HospitalInspections.org

Based on observation, interview and record review the hospital failed to ensure that an effective governing body was responsible for the conduct of the hospital.

1. The hospital failed to provide an effective governing body to ensure that patient care services were conducted in a safe manner when Patient #4 attempted to elope the hospital on 02/19/23. The hospital failed to implement precautions after the attempt and the patient succeeded in leaving the facility a day later, on 02/20/23. Patient #4 eloped with Patient #1 and remained away from the hospital for approximately four hours to be returned by police and Patient #1 was found with an unknown substance on his body at that time.

2. On 02/20/23, Patient #1 and Patient #4 eloped through a gate in the the patient courtyard and left the hospital grounds. Prior to the elopement the hospital had failed to identify as a potential risk for elopement.

3. On 02/22/23 the hospital placed Patient #1 in an ambulance for complaints of arm pain. The hospital did not facilitate a transfer of the patient. The physician then wrote an order to discharge the patient without discharge planning or follow-up. When the receiving facility attempted to return Patient #1 to the hospital, the hospital refused to take the patient back.

4. The hospital failed to provide adequate patient supervision for adolescent and preadolescent patients . On 02/26/23 Patient #3 and Patient #5 engaged in sexual activity. On 3/1/23 Patient #5 inappropriately touched Patient #11. Patient #11 required a transfer to another hospital.

Cross refer A083.

Based on record review and interview the hospital's governing body failed to ensure that services proved on the hospital's adolescent unit meet the health and safety of patients.

1. 2 of 11 (Patient #1 and Patient #4) were able to gain access to a stairwell and elope from the hospital through a gate in the courtyard.

2. 2 of 11 (Patient #3 and Patient #5) patients were left unsupervised and allowed to engage in sexual activity. 1 of 11 (Patient #5) was left unsupervised and was able to engage with inappropriate touching with Patient #11.

3. 1 of 11 (Patient #4) patients attempted to elope the hospital and the patient was not placed on elopement precautions until the next day after they were able to elope from the hospital on 02/20/23.

4. 1 of 11 (Patient #1) patients was discharged from the hospital without discharge planning or follow-up services.

Findings include:

On 02/19/23 Patient #4's Multidisciplinary Progress note reflected..."1505 Pt. (patient ) in the dayroom screaming, yelling, punching and kicking walls and doors in an attempt to elope..." There were no corresponding orders for elopement precautions.

On 02/20/23 Patient #4's Shift Progress Note reflected..."At about 1612 patient Eloped out of the building..." The Physician's Orders reflected an order without a date, that was written in between orders that were written on 02/20/23 timed at 1616..."Place pt. on Q5 (every 5) checks, UR, (unit restriction), elopement Precautions. TORB (Telephone Order Read Back)..."

On 02/20/23 Patient #1's Shift Progress Note reflected..."At about 1612 patient Eloped out of the building..."

On 02/22/23 Patient #1's Progress Note reflected..." the patient was aggressive and demanded to be taken to the hospital because he could not feel his hand. At about 1130 the patient left the hospital via ambulance and was discharged per the doctors orders. There was no documented assessment by the nurses or a physician of the patient's hand. The discharge order dated 02/22/23 and untimed reflected..."Treatment incomplete..." The Discharge Nursing Assessment/Summary undated and untimed did not evidence the destination the patient was to be discharged to, the mode of transportation, who the patient was to be discharged to, or the patients condition on discharge. Patient #1 was transferred to this hospital for psychiatric treatment from another state.

