HospitalInspections.org

Based on document review, observation and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to prevent 3 adolescent patients who were able to obtain a fire alarm key, activate the fire alarm, open a locked exit door and elope from the hospital and failed to conduct a root cause analysis of the event to prevent future elopements from the hospital. See deficiency A-144.

2. The hospital failed to ensure change in behaviors were monitored; failed to ensure appropriate interventions were in place; failed to adequately supervise patients and follow the physician's order for a patient that required higher level of monitoring to prevent abuse of 5 patients and failure to investigate incidents. See deficiency at A -145 (A).

3. The hospital failed to have a sexual abuse policy. See deficiency at 145 (C).

An immediate jeopardy began on 3/1/2025, due to the Hospital's failure to prevent the elopement of three adolescent patients who were able to obtain a fire alarm key, activate the fire alarm, open a locked exit door and elope from the hospital; and failure to conduct a root cause analysis of the event to prevent future elopements. The IJ was identified on 3/6/2025 at 42 CFR 482.13 Patient Rights. The elopement IJ was announced on 3/6/2025 at 4:30 PM during a meeting with the Chief Executive Officer [CEO] and Quality Director and was removed by the survey exit on 3/13/2025.

In addition, an immediate jeopardy was identified on 3/12/2025 at 42 CFR 482.13 Patient Rights, due to the facility's failure to ensure change in behaviors were monitored; failed to ensure appropriate interventions were in place; failed to adequately supervise patients and follow the physician's order for a patient that required higher level of monitoring to prevent abuse of 5 patients and failure to investigate incidents. The IJ was announced on 3/12/2025 at 10:45 AM during a meeting with the CEO and Quality Director. This IJ was not removed by survey exit date 3/13/2025.

Based on document review, video surveillance review, observation and interview, it was determined that for 3 of 3 adolescent female patients (Pt #1, Pt. #4 and Pt. #5) clinical records reviewed for elopement, the hospital failed to stop their elopement. These patients were able to obtain a fire alarm key to pull fire alarm, open exit door and subsequently elope from the hospital and failed to conduct a root cause analysis of the event to prevent future elopements. This could potentially affect 27 of 39 patients currently on elopement precautions and future patients at the hospital.

Findings include:

1. On 3/6/2025, the hospital's policy titled, "Elopement Precautions and Response" (dated 6/2022) was reviewed and indicated, "Staff shall provide appropriate assessment and observation of inpatients who have either verbally or non-verbally expressed a desire to elope from the hospital. Communicate Code Green (elopement) through the telephone paging system, walkie-talkie or face-to-face with staff on the unit."

2. On 3/6/2025, Pt. #1's clinical record (dated 1/30/2025 through 3/1/2025) was reviewed. Pt. #1 was admitted to the hospital on 1/30/2025 with the diagnoses of major depressive disorder and post traumatic stress disorder. Pt. #1 was on elopement precautions, suicide precautions and assault precautions (every 5-minute monitoring). Pt. #1's rounding sheets documented on 3/1/2025 noted Pt. #1 was last monitored prior to elopement on 3/1/2025 at 2:35 PM.

3. On 3/6/2025, Pt #4's clinical record (dated 12/17/2024 thru 3/1/2025) was reviewed. Pt. #4 was admitted to the hospital on 12/17/2024 with the diagnosis of post traumatic stress disorder. Pt. #4 was on elopement precautions and sexually acting out precautions (every 5-minute monitoring). Pt. #4's rounding sheets documented on 3/1/2025 noted Pt. #4 was last monitored prior to elopement on 3/1/2025 at 2:35 PM.

4. On 3/6/2025 Pt. #5's clinical record (dated 2/1/2025) was reviewed. Pt. #5 was admitted to the hospital on 2/1/2025 with the diagnoses oppositional defiant disorder and disruptive mood dysregulation disorder. Pt. #5 was on elopement precautions, suicide precautions and assault precautions (every 5-minute monitoring). Pt. #5's clinical record dated 2/1/2025 noted that Pt. #5's history was eloping from home. Pt. #5's rounding sheets documented on 3/1/2025 noted Pt. #5 was last monitored prior to elopement on 3/1/2025 at 2:35 PM.

