HospitalInspections.org

Based on a review of hospital policies and procedures, observation, medical record reviews, internal documents review, video record reviews, and staff interviews, the hospital's governing body failed to provide effective oversight and have systems in place to protect Patient's Rights to ensure care in a safe setting and failed to have an organized Nursing Service to meet patient care needs by failing to ensure there were systems in place in order to prevent patient elopement by 3 of 12 sampled patients (Patient #7, #8 and #9) and unauthorized access to restricted areas of the facility by 5 of 12 patients sampled. The following Tags are cross referred: A-0144, and A-0395.

The findings include:

1. Based on facility policy and procedure review, observation, medical record review, internal documents review, video record review, and staff reviews, the facility failed to promote and protect patient's rights to care in a safe setting by failing to ensure staff were able to effectively monitor and supervise care provided to patients to prevent elopement by 3 of 12 patients sampled, (Patient #7, #8, and #9). and to prevent unauthorized access to restricted areas of the facility by 5 of 12 patients sampled. (Patient #7, #8, #9, #11, and #12).

~ cross refer: Tag A-0144

2. Based on facility policy and procedure review, observation, medical record review, internal documents review, video record review, and staff reviews, the facility failed to have an effective nursing service that provided oversight of day to day operations to ensure patients received safe delivery of care by failing to ensure nursing staff were able to effectively supervise care to patients to prevent elopement by 3 of 12 patients sampled (Patient #7, #8, and #9) and to prevent unauthorized access to restricted areas of the facility by 5 of 12 patients sampled, (Patient #7, #8, #9, #11, and #12).

~ cross refer: Tag A-0395






33790

3. Based on policy and procedure review, medical record reviews and staff interviews, facility staff failed to document an update to patients' Master Treatment Plans at least weekly to ensure patient problems and progress were reviewed and updated timely for 2 of 12 patients reviewed (Patients #6, #7).

~ cross refer: Tag A-1640

Based on facility policy and procedure review, observations, medical record review, internal documents review, video record review, and staff reviews, the facility failed to promote and protect patient's rights to care in a safe setting by failing to ensure staff were able to effectively monitor and supervise care provided to patients in order to prevent elopement by 3 of 12 patients sampled, (Patient #7, #8, and #9) and unauthorized access to restricted areas of the facility by 5 of 12 patients sampled, (Patient #7, #8, #9, #11, and #12). The following tags are cross-referred: A-0144 and A-0395

The findings include:

1. Based on facility policy and procedure review, observations, medical record review, internal documents review, video record review, and staff reviews, the facility failed to promote and protect patient's rights to care in a safe setting by failing to ensure staff were able to effectively monitor and supervise care provided to patients in order to prevent elopement by 3 of 12 patients sampled, (Patient #7, #8, and #9) and unauthorized access to restricted areas of the facility by 5 of 12 patients sampled, (Patient #7, #8, #9, #11, and #12).

~ cross refer A: 0144

2. Based on facility policy and procedure review, observations, medical record review, internal documents review, video record review, and staff reviews, the facility failed to have an effective nursing service that provided oversight of day to day operations to ensure patients received safe delivery of care by failing to ensure nursing staff were able to effectively supervise care to patients in order to prevent elopement by 3 of 12 patients sampled (Patient #7, #8, and #9) and unauthorized access to restricted areas of the facility by 5 of 12 patients sampled, (Patient #7, #8, #9, #11, and #12).

~ cross refer A: 0395



33790

3. Based on policy and procedure review, medical record reviews and staff interviews, facility staff failed to document an update to patients' Master Treatment Plans at least weekly to ensure patient problems and progress were reviewed and updated timely for 2 of 12 patients reviewed (Patients #6, #7).

~ cross refer: Tag A-1640

Based on facility policy and procedure review, observations, medical record review, internal documents review, video record review, and staff interviews, the facility failed to promote and protect patient's rights to care in a safe setting by failing to ensure staff were able to effectively monitor and supervise care provided to patients which prevented elopement by 3 of 12 patients sampled, (Patient #7, #8, and #9) and unauthorized access to restricted areas of the facility by 5 of 12 patients sampled, (Patient #7, #8, #9, #11, and #12).

The findings include:

Review of the facility's policy "Patient Rights & Restriction of Patient Rights" last reviewed 01/2019 revealed, "POLICY: ...Any restriction of the rights of patients shall be for therapeutic measures as part of treatment and implementation of any restriction of patient rights shall conform to regulatory guidelines ...Patient Rights: ...e. Care in a safe and sanitary setting ..."

Review of the facility's policy "Elopements: Prevention and Response Guidelines" last reviewed 01/2019 revealed, POLICY It is the policy of (Facility Name) to implement appropriate precautions for any patient who presents as, or becomes, at risk for elopement (leaving the hospital without physician authorization). In the event an elopement does occur, staff will initiate appropriate action when a patient is found to be off the unit without authorization ...PURPOSE: To minimize the potential for elopement from the facility ...and to minimize risk in the event of an elopement ...PROCEDURE: Every effort should be made to reduce unauthorized leaves from the facility ... D. Response to Elopement ...patient is missing or otherwise unaccounted for ...overhead page 'Code Pink'."

Review of the facility's policy "Patient Observation Policy" last reviewed 10/2018 revealed, "PURPOSE: To ensure patient safety, as well as, to provide a process for observing and documenting patient location and behavior ...PROCEDURE: Nurse/Nursing Supervisor: Assigns responsibility for completion of 15minute/7minute patient observation rounds ...MHT(mental health technician): a. Remain with assigned patients at all times ...h. While monitoring hallways and patient care areas ensure patients are: not entering rooms not assigned to them, not in rooms or areas that are designated 'off limits' areas to patients ..."

Observation on 09/16/2020 at 1145 during a tour of Building-A where the elopement occurred on 09/14/2020 revealed a metal framed safety glass door in a short hall leading to a wooden entry/exit door into a lobby area. On entering the lobby, a locked ten bed male adolescent unit was to the right and a locked 12 bed female adolescent unit was to the left of a central nursing station which sat open to the lobby behind an approximately 40-inch high counter, staff work station. There was no door passage into the nursing station from the lobby. Keyed, locked, single wooden doors led into the adolescent male and adolescent female units. Once inside the male and female units, one small keyed, locked door on each side of the nurse's station provided access into the station from the male and female units. Each door required a key to access the nurse's station from the treatment area but did not require a key to exit into the treatment areas from inside the nurse's station. Observation revealed windows along the nurse's station allowed patients on each unit to look into the treatment hall on the other unit.

Observation on 09/18/2020 at 0930 during a tour of Building-B the entry area was structurally similar but slightly larger and accommodated more patients.

Interview on 09/15/2020 at 1055 shortly after entry to the facility with the CEO revealed "three adolescents eloped and returned late last night. They did not come back on their own ..." Interview revealed security camera video had not yet been reviewed and the patients were off facility grounds from approximately 2100 until approximately 2345.

Interview on 09/16/2020 at 1130 with the Director of Risk Management (DRM) revealed "...five exited the halls..." of Building A on 09/14/2020 and "...staff had retrieved two."

1. Open medical record review on 09/16/2020 and 09/18/2020 revealed Patient #7, a 17-year-old male involuntarily committed (IVC) to the hospital on 08/16/2020 after ingesting approximately 100 pills of Trileptal (an anticonvulsant/mood stabilizer medication used off label to treat bipolar disorder) in a suicide attempt. Review of the facility's "PSYCHIATRIC EVALUATION History and Physical" dated 08/17/2020 (no time indicated) by MD #1 revealed, " Bipolar ... S/P (status post) OD (overdose) c (with) Trileptal 100 pills. Broke up with his GF (girl-friend) ...ADMITTING DIAGNOSIS ...Schizophrenia Bipolar type (rapidly changing mood changes with extreme highs and extreme lows), DMDD (disruptive mood dysregulation disorder-extreme anger, frequent, intense temper outbursts with severe impairment) ..." Review of the facility's "Re-Assessment Tool" dated 08/17/2020 at 1850 revealed Patient #7 had no memory of taking the Trileptal after awakening at an outside hospital's emergency department (ED). Review revealed "High Risk Issues" included "History of suicidal ideation or attempts," and " History of AWOL." Record review revealed Patient #7 was placed on every 7-minute observations at admission. Review of the "Master Treatment Plan" revealed a "Depression Individual Treatment Plan" initiated 08/17/2020 at 1247.

