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Based on review of records, observations, and interview, the Governing Body failed to effectively carry out its oversight responsibilities for ensuring patient rights were protected for 36 of 36 patients (Patient #3, 6, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 28, 30, 31, 32, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50). The Governing Body failed to ensure processes were developed with effective implementation of policies and procedures that provided patients with a safe, nonviolent environment. More specifically, the facility failed to:

A) Ensure that patients could not gain access to staff's hospital keys. Because of this failure 5 of 29 patients in Youth Services (Patient #24, 47, 48, 49, and 50) eloped from the facility. The four adolescent girls and one male child could have been seriously harmed or killed in a high traffic area (Interstate 45 and FM 1960) or subjected to human trafficking. The child was picked up by a stranger at a convenience store and returned to the facility.

B) Ensure that 3 of 13 children (Patient #14, 16, and 47) were safely removed from an emergency crisis that occurred on the female adolescent unit. This failure resulted in Patient #47's eloped with four adolescent females (Patient #24, 48, 49, and 50). The children were programming in a group room at the far end of the Adolescent Girl's Unit. Three were allowed out of the group room without a staff escort. This resulted in two of the children comingled with the adolescent girls during an emergency crisis and a third child eloped with four adolescent females.

C) Ensure that 2 of 2 adolescent males (Patient #30 and Patient #31) were safely monitored on the Adolescent Boys Unit during an emergency crisis. These two patients breached the nurse's station, climbing across the counters into the Adolescent Girls Unit. During this breach, they had access to computer monitors and keyboards, telephones, and unit supplies. In addition, they could have slipped and fallen, resulting in serious injury, impairment, or death.

D) Ensure that the furniture on the adolescent and adult units cannot be used as a weapon. During an emergency crisis, 1 of 4 adolescent patients (Patient #50) pulled a chair from the day room, picked it up, and hurled across a 45-inch tall counter into the nurse's station. Other patients that had congregated near this patient, as well as staff in the nurse's station, could have been seriously injured, impaired, or killed.

E) Ensure that individuals being assessed in the Intake Department were safely monitored while using 2 of 2 bathrooms. The bathrooms were not designed with safety in mind as evidenced by numerous features that were not ligature resistant, lighting that allowed for easy access to the bulbs, and a large glass mirror. Staff were unclear about the procedure for escorting patients to the bathroom, adding that there was no policy.

F) Ensure that patients were provided safe sleeping quarters; 25 of 41 patients (Patient #13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 28, 31, 32, 33, 34, 36, 37, 38, 39, 40, 43, 44, 45, and 46) on Suicide Precautions were in bedrooms with headboards that had tie-off points that could be used for the purpose of hanging or strangulation. In addition, the facility failed to identify the head boards as a ligature risk during previous Hospital Risk Assessments.

G) Ensure that the investigation of sexual acting out between 2 of 2 patients (Patient #3 and Patient #6) was completed. Even though these two patients were roommates in a room that had been assigned as a "Sexually Acting Out Room," they were able to engage in mutual masturbation. At the time of the incident, Patient #6 was on Sexually Acting Out Precautions (SAO); Patient #3 was not.

H) Ensure that 8 of 12 adolescent patients (Patients #16, 18, 20, 21, 22, 23, 24, and 46) on Suicide Precautions were provided with a safe environment. Three packages of Styrofoam cups with the plastic sleeves still on them were stored in the day room (a commons area), allowing patients access to the plastic sleeves. The plastic sleeves can be used for suicidal asphyxiation.

I) Ensure that 13 of 14 adult patients (Patients #32, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43, 44, and 45) on Suicide Precautions were provided with a safe environment. Two phones with detachable handset cords were secured to furniture in the day room (a commons area), allowing patients access to the phones. When the flexible plastic phone cords were detached from both the jack on the phone's base and the handset, each stretched to about 18 inches.

J) Ensure that 8 of 12 adolescent patients (Patients #16, 18, 20, 21, 22, 23, 24, and 46) on Suicide Precautions were provided with a safe environment. A 44-gallon plastic trash container with lid was in the hallway of the Adolescent Girl's Unit just outside the door to the dayroom. On 3/26/2021, at 11:00pm (19 days earlier), the lid been used to break the plastic to a ceiling light fixture in the dayroom by Patient #50. She then cut herself with a piece of the plastic in her bathroom.

Cross reference Tag A0115. For specific findings for A through I, see Tag A0144 (Care in a Safe Setting).


K) Ensure processes were developed with effective implementation of policies and procedures that provided a modification to the patient's treatment plan following the use of restraint or seclusion for 5 of 5 patients (Patient #12, #24, #47, #48, and #50).

Cross reference Tag A0115. For specific findings for K, see Tag A0166 (Restraint or Seclusion).


L) Ensure that individuals being assessed in the Intake Department were safely monitored while using 2 of 2 bathrooms. The bathrooms were not designed with safety in mind as evidenced by numerous features that were not ligature resistant, lighting that allowed for easy access to the bulbs, and a large glass mirror. Staff were unclear about the procedure for escorting patients to the bathroom, adding that there was no policy.

M) Ensure that patients were provided safe sleeping quarters. 25 of 41 patients (Patient #13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 28, 31, 32, 33, 34, 36, 37, 38, 39, 40, 43, 44, 45, and 46) on Suicide Precautions were in bedrooms with headboards that had tie-off points that could be used for the purpose of hanging or strangulation. In addition, the facility failed to identify the head boards as a ligature risk during previous Hospital Risk Assessments.

Cross reference Tag A0700. For specific findings for L and M, see Tag A0701 (Maintenance of Physical Plant).

Based on review of records, observations, and interview, the facility failed to ensure processes were developed with effective implementation of policies and procedures that provided 36 of 36 patients (Patient #3, 6, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 28, 30, 31, 32, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) with a safe, nonviolent environment. More specifically, the facility failed to:

A) Ensure that patients could not gain access to staff's hospital keys. Because of this failure 5 of 29 patients in Youth Services (Patient #24, 47, 48, 49, and 50) eloped from the facility. The four adolescent girls and one male child could have been seriously harmed or killed in a high traffic area (Interstate 45 and FM 1960) or subjected to human trafficking. The child was picked up by a stranger at a convenience store and returned to the facility.

Cross reference Tag A0144.


B) Ensure that 3 of 13 children (Patient #14, 16, and 47) were safely removed from an emergency crisis that occurred on the female adolescent unit. This failure resulted in Patient #47's eloped with four adolescent females (Patient #24, 48, 49, and 50). The children were programming in a group room at the far end of the Adolescent Girl's Unit. Three were allowed out of the group room without a staff escort. This resulted in two of the children comingled with the adolescent girls during an emergency crisis and a third child eloped with four adolescent females.

Cross reference Tag A0144.


C) Ensure that 2 of 2 adolescent males (Patient #30 and Patient #31) were safely monitored on the Adolescent Boys Unit during an emergency crisis. These two patients breached the nurse's station, climbing across the counters into the Adolescent Girls Unit. During this breach, they had access to computer monitors and keyboards, telephones, and unit supplies. In addition, they could have slipped and fallen, resulting in serious injury, impairment, or death.

Cross reference Tag A0144.


D) Ensure that the furniture on the adolescent and adult units cannot be used as a weapon. During an emergency crisis, 1 of 4 adolescent patients (Patient #50) pulled a chair from the day room, picked it up, and hurled across a 45-inch tall counter into the nurse's station. Other patients that had congregated near this patient, as well as staff in the nurse's station, could have been seriously injured, impaired, or killed.

Cross reference Tag A0144.


E) Ensure that individuals being assessed in the Intake Department were safely monitored while using 2 of 2 bathrooms. The bathrooms were not designed with safety in mind as evidenced by numerous features that were not ligature resistant, lighting that allowed for easy access to the bulbs, and a large glass mirror. Staff were unclear about the procedure for escorting patients to the bathroom, adding that there was no policy.

Cross reference Tag A0144.


F) Ensure that patients were provided safe sleeping quarters. 25 of 41 patients (Patient #13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 28, 31, 32, 33, 34, 36, 37, 38, 39, 40, 43, 44, 45, and 46) on Suicide Precautions were in bedrooms with headboards that had tie-off points that could be used for the purpose of hanging or strangulation. In addition, the facility failed to identify the head boards as a ligature risk during previous Hospital Risk Assessments.

