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Based on interview and record review the facility failed to meet the Condition of Participation for Patient Rights by 1.) failing to provide care in a safe setting for 1 of 15 patients (#1) and 2.) failing to modify the plan of care to reflect a restraint application for 1 of 4 patients (#2) placing all current and future patients at risk for the loss of their rights.

Findings include:

1. The facility failed to provide care in a safe setting during group therapy for 1 of 15 patients (#1) resulting in a 17 year-old patient (#2) picking-up and throwing a 7 year-old patient (#1) to the floor causing Patient #1 to incur pain and various physical injuries. (See A-0144).

2. The facility failed to modify the plan of care to reflect a restraint application for 1 of 4 patients (#2) placing Patient #2 at risk for poor clinical outcomes. (See A-0166).

Based on interview and record review the facility failed to provide care in a safe setting during group therapy for 1 of 15 patients (#1) resulting in a 17 year-old patient (#2) picking-up and throwing a 7 year-old patient (#1) to the floor causing Patient #1 to incur pain and various physical injuries. Findings include:

Review of the medical record and other internal documentation revealed the following documents:

An incident report dated 03/29/19 indicated on 03/29/19 at approximately 1115 on the SIPU unit (Specialized Inpatient Pediatrics Unit) inside the activity room (East Day Room) Patient #2 attacked Patient #1. The summary of event section indicated Patient (Pt) #1 "was pick(ed) up and thrown to the floor" by Pt #2 "after screaming at each other. The nursing evaluation section indicated Pt #1 was evaluated by the registered nurse (RN H) and was found to have edematous (swelling) and ecchymotic (bruising) to the right cheek, ecchymosis (bruising) and abrasion to the right chin and ecchymosis to the right hip with pain intensity rated at 10 out of 10 (the highest degree of pain possible). This report indicated general first aid was performed (ice pack and Bacitracin ointment to abrasion), and after consultation with the physician and family, Pt #1 was transferred to a local emergency room for further medical evaluation.

Additional documentation from the integrated progress notes written by RN H on 03/29/19 at 1215 indicated Pt #1 was yelling in the dayroom with other peers present which eventually caused Pt #2 to escalate and pick-up up Pt #1 throwing him to the ground. The notes indicated Pt #1 did not lose consciousness per staff witnessing the event (Staff I). Additional nursing assessments within these notes indicated Pt #1 had additional complaints of pain to the stomach, upper right quadrant of the abdomen, and right ribs with difficulty breathing, however, the airway was open with a pulse oximetry measurement of 100% room air (no evidence of a lack of oxygen saturation).

Patient #1

Based on review of the medical record Pt #1 was a 7 year old male admitted to the facility on 03/28/19 arriving on the SIPU unit at 1423 with principal diagnosis of Disruptive Mood Dysregulation Disorder and secondary diagnoses including Autistic Disorder, Intermittent Explosive Disorder, and Attention-Deficit Hyperactivity Disorder (ADHD). Pt #1's course of stay was less than 24 hours based on a physician order to discharge Pt #1 to a local hospital emergency department on 03/29/19 at 1140. The nursing assessment dated 03/28/19 indicated Pt #1 was 4 feet 3 inches tall and weighed 58 pounds.

Patient #2

Based on review of the medical record Pt #2 was a 17 year old male admitted to the facility SIPU unit on 03/19/19 and discharged 04/05/19. The nursing assessment dated 03/19/19 indicated Pt #2 was 5 feet 5 inches tall and weighed 195 pounds. Pt #2's principal diagnosis was Intermittent Explosive Disorder with secondary diagnoses including Autistic Disorder, ADHD, and Borderline Intellectual Disorder. Pt #2's initial psychiatric evaluation dated 03/19/19 indicated Pt #2 was hospitalized due to aggressive behavior in the community when he punched an opponent player during a basketball game and began kicking furniture, ultimately leading to local police bringing him to the hospital. Other documentation regarding the same event indicated Pt #2 also shattered a window and was yelling at security staff to kill him.

