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 observation, interview, record review and document review, the facility failed to provide Patient Rights: a patient has the right to be free from all forms of abuse or harassment (Tag A0145); and continues to be non-compliant with the Condition of Participation of Patient's Rights.

Based on record review, interview and document review, the facility failed to protect a youth patient from the re-occurrence of physical abuse, assess a youth patient after being physically abused by a relative, update the plan of care to reflect interventions for the prevention of physical and psychological abuse, provide counseling and treatment to a youth patient after being physically abused by a relative and notify the Attending Physician and the Legal Representative about physical abuse against a youth patient (Patient #3).

Findings include:

Patient #3 (P3)

P3 was admitted on [DATE], with diagnoses including suicidal ideation.

History and physical examination dated 12/07/18, documented P3 was [AGE] years old and admitted for suicidal ideation. P3 was initially admitted to an acute care facility after threatening to cut the wrist with a kitchen knife following an argument with the stepmother (the partner of the biological mother).

Nursing progress note dated 1/23/19 at 5:39 PM, documented the step mother was in the unit checking P3's clothes to decide which clothes to bring home. The note revealed the step mother wanted the jacket P3 was wearing and P3 refused. The stepmother grabbed P3 by the jacket and began yelling at P3. P3 began screaming back and a staff member intervened. P3 was re-directed to P3's room.

Incident report completed on 1/24/19, documented P3's stepmother came to do an inventory of P3 belongings. The report indicated P3 became agitated after being questioned about missing clothes and used a swear word against the stepmother. The report revealed the stepmother grabbed P3 by the collar of P3 "hoodie" in an aggressive manner until a Milieu Manager stepped in and walked P3 to his room. The report documented the incident was reviewed by DCQR (the Director of Compliance, Quality and Risk) who determined the staff took appropriate action in response to the incident. The report indicated no severity was assigned and no other action needed at that time. The general comments of the report documented the Child Protective Service was notified on 01/24/19 at 10:00 AM and no report could be taken since P3 was not a DCFS (Division of Child and Family Services) child. In addition, the report documented law enforcement was notified on 01/24/19 at 11:00 AM and indicated a report could not be taken by the Police Department due to P3 had not the called to file the report.

Child Abuse/Neglect Referral Form filled by the Manager of Youth and PRTF (Psychiatric Residential Treatment Facility) and dated 01/24/19, described a minor redness on P3's neck as injury related to the incident.

On 01/29/19 at 4:20 PM, a video from the surveillance system was watched with the Chief Nursing Officer (CNO). The video was recorded on 01/23/18 at 5:26 PM in front of the nursing station located in the PRTF, at the time the incident occurred. The video revealed the stepmother was at the nursing station with P3 checking some clothes. Three staff members were also observed in the video, a female staff (a Registered Nurse RN) in the inside area of the station and two male staff (Mental Health Technicians MHT) outside of the station and close to P3 and the stepmother. The video documented the stepmother grabbed P3 in an aggressive manner by the collar of the jacket P3 was wearing pulling P3 back. The video revealed one of the MHT separated P3 from the stepmother and walked P3 out of the place followed by the RN and the other MHT. In the video it was observed the stepmother waiting for about two minutes in front of the nursing station until one of the MHT returned with the jacket P3 had been wearing. It was also observed the RN returned to the nursing station and continued working with some papers. The stepmother was observed leaving the unit after receiving the jacket from the Technician. The video lacked recorded evidence the stepmother was approached by the facility staff to discuss the incident.

On 01/29/19 at 4:30 PM, the CNO indicated the incident seamed to be an assault by the stepmother against P3 and acknowledged it was an abusive and aggressive action. The CNO verbalized actions were taken to prevent a re-occurrence of the incident including not allowing the stepmother to visit P3.

Review of visitors sign-in log revealed the stepmother had visited P3 after the incident on 01/28/19 at 5:50 PM. The CNO confirmed the finding.

On 01/30/19 at 12:55 PM, a MHT Lead Technician who supervised visitations indicated the Lead Technician supervised the visitation that occurred on 01/28/19 with P3 and the stepmother. The Lead Technician reported the stepmother was intimidating and was constantly drilling P3 and told P3 that P3 was at the facility because P3 was a failure and P3 never owned up to the failures or mistakes in life. The Lead Technician reported that P3's demeanor changed and P3 became agitated during the visit. The Lead Technician added P3 was respectful with the staff and obvious mood changes were observed in the presence of the stepmother.

