The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PINNACLE POINTE BEHAVIORAL HEALTH SYSTEM 11501 FINANCIAL CENTRE PARKWAY LITTLE ROCK, AR Aug. 31, 2015
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interviews and clinical record review, it was determined the Facility failed to ensure Patient #3 received care in a safe setting in that the Facility failed to adequately screen and consider staff documentation that could have made Patient #2 ineligible for Residential Care Unit. Failure to adequately screen and consider in-house information allowed Patient #2 contact with Patient #3 that resulted in inappropriate physical behavior. The failed practice affected Patient #3 on 08/09/15 and had the likelihood to affect any patient in the Facility. Findings follow:

A. Review of the Acute Care Unit clinical record for Patient #2 revealed the following entries made by Mental Health Technicians (MHT) on that Unit:
07/16/15 "sneaky behavior and likes to hang around a certain female peer".
07/17/15 "tries to get close to her peers".
07/19/15 "poor peer boundaries".
07/20/15 "asked to shower in a different bathroom with a female peer".
07/21/15 "redirections needed for poor boundaries with female peers".
07/21/15 "Patient convinced younger peer to go into her room".

B. Interviews were conducted with the CNO at 0900 on 08/28/15, the Director of Performance Improvement 1110 on 08/28/15 and the Patient Advocate at 1130 on 08/28/15. The above documentation was reviewed with each and each stated the above documentation should have been a red flag regarding Patient #2.

C. The Patient Advocate stated during an interview at 1130 on 08/28/15 when evaluating a child for possible placement on the Residential Care Unit she talked with the nurses, the Therapists and reviewed the initial assessment to make the determination for qualification for Residential Care. The Patient Advocate was asked if she read nursing notes or MHT notes for patients who were possible candidates for Residential Care and she stated no she did not.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interviews, clinical record review and incident reports, it was determined the Facility failed to notify the Child Abuse Hotline of reported inappropriate touching inflicted by Patient #2 upon Patient #3 at the time it was reported by the patient. Failure to notify the Child Abuse Hotline did not allow for a prompt investigation and resolution of the incident. The failed practice affected Patient #3. Findings follow:

A. Review of the Suspected Child Abuse Report for Patient #3 revealed the date of the report was 08/18/15 and was filed by the Patient Advocate.

B. Review of the clinical record of Patient #3 revealed the above incident was reported at 1600 on 08/09/15.

C. During an interview with the Patient Advocate at 1315 on 08/27/15 she verified the findings in A and B.




Based on interviews and document review it was determined the Facility was unaware staff failed to notify the Child Abuse Hotline of an incident of inappropriate touching of Patient #3 by Patient #2. The failed practice did not allow the Facility to conduct a timely investigation of the incident and formulate a plan to prevent any future incidents. The failed practice affected Patient #3 and had the likelihood to affect any patient in the Facility. Findings follow:

A. Review of the Suspected Child Abuse Report for Patient #3 revealed the date of the report was 08/18/15 and was filed by the Patient Advocate. During an interview with the Patient Advocate at 1315 on 08/27/15 she stated she filed the report with the Child Abuse Hotline on 08/18/15 when she was made aware of the incident by the father and found the Child Abuse Hotline had not been called by Registered Nurse #1.

B. During an interview with the Risk Manager at 0850 on 08/31/15 he stated he was unaware a report to the Child Abuse Hotline had not been made until he was informed by the Patient Advocate the day the father called.

C. During an interview with the Performance Improvement Director at 0855 on 08/31/15 he stated the Facility had no way of tracking Child Abuse Hotline reports unless staff goes through a stack of incident reports to see if the Child Abuse Hotline report was documented on the incident report.