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Based on record review, staff and patient interviews and facility Policy and Procedure review, it was determined that the facility failed to:

I. Ensure that for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6 and A7), the Master Treatment Plans (MTPs) had individualized goals and interventions. The MTP goals for these patients were preprinted for each problem, and physician and nursing interventions were generic discipline functions that that lacked any focus for treatment. Registered Nurses (RNs) did not attend treatment team meetings. In addition, the goals and interventions on the plans were not modified as treatment progressed. These deficient practices result in lack of a dynamic, working plan that can be understood and implemented by the treatment team. (Refer to B118)

II. Ensure that for 5 of 8 sample patients (A2, A3, A4, A7 and A8), physician orders gave specific directions for the administration of medications. For these patients, physician orders were written on a "PRN" (as necessary) basis with a choice of delivery methods. Nurses could choose to administer the medications by intramuscular injection ("IM") or by mouth ("PO"), which could negatively affect the dosage the patients received. In addition, according to the written physician orders, a nurse could administer the medications for "agitation or psychosis." Ambiguous physician orders have the potential for serious complications from improperly administered PRN medications. In addition, such physician orders allow nursing staff to function outside of their scope of practice. (Refer to B125-I)

III. Ensure that restrictive measures called "therapeutic holds" on the Child and Adolescent Units were carried out with appropriate protocols. The hospital-wide practice of "therapeutic holds" is was not regarded as a restrictive measure that requires a protocol for physical restraint, such as a physician's order, a physician's assessment within 1 hour, or any documentation in the clinical record. Failure to treat "therapeutic holds" as restrictive measures results in no documentation of the event, and no physician notification or timely physician assessment of the clinical state of the patient. The absence of this clinically relevant information also results in failure to revise the patient's treatment plan. (Refer to B125-II)

Based on record review and staff interview, it was determined that for 8 of 8 sample patients (A1, A2, A3, A4, A5, A6, A7 and A8), the Psychosocial Assessments did not specify the anticipated role for social services staff in treatment and discharge planning. This failure results in an absence of any information about what efforts will be pursued by the social work staff for patients.

Findings include:

A. Record Review

1. Patient A1: The Psychosocial Assessment dated 12/10/2010 did not record the role of the social service staff in treatment or discharge planning.

2. Patient A2: The Psychosocial Assessment dated 11/26/2010 did not record the role of the social service staff in treatment or discharge planning.

3. Patient A3: The Psychosocial Assessment dated 12/07/2010 did not record the role of the social service staff in treatment or discharge planning.

4. Patient A4: The Psychosocial Assessment dated 11/18/2010 did not record the role of the social service staff in treatment or discharge planning.

5. Patient A5: The Psychosocial Assessment dated 12/04/2010 did not record the role of the social service staff in treatment or discharge planning.

6. Patient A6: The Psychosocial Assessment dated 12/10/2010 did not record the role of the social service staff in treatment or discharge planning.

7. Patient A7: The Psychosocial Assessment dated 12/11/2010 did not record the role of the social service staff in treatment or discharge planning.

8. Patient A8: The Psychosocial Assessment dated 12/10/2010 did not record the role of the social service staff in treatment or discharge planning.

B. Staff Interview

In an interview on 12/14/2010 at 9:50AM, the Director of Social Work concurred that the role of the social work staff "...is not spelled out" for treatment or discharge planning.

Based on record review, patient interviews and staff interviews, the facility failed to ensure that cranial nerve testing during the physical examination was accurately reported for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). The facility used a preprinted form that listed the tests to be performed for cranial nerve testing. Documentations only included lines or checkmarks rather than specific patient findings. In addition, 4 of the 8 sample patients (A1, A2, A4 and A8) reported that the cranial nerve examinations had not occurred during physical examination. The physician who performed the examinations noted in the record that the tests were done. The lack of specific findings for patients and the discrepancy between physician reporting and patient experience makes it difficult to develop accurate diagnoses for patients. It also results in lack of baseline measures for future comparative purposes.

Findings include:

A. Record Review

1. The preprinted form for cranial nerve examination states that the following tests are utilized to determine the functioning status of the cranial nerves "I. Patient smells alcohol swab...II. Patient counts fingers, distinguishes movement in visual periphery...III. Upward gaze symmetrical...IV. Downward gaze symmetrical...V. 2-point touch discrimination of forehead, cheek and chin...VI. Lateral gaze symmetrical ...VII. Symmetrical movement of forehead, facial muscles...VIII, Hears finger snapping/rubbing equally both ears...IX Gag reflex intact...X. Initiation of guttural sound ...XI. Shrugs shoulders equally...XII. Protrudes tongue straight without tremor."

