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Based on a medical record review, interviews with facility staff, an interview with the complainant, a review of the Medical Staff Rules and Regulations, a review of policies and procedures, and a review of credential files, it was determined that the facility failed to comply with the facility's current policies and procedures in two of five sampled Patients (P#3 and P#5). Patients had a right to receive care in a safe setting and be free from all restraints/seclusions unless it was to ensure the immediate safety of the patient, staff, or others.

Cross- references A-0154, as it relates to the facility's failure to ensure that the facility staff complied with policies and procedures related to proper use and monitoring of physical/chemical restraints and seclusion in two of five sampled Patients (P#3 and P#5).

Based on a medical record review, interviews with facility staff, an interview with the complainant, a review of the Medical Staff Rules and Regulations, a review of policies and procedures, and a review of credential files, it was determined that the facility failed to comply with the facility's current policies and procedures in two of five sampled Patients (P#3 and P#5). Patients had a right to receive care in a safe setting and be free from all restraints/seclusions unless it was to ensure the immediate safety of the patient, staff, or others.

Findings Included:

A review of Patient's (P) #5 medical record (MR) revealed that P#5 was admitted involuntarily to the facility on 3/21/22. P#5 presented to the hospital with suicidal ideation. P#5 had a history of a significant conflict at home and a history of sexual abuse. P#5 was admitted for Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Oppositional Defiant Disorder (argumentative behavior towards people in authority), and Attention Deficit Hyperactivity Disorder (short attention span, inattention).

On 3/21/22 at 7:19 p.m., a review of the Nurse Practitioner (NP) HH orders included but was not limited to the following:

A. Admit to an involuntary adolescent inpatient unit.
B. Regular diet, medical consult, nursing.
C. Every (Q)15-minute observations, suicide precaution, elopement risk.

A review of P#5's 'Restraint/Seclusion Order' revealed the following:

On 3/30/22 at 9:05 p.m., P#5 was physically restrained and administered a combination of medications. A review of the Medication Administration Record (MAR) revealed that Haldol 2 milligrams (mg) was administered at 9:12 p.m., and Ativan 2 mg was administered at 9:13 p.m. Both medications were administered intramuscularly. Further review revealed that RN FF documented the order as needed (PRN).

A review of the restraint document titled 'Post-Intervention Face-to-Face Evaluation,' dated 3/30/22 at 9:47 p.m., revealed that P#5 was sitting in a seclusion room crying. Continued review failed to reveal the name, signature, date, and time the evaluation was completed. P#5 was on a physical restraint from 9:15 p.m. to 9:47 p.m. RN FF documented that the intervention occurred for 37 minutes.

On 3/30/22 at 11:00 p.m., a review of the 'Daily Nursing Note' revealed that RN FF documented that P#5 was defiant and taking markers from a peer, trying to jump over the nurse's desk, and running down the hall.

A review of the 'Seclusion/Restraint Order' dated 3/31/22 at 9:50 p.m. revealed that MD AA initiated a telephone order for an intervention of physical and chemical restraints (Lorazepam 2 mg, Haldol 5mg, and Benadryl 50 mg). Less restrictive interventions were ordered as well. Documentation revealed that staff could not de-escalate because P#5 was combative, belligerent, and screaming/yelling. P#5 was physically restrained at 9:50 p.m. A review of the MAR revealed that Haldol 5 mg was administered at 10:05 p.m., and Lorazepam 2 mg (sedative) was administered at 10:32 p.m. Benadryl 50 mg was administered on 4/1/22 at 12:37 a.m. All medications were administered intramuscularly. P#5 was released from restraints at 10:20 p.m. P#5 was restrained for 30 minutes. Further review failed to reveal that P#5's parent or guardian was notified about the restraint.

On 4/1/22 at 12:35 a.m., a review of the 'Nursing Discharged Progress Note' revealed that RN CC documented that P#5 was discharged due to behavior.

A review of P#5's 'Observation/Rounds Precaution' failed to reveal an observation and round precaution sheet for P#5 from 3/31/22 at 7:00 a.m. to when P#5 was discharged on 4/1/22 at 1:30 a.m.