On 01/29/19 at 3:20 PM, the MHT who intervened to separate P3 and the stepmother, explained the stepmother came to perform an inventory of P3's belongings and asked P3 questions about missing clothes and P3 responded with swear words. The MHT indicated the stepmother requested P3 to give the jacket P3 was wearing and P3 refused, it was then the stepmother grabbed P3 by the neck. The MHT verbalized the stepmother did not leave the facility until obtaining the jacket.

On 1/29/19 at 3:50 PM, the RN who witnessed the incident between P3 and the stepmother explained P3 was assessed after the incident and no pain or injuries were observed. The RN confirmed the assessment was not documented in the medical record, and the legal representative (the biological mother) and the Attending Psychiatrist were not notified about the incident.

On 01/30/19 at 10:10 AM, the MHT who accompanied P3 to his room after the incident with the stepmother, reported P3 used swear words when the stepmother asked about P3 personal belongings and the stepmother became upset and grabbed P3 by the collar of the jacket. The MHT verbalized P3 was walked to his room and was upset and emotionally affected due to the altercation and support was provided until P3 calmed down.

On 01/29/18 at 4:30 PM, the CNO could not provide evidence a nursing physical assessment had been performed on P#3 after the incident. The CNO could not produce documented evidence the Attending Psychiatrist and P3's Legal Representative were notified of the incident. The CNO verbalized it was the expectation nurses performed a physical assessment after an allegation of physical abuse and notified the patient's responsible party and the Attending Physician.

Review of the medical record revealed the last individual therapy P3 received was performed on 01/04/19, the last psycho- educational group therapy was done on 12/15/18 and the last psychiatric evaluation and care plan update was performed on 01/19/19. The record documented the last physical examination was performed on 01/23/19 at 3:59 PM before the incident.

The medical record lacked documented evidence of a physical or psychological assessment, Physician and the legal representative notifications, and plan of care interventions for the prevention of abuse.

On 1/30/19 at 11:51 AM, the Attending Psychiatrist confirmed he did not receive a notification about the physical altercation between P3 and the step mother. The Physician indicated it was expected that patient physical and psychological assessments would be performed after the incident. The Physician verbalized concerns about discharge planning since P3 was expected to return home with family after completing treatment and therapy. The Physician indicated an assessment and revision of the care plan would be done to ensure the safety of the patient.

On 01/30/19 at 1:45 PM, the DCQR indicated he initiated the investigation and documented the incident report. The DCQR verbalized during the incident investigation interviews were not performed with P3 and the staff who witnessed the incident.

The facility policy titled Patient Abuse or Neglect, dated 08/01/05, documented the patient victim would be encouraged to report the abuse allegation to the appropriate protective service and patient advocate and the staff would assist the patient by providing phone numbers to the appropriate agency. The policy indicated if the patient was unable to self-report the incident, the staff member who was aware of the incident was mandated to report the abuse allegation to the Physician, Social Worker and the Supervisor. The action taken should be documented in the clinical progress notes.

Patient Rights provided by the facility documented patients had the right to dignity, respect, privacy, humane care and freedom from mental and physical abuse, neglect and exploitation.

The facility policy titled Visitors and Visitations dated 01/01/16, documented the facility may impose clinically appropriate limitations when visitation would interfere with the care of the patient if the reason for the limitation or restriction of the visitation was determined by factors that included disruptive behaviors of visitors or another reason determined by the treatment team.

Complaint #NV 127
Based on interview, record review and document review, the facility failed to appropriately address a toilet that overflowed, resulting in a delay in a patient's change of room for 1 of 30 patients, (Patient #2).

Findings include:

On 2/20/19, in the morning, the Housekeeping Lead, Employee #3 (E3), indicated if a toilet overflowed, it was usually because a patient flushed something down that should not be flushed. The Nursing staff cleans the feces and then Housekeeping comes and sanitizes the bathroom. E3 indicated there was a clogged toilet on the unit and maintenance staff had turned off the water, but did not tell the Nursing staff, which resulted in a delay in moving Patient #2, P2, to another room.

Review of facility documentation revealed the facility provided a written response to P2 stated in part, "With regard to the clogged toilet, we found that there was a break-down in communication between the Plant Operations Department and the Nursing Department, which resulted in a delay in you being transferred to a different room."

Complaint #NV 125