1.a. Medical record review of a "Nursing Progress Note" by registered nurse, RN #28, dated 08/25/2020 at 1850 revealed "Pt (patient) upset that his Geodon was ordered for 1700 ...Pt began kicking the walls/doors and pacing @ (at) 1730. Code White called ...kicked the nurses (sic) station door in, jumped over the nurses (sic) station and kicked both doors in breaking the glass on the front door and ran. Code Pink called. 1800 Rapid response called and pt sent out." Review of a "Progress Note" by RN #28 dated 08/25/2020 at 2210 revealed Patient #7 "returned from the hospital in stable condition ..." after the 08/25/2020 attempted elopement. Review of a "Therapist Progress Note" dated 08/25/2020 at 1816 revealed a licensed clinical social worker, LCSW #3, had contacted family " ...to notify that pt's (patient has) eloped from the facility and is currently being transported by ambulance to ED (emergency department) due to collapsing in the parking lot ..." Review of a "Patient Observation" sheets dated 08/25/2020 and 08/26/2020 revealed Patient #7 was placed on 1:1 observation on 08/25/2020 at 2215, released from 1:1 observation on 08/26/2020 at 1745 and returned to 7-minute observations with "Elopement Precautions." Review of the "Master Treatment Plan" revealed no updated documentation which noted the elopement attempt or ongoing elopement concerns.

Review of a facility internal "Incident Reporting Information" document (not dated or timed) related to Patient #7's attempted elopement on 08/25/2020 revealed Patient #7's statement, "I really did not want to be here anymore ...I was cool because I knew the nurse station door was loose and I could get through the door ...The unit doors are harder to kick than the nurse station doors ...I kicked the nurse station 2x, the first it only loosened and then the second time I broke through, jumped the desk, kicked the other wood door once and the glass door once. Both doors I was aiming for the latch ...Nobody really caught me, I just sort of came to a stop because my muscles went weak ...and I was on the ground. Then I was surrounded and had an audience. I remember all of it ..." Review of the report included a "Camera Review" which revealed "18:26:25 (Patient #7) breaks through the nurse station door and jumps the counter. 18:26:30 (Patient #7) breaks through the wood door to the lobby. 18:26:36 (Patient #7) breaks through the glass door to the outside; staff follow outside."

Review of internal records revealed a "Code Pink After-Action Report/Improvement Plan" (not dated, not timed) completed for the 08/25/2020 incident. Review revealed "Core Capability" described as "Performed without Challenges," defined in the report as " ...critical tasks associated with core capability were completed in a manner that achieved the objectives ...Performance ...did not contribute to additional health and/or safety risks ..." Review of "Actions Taken" included " ...Patient made a 1:1; No injuries noted. Medically cleared ...(Family member) and Attending Provider notified. Debrief with staff performed ...Reviewed environmental code with Corporate Representative ...Fire Marshall called for consult to determine if door hinge can be located on the other side to strengthen door ...Onsite assessment completed. Unable to turn the hinge around ...Discussed with corporate and Fire Marshall another type of door ...May change door; however, if construction is needed (Facility) will need to have approval from the inspection department."

Review of a facility video recording on 09/17/2020 revealed on 08/25/2020 at 18:18:02 an individual identified by staff as Patient #7 stood in the hallway of the adolescent male unit (AMU). In the camera's view neither the nursing station door nor the unit exit door into the lobby were visible. Review revealed Patient #7, while being monitored by staff, ran in and out of camera view toward the far end of the hall and ran back toward the unit exit door multiple times. Review revealed at 18:26:22 staff moved quickly toward the nurse's station door area and Patient #7 was observed inside the nurse's station at 18:26:24. Review revealed Patient #7 was on the counter top at 18:26:25, and jumped into the empty lobby at 18:26:26. He briefly walked within the lobby and kicked the wooden exit door to the exit hall open at 18:26:30. Patient #7 was seen on the exit hall camera at 18:26:31, he kicked a glass exit door twice at 18:26:32-33 broke the glass and exited the building through the door at 18:26:34 and out of video range as staff continued to pursue. Total time from Patient #7's entry into the nurse's station until exit from the building was 12 seconds.

Interview request for RN #28 the staff nurse for the adolescent male unit on 08/25/2020 revealed she was not available.

Interview on 09/16/2020 at 1313 with a social worker, LCSW #3, revealed she had been assigned to Patient #7 on 08/31/2020. Interview revealed Patient #7 had a long history of psychiatric hospitalizations and the original plan was to transfer Patient #7 to a PRTF (psychiatric residential treatment facility) after stabilization. Interview revealed facilities refused admission because of the 08/25/2020 attempted elopement. LCSW #3 revealed Patient #7 had indicated he "was tired of being in facilities and was going to take things in his own hands," and she was currently working on his admission to a state behavioral health facility.

1.b. Record review revealed Patient #7 changed from 7-minute observations to 15-minute observations on 09/11/2020 at 1400 and remained on 15-minute observations until 09/14/2020 at the time of elopement. Review of a "Nursing Progress Note" dated 09/14/2020 at 2215 by RN #4 revealed "Pt began getting upset (after) dinner and told MHT he was not staying here anymore. MHT attempted to verbally de-escalate ...When MHT went into the nursing station, Pt got through the door. He jumped over the nursing station desk and then was able to bust through the two outer doors and eloped ..." Review of the "Patient Observation" check sheets for 09/14/2020 revealed at 1915 Patient #7's location was listed as "19 -Other" (not defined) with a comment "Broke Out." Review of a "Nursing Progress Note" dated 09/15/2020 at 0540 revealed "(2335) Pt returned to the facility post elopement via (Named police department) ..." Review of orders revealed Patient #7 was placed on 7-minute observation at return to the facility. Review of a "Therapist Progress Note" dated 09/15/2020 at 1714 revealed, "Clinician informed team of the events of the previous night including pt (patient) elopement ..." Review revealed a "Master Treatment Plan" update, dated 09/15/2020 at 1500, which indicated anticipated discharge to a "state hospital." Review revealed no elopement prevention measures, or an elopement concern were recorded on the updated "Master Treatment Plan."

Review of internal records revealed a "Code Pink After-Action Report/Improvement Plan" completed for incident 09/14/2020 (not dated, not timed). Review revealed "Core Capability" indicated as within expectations. Review of the document's "Corrective Actions" revealed "9.14.2020 Notifications made ...Debrief and Staff education ...Door monitor at (Building-A) ...9.15.2020 Door monitor at (Building-B) ...Debrief with Clinician and Patient Advocate ...Reinforced ...door stryker (sic) plates ...(Patient #11) was moved to (Building-B) ...and 1:1 initiated ..." Review revealed no specific documentation related to Patient #7 and his ability to access the nurse's station to elope and this time with another patient.

Review of a facility video recording on 09/17/2020 revealed on 09/14/2020 at 19:07:00, Patient #7, four peers and a staff member visible near the nurse's station. At 19:08:53 Patient #7 rushed toward the unit exit door, returned, and at 19:08:59 moved toward the entry door to the nurse's station. Review revealed Patient #7 within the nursing station at 19:09:07 as facility staff attempted to redirect him back to the adolescent male unit. At 19:09:11, Patient #11 was observed in the nurse's station moving toward the adolescent female (AFU) unit as staff confront Patient #7. Review revealed, at 19:09:36 the exit door on the AFU into the lobby area outside the nurse's station opened and Patient #11 and two female patients, entered the lobby area and departed through a broken exit door into the building's exit hallway. At 19:10:06, Patient #7 jumped over the nurse's station counter and departed through the broken exit door at 19:10:08. Review revealed, at 19:10:10 Patient #7 pushed open a broken exit door as facility staff confronted other eloping patients in the background and exited the building out of camera view. The total time from Patient #7's entry into the nursing station until exit from the building was 63 seconds.

Interview request for RN #27 the shift supervisor on the evening of 09/14/2020 revealed the supervisor was not available.

Interview on 09/18/2020 at 1520 with LPN #14 revealed, she worked with the adolescent female unit patients on 09/14/2020 when there was an elopement. LPN #14 revealed " ...It felt like forever, but it was maybe 20-30 seconds." LPN #14 revealed after the doors were forced open by a male patient, " ...Two girls went out after him ..." LPN #14 revealed she remained on the adolescent female unit "They were not trying to get out, but were just afraid ...It took them a while to calm ..."

