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Based on document review and interview, it was determined the Hospital failed to protect and promote each patient's rights. Therefore, the Condition of Participation 42 CFR 482.13, Patient Rights, was not met. This has the potential to affect all patients who receive care on the Youth Unit with the capacity of 30 patients.

Findings include:

1. The Hospital failed to ensure the Complaint/Grievance policy was followed. See A-0118 A

2. The Hospital failed to ensure patients were given the State Agency complaint hotline number. See A-0118 B

3. The Hospital failed to be responsible for the review and resolution of the grievance process. See A-0119

4. The Hospital failed to ensure the patient was involved in the development and implementation of the patient's discharge plan. See A-0130

5. The Hospital failed to ensure consents were obtained per policy. See A-0131 A

6. The Hospital failed to ensure the patient's representative was provided sufficient information to exercise the right to make informed decisions. See A-0131 B

7. The Hospital failed to ensure that the staff whom assisted and observed the patients were competent and qualified. See A-0144 A

8. The Hospital failed to ensure the record contained sufficient information to identify the patient to ensure appropriate services were provided to the proper patient. See A-0144 B

9. The Hospital failed to ensure that staff provided services post-injury/altercation; including medical assessments and nursing assessments. See A-0145.

A. Based on document review and interview, it was determined for 9 of 12 complaints listed on the complaint log, the Hospital failed ensure the Complaint/Grievance policy was followed. This has the potential to affect all patients who receive care on the Youth Unit with the capacity of 30 patients.

Findings include:

1. The policy titled "Patient Advocacy and Grievance Resolution" (last revision 3/30/18) was reviewed on 4/19/19 at approximately 1:50 PM. The policy required "complaint is considered resolved when the patient is satisfied with the actions taken on their behalf... IV. Procedure.... Patient Advocate will review the grievance and:... the time frame for completion of the investigation is 7 days after the receipt of the complaint.... document each step in the investigation thoroughly on the Grievance/Complaint Investigation form... provide the patient with a written notice of it's decision that contains: The name of the hospital, contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, the date of completion..."

2. The Complaint and Grievance log dated December 2018 through April 2019 was reviewed on 4/17/19 at approximately 1:30 PM. The log noted 9 of 12 grievances reported were not processed per policy. The following grievances lacked a date the grievance was resolved and that a determination letter was sent:

a) G#4 reported on 1/11/19,
b) G#5 reported on 1/13/19,
c) G#6 reported on 2/4/19,
d) G#7 reported on 2/5/19,
e) G#8 reported on 2/2/19,
f) G#9 reported on 1/24/19,
g) G#10 reported on 2/22/19,
h) G#11 reported on 2/25/19,
i) G#12 reported on 3/14/19.

3. During an interview on 4/18/19 at approximately 2:15 PM, the Chief Clinical Officer/Patient Advocate (E#4) verbally agreed the log lacked a date of resolution and if a determination letter was sent to the complainant. E#4 stated there had been some turn over with the position that handles complaints and E#4 was unaware of the process, as outlined in the policy.


B. Based on document review and interview, it was determined the Hospital failed to ensure patients were given the State Agency complaint hotline number. This has the potential to affect all patients who receive care on the Youth Unit with the capacity of 30 patients.

Findings include:

1. The "Patient Bill of Rights" was reviewed on 4/18/19 at approximately 9:30 AM. The Patient Bill of Rights lacked a phone number for filing a complaint with the State Agency.

2. The Patient Admission folder was reviewed on 4/18/19 at approximately 12:30 PM. The admission folder lacked a phone number for filing a complaint with the State Agency.

3. During an interview on 4/19/19 at approximately 8:50 AM, the Director of Performance Improvement Risk Management (E#1) verbally agreed there wasn't a phone number listed for filing a complaint with the State Agency.







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Based on document review and interview, it was determined the Hospital's Governing Body failed to be responsible for the review and resolution of the grievance process. This has the potential to affect all patients who receive care on the Youth Unit with the capacity of 30 patients.