A review of P#5's emergency department (ED) visits from another facility revealed that P#5 presented to the ED with a complaint of abdominal pain on 4/2/22 at 10:55 a.m. and a complaint of jaw pain on 4/3/22 at 12:24 p.m. P#5 was prescribed pain medications.

A telephone interview was conducted with the complainant on 5/3/22 at 9:20 a.m. The complainant stated she was a family member of P#5. When she arrived at the facility to pick up P#5, P#5 was in an unstable condition. P#5 was drowsy, couldn't walk, and slept all day. The complainant said she took P#5 to the ED because she was concerned about P#5's condition. P#5's gums were bleeding. The complainant said P#5 told her one of the facility staff kicked her in the stomach and hit her on the jaw, and there was blood on her shoes; that was why she had no shoes on when she was discharged. When she asked the staff about P#5's shoes, the complainant said the facility staff said they couldn't find them. The complainant said the facility did not want to give her P#5's shoes because there was blood on the shoe.

An interview was conducted with P#1 on 5/3/22 at 10:45 a.m. P#1 stated that she was being discharged today. P#1 said she felt that some facility staff did not show respect to others. Whenever the staff got agitated, their voices got aggressive and wild. P#1 said the last time she was admitted, a fight broke out, and she observed a staff sitting on P#5's chest. P#1 said that P#5 was in the middle of the fight, yelling, and the staff pulled her down and sat on her chest. P#1 said P#5 complained of not being able to breathe. P#1 explained that the staff sometimes threatened that they would fight the patients, resign, and turn in their badges. Although P#1 observed these things, P#1 said she felt safe returning to the facility and had never observed a staff physically assaulting another patient.

An interview was conducted with Psychiatrist (PS) AA on 5/4/22 at 9:58 a.m. in the conference room. PSY AA stated that she recalled that P#5 was admitted for suicidal ideation. PS AA said she was informed that P#5 was combative, so she came to the facility on 3/31/22 to try and talk to P#5 and find out what was wrong. PS AA said that P#5 was angry and aggressive, wanting to go home. PS AA said she did not see that P#5 was combative. PS AA said she ordered P#5 to be discharged around 9:30 p.m. on 4/1/22. However, P#5 continued to act out after deciding to let her go home. PS AA said she was not on call at the facility that night but came to see P#5 and then left the facility around 9:52 p.m. PS AA said it is unusual to discharge a patient after being chemically restrained. Still, it could be expected if the patient was combative. PS AA said P#5 should have been discharged home without being restrained. PS AA said she was not aware of the telephone restraint order on 3/31/22 at 9:50 p.m. PS AA said it was a PRN order, and the staff may have restrained P#5 because she was a danger to herself. PS AA said that the nursing staff had to get an order for restraint; however, the facility did not physically restrain adolescents. She said the staff would use the least restrictive measures to de-escalate an aggressive patient. PS AA said that when the nurses called regarding an aggressive patient, they would request the least restrictive medication. PS AA said if a patient was combative on multiple occasions, medications could be ordered as PRNs for the patient's agitation. PS AA said the physicians did not have to attend Code Green (Facility psychiatric response code) and were not present during P#5's code.

An interview was conducted with Psychiatrist (PS) GG on 5/4/22 at 11:50 a.m. PS GG explained that generally, the nurses would call the physician for a medication order for an agitated patient. PS GG stated there were instances where they put the patient in a physical hold. PS GG said medications for agitation could be ordered PRN if someone had a repeated pattern of agitation. PS GG said the intent to medicate was to address the patient's agitation and not sedate the patient. PS GG said it happened occasionally, but it was rare to administer medications for agitation and then discharge the patient afterward. PS GG stated that PRN medications for agitation were usually a single medication. PS GG further explained that if the staff had to combine medications and use them for chemical restraint purposes, they would call the provider for an order. PS GG said combination medications used as chemical restraints could not be ordered PRN. PS GG said nursing staff would fill out the chemical or physical restraints packet. Interventions that occurred would have a section for the physician to sign off on within 24 hours. PS GG stated that he would go through the signatures that had not been signed off once a patient was discharged. PS GG explained that 10% of the chart usually had something unsigned because nursing staff added paperwork for the provider later without the provider's awareness.

