'm not sure what our policy says about how the patient advocate handles family follow up with outcomes and letters ...I know the policy states that if I can handle the issue within 7 days then it is considered a complaint, anything after 7 days then it becomes a grievance ...

I remember [Patient #8]. Her mom called me after [Patient #8] was discharged. She stated that [Patient #8] told her that she was tongue kissed on the mouth and butt by her roommate. I sent an email to [Personnel #10] regarding the incident. I went and spoke with her roommate/perpetrator because she was still admitted when I received the call. The roommate admitted to liking [Patient #8]. She told me that she showed [Patient #8] how much she liked her by kissing her. I asked her where she kissed her, and she said mouth. I asked her if she kissed [Patient #8] anywhere else and she said no ...I went back and called mom and let her know that I was sending the complaint up. I did tell her that the roommate admitted to kissing [Patient #8] on the mouth. I apologized because we didn't know the incident had occurred or we would have acted ...An outcome letter was never sent to the family as far as I know."

During an interview with Personnel #10 in a 1st floor office on 05/15/2024 at 11:00 AM stated the following, "[Personnel #8] is responsible for closing the loop with patients and their families ...It is in her job description and listed on her competency checklist ... Grievance letters are supposed to be sent out by [Personnel #8] ..."

The facility policy on "Grievance Procedure" (Reference # 1004) effective 07/17/2019 reflected the following, " ...Definitions ...A 'patient grievance' is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP) ...If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purpose of these requirements. A complaint is considered resolve when the patient or other person is satisfied with the actions taken on their behalf ....A written complaint is always considered a grievance ...All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance with CMS requirements, are to be considered grievances for the purposes of these requirements ...Procedure ...Provide a response to a patient and/or other person making a grievance complaint within seven days of receiving the grievance ...Take action to resolve all grievances promptly and fairly; and document all grievances, including final disposition, and keep the documentation in a central file ...Resolution Activities ...When resolution has been determined, the person reporting the grievance should be notified of the result. Notification of the resolution must be documented and contain the following information: Steps taken on behalf of the patient to investigate the grievance; date investigation was completed; the results of the grievance process; and name of hospital contact person ...Grievance Coordinator/Committee ...The Patient Advocate shall operate as the grievance review and response coordinator. A committee may be called including the Chief Executive Officer, Chief Nursing Officer, Chief Operating Officer, Human Resources personnel, and/or other departmental leaders as warranted ...The Grievance Coordinator and/or Committee will review and manage grievances as delegated by the Hospital governing Board, in writing. A process will be established to provide periodic reports to the Performance Improvement Committee and Medical Executive Committee. The process is to include the aggregation, trending and analysis of data related to grievances, actions taken, and resolutions attempted."

Based on observation, interview and record review, the facility failed to ensure the rights of nine of nine patients (Patients #43, #45, #46, #47, #48, #4, #51, #53, and #56) to receive care in a safe setting.


1. Five out of five female preadolescent patients on suicide and self-harm precautions (Patients #43, #45, #46, #47, and #48) had access to non-food items potentially ingestible during a self-injurious attempt in form of in-wall insulation material and broken plasterboard for at least 24 hours at the time of survey. Patients #43, #45, #46, #47, and #48 had been admitted on suicide and self-harm precautionary staff observation based on the patients' intent to hurt or kill themselves and/or listening to voices telling them to kill themselves. In addition, Patient #43 had access to paint peeling off the wall in her patient room for potential non-food ingestion and self-harm. Patients #43, #45, #46, #47, and #48 were inpatient hospitalized at the time of survey and included
a) Patient #43, age 8, who had been admitted with physician ordered close staff observation to be treated in a therapeutic environment without access to hazardous triggers due to her impulsivity,
b) Patient #45, age 11, who was physician noted to be a danger to herself with poor response to treatment and unpredictable thought processes,
c) Patient #46, age 11, admitted for suicidal ideation and on self-harm precautions,
d) Patient # 47, age 11, who had been physician assessed to be a "ticking time bomb" with self-injurious behavior and heard "evil" voices that told her to kill herself,
e) Patient #48, age 10, who had auditory hallucinations of demons telling her to kill herself and was noted with poor response to behavior modification.


2. Four of four adolescent patients (Patients #4, #51, #53, #56) had access to objects and used them in self-harm attempts during their hospital stay.
a) Patient #4 had been inpatient hospital admitted for depression and self-harm after taking 12 pills of a veterinary medication without notifying anyone. Within 24 hours of admission, the patient found a piece of glass in the pause room, used it to make deep cuts onto her left arm that required an emergent transfer to acute care. Two days prior to her discharge, Patient #4 found a charger cord potentially usable in a self-harm attempt. Later, the patient refused to discharge, got upset, and found two plastic spoons in her treatment area that she used to self-harm.
b) Patient #51 was admitted with increased suicidality and plans to stab or shoot himself, cutting his throat, or hanging. One week into his hospital stay, Patient #51 found a screw in the courtyard and used it to scratch himself; two day later he ingested the Nitric Acid Ammonium Salt containing liquid of a hospital provided icepack and required emergency medical evaluation and poison control guidance.
c) Patient #53 had been admitted after a suicide attempt of hanging, self-cutting, and self-harming behavior. Within a week of hospitalization, the patient had access to a broken plastic spoon and used it in a self-harm attempt.
d) Patient #56 had been inpatient hospitalized for self-cutting behavior. One day after his admission, Patient #56 found a screwdriver on the floor and used it to cut on himself. Two days later, Patient #56 found a nail from a broken wall and, again, used that object to cut on his left arm.