Telephone interview on 09/16/2020 at 1425 with RN #4 revealed she worked on the adolescent male unit and had worked in Building-A on 09/14/2020 when three patients eloped. RN #4 indicated she had worked with Patient #7 on three occasions, Patient #7 had seemed anxious on 09/14/2020, and MHT #10 planned to take him in the yard for some exercise. Interview revealed Patient #7 had been banging on the unit exit door and as the MHT went into the nurse's "station to get help ...(Patient #7) ran by him ... then as I was trying to close the door (Patient #11) pushed by into the nursing station and ran into the girl's hall, turned left and kicked the door open." Interview revealed "It happened very quickly. "

Interview on 09/18/2020 at 1440 with MHT #10 revealed, he had "just arrived" for his shift on 9/14/2020
and noticed "a little bit of a commotion near the nursing station." Interview revealed he checked in with
the unit nurse and shortly after he entered the unit "(Patient #7) "went on a tear. I tried to hold him back, it was just me at the moment. I couldn't really use a proper hold, so I was trying to block him," and "Not sure how the other patient got through, but he ran to the girl's side and broke the door. Got a couple of girls out." Interview revealed "I was holding (Patient #7) but I was no longer safe to continuing to hold so I let go and he jumped the nursing station." Interview revealed after the elopement, MHT #10 remained on the male unit to get the remaining patients into the day room and "make sure they were safe."

1.c. Medical record review on 09/18/2020 revealed Patient #7 was involved in other incident of patients breaching the nurse's station on 09/17/2020." Review of a "PROGRESS NOTE" by MD #1 dated 09/17/2020 at 2000 revealed "pt became aggressive toward another patient ...after this the Pt broke through the nurse's station and entered the other side of the unit. MHT's responding to the Code White (paged request for staff assistance) were able to de-escalate him ..." Medical record review and requests for medical records on 09/18/2020 revealed no observation sheets or documentation in Patient #7's chart for a second event reported by staff as occurring two hours later, on the evening of 09/17/2020.

Review of a facility video recording on 09/18/2020 revealed Patient #7, and a staff member visible in the hall near the adolescent male unit exit on 09/17/2020 at 22:00:02. At 22:00:44 as staff within the nursing station reacted, a large piece of safety glass on the adolescent male unit side, fell out of its' window frame and onto equipment in the nursing station. Review revealed, at 22:01:16 as staff picked up fallen papers and equipment, Patient #7 came head first through the window area, and at 22:01:30 Patient #7 exited the nurse's station and entered the adolescent female unit. Patient #7 attempted to kick open the exit door from the adolescent female unit into the lobby, re-entered the nurse's station at 22:02:06 and at 22:02:08, jumped onto the nurse's station counter and moved toward the lobby area. Review revealed two staff who stood in the lobby at the counter blocked Patient #7's attempt to enter the lobby. As staff continued to deal with Patient #7, two peers entered the nursing station, and attempted to strike Patient #7 and RN #30. At 22:04:09, a law enforcement officer (LEO) climbed over the nurse's station counter and staff members and the LEO de-escalated both patients. The LEO returned to Patient #7 at 22:05:36 and appeared to apply something which was not clearly visible to Patient #7's wrists. Review revealed, as Patient #7's wrists were behind his back he was observed in a chair as he talked and smiled at a male patient who sat beside him. Review revealed. the second male patient was no longer observed within the nursing station and at 22:11:00 the LEO jumped back over the counter and exited the unit. Patient #7 and the visible patient continued to sit on the chairs and their hands were now in front of them. Total time from Patient #7's first entry into the nursing station through the window until Patient #7 sat in a chair without resisting was four minutes and six seconds. Request for the video record of the incident earlier in the evening on 09/17/2020 revealed it was not available for review.

Interview request for RN #30, one of two nurses who worked on the evening of 09/17/2020 revealed the RN was not available.

Interview on 09/18/2020 at 1825 with RN #15 revealed, he had been floated to Building-A's adolescent male unit on 09/17/2020. Interview revealed the other nurse on duty, RN #30, oversaw the adolescent female unit and was in the nursing station when "(Patient #7) pushed through the plexiglass at the nurse's station." RN #15 indicated the plexiglass did not break "but fell out and fell on (RN #30) then (Patient #7) quickly got up and went into the girls unit and kicked the door (exit door from the unit into the lobby) ..." Interview revealed the door did not open and Patient #7 returned through the door into the nursing station with the help of "two young girls." Interview revealed Patient #7 attempted to jump over the nursing station but was prevented by MHT #13. RN #15 indicated he had completed an incident report with the female patients' initials in it but did not know where the report was. Interview with RN #15 revealed two male peers had also entered the nursing station and attempted to hit both Patient #7 and RN #30. Further interview revealed after Patient #7 had been prevented from "bolting over" the nursing station, Patient #7 and one of the two male patients remained in the nursing station monitored by two staff.

Telephone interview on 09/19/2020 at 1247 with MHT #13 revealed he worked on the adolescent male unit side on 09/17/2020 when the first of two incidents occurred. Interview revealed he worked as the unit MHT and another MHT worked as a "one-to-one" for Patient #7. Interview revealed Patient #7 wanted to get to the adolescent female unit to attack a male patient programming on the adolescent female unit side after a fight earlier in the day. Interview revealed Patient #7 talked about getting into the nurse's station and wanted to kick the door in but MHT #13 stood front of the nurse's station door and the one-to-one MHT stood in front of the door leading to the lobby. Interview revealed Patient #7 instead banged on the plexiglass window and pushed it out of the frame into the nurse's station. Interview revealed Patient #7 then jumped through the hole left in the window frame. Interview revealed Patient #7 stood on top of the nurse's station after the MHT's tried to prevent him from getting inside, and as the MHT's dealt with that, two male patients kicked open the nurse's station door and entered. Interview revealed the two male patients were more followers than instigators. Interview revealed one of the male patients opened the door into the female unit, but the females stayed on their unit. Interview revealed MHT #13 considered it an elopement attempt, but no patients got out of the building. Interview revealed at least one of the patients hit a nurse. MHT #13 stated he thought Patient #7 " ...had tried to get (Patient #9) to escape with him but she never went with him."

Telephone interview on 09/19/2020 at 1322 with MHT #18 revealed he worked in Building-A on 09/17/2020. Interview revealed he was assigned to "watch the door. "Interview revealed during the first incident, Patient #7, and a peer kicked in the nurse's station door and Patient #7 ran onto the adolescent female unit. Interview revealed MHT # 18 left his post at the door to intervene between Patient #7 and a male patient programming on the adolescent female unit. Interview revealed when additional staff came, MHT #18 went back to his post. Interview revealed the second incident occurred around 2200-2215 when Patient #7 banged repeatedly on the plexiglass at the Nurse's Station and the plexiglass fell out of its' frame. Interview revealed a nurse in the station, RN #30, tried to catch the plexiglass. MHT #18 observed as Patient #7 slid over the desk and into the nurse's station. Interview revealed once Patient #7 went into the nurse's station through the window, two females started banging on the unit exit door and MHT #18 held the door closed. Interview revealed another patient on the adolescent male unit kicked the nurse's station door in again and he and a third male patient entered the nurse's station. MHT #18 saw Patient #7 in the station pick up computer monitors, and other objects to throw at the nurse, and the nurse was saying "stop, stop, stop" to all the patients. Interview revealed, eventually two staff members got Patient #7 to stop, and once Patient #7 stopped, the other patients stopped.

During discussion on 09/18/2020 at 1600 with the CEO, CNO and DRM they were asked if leadership was aware of incidents after 09/15/2020, and the CEO indicated she would "look into it." Follow up interview with the CEO on 09/19/2020 at 1730 revealed the CNO (Administrator on Call) had been called after the second incident on 09/17/2020, and "did not get the message."