On 2/26/23 Patient #5 was allowed to visit Patient #3's room without staff intervention. At 1550, Patient #5 could not be located and was eventually located leaving Patient #3's bathroom with Patient #3. Patient #3 and Patient #5 stated they were just talking. Later that shift, Patient #3 called mother to report having sexual intercourse with Patient #5. Patient #3 was transported for an emergency rape evaluation shortly after that. Patient #5 was placed on SAO precautions on 2/27/23 at 2115. On 3/1/23 Patient #5 admitted to inappropriately touching Patient #11 by touching private parts and kissing on the lips and cheeks. Patient #5's Patient Observation Sheet for 2/25/2023 reflected the following, 38 out of 51 fifteen-minute checks were not completed. Risk Flags: SI (Suicide), Patient #5's Patient Observation Sheet for 2/26/2023 reflected the following, 6 out of 96 fifteen-minute checks were not completed. Risk Flags: SI (Suicide), Patient #5's Patient Observation Sheet for 2/27/2023 reflected the following, 58 out of 96 fifteen-minute checks were not completed. Risk Flags: SI (Suicide), Patient #5's Patient Observation Sheet for 2/28/2023 reflected the following, 59 out of 96 fifteen-minute checks were not completed. Risk Flags: SI (Suicide)
Patient #5's Patient Observation Sheet for 3/1/2023 reflected the following, 11 out of 63 fifteen-minute checks were not completed. Risk Flags: SI (Suicide).

During an interview on 03/06/23 at 1405 Personnel #1 stated they were concerned when the patients eloped because one of them only had on pants and no shoes. The patients were in paper scrubs and it was getting cold outside. Personnel #1 stated when Patient #1 was discharged from the hospital the police called the ambulance when they arrived at the hospital. The police had been called because the patient was out of control. Personnel #1 confirmed that none of that information was reflected in Patient #1's medical record.

During an interview on 03/08/23 at 1000 Personnel #6 confirmed that Patient #4 was not placed on elopement precautions after attempting to elope on 02/19/23.

During an interview on 3/8/2023 at 1200, Personnel #12 confirmed the facility changed from paper observation checks to electronic observation checks with Observsmart at the end of February. Personnel #12 confirmed that there are gaps in the observation sheets and have a meeting scheduled to verify if data can be recovered. Email received on 3/9/2023 at 1151 from Personnel #12 reflected the following, "Upon review we checked with IT and Observsmart and sadly we are out of compliance with the observations."

The hospital Clinical Services Policy and Procedure titled "Observation Level & Precaution Protocol" (#1043) reflected the policy that "Patient precautions and monitors will be ordered by the physician and initiated by the registered nurse (RN).... patient precautions for monitoring include, but are not limited to, safety...sexually acting out (SAO) ...the purpose of precaution monitoring is to provide protection to the patient and to maintain a safe and therapeutic patient care environment ...specific precautions ...shall be documented in the patient's medical record..." (p.1). The procedure called for "staff making rounds shall observe patients' activity, behavior, whereabouts, and document observations as indicated ...concerns for patient safety and/or risk shall be reported immediately to the nurse..." (p. 2).

Based on record review and interview the hospital failed to protect the rights of each patient and failed to provide a safe environment for 5 of 5 (Patients # 1, #3, #4, #5, and #11) patients.

1) On 02/19/23 Patient #4 attempted to elope the facility and elopement precautions were not implemented. On 02/20/23 Patient #4 was able to elope the building with Patient #1.

2). On 02/26/23 Patient #3 and Patient #5 were left unsupervised and engaged in sexual activity.

3) On 03/02/23 Patient #5 was left unsupervised while on sexually acting out (SAO) precautions and engaged in inappropriate touching of Patient #11.


Cross refer A0144.

Based on record review and interview the hospital failed to ensure that a safe environment was provided for 5 out 5 (Patients #1, #3, #4, #5 and #11) patients.

Findings included:


On 02/19/23 Patient #4 attempted elope from the facility by kicking and pushing on doors. No elopement precautions were order for Patient #4. On 02/20/23 Patient #4 was able to elope with Patient #1 by busting through doors, running down the stairwell, pulling the fire alarms and going outside to the courtyard where they busted through a gate and left the hospital property. The patients were wearing paper scrubs and no shoes. The Physicians Orders for Patient #1 and Patient #4 reflected an order for elopement precautions on 02/20/23 at 1616 after they eloped the hospital at 1612.

