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.

ROGERS MEMORIAL HOSPITAL 34700 VALLEY RD OCONOMOWOC, WI Dec. 6, 2018
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on record review and interview, the hospital failed to ensure that behavioral health medical records information containing daily nursing staff assessments and treatments provided to their patients were kept as permanent parts of the medical record, in 3 of 3 "communication" books (Topaz, Jade and Opal).

Findings include:

Record review of the communication books (Topaz, Jade and Opal groups) for the 30 patients divided into children and adolescent groups revealed that each book contained a divided section for each patient in that group. Each patient identified divided section contained a care plan kardex documenting a picture of the patient, reason for admission, significant medical history, trauma/abuse history, triggers and coping skills, cognitive level, ADL level, ADL assistance level, legal guardian information, safety interventions, dietary information and labs, evaluations and diagnostics. Behind this kardex, there were forms labeled "Significant Events during hospitalization (self-harm, suicidal ideation attempts, boundary issues, aggressive episodes and prn (as needed medications)." Record review revealed that every patient had kardex documentation and significant event notes that wee hand-written by the direct care staff.

During interview with Staff RN (Registered Nurse) M on 12/5/18 at 10 a.m., M revealed that the communication book documentation was used for nursing staff to communicate with each other and was used by medical staff for updates on behavioral or other significant patient care issues. RN M stated that the medical records in the communication book were not keep as a permanent part of the medical record and were discarded after patient discharge.

Record review of current in-patients (#'s 3, 4, 6, 7 and 9) revealed significant hand-written event documentation regarding adverse behavioral episodes and medication compliance and meal intake under significant events, as well as documented kardex information for the guidance of nursing and medical care of the patients. None of the hand-written entries were authenticated with time of entry or author's name/initials.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview, the hospital failed to ensure that it protected the rights of each patient, in 10 of 10 patients (#'s 1-10), in a total sample of 10 patients.

Findings include:

1) The hospital failed to ensure patients/patient representatives were notified of the state hospital licensing agency's address, in order to protect their right to file a grievance, in 10 of 10 patient Rights and Responsibilities admission forms (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). (Reference A0118)

2) The hospital's governing body failed to have an effective system that identified, investigated and resolved grievances, in 2 of 2 patients (#1 and #2). (Reference A0119)

3) The hospital failed to ensure that written response notices were given to patients/patient representatives when grievances were filed, in 2 of 2 patients (#1 and #2). (Reference A0123)

4) The hospital failed to ensure patients/patient representatives had the right to participate in their care planning, in 1 of 10 patients (#'s 1-10). (Reference A0130)

5) The hospital failed to ensure that patients who were known to self-harm were given protections for re-occurrence prevention, in 1 of 7 patients known to self-harm (#1). (Reference A0144)

6) The hospital failed to ensure that patients were appropriately monitored per hospital policy for the prevention of abuse, in 2 of 2 patients (#1 and #2). (Reference A0145)

The cumulative effects of these patient rights failures resulted in the hospital's inability to promote the health, safety and welfare of the 30 patients on their child/adolescent behavioral health units.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record review and interview, the hospital failed to ensure that it notified patients/ patient representatives of the state hospital licensure agency's address for lodging a grievance, in 10 of 10 patients (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10), in a total sample of 10 patients.

Findings include:

Record review of the "Acknowledgement of Rogers' Notice of Privacy Practices (containing the patient rights and responsibilities)" revealed failed to contain the address of the state survey agency that governed hospital licensure: Division of Quality Assurance/ Bureau of Health Services, P.O. Box 2969, 1 West Wilson St., Room 455, Madison, WI -2969.

During interview with Social Services Director F on 12/4/18 at 11:10 a.m., F stated "We don't know of other (patient right's grievance) addresses."
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on record review and interview, the hospital's governing body failed to ensure an effective grievance resolution process with regard to identification, investigation and resolution of grievances from patients or patient representatives, with 2 of 2 patients (#1 and #2) in a total sample of 10 patients.

Findings include:

Record review of the hospital's "Patient Grievance Procedure, effective 8/16/17" revealed "All verbal and written complaints regarding abuse, neglect, any patient rights violation or hospital compliance with CMS (Centers for Medicare /Medicaid) requirements, are considered a grievance... 4. Within 48 hours of receiving the grievance, the social services staff will discuss the grievance with the patient and persons involved, and develop action plans for resolution as needed... Formal resolution: 1. If no resolution has been reached, the grievance is forwarded to the client rights specialists/social service manager or designee. The client rights specialist will facilitate a resolution of the concerns, conduct a review of the grievance, and propose a recommendation(s) for resolution to the patient, patient advocate, and the unit manager.