2. Review of the sample patient's medical records (see below) revealed that for all 8 sample patients, the physical examination records had either a straight line running vertically through the list of cranial nerves or a series of check marks indicating that the specific tests (noted above) were performed. There were no other reported findings for the patients.

1. Patient A1.The Physical Examination done 12/09/2010 had a straight line with no additional comments.

2. Patient A2.The Physical Examination done 11/25/2010 had a straight line with no additional comments.

3. Patient A3.The Physical Examination done 12/05/2010 had a series of check marks without comment.

4. Patient A4.The Physical Examination done 11/18/2010 had a straight line with no additional comments.

5. Patient A5.The Physical Examination done 12/03/2010 had a series of check marks without comments.

6. Patient A6.The Physical Examination done 12/102010 had a series of check marks without comment.

7. Patient A7.The Physical Examination done 12/10/2010 had a series of check marks without comment.

8. Patient A8.The Physical Examination done 12/10/2010 had a series of check marks without comment.

B. Patient Interviews

1. Patient A1.The patient was interviewed on 12/13/2010 at 1:00PM. When asked about the specific tests described in his Physical Exam for cranial nerve testing on 12/09/2010, he said they had not occurred.

2. Patient A2.The patient was interviewed on 12/13/2010 at 10:45AM. When asked about the specific tests described on his Physical Exam for cranial nerve testing on 11/25/2010, he said they had not occurred.

3. Patient A4. The patient was interviewed on 12/13/2010 at 2:05PM. When asked about the specific tests described in her Physical Exam for cranial nerve testing on 11/18/2010, she said they had not occurred.

4. Patient A8.The patient was interviewed on 12/13/2010 at 1:30PM. When asked about the specific tests described on her Physical Exam for cranial nerve testing on 12/10/2010, she said they had not occurred.

C. Physician Interviews

1. On 12/15/2010 at 9:15AM, the Clinical Director was presented with the findings discussed in Sections A and B above. He agreed that a summary line or series of check marks were not patient specific.

2. On 12/13/2010 at 1:00PM, the examining physician was interviewed on the Adolescent Unit. He expressed surprise that Patient A1, a 14 year old male, did not recall the details of his physical examination done on 12/09/2010.

Based on record review and staff interview, it was determined that for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8), the Psychiatric Evaluations either had no comment about memory functioning or did not contain detailed information to document the rationale for generalized statements made about memory functioning. This failure results in a lack of information to determine how the conclusions regarding memory functioning were reached. It also results in lack of specific data to use for future comparative assessments.

Findings include:

A. Record Review

1. Patient A1: The Psychiatric Evaluation dated 12/09/2010 stated "Memory is intact" without any supporting information.

2. Patient A2: The Psychiatric Evaluation dated 11/25/2010 had no comments regarding memory functioning.

3. Patient A3: The Psychiatric Evaluation dated 12/05/2010 stated "Memory is intact."

4. Patient A4: The Psychiatric Evaluation dated 11/18/2010 stated "Memory cognition intact, with some manipulation [sic]."

5. Patient A5: The Psychiatric Evaluation dated 12/03/2010 for recent memory stated "STM deficit;" for remote memory it stated "+" [blank] [sic].

6. Patient A6: The Psychiatric Evaluation dated 12/10/2010 stated "Memory is intact."

7. Patient A7: The Psychiatric Evaluation dated 12/09/2010 stated "Memory cognition intact."

8. Patient A8: The Psychiatric Evaluation dated 12/10/2010 stated "intact" for recent and remote memory.

B. Staff Interview

In an interview on 12/15/2010 at 9:15AM, the Clinical Director agreed that the findings above were insufficient data, and that such statements provided no data base which could be referenced in future assessments.

Based on record review, observation and staff interview, the facility failed to develop Master Treatment Plans with all elements critical to effective treatment planning and implementation for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). The treatment plans contained preprinted goals, and physician and nursing interventions were generic clinical responsibilities instead of being individualized for patients. Registered Nurses did not attend the treatment team meetings. In addition, the goals and interventions on the plans were not modified as treatment progressed. These deficient practices result in lack of a dynamic, working plan that can be understood and implemented by the treatment team.