On 2/26/23 Patient #5 was allowed to visit Patient #3's room without staff intervention. At 1550, Patient #5 could not be located and was eventually located leaving Patient #3's bathroom with Patient #3. Patient #3 and Patient #5 stated they were just talking. Later that shift, Patient #3 called mother to report having sexual intercourse with Patient #5. Patient #3 was transported for an emergency rape evaluation shortly after that. Patient #5 was placed on SAO precautions on 2/27/23 at 2115. On 3/1/23 Patient #5 admitted to inappropriately touching Patient #11 by touching private parts and kissing on the lips and cheeks. Patient #5's Patient Observation Sheet for 2/25/2023 reflected the following, 38 out of 51 fifteen-minute checks were not completed. Risk Flags: SI (Suicide), Patient #5's Patient Observation Sheet for 2/26/2023 reflected the following, 6 out of 96 fifteen-minute checks were not completed. Risk Flags: SI (Suicide), Patient #5's Patient Observation Sheet for 2/27/2023 reflected the following, 58 out of 96 fifteen-minute checks were not completed. Risk Flags: SI (Suicide), Patient #5's Patient Observation Sheet for 2/28/2023 reflected the following, 59 out of 96 fifteen-minute checks were not completed. Risk Flags: SI (Suicide), Patient #5's Patient Observation Sheet for 3/1/2023 reflected the following, 11 out of 63 fifteen-minute checks were not completed. Risk Flags: SI (Suicide).

During an interview on 03/06/23 at 1405 Personnel #1 stated they were concerned when the patients eloped because one of them only had on pants and no shoes. The patients were in paper scrubs and it was getting cold outside.

During an interview on 03/08/23 at 1000 Personnel #6 confirmed the above findings.

During a personal interview on 3/8/2023 at 1200, Personnel #12 confirmed the facility changed from paper observation checks to electronic observation checks with Observsmart the end of February. Personnel #12 confirmed that there are gaps in the observation sheets and have a meeting scheduled to verify if data can be recovered. Email received on 3/9/2023 at 1151 from Personnel #12 reflected the following, "Upon review we checked with IT and Observsmart and sadly we are out of compliance with the observations."

The policy titled AWOL Elopement effective 07/17/19 reflected..."Patients at Risk...A. The registered nurse will notify the attending psychiatrist of a patient who demonstrates elopement risk..."

The hospital Clinical Services Policy and Procedure titled "Observation Level & Precaution Protocol" (#1043) reflected the policy that "Patient precautions and monitors will be ordered by the physician and initiated by the registered nurse (RN).... patient precautions for monitoring include, but are not limited to, safety...sexually acting out (SAO) ...the purpose of precaution monitoring is to provide protection to the patient and to maintain a safe and therapeutic patient care environment ...specific precautions ...shall be documented in the patient's medical record..." (p.1). The procedure called for "staff making rounds shall observe patients' activity, behavior, whereabouts, and document observations as indicated ...concerns for patient safety and/or risk shall be reported immediately to the nurse..." (p. 2).

Based on record review the hospital failed to have an organized nursing services.

1. Nursing failed to assess 2 of 2 (Patient #1 and #4) patients according to their needs and hospital policy. Patient #1's and Patient #4's hand injuries did not evidence nursing wound assessments. The patients vitals signs were not assessed according to hospital policy after a change of patient condition or status.

Cross Refer A395

2. Nursing failed to follow hospital policy and authenticate verbal telephone orders for psychotropic medications for 3 of 11 patients.

Cross Refer A407

3. Nursing failed to address nursing needs of 2 of 2 (Patient #1 and #4) patients whose care plans did not reflect the patients' acute hand injuries for assessment and interventions.

Cross Refer A1640

Based on record review and interview the nurses failed


1. To assess a patient according to their needs (Patient #1). Patient #1 had been admitted with stitches in his left hand after he hit a plastic box in the Emergency Department (ED) during a prior visit at the medical hospital. The patient arrived with 6 stitches on his left hand and complained of numbness on two occasions. Nursing failed to evaluate the condition of his hand following his admission.

