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Based on record review and interview, the hospital failed to protect and promote patients' rights and ensure safety requirements were in place for 6 of 18 (pre)adolescent patients (Patients #2, #5, #7, #8, #17, and #9) to receive care in a safe patient environment.

1. Staff failed to document and/or were unaware of the location and behaviors of Patients #17 and Patient #8 for over 75 minutes.

1.1 Patient #17 had been assessed by a physician to have unpredictable behaviors the morning of 08/30/20; eleven hours later, staff members failed to observe the patient for 88 minutes and were unaware of Patient #17's unauthorized departure from the hospital during that time. Patient #17 was brought back by police officers.

1.2 For a total of 86 minutes on 08/23/20, the day of Patient #8's admission, staff failed to document the whereabouts and behaviors of the patient who had been admitted in an agitated, anxious, and depressed state with poor judgement and insight, and the desire to kill herself.

Refer to A142.



2. Staff failed to ensure the provision of a safe patient environment.

2.1 Staff failed to provide emergency patient behavior management. On 09/03/20, Patients #2, #5, #7, and #8 destroyed unit property and attacked staff. Unable to maintain unit safety, nursing staff called police to intervene. Patients #2, #5, #7, and #8 were placed in handcuffs and taken out of the hospital to juvenile detention. The incidents of patient-to-patient and/or patient-to-staff altercations had almost doubled between 07/2020 and 08/2020.

2.2 Staff failed to maintain patient safety in the hospital's inner courtyard that offered the opportunity for Patient #17 to climb up a drainpipe and crawl on the roof to elope on 08/30/20.

2.3 Staff failed to secure Patient #9's home medication that remained in the patient's possession for approximately twelve hours and allowed a medication overdose in Patient #9's self-harm attempt on 09/01/20, the day of her admission. Patient #9 heard voices that told her to kill herself, suffered from flashbacks of a sexual assault in early 2020, and was assessed to be highly suicidal.

Refer to A144.

Based on record review and interview, the facility failed to ensure safety requirements were met for two of 18 (pre)adolescent patients (Patient #17 and #8) whose whereabouts and behaviors had not been noted by staff and/or were unknown for more than 75 minutes.

1) Patient #17's had been admitted with the diagnosis of severe Major Depressive Disorder. Nine days into her hospital stay, staff failed to note the patient's location and behaviors for consecutive 88 minutes. Staff was unaware that the patient had an unauthorized departure from the hospital.

2) Patient #8 had been admitted per the hospital Crisis Team with diagnoses that included Major Depressive Disorder, Alcohol Dependence, and Cannabis Abuse. Patient #8 wanted to kill herself and was noted to have poor insight and judgement. Six hours after her admission, staff failed to document the patient's location and behavior for a total of 86 minutes. Noted to have a poor response to the hospital provided treatment, Patient #8 had an episode of self-harm, inappropriate patient-to-patient interaction, and physical altercation with staff and police on the unit later in her hospitalization.


Findings:


1) Record review of Patient #17's Physician Admission Orders dated 08/21/20 at 1452 reflected the patient's admission diagnoses that included Major Depressive Disorder, Severe, Single Episode.

Patient #17's Physician Daily Progress Note dated 08/30/20 at 0855 reflected the patient was upset, in a labile mood, and had "unpredictable behavior ..."

Patient #17's Daily Observation Form dated 08/30/20 reflected the patient was in the courtyard at 2000. The time slots for the patient's 15-minute staff observational checks were left blank and/or crossed out for 2015, 2030, 2045, 2100, 2115, and 2130. The patient's whereabouts were not noted and/or unknown for 88 minutes between 2001 and 2129.

Patient #17's Daily Night Shift Progress Note dated 08/30/20 at 2100 reflected the nurse was unable to find Patient #17. Patient #17 " ...was found off grounds by police and was returned to facility ..."

During an interview on 09/09/20 at 1430, Personnel #7 acknowledged staff had not realized for about an hour that Patient #17 had left hospital premises by climbing up a drainpipe and eloping over the roof. Patient #17's 15-minute staff observational checks had been left blank.


2) Record review of Patient #8's Information Face Sheet reflected an admission date of 08/23/20 at 0809. The patient was admitted by the Crisis Team. Admission diagnoses included Major Depressive Disorder, Alcohol Dependence, and Cannabis Abuse.

