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Based on observations as referenced in the Life Safety reports of survey completed 04/28/2010 and 05/20/2010, the hospital failed to have an effective governing body ensuring a safe environment for patients.

The findings include:

The hospital failed to develop and maintain the facilities in a manner to ensure the safety and well-being of patients.

~ cross refer 482.41 Physical Environment, Condition Tag A0700.

Based on hospital policy review, staff interview, activity schedule review and observation, the hospital failed to ensure staff was available to provide therapeutic activities on 1 of 8 (2NB) units toured.

The findings include:

Review of the hospital policy CLS002, Milieu Management Guidelines, (reviewed 9/09) revealed ..."There is an expectation that community members will participate in activities"..."The role of the patient is to: Participate in unit meetings and activities"..."When the therapeutic milieu is functioning well, all members of the peer group are actively engaged in the task of the therapeutic community. This task is to focus on the individual and common problems of members of the peer group"...

The Director of Social Services indicated on 05/24/2010 at 1535 that the activity schedules are developed to use proactively such to aid in meeting patient social/psychological needs.

Interview with the unit 2NB charge nurse on 05/24/2010 at 1300 revealed this unit had a current census of 9 patients.

Review of the 05/24/2010 activity schedule for unit 2NB (latency) included the following:

Recreation Therapy from 1300-1400
Activity with MHT (mental Health Tech) from 1400-1500
Snack/Room Time from 1500-1600
Room Time from 1600-1630

Observation on 05/24/2010 revealed the MHT did not initiate the unit activity until 1525 (1 hour and 25 minutes later than scheduled).

House Supervisor stated on 05/24/2010 at 1425 that he had made the decision for the children to stay in their rooms until staff was available to lead the MHT activity. He indicated that the unit had 1 MHT at lunch and the "floater" MHT (MHT used between both latency units) was leaving leaving due to not feeling well.

Based on hospital policy review, observation, medical record review, medical staff executive committee review and staff interview, the licensed staff failed to provide supervision ensuring ADLs (activities of daily living) were rendered for 1 of 15 (#35) current patients reviewed, and failed to complete orders and monitoring for approved medication protocols in 1 of 21 closed records reviewed (#7).

The findings include:

1. Review of the hospital policy CLS090B, Personal Hygiene Assistance Tub Bath, Shower, Bed Bath, (reviewed 9/09) revealed ..."The nursing staff of _______ will assist patients as needed with personal hygiene to include tub baths, showers or bed baths to ensure patient cleanliness"...

Observation on 05/24/2010 at 1330 during tour of unit 2NB revealed that patient #35 had a build up of black dirt underneath his fingernails.

Review of the medical record for patient #35 revealed this 11 year old male had been involuntarily committed on 04/03/2010 for suicidal ideations, and injuring his mother with a knife after auguring over taking a shower. Record review also revealed a psychiatric history that included bipolar disorder and attention Deficit Hyperactive Disorder.

Interview with the unit 2NB charge nurse on 05/24/2010 at 1345 revealed this patient is self sufficient regarding his ADLs.

Medical record review revealed daily ADL flow sheets from 04/03/2010- 05/23/2010 revealed the patient ADLs are performed by himself without assistance.

Interview on 05/26/2010 at 1515 with unit 2NB nursing staff revealed staff was not supervising this patient to ensure that he was actually performing his ADLs.



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2. A review of the facility's medical executive committee meeting minutes dated 09/22/2008, revealed that the medication "Zyprexa (anti psychotic medication) suggested protocol was approved by the medical staff for use in patient care. The review of the "Zyprexa Protocol" revealed that "Vital Signs would be obtained four (4) times a day for 48 hours after each episode of needing a shot, Intake and Output would be obtained every eight (8) hours for 48 hours after each episode of needing a shot, and the laboratory studies obtained for Serum Creatinine, BUN (Blood Urea Nitrogen), Serum Sodium Chloride, Chlorine, Potassium, Urine Analysis and Hemoglobin Stat within 24 hours after an injection is required."

