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Based on observation, record review and interview, the hospital failed to ensure patients received care in a safe setting for 1 (Patient #3) of 3 patients whose records were reviewed as evidenced by having large industrial staples in the walls of both seclusion rooms. As a result, Patient #3 obtained a staple from the seclusion room and self-injured herself with the staple.
Findings:

On 03/04/2024 at 10:20 a.m., observation of the seclusion room on the boys dorm revealed blue padded cushions on the walls and the floors. Further observations revealed the wall cushions were stapled to the wall with large industrial sized staples. The staples were approximately five feet up the wall and were easily accessible.

On 03/04/2024 at 10:55 a.m., observation of the seclusion room on the girls dorm revealed blue padded cushions on the walls and the floors. Further observations revealed the wall cushions were stapled to the wall with large industrial sized staples. The staples were approximately five feet up the wall and were easily accessible.

Review of the current medical record for Patient #3 revealed the 10 year old had an admission date of 10/27/23 with diagnoses including bipolar disorder. Review of the physician orders revealed the patient was frequently on room restrictions and in the seclusion room due to behaviors.

Review of the patient's nurses notes dated 02/28/2024 at 4:15 p.m. revealed that the patient had stuck an industrial sized staple that she found in the "blue room" (seclusion room) into the top of her left foot. The note further stated that the nurse pulled the staple out of the patient's foot.

Review of the NP progress note dated 02/29/2024 (no time) revealed "s/p incident with staple". The note further revealed a raised pustule to the left foot with a diagnosis of "wound to the left foot". Antibiotic ointment was ordered.

Review of the 2024 incident reports and LDH self reports provided by S1Compliance revealed none that addressed the staple incident with Patient #3.

On 03/05/2024 at 11:00 a.m., interview with S1Compliance confirmed there was no incident report or LDH self-report completed when Patient #3 obtained an industrial sized staple fromt the seclusion room and self-injured herself. When asked if S1Compliance was aware of the staple incident with Patient #3, he stated yes. When asked if there was any investigation or corrective action put into place after this incident to prevent further injuries, he stated no.

Based on observation, record review and interview, the hospital failed to track and analyze medical errors and adverse patient events. This deficient practice is evidenced by failure to complete incident reports and implement corrective actions 1) for a documented medication error (Patient #1) and 2) a patient injury involving safety (Patient #3) for 2 of 3 patients whose records were reviewed.
Findings:

Patient #1
Review of the medical record revealed an admission date of 01/08/2024 with diagnoses including ODD, anxiety and autism. The patient was discharged home on 01/16/2024.

Review of the nurses notes dated 01/16/2024 at 8:35 a.m. revealed the patient informed the nurse that he took another patient's medication last night. Patient #1 states he told the night nurse that he was another patient when asked during medication pass.

Review of the patient's January 2024 MAR with S1Complaince and S2DON revealed all night medications for 01/15/2024 were circled, indicating not given. Further review of documentation on the MAR revealed that Olanzapine and Fluoxetine was held because patient took another patient's Amitriptyline and Singulair "by mistake".

On 03/05/02024 at 11:30 a.m., S1Compliance and S2DON were asked if they were aware that Patient #1 was involved in a medication error on 01/16/2024 and they stated no. When asked if there was an incident report or medication variance completed and an investigation conducted in order to implement preventive actions, they stated no.


Patient #3
On 03/04/2024 at 10:20 a.m., observation of the seclusion room on the boys dorm revealed blue padded cushions on the walls and the floors. Further observations revealed the wall cushions were stapled to the wall with large industrial sized staples. The staples were approximately five feet up the wall and were easily accessible.

On 03/04/2024 at 10:55 a.m., observation of the seclusion room on the girls dorm revealed blue padded cushions on the walls and the floors. Further observations revealed the wall cushions were stapled to the wall with large industrial sized staples. The staples were approximately five feet up the wall and were easily accessible.

Review of the current medical record for Patient #3 revealed the 10 year old had an admission date of 10/27/23 with diagnoses including bipolar disorder. Review of the physician orders revealed the patient was frequently on room restrictions and in the seclusion room due to behaviors.

Review of the patient's nurses notes dated 02/28/2024 at 4:15 p.m. revealed that the patient had stuck an industrial sized staple that she found in the "blue room" (seclusion room) into the top of her left foot. The note further stated that the nurse pulled the staple out of the patient's foot.

Review of the NP progress note dated 02/29/2024 (no time) revealed "s/p incident with staple". The note further revealed a raised pustule to the left foot with a diagnosis of "wound to the left foot". Antibiotic ointment was ordered.

Review of the 2024 incident reports and LDH self reports provided by S1Compliance revealed none that addressed the staple incident with Patient #3.

On 03/05/2024 at 11:00 a.m., interview with S1Compliance confirmed there was no incident report or LDH self-report completed when Patient #3 obtained an industrial sized staple fromt the seclusion room and self-injured herself. When asked if S1Compliance was aware of the staple incident with Patient #3, he stated yes. When asked if there was any investigation or corrective action put into place after this incident to prevent further injuries, he stated no

Based on record review and interview, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient as evidenced by failing to assess for bowel movements for 3 of 3 patient medical records reviewed (Patient #1, 2, 3).
Findings:

Patient #1
Review of the medical record revealed the patient was admitted to the hospital on 01/08/2024 and discharged on 01/16/2024. Further review of the record revealed the patient was on multiple psychoactive medications.

Review of the patient's nurses notes for the entire admission revealed no evidence that bowel movements were assessed and documented.

