HospitalInspections.org

Based on document review, observation and interview, the facility failed to ensure patient personal privacy on 1 (Youth Unit) of 2 area toured (see tag 143), failed to ensure care in a safe setting in 2 (Youth and Adult Units) of 2 area toured (see tag 144) and failed to ensure patients are free from abuse/harassment in 1 (Youth Unit) of 2 area toured (see tag 145).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review, observation and interview, the facility failed to ensure patient personal privacy on 1 (Youth Unit) of 2 area toured:

Findings Include:

1. Policy/procedure 200.13, Patient Rights to Care and Treatment, revised/reviewed 1/18, indicated on page 2: "You will be treated with consideration and respect and with full recognition of your dignity and individuality".

2. At time of tour on 9/10/18 at approximately 1200 hours, a patient was observed wearing paper-like scrubs that did not fit the patient with pants dragging on the floor. The pants were greater than one foot too long for the patient causing a tripping hazard. At time of tour, a female patient was observed wearing paper-like scrubs that were too large. The scrub top was reversed so that the V-neck was exposing the majority of the patient's back.

3. On 9/10/18 at approximately 1200 hours, staff N33 (Chief Nursing Officer) was interviewed and confirmed that patients are sometimes admitted without extra clothing and are provided the paper scrubs until clothing can be obtained. Staff N33 acknowledged the scrubs worn by the above-mentioned patients were too large.

Based on document review, interview and observation, the facility failed to ensure care in a safe setting in 2 (Youth and Adult Units) of 2 area toured:

Findings include:

1. Policy/procedure 702.10, Levels of Observation and Precautions, revised/reviewed 1/18, indicated: "The physician will order one of two levels of observation at time of admission and as the patient's condition warrants a change: every 15 minute. One to one (requires precaution level)".

2. Policy/procedure 800.49, Staffing, revised/reviewed 2/18, indicated: "Staffing is adjusted each shift or more frequently based upon patient acuity, activity level, employee qualifications and census changes".

3. Policy/procedure 704.02, Patient Rights to Care and Treatment, revised/reviewed 1/18, indicated on page 2: "Parents have the right to be assured that their dependent minor is provided a safe and comfortable environment".

4. Policy/procedure EC.02.06.05-2, Pre-Construction Risk Assessment, revised/reviewed 4/18 indicated on page 2: "At any time during the course of the construction/renovation work it is discovered that the required infection control measures are in non-compliance with what is identified and approved on the permit, then the Infection Control Nurse and Safety Officer are notified immediately in order that corrective action may be instituted".

5. Patient 1's MR lacked documentation of a physician assessment and documentation to support a physician's order to decrease the patient's level of observation from 1:1 status to Q15 (every 15 minute) checks on 6/22/18, 9/3/18, 9/4/18, 9/5/18. Review of Psychiatric Evaluation dated 6/22/18 at 1419 hours per medical staff D 1 indicated: "History of Present Illness: Says he/she is absolutely going to kill himself/herself. He/She doesn't not know exactly how, it does not really matter. He/she has thought about hanging himself/herself. He/she tried to hang himself/herself in the last month". Review of Physician Order dated 6/21/18 at 2300 hours per medical staff D4 indicated: "1:1 all times. Strip room, related to safety risk to self". Review of Physician Order dated 6/22/18 at 0920 hours per medical staff D1 indicated: "1:1 care to keep him/her alive - as he/she is actively working on killing self on Meadows Adult unit". Review of Physician Order dated 6/22/18 at 1030 hours per medical staff D1 indicated: "Order for 1:1 is at all times - patient safety". Review of Physician Order dated 6/22/18 at 1315 hours per medical staff D4 indicated: Discontinue 1:1". The MR indicated the patient voiced SI on a daily basis. In the patient's second admission reviewed, a Physician Order dated 9/3/18 at 1945 hours per medical staff D7 indicated: "Place on 1:1 staff at all times as patient verbalized SI with plan to hang self with intent tonight". Review of Physician Order dated 9/3/18 at 2100 hours per medical staff D3 indicated: "Place patient on quad while asleep and 1:1 at all other time". The MR indicated the patient continued to voice SI and self harm. Review of Physician Order dated 9/4/18 at 0835 hours per medical staff D7 indicated: "Continue 1:1 until M.D. meets with patient". Review of Physician Order dated 9/4/18 at 1235 hours per medical staff D7 indicated: "Continue 1:1 until M.D. meets with patient". Review of Physician Order dated 9/4/18 at 1635 hours per medical staff D7 indicated: "Continue 1:1 for safety". Review of Physician Order dated 9/4/18 at 2030 hours per medical staff D4 indicated: "Continue 1:1 while awake for safety. Quad monitoring while asleep". Review of Physician Order dated 9/5/18 at 0030 hours per medical staff D4 indicated: "Continue 1:1 while awake for safety. Quad monitoring while asleep". Review of Physician Order dated 9/5/18 at 1000 hours per medical staff D7 indicated: "Continue 1:1 while awake given SI with plan and unit short staffed". Review of Physician Order dated 9/5/18 at 1710 hours per medical staff D3 indicated: "Discontinue 1:1 status". The MR lacked documentation to support a patient's change in condition to a lower level of observation.