A closed medical record review on 05/25/2010 for patient #7, a 6 year old male, revealed that the patient was admitted to the facility on 03/06/2010 with a diagnosis of "Mood Disorder." The review of the patient's physician orders dated 03/06/2010 at 1745 revealed that the medication order "Zyprexia Protocol." Documentation review of the patient's medication administration record revealed that on 03/21/2010 at 2010 and 04/01/2010 at 1345, the patient received by the facility nursing staff the medication "Zyprexa 5 milligrams intramuscular (by injection)." Further review in the patient's medical record revealed that the facility's nursing staff failed to obtain vital signs four times a day for 48 hours, intake and output monitoring every 8 hours for 48 hours and any laboratory studies for the patient after the "Zyprexa" medication was administered by injection on 03/21/2010 and 04/01/2010. The review revealed that the facility's nursing staff did not follow the guidelines of the facility's approved "Zyprexa Protocol" when administering the medication by injection.

An interview on 05/25/2010 at 1420 with the nursing administrative staff revealed that the facility's nursing staff did not monitor the patient by the guidelines of the "Zyprexa Protocol" after administering the medication by injection. The interview also revealed that the staff should have followed the approved guidelines of the protocol.

Based on the facility's policy review, medical record review and staff interview, the facility's nursing staff failed to administer medications in accordance with physician orders for 1 of 36 sampled patients (#7).

The findings include:

A review of the facility's policy "Medication Administration" (reviewed 09/2009) revealed that "Medication preparation, administration and documentation are carried out in a consistent and safe manner by all licensed staff at the hospital." Further review of the policy revealed "The five rights of medication administration will be followed, the right amount, the right medicine, the right patient, the right time and the right route."

A closed medical record review on 05/25/2010 for patient #7, a 6 year old male, revealed that the patient was admitted to the facility on 03/06/2010 with a diagnosis of "Mood Disorder." The review of the patient's physician orders dated 03/06/2010 at 1745 revealed that the medication order "Zyprexa Protocol." Review of the patient's medication administration record (MAR) revealed that the medication Zyprexa (anti psychotic medication) was documented and ordered as "Zyprexa 5 milligram tablet, order one tablet by mouth every 4 hours as needed for agitation/aggression." The documentation review in the patient's MAR dated 03/17/2010 revealed that the patient was administered by the nursing staff the medication at 1500 and 1639 (total of 1 hour and 39 minutes between). The review also revealed that on 04/07/2010, the patient was administered the medication at 1630 and 2020 (total of 3 hours and 50 minutes between). The documentation revealed that the facility's nursing staff failed to administer the medication "Zyprexa" on 03/17/2010 and 04/07/2010 in accordance with the physician order of every 4 hours.

An interview with the nursing administrative staff on 05/25/2010 at 1430 revealed that the patient did receive the medication "Zyprexa" more often than every 4 hours on 03/17/2010 and 04/07/2010. The interview revealed that the nursing staff did not follow the physician orders and the five rights of medication administration.

Based on the facility's policy review, closed medical record review and staff interview, the facility's nursing staff failed to verify and determine that an verbal/telephone physician order was obtained by an authorized staff member before administering medications in 1 of 36 sampled patients (#9).

The findings include:

A review of the facility's policy "Medication Administration" (revised 09/2009) revealed that medication preparation, administration and documentation are carried out in a consistent and safe manner by all licensed staff at the hospital. The review revealed that "When there is doubt about an order, the physician is contacted." The review also revealed that "Physician's order must be checked against medication sheet before preparing a new order, stat order, or one-time order."

A closed record review on 05/20/2010 for patient #9 revealed that the patient was a 33 year old male admitted to the hospital on 05/12/2010 at 2133 with diagnosis of "Bipolar Mixed." The review revealed that on 05/13/2010 (no time documented) an unidentified staff member documented a telephone physician medication order written as follows;

"05/13/2010 (No documented time) TO (telephone order) Dr. XXXXX
Haldol 10 milligrams liquid times one now
Ativan 3 milligrams by mouth times one now
Cogentin 2 milligrams by mouth times one now
If patient refuses, intramuscular now times one."