Cross reference Tag A0144.


G) Ensure that the investigation of sexual acting out between 2 of 2 patients (Patient #3 and Patient #6) was completed. Even though these two patients were roommates in a room that had been assigned as a "Sexually Acting Out Room," they were able to engage in mutual masturbation. At the time of the incident, Patient #6 was on Sexually Acting Out Precautions (SAO); Patient #3 was not.

Cross reference Tag A0144.


H) Ensure that 8 of 12 adolescent patients (Patients #16, 18, 20, 21, 22, 23, 24, and 46) on Suicide Precautions were provided with a safe environment. Three packages of Styrofoam cups with the plastic sleeves still on them were stored in the day room (a commons area), allowing patients access to the plastic sleeves. The plastic sleeves can be used for suicidal asphyxiation.

Cross reference Tag A0144.


I) Ensure that 13 of 14 adult patients (Patients #32, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43, 44, and 45) on Suicide Precautions were provided with a safe environment. Two phones with detachable handset cords were secured to furniture in the day room (a commons area), allowing patients access to the phones. When the flexible plastic phone cords were detached from both the jack on the phone's base and the handset, each stretched to about 18 inches.

Cross reference Tag A0144.


J) Ensure that 8 of 12 adolescent patients (Patients #16, 18, 20, 21, 22, 23, 24, and 46) on Suicide Precautions were provided with a safe environment. A 44-gallon plastic trash container with lid was in the hallway of the Adolescent Girl's Unit just outside the door to the dayroom. On 3/26/2021 at 11:00pm (19 days earlier), the lid been used to break the plastic to a ceiling light fixture in the dayroom by Patient #50. She then cut herself with a piece of the plastic in her bathroom.

Cross reference Tag A0144.


K) Ensure processes were developed with effective implementation of policies and procedures that provided a modification to the patient's treatment plan following the use of restraint or seclusion for 5 of 5 patients (Patient #12, #24, #47, #48, and #50).

Cross reference Tag A0166.

Based on observation, interview, and record review, the facility failed to ensure processes were developed with effective implementation of policies and procedures that provided patients with a safe environment.

The facility failed to:

A) Ensure that patients could not gain access to staff's hospital keys. Because of this failure, 5 of 29 patients in Youth Services (Patient #24, 47, 48, 49, and 50) eloped from the facility. The four adolescent girls and one male child could have been seriously harmed or killed in a high traffic area (Interstate 45 and FM 1960) or subjected to human trafficking.

B) Ensure that 3 of 13 children (Patient #14, 16, and 47) were safely removed from an emergency crisis that occurred on the female adolescent unit. This failure resulted in Patient #47's eloped with four adolescent females (Patient #24, 48, 49, and 50).

C) Ensure that 2 of 2 adolescent males (Patient #30 and Patient #31) were safely monitored on the Adolescent Boys Unit during an emergency crisis. These two patients breached the nurse's station, climbing across the counters into the Adolescent Girls Unit. During this breach, they had access to computer monitors and keyboards, telephones, and unit supplies. In addition, they could have slipped and fallen, resulting in serious injury, impairment, or death.

D) Ensure that the furniture on the adolescent and adult units cannot be used as a weapon. During an emergency crisis, 1 of 4 adolescent patients (Patient #50) pulled a chair from the day room, picked it up, and hurled across a 45-inch tall counter into the nurse's station. Other patients that had congregated near this patient, as well as staff in the nurse's station, could have been seriously injured, impaired, or killed.

E) Ensure that individuals being assessed in the Intake Department were safely monitored while using 2 of 2 bathrooms. The bathrooms were not designed with safety in mind as evidenced by numerous features that were not ligature resistant, lighting that allowed for easy access to the bulbs, and a large glass mirror.

F) Ensure that patients were provided safe sleeping quarters. 25 of 41 patients (Patient #13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 28, 31, 32, 33, 34, 36, 37, 38, 39, 40, 43, 44, 45, and 46) on Suicide Precautions were in bedrooms with headboards that had tie-off points that could be used for the purpose of hanging or strangulation. In addition, the facility failed to identify the head boards as a ligature risk during previous Hospital Risk Assessments.

G) Ensure that the investigation of sexual acting out between 2 of 2 patients (Patient #3 and Patient #6) was completed. Even though these two patients were roommates in a room that had been assigned as a "Sexually Acting Out Room," they were able to engage in mutual masturbation. At the time of the incident, Patient #6 was on Sexually Acting Out Precautions (SAO); Patient #3 was not.

H) Ensure that 8 of 12 adolescent patients (Patients #16, 18, 20, 21, 22, 23, 24, and 46) on Suicide Precautions were provided with a safe environment. Three packages of Styrofoam cups with the plastic sleeves still on them were stored in the day room (a commons area), allowing patients access to the plastic sleeves. The plastic sleeves can be used for suicidal asphyxiation.

I) Ensure that 13 of 14 adult patients (Patients #32, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43, 44, and 45) on Suicide Precautions were provided with a safe environment. Two phones with detachable handset cords were secured to furniture in the day room (a commons area), allowing patients access to the phones. When the flexible plastic phone cords were detached from both the jack on the phone's base and the handset, each stretched to about 18 inches.

J) Ensure that 8 of 12 adolescent patients (Patients #16, 18, 20, 21, 22, 23, 24, and 46) on Suicide Precautions were provided with a safe environment. A 44-gallon plastic trash container with lid was in the hallway of the Adolescent Girl's Unit just outside the door to the dayroom. On 3/26/2021 at 11:00pm (19 days earlier), the lid been used to break the plastic to a ceiling light fixture in the dayroom by Patient #50. She then cut herself with a piece of the plastic in her bathroom.



38015

A). Patient gained access to staff's hospital keys.

Findings:

Record review of facility policy titled "Assault Precautions," Number 760.300.08, stated that all patients on Assault Precautions must also be placed on Unit Restrictions, where the patient is not allowed to go off the unit without a doctor's order.

Record review on 4/15/21 of facility Occurrence Reports, written by staff on duty in Unit 2 (Staff-RN #Z, Staff MHT-#M) on the evening of 4/10/21, showed the following: On the evening of 4/10/21 at approximately 9:15 pm, 4 adolescent females (Patient #'s 24, 48, 49 and #50) and 1 (one) 11-year-old male child (Patient #47) had successfully eloped from the facility.

In an interview on 4/15/21 at 1:30 pm with DON-Staff #A, she stated that the elopement had indeed occurred and the facility was still investigating the occurrence. Staff #A stated that only two of the five patients who eloped had made it back to the facility (Patients #'s 24 and 47). The other patients (Patient #'s 48, 49, and 50) had never returned.

In an interview on 4/15/21 at 1:40 pm with Assistant Administrator (AA)-Staff #G, he stated that the investigation was not yet complete. However, he expressed what he had learned and understood at that time: He said a group of adolescent girls and boys were "acting up" and getting rowdy. An 11-year- old male child (Patient #47) had grabbed the door keys from Mental Health Technician (MHT)-Staff# M. The patient had pulled on a 'lanyard' from Staff #M's pocket, with which the keys to the exit door were attached to, took the keys, and gave them to an adolescent female peer. The door was opened by one of the adolescent females and 5 patients were able to elope and escape the building. A Code White (Behavioral emergency) was called by MHT-Staff #M.

AA-Staff #G added that at the same time as the elopement code, an adolescent female was having a seizure in the adolescent dayroom and a 'Code Blue' was called (Medical emergency). In addition, there was a simultaneous behavioral emergency, 'Code White,' because male adolescents from the male adolescent side on Unit 2 were slamming their bodies on doors double doors (locked) that led into the female adolescent and children's side. They were also trying to jump into the nurse's station in order to get to the female adolescent/children's side, since the double doors would not open. (The nurse's station is shared by the female adolescents and children on Unit 2, in the 'Long hallway" and the male adolescent patients on the short hallway of Unit 2. This configuration formed a type of L-shape with the shared nurses' s station located at the apex. The nursing station made a common connection between the long and short halls. Female adolescents and children were residing on the long part of the 'L', male adolescents were residing on the 'short' part of the L - the short hallway).