6. Patient 2's MR lacked documentation of behavior to support a physician's order for observation level status of Q15 (every 15 minute) checks on 6/25/18, 6/26/18, 6/27/18, 6/28/18, 6/29/18, 6/30/18, 7/1/18, 7/2/18, 7/3/18, 7/4/18 and 7/5/18, despite continued documentation of inappropriate behavior related to peer-to-peer boundaries. Review of MR lacked documentation of patient 2 specific room placement post sexual assault incident that occurred on 7/4/18. Review of patient 2's MR lacked documentation the patient was removed from treatment area or milieu from other patients on the unit, including the victim, post sexual assault incident on 7/4/18. Review of patient 2's MR lacked documentation of a physician's order for increased observation level status from Q15 (every 15 minute) checks to 1:1 post sexual assault incident occurring on 7/4/18.

7. Review of patient 3's MR lacked documentation of a physical assessment after being the victim of a sexual assault incident occurring on 7/4/18. Review of patient 3's MR lacked documentation of the patient's specific room placement after being the victim of a sexual assault incident occurring on 7/4/18. Review of patient 3's MR lacked documentation of physical separation from patient 2 outside the patient's room on the unit post sexual assault incident on 7/4/18.

8. Review of patient 4's MR lacked documentation of behavior to support a physician's order for an observation level status of Q15 (every 15 minute) checks on 9/1/18 and 9/2/18. Review of patient 4's MR lacked documentation of physician notification and/or assessment post incident. Review of Interdisciplinary Progress Note dated 9/1/18 indicated: "At approximately 1851 hours, staff entered patient's room to assist RN de-escalate patient that was self-harming by having a shirt around her neck. Review of MR indicated patient observation level was not assessed and/or changed after incident.

9. Review of patient 6's MR lacked documentation of behavior to support a physician's order for an observation level status of Q15 (every 15 minute) checks on 8/31/18 and 9/1/18. Review of patient 6's MR lacked documentation of physician notification and/or assessment post incident. Review of Nursing Progress Note dated 8/30/18 indicated: "Observation Level: Q15. Precautions: Suicide. Assault. Patient behavior became aggressive in recreation therapy. Attempted to wrap hands around peer throat. Staff removed patient from peer". Review of MR lacked documentation the patient's observation level was assessed after the incident.

10. On 9/10/18 at approximately 0800 hours, medical staff D7 was interviewed and confirmed patient 1's 1:1 observation level was discontinued due to low staffing. Medical staff D7 confirmed patient 2 and 3 were involved in an incident related to a sexual assault. Medical staff D7 confirmed patient 3 was the victim of sexual assault per patient 2. Medical staff D7 confirmed the patients were separated to different rooms at night but continued to co-participate in group activities on the unit. Medical staff D7 confirmed construction on the units has been disruptive to patient treatments and a danger to patient safety as patients find debris and sharp objects such as screws and/or nails on the floor of the units.