5. On 3/6/2025, the hospital's incident report dated 3/1/2025 noted, "Pt. #4 snatches lanyard which includes keys off Behavioral Health Associate (BHT/E #7). Pt. #4 throws keys to Pt. #1. Pt. #1 opens the fire alarm station and Pt. #4 pulls out the key to trigger the fire alarm. Fire alarm sounds which unlocks all doors. Pt. #1, Pt. #4 and Pt. #5 run out the stairwell from 4th floor which empties onto alley." No investigation was conducted.

6. On 3/6/2025, a video footage review was conducted of the 4th floor Adolescent Girls unit dated 3/1/2025 at 2:37 PM to 2:38 PM. Pt. #4 is noted grabbing keys from the E #7. Pt. #4 is seen throwing the keys down the hall to Pt. #1. Pt. #5 is seen running down the hall and Pt. #1, Pt. #4 and Pt. #5 are seen opening the door and leaving the unit.
E #7 is seen in the video footage watching Pt. #1, Pt. #4 and Pt. #5 using the fire alarm key to pull the fire alarm and exiting the door without trying to stop the patients.

7. On 3/6/2025 between 10:30 AM and 11:00 AM, an observational tour was conducted on each unit of the Hospital (3rd floor - pediatric unit and 4th floor adolescent female unit and 5th floor adolescent male unit. The 3rd floor had a census of 12. The Registered Nurse (E #9) and the BHT (E #9), each had a lanyard around their neck with keys to open doors. The 4th floor had a census of 14. The BHT (E #10) had a lanyard around E #10's neck with keys to open doors. The 5th floor had a census of 13. The Activity Therapist (E #11), the Medical Records Clerk (E #13) and the Therapist (E #12) had a neck lanyard around their neck with keys to open doors.

8. On 3/6/2025 at approximately 11:00 AM, an interview was conducted with the Risk Director (E #1). E #1 stated that the hospital has not conducted a root cause analysis yet. E #1 stated that E #1 is going to propose that staff do not wear the lanyard with the keys to the door around their neck. E #1 stated that 1 patient has returned (Pt. #1) but the other 2 patients are still missing. E #1 stated that the hospital is working with the police who have released a city wide search for Pt. #4 and Pt. #5.

A. Based on document review, video surveillance and interview, it was determined that for 1 of 1 patient (Pt. #3/alleged perpetrator) involved in multiple incidents of abuse, the hospital failed to ensure change in behaviors were monitored; failed to ensure appropriate interventions were in place; failed to adequately supervise patients and follow physician's orders for a patient (Pt. #3) that required higher level of monitoring to prevent abuse; the hospital also failed to conduct an investigation following each incident. This failure resulted in sexual assaults and physical abuse by Pt. #3 to 5 vulnerable behavioral health patients (Pt. #2, Pt. #6, Pt. #7, Pt. #13 and Pt. #14).

Findings include:

1. On 3/6/2025, the hospital's policy titled, "Abuse and Neglect" (dated 8/2023) was reviewed and required, "Patient-to-patient abuse - The registered nurse will place the patient committing the offense on every 5-minute observations or 1:1 observation ..."

2. On 3/6/2025, the hospital's policy titled, "Precautions, Sexually Acting Out" (dated 12/2022) was reviewed and required, "In the event that sexual intercourse between patients does occur or is strongly suspected, the following procedure is required: Patients need to be separated immediately, placed on 1:1 (one staff to one patient).

3. On 3/6/2025, Pt. #2's clinical record (dated 11/12/2024 through present) was reviewed and indicated: Pt. #2 was admitted to male adolescent unit on 11/12/2024 with diagnosis of schizophrenia. Pt. #2 was on assault and suicide precautions (every 15-minute monitoring).

4. On 3/6/2025, Pt. #3's clinical record (dated 10/14/2024 through 2/28/2025) included Pt. #3 was admitted to Male Adolescent unit on 1/12/2025 with diagnosis bipolar disorder (mental health disorder). Pt. #3 was on SAO - sexually acting out, suicide, elopement and assault precautions (every 5 minutes monitoring). Pt. #3 was assigned to different rooms and units throughout Pt. #3's admission. Pt. #3's rounding sheets dated 11/15/2024, 11/27/204, 11/29/2024, 2/25/2025 through 2/28/2025 noted that it was not documented that Pt. #3 was was on 1:1 monitoring as ordered on 11/27/2024 or every 5 minutes as ordered on 1/12/2025.

