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.

LONGLEAF HOSPITAL 44 VERSAILLES BLVD ALEXANDRIA, LA Oct. 14, 2015
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation of Medical Records as evidenced by:


1) Failing to ensure that medical records were accurately written and promptly completed as evidenced by:
a) Failure to ensure the patient's medical record contained documentation of a sentinel event that occurred on 10/02/15, patient assessment, treatment, and transfer to the acute care hospital of 1 (#2) of 1 patient record reviewed for a sentinel event from a total of 10 sampled patients.

b) Failure to ensure patient's observation records were complete and included documentation of the type of precaution for which the patient was to be monitored, such as suicide/aggression, and the type of observation and the signature of the RN reviewing the observation record for 7 (#1, #2, #3, #5, #6, #7, #8) of 10 patients' records reviewed for complete documentation of MHT observation sheets from a total sample of 10 patients. Patients #1, #6, #7, and #8 were current inpatients at the time of the survey.

c) Failure to ensure reported patient incidents were accurately documented in the patient's medical record for 1 (#5) of 1 patient medical record reviewed with no documentation of an incident from a total sample of 10 patient records reviewed.

d) Failure to ensure a telephone order received from the physician for admission of the patient was documented by the intake department for 6 (#1, #2, #3, #6, #7, #10) of 10 patient records reviewed for a physician's order to admit from a total of 10 patients. Patients #1, #6, #7, and #10 were current inpatients at the time of the survey (see findings in tag A0438).

2) Failing to ensure the medical record contained the physician's order for transfer, nursing notes, and reports of treatment provided related to a sentinel event that occurred on 10/02/15 for 1 (#2) of 1 patient record reviewed for a sentinel event from a total of 10 sampled patients (see findings in tag A0467).
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure that medical records were accurately written and promptly completed as evidenced by:
1) Failing to ensure the patient's medical record contained documentation of a sentinel event that occurred on 10/02/15, patient assessment, treatment, and transfer to the acute care hospital of 1 (#2) of 1 patient record reviewed for a sentinel event from a total of 10 sampled patients.

2) Failing to ensure patient's observation records were complete and included documentation of the type of precaution for which the patient was to be monitored, such as suicide/aggression, and the type of observation and the signature of the RN reviewing the observation record for 7 (#1, #2, #3, #5, #6, #7, #8) of 10 patients' records reviewed for complete documentation of MHT observation sheets from a total sample of 10 patients. Patients #1, #6, #7, and #8 were current inpatients at the time of the survey.

3) Failing to ensure reported patient incidents were accurately documented in the patient's medical record for 1 (#5) of 1 patient medical record reviewed with no documentation of an incident from a total sample of 10 patient records reviewed.

4) Failing to ensure a telephone order received from the physician for admission of the patient was documented by the intake department for 6 (#1, #2, #3, #6, #7, #10) of 10 patient records reviewed for a physician's order to admit from a total of 10 patients. Patients #1, #6, #7, and #10 were current inpatients at the time of the survey.

Findings:

1) Failing to ensure the patient's medical record contained documentation of the sentinel event, patient assessment, treatment, and transfer to the acute care hospital:
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Depression. Further review revealed he was PEC'd on 10/01/15 at 10:00 p.m. after having left a video apologizing for what he was about to do and taking an unknown amount of pills. His PEC revealed he was suicidal and a danger to self.

Review of an "Incident Report Form" documented on 10/02/15 at 3:15 p.m. by S6RM revealed Patient #2 was found with a red mark around his neck as a result of an attempted suicide by hanging himself around the neck with a cord from the television mounted on the wall.

Review of Patient #2's entire medical record on 10/10/08/15, 6 days after the sentinel event occurred, revealed no documented evidence of documentation of the above incident, the assessment and treatment of Patient #2 by the RN, the physician order for transfer to the emergency department of an acute care hospital, and the time and method by which Patient #2 was transferred.

In an interview on 10/09/15 at 10:05 a.m., S2DON, after reviewing Patient #2's medical record, confirmed the record had no documentation of the sentinel event that occurred, the assessment and treatment of Patient #2 by the RN, the physician order for transfer to the emergency department of an acute care hospital, and the time and method by which Patient #2 was transferred.

2) Failing to ensure patient's observation records were complete and included documentation of the type of precaution for which the patient was to be monitored, such as suicide/aggression, and the type of observation and the signature of the RN reviewing the observation record:
Patient #1
Review of Patient #1's medical record revealed he was a 9 year old male admitted on [DATE] with a diagnosis of Mood Disorder. Review of Patient #1's "Physician's Admit Order"obtained by the RN on 09/30/15 at 12:20 p.m. revealed no documented evidence that a level of observation was ordered by the physician.

Review of Patient #1's "Tech Observation Sheet" revealed the following days and times with no documented evidence of the type of observation, the code and treatment for all times, and/or a signature of the RN who had assigned the patient care to the MHT:
No documented evidence of the type of observation on the day shift (7:00 a.m. to 3:00 p.m.) on 10/03/15, the night shift (11:00 p.m. to 7:00 a.m.) of 10/03/15, the day shift of 10/04/15, the day and evening shift (3:00 p.m. to 11:00 p.m.) on 10/07/15;
No documented evidence of the code (location) and treatment for 30 minutes on the night shift on 10/02/15;
No documented evidence of the RN's signature indicating he/she had reviewed the observations of patients made by the MHTs on the day shift on 09/30/15, 10/03/15, 10/04/15, 10/05/15, 10/06/15, on the night shift on 10/05/15, and on the evening shifts of 10/03/15 and 10/06/15.

Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Depression. Review of Patient #2's "Physician's Admit Order" obtained by S32LPN on 10/02/15 at 8:45 a.m., with no documented evidence of the name of the physician who gave the orders, revealed no documented evidence that a level of observation was ordered by the physician.

Review of Patient #2's "Tech Observation Sheet" revealed no documented evidence of the signature of the RN who reviewed the observations made by the MHT.

Patient #3
Review of Patient #3's medical record revealed he was a 7 year old male admitted on [DATE] with a diagnosis of Mood Disorder. Review of Patient #3's "Physician's Admit Order" obtained by S14RN on 09/03/15 at 5:00 p.m. revealed no documented evidence that a level of observation was ordered by the physician.

Review of Patient #3's "Tech Observation Sheet" revealed the following days and times with no documented evidence of the type of observation, the code and treatment for all times, and/or a signature of the RN who had assigned the patient care to the MHT:
No documented evidence of the type of observation on the day shift on 09/06/15 and the evening shifts of 09/03/15, 09/04/15, 09/06/15 09/07/15, and 09/09/15;
No documented evidence of the code (location) and treatment for one hour on the evening shift on 09/08/15;
No documented evidence of the RN's signature indicating he/she had reviewed the observations of patients made by the MHTs on the day shifts on 09/05/15 and 09/07/15, on the night shifts on 09/03/15 and 09/08/15, and on the evening shift of 09/09/15.

Patient #5
Review of Patient #5's medical record revealed she was a [AGE] year old female, admitted on [DATE] and discharged on [DATE]. Further review revealed admission diagnoses including the following: adjustment disorder with mixed disturbance of emotions and conduct; rule out intermittent explosive disorder.

Review of Patient #5's Physician's Orders, dated 9/19/15 10:10 a.m., revealed the patient's Observation level was Status C (every 15 minutes) observations.

Review of Patient #5's observation sheets for 9/19/15, 11-7 shift through 9/22/15, 7-3 shift revealed the level of observation section of the observation sheet was blank for the above referenced shifts.

Patient #6
Review of Patient #6's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Mood Disorder. Review of Patient #6's "Physician's Admit Order" obtained by S32LPN on 10/02/15 at 12:00 p.m., with no documented evidence of the name of the physician who gave the orders, revealed no documented evidence that a level of observation was ordered by the physician.

Review of Patient #6's "Tech Observation Sheet" revealed the following days and times with no documented evidence of the type of observation and/or a signature of the RN who had assigned the patient care to the MHT:
No documented evidence of the type of observation on the day shifts on 10/05/15, 10/06/15, and 10/07/15, on the night shifts of 10/04/15 and 10/06/15, and on the evening shifts of 10/05/15, 10/06/15, and 10/07/15;
No documented evidence of the RN's signature indicating he/she had reviewed the observations of patients made by the MHTs on the day shift on 10/07/15 and on the evening shifts of 10/06/15 and 10/07/15.

Patient #7
Review of Patient #7's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Mood Disorder. Further review revealed he had a physician's order to observed line of sight.

Review of Patient #7's "Tech Observation Sheet" revealed the following days and times with no documented evidence of the type of observation, the code and treatment for all times, and/or a signature of the RN who had assigned the patient care to the MHT:
No documented evidence of the type of observation on the day shifts on 10/01/15, 10/02/15, 10/03/15, 10/04/15, 10/05/15, 10/06/15, and 10/07/15, on the evening shifts on 09/30/15, 10/02/15, 10/03/15, 10/04/15, 10/05/15, 10/06/15, and 10 07/15, and on the night shifts of 10/02/15, 10/03/15, 10/04/15, and 10/05/15;
No documented evidence of the code (location) and treatment for 30 minutes on the evening shift on 10/03/15 and for one hour and 15 minutes on the evening shift of 10/04/15;
No documented evidence of the RN's signature indicating he/she had reviewed the observations of patients made by the MHTs on the day shifts on 10/02/15, 10/04/15, and 10/07/15, on the night shifts on 09/30/15, 10/01/15, and 10/02/15, and on the evening shifts of 10/03/15, 10/05/15, 10/06/15, and 10/07/15.

Patient #8
Review of Patient #8's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Mood Disorder. Further review revealed his physician orders included an observation level of line of sight and every 15 minutes. There was no documented evidence of a clarification order to determine the specific observation level the physician wanted to be maintained for Patient #8, since line of sight and every 15 minutes were two separate types of observation levels.

Review of Patient #8's "Tech Observation Sheet" revealed the following days and times with no documented evidence of the type of observation, the code and treatment for all times, and/or a signature of the RN who had assigned the patient care to the MHT:
No documented evidence of the type of observation on the day shifts on 10/02/15, 10/03/15, 10/04/15, 10/05/15, 10/06/15, and 10/07/15, on the evening shifts on 10/01/15, 10/02/15, 10/03/15, 10/04/15, 10/05/15, 10/06/15,and 10/07/15, and on the night shifts of 10/02/15, 10/03/15, and 10/04/15;
No documented evidence of the code (location) and treatment for 30 minutes on the evening shift on 10/04/15;
No documented evidence of the RN's signature indicating he/she had reviewed the observations of patients made by the MHTs on the day shifts on 10/03/15, 10/04/15, 10/05/15, and 10/06/15, on the night shifts on 10/02/15 and 10/05/15, and on the evening shifts of 10/02/15, 10/03/15, 10/04/15, and 10/06/15.

In an interview on 10/14/15 at 8:40 a.m. with S1ADM and S2DON present, S1ADM and S2DON offered no explanation for the above-listed deficiencies noted on the MHT observation sheets. They could not explain the times of no observations documented on the MHT observation records. S1ADM indicated the hospital did not have a policy that addressed the completion of the MHT observation sheet.

3) Failing to ensure reported patient incidents were accurately documented in the patient's medical record:
Review of Patient #5's medical record revealed she was a [AGE] year old female, admitted on [DATE] and discharged on [DATE]. Further review revealed admission diagnoses including the following: adjustment disorder with mixed disturbance of emotions and conduct; rule out intermittent explosive disorder. Additional review revealed her legal status was PEC on 9/16/15 and CEC on 9/20/15.

Review of Hospital Incident Reports for Abuse/Neglect revealed an initial report for alleged physical abuse involving Patient #5 was filed on 9/22/15 by S6RM. The report revealed the following, in part:
Incident information: Date: 9/20/15, Time: 8:00 p.m.; Shift: 3-11; Date of Discovery: 9/21/15; Time of discovery: 10:00 a.m.; Shift: 7-3; Location: Main Campus; Unit: Children/Adolescent Unit-patient's room.
Alleged perpetrators: S23MHT; S20MHT
Patient was still hospitalized when allegation became known; reported by the patient; Name, title and position of 1st employee aware of situation and how they became aware: S21RN, nurse on Sunday 3-11 shift, called code white and was told by patient that her arm was hurting. Patient was aggressive, required hold, 2 MHTs (S20MHT, S23MHT) applied Crisis Prevention Intervention "control hold". Patient broke out and fell to left side injuring arm. Rule out break.
Date assessed: 9/20/15, time assessed: 10:00 p.m.; x-ray done; Patient sent to area hospital emergency department on 9/21/15; Patient sustained apparent injury/adverse effects: yes; injury/treatment: left arm broken; soft cast applied with hard plate.
Initial actions: S23MHT; S20MHT removed from unit
Physician (S7Psychiatrist) notified 9/20/15 9:10 p.m.; Mother notified 9/20/15 8:00 p.m.
Hospital Personnel notified, in order of notification:
S21RN: 9/20/15 9:10 p.m.; S1Administrator: 9/20/15 9:30 p.m.; S6RM: 9/20/15 10:00 p.m.

Review of Patient #5's medical record revealed the following Physician's Orders:
9/20/15 9:10 p.m.: 1. Therapeutic hold times 10 minutes for out of control behavior. 2. Ativan 1 milligram intramuscular, Haldol 5 milligrams intramuscular now times 1 dose for violent, aggressive behavior.
9/20/15 9:20 p.m.: Medical consult related to complaints of left arm pain. Telephone order S7Psychiatrist.
9/20/15 6:00 a.m.: Send to emergency room for evaluation and x-ray of left arm.

Review of Patient #5's nursing notes revealed the following entry, dated 9/20/15 at 8:30 p.m.: Patient pacing and agitated on unit. Refuses to listen to staff. Instigating discontent among peers. Ativan 1 milligram and Benadryl 25 milligram intramusular. Patient continues loud and aggressive and unable to redirect. Out of control behavior disrupting the unit milieu. Unable to calm verbally. S7Psychiatrist notified. New orders noted. Therapeutic hold initiated. Patient fought and kicked during hold. Ativan 1 milligram and Haldol 5 milligram intramuscular at 9: 15 p.m. Patient continues loud and defiant. Complaints left arm pain. Medical consult ordered. On assessment no swelling or bruising noted. Patient spoke with Mom and was assisted to bed at 10:00 p.m. Further review of the nurses notes revealed no documented evidence of a detailed account of the source/cause of the patient's reported arm pain.

Interview on 10/13/15 at 1:03 p.m. with S21RN, she indicated she wasn ' t sure if Patient #5 had fallen during the incident because she had gone to call a Code White and she had not witnessed the incident. She indicated Patient #5 told her she had heard a " pop " during the hold. S21RN also indicated the 2 MHTs performing the hold had not described to her that they heard any kind of " pop " during the incident. involving Patient #5 (while she was in a therapeutic hold). She agreed her documentation of the incident was not inclusive of all of the information reported to her by the MHTs and the patient.

4) Failing to ensure a telephone order received from the physician for admission of the patient was documented by the intake department:
Review of the admission orders for Patients #1, #2, #3, #6, #7, and #10 revealed no documented evidence of a documented telephone or verbal order received by the physician to admit the patients.

In an interview on 10/13/15 at 11:10 a.m., S31LPN indicated she worked in the intake department and was one of the LPNs who called physicians for orders to admit patients. After reviewing the medical records of Patients #1, #2, #3, #6, #7, and #10, she confirmed there was no telephone or verbal documented by the LPN in the intake department when he/she received the order to admit the patients.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Ruights as evidenced by:

1) Failing to ensure all patients were free from all forms of abuse, the alleged reported incidents of abuse were reported immediately and thoroughly investigated, and that patients were protected from abuse during the investigation by allowing the alleged perpetrators to continue to work before the investigation was complete for 3 (#3, #4, #5) of 3 patient records reviewed for allegations of abuse from a total sample of 10 patients. This failed practice provided the opportunity for alleged perpetrators to continue to provide direct patient care for any patient currently admitted to the hospital as well as any future admitted patients (see findings in tag A0145).