2. Open medical record review on 09/18/2020 revealed Patient #11, a 14-year-old male involuntarily committed to the hospital on 09/11/2020 after fighting with and threatening to kill a family member. Review of the "PSYCHIATRIC EVALUATION and History and Physical", dated 09/12/2020 at 0900, revealed " ...HISTORY OF PRESENT ILLNESS ...worsening behavioral and emotional difficulties. Has had mood swings, depressed, suicidal thoughts, obsessive worries about death, worries he is going to die ..." ADMITTING DIAGNOSES ...DMDD, IED (intermittent explosive disorder), sibling conflict ..." Review of the medical record revealed five restraint interventions which required medication, physical hold, or seclusion between 09/14/2020 at 1600 and 09/16/2020 at 2100. Review of the medical record revealed a "Restraint/Seclusion Order/Record" by RN # 22 dated 09/14/2020 at 1908, "Pt (patient) broke through a door and attempted to elope ..." and in an update at 2040 "Pt had elopement plan w/ (with) a peer ...Pt part of group that planned elopement-Agitated he did not elope ..." Review of a "Nursing Progress Note" dated 09/14/2020 at 2200 by RN #4 revealed, " ...Around 1830, he broke through the nursing station and then kicked a door to the girl's unit to try to elope. He and another male peer managed to break through the outer doors and get out of the building. An MHT intervened and brought the patient back inside ...taken ...into seclusion room ..." Review of the medical record revealed Patient #11 was moved from Building-A to Building-B on 09/16/2020 and was placed on 1 to 1 observation. Review of an "Inpatient Physician Note" dated 09/16/2020 at 1245 by MD #21 revealed, " ...Pt is noted to be extremely angry ...admits to engaging in destructive behaviors on (Building-A) unit. Insight and judgement are very poor ..." Review of a "Nursing Progress Note dated 09/16/2020 at 2100 revealed "Pt got agitated ...broke threw (sic) the exit door attempting to get out of the front door ..." Review of a "Restraint/Seclusion Order/Record" by LPN #14 dated 09/16/2020 at 2045 revealed, "Pt had rallied peers to help him break out. Pt broke lock out of door by kicking it and got into outside of nursing station. Pt punched RN in face and tried to leave ...Staff braced doors to keep pts on unit." Review of the facility census revealed Patient #11 remained on the adolescent male unit in Building-B as of 09/19/2020.

Review of internal records revealed "Code Pink After-Action Report/Improvement Plan" completed for incident 09/14/2020. Review revealed "Corrective Actions ...(Patient #11) was moved to (Building-B) ...and 1:1 initiated ..."
Review of a facility video recording on 09/17/2020 revealed on 09/14/2020 at 19:09:11, a patient identified by staff as Patient #11, in the nursing station headed in the direction of the adolescent female unit. At 19:09:36 the exit door on the adolescent female unit into the lobby outside the nurse's station opened and Patient #11 and two female patients entered the lobby area. Review revealed, Patient #11 kicked open the wooden exit door and the three patients departed through the door into the exit hallway. Review revealed, at 19:10:05 Patient #11 pushed open the locked exit metal/glass door and exited Building-A followed by two adolescent female patients. Further review revealed as staff attended to other eloping patients, a male staff member returned with Patient #11 in a hold and entered the hallway at 19:10:30.

Telephone interview on 09/16/2020 at 1425 with RN #4 revealed she worked on the adolescent male unit and had worked in Building-A on 09/14/2020 when three patients eloped. RN #4 indicated a male patient banged on the unit exit door and as the MHT went into the nurse's "station to get help ...(Patient #7) ran by him ... then as I was trying to close the door (Patient #11) pushed by into the nursing station and ran into the girl's hall, turned left and kicked the door open." Interview revealed "It happened very quickly."

During discussion on 09/18/2020 at 1600 with the CEO, CNO and DRM they were asked if leadership was aware of incidents after 09/15/2020, and the CEO indicated she would "look into it." Follow up interview with the CEO on 09/19/2020 at 1730 revealed the CNO had been called after the second incident on 09/17/2020, and "did not get the message."

3. Open medical record review on 09/17/2020 through 09/19/2020 revealed Patient #9, a 13-year-old female, admitted on 09/09/2020 at 1610. Review of the "INITIAL NURSING ASSESSMENT AND ADMISSION DATA" note dated 09/09/2020 at 1830 revealed "...13 y.o. (year old) female admitted IVC...Admitted for SI (suicidal ideations) threats and HI (homicidal ideations) towards others....Pt runs away from home often and has had traumatic experiences (with) friend's death and (family member). ..." Review of Orders revealed Patient #9 was placed on every 7-minute observation on 09/09/2020 at 2000 which continued until 09/12/2020 at 1214. The "PSYCHIATRIC EVALUATION and History and Physical", dictated 09/10/2020, revealed " ...HISTORY OF PRESENT ILLNESS ....acting out, suicidal, put a knife to her arm and threatened to kill (family member). She seems to engage in gang activities outside...She runs away....ADMITTING DIAGNOSES ....PTSD (Post traumatic stress disorder), DMDD, major depression moderate ... ." Review of the "PSYCHOSOCIAL ASSESSMENT, dated 09/11/2020 at 1235, revealed Patient #9 presented under involuntary commitment (IVC). Review of an "Inpatient Physician Note: dated 09/13/2020 at 1830, revealed "...had an episode of anger (and) agitation requiring prn (as needed) meds. Case discussed (with) staff. Needs to work on boundaries...anger mgt (management)....refrain from impulsive... ."

Review of Physician Orders, dated 09/12/2020 at 1200, revealed observation was changed from every 7 minutes to every 15 minutes. Review of "NURSING PROGRESS NOTES" dated 09/14/2020 at 1912, revealed "Patient from 10 bedside (adolescent male unit) attempted to elope by breaking open door on 12 bedside (adolescent female unit) ....eloped thru open door and exited building threw (sic) broken front door...." Review of "NURSING PROGRESS NOTES" dated 09/15/2020 at 0517, indicated "Pt returned to facility post-elopement @ (at) 2345 9/14/20 via (City Police Department)...Per MD pt on a level 2 (7-minute observations, unit restrictions, elopement precautions & to wear scrubs..." On 09/16/2020 at 0821, an "Inpatient Physician Note" documented "...She (Patient #9) continues to act fairly aggressive with tapping doors, etc. ..." Documentation dated 09/16/2020 at 1809 "Restraint/Seclusion Order/Record" documentation noted a physical restraint at 1805 followed by a medication restraint at 1807 for behaviors of "Defiance, Agitation, Threatening Staff, Verbal aggression toward peers, kicking door, kicking staff. ..." At 2300, "NURSING PROGRESS NOTES" documentation noted "After dinner pt began verbally aggressive comments towards peers and staff. Pt was becoming increasingly agitated and was informed that medication was needed to help minimize agitation. Pt... began cursing & threatening staff. Staff attempted to guide pt to a private place for medication and pt became aggressive, kicking and threatening staff. Pt kicked door to lobby open and physical hold required. ..." Restraint and seclusion documentation, dated 09/17/2020, noted a physical restraint at 1245, seclusion initiated at 1249, and medication administered at 1256 for " ...verbal altercation with peer...kicking door until it opened. Staff escorted her back on unit...". Review revealed the criteria for release were noted as "...stop aggressive and combative behavior. ..."

The "NURSING PROGRESS NOTES" at 1500 on 09/17/2020 stated "...She tried to get to (sic) peer to 'fight', staff redirected. She went to door saying, 'I'm getting to ....out of here' and she started kicking the door. Door came open staff escorted her back to unit..." At 2223 on 09/17/2020, restraint documentation noted a medication restraint and stated "...two patients were acting out when male pt made it across to their side, banging/ kicking a door tried to get out, punched MHT ..." At 2300 "NURSING PROGRESS NOTES" of the event noted "Pt was standing there in the window (with) direct view of boy's unit and communicating to one of the males to plan an escape attempt which was ultimately failed. She used the pieces of plaster and dry wall to write obscenities on the window to nurse's station....The MHT attempted and reattempted, along (with ) the help of this nurse and another nur

Based on facility policy and procedure review, medical record review, internal document review, video record review, and staff interviews, the facility failed to have an effective nursing service that provided oversight of day to day operations to ensure patients received safe delivery of care by failing to ensure nursing staff were able to effectively supervise care to patients to prevent elopement by 3 of 12 patients sampled (Patient #7, #8, and #9) and unauthorized access to restricted areas of the facility by 5 of 12 patients sampled, (Patient #7, #8, #9, #11, and #12). The following tags are cross-referred: A-0144, A-0395, and A-1640.

The findings include:

1. Based on facility policy and procedure review, medical record review, internal document review, video record review, and staff interviews, the facility failed to promote and protect patient's rights to care in a safe setting by failing to ensure staff were able to effectively monitor and supervise care provided to patients which prevented elopement by 3 of 12 patients sampled, (Patient #7, #8, and #9) and unauthorized access to restricted areas of the facility by 5 of 12 patients sampled, (Patient #7, #8, #9, #11, and #12).