11. On 9/11/18 at approximately 1330 hours, medical staff D1 was interviewed and confirmed Patient 1's MR lacked documentation of behavior to support a physician's order to decrease the patient's level of observation from 1:1 status to Q15 (every 15 minute) checks on 6/22/18, 9/3/18, 9/4/18, 9/5/18.

12. On 9/10/18 at approximately 1500 hours, staff N22 (Licensed Clinical Staff) was interviewed and confirmed nursing staff have been told to report physician orders to increase a patient's observation level from Q15 to 1:1 status to their immediate supervisor to determine if enough staff is available to support the patient need. Staff N22 confirmed staff are encouraged to obtain physician orders for a 'quad' rather than 1:1 observation level due to short staffing. Staff N22 confirmed a 'quad' is defined as a staff member sitting in a chair in the hallway outside four patient rooms. Staff N22 confirmed a 'quad' is often ordered per nursing supervisors when staffing is short and 1:1 observation level orders cannot be accommodated. Staff N22 confirmed a staff member assigned to watch a 'quad' is to visualize all beds in all four rooms throughout the night. Staff N22 confirmed it is not possible to visualize every bed in four rooms sitting in the hallway.

13. On 9/10/18 at approximately 1530 hours, staff N23 (Licensed Clinical Staff) was interviewed and confirmed nursing staff are instructed per supervisors to re-evaluate 1:1 observation level orders when staffing is short. Staff N23 confirmed nursing supervisors often obtain a physician order to discontinue 1:1 observation level orders in the evening and write a physician verbal order from the for a 'quad' level of observation.

14. On 9/10/18 at approximately 1600 hours, staff N24 (Licensed Clinical Staff) was interviewed and confirmed he/she was knowledgeable of the sexual assault incident that occurred on 7/4/18 involving patients 2 and 3. Staff N24 confirmed patient 2 was not separated from other patients during the day after the sexual assault incident and attended group therapy and other group activities on the unit with the victim. Staff N24 confirmed patient 2's observation level did not change immediately after the sexual assault incident on 7/4/18.

15. On 9/10/18 at approximately 1615 hours, staff N25 (Unlicensed Clinical Staff) was interviewed and confirmed when staff are required to respond to patient incidents/emergencies, the units become inadequately staffed resulting in a potentially unsafe envirnment for patients and lack of attention to potential escalating patient behaviors. Staff N25 confirmed construction that recently began on the patient units has resulted in patients not able to access their rooms. Staff N25 confirmed the gym area was remodeled during the day instead of at night resulting in canceling of recreation time which is part of patients' daily treatment plan. Staff N25 confirmed patients have been confined to dayrooms while construction occurs on youth 6-12 year old hallway and youth 13-18 year old hallway. Staff N25 confirmed the telephone in the gym was not working on 9/9/18 resulting in staff inability to call a 'Code Green' for help when a patient-to-patient aggression incident occurred that day.

16. On 9/10/18 at approximately 1645 hours, staff N26 (Licensed Clinical staff) was interviewed and confirmed a nursing and MHT position was vacant on 9/9/18 due to lack of staff. Staff N26 confirmed the 1:1 observation level orders were discontinued earlier in the evening on 9/9/18 due to short-staffing. Staff N26 confirmed administrative staff/supervisors encourage obtaining a physician order to discontinue 1:1 observation level and place patients at-risk patients in a quad. Staff N26 confirmed he/she responded to a patient incident that occurred on 9/9/18 in the intake/admission area leaving the youth unit short-staffed. Staff N26 confirmed a MHT also responded to the incident leaving the youth unit with one MHT.

17. On 9/11/18 at approximately 1530 hours, staff N27 (Licensed Clinical Staff) was interviewed and confirmed nursing supervisors obtain physician orders to discontinue 1:1 observation levels when staffing is short. Staff N27 confirmed supervisors will obtain 'verbal' orders to discontinue the increased level of patient observation due to low staffing. Staff N27 confirmed construction on the youth unit began in August with remodeling done to the walls in the dayrooms of the 6-12 year old hallway and the 13-18 year old hallway. Staff N27 confirmed on 8/28/18 construction on the 6-12 year old hallway began at 0720 hours prior to the patients waking-up. Staff N27 confirmed patients were in their rooms when construction began on 8/28/18. Staff N27 confirmed patients had to be escorted from the hallway prior to scheduled wake-up time of 0745 hours and were unable to complete hygiene and receive medications before leaving unit. Staff N27 confirmed a plan was not communicated to the nursing staff regarding construction and handling of patients. Staff N27 confirmed tools and equipment were on the unit while patients present. Staff N27 confirmed objects such as nail, screws and tools were accessible and found by patients on 8/27/18 and 9/6/18.