3. Two large screwdrivers were found on a vacant unit during the survey.

4. No records or current history of Fire Drills and Fire Inspection were available at the time of survey.




Findings included:

1. Observation on the preadolescent girls' unit on 05/14/2024 at around 11:01 PM reflected the dayroom had a hole in the wall. The hole was the size of approximately 10 cm by 15 cm, in reachable height for patients, and gave access to plasterboard wall edges and inside-wall insulation material.

Personnel #45 accompanied the surveyors and acknowledge the finding at that time.

The hole was observed again on 05/15/2024 at 01:30 PM. Personnel #73 stated at that time that the hole was due to a "patient incident last month." A patient room, Room #215, was observed with paint peeling off the wall leaving an area of three feet by three feet of exposed wall in reach and accessible to two patients observed in bed at that time.

Record review of the patient census sheet provided to the surveyor by Personnel #45 on 05/14/2024 at around 11:01 PM reflected there were five patients on the preadolescent unit at that time and included:

a) Patient #43's Face Sheet reflected an admission dated of 05/02/2024 at 04:53 PM. The patient was a transfer from a children's hospital.

Admission Evaluation dated 05/02/2024 at 05:07 PM reflected Patient #43 had command hallucinations and a psychiatric history of hurting self by head banging and "sucking on arms causing bruises." The patient was reported with "lying, impulsive, and hyperactive behaviors ...[that] have increased ..." and " ...psychosis ...auditory, visual hallucinations ..."

Physician's MOT (Memorandum of Transfer) Orders dated 05/02/2024 at 04:52 PM reflected Patient #43 was on every 10-minute staff observation in a "therapeutic environment removed from current triggers or stressors ...no access to ...open hazards, guarded from impulsive, accidental harm ..."

Patient #43's Comprehensive Psychiatric Evaluation dated 05/03/2024 at 11:05 AM reflected Patient #43 identified a problem to be addressed that the patient was a danger to herself and suffered from psychosis; the initial treatment plan included to "decrease suicidal ideation."

Physician Daily Progress Notes dated 05/14/2024 and 05/15/2024 noted Patient #43's insight and judgment were "fair" with "poor impulse control."

Close observation form dated 05/15/2024 reflected Patient #43 was on suicide and self-harm precautions. The patient was noted to be in Room 215 A.



b) Patient #45's Face Sheet reflected the 05/07/2024 at 12:26 AM admission date and time.

Patient #45's Comprehensive Psychiatric Evaluations dated 05/07/2024 at 08:40 AM reflected the patient had "poor coping skills" and was a "danger to self and others." She had been aggressive at home, was irritable, anxious, labile, and was physician-noted for "poor decision making."

Patient #45's Physician Daily Progress Notes dated 05/08/2024, 05/09/2024, 05/10/2024, 05/11/2024, 05/12/2024, 05/13/2024, 05/14/2024, and 05/15/2024 reflected the patient's response to behavior treatment was "poorly controlled" and her judgment was "fair." The physician noted on 05/12/2024 at 09:20 AM that Patient #45 had an "unpredictable mind."

Patient #45's Patient Observation Form dated 05/15/2024 reflected that the patient was on suicide and self-harm precautionary staff observation levels.



c) Patient #46's Nursing Shift Progress and Assessment dated 05/14/2024 at 07:50 PM reflected the patient's 05/10/2024 admission date. The patient had been admitted for suicidal ideation. The nurse noted that "safety checks were in progress ..." and the patient was on suicide precautionary status.

Patient #46's "Observation Form Q10" document dated 05/15/2024 reflected the patient was on suicide and self-harm precautions and staff observation.


d) Patient #47's Face Sheet reflected the patient was admitted on 05/13/2024 at 04:39 PM.

Patient #47's Assessment and Referral Evaluation dated 05/13/2024 reflected the patient's statement that "the doctor told us to come here ...because of suicide." The patient's behavior was noted to be highly irritable, a "ticking time bomb" with disruptive behaviors and emotional outbursts. Staff assessed Patient #47 to have "pressured" and "rambling" speech, display "bizarre" behavior, was in "anxious" and "manic" mood and her thought process was "disorganized." Her judgement and insight were "poor." She had engaged in self-injurious behavior within a month prior to her admission and was assessed to be of "high suicide risk" level.

Patient #47's Preadmission Evaluation and Medical Clearance screening dated 05/13/2024 at 05:23 PM reflected a suicide attempt "last week" together with self-injury behavior, auditory hallucinations, feelings of hopelessness and helplessness, sad and tearful mood, pressured speech, excessive worries and nervousness. The physician concluded "severe mental/physical deterioration or incompetence" based on 'currently available information."

Comprehensive Psychiatric Evaluation dated 05/14/2024 at 09:49 AM reflected Patient #47's suicidal plans to stab self; she heard "voices in her head" that sounded "like God ...an evil god that tells her to kill herself ..."

Patient #47's Physician Orders dated 05/14/2024 at 07:26 AM reflected the patient was on suicide and self-harm precautionary status.
Patient #47's Physician Daily Progress Notes dated 05/15/2024 at 07:31 AM reflected a "poorly controlled behavioral response to treatment." The patient's judgement and insight were "fair."

Patient #47's Patient Observation Form dated 05/15/2024 reflected that the patient was on suicide and self-harm precautionary staff observation levels.



e) Patient #48's Face Sheet reflected her admission date of 05/10/2024 at 09:46.PM
The Preadmission Evaluation dated 05/10/2024 at 11:55 PM reflected Patient #48 had suicidal ideation and "demons telling her to kill her." The patient reported thoughts of suicide and self-injurious behavior and was assessed to be of high risk of suicide, delusional, with auditory and visual hallucinations. Physician-ordered precautionary observation levels included self-harm, suicide, and aggression.