Findings include:

A. Record Review

1. Patient A1. The Master Treatment dated 12/10/10 contained only preprinted goals for the problem "Aggression." An example was: "Patient will demonstrate one adaptive response to stress/anger which is leading to aggression and/or violence toward others." There were only generic, preprinted physician interventions: "Psychiatric Evaluation" and "Prescribe medications." Nursing interventions were generic tasks rather than individualized interventions. Examples were: "Assess patient's mood" and "Educate patient regarding name, dosage, schedule, purpose and side effects of medications." There were no modifications to the plan by any discipline.

2. Patient A2. The Master Treatment Plan dated 12/09/10 contained only preprinted goals for the problem "Aggression" An example was: "Patient will demonstrate one adaptive response to stress/anger which is leading to aggression and/or violence toward others." There were only generic, preprinted physician interventions: "Psychiatric Evaluation" and "Prescribe medications." Nursing interventions were generic tasks rather than individualized interventions. Examples were "Assess patient's mood" and "Educate patient regarding name, dosage, schedule, purpose and side effects of medications." There were no modifications to the plan by any discipline.

3. Patient A3. The Master Treatment Plan dated 12/06/10 contained only preprinted goals for the problem of "Depressed Mood." An example was "Patient will verbalize one adaptive response to stress/depression." There were only generic, preprinted physician interventions: "Psychiatric Evaluation" and "Prescribe medications." Nursing interventions also were generic tasks rather than individualized interventions. Examples were "Assess patient's mood" and "Educate patient regarding name, dosage, schedule, purpose and side effects of medications." There were no modifications to the plan by any discipline.

4. Patient A4. The Master Treatment Plan dated 11/17/10 contained only preprinted goals for the problem "Substance abuse." An example was "Patient will safely complete detox." There were only generic, preprinted physician interventions: "Psychiatric Evaluation" and "Prescribe medications." Nursing interventions also were generic tasks rather than individualized interventions. Examples were "Assess patient's mood" and "Detox protocol ordered and followed to ensure safe detox from addictive substances." There were no modifications to the plan by any discipline.

5. Patient A5. The Master Treatment Plan dated 12/02/10 contained only preprinted goals for the problem "Depressed Mood." An example was "Patient will verbalize one adaptive response to stress/depression." There were only generic, preprinted physician interventions: "Psychiatric Evaluation" and "Prescribe medications." Nursing interventions also were generic tasks instead of individualized interventions. Examples were "Assess patient's mood" and "Educate patient regarding name, dosage, schedule, purpose and side effects of medications." There were no modifications to the plan by any discipline.

6. Patient A6. The Master Treatment Plan dated 12/09/10 contained only preprinted goals for the problem "Depressed Mood." An example was "Patient will verbalize one adaptive response to stress/depression." There were only generic, preprinted physician interventions: "Psychiatric Evaluation" and "Prescribe medications." Nursing interventions also were generic tasks instead of individualized interventions. Examples were: "Assess patient's mood" and "Educate patient regarding name, dosage, schedule, purpose and side effects of medications." There were no modifications to the plan by any discipline.

7. Patient A7. The Master Treatment Plan dated 12/10/10 contained only preprinted goals for the problem "Depressed Mood." An example was "Patient will verbalize one adaptive response to stress/depression." There were only generic, preprinted physician interventions: "Psychiatric Evaluation" and "Prescribe medications." Nursing interventions were generic tasks instead individualized interventions. Examples were "Assess patient's mood" and "Educate patient regarding name, dosage, schedule, purpose and side effects of medications." There were no modifications to the plan by any discipline.

8. Patient A8. The Master Treatment Plan dated 12/09/10 contained only preprinted goals for the problem "Substance Abuse." An example was "Patient will safely detox." There were only generic, preprinted physician interventions: "Psychiatric Evaluation" and "Prescribe medications." Nursing interventions were generic tasks instead of individualized interventions. Examples were: "Assess patient's mood" and "Detox protocol ordered and followed to ensure safe detox from addictive substances." There were no modifications to the plan by any discipline.

B. Observation

On 12/14/10 at 9:00a.m. during the treatment team meeting, it was observed that there was no unit nurse in attendance throughout the 90 minute meeting.

C. Staff Interviews

1. In an interview on 12/13/10 at 11:00a.m., RN #1 stated "We do not attend team; we are giving meds at that time (referring to 9:00a.m. meds)."

2. In an interview on 12/14/10 at 10:00a.m., MD #3 (the attending physician for Patient A5) stated "We do not have nurses in team."