-10/14/2024 through 11/27/2024: Pt. #3 was on the Adolescent Boys unit. Pt. #3 had a blocked room (no roommate).

-11/27/2024: Pt. #3 was moved to the Pediatric (boys and girls) unit due to an incident (unknown-not documented on incident log or Pt. #3's clinical record) on the Adolescent Boys unit. Pt. #3's clinical record had a physician's order dated 11/27/2024 for 1:1 monitoring (one staff to one patient). The rounding sheets indicated that Pt. #3 was on every 15 minutes rounding not on 1:1 monitoring. The clinical record failed to include that appropriate supervision per physician's order for 1:1 monitioring were followed. In Pt. #3 clinical record there is no indication that the order for 1:1 monitoring was discontinued.

-12/10/2024: Pt. #3 was moved back to the Adolescent Boys unit on 12/10/2024 following sexual abuse incident on Pediatric unit. Pt. #3 was on every 5 minute monitoring for SAO precautions, elopement precautions and assault precautions.

On 2/28/2025 at 10:05 PM, Pt. #3 was discharged from the hospital to police custody. This was done per Pt. #2's family request to call the police after Pt. #2 reported the allegation of abuse by Pt. #3.

5. Pt. #3 was involved in multiple allegations of abuse. The following incidents included:

-Pt. #6's Incident Report dated 11/7/2024 at 12:00 AM noted, "On 11/7/2024, Pt. #6 stated that on 11/5/2024 "in middle of the day, Pt. #3 came into Pt. #6's room, said "shut the door" then proceeded to shut the door himself (Pt. #3). Pt. #6 alleged that Pt. #3 then approached Pt. #6 who was laying in bed and put a hand on Pt. #6's throat, and then "yanked Pt. #6's dick a few times." Then Pt. #6 says Pt. #3 "punched Pt. #6 in the balls." There were no interventions or increased precautions for Pt. #3 following this incident. There was an incident report but no investigation.

-Pt. #7's (pediatric patient) Incident Report dated 12/4/2024 at 3:00 PM noted, "It was reported today from Pt. #7 that Pt. #3 fingered peer last Wednesday. It's unclear when it happened. MD (physician) notified and Patient Advocate notified." Pt. #3 was moved back to the Adolescent Boys unit following this incident on 12/10/2024. The result of the hospital investigation is that Pt. #3 was moved back to the Adolescent Boys unit.

-Pt. #14's Incident Report dated 12/14/2024 at 8:42 PM noted, "Pt. #3 went after Pt. #14. Pt.#3 wrapped Pt. #3's hands tightly around Pt. #14's neck. Staff immediately separated Pt. #3 and Pt. #14 and redirected. MD aware and prn (as needed) medications ordered were administered. Patients were unharmed. Pt. #14 denied pain and discomfort related to the incident. DCFS (Department of Children and Family Services) case manager aware for Pt. #3 and Pt. #14. There were no additional interventions or increase in precautions for Pt. #3 following this incident.

-Pt. #13's Incident report dated 12/24/2024 at 10:30 AM noted, "Pt. #3 attacked Pt. #13 in the dayroom at approximately 10:30 AM. Pt. #3 kicked Pt. #13 in Pt. #13's face, placed Pt.#13 in a choke hold. A code gray (emergency management of aggressive behavior - action necessary to ensure patients or staff are not injured) was called. Pt. #3 escorted from dayroom before forcefully leaving dayroom, threw a chair and hit peer (unknown), grabbed a piece of table and attempted to stab a peer (unknown). Staff intervened; Pt. #3's behavior relayed to MD, ordered Zyprexa (antipsychotic medication) 10 mg IM (intramuscular) stat (immediately)." There was no increase in precautions ordered for Pt. #3 following this incident.

-Pt. #2's Incident report dated 2/26/2025 noted, "Tech walked into room and witnessed Pt. #3 choking Pt. #2 in Pt. #2's room. Staff intervened and patients were separated. The MD (physician) was called and Pt. #3 received stat (immediately) medication." There was no documentation in Pt. #3's clinical record that any changes or increased monitoring was put in place for Pt. #3. There was no update to Pt. #2 or Pt. #3's treatment plan.