The review of the telephone physician's order revealed that no time was documented when the order was obtained and that no documentation was made from the staff member obtaining the telephone order. No documentation was found in the medication record anywhere that indicated who obtained the telephone physician's order for the medication administration. The review of the medication administration record for the patient revealed that the patient was administered all of the medications by the facility's nursing staff on 05/13/2010 at 1015.

An interview with facility's nursing administration on 05/20/2010 at 1610 revealed that the facility was not able to determine the identity of the staff member obtaining the telephone physician order for the medications. The interviews with the nursing administration also revealed that they thought a "licensed practical nurse" working on the unit 05/13/2010 obtained the order, but an interview with the nurse was not able to be obtained to confirm. The interview with the nursing administration further revealed that the staff member should have documented his or her identity and the time that the order was obtained.

Based on hospital policy review, video recording review, medical record review and staff interview, the hospital staff failed to ensure accurate recording of patient monitoring for suicidal precautions and failed to ensure the integrity of author authentication for 1 of 36 records reviewed (#9).

The findings include:

Review of the hospital's "Precautions Record" policy, reviewed September 2009 revealed "A precautions record will be documented on all patients who are placed on precautions for suicide, homicide, elopement, withdrawal, or other reasons. Procedure... 3. All staff documenting on the Precautions Record will sign and initial in the designated area. ...5. The staff member assigned to the patient must document all criteria which apply to the patient's location and status as applicable to the patient's level of precautions."

Review of the hospital's "Level of Observation and special Precaution Policy" reviewed/revised July 2009 revealed "... Procedure ... 12.3 Level III-Observation on an every 15 minute frequency. The precautions that may be ordered include Suicide Precautions (SP).... This is the minimal level of observation and all patients are on 15 minute frequency observation on all three shifts. Guidelines for implementation of this level of observation include, but are not limited to, the following: 12.3.1 Staff should maintain visual and verbal contact sufficient to monitor the patient's condition on a 15 minute frequency level as ordered by the physician.... Medical Record documentation for this level of observation includes: 12.3.7 an Observation and Precaution Record, which reflects the patient's location and observed behaviors, is completed on the 15 minute frequency level that has been ordered.... Staff will complete the patient observation record as rounds are made, using the coding system described on the record: staff will observe the patient and note behavior and location.... In addition to recording the whereabouts of patients at ordered intervals, the purpose of observations is to provide a system of progressive intensity of patient observation, precaution and oversight based on patient acuity, severity and type of symptoms and overall needs."

A closed record review on 05/20/2010 for patient #9 revealed that the patient was a 33 year-old male admitted to the hospital (Unit 1-west) on 05/12/2010 at 2133 with a diagnosis of "Bipolar Mixed." Record review revealed the patient was admitted under petition of involuntary commitment. Review of the "Precautions Record" dated 05/13/2010 revealed the patient was on Suicide Precautions with every 15 minute checks. Review of the record revealed the patient was "lying or sitting in patient's room" on 05/13/2010 at 1515. Review revealed the patient was "walking or pacing in the hall" at 1530 and 1545. Further review revealed initials of the staff member recording the entries at 1515, 1530 and 1545. Review of nursing notes dated 05/13/2010 at 1400 recorded the patient was upset, hostile and threatening nursing staff because he was not able to use the phone. Notes recorded that the patient came to the nursing station and started beating on the counter, then started to break through the doors and a Code One (emergency behavior response) was called. Review of a social worker progress note dated 05/13/2010 at 1600 revealed the staff member had responded to a "Code Walker" (patient elopement). Review of the note revealed the patient had kicked through the door between Units 1-west and 1-north breaking the glass door. The note recorded that the police and family member were notified. Nursing notes dated 05/13/2010 at 1645 recorded that the patient became upset after being told that the physician would see him later and walked down the hallway kicked the door open and escaped. Record review revealed the patient was "administratively discharged" at 1800 on 05/13/2010.