Patient #8's Comprehensive Psychiatric Evaluation dated 08/23/20 reflected the patient wanted to kill herself. She was agitated, depressed, anxious, and with poor insight and judgement.

Patient #8's Observation Form dated 08/23/20 reflected the patient was on 15-minute staff observation checks. The patient was noted to be in the "Rec Room" at 1415 and in the hallway at 1500. The time slots at 1430, 1445, 1515, and 1530 were left blank. Staff did not document the patient's location and behaviors between 1416 and 1459 for 43 minutes and again for another 43 minutes between 1501 and 1544.

Patient #8's Physician Daily Progress Notes dated 08/24/20, 08/25/20, 08/26/20, 08/27/20, 08/31/20, 09/01/20, 09/02/20, and 09/03/20 noted "poorly controlled progress and response to treatment" of the patient's behavior.

Patient #8's Nursing Day Shift Progress and Assessment Note dated 09/01/20 at 1215 reflected the patient "scratched left forearm." Multidisciplinary Progress Notes dated 09/01/20 at 1225 reflected Patient #8's self-harmed on left forearm ...was upset ..."

Nursing Progress Notes dated 09/03/20 at 1838 reflected that Patient #8 had been observed "in the corner with male pt [sic] hugging with one arm around each other ..."

Patient #8's Nursing Progress Note dated 09/03/20 at 1935 reflected the patient "... attempted to assault the police officer...being taken into police custody."

During an interview on 09/03/20 at 1330, Personnel # 11 acknowledged the above findings.

Based on record review and interview, the facility failed to ensure the patient right to receive care in a safe setting for 6 of 18 (pre)adolescent patients (Patients #2, #5, #7, #8, #17, and #9).

1. Patients #2, #5, #7, and #8 were treated on the hospital's Pediatric and Adolescent Unit. On 09/03/20 at or around 1900 at shift change, staff was ineffective in managing the patients' escalating behavior. The patients destroyed property, climbed onto the nurses' station, pulled down ceiling tiles, flipped furniture, and attacked staff. The nurse in charge called 911. Police arrived and gave instructions. Patients #2, #5, #7, and #8 refused and attacked the officers. The patients were placed in handcuffs and taken out of the hospital while their peers watched. Patients #2, #5, #7, and #8 were taken into juvenile detention.

2. Although Patient #17 had told her physician she wanted to leave the hospital, responded poorly to treatment interventions, had poor insight and judgement, and unpredictable behavior, the patient was able to elope from the hospital's inner courtyard on 08/30/20 by climbing up a drain pipe, crawling onto the roof and down the other side, to leave the hospital premises while two staff members turned their backs and/or had left the courtyard. The patient was brought back by police.

3. Patient #9 had been hospitalized with a history of multiple suicide attempts. Although noted to be of high suicidal risk and suffering from auditory hallucinations, the patient remained in possession of her home-brought thyroid medication against hospital policy. Approximately twelve hours into her hospital stay, the patient took an unknown amount of her thyroid medication and needed emergency medical care evaluation.


Findings

1. Personnel #7 state during an interview on 09/09/20 at 1140 that Patients #2, #5, #7, and #8 destroyed hospital unit property, stood on the nurses' station, and pulled down ceiling tiles on 09/03/20. The patients were removed from the hospital by police which was "not our protocol."


During an interview on 09/09/20 at 1310, Personnel #11 stated Personnel #3 was unable to control the unit the evening of 09/03/20 at or around shift change. Police had been called. The situation on the unit was "chaotic ...there was water on the unit, a ceiling tile had come off, patients were yelling and hitting staff." Patients #2, #5, #7, and #8 refused to follow police officers' instructions to sit down and attacked the officers instead. The patients were placed in handcuffs while several peers watched, taken out of the hospital, and admitted to juvenile detention.


1.1 Record Review of Patient #2's [Patient Information] Face Sheet reflected her admission date of 07/22/20 at 1910. Admission diagnoses included Major Depressive Disorder. Patient #2 was discharged on 09/03/20 at with discharge diagnoses that included Major Depressive Disorder and Post-Traumatic Stress Disorder.

Patient #2's Comprehensive Psychiatric Evaluation dated 07/22/20 at 0915 reflected the patient was depressed, anxious, and had overdosed on a family member's medication prior to her admission. Her judgement was poor, and she had a suicide plan.

