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Based on document review, staff interview and observation it was determined the facility failed to ensure patients were cared for in a safe setting; the facility failed to ensure staff followed protocol when taking patients outside for yard activities; the facility failed to ensure fencing was not damaged, which allowed for the opportunity to elope; the facility failed to ensure the gate was fully closed, even when locked, which allowed for elopement; the facility failed to ensure video monitoring was consistent and remained turned on, which resulted in gaps of up to thirty (30) minutes of blank video; the facility failed to ensure supervision of patients in the yard area; the facility failed to ensure staff dispersed around the yard area when patients were present; and, the facility failed to follow its policy for staffing yard activities when patients are outside in the yard (see Tag A 144).

A. Based on record review, document review and staff interview it was determined the facility failed to ensure care was provided in a safe setting relative to appropriate monitoring for three (3) of eleven (11) records reviewed (patients #8, 9 and 10). This failure has the potential to result in harm for all patients when adequate monitoring does not occur.

Findings include:

1. Review of the hospital's policy entitled, "Patient Monitoring", last revised 5/14, states, in part: "Hospital staff closely monitor all patients at a minimum of 15 minute intervals."

2. The medical record for patient #8 was reviewed on 4/28/15 and revealed the monitoring sheet used for the q (every) fifteen (15) minute checks was not documented on 3/13/15 at 7:00 a.m. and 7:15 a.m.

The above record was reviewed with the Director of Patient Care Services during an interview on 4/30/15 at 9:55 a.m. and she agreed with the findings.

3. The medical record for patient #9 was reviewed on 4/29/15 and revealed the monitoring sheets used for the q fifteen (15) minute checks were not documented for the following dates and times: 3/13/15 at 7:00 a.m. and 7:15 a.m.; 4/25/15 at 2:15 p.m., 2:20 p.m. and 2:45 p.m.; 4/27/15 at 5:30 p.m. and 5:45 p.m.; and, 4/29/15 at 6:45 a.m.

The above record was reviewed with the Director of Patient Care Services during an interview on 4/30/15 at 9:55 a.m. and she agreed with the findings.

4. The medical record for patient #10 was reviewed on 4/29/15 and revealed the monitoring sheet used for the q fifteen (15) minute checks was not documented on 3/13/15 at 7:00 a.m. and 7:15 a.m.

The above record was reviewed with the Director of Patient Care Services during an interview on 4/30/15 at 9:55 a.m. and she agreed with the findings.



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B. Based on document review, observation and staff interview it was determined the facility failed to ensure patient care was provided in a safe setting in one (1) of eleven (11) patients who received care at the facility. This failure has the potential to negatively impact all patients who require care at the facility.

Findings include:

1. A review of the policy entitled, "Activities therapy-Yard", last reviewed 12/2014, states, in part: "At least three (3) staff must be present to take the patients into the yard. They stay with the patients and do not sit apart from the group".

2. A review of the policy entitled, "Patient Care Shift Assignments", last revised on 9/2014, states, in part: "assignments of nursing care and interventions will be made by the designated shift charge nurses...".

3. In interviews with the Adolescent Unit Manager on 4/27/15 at about 8:00 a.m. and Registered Nurse (RN) #1 on 4/28/15 at about 3:15 p.m., it was revealed the staff did not follow the policy for Activities by having three (3) staff in the yard with patients. They further agreed the expectation is for one (1) of the staff accompanying patients to be a licensed nurse, and a count of the patients is to be confirmed by two (2) staff members before leaving and returning to the unit, which was not done.

4. During an observation of the facility yard area on 4/29/15 at about 3:00 p.m., it was determined the fence enclosing the area was damaged enough that patients could elope through it. The back fence had an area bent down approximately two (2) feet deep and four (4) feet wide. There was a large wooden post placed in front of the bent area. It was also noted there were numerous small gaps at the bottom of the fence all the way around, some up to about a foot high.