In an interview on 4/16/21 at 10:00am, MHT-Staff #M stated the following regarding the elopement: There was one Code White occurring due to male adolescents trying to breech the nurses station to enter the long hall, and a Code Blue medical emergency nearly simultaneously on 4/10/21 at approximately 9:00 pm. As per protocol, Staff #M's duties were to sequester all the children in the Children's dayroom and to keep the door closed. This was to avoid the patients from witnessing and/or being in the way of staff to address the code(s), as well as for the children's general safety. She added that all patients not involved in the code were supposed to be either in their rooms and monitored by staff, or the patients would be put in a common dayroom and be monitored; Children shared one common dayroom, adolescent girls another, and adolescent boys another.

Staff #M went on to say that while she was trying to keep all the children inside the dayroom, Patient #47 (male child) blocked the door, not allowing her to close it. At that time, an adolescent female, Patient-#24, grabbed the keys to the facility directly out of Staff #M's hands, and opened the exit door which was located within 10 feet of the children's dayroom (note: this statement was in conflict with the comments Staff #G, stated that it was the male child who grabbed the keys). Staff #M then called another Code White over the phone. However, 5 patients had already made it through the door, opened it, ran down two flights of stairs, and escaped/eloped through an exit door at the bottom of the stairwell.

Staff #M added that the police were called and reports of missing persons were filed. Patient-#47 (male child) was abandoned by the group near a convenience store. A stranger then returned Patient-#47 to facility a few hours after the elopement. The female adolescents were not returned that evening. As of time of survey, just one of the 4 missing adolescent females (Patient-#24) had been returned to facility.

Observation on 4/16/21 at 11:15 am of various MHTs' keys from Unit 2, showed each one had only three keys on their person. One key was for the elevators (a very short specialized rounded key), one for the fire extinguishers (a very short key), and one regular sized key which opened the doors, used for the elopement. This made identifying the door key easy to identify for the patients to elope.

Record review of the facility's video footage, with AA-Staff #G and Youth Services Program Manager - Staff #Q showed the following highlights: on 4/10/21 at 21:05 pm, 4 adolescent females were standing at the nurse's station, refusing to go to their rooms, per Staff #G. During this time, several male adolescent patients were trying to jump into nurse's station over their 45 inch counter, in order to get to the female adolescent and children's hall. Two adolescent males (Patient #'s 30 and 31) were able to jump over counter into nursing station, and then again into the long hallway on the female adolescent/children's side. Both of them had run to the exit door, pushed against it, but it would not open. They were seen being escorted back to their own side. This prompted a code white to be called by the nurses. At the same time, Staff #G stated there was also a code blue occurring in the female adolescent dayroom. A patient was having a seizure.

According to Staff #G, the four adolescent girls at the nursing station refused redirection to go to their rooms and remained in front of the nurse's station. The four adolescent girls, all of whom later eloped, then began jumping over the counter onto the nurse's station, attacking staff with their hands. According to Staff #G, two staff sustained injuries; RN-Staff #AA and MHT-Staff Y # (who never returned to the facility after the incident).

The video then showed male child-Patient #47, blocking the children's dayroom door from being closed by MHT-Staff #M while the 4 adolescent female patients at the nurse's station ran down the hallway. During and aroun this time, the video failed to capture who exactly took the keys and how the keys were actually confiscated. The video then showed Patient-#24 opening the exit door with the keys and 5 patients running through the door before it was closed.


Record review of the 5 patients who eloped showed the following:

1). Patient #24: 16-year-old female admitted to facility 4/6/21 under care of MD-Staff #U, from a Residential Treatment Facility (RTC) placed there by Child Protective Services (CPS). The patient had the diagnoses of Disruptive Mood Dysregulation disorder (DDMD), and Oppositional Defiant disorder (ODD). The patient was brought to the facility because she had run away from her RTC. She was brought back to the RTC, where she had destroyed property and reported she wanted to run away again so she could jump into traffic. She was under the guardianship of Child Protective Services (CPS). Her doctor's orders on admission to facility included placing patient on Assault Precautions, Unit Restrictions, and Suicide Precautions. Patient was later returned to facility by police.


2). Patient #49: 17-year-old female admitted to facility on 4/1/21 under the care of Medical Director-Staff #D from an RTC, was placed there by CPS. Patient's diagnoses were Depressive Disorder, unspecified, and history of Attention Deficit Hyperactivity disorder (ADHD). She was brought to the facility because she had eloped from the RTC, which she tried to return to about a week later. RTC would not accept her back. Her doctor's orders on admission included Assault Precautions, Suicide Precautions, Unit Restrictions. Patient never returned back to facility after elopement.


3). Patient #50: 17-year-old female admitted to facility on 3/1/21 under the care of MD-Staff # T, coming from an RTC where CPS had placed her. The patient's diagnoses were Major Depressive disorder, recurrent, severe, without psychotic features, Anxiety disorder, Rule Out Borderline Personality traits. She had suicidal ideations. The patient had a history of running away/eloping from her RTC. Her doctor's orders included Assault Precautions, Suicide Precautions, Unit Restrictions, Sexually Acting-Out Precautions. The patient never returned to facility after elopement.


4). Patient # 48: 16-year-old female admitted to facility on 1/11/21 under the care of MD-Staff #T. The patient, who was under CPS custody, had the diagnoses of Major Depressive disorder, recurrent, severe, without psychotic features, DMDD, Rule Out Oppositional Defiant disorder (ODD), Rule out Borderline Personality Trait. She had a history of multiple suicide attempts and self-mutilation. Her doctor's orders included Sexually Acting Out Precautions, Suicide Precautions, Unit Restrictions. Patient never returned to facility after elopement.


5). Patient #47: 11-year-old male child admitted to facility on 3/25/21 under the care of MD-Staff #T. The patient, who was in CPS custody and was residing at an RTC prior to admission, had the diagnoses of DMDD, Intermittent Explosive disorder, ADHD, ODD. He had a history of aggression toward staff and self-harm at his RTC. His doctor's orders included Assault Precautions, Sexually Acting Out (SAO) Precautions, Unit Restrictions.



B). Children not safely removed from an emergency crisis.

Findings:

Review of facility policy titled "Code White," number 760.200.256., stated that the registered nurse, 6.2.2 "Assigns staff member to clear area of patients, visitors, and staff ....." during a Code White.

Review of video footage of a violent patient uprising in facility's Unit 2, revealed the following: On 4/10/21, starting at approximately 9:00 pm, per Assistant Administrator (AA)-Staff #G who was viewing the video with surveyors, showed that adolescent boys, located in Unit 2's short hall, were trying to break through locked double doors in order to get to the adolescent female/children's side. This was unsuccessful. The adolescent boys were also trying to jump over into the common nurse's station; two of them had made it over into the long hallway and ran down the hall to the exit door. (The nurse's station is shared by the female adolescents and children on Unit 2, in the 'Long hallway" and the male adolescent patients on the short hallway of Unit 2. This configuration formed a type of L-shape with the shared nurses' s station located at the apex. The nursing station made a common connection between the long and short halls).

A Code White (Behavioral Emergency) was called by staff due to adolescent boys attempting to break-down locked double doors separating the adolescent girls and children on the unit's 'Long Hall'. Meanwhile, two of the adolescent boys had climbed-over the nurse's station's counter, into the station, then climber over the conter in the long hallway, and ran down the adolescent girls/children's long hallway towards the exit door. Video shows both being escorted back to their side by staff, one at a time. During this time, another Code White was called because of 4 adolescent girls refusing to go into their appointed rooms (Patients #24, 48,49, and #50).

It was explained by Assistent Administrator (AA)-Staff #G that it is the practice of the facility to place patients in their rooms or common dayrooms with the doors closed until the emergency had been cleared. Per AA-Staff #G, there was also a Code Blue, (medical emergency) occurring in the adolescent girl's dayroom-a patient was having a seizure.


Further review if video footage showed the 4 adolescent girls at the nurse's station jump over the nurse's station over a 45 inch high countertop of the desk, and physically attack staff, hitting at least 2 staff with their fists.

Patient-#50 was subsequently seen dragging a heavy chair from adolescent girl's dayroom and throwing it over and into the nurse's station, where several staff were.

During the time of the incidents with both female and male adolescent patients displaying violent and assaultive, defiant behaviors, there were three children seen in the video walking unaccompanied in the long hallway:

-Patient #47, an 11-year-old male, who was currently on Assault Precautions, Sexually Acting Out Precautions, Unit Restrictions.