Patient #2's Nursing Day Shift Progress Note dated 09/03/20, timed as "7 AM - 7 PM" reflected the patient was " ...no risk for assaultive behavior."

Patient #2's Nursing Progress Note dated 09/03/20 at 1935 reflected "several patients were noted to be out of control: attacking staff, flipping furniture, charging nurses station ...[attempted] to assist staff in gaining control of the unit ...unit nurse ...had contacted...[Police Department]...officers were onsite. This patient was uncooperative with police and attempted to assault the police officer leading to the patient being taken into police custody."


1.2 Record review of Patient #5's Patient Information Face Sheet reflected an admission date of 08/12/20 at 1526. Admitting diagnoses included Major Depressive Disorder. Discharge date was noted to be 09/03/20 with diagnoses that included Disruptive Mood Dysregulation.

Patient #5's Comprehensive Psychiatric Evaluation dated 08/13/20 at 1030 reflected she had been admitted after a suicide attempt by hanging. She was depressed, angry, and suicidal with a plan. She had poor insight and judgment at that time and was placed on 15-minute staff observational checks.

Patient #5's Nursing Day Shift Progress and Assessment Note dated 09/03/20 at 1000 reflected the patient had a flat affect and seemed irritable. The patient's primary psychiatric treatment plan was to address the patient's recurrent, severe Major Depressive Disorder.


Patient #5's Nursing Progress Note dated 09/03/20 at 1935 by Personnel #11 reflected "several patients were noted to be out of control: attacking staff, flipping furniture, charging nurses station ...[attempted] to assist staff in gaining control of the unit ...unit nurse ...had contacted... [Police Department] ...officers were onsite. This patient was uncooperative with police and attempted to assault the police officer leading to the patient being taken into police custody."


1.3 Record review of Patient #7's Patient Information Face Sheet reflected an admission date of 08/12/20 at 1812. Admission diagnoses included Bipolar Disorder. The patient was discharged on 09/03/20.

Patient #7's Comprehensive Psychiatric Evaluation dated 08/13/20 at 1042 reflected the patient had been admitted after an altercation with her care takers; the patient destroyed property, punched walls, and "busted a window." The patient was noted to have weekly emotional outbursts, was dysphoric, anxious, labile, with poor insight and judgement.


Patient #7's Nursing Day Shift Progress and Assessment Note dated 09/03/20 timed "7 AM -7 PM" reflected the patient affect was flat and demonstrated "agitated behavior." The patient was assessed to present no risk to be assaultive. The nurse noted the patient's goal "to be positive today."


Patient #7's Nursing Progress Note dated 09/03/20 at 1935 reflected "several patients were noted to be out of control: attacking staff, flipping furniture, charging nurses station ...[attempted] to assist staff in gaining control of the unit ...unit nurse ...had contacted...[Police Department] ...officers were onsite. This patient was uncooperative with police and attempted to assault the police officer leading to the patient being taken into police custody."


1.4 Record review of Patient #8's Information Face Sheet reflected an admission date of 08/23/20. Admission diagnoses included Major Depressive Disorder, Alcohol Dependence, and Cannabis Abuse. The patient was discharged on 09/03/20 at 2015 with the same diagnoses.

Patient #8's Discharge Orders dated 09/03/20 reflected a "routine discharge." Physician orders dated 09/04/20 at 0935 reflected to discharge the patient "from [the] system as ...[Patient #8] was arrested on 09/03[20]."

Patient #8's Comprehensive Psychiatric Evaluation dated 08/23/20 reflected the patient wanted to kill herself. She was agitated, depressed, anxious, and with poor insight and judgement.

Patient #8's Nursing Day Shift Progress and Assessment Note dated 09/03/20 timed "7 AM-7 PM" reflected the patient's affect was "flat, sad, and depressed...withdrawn, isolative...no risk for assaultive behavior..."

Patient #8's Nursing Progress Note dated 09/03/20 at 1935 reflected "several patients were noted to be out of control: attacking staff, flipping furniture, charging nurses station ...[attempted] to assist staff in gaining control of the unit ...unit nurse ...had contacted...[Police Department]...officers were onsite. This patient was uncooperative with police and attempted to assault the police officer leading to the patient being taken into police custody."

