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Based on review of hospital policies/procedures, job descriptions, hospital documents, medical records and interviews, it was determined that the hospital failed to protect and promote each patient's rights as evidenced by:

(A144) failure to ensure that patients received care in a safe setting, when 10 of 13 minor patients engaged in behavior which was dangerous to self or others, or who were assaulted while residing in the hospital's adolescent unit and under the care of the hospital staff.

The seriousness of these systemic problems which resulted in injuries and transfers to acute medical hospitals for emergency medical care, resulted in the hospital's failure to meet the requirements of the Condition of Participation for Patient Rights.

Based on review of hospital policies/procedures, job descriptions, hospital documents, medical records and interviews, it was determined that the hospital failed to ensure that patients receive care in a safe setting for 10 of 13 minor patients who engaged in behavior which was dangerous to self or others, or who were assaulted while residing in the hospital's adolescent unit (Pt #s 14, 15, 13, 12, 17, 18, 4, 16, 24 and 23), which poses a grave risk to the health and safety of patients.

Findings include:

Review of hospital policy/procedure titled Admission, Exclusionary, Continued Stay and Discharge Criteria revealed: "...Admission Criteria (Severity)...for the adolescent program is at least 11 years old and...has at least one of the following:...Behavior which is life threatening, destructive or disabling to self or others...."

Review of hospital document titled BHT (Behavioral Health Technician) Acute Job Description revealed: "...Under the supervision of Nursing, provides age specific direct patient care to patients as assigned. Maintains a safe and efficient working and treatment environment per facility policies and procedures. Communicates effectively with the treatment team to ensure safety, quality care is provided to all patients...Carry out all aspects of patient care and other assignments as directed by the Nurse...."

Review of hospital document titled Registered Nurse Job Description revealed: "...directs and supervises nursing activities of team members...."

Review of hospital document titled Patient Handbook for Hospital Services revealed: "...Unit Guidelines...To ensure that you maximize your experience here at Oasis Behavioral Health, it is important for you to be aware of the program guidelines and expectations...No obscene language, name calling, physical striking out, fighting, threatening others and/or self-destructive behavior. They are considered inappropriate, unproductive, and unsafe...Destruction of hospital property will not be tolerated...Safety...Patient safety is everyone's responsibility because everyone has a part in making the healthcare environment safe. Oasis Behavioral Health is committed to your safety so we have policies and procedures in place to protect you...Patient Rights...A patient is not subjected to:...Abuse...."

Review of adolescent patient medical records revealed a hospital document in each record, signed by the patient's Parent/Guardian: "...Dear Parents/Guardians, Thank you for choosing Oasis Behavioral Health Hospital for the treatment of your loved one. Our adolescent unit multidisciplinary team consists of the Psychiatric Team, Nurses, Social Workers, Psychiatric Technicians, Art Therapists, Recreational Therapists, Discharge Planners, Utilization Review Managers, Pharmacist and Administration. All of us work toward one specific goal: Your Child's Safety...."

Patient # 14

Review of Pt # 14's medical record revealed:

On 6/8/16, at 0900, an RN documented: "Pt admitted to cutting self with rusty screw/nail last night...Pt to see MD today for superficial cuts on arm by rusty nail/screw that pt pulled out of shower drain...."

On 6/8/16, at 1246, a therapist documented: "...Pt (# 14) stated that her roommate had a nail and that her roommate asked Pt if she wanted her to cut Pt with it 'too'...allowed roommate to cut her...roommate cut herself as well...staff 'found out'...."

On 6/8/16, at 1800, an RN documented: "Approximately 1525 Pt (Pt # 14) punched 4 times in head/face area by another peer (Pt # 13) on the unit while sitting in a chair in the day room. Pt did not sustain any injuries at that time. Pt and peer separated...Approximately 1545 Pt (Pt # 14) was standing at nurse (sic) station when the same peer (Pt # 13) attaked (sic) pt again and punched pt in the face/head 4-5 times. Pt (Pt # 14) appeared to have lost consciousness and fell to the ground...Pt sustained injuries to head/face including bloody nose, swollen lip (upper). Pt (complained of) throbbing head and painful (left) ear. Pt unable to stand or sit up with out support. Pt (A & O ) x1 (Alert and Oriented to self) after assault...Pt transported via ambulance to (name of acute children's hospital) ER...."