Findings include:

1. The policy titled "Patient Advocacy and Grievance Resolution" (reviewed by Hospital on 3/30/18) was reviewed on 4/19/19. The policy noted "Grievance: A "patient grievance" is a formal... verbal complaint that is made to the hospital by... the patient's representative, regarding patient's care... abuse... Data collected regarding patient grievances... must be incorporated in the Hospital's Quality Assessment and Performance Improvement (QAPI) Program... the Performance Improvement Committee is the committee designated responsible for the effective operation of the grievance process... The grievance will be logged into the Grievance Log..."

2. Pt #4 Start of Care: 12/14/18
Diagnosis: Major Depressive Disorder. The clinical record was reviewed throughout the survey on 4/17/19 through 4/19/19. A Psychiatric Progress Note dated 12/29/18 by MD #1 noted "Pt #4 was in the hallway... another adolescent peer became upset... pushed Pt #4 and then started kicking Pt #4 and hitting Pt #4. Pt #4 was hit in the right eye and Pt #4 currently has a black eye." The Nursing Reassessment Progress Note dated 12/30/18 at 10:40 AM noted "Pt to be seen by medical doctor to d/t (due to) eye being bruised and swollen." On 12/31/18 a discharge order was obtained which instructed Pt #4 to follow up with primary care doctor after discharge for an eye injury.

3. The Youth Complaint Log dated 12/1/18 to 4/17/19 was reviewed on 4/18/19. The log lacked documentation a complaint was received from Pt #4 or Pt #4's representative.

4. The Performance Improvement Committee Meeting Information dated 1/24/19 was reviewed on 4/18/19. The section titled "Patient Grievance" noted "11 total patient advocacy calls received in Quarter 4.... All calls were received and responded to timely. All calls were logged and forwarded to the unit manager/Director for follow up if needed... Interim PA (patient Advocate) to be assigned... Unable to gather reports due to FT (Full Time) PA (Patient Advocate) being out for past month..." The summary of the 11 calls lacked any complaints regarding physical altercations or abuse.

5. During an interview on 4/19/19 at approximately 12:15 PM, the Chief Executive Officer (E#3) stated "Pt #4's representative did come back to facility after discharge. I met with Pt #4's representative. Pt #4's representative said the representative was going to call DCFS (Division of Children and Family Services) and make a report ... Pt #4's representative wanted to just make sure I was aware there was a kid on the unit that hit Pt #4." E#3 stated "I knew about the situation. We (administration) review the videos of each altercation... Our cliental is unique and there are always going to be altercations between these kids... I guess I didn't really think of it as an allegation of abuse. I didn't know until now about all the issue with Pt #4's record pertaining to lack of documentation by the physician, nurses and techs (Mental Health Technicians) regarding Pt #4's injury. I see now that I should have documented it (the complaint by Pt #4's representative on the log). We need to ensure we investigate these situations." E#3 verbally agreed, if the complaint would have been documented and investigated, the event would have been considered an altercation with injury which effects the quality of data reported and tracked by the Hospital.

Based on document review and interview, it was determined in 2 of 7 (Pt #1, Pt #6) patients' records reviewed, the Hospital failed to ensure the patient was involved in the development and implementation of the patients' discharge plan of care. This has the potential to affect all patients who receive care on the Youth Unit with the capacity of 30 patients.

Findings Include:

1. The policy titled "Patient Discharge Management Policy #: POC-14" (last revision review 03/23/2018). The policy required...IV. Procedure: 2. The nurse will review all sections of the Discharge and Continuing Care Plan with the patient and family at discharge... the patient and parent/ guardian/significant other is to sign the Discharge and Continuing Care Plan...If the family/support is not available at discharge, the nurse or case manager may review by phone and document on the crises plan accordingly..."

2. Pt # 1 Date of Service (DOS): 1/15/19
Diagnosis: Disruptive Mood Dysregulation Disorder. The record was reviewed through out the survey on 4/17/19 to 4/19/19. The record included a discharge continuing care plan dated 1/25/19. The discharge care plan lacked a nurse's signature, which indicated the discharge plan of care was reviewed with the patient.

