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.

MONTEVISTA HOSPITAL 5900 WEST ROCHELLE AVENUE LAS VEGAS, NV 89103 Jan. 17, 2019
VIOLATION: MEDICAL ORDERS FOR RADIOLOGY SERVICES Tag No: A0539
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to obtain physician orders for a chest and shoulder x-rays for two sampled patients (Patient #27 and #28).

Findings include:

Patient #27

Patient #27 was admitted on [DATE], with diagnoses including unspecified dementia with behavioral disturbance.

A radiology interpretation form dated 1/7/19, documented a single x-ray view of the patient's chest was completed and the results were normal.

There was no documented evidence a physician order was completed to obtain the chest x-ray.

On 1/8/19 in the at 11:30 AM, the Chief Nursing Officer (CNO) indicated a physician order was needed before an x-ray could be done for Patient #27.

Patient #28

Patient #28 was admitted on [DATE], with diagnoses including psychosis, pain in left shoulder and pain in left arm.

A radiology interpretation form dated 1/7/19, documented an x-ray view of the patient's left wrist and shoulder were completed.

There was no documented evidence a physician order was completed to obtain the left wrist and shoulder x-ray.

On 1/8/19 in the at 11:30 AM, the Chief Nursing Officer (CNO) indicated a physician order was needed before an x-ray could be done for Patient #28.
VIOLATION: LABORATORY SERVICES Tag No: A0576
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review and document review, the facility failed to: 1) integrate laboratory services into the facility's Quality Assurance Performance Improvement (QAPI) program; 2) properly label, store and send patient laboratory specimens out for testing for 1 of 37 sampled patients (Patient #6).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory-mandated care to patients.

Findings include:

1) First Addendum To Laboratory Services Agreement form dated October 1, 2015, documented performance expectations. The form indicated the contracted laboratory company would provide monthly reports to the facility regarding compliance with agreed testing procedures for monitoring and evaluation purposes. The following were to be obtained by the facility from the contracted laboratory company:

-Turn around time
-Critical Lab values
-QNS/TNP (quantity not sufficient/test not performed)
-Utilization by test (dollar and units)

There was no documented evidence the facility integrated the laboratory services into the facility QAPI program. There was no documented evidence the facility obtained monthly data from the laboratory contractors for their QAPI program.

On 1/11/19 at 2:00 PM, the Director of Compliance and the Chief Nursing Officer (CNO), indicated laboratory contracted services were not integrated with the facility QAPI program. The CNO and the Director of Compliance indicated they did not request and obtain monthly reports from the laboratory contractor.

2 a.) On 1/8/19 at 8:45 PM, the laboratory specimen refrigerator located on the adult unit had two urine samples being stored in the refrigerator. The first urine specimen was in a screw top clear container approximately 60 milliliters (ml) . The 60 ml container filled with urine was placed in an 8 ounce styrofoam white cup. The 60 ml container and the styrofoam cup were not labeled with any name, identification number, date or contents of the container. There was no corresponding laboratory paperwork with the specimen to identify what test was to be done, what patient the specimen belonged to and when it was collected.

On 1/8/19 at 8:45 PM, the Chief Nursing Officer (CNO) and other staff were unaware who placed the unlabeled, no paperwork, wrongly stored (in a styrofoam cup) specimen in the refrigerator. The CNO indicated the styrofoam container was not an approved collection container for urine specimens and the 60 ml container should have been properly labeled with the name of a patient, the date collected and placed in a approved laboratory plastic bag. The CNO indicated the specimen should have had laboratory paperwork attached to a correctly labeled container.

b.) Patient #6

Patient #6 was admitted on [DATE], with diagnoses including major depressive disorder and suicidal ideations. The patient was discharged on [DATE].

A physician order dated 10/22/18 documented for a urine analysis with a culture and sensitivity test.

On 1/8/19 at 8:50 PM, the laboratory specimen refrigerator located on the adult unit had two urine samples being stored in the refrigerator. One urine specimen was in a urine test tube container. The urine was cloudy yellow with sediments. The tube was not labeled with any name and identification number. The tube was in a small clear laboratory collection bag and attached to the bag was a laboratory slip which contained the name of Patient #6.

The laboratory slip and tube filled with cloudy urine also did not have a collection date. Written on the plastic bag, where the urine filled tube was in, indicated the specimen could not be collected due to the specimen container and the paperwork were not filled out correctly.

On 1/8/19 at 8:50 PM, the CNO confirmed the Patient #6's urine sample collection tube and laboratory paperwork were not labeled and filled out correctly. The CNO indicated the collection tube was missing the name of the patient and the collection date. The laboratory paperwork was missing the collection date of the specimen. The CNO indicated the laboratory company probably placed the note indicating the specimen was unacceptable and left it in the refrigerator with no staff taking the specimen and disposing of it properly.

It was later identified by the CNO on 1/8/19 in the afternoon, the specimen had been in the refrigerator possibly for over two months since the patient was discharged on [DATE].
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation, interview, record review and document review, the facility must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. The facility failed to: 1) to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured (Tag A0701); 2) properly dispose of biohazard trash (Tag A0713); and 3) failed to have the supplies and equipment maintained to ensure an acceptable level of safety and quality (Tag A0724).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory mandated care to patients.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and interview, the facility failed to maintain the physical structure of the roof, facility offices, common areas and units.

Findings include:

On 1/7/19 at 10:00 AM, during a tour of the pharmacy and hallways, a number of areas had 5 gallon buckets placed in the hallways to catch rain water which had poured through the facility's roof over the weekend. Several light fixtures had standing water inside the horizontal light covers and ceiling tiles with significant water damage and staining in the pharmacy, utilization review office and electroconvulsive therapy suite.

A number of employees in utilization review as well as maintenance staff acknowledged the roof had been leaking for 3-6 years, depending on the employee. The Plant Operations Director indicated the facility was currently waiting for approval for a bid to do roof work, but until then, the facility appointed a number of employees throughout the building to check for ceiling leaks and set-up buckets where ever needed whenever it rained.

On 1/7/19 in the afternoon during a tour of the PRTF areas, the following was identified:

Room 102: a fist-size hole in a bathroom sink.
Room 201: a foot-size hole in a shower stall.

On 1/15/19 in the morning during a tour of the 100/200 rooms with the Outpatient Services Director present, the following was identified:

Room 101: profanity written in magic marker on the ceiling.
Room 102: magic marker written on the walls.
Room 105: walls marked up; patches exposed.
Room 200: profanity etched into the bathroom mirror.
Room 201: magic marker written on the ceiling.
Room 202: magic marker written on the ceiling and an obscene reference etched into the bathroom mirror.
Room 203: magic marker written on the ceiling.
Room 205: writing on the bathroom mirror and walls.




On 01/07/19, in the morning, a tour of the Adult Acute Psychiatric Unit was conducted with the Nurse Manager of Youth and PRTF, the following were observed:

1. Areas of paint damage to the walls in patient Rooms 116, 117, 121, 122, 126, and 129. The areas were covered in a white friable material resembling spackle. The damaged areas ranged in size from about one foot square with the largest measuring about five feet square. The hallway for Rooms 123-130 had large areas of similar paint damage to the lower half of the walls. The Nurse Manager of Youth and PRTF verbalized these were areas that were caused by patients kicking or hitting the walls and the damaged areas had been partially repaired.

2. In patient Rooms 117, 119, 124, and 126, bathrooms had shower-head fixtures which were continuously leaking small amounts of water and could not be turned off completely. Water was noted on the floor adjacent to the bathroom door areas of these rooms. The shower water control fixtures had water dripping onto them and were noted to have dark areas consistent with corrosion. The shower stalls in Rooms 117 and 119 were soiled with tan stains and had areas of dark material consistent with mildew. The Nurse Manager of Youth and PRTF verbalized the showers were soiled and mildewed, and there should not be water on the floors.

In the unit laundry room used by patient to wash their clothing, soiled bed sheets and blankets were in mesh container with the top covered next to the washing machine. The front of the mesh container was also unzipped and exposing the soiled bedding. The Housekeeper viewed the container and reported the container with soiled bedding should not be in the patient-use laundry room. Soiled bedding was collected daily by housekeeping staff and should be stored in a closed container in a separate soiled utility room to wait for collection by a contracted laundry service. The Housekeeper did not know why the soiled bedding container was in the patient use laundry room and uncovered.

Patient #18 reported being housed in Room 119 and was unhappy the shower would not turn off and the shower stall was dirty.

On 01/07/19, at 2:00 PM, inspection of the Adult Acute Psychiatric Unit was conducted with the Maintenance Director.

The Maintenance Director was shown the damaged paint areas and leaking shower head fixtures and mildew in shower stalls. The Maintenance Director explained patients damaged the room walls by kicking or hitting them, and completion of repairs with re-painting was needed for all areas. The areas of damaged paint in the hallway required repair with impact resistant panels. Multiple showers needed replacement parts. The Maintenance Director reported 11 shower fixtures were leaking, in Rooms 104, 110, 117, 121, 122, 124, 126, 128, 131, and 133. The leaks were caused by faulty parts. The Maintenance Director verbalized continuous moisture from leaking shower-heads created unsanitary conditions for patients, and mildew could trigger allergies. The Maintenance Director verbalized repairs had to be prioritized, and there were a large number of maintenance repairs needed in the hospital.

The Maintenance Director described Rooms 118 and 120 were closed from usage and under repairs for mold abatement. The Maintenance Director explained a water leak occurred in a temperature valve in a wall conjoining these rooms. Room 118 had the floor partially removed, and Room 120 was partitioned with a temporary wall of plastic sheets, with a fan going behind the plastic sheets. Room 118 had been tested and found free of mold. Room 120 was tested and results were pending. The Maintenance Director explained the fan was running to help dry out Room 120.

In the South Day Room, used by patients as a community room, the ceiling adjacent to a wall had a 30 square foot area with ceiling panels missing, exposing pipes. The area was loosely covered by two plastic sheets secured with masking tape. There were three patients in the Day Room, and one patient was directly underneath the damaged area and plastic sheets. The Maintenance Director indicated the plastic sheets should not have been placed, as they posed a suffocation risk for patients. The floor of the room under the damage area was littered with whitish friable material consistent with parts of ceiling panels. The Maintenance Director explained the roof was damaged and allowed rain water to come in to damage the ceiling panels and fall on to the floor. The floor should have been cleaned. The hospital had a leaking roof in multiple areas which had been evident for 3-4 years and management was aware. The entire roof needed to be replaced.

On 01/15/19, in the afternoon during rainy weather, water was coming through and around light fixtures in the ceiling and dripping into 5 gallon paint buckets placed in the middle of hallway adjacent to the ECT room, and to the Pharmacy. A group of patients from the Youth Unit were observed walking past the leaking area in front of the ECT room on their way to the Gymnasium. The Maintenance Director acknowledged these two leaking areas were caused by the rain coming through the roof.

On 01/08/19 at 10:30 am, the Outpatient Building was observed with the Outpatient Services Manager. The small room described as the quiet room used by children had an electrical fixture plate partially broken away from the wall revealing a hole about 6 inches by 4 inches in the wall. In the same room a smoke detector on the ceiling was missing the cover. The Outpatient Services Manager stated the broken plate could be hazardous to patients and should be fixed and the smoke detector should have a cover.








On 01/08/19 in the morning an inspection of patient rooms and bathrooms in the Acute Pediatric Adolescent Unit revealed the following:
Room 101 Shower leaking, and shower wall rusted. Bedroom wall missing paint.
Room 102 Bedroom wall with extensive paint missing, bubbling of paint by sink area, shower leaking.
Room 103 Paint missing to an entire wall, and paint missing on the wall above the sink.
Room 104 Shower leaking and water on bathroom floor.
Room 105 Paint missing on walls.




On 1/7/19 at 9:15 AM, a portion of a wall located next to the deep fryers and below the exhaust ventilation hoods were repaired with plaster which was cracking and crumbling off onto the floor. Another portion of wall, next to the repaired wall, had the paint bubbling and peeling off looking like the paint was melting.

On 1/7/19 in the morning, the Food Service Director indicated the facility attempted to fix the wall with plaster. The Food Service Director indicated the ventilation exhaust material which was sheet metal should have continued on the wall covering the damaged walls to protect it from the heat.
VIOLATION: DISPOSAL OF TRASH Tag No: A0713
Based on observation and interview, the facility failed to securely store bio-hazardous waste.

Findings include:

On 1/7/19 at 9:33 AM during a tour, biohazardous waste was observed stored outside, unsecured and accessible to the public.

Seven red, biohazardous waste bags and six used sharps bins were observed outside on the ground, in and around the entryway of an unlocked storage shed.

The Plant Operations Director indicated pick-up dates landed on holidays the last two weeks, and the vendor had not made good on an earlier request to pick-up on another day.

The Plant Operations Director acknowledged the waste should have been locked up and secured.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and document review, the facility failed to check and maintain the correct supplies in two bags kept in readiness for patient first aid, keep chilled normal saline intravenous fluid available in the Electroconvulsive (ECT) refrigerator, label a bottle of cleaning solution, and keep dryers free of excessive lint.

Findings include:

1. On 01/07/19, in the Adult Acute Psychiatric Unit, a blue bag was in the nursing station. The Registered Nurse (RN) described the bag was kept in readiness to render first aid to patients in case of injury or Code Blue (cardiac arrest). Contents in a side pocket of the bag included an unopened 240 milliliter (ml) container labeled sterile water, with an expiration date of 04/2011. The container was intact but the there was no fluid in the container. The RN described sterile water was kept in the bag for cleaning wounds. The RN verbalized the sterile water was beyond the expiration date and contained no liquid. The RN wasn't sure when the bag was last used, and did not know which staff were responsible for checking and replenishing the contents of the bag.

The hospital policy and procedure titled Blue Bag Process, revised 01/2018, indicated a list of contents to be in the bag which did not include sterile water. The policy and procedure indicated an opened bag would be taken to Purchasing for cleaning and restocking. Purchasing would check blue bags monthly to ensure supplies were up to date.

2. On 01/11/19 at 2:00 PM, the combo refrigerator/freezer in the ECT Room contained a liter bag of frozen 0.9% Sodium Chloride fluid (normal saline) for intravenous use. The ECT Nurse Manager stated a liter of normal saline was kept in the refrigerator for use in the event of a [DIAGNOSES REDACTED] reaction to help cool the patient with a high fever. The normal saline should be refrigerated (chilled), but not frozen. The ECT Nurse Manager stated their responsibilities included checking and restocking the refrigerator/freezer daily. The ECT nurse manager didn't know know why the normal saline was in the freezer and stated it would not be useable in frozen form.

The hospital policy and procedure titled Anesthesia Medications/Cart Security, revised 07/03/18, indicated the ECT refrigerator should contain two 500 milliliter bags of 0.9% Sodium Chloride IV fluid, in the even of a [DIAGNOSES REDACTED]. The policy and procedure lacked specifics on how often the refrigerator should be checked and staff responsible.




On 1/7/19 in the afternoon during a tour of the PRTF areas, the following was identified:

Room 302: a Maintenance Tech used an unlabeled spray bottle, acknowledging the disinfectant Virex was in the bottle, and that it should have been labeled.

The Container Sizes and Labeling section of the Housekeeping Chemicals policy (800.902, last reviewed 1/17), revealed each container should be clearly labeled as to contents, instructions for use and safety precautions.

Lint traps in the dryers of the laundry rooms were full of lint.

On 1/8/19 at 1:30 PM, the Central Supply Tech indicated blue bags were returned to be restocked after being used by unit staff. The Blue Bag Contents list included the items that should be in each blue bag on the units.

On 1/8/19 at 2:00 PM on the 300/400 nurse station in the PRTF area, the blue bag contents were inspected. A portable suction device and a container of sterile water were in the blue bag, but neither item was on the contents list for the blue bags. There was no flashlight in the blue bag, even though it was listed on the blue bag contents checklist.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on observation, interview and document review, the hospital failed to implement policies regarding infection control, as evidenced by soiled bedding stored in a patient use laundry area, two dirty showers with mildew, multiple leaking shower fixtures, a soiled refrigerator with opened and unlabeled milk containers, failure to label foods stored in a walk-in cooler and reach in refrigerators, and failure of staff to perform hand hygiene.

Findings include:

On 01/07/19 at 10:10 AM, on the Adult Acute Psychiatric Unit, a room with a washing machine and dryer, soiled bed sheets and blankets were stored in an uncovered mesh container next to the washing machine. The front of the mesh container was also unzipped exposing soiled bedding. The Housekeeper reported the room was used by patients to wash their clothing. The housekeeper verbalized the container with soiled bedding should not be in the patient-use laundry room. Soiled bedding was to be collected daily by housekeeping staff and should be stored in a closed container in a separate soiled utility room to wait for collection by a contracted laundry service. The Housekeeper did not know why the uncovered soiled bedding container was in the patient use laundry room.

The facility policy and procedure titled Linen Management, revised 07/2005, indicated staff would remove soiled linen from the bed and place in the linen hamper. Keep linen hamper covered until hamper was full, and transport closed dirty linen bag to the soiled untiity room immediately.

On 01/07/19, in the Adult Acute Psychiatric Unit, patient Rooms 117, 119, 124 and 126, bathrooms had shower-head fixtures which were continuously leaking small amounts of water and could not be turned off completely. Water was noted on the floor adjacent to the bathroom door areas of these rooms. The shower water control fixtures had water dripping onto them and were noted to have dark areas consistent with corrosion. The shower stalls in Rooms 117 and 119 were soiled with tan stains and had areas of dark material consistent with mildew. The Nurse Manager of Youth and PRTF verbalized the showers were soiled and mildewed, and there should not be water on the floors

On 01/08/19 at 10:30 AM, in the Outpatient Building snack room, a refrigerator was soiled with particulate matter. Two opened partially consumed four ounce containers of milk were in the refrigerator. The Director of Outpatient Services stated the snack room was used by patients attending classes in the building. The Director of Outpatient Services indicated the refrigerator should be kept clean, and opened containers of milk should be labeled as to date opened and with a name to indicate who opened the milk.

On 01/14/19 at 1:50 PM, the Infection Control Nurse indicated being responsible for identifying and controlling infection risks in the hospital. The Infection Preventionist reported making rounds of the hospital daily, and every two weeks to the outpatient unit. The Infection Control Nurse stated hand hygiene was a concern, and staff should wash their hands between patient contacts. The Infection Control Nurse reported being aware of the many leaking shower head fixtures and mildewed showers, and acknowledged the constant moisture from the shower head fixtures created conditions for the spread of micro-organisms, and showers should be kept free of mildew. Soiled linens should be kept in a dirty utility room until pick-up, and soiled linen containers should be covered to prevent cross-contamination. Refrigerators should be kept clean. Food items should be labeled. The Infection Control Nurse verified having observed these situations and reported the concerns to the Unit Managers, to take appropriate action. The Infection Control Nurse acknowledged the concerns were ongoing and not resolved.