2) Failing to ensure patients admitted to the Little Boys' Unit and the Big Boys' Unit had the right to privacy as evidenced by having the glass windows that provided a view into the room from the outside (and a wing that faced the patient rooms of other units of the hospital) in all patient rooms, except Rooms "a", "b", "c", "d", "e", and "f" (that had part of the glass window with shading that blocked the view from the outside), and had no means of providing privacy of the patients (see findings in tag A0143).
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure there was an effective operation of its grievance process as evidenced by:
1) Failing to ensure the staff reported patient's or family member's grievances to the appropriate person for review and investigation for 1 (#3) of 3 (#3, #4, #5) grievances reviewed from a sample of 10 patients.
2) Failing to ensure each grievance was fully investigated for 1 (#4) of 3 (#3, #4, #5) grievances reviewed from a sample of 10 patients.
Findings:

Review of the hospital policy titled " Grievance, Patient", presented as a current policy by S2DON, revealed that the hospital would provide an effective mechanism for handling patient/family grievances as an important part of providing quality care and service to their patients. Further review revealed all patient grievances will be investigated and the results of the investigation reported back to the complainant. A grievance is considered resolved when the patient is satisfied with the actions taken on his/her behalf or if hospital had taken appropriate and reasonable action and followed the CMS (Centers for Medicare and Medicaid Services)/State required processes. Any reported grievances by patients, families, staff and/or visitors that directly relate to patient neglect or abuse will be forwarded to the Administrator On- Call IMMEDIATELY for review. Staff present who receive a grievance from a patient/patient's legal representative will acknowledge receipt of the grievance/concern by documenting the time and date of the grievance on the Patient Concern Notification form. The staff will attempt to resolve the issue at the time of the receipt and document actions taken on the form. The Patient Concern Notification form is to be forwarded to the Patient Advocate.

1) Failing to ensure the staff reported patient's or family member's grievances to the appropriate person for review and investigation:
Review of Patient #3's "Nursing Reassessment" documented by S8RN on 09/07/15 at 11:00 a.m. revealed "Patient's mother reported bruising to patient's right upper arm. Fingerprint sized bruise noted. No pain reported." Review of S8RN's documentation on 09/08/15 at 2:30 p.m. revealed "Mother called concerned about small bruise to patient's right upper arm. Fingerprint sized bruise noted to rt. upper arm. Patient denies pain." There was no documented evidence that she reported this potential abuse to anyone in management for investigation.

Review of an "Incident Report Form" documented by S8RN on 09/07/15 at 11:00 a.m. revealed the "Facts Summary of Event" included "Patient's mother reported bruise to patient's right upper arm." The "Nursing Evaluation & (and) Intervention" included "small fingerprint sized bruise noted to right upper inside arm." Further review revealed S7Psychiatrist was notified on 09/07/15 at 11:00 a.m. with the response of "follow-up with patient and staff to assess situation." Further review revealed the section titled "Notification as Applicable..." revealed the choices of RN Supervisor, Shift Supervisor, Administration, Risk manager, Family, Family/Legal Guardian Name and Relationship, and External Agency had no documented evidence that anyone had been notified. S6RM signed the report on 09/08/15.

In an interview on 10/12/15 at 3:15 p.m., S8RN indicated Patient #3's mother reported the concern of the bruise during the treatment team meeting that was attended by S7Psychiatrist, the social worker, and S36NP. She further indicated S7Psychiatrist said it needed to be looked into for the cause and asked a nurse (don't remember who the nurse was) to call S6RM. She confirmed that the incident report documentation "doesn't look like" she spoke with S6RM. S8RN indicated she followed up with staff about Patient #3 possibly being held to cause a bruise. She further indicated she was told by all staff they had not held the patient, but she didn't document it. S8RN indicated she was supposed to notify the physician or management on 09/07/15 when she was notified by the mother of a grievance, but she didn't. She confirmed that she did not complete a "Patient Concern Notification form."

In a telephone interview on 10/13/15 at 12:45 p.m., S38RN indicated she didn't remember if she spoke with Patient #3's mother. She further indicated she remembered seeing a bruise on his arm and asked how he got it. She indicated she usually documents what's told to her, but if she didn't document it, it's probably because she wanted to "collaborate his story with the other staff." She further indicated Patient #3's mother or grandmother told her Patient #3 shouldn't be bruised when he's handled by the MHT. When asked about not seeing any documentation in her notes on 09/05/15 and 09/06/15 of the bruise to Patient #3's arm or her discussion with Patient #3's mother or grandmother, S38RN indicated "I evidently missed the boat."

In an interview on 10/13/15 at 4:20 p.m., S6RM indicated the investigation into Patient #3's grievance was not begun until 09/08/15, because S38RN's conversation with Patient #3's mother was not reported timely. When asked why Patient #3's mother's grievance wasn't on the hospital's grievance log when the prior surveyors were on site, she indicated she may have jotted it on a sheet and not added it to the log until the end of the month. She further indicated she doesn't know if the surveyors were informed at the time of the survey in September 2015. She further indicated she "could cry right now, it's a 2 person job. She further indicated she wasn't sure of the process, as she had only been in the position of Risk Manager for 5 months and had a 3 day training with corporate staff.

2) Failing to ensure each grievance was fully investigated:
Review of the medical record for Patient #4 revealed he was an eight year old male admitted on [DATE] with a legal status of PEC and discharged on [DATE]. Patient #4's admitting diagnosis was Depression , ODD, ADHD.

Review of the Hospital Incidence and Accident report revealed an occurrence dated 09/20/15 completed by S12LPN. The report indicated that Patient #4 was slapped by another patient (unidentified) on 09/20/15, and MHT broke up the patients by pulling them apart. S4's mother telephoned the hospital speaking to the S12LPN stating, "We left bruises on and marks on pt. (as written). We are abusing pts. and she will is going to report to DHH."

Review of a nurse's note dated 09/20/15 at 3:00 p.m. written by S12LPN read in part: Patient #4's mother called nurses' station complaining that the techs "grabbed her son and left bruises and marks on him. "Mother stated that she was calling Dept. of Health and Hospitals because she's a "nurse and that's patient abuse. "I explained to Mom that this pt. called his peer a "nigger" and his peer started slapping him in the face. Two MHTs grabbed the patients and separated them. S1ADM, AOC (administrator on-call) notified, pictures taken of patient's shoulder/arm area, PI (performance improvement)/Risk Manager notified no marks or bruises are noted at present. Nurse did not witness the incident. Pt. stated that his peer was hitting him before he called him that name, but MHT did not witness that. Further review of the nurses' notes revealed no documented evidence of an assessment by a RN of Patient #4 after involvement in a patient-to-patient physical confrontation.

Review of the hospital grievance log revealed that Patient #4's mother's allegation of abuse/neglect was not listed as a grievance.

In an interview on 10/12/15 at 10:35 a.m.,S6RM indicated the hospital concluded the allegation (abuse/neglect) was not valid and did not classify this as a grievance/complaint. S6RM indicated that Patient #4's family was not provided with any of the findings of the allegations. S6RM indicated that a contact on 09/21/15 was unsuccessful (left voice message). S6RM indicated that once learning of the mother's accident and inability to speak with the mother, no contact was made with Patient #4's responsible party. S6RM indicated that she had no forwarding contact information for Patient #4's responsible party.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record reviews, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Governing Body as evidenced by:

1) Failing to ensure that the medical staff was accountable for the quality of care provided to patients as evidenced by:

a) Having no physician orders for the level of observation for 2 current patient records reviewed (#1, #6) and for 2 closed medical records reviewed (#2, #4) from a total of 10 sampled patient records reviewed for physician orders for observation level. This resulted in Patient #2, who was PEC'd for being suicidal and being a danger to self, attempting suicide by hanging while not being observed.

b) Failing to ensure a clear and concise policy was developed for levels of observation as evidenced by having a policy for a level of observation of line of sight during waking hours without a clear understanding of the physician's expectation of what observation was to be maintained for patients during night/bedtime hours.

c) Failing to ensure a patient, who had a CEC signed on 09/05/15 at 2:15 p.m. due to being suicidal and a danger to self and was evaluated as remaining a danger to self on 09/09/15, was not allowed to be discharged AMA without being evaluated by a licensed practitioner to determine that he was no longer a danger to self for 1 (#3) of 1 patient record reviewed who was discharged AMA from a total of 10 sampled patients.

d) Failing to ensure an alleged abuse incident which resulted in a patient sustaining an arm fracture during a therapeutic hold (Patient#5) was analyzed (root cause analysis) to determine if there was a delay in medical treatment for 1 (#5) of 3 (#3, #4, #5) patient records reviewed for abuse from a total of 10 sampled patients (see findings in tag A0049).

2) Failing to ensure the CEO managed the hospital as evidenced by:

a) Failing to meet the requirements of the Condition of Participation of Patient Rights as evidenced by:

i) Failing to ensure all patients were free from all forms of abuse, the alleged reported incidents of abuse were reported immediately and thoroughly investigated, and that patients were protected from abuse during the investigation by allowing the alleged perpetrators to continue to work before the investigation was complete for 3 (#3, #4, #5) of 3 patient records reviewed for allegations of abuse from a total sample of 10 patients. This failed practice provided the opportunity for alleged perpetrators to continue to provide direct patient care for any patient currently admitted to the hospital as well as any future admitted patients.

ii) Failing to ensure patients admitted to the Little Boys' Unit and the Big Boys' Unit had the right to privacy as evidenced by having the glass windows that provided a view into the room from the outside (and a wing that faced the patient rooms of other units of the hospital) in all patient rooms, except Rooms "a", "b", "c", "d", "e", and "f" (that had part of the glass window with shading that blocked the view from the outside), and had no means of providing privacy of the patients (see findings in tag A0115).

b) Failing to ensure the requirements of the Condition of Participation was met for Nursing Services as evidenced by:

i) Failing to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by:
An Immediate Jeopardy situation was identified on 10/08/15 at 5:25 p.m. due to the hospital:
(aa) Failing to ensure the RN assured that line of sight visual observation was maintained as ordered for Patient #6 on 10/08/15 at 9:15 a.m. and for Patient #7 on 10/08/15 at 9:20 a.m.. Both patients were not within line of sight visual observation when they went to the bathroom.
(bb) Failing to ensure a RN was immediately available on the boys' acute care psychiatric unit. S4RN was observed leaving the "Little Boys' Unit" on 10/08/15 at 12:11 p.m., returning at 12:16 p.m. There was no RN on the unit during this time frame and patients were noted to be on the unit. S5RN was observed leaving the "Big Boys' Unit" on 10/08/15 at 12:15 p.m. leaving the unit without a RN, and patients were noted to be on the unit.
(cc) The RN failed to obtain physician orders at admit for the observation level of each patient for 2 (#1, #6) of 6 (#1, #6, #7, #8, #9, #10) current inpatients and 3 (#2, #3, #4) of 4 (#2, #3, #4, #5) closed medical records reviewed for observation level orders from a total of 10 sampled records.
(dd) The RN failed to ensure the patient's medical record contained documentation of the sentinel event, patient assessment, treatment, and transfer to the acute care hospital of 1 (#2) of 1 patient record reviewed for a sentinel event from a total of 10 sampled patients.
(ee) The RN failed to assign the MHTs and review their documentation as evidenced by having patient's observation records with no documented evidence of the type of precaution for which the patient was to be monitored, such as suicide/aggression, and the type of observation and the signature of the RN reviewing the observation record for 7 (#1, #2, #3, #5, #6, #7, #8) of 10 patients' records reviewed for documentation of levels of observation from a total sample of 10 patients. Patients #1, #6, #7, and #8 were current inpatients at the time of the survey.

ii) The DON failed to ensure the hospital had a system for determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital as evidenced by having no policy developed for the staffing ratio of MHTs to patients. This lack of policy resulted in 1 MHT being assigned the observation of 10 to 11 patients who were ordered to be on line of sight observation and 1 MHT assigned to observe 17 patients during their outdoor break who were ordered to be on line of sight observation.

iii) Failing to ensure there was an adequate number of RNs, LPNs, and MHTs to provide nursing care to all patients as needed as evidenced by:
(aa) Failure to have a RN on the Little Boys' Unit from 2:00 a.m. to 6:00 a.m. on 10/10/15, 10/11/15, and 10/12/15 while the hospital had an Immediate Jeopardy in place for failing to ensure a RN was on each nursing unit each shift.
(bb) Failure to have an adequate ratio of MHTs to patients on the Boys' Unit on 10/03/15, 10/04/15, 10/05/15, and 10/08/15.
(cc) Failure to ensure the Boys' Unit had a RN from 2:45 p.m. to 4:15 p.m. on 09/20/15 (see findings in tag A0385).

In an interview on 10/14/15 at 1:55 p.m., S29CEO indicated he, as a member of the governing body, was aware of the "broken system" of the hospital, but "not to the extent I've heard over the last 3 days." He further indicated he reviews the staffing when he comes to the hospital once a week, usually in the mornings. He indicated he had not seen a staffing of 1 MHT to 10 patients or 1 MHT to 17 patients during his visits. He further indicated it was reported to him that the previous "surveyors matched staffing to payroll and had no problems." S29CEO indicated no directive from the governing body prevented Administration from increasing staff.

c) Failing to ensure the requirements for the Condition of Participation of Medical Records Services were met as evidenced by:

i) Failure to ensure that medical records were accurately written and promptly completed as evidenced by:
(aa) Failure to ensure the patient's medical record contained documentation of a sentinel event that occurred on 10/02/15, patient assessment, treatment, and transfer to the acute care hospital of 1 (#2) of 1 patient record reviewed for a sentinel event from a total of 10 sampled patients.
(bb) Failure to ensure patient's observation records were complete and included documentation of the type of precaution for which the patient was to be monitored, such as suicide/aggression, and the type of observation and the signature of the RN reviewing the observation record for 7 (#1, #2, #3, #5, #6, #7, #8) of 10 patients' records reviewed for complete documentation of MHT observation sheets from a total sample of 10 patients. Patients #1, #6, #7, and #8 were current inpatients at the time of the survey.
(cc) Failure to ensure reported patient incidents were accurately documented in the patient's medical record for 1 (#5) of 1 patient medical record reviewed with no documentation of an incident from a total sample of 10 patient records reviewed.
(iv) Failure to ensure a telephone order received from the physician for admission of the patient was documented by the intake department for 6 (#1, #2, #3, #6, #7, #10) of 10 patient records reviewed for a physician's order to admit from a total of 10 patients. Patients #1, #6, #7, and #10 were current inpatients at the time of the survey (see findings in tag A0438).

ii) Failing to ensure the medical record contained the physician's order for transfer, nursing notes, and reports of treatment provided related to a sentinel event that occurred on 10/02/15 for 1 (#2) of 1 patient record reviewed for a sentinel event from a total of 10 sampled patients (see findings in tag A0467).

3) Failing to ensure its written visitation policy allowed for open visitation as evidenced by allowing visitation twice a week with no documented evidence that restrictions or limitations to visitation were clinically necessary or reasonable (see findings in tag A0215).

In an interview on 10/09/15 at 11:00 a.m., S29CEO indicated he was the Divisional Manager and was the responsible person above S1ADM.

In an interview on 10/14/15 at 1:55 p.m., S29CEO indicated he, as a member of the governing body, he was aware of the "broken system" of the hospital, but "not to the extent I've heard over the last 3 days."
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the governing body failed to ensure that the medical staff was accountable for the quality of care provided to patients as evidenced by:
1) Failing to ensure the physician ordered the observation level for each patient upon admission as evidenced by having no physician orders for the level of observation for 2 current patient records reviewed (#1, #6) and for 2 closed medical records reviewed (#2, #4) from a total of 10 sampled patient records reviewed for physician orders for observation level. This resulted in Patient #2, who was PEC'd for being suicidal and being a danger to self, attempting suicide by hanging while not being observed.
2) Failing to ensure a clear and concise policy was developed for levels of observation as evidenced by having a policy for a level of observation of line of sight during waking hours without a clear understanding of the physician's expectation of what observation was to be maintained for patients during night/bedtime hours.
3) Failing to ensure a patient, who had a CEC signed on 09/05/15 at 2:15 p.m. due to being suicidal and a danger to self and was evaluated as remaining a danger to self on 09/09/15, was not allowed to be discharged AMA without being evaluated by a licensed practitioner to determine that he was no longer a danger to self for 1 (#3) of 1 patient record reviewed who was discharged AMA from a total of 10 sampled patients.
4) Failing to ensure an alleged abuse incident which resulted in a patient sustaining an arm fracture during a therapeutic hold (Patient#5) was analyzed (root cause analysis) to determine if there was a delay in medical treatment for 1 (#5) of 3 (#3, #4, #5) patient records reviewed for abuse from a total of 10 sampled patients.
Findings:

1) Failing to ensure the physician ordered the observation level for each patient upon admission:
Review of the hospital policy titled "Observation Status Categories", presented as a current policy by S1ADM, revealed at the time of admission the physician will give an order for the required observation status. Further review revealed the Charge RN is responsible for assigning the staff members to perform designated special observation status for each patient on his/her assigned unit.

Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with a provisional diagnosis of Depression. Review of his PEC, signed 10/01/15 at 10:00 p.m. revealed he was very depressed, left a video apologizing for what he was about to do, and had taken an unknown amount of pills. He was PEC'd as being suicidal and dangerous to self. Review of Patient #2's "Physician's Admit Order" revealed his accepting physician was S28MD, and he was to be admitted to the services of S7Psychiatrist. Further review revealed no documented evidence of the date, time, and signature of the nurse who received this order from S28MD. Review of the section titled "Admission Orders" revealed "Unit Restricted Until Evaluated by Physician" was chosen as evidenced by a check mark. Further review revealed the choices for observation levels of every 15 minutes, line of sight, one-to-one, line of sight while awake, and one-to-one while awake had no check mark in the space in front of the wording for any of the choices. This section was signed, dated, and timed by S32LPN with no documented evidence of the name of the physician who gave the telephone orders.

Review of the MHT's observation sheet dated 10/02/15 revealed no documented evidence of the the special observations and special precautions for which the MHT was to observe Patient #2.

Review of the "Incident Report Form" presented by S6RM revealed that Patient #2 made a suicide attempt by hanging himself by tying the cord (from the television mounted on the wall) around his neck on 10/02/15 when he was left unattended in the Day Room.

In an interview on 10/13/15 at 11:10 a.m., S31LPN indicated after she gets a report from the social worker who did the patient's psychosocial assessment and reviews the patient's medications and allergies, she calls the physician to get orders to admit the patient to the unit. She further indicated she doesn't get the patient's observation level orders at this time, because the RN on the nursing unit gets those orders from the physician after she does the admission assessment.

In an interview on 10/13/15 at 1:25 p.m., S32LPN indicated she didn't document the admission orders for Patient #2 as a verbal or telephone order and the name of the doctor who gave her orders. She further indicated she didn't get orders for observation, because the LPN working in the intake department usually got observation orders. After reviewing Patient #2's physician admit orders, S32LPN confirmed she didn't speak with the physician to get orders. When asked how she knew which orders on the pre-printed order sheet the physician wanted if she didn't speak with a physician, S32LPN indicated "it's normally what we do ... don't know of anyone I work with who calls the doctor."

In an interview on 10/14/15 at 3:00 p.m., S28MD indicated he was the hospital's Medical Director. He further indicated the S31LPN usually calls him for orders. S28MD indicated he usually admits his patients BOUP (line of sight with off unit privileges), "unless there's a significant suicidal risk above and beyond." He further indicated he doesn't have a signed standing order for observation levels , and the floor nurses calling him for orders "doesn't always happen." He indicated that they (the hospital) have "painted themselves in a corner for having too many patients on line of sight." S28MD indicated management counts nursing in the staffing ratio and shouldn't, because the nurses have other responsibilities and rely on the MHTs to observe patients. He further indicated he was aware he's responsible for the quality of care at the hospital, but he can only advise and cannot implement any action. S28MD indicated since the current owners acquired the hospital on [DATE], they have grown and increased beds by 24 beds. As soon as more beds became available, the was more pressure to admit more patients, and there were heavier admission days with a census above 70 patients. He indicated it became difficult for staff with 14 to 16 admissions not being unusual for a Friday. He further indicated he didn't know if the staff was increased to accommodate this growth.

2) Failing to ensure a clear and concise policy was developed for levels of observation:
Review of the hospital policy titled "Observation Status Categories", presented as a current policy by S1ADM, revealed the observation status categories included Status A which was one-to-one, Status B which was line of sight during waking hours, and Status C which was every 15 minutes. Further review revealed line of sight was defined as staff visually observing the assigned patient(s) by scanning the patient care area. This status consists of line of sight visual observation by staff during waking hours. During the hours of sleep, staff members will be strategically placed down hallways to ensure that patients are monitored. Each patient care unit will have an additional staff member assigned to accomplish observation of each patient in their bed area every five minutes by making continuous walking rounds of the unit during sleeping hours.

In an interview on 10/12/15 at 2:15 p.m. when asked what clinical justification is there to change the level of observation of a patient who is on line of sight during waking hours to every 5 minutes observation during sleeping hours and how a staff member can determine when a patient is asleep, S7Psychiatrist indicated "line of sight is line of sight period." He further indicated a staff member should always have their eyes on the patient. He further indicated the policy should not be "line of sight during waking hours." S7Psychiatrist indicated sometimes there's not enough staff to provide line of sight at all times, but his expectation is that Status B line of sight means line of sight "at all times." he further indicated (after being informed that an observation was made on 10/08/15 at 10:08 a.m. of 1 MHT observing 17 patients in the outdoor area who were on line of sight) 1 MHT to 17 patients is not "practical to observe them line of sight."

In an interview on 10/14/15 at 3:00 p.m., S28MD indicated the policy of line of sight during waking hours is "confusing for staff." He further indicated they "have painted themselves into a corner for having too many patients on line of sight." S28MD indicated management counts nursing in the staffing ratio and shouldn't, because the nurses have other responsibilities and rely on the MHTs to observe patients. He further indicated he was aware he's responsible for the quality of care at the hospital, but he can only advise and cannot implement any action.

3) Failing to ensure a patient, who had a CEC signed on 09/05/15 at 2:15 p.m. due to being suicidal and a danger to self and was evaluated as remaining a danger to self on 09/09/15, was not allowed to be discharged AMA without being evaluated by a licensed practitioner to determine that he was no longer a danger to self:
Review of Patient #3's medical record revealed he was a 7 year old male admitted on [DATE] with a provisional diagnosis of Mood Disorder. Further review revealed a PEC was signed on 09/02/15 at 6:45 p.m. due to Patient #3 telling a psychiatrist that "he wanted to die", being suicidal, and a danger to himself. Further review revealed a CEC was signed on 09/05/15 at 2:15 p.m. due to Patient #3 being suicidal and a danger to self.

Review of Patient #3's "Psychiatric Evaluation", conducted by S36NP on 09/04/15 at 12:40 p.m., revealed his (S36NP) risk assessment was documented as suicidal, assaultive, aggressive behavior, and a danger to self and others due to active suicidal ideation and recent assaultive behavior. Further review revealed Patient #3 had attempted suicide in the last two weeks.

Review of S36NP's progress notes revealed the following documentation:
09/05/15 at 11:45 a.m. - Mood Disorder rule out Bipolar Disorder, Psychosis, ADHD by history, and continue hospital treatment plan;
09/07/15 at 1:00 p.m. - patient is danger to self and others due to impulsivity and labile mood at times;
09/08/15 at 8:55 a.m. - remains a danger to self and others but risk level decreasing;
Undated and untimed documentation - danger to self remains but is decreasing.

Review of Patient #3's "Physician's Orders" revealed a telephone order was received from S36NP by S2DON on 09/09/15 at 5:20 p.m. to "discharge patient AMA to care of mother (name of mother) (she agrees to take full responsibility for the patient."

In an interview on 10/12/15 at 11:00 a.m., S22RN indicated he worked as the House Supervisor from 2:00 p.m. to 2:00 a.m. on a rotating schedule of 3 days one week and 4 days the next week. When asked what his role as House Supervisor was in discharging Patient #3 AMA, S22RN indicated he probably explained what AMA meant and had his mother sign the form. He confirmed that Patient #3 was on a CEC when he was discharged AMA. He further indicated he signed him out AMA, because he saw the order, but he didn't check to see if Patient #3 had been assessed by a physician.

In an interview on 10/12/15 at 12:15 p.m., S36NP indicated his psychiatric evaluation risk assessment revealed Patient #3 was not actively suicidal. He further indicated Patient #3's biggest problem was that he was "overmedicated, bullied at school, and his mother tried to micromanage his care from day one." He further indicated Patient #3's "mother was stupid." He confirmed that the undated and untimed note was written by him on 09/09/15. S36NP indicated Patient #3's mother was insisting she was taking him out the hospital. He further indicated he always documents and says that patients are a danger to self until the day of discharge. When asked if he had evaluated Patient #3 before he (Patient #3) left AMA, S36NP indicated "No, I was at home out of town and wasn't coming here (hospital)." S36NP further indicated it (the interview) "was a witch hunt and you're trying to say I did something wrong," and asked if he needed legal counsel. S36NP was speaking continuously in a loud voice and appeared angry, so the interview ended due to the hostile environment.

In an interview on 10/12/15 at 2:15 p.m., S7Psychiatrist indicated Patient #3's mother wasn't satisfied with her son's care and asked to have him discharged . He further indicated that S36NP saw Patient #3 the day after he was admitted . S7Psychiatrist indicated this was S36NP's first week working at the hospital. He further indicated that since Patient #3 was a minor, he could be released to his parent. S7Psychiatrist indicated that for a patient to go from involuntary status to voluntary status, the patient needs to be evaluated by a physician. He confirmed that Patient #3's medical record had no documentation that S36NP had evaluated Patient #3 and determined that he (Patient #3) was not a danger to himself before he was discharged AMA.

In an interview on 10/13/15 at 1:15 p.m., S32LPN indicated S6RM called the unit and asked if someone could call the physician to see if Patient #3 could go home AMA, since she was coming to the hospital for visitation and lived so far away. She further indicated she called S36NP, and he said he would have to see the patient. S32LPN indicated she then called S2DON to inform her of the conversations she had with S6RM and S36NP, and S2DON took over from that point.

In an interview on 10/13/15 at 5:10 p.m., S2DON indicated she was aware that a practitioner had to evaluate a patient with a CEC in place before discharging the patient, but she thought it was alright, because S36NP had evaluated Patient #3 earlier in the day. She further indicated S36NP also stated he was comfortable discharging Patient #3 that evening. When informed that S36NP's documentation from his earlier evaluation revealed that Patient #3 remained a danger to himself, S2DON made no comment.

4) Failing to ensure an alleged abuse incident which resulted in a patient sustaining an arm fracture during a therapeutic hold (Patient#5) was analyzed (root cause analysis) to determine if there was a delay in medical treatment:

Review of Patient #5's medical record revealed she was a [AGE] year old female, admitted on [DATE] and discharged on [DATE]. Further review revealed admission diagnoses including the following: adjustment disorder with mixed disturbance of emotions and conduct; rule out intermittent explosive disorder. Additional review revealed her legal status was PEC on 9/16/15 and CEC on 9/20/15.

Review of Hospital Incident Reports for Abuse/Neglect revealed an initial report for alleged physical abuse involving Patient #5 was filed on 9/22/15 by S6RM. The report revealed the following, in part:
Incident information: Date: 9/20/15, Time: 8:00 p.m.; Shift: 3-11; Date of Discovery: 9/21/15; Time of discovery: 10:00 a.m.; Shift: 7-3; Location: Main Campus; Unit: Children/Adolescent Unit-patient's room.
Alleged perpetrators: S23MHT; S20MHT
Patient was still hospitalized when allegation became known; reported by the patient; Name, title and position of 1st employee aware of situation and how they became aware: S21RN, nurse on Sunday 3-11 shift, called code white and was told by patient that her arm was hurting. Patient was aggressive, required hold, 2 MHTs (S20MHT, S23MHT) applied Crisis Prevention Intervention "control hold". Patient broke out and fell to left side injuring arm. Rule out break.
Date assessed: 9/20/15, time assessed: 10:00 p.m.; x-ray done; Patient sent to area hospital emergency department on 9/21/15; Patient sustained apparent injury/adverse effects: yes; injury/treatment: left arm broken; soft cast applied with hard plate.
Initial actions: S23MHT; S20MHT removed from unit
Physician (S7Psychiatrist) notified 9/20/15 9:10 p.m.; Mother notified 9/20/15 8:00 p.m.
Hospital Personnel notified, in order of notification:
S21RN: 9/20/15 9:10 p.m.; S1Administrator: 9/20/15 9:30 p.m.; S6RM: 9/20/15 10:00 p.m.

Review of Patient #5's medical record revealed the following Physician's Orders:
9/20/15 9:10 p.m.: 1. Therapeutic hold times 10 minutes for out of control behavior. 2. Ativan 1 milligram intramuscular, Haldol 5 milligrams intramuscular now times 1 dose for violent, aggressive behavior.
9/20/15 9:20 p.m.: Medical consult related to complaints of left arm pain. Telephone order S7Psychiatrist.
9/20/15 6:00 a.m.: Send to emergency room for evaluation and x-ray of left arm.

Review of Patient #5's nursing notes revealed the following entry, dated 9/20/15 at 8:30 p.m.: Patient pacing and agitated on unit. Refuses to listen to staff. Instigating discontent among peers. Ativan 1 milligram and Benadryl 25 milligram intramusular. Patient continues loud and aggressive and unable to redirect. Out of control behavior disrupting the unit milieu. Unable to calm verbally. S7Psychiatrist notified. New orders noted. Therapeutic hold initiated. Patient fought and kicked during hold. Ativan 1 milligram and Haldol 5 milligram intramuscular at 9: 15 p.m. Patient continues loud and defiant. Complaints left arm pain. Medical consult ordered. On assessment no swelling or bruising noted. Patient spoke with Mom and was assisted to bed at 10:00 p.m. Further review revealed no documented evidence of further assessments of the status of the patient's arm or the patient's pain level/ interventions related to management of pain until 9/21/15 at 6:30 a.m. Additional review revealed no documented evidence of further notification of a physician/licensed independent practitioner of patient ' s complaints of arm pain after the patient had been in a therapeutic hold other than when the order was obtained for the medical consult on 9/20/15 at 9:20 p.m.
Review of the 11-7 shift nurses notes for 9/20-9/21/15 revealed the following entries: Restless, slept on and off, awake at start of shift. Slept for a short time on couch in day area. Noted to be sitting on bed with eyes closed. Encouraged to lie down at 4:30 a.m.
6:30 a.m.: Continues to complain of pain on left upper arm. Seen this a.m. by S16FNP for medical consult. Order received to send patient to emergency room for evaluation. The Mom informed of above. S2DON, also informed. Instructed patient to keep affected arm immobile or supported.

Review of Patient #5's medical record revealed the following documentation of a medical consult, dated 9/21/15 at 6:00 a.m. , completed by S16FNP revealed the following, in part: Reason for consultation: complains of left arm pain related to therapeutic hold on 9/20/15. Consult: Consulted for complaints of left arm pain. Patient reports left arm pain starting last night after therapeutic hold. Reports arm started hurting immediately and has worsened through the night. Pain to elbow and upper arm. Worse with forearm movement. Decreased range of motion of elbow by left arm. Patient holding in semi-flexed position. Positive tenderness to elbow and lower humerus, limited of range of motion of elbow. Positive edema of upper arm, positive warmth. Impression: upper arm pain. Recommendations: need x-ray and further evaluation. Discussed with nurse regarding emergency room evaluation as soon as possible.

Review of Patient #5's emergency room record, dated 9/21/15 at 8:15 a.m. revealed the following, in part: Complaint: arm injury: [AGE] year old African American female arrived to emergency room from area Psychiatric hospital .... She is somewhat somnolent but answers questions. She is complaining of pain in her left arm, mainly at elbow. The arm is tense at this area. However, she has no evidence of distal neurovascular compromise. Her radial pulses intact. She is able to move all 5 digits. She has sensation to all 5 digits of her left hand.
Physical exam: Arm/Shoulder: shoulder stable, swelling-distal humerus; Neurological: Patient has no distal neurovascular compromise to left upper extremity.
Disposition:Extremity Injury Upper; Primary impression: Fracture of Distal Humerus.
Discharge to home: yes
Supervising Physician Note: Patient was seen and evaluated by orthopedic staff. Splint was placed by orthopedist Physician's Assistant.

Review of the Radiological reports from Patient #5's hospital record, dated 9/21/15 8:57 a.m. revealed the following: Humerus: Anteroposterior & Lateral: Left portable x-ray: impression: Distal humerus fracture. Further review revealed the following report, dated 9/21/15 2:32 p.m.: Humerus: Anteroposterior &Lateral report, Findings: A splint has been applied across the comminuted distal humeral fracture. The 2 views demonstrate near anatomic alignment of the major fracture fragments. There is some medial displacement of several medial fracture fragments, similar to that present previously.