~ Cross refer A: 0144

2. Based on facility policy and procedure review, medical record review, internal document review, video record review, and staff interviews, the facility failed to have an effective nursing service that provided oversight of day to day operations to ensure patients received safe delivery of care by failing to ensure nursing staff were able to effectively supervise care to patients to prevent elopement by 3 of 12 patients sampled (Patient #7, #8, and #9)\and unauthorized access to restricted areas of the facility by 5 of 12 patients sampled, (Patient #7, #8, #9, #11, and #12).

~ Cross refer A: 0395


33790

-3. Based on policy and procedure review, medical record reviews and staff interviews, facility staff failed to document an update to patients' Master Treatment Plans at least weekly to ensure patient problems and progress were reviewed and updated timely for 2 of 12 patients reviewed (Patients #6, #7).

~ cross refer: Tag A-1640

Based on facility policy and procedure review, observation, medical record review, internal documents review, video record review, and staff interviews, the facility failed to have an effective nursing service that provided oversight of day to day operations to ensure patients received safe delivery of care by failing to ensure nursing staff were able to effectively supervise care to patients to prevent elopement by 3 of 12 patients sampled (Patient #7, #8, and #9) and unauthorized access to restricted areas of the facility by 5 of 12 patients sampled, (Patient #7, #8, #9, #11, and #12).

The findings include:

Review of the facility's policy "Nursing Assessment and Reassessment" last reviewed 04/2018 revealed, "POLICY: It is the policy of (Facility name) to conduct a complete nursing assessment within 8 hours of admission ...PROCEDURE: ...1.1 Ongoing reassessments are conducted ...as warranted by the patient's condition, and documented ...2.0 The patient's nursing care is consistent with the unit to which the patient is admitted. Adjunctive therapies and other hospital disciplines including ...environmental, self-care, educational ...are also included when planning nursing care ..."

Review of the facility's policy "Patient Rights & Restriction of Patient Rights" last reviewed 01/2019 revealed, "POLICY: ...Any restriction of the rights of patients shall be for therapeutic measures as part of treatment and implementation of any restriction of patient rights shall conform to regulatory guidelines ...Patient Rights: ...e. Care in a safe and sanitary setting ..."

Review of the facility's policy "Elopements: Prevention and Response Guidelines" last reviewed 01/2019 revealed, POLICY It is the policy of (Facility Name) to implement appropriate precautions for any patient who presents as, or becomes, at risk for elopement (leaving the hospital without physician authorization). In the event an elopement does occur, staff will initiate appropriate action when a patient is found to be off the unit without authorization ...PURPOSE: To minimize the potential for elopement from the facility ...and to minimize risk in the event of an elopement ...PROCEDURE: Every effort should be made to reduce unauthorized leaves from the facility ... D. Response to Elopement ...patient is missing or otherwise unaccounted for ...overhead page 'Code Pink'."

Review of the facility's policy "Patient Observation Policy" last reviewed 10/2018 revealed, "PURPOSE: To ensure patient safety, as well as, to provide a process for observing and documenting patient location and behavior ...PROCEDURE: Nurse/Nursing Supervisor: Assigns responsibility for completion of 15minute/7minute patient observation rounds ...MHT(mental health technician): a. Remain with assigned patients at all times ...h. While monitoring hallways and patient care areas ensure patients are: not entering rooms not assigned to them, not in rooms or areas that are designated 'off limits' areas to patients ..."

Observation on 09/16/2020 at 1145 during a tour of Building-A where the elopement occurred on 09/14/2020 revealed a metal framed safety glass door in a short hall leading to a wooden entry/exit door into a lobby area. On entering the lobby, a locked ten bed male adolescent unit was to the right and a locked 12 bed female adolescent unit was to the left of a central nursing station which sat open to the lobby behind an approximately 40-inch high counter, staff work station. There was no door passage into the nursing station from the lobby. Keyed, locked, single wooden doors led into the adolescent male and adolescent female units. Once inside the male and female units, one small keyed, locked door on each side of the nurse's station provided access into the station from the male and female units. Each door required a key to access the nurse's station from the treatment area but did not require a key to exit into the treatment areas from inside the nurse's station. Observation revealed windows along the nurse's station allowed patients on each unit to look into the treatment hall on the other unit.

Observation on 09/18/2020 at 0930 during a tour of Building-B the entry area was structurally similar but slightly larger and accommodated more patients.

Interview on 09/15/2020 at 1055 shortly after entry to the facility with the CEO revealed "three adolescents eloped and returned late last night. They did not come back on their own ..." Interview revealed security camera video had not yet been reviewed and the patients were off facility grounds from approximately 2100 until approximately 2345.

Interview on 09/16/2020 at 1130 with the Director of Risk Management (DRM) revealed "...five exited the halls..." of Building A on 09/14/2020 and "...staff had retrieved two."

1. Open medical record review on 09/16/2020 and 09/18/2020 revealed Patient #7, a 17-year-old male involuntarily committed (IVC) to the hospital on 08/16/2020 after ingesting approximately 100 pills of Trileptal (an anticonvulsant/mood stabilizer medication used off label to treat bipolar disorder) in a suicide attempt. Review of the facility's "PSYCHIATRIC EVALUATION History and Physical" dated 08/17/2020 (no time indicated) by MD #1 revealed, " Bipolar ... S/P (status post) OD (overdose) c (with) Trileptal 100 pills. Broke up with his GF (girl-friend) ...ADMITTING DIAGNOSIS ...Schizophrenia Bipolar type (rapidly changing mood changes with extreme highs and extreme lows), DMDD (disruptive mood dysregulation disorder-extreme anger, frequent, intense temper outbursts with severe impairment) ..." Review of the facility's "Re-Assessment Tool" dated 08/17/2020 at 1850 revealed Patient #7 had no memory of taking the Trileptal after awakening at an outside hospital's emergency department (ED). Review revealed "High Risk Issues" included "History of suicidal ideation or attempts," and " History of AWOL." Record review revealed Patient #7 was placed on every 7-minute observations at admission. Review of the "Master Treatment Plan" revealed a "Depression Individual Treatment Plan" initiated 08/17/2020 at 1247.

1.a. Medical record review of a "Nursing Progress Note" by registered nurse, RN #28, dated 08/25/2020 at 1850 revealed "Pt (patient) upset that his Geodon was ordered for 1700 ...Pt began kicking the walls/doors and pacing @ (at) 1730. Code White called ...kicked the nurses (sic) station door in, jumped over the nurses (sic) station and kicked both doors in breaking the glass on the front door and ran. Code Pink called. 1800 Rapid response called and pt sent out." Review of a "Progress Note" by RN #28 dated 08/25/2020 at 2210 revealed Patient #7 "returned from the hospital in stable condition ..." after the 08/25/2020 attempted elopement. Review of a "Therapist Progress Note" dated 08/25/2020 at 1816 revealed a licensed clinical social worker, LCSW #3, had contacted family " ...to notify that pt's (patient has) eloped from the facility and is currently being transported by ambulance to ED (emergency department) due to collapsing in the parking lot ..." Review of a "Patient Observation" sheets dated 08/25/2020 and 08/26/2020 revealed Patient #7 was placed on 1:1 observation on 08/25/2020 at 2215, released from 1:1 observation on 08/26/2020 at 1745 and returned to 7-minute observations with "Elopement Precautions." Review of the "Master Treatment Plan" revealed no updated documentation which noted the elopement attempt or ongoing elopement concerns.

Review of a facility internal "Incident Reporting Information" document (not dated or timed) related to Patient #7's attempted elopement on 08/25/2020 revealed Patient #7's statement, "I really did not want to be here anymore ...I was cool because I knew the nurse station door was loose and I could get through the door ...The unit doors are harder to kick than the nurse station doors ...I kicked the nurse station 2x, the first it only loosened and then the second time I broke through, jumped the desk, kicked the other wood door once and the glass door once. Both doors I was aiming for the latch ...Nobody really caught me, I just sort of came to a stop because my muscles went weak ...and I was on the ground. Then I was surrounded and had an audience. I remember all of it ..." Review of the report included a "Camera Review" which revealed "18:26:25 (Patient #7) breaks through the nurse station door and jumps the counter. 18:26:30 (Patient #7) breaks through the wood door to the lobby. 18:26:36 (Patient #7) breaks through the glass door to the outside; staff follow outside."