An interview was conducted on 5/4/22 at 5:09 p.m. with Mental Health Technician (MHT) KK. MHT KK stated that she recalled P#5. MHT KK said she remembered when P#5 arrived at the facility, P#5 would always cry in a corner and say she didn't want to go home. MHT KK said some of the things P#5 wrote in her journal were alarming. MHT KK said she remembered the night P#5 was discharged. MHT KK said she was attending a code called for P#5's friend, who was being restrained. MHT KK said P#5 was behind the door swinging, banging for about 15 minutes, and viciously screaming. MHT KK stated that P#5 was given a medication injection and then discharged. MHT KK said she was part of the team that walked P#5 to her mother. MHT KK said P#5 was drowsy and had her head bent down, and they had to assist P#5 out because they were concerned that she would fall. MHT KK said she could not remember the other nurse's name with them, but she remembered P#5 walked out with no shoes because they couldn't find her shoes. MHT KK stated she heard P#5's mom asking the nurse about P#5's shoe, and the staff said she couldn't find it. MHT KK said she did not observe the facility staff physically assaulting P#5. MHT KK said P#5 was discharged around midnight to 1:00 a.m. MHT KK said the facility staff was surprised that P AA discharged P#5 because it was instant and in the middle of the night.

An interview was conducted with the RN CC on 5/5/22 at 9:06 a.m. RN CC stated that the process of de-escalating agitated patients was by trying to convince them verbally. However, if that did not work, they would use the least restrictive measure to de-escalate the situation. RN CC said if a patient were in danger of harming themself or others, the staff would call the physician for medication orders. RN CC explained that they could not administer chemical restraints without receiving a physician's order. RN CC said she always called the physician for a chemical restraint order. RN CC said it was not normal to discharge a patient after chemical restraint. RN CC recalled that the medication administered to P#5 had no effect. RN CC further explained that after P#5 was administered the medication, she was still riled up and rounding the nursing station. RN CC stated that PS AA came to examine P#5 and decided to discharge her. RN CC said that PS AA assessed P#5 before discharging her. RN CC said she could not recall the staff that assisted, but P#5 was still agitated when she walked out of the facility. RN CC said P#5 was not bleeding, and she did not talk to P#5's mother. RN CC said she did not observe staff assaulting P#5.

An additional review of a MR revealed that P#3 was admitted involuntarily to the facility on 4/1/22. P#3 presented to the facility with suicidal ideation and recent reports of sexual assault. P#3 had a history of numerous suicide attempts.

A review of the MAR revealed that Benadryl 50 mg was administered intramuscularly at 7:10 p.m. The order was STAT (administer now) for severe agitation.
A continued review of the MAR revealed that Lorazepam 2 mg tablet was ordered PRN orally (by mouth) every two hours for anxiousness. A dosage of Lorazepam was administered at 7:31 p.m.
Haldol 5 mg tablet was ordered PRN orally every six hours for psychosis. A dosage of Haldol was administered at 7:31 p.m.

A review of the 'Restraint/Seclusion Order' dated 4/5/22 at 7:40 p.m., revealed that a telephone order was initiated for an intervention of physical and chemical restraints (Lorazepam 2 mg, Haldol 5mg, and Benadryl 50 mg). A less restrictive intervention of verbal de-escalation/redirection was also ordered. Documentation revealed that P#3 was banging her head into walls, not following directions, and was combative and aggressive. A detailed review failed to reveal the practitioner or nurses' name, signature, date, or time the medication was ordered.

A review of the 'Post-Intervention Face-to-Face Evaluation,' dated 4/5/22 at 7:40 p.m., failed to reveal the name, signature, date, and time when it was completed.

A review of the MAR revealed that an additional dose of Benadryl 50 mg was administered intramuscularly at 8:00 p.m. The order was STAT for severe agitation.

A review of the "Post-Intervention Notification," dated 4/5/22 at 9:45 p.m., revealed that P#3 was on physical restraint for 10 minutes from 7:40 p.m. to 7:50 p.m. In addition, medication/chemical restraints were also administered. Continued review failed to reveal that P#3's parent/family or guardian was notified.