Physician Orders dated 05/11/2024, 05/12/2024, 05/13/2024, 05/14/2024, and 05/15/2024 reflected the patient was on physician ordered suicide and self-harm precautionary staff observation levels.

Physician Daily Progress Notes dated 05/14/2024 at 09:45 AM and 05/15/2024 at 07:20 AM reflected Patient #48 had a "poorly controlled behavioral response" to treatment, and her "judgement and insight ...[were] fair."

The above findings were discussed with Personnel #10 on 05/15/2024 at 04:20 PM who acknowledged the findings at that time.


Research at the University of Michigan (2021) identified at least 55 "chemicals of concern" found in walls (Research Identifies 55 Dangerous Chemicals in Building Materials | News | University of Michigan School of Public Health | Environmental Health Sciences | Building | Construction | Health | (umich.edu)




2. During the time of hospitalization, adolescent patients #4, #51, #53, #56 had access to objects that included a piece of glass, a nail, a screw and screwdriver, and broken plastic spoons. The patients used them in self-harm attempts during their hospital stay and required medical and nursing attention and/or emergency care.

a) Patient #4's Face Sheet reflected her admission date of 05/03/24 at 04:00 PM.
The Assessment and Referral Evaluation dated 05/03/24 at 104:18 PM reflected Patient #4 had multiple cuts on her left arm and both upper and lower legs. The week prior to admission the patient had taken 12 Vistaril tablets that belonged to the dog and did not tell anyone.

The Multidisciplinary Progress Notes dated 05/04/24 with no time noted reflected ..."she was scared about how deep she cut her arm. Pt (patient) shared she hadn't meant to cut that deep, that she'd found a piece of glass in Pause Place and just wanted to feel it ..." Patient #4 was transferred to an acute care hospital for stitches to the left forearm.

The Multidisciplinary Progress Notes dated 05/15/24 at 04:00 PM reflected..."Pt (patient) was discussing thoughts of SH & SI (self-harm/suicidal ideation) w/ (with) therapist. She handed Th (therapist) a charging cord and said 'Here, take this. I found it and was keeping it to SH..."

The Multidisciplinary Progress Notes dated 05/17/27 at 08:30 PM reflected..."patient still continued to refuse to be discharged...patient grabbed the trash bag and threw it on the floor, grabbed one of the spoons, cut herself. Staff members intervened and removed the broken spoon from her hand, continue to make attempts to take another spoon to cut herself..."

The above findings were discussed with Personnel #10 on 05/21/24 at 04:49 PM who acknowledged the findings at that time.



b) Record review of Patient #51's Face Sheet reflected the 16-year old patient was hospital admitted on 02/08/2024 at 02:03 PM. He was discharged on 02/18/2024 at 11:00 AM.

Patient #51's Discharge Summary dated 03/01/2024 at 04:21 PM noted the patient's admission and discharge diagnoses that included Disruptive Mood Dysregulation Disorder. The patient was admitted with increased suicidality and plans to stab or shoot himself, cutting his throat, or hanging. He was aggressive, impulsive, with low frustration tolerance, and "hearing his father's voice and others telling him to hurt himself and others ..."

Patient #51's Progress Notes dated 02/15/2024 at 01:50 PM reflected the patient had found a screw in the courtyard and scratched his right and left arm. Notes timed at 01:55 PM reflected the patient was assessed with "multiple cuts on both forearms" and "patient stated he was frustrated ..."

Patient #51's Multidisciplinary Treatment Plan Update dated 02/15/2024 reflected the patient "still reports thoughts of SI [Suicide Ideation] ..."

Patient #51's Physician Orders dated 02/17/2024 at 05:00 PM reflected to transfer the patient to the ED for immediate evaluation due to "Patient swallowed instant cold pack medline and call poison control ..."

The manufacturer's Material Safety Sheet for Icepacks listed Nitric Acid Ammonium Salt as one of the main ingredients and noted in case of ingestion "do not induce vomiting ...call physician immediately ..." (SDS0186_Standard Instant Cold Packs.pdf (medline.com)



c) Patient #53's Face Sheet reflected the 14-year-old patient's admission date of 03/24/2024 at 11:36 AM as a transfer from an acute care hospital. Admitting diagnoses included Disruptive Mood Dysregulation Disorder.

Patient #53's Progress Notes dated 04/01/2024 at 02:00 PM reflected nursing documentation that the patient used a broken plastic half spoon in a self-harm attempt and cut a wound to her left forearm.

Patient #53 Discharge Summary dated 04/18/2024 at 07:01 AM reflected the patient had been admitted after a suicide attempt of hanging, self-cutting and self-harming behavior.

Patient #53's Initial Treatment Plan dated 03/24/2024 at 10:44 AM reflected the patient's treatment goals to decrease suicidal, homicidal and disruptive behavior.


d) Patient #56's Discharge Summary dated 04/18/2024 at 07:01 AM reflected the 15-year-old patient was admitted on 03/27/2024 for self-cutting behavior. Prior to his admission, the patient was struggling with poor impulse control, low frustration tolerance, and the thoughts of hanging himself. He was noted with "disregard for his safety of self ...finding a screwdriver on the floor on 03/29/2024 and making cuts to self ..."

Patient #56's Shift Progress Notes dated 03/30/2024 at 07:15 PM reflected the patient "was found with wall nail from broken wall ...making many small cuts to his LUE [left upper extremity] ...."

Patient #56's Shift Progress Notes dated 03/30/2024 at 08:10 PM reflected the patient stating that self-harm was "a way for me to take care of things."

Personnel #10 acknowledged the above findings during an interview on 5/21/24 at 04:25 PM.