Review of internal records revealed a "Code Pink After-Action Report/Improvement Plan" (not dated, not timed) completed for the 08/25/2020 incident. Review revealed "Core Capability" described as "Performed without Challenges," defined in the report as " ...critical tasks associated with core capability were completed in a manner that achieved the objectives ...Performance ...did not contribute to additional health and/or safety risks ..." Review of "Actions Taken" included " ...Patient made a 1:1; No injuries noted. Medically cleared ...(Family member) and Attending Provider notified. Debrief with staff performed ...Reviewed environmental code with Corporate Representative ...Fire Marshall called for consult to determine if door hinge can be located on the other side to strengthen door ...Onsite assessment completed. Unable to turn the hinge around ...Discussed with corporate and Fire Marshall another type of door ...May change door; however, if construction is needed (Facility) will need to have approval from the inspection department."

Review of a facility video recording on 09/17/2020 revealed on 08/25/2020 at 18:18:02 an individual identified by staff as Patient #7 stood in the hallway of the adolescent male unit (AMU). In the camera's view neither the nursing station door nor the unit exit door into the lobby were visible. Review revealed Patient #7, while being monitored by staff, ran in and out of camera view toward the far end of the hall and ran back toward the unit exit door multiple times. Review revealed at 18:26:22 staff moved quickly toward the nurse's station door area and Patient #7 was observed inside the nurse's station at 18:26:24. Review revealed Patient #7 was on the counter top at 18:26:25, and jumped into the empty lobby at 18:26:26. He briefly walked within the lobby and kicked the wooden exit door to the exit hall open at 18:26:30. Patient #7 was seen on the exit hall camera at 18:26:31, he kicked a glass exit door twice at 18:26:32-33 broke the glass and exited the building through the door at 18:26:34 and out of video range as staff continued to pursue. Total time from Patient #7's entry into the nurse's station until exit from the building was 12 seconds.

Interview request for RN #28 the staff nurse for the adolescent male unit on 08/25/2020 revealed she was not available.

Interview on 09/16/2020 at 1313 with a social worker, LCSW #3, revealed she had been assigned to Patient #7 on 08/31/2020. Interview revealed Patient #7 had a long history of psychiatric hospitalizations and the original plan was to transfer Patient #7 to a PRTF (psychiatric residential treatment facility) after stabilization. Interview revealed facilities refused admission because of the 08/25/2020 attempted elopement. LCSW #3 revealed Patient #7 had indicated he "was tired of being in facilities and was going to take things in his own hands," and she was currently working on his admission to a state behavioral health facility.

1.b. Record review revealed Patient #7 changed from 7-minute observations to 15-minute observations on 09/11/2020 at 1400 and remained on 15-minute observations until 09/14/2020 at the time of elopement. Review of a "Nursing Progress Note" dated 09/14/2020 at 2215 by RN #4 revealed "Pt began getting upset (after) dinner and told MHT he was not staying here anymore. MHT attempted to verbally de-escalate ...When MHT went into the nursing station, Pt got through the door. He jumped over the nursing station desk and then was able to bust through the two outer doors and eloped ..." Review of the "Patient Observation" check sheets for 09/14/2020 revealed at 1915 Patient #7's location was listed as "19 -Other" (not defined) with a comment "Broke Out." Review of a "Nursing Progress Note" dated 09/15/2020 at 0540 revealed "(2335) Pt returned to the facility post elopement via (Named police department) ..." Review of orders revealed Patient #7 was placed on 7-minute observation at return to the facility. Review of a "Therapist Progress Note" dated 09/15/2020 at 1714 revealed, "Clinician informed team of the events of the previous night including pt (patient) elopement ..." Review revealed a "Master Treatment Plan" update, dated 09/15/2020 at 1500, which indicated anticipated discharge to a "state hospital." Review revealed no elopement prevention measures, or an elopement concern were recorded on the updated "Master Treatment Plan."

Review of internal records revealed a "Code Pink After-Action Report/Improvement Plan" completed for incident 09/14/2020 (not dated, not timed). Review revealed "Core Capability" indicated as within expectations. Review of the document's "Corrective Actions" revealed "9.14.2020 Notifications made ...Debrief and Staff education ...Door monitor at (Building-A) ...9.15.2020 Door monitor at (Building-B) ...Debrief with Clinician and Patient Advocate ...Reinforced ...door stryker (sic) plates ...(Patient #11) was moved to (Building-B) ...and 1:1 initiated ..." Review revealed no specific documentation related to Patient #7 and his ability to access the nurse's station to elope and this time with another patient.

Review of a facility video recording on 09/17/2020 revealed on 09/14/2020 at 19:07:00, Patient #7, four peers and a staff member visible near the nurse's station. At 19:08:53 Patient #7 rushed toward the unit exit door, returned, and at 19:08:59 moved toward the entry door to the nurse's station. Review revealed Patient #7 within the nursing station at 19:09:07 as facility staff attempted to redirect him back to the adolescent male unit. At 19:09:11, Patient #11 was observed in the nurse's station moving toward the adolescent female (AFU) unit as staff confront Patient #7. Review revealed, at 19:09:36 the exit door on the AFU into the lobby area outside the nurse's station opened and Patient #11 and two female patients, entered the lobby area and departed through a broken exit door into the building's exit hallway. At 19:10:06, Patient #7 jumped over the nurse's station counter and departed through the broken exit door at 19:10:08. Review revealed, at 19:10:10 Patient #7 pushed open a broken exit door as facility staff confronted other eloping patients in the background and exited the building out of camera view. The total time from Patient #7's entry into the nursing station until exit from the building was 63 seconds.

Interview request for RN #27 the shift supervisor on the evening of 09/14/2020 revealed the supervisor was not available.

Interview on 09/18/2020 at 1520 with LPN #14 revealed, she worked with the adolescent female unit patients on 09/14/2020 when there was an elopement. LPN #14 revealed " ...It felt like forever, but it was maybe 20-30 seconds." LPN #14 revealed after the doors were forced open by a male patient, " ...Two girls went out after him ..." LPN #14 revealed she remained on the adolescent female unit "They were not trying to get out, but were just afraid ...It took them a while to calm ..."

Telephone interview on 09/16/2020 at 1425 with RN #4 revealed she worked on the adolescent male unit and had worked in Building-A on 09/14/2020 when three patients eloped. RN #4 indicated she had worked with Patient #7 on three occasions, Patient #7 had seemed anxious on 09/14/2020, and MHT #10 planned to take him in the yard for some exercise. Interview revealed Patient #7 had been banging on the unit exit door and as the MHT went into the nurse's "station to get help ...(Patient #7) ran by him ... then as I was trying to close the door (Patient #11) pushed by into the nursing station and ran into the girl's hall, turned left and kicked the door open." Interview revealed "It happened very quickly. "

Interview on 09/18/2020 at 1440 with MHT #10 revealed, he had "just arrived" for his shift on 9/14/2020
and noticed "a little bit of a commotion near the nursing station." Interview revealed he checked in with
the unit nurse and shortly after he entered the unit "(Patient #7) "went on a tear. I tried to hold him back, it was just me at the moment. I couldn't really use a proper hold, so I was trying to block him," and "Not sure how the other patient got through, but he ran to the girl's side and broke the door. Got a couple of girls out." Interview revealed "I was holding (Patient #7) but I was no longer safe to continuing to hold so I let go and he jumped the nursing station." Interview revealed after the elopement, MHT #10 remained on the male unit to get the remaining patients into the day room and "make sure they were safe."

1.c. Medical record review on 09/18/2020 revealed Patient #7 was involved in other incident of patients breaching the nurse's station on 09/17/2020." Review of a "PROGRESS NOTE" by MD #1 dated 09/17/2020 at 2000 revealed "pt became aggressive toward another patient ...after this the Pt broke through the nurse's station and entered the other side of the unit. MHT's responding to the Code White (paged request for staff assistance) were able to de-escalate him ..." Medical record review and requests for medical records on 09/18/2020 revealed no observation sheets or documentation in Patient #7's chart for a second event reported by staff as occurring two hours later, on the evening of 09/17/2020.