-Patient #16, an 8-year-old female, who was currently on Assault Precautions, Suicide Precautions, Unit Restrictions.

-Patient #14, an 11-year-old male, who was currently on Assault Precautions, Sexually Acting Out Precautions, Unit Restrictions.


Further review of video footage showed Patient #47 blocking the door to the children's dayroom, which allowed for one of the adolescent girls involved in the Code White (Patient #24) to take the keys to the exit door from Mental Health Technician (MHT)-Staff #M. The door was opened with the keys, allowing all 4 of the adolescent girls (Patients #24, 48,49, and #50) as well as male child Patient #47, to successfully elope from the building.

Patient #47 was abandoned by the adolescent girls near a convenience store. A stranger brought the boy back to the facility within a few hours post elopement.

The video did not show the remaining two children on the lonh hall being escorted to their dayroom, where they should have been during all the commotion and violent behaviors exhibited by both female and male adolescents.


C). Adolescent males not safely monitored during emergency crisis

Findings:

Review of facility policy titled "Code White," number 760.200.256., stated that the registered nurse, 6.2.2 "Assigns staff member to clear area of patients, visitors, and staff ....." during a Code White.

Review of video footage on 4/16/21 at 1:00 pm with Mental Health Technician (MHT)Staff-#M, Administrative Assistant-Staff-#C, and Youth Services Director-Staff #Q, showed a violent patient uprising in facility's Unit 2, occurring on 4/10/21 starting at approximately 9:00 pm. There were 3 codes occurring at the same time, as explained by Staff #G; 2 Code Whites (Behavioral Emergencies) and 1 Code Blue (Medical Emergency). One Code White involved the defiance, assaultive actions towards staff, and subsequent elopement of 4 adolescent females and one 11 year old male child. The other code white involved the adolescent boys breeching and climbing over the 45 inch nurse's station counter and into the nurse's station, then climbling into the adolescent girls/children's unit head first.

The nurse's station is shared by the female adolescents and children on Unit 2, in the 'Long hallway", and the male adolescent patients on the short hallway of Unit 2. This configuration formed a type of L-shape with the shared nurse's station located at the apex. The nursing station made a common connection between the long and short halls.

The Code Blue was due to an adolescent girl having a seizure.

The video went on to show that two of the male adolescents (first Patient #31 then Patient #30) jumping head-first into nurse's station on to the floor, then jumping out of the nurse's station head-first onto the floor in the adolescent girls/children's long hall, then running at full speed towards the exit door, then body-slamming the exit door, which was locked. Both boys were then seen being escorted back to their own hall (Short Hall) by various Mental Health Technician (MHT) staff.


Record review of Patient #31's clinical records showed the following: Patient was a 16-year-old male who was admitted to facility on 3/29/21 under the care of MD-Staff #U. The patient, who's guardian was Child Protective Services (CPS) was previously living at a Residential Treatment Center (RTC), where he had wrapped a cord around his neck and threatened to stab self in the heart. The patient also had made homicidal threats. He was brought to an Emergency Room (ER) following the incident, then admitted to facility. The patient's diagnosis was Bipolar 1 disorder, most recent episode depressed, severe, without psychosis. His doctor's orders at the time of event included Assault Precautions, Suicide Precautions, Unit Restrictions.


Record review of patient #30's clinical records showed the following: Patient was a 15-year-old male admitted to facility on 3/28/21 under the care of MD-Staff #D. The patient's diagnoses were Disruptive Mood Dysregulation disorder (DMDD), Attention Deficit Hyperactivity disorder (ADHD), Rule out Post Traumatic Stress disorder (PTSD) and Oppositional Defiant disorder (ODD). His current doctor's orders at the time of the incident included Assault Precautions, Suicide Precautions.



D). Furniture used as a weapon.

Findings:

Review of facility policy titled "Code White," number 760.200.256., stated that the registered nurse, 6.2.2 "Assigns staff member to clear area of patients, visitors, and staff ....." during a Code White.

Review of video footage on 4/16/21 at 1:00 pm with Assistant Administrator (AA) Staff #G, Administrative Assistant Staff-#C, and Youth Services Program Director Staff #Q, showed a violent patient uprising in facility's Unit 2, occurring on 4/10/21 starting at approximately 9:00 pm. There were 3 codes occurring at the same time, as explained by Staff #G; 2 Code Whites (Behavioral Emergencies) and 1 Code Blue (Medical Emergency). One Code White involved the defiance, aggressive assaultive actions towards staff resulting in staff injuries, where at least two staff were struck by the adolescent girls, and 4 adolescent females subsequently eloped. The other code white involved adolescent boys breeching and climbing over the nurse's station 45 inch high counter and into the adolescent girls/children's unit. The Code Blue was due to an adolescent girl having a seizure.


Further review of the video footage showed that during the Code White involving the 4 adolescent girls and male child, showed one of the adolescent girls, Patient-#50 pulling a heavy chair from the adolescent girl's dayroom and throw/hurl over the nurse's station counter and into the nurse's station, potentially injuring several of the staff who were in the nurse's station as well as 3 children who were walking the hallways (Patient #'s 14, 16, and #47)


Record review of clinical chart for Patient #50 showed the following: 17-year-old female admitted to facility on 3/1/21 under the care of MD-Staff #T, coming from a Residential Treatment Center (RTC) where Child Protective Services (CPS), her guardians had placed her. The patient's diagnoses were Major Depressive disorder, recurrent, severe, without psychotic features, Anxiety disorder, Rule Out borderline personality traits. She had suicidal ideations. The patient had a history of running away/eloping from the RTC. Her doctor's orders included Assault Precautions, Suicide Precautions, Unit Restrictions, Sexually Acting-Out Precautions. The patient never returned to facility after elopement.


E) Unsafe bathrooms utilized by the Intake Department.

Findings:

In an interview with Staff G (Intake Director) on 4/14/2021 at 2:50pm, he stated that individual's in the process of being assessed for admission utilize the two bathrooms adjacent to the lobby elevators.

On 4/21/2021 at 9:00am, during a tour of the two bathrooms (one men's and one women's) adjacent to the lobby elevators, it was noted that both bathrooms had numerous safety issues.

In the men's bathroom, the chrome manual flush valves atop the two wall mounted urinals were exposed, creating a ligature risk. The following safety issues were found in both bathrooms:

1) Two lavatories that had a two-handle faucet with a metal gooseneck spout and metal lever handles. They were mounted in three-hole applications. The faucet and handles created tie-off points, creating a ligature risk.

2) The exposed plumbing under the lavatory sinks created a ligature risk.

3) A paper towel dispenser mounted flush to the wall to the right of the lavatories had an indention at the back-top edge. The indention created a tie-off point, creating a ligature risk.

4) Open metal hand rails in both bathroom stalls provided multiple tie-off points, creating a ligature risk.

5) The toilets in the stalls had exposed plumbing that provided a tie off point, creating a ligature risk.

6) The two metal stalls and doors were constructed in such a way that they provided numerous tie-off points, creating ligature risks.

7) The bathroom door had a metal door closer mounted to the inside of the door. The return arm protruded into the bathroom creating a ligature risk.

8) The bathroom door had a metal door handle. The door handle was constructed to form an elongated U, creating a ligature risk.

9) The ceiling light troffer had a plastic cover that enclosed florescent bulbs. The plastic cover and the bulbs have the potential of being reached by standing on the lavatory. The plastic cover and bulbs can be broken and used for self-mutilation. Pieces of glass can be swallowed. Pieces of broken plastic or glass can be hidden in clothing and taken to the unit.

10) On the back wall, directly over the lavatory counter, were three round light bulbs. The bulbs can be broken and used for self-mutilation. Pieces of glass can be swallowed. Pieces of broken plastic or glass can be hidden in clothing and taken to the unit.

11) Attached to the back wall of the lavatory counter is a large mirror that can be broken and used for self-mutilation.


In an interview with Staff E (Director of Plant Operations - DPO) on 4/14/2021 at 9:20am, he stated that a hospital risk assessment is conducted every six months. (He later provided a copy of the "Hospital Risk Assessment.")


Review of the "Hospital Risk Assessment" examined by the Risk Committee on April 2021 [day was not documented] showed the following items as "Risk Vulnerability": Door hinges, closures, and knobs; plumbing under sink; toilet, urinal, and faucet plumbing; board over sink; lights over sink; and toilet stalls. Many items listed above were missing from the assessment. The Interim Life Safety Measure was, "Patients are escorted by staff in this area."