I. Based on record review and interview, the facility failed to ensure that physician medication orders gave specific parameters for the administration of medications for 5 of 8 active sample patients (A2, A3, A4, A7 and A8). For these patients, physician orders were written on a PRN (as necessary) basis for the vague conditions of "anxiety", "agitation" and "psychosis," and could be administered by intramuscular injection (IM) or by mouth (PO). For most medications, this can result in a different effective dosage delivered, depending on the method of administration chosen. Ambiguous physician orders result in nursing staff being required to function outside of the scope of nursing practice. They also can result in serious complications from improperly administered PRN medications.

Findings include:

A. Record Review

1. Patient A2 (admitted on 12/09/10). A physician order dated 12/09/10 at 1400 (2:00p.m.) stated "Benadryl 25 mg for itching or rash Q 6 hrs PRN PO may give IM if PO not tolerated" and "Haldol 5mg for agitation or psychosis Q 6 hrs PRN PO may give IM if PO not tolerated." The phrase, "if PO not tolerated" is not specific.

2. Patient A3 (admitted on 12/05/10). A physician order dated 12/05/10 at 0707 (7:07a.m.) stated "Phenergan 25 mg PO q 4 hrs PRN for nausea/vomiting: if PO not tolerated, may give IM." The phrase, "if PO not tolerated" is not specific.

3. Patient A4 (admitted on 11/17/10). A physician order dated 11/17/10 at 1500 (3:00p.m.) stated "Benadryl 25mg for itching or rash Q 6 hrs PRN PO may give IM if PO not tolerated," "Haldol 5mg for agitation or psychosis Q 6 hrs PRN PO may give IM if PO not tolerated" and "Geodon 20 mg IM with Ativan 2 mg IM q 12 hrs prn agitation/psychosis." The phrase, "if PO not tolerated" is not specific.

4. Patient A7 (admitted on 12/09/10). A physician order dated 12/10/10 at 0115 (1:15p.m.) stated "Zyprexa 5 mg PO or IM every 8 hrs PRN for severe agitation" and "Benadryl 50 mg PO or IM every 8 hrs PRN for severe agitation." The phrase, "PO or IM" is not specific.

5. For Patient A8 (admitted on 12/09/10), the physician order dated 12/09/10 and timed at 2350 (11:50p.m.) stated "Haldol 5 mg PO or IM q 6 hrs PRN for severe agitation," "Benadryl 25mg PO or IM q 6 hrs PRN for severe agitation," "Ativan 1mg PO or IM q 6 hrs PRN for severe agitation." The phrase, "PO or IM" is not specific.

B. Interview

1. In an interview on 12/13.10 at 1:30p.m., RN #3 stated "Yes, we can give all or part of the prns ordered; it is up to the nurse. We can choose IM or PO too."

2. In an interview on 12/.13/10 at 3:45p.m., the Director of Nursing stated "I believe we are too liberal in our medication ordering practices."

II. Based on staff interviews and facility Policy and Procedure Review, it was determined that the hospital-wide practice of "therapeutic holds" is not regarded as a restrictive measure that requires a protocol for physical restraint, such as a physician's order, a physician's assessment within 1 hour, or any documentation in the clinical record. Failure to treat "therapeutic holds" as restrictive measures results in no documentation of the event, and no physician notification or timely physician assessment of the clinical state of the patient. The absence of this clinically relevant information also results in failure to revise the patient's treatment plan.

Findings include:

A. Staff Interviews:

1. On 12/13/2010 at 10:45AM, charge nurse RN#1 was interviewed about the use of restrictive measures on the Children's Unit. She replied "We use those restraints called holds." She explained that these "holds" are only for a few seconds or minutes. She stated that if these measures do not calm the patient within5 minutes, an order for the use of Seclusion would be requested from the physician staff.

2. In an interview on 12/13/2010 at 3:45PM, the Director of Nursing was asked by the surveyors about the use of "therapeutic holds" on the Children's Unit. The DON replied "They [the holds] are not considered restrictive if they are less than 5 minutes." He confirmed that no physician orders were obtained if these "therapeutic holds" last less than 5 minutes.