5. During an observation of the facility yard area on 4/29/15 at about 3:00 p.m., it was determined the gate on the right of the entry to the yard had a large gap at the top about a foot high. The gate is locked but when pushed forward the gap widens to about a foot and a half. The Quality and Risk Management Director stated she climbed this gate to demonstrate to other facility staff how easy it would be for a patient to elope by this gate.

6. A review of the staff assignment sheet for the 4/6/15 evening shift (3 p.m. - 11 p.m.) revealed RN #1 had assigned three (3) Behavior Health Technicians (BHTs) and one (1) Licensed Practical Nurse (LPN) to accompany the patients off the Adolescent Unit to the yard area for activities time.

7. In an interview with RN #1 on 4/28/15 at about 3:15 p.m., she agreed she had not made sure all four (4) staff went off the unit with the patients and only two (2) staff had gone to the yard with the patients. She stated she had not ensured the LPN went with the patients and had allowed the third BHT to remain on the floor.

8. In an observation on 4/29/15 at about 12:50 p.m., two (2) state agency (SA) surveyors observed the facility yard area where four (4) staff were sitting in the yard in the entry corner on the picnic table/bench area while most of the patients were in the opposite diagonal corner (approximately seventy (70) feet away).

9. During an interview with BHT #1 on 4/28/15 at about 1:20 p.m., she revealed she was one of the staff members assigned to escort patients to the yard on 4/6/15 and agreed two (2) staff escorted the patients even though policy states a minimum of three (3) staff must accompany patients for activities in the yard. She stated she "didn't want to make trouble". She stated BHT #2 was more experienced and he 'knew what he was doing'. She also revealed she did not confirm the patient count with BHT #2 when returning to the unit on 4/6/15.

10. In an interview with BHT #2 on 4/28/15 at about 2:55 p.m., it was revealed he reported to RN #1 he was taking eleven (11) patients to the yard. He admitted he did not confirm the patient count with BHT #1 on return to the unit at about 7:41 p.m. on 4/6/15.

10. In an interview with the Director of Quality and Risk Management on 4/28/15 at about 2:40 p.m., she stated the video monitoring in the yard was erratic and turns off intermittently, leaving gaps of up to thirty (30) minutes of patient video monitoring blank. She revealed the video monitor turned itself off on 4/6/15 during the last thirty (30) minutes of yard time and there is no record of the patient eloping from the facility.

11. On 9/15/14, the facility was previously cited at tag A 144 (providing a safe setting for patient care) for the same scenario of a patient not being monitored per their own policy in the yard area. No change was completed to this policy. There are no other policies at the facility that address safe patient care in the yard area.

Based on document review and staff interview it was determined the facility failed to ensure the Quality and Risk Manager could provide evidence of Quality Assurance/Performance Improvement (QA/PI) monitoring related to each service the facility provides. This failure creates the potential for the care and condition of all patients to be adversely impacted.

Findings include:

1. A review of the QA/PI plan for 2014 revealed there was no evidence of each service the facility provides performing QA/PI monitoring activities.

2. In an interview with the Director of Quality and Risk Management on 4/29/15 at about 1:15 p.m., she agreed the facility does not have every department performing QA/PI monitoring activities.

Based on document review and staff interview it was determined the facility failed to ensure the Governing Body approved a distinct number of improvement projects for the year. This failure has the potential to negatively affect all patients by not monitoring patient safety.

Findings include:

1. Review of the Quality Assessment/Performance Improvement plan for 2014 revealed the Governing Body did not approve a distinct number of improvement projects to be conducted annually.

2. An interview was conducted with the Director of Quality and Risk Management on 4/29/15 at 1:15 p.m. and she revealed the facility only had "focus areas".

Based on document review and staff interview it was determined the facility failed to ensure an adequate number of licensed staff and other personnel were available to provide nursing care to all patients served by the hospital during fifty (50) out of fifty-one (51) days from 3/8/15 through 4/27/15. This failure has the potential to negatively impact the quality of patient care and the safety of all patients.