3. Observational rounds were conducted on patient care units 05/14/2024 at around 11:00 AM and Staff #68 and the surveyor entered the hospital vacant unit. On this Unit two large screw drivers were found and unattended.

During an interview on 05/14/2024 at 11:00AM Hospital Staff #68 stated in response to obtaining the screw drivers, "I do not know who is responsible for the screw drivers or do I know how long they have been there."

During Interview with Hospital staff #10 on 05/14/2024 at 11:45AM. "I am not certain who is responsible for any equipment, in reference to the screw drivers on the vacant unit. I believe the EOC department is responsible. We are looking to open the vacant unit as soon as possible."

During Interview with Hospital Staff #58 at 12:15PM on 05/14/2024. "I was told that two screws were found on the unit, not 2 screw drivers. I hold my staff accountable for hospital equipment. This may belong to outside vendor."



4. During Interview with hospital Staff #58 on 5/14/2024 at 12:20PM, "Can you provide the fire inspection reports and fire drills?" Staff #58 reported that he has been employed for that past 44 days at the hospital and has not observed a Fire Drill or has there been a fire inspection. Staff #58 indicated that he has placed calls to the fire department but has not received a return call to schedule fire inspection. Staff #58 reported there are no previous records that hospital has provided him with or that he is aware the hospital has.

The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law

Based on observation, record review and interview the facility failed to obtain a physician's order for the restraint of 1 of 1 (Patient #4) patients.

Findings included:

Patient #4's The Multidisciplinary Progress Notes dated 05/27/24 at 08:30 PM reflected ..."writer received a call from office stated patient's mom at the front desk for discharge. Patient was informed about going home, patient bluntly refused stated 'I am not going home to those (unreadable), I am not going anywhere' ... Patient continued behavior, refused for discharge, pack her stuff to go home ...Patient began to be physical aggressive, irritable, anxious, and agitated towards staff members. Patient jumped the nursing station by climbing and ran to the other side of the unit, banged at the exit door in an attempt to elope, banged on the wall severely to self-harm. Patient continues to bang on the wall, glass to the nursing station and seclusion door. Patient unable to calm down, continues to be physically and verbally aggressive... 09:00 PM Patient was restrained and escorted out of the unit for discharge. At the exit door, patient was banging the wall, attempted to yank off the time clock, banged at the glass to the exit door. Patient refused to calm down, refused to go to the car of her family member...Patient continues to be physically aggressive towards hospital property by banging on the glass and wall at the exit door and still refused to go...09:11 PM House Supervisor called 911 for intervention and safety in cooperation with family member...10:00 PM Police officers arrived, before the police arrived, patient continues to pick on her left hands, picking on the old wounds to make it more open. Patient refused to be redirected. Police officers called for EMS (Emergency Medical Service)." After Patient #4 was sitting on the floor between the exit doors for 1 hour and 45 minutes EMS arrived and took patient to an acute care hospital.

During an interview on 05/21/24 at 03:57 PM Personnel #74 acknowledged the findings. Personnel #74 acknowledged the patient was secluded without an physician's order.

Based on record review and interview, the facility failed to document in the staffing personnel records that restraint/seclusion training and skill's competencies were successfully completed for 1 of 15 employees (Personnel #21).

Finding include:

On 05/15/2024, a review of the personnel file for Personnel #21 did not evidence that a skill's competency checklist had been performed since her date of hire of 03/18/2024.

During an interview with Personnel #9 in a 1st floor office on 05/15/2024 at 9:30 AM stated the following, "[Personnel #21] did participate in Handle with Care...[Emergency Patient Behavior Management] training during orientation.

During an interview with Personnel #10 in a 1st floor office on 05/15/2024 at 11:00 AM he confirmed the above findings that Personnel #21's skill's competency checklist had not been completed.

During a phone interview with Personnel #21 on 05/23/2024 at 3:02 PM Personnel #21 stated they did not recall completing a competency for emergency patient behavior management. Personnel #21 recalled an incident where they attempted to manage Patient #11's emergency behavior; the patient struggled and fought Personnel #21. Patient #11 was dropped to the floor.

The facility policy on "Abuse, Neglect, Exploitation, Unethical, or Unprofessional Conduct" (Reference #1030) effective 07/17/2029 reflected the following, " ...Perimeter Healthcare shall monitor the qualifications and competencies of providers of services and/or staff. Perimeter Healthcare shall not allow unqualified persons or entities to provide services ..."

Based on record review and interview the hospital failed to have an organized nursing service that provides 24-hour nursing care.

1. Nursing staff failed to ensure that 2 of 3 patients (Patient #2 and Patient #4) received a nursing assessment for their medical conditions that included Patient #2's fractured hand on admission and Patient #4's deeply lacerated arm wound after the patient found a piece of glass in her treatment environment and used it to cut herself. In addition, 1 of 3 patients (Patient #70) did not receive a nursing admission assessment after being admitted to the facility.
Cross refer to A 395

2. Nursing staff failed to ensure that the care plan for 12 of 12 patients (Patients #51, #52, #53, #56, #54, #4, #57, #61, #65, #2, #55, #83) were kept current to reflect the patients' self-harm attempts, critical medical conditions, and/or emergency behavior interventions..
Cross refer to A 396

A registered nurse must supervise and evaluate the nursing care for each patient.

Based on record review and interview a registered nurse failed to evaluate the care of each patient
1. 2 of 3 (Patient #2 and Patient #4) patients did not receive a nursing assessment for medical conditions. The nurses failed to assess the fractured right hand of Patient #2 and to reassess the patient after administration of pain medications. The nurses failed to assess the lacerations on Patient #3's arm after they cut themselves with glass found her treatment environment.