The hospital policy and procedure titled Job Description of Infection Control Nurse indicated the Infection Control Nurse acts as a liaison between all departments of the hospital concerning the possible transmission of bacteria and methods for preventing and/or controlling infections and communicable diseases. The Infection Control Nurse would make visual observations and discuss with department heads, and evaluate the effectiveness of the program.





On 1/7/19 at 9:40 AM during a tour of the walk-in cooler adjacent to the outside delivery area, a pan of pineapple slices was observed on a shelf without a date label. Nearby a pan of Genoa salami slices was observed on a shelf without a date label.

The Outpatient Services Director confirmed the lack of labels on the two pans.

Procedure #6.3 of the Food Services Infection Control policy (1900.48, last approved 10/06) revealed:

Place foods that are taken from their original, properly labeled containers and place in metal or plastic container.

Label the container and lid immediately. The label should state the name of the food. The lettering should be approximately one inch high and easily readable.





On 1/7/19 at 9:15 AM, the reach in refrigerator in the kitchen and across from the ventilation hoods had staff food being stored in it. On the top shelf was a crate of eggs and a food item which was wrapped in foil and in a plastic bag. Both items were not labeled or dated. The Food Service Director confirmed both food items were a staff members own personal food to cook and eat.

On 1/14/19 in the afternoon, the Infection Control Coordinator confirmed staff food was not allowed to be stored in the kitchen reach in refrigerator. The staff had their own refrigerator in the employee lounges.

On 1/9/19 in the morning, medication administration observation was conducted with the Registered Nurse (RN) on the 500 unit for Patient #30. Prior to starting the observation, the RN was assisting another patient. After completing care for another patient the RN returned to the medication room to set up the medications for Patient #30.

As the RN proceeded to gather and open up Patient #30's medications, the RN was stopped by the Inspector and reminded hand washing was not conducted after patient care was completed on another patient or prior to starting medication administration for Patient #30.

On 1/9/19 in the morning, the RN confirmed hand washing was not conducted and should have been done after patient care was performed on another patient.

On 1/14/19 in the afternoon, the Chief Nursing Officer confirmed the RN conducting medication administration should have washed their hands prior to starting the medication pass.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and and document review, the facility failed to ensure the outpatient program had staff to monitor patients for safety and prevent an occurrence of inappropriate sexual behavior between patients (Patient #32 and Patient #31).

Findings include:

Patient #32

Patient #32 was admitted to the adolescent partial hospital program (PHP) on 12/04/18 with diagnoses including attention deficit hyperactivity disorder (ADHD) predominately inattentive type, anxiety disorder, unspecified, and recurrent major depressive disorder. The patient was discharged on [DATE].

An Initial Psychiatric Evaluation dated 12/04/18, documented the patient claimed being abused sexually (touched inappropriately) at a foster home.

A Psychiatric Progress Note dated 12/12/18, documented Patient #32 disclosed that a peer in the program exposed himself to her in the bathroom a week ago.

Patient #31

Patient #31 was admitted to the adolescent partial hospital program (PHP) on 11/30/18 with diagnoses including attention deficit hyperactivity disorder (ADHD) combined, asperger's syndrome, recurrent depression and mood disorder. The patient was discharged on [DATE].

A Psychiatric Progress Note dated 12/05/18, documented Patient #31 was released from the Acute Unit due to impulsive behaviors and safety concerns.

A Treatment Plan Assessment Update dated 12/12/18, documented Patient #31 did not attend PHP treatment or participate in treatment team meeting. The Treatment Plan Assessment Update indicated to continue current medications as prescribe and discharge with outpatient therapeutic referrals for therapy and psychiatric services.

An incident report dated 12/11/18 documented the allegation was reported to the Las Vegas Metropolitan (Metro) Police Department and Child Protective Services (CPS). Both patients were processed with the therapist. All PHP staff were alerted to the incident, advised to be alert for any ongoing behaviors related to the incident, and the patient interactions were to be monitored closely by staff.

The event description documented Patient #31 asked Patient #32 into the restroom saying that it was an "emergency". Once in the restroom Patient #32 was told to close her eyes. When Patient #32 opened her eyes Patient #31's pants was seated on the toilet with pants down exposing self, and asked Patient #32 to touch him.

On 01/08/19 at 10:35 AM, the Director of Outpatient Services explained the patients were monitored by the Mental Health Technicians (MHT's) along with other assigned staff. The staff not leading the group monitored the patients going to the bathroom. The Director of Outpatient Services indicated the staff who escorted Patient #32 did not escort the patient to the adolescent group, but stood at the exit of the program space and did not see Patient #32 go into the restroom. The Director of Outpatient Services disclosed Patient #32 was told by Patient #31 to close her eyes and Patient #31 pulled his pants down. The Director of Outpatient Services indicated a week later Patient #32 told someone when it was time for her scheduled discharge.

The Director of Outpatient Services indicated the MHT's were responsible for running the group. If therapy staff lead the group there were two staff. The Director of Outpatient Services confirmed a MHT lead the adolescent group and no one monitored the patients going to the bathroom during the time the incident occurred.

On 01/15/19 at 5:33 PM, the Chief Nursing Officer (CNO) explained the outpatient area does their own staffing, but MHT's could have been pulled to cover the outpatient area if needed. The CNO indicated the Director of Outpatient Services should have called if additional staff was needed.

The outpatient program lacked staff to monitor patients for safety and prevent an occurrence of inappropriate sexual behavior between patients.
VIOLATION: SAFETY POLICY AND PROCEDURES Tag No: A0535
Based on interview and document review, the facility failed to integrate radiological services into the facility's Quality Assurance Performance Improvement (QAPI) program to maintain safety for patients and personnel.

Findings include:

The Service Agreement form dated January 18, 2018 for radiological services documented the provider (x-ray contractor) agreed to perform quarterly quality assurance/performance improvement studies as requested by the facility.

There was no documented evidence the facility integrated the radiological services into the facility QAPI program to maintain safety for the patients and personnel. There was no documented evidence the facility obtained quarterly data from the radiological contractors for their QAPI program.

On 1/11/19 at 2:00 PM, the Director of Compliance and the Chief Nursing Officer (CNO), indicated radiological contracted services were not integrated with the facility QAPI program. The CNO and the Director of Compliance indicated they did not request and obtain quarterly reports from the radiological contractor.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on observation, interview, record review and document review, the facility failed to integrate laboratory and radiological services into the facility's Quality Assurance Performance Improvement (QAPI) program.

Findings include:

1) First Addendum To Laboratory Services Agreement form dated October 1, 2015, documented performance expectations. The form indicated the contracted laboratory company would provide monthly reports to the facility regarding compliance with agreed testing procedures for monitoring and evaluation purposes. The following were to be obtained by the facility from the contracted laboratory company:

-Turn around time
-Critical Lab values
-QNS/TNP (quantity not sufficient/test not performed)
-Utilization by test (dollar and units)

There was no documented evidence the facility integrated the laboratory services into the facility QAPI program. There was no documented evidence the facility obtained monthly data from the laboratory contractors for their QAPI program.

On 1/11/19 at 2:00 PM, the Director of Compliance and the Chief Nursing Officer (CNO), indicated laboratory contracted services were not integrated with the facility QAPI program. The CNO and the Director of Compliance indicated they did not request and obtain monthly reports from the laboratory contractor.

2) The Service Agreement form dated January 18, 2018 for radiological services documented the provider (x-ray contractor) agreed to perform quarterly quality assurance/performance improvement studies as requested by the facility.

There was no documented evidence the facility integrated the radiological services into the facility QAPI program to maintain safety for the patients and personnel. There was no documented evidence the facility obtained quarterly data from the radiological contractors for their QAPI program.

On 1/11/19 at 2:00 PM, the Director of Compliance and the Chief Nursing Officer (CNO), indicated radiological contracted services were not integrated with the facility QAPI program. The CNO and the Director of Compliance indicated they did not request and obtain quarterly reports from the radiological contractor.
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 implement a Quality Assurance/Process Improvement (QAPI) program to identify, investigate, analyze and implement preventive actions regarding incidents of self injury and attempted suicide for 5 of 37 sampled patients (Patient #4, #5, #6, #24 and #36)

Findings include:

Patient #24

Patient #24 was admitted on [DATE] with diagnoses including major depressive disorder and suicidal ideations.

A Nursing Progress Note, dated 10/29/18, documented the patient was found by a social worker trying to hang self with the bed sheets. The Nurse Practitioner was notified and ordered medication to be given.

On 01/14/19 at 1:25 PM, the Registered Nurse (RN) reported Patient #24 was discovered attempted to harm himself by wrapping the bedding around his neck and then pulling on the bedding with his arms held behind the back. The RN stated an incident report should be submitted and sent to the Risk Manager for attempted suicide. The RN believed the Social Worker, who found the patient, submitted an incident report but wasn't sure.

On 01/09/18 at 1:45 PM, the Risk Manager stated patient suicide attempts were to be reported by staff, utilizing a documented incident report. After the incident report was received by the Risk Manager, the incident was to be investigated. The Risk Manager revealed he had not received an incident report regarding Patient #24's attempted hanging and had no prior knowledge of the incident. The Risk Manager did not know why the serious incident had not been reported as required by the hospital process.

Patient #36

Patient #36 was admitted on [DATE] with diagnoses including Bipolar Disorder.

A Nursing Progress Note dated 06/08/18, documented Patient #36 was found in the bathroom with blankets and clothing tied together around the neck, and around the bathroom door and the shower seat leg trying to hang themselves. A Registered Nurse (RN) called a Mental Health Technician (MHT) to assist in helping to get the door open and clothing and blankets unwound from Patient #36's neck.

A Hospital Incident Report, dated 06/08/18, indicated the incident was a suicide attempt. The attempt occurred in the bathroom of Room 405 on the Psychiatric Residential Treatment Facility (PRTF) section of the hospital. The incident report indicated Patient #36 was found in the bathroom with blankets and clothing tied together around the neck, and around the bathroom door and the shower seat leg trying to hang themselves. Patient #36 was relocated to a different unit following the incident. The incident report was reviewed by the Quality Assurance/Process Improvement Department on 06/12/18. The report documented the incident did not require investigation, a Root Cause Analysis (RCA), or further action. No recommendations were listed. The incident was closed on 06/12/18, and signed by the Risk Manager.

On 01/09/19, at 1:45 PM, the Risk Manager reported his duties included the investigation of incidents in the facility, and deciding which incidents required a formal investigation to determine actions for reducing further risk of harm. The Risk Manager verified reviewing the incident report on 06/12/18. The Risk Manager verified staff documented Patient #36 wrapped blankets and clothing around a shower seat in the bathroom of Room 405 as a means of attempting suicide. The Risk Manager acknowledged the shower seat was a ligature point where clothing or other objects could be secured for the purpose of attempted hanging, and as such were hazardous to patients. The Risk Manager reported further action should have have been taken, such as removing the shower seat or any other ligature points identified. The Risk Manager stated he was not aware if that shower seat or others like it were in continued use in the hospital.

During observations conducted from 01/09/19 though 01/11/19, Resident Room #100, #200, #204, #301, #305 and #405 contained shower chairs that were "bolted" to the shower panel.





Patient #4

On 10/12/18, Patient #4 was admitted with major depressive disorder.

On 11/17/18, a Nursing Progress Note showed Patient #4 received emergency medication per protocol because patient went into bathroom and attempted to hang self with shower curtain.

On 11/17/18, a Denial of Rights document showed Patient #4 received emergency medication per protocol because patient went into bathroom and attempted to hang self with shower curtain.

On 1/11/19, an electronic Incident Report revealed the Risk Manager received information related to the above report. The Incident Report failed to include any information regarding the patient in the bathroom attempting to hang self with shower curtain and did not investigate.

On 11/20/18 at 1:35 PM, the Psychiatrist saw the patient and documented the patient denied self harm in the past few weeks.

On 11/25/18, a Nursing Progress Note showed a suicidal ideation event related to the patient seeking assistance for a nose bleed with the revelation the patient caused the injury with broken glass.

On 11/25/18, an electronic Incident Report revealed a suicidal ideation event related to the patient seeking assistance for a nose bleed with the revelation the patient caused the injury with broken glass. The Risk Manager documented the report did not require an investigation and root cause analysis.

On 11/29/18 at 12:18 PM, a Psychiatrist saw the patient and documented treatment team was held no self injurious behavior.

On 12/27/18, a Nursing Progress Note showed the patient had self harm marks on arms after sneaking a blade in from a pass on 11/18/18. The patient indicated committing self harm days prior. The Risk Manager lacked documented evidence of an incident report and investigation by the time of the exit.

On 12/28/18, a Nursing Progress Note showed a Mental Health Tech found a needle on the floor by the patient's bed. The patient was diabetic.

On 12/28/18, a Psychiatrist saw the patient but did not document the visit until 1/8/19, after the inspection was initiated on 1/7/19.

On 1/9/19 at 8:50 PM, a Nursing Progress Note showed the patient had a shower curtain tied around neck and was discovered pulling the ends tight.

On 1/9/19 at 8:50 PM, an electronic Incident Report revealed the patient had a shower curtain tied around neck and was discovered pulling the ends tight. The Risk Manager documented an investigation was initiated on 1/10/19.

As of 1/10/19 at 6:38 PM, the medical record lacked documented evidence the Psychiatrist had evaluated the patient since 12/31/18.

Patient #5

On 10/8/18, Patient #5 was admitted with major depressive disorder.

On 10/9/18, the Psychosocial Assessment revealed the patient had history of suicidal ideation with plan to hang self and tried to kill self the day of admission.

The History and Physical documentation revealed the patient tried to kill self the day of admission and had suicidal ideation and multiple previous suicide attempts requiring hospitalization .

On 10/9/18, the Initial Psychiatriac Evaluation revealed the patient had suicidal thoughts as described in patient's own words. The Psychiatrist documented reviewing the two above documents.

On 10/8/18, the Admission Nursing Assessment revealed the nurse documented reviewing the Psychosocial Assessment.

On 1/11/19, the Treatment Plan showed the patient was programmed with Potential for Harm to Others during the first week of admission.

On 12/2/18, a Nursing Progress Note showed Patient #5 received emergency medication per protocol because of banging head on nursing desk and window, and then went to bedroom and tied a sheet around neck, tore shirt and tried to choke self in quiet room.

On 12/2/18, a Denial of Rights document showed Patient #5 received emergency medication per protocol because of banging head on nursing desk and window, and then went to bedroom and tied a sheet around neck, tore shirt and tried to choke self in quiet room.

On 12/2/18, the patient's Treatment Plan was first updated for Potential for Self Harm.

On 1/9/19 in the afternoon, the Risk Manager indicated he did not receive the Denial of Rights report, and the facility did not investigate the incidents.

On 1/11/19, an electronic Incident Report revealed the Risk Manager received information related to the above report, including the head-banging. The Incident Report failed to include any information regarding tying a sheet around neck or choking self.

Medical Record documentation showed the Psychiatrist entered the last three visits on 1/7/19 at lunch time, after the inspection began. These visits were dated 12/28/18, 12/31/18 and 1/7/19. None of the notes were identified as late entries.

Patient #6

On 10/10/18, Patient #6 was admitted with major depressive order, anxiety disorder, impulse disorder and suicidal ideation.

A Nursing Progress Note, dated 10/15/18, revealed Patient #6 wanted to die and began choking self with article of clothing.

A Nursing Progress Note, dated 10/17/18, revealed Patient #6 tied a sheet around neck, which was taken by staff. Patient #6 ripped shirt for choking self in quiet room.

On 10/17/18, a Denial of Rights document showed Patient #6 received emergency medication per protocol because of tying a sheet around neck, tore shirt and tried to choke self in quiet room.

On 1/9/19 in the afternoon, the Risk Manager indicated he did not receive the report, and the facility did not investigate the incidents.

The Critical Event Review and Reporting policy (200.14, last revised 9/2017), revealed under its definitions section: The Critical Event Policy applies to events that meet the following criteria:

1. The event results in or has the potential to cause serious harm or death (even if the outcome was not serious harm or death):
b. Attempted suicide of any patient (that does not result in a major loss of permanent function), or

3. Sexual contact between patients involving any touching of genitalia, or

4. Patient elopement, or

Staff/patient or patient/patient aggression resulting in injury to the patient...

8. Falls with significant injury...

Critical Event Analysis:

An evaluative process structured to attempt to:

Determine underlying causes of the critical event and whether there is a reasonable potential for process improvement to reduce the likelihood of such events in the future.

Procedure #6: The critical event analysis will be completed within 30 days of knowledge of the event and should include the following:

a. A determination of what happened in terms of the details of the event and the areas or services impacted.

b. Identification of why the event occurred, was there human error, a missing or weak step in the process, equipment failure, environmental or other external factors that directly affected or influenced the occurrence.

c. A flow chart of the process with identification of the steps that may have contributed to the critical event.

d. A review of the cause and effect factors contributing to the critical event.

e. An analysis of the process to prevent a repeat of the critical event specifically asking 'why' multiple times during the review of the following issues.

f. The human factor (staffing, staff competencies, performance of the staff involved, in-service education needs of the staff);

g. Information management (communication among staff, the availability of accurate, complete, unambiguous information);

h. Environmental management (physical environment appropriate to the process performed...)

i. Leadership (corporate culture conducive to risk identification and reduction, barriers to communication of potential risk factors on the unit/within the facility, priority of prevention of adverse outcomes within the unit/facility); and,

j. Any uncontrollable factors (special cause variations).

None of the incident reports inquired about during the inspection resulted in an investigation and critical event review or root cause analysis with the exception of those that occurred after the Risk Manager was informed about this administrative lapse on the afternoon of 1/9/19.

On 1/14/19 at noon, the Medical Director indicated there should be an Incident of Unknown Origin policy, if the facility did not have one. Ligature issues were previously identified during the facility's accreditation inspection in June 2018.