In an interview with Staff G (Intake Director) on 4/14/2021 at 2:50pm, he stated:

" The parent or guardian of an adolescent patient will escort the patient to the bathroom from the Intake Department;

" For an adult patient, staff will go with the patient to the bathroom, adding that staff "stays outside and checks on" the patient;

" Staff will check on patients in the bathroom after "about two minutes";

" A lot can happen within a short amount of time when a patient has hung self; and

" Training needs to be done with the staff in the Intake Department about the timeframe for checking on patients.


And then on 4/20/2021 at 1:25pm, Staff G (Intake Director) and Staff E (DPO) Staff G stated that if the patient takes longer than two minutes and is of the opposite sex from the staff member, the staff member will get a staff member of the same sex to go into the bathroom to check on the patient. Staff E (DPO) also stated that he was developing a policy on taking patients from Intake to the bathroom.


In an interview with Staff E (DPO) on 4/20/2021 at 3:05pm, he stated that he was not comfortable with waiting for a staff member of the same sex as the patient to be found before going into the bathroom to check on the patient after a two-minute wait.


In an interview with Staff FF (Intake RN) on 4/21/2020 at 10:11am, she stated she worked full time in the Intake Department. She also stated:

" Patients are escorted to the bathroom by Intake staff one patient at a time;

" Staff wait outside the door while the patient is in the bathroom;

" She waits "a decent amount of time" before she checks on the patient in the bathroom, adding, "For me, I would say 2-3 minutes. If the patient is taking a little loner, I will go in. I gauge it off how long my kids go into the restroom. I use my judgement on the amount of time it takes to go to the restroom";

" She was not sure if there was a policy on taking patients to the bathroom;

" She has been in the women's bathroom but not the men's bathroom; and

" She thinks the women's bathroom is psych safe.


F) Headboards with ligature risk.

Findings:

On 4/13/2021 at 10:00am, during a tour of Youth Services (2nd floor) and Adult Services (3rd floor), it was observed that many of the bedrooms had headboards that were positioned in such a way that a gap was created between the headboard and the wall, creating a tie-off point. 31 of 34 rooms had beds with this ligature risk. Those rooms included:

Rooms 201, 202, 203, 204, 205, 206, 207, 208, 211, 212, 252, 253, 254, 255, and 257 on Youth Services.

Rooms 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 350, 352, 353, 354, 355, and 357 on Adult Services.


A knot was tied in one corner of a flat sheet taken from a patient's bed. The knot was wedged into the gap between the headboard and the wall and stayed in place when Staff A (DON) and Staff E (DPO) pulled on it. They both stated that the gap created a tie off point that could be used for hanging oneself or strangulation. They also stated that the bed headboards had not been identified as a risk vulnerability.


Review of the "Hospital Risk Assessment" examined by the Risk Committee on April 2021 [day was not documented] showed that the bed headboards were not listed as a "Risk Vulnerability."

Review of policy # 760.300.24, "Suicide Precautions," revised 5/2020, showed:

"Purpose ... To provide the patient with a safe environment ... Patients exhibiting a high-risk for suicide by verbalization of intent, exhibiting suicidal tendencies, or recent history will be placed on suicide precautions ... Upon admission all patients are placed in a safe room ... Patients who present as high risk for suicide and/or who refuse to contract for safety will be placed in a saferoom and will be flagged for High Suicide Risk and on Suicide Precautions."


Review of the Bed Board Log dated 4/13/2021 showed that 25 patients on Suicide Precautions were in the rooms with headboards that created a tie-off point: Patient #13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 28, 31, 32, 33, 34, 36, 37, 38, 39, 40, 43, 44, 45, and 46. Three of these patients (Patient #13, 23, and 31) were identified as "Suicide High Risk."


Review of the Physician's Orders for these 25 patients confirmed that they were on Suicide Precautions:

Patient #13.
Review of the Face Sheet for Patient #13 showed a 10y/o male admitted into Youth Services on.4/9/2021 at 8:44pm under the care of Staff T (Attending MD).
Review of the Physician Orders for Patient #13 showed an order for Suicide Precautions dated 4/9/2021 at 8:45pm.

Patient #14.
Review of the Face Sheet for Patient #14 showed an 11y/o male admitted into Youth Services on 4/9/2021 at 6:17pm under the care of Staff D (Attending MD).
Review of the Physician Orders for Patient #14 showed an order for Suicide Precautions dated 4/9/2021 at 6:05pm.

Patient #16.
Review of the Face Sheet for Patient #16 showed an 8y/o female admitted into Youth Services on 4/10/2021 at 2:54pm under the care of Staff D (Attending MD).
Review of the Physician Orders for Patient #16 showed an order for Suicide Precautions dated 4/10/2021 at 2:53pm.

Patient #17.
Review of the Face Sheet for Patient #17 showed an 11y/o male admitted into Youth Services on 4/11/2021 at 9:53pm under the care of Staff T (Attending MD).
Review of the Physician Orders for Patient #17 showed an order for Suicide Precautions dated 4/11/2021 at 9:51pm.

Patient #18.
Review of the Face Sheet for Patient #18 sho

Based on observation, interview, and record review, the facility failed to ensure processes were developed with effective implementation of policies and procedures that provided a modification to the patient's treatment plan following the use of restraint or seclusion for 5 of 5 patients (Patient #12, #24, #47, #48, and #50). The instances of physical restraint and/or emergency medication and/or seclusions were:

Patient #12 - 11;
Patient #24 - 3;
Patient #47 - 4;
Patient #48 - 7 and
Patient #50 - 10.


Findings:

Review of policy #760.300.18, "Seclusion and Restraint," revised May 2020, showed: "It is the policy of IntraCare Hospital to utilize seclusion and restraint as the absolute last resort in an effort to provide patient safety ... The purpose of this policy is to outline procedures for use of clinical timeout, quiet time, restraints and seclusions ...

PRINCIPLES ...

8. The treatment team reviews alternative strategies for dealing with behaviors necessitating the use of restraint or seclusion during treatment team planning meetings."


In an interview with Staff A (DON) on 4/21/2021 at 11:00am, she stated that the patient's care plans are not updated following incidents of restraint or seclusion, adding that restraints and seclusions are discussed in the administrative meeting conducted each morning. She also stated that prior to the electronic medical record, there was a form for modification of the care plan.


Review of the "Seclusion and Restraint" packets for Patient #12, #24, #47, #48, and #50 showed the following.


Patient #12.

Review of Psychosocial Update for Readmissions Within 90 Days dated 8/3/2020 at 4:00pm by Staff F (LPC Associate) and Staff X (Therapist) showed that Patient #12 was "triggered" because she was not discharged from the RTC due to a diagnosis of COVID-19.

Further review of the medical record showed documentation of 11 instances of restraint/seclusion/emergency medications. In each instance, there was no evidence that treatment team reviewed alternative strategies for dealing with behaviors necessitating the use of restraint or seclusion during treatment team planning meetings.

#1: Seclusion dated 8/3/2020 at 3:00pm by Staff HH (RN) showed, Patient #12 was removing her mask and "intentionally coughing at staff." She refused to leave the nurse's station. She stated, "I don't care if you get the virus." She was released from seclusion at 3:54pm.

#2: Physical restraint, emergency medication (IM Haldol 5mg, Ativan 2mg, and Benadryl 50mg), and seclusion dated 8/16/2020 at 8:52am - 8:56am by Staff II (RN) showed, Patient #12 grabbed items off the desk at the nurse's station, pulled items off the walls, attempted to bite staff, disrobed, and tied her clothing around her neck.

#3: Physical restraint, emergency medication (IM Thorazine 50mg), and seclusion dated 8/27/2020 at 9:00pm - 10:00pm by Staff JJ (RN) showed Patient #12 yelled, screamed, kicked walls, and threatened to hit staff because she could not get more medication.

#4: Physical restraint and seclusion dated 9/2/2020 at 7:46pm - 8:30pm by Staff AA (RN) showed Patient #12 became an imminent danger to herself and others and attempted to grab objects off desk at nurse's station.

#5: Physical restraint and seclusion dated 9/7/2020 at 7:30pm - 8:30pm by Staff KK (RN) showed Patient #12 refused to return to the unit from the playground. She hit and kicked staff.