-Pt. #2's Incident Report dated 2/28/2025 noted, "Pt. #2 reported Pt. #3 inserted Pt. #3's fingers into Pt. #2's rectum, on 3 occasions, once today when Pt. #2 was attacked by Pt. #3.

6. On 3/6/2025, the hospital's video footage from the adolescent male unit dated 2/28/2025 from 1:58 PM to 4:20 PM was reviewed with E #5 (Risk Manager). Pt. #3 is seen going into Pt. #2's room at 3:58 PM. Pt. #2 and Pt. #3 had separate rooms across the hall from each other. The video footage shows Pt. #2's door gets closed. The Behavioral Health Technician (BHT/E #6) goes into Pt. #2's room approximately 35 seconds later per video review and Pt. #3 is witnessed choking Pt. #2 (per interview with E#2 - Registered Nurse). Pt. #3 then leaves Pt. #2's room and paces in the hallway until 4:20 PM. Pt. #3 is seen pushing E #6 as Pt. #3 continues to pace in the hallway.

7. On 3/6/2025 at approximately 10:00 AM, an interview was conducted with Pt. #2 with translator. Pt. #2 stated that Pt. #3 had attacked Pt. #2 three times. Pt. #2 stated that Pt. #3 entered Pt. #2's room, touched Pt. #2's private parts and try to choke Pt. #2. Pt.#2 stated that after the last incident on 2/28/2025, Pt. #2 fainted. Pt. #2 stated that Pt. #2 told Pt. #2's mother and Pt. #2's mother called the unit to report the incident. Pt. #2 stated that Pt. #2 did not report anything to the staff because Pt. #2 was afraid. Pt. #2 stated that Pt. #2 does not feel safe at the hospital. Pt. #2 stated that Pt. #2 went to the hospital the day after the last incident to get checked out and everything was ok.

8. On 3/10/2025 at approximately 9:00 AM, an interview was conducted with the BHT (E #9). E #9 stated that E #9 works on the Pediatric unit (boys and girls up to age 12). E #9 stated that E #9 cannot remember the exact date, but sometime last November 2024, Pt. #3 was on 1:1 monitoring (one staff to one patient) on the Pediatric unit because Pt.#3 had been touching Pt. #2 on the Adolescent Boys unit. E #9 stated that Pt. #3 "fingered Pt. #12 (pediatric female) in the day room and hallway. E #9 stated that the 1:1 staff member was redirecting another patient and so Pt. #3 was able to "finger Pt. #12." E #9 reported the incident to the nurse and Pt. #3 was moved back to the boys unit the next day.

9. On 3/10/2025 at approximately 3:00 PM, an interview was conducted with the BHT (E #6). E #6 stated that E #6 was doing every 5 minute rounds for Pt. #3 and every 15 minute rounds for Pt. #2 on 2/28/2025. E #6 stated that E #6 went into Pt. #2's room (door was closed) and found Pt. #3 choking Pt. #2. E #6 stated that Pt. #2 was blue in color and Pt. #2's arms were limp. E #6 stated E #6 yelled for help and removed Pt. #3's arm from Pt. #2's neck. E #6 stated that the police was called and Pt. #3 was arrested. E #6 stated that Pt. #3 almost killed Pt. #2.

10. On 3/6/2025 at approximately 1:50 PM, an interview was conducted with Registered Nurse (E#2). E#2 stated that a tech (BHT) reported to her that the tech (BHT) saw Pt.#3 choke Pt.#2. E#2 stated that E#2 assessed Pt.#2 who was on the bed and conscious and had turned blue. E#2 stated that attempts to redirect Pt.#3 were unsuccessful and an order to administer PRN (as needed) medication was obtained which the CNO (Chief Nursing Officer) manage to convince Pt.#3 to take willingly. E#2 stated that E#2 reported the incident to Pt.#2's mother who then informed E#2 that Pt.#2 informed Pt.#2's mother that Pt.#3 locked Pt.#2 in the room and forced Pt.#2 to perform oral sex on Pt.#3. E#2 reported the incident to the Supervisor who then called the police. E#2 stated that Pt.#2 and Pt.#3 were kept away from each other. E#2 stated that neither Pt.#2 or Pt.#3 were placed on 1:1 monitoring.