On 6/14/16, at 1830, an RN documented: "Pt (Pt # 14) was standing by water machine in dayroom when a peer (Pt #15) grabbed pt's head and punched pt in the face 6-7 times. No words were exchanged between pt and peer. Pt and peer separated into 2 separate rooms...Tylenol 650 mg given. ice pack given to put on bridge of nose for bloody nose...Pt (complained of) pain and redness...."

Patient # 13

Review of Pt # 13's medical record revealed:

On 6/9/16, at 1235, Nurse Practioner (NP) # 5 documented: "...'I attacked (another patient). She said I'm pathetic, she calls me a loser, a tramp,...and them (sic) I hit her'...Discussed actions yesterday...."

Patient # 15

Review of hospital document revealed: "...6/14/16...1737...(Pt # 15) was in the dayroom when she approached a peer (Pt # 14), by the water machine & punched a peer multiple times (6-7) in the facial area...."

Review of Pt # 15's medical record revealed:

A psychiatrist documented in the Inpatient Psychiatric Evaluation, on 5/24/16: "...she was involved in an altercation with her sister and threatened to stab her...she has been having difficulty concentrating, being irritated, experiencing rage episodes, easily irritated...."

On 6/14/16, at 1915, an RN documented: "...Pt ( # 15) was in day room when she approached a peer (Pt # 14). She punched the peer multiple times in the face (6-7). Pt stated peer told her to go kill herself this morning before gym time & called her names. Pt stated when no staff was near, she punched peer by the water machine...Physician was contacted, & placed pt on close ops (sic)...."

Nursing assessed Pt # 15, on 6/15/16 at 0250, with a DTO (Danger to Others) Score of 5 (Routine Q 15 monitoring); approximately 9 hours after she assaulted Pt # 14.

Pt # 15's Multidisciplinary Treatment Plan Review contained documentation on 6/15/16 at 0905: "...Pt to verbalize 2 triggers to thoughts to harm others to SW (Social Worker)...Nursing will continue to monitor & assess pt for triggers & redirect as needed...."

Review of hospital policy titled Patient Observation & Rounding revealed: "...Close Observation:...Unit restriction: patient is not permitted to leave unit for off unit activities or outside patio use until cleared by provider...Staff will engage patient to remain in common unit areas and discourage extensive stay in patient room...Routine 15 minute observations:...Minimum level of observation for all patients...Staff will observe and document patient's location and behavior every 15 minutes...."

The Close Observation procedure does not require staff to directly observe or supervise patients any more frequently or closely than the minimum level of observation for all patients. It does require that the patient be restricted to the unit. The assault occurred on the unit.

Continued review of Pt # 15's medical record revealed:

On 6/24/16, at 1935, an RN documented: "Staff seen pt (Pt # 15) in day room, pulled another female pt (Pt # 12) by her hair, hit her in face. (Pt # 12's) nose started to bleed heavily. Staff able to separate (sic) this pt from (Pt # 12) for safety. On enquiry (sic), pt states (Pt # 12) called her a...& so she decided to hit her...writer notified on call psychiatrist...pt placed on DTO (Danger to Others) precautions...."

Review of hospital policy/procedure titled Level of Precautions revealed: "...Danger to Others (DTO) Precautions...Remove the patient from peer audience...Ensure safety of vulnerable patients...."

On 6/24/16, at 2100, an RN documented: "Pt (Pt # 15) comes up to nsg station & states right pinky of rt hand hurts bad. On enquiry (sic) pt states after hitting another female pt (Pt # 12) in dayroom in face, pt went outside & punched walls with her right hand. Pt stated she was just mad that she decided to punch the walls...prn tylenol given & ice prn applied to area...writer notified medical Dr...no new orders. Continue to monitor area...."

Pt # 15 was still on Close Observation when she assaulted Pt # 12 on 6/24/16, and when she "went outside" and punched the walls with her right hand.