2. To evaluate the care of patient #4. Patient #4 was admitted 02/14/23, injured his hands five days into his hospitalization, and was bleeding. Nursing failed to evaluate the condition of Patient #4's hands for the following 72 hours.

3. To follow doctors orders and hospital policy to perform routine vital signs on 2 of 2 (Patient #1 and #4) patients. Patient #1's vital signs were taken only once during his four day hospitalization. The patient required emergency medication on two occasions and vital signs taken according to hospital policy.
Patient #4 required emergency medication on two occasions and vital signs were not taken according to hospital policy.

Findings included:

1. Patient #1 was admitted to the hospital on 02/18/23. Patient #1's Admission Nursing Assessment diagram reflected the patient arrived at the hospital with stitches in their left hand. The Nursing Shift Progress and Assessment Notes dated 02/18/23 through 02/22/23 reflected ..."Skin No issues reported/Noted..." There was no evidence of a wound assessment.
The Shift Progress Note dated 02/20/23 at "about 1430"[sic] Patient #1 was noted to "...demand to be taken to the hospital....he can't feel his hand." There was no evidence the nurse evaluated the condition of Patient #1s hand at that time. The notes reflected that following the patient's complaint, Patient #1 required emergency medication and seclusion over the following five hours.
The Shift Progress Notes dated 02/22/23 at 0955 reflected Patient #1 made a second outcry of numbness in his left hand and demanded to be taken to the hospital. There was no evidence of a nursing assessment of Patient #1's hand. The notes reflected at that time that Patient #1 was threatening staff and peers and throwing chairs. Approximately 90 minutes later the patient was transported to the hospital via ambulance.

During an interview on 03/06/23 at 1330 Personnel #6 acknowledged the above findings.

During an interview on 03/06/23 at 1415 Personnel #1 stated the hospital did not call the ambulance. The hospital called the police. The police facilitated the hospital transfer.

2. The Physician's Orders for Seclusion/Physical Restraint/Emergency Medication packet dated 02/19/23 reflected at 1500 the patient was placed into seclusion. the face to face evaluation timed 1516 reflected..."hitting walls/attempting to elope...lacerations on bilateral hands after pt. (patient) began hitting walls and doors...lacerations on bilateral hands after hitting walls and doors..."
The Nursing Shift Progress and Assessment Notes dated 02/19/23 through 02/22/23 reflected..."Skin No issue reported/Noted..."

During an interview on 03/06/23 at 1330 Personnel #6 acknowledged the above findings.

3. Patient #1's admission orders dated 02/18/23 at 0308 reflected..." Vital Signs: Routine...". The Vitals Flow Sheet reflected one entry for vital signs on 02/18/23 at 1230. The Shift Progress Note dated 02/22/23 at 1130 reflected the patient was discharged via ambulance.

The admission order for Patient#4 dated 02/14/23 at 1820 reflected...Vital Signs: Routine..." The Vitals Flow Sheet reflected the patient had vital signs taken on 02/15/23, 02/16/23, 02/17/23 and 02/22/23 only once a day.

During an interview on 03/06/23 at 1330 Personnel #6 acknowledged the above findings.

During an interview on 03/06/23 at 1330 Personnel #6 acknowledged the above findings.

The policy titled Performing Routine Vitals effective 07/17/19 reflected..."Routine vital signs will be measured on all patients a minimum of twice daily..."

The policy titled Assessment and Reassessment of Patients effective 07/17/19 reflected..."An accurate record of the patient's condition, care and treatment is provided throughout the hospital visit...Reassessments of patients are to completed when there is a significant change in patient conditions or status..."

Based on record review and interview the nursing staff have received multiple verbal/telephone orders for 3 of 11 (Patient #1, #4, and #5) patients. The orders are not signed or authenticated by the physician.