1) Record review of "Patient Care Notes" written by RN (Registered Nurse) I on 11/11/18 at 4:07 p.m. revealed that Patient #1's parents were phoned regarding a self-harm incident during group therapy at 2 p.m. on 11/11/18. Patient #1's parent's "expressed anger about lack of safe care" and the "lack of insight" into how the incident happened when talking with RN I. RN I documented that parents began to inquire about transferring Patient #1 to another mental health facility. There was no documented evidence that RN I identified these concerns as a grievance and initiated the hospital's grievance process. There was no documented evidence the hospital validated Patient #1's parent's concerns through the hospital's complaint/grievance process and conducted a thorough investigation of patient safety allegations in an attempt to provide a resolution.

During interview on 12/4/18 at 3 p.m. with Nursing Officer A, Nursing Director C and Compliance Specialist D, A stated "There was an incident report filed, but the concerns had not been formalized as a grievance."

During interview with SS (Social service) Manager F on 12/5/18 at 2 p.m., F stated that a "complaint/grievance had not been initiated for Patient #1's parents" after their patient safety concerns were expressed on 11/11/18.

2) Record review of Patient #2's 11/10/18 at 3:03 p.m. "Patient Care Notes" revealed at 12:45 p.m. on 11/10/18, Patient #2 told Behavioral Staff G that roommate had sexually assaulted Patient #2 at 10 p.m. on 11/9/18.

Record review of the 11/10/18 at 4:55 p.m. "Incident Follow-Up" report revealed that Nursing Officer A documented on 11/12/18 at 9:30 a.m. that Patient #2's parent was phoned and told the hospital was following up on the incident and parent's desire to file grievance. The parent expressed concerns about Patient #2's safety, transferring Patient #2 to another treatment location and House Supervisor H's behavior when they arrived to visit Patient #2 after assault occurred.

Record review of the 11/10/18 at 4:55 p.m. "Incident Follow-Up" report" revealed that SS Manager F documented on 11/12/18 at 9:40 a.m. that Patient #2's parents were contacted by phone and expressed concerns about Patient #2's safety on the (behavioral health) unit and how they were treated by House Supervisor H upon hospital arrival on 11/10/18. F documented that assistance was offered for filing a grievance or complaint.

There was no documented evidence the hospital validated Patient #2's parent's concerns through the hospital's complaint/grievance process in an attempt to provide a resolution.

During interview with SS Manager F on 12/5/18 at 2 p.m., F stated that a formal complaint/grievance had not been initiated for Patient #2's parents after their safety and treatment concerns were expressed on 11/12/18.

During interview with Compliance Officer B on 12/5/18 at 2 p.m., B stated that all "grievance are reviewed" by the regulatory compliance office. When asked if there were any quality audits measures put in place to ensure that complaints or grievances were handled according to CMS hospital regulations, B did not answer. There was no documented evidence that the hospital had a process to review concerns, complaints and/or grievances to ensure all patient concerns/complaints/grievances were identified, evaluated/investigated thoroughly and resolved when possible.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview, the hospital failed to ensure it provided patients/patient representatives with a written grievance response containing the required regulatory elements, in 2 of 2 patients (#1 and #2) in a total sample of 10 patients.

Findings include:

Record review of the hospital's "Patient Grievance Procedure, effective 8/16/17" revealed "All verbal and written complaints regarding abuse, neglect, any patient rights violation or hospital compliance with CMS (Centers for Medicare /Medicaid) requirements, are considered a grievance... 4. Within 48 hours of receiving the grievance the social services staff will discuss the grievance with the patient and persons involved, and develop action plans for resolution as needed. 5. The social service staff, or designee, provides the patient/guardian/family with a written copy of results of the grievance process within 10 days of completion. A written response includes the hospital contact persons name, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

1) Record review of "Patient Care Notes" written by RN (Registered Nurse) I on 11/11/18 at 4:07 p.m. revealed that Patient #1's parents were phoned regarding a self-harm incident during group therapy at 2 p.m. on 11/11/18. Patient #1's parent's "expressed anger about lack of safe care" and the "lack of insight" into how the incident happened when talking with RN I. RN I documented that parents began to inquire about transferring Patient #1 to another mental health facility.