During course of stay at the hospital, Pt #2 continued to display episodes of aggressive behavior on the SIPU unit. As evidenced by:

Review of restraint documentation dated 03/24/19 indicated Pt #2 was placed in a physical restraint (therapeutic hold) on 03/24/19 from 1540 to 1543 for threats to the immediate physical safety of others. Further review of the incident leading to the restraint indicated Pt #2 became very agitated and went to attack a 9 year old patient that was screaming at him. Medication administration records showed Pt #2 received an oral dosage of Haldol (antipsychotic) 5 milligrams (mg) and Lorazepam (antianxiety) 2 mg for agitation and aggression on 03/24/19 at 1545. Additional post restraint debriefing documentation dated 03/24/19 at 1900 indicated Pt #2 said he became "overstimulated and went after (the 9 year old patient)", and when asked what staff could have done to prevent restraints, Pt #2 said, " ...maybe not let me near (the 9 year old patient)".

Medication administration records showed Pt #2 received an intramuscular injection of Haldol (antipsychotic) 5 milligrams (mg) and Lorazepam (antianxiety) 2 mg for agitation and aggression on 03/25/19 at 1120.

Progress Notes dated 03/26/19 at 1210 indicated Pt #2's chief complaint as, "I need certain things or I am going to beat up everyone in here." These notes also indicated Pt #2 stated he would "attack other peers and staff" and made multiple threatening comments about how he "is stronger than everyone else and he does not care if he causes damage to others or hurts their families".

Progress Notes dated 03/27/19 at 1145 indicated that staff reported Pt #2 had been making multiple threatening statements to peers and staff and posturing aggressively towards others when he was unable to get access to desired items. These notes also indicated Pt #2 "has been irritable and challenging in group sessions and needing significant prompting to participate in group activities".

A Behavior Support Plan was written for Pt #2 signed by the Director of the SIPU unit (Staff E), however the origin of this plan was indeterminable as it did not contain a date. The plan did contain Staff E's signature and a time of 1530. This support plan indicated, under proactive and reactive strategies section, "Caregivers must position themselves between (Pt #2) and others anytime he is in the same vicinity as a peer. This means, caregivers will be able to intercept and intervene before (Pt #2) can make contact with a peer".

The patient census sheet revealed there was a total of 10 patients admitted to the SIPU Unit on 03/29/19. Of these patients, seven were ages 12 or younger, and three were ages 15-17. There were no patients on 1:1 supervision prior to the event. Pt #1 and Pt #2 required 15 minute checks at the time of the event.

Review of staffing documentation showed there were a total of 5 staff assigned to provide direct care for the 10 patients on the SIPU unit on 03/29/19 during the time frames prior to the event. The 5 staff consisted of one registered nurse (RN H) and four behavioral health associates (Staff I, Staff J, Staff L, and Staff M).

Review of video recording of the event was initiated on 04/24/19 at 1325 with the Director of Quality and Risk (Staff B) and Recipient Rights Officer (Staff C) present. Note Staff B indicated the video camera stationed inside the East Day Room was not operational during the time frames of the event, however multiple other camera views outside of the room were available. Also note the East Day Room was enclosed by walls and windows with one entry/exit point through a door adjacent to the nursing station. The video time frames reviewed occurred on the SIPU unit on 03/29/19. Time frames of the observation are provided in hour/minute/second format, as follows:

11:17:54, Staff I enters East Day Room with supplies, followed by Pt #1 and Pt #2. At this point there are a total of 5 patients in the room participating in the group.

11:19:50, Staff I and Staff J are inside the East Day Room with 7 patients.

11:20:20. Staff J leaves the East Day Room with a patient. Staff I remains inside the room.

11:20:43, Staff L is sitting behind the nursing station. RN H enters into the nursing station. Staff J enters into supply room behind the nursing station. Staff M is in the common area, approximately 30-35 feet from the East Day Room completing patient rounds. Staff J departs supply room, uses hand sanitizer, and remains in the nursing station. Staff I remains inside the East Day Room alone with 7 patients.