2. 1 of 1 (Patient #70) did not receive a nursing admission assessment after being admitted to the facility on 04/23/24
Findings included:


Patient #2 was admitted to the facility on 04/19/24 for Major Depressive Disorder and a fractured right metacarpal. The Nursing Shift Progress and Assessment note dated 04/19/24 at 08:30 PM reflected Patient #2 was given Tylenol 325 mg for pain to the arm. The progress note did not reflect an assessment of the hand, did not identify which hand was painful, and the progress note did not reflect a follow-up assessment for the effectiveness of the pain medication. The Nursing Shift Progress and Assessment note dated 04/22/24 reflected Patient #2 complained of hand pain. There was no documentation of which hand was painful and there was no documentation of an assessment of the hand. The Nursing Shift Progress and Assessment note dated 04/22/24 at 08:59 PM reflected Patient #2 was given Tylenol 325mg for right hand pain. There was no documentation of an assessment of the right hand and no documentation of a reassessment to verify if the pain medication was effective.

Patient #4 was admitted to the facility on 05/03/24 for Major Depressive Disorder. The Multidisciplinary Progress Notes dated 05/04/24 with no time noted reflected ..."she was scared about how deep she cut her arm. Pt (patient) shared she hadn't meant to cut that deep, that she'd found a piece of glass in Pause Place [the quite room] and just wanted to feel it ..." There was no documentation of the laceration nor an assessment of the laceration in the nursing documentation.
The Shift Progress Note dated 05/08/24 at 01:42 PM reflected the patient complained of a cough and sore throat. There was not a documented assessment of the patient's throat or lungs. The Shift Progress Note dated 05/15/24 at 08:15 PM reflected ..."PRN (as needed) inhaler used for SOB (short of breath) via MAR (medication administration record)" ... There was no documentation of an assessment of the patient's lungs on the chart. There was no documentation regarding the effectiveness of the inhaler.

Patient #70 was admitted to the facility on 04/23/24 for bipolar disorder and discharged from the facility on 05/18/24. The Nursing Admission Assessment in the medical record is blank.
During an interview on 05/15/24 at 12:15 PM Personnel #10 verified the missing documentation for Patient #2 and Patient #4. During an interview on 05/21/24 at 02:49 PM Personnel #10 verified the missing documentation for Patient #70.

The policy titled Assessment and Reassessment of Patients effective 07/17/19 reflected ..."3. The RN (Registered Nurse) Nursing Admission Assessment is completed within eight hours of admission ...Reassessments of patients are to be completed when there is a significant change in patient condition ..."

Based on record review and interview, the hospital failed to ensure that nursing staff kept a current care plan for each patient that reflected the patient's goals and the nursing care to be provided to meet the patients' needs for 12 of 12 patients who

a) had a self-injurious incident during their hospitalization including acts of self-harm using objects such as a nail, screw and screwdriver, broken plastic spoons, and a piece of glass the patients found in their treatment environment (Patients #51, #52, #53, #56, #54, #4),
b) suffered medical conditions including Diabetes Mellitus to address severe blood sugar swings, and acute musculoskeletal and integumentary injuries requiring nursing interventions (Patient #57, #61, #65, #2), and/or
c) had an emergency behavior management episode (Patient #55, #83).

The hospital failed to reflect the events in the patients' care plans as part of the care teams' evaluation of interventions and care provision.



Finding included

a) Record review of Patient #51's Face Sheet reflected the 16-year old patient was hospital admitted on 02/08/2024 at 1403. He was discharged on 02/18/2024 at 1100.

Patient #51's Progress Notes dated 02/15/2024 at 1350 reflected the patient had found a screw in the courtyard and scratched his right and left arm. Notes timed at 1355 reflected the patient was assessed with "multiple cuts on both forearms" and "patient stated he was frustrated ..."

Patient #51's Physician Orders dated 02/17/2024 at 1700 reflected to transfer the patient to the ED for immediate evaluation due to "Patient swallowed instant cold pack medline and "call poison control ..."

Patient #51's Multidisciplinary Treatment Plan Update dated 02/15/2024 reflected the patient "still reports thoughts of SI [Suicide Ideation] ...." Revised interventions included for clinical staff to "monitor pt for manipulation when he is not getting attention or his way ..." The document was not signed by nursing or medical staff. There was no evidenced documentation of treatment plan updated after the 02/17/2024 incident.

Patient #51's Discharge Summary dated 03/01/2024 at 1621 noted the patient's admission and discharge diagnoses that included Disruptive Mood Dysregulation Disorder. The patient was admitted with increased suicidality and plans to stab or shoot himself, cutting his throat, or hanging. He was aggressive, impulsive, with low frustration tolerance, and "hearing his father's voice and others telling him to hurt himself and others." During the course of treatment, the patient was noted to have continued auditory and visual hallucinations, "difficulties with impulsivity ...feeling hopeless ...helpless ...continued levels of depression ....still feeling suicidal ...." The patient emergently required a medical evaluation on 02/17/2024 after having " ...ingested liquid from the torn icepack ..."

The manufacturer's Material Safety Sheet for Icepacks listed Nitric Acid Ammonium Salt as one of the main ingredients and noted in case of ingestion "do not induce vomiting ...call physician immediately ..." (SDS0186_Standard Instant Cold Packs.pdf (medline.com)




Patient #52's Face Sheet reflected the 14-year-old patient was admitted on 03/01/2024 at 0923. Admitting diagnoses included Bipolar Disorder, Generalized Anxiety Disorder, and Attention-Deficit-Hyperactivity Disorder.
Patient #52's Comprehensive Psychiatric Evaluation dated 03/02/2024 at 2158 reflected was admitted in patient hospital care due to a recent suicide attempt by hanging; the patient had wrapped a curtain around her neck until she passed out. The admitting diagnoses included Bipolar Disorder, current episode, depressed, severe, with psychosis.
Patient #52's Shift Progress Notes dated 03/05/2024 at 2142 reflected the patient "had earlier been involved in physical altercation with another patient ...is intrusive, calling peers names ...threatening to beat them up ..."
Physician Order dated 03/05/2024 at 2225 noted a telephone order to transfer Patient #52 to a different unit for "safety."