There was no documented evidence the hospital validated Patient #1's parent's concerns with a written notice containing requirement elements: hospital contact persons name, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

During interview with SS (Social Service) Manager F on 12/5/18 at 2 p.m., F stated "a written notice was not completed" for Patient #1's parents.

2) Record review of Patient #2's 11/10/18 at 3:03 p.m. "Patient Care Notes" revealed at 12:45 p.m. on 11/10/18, Patient #2 told Behavioral Staff G that roommate had sexually assaulted Patient #2 at 10 p.m. on 11/9/18.

Record review of the 11/10/18 at 4:55 p.m. "Incident Follow-Up" report" revealed that Nursing Officer A documented on 11/12/18 at 9:30 a.m. that Patient #2's parent was phoned and told the hospital was following up on the incident and desire to file grievance. The parent expressed concerns about Patient #2's safety, transferring Patient #2 to another treatment location and House Supervisor H's behavior when they arrived to visit Patient #2 after assault occurred.

Record review of the 11/10/18 at 4:55 p.m. "Incident Follow-Up" report" revealed that SS Manager F documented on 11/12/18 at 9:40 a.m. that patient's parents were contacted by phone and expressed concerns about Patient #2's safety on the (behavioral health) unit and how they were treated by House Supervisor H upon hospital arrival on 11/10/18. F documented that assistance was offered for filing a grievance or complaint.

There was no documented evidence the hospital validated Patient #2's parent's concerns with a written notice containing requirement elements: hospital contact persons name, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

During interview with SS (Social service) Manager F on 12/5/18 at 2 p.m., F stated "a written notice was not completed" for Patient #2's parents.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on record review and interview, the hospital failed to ensure that patients/patient representatives were given the right to participate in their care planning, in 1 of 10 patients (Patient #1) in a total sample of 10 patients.

Findings include:

Record review of the hospital's "Patient Rights and Responsibilities Notice", signed by the patient/patient representative upon admission, revealed "You have the right to have an individual treatment plan and be an active member in it's planning."

Record review of "Patient care notes" by RN (Registered Nurse) I dated 11/11/18 at 4:07 p.m. revealed Patient #1 was permitted to call family after patient self-harmed arms and destroyed personal property in incident occurring on 11/11/18 at 2 p.m. while attending group therapy. In RN I's follow-up phone call to Patient #1's parents, I's documentation revealed parent's were "very angry" about incident, and the hospital's "lack of insight into how it happened... They asked that Patient #1 sit next to staff during every (therapy) group. They felt there was lack of care occurring."

Record review of the interdisciplinary "Master Treatment Plan" dated 11/10/18 at 2: 08 p.m. and the physician's "Orders" dated 11/9/18 (admission) through 11/12/18 (discharge) revealed no documented evidence that care plan changes were made to ensure that Patient #1 sat next to a staff member during group activities, per parents request, in an attempt to provide increased safety to Patient #1.

During interview with Compliance Officer D on 12/5/18 at 2:30 p.m., D stated that there was no documented evidence of group therapy safety care planning based on Patient #1's parents seating request.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record review and interview, the facility failed to ensure that patients known to self-harm were given protections for re-occurrence prevention, in 1 of 7 patients with a history of self-harm (#1), in a total sample of 10 patients.

Findings include:

Record review of hospital policy "Incident Debriefing or Case Review, effective 8/1/17" revealed "Purpose: 1. To determine causes of a potential or real incident... 2. To communicate with staff ways to improve services. 3. To obtain facts of a situation in order to prepare a response and action plan as necessary. Procedure: a. Upon learning of a situation that has been identified as a potential risk to the organization or safety of patients or staff, the staff member will contact the regulatory compliance department regarding the concern... d. During the incident debriefing meeting, the manager of regulatory compliance or designee will obtain the facts, the members will discuss and determine areas for improvement and development of an action plan."

1) Record review of the 11/12/18 at 10:08 a.m. "Incident Information" revealed that Patient #1 self-harmed arms with spoon during (therapy) group. Documentation revealed the parents of Patient #1 were "very angry" about the lack of insight into "how it happened". The "Incident Information" form failed to document details of staff present during self-harm incident and failed to give any details of an investigation into how/where the incident occurred or if any individualized care planning was done to prevent Patient #1 from further self-injury.