Review on 05/21/2010 at 1015 of a video recording of Unit 1-west on 05/13/2010 revealed at 1514 patient #9 kicked a door open and left the unit. Review of another camera video recording of the hallway outside Unit 1-west revealed at 1515 patient #9 kicked a glass door open and eloped. Review of the video revealed the patient was not lying or sitting in the patient's room at 1515 as recorded on the "Precautions Record." Review revealed the patient was not walking or pacing in the hallway at 1530 and 1545 as recorded on the "Precautions Record."

Interview on 05/21/2010 at 1200 with the charge nurse assigned to the patient on 05/13/2010 revealed the staff member was not able to determine the time the patient eloped because he had failed to record the time of elopement in the medical record. The staff member was unable to identify the initials of staff that recorded the behavior and location of the patient on the "Precautions Record" on 05/13/2010 at 1515, 1530 and 1545.

Interview on 05/21/2010 at 1120 with a mental health technician assigned to Unit 1-west during the patient's elopement on 05/13/2010 revealed the documentation in the "Precautions Record" on 05/13/2010 at 1515, 1530 and 1545 were not his.

Interview on 05/21/2010 at 1130 with a mental health technician assigned to Unit 1-west during the patient's elopement on 05/13/2010 revealed the documentation in the "Precautions Record" on 05/13/2010 at 1515, 1530 and 1545 were not hers.

Interview on 05/21/2010 at 1240 with nursing administration staff revealed the initials of the staff member(s) that documented on the "Precautions Record" on 05/13/2010 at 1515, 1530 and 1545 were not able to be determined. The interview confirmed that based on the video recording review, the patient eloped at 1515 and the documentation on the "Precautions Record" was not consistent with the video and that some of the documentation was falsified. The staff member revealed that staff were not following hospital policies and procedures.

Based on observation and staff interviews the facility failed to store medication in accordance with accepted professional principles as evidenced by the storage of beverages in the medication refrigerator for 1 of 3 observed medication refrigerators (refrigerator #1).

The findings include:

Review of hospital "Policy #60, Storage of Medications (last revision 09/2008)" revealed no process for separating food and drink from drugs and biologicals requiring refrigeration and no other policy was provided addressing food and drink storage with drugs and biologicals.
Observation on 05/24/2010 at 1100 of the shared medication refrigerator #1 located between Units 2-East and 2-West revealed storage of 1 open soda can, 14 unopened soda cans, and 2 pitchers (tops covered with cellophane) of water stored with 1 vial of tuberculin purified protein derivative (PPD-medication used for Tuberculosis Skin Test) and 1 empty Ativan (medication used to treat anxiety) package. Observation further revealed a sign posted inside and outside of the medication refrigerator, stating "no food or drink allowed."
Interview on 05/24/2010 at 1100 with administrative staff during observation revealed that food and beverages should not be stored with medications.

Based on observations as referenced in the Life Safety reports of survey completed 04/28/2010 and 05/20/2010, policy review, observations during tour and staff interview, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

1. The hospital staff failed to ensure the safety and well being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~cross refer to 482.41(b)(1)(2)(3) Physical Environment, Standard Tag A0710.

2. The hospital staff failed to develop and maintain a safe physical plant and overall safe environment to assure the safety and well being of patients.

~cross refer to 482.41(a) Physical Environment, Standard Tag A0701.

3. The hospital staff failed to ensure the safety of patients by failing to ensure the proper function of emergency power and lighting systems.

~cross refer to 482.41(a)(1) Physical Environment, Standard Tag A0702.

4. The hospital staff failed to monitor medication storage equipment to ensure safety and quality for 2 of 3 medication refrigerators observed (refrigerator #1 and #2).

~cross-refer to 482.41(c)(2) Physical Environment Standard Tag A0724.

Based on observations as referenced in the Life Safety report of survey completed 05/20/2010, the hospital staff failed to develop and maintain a safe physical plant and overall safe environment assuring the safety and well being of patients.