Patient #52's Multidisciplinary Progress Notes dated 03/06/2024 at 2057 reflected the patient got into a physical altercation with a peer, was choked and left with red marks on her neck.

Physician Orders dated 03/06/2024 at 2137 reflected an order to place Patient #52 on one-to-one staff observation "for safety."

Patient #52's Shift Progress Notes dated 03/07/2024 at 0825 reflected the patient was " ...self-harming via using the fingernail to scratch self ...[at 1400] patient continued cutting self to blood on the forehead ..."

Clinical Services Group dated 03/07/2024 from 1100 to 1200 reflected Patient #52 was observed "self-harming in a corner despite being on 1:1 [staff observation]." Clinical Services Group dated 03/07/2024 for the 1400 Psych Education Group that the patient "was trying to self-harm at the end of the hallway and mostly refused to talk with Therapist and refused to practice any coping skills to calm down ..."

Shift Progress Notes dated 03/08/2024 at 1350 reflected Patient #52 was "bleeding from the cuts on the hands ...cleaned up by RN ..."

Multidisciplinary Progress Notes dated 03/09/2024 at 1700 reflected that Patient #52 was in the seclusion room after she had thrown a heating pad at the nurse and attempted to kick staff. The patient "started pulling the wall using the pieces to try to hurt self ...slapped the MHT [Mental Health Technician] ..."

Patient #52's Discharge Summary dated 03/25/2024 at 1928 reflected the patient had suffered from auditory and visual hallucinations, felt hopeless and helpless, with high risk behavior such as sending naked pictures to a man. During the course of treatment, the patient was noted to be unpredictable, with peer conflict, prone to mood swings and self-scratching and self-abusing behaviors and was placed on one-on-one "to address the self-harm ....significant loss of control of behaviors on 03/09/2024 ...discharged on 03/11/2024 with recommendations to follow up with RTC [Residential Treatment Center]."

During an interview on 05/21/2024 at 1547, Personnel #10 acknowledged that the treatment plan did not reflect the events.




Patient #53's Face Sheet reflected the 14-year-old patient's admission date of 03/24/2024 at 1136 as a transfer from an acute care hospital. Admitting diagnoses included Disruptive Mood Dysregulation Disorder.

Initial Treatment Plan dated 03/24/2024 at 1044 reflected the patient's treatment goals to decrease suicidal, homicidal and disruptive behavior.

Progress Notes dated 04/01/2024 at 1400 reflected nursing documentation that the patient used a broken plastic half spoon in a self-harm attempt and cut a wound to her left forearm.

Physician Orders dated 04/01/2024, untimed, reflected the patient was restricted to finger foods and was not to use utensils.

Multidisciplinary Treatment Plan Updated dated 04/01/2024 at 1000 reflected that Patient #53 "has been actively engaging and has not reported SI [suicidal ideation] since 03/28 but has reported SH [self-harm] and HI [homicidal ideation] thoughts." The document was signed by nursing staff on 04/03/2024 at 1300. There was no evidence of a self-harming incident on 04/01/2024 with a broken plastic spoon or the patient's restriction to finger foods as of 04/01/2024.

Patient #53 Discharge Summary dated 04/18/2024 at 0701 reflected the patient had been admitted after a suicide attempt of hanging, self-cutting and self-harming behavior. Admitting and discharge diagnoses included Major Depressive Disorder, recurrent, severe, without psychotic features. During her course of treatment, Patient #53 was assessed with remaining suicidal ideation, impulsivity and labile mood. She was discharged on 04/05/2024 to a lesser level of care in residential treatment.

Personnel #10 reviewed the chart and acknowledged the above findings during an interview on 5/21/24 at or around 1630.



Patient #56's Discharge Summary dated 04/18/2024 at 0701 reflected the 15-year-old patient was admitted on 03/27/2024 for self-cutting behavior. He discharged on 04/03/2024. Prior to his admission, the patient was struggling with poor impulse control, low frustration tolerance, and the thoughts of hanging himself. He was noted with "disregard for his safety of self." Admission and discharge diagnoses included Major Depressive Disorder, recurrent, severe, without psychotic features, and Fetal Alcohol Syndrome as medical diagnosis. During the treatment course, Patient #56 was limited to finger foods "for safety" on 03/28/2024; wound care was ordered "to address cuts on arms and stomach ...finding a screwdriver on the floor on 03/29/2024 and making cuts to self ..."

Physician Orders dated 03/30/2024 at 1150 reflected the patient was ordered on every 5-minute staff observation rounds for self-harm. Physician Orders dated 03/30/2024 at 2200, on 03/31/2024 at 1210, on 04/01/2024 at 0840, and 04/02/2014 at 0830 reflected the patient remained on every 10-minute observational rounds.
Patient #56's Shift Progress Notes dated 03/30/2024 at 1000 reflected the patient got into a "physical confrontation with peers ..."

Patient #56's Shift Progress Notes dated 03/30/2024 at 1915 reflected the patient "was found with wall nail from broken wall ...making many small cuts to his LUE [left upper extremity] ...."