11:21:12, Staff I opens East Day Room door to allow two patients to enter the group. Staff J departs the nursing station and walks toward the East Day Room door. Staff J remains outside the East Day Room. Another patient departs the group. Staff I walks away from the doorway back into the room. At this point, Staff I remains alone inside the East Day Room with 7 patients, including Pt #1 and Pt #2.

11:21:30, Staff J is standing just outside of the East Day Room door and peers in. Staff J opens the door. Other staff outside room appear alerted. It is at this point the event appears to have occurred as Staff I was alone inside the East Day Room with 7 patients also inside the room. Note the actual event could not be visualized as the cameras inside the East Day Room were, per Staff B, inoperable.

11:21:40, Pt #2 walks out of East Day Room.

11:21:53, Staff I exits East Day Room carrying Pt #1 in his arms.

11:22:00 Auxiliary staff begin arriving to the area to assist.

In summary, Pt #2 picked up and threw Pt #1 to the floor inside the East Day Room on 03/29/19 at approximately 11:21:30. At the time of the event, one staff was supervising 7 patients, including Pt #1 and Pt #2, inside the enclosed room while the other 4 staff remained outside the room.

During an interview with Staff I on 04/24/19 at approximately 1400, Staff I said he was the only staff present in the East Day Room with "6 or 7 patients" when the event occurred on 03/29/19. Staff I said Pt #1 and Pt #2 were both in day room when Pt #1 began screeching toward Pt #2 which provoked Pt #2. Staff I said Pt #2 went toward Pt #1 picked Pt #1 off the floor at chest/shoulder level and slammed Pt #1 to the floor. Staff I said Pt #1 did not lose consciousness but appeared dazed, shocked and injured. Staff I said he scooped Pt #1 off the floor and carried him out of the room for safety and further medical assessment. Staff I said he could not prevent Pt #2 from attacking Pt #1 due to the physical distance from himself to the patients and room furniture blocking the path. Staff I said Pt #2 did have a behavior support plan in place during the time frames of the event that was written by the SIPU Director (Staff E) however it had been revised with additional details after the event at an unknown date. Staff I said he believed Pt #1 and Pt #2 were on 15 minute checks at the time of the event.

During an interview with Staff E on 04/24/19 at approximately 1430, Staff E acknowledged it was not uncommon to see a mixture of patient ages on the SIPU unit as the admission criteria was based more on cognitive and developmental level than chronological age and physical size. Staff E said the SIPU unit did not admit patients older than 17 years of age. Staff E said she wrote Pt #2's initial behavior support plan on 03/29/19 at 1530 post-event. Staff E acknowledged that she forgot to date the support plan. When asked why a behavior support plan had not been created sooner for Pt #2 in lieu of Pt #2's previously documented aggression toward younger peers, Staff E said Pt #2's behavior requiring a restraint (therapeutic hold) occurred on the weekend and she was not working that day.

During an interview with the Director of Quality and Risk (Staff B) on 04/25/19 at approximately 0910, Staff B acknowledged there should have been more staff present in the day room when the event occurred however there was no current policy to address such. Staff B said the facility was in the process of addressing the procedure for the number of staff to be present during SIPU group activities.

Based on interview and record review, the facility failed to modify the plan of care to reflect a restraint application for 1 of 4 patients (#2) reviewed for restraint application placing Patient #2 at risk for poor clinical outcomes. Findings include:

Review of the medical record revealed Patient (Pt) #2 was placed in a physical restraint (therapeutic hold) on 03/24/19 from 1540 to 1543 for threats to the immediate physical safety of others. Additional review of Pt #2's plan of care and interdisciplinary treatment plan showed no evidence that this restraint episode had been documented in an update or modification of these plans.

During an interview with the Director of Quality and Risk (Staff B) on 04/25/19 at approximately 0910, Staff B acknowledged the restraint episode had not been updated or modified within Pt #2's plan of care or interdisciplinary care plan. Staff B said the facility places seclusion and restraint documentation packets on each living area providing explicit instructions in a checklist format to assist staff with required documentation.