A review of the facility's Medical Staff Rules and Regulations titled "Seclusion and/or Restraint," last reviewed 3/4/22, revealed that the use and documentation related to restraint or seclusion would comply with the current facility policy. Further review revealed that members of the medical staff would receive training upon appointment and at least annually on the approved use of seclusion and/or restraint.

A review of three credential files Psychiatrists (PS AA, PS GG, and PS HH) failed to reveal evidence of current training on the approved use of restraint and/or seclusion.

A review of the facility's policy titled "Proper Use and Monitoring of Physical/Chemical Restraints and Seclusion," last revised August 2020, revealed that restraint or seclusion should be used in emergency situations only and required a physician's order. Prior to initiation of restraint or seclusion, the physician and nurse would be aware of any considerations that should be taken based upon the initial assessment completed at the time of admission.

The policy stated that the physician/LIP orders were not written as standing or PRN orders.
Exceptions to using PRN or Standing Orders included:

1. Geri Chair: If a patient requires the use of a Geri Chair with the tray locked in place in order for the Patient to safely be out of bed.
2. Repetitive self-mutilative behavior: If a patient was diagnosed with a chronic medical or psychiatric condition, such as Lesch-Nyhan Syndrome, and the patient engaged in repetitive self-mutilating behavior.

In the absence of a physician/PMHNP, the RN may authorize the initiation of restraint or seclusion in an emergency.

Medication orders must be provided by the physician/PMHNP.

The physician must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/ seclusion had been initiated. Telephone/verbal orders for restraint/seclusion may be received and recorded by an RN.

The physician shall authenticate the telephone/verbal orders within 24 hours.

Within one hour of the initiation of restraint or seclusion, the patient would be evaluated in person by a physician, authorized PMHNP, or trained RN/Physician Assistant (PA). A telephone call or telemedicine methodology was not allowed for these evaluations. The evaluation would be documented in the medical record to include the following:

1 The date and time of the evaluation
2 An assessment of the patient's immediate situation
3 An evaluation of the patient's reaction to the intervention
4 An assessment of the patient's medical and behavioral condition, to include a complete review of systems assessment, behavioral assessment, as well as a review and assessment of the patient's history, drugs, and medications.

If the evaluation was conducted by a trained RN or PA, he/she must consult with the attending physician or other LIP responsible for the patient's care as soon as possible (within 30 minutes) after the evaluation. This consultation should include a discussion of the findings of the 1-hour evaluation, the need for other interventions or treatments, and the need to continue or discontinue the use of restraint/seclusion. The consultation must always be conducted prior to a renewal of the order.

Post-Restraint/Seclusion Debriefing:

Debriefing following the use of restraint/seclusion was important in reducing the use of recurrent restraint/ seclusion. The patient and staff participated in a debriefing session following the restraint/seclusion episode. The patient and, if appropriate, the patient's family participated with the staff who were involved in the episode and who were available in a debriefing about each episode of restraint/seclusion use. The debriefing occurred as soon as possible and as appropriate, but no longer than 24 hours after the episode.

Staff Training and Competency Assessment:

Medical staff, direct care staff, and RNs/PAs were oriented to the standards for the use of restraint/seclusion. Direct care staff and PAs were required to attend a nationally recognized physical/aggression management training program and show evidence of competency related to participating in a code situation, application of restraints, or the monitoring, assessment, and care of a patient in restraints or seclusion. Physicians and other LIPs authorized to order restraint or seclusion must have a working knowledge of the facility's policy regarding the use of restraint/seclusion. Nurses and PAs authorized to conduct the 1-hour face-to-face evaluation would receive additional training and demonstrate competency in conducting both a physical and behavioral assessment of the patient. All records documenting completion of training and competency demonstration would be maintained in staff personnel files or credentials files.

A review of the facility's policy titled "Patient Rights," policy #PC114, last reviewed on 1/22, revealed that without limitation, patients shall be entitled to:

i. Be free from neglect, exploitation; verbal, mental, physical, sexual abuse, and all forms of abuse, harassment, and corporal punishment.

A review of the facility's policy titled "Level of Observation," policy # PC114, last reviewed on 1/22, revealed that the physician would order one of three types of observation at the time of admission and may change the level of observation if the Patient's condition warranted a change.
1. Q 15 minute (may order a precaution type if indicated)
2. CVO (requires a precaution type)
3. One-to-one (requires a precaution type).

