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.

Based on record review, document review, and interview it is determined the facility failed to provide patient care in a safe setting in one (1) of one (1) records reviewed (patient #1) who had an incident in the playground/yard area. This can result in all patients receiving care at the facility to have the potential for grave harm.

Findings include:

1. Review of the nursing notes for patient #1 revealed on 9/15/14 at 11 a.m. the patient received a bite from another patient while outside in the yard (playground) of the facility on 9/4/14 at about 4:30 p.m. An incident report dated 9/4/14 was completed by RN #5 who was in charge of the Children's Unit that evening.

2. An interview with the activities aide on 9/16/14 at 11 a.m. revealed she was outside with the patients on 9/4/14. She was unable to recall who the staff were on that date in the yard area with her and was unable to recall the child being bitten as she states she left the yard to go to the bathroom. She estimated she was away from the yard for five to seven minutes. She stated when she returned the incident was over and the patients were being lined up to go back to the Children's Unit.

3. An interview with the Activities Director on 9/16/14 at 11:30 a.m. reveals there is a facility policy for the yard that states at least two staff must be with patients while in the yard. The Acitivities Director agreed there is not and never has been any documentation to show that at least two staff are with the patients in the yard, nor how many patients are allowed to be with the two staff.

4. An interview with the Quality Improvement (QI) Coordinator on 9/16/14 at 12 p.m. revealed there was no daily documentation of overall staff and patients in the yard to ensure there is enough staff with patients at all times. There is a unit schedule that shows all the assigned staff, but there is no documentation to recall which staff left the floor with the patients that are allowed to go to the yard and which staff stay with the patients on the unit. The QI Coordinator stated the cameras that were to be put up according to the previous plan of correction for this same type of incident had not been installed yet. The cameras were installed while this survey was in progress.

Based on medical record review, various document reviews, and interview it was determined the facility failed to ensure the patients on the Children's Unit were free from all forms of abuse in one (1) of one (1) record reviewed that alleged abuse occurred to the patient. This can result in grave harm to all patients at the facility.

Findings include:

1. Review of the medical record for patient #1 revealed the patient was admitted to the facility on [DATE]. On 8/30/14 the patients mother told RN #3 that her son told her a behavior health technicican (BHT) had grabbed her son, who is seven years old, and set him down hard enough to put red marks on his arms.

2. Interview with RN #3 on 9/16/14 at 1:20 p.m. by telephone revealed that she agreed that on 8/30/14 (Saturday) the mother did tell her the patient said a BHT grabbed him by the arm and left a red mark. She stated she looked at the child and didn't see a red mark, so she told the mother the Program Manager could review the facility tape recordings of the unit on Monday (9/1/14). When asked why she didn't report this as alleged abuse, she thought about it and then said 'I probably should have reported it.'

3. Interview with the Program Director on 9/15/14 at 3 p.m. revealed she was told about the alleged abuse on Monday 9/1/14. She stated she reviewed the tape recordings of the unit and did not observe any inappropriate actions by the BHTs. She states she called the mother and told her this. When asked for her documentation of the investigation, she stated she did not document the investigation because she did not see a problem. She also did not report the alleged abuse to the appropriate authorities. She stated 'I probably should have documented it'.

4. Review of the facility policy titled ' Allegations of Patient Abuse' last reviewed 12/2013 reveals the policy states in part "all allegations will be fully investigated, and the individual receiving the abuse allegation will obtain and carefully document all pertinent information regarding the complaint, including the exact time, the nature of the abuse, and the name of the alleged perpetrator.' That individual is further instructed to 'immediately notify the Administrator of the allegation...,and when physical abuse is alleged the Administrator or designated representative will fully investigate the allegation...A written report...will be completed and given to the Administrator within 48 hours following receipt of the allegations. The Administrator will render a decision as to the validity of the allegations and the action to be taken." The allegation was not reported to the Department of Health and Human Resources by the facility staff, but by the patient's mother.