On 1/14/19 at 3:00 PM, the Risk Manager indicated nobody reported Patient #4, #5 and #6 as suicide attempts, only as restraint/seclusion incidents; otherwise, there would have been a full investigation for the suicide attempts. The Risk Manager acknowledged there was no Community Committee, no Grievance Committee and no grievance investigations.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interview, record review and document review, the facility failed to ensure an effective governing body was legally responsible for the conduct of the hospital and failed to: 1) ensure that the medical staff was accountable to the governing body for the quality of care provided to patients (Tag A 0049); 2) have physicians responsible for the care of each patient with respect to psychiatric problems that were present on admission or developed during hospitalization (Tag A0068). integrate Anesthesia services into the facility's Quality Assurance Performance Improvement (QAPI) program (Tag 0083).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory mandated care to patients.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, record review, interview and document review, the Governing Body failed to ensure the medical staff was accountable to the Governing Body for the quality of care provided to patients. The physicians failed to ensure care and treatment was provided to patients with inappropriate sexual activity histories when present at admission and/or after they became known during hospitalization for 14 of 37 patients (Patient #1, #2, #3, #7, #8, #9, #32, #31, #13, #33, #37, #10, #26 and #35).

Findings include:

42 CFR Part 488.301 Definitions:

Neglect is the failure of the facility, its employees or service providers to provide goods and services to patients that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Facility Policy: The Patient Abuse or Neglect policy (1800.30, last revised September 2017) revealed neglect was a form of abuse in which there was failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Facility Policy: The Patient Abuse or Neglect policy (1800.30, last revised September 2017) revealed sexual abuse was defined as any unwanted sexual activity, without regard to contact or injury; any sexual activity with a person whose capacity to consent or resist is limited.

Facility Procedures:
Procedure #2 of the Unit/Bed Assignment of Patients Upon Admission or Transfers During Treatment policy (1000.132, last reviewed October 2018) revealed bed assignment would be made by the Charge Nurse. Bed assignment would be based on program assignment; social and/or emotional maturity; and special protocol. The charge nurse would review with the admitting physician history of physical/sexual/emotional abuse and perpetration as well as history of acting out behaviors in order to help determine appropriate bed assignment.

Procedure #2 of the Levels of Observation policy (1000.24, last revised October 2018), patients identified to be at risk for displaying sexually inappropriate behaviors would be put on SRP precautions on the electronic medical record and would be assigned to a room without a roommate.

Procedure #3 of the Levels of Observation policy (1000.24, last revised October 2018), the Registered Nurse may increase the level of observation if the patient's condition changes...If a client's behavior/mood necessitated a more intensive level of observation...

Patient Rights provided by the facility:

1. The right to dignity, respect, privacy, humane care and freedom from mental and physical abuse, neglect and exploitation.

17. The right to have an individualized treatment plan specific to your individualized needs...

On 1/10/19 at 11:30 AM, a Registered Nurse (RN) who conducted an Admission Nursing Assessment was interviewed regarding the facility's policy of using sexual restrictive precautions (SRP). The RN indicated it meant patients would have their own room, and other patients could not be in the room. The patient with these precautions either had a solo room or slept near the nurse station.


Patient #1

On 11/30/18, Patient #1 was admitted with major depressive disorder and bipolar disorder. Patient #1 had a history of inappropriate sexual behavior during previous stays at the facility.

Patient #1 History and Physical, the Psychosocial Assessment, the initial Psychiatric Evaluation and the Nursing Admission Assessment all dated 11/30/18, revealed a history of sexual abuse.

Procedure #2 of the Levels of Observation policy (1000.24, last revised October 2018), patients identified to be at risk for displaying sexually inappropriate behaviors would be put on SRP precautions on the electronic medical record and would be assigned to a room without a roommate.

On 1/7/19 in the morning, a patient census report was observed and obtained for patients in the Psychiatric Residential Treatment Facility (PRTF) area. Patient #1 was not on sexual restrictive precautions (SRP) and was placed with a roommate.

On 12/12/18, Patient #1 saw a therapist for a Treatment Plan Assessment.

Patient #1's Treatment Plan initiated in December 2018 revealed the following:

Therapist will assist in developing a safety plan.
Therapist will facilitate groups.
Therapist will assist with support and psychoeducation.
Therapist will assist with identifying role of drugs as means of numbing and escaping feelings.
Therapist will assess for patterns of impulsivity.
Client will be referred for psychological testing.

On 12/20/18, a Licensed Clinical Social Worker documented a check in with the patient due to the therapist being out.

Patient #1's medical record lacked documented evidence of a Treatment Plan for sexually inappropriate behavior until 1/13/19, after the complaint inspection revealed the facility treatment team failed to design a Treatment Plan for this problem.

On 1/15/19 at 12:52 PM, Patient #1 verbalized the following: being told two therapists were terminated, and Patient #1 had not received therapy since. Patient #1 expressed the need for having a therapist but did not have one assigned. Patient #1 saw a therapist a few times per month during an earlier stay, but a parent had to prompt the therapist to see Patient #1. Patient #1 was unable to speak to parents frequently enough and became emotional when speaking. The facility stopped doing nursing/therapy groups because of staffing. Patient #1 was bothered by the fact the facility moved Patient #1 a number of times, and Patient #1 did not know why.

As of 1/15/19 at 1:43 PM with the Medical Records Director present, Patient #1's medical record lacked documented evidence of having an assigned clinical therapist for individual therapy.

Patient #2

On 12/10/18, Patient #2 was admitted with self harm and placed on sexual restrictive precautions.

The History and Physical dated 12/10/18, revealed hypersexuality and sexual abuse.

On 12/11/18, a Psychiatrist documented an Initial Psychiatric Evaluation revealing hypersexuality.

On 12/11/18, a Psychosocial Assessment revealed Patient #2 was acting hypersexual with an admitted history of abuse/exploitation.

On 12/10-11/18, the Nursing Admission Assessment revealed no connection to the patient's hypersexuality and sexual abuse history. Although the nurse acknowledged reviewing the Psychosocial Assessment.

On 12/21/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate touching with another patient. Facility census data showed Patient #2 had a roommate.

On 12/22/18, an Incident Report revealed staff saw Patient #2 engaged in inappropriate touching with another patient, but Patient #2 denied it. The Risk Manager documented the report did not require an investigation and root cause analysis.

On 12/24/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate sexual behavior with a second patient. Facility census data showed Patient #2 had a roommate until 12/25-26/18.

On 12/24-25/18, an Incident Report revealed a patient was told by Patient #2 and another patient the two had sex, but when confronted by staff, the two denied it. A Mental Health Tech was involved in the incident as redirecting the participants, and that staff member was not prompted for a statement about the incident. The Risk Manager documented the report did not require an investigation and root cause analysis.

On 1/3/19, a Psychiatric Progress Note revealed Patient #2's family member expressed anger regarding the two sexual incidents. The Psychiatrist assured the facility did its best to ensure the safety of every patient.

On 1/5/19, Patient #2's medical record revealed the only documented clinical therapy session for the month of January 2019.

On 1/7/19, the same Psychiatrist, who reassured the family member, entered three visits for 12/28/18, 1/3/19 and 1/7/19, after the inspection was initiated. None of the notes were designated as late entries. The documents were all initiated and time/date stamped on 1/7/19; the software allowed clinicians to manipulate the date by scrolling to the date intended for a past entry.

On 1/10/19 at noon, a Registered Nurse (RN) currently working on the PRTF unit indicated the following: The RN was familiar with Patient #2. The RN indicated Patient #2 should have had SRP precautions. It meant not being in close contact with peers, line of sight/1:1 observation, but it required a physician order. The RN was unaware if the SRP patients had to have their own room, but it usually lasted the length of the stay. The RN was unaware Patient #2 already had two sexually inappropriate incidences within the building.

On 1/11/19 in the afternoon, the Medical Records Director acknowledged and demonstrated the aforementioned entries in the Medical Records Office.

Patient #2's medical record lacked documented evidence of a Treatment Plan for sexually inappropriate behavior until 1/13/19, after the inspection revealed the treatment team failed to design a Treatment Plan for this problem. The Treatment Plan lacked documented evidence of any updates between the 12/10-18/18 plan goals initiated during the first week of post admission and 1/13/19.

On 1/15/19 at 12:30 PM, Patient #2 verbalized the following: The patient wanted a therapist to talk to and felt there should be more therapeutic activities available, but had not seen a therapist in some time because no therapist was assigned, and the previous therapist was terminated. The patient was told the terminated therapist had to take care of a dog. The patient did not want a social worker. The patient was unable to recall the last Psychiatrist visit.

Patient #3

On 12/4/18, Patient #3 was admitted for major depressive disorder.

On 12/13/18, an Incident Report revealed the patient had sex with another patient from the unit in the bathroom. The patient indicated being the initiator. Patient #3 was not placed on SRP precautions. The Risk Manager wrongfully indicated the police did not need to be called because both parties were above the legal age of consent. The perpetrator was of legal age, but the victim was not.

On 12/17/18, Patient #3 was transferred to another unit.

On 12/17/18, a Nursing Admission Assessment revealed the patient was sexually active and did not practice safe sex.

On 12/18/18, a Psychosocial Assessment revealed the patient's sexual abuse history as a victim.

On 12/18/18, the Initial Psychiatric Assessment revealed sexual preoccupation. Patient #3 still was not placed on SRP precautions.

On 12/24/18, a Nursing Progress Note revealed the patient engaged in sexual activity with another patient.

On 12/24/18, an Incident Report revealed the patient had a sexual incident with another patient on the unit. Facility census data showed Patient #3 continued to have a roommate and was still not placed on SRP precautions.

On 12/27/18, a Nursing Progress Note revealed the patient had self harm and a blade was used. The nurse did not find a blade initially. The patient turned the blade in.

On 12/28/18, a Psychiatrist documented a progress note showing awareness of the sexual incident dated 12/24/18. Patient #3 still was not placed on SRP precautions.

On 1/3/19, a Psychiatrist documented a progress note.

Patient #3's medical record lacked documented evidence of a clinical therapy visit except for one documented on 1/4/19.

On 1/4/19, a Nursing Progress Note showed the patient first threatened and then removed shirt and pulled pants down in class when another patient did not apologize for something. An hour later, the patient received emergency Zydis per protocol for agitation, pacing and verbalizing a desire for sex. Patient #3 still was not placed on SRP precautions.

On 1/7/19 in the morning, a patient census report was observed and obtained for patients in the Psychiatric Residential Treatment Facility area (PRTF). Patient #3 was not placed on SRP precautions and was placed with a roommate.

On 1/10/19 at noon, a Registered Nurse (RN) currently working on the PRTF unit indicated the following: The RN was familiar with Patient #3. The RN indicated Patient #3 should have had SRP precautions. It meant not being in close contact with peers, line of sight/1:1 observation, but it required a physician order. The RN was unaware if the SRP patients had to have their own room, but it usually lasted the length of the stay. The RN was unaware Patient #3 already had two sexually inappropriate incidences within the building.

On 1/10/19 at 1:00 PM, the Unit Manager (UM) verbalized the following: The UM Knew of the two incidents with Patient #3. Patient #3 was previously on another unit before being transferred to the present unit. The UM was unable to answer why unit nurses were not informed or why patients were not placed on SRP, except to say the unit relied on a verbal report at the time of transfer from one unit to the next. Treatment plans were supposed to be updated with new problems/interventions as they presented.

On 1/11/19, a Psychiatric Progress Note showed an increase in medication for persistent sexual urges.

Patient #3's medical record lacked documented evidence of a treatment plan for sexually inappropriate behavior until 1/13/19, after the complaint inspection revealed the treatment team failed to assess the behavior and update the treatment plan for this problem.

On 1/15/19 at 12:20 PM, Patient #3 had a difficult time discussing urges with the therapist, but indicated seeing a therapist for a total of twenty minutes so far during the stay.

Patient #7

On 12/13/18, Patient #7 was admitted with recurrent major depressive disorder.

On 12/20/18, a Psychiatric Progress Note revealed patient had a significant history of sexual abuse and neglect. The Psychiatrist did not place Patient #7 on SRP precautions.

On 12/21/18, a Nursing Progress Note showed Patient #7 engaged in inappropriate touching with another patient. Facility census data showed Patient #7 had a roommate and was not placed on SRP precautions.

On 1/7/19 in the morning, a patient census report was observed and obtained for patients in the Psychiatric Residential Treatment Facility area (PRTF). Patient #7 was not placed on SRP precautions and was placed with a roommate.

Patient #7's medical record lacked documented evidence of a treatment plan for sexual abuse history until 1/13/19, after the inspection revealed the treatment team failed to identify the behavior/history as a problem and design/update the treatment plan for this problem.

On 1/15/19 at 12:10 PM, Patient #7 expressed not receiving therapy because the therapist disappeared three weeks ago.

Patient #8

On 9/7/18, Patient #8 was admitted with bipolar disorder.

On 9/8/18, the initial Psychiatric Evaluation showed Patient #8 had a traumatic victim of sexual abuse history.

On 1/7/19 in the morning, a patient census report was observed and obtained for patients in the Psychiatric Residential Treatment Facility area (PRTF). Patient #8 was not placed on SRP precautions.

The successive Psychiatric Progress Notes highlighted the sexual abuse history, but Patient #8's medical record lacked documented evidence of a treatment plan for sexual abuse history until 1/13/19.

Patient #9

Patient #9 was admitted on [DATE] with diagnoses including ADHD, Bipolar I Disorder, Oppositional Defiant Disorder, post-traumatic stress disorder (PTSD). The patient was ordered precautions and observations including assault precaution, sexual aggressor precaution, and sexual reactive precautions (SRP).

On 1/15/19 at 4:00 PM, Patient #9 verbalized frustration there was no treatment plan discussion and no therapist assigned. Nobody discussed accomplishing goals. Groups were run more frequently during the previous stay at the facility.


Patient #26

Patient #26 was admitted [DATE] with diagnoses including dementia and psychotic disorder.

On 1/9/19 at 9:15 AM, Patient #26 was sitting in a wheelchair in the common area of Unit 500. The patient had a laceration to the bridge of the nose, swelling and discolored bruising surrounding the left orbital area a "black eye."

On 1/9/19 in the morning, the charge nurse indicated Patient #26 fell in the bedroom during the night and sustained injuries to the left side of the head, nose and left eye. The nurse also indicated the patient was complaining of of pain to the hips and legs. The charge nurse indicated the fall was not witnessed by any staff and the patient's roommate indicated Patient #26 fell . The patient also indicated a fall occurred in the room. The charge nurse indicated both patients were confused. The charge nurse indicated there was no investigation completed or needed due to what the patients said. The charge nurse indicated Patient #26 and the roommate slept in the same room during the night after the injuries were identified by the staff.

On 1/9/19 at 9:20 AM, Patient #26 was alert and oriented x1 to person only. The patient rambled some incoherent sentences and was asked by the Inspector on how the injuries to the face and head were sustained with no mention of the patient's roommate or any fall during the conversation. The patient indicated the roommate kept taking her things and the roommate wanted to be the boss. Patient #26 indicated the roommate kept hitting her.

The Psychiatric Progress Note form dated 1/8/19 at 18:59 (6:59 PM), documented the patient was confused.

The Nursing Progress Note form dated 1/8/19 at 21:40 (9:40 PM), the patient was found standing in the room with a cut on the nose. The staff interviewed the roommate and the roommate stated Patient #26 fell .

On 1/9/19 at 9:55 AM, Patient #34 (roommate of Patient #26) was alert and oriented times (x) 1-2, to person and place. The patient indicated the year was 1998, was not able to give the month and was aware the city was Las Vegas but was unable to give what building she was in.

On 1/9/19 in the morning, the Quality Assurance Coordinator indicated the facility had no policy regarding investigating injuries of unknown origin. The Coordinator indicated since both residents were confused and no staff witnessed the incident an investigation should have been conducted.

There was no documented evidence an investigation was performed to determine how the patient sustained numerous injuries to the facial area from a single fall. There was no documented evidence interviews were obtained from other possible witnesses due to both patients who were interviewed were known to have confusion to determine if the unwitnessed incident was an actual fall or a physical abuse altercation.

Patient #35

Patient #35 was admitted on [DATE] and discharged on [DATE], with diagnoses including personal history of adult physical and sexual abuse, suicidal ideation and major depressive disorder.

Patient #35 documented on a Compliment/Complaint/Suggestion Form dated 11/11/18, the patient's rights were violated and threatened my a roommate.

An event follow-up on 11/12/18 at 1:59 PM, indicated the response to the complaint IR (incident reports were confidential and could not be printed out and the patient had the right to consult an attorney.

On 1/11/19 in the Quality Assurance Coordinator confirmed there was no investigation completed for Patient #35's allegations of being threatened by the roommate and there should have been one conducted.

Complaint #NV 061


A High Risk/High alert Handoff was not completed on admission to identify Patient #9 for behaviors of sexually acting out as an aggressor or victim.

Patient #9's Treatment Plans were not updated to include the patient's inappropriate sexual behaviors. An actual incident of inappropriate sexual behavior occurred on 12/13/18.

Patient #13

Patient #13 was admitted on [DATE] with diagnoses including conduct disorder, group type, unspecified mood affective disorder, and potential harm to others (aggressive and defiant behavior).

Patient #13 was ordered precautions and observations including Sexually acting out precaution, line of sight (LOS) while awake (WA), suicide precaution, observation every (q) 15 minutes, and sexual aggressor.

The staff unit work sheet dated 01/11/19 documented "Watch with [Female Patient]" and indicated the patient was planning to have sex in the bathroom". The patient was not placed on SRP.

An order for precautions for sexually acting and Line of Sight (LOS) was not done or precautions initiated until 01/12/19.

Patient #33

Patient #33 was admitted on [DATE] with diagnoses including attention deficit hyperactivity disorder (ADHD) combined type, bipolar I disorder, family discord, major depressive disorder no-psychotic recurrent, severe, post-traumatic stress disorder (PTSD), social discord, potential for self-harm.

Patient #33 was ordered precautions and observations including sexually acting out precautions, suicide precautions, line of sight while awake, every 15 minute observation, and sexual aggressor precautions.

Patient #33's Treatment Plan not updated to include SRP.

A High Risk/High Alert Handoff dated 01/06/19, documented the patient was sexually acting out (SAO) and an aggressor and a victim. An order for SRP precautions was not initiated until 01/12/19.

Patient #37

Patient #37 was admitted on [DATE] with diagnoses including major depressive disorder and recurrent severe psychosis.

The staff unit work sheet dated 01/11/19 identified Patient #37 as planning to have inappropriate sexual contact with a peer in the bathroom. The Patient #37 was not placed on SRP until it was identified the patient had planned to attempt inappropriate sexual contact with a second peer on 01/13/19.

Patient #10

Patient #10 was admitted on [DATE], with diagnoses including major depressive disorder and recurrent severe psychosis, ADHD combined type , and unspecified mood disorder. Patient #10 was ordered precautions and observations including SRP, LOS WA, q 15 min checks, assault, and suicide.

Patient #10's Treatment Plans were not updated to include the patient's inappropriate sexual behaviors.

