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Based on observation, interview, and record review, the facility failed to ensure self-harming items were removed from areas where patients at risk for harm may obtain access, resulting in the increased likelihood of negative consequences for all patients at risk for self harm who receive access to that area. Findings include:

One 6/23/2025 at 1010, after unlocking and entering the restroom associated with the facility's adolescence behavioral health unit seclusion room, a 200-milliliter glass bottle of air freshener was observed next to the sink. Director of Behavioral Health Staff M was immediately queried if the bottle was appropriate for this location and Staff M confirmed that it was not appropriate.

According to the facility's patient guide, dated 5/7/2024, under "Patient Rights" that the (Facility) Recognizes That Patients Have a Right to: Receive care in a safe setting."

Based on interview and record review, the facility failed to renew a violent restraint order after four hours for 1 (P-14) of 3 patients reviewed for restraint and seclusion resulting in the loss of patient rights. Findings include:

On 6/24/2025 at 1230, during medical record review with Director of Nursing Staff L and Quality and Patient Safety Director Staff B, P-14 had an order for 4-point violent restraints on 3/11/2025 at 1106 for four hours and the order was discontinued on 3/11/2025 at 1838. P-14 was in 4-point restraints for 7 hours and 22 minutes. Director of Nursing Staff L was queried at the time of discovery and confirmed there was no renewal order present four hours after the initial order at 1106.

According to the facility's policy "Restraint and Seclusion," dated 6/26/2024, "Each order for restraint or seclusion used for the management of violent or self-destructive behavior may only be ordered in accordance with the following limits; 4 hours for adults 18 years of age or older." The policy also revealed that If the patient needs restraint or seclusion order renewed, it must be completed prior to the expiration of the current order but not greater than 30 minutes prior to expiration: otherwise a new order must be obtained.