HospitalInspections.org

Based on observation, interview, and record review, the facility failed to involve patient participation in the plan of care, failed to provide the right to be informed and ask questions, failed to provide care in a safe setting, and failed to ensure the right to be free from all forms of abuse or harassment, resulting in the potential for less than optimal outcomes for all pts served by the facility.

See tags:
A0130 - Participation in Care Planning
A0131 - Right to make informed decisions
A0144 - Right to care in a Safe Setting
A0145 - Right to be free from Abuse/Harassment

Based on interview and record review, the facility failed to involve patient participation in the plan of care for 1 (P-4) of 13 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include:

P-4: This 16-year-old male was admitted to the facility on 4/8/25 with brief psychotic disorder and homicidal ideation. He has a past medical history of diabetes mellitus type 2, with long term use of insulin.

During record review, it was noted that the master treatment plan included acute psychosis, possible major depressive disorder, and depression with suicidal ideations. The plan failed to include diabetes, blood glucose monitoring, or insulin use.

This finding was reviewed and acknowledged by the chief nursing officer (Staff D) during an interview on 9/23/25 at 1405.

Policy -187673129, Interdisciplinary Treatment Plan for Inpatient Services (revised 08/25) states, "Any medical problems or diagnoses that are not receiving treatment will be listed on the Treatment Plan cover sheet/problem list as deferred with justification provided. If the medical problem requires active treatment, it will either be included in the plan as "chronic/stable" medical problem if only routine care is provided or on a separate problem sheet if more than routine care is indicated."

Based on interview and record review, the facility failed to provide the patient representative with the right to make informed decisions regarding care in 1 (P-3) of 13 records reviewed, resulting in the potential for unmet care needs. Findings include:

P-3: This 14-year-old male was voluntarily admitted to the facility on 8/9/25 for suicidal ideation, disruptive mood regulation disorder, auditory hallucinations, and insomnia. P-3 has a history of autism spectrum disorder and attention deficit hyperactivity disorder.

Record review indicates the guardian was contacted by the physician assistant (Staff N) on 8/10/25 to discuss treatment plan and to obtain consent for medication, and on 8/13/25 and 8/15/25 by social work to discuss treatment plan, family therapy session, and to review discharge safety plan.

The adolescent unit charge nurse (Staff G) was interviewed on 9/23/25 at 1410. Staff G was queried on communication and stated communication can be documented on the guardian communication log, in nursing progress notes, or in additional progress notes
added to the medical record.

The medical record also contained a "guardian communication log," which was blank.

Nursing progress notes were reviewed and there was no documentation of communication with the guardian.

The facility failed to document communication with the guardian. This finding was reviewed and acknowledged by the chief nursing officer (Staff D) during an interview on 9/23/25 at 1405.

In addition, it was noted that the "transition of care: discharge plan - part II" contained handwritten information regarding follow-up appointments and that education was provided on healthcare disparities. The handwriting was not legible.

The limited licensed professional counselor (Staff L) was interviewed on 9/23/25 at 0849. Staff L confirmed that she had completed the discharge plan. Staff L acknowledged that her handwriting can be difficult to read and stated that she will provide families with her contact information if they have questions or have difficulty reading her writing.

Based on observation and interview, the facility failed to provide care in a safe setting, resulting in the potential for injury or harm for all patients served by the facility. Findings include:

During a tour of the Adult B-Female unit on 9/22/25 at 1335, a patient (P-13) was observed pacing the halls, throwing a stress ball against the wall. The census on this unit at that time was 39 with 28 patients documented with assault precautions, and 19 patients documented with suicide precautions.

An interview was conducted with the chief executive officer (Staff A) on 9/22/25 at 1612. Staff A was queried on screening process for appropriate use of stress ball. Staff A stated there is not a specific screening tool, the patient is assessed on what helps them calm down. Staff A stated that stress balls are provided throughout the facility.

The nurse manager of C-Unit (Staff O) was interviewed on 9/25/25 at 1300. Staff O stated stress balls are on every unit in the facility. Staff O stated that patients may request a stress ball or staff can offer one. Staff O stated that it is not documented who on the unit may have a stress ball in their possession and there are no restrictions relating to use in patient rooms or if a staff member must be present while in use. Staff O was queried on when a stress ball would be considered a risk and replied if the patient has a history of attempting to choke or asphyxiate themselves.

The recreational therapist (Staff P) was interviewed on 9/25/25 at 1310. Staff P states she will provide a patient with a stress ball if they ask for one. Staff P stated, she was "told they are considered safe."

The original packaging and order information was requested and provided by the facility. A box of stress balls was provided, which were observed in a cardboard box without individual packaging. A stress ball was inspected and torn in half. The core of the ball appeared to contain foam, which was easily manipulated and the piece re-expanded. The order for the stress ball was placed online and the description failed to include choking hazard information.