Findings included:

The Physician's Orders for Patient #1 reflected on 02/20/23 at 1549 and 2025 there was an order for Zyprexa 5 mg and Benadryl 50mg IM X1. The order is noted as being TORB (telephone order read back). There is no physician's signature on the orders. On 02/21/23 there was an order for Zyprexa 10mg and Benadryl 50mg IM Now . The order was noted as being TORB. This order was signed on 03/06/23 in front of this surveyor while interviewing Personnel #2. The Physician's Orders reflect 4 orders from 02/20/23 at 1616 until 02/21/23 at 1450. All of the orders were verbal orders, 3 of the orders were for medication.

The Physician's Orders for Patient #4 reflected on 02/20/23 at 1549 and 2026 there was an order for Zyprexa 5 mg and Benadryl 50mg IM X1. The order is noted as being TORB (telephone order read back). There were 5 orders on the patient's chart for 02/20/23, 3 orders are verbal orders and 2 orders are for medication.

The Physician's Orders for Patient #5 reflected on 02/25/23 at 1720 there was an order for Benadryl 25 mg IM X1 or 25 mg PO X1 for psychosis. The order was noted as being TORB. On 02/28/23 at 1251 there was an order for Vistaril 25mg PO X! now. The order is noted as being TORB. There was no physician's signature on the order. On 02/28/23 at 1350 there was an order to cancel the previous order and give Vistaril 25 mg PO Q6 hours PRN. (by mouth every 6 hours as needed). From 02/25/23 at 1720 through 02/28/23 at 1350 there were 5 orders; 4 orders are verbal orders and 3 of those orders are for medication.

During an interview on 03/08/23 at 1000 Personnel #6 and Personnel #12 verified the orders that did not have physician signatures times and dates. Personnel #6 stated so many of the orders are because the physicians come in early in the day and then leave.

The policy titled Orders: Physician effective 07/17/19 reflected..a. All orders must be dated, timed, and authenticated. A. All verbal and/or telephones must be dated, timed and authenticated within 2 days by the ordering physician..."

Based on observation and record review the hospital failed to provide discharge planning for 2 of 11 (Patient #1 and #11) patients.

Findings included:

Patient #1, a 17-year-old male, was admitted on 02/18/23 from an out of state acute care facility. Patient #1 was discharged from the hospital via ambulance to an acute care hospital on 02/22/23. The medical record did not evidence hospital personnel contacting the receiving hospital to relay the patient's current treatment or medications. Patient #1's medical record evidenced an untimed order on 02/22/23 to discharge Patient #1. Patient #1's medical record did not evidence any follow-up medical care or appointments. The Discharge Nursing Assessment/Summary dated 02/22/23 and untimed did not evidence a discharge destination, a mode of transportation, a person contacted prior to discharge or the patient's condition on discharge. The receiving hospitals medical record reflected this Hospital A refused to take the patient back after the receiving Hospital B had completed treatment for the patient's complaint of not being able to feel their hand.

During on interview on 03/06/23 at 1410 Personnel #1 stated the police were called to the facility because the patient was out of control. The police are the ones that called the ambulance to transport the patient to acute care Hospital B. Personnel #1 verified that none of this information was documented in the medical record.

During an interview on 03/08/23 at 1000 Personnel #6 verified there was no discharge planning documented in the medical record.

Based on interview and record review the hospital failed to have an individualize, comprehensive treatment plan on 2 of 11 (Patient #1 and #4) patients.

Findings included:

Patient #1, a 17-year-old male, was admitted to the hospital on 02/18/23 from an out of state acute care hospital. Patient #1's admission assessment reflected the patient had stitches in their left hand. The initial treatment plan did not address the patient had stitches in their hand.

Patient #4, a 13-year-old male, was placed in seclusion on 02/19/23. While in seclusion Patient #4 sustained lacerations to both hands while hitting the walls in the seclusion room. Patient#4's treatment plan was not updated to address the treatment of the hand lacerations.

During an interview on 03/08/23 at 1000 Personnel #6 and Personnel #12 confirmed the nurses did not update the treatment plans to reflect the patients' hands lacerations.