During an interview on 09/09/20 at 1135 Personnel #7 stated that the patient-to-patient and/or patient-to-staff altercations had increased from 77 incidents in 07/2020 to 139 incidents in 08/2020. The first five days in 09/2020 saw twenty incidents of patient-to-patient and/or patient-to-staff altercations.


2. On 09/09/20 at 1005, Personnel #7 was interviewed and stated that Patient #17 had climbed up a drain pipe during an activity in the hospital's inner courtyard, climbed up on the roof and "shimmied her way down the other side." At that time, one staff member was taking patients back to the unit for vital signs while a second staff member had "turned their back on the patients."

Record review of Patient #17's Information Face Sheet reflected an admission date of 08/21/20. Admission diagnoses included Major Depressive Disorder. Patient #17 was discharged on 08/31/20 at 1728 with diagnoses than included Bipolar Disorder.

Patient #17 Physician Daily Progress Note dated 08/29/20 at 0825 reflected the patient statement "I just want to get out of here ..." The patient was noted with poor judgment and insight at that time; she was assessed to have a "poorly controlled behavioral response" to treatment.

Patient #17's Physician Daily Progress Note dated 08/30/20 at 0855 reflected the patient was upset, in a "labile mood with some agitation about going to RTC [Residential Treatment Care] ...low frustration tolerance with unpredictable behavior ..."

Patient #17's Daily Night Shift Progress Note dated 08/30/20 at 2100 reflected the nurse "attempted to give patient meds [medications] ...unable to find pt [Patient #17]. Searched several rooms with techs to attempt to find." At 2105 nursing noted that Patient #17 "...was found off grounds by police and was returned to facility..."

Patient #17's Physician Discharge Summary dated 09/01/20 at 1401 reflected the patient "eloped from facility...wanted to see if she could get away with running away ...brought back by Police..."


3) Record review of Patient #9's Admission Orders dated 08/31/20 at 2257 reflected Patient #9 was admitted after a suicide attempt by cutting her wrist with a razor blade. Admission diagnoses included Major Depressive Disorder (MDD), Recurrent, Severe. Synthroid 50 mcg (microgram) was ordered daily for the patient's thyroid condition.

Patient #9's Belongings Inventory Form dated 09/01/20 at 0254 did not reflect any home medications. Patient #9's Safety Search Checklist dated 09/01/20 at 0508 reflected staff did not find any contraband on Patient #9.

Patient #9's Admission and Referral Evaluation dated 09/01/20 at 1243 reflected Patient #9 had been admitted after a suicide attempt. Previously, Patient #9 had attempted to commit suicide three times by overdose, jumping in front of a car, and cutting her wrists. The patient had collected sleeping pills and razor blades in preparation for her suicide attempts. During her assessment, Patient #9 reported auditory of a "mean voice telling her to kill herself." Patient #9 had flashbacks of a prior sexual assault. She was assessed to be of high suicidal risk.

Patient #9's Daily Day Shift Progress Note dated 09/01/20 timed at 1010 reflected the patient was flat and depressed; the patient had the potential for self-harming behavior and was on suicide precautions with staff observations every 15 minutes. Nursing Notes dated 09/01/20 at 1547 reflected the nurse was "notified by tech [Mental Health Technician] that "Patient [#9] ingested a bottle of pills ...bottle of Synthroid ...[illegible] empty ..." Nursing staff called Patient #9's family member who stated the patient "may have taken 27 pills ...[family member] was asked to leave the medication during admission in Intake ...patient [to] be sent to ER and call Poison Control ..."

Patient #9's staff 15-minute observation form dated 09/01/20 reflected that "at 1535 the patient stated she took 10 pills that was inside her bedroom ...pill bottle was found ...medication was 50 mcg 15 quantity of pills ..."

Patient #9's Physician Orders dated 09/01/20 at 1714 reflected to send the patient "out to ER ...call Poison Control."


Personnel #7 acknowledged the contraband incident on 09/01/20 during an interview on 09/04/20 at 1415. Personnel #7 stated that Patient #9 had brought Synthroid, a thyroid medication, into the facility on admission. Intake personnel "stuck it back into the bag that went into the patient's room..."

During an interview on 09/09/20 at 1310, Personnel #11 stated the medication should not have been in the patient's belonging,


Record review of the Hospital Policy #1014 dated 07/17/19 and titled Patient Rights and Responsibilities reflected the procedure (#9) "the patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned ..."