In an interview on 10/13/15 at 10:56 a.m. with S19MHT,she indicated she had accompanied Patient #5 to the hospital the next morning after the incident happened. She said Patient #5 was complaining of arm pain and her arm was swollen. S19MHT said the emergency room physician came in and told Patient #5 they were going to x-ray her arm. She said when they manipulated Patient #5's left arm she screamed.

In an interview on 10/13/15 at 11:24 a.m. with S18RN, she indicated she had cared for Patient #5 on the 11-7 shift of 9/20-9/21/15. She indicated a medical consult had been obtained prior to her shift (on the 3-11 shift). S18RN indicated if a patient's condition declined/changed they would have called the physician again to see if the patient needed to be sent out. She said during the night Patient #5 couldn't sleep and indicated Patient #5 had preferred being on the couch because she was more comfortable there than in her bed. S18RN confirmed after the 8:30 p.m. nurses note entry on 9/20/15 that there were no other entries documenting the patient ' s pain level, the appearance of her arm, or administration of any type of pain medication until the 6:30 a.m. entry on 9/21/15. She confirmed there should have been more assessments of the patient's arm and her pain level. S18RN also confirmed Patient #5 had been sent out to the emergency room for as soon as possible evaluation and treatment of her left arm after she had been examined on 9/21/15 by S16FNP.

In an interview on 10/13/15 at 5:49 p.m. with S1ADM, she indicated S6RM had not done a root cause analysis of the adverse event involving Patient #5. She also indicated S6RM investigated based upon the directive of the corporate risk manager. S1ADM said there had been no policy review/revisions related to the incident. S1ADM indicated the incident was handled with the individual staff involved.

In an interview on 10/14/15 at 11:34 a.m. with S6RM, she indicated that she had notified corporate when the incident occurred and they, in turn, rated the incident. S6RM further indicated that the corporate risk manager usually directed her to conduct an investigation and/or to perform a root cause analysis of the incident after review of the reported incident. She confirmed she had not conducted a root cause analysis of the incident involving Patient #5.

In an interview on 10/14/15 at 3:11 p.m. with S28MD (Medical Director), he indicated in a situation like the incident involving Patient#5, where an injury occurred during a therapeutic hold, the nurse practitioner should have been notified. He agreed the patient should have been sent to the emergency room for evaluation and treatment (due to the nature of the injury) soon after the injury occurred. He acknowledged that he is responsible for the quality of care provided to the patients in the hospital.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on record reviews, observations, and interviews, the CEO failed to manage the hospital as evidenced by:

1) Failing to meet the requirements of the Condition of Participation of Patient Rights as evidenced by:

a) Failing to ensure all patients were free from all forms of abuse, the alleged reported incidents of abuse were reported immediately and thoroughly investigated, and the alleged perpetrators were relieved of all duties until the investigation was complete for 3 (#3, #4, #5) of 3 patient records reviewed for allegations of abuse from a total sample of 10 patients. This failed practice provided the opportunity for alleged perpetrators to continue to provide direct patient care for any patient currently admitted to the hospital as well as any future admitted patients.

b) Failing to ensure patients admitted to the Little Boys' Unit and the Big Boys' Unit had the right to privacy as evidenced by having the glass windows that provided a view into the room from the outside (and a wing that faced the patient rooms of other units of the hospital) in all patient rooms, except Rooms "a", "b", "c", "d", "e", and "f" (that had part of the glass window with shading that blocked the view from the outside), and had no means of providing privacy of the patients.


2) Failing to ensure the requirements of the Condition of Participation was met for Nursing Services as evidenced by:

a) Failing to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by:
An Immediate Jeopardy situation was identified on 10/08/15 at 5:25 p.m. due to the hospital:
(i) Failing to ensure the RN assured that line of sight visual observation was maintained as ordered for Patient #6 on 10/08/15 at 9:15 a.m. and for Patient #7 on 10/08/15 at 9:20 a.m.. Both patients were not within line of sight visual observation when they went to the bathroom.
(ii) Failing to ensure a RN was immediately available on the boys' acute care psychiatric unit. S4RN was observed leaving the "Little Boys' Unit" on 10/08/15 at 12:11 p.m., returning at 12:16 p.m. There was no RN on the unit during this time frame and patients were noted to be on the unit. S5RN was observed leaving the "Big Boys' Unit" on 10/08/15 at 12:15 p.m. leaving the unit without a RN, and patients were noted to be on the unit.
(iii) The RN failed to obtain physician orders at admit for the observation level of each patient for 2 (#1, #6) of 6 (#1, #6, #7, #8, #9, #10) current inpatients and 3 (#2, #3, #4) of 4 (#2, #3, #4, #5) closed medical records reviewed for observation level orders from a total of 10 sampled records.
(iv) The RN failed to ensure the patient's medical record contained documentation of the sentinel event, patient assessment, treatment, and transfer to the acute care hospital of 1 (#2) of 1 patient record reviewed for a sentinel event from a total of 10 sampled patients.
(v) The RN failed to assign the MHTs and review their documentation as evidenced by having patient's observation records with no documented evidence of the type of precaution for which the patient was to be monitored, such as suicide/aggression, and the type of observation and the signature of the RN reviewing the observation record for 7 (#1, #2, #3, #5, #6, #7, #8) of 10 patients' records reviewed for documentation of levels of observation from a total sample of 10 patients. Patients #1, #6, #7, and #8 were current inpatients at the time of the survey.

b) The DON failed to ensure the hospital had a system for determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital as evidenced by having no policy developed for the staffing ratio of MHTs to patients. This lack of policy resulted in 1 MHT being assigned the observation of 10 to 11 patients who were ordered to be on line of sight observation and 1 MHT assigned to observe 17 patients during their outdoor break who were ordered to be on line of sight observation.

c) Failing to ensure there was an adequate number of RNs, LPNs, and MHTs to provide nursing care to all patients as needed as evidenced by:
(i) Failure to have a RN on the Little Boys' Unit from 2:00 a.m. to 6:00 a.m. on 10/10/15, 10/11/15, and 10/12/15 while the hospital had an Immediate Jeopardy in place for failing to ensure a RN was on each nursing unit each shift.
(ii) Failure to have an adequate ratio of MHTs to patients on the Boys' Unit on 10/03/15, 10/04/15, 10/05/15, and 10/08/15.
(iii) Failure to ensure the Boys' Unit had a RN from 2:45 p.m. to 4:15 p.m. on 09/20/15.

3) Failing to ensure the requirements for the Condition of Participation of Medical Records Services were met as evidenced by:

a) Failure to ensure that medical records were accurately written and promptly completed as evidenced by:
(i) Failure to ensure the patient's medical record contained documentation of a sentinel event that occurred on 10/02/15, patient assessment, treatment, and transfer to the acute care hospital of 1 (#2) of 1 patient record reviewed for a sentinel event from a total of 10 sampled patients.
(ii) Failure to ensure patient's observation records were complete and included documentation of the type of precaution for which the patient was to be monitored, such as suicide/aggression, and the type of observation and the signature of the RN reviewing the observation record for 7 (#1, #2, #3, #5, #6, #7, #8) of 10 patients' records reviewed for complete documentation of MHT observation sheets from a total sample of 10 patients. Patients #1, #6, #7, and #8 were current inpatients at the time of the survey.
(iii) Failure to ensure reported patient incidents were accurately documented in the patient's medical record for 1 (#5) of 1 patient medical record reviewed with no documentation of an incident from a total sample of 10 patient records reviewed.
(iv) Failure to ensure a telephone order received from the physician for admission of the patient was documented by the intake department for 6 (#1, #2, #3, #6, #7, #10) of 10 patient records reviewed for a physician's order to admit from a total of 10 patients. Patients #1, #6, #7, and #10 were current inpatients at the time of the survey.

b) Failing to ensure the medical record contained the physician's order for transfer, nursing notes, and reports of treatment provided related to a sentinel event that occurred on 10/02/15 for 1 (#2) of 1 patient record reviewed for a sentinel event from a total of 10 sampled patients.

4) Failing to ensure its written visitation policy allowed for open visitation as evidenced by allowing visitation twice a week with no documented evidence that restrictions or limitations to visitation were clinically necessary or reasonable.

In an interview on 10/09/15 at 11:00 a.m., S29CEO indicated he was the Divisional Manager and was the responsible person above S1ADM.

In an interview on 10/14/15 at 1:55 p.m., S29CEO indicated he, as a member of the governing body, was aware of the "broken system" of the hospital, but "not to the extent I've heard over the last 3 days." He further indicated he reviews the staffing when he comes to the hospital once a week, usually in the mornings. He indicated he had not seen a staffing of 1 MHT to 10 patients or 1 MHT to 17 patients during his visits. He further indicated it was reported to him that the previous "surveyors matched staffing to payroll and had no problems." S29CEO indicated no directive from the governing body prevented Administration from increasing staff.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observations, record review, and interview, the hospital failed to ensure patients admitted to the Little Boys' Unit and the Big Boys' Unit had the right to privacy as evidenced by having the glass windows that provided a view into the room from the outside (and a wing that faced the patient rooms of other units of the hospital) in all patient rooms, except Rooms "a", "b", "c", "d", "e", and "f" (that had part of the glass window with shading that blocked the view from the outside), and had no means of providing privacy of the patients.
Findings:

Observations on 10/08/15 from 8:50 a.m. through 9:40 a.m. on the Little Boys' Unit and the Big Boys' Units revealed the glass window in all patient rooms except Rooms "a", "b", "c", "d", "e", and "f" had no curtain or means of providing privacy. Further observation revealed the view on one side of the Big Boys' Unit faced the patient rooms on the Little Boys' Unit and some offices on that wing. The view on both sides of the Little Boys' Unit faced the patient rooms on other units of the hospital. The window in Rooms "a", "b", "c", "d", "e", and "f" had a glazing/shading on a portion of the window that provided privacy but no view of the outdoors other than a view of the sky or the top of the trees.

Review of the hospital policy titled "Patient Rights and Responsibilities", presented as a current policy by S1ADM, revealed that the patient has a right to every consideration of privacy concerning his/her own medical care program, and the patient's personal dignity is recognized and respected in the provision of care and treatment.

In an interview on 10/08/15 at 9:15 a.m., S42LMSW confirmed the above findings.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure all patients were free from all forms of abuse, the alleged reported incidents of abuse were reported immediately and thoroughly investigated, and that patients were protected from abuse during the investigation by allowing the alleged perpetrators to continue to work before the investigation was complete for 3 (#3, #4, #5) of 3 patient records reviewed for allegations of abuse from a total sample of 10 patients. This failed practice provided the opportunity for alleged perpetrators to continue to provide direct patient care for any patient currently admitted to the hospital as well as any future admitted patients
Findings:

Review of the hospital policy titled "Identifying and Reporting Patient Abuse and Neglect", presented as a current policy by S1ADM, revealed that child abuse was defined as any physical injury, sexual abuse, or emotional abuse inflicted on a child by those responsible for his/her care, custody, and control. Each employee who has cause to believe that a patient has been or may be adversely affected by abuse or neglect must report the incident promptly to their supervisor and to the Administrator or his/her designee. Upon receipt of verbal or written complaint that alleges patient abuse or neglect, the charge nurse is to contact the Administrator or his/her designee, the physician, the DON or designee, and the Director of Risk Management and to immediately relieve the alleged perpetrator of his/her duties.

Review of the hospital policy titled "Utilization of Time Out (Quiet Time)", presented as a current policy by S1ADM, revealed that time out is the voluntary removal of a patient to a private, unlocked, and open room to enable the patient to de-escalate. Team members evaluate with the charge nurse the need for use of time out.

Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Depression. Further review revealed he was PEC'd on 10/01/15 at 10:00 p.m. after having left a video apologizing for what he was about to do and taking an unknown amount of pills. His PEC revealed he was suicidal and a danger to self. Review of his physician admit orders revealed no documented evidence of the physician who gave orders to S32LPN, and there was no observation level ordered by the physician.

Review of an "Incident Report Form" documented on 10/02/15 at 3:15 p.m. by S6RM revealed Patient #2 was found with a red mark around his neck as a result of an attempted suicide by hanging himself around the neck with a cord from the television mounted on the wall at 2:50 p.m.

Review of Patient #2's "Tech Observation Sheet" documented on 10/02/15 by S45MHT revealed at 2:15 p.m. Patient #2 was on line of sight in the dayroom. There was no documented evidence of Patient #2 being observed by staff from 2:15 p.m. until the time he was found at 2:50 p.m. with a cord wrapped around his neck.

Review of Patient #2's entire medical record revealed no documented evidence of documentation of the above incident, the assessment and treatment of Patient #2 by the RN, the physician order for transfer to the emergency department of an acute care hospital, and the time and method by which Patient #2 was transferred.

Review of the "Hospital Abuse/Neglect Initial Report" documented by S6RM revealed the alleged perpetrator was S12LPN.

In a telephone interview on 10/13/15 at 10:05 a.m., S12LPN indicated they (Administration) "didn't give me a chance" to document anything. She further indicated immediately after the event, S15Staffing came to get her, and she sat in S2DON's office for about 45 minutes when S2DON came and said "she had to let me go since I was the last person who spoke with him." S12LPN indicated she had spoken with Patient #2's father when she came on duty about 2:00 p.m. that day, and he reported that Patient #2 told him "he was scared to be here because the staff leaves us unattended and ya'll don't have enough people watching us, so I'm scared of the other pts. (patients)." She indicated she spoke with Patient #2 after her conversation with his father to assure him that staff wouldn't let other patients harm him. She further indicated she went to call Patient #2's physician to get an order for anxiety medication and asked S27WC to check on Patient #2 when she didn't see him in the hall. S12LPN indicated the RN wasn't on the unit, but she didn't know where she was. She further indicated they had 5 patients to be admitted to this unit, and they didn't have enough MHTs "to handle it." When asked what type of observation was ordered, S12LPN indicated she thought line of sight with unit restriction, but "it should have been one-to-one. She further indicated she had not received report at the time of the incident and had only looked at his list of medications and only knew what his father had told her earlier. She further indicated she didn't know who was assigned to observe him and was never asked to take over the observation of Patient #2. S12LPN confirmed that Patient #2 was not in line of sight of any staff when he hung himself.

In an interview on 10/13/15 at 1:25 p.m., S32LPN confirmed she didn't document the physician order she signed as a verbal or telephone order and the name of the physician who gave the orders. She further indicated the LPN in the intake department usually gets physician orders. She confirmed that she did not speak with any physician to obtain the orders to which she had signed her name.

In an interview on 10/13/15 at 2:05 p.m., S5RN indicated she thought the admit orders were done by the intake nurse, including the orders for observation level. She indicated that "technically the whole unit is under her." She further indicated she didn't document anything in Patient #2's chart, because as soon as the event happened, S6RM took the chart. She further indicated she wrote a witness statement, but she didn't see the chart until today for the first time since the event occurred. S5RN indicated Patient #2 was her responsibility. She further indicated when S12LPN came on duty, she (S12LPN) took Patient #2 to speak with him in the hallway. S12LPN then told S5RN that she told Patient #2 to sit and calm down and take deep breaths while she called to get an order for Vistaril. When she (S5RN) looked up and saw the dayroom door closed, she questioned it, and at this time S12LPN asked S27WC to check on Patient #2. S5RN indicated S3MHT was with Patient #2 when the incident occurred, and it was her understanding that S3MHT was watching him at that moment. She further indicated that S3MHT told her the morning of this interview that he had the tech observation sheet at the time of the incident.

In an telephone interview on 10/13/15 at 3:55 p.m., S3MHT indicated that he had passed his tech sheet to S12LPN at 2:00 p.m. when he took the other patients to the gym. He further indicated S45MHT had passed the tech observation sheet for Patient #2 to him earlier when S45MHT went on break.

A request was made to interview S45MHT during the survey, but he was unavailable due to working offshore at the time.

In an interview on 10/09/15 at 10:05 a.m., S2DON, after reviewing Patient #2's medical record, confirmed the record had no documentation of the sentinel event that occurred, the assessment and treatment of Patient #2 by the RN, the physician order for transfer to the emergency department of an acute care hospital, and the time and method by which Patient #2 was transferred.

In an interview on 10/13/15 at 5:20 p.m., S2DON indicated she didn't do any investigation of the incident. She further indicated she did tell S6RM that S12LPN was responsible. When asked how she came to that conclusion without an investigation being conducted, S2DON indicated "S12LPN told me." She further indicated she didn't document that S12LPN had told her she was responsible, because she (S2DON) thought it would be hearsay."