On 01/08/19 at approximately 9:10 AM, a Registered Nurse (RN) identified having two patients in the acute pediatric and adolescent unit on sexual reactive precautions (SRP).

On 01/08/19 in the morning, a Registered Nurse (RN) explained the SRP precautions were when a patient was on sexual restrictive precautions, on One-to-One Observation (1:1) and placed in a private room. The RN indicated not being aware of a policy.

On 01/08/19 in the morning, another RN indicated SRP a patient was placed on SRP precautions when a need was identified such as being sexually traumatized. The RN indicated they needed to watch the patient, the patient was roomed by self and monitored with peers. The RN indicated not knowing if the SRP protocol was an official process.

Patient #32

Patient #32 was admitted to the adolescent partial hospital program (PHP) on 12/04/18 with diagnoses including attention deficit hyperactivity disorder (ADHD) predominately inattentive type, anxiety disorder, unspecified, and recurrent major depressive disorder. The patient was discharged on [DATE].

An Initial Psychiatric Evaluation dated 12/04/18, documented the patient claimed being abused sexually (touched inappropriately) at a foster home.

A Psychiatric Progress Note dated 12/12/18, documented Patient #32 disclosed that a peer in the program exposed himself to her in the bathroom a week ago.

Patient #31

Patient #31 was admitted to the adolescent partial hospital program (PHP) on 11/30/18 with diagnoses including attention deficit hyperactivity disorder (ADHD) combined, asperger's syndrome, recurrent depression and mood disorder. The patient was discharged on [DATE].

A Psychiatric Progress Note dated 12/05/18, documented Patient #31 was released from the Acute Unit due to impulsive behaviors and safety concerns.

A Treatment Plan Assessment Update dated 12/12/18, documented Patient #31 did not attend PHP treatment or participate in treatment team meeting. The Treatment Plan Assessment Update indicated to continue current medications as prescribe and discharge with outpatient therapeutic referrals for therapy and psychiatric services.

An incident report dated 12/11/18 documented the allegation was reported to the Las Vegas Metropolitan (Metro) Police Department and Child Protective Services (CPS). Both patients were processed with the therapist. All PHP staff were alerted to the incident, advised to be alert for any ongoing behaviors related to the incident, and the patient interactions were to be monitored closely by staff.

The event description documented Patient #31 asked Patient #32 into the restroom saying that it was an "emergency". Once in the restroom Patient #32 was told to close her eyes. When Patient #32 opened her eyes Patient #31's pants was seated on the toilet with pants down exposing self, and asked Patient #32 to touch him.

The report document of the incident was reviewed by the Director of Compliance Quality and Risk (DCQR) which indicated the staff took the appropriate action in response to the incident. The DCQR indicated the incident did not meet the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) nor the State of Nevada definition of a Sentinel event and did not require a formal investigation, and a formal Root Cause Analysis was not recommended.

On 01/08/19 at 10:35 AM, the Director of Outpatient Services explained the patients were monitored by the Mental Health Technicians (MHT's) along with other assigned staff. The staff not leading the group monitored the patients going to the bathroom. The Director of Outpatient Services indicated the staff who escorted Patient #32 did not escort the patient to the adolescent group, but stood at the exit of the program space and did not see Patient #32 go into the restroom. The Director of Outpatient Services disclosed Patient #32 was told by Patient #31 to close her eyes and Patient #31 pulled his pants down. The Director of Outpatient Services indicated a week later Patient #32 told someone when it was time for her scheduled discharge.

The Director of Outpatient Services indicated the MHT's were responsible for running the group. If therapy staff lead the group there were two staff. The Director of Outpatient Services confirmed a MHT lead the adolescent group and no one monitored the patients going to the bathroom during the time the incident occurred.

On 01/15/19 at 5:33 PM, the Chief Nursing Officer (CNO) explained the outpatient area does their own staffing, but MHT's could have been pulled to cover the outpatient area if needed. The CNO indicated the Director of Outpatient Services should have called if additional staff was needed.

The outpatient area lacked staff to monitor patients for safety and prevent an occurrence of inappropriate sexual behavior between patients.

On 01/08/19 at 10:48 AM, the Director of Outpatient Services explained an investigation was done and the outcome was there was no touching. The Director of Outpatient Services indicated the family, CPS and Metro were called per facility policy. The Director of Outpatient Services indicated the Therapist spoke to the MHT's regarding the incident, talked to the family, the male patient was discharged the next day and we set staffing.

On 01/09/19 at 1:50 PM, the Director of Compliance Quality and Risk (DCQR) confirmed no formal investigation or root cause analysis was done for the complaint. The DCQR indicated not being aware if training was done with the staff in the outpatient area.

A facility policy entitled Critical Event Review and Reporting, 200.14, Effective date: 10/01/16, Revised 09/2017, documented guidelines for communicating, investigating and acting upon critical events. The policy indicated any actual or alleged inappropriate sexual contact between staff and current patients or individuals who were patients within two years from discharge, (to include inappropriate verbal or written communication and/or inappropriate physical contact).

The critical event analysis will completed with 30 days of knowledge of the event, and should include the following:
-A determination of what happened in terms of the details of the event and the areas or services impacted.
-Identification of hwy the event occurred, i.e. was there human error, a missing or weal step in the process, equipment failure, environmental or other external factors that directly affected or influenced the occurrence.
-A flow chart of the process with identification of the steps that may have contributed to the critical event.
-A review of the cause and effect factors contributing to the critical event.
-An analysis of the process to prevent a repeat of the critical event specifically asking "why" multiple times during the review of the following issues.
-The human factor (staffing, staff competencies, performance of the staff involved, in-service education needs of the staff);
-Information management (communication among staff, the availability of accurate,complete, unambiguous information;
-Environmental management(physical environment appropriate to the process performed, emergency preparedness planed and tested , identification of environmental risks such as lighting);
-Leadership (corporate culture conducive to risk identification and reduction, barriers to communication of potential risk factors on the unit/within the facility, priority of prevention of adverse outcomes within the unit/facility; and,
-Any uncontrollable factors.

Complaint #NV 530

On 1/11/19 at 9:00 AM, the Medical Director of the Unit (housing Patient #1, #2 and #3), a Psychiatrist indicated the following: The main part of the job was initial psychiatric evaluations and weekly progress notes for one unit and daily progress notes for the other unit. Sexual restrictive precautions (SRP) meant line of sight observation, single rooms with the precautions reviewed every other day. Patient #2 was known, so Patient #2 was placed on SRP precautions since admission. The rooms were probably full, which would explain why Patient #3 had a roommate when the bureau walked in on 1/7/19. The first incident of Patient #3, dated 12/13/18, was acknowledged. The second incident of Patient #3, dated 12/24/18, was acknowledged. Not everyone with sexually inappropriate behavior history needed to be on precautions. There was no explanation as to why Patient #3 was not placed on SRP precautions, except probably should be now. The Psychiatrist was unable to recall the history of Patient #1, which was documented in the initial Psychiatric Evaluation. The Psychiatrist was unable to recall if Patient #1 was on SRP precautions or a request for the order. [The request was made on 1/10/19]. The Psychiatrist acknowledged notes were entered weekly until hearing three sets of Patient #2's visits were entered on 1/7/19. Then the Psychiatrist verbalized there had been no discussion regarding late notes entered for visits and indicated maybe the scribe was late and it was a trick question.

After the immediate jeopardy was called regarding the protection of patients with sexual inappropriate behavior histories or acting out during their stays on 1/9/19, the facility provided a precaution list for each patient in the building: the facility only identified three patients with sexual restrictive precautions on 1/10/19.

On 1/11/19 from 10:30 AM to noon, interviews were conducted with the following staff:

Chief Clinical Officer (a Clinical Psychologist) who served on the Med-Executive Committee, Quality Committee and Governing Body.

The Director of Clinical Services who oversaw day to day functions of therapists.

The Chief Nursing Officer.

The treatment team designed the full continuum of care. Goals were supposed to be set and individualized at admission with a start date. The target date was set to assess whether the patient accomplished the goal. The treatment team included the Psychiatrist, Medical Doctor, Nurse, Family Members, Patient and Case Worker. The History and Physical was completed within 24 hours of admission. Patients were placed on daily medical log for issues to be seen by a medical doctor. The History and Physical was updated every 30 days. Nurse Practitioners could see patients also. In the Acute Youth unit, patients were seen daily with notes required. The treatment team met weekly. In the PRTF, patients were seen weekly with notes required. The treatment team met monthly. The treatment team discussed the past month. Therapists and nurses were responsible for goal setting/reviewing, u
VIOLATION: CARE OF PATIENTS - RESPONSIBILITY FOR CARE Tag No: A0068
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, interview and document review, the facility failed to ensure a physician monitored the care and treatment of patients with inappropriate sexual activity histories when present at admission and/or after they became known during hospitalization for 14 of 37 patients (Patient #1, #2, #3, #7, #8, #9, #32, #31, #13, #33, #37, #10, #26 and #35).

Findings include:

42 CFR Part 488.301 Definitions:

Neglect is the failure of the facility, its employees or service providers to provide goods and services to patients that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Facility Policy: The Patient Abuse or Neglect policy (1800.30, last revised September 2017) revealed neglect was a form of abuse in which there was failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Facility Policy: The Patient Abuse or Neglect policy (1800.30, last revised September 2017) revealed sexual abuse was defined as any unwanted sexual activity, without regard to contact or injury; any sexual activity with a person whose capacity to consent or resist is limited.

Facility Procedures:
Procedure #2 of the Unit/Bed Assignment of Patients Upon Admission or Transfers During Treatment policy (1000.132, last reviewed October 2018) revealed bed assignment would be made by the Charge Nurse. Bed assignment would be based on program assignment; social and/or emotional maturity; and special protocol. The charge nurse would review with the admitting physician history of physical/sexual/emotional abuse and perpetration as well as history of acting out behaviors in order to help determine appropriate bed assignment.

Procedure #2 of the Levels of Observation policy (1000.24, last revised October 2018), patients identified to be at risk for displaying sexually inappropriate behaviors would be put on SRP precautions on the electronic medical record and would be assigned to a room without a roommate.

Procedure #3 of the Levels of Observation policy (1000.24, last revised October 2018), the Registered Nurse may increase the level of observation if the patient's condition changes...If a client's behavior/mood necessitated a more intensive level of observation...

Patient Rights provided by the facility:

1. The right to dignity, respect, privacy, humane care and freedom from mental and physical abuse, neglect and exploitation.

17. The right to have an individualized treatment plan specific to your individualized needs...

On 1/10/19 at 11:30 AM, a Registered Nurse (RN) who conducted an Admission Nursing Assessment was interviewed regarding the facility's policy of using sexual restrictive precautions (SRP). The RN indicated it meant patients would have their own room, and other patients could not be in the room. The patient with these precautions either had a solo room or slept near the nurse station.


Patient #1

On 11/30/18, Patient #1 was admitted with major depressive disorder and bipolar disorder. Patient #1 had a history of inappropriate sexual behavior during previous stays at the facility.

Patient #1 History and Physical, the Psychosocial Assessment, the initial Psychiatric Evaluation and the Nursing Admission Assessment all dated 11/30/18, revealed a history of sexual abuse.

Procedure #2 of the Levels of Observation policy (1000.24, last revised October 2018), patients identified to be at risk for displaying sexually inappropriate behaviors would be put on SRP precautions on the electronic medical record and would be assigned to a room without a roommate.

On 1/7/19 in the morning, a patient census report was observed and obtained for patients in the Psychiatric Residential Treatment Facility (PRTF) area. Patient #1 was not on sexual restrictive precautions (SRP) and was placed with a roommate.

On 12/12/18, Patient #1 saw a therapist for a Treatment Plan Assessment.

Patient #1's Treatment Plan initiated in December 2018 revealed the following:

Therapist will assist in developing a safety plan.
Therapist will facilitate groups.
Therapist will assist with support and psychoeducation.
Therapist will assist with identifying role of drugs as means of numbing and escaping feelings.
Therapist will assess for patterns of impulsivity.
Client will be referred for psychological testing.

On 12/20/18, a Licensed Clinical Social Worker documented a check in with the patient due to the therapist being out.

Patient #1's medical record lacked documented evidence of a Treatment Plan for sexually inappropriate behavior until 1/13/19, after the complaint inspection revealed the facility treatment team failed to design a Treatment Plan for this problem.

On 1/15/19 at 12:52 PM, Patient #1 verbalized the following: being told two therapists were terminated, and Patient #1 had not received therapy since. Patient #1 expressed the need for having a therapist but did not have one assigned. Patient #1 saw a therapist a few times per month during an earlier stay, but a parent had to prompt the therapist to see Patient #1. Patient #1 was unable to speak to parents frequently enough and became emotional when speaking. The facility stopped doing nursing/therapy groups because of staffing. Patient #1 was bothered by the fact the facility moved Patient #1 a number of times, and Patient #1 did not know why.

As of 1/15/19 at 1:43 PM with the Medical Records Director present, Patient #1's medical record lacked documented evidence of having an assigned clinical therapist for individual therapy.

Patient #2

On 12/10/18, Patient #2 was admitted with self harm and placed on sexual restrictive precautions.

The History and Physical dated 12/10/18, revealed hypersexuality and sexual abuse.

On 12/11/18, a Psychiatrist documented an Initial Psychiatric Evaluation revealing hypersexuality.

On 12/11/18, a Psychosocial Assessment revealed Patient #2 was acting hypersexual with an admitted history of abuse/exploitation.

On 12/10-11/18, the Nursing Admission Assessment revealed no connection to the patient's hypersexuality and sexual abuse history. Although the nurse acknowledged reviewing the Psychosocial Assessment.

On 12/21/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate touching with another patient. Facility census data showed Patient #2 had a roommate.

On 12/22/18, an Incident Report revealed staff saw Patient #2 engaged in inappropriate touching with another patient, but Patient #2 denied it. The Risk Manager documented the report did not require an investigation and root cause analysis.

On 12/24/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate sexual behavior with a second patient. Facility census data showed Patient #2 had a roommate until 12/25-26/18.

On 12/24-25/18, an Incident Report revealed a patient was told by Patient #2 and another patient the two had sex, but when confronted by staff, the two denied it. A Mental Health Tech was involved in the incident as redirecting the participants, and that staff member was not prompted for a statement about the incident. The Risk Manager documented the report did not require an investigation and root cause analysis.

On 1/3/19, a Psychiatric Progress Note revealed Patient #2's family member expressed anger regarding the two sexual incidents. The Psychiatrist assured the facility did its best to ensure the safety of every patient.

On 1/5/19, Patient #2's medical record revealed the only documented clinical therapy session for the month of January 2019.

On 1/7/19, the same Psychiatrist, who reassured the family member, entered three visits for 12/28/18, 1/3/19 and 1/7/19, after the inspection was initiated. None of the notes were designated as late entries. The documents were all initiated and time/date stamped on 1/7/19; the software allowed clinicians to manipulate the date by scrolling to the date intended for a past entry.

On 1/10/19 at noon, a Registered Nurse (RN) currently working on the PRTF unit indicated the following: The RN was familiar with Patient #2. The RN indicated Patient #2 should have had SRP precautions. It meant not being in close contact with peers, line of sight/1:1 observation, but it required a physician order. The RN was unaware if the SRP patients had to have their own room, but it usually lasted the length of the stay. The RN was unaware Patient #2 already had two sexually inappropriate incidences within the building.

On 1/11/19 in the afternoon, the Medical Records Director acknowledged and demonstrated the aforementioned entries in the Medical Records Office.

Patient #2's medical record lacked documented evidence of a Treatment Plan for sexually inappropriate behavior until 1/13/19, after the inspection revealed the treatment team failed to design a Treatment Plan for this problem. The Treatment Plan lacked documented evidence of any updates between the 12/10-18/18 plan goals initiated during the first week of post admission and 1/13/19.

On 1/15/19 at 12:30 PM, Patient #2 verbalized the following: The patient wanted a therapist to talk to and felt there should be more therapeutic activities available, but had not seen a therapist in some time because no therapist was assigned, and the previous therapist was terminated. The patient was told the terminated therapist had to take care of a dog. The patient did not want a social worker. The patient was unable to recall the last Psychiatrist visit.

Patient #3

On 12/4/18, Patient #3 was admitted for major depressive disorder.

On 12/13/18, an Incident Report revealed the patient had sex with another patient from the unit in the bathroom. The patient indicated being the initiator. Patient #3 was not placed on SRP precautions. The Risk Manager wrongfully indicated the police did not need to be called because both parties were above the legal age of consent. The perpetrator was of legal age, but the victim was not.

On 12/17/18, Patient #3 was transferred to another unit.

On 12/17/18, a Nursing Admission Assessment revealed the patient was sexually active and did not practice safe sex.

On 12/18/18, a Psychosocial Assessment revealed the patient's sexual abuse history as a victim.

On 12/18/18, the Initial Psychiatric Assessment revealed sexual preoccupation. Patient #3 still was not placed on SRP precautions.

On 12/24/18, a Nursing Progress Note revealed the patient engaged in sexual activity with another patient.

On 12/24/18, an Incident Report revealed the patient had a sexual incident with another patient on the unit. Facility census data showed Patient #3 continued to have a roommate and was still not placed on SRP precautions.

On 12/27/18, a Nursing Progress Note revealed the patient had self harm and a blade was used. The nurse did not find a blade initially. The patient turned the blade in.

On 12/28/18, a Psychiatrist documented a progress note showing awareness of the sexual incident dated 12/24/18. Patient #3 still was not placed on SRP precautions.

On 1/3/19, a Psychiatrist documented a progress note.

Patient #3's medical record lacked documented evidence of a clinical therapy visit except for one documented on 1/4/19.

On 1/4/19, a Nursing Progress Note showed the patient first threatened and then removed shirt and pulled pants down in class when another patient did not apologize for something. An hour later, the patient received emergency Zydis per protocol for agitation, pacing and verbalizing a desire for sex. Patient #3 still was not placed on SRP precautions.

On 1/7/19 in the morning, a patient census report was observed and obtained for patients in the Psychiatric Residential Treatment Facility area (PRTF). Patient #3 was not placed on SRP precautions and was placed with a roommate.

On 1/10/19 at noon, a Registered Nurse (RN) currently working on the PRTF unit indicated the following: The RN was familiar with Patient #3. The RN indicated Patient #3 should have had SRP precautions. It meant not being in close contact with peers, line of sight/1:1 observation, but it required a physician order. The RN was unaware if the SRP patients had to have their own room, but it usually lasted the length of the stay. The RN was unaware Patient #3 already had two sexually inappropriate incidences within the building.