3. Pt.# 6 DOS: 2/12/19
Diagnosis: Unspecified Mood Disorder. The record was reviewed through out the survey on 4/17/19 to 4/19/19. The record included a discharge continuing care plan dated 2/28/19. The discharge care plan lacked a nurse's signature and patient/family/or significant other, which indicated the discharge plan of care was reviewed with the patient.

4. During an interview on 4/18/19 at approximately 8:45 AM, Director of Performance Improvement Risk Management (E#1) verbally agreed there was no appropriate signatures for Pt #1's and Pt #6's discharge plan of cares and should have been signed by the nurse.

A. Based on document review and interview, it was determined in 4 of 7 (Pt #1, Pt #2, Pt #4, Pt #6) patients' records reviewed, the Hospital failed to ensure consents were obtained per policy. This has the potential to affect all patients who receive care on the Youth Unit with the capacity of 30 patients.

Findings Include:

1. The policy titled "Informed Consent" (last review revision: 1/2/18), was reviewed on 4/18/19 at approximately 10:00 AM. The policy required "V. Informed Consents for Minors a. Informed consent for treatment will be obtained from the DCFS (Division of Children and Family Services) consent hotline for DCFS wards...b. Minors under the age of 16 who are not DCFS wards: informed consent for treatment will be obtained from the youth's legal guardian."

2. Pt#1 Start of Care: 1/15/19
Diagnosis: Disruptive Mood Disorder. The clinical record was reviewed throughout the survey on 4/17/19 to 4/19/19. Pt #1's age was less than 12 years old during this admission. The Family Treatment Contract, the Patient Teaching Sheet, and the Influenza Consent lacked the name of the Guardian, whom provided verbal consent or the Guardian's signature.

3. Pt #2 Start of Care: 12/16/18
Diagnosis: Major Depressive Disorder. The clinical record was reviewed throughout the survey on 4/17/19 to 4/19/19. Pt #2 was 16 years old during this admission. The Patient Bill of Rights dated 12/16/18 noted an oral consent was given by the Guardian, although the document lacked a name of the Guardian.

4. Pt #4 Start of Care: 12/14/18
Diagnosis: Major Depressive Disorder. The clinical record was reviewed throughout the survey on 4/17/19 to 4/19/19. The Photograph Consent lacked a signature of consent. The record included a picture of Pt #4. The Youth Unit Guidelines lacked a signature of consent.

5. Pt #6 Start of Care: 2/12/19
Diagnosis: Unspecified Mood Affective Disorder. The clinical record was reviewed throughout the survey on 4/17/19 to 4/19/19. Pt #6 was 17 years old during this admission. The Patient Bill of Rights dated 3/21/19 noted an oral consent was given by the Guardian, although the document lacked a name of the Guardian. The Medication Consent dated 3/24/19 and 3/27/19 lacked the name of the Guardian, whom gave verbal consent.

6. During an interview on 4/18/19 at approximately 8:45 AM, the Director of Performance Improvement Risk Management (E#1) reviewed the above documents and verbally agreed with the above findings.



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B. Based on document review and interview, it was determined for 1 of 9 (Pt #4) patients' records reviewed who were involved in altercations, the Hospital failed to ensure the patient's representative was provided sufficient information to exercise the right to make informed decisions. This has the potential to affect all patients who receive care on the Youth Unit with the capacity of 30 patients.

Findings include:

1. Pt #4 Start of Care: 12/14/18
Diagnosis: Major Depressive Disorder. The clinical record was reviewed throughout the survey on 4/17/19 to 4/19/19. The Patient Progress Note dated 12/28/18 at 2:00 PM authored by Registered Nurse (E #5) noted, "Pt was irritated d/t (due to) not being able to have cards ... going around hitting and kicking the door. Peer became agitated with patient doing this and peer hit patient and kicked him. Pt has hematoma (localized bleeding outside of blood vessels, due to either disease or trauma) to right eye and red mark to left arm ... pt placed on med (medical) board to be examined by medical doctor. Pt will be monitored for need of any further care. Pt has ice to right eye and currently sitting in the OTR (Open Therapy Room). (Name of Pt #4's representative) notified 12/28/18 1430 (2:30 PM)." The clinical record lacked documentation that Pt #4's representative was notified of the injuries. The Nursing Reassessment Progress Note dated 12/30/18 at 10:40 AM authored by E#5 noted "Pt to be seen by medical doctor to d/t eye being bruised and swollen." The record lacked documentation the eye injury or arm injury had been re-assessed prior to discharge; that the Psychiatrist was immediately notified of the altercation/injury; that an order for a medical evaluation was obtained; or that a medical evaluation had been conducted by a medical doctor prior to discharge. A telephone order to follow up with Pt #4's primary care doctor due to left [sic] eye injury after discharge was obtained by medical doctor (MD#3) dated 12/31/18 at 8:56 AM.

2. During an interview on 4/19/19 at approximately 11:00 AM, the Registered Nurse (RN) (E#5) stated "There was redness to the eye and arm. Pt #4 was still aggressive and escalated after the incident so, I was not able to do a full assessment. Pt #4's answers were limited related to Pt #4's escalation ... Pt #4 asked for ice but didn't keep it on there. Pt #4 refused neuro (neurological) checks or for vitals (vital signs- blood pressure, pulse, temperature and respirations) to be evaluated ... I did not tell Pt #4's representative about any injuries because there were none." When asked what the definition of a hematoma was, E#5 replied "It was a little red and swollen but no bruising ..." E#5 went on further to state that the eye had extensive bruising and swelling on 12/30/18 and verbally agreed the medical doctor had not evaluated Pt #4's injuries.

3. During an interview on 4/19/19 at approximately 10:40 AM, the Psychiatrist (MD#1) stated "Clinic #2 has Internist that do H&Ps (history and physicals) on all new admits (Youth Unit) and provide medical care when needed. The nurses call us (Psychiatrist) and get an order for a medical evaluation if needed. Based on the complaint or extent of the injury we can also send them (patient) to the ED (Emergency Department)."

4. During an interview on 4/19/19 at approximately 12:30 PM, E#1 verbally agreed the medical doctors from Clinic #2 had not medically evaluated Pt #4 prior to discharge and the telephone order obtained by MD#3 (medical doctor from Clinic #2) on 12/31/18 at 8:56 AM, (order for Pt #4's primary Physician to evaluated Pt #4's injuries after discharge) noted a left eye injury, although the right eye was the injured eye.

5. During an interview on 4/19/19 at approximately 12:15 PM, the Chief Executive Officer (E#3) verbally agreed Pt #4's mother should have been notified of the injuries and had the option to come visit the patient, talk to the patient, or request a medical evaluation.

A. Based on document review and interview, it was determined in 2 of 2 (Pt #2, Pt #4) Patients' record reviewed, the Hospital failed to ensure that the staff whom assisted and observed the patients were competent and qualified. This has the potential to affect all patients who receive care on the Youth Unit with the capacity of 30 patients.

Findings include:

1. The policy titled "Patient Care Staffing" (revised 4/2/18) was reviewed on 4/17/19. The policy noted "The staffing Plan for Patient Care is reviewed on an ongoing basis to ensure appropriate staff composition, number of staff, skill mix and budget."

2. The policy titled "Behavioral Interventions: Physical Hold, Seclusion, and Less Restrictive Alternatives" (revised 4/2018) was reviewed on 4/18/19. The policy noted "If... the patient is unable to control aggression, dangerous behaviors towards self or others and has progressed to acting out this behavior... call for staff assistance or call switchboard to announce a Support Code... "

3. Pt #2 Start of Care: 12/16/18
Diagnosis: Major Depressive Disorder. The clinical record was reviewed throughout the survey on 4/17/19 through 4/19/19. The Observation Flow Records dated 12/28/18, 1/1/19 and 1/19/19 were reviewed with the Director of Performance Improvement and Risk Management (E#1) on 4/17/19 at approximately 2:30 PM. The Observation Flow Records had multiple staff members' signatures and/or initials which were not identifiable.