After review of Patient #2's medical record and interviews with staff, no evidence was presented that Patient #2 was being observed by any staff at the time of the incident.

Patient #3
Review of an "Incident Report Form" documented by S8RN on 09/07/15 at 11:00 a.m. revealed the "Facts Summary of Event" included "Patient's mother reported bruise to patient's right upper arm." The "Nursing Evaluation & (and) Intervention" included "small fingerprint sized bruise noted to right upper inside arm." Further review revealed S7Psychiatrist was notified on 09/07/15 at 11:00 a.m. with the response of "follow-up with patient and staff to assess situation." Further review revealed the section titled "Notification as Applicable..." revealed the choices of RN Supervisor, Shift Supervisor, Administration, Risk manager, Family, Family/Legal Guardian Name and Relationship, and External Agency had no documented evidence that anyone had been notified. S6RM signed the report on 09/08/15.

Review of an "Incident Report Form" documented by S8RN on 09/08/15 at 2:30 p.m. revealed the following under the heading "Facts Summary of Event""
1) "9-7-15 patient's mother voiced concern about small bruise to pt. (patient) R (right) upper arm."
2) "Patient's mother called 9/8/15 and stated patient called her last night and told her he got in trouble and a lady tech and (male first name) held his arm behind his back after patient was accused of exposing penis to peers. I talked to Patient #3 9/8/15 after mother's phone call and patient reported same to me as his mother had reported. I instructed Patient #3 to come talk to me with any questions or concerns. Patient stated he would. I spoke to staff from last night and neither the male or female tech reported having to use physical restraint or redirection on patient."
Nursing evaluation and intervention documented included "09/09/15 spoke with pt. noted small dime sized darkened skin circle area to R upper arm area. S8RN documented that she notified S28MD on 09/09/15 at 10:30 a.m. (day after she received report from mother), Administration and S2DON verbally on 09/08/15 at 7:32 p.m. and Risk Manager verbally on 09/08/15 at 2:20 p.m. Further review revealed documentation by S6RM that she was notified on 09/08/15 at 5:56 p.m. by the social worker of the incident and called the mother at 7:00 p.m. Further review revealed S6RM documented she spoke with Patient #3 on 09/09/15 at 9:00 a.m. and reported it in the operational meeting at 10:30 a.m.. She spoke with S40MHT at 3:00 p.m., obtained a witness statement, and called Patient #3's mother with an update at 3:30 p.m. Review of documentation written by S35MHT on 09/08/15 revealed "I never physically redirected Patient #3." There was a note written by S6RM on the bottom of the witness statement by S35MHT that this was the female MHT Patient #3 was accusing of holding his arm behind his back.

Review of the "Incident Investigation Report", presented by S6RM, revealed S6RM spoke with S40MHT on 09/09/15 at 3:00 p.m. at which time S40MHT reported Patient #3 was cursing and calling the staff names, so "he took Patient #3 by the arm and pulled toward him to remove him from group and placed aganst the wall for time out." Further review revealed S6RM documented after thorough review of the allegation of abuse, "we did not find sufficient information to support a finding of abuse. Therefore, the finding for this investigation is invalid (not justified). S40MHT removed from the Children/Adolescent Unit at this time."

In an interview on 10/12/15 at 11:50 a.m., S35MHT indicated when she came back from break on 09/07/15 about 8:30 p.m., Patient #3 was crying in the hall with another MHT. She further indicated the other patients told her Patient #3 had exposed himself. She confirmed she wasn't present when this occurred, and she had never touched Patient #3.

In an interview on 10/12/15 at 3:15 p.m., S8RN indicated she did not report to management the allegation of abuse reported by Patient #3's mother, because she didn't remember exactly what his mother said, and "it could be abuse but not necessarily."

In an interview on 10/13/15 at 4:05 p.m., S40MHT indicated there were female MHTs working, and Patient #3 was sitting on the couch cursing and calling the MHTs names. He further indicated "I grabbed his right upper arm and pulled him toward me." He further indicated he didn't report this incident to the RN, because "it wasn't that serious and putting in time out is normal for little kids." S40MHT indicated the "grabbing" of Patient #3's arm was not an appropriate CPI technique.

In an interview on 10/13/15 at 4:20 p.m., S6RM indicated she reviewed Patient #3's medical record and noted no incident of a restraint being used. She further indicated S40MHT was removed from the Boys' Unit due to the allegation of abuse and was sent to work on another unit. She confirmed that S40MHT should have been removed from all direct patient care until the investigation was completed. When asked what she would expect to find to support a confirmation of abuse, S6RM indicated an intent to harm, and she couldn't find proof that the incident of S40MHT grabbing Patient #3's arm caused the bruise.

Patient #4
Review of the medical record for Patient #4 revealed he was an eight year old male admitted on [DATE], legal status PEC, and discharged on [DATE]. Patient #4's admitting diagnoses were Depression , ODD, and ADHD.

Review of the Hospital Incidence and Accident report revealed an occurrence dated 09/20/15 completed by S12LPN. The incidence indicated that Patient #4 was slapped by another patient (unidentified) on 09/20/15 and MHT broke up the patients by pulling them apart. S4's mother telephoned the hospital speaking to the S12LPN stating "We left bruises on and marks on pt. (as written). We are abusing pts. and she will is going to report to DHH."

Review of the investigation information provided by S6RM on 10/09/15 at 2:15 p.m. included statements from S10MHT & S11MHT that indicated that Patient #4 was slapped by another patient (not identified) and both patients had to be separated.

Review of notes attached to a sheet of paper read: " (Name) S10MHT & (Name) S11MHT removed from C/AB unit 9/20/15." (Name) S10MHT & (Name) S11MHT moved to Adult Unit on 09/22/15.

In an interview on 10/13/15 at 4:30 p.m., S6RM indicated that S10MHT & S11MHT were moved from the boys unit (09/20/15) and to the Adult unit on 09/22/15 pending an investigation & re-training. S6RM indicated that both MHTs were re-trained (CPI) on 10/01/15. S6RM indicated that she was not certain about the re-assignment back to the boys unit. S6RM indicated that the hospital process is re-assignment of staff of alleged abuse/neglect to another unit pending the investigation outcome. S6RM indicated the hospital had no written policy for this process.

In an interview on 10/14/15 at 12:30 p.m., S15Staffing indicated that S11MHT was reassigned back to the boys unit on 09/24/15 and S10MHT on 09/25/15. S15Staffing indicated that the MHTs are re-trained and then re-assigned back to the unit. She confirmed after checking the staffing schedule, S10MHT & S11MHT were returned back to the assigned units prior to re-training.

Patient #5
Review of Patient #5's medical record revealed she was a [AGE] year old female, admitted on [DATE] and discharged on [DATE]. Further review revealed admission diagnoses including the following: adjustment disorder with mixed disturbance of emotions and conduct; rule out intermittent explosive disorder. Additional review revealed her legal status was PEC on 9/16/15 and CEC on 9/20/15.

Review of Hospital Incident Reports for Abuse/Neglect revealed an initial report for alleged physical abuse involving Patient #5 was filed on 9/22/15 by S6RM. The report revealed the following, in part:
Incident information: Date: 9/20/15, Time: 8:00 p.m.; Shift: 3-11; Date of Discovery: 9/21/15; Time of discovery: 10:00 a.m.; Shift: 7-3; Location: Main Campus; Unit: Children/Adolescent Unit-patient's room.
Alleged perpetrators: S23MHT; S20MHT
Patient was still hospitalized when allegation became known; reported by the patient; Name, title and position of 1st employee aware of situation and how they became aware: S21RN, nurse on Sunday 3-11 shift, called code white and was told by patient that her arm was hurting. Patient was aggressive, required hold, 2 MHTs (S20MHT, S23MHT) applied Crisis Prevention Intervention "control hold". Patient broke out and fell to left side injuring arm. Rule out break.
Date assessed: 9/20/15, time assessed: 10:00 p.m.; x-ray done; Patient sent to area hospital emergency department on 9/21/15; Patient sustained apparent injury/adverse effects: yes; injury/treatment: left arm broken; soft cast applied with hard plate.
Initial actions: S23MHT; S20MHT removed from unit.
Physician (S7Psychiatrist) notified 9/20/15 9:10 p.m.; Mother notified 9/20/15 8:00 p.m.
Hospital Personnel notified, in order of notification:
S21RN: 9/20/15 9:10 p.m.; S1Administrator: 9/20/15 9:30 p.m.; S6RM: 9/20/15 10:00 p.m.
Review of Patient #5's nursing notes revealed the following entry, in part, dated 9/20/15 at 8:30 p.m.: Patient pacing and agitated on unit. Refuses to listen to staff. Instigating discontent among peers....Therapeutic hold initiated. Patient fought and kicked during hold.... Complaints left arm pain. Medical consult ordered. On assessment no swelling or bruising noted. Patient spoke with Mom and was assisted to bed at 10:00 p.m.

Review of Patient #5's medical record revealed the following documentation of a medical consult, dated 9/21/15 at 6:00 a.m. , completed by S16FNP revealed the following, in part: Reason for consultation: complains of left arm pain related to therapeutic hold on 9/20/15. Consult: Consulted for complaints of left arm pain. Patient reports left arm pain starting last night after therapeutic hold. Reports arm started hurting immediately and has worsened through the night. Pain to elbow and upper arm. Worse with forearm movement. Decreased range of motion of elbow by left arm. Patient holding in semi-flexed position. Positive tenderness to elbow and lower humerus, limited of range of motion of elbow. Positive edema of upper arm, positive warmth. Impression: upper arm pain. Recommendations: need x-ray and further evaluation. Discussed with nurse regarding emergency room evaluation as soon as possible.

Review of the Radiological reports from Patient #5's hospital record, dated 9/21/15 8:57 a.m. revealed the following: Humerus: Anteroposterior & Lateral: Left portable x-ray: impression: Distal humerus fracture. Further review revealed the following report, dated 9/21/15 2:32 p.m.: Humerus: Anteroposterior &Lateral report, Findings: A splint has been applied across the comminuted distal humeral fracture. The 2 views demonstrate near anatomic alignment of the major fracture fragments. There is some medial displacement of several medial fracture fragments, similar to that present previously.

Interview on 10/12/15 at 3:52 p.m. with S6RM (Risk Management) she indicated her initial actions were to remove S23MHT and S20MHT from the girls' unit pending investigation of the alleged abuse of Patient #5. She confirmed they had been re-assigned to another unit and not placed on any kind of administrative leave/suspension.

In an interview on 10/13/15 at 12:39 p.m. with S20MHT she indicated she had been removed from the girls unit and re-assigned until the investigation had been completed and she had been cleared of the alleged abuse allegations made by Patient #5.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0215
Based on record reviews and interviews, the hospital failed to ensure its written visitation policy allowed for open visitation as required by LA R.S. (Louisiana Revised Statute) 28:171 Part VI. Rights of Persons Suffering From Mental Illness and Substance Abuse as evidenced by allowing visitation twice a week with no documented evidence that restrictions or limitations to visitation were clinically necessary or reasonable.
Findings:

Review of the hospital policy titled "Hospital Visitation - Patient and Other", presented as a current policy by S1ADM, revealed that the purpose of the policy was to provide the patient the opportunity to have visitors with a minimum of interference to therapy. Each unit has established visiting hours that will be compatible to the patient's therapy and follow community standards. Further review revealed the visitation for patients on the adult unit is 6:15 p.m. to 7:45 p.m. on Tuesday and 1:00 p.m. to 3:00 p.m. on Saturday. The visitation for patients on the adolescent units was 6:15 p.m. to 7:45 p.m. on Wednesday and from 1:00 p.m. to 2:00 p.m. for girls and from 2:00 p.m. to 3:00 p.m. for boys on Sunday.

Review of LA R.S. 28:171 Part VI. Rights of Persons Suffering From Mental Illness and Substance Abuse revealed that reasonable times and places for the use of telephones and for visits may be established in writing by the director of any treatment facility. However, the times and places must allow patients, at a minimum, reasonable daily communication by telephone and visitation. These rights may be restricted by the director of the treatment facility if sufficient cause exists and is so documented in the patient's medical record. The patient's legal counsel, as well as his/her next of kin or responsible party, must be notified in writing of any such restrictions and the reasons therefor. When the cause for any restriction ceases to exist, the patient's full rights shall be reinstated.

In a telephone interview on 10/07/15 at 8:18 p.m., Patient #3's mother indicated Patient #3 (7 years of age) was transported by ambulance on 09/03/15 from New Orleans to Alexandria and was scared and upset that she could not ride with him. She further indicated she assured him that she would follow in her own vehicle and would see him when he got to the hospital. Patient #3's mother indicated she had to stop for gas, so Patient #3 was already admitted when she arrived at the hospital. She further indicated she was not permitted to see her son before leaving to return to New Orleans and would not be able to see him until Sunday, since visitation was allowed twice a week.

In an interview on 10/13/15 at 5:10 p.m., S1ADM indicated the hospital's visitation policy allowed visitation twice a week and did not include restrictions or limitations to visitation that were clinically necessary or reasonable. She further indicated she wasn't aware of the certification regulations related to visitation.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to analyze adverse events to assess processes of care, hospital services and operations for 2 (#2, #5) of 2 patient records reviewed for adverse events from a total of 10 sampled patients. Patient #2 had a suicide attempt by hanging himself, and Patient #5 sustained an arm fracture during a therapeutic hold.
Findings:

Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with a provisional diagnosis of Depression. Review of his PEC, signed 10/01/15 at 10:00 p.m. revealed he was very depressed, left a video apologizing for what he was about to do, and had taken an unknown amount of pills. He was PEC'd as being suicidal and dangerous to self. Review of Patient #2's "Physician's Admit Order" revealed no documented evidence of an order for the observation level.

Review of the MHT's observation sheet dated 10/02/15 revealed no documented evidence of the the special observations and special precautions for which the MHT was to observe Patient #2.

Review of the "Incident Report Form" presented by S6RM revealed that Patient #2 made a suicide attempt by hanging himself by tying the cord (from the television mounted on the wall) around his neck on 10/02/15 when he was left unattended in the Day Room.

Review of Patient #2's medical record revealed no documented evidence of the adverse event that occurred, the assessment and treatment that was provided, the physician's order for transfer to the acute care hospital, and the time Patient #2 was transferred.

In an interview on 10/13/15 at 4:45 p.m., S6RM indicated she had talked with employees and collected witness statements. She further indicated she had just received a statement from S32LPN on 10/12/15 (10 days after the event). S6RM indicated she had "sticky notes" with information, but she had not completed an investigation report of the adverse event as of the date of this interview. She further indicated the medical record of Patient #2 did not have documentation of the event of his hanging.

In an interview on 10/14/15 at 3:00 p.m., S28MD indicated the events of Patient #2's suicide attempt should be documented in his medical record.

Patient #5
Review of Patient #5's medical record revealed she was a [AGE] year old female, admitted on [DATE] and discharged on [DATE]. Further review revealed admission diagnoses including the following: adjustment disorder with mixed disturbance of emotions and conduct; rule out intermittent explosive disorder. Additional review revealed her legal status was Physician ' s Emergency Certificate on 9/16/15 and Coroner's Emergency Certificate on 09/20/15.

Review of Hospital Incident Reports for Abuse/Neglect revealed an initial report for alleged physical abuse involving Patient #5 was filed on 09/22/15 by S6RM (Risk Manager). The report revealed the following, in part:
Incident information: Date: 09/20/15, Time: 8:00 p.m.; Shift: 3-11; Date of Discovery: 09/21/15; Time of discovery: 10:00 a.m.; Shift: 7-3; Location: Main Campus; Unit: Children/Adolescent Unit-patient's room.
Alleged perpetrators: S23MHT; S20MHT
Patient was still hospitalized when allegation became known; reported by the patient; Name, title and position of 1st employee aware of situation and how they became aware: S21RN, nurse on Sunday 3-11 shift, called code white and was told by patient that her arm was hurting. Patient was aggressive, required hold, 2 MHTs (S20MHT, S23MHT) applied Crisis Prevention Intervention "control hold". Patient broke out and fell to left side injuring arm. Rule out break.
Date assessed: 09/20/15, time assessed: 10:00 p.m.; x-ray done; Patient sent to area hospital emergency department on 09/21/15; Patient sustained apparent injury/adverse effects: yes; injury/treatment: left arm broken; soft cast applied with hard plate.
Initial actions: S23MHT; S20MHT removed from unit
Physician (S7Psychiatrist) notified 09/20/15 9:10 p.m.; Mother notified 09/20/15 8:00 p.m.
Hospital Personnel notified, in order of notification:
S21RN: 09/20/15 9:10 p.m.; S1Administrator: 09/20/15 9:30 p.m.; S6RM: 09/20/15 10:00 p.m.