Patient # 12

Review of Pt # 12's medical record revealed:

RN's documented Pt # 12's Vulnerability Score as "10", on 6/22/16, at 2100, 6/23/16, at 1800, 6/24/16, at 0100, 6/24/16, at 1750 and 6/24/16, at 2015. A score of 10+ is "High Risk".

DTO Precautions required that staff "ensure the safety of vulnerable patients."

On 6/23/16, at 1130, Pt # 12 was placed on Close Observation with AWOL Precautions.

On 6/24/16, at 1935, an RN documented: "Pt (Pt # 12) was in the day room with other peers. Another pt ( # 15) pulled pt by hair & hit pt on face & nose. pt started bleeding severely. Staff was able to separate (sic) both pt's to safety. pt was seperated (sic), staff with her & applied pressure on nose to control bleeding. pt states 'let me die' and went bsirk (sic) pt initially refused to apply pressure on nose to stop bleeding, but later (with) staff assistance bleeding controlled...nurse called Dr...got new orders to place pt on 1:1 for DTO bx (Danger to Others behavior) & got an xray of nose...2130...pt states her pain is increased on her nose, on assessment; area above (right) eyes (sic) appears swollen & bruised. pt stated her pain on head, ribs is 10/10 & feels nauseated per pt she thru up 3-4 times already, non witnessed by staff. writer taken pt vs (vital signs) again...notified Dr...got orders to transfer pt to ER...6/25/16 approx 0130...ER report for pt-x-ray of hand, ribs...CT of face the nasal fracture, (right) orbits bruised...."

On 6/25/16, at 1455, PA-C # 6 documented: "...Yesterday, female peer (Pt # 15) assaulted her resulting in her going to ER. Records indicate assault resulted in 'nondisplaced fractures of right nasal bone and frontal process of maxilla'...."

Pt # 12 remained on 1:1 Observation until it was discontinued on 6/30/16 at 1344.

Patient # 17

Review of Pt #17's medical record revealed:

On 6/7/16, at 2136, an RN documented: "pt stated to writer that she needs a room change since roommate (Pt # 14) is spreading rumors about her...later per staff, pt (# 17) went to dayroom & talked bad about roommate (Pt # 14) to other teens. staff asked pt to go to her room & to stop behaviors. pt got upset & cussed @ staff. Other teens said to staff that pt & her roommate (Pt # 14) had taken nails from bed & shower & used to harm selves. pt's roommate (Pt # 14) confirmed that this was true...bed end coming off & no nail in place & no nails in shower drain...(Pt # 14) states they hid nails in desk/bedboard/walls of hallway...(Pt # 17)...guarded...nails on her bed disappeared mysteriously...got angry, hit her hands & legs on walls of her room & hallway...'I might kill self or others, feeling like it', kicked back door hard in order to get out. pt refused to calm down, declined prn meds...pt went out of her room, kicked exit door (with) legs & arms testing door pt unable to calm (with) staff verbal commands...new orders to place 1:1 & AWOL prec. pt shoes secured from pt. pt tore the walls on her new room...order from Dr...to sleep on matress (sic) in day room due to wall damage in her room...pt still agitated, continued to hit walls with her extremities & cuzzed (sic) staff out loudly. staff (with) pt to monitor. pt was finally redirected to small day room (with) her matress (sic) so she can calm down & vistaril for anxiety, given prn tylenol & ice for pain on rt hand...showed staff some superficial cutting areas on both her hands. per pt, her roommate (Pt # 14) took nail & carved on her Rt hand & made cutting imprints. per pt, roommate (Pt # 14) sucked blood off her hand then. per pt, on left hand, pt had tried to use nail to make cutting marks...rt hand hurts after hitting on wall...2214...new orders for Rt hand x-ray & to apply cold compress...Finally pt calmed down & went to sleep...continued to be monitored 1:1...."

On 6/11/16, at 1639, an RN documented: "Patient ( # 17) came back from gym assisted by BHT crying and stated another peer (Pt # 18) punched her mouth and doesn't know why...."