On 1/10/19 at 1:00 PM, the Unit Manager (UM) verbalized the following: The UM Knew of the two incidents with Patient #3. Patient #3 was previously on another unit before being transferred to the present unit. The UM was unable to answer why unit nurses were not informed or why patients were not placed on SRP, except to say the unit relied on a verbal report at the time of transfer from one unit to the next. Treatment plans were supposed to be updated with new problems/interventions as they presented.

On 1/11/19, a Psychiatric Progress Note showed an increase in medication for persistent sexual urges.

Patient #3's medical record lacked documented evidence of a treatment plan for sexually inappropriate behavior until 1/13/19, after the complaint inspection revealed the treatment team failed to assess the behavior and update the treatment plan for this problem.

On 1/15/19 at 12:20 PM, Patient #3 had a difficult time discussing urges with the therapist, but indicated seeing a therapist for a total of twenty minutes so far during the stay.

Patient #7

On 12/13/18, Patient #7 was admitted with recurrent major depressive disorder.

On 12/20/18, a Psychiatric Progress Note revealed patient had a significant history of sexual abuse and neglect. The Psychiatrist did not place Patient #7 on SRP precautions.

On 12/21/18, a Nursing Progress Note showed Patient #7 engaged in inappropriate touching with another patient. Facility census data showed Patient #7 had a roommate and was not placed on SRP precautions.

On 1/7/19 in the morning, a patient census report was observed and obtained for patients in the Psychiatric Residential Treatment Facility area (PRTF). Patient #7 was not placed on SRP precautions and was placed with a roommate.

Patient #7's medical record lacked documented evidence of a treatment plan for sexual abuse history until 1/13/19, after the inspection revealed the treatment team failed to identify the behavior/history as a problem and design/update the treatment plan for this problem.

On 1/15/19 at 12:10 PM, Patient #7 expressed not receiving therapy because the therapist disappeared three weeks ago.

Patient #8

On 9/7/18, Patient #8 was admitted with bipolar disorder.

On 9/8/18, the initial Psychiatric Evaluation showed Patient #8 had a traumatic victim of sexual abuse history.

On 1/7/19 in the morning, a patient census report was observed and obtained for patients in the Psychiatric Residential Treatment Facility area (PRTF). Patient #8 was not placed on SRP precautions.

The successive Psychiatric Progress Notes highlighted the sexual abuse history, but Patient #8's medical record lacked documented evidence of a treatment plan for sexual abuse history until 1/13/19.

Patient #9

Patient #9 was admitted on [DATE] with diagnoses including ADHD, Bipolar I Disorder, Oppositional Defiant Disorder, post-traumatic stress disorder (PTSD). The patient was ordered precautions and observations including assault precaution, sexual aggressor precaution, and sexual reactive precautions (SRP).

On 1/15/19 at 4:00 PM, Patient #9 verbalized frustration there was no treatment plan discussion and no therapist assigned. Nobody discussed accomplishing goals. Groups were run more frequently during the previous stay at the facility.


Patient #26

Patient #26 was admitted [DATE] with diagnoses including dementia and psychotic disorder.

On 1/9/19 at 9:15 AM, Patient #26 was sitting in a wheelchair in the common area of Unit 500. The patient had a laceration to the bridge of the nose, swelling and discolored bruising surrounding the left orbital area a "black eye."

On 1/9/19 in the morning, the charge nurse indicated Patient #26 fell in the bedroom during the night and sustained injuries to the left side of the head, nose and left eye. The nurse also indicated the patient was complaining of of pain to the hips and legs. The charge nurse indicated the fall was not witnessed by any staff and the patient's roommate indicated Patient #26 fell . The patient also indicated a fall occurred in the room. The charge nurse indicated both patients were confused. The charge nurse indicated there was no investigation completed or needed due to what the patients said. The charge nurse indicated Patient #26 and the roommate slept in the same room during the night after the injuries were identified by the staff.

On 1/9/19 at 9:20 AM, Patient #26 was alert and oriented x1 to person only. The patient rambled some incoherent sentences and was asked by the Inspector on how the injuries to the face and head were sustained with no mention of the patient's roommate or any fall during the conversation. The patient indicated the roommate kept taking her things and the roommate wanted to be the boss. Patient #26 indicated the roommate kept hitting her.

The Psychiatric Progress Note form dated 1/8/19 at 18:59 (6:59 PM), documented the patient was confused.

The Nursing Progress Note form dated 1/8/19 at 21:40 (9:40 PM), the patient was found standing in the room with a cut on the nose. The staff interviewed the roommate and the roommate stated Patient #26 fell .

On 1/9/19 at 9:55 AM, Patient #34 (roommate of Patient #26) was alert and oriented times (x) 1-2, to person and place. The patient indicated the year was 1998, was not able to give the month and was aware the city was Las Vegas but was unable to give what building she was in.

On 1/9/19 in the morning, the Quality Assurance Coordinator indicated the facility had no policy regarding investigating injuries of unknown origin. The Coordinator indicated since both residents were confused and no staff witnessed the incident an investigation should have been conducted.

There was no documented evidence an investigation was performed to determine how the patient sustained numerous injuries to the facial area from a single fall. There was no documented evidence interviews were obtained from other possible witnesses due to both patients who were interviewed were known to have confusion to determine if the unwitnessed incident was an actual fall or a physical abuse altercation.

Patient #35

Patient #35 was admitted on [DATE] and discharged on [DATE], with diagnoses including personal history of adult physical and sexual abuse, suicidal ideation and major depressive disorder.

Patient #35 documented on a Compliment/Complaint/Suggestion Form dated 11/11/18, the patient's rights were violated and threatened my a roommate.

An event follow-up on 11/12/18 at 1:59 PM, indicated the response to the complaint IR (incident reports were confidential and could not be printed out and the patient had the right to consult an attorney.

On 1/11/19 in the Quality Assurance Coordinator confirmed there was no investigation completed for Patient #35's allegations of being threatened by the roommate and there should have been one conducted.

Complaint #NV 061


A High Risk/High alert Handoff was not completed on admission to identify Patient #9 for behaviors of sexually acting out as an aggressor or victim.

Patient #9's Treatment Plans were not updated to include the patient's inappropriate sexual behaviors. An actual incident of inappropriate sexual behavior occurred on 12/13/18.

Patient #13

Patient #13 was admitted on [DATE] with diagnoses including conduct disorder, group type, unspecified mood affective disorder, and potential harm to others (aggressive and defiant behavior).

Patient #13 was ordered precautions and observations including Sexually acting out precaution, line of sight (LOS) while awake (WA), suicide precaution, observation every (q) 15 minutes, and sexual aggressor.

The staff unit work sheet dated 01/11/19 documented "Watch with [Female Patient]" and indicated the patient was planning to have sex in the bathroom". The patient was not placed on SRP.

An order for precautions for sexually acting and Line of Sight (LOS) was not done or precautions initiated until 01/12/19.

Patient #33

Patient #33 was admitted on [DATE] with diagnoses including attention deficit hyperactivity disorder (ADHD) combined type, bipolar I disorder, family discord, major depressive disorder no-psychotic recurrent, severe, post-traumatic stress disorder (PTSD), social discord, potential for self-harm.

Patient #33 was ordered precautions and observations including sexually acting out precautions, suicide precautions, line of sight while awake, every 15 minute observation, and sexual aggressor precautions.

Patient #33's Treatment Plan not updated to include SRP.

A High Risk/High Alert Handoff dated 01/06/19, documented the patient was sexually acting out (SAO) and an aggressor and a victim. An order for SRP precautions was not initiated until 01/12/19.

Patient #37

Patient #37 was admitted on [DATE] with diagnoses including major depressive disorder and recurrent severe psychosis.

The staff unit work sheet dated 01/11/19 identified Patient #37 as planning to have inappropriate sexual contact with a peer in the bathroom. The Patient #37 was not placed on SRP until it was identified the patient had planned to attempt inappropriate sexual contact with a second peer on 01/13/19.

Patient #10

Patient #10 was admitted on [DATE], with diagnoses including major depressive disorder and recurrent severe psychosis, ADHD combined type , and unspecified mood disorder. Patient #10 was ordered precautions and observations including SRP, LOS WA, q 15 min checks, assault, and suicide.

Patient #10's Treatment Plans were not updated to include the patient's inappropriate sexual behaviors.

On 01/08/19 at approximately 9:10 AM, a Registered Nurse (RN) identified having two patients in the acute pediatric and adolescent unit on sexual reactive precautions (SRP).

On 01/08/19 in the morning, a Registered Nurse (RN) explained the SRP precautions were when a patient was on sexual restrictive precautions, on One-to-One Observation (1:1) and placed in a private room. The RN indicated not being aware of a policy.

On 01/08/19 in the morning, another RN indicated SRP a patient was placed on SRP precautions when a need was identified such as being sexually traumatized. The RN indicated they needed to watch the patient, the patient was roomed by self and monitored with peers. The RN indicated not knowing if the SRP protocol was an official process.

Patient #32

Patient #32 was admitted to the adolescent partial hospital program (PHP) on 12/04/18 with diagnoses including attention deficit hyperactivity disorder (ADHD) predominately inattentive type, anxiety disorder, unspecified, and recurrent major depressive disorder. The patient was discharged on [DATE].

An Initial Psychiatric Evaluation dated 12/04/18, documented the patient claimed being abused sexually (touched inappropriately) at a foster home.

A Psychiatric Progress Note dated 12/12/18, documented Patient #32 disclosed that a peer in the program exposed himself to her in the bathroom a week ago.

Patient #31

Patient #31 was admitted to the adolescent partial hospital program (PHP) on 11/30/18 with diagnoses including attention deficit hyperactivity disorder (ADHD) combined, asperger's syndrome, recurrent depression and mood disorder. The patient was discharged on [DATE].

A Psychiatric Progress Note dated 12/05/18, documented Patient #31 was released from the Acute Unit due to impulsive behaviors and safety concerns.

A Treatment Plan Assessment Update dated 12/12/18, documented Patient #31 did not attend PHP treatment or participate in treatment team meeting. The Treatment Plan Assessment Update indicated to continue current medications as prescribe and discharge with outpatient therapeutic referrals for therapy and psychiatric services.

An incident report dated 12/11/18 documented the allegation was reported to the Las Vegas Metropolitan (Metro) Police Department and Child Protective Services (CPS). Both patients were processed with the therapist. All PHP staff were alerted to the incident, advised to be alert for any ongoing behaviors related to the incident, and the patient interactions were to be monitored closely by staff.

The event description documented Patient #31 asked Patient #32 into the restroom saying that it was an "emergency". Once in the restroom Patient #32 was told to close her eyes. When Patient #32 opened her eyes Patient #31's pants was seated on the toilet with pants down exposing self, and asked Patient #32 to touch him.

The report document of the incident was reviewed by the Director of Compliance Quality and Risk (DCQR) which indicated the staff took the appropriate action in response to the incident. The DCQR indicated the incident did not meet the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) nor the State of Nevada definition of a Sentinel event and did not require a formal investigation, and a formal Root Cause Analysis was not recommended.

On 01/08/19 at 10:35 AM, the Director of Outpatient Services explained the patients were monitored by the Mental Health Technicians (MHT's) along with other assigned staff. The staff not leading the group monitored the patients going to the bathroom. The Director of Outpatient Services indicated the staff who escorted Patient #32 did not escort the patient to the adolescent group, but stood at the exit of the program space and did not see Patient #32 go into the restroom. The Director of Outpatient Services disclosed Patient #32 was told by Patient #31 to close her eyes and Patient #31 pulled his pants down. The Director of Outpatient Services indicated a week later Patient #32 told someone when it was time for her scheduled discharge.

The Director of Outpatient Services indicated the MHT's were responsible for running the group. If therapy staff lead the group there were two staff. The Director of Outpatient Services confirmed a MHT lead the adolescent group and no one monitored the patients going to the bathroom during the time the incident occurred.

On 01/15/19 at 5:33 PM, the Chief Nursing Officer (CNO) explained the outpatient area does their own staffing, but MHT's could have been pulled to cover the outpatient area if needed. The CNO indicated the Director of Outpatient Services should have called if additional staff was needed.

The outpatient area lacked staff to monitor patients for safety and prevent an occurrence of inappropriate sexual behavior between patients.

On 01/08/19 at 10:48 AM, the Director of Outpatient Services explained an investigation was done and the outcome was there was no touching. The Director of Outpatient Services indicated the family, CPS and Metro were called per facility policy. The Director of Outpatient Services indicated the Therapist spoke to the MHT's regarding the incident, talked to the family, the male patient was discharged the next day and we set staffing.

On 01/09/19 at 1:50 PM, the Director of Compliance Quality and Risk (DCQR) confirmed no formal investigation or root cause analysis was done for the complaint. The DCQR indicated not being aware if training was done with the staff in the outpatient area.

A facility policy entitled Critical Event Review and Reporting, 200.14, Effective date: 10/01/16, Revised 09/2017, documented guidelines for communicating, investigating and acting upon critical events. The policy indicated any actual or alleged inappropriate sexual contact between staff and current patients or individuals who were patients within two years from discharge, (to include inappropriate verbal or written communication and/or inappropriate physical contact).

The critical event analysis will completed with 30 days of knowledge of the event, and should include the following:
-A determination of what happened in terms of the details of the event and the areas or services impacted.
-Identification of hwy the event occurred, i.e. was there human error, a missing or weal step in the process, equipment failure, environmental or other external factors that directly affected or influenced the occurrence.
-A flow chart of the process with identification of the steps that may have contributed to the critical event.
-A review of the cause and effect factors contributing to the critical event.
-An analysis of the process to prevent a repeat of the critical event specifically asking "why" multiple times during the review of the following issues.
-The human factor (staffing, staff competencies, performance of the staff involved, in-service education needs of the staff);
-Information management (communication among staff, the availability of accurate,complete, unambiguous information;
-Environmental management(physical environment appropriate to the process performed, emergency preparedness planed and tested , identification of environmental risks such as lighting);
-Leadership (corporate culture conducive to risk identification and reduction, barriers to communication of potential risk factors on the unit/within the facility, priority of prevention of adverse outcomes within the unit/facility; and,
-Any uncontrollable factors.

Complaint #NV 530

On 1/11/19 at 9:00 AM, the Medical Director of the Unit (housing Patient #1, #2 and #3), a Psychiatrist indicated the following: The main part of the job was initial psychiatric evaluations and weekly progress notes for one unit and daily progress notes for the other unit. Sexual restrictive precautions (SRP) meant line of sight observation, single rooms with the precautions reviewed every other day. Patient #2 was known, so Patient #2 was placed on SRP precautions since admission. The rooms were probably full, which would explain why Patient #3 had a roommate when the bureau walked in on 1/7/19. The first incident of Patient #3, dated 12/13/18, was acknowledged. The second incident of Patient #3, dated 12/24/18, was acknowledged. Not everyone with sexually inappropriate behavior history needed to be on precautions. There was no explanation as to why Patient #3 was not placed on SRP precautions, except probably should be now. The Psychiatrist was unable to recall the history of Patient #1, which was documented in the initial Psychiatric Evaluation. The Psychiatrist was unable to recall if Patient #1 was on SRP precautions or a request for the order. [The request was made on 1/10/19]. The Psychiatrist acknowledged notes were entered weekly until hearing three sets of Patient #2's visits were entered on 1/7/19. Then the Psychiatrist verbalized there had been no discussion regarding late notes entered for visits and indicated maybe the scribe was late and it was a trick question.

After the immediate jeopardy was called regarding the protection of patients with sexual inappropriate behavior histories or acting out during their stays on 1/9/19, the facility provided a precaution list for each patient in the building: the facility only identified three patients with sexual restrictive precautions on 1/10/19.

On 1/11/19 from 10:30 AM to noon, interviews were conducted with the following staff:

Chief Clinical Officer (a Clinical Psychologist) who served on the Med-Executive Committee, Quality Committee and Governing Body.

The Director of Clinical Services who oversaw day to day functions of therapists.

The Chief Nursing Officer.

The treatment team designed the full continuum of care. Goals were supposed to be set and individualized at admission with a start date. The target date was set to assess whether the patient accomplished the goal. The treatment team included the Psychiatrist, Medical Doctor, Nurse, Family Members, Patient and Case Worker. The History and Physical was completed within 24 hours of admission. Patients were placed on daily medical log for issues to be seen by a medical doctor. The History and Physical was updated every 30 days. Nurse Practitioners could see patients also. In the Acute Youth unit, patients were seen daily with notes required. The treatment team met weekly. In the PRTF, patients were seen weekly with notes required. The treatment team met monthly. The treatment team discussed the past month. Therapists and nurses were responsible for goal setting/reviewing, usually 7-14 days initially.

Incidents of Suicidal Ideation and Sexual Acting Out should have caused the treatment team to have
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on observation, interview, record review and document review, the facility failed to integrate contracted laboratory and radiological services into the facility's Quality Assurance Performance Improvement (QAPI) program.

Findings include:

1) First Addendum to Laboratory Services Agreement form dated October 1, 2015, documented performance expectations. The form indicated the contracted laboratory company would provide monthly reports to the facility regarding compliance with agreed testing procedures for monitoring and evaluation purposes. The following were to be obtained by the facility from the contracted laboratory company:

-Turn around time
-Critical Lab values
-QNS/TNP (quantity not sufficient/test not performed)
-Utilization by test (dollar and units)

There was no documented evidence the facility integrated the laboratory services into the facility QAPI program. There was no documented evidence the facility obtained monthly data from the laboratory contractors for their QAPI program.

On 1/11/19 at 2:00 PM, the Director of Compliance and the Chief Nursing Officer (CNO), indicated laboratory contracted services were not integrated with the facility QAPI program. The CNO and the Director of Compliance indicated they did not request and obtain monthly reports from the laboratory contractor.

2) The Service Agreement form dated January 18, 2018 for radiological services documented the provider (x-ray contractor) agreed to perform quarterly quality assurance/performance improvement studies as requested by the facility.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, record review and document review, the facility failed to: 1) establish a process for prompt resolution of patient grievances and inform each patient whom to contact to file a grievance. The hospital's governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.(Tag A0119); 2) protect patients, identify/investigate incidents with inappropriate sexual activity histories/incidents, and failed to screen/review complaints and identify/investigate grievances in a timely manner according to policy (Tag A0120); 3) provide the patient with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.(Tag A0123); 4) provide Patient Rights: Privacy and Safety (Tag A0142); 5) patient has the right to receive care in a safe setting (Tag A ); 6) patient has the right to be free from all forms of abuse or harassment (Tag A0145); 7) ensure its staff members renewed their certifications for providing care for patients in restraint/seclusion (Tag A0196).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory-mandated care to patients.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on observation, record review, interview and document review, the Risk Manager failed to investigate incidents with inappropriate sexual activity histories and incidents, failed to screen or review complaints and investigate grievances according to facility policy.