B. Policy and Procedure Review

On 12/13/2010 at 11:30AM, the surveyors were provided with the facility's Nursing Services Policy and Procedure for "Brief Non-Verbal Redirection for a young child" (Policy #NS400.13 revised 6/10). The Policy states: "A Brief Non-verbal intervention involving physical contact, lasting more than 5 minutes may indicate a clinically significant episode of potentially dangerous behavior which is not self- abating and which requires sustained physical restraint to safely contain. Thus, brief non-verbal interventions, exceeding 5 minutes in duration constitute a physical restraint requiring a physician's order [sic]." This Policy was approved by the Director of Nursing with an Effective date 7/2007 and Revised 6/10.

Based on record reviews, patient and staff interviews, and Policy and Procedure reviews, it was determined that the Clinical Director (Medical Director) failed to provide adequate oversight to ensure safe treatment for patients on the children's unit, and assure that adequate physical examinations, psychiatric assessments, and treatment plans were completed for patients. Specifically, the Medical Director failed to:

I. Assure that cranial nerve testing was accurately reported for 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). The facility used a preprinted form that listed the cranial nerve tests to be performed. Documentations only included lines or checkmarks, not specific patient findings. In addition, 4 of the sample patients (A1, A2, A4 and A8) reported that the cranial nerve examinations had not occurred during physical examination. The physician who performed the examinations noted in the record that the tests were done. The lack of specific findings for patients and the discrepancy between physician reporting and patient experience makes it difficult to develop accurate diagnoses for patients. It also results in lack of baseline measures for future comparative purposes. (Refer to B109)

II. Assure that 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) received Psychiatric Evaluations that included detailed information regarding memory functioning. The Psychiatric Evaluations either had no comment about memory functioning or did not contain detailed information to document the rationale for generalized statements made about memory functioning. This failure results in a lack of information to determine how the conclusions regarding memory functioning are reached. It also results in lack of specific data to use for future comparative assessments. (Refer to B116)

III. Assure that 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8) had Master Treatment Plans that included all needed elements for effective treatment planning and implementation. The treatment plans contained preprinted goals, and physician and nursing interventions that were generic clinical responsibilities instead of being individualized for patients. Registered Nurses did not attend the treatment team meetings. In addition, the goals and interventions on the plans were not modified as treatment progressed. These deficient practices result in lack of a dynamic, working plan that can be understood and implemented by the treatment team. (Refer to B118)

IV. Assure that physician medication orders gave specific parameters for the administration of medications for 5 of 8 active sample patients (A2, A3, A4, A7 and A8). For these patients, physician orders were written on a PRN (as necessary) basis for the vague conditions of "anxiety", "agitation" and "psychosis" and could be administered by intramuscular injection (IM) or by mouth (PO). For most medications, this would result in a different effective dosage delivered, depending on the method of administration chosen. Ambiguous physician orders result in nursing staff being required to function outside of the scope of nursing practice. They also can result in serious complications from improperly administered PRN medications. (Refer to B125-I)

V. Assure that restrictive measures administered to patients on the children's unit followed appropriate protocols for the therapeutic use of restraint and that all required documentations were completed. Nursing staff use "therapeutic holds" for child patients for less than 5 minutes without having physician orders, 1 hour assessments by a physician, or documentation in the clinical record. Failure to treat "therapeutic holds" as restrictive measures (restraint) results in no documentation of the event, and no physician notification or timely physician assessment of the clinical state of the patient. The absence of this clinically relevant information also results in failure to revise the patient's treatment plan. (Refer to B125- II)

VI. Assure that latency aged (under 12 years old) children are provided safe, secure sleeping quarters, separate from adolescents. Active sample patient A2 was 10 years old and was housed in a room with 3 adolescent patients. Failure to provide separate sleeping quarters for child and adolescent patients potentially compromises the younger child's safety and is incongruent with the growth and developmental needs of both children and adolescents.

Findings include:

A. Observation

On 12/13/2010 at 10:30AM during a tour of the Unit where patient A2 (a 10 year old male) resided, the surveyor was told by RN #1 that A2 shared a room with adolescent males as a bedroom. Nursing staff on the Unit identified the ages of the other 3 patients in the bedroom as 14 years, 16 years, and 12 years.

B. Interview

On 12/14/2010 at 2:00p.m., in response to an enquiry about patient A2, the Director of Nursing stated "We do have the 10 year old sleeping in the same bedroom as the older boys."

Based on observation, record review and staff interview, the Director of Nursing failed to:

I. Ensure that Registered Nurses attended treatment team meetings and developed and documented patient specific nursing interventions on the Master Treatment Plans of 8 of 8 active sample patients (A1, A2, A3, A4, A5, A6, A7 and A8). A Registered Nurse did not attend the treatment planning meetings, and nursing interventions on the MTPs were generic nursing tasks instead of being individualized for patients. These deficient practices result in failure to produce a dynamic, working plan for nurses that can be understood and implemented by the treatment team.