The Charge Nurse would assign staff to perform routine observations on a designated set of patients.
Staff would complete the Patient Observation Record as rounds were made, using the coding system described on the record.
Patient observation monitoring was initiated, conducted, and documented using the facility Patient Observation Monitoring record for all patients who entered the facility requesting an assessment.
Staff would observe the patient and document it on the Patient Observation Record Q 15 minutes.

The facility failed to follow its policy and procedures by not completing a restraint debriefing, notifying family, staff training and competency completion, and staff receiving an order before treatment (medication, restraints, etc.).

Based on a review of the medical record, interviews with staff, an interview with the complainant, a review of the Medical Staff Rules and Regulations, and a review of policies and procedures, it was determined that the facility failed to re-evaluate one of five sampled Patients (P#5), after being restrained prior to discharge.

Cross- references A-0802, as it relates to the facility's failure to ensure a safe discharge in one of five sampled Patients(P#5).

Based on a review of the medical record, interviews with staff, an interview with the complainant, a review of the Medical Staff Rules and Regulations, and a review of policies and procedures, it was determined that the facility failed to re-evaluate one of five sampled Patients (P#5), after being restrained prior to discharge.

Findings included:

A review of Patient's (P) #5 medical record (MR) revealed that P#5 was admitted involuntarily to the facility on 3/21/22. P#5 presented to the hospital with suicidal ideation. P#5 had a history of a significant conflict at home and a history of sexual abuse. P#5 was admitted for Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Oppositional Defiant Disorder (argumentative behavior towards people in authority), and Attention Deficit Hyperactivity Disorder (short attention span, inattention).

On 3/21/22 at 7:19 p.m., a review of the Nurse Practitioner (NP) HH orders included but was not limited to the following:

A. Admit to an involuntary adolescent inpatient unit.
B. Regular diet, medical consult, nursing.
C. Every (Q)15-minute observations, suicide precaution, elopement risk.

A review of P#5's 'Restraint/Seclusion Order' revealed the following:

On 3/30/22 at 9:05 p.m., P#5 was physically restrained and administered a combination of medications. A review of the Medication Administration Record (MAR) revealed that Haldol 2 milligrams (mg) was administered at 9:12 p.m., and Ativan 2 mg was administered at 9:13 p.m. Both medications were administered intramuscularly. Further review revealed that RN FF documented the order as needed (PRN).

A review of the restraint document titled 'Post-Intervention Face-to-Face Evaluation,' dated 3/30/22 at 9:47 p.m., revealed that P#5 was sitting in a seclusion room crying. Continued review failed to reveal the name, signature, date, and time the evaluation was completed. P#5 was on a physical restraint from 9:15 p.m. to 9:47 p.m. RN FF documented that the intervention occurred for 37 minutes.

On 3/30/22 at 11:00 p.m., a review of the 'Daily Nursing Note' revealed that RN FF documented that P#5 was defiant and taking markers from a peer, trying to jump over the nurse's desk, and running down the hall.

A review of the 'Seclusion/Restraint Order' dated 3/31/22 at 9:50 p.m. revealed that MD AA initiated a telephone order for an intervention of physical and chemical restraints (Lorazepam 2 mg, Haldol 5 mg, and Benadryl 50 mg). Less restrictive interventions were ordered as well. Documentation revealed that staff could not de-escalate because P#5 was combative, belligerent, and screaming/yelling. P#5 was physically restrained at 9:50 p.m. A review of the MAR revealed that Haldol 5 mg was administered at 10:05 p.m., and Lorazepam 2 mg (sedative) was administered at 10:32 p.m. Benadryl 50 mg was administered on 4/1/22 at 12:37 a.m. All medications were administered intramuscularly. P#5 was released from restraints at 10:20 p.m. P#5 was restrained for 30 minutes. Further review failed to reveal that P#5's parent or guardian was notified about the restraint.

On 4/1/22 at 12:35 a.m., a review of the 'Nursing Discharged Progress Note' revealed that RN CC documented that P#5 was discharged due to behavior.