Findings include:

1. Review of the staffing sheets for 3/8/15 through 4/27/15 revealed inadequate staffing for twenty-nine (29) days on the 7:00 a.m. to 3:00 p.m. shift (3/8, 3/11, 3/13, 3/14, 3/15, 3/16, 3/17, 3/19, 3/20, 3/21, 3/22, 3/23, 3/25, 3/26, 3/27, 3/30, 3/31/15, 4/1, 4/3, 4/4, 4/14, 4/17, 4/18, 4/19, 4/20, 4/21, 4/22, 4/23 and 4/27/15).

2. Review of the staffing sheets for 3/8/15 through 4/27/15 revealed inadequate staffing for thirty-eight (38) days on the 3:00 p.m. to 11:00 p.m. shift (3/11, 3/12, 3/13, 3/14, 3/15, 3/16, 3/17, 3/18, 3/19, 3/20, 3/23, 3/24, 3/26, 3/27, 3/29, 3/30, 3/31, 4/1, 4/2, 4/3, 4/4, 4/5, 4/6, 4/8, 4/9, 4/10, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 4/22, 4/23, 4/24, 4/25 and 4/26/15).

3. Review of the staffing sheets for 3/8/15 through 4/27/15 revealed inadequate staffing for fifty (50) days on the 11:00 p.m. to 7:00 a.m. shift (3/8, 3/9, 3/11, 3/12, 3/13, 3/14, 3/15, 3/16, 3/17, 3/18, 3/19, 3/20, 3/21, 3/22, 3/23, 3/24, 3/25, 3/26, 3/27, 3/28, 3/29, 3/30, 3/31, 4/1, 4/2, 4/3, 4/4, 4/5, 4/6, 4/7, 4/8, 4/9, 4/10, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 4/22, 4/23, 4/24, 4/25, 4/26 and 4/27/15).

A. Based on record review, document review and staff interview it was determined the facility failed to ensure the Registered Nurse adequately supervised the Behavioral Health Technicians (BHTs) in performing their assignment of doing a face-to-face check of every patient every fifteen (15) minutes as a required hospital procedure. This deficient practice was identified in three (3) of eleven (11) records reviewed (patients #8, 9, and 10). This failure has the potential for harm of all patients when adequate monitoring does not occur.

Findings include:

1. Review of the medical record for patient #8 revealed the monitoring sheet used for the q (every) fifteen (15) minute checks were not documented on 3/13/15 at 7:00 a.m. and 7:15 a.m.

2. Review of the medical record for patient #9 revealed the monitoring sheet used for the q fifteen (15) minute checks were not documented for the following dates and times: 3/13/15 at 7:00 a.m. and 7:15 a.m.; 4/25/15 at 2:15 p.m., 2:20 p.m. and 2:45 p.m.; 4/27/15 at 5:30 p.m. and 5:45 p.m.; and, 4/29/15 at 6:45 a.m.

3. Review of the medical record for patient #10 revealed the monitoring sheet used for the q fifteen (15) minute checks were not documented on 3/13/15 at 7:00 a.m. and 7:15 a.m.

4. During an interview with the Director of Patient Care Services on 4/30/15 at 9:55 a.m., she concurred with the findings and agreed the failure to monitor patients was in violation of hospital policy, as the Registered Nurse in charge of the unit on each shift is ultimately responsible for the monitoring of patients who are assigned to the BHTs.






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B. Based on document review, record review and staff interview it was determined the facility failed to ensure a Registered Nurse (RN) supervised the care of the patient in one (1) of eleven (11) medical records reviewed (patient #1). This failure has the potential to negatively affect patient care by leaving patients inadequately supervised with a potential for an adverse event.

Findings include:

1. Review of policy titled, "Yard Activities", last reviewed 12/14, states, in part: "At least three (3) staff must be present to take the patient into the yard."

2. Review of the medical record for patient #1 revealed the patient did not return from yard activities on 4/6/15 at approximately 7:41 p.m.

3. In an interview with RN #1 on 4/28/15 at about 3:15 p.m., she stated she did not make sure all scheduled staff went off the unit with the patients. She also stated only two (2) staff had gone with the patients.