18. On 9/11/18 at approximately 1630 hours, Staff N28 (Licensed Clinical staff) was interviewed and confirmed the youth and adult units are often short-staffed. Staff N28 confirmed construction occurred on the youth unit (6-12 year old hallway) on 8/28/18 around 0720 prior to patients waking-up. Staff N28 confirmed administration/supervisors did not communicate a plan of how to care for patients during construction. Staff N28 confirmed patients find objects such as nails, screws and tools related to the construction. Staff N28 confirmed patients did not have access to their rooms during construction and were kept in the dayrooms and/or activity room interfering with patient treatment plans.

19. On 9/11/18 at approximately 1430 hours, staff N33 (Chief Nursing Officer), N34 (Infection Preventionist) and N35 (Maintenance Supervisor) were interviewed and confirmed construction/remodeling on patient units began on 9/4/18 and includes floor and ceiling replacement. Staff N33, N34 and N35 confirmed the Infection Control Risk Assessment completed prior to the start date of construction rated the areas of construction/remodeling as a 'Low Risk' group identified as 'Office Space'. Staff N33, N34 and N35 confirmed the areas being remodeled were patient areas which includes patient rooms and treatment areas and not office space as indicated on the risk assessment.

20. On 9/12/18 at approximately 1315 hours, staff N31 (Licensed Clinical staff) was interviewed and confirmed staff are encouraged by nursing supervisors to obtain a physician's order to discontinue increased observation levels (1:1) and initiate a 'quad' when staffing is inadequate.

21. On 9/12/18 at approximately 1730 hours, staff N32 (Licensed Clinical staff) was interviewed and confirmed on 9/9/18 an MHT was alone in the gym with patients ages 6-12 years old for recreation time. Staff N32 confirmed a patient-on-patient aggression incident occurred and the MHT was unable to phone for help due to the gym telephone not operating. Staff N32 confirmed an MHT, 2 RN's and a nursing supervisor were needed to respond to another patient emergency in the intake/admissions area leaving him/her the only staff member on the youth unit.

22. On 9/13/18 at approximately 1300 hours, staff N33 (Chief Nursing Officer) was interviewed and confirmed the facility did not have a specific policy/procedure for defining and/or implementing a 'quad'. Staff N32 confirmed a quad is 'just something we do to keep patients safe when a higher level of patient observation is needed and means a staff member sits in the hallway between 4 rooms and is expected to visualized/watch patients in all 4 rooms'.

23. On 9/13/18 at approximately 1530 hours, staff N37 (Unlicensed Clinical Staff) was interviewed and confirmed he/she has worked as a staff member responsible for a 'quad'. Staff N33 confirmed his/her understanding of a quad is having a staff member sit in the hallway between four patient rooms. Staff N33 confirmed a staff member sitting in a quad is responsible for viewing each bed in all four patient rooms. Staff N33 confirmed patients placed in a quad are at an increased safety risk and require a higher level of observation. Staff N33 confirmed it is not possible to view all beds in each of the 4 rooms at the same time.

24: On 9/13/18 at approximately 1300 hours, staff N36 (Clinical Director) was interviewed and confirmed staff do not have an ability via facility communication systems to initiate an emergency response code in the patient courtyard/outdoor space. Staff N36 confirmed the facility did not have an emergency response process for staff to follow when patient incidents occur in the courtyard/outdoor space.

25. Review of Incident Report dated 7/4/18 indicated: "At 2115, staff entered room during Q15 checks. Patient 3 was found underneath his/her male/female peer. Said peer had no pants on, and patient 2 appeared to have his/her own pants pulled down. Peer was touching the patient 3 inappropriately. Upon being discovered, peer quickly removed self from bed and stated 'it's just a prank'. When staff spoke to patient 3 privately, patient 3 stated 'he/she climbed on me and said he/she was pulling a prank. I told him/her no and to stop, and he/she wouldn't. He/she kept saying it was a prank".