Based on observation, interview, and record review the facility failed to prevent peer to peer abuse for three patients (P-2, P-3 and P-12) out of 13 patients reviewed resulting in harm. Findings include:

P2
A record review on 9/22/25 revealed that P-2 was a 16-year-old patient admitted to the facility on 8/11/25 with a diagnosis of Oppositional Defiance Disorder, Depression, and suicidal ideation.

A review of the facility's event log revealed events involving P-2 as follows: 8/17/25 "aggression by another patient" and 8/18/25 "physical confrontation with another patient".

A review of psychiatry progress note dated 8/15/25 revealed "patient was seen, she was overheard arguing with a peer, screaming in the hallway. Patient reports that a peer was bullying another friend of hers and she stepped in to defend her friend ...patient appears to become easily agitated by minor events around her. Discussed with patient that each interaction and even encounter is usually after she has had a major emotional outburst on the unit."

A review of a guardian communication log dated 8/18/25 0700 revealed "another patient made contact by slap."

A review of a document titled "seclusion restraint order" dated 8/18/25 0900 revealed "imminent danger to others. Going after and trying to attack peer."

A review of daily nurse progress note dated 8/18/25 0900 revealed "pt (patient) observed to be yelling cussing at staff. pt started argument with peer then was attacked by peer. Pt ended up having hair ripped out. Pt examined by dr. (doctor). Pt given IM (intramuscular medication). Guardian notified."

A review of psychiatry progress note dated 8/18/25 at 0930 revealed "she states she is extremely agitated on the unit. 'I got my hair pulled out this morning' she states she needed a few medications to help calm down. 'I do not feel safe here, get me out of here' patient became tearful with writer."

Psychiatry progress note dated 8/19/25 revealed "patient is extremely focused on discharge. Patient is tearful. 'I've already lost my hair here. I don't feel safe here."

P12
A review of P-12's record revealed they were a 14-year-old patient admitted to the facility on 8/7/25 with a diagnosis of psychosis, and disruptive mood dysregulation disorder. P-12 was also having suicidal ideations.

A review of a seclusion restraint order dated 8/9/25 revealed "imminent danger to others. throwing food, disrupting milieu, trying to attack peers and fight." A line on the document with the directive, "describe actions taken to lessen physical and/or psychological risk is indicated" is left blank.

A psychiatric progress note dated 8/11/25 revealed "She has positive anger issues, poor impulse control, decreased impulse awareness; delusional in nature; threatening physical harm to others; potential risk of injury to self and to others due to her aggression, anger, and lack of impulse control. She will continue to be on suicidal precautions, also on homicidal precautions due to her violent behavior."

Psychiatry progress note dated 8/15/25 revealed "other risk assessment formulations: homicidal/violence."

Psychiatry progress note dated 8/18/25 revealed "(P-12) got into an altercation with one of her peers and she admits to pulling the peers hair. She claims that the peer was mean and making her mad. (P-12) has been having increased physical altercations with her peers, and it has been difficult to redirect her"

On 9/22/25 at 1048 Nurse Manager, Staff E, explained that if there is an altercation between patients, they de-escalate then separate them. If the patients are roommates they would switch their rooms, then notify the Dr (physician), notify the parents, and an incident report is filled out.

On 9/22/25 at 1200 Chief Executive Officer, Staff A, explained that they put precautions in place for violent patients including blocking beds, separating patients, and increasing monitoring.

On 9/22/25 at 1316 Patient Care Specialist, Staff J, was observed sitting in the hall on a rolling office chair. They explained that if there is fighting between patients they deescalate and try to intervene early, so it doesn't escalate, they get the nurse involved and try to get to the root cause of the argument. Staff J explained that if it does escalate to a physical altercation they call "dr white" (an overhead page indicating more help is needed), they keep the patients separated and they may remove a patient from the unit. Staff J explained that the nurse will notify them ahead of time if a patient has a potential for violence so they can be watched more closely.

On 9/22/25 at 1330 a group of 4 patients in the adult female unit were observed sitting on the floor in the hallway and sought surveyors' attention to report a concern. They explained that there are patients on the unit that have frequent violent outbursts. The patients explained that they had been feeling better and making progress in their treatment but now are having more anxiety and are feeling "triggered" and unsafe with the violent patients on the unit and have needed additional medication as a result. They explained that some of the violent patients throw things, tv remotes for example, and that one of them got hit in the head with a thrown object. They explained that when they report the violence to the staff they are told that since the staff did not witness it occur there was nothing they could do. The patient exhibiting violent behaviors continue to remain in the general population with the other patients.