Record review of the "Patient Care Note" written by RN I on 11/11/18 at 4:07 p.m. revealed "around 2 p.m. Patient #1 became very irritable with some peers, and took spoon that was used for pudding and began to self-harm. Patient #1 felt triggered by peers because they were discussing inappropriate things... the patient's arms were bandaged." There was no documented evidence that RN I documented details of how/where the incident occurred or documented if any individualized care planning was done to prevent Patient #1 from further self-injury.

Record review of 11/11/18 at 4:44 p.m. "Therapeutic Notes" revealed from "2:40 p.m. through 4:15 p.m., the patient did not attend any groups". It was unknown what type of group setting the patient was in or how Patient #1 and peers were being monitored to prevent individual or group agitation that could have led to Patient #1's self-injury.

During interview with Nursing Officer A and Nursing Director C on 12/4/18 at 3 p.m., A stated "I don't know how plastic utensils, used on the nursing units (location of therapy rooms), are monitored." Nursing Director C stated "Therapy groups have staff assigned to monitor patients during attendance."

The hospital was unable to provide documented evidence that this incident was thoroughly investigated, and care planned protections for Patient #1 were initiated.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to ensure that staff monitoring occurred per hospital policy for the prevention of abuse, in 2 of 2 patients (#1 and #2), in a total sample of 10 patients.

Findings include:

Record review of hospital policy "Precautions and Observations, effective 9/15/18 revealed "Purpose:... to provide a safe and therapeutic environment for patients, and takes safeguards to minimize the opportunity for patients to harm themselves or others. B. Observation types: 1. Observations that have a specific interval of time that the patient must be visually observed within and documented on. Types of frequency based observations are as follows: a. Fifteen (15) minute observation intervals-This requires a patient be monitored visually in-person in intervals no longer than 15 minutes. Standard inpatient intervals are typically 15 minutes." "Assessment and Application: ... 2. The patient will be assessed on admission and on an ongoing basis throughout the patients length of stay... The assessment shall include documentation of patient's need for precautions and observations as indicated by: suicidal thoughts, potential for self injury or harm to others... 3. Based upon the assessment, the appropriate type of precaution or observation will be initiated immediately with a physician's order obtained as soon as possible." "Monitoring: 1. Nursing staff is responsible for adequately monitoring the condition and location of all patients according to the precaution or observation type designated by assessment or as determined by the physician order." "Documentation: a. Documentation is to be done in real time and will not be pre-entered prior to visualizing the patient or timed prior to the observation occurring."

1) Record review revealed Patient #2 ([AGE] years old) was admitted on [DATE] for Overdose (Suicide Attempt). The 11/10/18 at 3:03 p.m. "Patient Care Notes" revealed Patient #2 made a report to Behavioral Therapist G that roommate (Patient #1, [AGE] years old) had sexually assaulted Patient #2, in patient room, on 11/9/18 at 10 p.m. Patient #2 told of feeling pressured by Patient #1 to perform sexual acts.

Record review of the Patient #2's physician's "Orders" revealed initiation of "Safety Precautions (standard 15 minutes checks)" on 11/1/18 at 10:28 p.m.

Record review of the "Admit/ Transfer-Discharge Information" forms which contain documentation of 15 minute checks revealed that observational checks were not documented within the required 15 minute period after Patient #1 was admitted into the room with Patient #2 on 11/9/18 at 9:38 p.m. Fifteen minute room checks failed to occurred during the following time intervals while Patient #1 and Patient #2 were alone in their room:
Between 10 p.m. and 10:21 p.m. (21 minutes),
between 10:46 p.m. and 11:06 p.m. (20 minutes),
between 11:17 p.m. and 11:44 p.m. (27 minutes),
between 12:18 a.m. and 12:39 a.m. (21 minutes),
between 1:31 a.m. and 1:51 a.m. (20 minutes),
between 3:16 a.m. and 3:38 a.m. (22 minutes),
between 4 a.m. and 4:20 a.m. (20 minutes),
between 4:20 a.m. and 4:39 a.m. (19 minutes) and
between 6:09 a.m. and 6:27 a.m. (18 minutes).

Record review of the hospital's investigative interviews with supervisory RN (Registered Nurse) J and supervisory behavioral technicians (K and L) revealed no documented evidence of why 15 minute checks were not done per policy.

During interview with Nursing Director C on 12/4/18 at 10:30 a.m., C stated that "the investigation revealed that 15 minute checks were not done within the 15 minute timeframe."