Patient #2
Review of the medical record revealed the patient was admitted to the hospital on 01/25/2024 and discharged on 02/07/2024. Further review of the record revealed the patient was on multiple psychoactive medications.

Review of the patient's nurses notes for the entire admission revealed no evidence that bowel movements were assessed and documented.

Patient #3
Review of the medical record revealed the patient was admitted to the hospital on 10/27/202 and was a current patient in the hospital. Further review of the record revealed the patient was on multiple psychoactive medications.

Review of the patient's nurses notes from admit until present (over 4 months) revealed the patient's bowel movements were assessed and documented only 5 times.

On 03/05/2024 at 9:45 a.m., interview with S4RN revealed that the nurses should be assessing for bowel movements on all patients daily. S4RN stated there is no check off box on the daily shift assessment form, so assessments of bowel movements must be documented in the nurses notes daily.

On 03/05/2024 at 11:40 a.m., interview with S2DON confirmed that the nurses should be assessing all patients for bowel movements daily. When asked if psychoactive medications cause constipation, S2DON stated yes.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients.
Findings:

On 03/04/2024 at 10:00 a.m., tour of the boys dorm building with S1Compliance revealed the following observations:
- Room a had loose and missing floor tiles in the bathroom. When the button was pressed on the sink for water, the water sprayed over the sink and onto the floor.
- Room b had loose and missing floor tiles in the bathroom.
- Room d had the only window in the room boarded up with wood. There was missing floor tile in the bathroom. The bathroom light did not work.
- Rooms e and f had missing floor tiles in the bathrooms.
- Room g had a screw missing from the light switch cover. The cover was loose and the light in the room flickered when the cover was moved.
- The seclusion room had blue padded cushions on the walls and the floors. The wall cushions were stapled to the wall with large industrial sized staples. The staples were approximately five feet up the wall and were easily accessible to patients.
- Room s had water spraying over the sink onto the floor when the water was turned on at the bathroom sink.
- Room h had missing floor tiles in the bathroom. When the water was turned on, the water sprayed over the sink onto the back wall in the bathroom.

On 03/04/2024 at 10:30 a.m., tour of the boys dorm building with S1Compliance revealed the following observations:
- Room i had water spraying over the sink onto the back wall when the water was turned on at the bathroom sink.
- Room l had a commode that did not flush.
- Rooms m and n had missing floor tiles in the bathrooms.
- The seclusion room had blue padded cushions on the walls and the floors. The wall cushions were stapled to the wall with large industrial sized staples. The staples were approximately five feet up the wall and were easily accessible to patients.

At that time, interview with S1Complaince revealed that the dorms were in need of maintenance.

On 03/05/2024 at 1:15 p.m., observation of Room e revealed a piece of bread was stuck between the plexiglass and the window. At that time, S1Compliance pushed on the plexiglass and it buckled, causing an open area (approximately 2-3 inches) at the top of the window.

Based on observation and interview, the hospital failed to develop and implement an effective system in controlling infections and communicable diseases of patients as evidenced by failing to maintain an sanitary environment.
Findings:

On 03/04/2024 at 10:00 a.m., tour of the boys dorm building with S1Compliance revealed the following observations:
- The shower room (short hall) had multiple old dirty towels in the shower stalls and on the floor. Mildew was observed in the shower stalls. Old toilet paper balls were all over the ceiling. The storage cabinet that held small containers of personal hygiene supplies (uncovered toothbrushes, uncapped toothpaste) for the patients had several pairs of dirty underwear, socks and trash and debris in the bottom of the cabinet.
- Room a had trash and debris all over the floor. There was a large build up of grime in all corners of the floor. There was a horrible odor in the bathroom.
- Room b had a mattress on the bed that had the inside foam exposed. The cabinets had thick build up of dirt and grime and trash. The faucet in the bathroom had no working water.
- Room c had build up of grime and debris and trash in the closets.
- Room d had no working water at the bathroom faucet.
- Rooms e and f had no working water at the bathroom faucet.
- The seclusion room had a thick powdery substance on the floor. Two tears in the floor mat vinyl was observed. There was a white dried smeared substance on the floor mat.
- The shower room (long hall) had a dead roach in the shower stall. The other stall had multiple old wet towels in the floor. Mold was observed on the ceiling in multiple spots.
- Room g had no working water at the faucet. Thick build up of dirt and grime was observed in all corners of the room. Two pillows were on the floor. The pillows had multiple tears in them exposing the inside foam.
- Room h had multiple tears in the mattress, exposing the inside foam.

On 03/04/2024 at 10:30 a.m., tour of the girls dorm building with S1Compliance revealed the following observations:
- Room i had multiple tears in the mattress, which makes it unable to be adequately disinfected.
- Room j had a build up of dirt and grime in all corners of the room. At this time, interview with the patient in the room revealed that the water did not work at the bathroom faucet.
- Room k had no running water at the bathroom faucet.
- Room l had a pillow on the bed with multiple tears in the outside covering. There was no running water at the sink. The air vents were covered in a thick build up of dust.
- Room m had a tear in the mattress with the insides exposed. The air vents were covered in a thick build up of dust.
- Room n had multiple tears in the mattress. There was no running water at the bathroom faucet.
- The seclusion room had old dried substances on the floor.
- Room o had a torn mattress.
- Rooms p, q and r had no running water at the bathroom faucet.

At this time, S1Complaince confirmed all above observations.

On 03/05/2024 at 1:15 p.m., S1Compliance stated that there were issues with water pressure on 03/04/2024 and all sinks should have running water now. At this time, the surveyor checked the water in random rooms and rooms e, l, j, k, q and r still had no running water at the bathroom faucets.