Findings include:

The hospital's Governing Body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.

On 1/10/19 at 11:30 AM, a Registered Nurse (RN) who conducted an Admission Nursing Assessment was interviewed regarding the facility's policy of using sexual restrictive precautions (SRP). The RN indicated patients would have their own room, and other patients could not be in the room. No special observation was required. The patient with these precautions either had a solo room or slept near the nurse station. When discussing a peer to peer abuse situation, the nurse had to be prompted three times to verbalize separation of patients as a priority.

On 1/10/19 at noon, a Registered Nurse (RN) currently working on the PRTF unit indicated the following: The RN was familiar with Patient #2 and Patient #3. The RN indicated both patients should have SRP precautions. It meant not being in close contact with peers, line of sight with one on one observation, but it required a physician order. The RN was unaware if patients on SRP precautions had to have their own room, but it usually lasted the length of the stay. The RN was unaware Patient #2 and Patient #3 already had two sexually inappropriate incidences within the building (see references below).

On 1/10/19 at 1:00 PM, the Unit Manager (UM) verbalized the following: The UM was aware of the two incidents with Patient #3. Patient #3 was previously on another unit before being transferred to the present unit. The UM was unable to answer why unit nurses were not informed or why patients were not placed on SRP, except to say the unit relied on a verbal report at the time of transfer from one unit to the next. Treatment plans were supposed to be updated with new problems/interventions as they presented.

Patient #2

On 12/10/18, Patient #2 was admitted with self harm and placed on sexual restrictive precautions.

On 12/10/18, the History and Physical revealed hypersexuality and sexual abuse.

On 12/11/18, a Psychiatrist documented an Initial Psychiatric Evaluation revealing hypersexuality.

On 12/11/18, a Psychosocial Assessment revealed Patient #2 was acting hypersexual with an admitted history of abuse/exploitation.

On 12/10-11/18, the Nursing Admission Assessment revealed no connection to the patient's hypersexuality and sexual abuse history. The nurse acknowledged reviewing the Psychosocial Assessment.

On 12/21/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate touching with another patient. Facility census data showed Patient #2 had a roommate.

On 12/22/18, an electronic Incident Report revealed staff saw Patient #2 engaged in inappropriate touching with another patient, but Patient #2 denied it. The Risk Manager documented the report did not require an investigation and root cause analysis.

On 12/24/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate sexual behavior with a second patient. Facility census data showed Patient #2 had a roommate until 12/25-26/18.

On 12/24-25/18, an electronic Incident Report revealed a patient was told by Patient #2 and another patient the two had sex, but when confronted by staff, the two denied it. A Mental Health Tech was involved in the incident as redirecting the participants, and that staff member was not prompted for a statement about the incident. The Risk Manager documented the report did not require an investigation and root cause analysis.

Patient #3

On 12/4/18, Patient #3 was admitted for major depressive disorder.

On 12/13/18, an electronic Incident Report revealed the patient had sex with another patient from the unit in the bathroom. The patient indicated being the initiator. Patient #3 was not placed on SRP precautions. The Risk Manager wrongfully indicated the police did not need to be called because both parties were above the legal age of consent. The perpetrator was of legal age, but the victim was not.

On 12/17/18, Patient #3 was transferred to another unit.

On 12/17/18, a Nursing Admission Assessment revealed the patient was sexually active and did not practice safe sex.

On 12/18/18, a Psychosocial Assessment revealed the patient's sexual abuse history as a victim.

On 12/18/18, the Initial Psychiatric Assessment revealed sexual preoccupation. Patient #3 still was not placed on SRP precautions.

On 12/24/18, a Nursing Progress Note revealed the patient engaged in sexual activity with another patient.

On 12/24/18, an electronic Incident Report revealed the patient had a sexual incident with another patient on the unit. Facility census data showed Patient #3 continued to have a roommate and was still not placed on SRP precautions.

On 12/27/18, a Nursing Progress Note revealed the patient had self harm and a blade was used. The nurse did not find a blade initially. The patient turned the blade in.

On 12/28/18, a Psychiatrist documented a progress note showing awareness of the sexual incident dated 12/24/18. Patient #3 still was not placed on SRP precautions.

On 1/3/19, a Psychiatrist documented a progress note.

Patient #3's medical record lacked documented evidence of a clinical therapy visit except for one documented on 1/4/19.

On 1/4/19, a Nursing Progress Note showed the patient first threatened and then removed shirt and pulled pants down in class when another patient did not apologize for something. An hour later, the patient received emergency Zydis per protocol for agitation, pacing and verbalizing a desire for sex. Patient #3 still was not placed on SRP precautions.

On 1/8/19, a Psychiatrist documented a progress note.

On 1/11/19, a Psychiatric Progress Note showed an increase in medication for persistent sexual urges.

Patient #3's medical record lacked documented evidence of a treatment plan for sexually inappropriate behavior until 1/13/19, after the inspection revealed the treatment team failed to identify the behavior as a problem and design/update the treatment plan for this problem.

On 1/15/19 at 12:20 PM, Patient #3 had a difficult time discussing urges with the therapist, but indicated seeing a therapist for a total of twenty minutes so far during the stay.

Patient #7

On 12/13/18, Patient #7 was admitted with recurrent major depressive disorder.

On 12/20/18, a Psychiatric Progress Note revealed patient had a significant history of sexual abuse and neglect. The Psychiatrist did not place Patient #7 on SRP precautions.

On 12/21/18, a Nursing Progress Note showed Patient #7 engaged in inappropriate touching with another patient.

On 1/14/19 at noon, the facility's Medical Director verbalized and acknowledged the following: The Medical Director participated in the Governing Body and Quality Assurance. The Medical Director was not aware of a policy or program in place to guide facility clinicians/providers regarding the care and treatment of patients with sexually inappropriate/hypersexual behavior. The Medical Director was familiar with the SRP designation and indicated a physician ordered or revoked it when appropriate. If patients were underage, SRP applied to patients with those kind of abuse or inappropriate sexual activity histories as victims as well as perpetrators in the facility. The Medical Director acknowledged patients with a prostitution history or history of multiple inappropriate incidents should "probably" be on SRP. The Medical Director indicated the need for developing a screening tool for these patients at the Admission/Referral level. The Medical Director indicated The Risk Manager did not indicate sexual inappropriate behavior in the facility was a problem at any meetings.

The Medical Director was responsible for the clinical operations of the hospital; for improving patient safety; for continually assessing and improving the activities and quality of patient care; for making recommendations to the hospital's administrative staff regarding the planning of hospital facilities, equipment, routine procedures and other patient care matters.

On 1/11/19 at 2:30 PM, the Risk Manager verbalized there was an issue in the building of protecting patients from abuse and incidents not being reported to Quality Assurance. In-house complaint trends involved therapy groups not being conducted and retention of staff.

On 1/11/19 at 2:50 PM, the Risk Manager acknowledged sexual impropriety incidents were tracked but not trended until the bureau requested it for 2018. The Risk Manager provided a tabulation of sexual impropriety incidents for 2018. The individual reports of each incident did not match the monthly totals as follows: Two incidents were tabulated in February 2018, but only one report was received. Five incidents were tabulated in July 2018, and no reports were received. Four incidents were tabulated in August 2018, but only two reports were received. Two incidents were tabulated in September 2018, but only one report was received. The Risk Manager failed to locate/provide the remaining reports for review despite repeated requests.

On 1/11/19 at 3:00 PM, several complaints from June through October 2018 were reviewed with the Risk Manager. Only one complaint was characterized as a grievance in the complaint log, and it was dated 8/23/18. The log failed to document a summary of action taken or concerns addressed or individuals interviewed. Both the Risk Manager and later the Patient Advocate had no knowledge of the situation or documentation of an investigation or patient letter. Several complaints, characterized as such, also lacked a summary of action, concerns addressed and/or individuals interviewed, including the following:

An incident where a patient left medication in the facility after discharge and nobody followed up, dated 9/11/18.
An incident regarding student doctors with no follow-up, dated 8/4/18.
Two incidents of verbal abuse dated 8/25/18 were referred to a department head with no documented follow-up.
A patient complaint regarding a nurse's behavior that was simply logged dated 9/15/18.
A patient complaint regarding a list of patient care issues for which the resolution was documented as apologizing dated 9/14/18.
A patient complaint after discharge which the facility addressed by calling and leaving messages and then using the excuse of not getting a return call to close the complaint, dated 9/18/18. Another complaint handled the same way dated 9/25/18.
A patient complained about a fall with alleged injury revealed after discharge, but the facility did not investigate or follow policy according to the complaint description dated 10/18/18. Facility marked "no resolution needed."

The Risk Manager acknowledged the above complaints met the definition of a grievance.

Many complaints were simply logged or referred to a department head for follow-up, but nobody ensured that follow-up took place, such as 6/3/18, 7/30/18, 8/2/18...

Complaints for October 2018, were marked mostly as "no resolution needed" or forwarded to someone else for resolution with no documentation regarding the resolution.

The Patient Complaint and Grievance policy (1800.23, last revised 12/15), revealed complaints and concerns that could not be resolved by the unit staff, unit manager, or patient advocate by discharge became a grievance. Grievances required an investigation and should be responded to in the form of a letter to the patient or the patient's representative within seven (7) days from the initial time the problem or concern was brought to the attention of Risk Management. Grievances could be either verbal or written.

A patient grievance was a formal or informal written or verbal complaint made to the hospital by a patient, or patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present or by discharge), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation. All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements were considered grievances. Whenever the patient or the patient's representative requested that his/her complaint be handled as a formal complaint or grievance, or when the patient requested a written response from the hospital, the complaint was considered a grievance.

If the complaint was postponed, required investigation and/or further actions and could not be resolved by the time the patient was discharged , then the complaint became a grievance.
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
Based on observation, record review, interview and document review, the facility failed to protect patients, identify/investigate incidents with inappropriate sexual activity histories/incidents, and failed to screen/review complaints and identify/investigate grievances in a timely manner according to policy.

Findings include:

The hospital's Governing Body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.

On 1/10/19 at 11:30 AM, a Registered Nurse (RN) who conducted an Admission Nursing Assessment was interviewed regarding the facility's policy of using sexual restrictive precautions (SRP). The RN indicated it meant patients would have their own room, and other patients could not be in the room. No special observation was required. The patient with these precautions either had a solo room or slept near the nurse station. When discussing a peer to peer abuse situation, the nurse had to be prompted three times to verbalize separation of patients as a priority.

On 1/10/19 at noon, a Registered Nurse (RN) currently working on the PRTF unit indicated the following: The RN was familiar with Patient #2 and Patient #3. The RN indicated both patients should have SRP precautions. It meant not being in close contact with peers, line of sight/1:1 observation, but it required a physician order. The RN was unaware if the SRP patients had to have their own room, but it usually lasted the length of the stay. The RN was unaware Patient #2 and Patient #3 already had two sexually inappropriate incidences within the building (see references below).

On 1/10/19 at 1:00 PM, the Unit Manager (UM) verbalized the following: The UM Knew of the two incidents with Patient #3. Patient #3 was previously on another unit before being transferred to the present unit. The UM was unable to answer why unit nurses were not informed or why patients were not placed on SRP, except to say the unit relied on a verbal report at the time of transfer from one unit to the next. Treatment plans were supposed to be updated with new problems/interventions as they presented.

Patient #2

On 12/10/18, Patient #2 was admitted with self harm and placed on sexual restrictive precautions.

On 12/10/18, the History and Physical revealed hypersexuality and sexual abuse.

On 12/11/18, a Psychiatrist documented an Initial Psychiatric Evaluation revealing hypersexuality.

On 12/11/18, a Psychosocial Assessment revealed Patient #2 was acting hypersexual with an admitted history of abuse/exploitation.

On 12/10-11/18, the Nursing Admission Assessment revealed no connection to the patient's hypersexuality and sexual abuse history. The nurse acknowledged reviewing the Psychosocial Assessment.

On 12/21/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate touching with another patient. Facility census data showed Patient #2 had a roommate.

On 12/22/18, an electronic Incident Report revealed staff saw Patient #2 engaged in inappropriate touching with another patient, but Patient #2 denied it. The Risk Manager documented the report did not require an investigation and root cause analysis.

On 12/24/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate sexual behavior with a second patient. Facility census data showed Patient #2 had a roommate until 12/25-26/18.

On 12/24-25/18, an electronic Incident Report revealed a patient was told by Patient #2 and another patient the two had sex, but when confronted by staff, the two denied it. A Mental Health Tech was involved in the incident as redirecting the participants, and that staff member was not prompted for a statement about the incident. The Risk Manager documented the report did not require an investigation and root cause analysis.

Patient #3

On 12/4/18, Patient #3 was admitted for major depressive disorder.

On 12/13/18, an electronic Incident Report revealed the patient had sex with another patient from the unit in the bathroom. The patient indicated being the initiator. Patient #3 was not placed on SRP precautions. The Risk Manager wrongfully indicated the police did not need to be called because both parties were above the legal age of consent. The perpetrator was of legal age, but the victim was not.

On 12/17/18, Patient #3 was transferred to another unit.

On 12/17/18, a Nursing Admission Assessment revealed the patient was sexually active and did not practice safe sex.

On 12/18/18, a Psychosocial Assessment revealed the patient's sexual abuse history as a victim.

On 12/18/18, the Initial Psychiatric Assessment revealed sexual preoccupation. Patient #3 still was not placed on SRP precautions.

On 12/24/18, a Nursing Progress Note revealed the patient engaged in sexual activity with another patient.

On 12/24/18, an electronic Incident Report revealed the patient had a sexual incident with another patient on the unit. Facility census data showed Patient #3 continued to have a roommate and was still not placed on SRP precautions.

On 12/27/18, a Nursing Progress Note revealed the patient had self harm and a blade was used. The nurse did not find a blade initially. The patient turned the blade in.

On 12/28/18, a Psychiatrist documented a progress note showing awareness of the sexual incident dated 12/24/18. Patient #3 still was not placed on SRP precautions.

On 1/3/19, a Psychiatrist documented a progress note.

Patient #3's medical record lacked documented evidence of a clinical therapy visit except for one documented on 1/4/19.

On 1/4/19, a Nursing Progress Note showed the patient first threatened and then removed shirt and pulled pants down in class when another patient did not apologize for something. An hour later, the patient received emergency Zydis per protocol for agitation, pacing and verbalizing a desire for sex. Patient #3 still was not placed on SRP precautions.

On 1/8/19, a Psychiatrist documented a progress note.

On 1/11/19, a Psychiatric Progress Note showed an increase in medication for persistent sexual urges.

Patient #3's medical record lacked documented evidence of a treatment plan for sexually inappropriate behavior until 1/13/19, after the inspection revealed the treatment team failed to identify the behavior as a problem and design/update the treatment plan for this problem.

On 1/15/19 at 12:20 PM, Patient #3 had a difficult time discussing urges with the therapist, but indicated seeing a therapist for a total of twenty minutes so far during the stay.

Patient #7

On 12/13/18, Patient #7 was admitted with recurrent major depressive disorder.

On 12/20/18, a Psychiatric Progress Note revealed patient had a significant history of sexual abuse and neglect. The Psychiatrist did not place Patient #7 on SRP precautions.

On 12/21/18, a Nursing Progress Note showed Patient #7 engaged in inappropriate touching with another patient.

On 1/14/19 at noon, the facility's Medical Director verbalized and acknowledged the following: The Medical Director participated in the Governing Body and Quality Assurance. The Medical Director was not aware of a policy or program in place to guide facility clinicians/providers regarding the care and treatment of patients with sexually inappropriate/hypersexual behavior. The Medical Director was familiar with the SRP designation and indicated a physician ordered or revoked it when appropriate. If patients were underaged, SRP applied to patients with those kind of abuse/inappropriate sexual activity histories as victims as well as perpetrators in the facility. The Medical Director acknowledged patients with a current prostitution history or current history of multiple inappropriate incidents should probably be on SRP. The Medical Director indicated the need for developing a screening tool for these patients at the Admission/Referral level. The Medical Director indicated The Risk Manager did not indicate sexual inappropriate behavior in the facility was a problem at any meetings.

The Medical Director was responsible for the clinical operations of the hospital; for improving patient safety; for continually assessing and improving the activities and quality of patient care; for making recommendations to the hospital's administrative staff regarding the planning of hospital facilities, equipment, routine procedures and other patient care matters.

On 1/11/19 at 2:30 PM, the Risk Manager verbalized there was an issue in the building of protecting patients from abuse and incidents not being reported to Quality Assurance. In-house complaint trends involved therapy groups not being conducted and retention of staff.

On 1/11/19 at 2:50 PM, the Risk Manager acknowledged sexual impropriety incidents were tracked but not trended until the bureau requested it for 2018. The Risk Manager provided a tabulation of sexual impropriety incidents for 2018. The individual reports of each incident did not match the monthly totals as follows: Two incidents were tabulated in February, but only one report was received. Five incidents were tabulated in July, and no reports were received. Four incidents were tabulated in August, but only two reports were received. Two incidents were tabulated in September, but only one report was received. The Risk Manager failed to locate/provide the remaining reports for review despite repeated requests.

On 1/11/19 at 3:00 PM, several complaints from June through October 2018 were reviewed with the Risk Manager. Only one complaint was characterized as a grievance in the complaint log, and it was dated 8/23/18. The log failed to document a summary of action taken or concerns addressed or individuals interviewed. Both the Risk Manager and later the Patient Advocate had no knowledge of the situation or documentation of an investigation or patient letter. Several complaints, characterized as such, also lacked a summary of action, concerns addressed and/or individuals interviewed, including the following:

An incident where a patient left medication in the facility after discharge and nobody followed up, dated 9/11/18.
An incident regarding student doctors with no follow-up, dated 8/4/18.
Two incidents of verbal abuse dated 8/25/18 were referred to a department head with no documented follow-up.
A patient complaint regarding a nurse's behavior that was simply logged dated 9/15/18.
A patient complaint regarding a list of patient care issues for which the resolution was documented as apologizing dated 9/14/18.
A patient complaint after discharge which the facility addressed by calling and leaving messages and then using the excuse of not getting a return call to close the complaint, dated 9/18/18. Another complaint handled the same way dated 9/25/18.
A patient complained about a fall with alleged injury revealed after discharge, but the facility did not investigate or follow policy according to the complaint description dated 10/18/18. Facility marked "no resolution needed."

The Risk Manager acknowledged the above complaints met the definition of a grievance.