Patient # 18

Review of Pt # 18's medical record revealed:

On 6/11/16, at 1430, PA-C # 6 documented: '...reports she feels like her emotions are 'all over the place'...she has been easily agitated by people and feeling angry...one peer (Pt # 17) is bothering her bc (because) 'she is different now'. Her Lexapro was increased to 10 mg a few days ago and it has been over the past few days where she has been feeling more irritable and labile...."

On 6/11/16, at 1430, PA-C wrote an order: "Decrease Lexapro to 5 mg...."

Review of hospital document, dated 6/11/16, at 1645, revealed: "...(Pt # 18) attacked peer by grabbing her hair and hitting her in the face several times...Physician Notified...(PA-C # 6)...."

On 6/12/16, at 1300, PA-C documented: "(Pt # 18) reports she feels like her aggression has been really high. Yesterday she got into a fight with another peer (Pt # 17). (Pt # 18) attacked (Pt # 17) while in the gym, unprovoked, she grabbed (Pt # 17's) hair and hit her multiple times in the face. (Pt # 17) now has a abrasion on the inside of her lip. She says that she has no idea what caused it, wasn't planning on doing it...."

Patient #4

Review of Pt # 4's medical record revealed:

On 6/26/16, at 1630, an RN documented: "Pt began verbal altercation with peer while playing Wii in the dayroom. Pt spit on peer (Pt # 16). Peer (Pt # 16) then pushed pt over a chair. Pt's R shoulder bruised and R flank area has an abrasion. Ice pack given for R shoulder pain...Provider aware. Room switched for safety so pt does not have to room with peer...."

Patient # 16

Review of Pt # 16's medical record revealed:

On 6/26/16, at 1430, an RN documented: "Pt was in a verbal altercation with peer while playing Wii. Peer spit on pt. Pt pushed peer over a chair. Pt and peer separated.

On 6/28/16, a Provider wrote an order: "...R hand xray due to multiple punches to walls/windows.

Patient # 24

Review of Pt # 24's medical record revealed:

On 7/21/16, at 1805, an RN documented: "...When (Pt # 24) came back from dinner she began her disruptive behavior of kicking banging and throwing things around the unit. She was screaming and approached to explain what was troubling her. She will not say anything...she ended up in the seclusion room...."

On 7/21/16, at 2020, an RN documented: "(Pt # 24) and one of her peers (Pt # 23) were arguing in the hallway. (Pt # 24) hit (Pt # 23) in the nose, cause (sic) her nose to bleed. (Pt # 23) then push (Pt # 24) into the door, resulting in a 2 cm scratch on R elbow..."

Patient # 23

Review of Pt # 23's medical record revealed:

On 7/21/16, at 1825, an RN documented: "....At 1805 (Pt # 24) became disruptive shouting kicking and banging doors. (Pt # 23) told (Pt # 24) to stop and (Pt # 24) got angry and tried to reach (Pt # 23). Both were separated...(Pt # 23)...walked to her room and used the color pencils and started scratching her hand until it bled. A band aide was placed on the hand by the BHT...."

On 7/21/16, at 2020, an RN documented: "...Words became threatening by peer at the door. (Pt # 23) came to the door and dared (Pt # 24) this angered (Pt # 24) and she hit (Pt # 23's) nose-causing slight bleeding from L nares. This caused (Pt # 23) to strike (Pt # 24), causing a scratch to R forearm near elbow when she struck the door frame...."

The Director of Risk Management confirmed, during interview conducted on 7/28/16, that there was an increased number of "physical confrontations" between adolescent patients during the month of June. She presented documentation of the Incident Report Trending Analysis which included Action Steps taken to decrease incidents: "...1) During the daily FLASH meeting all incident reports will be shared with the Leadership Team; 2) When there is an occurrence of physical aggression, the Multidisciplinary Treatment Team will perform a Treatment Plan Review and update the treatment plan as needed; 3) Leadership rounds will be conducted by the Administrator On Call at least 4 times a day, 7 days a week; 4) Clinical staff have been re-educated on Treatment Planning and Documentation; 5) Staff will receive training on imminent risk and how to intervene when patient's exhibit at risk behaviors...."

The Action Steps did not include efforts to provide preventive interventions.