2) Record review revealed Patient #1 was admitted on [DATE] 7:07 p.m. for setting fires at school, Depression and Conduct Disorder and had history of self-harm. Record review of the Patient #1's physician's "Orders" revealed initiation of "Safety Precautions (standard 15 minutes checks)" on 11/9/18 at 10:12 p.m.

Record review of Patient #1's 11/10/18 at 4:41 p.m. "Patient Care Notes" revealed that Patient #1's roommate (Patient #2) made an allegation that sexual abuse occurred in patient room with Patient #1 at 10 p.m. on 11/9/18. Patient #1 was immediately removed from room, separated from any contact with Patient #2, and given constant visual supervision until discharge on 11/12/18.

Record review of the "Admit/ Transfer-Discharge Information" forms which contain documentation of 15 minute checks revealed that observational checks were not documented within the required 15 minute period for Patient #2, after admission, during the following times:
Between 10 p.m. and 10:21 p.m. (21 minutes),
between 10:46 p.m. and 11:06 p.m. (20 minutes),
between 11:17 p.m. and 11:44 p.m. (27 minutes),
between 12:18 a.m. and 12:39 a.m. (21 minutes),
between 1:31 a.m. and 1:51 a.m. (20 minutes),
between 3:16 a.m. and 3:38 a.m. (22 minutes),
between 4 a.m. and 4:20 a.m. (20 minutes),
between 4:20 a.m. and 4:39 a.m. (19 minutes) and
between 6:09 a.m. and 6:27 a.m. (18 minutes).

Record review of the hospital's investigative interviews with supervisory RN (Registered Nurse) J and supervisory Behavioral Technicians (K and L) on 11/12/18 revealed no documented evidence of why 15 minute checks were not done per policy.

During interview with Nursing Director C on 12/4/18 at 10:30 a.m., C stated that "the investigation revealed that 15 minute checks were not done within the 15 minute timeframe."
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record review and interview, the hospital failed to ensure that measured data of missed patient safety check rounds (the visual patient assessment conducted at least every 15 minutes) was analyzed for root causes in an attempt to improve staff compliance, in 1 of 4 safety programs reviewed (safety precaution rounding).

Findings include:

During interview with Nursing Director C on 12/4/18 at 4:30 p.m. regarding the investigation of a patient peer to peer sexual assault (between Patient #1 and Patient #2) occurring on 11/9/18 at 10 p.m., C stated the investigation revealed that "15 minute safety checks were not done when they were suppose to" by the staff (K and L). C stated that when interviewing the 2 direct care staff (K and L) responsible for the 15 minutes safety checks, A did not ask the reason why safety checks were not done in a timely manner.

Record review of the "90-day Report Out, for the week of Feb. 19-23, 2018" revealed an action plan for inconsistent safety rounds (every 15 minute visual checks of patients). The plan identifies the following "gaps": 1) variation in hand-off communication, 2) inconsistent presence of staff, 3) variation in shift change hand off, 4) unassigned responsibilities among PCAs (Patient Care Assistants), and 5) No safety evaluation standard. Under "root causes", the documentation in all "gaps" revealed the words "no standard". The plan stated that the hospital was going to develop a standard for: handoff communication, inconsistent presence of staff taking into consideration the building (environment), assigning rounding responsibilities, and safety evaluations.

There was no documented evidence of investigation into root causes of why direct care givers had differences in communication/staff presence/variance/responsibilities based on staffing issues, time constraints, patient acuity needs or other scheduled duties such as medication pass tasks, cleaning, group therapy activities, the number of patient's needing increased individualized 1 to 1 care (1 staff to 1 patient's at all times) or management of patient's accidents/incidents. The hospital failed to have data that analyzed what was happening on the nursing unit when safety rounds were missed. The hospital failed to have root cause analysis of day to day direct care staff duties to ensure that these duties could be accomplished within the shift timeframe.

There was no documented evidence the hospital had analyzed peer to peer assault "Incident Information" report investigations to determine the root cause(s) of the inappropriate interactions, patient's behavioral triggers, medication effectiveness, patient's tolerance of environment and the staff presence/monitoring of inappropriate peer to peer interactions.