Review of Patient #5's emergency room record, dated 09/21/15 at 8:15 a.m. revealed the following, in part:
Complaint: arm injury: [AGE] year old African American female arrived to emergency room from area Psychiatric hospital .... She is somewhat somnolent but answers questions. She is complaining of pain in her left arm, mainly at elbow. The arm is tense at this area. However, she has no evidence of distal neurovascular compromise. Her radial pulses intact. She is able to move all 5 digits. She has sensation to all 5 digits of her left hand.
Physical exam: Arm/Shoulder: shoulder stable, swelling-distal humerus; Neurological: Patient has no distal neurovascular compromise to left upper extremity.
Disposition:
Extremity Injury Upper
Primary impression: Fracture of Distal Humerus.
Secondary Impression: Anger, Physician Emergency Certificate
Discharge to home: yes
Supervising Physician Note: Patient was seen and evaluated by orthopedic staff. Splint was placed by orthopedist Physician's Assistant.

Review of the Radiological reports from Patient #5's hospital record, dated 09/21/15 8:57 a.m. revealed the following: Humerus: Anteroposterior & Lateral: Left portable x-ray: impression: Distal humerus fracture. Further review revealed the following report, dated 09/21/15 2:32 p.m.: Humerus: Anteroposterior &Lateral report, Findings: A splint has been applied across the comminuted distal humeral fracture. The 2 views demonstrate near anatomic alignment of the major fracture fragments. There is some medial displacement of several medial fracture fragments, similar to that present previously.

In an interview on 10/13/15 at 5:49 p.m. with S1ADM (Administrator), she indicated S6RM had not done a root cause analysis of the adverse event involving Patient #5. She also indicated S6RM investigated based upon the directive of the corporate risk manager. S1ADM said there had been no policy review/revisions related to the incident. S1ADM indicated the incident was handled with the individual staff involved.

In an interview on 10/14/15 at 11:34 a.m. with S6RM, she indicated that she had notified corporate when the incident occurred and they, in turn, rated the incident. S6RM further indicated that the corporate risk manager usually directed her to conduct an investigation and/or to perform a root cause analysis of the incident after review of the reported incident. She confirmed she had not conducted a root cause analysis of the incident involving Patient #5.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record reviews, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Nursing Services as evidenced by:

1) Failing to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by:

An Immediate Jeopardy situation was identified on 10/08/15 at 5:25 p.m. due to the hospital:

a) Failing to ensure the RN assured that line of sight visual observation was maintained as ordered for Patient #6 on 10/08/15 at 9:15 a.m. and for Patient #7 on 10/08/15 at 9:20 a.m.. Both patients were not within line of sight visual observation when they went to the bathroom.

b) Failing to ensure a RN was immediately available on the boys' acute care psychiatric unit. S4RN was observed leaving the "Little Boys' Unit" on 10/08/15 at 12:11 p.m., returning at 12:16 p.m. There was no RN on the unit during this time frame and patients were noted to be on the unit. S5RN was observed leaving the "Big Boys' Unit" on 10/08/15 at 12:15 p.m. leaving the unit without a RN, and patients were noted to be on the unit (see findings in tag A0395).

The hospital presented a Corrective Action Plan to lift the Immediate Jeopardy on 10/14/15 at 6:30 p.m. that included the following:
1) Revision of Policy AS Observation Status Categories to clarify Status B (line of sight) with approval of the Governing Board on 10/13/15. Staff re-training on the revised policy began on 10/13/15 with a completion date of 10/19/15. Anyone not trained will not be allowed to return to work until re-training on the revised policy is completed.
2) The DON and/or Director of RM/designee will perform rounds each shift on all units to ensure monitoring is performed as ordered. Any failure to perform line of sight observation will be immediately addressed. Results of observations will be reported weekly to the Governing Board for a period of 4 weeks or until monitoring is maintained at 100% for one month. When 4 weeks has passed or 100% is maintained, monitoring will continue as follows: units will be randomly monitored daily by Administration/designee and reported in Leadership meeting every morning for 3 months. This will also be reported monthly to the Performance Improvement Committee. After 3 months, weekly random monitoring will be done by Administration/designee and reported in Leadership meeting every week for 3 months. This will also be reported monthly to the Performance Improvement Committee, If at any time compliance is not maintained, units will be randomly monitored daily by Administration/designee and reported in Leadership meeting every morning until 100% compliance is maintained for at least 2 weeks then resume random weekly monitoring.
3) Revision of Policy HR 20 Attendance to include process for providing shift coverage for last minute clinical staff call-ins that was approved by the Governing Board on 10/13/15. Staff re-training of the revised policy began 10/13/15 with a completion date of 10/19/15. Anyone not trained will not be allowed to return to work until re-training is completed.
4) The monitoring plan for RN coverage will be the same process as the one stated above for MHT observations.
5) An updated contract with a staffing agency was submitted by S1ADM, as well as a staffing schedule for 2 weeks with a documented assurance statement by S1ADM and S2DON that staffing will be based on a staffing ratio of 1 MHT to 6 patients.

Non-compliance continues at the Condition Level.

c) The RN failed to obtain physician orders at admit for the observation level of each patient for 2 (#1, #6) of 6 (#1, #6, #7, #8, #9, #10) current inpatients and 3 (#2, #3, #4) of 4 (#2, #3, #4, #5) closed medical records reviewed for observation level orders from a total of 10 sampled records.

d) The RN failed to ensure the patient's medical record contained documentation of the sentinel event, patient assessment, treatment, and transfer to the acute care hospital of 1 (#2) of 1 patient record reviewed for a sentinel event from a total of 10 sampled patients.

e) The RN failed to assign the MHTs and review their documentation as evidenced by having patient's observation records with no documented evidence of the type of precaution for which the patient was to be monitored, such as suicide/aggression, and the type of observation and the signature of the RN reviewing the observation record for 7 (#1, #2, #3, #5, #6, #7, #8) of 10 patients' records reviewed for documentation of levels of observation from a total sample of 10 patients. Patients #1, #6, #7, and #8 were current inpatients at the time of the survey (see findings in tag A0395).

2) The DON failed to ensure the hospital had a system for determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital as evidenced by having no policy developed for the staffing ratio of MHTs to patients. This lack of policy resulted in 1 MHT being assigned the observation of 10 to 11 patients who were ordered to be on line of sight observation and 1 MHT assigned to observe 17 patients during their outdoor break who were ordered to be on line of sight observation (see findings in tag A0386).

3) Failing to ensure there was an adequate number of RNs, LPNs, and MHTs to provide nursing care to all patients as needed as evidenced by:
a) Failure to have a RN on the Little Boys' Unit from 2:00 a.m. to 6:00 a.m. on 10/10/15, 10/11/15, and 10/12/15 while the hospital had an Immediate Jeopardy in place for failing to ensure a RN was on each nursing unit each shift.
b) Failure to have an adequate ratio of MHTs to patients on the Boys' Unit on 10/03/15, 10/04/15, 10/05/15, and 10/08/15.
c) Failure to ensure the Boys' Unit had a RN from 2:45 p.m. to 4:15 p.m. on 09/20/15 (see findings in tag A0392).
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations and interviews, the DON failed to ensure the hospital had a system for determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital as evidenced by having no policy developed for the staffing ratio of MHTs to patients. This lack of policy resulted in 1 MHT being assigned the observation of 10 to 11 patients who were ordered to be on line of sight observation and 1 MHT assigned to observe 17 patients during their outdoor break who were ordered to be on line of sight observation.
Findings:

Observation on the Big Boys' Unit on 10/08/15 at 8:52 a.m. revealed staffing included 1 RN, a LPN shared between the Big Boys' Unit and the Little Boys' Unit, and 2 MHTs with a census of 21 patients who all had physician orders to be on line of sight observation.

Observation on the Big Boys' Unit on 10/08/15 at 9:15 a.m. revealed S3MHT took Patient #6 to the bathroom. Further observation revealed the other MHT was left to observe 20 patients who were on line of sight observation when S3MHT took Patient #6 to the bathroom.

Observation on 10/08/15 at 9:20 a.m. on the Big Boys' Unit revealed S3MHT took Patient #7 to the bathroom which left the other MHT to observe 20 patients who were on line of sight observation.

Observation on the Little Boys' Unit on 10/08/15 at 9:40 a.m. revealed staffing included 1 RN, a LPN shared between the Little Boys' Unit and the Big Boys' Unit, 3 MHTs , and 1 MHT in orientation with a census of 11 patients who all had physician orders to be on line of sight observation.

Observation on 10/08/15 at 10:08 a.m. revealed S26MHT was in the outdoor area that exited from the Little Boys' Unit with 17 patients.

In an interview on 10/08/15 at 8:52 a.m., S5RN confirmed the above stated staffing for the Big Boys' Unit. She also confirmed that all 21 patients were on line of sight observation.

In an interview on 10/08/15 at 9:40 a.m., S4RN confirmed the above stated staffing for the Little Boys' Unit. She also confirmed that all 11 patients were on line of sight observation.

In an interview on 10/08/15 at 1:10 p.m., S2DON indicated the hospital did not have a policy that addressed the staff to patient ratio.

In an interview on 10/09/15 at 11:00 a.m., S29CEO indicated the staff to patient ratio should be 1 staff to 6 patients.

In a telephone interview on 10/13/15 at 2:05 p.m., S12LPN indicated she was working the Boys' Unit on 10/02/15 when Patient #2 attempted suicide by hanging himself with a television cord wrapped around his neck while not directly observed by staff. She indicated when she came to work on 10/02/15 at 2:00 p.m., the day shift had been so busy they had not completed their nursing notes for the day shift. She further indicated at the time there were 5 patients waiting to be admitted , and they didn't have enough MHTs to handle the census. S12LPN indicated by the time she arrived, only one MHT had shown up for the 3:00 p.m. to 11:00 p.m. shift, with 28 patients present, 2 boys waiting to be admitted , and 5 more patients to come for admission. S12LPN indicated when she met with Patient #2's father at the start of her shift (before the event occurred), his father told her that Patient #2 reported to him that the "staff leaves us unattended and ya'll don't have enough people watching us, so I'm scared of the other pts. (patients)." When asked if she thought the sentinel event was related to inadequate staffing, S12LPN indicated "it's absolutely horrendous. They put people on the schedule who they know won't show up, people who aren't even there." She further indicated S15Staffing said "it looks good on paper."

In an interview on 10/13/15 at 1:25 p.m., S32LPN indicated "sometimes" there's a problem with staffing when there's not enough MHTs to cover the unit.

In an interview on 10/14/15 at 3:00 p.m., S28MD indicated he was the hospital's Medical Director. He indicated management counts nursing in the staffing ratio and shouldn't, because the nurses have other responsibilities and rely on the MHTs to observe patients. He further indicated he was aware he's responsible for the quality of care at the hospital, but he can only advise and cannot implement any action. S28MD indicated since the current owners acquired the hospital on [DATE], they have grown and increased beds by 24 beds. As soon as more beds became available, the was more pressure to admit more patients, and there were heavier admission days with a census above 70 patients. He indicated it became difficult for staff with 14 to 16 admissions not being unusual for a Friday. He further indicated he didn't know if the staff was increased to accommodate this growth.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure there was an adequate number of RNs, LPNs, and MHTs to provide nursing care to all patients as needed as evidenced by:
1) Failure to have a RN on the Little Boys' Unit from 2:00 a.m. to 6:00 a.m. on 10/10/15, 10/11/15, and 10/12/15 while the hospital had an Immediate Jeopardy in place for failing to ensure a RN was on each nursing unit each shift.
2) Failure to have an adequate ratio of MHTs to patients on the Boys' Unit on 10/03/15, 10/04/15, 10/05/15, and 10/08/15.
3) Failure to ensure the Boys' Unit had a RN from 2:45 p.m. to 4:15 p.m. on 09/20/15.
Findings:

1) Failure to have a RN on the Little Boys' Unit from 2:00 a.m. to 6:00 a.m. on 10/10/15, 10/11/15, and 10/12/15 while the hospital had an Immediate Jeopardy in place for failing to ensure a RN was on each nursing unit each shift:
Review of the staffing assignment sheets presented by S2DON revealed no documented evidence that a RN was present on the Little Boys' Unit from 2:00 a.m. to 6:00 a.m. on 10/10/15, 10/11/15, and 10/12/15 while the hospital had an Immediate Jeopardy in place for failing to ensure a RN was on each nursing unit each shift:

In an interview on 10/13/15 at 9:05 a.m., S2DON indicated she had a RN call in on the night shifts of 10/09/15, 10/10/15, and 10/11/15, and she didn't have anyone to work. She further indicated the night shift is difficult to cover when someone calls in. When asked why she didn't cover these hours, S2DON indicated "I was exhausted."

2) Failure to have an adequate ratio of MHTs to patients on the Boys' Unit on 10/03/15, 10/04/15, 10/05/15, and 10/08/15:
Review of the staffing assignment sheets for the Boys' Unit presented by S2DON revealed the following days with a staffing ratio of MHT to patients on line of sight observation that was below the stated ratio of 1 staff to 6 patients by S29CEO:
10/03/15 - 3:00 p.m. to 11:00 p.m. shift with a census of 29 patients (28 patients on line of sight) with 4 MHTs and 11:00 p.m. to 7:00 a.m. (10/04/15) with a census of 29 patients with 2 MHTs;
10/04/15 - 7:00 a.m. to 3:00 p.m. shift with a census of 29 patients (27 patients on line of sight) with 4 MHTs;
10/05/15 - 7:00 a.m. to 3:00 p.m. shift with a census of 29 patients (all on line of sight) with 5 MHTs; 11:00 p.m. to 7:00 a.m. (10/06/15) shift with a census of 29 patients with 4 MHTs.

In an interview on 10/09/15 at 11:00 a.m., S29CEO indicated the staff to patient ratio should be 1 staff to 6 patients.

In an interview on 10/14/15 at 1:55 p.m., S29CEO indicated he, as a member of the governing body, was aware of the "broken system" of the hospital, but "not to the extent I've heard over the last 3 days." He further indicated he reviews the staffing when he comes to the hospital once a week, usually in the mornings. He indicated he had not seen a staffing of 1 MHT to 10 patients or 1 MHT to 17 patients during his visits. He further indicated it was reported to him that the previous "surveyors matched staffing to payroll and had no problems." S29CEO indicated no directive from the governing body prevented Administration from increasing staff.

In an interview on 10/14/15 at 3:00 p.m., S28MD indicated he was the hospital's Medical Director. He indicated management counts nursing in the staffing ratio and shouldn't, because the nurses have other responsibilities and rely on the MHTs to observe patients. He further indicated he was aware he's responsible for the quality of care at the hospital, but he can only advise and cannot implement any action. S28MD indicated since the current owners acquired the hospital on [DATE], they have grown and increased beds by 24 beds. As soon as more beds became available, the was more pressure to admit more patients, and there were heavier admission days with a census above 70 patients. He indicated it became difficult for staff with 14 to 16 admissions not being unusual for a Friday. He further indicated he didn't know if the staff was increased to accommodate this growth.

3) Failure to ensure the Boys' Unit had a RN from 2:45 p.m. to 4:15 p.m. on 09/20/15:
Review of the medical record for Patient #4 revealed he was an eight year old male admitted on [DATE] legal status PEC and discharged on [DATE]. Patient #4's admitting diagnosis was Depression , ODD, ADHD.

In a telephone interview on 10/13/15 at 10:30 a.m., S12LPN indicated that Patient #4 was not assessed by a RN or any nurse on 09/20/15 after an alteration with another patient. S12LPN indicated that she was the only nurse assigned to the boys unit without a RN from approximately 2:45 p.m. to 4:15 p.m.
In an interview on 10/13/15 at 3:45 p.m., S2DON confirmed that on 09/20/15 the hospital had no RN coverage on the boys' unit from approximately 2:45 p.m. to 4:15 p.m.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews, observations, and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by:

1) The RN failed to ensure that line of sight visual observation was maintained as ordered for Patient #6 on 10/08/15 at 9:15 a.m. and for Patient #7 on 10/08/15 at 9:20 a.m.. Both patients were not within line of sight visual observation when they went to the bathroom. This resulted in an Immediate Jeopardy being called on 10/08/15 at 5:25 p.m.