Employee # 14 confirmed, during interview conducted on 7/26/16, that 1 BHT for 8 patients is a lot of patients to supervise. S/he confirmed that the facility accepts autistic patients and patients from Juvenile Detention, but staff have not received training regarding the management of either of these special patient populations.

Employee # 15 confirmed, during interview conducted on 7/26/16, that Pt # 14 was a "transgender" patient and many of the altercations were related to a particular male patient. Staff have not received training regarding approaches to "transgender" patients.

Employee # 18 confirmed, during interview conducted on 7/28/16, that staff had been trained, until approximately 3 weeks ago, that the facility is a "hands off" facility. S/he stated that if staff could "intervene physically earlier to help kids, they may not get hurt." S/he stated that some assaults happened because staff present were not permitted to physically intervene before physical contact between patients occurred.

Employee # 12 confirmed, during interview conducted on 7/28/16, that some aggressive behavior could be prevented if programmatic changes were implemented for patients to have time in smaller groups or in individual quiet therapeutic activities.

Employees 14, 15, 18 and 12 confirmed that the patient assaults need to be prevented for patient safety.

29578

Based on review of job descriptions, hospital policy and procedures, medical records and interviews, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the care of each patient as evidenced by failure to implement Levels of Precautions and Level of Observation, per hospital policy and procedure for 1 of 1 patients (patient #1) who required 1:1 supervision. This poses a high potential safety risk for a patient on fall precautions, and DTO/DTS precautions.

Findings include:

Review of Registered Nurse Job Description dated 5/30/16 revealed: "...Evaluates patient's behavior changes and choices...directs and supervises nursing activities of team members...Evaluates intervention outcomes...."

Review of Behavioral Health Technician (BHT) Job Description dated 5/11/16 revealed: "...Maintains a safe and efficient working and treatment environment per facility policies and procedures...Report Changes in patients (sic) condition or behavior to the Nurse, including agitation, high-risk behaviors...intervene appropriately with patients ' experiencing a behavioral crisis ...using approved interventions ...Act to preserve patient and family dignity and safety...."

Review of hospital policy/procedure titled Fall Assessment and Precautions dated 1/31/15 revealed: "...All patients will be assessed and identified for the potential of being at risk for falls, upon admission ...In the event of a fall occurrence, the patient will be assessed for injuries by the nurse and the attending physician will be notified ...implement fall precautions as indicated ...Patient is not left unattended during activities that place the patient at increased risk of falling ...All Staff Guidelines for Patient Safety ...Eliminate environmental hazards ...instruct patient to notify staff of any spills .... "

Review of hospital policy/procedure titled Level of Precautions dated 7/1 /16 revealed: "...All patients admitted to Oasis Behavioral Health (OBH) will be assessed for needs of various precautions...Staff responsible for monitoring precautions shall maintain the patient in a safe environment and take measures to protect the patient... Self Harm (DTS) Precautions ...Admitting RN will notify provider of all patients identified as a High Risk and Provider will determine an appropriate level of observation 1:1 ...Other precautions for a patient with potential for self harm may include: Vigilant monitoring by staff Vigilant monitoring of the environment for patient ' s rooms for items that could be used for self harm...All linen and shower curtains are accounted for ...Communicate clearly with all staff members about patient behavior, statements, and mood/affect observed ...Danger to Others (DTO) Precautions: Admitting RN will notify provider of all patients at high risk of danger to others and provider may order a heightened level of observation ...Precautions for Danger to Others may include ...Monitor the environment closely for contraband ...Thorough and active hand-off communication to other staff during breaks, meals and change of shift report ...AWOL/Elopement Precautions ...Admitting RN will notify provider of patients determined to be at high risk of AWOL/ Elopement ... Provider may consider increased level of observation ...Precautions for AWOL/ Elopement may include ...Maintaining close proximity to the patient.... "

Review of hospital policy/procedure titled Patient Observation and Rounding dated 4/28/16 revealed: "...Each patient at all times will be routinely observed in compliance with provider orders and prescribed protocols ...1:1 Supervision ...Specified and dedicated staff member is assigned to the patient ...Staff member will remain within a safe distance ...Distance should support timely (immediate) intervention ...The patient should never be left alone ...This level of observation is maintained even in the event of patient showering, changing clothes or using the restroom.... "

Review of Patient #1 ' s medical record revealed:

Pt # 1 was a minor who had been admitted on 7/8/16 for suicidal ideation and self injurious behaviors, with possible psychosis. S/he is impulsive and attempting AWOL at time of admission, s/he has a history of non-compliance, and self harm behaviors of scratching, biting, cutting and head banging and suicide attempts. S/he stated at the time of admission that s/he did not want to be in the facility.

