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Based on observation, interview, and record review, the facility failed to ensure children and adolescents received care in a safe setting.

a. The facility failed to fully assess an incident of a physical altercation between a 16 year old and an 11 year old male patients. The 11 year old sustained an injury.

b. Following the incident, the facility failed to examine patient safety processes or implement any measures to ensure a safe setting for children & adolescents currently housed together on the same hallways.

c. The faciltiy failed to follow its stated process & policy for safe room placement of children.

d. Current deficient practices placed 23 children and adolecents at risk for serious injury or harm (Patients # 1-23)


Refer to Tag A- 0144

Based on observation, interview, and record review, the facility failed to ensure two (2) patients received care in a safe setting (citing Patient # 27 , # 3) .

*The facility failed to fully assess an incident of a physical altercation between a 16 year old and an 11 year old male patients. The 11 year old sustained an injury.

*Following the incident, the facility failed to examine patient safety processes or implement any measures to ensure a safe setting for the children and adolescents currently housed together on the same hallways.

*The facility failed to follow its stated process & policy for safe room placement of children.

Current deficient practices placed 23 children and adolescents at risk for serious injury or harm (Patients # 1-23)


Findings:

Review of facility's policy titled "Patient Rights," dated 02/08/2005, showed "patients had the right to a humane treatment environment that ensures protection from harm...the right to be free from mistreatment..."

Observation on 08/23/19 between 10 AM and 12 PM showed the following:

a. 400 hallway (boys hall) : census of 14 patients. Two (2) of the patients were ages 9 years old and 11 years old. The remainder of the patients were adolescents between ages of 13 & 17 years.

b. 600 hallway (girls hall) : census of 11 patients. One patient was 11 years old; two patients were 12 years old. The remainder of the patients were adolescents between the ages of 13 & 17 years old.


Staff Interviews:


During a series of interviews conducted on 08/23/19 and 08/26/19 with Registered Nurses (RN)s who work on the adolescent/children's unit [RNs # E, H, I, and J], the following information was communicated:


*All four (4) RNs (E, H, I, and J), stated that children had just recently been admitted to the same unit as the adolescents-within the last 2 to 3 weeks. it was very challenging and a struggle to keep the children and adolescents separated. One of the RN's said "we do the best we can because these children are so vulnerable."


*All four (4) RNs stated that since the children had been placed on the unit, the staffing remained the same and no additional training had been provided. One RN stated that a tech was always assigned to the children when they were in the unit. The children were placed in rooms close to the nurse's station for safety. The children programmed separately from the adolescents.


*RNs E & J both stated that they had knowledge of a recent physical altercation between a 16 year old and a 11 year old male patients. Both said, the 11 year old had been injured, it happened on the playground. Both RNs said, there had been no facility-directed safety measures implemented after the incident. There had been no staff education or policy changes. RN E said, since the incident, the nurses have decided never to take the adolescents & kids out to the playground together. Both RNs E & J said, this was based on nursing judgement.


Facility Incident Log: July & August 2019:

Record review of facility Incident Log for August 2019 showed a documented physical altercation between Patient # 27 and Patient # 3 occurred on 08/20/19 at 5:10 PM.


Patient # 27

Review of Patient# 27's record showed:

He was an 11 year old male, admitted to the facility on 08/09/19 with a diagnosis of disruptive mood disorder. Chief complaint was anger and aggression .

Patient # 27 had a history of being very physically aggressive. He attempted to hit and kick staff repeatedly during the intake process.

Nurses note dated 08/20/19 ( 5:30 PM) showed that while outside on the playground, Patient # 27 began verbally assaulting a peer. The peer (Patient # 3) jumped from the playground equipment and kicked Patient # 27 in the chest, knocking him to the ground. Patient # 27 balled up into a fetal position. Patient # 27 began crying and his nose began to bleed. He was taken inside to the shower and cleaned up. Patient # 27's mother and physician were notified.