Many complaints were simply logged or referred to a department head for follow-up, but nobody ensured that follow-up took place, such as 6/3/18, 7/30/18, 8/2/18...

The whole month of October 2018 complaints were marked mostly as "no resolution needed" or forwarded to someone else for resolution with no documentation regarding the resolution.

The Patient Complaint and Grievance policy (1800.23, last revised 12/15) revealed complaints and concerns that could not be resolved by the unit staff, unit manager, or patient advocate by discharge became a grievance. Grievances required an investigation and should be responded to in the form of a letter to the patient or the patient's representative within seven (7) days from the initial time the problem or concern was brought to the attention of Risk Management. Grievances could be either verbal or written.

A patient grievance was a formal or informal written or verbal complaint made to the hospital by a patient, or patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present or by discharge), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation. All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements were considered grievances. Whenever the patient or the patient's representative requested that his/her complaint be handled as a formal complaint or grievance, or when the patient requested a written response from the hospital, the complaint was considered a grievance.

If the complaint was postponed, required investigation and/or further actions and could not be resolved by the time the patient was discharged , then the complaint became a grievance.

The Patient Complaint and Grievance policy (1800.23, last revised 12/15) revealed under III Procedure:

d. All grievances must be initially responded to in writing within seven business days of notification or resolution of the grievance.
e. Grievances will be investigated and a written response will be provided to the patient within 30 days, if the grievance is not resolved within the first 7 business days.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on observation, record review, interview and document review, the facility failed to protect patients, identify/investigate incidents with inappropriate sexual activity histories/incidents, and failed to screen/review complaints and identify/investigate grievances and respond to patients in a timely manner according to policy.

Findings include:

The hospital's Governing Body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.

On 1/10/19 at 11:30 AM, a Registered Nurse (RN) who conducted an Admission Nursing Assessment was interviewed regarding the facility's policy of using sexual restrictive precautions (SRP). The RN indicated it meant patients would have their own room, and other patients could not be in the room. No special observation was required. The patient with these precautions either had a solo room or slept near the nurse station. When discussing a peer to peer abuse situation, the nurse had to be prompted three times to verbalize separation of patients as a priority.

On 1/10/19 at noon, a Registered Nurse (RN) currently working on the PRTF unit indicated the following: The RN was familiar with Patient #2 and Patient #3. The RN indicated both patients should have SRP precautions. It meant not being in close contact with peers, line of sight/1:1 observation, but it required a physician order. The RN was unaware if the SRP patients had to have their own room, but it usually lasted the length of the stay. The RN was unaware Patient #2 and Patient #3 already had two sexually inappropriate incidences within the building (see references below).

On 1/10/19 at 1:00 PM, the Unit Manager (UM) verbalized the following: The UM Knew of the two incidents with Patient #3. Patient #3 was previously on another unit before being transferred to the present unit. The UM was unable to answer why unit nurses were not informed or why patients were not placed on SRP, except to say the unit relied on a verbal report at the time of transfer from one unit to the next. Treatment plans were supposed to be updated with new problems/interventions as they presented.

Patient #2

On 12/10/18, Patient #2 was admitted with self harm and placed on sexual restrictive precautions.

On 12/10/18, the History and Physical revealed hypersexuality and sexual abuse.

On 12/11/18, a Psychiatrist documented an Initial Psychiatric Evaluation revealing hypersexuality.

On 12/11/18, a Psychosocial Assessment revealed Patient #2 was acting hypersexual with an admitted history of abuse/exploitation.

On 12/10-11/18, the Nursing Admission Assessment revealed no connection to the patient's hypersexuality and sexual abuse history. The nurse acknowledged reviewing the Psychosocial Assessment.

On 12/21/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate touching with another patient. Facility census data showed Patient #2 had a roommate.

On 12/22/18, an electronic Incident Report revealed staff saw Patient #2 engaged in inappropriate touching with another patient, but Patient #2 denied it. The Risk Manager documented the report did not require an investigation and root cause analysis.

On 12/24/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate sexual behavior with a second patient. Facility census data showed Patient #2 had a roommate until 12/25-26/18.

On 12/24-25/18, an electronic Incident Report revealed a patient was told by Patient #2 and another patient the two had sex, but when confronted by staff, the two denied it. A Mental Health Tech was involved in the incident as redirecting the participants, and that staff member was not prompted for a statement about the incident. The Risk Manager documented the report did not require an investigation and root cause analysis.

Patient #3

On 12/4/18, Patient #3 was admitted for major depressive disorder.

On 12/13/18, an electronic Incident Report revealed the patient had sex with another patient from the unit in the bathroom. The patient indicated being the initiator. Patient #3 was not placed on SRP precautions. The Risk Manager wrongfully indicated the police did not need to be called because both parties were above the legal age of consent. The perpetrator was of legal age, but the victim was not.

On 12/17/18, Patient #3 was transferred to another unit.

On 12/17/18, a Nursing Admission Assessment revealed the patient was sexually active and did not practice safe sex.

On 12/18/18, a Psychosocial Assessment revealed the patient's sexual abuse history as a victim.

On 12/18/18, the Initial Psychiatric Assessment revealed sexual preoccupation. Patient #3 still was not placed on SRP precautions.

On 12/24/18, a Nursing Progress Note revealed the patient engaged in sexual activity with another patient.

On 12/24/18, an electronic Incident Report revealed the patient had a sexual incident with another patient on the unit. Facility census data showed Patient #3 continued to have a roommate and was still not placed on SRP precautions.

On 12/27/18, a Nursing Progress Note revealed the patient had self harm and a blade was used. The nurse did not find a blade initially. The patient turned the blade in.

On 12/28/18, a Psychiatrist documented a progress note showing awareness of the sexual incident dated 12/24/18. Patient #3 still was not placed on SRP precautions.

On 1/3/19, a Psychiatrist documented a progress note.

Patient #3's medical record lacked documented evidence of a clinical therapy visit except for one documented on 1/4/19.

On 1/4/19, a Nursing Progress Note showed the patient first threatened and then removed shirt and pulled pants down in class when another patient did not apologize for something. An hour later, the patient received emergency Zydis per protocol for agitation, pacing and verbalizing a desire for sex. Patient #3 still was not placed on SRP precautions.

On 1/8/19, a Psychiatrist documented a progress note.

On 1/11/19, a Psychiatric Progress Note showed an increase in medication for persistent sexual urges.

Patient #3's medical record lacked documented evidence of a treatment plan for sexually inappropriate behavior until 1/13/19, after the inspection revealed the treatment team failed to identify the behavior as a problem and design/update the treatment plan for this problem.

On 1/15/19 at 12:20 PM, Patient #3 had a difficult time discussing urges with the therapist, but indicated seeing a therapist for a total of twenty minutes so far during the stay.

Patient #7

On 12/13/18, Patient #7 was admitted with recurrent major depressive disorder.

On 12/20/18, a Psychiatric Progress Note revealed patient had a significant history of sexual abuse and neglect. The Psychiatrist did not place Patient #7 on SRP precautions.

On 12/21/18, a Nursing Progress Note showed Patient #7 engaged in inappropriate touching with another patient.

On 1/14/19 at noon, the facility's Medical Director verbalized and acknowledged the following: The Medical Director participated in the Governing Body and Quality Assurance. The Medical Director was not aware of a policy or program in place to guide facility clinicians/providers regarding the care and treatment of patients with sexually inappropriate/hypersexual behavior. The Medical Director was familiar with the SRP designation and indicated a physician ordered or revoked it when appropriate. If patients were underage, SRP applied to patients with those kind of abuse/inappropriate sexual activity histories as victims as well as perpetrators in the facility. The Medical Director acknowledged patients with a current prostitution history or current history of multiple inappropriate incidents should probably be on SRP. The Medical Director indicated the need for developing a screening tool for these patients at the Admission/Referral level. The Medical Director indicated The Risk Manager did not indicate sexual inappropriate behavior in the facility was a problem at any meetings.

The Medical Director was responsible for the clinical operations of the hospital; for improving patient safety; for continually assessing and improving the activities and quality of patient care; for making recommendations to the hospital's administrative staff regarding the planning of hospital facilities, equipment, routine procedures and other patient care matters.

On 1/11/19 at 2:30 PM, the Risk Manager verbalized there was an issue in the building of protecting patients from abuse and incidents not being reported to Quality Assurance. In-house complaint trends involved therapy groups not being conducted and retention of staff.

On 1/11/19 at 2:50 PM, the Risk Manager acknowledged sexual impropriety incidents were tracked but not trended until the bureau requested it for 2018. The Risk Manager provided a tabulation of sexual impropriety incidents for 2018. The individual reports of each incident did not match the monthly totals as follows: Two incidents were tabulated in February, but only one report was received. Five incidents were tabulated in July, and no reports were received. Four incidents were tabulated in August, but only two reports were received. Two incidents were tabulated in September, but only one report was received. The Risk Manager failed to locate/provide the remaining reports for review despite repeated requests.

On 1/11/19 at 3:00 PM, several complaints from June through October 2018 were reviewed with the Risk Manager. Only one complaint was characterized as a grievance in the complaint log, and it was dated 8/23/18. The log failed to document a summary of action taken or concerns addressed or individuals interviewed. Both the Risk Manager and later the Patient Advocate had no knowledge of the situation or documentation of an investigation or patient letter. Several complaints, characterized as such, also lacked a summary of action, concerns addressed and/or individuals interviewed, including the following:

An incident where a patient left medication in the facility after discharge and nobody followed up, dated 9/11/18.
An incident regarding student doctors with no follow-up, dated 8/4/18.
Two incidents of verbal abuse dated 8/25/18 were referred to a department head with no documented follow-up.
A patient complaint regarding a nurse's behavior that was simply logged dated 9/15/18.
A patient complaint regarding a list of patient care issues for which the resolution was documented as apologizing dated 9/14/18.
A patient complaint after discharge which the facility addressed by calling and leaving messages and then using the excuse of not getting a return call to close the complaint, dated 9/18/18. Another complaint handled the same way dated 9/25/18.
A patient complained about a fall with alleged injury revealed after discharge, but the facility did not investigate or follow policy according to the complaint description dated 10/18/18. Facility marked "no resolution needed."

The Risk Manager acknowledged the above complaints met the definition of a grievance.

Many complaints were simply logged or referred to a department head for follow-up, but nobody ensured that follow-up took place, such as 6/3/18, 7/30/18, 8/2/18...

The whole month of October 2018 complaints were marked mostly as "no resolution needed" or forwarded to someone else for resolution with no documentation regarding the resolution.

The Patient Complaint and Grievance policy (1800.23, last revised 12/15) revealed complaints and concerns that could not be resolved by the unit staff, unit manager, or patient advocate by discharge became a grievance. Grievances required an investigation and should be responded to in the form of a letter to the patient or the patient's representative within seven (7) days from the initial time the problem or concern was brought to the attention of Risk Management. Grievances could be either verbal or written.

A patient grievance was a formal or informal written or verbal complaint made to the hospital by a patient, or patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present or by discharge), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation. All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements were considered grievances. Whenever the patient or the patient's representative requested that his/her complaint be handled as a formal complaint or grievance, or when the patient requested a written response from the hospital, the complaint was considered a grievance.

If the complaint was postponed, required investigation and/or further actions and could not be resolved by the time the patient was discharged , then the complaint became a grievance.

The Patient Complaint and Grievance policy (1800.23, last revised 12/15) revealed under III Procedure:

d. All grievances must be initially responded to in writing within seven business days of notification or resolution of the grievance.
e. Grievances will be investigated and a written response will be provided to the patient within 30 days, if the grievance is not resolved within the first 7 business days.

On 1/11/19 at 3:00 PM, the Risk Manager acknowledged no letters were sent to complainants/grievants, unless the situation involved missing items.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on observation and interview, the facility's nurse failed to provide privacy when administering subcutaneous Insulin for 1 of 37 patients (Patient #4).

Findings include:

On 1/8/19 at 2:00 PM, a Registered Nurse was observed administering subcutaneous Insulin to Patient #4 in a hallway near the nurse station. Several other patients were lined up in front of and behind Patient #4. The Registered Nurse injected Patient #4, while the patient stood in line with the other patients.

On 1/8/19 at 2:00 PM, the Unit Manager acknowledged the nurse should have attempted to provide privacy for the patient.

On 1/8/19 at 2:00 PM, the Registered Nurse acknowledged the privacy issue, and was also unable to explain the quality control process for the glucometer strips and control solution, indicating the night nurse performed the tests.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Center for Clinical Standards and Quality/Survey & Certification Group Memo 18-06-Hospitals 12/08/17: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation.

Based on observation and interview, the facility failed to provide a safe, ligature "resistant" or "free" environment for the residents in six out of six units, and the facility failed to identify and investigate incidents of suicide attempts per policies (Patient #4, #5, #6, #14, #15, #16, #24 and #36).

Findings include:

On 1/08/19 - 1/11/19, the following ligature concerns throughout the facility were observed:

1) Geriatric Unit 500/600
A) The following rooms revealed top door closers located on the outside of the doors facing the resident common areas:
i) Two Consult Rooms.
ii) Two Group Rooms.
iii) Two doors that lead to the dining room.
iv) Two Exam Consult Rooms.
v) Two sets of Double Doors to main long hallway.

B) Resident Room #502 contained two crank style beds.

C) The following rooms contained "removable" shower chairs in the bathroom:
i) Resident Room #502, #503, #505, #506, #509 and #602

D) The shower heads in the bathrooms were observed with a sizable gap between the shower head fixture and the wall.

2) PRTF Area
A) Activity Room Door: The hinges and the door handle in the activity rooms were not anti-ligature.

B) Automatic Fire Sprinkler Guards were used throughout the units. The facility failed to assess the weight limit on the sprinkler guards. A list of residents in the unit was provided which revealed a resident weight of at least eighty pounds.

C) Desks with attached benches were located in all of the resident rooms.

E) The following rooms contained shower chairs (with several gaps) that were "bolted" to the shower panel:
i) Resident Room #100, #200, #204, #301, #305 and #405.

F) The shower heads in the bathrooms had a sizable gap between the shower head fixture and the wall.

G) The activity room chairs had a number of gaps within the wooden materials.

H) Classroom Hallway Bathrooms (Male and Female):
i) The entrance doors revealed top door closers that were located on the inside of the bathroom.
ii) Loop handles were on the inside of the entrance door.
iii) Loop door handles were on the inside of the bathroom stall doors.
iv) There was a sizable gap under the sink that provided access points to the piping.
v) The bathroom stall partitions provided several access points for hanging.

Note: On two separate occasions, Facility staff were observed to walk a resident to the bathroom. The staff observed, waited for the resident in another area, outside of the bathroom.

3) Adult Units
A) Metal window shades with a roller were installed in the resident rooms.

B) Desks with attached benches were located in all of the resident rooms.

C) The shower heads in the bathrooms had a sizable gap between the shower head fixture and the wall.

E) Southside Tub Room #2:
i) A weight scale was bolted to the wall by a metal bracket that had a sizable gap between the scale and the wall.
ii) There was a stainless steel pull down shower seat.
iii) There was a sizable gap around the shower knob.

F) Adult North Dayroom
i) A bracket handle was on the exit door that lead to the courtyard.
ii) The sink faucets were not anti-ligature.
iii) There were two areas with exposed capped water pipes.
iv) The chairs had a number of gaps within the wooden materials.

G) Adult South Dayroom
i) A bracket handle was on the exit door that lead to the courtyard.
ii) The sink faucets were not anti-ligature.
iii) There was one missing automatic fire sprinkler cover.
iv) There were two areas with exposed capped water pipes.
v) The chairs had a number of gaps within the wooden materials.
vi) There was a white metal bracket above the refrigerator that bolted the refrigerator to the wall. The placement of the refrigerator provided a hidden area. The area was obscured from view by the refrigerator.

Note: On 1/09/19, observation of the Adult South Dayroom revealed two unsupervised residents. Resident #1 was observed sitting in one of the chairs without supervision from approximately 5:08 pm to 5:27 pm. Surveyors informed the facility staff of the concern and resident #1 was escorted to the resident's room at approximately 5:27 pm. At approximately 5:08 pm, facility staff unlocked the exit door that lead to the courtyard to allow Resident #2 to smoke. Resident #2 proceeded to the courtyard to smoke and was without supervision. At approximately 5:10 pm, staff walked outside for approximately one minute and stated to the resident that she had to leave to continue her rounds. At approximately 5:12 pm, Resident #2 walked back into the dayroom and sat on one of the chairs nearest the entrance. At 5:15 pm, a second facility staff came in to talk to Resident #2 for approximately two minutes. The facility staff left for approximately four minutes and returned to take Resident #2's vitals.

H) Youth (A Unit)
A) Seclusion Room #2
i) The bed used in the room was a restraint type bed that had three restraint anchors (metal bars) on each side of the bed.
B) The resident beds had two pull out drawers.
C) Sharp metal brackets were used to anchor the resident beds. There were gaps between the bracket and the bed.
D) Several screws used throughout the resident rooms were not tamper resistant.
E) Marble window sills were installed in some of the resident rooms. The corners were sharp and there was a gap between the two marble slabs.
F) Dayroom
i) The chairs had a number of gaps within the wooden materials.
ii) The paper toilet seat cover holder installed in the bathroom had a sizable gap.
iii) There were sharp metal brackets used to anchor the toilet bowl cover. There was a gap between the toilet bowl cover and the metal brackets.

On 1/8/19 the Director of Plant Operations revealed an environmental risk assessment had been completed by the facility on October 2017 and was provided for review. The environmental risk assessment dated 2017 identified the use of crank beds and automatic sprinkler guards as a ligature risk; however the other items noted were not identified. The environmental risk assessment that was completed in 2018 was not provided.





Patient #4

On 10/12/18, Patient #4 was admitted with major depressive disorder.

On 11/17/18, a Nursing Progress Note showed Patient #4 received emergency medication per protocol because patient went into bathroom and attempted to hang self with shower curtain.

On 11/17/18, a Denial of Rights document showed Patient #4 received emergency medication per protocol because patient went into bathroom and attempted to hang self with shower curtain.

On 1/11/19, an electronic Incident Report revealed the Risk Manager received information related to the above report. The Incident Report failed to include any information regarding the patient in the bathroom attempting to hang self with shower curtain and did not investigate.

On 11/20/18 at 1:35 PM, the Psychiatrist saw the patient and documented the patient denied self harm in the past few weeks.

On 11/25/18, a Nursing Progress Note showed a suicidal ideation event related to the patient seeking assistance for a nose bleed with the revelation the patient caused the injury with broken glass.