Review of a facility video recording on 09/18/2020 revealed Patient #7, and a staff member visible in the hall near the adolescent male unit exit on 09/17/2020 at 22:00:02. At 22:00:44 as staff within the nursing station reacted, a large piece of safety glass on the adolescent male unit side, fell out of its' window frame and onto equipment in the nursing station. Review revealed, at 22:01:16 as staff picked up fallen papers and equipment, Patient #7 came head first through the window area, and at 22:01:30 Patient #7 exited the nurse's station and entered the adolescent female unit. Patient #7 attempted to kick open the exit door from the adolescent female unit into the lobby, re-entered the nurse's station at 22:02:06 and at 22:02:08, jumped onto the nurse's station counter and moved toward the lobby area. Review revealed two staff who stood in the lobby at the counter blocked Patient #7's attempt to enter the lobby. As staff continued to deal with Patient #7, two peers entered the nursing station, and attempted to strike Patient #7 and RN #30. At 22:04:09, a law enforcement officer (LEO) climbed over the nurse's station counter and staff members and the LEO de-escalated both patients. The LEO returned to Patient #7 at 22:05:36 and appeared to apply something which was not clearly visible to Patient #7's wrists. Review revealed, as Patient #7's wrists were behind his back he was observed in a chair as he talked and smiled at a male patient who sat beside him. Review revealed. the second male patient was no longer observed within the nursing station and at 22:11:00 the LEO jumped back over the counter and exited the unit. Patient #7 and the visible patient continued to sit on the chairs and their hands were now in front of them. Total time from Patient #7's first entry into the nursing station through the window until Patient #7 sat in a chair without resisting was four minutes and six seconds. Request for the video record of the incident earlier in the evening on 09/17/2020 revealed it was not available for review.

Interview request for RN #30, one of two nurses who worked on the evening of 09/17/2020 revealed the RN was not available.

Interview on 09/18/2020 at 1825 with RN #15 revealed, he had been floated to Building-A's adolescent male unit on 09/17/2020. Interview revealed the other nurse on duty, RN #30, oversaw the adolescent female unit and was in the nursing station when "(Patient #7) pushed through the plexiglass at the nurse's station." RN #15 indicated the plexiglass did not break "but fell out and fell on (RN #30) then (Patient #7) quickly got up and went into the girls unit and kicked the door (exit door from the unit into the lobby) ..." Interview revealed the door did not open and Patient #7 returned through the door into the nursing station with the help of "two young girls." Interview revealed Patient #7 attempted to jump over the nursing station but was prevented by MHT #13. RN #15 indicated he had completed an incident report with the female patients' initials in it but did not know where the report was. Interview with RN #15 revealed two male peers had also entered the nursing station and attempted to hit both Patient #7 and RN #30. Further interview revealed after Patient #7 had been prevented from "bolting over" the nursing station, Patient #7 and one of the two male patients remained in the nursing station monitored by two staff.

Telephone interview on 09/19/2020 at 1247 with MHT #13 revealed he worked on the adolescent male unit side on 09/17/2020 when the first of two incidents occurred. Interview revealed he worked as the unit MHT and another MHT worked as a "one-to-one" for Patient #7. Interview revealed Patient #7 wanted to get to the adolescent female unit to attack a male patient programming on the adolescent female unit side after a fight earlier in the day. Interview revealed Patient #7 talked about getting into the nurse's station and wanted to kick the door in but MHT #13 stood front of the nurse's station door and the one-to-one MHT stood in front of the door leading to the lobby. Interview revealed Patient #7 instead banged on the plexiglass window and pushed it out of the frame into the nurse's station. Interview revealed Patient #7 then jumped through the hole left in the window frame. Interview revealed Patient #7 stood on top of the nurse's station after the MHT's tried to prevent him from getting inside, and as the MHT's dealt with that, two male patients kicked open the nurse's station door and entered. Interview revealed the two male patients were more followers than instigators. Interview revealed one of the male patients opened the door into the female unit, but the females stayed on their unit. Interview revealed MHT #13 considered it an elopement attempt, but no patients got out of the building. Interview revealed at least one of the patients hit a nurse. MHT #13 stated he thought Patient #7 " ...had tried to get (Patient #9) to escape with him but she never went with him."

Telephone interview on 09/19/2020 at 1322 with MHT #18 revealed he worked in Building-A on 09/17/2020. Interview revealed he was assigned to "watch the door. "Interview revealed during the first incident, Patient #7, and a peer kicked in the nurse's station door and Patient #7 ran onto the adolescent female unit. Interview revealed MHT # 18 left his post at the door to intervene between Patient #7 and a male patient programming on the adolescent female unit. Interview revealed when additional staff came, MHT #18 went back to his post. Interview revealed the second incident occurred around 2200-2215 when Patient #7 banged repeatedly on the plexiglass at the Nurse's Station and the plexiglass fell out of its' frame. Interview revealed a nurse in the station, RN #30, tried to catch the plexiglass. MHT #18 observed as Patient #7 slid over the desk and into the nurse's station. Interview revealed once Patient #7 went into the nurse's station through the window, two females started banging on the unit exit door and MHT #18 held the door closed. Interview revealed another patient on the adolescent male unit kicked the nurse's station door in again and he and a third male patient entered the nurse's station. MHT #18 saw Patient #7 in the station pick up computer monitors, and other objects to throw at the nurse, and the nurse was saying "stop, stop, stop" to all the patients. Interview revealed, eventually two staff members got Patient #7 to stop, and once Patient #7 stopped, the other patients stopped.

During discussion on 09/18/2020 at 1600 with the CEO, CNO and DRM they were asked if leadership was aware of incidents after 09/15/2020, and the CEO indicated she would "look into it." Follow up interview with the CEO on 09/19/2020 at 1730 revealed the CNO (Administrator on Call) had been called after the second incident on 09/17/2020, and "did not get the message."

2. Open medical record review on 09/18/2020 revealed Patient #11, a 14-year-old male involuntarily committed to the hospital on 09/11/2020 after fighting with and threatening to kill a family member. Review of the "PSYCHIATRIC EVALUATION and History and Physical", dated 09/12/2020 at 0900, revealed " ...HISTORY OF PRESENT ILLNESS ...worsening behavioral and emotional difficulties. Has had mood swings, depressed, suicidal thoughts, obsessive worries about death, worries he is going to die ..." ADMITTING DIAGNOSES ...DMDD, IED (intermittent explosive disorder), sibling conflict ..." Review of the medical record revealed five restraint interventions which required medication, physical hold, or seclusion between 09/14/2020 at 1600 and 09/16/2020 at 2100. Review of the medical record revealed a "Restraint/Seclusion Order/Record" by RN # 22 dated 09/14/2020 at 1908, "Pt (patient) broke through a door and attempted to elope ..." and in an update at 2040 "Pt had elopement plan w/ (with) a peer ...Pt part of group that planned elopement-Agitated he did not elope ..." Review of a "Nursing Progress Note" dated 09/14/2020 at 2200 by RN #4 revealed, " ...Around 1830, he broke through the nursing station and then kicked a door to the girl's unit to try to elope. He and another male peer managed to break through the outer doors and get out of the building. An MHT intervened and brought the patient back inside ...taken ...into seclusion room ..." Review of the medical record revealed Patient #11 was moved from Building-A to Building-B on 09/16/2020 and was placed on 1 to 1 observation. Review of an "Inpatient Physician Note" dated 09/16/2020 at 1245 by MD #21 revealed, " ...Pt is noted to be extremely angry ...admits to engaging in destructive behaviors on (Building-A) unit. Insight and judgement are very poor ..." Review of a "Nursing Progress Note dated 09/16/2020 at 2100 revealed "Pt got agitated ...broke threw (sic) the exit door attempting to get out of the front door ..." Review of a "Restraint/Seclusion Order/Record" by LPN #14 dated 09/16/2020 at 2045 revealed, "Pt had rallied peers to help him break out. Pt broke lock out of door by kicking it and got into outside of nursing station. Pt punched RN in face and tried to leave ...Staff braced doors to keep pts on unit." Review of the facility census revealed Patient #11 remained on the adolescent male unit in Building-B as of 09/19/2020.

Review of internal records revealed "Code Pink After-Action Report/Improvement Plan" completed for incident 09/14/2020. Review revealed "Corrective Actions ...(Patient #11) was moved to (Building-B) ...and 1:1 initiated ..."
Review of a facility video recording on 09/17/2020 revealed on 09/14/2020 at 19:09:11, a patient identified by staff as Patient #11, in the nursing station headed in the direction of the adolescent female unit. At 19:09:36 the exit door on the adolescent female unit into the lobby outside the nurse's station opened and Patient #11 and two female patients entered the lobby area. Review revealed, Patient #11 kicked open the wooden exit door and the three patients departed through the door into the exit hallway. Review revealed, at 19:10:05 Patient #11 pushed open the locked exit metal/glass door and exited Building-A followed by two adolescent female patients. Further review revealed as staff attended to other eloping patients, a male staff member returned with Patient #11 in a hold and entered the hallway at 19:10:30.