A review of the 'Physician Daily Progress Note' dated 3/31/22 at 9:52 p.m. and written by Psychiatrist (PSYAA revealed that P#5 had been fixated on the idea of going home and had become destructive, loud, and agitated in her effort to leave. PSY AA noted that P#5 had demonstrated that she knew how to handle her anger but had chosen to use it as a tool to secure her discharge. PSY AA documented that after contacting P#5's guardian, the decision was made that she would be discharged as she denied suicidal or homicidal ideation and demonstrated no delusional thoughts.

A review of the 'Physician Orders' revealed that P#5 was ordered by PS AA to be discharged on 3/31/22 at 9:52 p.m.

On 4/1/22 at 12:35 a.m., a review of the 'Nursing Discharged Progress Note' revealed that RN CC documented that P#5 was discharged due to behavior.

A review of the facility's 'Aftercare/Discharge Plan Part II' revealed that P#5 was discharged on 4/1/22 at 1:30 a.m. However, further review failed to reveal a discharge status, disposition, mode of transport, and follow-up appointments.

A review of P#5's 'Observation/Rounds Precaution' failed to reveal an observation and round precaution sheet for P#5 from 3/31/22 at 7:00 a.m. to when P#5 was discharged on 4/1/22 at 1:30 a.m.

A review of P#5's emergency department (ED) visits from another facility revealed that P#5 presented to the ED with a complaint of abdominal pain on 4/2/22 at 10:55 a.m. and a complaint of jaw pain on 4/3/22 at 12:24 p.m. P#5 was prescribed pain medications.

A telephone interview was conducted with the complainant on 5/3/22 at 9:20 a.m. The complainant stated that she was a family member of P#5. When she arrived at the facility to pick up P#5, P#5 was in an unstable condition. P #5 was drowsy, couldn't walk, and slept all day. The complainant said she took P#5 to the ED because she was concerned about P#5's condition. P#5's gums were bleeding. The complainant said P#5 told her one of the facility staff kicked her in the stomach and hit her on the jaw, and there was blood on her shoes; that was why she had no shoes on when she was discharged. When she asked the staff about P#5's shoes, the complainant said the facility staff said they couldn't find them. The complainant said the facility did not want to give her P#5's shoes because there was blood on the shoe. The complainant said she was told by P AA that she would not be discharging P#5 until 4/4/22 but later received a call around 9:45 p.m. on 3/31/22 to pick up P#5. The complainant informed the facility she was three hours away, but the facility said she had to come to pick up P#5. The complainant said she got to the facility around 1:12 a.m. on 4/1/22. The complainant stated that she complained to the staff about P#5's condition, and she was given a phone number to leave her complaint. The complainant said she left a voice message, but she had not received a call back from the facility. The complainant said she also tried reaching out to PS AA several times, but PS AA had not responded to her calls. The complainant continued saying that she had not gotten any response from the facility concerning her complaint. She said P#5 had been traumatized and cried every day because the facility had physically abused her.

An interview was conducted with P #1 on 5/3/22 at 10:45 a.m. P#1 stated that she was being discharged today. P#1 said she felt that some facility staff did not show respect to others. Whenever the staff got agitated, their voices got aggressive and wild. P#1 said the last time she was admitted, a fight broke out, and she observed a staff sitting on P#5's chest. P#1 said that P#5 was in the middle of the fight, yelling, and the staff pulled her down and sat on her chest. P#1 said P#5 complained of not being able to breathe. P#1 explained that the staff sometimes threatened that they would fight the patients, resign, and turn in their badges. Although P#1 observed these things, P#1 said she felt safe returning to the facility and had never observed a staff physically assaulting another patient.