Review of facility policy titled, "Seclusion And Restraint" last revised November 2017 indicated, under section XVI, "A modification to the patient's plan of care will be completed following every seclusion or restraint episode".

Based on interview and record review, the facility failed to develop interventions and revise the nursing care plan for 2 of 10 patients (#2, #3) to reflect current nursing needs resulting in the potential for poor clinical outcomes. Findings include:

Patient #2

Review of the initial nursing treatment plan initiated on 03/19/19 at 2315 revealed Patient (Pt) #2 had identified problems related to anger and aggression, with goals to have no signs of aggression by discharge and interventions to monitor for overt symptoms of aggression and provide support and redirection and to set limits and offer choices of appropriate options.

The Interdisciplinary Treatment Plan Master sheet dated 03/21/19 listed Pt #2's active psychiatric problem as Anger/Aggression. This sheet was signed by Pt #2 on 03/21/19 at 0702 and other members of the treatment team, however there was no signature or date or time from a nursing representative based on the nursing portion of the sheet being completely blank.

The Interdisciplinary Treatment Plan Psychiatric Problem sheet initiated 03/21/19 with target dates of 04/01/19 lists the specific short term goals and interventions (what staff will do to assist the patient to achieve the goals), frequency, and responsible person for each discipline. The nursing portion within the intervention section was completely blank and did not identify any initiation date, interventions, frequency of the intervention, or responsible person.

The Interdisciplinary Treatment Plan Updates dated 03/25/19 at 1643 and 04/01/19 at 1500 did not address Pt #2's restraint episode on 03/24/19 or the administration of psychoactive medication to control behavioral disturbances on 03/24/19 and 03/25/19. Also, additional review of these updates showed no evidence of nursing staff's response to carrying out the specific interventions listed within Pt #2's behavior support plan. Note this behavior support plan provided very specific interventions to be completed by direct care staff under the supervision of nursing.

Patient #3

Review of the initial nursing treatment plan initiated on 04/03/19 at 1400 revealed Patient (Pt) #3 had identified problems related to disturbed thoughts, with goals to have reality based conversation and interventions to monitor for obvious symptoms of delusion and engage in reality based conversations. Further review revealed the nursing portion of this plan was incorporated into the Interdisciplinary Treatment Plan Master Sheets on 04/06/19 at 1930.

The Interdisciplinary Treatment Plan Update sheets dated 04/09/19 showed evidence that other disciplines provided updates on Pt #3's progress, however the Nursing section was completely blank in all areas with no signatures from persons representing nursing.

During an interview with the Director of Quality and Risk (Staff B) on 04/25/19 at approximately 0910, Staff B said the initial nursing plan of care is completed at admission and is then incorporated into the Interdisciplinary Treatment Plan once the interdisciplinary team meets to further develop such. Staff B said the facility policy for IPOS (Individualized Plan Of Service) and Treatment Planning set the standards for Nursing staff expectations in developing and revising the plan of care. Staff B had no answer when asked why nursing failed to participate in the development of the Interdisciplinary Treatment Plan and provide accurate revisions as needed.

Review of facility policy titled, "Individualized Plan Of Service (IPOS)/ Treatment Planning" last reviewed October 2015 indicated, under policy section, "The plan shall establish specific, measurable objectives and methods for their achievement, the frequency of treatment, and the names of staff responsible for delivery of treatment in conjunction with the patient", and under section performed by, "All Professional Staff". Also, under procedures section 2, "The IPOS is completed within 72 hours of admission and is based on the initial assessments of the physician, nurse, behavioral health clinician and other professionals ...", and 3, "The IPOS for each patient shall be reviewed and updated each week in order to evaluate the progress toward goal attainment and effectiveness of treatment approaches. The patient and significant others (if appropriate) should be present at this meeting along with the Attending Physician, RN and Behavioral Health Clinician.".