Telephone interview on 09/16/2020 at 1425 with RN #4 revealed she worked on the adolescent male unit and had worked in Building-A on 09/14/2020 when three patients eloped. RN #4 indicated a male patient banged on the unit exit door and as the MHT went into the nurse's "station to get help ...(Patient #7) ran by him ... then as I was trying to close the door (Patient #11) pushed by into the nursing station and ran into the girl's hall, turned left and kicked the door open." Interview revealed "It happened very quickly."

During discussion on 09/18/2020 at 1600 with the CEO, CNO and DRM they were asked if leadership was aware of incidents after 09/15/2020, and the CEO indicated she would "look into it." Follow up interview with the CEO on 09/19/2020 at 1730 revealed the CNO had been called after the second incident on 09/17/2020, and "did not get the message."

3. Open medical record review on 09/17/2020 through 09/19/2020 revealed Patient #9, a 13-year-old female, admitted on 09/09/2020 at 1610. Review of the "INITIAL NURSING ASSESSMENT AND ADMISSION DATA" note dated 09/09/2020 at 1830 revealed "...13 y.o. (year old) female admitted IVC...Admitted for SI (suicidal ideations) threats and HI (homicidal ideations) towards others....Pt runs away from home often and has had traumatic experiences (with) friend's death and (family member). ..." Review of Orders revealed Patient #9 was placed on every 7-minute observation on 09/09/2020 at 2000 which continued until 09/12/2020 at 1214. The "PSYCHIATRIC EVALUATION and History and Physical", dictated 09/10/2020, revealed " ...HISTORY OF PRESENT ILLNESS ....acting out, suicidal, put a knife to her arm and threatened to kill (family member). She seems to engage in gang activities outside...She runs away....ADMITTING DIAGNOSES ....PTSD (Post traumatic stress disorder), DMDD, major depression moderate ... ." Review of the "PSYCHOSOCIAL ASSESSMENT, dated 09/11/2020 at 1235, revealed Patient #9 presented under involuntary commitment (IVC). Review of an "Inpatient Physician Note: dated 09/13/2020 at 1830, revealed "...had an episode of anger (and) agitation requiring prn (as needed) meds. Case discussed (with) staff. Needs to work on boundaries...anger mgt (management)....refrain from impulsive... ."

Review of Physician Orders, dated 09/12/2020 at 1200, revealed observation was changed from every 7 minutes to every 15 minutes. Review of "NURSING PROGRESS NOTES" dated 09/14/2020 at 1912, revealed "Patient from 10 bedside (adolescent male unit) attempted to elope by breaking open door on 12 bedside (adolescent female unit) ....eloped thru open door and exited building threw (sic) broken front door...." Review of "NURSING PROGRESS NOTES" dated 09/15/2020 at 0517, indicated "Pt returned to facility post-elopement @ (at) 2345 9/14/20 via (City Police Department)...Per MD pt on a level 2 (7-minute observations, unit restrictions, elopement precautions & to wear scrubs..." On 09/16/2020 at 0821, an "Inpatient Physician Note" documented "...She (Patient #9) continues to act fairly aggressive with tapping doors, etc. ..." Documentation dated 09/16/2020 at 1809 "Restraint/Seclusion Order/Record" documentation noted a physical restraint at 1805 followed by a medication restraint at 1807 for behaviors of "Defiance, Agitation, Threatening Staff, Verbal aggression toward peers, kicking door, kicking staff. ..." At 2300, "NURSING PROGRESS NOTES" documentation noted "After dinner pt began verbally aggressive comments towards peers and staff. Pt was becoming increasingly agitated and was informed that medication was needed to help minimize agitation. Pt... began cursing & threatening staff. Staff attempted to guide pt to a private place for medication and pt became aggressive, kicking and threatening staff. Pt kicked door to lobby open and physical hold required. ..." Restraint and seclusion documentation, dated 09/17/2020, noted a physical restraint at 1245, seclusion initiated at 1249, and medication administered at 1256 for " ...verbal altercation with peer...kicking door until it opened. Staff escorted her back on unit...". Review revealed the criteria for release were noted as "...stop aggressive and combative behavior. ..."

The "NURSING PROGRESS NOTES" at 1500 on 09/17/2020 stated "...She tried to get to (sic) peer to 'fight', staff redirected. She went to door saying, 'I'm getting to ....out of here' and she started kicking the door. Door came open staff escorted her

Based on policy and proceudre review, medical record reviews and staff interviews, facility staff failed to document an update to patients' Master Treatment Plans at least weekly to ensure patient problems and progress were reviewed and updated timely for 2 of 12 patients reviewed (#6 and #7).

The findings include:

Review of the "Treatment Planning" policy, revised 02/2019, revealed "...POLICY....strives to provide therapeutic services to patients in a planned, coordinated, multi-disciplinary manner .... PROCEDURE....3. Treatment Plan Updates: a. The master treatment plan is reviewed weekly by the multi-disciplinary treatment team utilizing the Master treatment plan Update form. b. Each individual problem and the patient's progress are reviewed and documented. Problems and goals may be added during this time. c. Each member of the team should document treatment, patient progress and sign the Master treatment plan Update form. ..."

1. Medical record review for Patient #6 revealed a 14-year old admitted 08/10/2020 with admitting diagnoses of DMDD (Disruptive mood dysregulation disorder, childhood mental health disorder with severe irritability, anger, outbursts) and Borderline personality traits (mental health disorder with unstable moods, behavior, relationships). Record review revealed an Initial Nursing Treatment plan was started on 08/10/2020 and the Master Treatment Plan was initiated on 08/13/2020. The initial problem identified was noted as Depression and a "DEPRESSION INDIVIDUAL TREATMENT PLAN" sheet was initiated at that time. On 08/17/2020 at "Specific Intervention Focus" of "...will assist patient )with) demonstrating 2 positive techniques to decrease SI (suicidal) threats and urges to self-harm" with another focus note on 08/18/2020 that stated "Med (medication) education and compliance". Record review revealed an update to the Master Treatment Plan, signed 09/15/2020 (28 days after the last entry on the initial Master Treatment Plan). Review failed to reveal weekly updates to the Master treatment plan to ensure problems and progress were reviewed.

Interview on 09/18/2020 at 1215 with LCSW #3 (licensed clinical social worker), revealed Master treatment plans should be updated every six to seven days for timely review. Interview revealed if treatment planning updates were not documented weekly policy was not followed. Interview revealed a therapist had left the facility and during the transition there could have been some delay.



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2. Medical record review for Patient #7 revealed a 17-year old male admitted 08/16/2020 after a suicide attempt and admitting diagnoses of Schizophrenia Bipolar type (rapidly changing mood changes with extreme highs and extreme lows), DMDD (disruptive mood dysregulation disorder-extreme anger, frequent, intense temper outbursts with severe impairment) ..." Record review revealed an Initial Nursing Treatment plan was started on 08/16/2020 at 2242 and the Master Treatment Plan was initiated on 08/17/2020 at 1247. The initial problem identified was noted as Depression with the initial problem identified as Depression and a "DEPRESSION INDIVIDUAL TREATMENT PLAN" sheet was initiated at that time. On 08/17/2020 a "Specific Intervention Focus" indicated involvement by a physician planned to initiate "Geodon," a unit clinician, LCSW " ...will educate pt on emotion regulation skills to improve coping...," nursing " ...will educate pt on medications and provide medication as ordered," and on 08/21/2020, recreation therapy " ...will assist pt (patient ) in practicing 2 coping skills to manage intense emotions." Record review revealed an update to the Master Treatment Plan dated 09/17/2020 (26 days after the last entry on the Master Treatment Plan). Review revealed absence of weekly updates to the Master treatment plan to ensure problems and progress were reviewed.

Interview on 09/18/2020 at 1215 with LCSW #3, revealed Master treatment plans should be updated every six to seven days for timely review. Interview revealed if treatment planning updates were not documented weekly policy was not followed. Interview revealed a therapist had left the facility and during the transition there could have been some delay.

NC00166793
NC00167927
NC00168160