2) Failing to ensure that a RN was immediately available on the boys' acute care psychiatric unit. S4RN was observed leaving the "Little Boys' Unit" on 10/08/15 at 12:11 p.m., returning at 12:16 p.m. There was no RN on the unit during this time frame and patients were noted to be on the unit. S5RN was observed leaving the "Big Boys' Unit" on 10/08/15 at 12:15 p.m. leaving the unit without a RN, and patients were noted to be on the unit. This resulted in an Immediate Jeopardy being called on 10/08/15 at 5:25 p.m.

3) The RN failed to ensure S26MHT maintained line of sight visual observation of 17 patients who were ordered to be on line of sight when he turned his head to speak with someone inside the hospital while he was observing the 17 patients during their outdoor time in the courtyard of the Little Boys' Unit.

4) The RN failed to obtain physician orders at admit for the observation level of each patient for 2 (#1, #6) of 6 (#1, #6, #7, #8, #9, #10) current inpatients and 3 (#2, #3, #4) of 4 (#2, #3, #4, #5) closed medical records reviewed for observation level orders from a total of 10 sampled records.

5) The RN failed to ensure the patient's medical record contained documentation of the sentinel event, patient assessment, treatment, and transfer to the acute care hospital of 1 (#2) of 1 patient record reviewed for a sentinel event from a total of 10 sampled patients.

6) The RN failed to assign the MHTs and review their documentation as evidenced by having patient's observation records with no documented evidence of the type of precaution for which the patient was to be monitored, such as suicide/aggression, and the type of observation and the signature of the RN reviewing the observation record for 7 (#1, #2, #3, #5, #6, #7, #8) of 10 patients' records reviewed for documentation of levels of observation from a total sample of 10 patients.

7) The RN failed to report the observation of homicidal expression and hypersexual activity to the physician and revise the treatment plan for 1 (#3) of 1 patient record reviewed with observations of homicidal expression and hypersexual activity from a total of 10 sampled patients.

8) Failing to perform physical assessments and pain evaluations on a patient (#5) post arm injury for 1 (#5) of 1 patient reviewed for pain out of a total of 10 sampled patients.

9) Failing to clarify Medical Consult order obtained for complaint of arm pain after an injury was sustained during a therapeutic hold for 1 (#5) of 1 patient record reviewed for medical intervention from a total sample of 10 patients.

10) The RN failed to ensure line of sight visual observation was maintained when Patient #4 was outdoors on 09/19/15.

11) The RN failed to ensure Patient #4 was assessed after a physical altercation with a peer on 09/20/15.

Findings:

1) The RN failed to ensure that line of sight visual observation was maintained as ordered for Patient #6 on 10/08/15 at 9:15 a.m. and for Patient #7 on 10/08/15 at 9:20 a.m.. Both patients were not within line of sight visual observation when they went to the bathroom. This resulted in an Immediate Jeopardy being called on 10/08/15 at 5:25 p.m.:
Review of the hospital policy titled "Observation Status Categories", presented as a current policy by S1ADM, revealed at the time of admission the physician will give an order for the required observation status. Further review revealed the Charge RN is responsible for assigning the staff members to perform designated special observation status for each patient on his/her assigned unit. Further review revealed line of sight means staff must visually observe assigned patients by scanning the patient care area. A staff member may observe more than one patient at a time, but the patient must remain in the assigned staff member's eyesight at all times.

Patient #6
Review of Patient #6's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Mood Disorder and a CEC signed on 10/03/15 at 11:50 a.m. for being suicidal and dangerous to self. Review of his physician orders revealed an order on 10/04/15 (no time documented) for BUR (line of sight with unit restriction) observation until Patient #6 is cooperative with his treatment. Further review revealed an order on 10/05/15 at 9:05 a.m. that read may change status to BOUP (line of sight with off unit privileges) as soon as he's taking his medications.

Patient #7
Review of Patient #7's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Mood Disorder and a physician observation level of line of sight.

Observation on 10/08/15 at 9:15 a.m. on the Big Boys' Unit revealed S3MHT accompanied Patient #6, who was on line of sight observation status, to the bathroom and stood outside the bathroom door that was partially opened. Further observation revealed S3MHT could see Patient #6 while he used the toilet but could not visualize him when he was washing his hands.

In an interview on 10/08/15 at 9:15 a.m., S3MHT confirmed he could not see Patient #6 when he went to wash his hands.

Observation on 10/08/15 at 9:20 a.m. on the Big Boys' Unit revealed S3MHT accompanied Patient #7, who was on line of sight observation status, to the bathroom and stood outside the bathroom door that was partially opened. Further observation revealed S3MHT could not visualize Patient #7 at all times while he (Patient #7) was in the bathroom.

In an interview on 10/08/15 at 9:20 a.m., S3MHT confirmed he couldn't see Patient #7 when he (Patient #7) was in the bathroom. He indicated line of sight means "I can see him at all times." He confirmed that he did not follow the hospital's observation policy for line of sight, and "I was just trying to give him a little privacy."

S1ADM was notified of an Immediate Jeopardy due to the above observations on 10/08/15 at 5:25 p.m.

2) Failing to ensure that a RN was immediately available on the boys' acute care psychiatric unit. S4RN was observed leaving the "Little Boys' Unit" on 10/08/15 at 12:11 p.m., returning at 12:16 p.m. There was no RN on the unit during this time frame and patients were noted to be on the unit. S5RN was observed leaving the "Big Boys' Unit" on 10/08/15 at 12:15 p.m. leaving the unit without a RN, and patients were noted to be on the unit. This resulted in an Immediate Jeopardy being called on 10/08/15 at 5:25 p.m.:
Observation on 10/08/15 at 12:11 p.m. on the Little Boys' Unit revealed S4RN left the unit to discharge a patient, leaving no nurse (LPN or RN) on the unit with patients present on the unit. Continuous observation revealed S4RN did not return to the unit until 12:16 p.m. (5 minutes without a RN on the unit).

Observation on 10/08/15 at 12:15 p.m. revealed S5RN left the Big Boys' Unit while patients were on the unit with no RN present on the unit.

In an interview on 10/08/15 at 12:16 p.m., S4RN confirmed she left the Little Boys' Unit for 5 minutes with no other RN or LPN on the unit while patients were present on the unit. After being informed that S5RN had left the Big Boys' Unit at 12:15 p.m. with patients present and no RN on the unit, S4RN walked to the Big Boys' Unit and confirmed there was no RN present, and patients were present on the unit.

S1ADM was notified of an Immediate Jeopardy due to the above observations on 10/08/15 at 5:25 p.m.

3) The RN failed to ensure S26MHT maintained line of sight visual observation of 17 patients who were ordered to be on line of sight when he turned his head to speak with someone inside the hospital while he was observing the 17 patients during their outdoor time in the courtyard of the Little Boys' Unit:
Observation on the Big Boys' Unit on 10/08/15 at 8:52 a.m. revealed staffing included 1 RN, a LPN shared between the Big Boys' Unit and the Little Boys' Unit, and 2 MHTs with a census of 21 patients who all had physician orders to be on line of sight observation.

Observation on the Little Boys' Unit on 10/08/15 at 9:40 a.m. revealed staffing included 1 RN, a LPN shared between the Little Boys' Unit and the Big Boys' Unit, 3 MHTs , and 1 MHT in orientation with a census of 11 patients who all had physician orders to be on line of sight observation.

In an interview on 10/08/15 at 8:52 a.m., S5RN confirmed the above stated staffing for the Big Boys' Unit. She also confirmed that all 21 patients were on line of sight observation.

In an interview on 10/08/15 at 9:40 a.m., S4RN confirmed the above stated staffing for the Little Boys' Unit. She also confirmed that all 11 patients were on line of sight observation.

Observation in the outdoor area reached by exiting from the Little Boys' Unit on 10/08/15 at 10:08 a.m. revealed S26MHT was observing 17 patients who were ordered to be on line of sight. Continuous observation revealed S26MHT had his back to the 17 patients when he turned to speak to a staff member in the day room while he was standing on the patio area of the outdoor area.

In an interview on 10/08/15 at 10:08 a.m., S42LMSW confirmed S26MHT turned his back to the 17 patients who were on line of sight observation as written above.

4) The RN failed to obtain physician orders at admit for the observation level of each patient:
Review of the hospital policy titled "Observation Status Categories", presented as a current policy by S1ADM, revealed at the time of admission the physician will give an order for the required observation status.

Patient #1
Review of Patient #1's medical record revealed he was a 9 year old male admitted on [DATE] with a diagnosis of Mood Disorder. Further review revealed he was PEC's on 09/29/15 at 4:05 p.m. after throwing a chair at a teacher, hitting another child in the head, and kicking, biting, and fighting while at the pediatrician's office. His PEC revealed he was a danger to self and others. Further review revealed a CEC was signed on 09/30/15 at 10:10 a.m. due to Patient #1 being violent and a danger to others.

Review of Patient #1's "Physician's Admit Order"obtained by the RN on 09/30/15 at 12:20 p.m. revealed no documented evidence that a level of observation was ordered by the physician.

Patient #6
Review of Patient #6's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Mood Disorder. Further review revealed he was PEC'd on 10/01/15 at 8:30 p.m. and CEC'd on 10/03/15 at 11:50 a.m. for being suicidal and a danger to self.

Review of Patient #6's "Physician's Admit Order" obtained by S32LPN on 10/02/15 at 12:00 p.m., with no documented evidence of the name of the physician who gave the orders, revealed no documented evidence that a level of observation was ordered by the physician.

In an interview on 10/14/15 at 8:40 a.m. with S1ADM and S2DON present, S1ADM and S2DON offered no explanation for not having physician orders for Patient #1's and Patient #6's level of observation.

Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Depression. Further review revealed he was PEC'd on 10/01/15 at 10:00 p.m. after having left a video apologizing for what he was about to do and taking an unknown amount of pills. His PEC revealed he was suicidal and a danger to self.

Review of Patient #2's "Physician's Admit Order" obtained by S32LPN on 10/02/15 at 8:45 a.m., with no documented evidence of the name of the physician who gave the orders, revealed no documented evidence that a level of observation was ordered by the physician.

In an interview on 10/13/15 at 11:10 a.m., S31LPN indicated she worked in the intake department and was one of the LPNs who called physicians for orders to admit patients. She further indicated she only gets an order to admit the patient and does not get the order for the observation level that the patient is to be monitored. S31LPN indicated once the patient is admitted and after the RN assesses the patient, the RN on the nursing unit calls the physician to get orders for the patient's observation level.

In an interview on 10/13/15 at 1:25 p.m., S32LPN indicated she didn't document Patient #2's physician order as a telephone or verbal order or write the name of the physician who gave the order. She further indicated the LPN in the intake department usually gets the orders for the observation level. She confirmed that she did not speak with a physician to obtain the orders that were checked on the "Physician's Admit Order". When asked if she didn't speak with a physician, how did she know what orders the physician wanted for Patient #2, S32LPN indicated "that's normally what we do... I don't know of anyone I work with who calls the doctor."

Patient #3
Review of Patient #3's medical record revealed he was a 7 year old male admitted on [DATE] with a diagnosis of Mood Disorder. Further review revealed he was PEC'd on 09/02/15 at 6:45 p.m. and CEC's on 09/05/15 due to being suicidal and a danger to self.

Review of Patient #3's "Physician's Admit Order" obtained by S14RN on 09/03/15 at 5:00 p.m. revealed no documented evidence that a level of observation was ordered by the physician.

In a telephone interview on 10/13/15 at 1:00 p.m., S14RN indicated she didn't know why the level of observation wasn't checked on the "Physician's Admit Order", and she didn't remember Patient #3. She further indicated "I don't know if I'm supposed to get physician orders for observation."

Patient #4
Review of the medical record for Patient #4 revealed he was an eight year old male admitted on [DATE], legal status PEC, and discharged on [DATE]. Patient #4's admitting diagnosis was Depression , ODD, ADHD. Admit orders revealed no orders for observation status.

In an interview on 10/09/15 at 1:11 p.m., S2DON confirmed that after review of Patient#4's medical record, there was no order for an observation level. S2DON indicated that Patient #4's observation level should have been line of sight unit restricted until evaluated by a physician. S2DON indicated that from the time of admission (09/13/15) at 2:00 p.m. until 09/14/15 12:55 p.m., Patient #4 was without an observation status ordered by a practitioner.

5) The RN failed to ensure the patient's medical record contained documentation of the sentinel event, patient assessment, treatment, and transfer to the acute care hospital:
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Depression. Further review revealed he was PEC'd on 10/01/15 at 10:00 p.m. after having left a video apologizing for what he was about to do and taking an unknown amount of pills. His PEC revealed he was suicidal and a danger to self.

Review of an "Incident Report Form" documented on 10/02/15 at 3:15 p.m. by S6RM revealed Patient #2 was found with a red mark around his neck as a result of an attempted suicide by hanging himself around the neck with a cord from the television mounted on the wall.

Review of Patient #2's entire medical record revealed no documented evidence of documentation of the above incident, the assessment and treatment of Patient #2 by the RN, the physician order for transfer to the emergency department of an acute care hospital, and the time and method by which Patient #2 was transferred.

In a telephone interview on 10/13/15 at 10:05 a.m., S12LPN indicated they (Administration) "didn't give me a chance" to document anything. She further indicated immediately after the event, S15Staffing came to get her, and she sat in S2DON's office for about 45 minutes when S2DON came and said "she had to let me go."

In an interview on 10/13/15 at 2:05 p.m., S5RN indicated she didn't document anything in Patient #2's chart, because as soon as the event happened, S6RM took the chart. She further indicated she wrote a witness statement, but she didn't see the chart until today for the first time since the event occurred.

In an interview on 10/09/15 at 10:05 a.m., S2DON, after reviewing Patient #2's medical record, confirmed the record had no documentation of the sentinel event that occurred, the assessment and treatment of Patient #2 by the RN, the physician order for transfer to the emergency department of an acute care hospital, and the time and method by which Patient #2 was transferred.

6) The RN failed to assign the MHTs and review their documentation as evidenced by having patient's observation records with no documented evidence of the type of precaution for which the patient was to be monitored, such as suicide/aggression, and the type of observation and the signature of the RN reviewing the observation record:
Patient #1
Review of Patient #1's medical record revealed he was a 9 year old male admitted on [DATE] with a diagnosis of Mood Disorder. Review of Patient #1's "Physician's Admit Order"obtained by the RN on 09/30/15 at 12:20 p.m. revealed no documented evidence that a level of observation was ordered by the physician.

Review of Patient #1's "Tech Observation Sheet" revealed the following days and times with no documented evidence of the type of observation, the code and treatment for all times, and/or a signature of the RN who had assigned the patient care to the MHT:
No documented evidence of the type of observation on the day shift (7:00 a.m. to 3:00 p.m.) on 10/03/15, the night shift (11:00 p.m. to 7:00 a.m.) of 10/03/15, the day shift of 10/04/15, the day and evening shift (3:00 p.m. to 11:00 p.m.) on 10/07/15;
No documented evidence of the code (location) and treatment for 30 minutes on the night shift on 10/02/15;
No documented evidence of the RN's signature indicating he/she had reviewed the observations of patients made by the MHTs on the day shift on 09/30/15, 10/03/15, 10/04/15, 10/05/15, 10/06/15, on the night shift on 10/05/15, and on the evening shifts of 10/03/15 and 10/06/15.

Patient #2
Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Depression. Review of Patient #2's "Physician's Admit Order" obtained by S32LPN on 10/02/15 at 8:45 a.m., with no documented evidence of the name of the physician who gave the orders, revealed no documented evidence that a level of observation was ordered by the physician.

Review of Patient #2's "Tech Observation Sheet" revealed no documented evidence of the signature of the RN who reviewed the observations made by the MHT.

Patient #3
Review of Patient #3's medical record revealed he was a 7 year old male admitted on [DATE] with a diagnosis of Mood Disorder. Review of Patient #3's "Physician's Admit Order" obtained by S14RN on 09/03/15 at 5:00 p.m. revealed no documented evidence that a level of observation was ordered by the physician.