26. Review of Incident Report dated 9/9/18 at 1311 hours indicated: "Patient was in gym with peers. Patient was hit in the testicles by a peer, patient then reacted by placing patient in a choke hold. Patient was separated from peer by MHT. Staff called units for help". Review of Incident Report dated 9/9/18 at 1423 hours indicated: "Peer was hit in the testicles. Peer was agitated about being hit and attacked patient and other peers. MHT had to call unit (adult unit was only number he/she knew) and adult nurse responded to escort peer back". Review of Incident Report dated 9/9/18 at 1914 hours indicated: "Patient transported from facility via ambulance service. Per staff report, upon leaving, ambulance crew told staff that patient had access to his/her home meds during transport and just before arrival ingested unknown quantity/type of meds. 2 pills fell off patient when standing up. Patient ordered to the Emergency Department for medical clearance". Review of Incident Report dated 9/9/18 at 1953 hours indicated: "Patient became agitated after peer threw book at him/her and punched peer in the face". Review of Incident Report dated 9/9/18 at 2019 hours indicated: "Patient threw book at peer and peer retaliated by punching patient in the face. Right cheek red upon being hit, ice pack provided. No bruising or swelling noted".

27. Review of facility staffing sheet dated 7/4/18 indicated patient units were short 2 MHT's and 0.5 RN's.

28. Review of facility staffing sheet dated 9/4/18 indicated patient units were short 2 MHT's and 1 RN.

29. Review of facility staffing sheet dated 9/9/18 indicated patient units were short 1 RN.

30. Review of facility staffing sheet dated 9/10/18 indicated patient units were short 1 MHT and 1 RN.

31. Review of facility staffing sheet dated 9/11/18 indicated patient units were short 2 MHT's and 1 RN.

32. Review of facility maintenance work-orders indicated the phone in the gym was not working on 9/4/18 and 9/9/18.

33. On 9/10/18 at approximately 1200 hours, the Youth Unit was toured accompanied by staff N36. Construction was observed on the hallway of containing rooms for patients 6-12 year olds. Patients were observed in the adolescent dayroom. No patrician or barrier was separating the area of construction from the nurse's station or the adolescent hallway/dayroom. At time of tour, the dayroom floor was observed to need swept/mopped as there were multiple small items and debris. Items in the debris noted for potential to be used by patient to perform self-harm in unsupervised situations.
On 9/11/18 at approximately 1200 hours, the Youth Unit was toured accompanied by staff N33. Construction was observed occurring on the unit. No barrier or partition was in place. Replacement of flooring was observed in area in front of the nurse's station. Upon arrival to the unit, construction workers were observed using power tools. Nurses/staff were observed raising their voices trying to communicate patient care issues on the phone and with one another. The volume of noise from power tools prohibited staff from effectively communicating with each other and patients. Patients 6-12 years old were observed being escorted by staff through the construction area to a treatment room. The treatment room was in the area of the construction.
At approximately 1230 hours on 9/11/18 remodeling of the dayroom located off the 6-12 year old hallway was observed. Ceiling tiles had been removed and electrical and venting was observed dangling from the ceiling. Tools, construction debris, sharp objects observed on the unit. No partition or barrier was in place. At this time, a patient was being assessed for admission and seen escorted by a nurse to one of the patient rooms to receive a lice treatment on the unit.
At approximately 1245 hours on 9/11/18 patients ages 6 to 12 year olds were observed in the activity room located off the adolescent hallway. A patient was observed crying and his/her face was swollen and scraped due to another patient throwing an object at that patient. An MHT was not present in the activity room at the time of the incident. The MHT was observed taking another patient to the bathroom at the time of the incident. At time of tour, patients verbalized need for rest but due to construction were unable to access patient rooms. At time of tour, one MHT was observed watching 12 patients ages 6 to 12 years old. The MHT appeared to be having difficulty meeting the needs/requests of the patient who were requesting to use the bathroom, asking to nap, walking the hall and attempting an art activity. At time of tour, 2 of 2 youth hallways and 2 of 2 day rooms appeared to have dirty unswept floors with small debris and objects with potential to be used by unsupervised patients to self-harm.
On 9/12/18 at approximately 1700 hours, the youth unit was toured. The unit was short staffed due to staff responding to a Code Green (patient emergency) in another area of the facility. When the emergency occurred, 1 RN and 1 MHT were on the unit to care for greater than 20 patients.
On 9/13/18 at approximately 1300 hours, the outdoor courtyard was toured with staff N36. Greater than 6 patients were observed with a MHT performing a group activity in the courtyard and did not have an emergency response process for staff to follow when patient incidents occur.