An interview was conducted with Psychiatrist (PS) AA on 5/4/22 at 9:58 a.m. in the conference room. PS AA stated that she recalled that P#5 was admitted for suicidal ideation. PS AA said she was informed that P#5 was combative, so she came to the facility on 3/31/22 to try and talk to P#5 and find out what was wrong. PS AA said that P#5 was angry and aggressive, wanting to go home. PS AA said she did not see that P#5 was combative. PS AA said she ordered P#5 to be discharged around 9:30 p.m. on 4/1/22. However, P#5 continued to act out after deciding to let her go home. AA said she was not on call at the facility that night but came to see P#5 and then left the facility around 9:52 p.m. PS AA said it is unusual to discharge a patient after being chemically restrained. Still, it could be expected if the patient was combative. PS AA said P#5 should have been discharged home without being restrained. PS AA said she was not aware of the telephone restraint order on 3/31/22 at 9:50 p.m. PS AA said it was a PRN order, and the staff may have restrained P#5 because she was a danger to herself. PS AA said that the nursing staff had to get an order for restraint; however, the facility did not physically restrain adolescents. She said the staff would use the least restrictive measures to de-escalate an aggressive patient. PS AA said that when the nurses called regarding an aggressive patient, they would request the least restrictive medication. PS AA said if a patient was combative on multiple occasions, medications could be ordered as PRNs for the patient's agitation. PS AA said the physicians did not have to attend Code Green and were not present during P#5's code.

An interview was conducted on 5/4/22 at 5:09 p.m. with Mental Health Technician (MHT) KK. MHT KK stated that she recalled P#5. MHT KK said she remembered when P#5 arrived at the facility, P#5 would always cry at a corner and say she didn't want to go home. MHT KK said some of the things P#5 wrote in her journal were alarming. MHT KK said she remembered the night P#5 was discharged. MHT KK said she was attending a code called for P#5's friend, who was being restrained. MHT KK said P#5 was behind the door swinging, banging for about 15 minutes, and viciously screaming. MHT KK stated that P#5 was given a medication injection and then discharged. MHT KK said she was part of the team that walked P#5 to her mother. MHT KK said P#5 was drowsy and had her head bent down, and they had to assist P#5 out because they were concerned that she would fall. MHT KK said she could not remember the other nurse's name with them, but she remembered P#5 walked out with no shoes because they couldn't find her shoes. MHT KK stated she heard P#5's mom asking the nurse about P#5's shoe, and the staff said she couldn't find it. MHT KK said she did not observe the facility staff physically assaulting P#5. MHT KK said P#5 was discharged around midnight to 1:00 a.m. MHT KK said the facility staff was surprised that PS AA discharged P#5 because it was instant and in the middle of the night.

A review of the facility's Medical Staff Rules and Regulations titled "Care and Treatment of Patients" revealed that the attending physician was responsible for the patient's treatment through the course of hospitalization and was responsible for all treatment decisions.

A review of the facility's policy titled "Patient Rights," policy #PC114, last reviewed on 1/22, revealed that without limitation, patients would be entitled to:

1. Receive prompt evaluation and care, treatment, habilitation, or rehabilitation about which he/she was informed in so far, he /she was capable of understanding.

2. Be evaluated, treated, and habilitated in the least restrictive environment.

3. Be treated with human dignity and in an environment that contributed to a positive self-image.

4. Medical care and treatment in accordance with the highest standards accepted in medical practice to the extent that the facilities, equipment, and personnel were available.

5. Care in a safe and sanitary setting.

6. Be free from neglect, exploitation; verbal, mental, physical, sexual abuse, and all forms of abuse, harassment, and corporal punishment.

7. Considerate, respectful, humane care and treatment

A review of the facility policy titled "Reassessment", policy #PC020, last reviewed 5/21, revealed that reassessments occurred under the following circumstances:

1.0 Reassessment is conducted by a Registered Nurse (RN) every 12 hours at a minimum. Additionally, reassessment occurs in the following circumstances:

1.1 To evaluate the patient's response to treatment,

1.2 Change in the patient's condition, status or diagnosis,

1.3 Physical complaint,

1.4 Seclusion and/or Restraint Procedures,

1.5 Medication Side Effects,

1.6 Patient ' s response to pain interventions.

2.0 RN findings from the reassessment are documented in the patient ' s chart.

3.0 The physician reassesses at the time of each daily patient visit. The reassessment is documented in the patient's chart.

4.0 Vital signs are to be reassessed every shift or more often as indicated by medical condition or physician order.

The facility failed to reassess P#5 prior to discharge after PS AA completed the discharge evaluation. P#5 was given a PRN chemical restraint prior to discharge and was observed to be lethargic and required assistance to the discharge vehicle.