#6: Physical restraint dated 9/12/2020 at 10:07pm - 10:12pm by Staff LL (RN) showed Patient #12 insisted she need an injection of medication. She refused oral medication. She sat under the running water in her shower, flooded her room, and poured water on staff.

#7: Physical restraint and seclusion dated 9/14/2020 at 8:00pm - 9:00pm by Staff KK (RN) showed Patient #12 kicked and hit staff and banged head on the wall.

#8: Physical restraint and seclusion dated 9/16/2020 at 3:36pm - 3:40pm by Staff MM (RN) showed Patient #12 refused to leave the nurse's station, cursed and threatened staff, threw water at staff, and banged on wall.

#9: Physical restraint and seclusion dated 9/26/2020 at 7:35pm - 9:30pm by Staff AA (RN) showed Patient #12 demanded to go to the quiet room to get an injection of medication. She became physically aggressive, banged on the door and wall. In the seclusion room, she removed her clothes and wrapped her clothes around her neck. Staff D (attending physician) noted in his Psychiatric Reassessment on 9/28/2020 at 11:03a that Patient #12 had been more labile over the most recent 36-hour period. She told him she wanted attention, adding, "When I get older, I'm going to come back and shoot up this place. She was also upset over her prolonged stay at the facility. She complained of leg pain.

#10: Physical restraint and seclusion dated 10/4/2020 at 6:54pm - 9:00pm by Staff AA (RN) showed Patient #12 became upset when staff got involved in an emergency with another patient. She cursed and kicked staff and slapped a staff member in the face.

#11: Physical restraint, emergency medication (IM Haldol 5mg, Ativan 2mg, and Benadryl 50mg), and seclusion dated 10/27/2020 at 11:05am - 11:50am by Staff NN (RN) showed Patient #12 threatened to fight staff, pushed and swung at staff, ripped items from the wall. She complained of pain to elbow.


Patient #24.

Review of the medical record showed documentation of 3 instances of restraint/seclusion/emergency medications. In each instance, there was no evidence that treatment team reviewed alternative strategies for dealing with behaviors necessitating the use of restraint or seclusion during treatment team planning meetings.

#1: Physical restraint and emergency medication dated 4/16/2021 at 8:54pm - 8:56pm by Staff UU showed Patient #24, a 16y/o female, hit a peer.

#2: Physical restraint, clinical time out, and seclusion dated 4/17/2021 at 9:55pm - 10:40pm by Staff AA showed Patient #24 attempted to instigate a riot on the unit so she could elope from the hospital.

#3: Physical restraint and seclusion dated 4/18/2021 at 8:55pm - 9:03pm by Staff TT (RN) showed Patient #24 threatened to physically assault staff and peer, stating, "I am gonna cut someone's throat."


Patient #47.

Review of the medical record showed documentation of 4 instances of restraint / seclusion / emergency medications. In each instance, there was no evidence that treatment team reviewed alternative strategies for dealing with behaviors necessitating the use of restraint or seclusion during treatment team planning meetings.

#1: Seclusion dated 3/25/2021 at 8:05pm - 8:20pm by Staff PP (RN) showed Patient #47, an 11 y/o male, had a physical fight with a peer, in which he was bitten. He attempted to remove a peer from seclusion.

#2: Physical restraint and emergency medication (Thorazine 50mg and Benadryl 50mg) dated 3/30/2021 at 8:10am - 9:10am by Staff L (RN) showed Patient #47 went into another patient's room and refused to come out. He cursed and hit staff.

#3: Seclusion dated 4/10/2021 at 7:50pm - 8:10pm by Staff Z (RN) showed Patient #47 cursed staff, refused to go to dayroom, and became aggressive with staff.

#4: Physical restraint, emergency medication (IM Thorazine 50mg and Benadryl 50mg), seclusion, and clinical time out dated 4/15/2021 at 5:45pm - 6:10pm by Staff QQ (RN) showed Patient #47 kicked staff and get into a staff's desk.



Patient #48.

Review of the medical record showed documentation of 7 instances of restraint / seclusion / emergency medications. In each instance, there was no evidence that treatment team reviewed alternative strategies for dealing with behaviors necessitating the use of restraint or seclusion during treatment team planning meetings.

#1: Physical restraint and clinical time out dated 1/21/2021 at 8:20pm - 9:35pm by Staff SS (RN) showed Patient #48, a 15y/o female, attacked a peer.

#2: Physical restraint, emergency medication (IM Thorazine 50mg and Benadryl 50mg), and seclusion dated 2/9/2021 at 7:25pm - 8:25pm by Staff RR (RN) showed Patient #48 slammed doors, kicked walls, overturned the trash can, and was aggressive towards staff.

#3: Physical restraint and clinical time out dated 2/15/2021 at 7:30pm - 7:50pm by Staff QQ (RN) showed Patient #48 attacked her peers, punched the fire extinguisher box, and cursed staff. She attempted to hit staff.

#4: Physical restraint and seclusion dated 3/14/2021 at 9:45am - 10:15am by Staff II (RN) showed Patient #48 attempted to go into another patient's bedroom. She threatened and attempted to hit a staff member.

#5: Physical restraint and emergency medication (IM Haldol 5mg and Benadryl 50mg) dated 3/20/2021 at 8:30am - 8:46am by Staff KK (RN) showed Patient #48 walked into the dayroom and "started hitting and kicking peer on her back and arms and was restrained to prevent injury."

#6: Emergency medication (IM Haldol 5mg and Benadryl 50mg) dated 3/26/2021 at 9:00pm - 9:05pm by Staff PP (RN) showed Patient #48 was running the hallway and yelling. She stated she and other female patients had plans to "riot against the staff together."

#7: Physical restraint, emergency medication (IM Thorazine 50mg and Benadryl 50mg), and seclusion dated 4/6/2021 at 1:10pm - 2:10pm by Staff OO (RN) showed Patient #48 attempted to jump over a nurse's table to hit a staff member. She threatened to harm herself and anyone that got in her way.


Patient #50.

Review of the medical record showed documentation of 10 instances of restraint / seclusion / emergency medications. In each instance, there was no evidence that treatment team reviewed alternative strategies for dealing with behaviors necessitating the use of restraint or seclusion during treatment team planning meetings.

#1: Physical restraint and emergency medication (IM Thorazine 50mg and Benadryl 50mg) dated 3/13/2021 at 9:00pm by Staff VV (RN) showed Patient #50, 17y/o female, threated to attack staff, interfered with the administration of medications, and entered another patient's bedrooms.

#2: Physical restraint and emergency medication (IM Haldol 5mg and Benadryl 50mg) dated 3/17/2021 at 10:30pm - 11:05pm by Staff PP (RN) showed patient physically attacked a staff member. She grabbed staff's keys and handed them to a peer. Peer went to the elevator and opened it. Staff intervened before the peer could leave the unit. Patient #50 then attacked the staff member who restrained the peer, hitting him in the face multiple times with her fist. She stomped another staff member in the chest. Patient #50 was physically restrained. She scratched and bit staff members.

#3: Physical restraint, emergency medication (IM Thorazine 50mg and Benadryl 50mg), and seclusion dated 3/18/2021 at 11:35am - 11:035am by Staff QQ (RN) showed Patient #50 attempted to hit staff in the face.

#4: Physical restraint and emergency medication (IM Haldol 5mg and Benadryl 50mg) dated 3/20/2021 at 8:30am - 8:46am by Staff KK (RN) showed Patient #50 tried to fight peers.

#5: Emergency medication (IM Haldol 5mg and Benadryl 50mg) dated 3/25/2021 at 10:55 pm by Staff Z (RN) showed Patient #50 and fellow peers ran the hallways and threatened to "start up a riot tonight again."

#6: Emergency medication (IM Haldol 5mg and Benadryl 50mg) dated 3/26/2021 at 11:00pm by Staff Z (RN) showed Patient #50 and a group of peers joined together and refused to go to bed. They threatened to fight staff. Patient threw an object at the light in the ceiling and broke the plastic. She took a piece of the broken plastic to her bathroom and used it to make cuts to her left forearm. Wound care was provided.

#7: Emergency medication (IM Thorazine 50mg and Benadryl 50mg) dated 3/27/2021 at 9:00pm by Staff AA (RN) showed Patient #50 took another female peer into her bathroom and both refused to come out.