11. On 3/10/2025 at approximately 11:15 AM, an interview was conducted with MD #1. MD #1 stated that MD #1 cared for Pt. #2 and Pt. #3. MD #1 stated that Pt. #3 was placed on every 5 minute monitoring for physical and sexual acting out behaviors. MD #1 stated that a patient should be placed on 1:1 monitoring if the patient is a danger to others. MD #1 stated that MD #1 felt that every 5 minute monitoring was adequate for Pt. #3. MD #1 stated there was no need to put Pt. #3 on 1:1 monitoring.

12. On 3/11/2025 at approximately 9:45 AM, an interview was conducted with the Director of Risk (E #1). E #1 stated that after reviewing the video footage with Pt. #2 and Pt. #3, E #1 felt that everything was done appropriately. E#1 stated that Pt. #2's mother wanted to press charges and have the police called. E #1 stated that a patient advocate communicates daily (since the incident on 2/28/2025) with Pt. #2 to see if Pt. #2 any concerns. E #1 stated that an investigation should be conducted following each incident.


B. Based on document review and interview, it was determined that for 1 of 2 adolescent male patients (Pt.#3) clinical records reviewed for monitoring, the hospital failed to ensure that patient's ordered observation level was marked accurately, according to physician's order on the rounding/observation sheets to ensure patient safety.

Findings include:

1. On 3/6/2025, the clinical record of Pt. #3 was reviewed. Pt. #3 was admitted to the hospital on 10/14/2024 with a diagnosis of Disruptive Mood Dysregulation Disorder. Pt.#3 was placed on sexually acting out, elopement, assault, blocked room precautions and admitted to the 5th floor Adolescent Boys unit. On 11/27/2024, Pt.#3 was transferred to the 3rd floor Pediatric unit. MD #1's order (dated 11/27/2024) was entered to place Pt.#3 on 1:1 observation (Q15) [every 15 minute] due to Pt#3 exhibiting sexually acting out behaviors towards staff, physically aggressive and destructive behaviors while on the Adolescent Boys unit.

2. On 3/11/2025, Pt. #3's Patient Observation Record (dated 11/27/2024 to 12/9/2024) was reviewed and indicated that the observation records for Pt.#3 on 11/28/2024, 12/1/2024, and 12/2/2024 did not indicate the appropriate observation level as required.

3. On 3/11/2025, the hospital's policy titled "Observations, Patient" (Last Revision 11/2024) included "...i. Staff documents all levels of observation on each patient's observation form...Each entry is to include the following... - level of observation..."

4. On 3/11/2025 at approximately 9:43 AM, an interview was conducted with the Risk Manager (E#5). E#5 stated that the patient observation levels should be indicated on the patient's observation record.

C. Based on document review and interview, it was determined that the hospital failed to have a sexual abuse policy.

Findings include:

1. On 3/11/2025, the hospital failed to have a sexual abuse policy.

2. On 3/12/2025 at 2:00 PM, an interview was conducted with the Risk Manager (E #5). E #5 stated that the hospital follows the general abuse policy. E #5 stated that the hospital does not have a sexual abuse policy.

Based on document review and interview, it was determined that for 1 of 3 Behavioral Health Units (5th floor Adolescent Male unit) reviewed for staffing, the hospital failed to failed to ensure the unit had the appropriate number of nurses and mental health workers in order provider the nursing care listed in each patient's active treatment program per hospital policy.

Findings include:

1. The hospital's policy titled "Plan for Nursing Services" (Date of Approval 6/2022) included "... B. Acute Care: Core coverage includes ensuring there is always 1 RN (Registered Nurse) on each unit and that there is at minimum 2 staff on each unit at all times..."