4. During an interview on 4/17/19 at approximately 2:30 PM, Director of Performance Improvement and Risk Manger (E#1) verified the above findings for Pt #2's observation sheets

5. Pt #4 Start of Care: 12/14/18
Diagnosis: Major Depressive Disorder. The clinical record was reviewed throughout the survey on 4/17/19 through 4/19/19. The record noted Pt #4 was in Self Harm, Suicide and Assault Precautions which required every 15 minute observation. The incident log noted Pt #4 was attacked by/injured by another patient on 12/28/18 at 2:00 PM. Pt #4's Observation Flow Records dated 12/27, 12/28/18, 12/29/18, 12/30/18, and 12/31/19 had multiple staff members' signatures and/or initials which were not identifiable.

6. During an interview on 4/17/19 at approximately 2:30 PM, E#1 was asked to identify the nurse who signed the Observation Flow Record on 12/28/18. E#1 compared the signature/initials on the Observation Flow Record to the Signature and Credential sheet and stated the signature/initials did not match, although E#1 recognized the signature/initials as a Registered Nurse (E#5). When asked who made the observations on 12/28/18 between 2:00 PM and 3:15 PM, E#1 was unable to find the staff's initials on the Signature and Credential sheet or recognize the initials. At approximately 3:30 PM, E#1 stated upon inquiry the initials on the Observation Flow Record dated 12/28/18 between 2:00 PM and 3:15 PM was a Mental Health Technician from the Adult Unit (E#8). E#1 explained staff come from other units to assist when a Support Code is called. Pt #4's Observation Flow Record dated 12/27/18, 12/28/18, 12/29/18, 12/30/18 and 12/31/18 were reviewed and E#1 verbally agreed the majority of the staff that documented observations were unable to be identified due to the lack of legibility and/or their initials did not match the Signature and Credential sheet. When asked how often staff was utilized from other units to ensure the unit was appropriately staffed and the staff who respond were appropriately trained, E#1 stated "We don't look at that." (Amount of time and qualifications of staff from other unit, whom respond and work on the youth unit)


B. Based on document review and interview, it was determined in 3 of 5 (Pt #2, Pt #4, Pt #9) patients' records reviewed, the Hospital failed to ensure the records contained sufficient information to identify the patient to ensure appropriate services were provided to the proper patient. This has the potential to affect all patients who receive care on the Youth Unit with the capacity of 30 patients.

Findings include:

1. Pt #2 Start of Care: 12/16/18
Diagnosis: Major Depressive Disorder. The clinical record was reviewed throughout the survey on 4/17/19 through 4/19/19. The Nursing Reassessment Progress Notes dated 12/25/18, 12/26/18, 12/29/18, 1/8/19 x 2 and the Patient Progress Notes dated 12/26/18, 1/1/19, 1/5/19, and 1/9/19 noted only Pt #2's first name and lacked the last name or an unique identifier. The Patient Progress Note dated 1/10/19 lacked documentation of any name.

2. Pt #4 Start of Care: 12/14/18
Diagnosis: Major Depressive Disorder. The clinical record was reviewed throughout the survey on 4/17/19 through 4/19/19. The Case Management Collateral Contact Note noted only Pt #4's first name and lacked the last name or an unique identifier.

3. Pt #9 Start of Care: 1/331/19
Diagnosis: Major Depressive Disorder. The clinical record was reviewed throughout the survey on 4/17/19 through 4/19/19. The Nursing Reassessment Progress Notes dated 2/2/19 and an undated note lacked documentation of Pt #9's last name or an unique identifier.

4. During an interview on 4/18/19 at approximately 11:00 AM, Director of Performance Improvement and Risk Manager (E#1) verbally agreed the above documentation lacked the required patient identification and the documents were unidentifiable. E#1 stated that every entry and every form should have a patient label that included the patient's full name, birth date, medical record number and admission date. E#1 stated "I thought we audited the records for this kind of thing. Apparently we aren't doing a very good job."