Nurses note dated 8/21/19 (2:56 PM) by Staff L, Risk Manager, showed she spoke with Patient # 27's mother to advise her a medical team had assessed her son and ordered a facial x-ray. Risk manager also informed the mother during the call that two (2) scratches or bruises assessed on the patient's chest and upper mid-back, were believed to be where he was kicked by a peer. The bruise on his back was thought to be where the patient fell back when he was kicked by a peer. The mother requested a documented skin assessment and stated her son had no injuries when he was admitted. Patient # 27 was discharged shortly thereafter.


Review of both patients' medical records showed:

On 08/09/19, Patient #27's documented height was 4' 10" ; weight was 97 pounds;

On 8/20/19, Patient #3's documented height was 5' 11" ; weight was 280 pounds.


Patient # 3

Review of Patient# 3's record showed:

He was an 16 year old male, admitted to the facility on 08/20/19 with a diagnosis of disruptive mood disorder. Patient # 3 had unspecified bipolar related disorder, history of methamphetamine and alcohol use, violent ideations present.

Review of nurses notes dated 08/20/19 made no mention of the physical altercation that occurred with Patient # 27.

Review of physician progress note dated 08/21/19 showed "patient got into a fight with another peer on the unit and behavior was redirected by staff."

During an interview 08/26/19 at 3:30 PM. with Staff L , Risk Manager, she stated that following the incident there were conversations with the treatment team. Patients # 3 & 27 were separated and were not in contact after the incident. They were already in appropriate precautions. The proper notifications were done; no other actions were taken. Patient # 27 had history of assaultive behavior.

During an interview on 08/26/19 at 2:30 PM with Staff D, Chief Nursing Officer (CNO), she stated that the children had been moved upstairs about 3 weeks ago. She confirmed the actual date was 08/07/19. CNO said the reason was a higher volume of adult admissions and a decreased volume of children. She stated the younger kids were grouped together and programmed separately from the adolescents. The children were placed in rooms near the nurses' station for increased safety. There was no intermingling of the children and the adolescents. The CNO was asked if she was aware of the physical altercation between the 16 year old and the 11 year old.

The CNO said that she had heard there was some incidents. Patient # 27 was autistic and really aggressive with children. He was switched back and forth from the boys to the girls side and had problems on both sides. "He ended up on the 400 hallway; he got along with the boys; they knew how to handle him."


Safe Room Placement :

Review of facility policy titled "Admissions, Patient Care Units, Patient Services," dated 8/2015, showed that upon admission, patients shall be assigned rooms on the basis of gender, program, and/or precautions and other clinical needs. The policy does not address room assignments according to ages.

During a series of interviews conducted on 08/23/19 and 08/26/19 with RNs E, H, I, and J, and with the CNO, all stated that children were grouped together and placed in rooms near the nurses station for safety.

Record review of "Patient Unit Report Sheets" for the 400 and 600 hallways for August 7 through August 23, 2019, along with a schematic map of the units with room numbers identified, showed the following:

400 hallway:

08/20/19 : Patient # 27 (age 11 years old) was placed in room 414 by himself. This room was the last room at the end of the hall; farthest possible distance from the nurses' station. Directly across the hall from him, Patient # 13 was placed in room 413 , by himself. Patient #13 was 16 years old and admitted on 08/14/19 for threatening to kill his parents.

08/19/19 : Patient # 24 and Patient # 25 ( both 12 years old) were placed in room 411; the second to last room at the end of the hall. Patient # 9 , who was 16 years old , was in room 411, directly across from the 12 year olds.

08/21/19 : Patient # 24 (age 9 years old) and Patient # 25 (11 years old) were admitted to room 411; the second to the last room at the end of the hall. Patient # 9 (16 years old) was in room 412, directly across the hall from the children.


600 hallway


08/07/19 : Patient # 26 (5 years old) was placed in room 609 by herself; Patient # 28 (16 years old) & Patient # 29 (17 years old) were placed in room 607, directly next door to the 5 year old. Both adolescent patients were currently on Assaultive Precautions. Room 607 was closest to the nurses station; room 609 was the next door down.