Based on document review, interview and observation, the facility failed to ensure patients are free from abuse/harassment in 1 (Youth Unit) of 2 area toured:

Findings include:

1. Policy/procedure 200.13, Patient Rights and Responsibilities, revised/reviewed 1/18, indicataed: "You are assured of adequate and appropriate treatment. You will be free from mental and physical abue".

2. Policy/procedure 701.08, Abuse Assessment and Reporting, revised/reviewed 1/18, indicated: "Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation".

3. Policy/procedure 800.49, Staffing, revised/reviewed 2/18, indicated: "Staffing is adjusted each shift or more frequently based upon patient acuity, activity level, employee qualifications and census changes".

4. Patient 2's MR lacked documentation of behavior to support a physician's order for observation level status of Q15 (every 15 minute) checks on 6/25/18, 6/26/18, 6/27/18, 6/28/18, 6/29/18, 6/30/18, 7/1/18, 7/2/18, 7/3/18, 7/4/18 and 7/5/18, despite continued documentation of inappropriate behavior related to peer-to-peer boundaries. Review of MR lacked documentation of patient 2 specific room placement post sexual assault incident that occurred on 7/4/18. Review of patient 2's MR lacked documentation the patient was removed from treatment area or milieu from other patients on the unit, including the victim, post sexual assault incident on 7/4/18. Review of patient 2's MR lacked documentation of a physician's order for increased observation level status from Q15 (every 15 minute) checks to 1:1 post sexual assault incident occurring on 7/4/18.

5 Review of patient 3's MR lacked documentation of a physical assessment after being the victim of a sexual assault incident occurring on 7/4/18. Review of patient 3's MR lacked documentation of the patient's specific room placement after being the victim of a sexual assault incident occurring on 7/4/18. Review of patient 3's MR lacked documentation of physical separation from patient 2 outside the patient's room on the unit post sexual assault incident on 7/4/18.

6. On 9/10/18 at approximately 0800 hours, medical staff D7 was interviewed and confirmed patient 1's 1:1 observation level was discontinued due to low staffing. Medical staff D7 confirmed patient 2 and 3 were involved in an incident related to a sexual assault. Medical staff D7 confirmed patient 3 was the victim of sexual assault perpetrated by patient 2. Medical staff D7 confirmed the patients were separated to different rooms at night but continued to co-participate in group activities on the unit.

7. On 9/10/18 at approximately 1600 hours, staff N24 (Licensed Clinical staff) was interviewed and confirmed he/she was knowledgeable of the sexual assault incident that occurred on 7/4/18 involving patient 2 and 3. Staff N24 confirmed patient 2 was not separated from other patients during the day after the sexual assault incident and attended group therapy and other group activities on the unit. Staff N24 confirmed patient 2's observation level did not change immediately after the sexual assault incident on 7/4/18.

8. Review of Incident Report dated 7/4/18 indicated: "At 2115, staff entered room during Q15 checks. Patient 3 was found underneath his/her male/female peer. Said peer had no pants on, and patient 2 appeared to have his/her own pants pulled down. Peer was touching the patient 3 inappropriately. Upon being discovered, peer quickly removed self from bed and stated 'it's just a prank'. When staff spoke to patient 3 privately, patient 3 stated 'he/she climbed on me and said he/she was pulling a prank. I told him/her no and to stop, and he/she wouldn't. He/she kept saying it was a prank".