During interview with Nursing Officer E on 12/4/18 at 4:30 p.m., E stated that data on missed patient safety rounds was aggregated every month for each patient care unit. E could not provide documented evidence that when rounding data was below unit goal that it was shared with the unit manager(s) for the development of individualized (children and adolescent ) unit action plans based on a root cause analysis.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review and interview, the hospital failed to provide nursing services that assessed harmful behavioral triggers, in 2 of 7 patients with history of self-harm behaviors (#1 and #7) and and failed to develop individualized care plans based on assessed care needs with measurable goals and interventions, in 5 of 10 patients (#'s 1, 3, 4, 7 and 10). This occurred in a total sample of 10 patients.

Findings include:

1) The hospital failed to ensure that behavioral triggers that caused self harm or harm to others were assessed for the development of preventative care planning, in 2 of 7 patients (#1 and #7) with history of self-harm behaviors, in a total sample of 10 patients. (Reference A0395)

2) The hospital failed to ensure that individualized behavioral and ADL (activities of daily living) care plans were developed, 5 of 10 patients (#'s 1, 3, 4, 7 and 10), in a total sample of 10 patients. (Reference A0396)

The cumulative effects of these nursing service failures resulted the hospital's inability to promote the health and safety of the 30 patients on their child/adolescent behavioral health units.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and interview, the hospital failed to assess behavioral triggers that caused harm to themselves or others, in 2 of 7 patients with harmful behaviors (#1 and #7), in a total sample of 10 patients.

Findings include:

1) Record review of the 11/10/18 at 4:41 p.m. "Patient Care Notes" revealed that Patient #1's roommate (Patient #2) made an allegation that sexual abuse occurred in their shared patient room on 11/9/18 at 10 p.m.

Record review of the investigative report submitted by Nursing Director C on 12/4/18 revealed a 11/10/18 written statement by Patient #1 denying the sexual contact with Patient #2. Record review of the 11/12/18 at 12:14 p.m. psychiatric evaluation revealed Patient #1 later admitted to sexual contact with Patient #2.

Record review of the investigation documentation and the 11/10/18 at 4:55 p.m. "Incident Information (adverse occurrence)" documentation revealed no documented evidence that patient was assessed for triggers that initiated the sexual aggression on 11/9/18.

Record review of the "Patient Care Notes" dated 11/10/18 at 11: 22 p.m. revealed Patient #1's behavior was "calm". The 11/11/18 at 4 p.m. "Patient Care Note" revealed behavior was "agitated, calm, irritable and labile." The 11/12/18 at 9:54 p.m. "Patient Care Note" revealed "Patient #1 was "sculpting penises and making sexual gestures towards peers." The 11/12/18 at 3:51 p.m. "Patient Care Note" revealed "Speech: ...Hypersexual, Hyperverbal, Intrusive...". There is no documented evidence that Patient #1 was assessed for behavior triggers in an attempt to individualize a care plan to reduce these adverse behaviors.

2) Record review of Patient #7's 11/21/18 at 9:16 a.m. "Psychiatric Evaluation" revealed problem list of Depression, Homicidal and Suicidal Ideation. The evaluation stated that Patient #7 was transferred from an acute care medical facility due to increasing "confusion with memory deficits".

Record review of the "communication book" notations revealed Patient #7 required 1:1 supervision (one staff member assigned to patient at all times) while patient was awake based on severely aggressive behaviors towards staff member on 11/30/18, causing staff injury requiring hospital evaluation.

Record review of the "Patient Care Notes" for this incident revealed no nursing assessment of cognitive status during for this event.

During interview on 4/5/18 from 2:25 p.m. through 5:30 p.m. with Compliance Specialist D, who was assisting with medical record reviews of Patient #'s 1 and 7, D stated "I cannot find any additional information."
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on record review and interview, the hospital failed to develop individualized patient care plans in 5 of 10 patients (#'s 1, 3, 4, 7 and 10), in a total sample of 10 patients.

Findings include:

1) Record review of Patient #1's 11/10/18 at 4:41 p.m. "Patient Care Notes" revealed Patient #1's roommate (Patient #2) alleged that Patient #1 sexually assaulted Patient #2 on 11/9/18 at 10 p.m.

The 11/12/18 at 9:54 p.m. "Patient Care Note" revealed "Patient #1 was "sculpting penises and making sexual gestures towards peers." The 11/12/18 at 3:51 p.m. "Patient Care Note" revealed "Speech: ...Hypersexual, Hyperverbal, Intrusive...".

Record review of the 11/10/18 at 2:07 p.m. interdisciplinary "Master Treatment Plan (care plan)" revealed no documented evidence of a care plan (problem/measurable goal/interventions) for the reduction of sexual aggressive behaviors.