Findings include:

A. Record Review

1. The Master Treatment Plan for Patient A1 dated 12/10/10 contained only nursing interventions which were generic tasks rather than individualized interventions for the problem "Aggression." Examples were "Assess patient's mood" and "Educate patient regarding name, dosage, schedule, purpose and side effects of medications." There were no modifications to the plan by nursing.

2. The Master Treatment Plan for Patient A2 dated 12/09/10 contained only nursing interventions which were generic tasks rather than individualized interventions for the problem "Aggression." Examples were "Assess patient's mood" and "Educate patient regarding name, dosage, schedule, purpose and side effects of medications." There were no modifications to the plan by nursing.

3. The Master Treatment Plan for Patient A3 dated 12/06/10 contained only nursing interventions which were generic tasks rather than individualized interventions for the problem "Depressed Mood." Examples were "Assess patient's mood" and "Educate patient regarding name, dosage, schedule, purpose and side effects of medications." There were no modifications to the plan by nursing.

4. The Master Treatment Plan for Patient A4 dated 11/17/10 contained only nursing interventions which were generic tasks rather than individualized interventions for the problem "Substance Abuse." Examples were "Assess patient's mood" and "Detox protocol ordered and followed to ensure safe detox from addictive substances." There were no modifications to the plan by nursing.

5. The Master Treatment Plan for Patient A5 dated 12/02/10 contained only nursing interventions which were generic tasks rather than individualized interventions for the problem "Depressed Mood." Examples were "Assess patient's mood" and "Educate patient regarding name, dosage, schedule, purpose and side effects of medications." There were no modifications to the plan by nursing.

6. The Master Treatment Plan for Patient A6, dated 12/09/10, contained only nursing interventions which were generic tasks rather than individualized interventions for the problem "Depressed Mood." Examples were "Assess patient's mood" and "Educate patient regarding name, dosage, schedule, purpose and side effects of medications." There were no modifications to the plan by nursing.

7. The Master Treatment Plan for Patient A7, dated 12/10/10, contained only nursing interventions which were generic tasks rather than individualized interventions for the problem "Depressed Mood." Examples were "Assess patient's mood" and "Educate patient regarding name, dosage, schedule, purpose and side effects of medications." There were no modifications to the plan by nursing.

8. The Master Treatment Plan for Patient A8, dated 12/09/10, contained only nursing interventions which were generic tasks rather than individualized interventions for the problem "Substance Abuse." Examples were "Assess patient's mood" and "Detox protocol ordered and followed to ensure safe detox from addictive substances." There were no modifications to the plan by nursing.

B. Observation

On 12/14/10 at 9:00a.m. during the treatment team meeting, it was observed that there was no unit nurse in attendance throughout the 90 minute meeting.

C. Staff interview

In an interview on 12/13/10 at 11:00a.m., RN 1 stated "We do not attend team; we are giving meds at that time (referring to 9:00 a.m. meds)."


II. Ensure that Registered Nurses only administer PRN medications within their scope of practice. For 5 of 8 active sample patients (A2, A3, A4, A7 and A8), PRN medications were ordered by the physician and administered by nursing staff for a variety of non-specific rationale ("anxiety", "agitation", "psychosis") and with a choice of route (PO or IM). The nursing practice of accepting and implementing ambiguous physician orders can result in serious complications for patients. (Refer to B125-I)

III. Ensure that latency aged (under 12 years old) children are provided safe, secure sleeping quarters, separate from adolescents. Active sample patient A2 was 10 years old and was housed in a room with 3 adolescent patients. Failure to provide separate sleeping quarters for child and adolescent patients potentially compromises the younger child's safety and is incongruent with the growth and developmental needs of both children and adolescents.

Findings include:

A. Observation

On 12/13/2010 at 10:30 AM during a tour of the Unit where patient A2 (a 10 year old male) resided, the surveyor was told by RN #1 that A2 shared a room with three adolescent males. Nursing staff on the Unit identified the ages of the other 3 patients in the bedroom as 14 years, 16 years, and 12 years.

B. Interview

On 12/14/2010 at 2:00p.m., in response to an enquiry about patient A2, the Director of Nursing stated "We do have the 10 year old sleeping in the same bedroom as the older boys."