9. Review of facility staffing sheet dated 7/4/18 indicated patient units were short 2 MHT's and 0.5 RN's.

Based on document review, interview and observation, the facility failed to ensure appropriate staffing for patients in 2 (Youth and Adult Units) of 2 area toured (see tag 0392) and failed to ensure nursing staff administered medications as ordered per physician in 2 (Youth and Adult Units) of 2 area toured (see tag 0405).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure that Nursing Services provided quality health care in a safe environment.

Based on document review and interview the facility failed to ensure appropriate staffing for patients in 2 (Youth and Adult Units) of 2 area toured:

Findings include:

1. Policy/procedure 800.49, Staffing, revised/reviewed 2/18, indicated: "Staffing is adjusted each shift or more frequently based upon patient acuity, activity level, employee qualifications and census changes".

2. Policy/procedure 1/18, Budgeting and Allocation of Staff Resources for Patient Care, revised/reviewed 1/18, indicated: "The facility works with an appropriate staff-to-patient ratio designed to meet the patient care needs of the different groups of patients based on age, acuity, and treatment program".

3. Policy/procedure 800.01, Patient Acuity and Staffing Factors, revised/reviewed 1/18, indicated:
A. Page 1: "Staffing increases with acuity changes in census, as assessed by Nursing Leadership".
B. Page 2: "Nursing Leadership assess additional workloads including but not limited to: a. Four or more admissions, transfers or discharges to any Program during one shift. c. For disruptive psychotic patients on a unit. d. High assault potential where milieu is grossly disturbed by threatening behavior of one or more patients. e. Assault on unit. h. Patient who is hyperactive to degree that he/she cannot tolerate any program participation and who requires constant attention. k. Patient who is on suicide precautions, who is non-compliant, unable to contract and in need of 1:1 contact".

4. On 9/10/18 at approximately 0800 hours, medical staff D7 was interviewed and confirmed patient 1's 1:1 observation levels had been discontinued due to low staffing.

5. On 9/10/18 at approximately 1500 hours, staff N22 (Licensed Clinical Staff) was interviewed and confirmed nursing staff are encouraged by nursing supervisors to obtain physician orders for a 'quad' rather than 1:1 observation level due to short staffing. Staff N22 confirmed a 'quad' is defined as a staff member sitting in a chair in the hallway outside four patient rooms. Staff N22 confirmed a 'quad' order is often obtained per nursing supervisors when staffing is short and 1:1 observation level orders cannot be accommodated. Staff N22 confirmed a staff member assigned to watch a 'quad' is to visualize all beds in all four rooms throughout the night. Staff N22 confirmed it is not possible to visualize every bed in four rooms sitting in the hallway.

6. On 9/10/18 at approximately 1530 hours, staff N23 (Licensed Clinical Staff) was interviewed and confirmed nursing staff are instructed per supervisors to re-evaluate 1:1 observation level orders when staffing is short. Staff N23 confirmed nursing supervisors obtain physician order to discontinue 1:1 observation level orders in the evening and write a physician verbal order for a 'quad' level of observation.

7. On 9/10/18 at approximately 1615 hours, staff N25 (Unlicensed Clinical Staff) was interviewed and confirmed when staff are required to respond to patient incidents/emergencies, the units become inadequately staffed resulting in a potentially unsafe environment for patients and lack of attention to potential escalating patient behaviors. Staff N25 confirmed construction that recently began on the patient units has resulted in patients not able to access their rooms. Staff N25 confirmed the gym area was remodeled during the day instead of at night resulting in canceling of recreation time which is part of patients' daily treatment plan. Staff N25 confirmed patients have been confined to dayrooms while construction occurs on youth 6-12 year old hallway and youth 13-18 year old hallway. Staff N25 confirmed the telephone in the gym was not working on 9/9/18 resulting in staff inability to call a 'Code Green' for help when a patient-to-patient aggression incident occurred that day.

8. On 9/10/18 at approximately 1645 hours, staff N26 (Licensed Clinical staff) was interviewed and confirmed a nursing and MHT position was vacant on 9/9/18 due to lack of staff. Staff N26 confirmed the 1:1 observation level orders were discontinued earlier in the evening on 9/9/18 due to short-staffing. Staff N26 confirmed administrative staff/supervisors encourage obtaining a physician order to discontinue 1:1 observation level and place patients at-risk patients in a quad. Staff N26 confirmed he/she responded to a patient incident that occurred on 9/9/18 in the intake/admission area leaving the youth unit short-staffed. Staff N26 confirmed an MHT also responded to the incident leaving the youth unit short-staffed.