2) Record review of Patient #1's "Patient Care Note" written by RN I on 11/11/18 at 4:07 p.m. revealed "around 2 p.m. Patient #1 became very irritable with some peers, and took spoon that was used for pudding and began to self-harm. Patient #1 felt triggered by peers because they were discussing inappropriate things... the patient's arms were bandaged."

Record review of "Patient care notes" by RN (Registered Nurse) I dated 11/11/18 at 4:07 p.m. revealed that patient's parents were "very angry" about incident and asked that Patient #1 "sit next to staff during every (therapy) group."

Record review of the 11/10/18 at 2:07 p.m. interdisciplinary "Master Treatment Plan (care plan)" revealed no documented evidence that care plan revisions were put in place as requested by Patient #1's parents, in an attempt to provide increased safety for Patient #1.

3) Record review of Patient #3's 11/19/18 at 12:36 p.m. "Psychiatric Evaluation" revealed the "goals of treatment" were "... 2. medication management" for behaviors.

Record review of the 11/30/18 at 2:04 p.m. interdisciplinary "Master Treatment Plan (care plan)" revealed no documented evidence of development of care plan (problem/ measurable goal/interventions) for medication management.

4) Record review of Patient #4's 11/30/18 at 2:20 p.m. "Psychiatric Evaluation" revealed problems with medication compliance "over the past month" with "goals of treatment" being "3. symptom reduction".

Record review of the "Nursing Admission Assessment" dated 11/30/18 at 3:16 a.m. revealed under "functional assessment" that Patient #4 was dependent in bathing,dressing and toileting, and during admission that Patient #4 "rubbed naked vagina and butt on 1:1's (constant supervision staff person's) leg and pants.

Record review of the 11/30/18 at 11:45 p.m. interdisciplinary "Master Treatment Plan (care plan)" revealed no documented evidence of development of care plans (problem/ measurable goal/interventions) for the reduction of sexually aggressive behaviors or for ADL assistance regarding the assessment of patient's problems with hygiene, toileting and dressing.

5) Record review of Patient #10's 8/8/18 at 9:42 a.m. "Incident Information" forms revealed that Patient #10 was "noticed to be scratching self on both inner arms. Patient had previously self-harmed on these arms and picked scabs as well as made new cuts... Patient then asked for a marker and stated that patient was going to self-harm in room." This incident form states that "markers and other items in room that patient could use to self-harm were taken to avoid further injury."

Record review of the 8/9/18 at 10:45 a.m. interdisciplinary "Master Treatment Plan (care plan)" revealed no documented evidence of development of care planned interventions for increased safety supervision, such as counted supplies that could be used for self-harm or room inspections for items that could be used for self-harm.

6) Record review of Patient #7's 11/21/18 at 9:16 a.m. "Psychiatric Evaluation" revealed problem list of Depression, Homicidal and Suicidal Ideation. The evaluation stated that Patient #7 was transferred from an acute care medical facility due to increasing "confusion" with memory deficits".

Record review of the "communication book" notations revealed Patient #7 required 1:1 supervision (one staff member assigned to patient at all times) while patient was awake based severely aggressive behaviors towards staff member on 11/30/18, causing staff injury requiring hospital evaluation.

Record review of the 11/28/18 at 11:25 a.m. interdisciplinary "Master Treatment Plan (care plan)" revealed no documented evidence of measurable goals for the reduction of aggression towards self or others. There was no care planning for the assessment of behavioral triggers that may have led to aggressive episodes, and there were no evaluations for the level of cognitive impairment when aggressive behaviors occurred.

During interview on 12/5/18 from 2:25 p.m. through 5:30 p.m. with Compliance Specialist D, who was assisting with medical record reviews of Patient #'s 1, 3, 4, 7 and 10, D stated "I cannot find any additional information."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on record review and interview, the hospital failed to ensure that all medical records that contained information regarding the condition of the patient was not destroyed, in 3 of 3 nursing "communication" books (Topaz, Jade and Opal).

Findings include:

Based on record review and interview, the hospital failed to ensure that child and adolescent behavioral health medical records information containing daily nursing staff assessments and treatments were kept as permanent parts of the medical record, in 3 of 3 "communication" books on the child and adolescent nursing units. (Topaz, Jade and Opal). (Reference A0438)

The cumulative effects of this medical records failure resulted in the hospital's inability to provide complete and accurate medical records for the 30 patients on their child/adolescent behavioral health units.