The findings include:

Based on observation in Building 2 on 5/20/2010 between 12:00 PM and 4:30 PM, the annunicator panel for the generator for building 2 did not indicate the generator was supplying emergency power when tested under load.

~cross refer to Life Safety Code 2000 Health New K01.03, Standard NFPA 101, Tag K0146.

Based on observations as referenced in the Life Safety report of survey completed 05/20/2010, the hospital staff failed to ensure the safety of patients by failing to ensure the proper function of emergency power and lighting systems.

The findings include:

Based on observation on 5/20/2010 between 12:00 PM and 4:30 PM, the Battery powered emergency light was not provided for in the Main Electrical Room, Transfer Switch Room or at the generator.

~cross refer to Life Safety Code 2000 Health New K01.03, Standard NFPA 101, Tag K0045.

Based on observations as referenced in the Life Safety reports of survey completed 04/28/2010 and 05/20/2010, the hospital staff failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association assuring the safety and well being of patients.

The findings include:

1. Observation of Building One on 04/27/2010 between 1100 and 1700 the following was noted: on 1-west and 1-east there are a number of patient bedroom doors that did not close smoke tight in their frames.
This is waivered item with a waiver date of 7/27/2010.

~cross refer to Life Safety Code 2000 Health Existing K01.03, Standard NFPA 101, Tag K0018.

2. Observation on 5/20/2010 between 12:00 PM and 4:30 PM the following was noted: on 1-East, the patient storage room will need to meet the requirements for hazardous areas. At the time of the survey the room was not in compliance with this requirement.

~cross refer to Life Safety Code 2000 Health Existing K01.03, Standard NFPA 101, Tag K0029.

Based on policy review, observation, and pharmacy staff interview the facility staff failed to monitor medication storage equipment to ensure safety and quality for 2 of 3 medication refrigerators observed (refrigerator #1 and #2).

The findings include:

Review of hospital "Policy #60, Storage of Medications (last revision 09/2008)" revealed "Procedure: A. Storing of Medications - Nursing Units...2. Refrigerators...The temperature of each refrigerator on each nursing unit will be recorded by nursing personnel on a daily basis on a log sheet, which will be retained on the nursing unit. Refrigerator temperatures will also be monitored by the Department of Pharmacy during its monthly nursing unit inspections..."

Observation on 05/24/2010 at 1115 of medication refrigeration (#2) located in the House Supervisor's office revealed storage of "Insulin" and "Bicillin" medications.

Review on 05/24/2010 of "TEMPERATURE LOG ," for the medication refrigerator (#2) located in the House Supervisor's office and identified as "Special Considerations" revealed the sheet was for January-December 2010. Document revealed no temperature recordings from Jan. 1- May 12, 2010 of the "Special Considerations" medication refrigerator.

Observation on 05/24/2010 at 1115 revealed a medication storage Refrigerator #1 located
between Units 2-East and 2-West. Observation of the refrigerator temperature log for Refrigerator #1 revealed temperatures for month of May were not recorded on 5/16 and 5/18 (2 of 24 days).

Interview during observation on 05/24/2010 at 1115 with Pharmacy staff revealed she had been at the facility for 1 and 1/2 years and during this time daily temperatures were not monitored on medication refrigerator #2 prior to 05/13/2010 and medications were stored in refrigerator #2 prior to 05/13/2010.

Based on facility policy medical record review, and staff interview, the hospital's infection control officer failed to report communicable diseases the Public Health Department as required for 2 of 4 (#31, 36) patients reviewed who tested positive for sexually transmitted diseases.

The findings include:

Review of hospital policy IFC001, Infection Control Program, (reviewed 3/10) revealed the infection control coordinator will report communicable diseases as required by law.

Review of hospital policy IFC010, Reporting of Communicable Diseases, (reviewed 3/10) revealed that Chlamydial infection is required to be reported to the public Health Department within 7 days, and Syphilis is reportable within 24 hours.