9. On 9/11/18 at approximately 1530 hours, staff N27 (Licensed Clinical Staff) was interviewed and confirmed nursing supervisors obtain physician orders from to discontinue 1:1 observation levels when staffing is short. Staff N27 confirmed supervisors will obtain 'verbal' orders to discontinue the increased level of patient observation due to low staffing.

10. On 9/12/18 at approximately 1315 hours, staff N31 (Licensed Clinical staff) was interviewed and confirmed staff are encouraged by nursing supervisors to obtain a physician's order to discontinue increased observation levels (1:1) and initiate a 'quad' when staffing is short.

11. On 9/13/18 at approximately 1300 hours, staff N33 (Chief Nursing Officer) was interviewed and confirmed the facility does not have a specific policy/procedure for defining and/or implementing a 'quad'. Staff N32 confirmed a quad is 'just something we do to keep patients safe when a higher level of patient observation is needed and means a staff member sits in the hallway between 4 rooms and is expected to visualized/watch patients in all 4 rooms'.

12. On 9/13/18 at approximately 1530 hours, staff N37 (Unlicensed Clinical Staff) was interviewed and confirmed he/she has worked as a staff member responsible for a 'quad'. Staff N33 confirmed his/her understanding of a quad is having a staff member sit in the hallway between four patient rooms. Staff N33 confirmed a staff member sitting in a quad is responsible for viewing each bed in all four patient rooms. Staff N33 confirmed patients placed in a quad are at an increased safety risk and require a higher level of observation. Staff N33 confirmed it is not possible to view all beds in each of the 4 rooms at the same time. Staff N33 confirmed he/she believes a quad is implemented when staffing is short and higher observation levels such as 1:1 cannot be accommodated due to low staffing.

13. Review of facility staffing sheet dated 7/4/18 indicated patient units were short 2 MHT's and 0.5 RN's.

14. Review of facility staffing sheet dated 9/4/18 indicated patient units were short 2 MHT's and 1 RN.

15. Review of facility staffing sheet dated 9/9/18 indicated patient units were short 1 RN and 1 MHT.

16. Review of facility staffing sheet dated 9/10/18 indicated patient units were short 1 MHT and 1 RN.

17. Review of facility staffing sheet dated 9/11/18 indicated patient units were short 2 MHT's and 1 RN.

Based on document review and interview the facility failed to ensure nursing staff administer medications as ordered per physician in 2 (Youth and Adult Units) of 2 area toured:

Findings include:

1. Policy/procedure 800.17, Medication Administration Compliance, revised/reviewed 2/18, indicated: "All medications will be administered by a licensed nurse as ordered by the Physician".

2. Review of patient 4's MR lacked documentation of administration of Guanfacine HCL ER 3 mg by mouth every evening; Miralax 17 gm in 8 ounces of water daily; Aripiprazole 10 mg oral every evening; Vyvanse 30 mg oral every morning as ordered per medical staff D4 on 8/31/18. Review of patient 4's MR lacked documentation of administration of Augmentin 500 mg oral on 9/3/18 as ordered per physician.

3. Review of patient 5's MR indicated the patient was admitted to the facility on 8/29/18. Review of Physician Order dated 9/2/18 at 0937 hours indicated: "Prazosin 1 mg oral at night". Review of medication administration record lacked documentation of administration of Pozosin on 9/3/18. Review of Daily Self Assessment dated 9/4/18 per patient 5 indicated: "How did you sleep? Poor because I didn't get all my medications!".

4. On 9/10/18 at approximately 0800 hours, medical staff D7 was interviewed and confirmed patient 4 was not administered medications as ordered.

5. On 9/12/18 at approximately 1600 hours, staff N33 (Chief Nursing Officer) was interviewed and confirmed patient 5 missed a dose of medication, Prazosin, on 9/3/18.