Patient #56's Shift Progress Notes dated 03/30/2024 at 2010 reflected the patient stating that self-harm was "a way for me to take care of things."

Patient #56's Master Treatment Plan dated 03/27/2024 reflected the patient's level of monitoring to be every 15 minutes. There was no evidenced the care plan was updated to reflect the increased, 10-minute observational staff rounds for 03/30/2024 through the patient's discharge day. There was no evidence that the patient's two self-harming incidents, using a screwdriver on 03/29/2024 and a nail on 03/30/2024, were addressed in the treatment plan.

Personnel #10 acknowledged the above findings during an interview on 5/21/24 at 1625 and stated that "the care plan had not been updated."





Patient # 54's Face Sheet reflected the 13-year-old patient's 04/17/2024 admission and 05/02/2024 discharge dates.

Patient #54's Admission Evaluation dated 04/17/2024 at 1557 reflected the patient had made a suicide attempt by overdosing on "5 to 6 Depakote 175mg [milligram]" and stating that the attempt "was a good idea."

Patient #54's Physician Memorandum of Transfer Orders dated 04/17/2024 at 2229 included orders to place the patient on self-harm precautions.

Patient #54's Comprehensive Psychiatric Evaluation dated 04/18/2024 at 0800 noted the patient's chief complaint that she "tried to OD [overdose]." The physician noted a conversation with a patient's family member who stated Patient #54 was "cheeking meds [keeping medication in her mouth instead of swallowing them]."

Physician Orders dated 04/19/2024 at 0046 required nursing staff to "check mouth for cheeking after meds." Orders dated 04/20/2024 at 0900, 04/21/2024 at 1218, 04/22/2024 at 0820, and 04/23/2024 at 0830 noted that nursing staff should "check for cheeking (meds).

The Initial Treatment Plan dated 04/17/2024, not timed, and the Master Treatment Plan dated 04/19/2024 reflected the patient's suicide attempt. There was no evidence of family contributing information to the plan, and neither plan reflected the patient's previous "cheeking meds" self-harming behavior. The Multidisciplinary Treatment Plan Updated dated 04/24/2024 at 0915 noted that the patient had continuous suicidal and self-harming ideation with a plan; the revised interventions did not reflect the order for nursing to check the patient's mouth for retained medication.

Personnel #10 reviewed the patient chart during a personal interview on 5/21/24 at 1546 and acknowledged the findings.



Patient #4 was admitted to the facility on 05/03/24 according to the patient Face Sheet.

The Multidisciplinary Progress Notes dated 05/04/24, not time noted, reflected ..."she was scared about how deep she cut her arm. Pt (patient) shared she hadn't meant to cut that deep, that she'd found a piece of glass in Pause Place and just wanted to feel it ..." Patient #4 was transferred to an acute care facility on 05/04/24 for stitches to the left forearm.

The Master Treatment Plan did not reflect Patient #4's left forearm laceration as a medical problem.

During an interview on 5/15/24 at 1215 Personnel #10 verified the findings for Patient #4.



b) Patient #57's Face Sheet reflected the 15-year-old female patient's admission date of 02/12/2024, timed at 2255. The patient was discharged on 02/16/2024 at 1320.

Discharge Summary dated 02/27/2024 at 1551 reflected Patient #57 was admitted after refusing her diabetic medications in order to try to kill herself and a previous suicide attempt by grabbing a knife. The patient felt hopeless, helpless, and felt her life was worthless. She was admitted for inpatient crisis stabilization. Admitting diagnoses included Disruptive Mood Dysregulation Disorder, Generalized Anxiety Disorder, Diabetes Mellitus, Hypothyroidism, Gastroesophageal Reflux Disease.

Patient #57's History and Physical Physician Examination dated 02/13/2024 at 1250 reflected the patient was noncompliant with her insulin administration and had a history of Diabetic Keto Acidosis.

Multidisciplinary Progress Notes dated 02/15/2024 at 0310 reflected Patient #57's blood sugar was 56 mg/dL, rose to 227 mg/dL at 0430, and 316 mg/dL at 0733.

Physician Orders dated 02/16/2024 at 1305 reflected Patient #57's emergency transfer to an acute care hospital "for hyperglycemia."

The Master Treatment Plan dated 02/13/2024 reflected "Diabetes" as a medical diagnosis; the problem list with medical problem resolution was left blank, and there was no evidence of a nurse review as the space for nursing to sign as part of the interdisciplinary treatment team was left blank.





Patient #61's Face Sheet reflected the 11-year-old patient was admitted on 02/15/2024 at 0400 and discharged on 02/23/2024 at 1118.

History and Physical Examination dated 02/15/2024 at 1000 reflected the patient had been admitted due to suicidal ideation and threats. She had made a suicide attempt by cutting herself on a rock. She had pain in her right hand due to an injury due to physical altercation.

Physician Orders dated 02/15/2024 at 1105 directed nursing staff to apply ice to the patient's right hand every six hours for 15 minutes for a right-hand injury.

Patient #61's Initial Treatment Plan dated 02/15/2024 reflected as medical problems "none." The Master Treatment Plan dated 02/15/2024 did not reflect any medical diagnoses and did not reflect the right-hand injury. There was no evidence of a Multidisciplinary Treatment Plan for Patient #61's right hand injury and ice application. The patient's Multidisciplinary Treatment Plan Updated dated 02/22/2024 at 0900 did not reflect a right-hand injury; the plan was not reviewed by nursing staff as evidenced by a blank signature line.




Patient #65's Face Sheet reflected the 12-year-old patient had been admitted on 05/01/2024 at 1255. She was discharged on 05/13/2024 at 1630.