On 9/22/25 at 1441 Recipient Rights and Patient Advocate, Staff K, explained that an incident report is created for all alterations between patients. The incident reports are then reviewed by Staff K and are discussed daily with the appropriate leadership. Staff K explained that if there is an altercation between patients, the staff will meet to discuss the patients' switching rooms or switching units entirely. Staff K explains that when the patients are adolescents' separation is harder because the facility does not have another adolescent unit to move the patient to so other interventions may be needed. Staff K was queried regarding the incident involving P-2's altercation with a peer. At the time of this interview Staff K did not recall the situation but stated they would look into it and produce the incident report file.

On 9/23/25 at 1256 the Director of Risk, Staff M, was interviewed regarding the altercation involving P-2 and explained that there was no investigation into the incident since there was no harm but that there would be an incident report completed for any patient-to-patient altercation regardless of harm status.

On 9/23/25 at 1329 Recipient Rights and Patient Advocate, Staff K provided a letter to P-2's guardian regarding the altercation. The letter dated 8/18/2025 revealed the following: "your child was involved in a physical altercation with a peer. Staff separated your child and the peer immediately and additional precautions were taken to ensure their safety and wellbeing." Staff K was queried regarding what additional precautions were taken and where the precautions were documented. Staff K explained that any precautions would be documented throughout the chart but was unable to provide specific details.

On 9/23/25 at 1415 the Adolescent Unit Charge Nurse, Staff G, was queried regarding the altercation involving P-2. Staff G explained that they were present for the incident and recalled the incident involving P-2 on 8/18/25. Staff G explained that P-2 had gotten into another altercation with the same patient the night prior. Staff G recalled that the two patients had gotten into a fight on 8/17/25 and that the staff separated them into different day rooms so they would not interact. Staff G explained that on 8/18/25 P-2 and the other patient were together in the hall and the other patient assaulted P-2 and pulled P-2's hair out. Staff G identified the other patient as P-12. Staff G explained that one of P-2's braids was ripped out of her scalp, P-2 then had to receive some medication and went to lie down. The letter to P-2's guardian was reviewed with Staff G and staff G was queried about what additional precautions where implemented and where they were documented. Staff G explained that they would normally be separated and be put on one-to-one observation and confirmed that those precautions were not taken with P-2 or P-12.

On 9/25/25 at 1218 Physician Assistant, Staff N, explained that when there is a new patient with violent behaviors admitted they observe them for a few days to determine their triggers and then the triggers are mitigated. Staff N explained that if another patient is a trigger then the two patients should be kept separated for their safety. The staff provides solitary space or quiet space, so the patients are not triggered. Sometimes one-to-one observation is initiated to ensure they remain calm. Staff N explains that restraints and pharmaceuticals are used as a last resort. Staff N was queried regarding the definition and procedure for homicidal precautions. Staff N explained that a patient on homicidal precautions should be watched more closely and placed on one-to-one observation. Staff N explained that a homicidal patient should be removed from the general activity and would engage in one-on-one activity with a staff member present at all times. Staff N was queried regarding P-2. Staff N recalled that P-2 was triggering the other patients in the unit. Staff N explained that P-2 would trigger others and for the safety of others P-2 needed to be isolated from the other patients to keep everyone safe.

A review of the observation sheets for both P-2 and P-12 revealed they were never on one-to-one supervision during their hospitalization.


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P-3: This 14-year-old male was voluntarily admitted to the facility on 8/9/25 for suicidal ideation, disruptive mood regulation disorder, auditory hallucinations, and insomnia. P-3 has a history of autism spectrum disorder and attention deficit hyperactivity disorder.

Record review indicated that on 8/18/25, an incident report stated P-3 was slapped in the face when a peer said he was sitting in his chair. The peer was removed. The report stated, "no injury noted. Face reddened, ice pack applied."

The adolescent unit charge nurse (Staff G) was interviewed on 9/22/25 at 1353. When queried on preventing altercations between residents, Staff G stated they try to eliminate stressors and try to figure out what is going on. Staff G stated they will make changes to room assignments or seating charts for group sessions if there are issues between patients. Staff G stated if altercation becomes physical, they will intervene immediately, separate the individuals, assess for harm, and notify physician and parents/guardians.

The adolescent unit charge nurse (Staff G) was re-interviewed on 9/23/25 at 1410. Staff G was queried if she recalled the altercation involving P-3 on 8/18/25. She stated it happened very quickly with no indication. Staff G stated the alleged perpetrator and P-3 were far apart in age, that they were not roommates.

During an interview with the Chief Nursing Officer (Staff D) on 9/23/25 at 1345, Staff D stated the incident with P-3 happened so close to discharge that the parent/guardian was already on route to pick him up from the facility so the event couldn't be addressed in real time. Staff D stated P-3's guardian was informed of the incident at discharge.

A review of the facility's policy titled "Identifying and Reporting Abuse and Neglect" dated 11/2024 revealed the following: "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish ...Procedure a. All employees, volunteers and agents of (facility's name) shall: i. Safeguard recipient from abuse and/or neglect and act to obtain treatment for observed injuries and to prevent additional harm."