#8: Physical restraint dated 4/4/2021 at 9:45pm - 9:50pm by Staff AA (RN) showed Patient #50 physically attacked staff while staff was restrained another patient.

#9: Physical restraint, emergency medication administration (IM Thorazine 50mg and Benadryl 50mg) and seclusion dated 4/5/2021 at 3:46pm - 4:50pm by Staff OO (RN) showed Patient #50 was pacing and threatened to hit staff. She threw water on staff.

#10: Physical restraint dated 4/5/2021 at 4:53pm - 5:08pm by Staff I (RN) showed Patient #50 went into a peer's bedroom and refused to come out.

Based on review of records, observations, and interview, the facility failed to ensure that all patient care areas were constructed to ensure the safety of the patients. Specifically, the facility failed to:

L) Ensure that individuals being assessed in the Intake Department were safely monitored while using 2 of 2 bathrooms. The bathrooms were not designed with safety in mind as evidenced by numerous features that were not ligature resistant, lighting that allowed for easy access to the bulbs, and a large glass mirror. Staff were unclear about the procedure for escorting patients to the bathroom, adding that there was no policy.

Cross reference Tag A0701.


M) Ensure that patients were provided safe sleeping quarters. 25 of 41 patients (Patient #13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 28, 31, 32, 33, 34, 36, 37, 38, 39, 40, 43, 44, 45, and 46) on Suicide Precautions were in bedrooms with headboards that had tie-off points that could be used for the purpose of hanging or strangulation. In addition, the facility failed to identify the head boards as a ligature risk during previous Hospital Risk Assessments.

Cross reference Tag A0701.

Based on review of records, observations, and interview, the facility failed to ensure that all patient care areas were constructed to ensure the safety of the patients. Specifically, the facility failed to:

L) Ensure that individuals being assessed in the Intake Department were safely monitored while using 2 of 2 bathrooms. The bathrooms were not designed with safety in mind as evidenced by numerous features that were not ligature resistant, lighting that allowed for easy access to the bulbs, and a large glass mirror. Staff were unclear about the procedure for escorting patients to the bathroom, adding that there was no policy.

M) Ensure that patients were provided safe sleeping quarters. 25 of 41 patients (Patient #13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 28, 31, 32, 33, 34, 36, 37, 38, 39, 40, 43, 44, 45, and 46) on Suicide Precautions were in bedrooms with headboards that had tie-off points that could be used for the purpose of hanging or strangulation. In addition, the facility failed to identify the head boards as a ligature risk during previous Hospital Risk Assessments.

Findings:


L) Bathrooms utilized by the Intake Department.

In an interview with Staff G (Intake Director) on 4/14/2021 at 2:50pm, he stated that individual's in the process of being assessed for admission utilize the two bathrooms adjacent to the lobby elevators.

On 4/21/2021 at 9:00am, during a tour of the two bathrooms (one men's and one women's) adjacent to the lobby elevators, it was noted that both bathrooms had numerous safety issues.

In the men's bathroom, the chrome manual flush valves atop the two wall mounted urinals were exposed, creating a ligature risk. The following safety issues were found in both bathrooms:

1) Two lavatories that had a two-handle faucet with a metal gooseneck spout and metal lever handles. They were mounted in three-hole applications. The faucet and handles created tie-off points, creating a ligature risk.

2) The exposed plumbing under the lavatory sinks created a ligature risk.

3) A paper towel dispenser mounted flush to the wall to the right of the lavatories had an indention at the back-top edge. The indention created a tie-off point, creating a ligature risk.

4) Open metal hand rails in both bathroom stalls provided multiple tie-off points, creating a ligature risk.

5) The toilets in the stalls had exposed plumbing that provided a tie off point, creating a ligature risk.

6) The two metal stalls and doors were constructed in such a way that they provided numerous tie-off points, creating ligature risks.

7) The bathroom door had a metal door closer mounted to the inside of the door. The return arm protruded into the bathroom creating a ligature risk.

8) The bathroom door had a metal door handle. The door handle was constructed to form an elongated U, creating a ligature risk.

9) The ceiling light troffer had a plastic cover that enclosed florescent bulbs. The plastic cover and the bulbs have the potential of being reached by standing on the lavatory. The plastic cover and bulbs can be broken and used for self-mutilation. Pieces of glass can be swallowed. Pieces of broken plastic or glass can be hidden in clothing and taken to the unit.

10) On the back wall, directly over the lavatory counter, were three round light bulbs. The bulbs can be broken and used for self-mutilation. Pieces of glass can be swallowed. Pieces of broken plastic or glass can be hidden in clothing and taken to the unit.

11) Attached to the back wall of the lavatory counter is a large mirror that can be broken and used for self-mutilation.


In an interview with Staff E (Director of Plant Operations - DPO) on 4/14/2021 at 9:20am, he stated that a hospital risk assessment is conducted every six months. (He later provided a copy of the "Hospital Risk Assessment.")


Review of the "Hospital Risk Assessment" examined by the Risk Committee on April 2021 [day was not documented] showed the following items as "Risk Vulnerability": Door hinges, closures, and knobs; plumbing under sink; toilet, urinal, and faucet plumbing; board over sink; lights over sink; and toilet stalls. Many items listed above were missing from the assessment. The Interim Life Safety Measure was, "Patients are escorted by staff in this area."


In an interview with Staff G (Intake Director) on 4/14/2021 at 2:50pm, he stated:

" The parent or guardian of an adolescent patient will escort the patient to the bathroom from the Intake Department;

" For an adult patient, staff will go with the patient to the bathroom, adding that staff "stays outside and checks on" the patient;

" Staff will check on patients in the bathroom after "about two minutes";

" A lot can happen within a short amount of time when a patient has hung self; and

" Training needs to be done with the staff in the Intake Department about the timeframe for checking on patients.


On 4/20/2021 at 1:25pm, Staff G (Intake Director) and Staff E (DPO) Staff G stated that if the patient takes longer than two minutes and is of the opposite sex from the staff member, the staff member will get a staff member of the same sex to go into the bathroom to check on the patient. Staff E (DPO) also stated that he was developing a policy on taking patients from Intake to the bathroom.


In an interview with Staff E (DPO) on 4/20/2021 at 3:05pm, he stated that he was not comfortable with waiting for a staff member of the same sex as the patient to be found before going into the bathroom to check on the patient after a two-minute wait.


In an interview with Staff FF (Intake RN) on 4/21/2020 at 10:11am, she stated she worked full time in the Intake Department. She also stated:

" Patients are escorted to the bathroom by Intake staff one patient at a time;

" Staff wait outside the door while the patient is in the bathroom;

" She waits "a decent amount of time" before she checks on the patient in the bathroom, adding, "For me, I would say 2-3 minutes. If the patient is taking a little loner, I will go in. I gauge it off how long my kids go into the restroom. I use my judgement on the amount of time it takes to go to the restroom";

" She was not sure if there was a policy on taking patients to the bathroom;

" She has been in the women's bathroom but not the men's bathroom; and

" She thinks the women's bathroom is psych safe.


M) Headboards with ligature risk.

On 4/13/2021 at 10:00am, during a tour of Youth Services (2nd floor) and Adult Services (3rd floor), it was observed that many of the bedrooms had headboards that were positioned in such a way that a gap was created between the headboard and the wall, creating a tie-off point. 31 of 34 rooms had beds with this ligature risk. Those rooms included:

Rooms 201, 202, 203, 204, 205, 206, 207, 208, 211, 212, 252, 253, 254, 255, and 257 on Youth Services.

Rooms 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 350, 352, 353, 354, 355, and 357 on Adult Services.


A knot was tied in one corner of a flat sheet taken from a patient's bed. The knot was wedged into the gap between the headboard and the wall and stayed in place when Staff A (DON) and Staff E (DPO) pulled on it. They both stated that the gap created a tie off point that could be used for hanging oneself or strangulation. They also stated that the bed headboards had not been identified as a risk vulnerability.


Review of the "Hospital Risk Assessment" examined by the Risk Committee on April 2021 [day was not documented] showed that the bed headboards were not listed as a "Risk Vulnerability."