Patient #65's Physician History and Physical Examination dated 05/02/2024 at 0800 noted the patient was admitted due to worsening anger, self-harm and suicide ideation. The patient used a razor to cut her arms. The physician noted left forearm laceration and recommended to "monitor wounds."

Patient #65's Master Treatment Plan dated 05/01/2024 did not reflect the left forearm laceration as a medical problem. There was no evidence of a Multidisciplinary Treatment Plan Problem Sheet in Patient #65's medical record that addressed the potential for infection or worsening of wound on the patient's left forearm.

Personnel #10 reviewed the medical records of Patients #57, #61, and #65 during a personal interview time on 05/21/2024 at or around 1630 and acknowledged the findings.


Patient #2 was admitted to the facility on 04/19/24 with a fractured right 4th metacarpal. The right had was splinted and the patient was wearing a sling to the right arm.
The Initial Treatment Plan dated 04/19/24 and the Master Treatment Plan dated 04/25/24 do not reflect the patient had a fractured right hand.

During an interview on 5/15/24 at 1215 Personnel #10 verified the findings for Patient #2.



c) Patient #55's Face Sheet reflected the 12-year-old was admitted on 04/15/2024 at 1732. Admitting diagnoses included Major Depressive Disorder, recurrent. The patient was discharged on 04/29/2024 at 1251.

Patient #55's Physician Comprehensive Psychiatric Evaluation dated 04/16/2024 at 0950 noted the patient had been admitted for aggression and voicing suicidal ideation at school and jumping off a balcony in a suicide attempt. He suffered from auditory and visual hallucinations and saw "shadow people ...out to get him." Psychiatric diagnoses included Major Depressive Disorder, Recurrent, Severe, with Psychotic Features.

Emergency Safety Intervention Justification dated 04/22/2024 at 1026, 04/22/2024 at 1127, and 04/24/2024 at 1735 reflected physician ordered restraints for Patient #55 for imminent harm to self.

Interventions to assist Patient #55 in achieving his goal of no risk to himself, dated 04/15/2024 at 2330, were left blank.

Interventions to assist Patient #55 in achieving his goal of no risk to himself dated 04/22/2024 at 1103, 04/22/2024 at 1228, and 04/24/2024 at 1819 reflected the intervention that nursing "shall insure availability and correct dosage and administration of medication as prescribed by the attending medical provider...as needed." There was no evidence of specific nursing interventions to decrease the patient's self-harming behavior.

Multidisciplinary Treatment Plan Update dated 04/23/2024 at 0900 did not reflect nursing staff' reviewed Patient #55's care plan.

Multidisciplinary Progress Notes dated 04/25/2024 at 1510 reflected an attempt by Patient #55 to hurt himself; the patient "repeatedly hit his head with a volleyball ...grabbed a basketball to hit his face."





Patient #83's Face Sheet reflected the 13-year-old was admitted on 04/30/2024 at 1316 and discharged on 05/11/2024 at 1245.

Patient #83's Psychiatric Evaluation dated 05/11/2024, time not legible, reflected the patient was admitted with hearing voices saying, "your time is up." The patient stated she was "depressed."

Emergency Safety Intervention Justification document dated 04/30/2024 at 1502 reflected the patient tried to attack a peer physically and required a restraint. The document to reflect the patient's long- and short-term treatment goal and interventions after the emergency behavior intervention was left blank.

Patient #83's Initial Treatment Plan dated 04/30/2024 at 1528 reflected the patient chief complaint of aggression; the patient was placed on suicide and self-harming precautions. The Master Treatment plan was dated 05/06/2024 and did not reflect the emergency behavioral interventions that occurred within two hours of the patient's admission.
Multidisciplinary Treatment Plan Updated dated 05/07/2024 at 0915 did not reflect the patient restraint on 04/30/2024; there was no evidence of nursing interventions to prevent emergency behavior management incidents.


Personnel #10 reviewed Patient #55's and Patient #83's chart during a personal interview on 5/21/24 at 1549 and acknowledged the findings.


Hospital Policy titled Treatment Plan: Interdisciplinary Master Treatment Plan (Reference #1020) was dated 03/01/2024 and noted the policy that patients "have an individualized written treatment plan which is based on interdisciplinary clinical assessments ...directed toward restoring and maintaining optimal levels of physical and psychological functioning as well as preparing for discharge ..."


37325

The discharge planning evaluation must be included in the patient's medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient's representative).

Based on record review and interview the facility failed to complete a discharge plan for 1 of 1 (Patient #4) patients.


Finding included:

Patient #4 was admitted to the facility on 05/03/24 and discharged on 05/17/27. The Discharge Nursing Assessment/Summary dated 05/17/24 at 08:30 PM does not list a post discharge psychiatric or medical provider. The medical record did not contain a discharge plan. On 05/22/24 the surveyor received via email a discharge plan that reflected ..."D/C (discharge) planner (Personnel #63) was in process of arranging PHP (partial hospitalization program) appt. (appointment) before discharge, however, was notified after the fact that Patient #4 was brought to ...[acute care hospital] for further inpatient care on 05/17/24 ..."
During an interview on 05/22/24 at 11:29 AM Personnel #63 stated they had originally started the discharge planning for Patient #4. Personnel #63 stated they had escalated the process up to their supervisor because they were having issues with the discharge plan. Personnel #63 stated the mother had stated they would not pick the patient up from the facility.
During an interview on 05/22/24 at 12:01 PM Personnel #66 stated that Patient #4's mother wanted a referral to a state hospital. Personnel #66 stated they told the mother that the facility did not make referrals to state hospitals.
During an interview on 05/22/24 at 12:08 PM Personnel #66 stated Discharge planning was conducted, but acknowleged it was not part of the medical record.