1. Review of the medical record for patient #31 revealed this 16 year old male had been admitted to the hospital on 01/17/2010 for suicidal ideation. Record review revealed this patient had been tested for Syphilis with a positive RPR (Rapid plasma reagin-a blood test for syphilis that looks for an antibody that is present in the bloodstream when a patient has syphilis) result on 01/18/2010 and a reactive TPPA (Treponema pallidum particle agglutination assay- test used to confirm a syphilis infection after another method tests positive for the syphilis bacteria) of 1:12.8 on 01/19/2010. Medical record review revealed the Public Health Department was not notified until 01/23/2010 (96 hours after positive test results were received).
2. Review of the medical record for patient #36 revealed this 14 year old female had been admitted to the hospital on 02/02/2010 for psychosis and paranoia. Record review revealed this patient tested positive for Chlamydia on 02/08/2010. Medical record review revealed no documented evidence that the Public Health Department was notified.
Interview with the Interim Infection Control Coordinator on 05/25/2010 at 1545 revealed as of 05/10/2010, when the previous Infection Control Coordinator resigned, she has been "re-vamping" the systems in place for reporting communicable infections. Interview also revealed no documented evidence that the Public Health Department had been notified as required for the respective patients.

Based on the facility's medical staff rules and regulations review, closed and open medical record review and staff interview, the facility failed to ensure that the medical staff performed a neurological screening examination in 5 of 36 sampled patients (#25, 9, 22, 6, 34).

The findings include:

A review of the facility's medical staff rules and regulations (approved 07/30/2009) revealed that "Within 24 hours of admission, the complete physical examination shall be performed according to medical record guidelines and approved clinical privilege guidelines." The review further revealed that cranial nerves for adults should be included in the History and Physical examination. The review revealed no evidence that the medical staff rules and regulations included cranial nerves for all patient History and Physical examinations.

1. Review on 05/24/2010 of the open medical record for patient #25, a 19 year old male, revealed this patient was admitted on 05/15/2010. Record review revealed diagnoses that included Psychosis for the patient. Record review revealed a History and Psychiatric Evaluation had been conducted by the physician on 05/16/2010. Review of the History and Psychiatric Evaluation revealed no documented evidence that this patient's cranial nerves had been evaluated. Review of the History and Psychiatric Evaluation revealed the Cranial Nerve section of the evaluation had been left blank.

An interview on 05/24/2010 at 1500 with the facility's administrative staff revealed that the facility's medical staff failed to complete the patient's Cranial Nerve section of the History and Physical evaluation.

2. Review on 05/24/2010 of the closed medical record for patient #9, a 33 year old male, revealed this patient was admitted on 05/12/2010. Record review revealed diagnoses that included Bipolar Mixed for the patient. Record review revealed a History and Psychiatric Evaluation had been conducted by the physician on 05/13/2010. Review of the History and Psychiatric Evaluation revealed no documented evidence that this patient's cranial nerves had been evaluated. Review of the History and Psychiatric Evaluation revealed the Cranial Nerve section of the evaluation had been left blank.

An interview on 05/24/2010 at 1500 with the facility's administrative staff revealed that the facility's medical staff failed to complete the patient's Cranial Nerve section of the History and Physical evaluation.

3. Review on 05/24/2010 of the open medical record for patient #22, a 53 year old female, revealed this patient was admitted on 05/01/2010. Record review revealed diagnoses that included Schizoaffective for the patient. Record review revealed a History and Psychiatric Evaluation had been conducted by the physician on 05/01/2010. Review of the History and Psychiatric Evaluation revealed no documented evidence that this patient's cranial nerves had been evaluated. Review of the History and Psychiatric Evaluation revealed the Cranial Nerve section of the evaluation had been left blank.

An interview on 05/24/2010 at 1500 with the facility's administrative staff revealed that the facility's medical staff failed to complete the patient's Cranial Nerve section of the History and Physical evaluation.