2. The hospital's staffing schedule for February 3, 2025 indicates that the Adolescent Girls unit was staffed with 1 RN (Registered Nurse) from 7:30am to 10:15 AM; 1 RN from 10:00 AM to 10:30 AM; 1 RN from 10:30 AM to 5:15 PM; 1 BHT (Behavioral Health Technician) from 6:45 AM to 7:45 PM; 1 BHT from 7:15 AM to 7:30 PM; 1 BHT from 7:30 AM to 9:45 AM; 1 RN from 7:15 PM to 11:00 PM; and 1 RN from 7:30 PM to 7:45 AM. The schedule for February 3, 2025 indicates that there was no RN on the unit from 5:15 PM to 7:15 PM. The census on the Adolescent Girls unit on February 3, 2025 was 16 patients.

3. The hospital's staffing schedule for March 1, 2025 indicates that the Adolescent Girls unit was staffed with 1 RN (Registered Nurse) from 7 PM to 3 AM; 1 RN from 7 PM to 4 AM; 1 BHT from 7 PM to 9:15 PM; 1 BHT from 7 PM to 3:45 AM; 1 BHT from 7:30 PM to 3:30 AM; and 1 BHT from 11PM to 7:30 AM. The schedule indicates that there was no RN on the unit from 4 AM to 7 AM and only 1 BHT from 3:45 AM to 7 AM. The census on the Adolescent Girls unit on March 1, 2025 was 19 patients.

4. On 3/11/2025 at approximately 8:40 AM, an interview was conducted with the Chief Nursing Officer (CNO/E#4). E#4 stated that one nurse should always be present in the unit and there should always be 2 staff working on the unit, one of which should always be an RN.

Based on document review and interview, it was determined that for 2 of 2 patients (Pt #2 and Pt.#3) reviewed for treatment planning, the hospital failed to ensure that treatment plan was updated, per hospital policy.

Findings include:

1. The hospital's policy titled Treatment Planning (Date of Approval 6/2022) included "...Procedure...g. A review of the patient's Interdisciplinary Treatment Plan following any major clinical change shall be conducted, and appropriate modifications made..."

2. The hospital's policy titled Observations, Patient (Last Revision 11/2024) included "... k. The Interdisciplinary Treatment Plan will include or be revised to include the 1:1 observation..."

3. On 3/10/2025, the incident log was reviewed and indicated that an incident occurred on 12/4/2024 involving Pt.#3. It was documentation included: "...It was reported today from [Pt.#3] the patient [Pt.#3] fingered peer last Wednesday and [peer] was playing with [Pt.#3]...MD [physician] notified and patient advocate notified..."

4. On 3/10/2025, the clinical records for Pt.#3 (dated 10/14/2024 to 2/28/2025) was reviewed and indicated:

- Pt.#3 was admitted to the hospital on 10/14/2024 with a diagnosis of Disruptive Mood Dysregulation Disorder.
- Pt.#3 was placed on sexually acting out, elopement, assault, blocked room precautions and admitted to the 5th floor Adolescent Boys unit. Pt.#3 was placed on 1:1 monitoring on 11/27/2024.
- Pt.#3's treatment plan for 12/5/2024 does not indicate an updated treatment plan to address the incident on 12/4/2024.

5. On 3/10/2025, the incident log (dated 8/2024 through 3/2025) was reviewed and indicated:

- An incident on 2/26/2025 involving Pt.#2 was documented which indicated that Pt.#1 was being choked by Pt.#3
- An incident on 2/28/2025 involving Pt.#2 was documented which indicated that Pt#3 had inserted his finger into Pt.#1's rectum.

6. On 3/10/2025, the clinical record for Pt. #2 (dated 11/12/2024 to 3/6/2025) was reviewed and indicated:

- Pt.#2 was admitted to the hospital on 11/12/2024 with a diagnosis of schizophrenia (mental disorder characterized by hallucinations, delusions, disorganized thinking and behavior and flat or inappropriate affect).
- Pt.#2 was placed on assault precautions and Q15 [every 15] minute observation and admitted to the 5th floor Adolescent Boys unit. Pt.#1's treatment plan does not indicate an updated treatment plan to address the incidents on 2/26/2025 and 2/28/2025.

7. On 3/11/2025 at approximately 8:40 AM, an interview was conducted with the CNO (Chief Nursing Officer - E#4). E#4 stated that the patient's treatment plan should be updated whenever an incident occurs involving the patient.

8. On 3/11/2025 at approximately 10:05 AM, an interview was conducted with the Therapist (E#15). E#15 stated that the patient's treatment plan should be updated after an incident involving the patient.