Based on document review and interview, it was determined in 1 of 9 (Pt #4) patients' records reviewed who were involved in altercations, the Hospital failed to ensure that staff provided services post-injury/altercation; including medical assessments and nursing assessments. This has the potential to affect all patients who receive care on the Youth Unit with the capacity of 30 patients.

Findings include:

1. The policy titled, "Patient Bill Of Rights" (no date) was reviewed during the survey. The policy required that, "3. you have the right to treatment..."6. You have the right to be treated with dignity and respect in the provision of all services. You have the right not to be mentally or physically abused, neglected, and/or exploited by anyone including staff..."

2. The document titled, "Medical Team Consult Log" (No date) was reviewed during the survey. The document required that, " Medical Issues/Complaint: Requires an order from the Psychiatrist for medical consult to occur...Call Med Team With Medical Consults Each Morning."

3. Pt #4 Start of Care: 12/14/18
Diagnosis: Major Depressive Disorder. The clinical record was reviewed throughout the survey on 4/17/19 to 4/19/19. The Patient Progress Note dated 12/28/18 at 2:00 PM authored by Registered Nurse (E #5) noted, "Pt was irritated d/t (due to) not being able to have cards ... going around hitting and kicking the door. Peer became agitated with patient doing this and peer hit patient and kicked him. Pt has hematoma (localized bleeding outside of blood vessels, due to either disease or trauma) to right eye and red mark to left arm ... pt placed on med (medical) board to be examined by medical doctor. Pt will be monitored for need of any further care. Pt has ice to right eye and currently sitting in the OTR (Open Therapy Room). (Name of Pt #4's representative) notified 12/28/18 1430 (2:30 PM)." The clinical record lacked documentation that Pt #4's representative was notified of the injuries. The Nursing Reassessment Progress Note dated 12/30/18 at 10:40 AM authored by E#5 noted "Pt to be seen by medical doctor to d/t eye being bruised and swollen." The record lacked documentation the eye injury or arm injury had been re-assessed prior to discharge; that the Psychiatrist was immediately notified of the altercation/injury; that an order for a medical evaluation was obtained; or that a medical evaluation had been conducted by a medical doctor prior to discharge. A telephone order to follow up with Pt #4's primary care doctor due to left [sic] eye injury after discharge was obtained by medical doctor (MD#3) dated 12/31/18 at 8:56 AM.

4. During an interview on 4/19/19 at approximately 11:00 AM, the Registered Nurse (RN) (E#5) stated "There was redness to the eye and arm. Pt #4 was still aggressive and escalated after the incident so, I was not able to do a full assessment. Pt #4's answers were limited related to Pt #4's escalation ... Pt #4 asked for ice but didn't keep it on there. Pt #4 refused neuro (neurological) checks or for vitals (vital signs- blood pressure, pulse, temperature and respirations) to be evaluated ... I did not tell Pt #4's representative about any injuries because there were none." When asked what the definition of a hematoma was, E#5 replied "It was a little red and swollen but no bruising ..." E#5 went on further to state that the eye had extensive bruising and swelling on 12/30/18 and verbally agreed the medical doctor had not evaluated Pt #4's injuries.

5. During an interview on 4/19/19 at approximately 10:40 AM, the Psychiatrist (MD#1) stated "Clinic #2 has Internist that do H&Ps (history and physicals) on all new admits (Youth Unit) and provide medical care when needed. The nurses call us (Psychiatrist) and get an order for a medical evaluation if needed. Based on the complaint or extent of the injury we can also send them (patient) to the ED (Emergency Department)."

6. During an interview on 4/19/19 at approximately 12:30 PM, Director of Performance Improvement and Risk Manager (E#1) verbally agreed the medical doctors from Clinic #2 had not medically evaluated Pt #4 prior to discharge and the telephone order obtained by MD#3 (medical doctor from Clinic #2) on 12/31/18 at 8:56 AM, (order for Pt #4's primary Physician to evaluated Pt #4's injuries after discharge) noted a left eye injury, although the right eye was the injured eye.