Patient #1 was ordered the following precautions levels: 1:1 for danger to self (DTS) on 7/8/16 at 1332, AWOL precautions on 7/8/16 at 1345, danger to others (DTO) on 7/13/16 at 2329, and fall precautions on 7/14/16 at 1111.

RN # 5 ' s nursing flow sheet from 7/14/16 at 0130 revealed: " ...At approx. (sic) 1845 , at change of shift, pt (sic) found in shower, nude, with sheet wrapped around her, her pillow in the shower and her room flooded .... "

RN # 5 confirmed in an interview conducted on 7/28/16 that the patient was found in the shower, naked, with a wet sheet wrapped around her body, with pillows blocking the running water. She confirmed that the bathroom and the patient ' s room were flooded. She verified that the 1:1 did not call for assistance when the patient went into the bathroom with a pillow and sheet. She stated that she did not hear or get any calls while in report that the 1:1 staff needed assistance with the patient. She confirmed that at the time of the incident on 7/14/16, Patient # 1 was on 1:1 for DTS, AWOL precautions, DTO and fall precautions. she confirmed that the patient should not have been allowed to take a sheet, and pillow into the bathroom.

BHT # 10 confirmed in an interview conducted on 7/28/16 that s/he cannot recall any incident with Patient # 1 in the shower. S/he was assigned to Patient # 1 on 7/14/16 from 7am to 1830 when the night shift BHT took over the 1:1 assignment of patient # 1. S/he commented that when assigned a 1:1 that s/he needs to observe the patient even when the patient is in the bathroom. S/he stated that sheets, and pillows are not allowed in the patient ' s bathroom. S/he confirmed that if a patient attempted to take sheets and/or a pillow into the bathroom, s/he would redirect the patient, and if the redirection did not work, would call for the RN to assist.
BHT # 12 confirmed in an interview conducted on 7/28/16 that s/he has taken care of Patient # 1. S/he stated completes a 1:1 assignment by shadowing the patient, unless the patient needs to use the restroom, then s/he stands in the doorway of the patient ' s bedroom and allows the patient to close the bathroom door for privacy.
BHT #13 confirmed in an interview conducted on 7/28/16 at 0850 that she cannot recall any incidents with Patient # 1. BHT # 13 stated she has only worked with the patient one day and there were no problems or outbursts on that day. S/he commented that when assigned a 1:1 that s/he needs to observe the patient even when the patient is in the bathroom. S/he stated that sheets, and pillows are not allowed in the patient ' s bathroom. S/he confirmed that if a patient attempted to take sheets and/or a pillow into the bathroom, s/he would redirect the patient, and if the redirection did not work, would call for the RN to assist.
The Q.I. Coordinator # 9 confirmed in an interview conducted on 7/27/16 that Patient # 1 can use sheets and pillows in the bathroom for comfort, and it is on the treatment plan.
Director of Quality# 2 confirmed in an interview conducted on 7/27/16 that the use of sheets and pillows in the bathroom are not on the treatment plan for Patient # 1.
Director of Quality confirmed in an interview conducted on 7/28/16 at 1430 that it cannot be determined where or how the 1:1 staff was interacting with the patient #1 at the time of the incident on 7/14/16. She also confirmed that there is no documented reason why the sheet and pillow was allowed to be taken into the bathroom with Patient #1. She also confirmed that there is no documentation if the staff called for assistance to help with the Patient#1 flooding the bathroom and bedroom on 7/14/16 at 1845. She confirmed that at the time of the incident on 7/14/16, Patient # 1 was on 1:1 for DTS, AWOL precautions, DTO and fall precautions.