Review of policy # 760.300.24, "Suicide Precautions," revised 5/2020, showed: "Purpose ... To provide the patient with a safe environment ... Patients exhibiting a high-risk for suicide by verbalization of intent, exhibiting suicidal tendencies, or recent history will be placed on suicide precautions ... Upon admission all patients are placed in a safe room ... Patients who present as high risk for suicide and/or who refuse to contract for safety will be placed in a saferoom and will be flagged for High Suicide Risk and on Suicide Precautions."


Review of the Bed Board Log dated 4/13/2021 showed that 25 patients on Suicide Precautions were in the rooms with headboards that created a tie-off point: Patient #13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 28, 31, 32, 33, 34, 36, 37, 38, 39, 40, 43, 44, 45, and 46. Three of these patients (Patient #13, 23, and 31) were identified as "Suicide High Risk."


Review of the Physician's Orders for these 25 patients confirmed that they were on Suicide Precautions:

Patient #13.
Review of the Face Sheet for Patient #13 showed a 10y/o male admitted into Youth Services on.4/9/2021 at 8:44pm under the care of Staff T (Attending MD).
Review of the Physician Orders for Patient #13 showed an order for Suicide Precautions dated 4/9/2021 at 8:45pm.

Patient #14.
Review of the Face Sheet for Patient #14 showed an 11y/o male admitted into Youth Services on 4/9/2021 at 6:17pm under the care of Staff D (Attending MD).
Review of the Physician Orders for Patient #14 showed an order for Suicide Precautions dated 4/9/2021 at 6:05pm.

Patient #16.
Review of the Face Sheet for Patient #16 showed an 8y/o female admitted into Youth Services on 4/10/2021 at 2:54pm under the care of Staff D (Attending MD).
Review of the Physician Orders for Patient #16 showed an order for Suicide Precautions dated 4/10/2021 at 2:53pm.

Patient #17.
Review of the Face Sheet for Patient #17 showed an 11y/o male admitted into Youth Services on 4/11/2021 at 9:53pm under the care of Staff T (Attending MD).
Review of the Physician Orders for Patient #17 showed an order for Suicide Precautions dated 4/11/2021 at 9:51pm.

Patient #18.
Review of the Face Sheet for Patient #18 showed a 13y/o female admitted into Youth Services on 4/6/2021 at 6:30pm under the care of Staff T (Attending MD).
Review of the Physician Orders for Patient #18 showed an order for Suicide Precautions dated 4/6/2021 at 6:24pm.

Patient #19.
Review of the Face Sheet for Patient #19 showed a 16y/o female admitted into Youth Services on 4/11/2021 at 5:43pm under the care of Staff T (Attending MD).
Review of the Physician Orders for Patient #19 showed an order for Suicide Precautions dated 4/11/2021 at 5:39pm.

Patient #20.
Review of the Face Sheet for Patient #20 showed a 14y/o female admitted into Youth Services on 4/1/2021 at 1:42m under the care of Staff T (Attending MD).
Review of the Physician Orders for Patient #20 showed an order for Suicide Precautions dated 4/1/2021 at 9:19am.

Patient #21.
Review of the Face Sheet for Patient #21 showed a 15y/o female admitted into Youth Services on 4/7/2021 at 7:34pm under the care of Staff U (Attending MD).
Review of the Physician Orders for Patient #21 showed an order for Suicide Precautions dated 4/7/2021 at 3:01pm.

Patient #22.
Review of the Face Sheet for Patient #22 showed a 16y/o female admitted into Youth Services on 4/12/2021 at 9:02pm under the care of Staff T (Attending MD).
Review of the Physician Orders for Patient #22 showed an order for Suicide Precautions dated 4/12/2021 at 9:02pm.

Patient #23.
Review of the Face Sheet for Patient #23 showed a 13y/o female admitted into Youth Services on 4/7/2021 at 6:11pm under the care of Staff D (Attending MD).
Review of the Physician Orders for Patient #23 showed an order for Suicide Precautions dated 4/7/2021 at 6:07pm.

Patient #24.
Review of the Face Sheet for Patient #24 showed a 16y/o female admitted into Youth Services on 4/6/2021 at 5:02pm under the care of Staff U (Attending MD).
Review of the Physician Orders for Patient #24 showed an order for Suicide Precautions dated 4/6/2021 at 4:49pm.

Patient #28.
Review of the Face Sheet for Patient #28 showed a 7y/o male admitted into Youth Services on 4/8/2021 at 6:46pm under the care of Staff U (Attending MD).
Review of the Physician Orders for Patient #28 showed an order for Suicide Precautions dated 4/8/2021 at 1:53pm.

Patient #31.
Review of the Face Sheet for Patient #31 showed a 16y/o male admitted into Youth Services on 3/29/2021 at 2:53pm under the care of Staff U (Attending MD).
Review of the Physician Orders for Patient #31 showed an order for Suicide Precautions dated 3/28/2021 at 1:41pm.

Patient #32.
Review of the Face Sheet for Patient #32 showed a 56y/o female admitted into Adult Services on 4/11/2021 at 7:34pm under the care of Staff V (Attending MD).
Review of the Physician Orders for Patient #32 showed an order for Suicide Precautions dated 4/11/2021 at 7:21pm.

Patient #33.
Review of the Face Sheet for Patient #33 showed a 30y/o male admitted into Adult Services on 4/9/2021 at 2:20am under the care of Staff U (Attending MD).
Review of the Physician Orders for Patient #33 showed an order for Suicide Precautions dated 4/8/2021 at 8:04pm.

Patient #34.
Review of the Face Sheet for Patient #34 showed a 56y/o male admitted into Adult Services on 4/9/2021 at 6:18pm under the care of Staff D (Attending MD).
Review of the Physician Orders for Patient #34 showed an order for Suicide Precautions dated 4/9/2021 at 6:19pm.

Patient #36.
Review of the Face Sheet for Patient #36 showed a 31y/o male admitted into Adult Services on 4/11/2021 at 1:51pm under the care of Staff V (Attending MD).
Review of the Physician Orders for Patient #36 showed an order for Suicide Precautions dated 4/11/2021 at 1:28pm.

Patient #37.
Review of the Face Sheet for Patient #37 showed a 35y/o male admitted into Adult Services on 4/12/2021 at 4:09am under the care of Staff V (Attending MD).
Review of the Physician Orders for Patient #37 showed an order for Suicide Precautions dated 4/11/2021 at 3:19pm.

Patient #38.
Review of the Face Sheet for Patient #38 showed a 43y/o male admitted into Adult Services on 4/12/2021 at 5:39pm under the care of Staff V (Attending MD).
Review of the Physician Orders for Patient #38 showed an order for Suicide Precautions dated 4/12/2021 at 5:38pm.

Patient #39.
Review of the Face Sheet for Patient #39 showed a 29y/o female admitted into Adult Services on 4/7/2021 at 1:27pm under the care of Staff V (Attending MD).
Review of the Physician Orders for Patient #39 showed an order for Suicide Precautions dated 4/7/2021 at 1:37pm.

Patient #40.
Review of the Face Sheet for Patient #40 showed a 52y/o female admitted into Adult Services on 4/6/2021 at 1:23pm under the care of Staff V (Attending MD).
Review of the Physician Orders for Patient #40 showed an order for Suicide Precautions dated 4/6/2021 at 1:18pm.

Patient #43.
Review of the Face Sheet for Patient #43 showed a 44y/o male admitted into Adult Services on 4/6/2021 at 9:49pm under the care of Staff (Attending MD).
Review of the Physician Orders for Patient #43 showed an order for Suicide Precautions dated 4/6/2021 at 9:49pm.

Patient #44.
Review of the Face Sheet for Patient #44 showed a 19y/o female admitted into Adult Services on 4/9/2021 at 2:20am under the care of Staff V (Attending MD).
Review of the Physician Orders for Patient #44 showed an order for Suicide Precautions dated 4/8/2021 at 1:26pm.

Patient #45.
Review of the Face Sheet for Patient #45 showed a 30y/o female admitted into Adult Services on 4/6/2021 at 5:07pm under the care of Staff V (Attending MD).
Review of the Physician Orders for Patient #45 showed an order for Suicide Precautions dated 4/6/2021 at 4:56pm.

Patient #46.
Review of the Face Sheet for Patient #46 showed a 12y/o female admitted into Youth Services on 1/4/2021 at 3:21pm under the care of Staff T (Attending MD).
Review of the Physician Orders for Patient #46 showed an order for Suicide Precautions dated 1/3/2021 at 9:00pm.