Review of Patient #3's "Tech Observation Sheet" revealed the following days and times with no documented evidence of the type of observation, the code and treatment for all times, and/or a signature of the RN who had assigned the patient care to the MHT:
No documented evidence of the type of observation on the day shift on 09/06/15 and the evening shifts of 09/03/15, 09/04/15, 09/06/15 09/07/15, and 09/09/15;
No documented evidence of the code (location) and treatment for one hour on the evening shift on 09/08/15;
No documented evidence of the RN's signature indicating he/she had reviewed the observations of patients made by the MHTs on the day shifts on 09/05/15 and 09/07/15, on the night shifts on 09/03/15 and 09/08/15, and on the evening shift of 09/09/15.

Patient #5
Review of Patient #5's medical record revealed she was a [AGE] year old female, admitted on [DATE] and discharged on [DATE]. Further review revealed admission diagnoses including the following: adjustment disorder with mixed disturbance of emotions and conduct; rule out intermittent explosive disorder.

Review of Patient #5's Physician's Orders, dated 9/19/15 10:10 a.m., revealed the patient's Observation level was Status C (every 15 minutes) observations.

Review of Patient #5's observation sheets for 9/19/15, 11-7 shift through 9/22/15, 7-3 shift revealed the level of observation section of the observation sheet was blank for the above referenced shifts.

Patient #6
Review of Patient #6's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Mood Disorder. Review of Patient #6's "Physician's Admit Order" obtained by S32LPN on 10/02/15 at 12:00 p.m., with no documented evidence of the name of the physician who gave the orders, revealed no documented evidence that a level of observation was ordered by the physician.

Review of Patient #6's "Tech Observation Sheet" revealed the following days and times with no documented evidence of the type of observation and/or a signature of the RN who had assigned the patient care to the MHT:
No documented evidence of the type of observation on the day shifts on 10/05/15, 10/06/15, and 10/07/15, on the night shifts of 10/04/15 and 10/06/15, and on the evening shifts of 10/05/15, 10/06/15, and 10/07/15;
No documented evidence of the RN's signature indicating he/she had reviewed the observations of patients made by the MHTs on the day shift on 10/07/15 and on the evening shifts of 10/06/15 and 10/07/15.

Patient #7
Review of Patient #7's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Mood Disorder. Further review revealed he had a physician's order to observed line of sight.

Review of Patient #7's "Tech Observation Sheet" revealed the following days and times with no documented evidence of the type of observation, the code and treatment for all times, and/or a signature of the RN who had assigned the patient care to the MHT:
No documented evidence of the type of observation on the day shifts on 10/01/15, 10/02/15, 10/03/15, 10/04/15, 10/05/15, 10/06/15, and 10/07/15, on the evening shifts on 09/30/15, 10/02/15, 10/03/15, 10/04/15, 10/05/15, 10/06/15, and 10 07/15, and on the night shifts of 10/02/15, 10/03/15, 10/04/15, and 10/05/15;
No documented evidence of the code (location) and treatment for 30 minutes on the evening shift on 10/03/15 and for one hour and 15 minutes on the evening shift of 10/04/15;
No documented evidence of the RN's signature indicating he/she had reviewed the observations of patients made by the MHTs on the day shifts on 10/02/15, 10/04/15, and 10/07/15, on the night shifts on 09/30/15, 10/01/15, and 10/02/15, and on the evening shifts of 10/03/15, 10/05/15, 10/06/15, and 10/07/15.

Patient #8
Review of Patient #8's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Mood Disorder. Further review revealed his physician orders included an observation level of line of sight and every 15 minutes. There was no documented evidence of a clarification order to determine the specific observation level the physician wanted to be maintained for Patient #8, since line of sight and every 15 minutes were two separate types of observation levels.

Review of Patient #8's "Tech Observation Sheet" revealed the following days and times with no documented evidence of the type of observation, the code and treatment for all times, and/or a signature of the RN who had assigned the patient care to the MHT:
No documented evidence of the type of observation on the day shifts on 10/02/15, 10/03/15, 10/04/15, 10/05/15, 10/06/15, and 10/07/15, on the evening shifts on 10/01/15, 10/02/15, 10/03/15, 10/04/15, 10/05/15, 10/06/15,and 10/07/15, and on the night shifts of 10/02/15, 10/03/15, and 10/04/15;
No documented evidence of the code (location) and treatment for 30 minutes on the evening shift on 10/04/15;
No documented evidence of the RN's signature indicating he/she had reviewed the observations of patients made by the MHTs on the day shifts on 10/03/15, 10/04/15, 10/05/15, and 10/06/15, on the night shifts on 10/02/15 and 10/05/15, and on the evening shifts of 10/02/15, 10/03/15, 10/04/15, and 10/06/15.

In an interview on 10/14/15 at 8:40 a.m. with S1ADM and S2DON present, S1ADM and S2DON offered no explanation for the above-listed deficiencies noted on the MHT observation sheets. They could not explain the times of no observations documented on the MHT observation records. S1ADM indicated the hospital did not have a policy that addressed the completion of the MHT observation sheet.

7) The RN failed to report the observation of homicidal expression and hypersexual activity to the physician and revise the treatment plan:
Review of Patient #3's medical record revealed he was a 7 year old male admitted on [DATE] with a diagnosis of Mood Disorder. Further review revealed he was PEC'd on 09/02/15 at 6:45 p.m. and CEC's on 09/05/15 due to being suicidal and a danger to self.

Review of Patient #3's "Interdisciplinary Treatment Plan" revealed problems identified on 09/03/15 by S8RN were anger and seasonal allergies. Further review revealed a care plan was developed for anger, seasonal allergies, and being a danger to self and others. There was no documented evidence that Patient #3's care plan was revised to include the problems of homicidal expression and hypersexual activity.

Review of Patient #3's "Nursing Reassessment" documented on 09/05/15 at 10:40 a.m. by S38RN revealed the note of "want to hurt people who are mean to me - want to punch them in the face."

In a telephone interview on 10/13/15 at 12:45 p.m., S38RN indicated Patient #3's homicidal expression on 09/05/15 was told to her by Patient #3. She further indicated she "probably reported it to the MHT assigned, counseled the patient, and also mentioned it to the LPN who came on 2:00 p.m. to 10:00 p.m." She further indicated she didn't remember if she reported it to the physician or RN and revised the treatment plan, but "I might should have."

Review of Patient #3's "Nursing Reassessment" documented on 09/07/15 at 4:00 p.m. by S8RN revealed a note of "Required redirection for exposing penis to peers..."

In an interview on 10/12/15 at 3:15 p.m., S8RN indicated Patient #3 exposing himself was reported to her, and she doesn't remember who reported it. She further indicated the redirection was a "time out", but she didn't document the "time out" in the medical record. S8RN confirmed she didn't revise the care plan, because "hypersexual behavior would fall under social services, not nursing." She indicated whenever a patient acts out, "we talk to one another, but documentation is poor."

Review of Patient #3's "Nursing Reassessment" documented on 09/09/15 at 6:00 p.m. by S14RN revealed a note of "Showed penis to younger children. Pt. (patient) removed from group."

In an interview on 10/13/15 at 1:00 p.m., S14RN indicated, regarding her note of 09/09/15, she thinks that would have been reported to her and not her actual observation. She confirmed that the way she wrote her note "sounds like I made the observation."

8) Failing to perform physical assessments and pain evaluations on a patient post arm injury:
Patient #5
Review of the hospital policy titled, "Pain Management Assessment and Reassessment", Policy #: AS-00-019, revealed the following, in part:
I. Policy: It is the policy of this hospital to assess patient complaints of pain or discomfort, assess treatment alternatives with regard to diagnosis or cause, and provide for the effective management of pain through pharmacologic and/or non-pharmacologic action through multidisciplinary and interdisciplinary action.
II. Purpose: This facility will maintain appropriate standards for assessing pain in children, adolescents, adults and senior adults, by utilizing the Wong-Baker Faces Pain Rating Scale.
V. Procedures: 1. All patients shall have access to pain management once the presence of pain is assessed. 3. All patients shall be assessed/reassessed by the RN for the duration of presence of pain and up to 24 hours after "0" pain has occurred. Pain assessment will also include documentation of location of the pain, intensity, non-pharmacological interventions and medication administration. Pain assessment will also include the pain scale using Wong-Baker Pain Scale. 4. All patients shall be provided optimal patient comfort through pro-active pain management. 6. All licensed staff shall be competent in pain management.

Review of Patient #5's medical record revealed she was a [AGE] year old female, admitted on [DATE] and discharged on [DATE]. Further review revealed admission diagnoses including the following: Adjustment Disorder with mixed disturbance of emotions and conduct; rule out Intermittent Explosive Disorder.

Review of Hospital Incident Reports for Abuse/Neglect revealed an initial report for alleged physical abuse involving Patient #5 was filed on 09/22/15 by S6RM. The report revealed the following, in part:
Incident information: Date: 09/20/15, Time: 8:00 p.m.; Shift: 3-11
S21RN, nurse on Sunday 3-11 shift, called code white and was told by patient that her arm was hurting. Patient was aggressive, required hold, 2 MHTs (S20MHT, S23MHT) applied Crisis Prevention Intervention "control hold ". Patient broke out and fell to left side injuring arm. Rule out break.

Review of Patient #5's medical record revealed the following Physician's Orders:
09/20/15 9:20 p.m.: Medical consult related to complaints of left arm pain. Telephone order S7Psychiatrist.
09/20/15 6:00 a.m.: Send to emergency room for evaluation and x-ray of left arm.

Review of Patient #5's nursing notes revealed the following entry, dated 09/20/15 at 8:30 p.m., in part: Patient pacing and agitated on unit. .....Therapeutic hold initiated. Patient fought and kicked during hold. Ativan 1 milligram and Haldol 5 milligram intramuscular at 9: 15 p.m. Patient continues loud and defiant. Complaints left arm pain. Medical consult ordered. On assessment no swelling or bruising noted. Patient spoke with Mom and was assisted to bed at 10:00 p.m. Further review revealed no documented evidence of further assessments of the status of the patient's arm or the patient's pain level/ interventions related to management of pain until 09/21/15 at 6:30 a.m. Additional review revealed no documented evidence of further notification of a physician/licensed independent practitioner of patient's complaints of arm pain after the patient had been in a therapeutic hold other than when the order was obtained for the medical consult on 09/20/15 at 9:20 p.m.

Review of the 11-7 shift nurses notes for 09/20-9/21/15 revealed the following entries: Restless, slept on and off, awake at start of shift. Slept for a short time on couch in day area. Noted to be sitting on bed with eyes closed. Encouraged to lie down at 4:30 a.m.
6:30 a.m.: Continues to complain of pain on left upper arm. Seen this a.m. by S16FNP for medical consult. Order received to send patient to emergency room for evaluation. The Mom informed of above. S2DON, also informed. Instructed patient to keep affected arm immobile or supported.

Review of Patient #5's medical record revealed the following documentation of a medical consult, dated 09/21/15 at 6:00 a.m., completed by S16FNP revealed the following, in part: Reason for consultation: complains of left arm pain related to therapeutic hold on 09/20/15. Consult: Consulted for complaints of left arm pain. Patient reports left arm pain starting last night after therapeutic hold. Reports arm started hurting immediately and has worsened through the night. Pain to elbow and upper arm. Worse with forearm movement. Decreased range of motion of elbow by left arm. Patient holding in semi-flexed position. Positive tenderness to elbow and lower humerus, limited of range of motion of elbow. Positive edema of upper arm, positive warmth. Impression: upper arm pain. Recommendations: need x-ray and further evaluation. Discussed with nurse regarding emergency room evaluation as soon as possible.

Review of Patient #5's emergency room record, dated 09/21/15 at 8:15 a.m. revealed the following, in part: Complaint: arm injury: [AGE] year old African American female arrived to emergency room from area Psychi
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current an individualized and comprehensive nursing care plan for each patient as evidenced by failure to have a patient's nursing care plan completed within 8 hours of admission in accordance with hospital policy for 1 (#9) of 10 nursing care plans reviewed from a total sample of 10 patients.
Findings:

Review of the medical record for Patient #9 on 10/08/15 at 10:00 a.m. revealed she was admitted on [DATE] with the Axis I Diagnoses: Other Specified Depressive Disorder; Oppositional Defiant Disorder; History of Attention Deficit Hyperactivity Disorder and History of Seizure Disorder.

Review of Patient #4's Initial Treatment Plan (Nursing) on 10/08/15 at 10:00 a.m. was noted to be blank.

Review of the Hospital's Policy & Procedure titled " Nursing Assessment/Reassessment" (MDS) dated [DATE] at 1:30 p.m. by S2DON as being current (07/2015) read in part: Nursing Assessment- A comprehensive nursing assessment is performed by a Registered Nurse within eight (8) hours of admission.

In an interview on 10/08/15 at 11:55 a.m., S21RN indicated the Initial Treatment Plan (Nursing) was incomplete and should have been completed within 24 hours of admission
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with the physician orders for 1 (#4) of 1 patient record reviewed with medication errors from a total of 10 sampled patient records reviewed for medication administration.
Findings:

Review of the Hospital's Policy & Procedure tilted "Medication Administration and Records", presented as a current policy by S2DON, read in part: 2.9 Orders for medications shall be completed and understandable. 4.2.6.3 Should any medication dose be missed for any reason, MD (medical doctor) shall be notified and record of such incident is recorded in the chart. This action is done to ensure all medications are administered as ordered and documented according to policy. 4.3.1.8 Unless otherwise ordered by the physician, routine medications will be administered at designated military times.

Review of the medical record for Patient #4 revealed he was an eight year old male admitted on [DATE] with a legal status of PEC and discharged on [DATE]. Patient #4's admitting diagnoses were Depression , ODD, and ADHD.

Review of the physician orders dated on 09/18/15 at 9:30 a.m. revealed an order for House Supplement at 10:00 a.m., 2:00 p.m., and 7:00 p.m. (vanilla). An order written on 09/19/15 at 10:00 a.m. revealed an order for TAB ( triple antibiotic ointment) to lt.(left) cheek and rt (right) elbow topical bid (twice a day).

Review of the MAR for Patient #4 revealed that on 09/18/15 at 2:00 p.m. and 7:00 p.m. the times were noted to be blank (no nurse's initial). An order for TAB ointment ordered on [DATE] was not listed on the MARs. There was no documented evidence that the ointment was administered as ordered.
In an interview on 10/09/15 at 1:11 p.m., S2DON indicated that after review of the MARs for Patient #4, the house supplement was not administered on 09/18/15 at 2:00 p.m. and 7:00 p.m. and TAB ordered on [DATE] was never administered. She indicated the missed and omitted medications were both medication errors and should have been noted during 24 hour medical record check by the night nurse.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the hospital failed to ensure the medical record contained the physician's order for transfer, nursing notes, and reports of treatment provided related to a sentinel event that occurred on 10/02/15 for 1 (#2) of 1 patient record reviewed for a sentinel event from a total of 10 sampled patients.
Findings:

Review of Patient #2's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Depression. Further review revealed he was PEC'd on 10/01/15 at 10:00 p.m. after having left a video apologizing for what he was about to do and taking an unknown amount of pills. His PEC revealed he was suicidal and a danger to self.

Review of an "Incident Report Form" documented on 10/02/15 at 3:15 p.m. by S6RM revealed Patient #2 was found with a red mark around his neck as a result of an attempted suicide by hanging himself around the neck with a cord from the television mounted on the wall.

Review of Patient #2's entire medical record revealed no documented evidence of documentation of the above incident, the assessment and treatment of Patient #2 by the RN, the physician order for transfer to the emergency department of an acute care hospital, and the time and method by which Patient #2 was transferred.

In a telephone interview on 10/13/15 at 10:05 a.m., S12LPN indicated they (Administration) "didn't give me a chance" to document anything. She further indicated immediately after the event, S15Staffing came to get her, and she sat in S2DON's office for about 45 minutes when S2DON came and said "she had to let me go."

In an interview on 10/13/15 at 2:05 p.m., S5RN indicated she didn't document anything in atient #2's chart, because as soon as the event happened, S6RM took the chart. She further indicated she wrote a witness statement, but she didn't see the chart until today for the first time since the event occurred.

In an interview on 10/09/15 at 10:05 a.m., S2DON, after reviewing Patient #2's medical record, confirmed the record had no documentation of the sentinel event that occurred, the assessment and treatment of Patient #2 by the RN, the physician order for transfer to the emergency department of an acute care hospital, and the time and method by which Patient #2 was transferred.