4. Review on 05/24/2010 of the closed medical record for patient #6, a 23 year old male, revealed this patient was admitted on 04/04/2010. Record review revealed diagnoses that included Bipolar Manic for the patient. Record review revealed a History and Psychiatric Evaluation had been conducted by the physician on 04/05/2010. Review of the History and Psychiatric Evaluation revealed no documented evidence that this patient's cranial nerves had been evaluated. Review of the History and Psychiatric Evaluation revealed the Cranial Nerve section of the evaluation had been left blank.

An interview on 05/24/2010 at 1500 with the facility's administrative staff revealed that the facility's medical staff failed to complete the patient's Cranial Nerve section of the History and Physical evaluation.



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5. Review of the open medical record for patient #34, a 12 year old female, revealed this patient was involuntarily committed on 05/22/2010. Record review revealed diagnoses that included attention deficit and hyperactivity disorder and mood disorder. Record review revealed a History and Psychiatric Evaluation had been conducted by the physician on 05/23/2010. Review of the History and Psychiatric Evaluation revealed no documented evidence that this patient's cranial nerves had been evaluated. Review of the History and Psychiatric Evaluation revealed the Cranial Nerve section of the evaluation had been left blank.

An interview on 05/24/2010 at 1500 with the facility's administrative staff revealed that the facility's medical staff failed to complete the patient's Cranial Nerve section of the History and Physical evaluation.

Based on hospital policy review, activity schedule review, observation and staff interview, the hospital failed to ensure therapeutic activities were provided as scheduled to patients on 1 of 8 (2NB) units toured.

The findings include:

Review of the hospital policy CLS002, Milieu Management Guidelines, (reviewed 9/09) revealed ..."There is an expectation that community members will participate in activities"..."The role of the patient is to: Participate in unit meetings and activities"..."When the therapeutic milieu is functioning well, all members of the peer group are actively engaged in the task of the therapeutic community. This task is to focus on the individual and common problems of members of the peer group"..."some critical needs of patients are the need for recreation"...

Review of the 05/24/2010 activity schedule for unit 2NB (latency) included the following:

Recreation Therapy from 1300-1400
Activity with MHT (mental Health Tech) from 1400-1500
Snack/Room Time from 15500-1600
Room Time from 1600-1630

Interview with the unit 2NB charge nurse on 05/24/2010 at 1300 revealed this unit had a current census of 9 patients.

Observation on 05/24/2010 at 1335 during the patient observation tour revealed that of the 9 patients housed on unit N2B, only 3 patients were in the gym receiving Recreation Therapy.

The unit 2NB charge nurse stated on 05/24/2010 at 1425 that 6 of the 9 patients were on unit restriction, and therefore, were not allowed to leave the unit as punishment for their inappropriate behavior on 05/23/2010. Interview revealed that unit restriction could be implemented by any staff when warranted for inappropriate behaviors.

The Director of Social Services indicated on 05/24/2010 at 1535 that the activity schedules are developed to use proactively such to aid in meeting patient social/psychological needs. Interview also revealed that if the patients were on unit restriction, the Director of Social Services should have been notified such that the patients could have received Recreation Therapy on the unit. Interview revealed the Director of Social Services had no knowledge that the respective patients had been placed on unit restriction and did not receive Recreation Therapy.

Observation during unit tour on 05/24/2010 from 1330-1640 revealed 6 of the 9 patients housed on unit 2NB were in their rooms until 1510 when they were instructed to come out of their rooms for snacks.

Interview with the "floater" MHT on 5/24/10 at 1455 revealed the patients on unit restriction had been in their rooms since 1330.

Observation revealed at 1525 the MHT activity initiated (1 hour and 25 minutes later than scheduled).

House Supervisor stated on 05/24/2010 at 1425 that he had made the decision for the children to stay in their rooms until staff was available to lead the MHT activity. He indicated that the unit had 1 MHT at lunch and the "floater" MHT (MHT used between both latency units) was leaving leaving due to not feeling well.

The Director of Social Services stated on 05/24/2010 at 1535 that she had no knowledge that the unit activities were not conducted as scheduled.