On 11/25/18, an electronic Incident Report revealed a suicidal ideation event related to the patient seeking assistance for a nose bleed with the revelation the patient caused the injury with broken glass. The Risk Manager documented the report did not require an investigation and root cause analysis.

On 11/29/18 at 12:18 PM, a Psychiatrist saw the patient and documented treatment team was held no self injurious behavior.

On 12/27/18, a Nursing Progress Note showed the patient had self harm marks on arms after sneaking a blade in from a pass on 11/18/18. The patient indicated committing self harm days prior. The Risk Manager lacked documented evidence of an incident report and investigation by the time of the exit.

On 12/28/18, a Nursing Progress Note showed a Mental health Tech found a needle on the floor by the patient's bed. The patient was diabetic.

On 12/28/18, a Psychiatrist saw the patient but did not document the visit until 1/8/19, after the inspection was initiated on 1/7/19.

On 1/9/19 at 8:50 PM, a Nursing Progress Note showed the patient had a shower curtain tied around neck and was discovered pulling the ends tight.

On 1/9/19 at 8:50 PM, an electronic Incident Report revealed the patient had a shower curtain tied around neck and was discovered pulling the ends tight. The Risk Manager documented an investigation was initiated on 1/10/19.

As of 1/10/19 at 6:38 PM, the medical record lacked documented evidence the Psychiatrist had evaluated the patient since 12/31/18.

Patient #5

On 10/8/18, Patient AW was admitted with major depressive disorder.

On 10/9/18, the Psychosocial Assessment revealed the patient had history of suicidal ideation with plan to hang self and tried to kill self the day of admission.

The History and Physical documentation revealed the patient tried to kill self the day of admission and had suicidal ideation and multiple previous suicide attempts requiring hospitalization .

On 10/9/18, the Initial Psychiatriac Evaluation revealed the patient had suicidal thoughts as described in patient's own words. The Psychiatrist documented reviewing the two above documents.

On 10/8/18, the Admission Nursing Assessment revealed the nurse documented reviewing the Psychosocial Assessment.

On 1/11/19, the Treatment Plan showed the patient was programmed with Potential for Harm to Others during the first week of admission.

On 12/2/18, a Nursing Progress Note showed Patient AW received emergency medication per protocol because of banging head on nursing desk and window, and then went to bedroom and tied a sheet around neck, tore shirt and tried to choke self in quiet room.

On 12/2/18, a Denial of Rights document showed Patient AW received emergency medication per protocol because of banging head on nursing desk and window, and then went to bedroom and tied a sheet around neck, tore shirt and tried to choke self in quiet room.

On 12/2/18, the patient's Treatment Plan was first updated for Potential for Self Harm.

On 1/9/19 in the afternoon, the Risk Manager indicated he did not receive the above Denial of Rights report, and the facility did not investigate the incident(s).

On 1/11/19, an electronic Incident Report revealed the Risk Manager received information related to the above report, including the head-banging. The Incident Report failed to include any information regarding tying a sheet around neck or choking self.

Medical Record documentation showed the Psychiatrist entered the last three visits on 1/7/19 at lunch time, after the inspection began. These visits were dated 12/28/18, 12/31/18 and 1/7/19. None of the notes were identified as late entries.

Patient #6

On 10/10/18, Patient #6 was admitted with major depressive order, anxiety disorder, impulse disorder and suicidal ideation.

A Nursing Progress Note, dated 10/15/18, revealed Patient #6 wanted to die and began choking self with article of clothing.

A Nursing Progress Note, dated 10/17/18, revealed Patient #6 tied a sheet around neck, which was taken by staff. Patient #6 ripped shirt for choking self in quiet room.

On 10/17/18, a Denial of Rights document showed Patient #6 received emergency medication per protocol because of tying a sheet around neck, tore shirt and tried to choke self in quiet room.

On 1/9/19 in the afternoon, the Risk Manager indicated he did not receive the above report, and the facility did not investigate the incident(s).

The Critical Event Review and Reporting policy (200.14, last revised 9/2017), revealed under its definitions section: The Critical Event Policy applies to events that meet the following criteria:

1. The event results in or has the potential to cause serious harm or death (even if the outcome was not serious harm or death):
b. Attempted suicide of any patient (that does not result in a major loss of permanent function), or

3. Sexual contact between patients involving any touching of genitalia, or

4. Patient elopement, or

Staff/patient or patient/patient aggression resulting in injury to the patient...

8. Falls with significant injury...

Critical Event Analysis:

An evaluative process structured to attempt to:

Determine underlying causes of the critical event and whether there is a reasonable potential for process improvement to reduce the likelihood of such events in the future.

Procedure #6: The critical event analysis will be completed within 30 days of knowledge of the event and should include the following:

a. A determination of what happened in terms of the details of the event and the areas or services impacted.

b. Identification of why the event occurred, was there human error, a missing or weak step in the process, equipment failure, environmental or other external factors that directly affected or influenced the occurrence.

c. A flow chart of the process with identification of the steps that may have contributed to the critical event.

d. A review of the cause and effect factors contributing to the critical event.

e. An analysis of the process to prevent a repeat of the critical event specifically asking 'why' multiple times during the review of the following issues.

f. The human factor (staffing, staff competencies, performance of the staff involved, in-service education needs of the staff);

g. Information management (communication among staff, the availability of accurate, complete, unambiguous information);

h. Environmental management (physical environment appropriate to the process performed...)

i. Leadership (corporate culture conducive to risk identification and reduction, barriers to communication of potential risk factors on the unit/within the facility, priority of prevention of adverse outcomes within the unit/facility); and,

j. Any uncontrollable factors (special cause variations).

None of the incident reports inquired about during the inspection resulted in an investigation and critical event review or root cause analysis with the exception of those that occurred after the Risk Manager was informed about this administrative lapse on the afternoon of 1/9/19.

On 1/14/19 at noon, the Medical Director indicated there should be an Incident of Unknown Origin policy, if the facility did not have one. Ligature issues were previously identified during the facility's accreditation inspection in June 2018.

On 1/14/19 at 3:00 PM, the Risk Manager indicated nobody reported Patient #4, #5 and #6 as suicide attempts, only as restraint/seclusion incidents; otherwise, there would have been a full investigation for the suicide attempts. The Risk Manager acknowledged there was no Community Committee, no Grievance Committee and no grievance investigations.




Patient #14 was admitted on [DATE], with diagnoses including major depressive disorder non-psychotic recurrent, severe.

A Seclusion and Restraint Emergency Procedure for Children and Youth Denial of Rights document dated 10/28/18 documented Patient #14 got upset during a visit with a family member, threatened to harm the family member, attempted to throw a chair, swung a closed fist and attempted to choke self. The document indicated the Handle With Care (HWC) Restraint Technique (PRT) was implemented.

An Incident Report dated 10/28/18, documented the type of incident that occurred was Restraint-Physical-PRT-HWC. for 2 minutes. The designated selection for suicide attempt/gesture and self-harm/self-inflicted injury were left blank. The summary of the incident documented the patient "choked himself". The section completed by the Quality Assurance Performance Improvement, Risk Management and Compliance Department indicated the incident did not require a formal investigation. The severity index was noted as inconsequential (not important or significant). The document was signed and dated by the Compliance Officer on 10/30/18.

Patient #15 was admitted on [DATE], with diagnoses including bipolar I disorder.

A Seclusion and Restraint Emergency Procedure for Children and Youth Denial of Rights document dated 10/06/18 documented Patient #15 ran into the vitals room under a table pulled cords and tired to put the phone cord around his neck.

An Incident Report dated 10/06/18, documented the type of incident that occurred was Restraint-Physical-PRT-HWC for 15 minutes and seclusion of 30 minutes with emergency medications given. The designated selection for suicide attempt/gesture and self-harm/self-inflicted injury were left blank. The summary of the incident documented the patient "attempted self harm by using a screw" retrieved from a fire box. The section completed by the Quality Assurance Performance Improvement, Risk Management and Compliance Department indicated the incident did not require a formal investigation. The severity index was noted as inconsequential (not important or significant). The document was signed and dated by the Compliance Officer on

Patient #16 was admitted on [DATE] with diagnoses including recurrent major depressive disorder.

A Seclusion and Restraint Emergency Procedure for Children and Youth Denial of Rights document dated 10/25/18 documented Patient #16 got a nail from a fire box and started to self harm.

An Incident Report dated 10/25/18, documented the type of incident that occurred was Restraint-Physical-PRT-HWC for 5 minutes. The designated selection for suicide attempt/gesture and self-harm/self-inflicted injury were left blank. The summary of the incident documented the patient "attempted self harm by using a screw" retrieved from a fire box. The section completed by the Quality Assurance Performance Improvement, Risk Management and Compliance Department indicated the incident did not require a formal investigation. The severity index was noted as inconsequential (not important or significant). The document was signed and dated by the Compliance Officer on 10/30/18.

On 01/09/19 at 4:06 PM, the Director of Risk Managment indicated the staff should have notified of self harm events. The Director of Risk Managment inidcated the staff used the drop down and selected restraints.

On 01/18/19 at 11:18 AM, the Chief Nursing Officer verified the signature of the compliance officer on the incident reports for Patient #14, #15 and #16.




Patient #24

Patient #24 was admitted on [DATE] with diagnoses including major depressive disorder and suicidal ideations.

A Nursing Progress Note, dated 10/29/18, documented the patient was found by a social worker trying to hang self with the bed sheets. The Nurse Practitioner (NP) was notified and ordered medication to be given.

On 01/14/19 at 1:25 PM, the Registered Nurse (RN) reported Patient#24 was discovered attempted to harm himself by wrapping the bedding around his neck and then pulling on the bedding with his arms held behind the back. The RN stated an incident report should be submitted and sent to the Risk Manger for suicide attempts. The RN believed the Social Worker, who found the patient, submitted an incident report but wasn't sure.

On 01/09/18 at 1:45 PM, the Risk Manager stated patient suicide attempts were to be reported by staff by submitting an incident report. After the incident report was received by the Risk Manger, the incident was to be investigated. The Risk Manager revealed he had not received any incident report regarding Patient#24's attempted hanging and had no prior knowledge of the incident. The Risk Manager did not know why the incident was not reported per the hospital process.

Patient #36

Patient #36 was admitted on [DATE] with diagnoses including Bipolar Disorder.

A Nursing Progress Note dated 06/08/18 documented Patient #36 was found in the bathroom with blankets and clothing tied together around the neck, and around the bathroom door and the shower seat leg trying to hang themselves. A Registered Nurse (RN) called a Mental Health Technician (MHT) to assist in helping to get the door open and clothing and blankets unwound from Patient #36's neck.

A hospital Incident Report, dated 06/08/18, indicated the incident was a suicide attempt. The attempt occurred in the bathroom of Room 405 on the Psychiatric Residential Treatment Facility (PRTF) section of the hospital. The incident report indicated Patient #36 was found in the bathroom with blankets and clothing tied together around the neck, and around the bathroom door and the shower seat leg trying to hang themselves. Patient #36 was relocated to a different unit following the incident. The incident report was reviewed by the Quality Assurance/Process Improvement Department on 06/12/18. The report documented the incident did not require investigation, a Root Cause Analysis (RCA), or further action. No recommendations were listed. The incident was closed on 06/12/18, and signed by the Risk Manager.

On 01/09/19, at 1:45 PM, the Risk Manager reported his duties included the investigation of incidents in the facility, and deciding which incidents required a formal investigation to determine actions for reducing further risk of harm. The Risk Manager verified reviewing the incident report on 06/12/18. The Risk Manager verified staff documented Patient #36 wrapped blankets and clothing around a shower seat in the bathroom of Room 405 as a means of attempting suicide. The Risk Manager acknowledged the shower seat was a ligature point where clothing or other objects could be secured for the purpose of attempted hanging, and as such were hazardous to patients. The Risk Manager reported further action should have have been taken, such as removing the shower seat or any other ligature points identified. The Risk Manger stated he was not aware if that shower seat or others like it were in continued use in the hospital.

During observations conducted from 01/09/19 though 01/11/19, Resident Room #100, #200, #204, #301, #305 and #405 contained shower chairs that were "bolted" to the shower panel.

The hospital 2018 Bylaws of the Medical Staff indicated the Medical Director was appointed by the Governing Board upon the recommendation of the CEO.

-The Medical Director was responsible for the clinical operations of the hospital; for improving patient safety; for continually assessing and improving the activities and quality of patient care; for making recommendations to the hospital's administrative staff regarding the planning of hospital facilities, equipment, routine procedures and other patient care matters.

-The Medical Director and any Associate Medical Directors appointed by the Governing Board were responsible for the development and implementation of policies and procedures that guide and support the provision of services, and the continuous assessment and improvement of the care and services provided.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, interview and document review, the facility failed to screen, assess, initiate and update treatment plans, ensure clinicians provided and documented services, protect patients, identify and investigate incidents, formulate policy guidelines for the care and treatment of patients with inappropriate sexual activity histories or incidents resulting in neglect of 14 of 37 patients (Patient #1, #2, #3, #7, #8, #9, #32, #31, #13, #33, #37, #10, #26 and #35).

Findings include:

42 CFR Part 488.301 Definitions:

Neglect is the failure of the facility, its employees or service providers to provide goods and services to patients that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Facility Policy: The Patient Abuse or Neglect policy (1800.30, last revised September 2017) revealed neglect was a form of abuse in which there was failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Facility Policy: The Patient Abuse or Neglect policy (1800.30, last revised September 2017) revealed sexual abuse was defined as any unwanted sexual activity, without regard to contact or injury; any sexual activity with a person whose capacity to consent or resist is limited.

Facility Procedures:
Procedure #2 of the Unit/Bed Assignment of Patients Upon Admission or Transfers During Treatment policy (1000.132, last reviewed October 2018) revealed bed assignment would be made by the Charge Nurse. Bed assignment would be based on program assignment; social and/or emotional maturity; and special protocol. The charge nurse would review with the admitting physician history of physical/sexual/emotional abuse and perpetration as well as history of acting out behaviors in order to help determine appropriate bed assignment.

Procedure #2 of the Levels of Observation policy (1000.24, last revised October 2018), patients identified to be at risk for displaying sexually inappropriate behaviors would be put on SRP precautions on the electronic medical record and would be assigned to a room without a roommate.

Procedure #3 of the Levels of Observation policy (1000.24, last revised October 2018), the Registered Nurse may increase the level of observation if the patient's condition changes...If a client's behavior/mood necessitated a more intensive level of observation...

Patient Rights provided by the facility:

1. The right to dignity, respect, privacy, humane care and freedom from mental and physical abuse, neglect and exploitation.

17. The right to have an individualized treatment plan specific to your individualized needs...

On 1/10/19 at 11:30 AM, a Registered Nurse (RN) who conducted an Admission Nursing Assessment was interviewed regarding the facility's policy of using sexual restrictive precautions (SRP). The RN indicated it meant patients would have their own room, and other patients could not be in the room. The patient with these precautions either had a solo room or slept near the nurse station.


Patient #1

On 11/30/18, Patient #1 was admitted with major depressive disorder and bipolar disorder. Patient #1 had a history of inappropriate sexual behavior during previous stays at the facility.

Patient #1 History and Physical, the Psychosocial Assessment, the initial Psychiatric Evaluation and the Nursing Admission Assessment all dated 11/30/18, revealed a history of sexual abuse.

Procedure #2 of the Levels of Observation policy (1000.24, last revised October 2018), patients identified to be at risk for displaying sexually inappropriate behaviors would be put on SRP precautions on the electronic medical record and would be assigned to a room without a roommate.

On 1/7/19 in the morning, a patient census report was observed and obtained for patients in the Psychiatric Residential Treatment Facility (PRTF) area. Patient #1 was not on sexual restrictive precautions (SRP) and was placed with a roommate.

On 12/12/18, Patient #1 saw a therapist for a Treatment Plan Assessment.

Patient #1's Treatment Plan initiated in December 2018 revealed the following:

Therapist will assist in developing a safety plan.
Therapist will facilitate groups.
Therapist will assist with support and psychoeducation.
Therapist will assist with identifying role of drugs as means of numbing and escaping feelings.
Therapist will assess for patterns of impulsivity.
Client will be referred for psychological testing.

On 12/20/18, a Licensed Clinical Social Worker documented a check in with the patient due to the therapist being out.

Patient #1's medical record lacked documented evidence of a Treatment Plan for sexually inappropriate behavior until 1/13/19, after the complaint inspection revealed the facility treatment team failed to design a Treatment Plan for this problem.

On 1/15/19 at 12:52 PM, Patient #1 verbalized the following: being told two therapists were terminated, and Patient #1 had not received therapy since. Patient #1 expressed the need for having a therapist but did not have one assigned. Patient #1 saw a therapist a few times per month during an earlier stay, but a parent had to prompt the therapist to see Patient #1. Patient #1 was unable to speak to parents frequently enough and became emotional when speaking. The facility stopped doing nursing/therapy groups because of staffing. Patient #1 was bothered by the fact the facility moved Patient #1 a number of times, and Patient #1 did not know why.

As of 1/15/19 at 1:43 PM with the Medical Records Director present, Patient #1's medical record lacked documented evidence of having an assigned clinical therapist for individual therapy.

Patient #2

On 12/10/18, Patient #2 was admitted with self harm and placed on sexual restrictive precautions.

The History and Physical dated 12/10/18, revealed hypersexuality and sexual abuse.

On 12/11/18, a Psychiatrist documented an Initial Psychiatric Evaluation revealing hypersexuality.

On 12/11/18, a Psychosocial Assessment revealed Patient #2 was acting hypersexual with an admitted history of abuse/exploitation.

On 12/10-11/18, the Nursing Admission Assessment revealed no connection to the patient's hypersexuality and sexual abuse history. Although the nurse acknowledged reviewing the Psychosocial Assessment.

On 12/21/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate touching with another patient. Facility census data showed Patient #2 had a roommate.

On 12/22/18, an Incident Report revealed staff saw Patient #2 engaged in inappropriate touching with another patient, but Patient #2 denied it. The Risk Manager documented the report did not require an investigation and root cause analysis.

On 12/24/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate sexual behavior with a second patient. Facility census data showed Patient #2 had a roommate until 12/25-26/18.

On 12/24-25/18, an Incident Report revealed a patient was told by Patient #2 and another patient the two had sex, but when confronted by staff, the two denied it. A Mental Health Tech was involved in the incident as redirecting the participants, and that staff member was not prompted for a statement about the incident. The Risk Manager documented the report did not require an investigation and root cause analysis.

On 1/3/19, a Psychiatric Progress Note revealed Patient #2's family member expressed anger regarding the two sexual incidents. The Psychiatrist assured the facility did its best to ensure the safety of every patient.

On 1/5/19, Patient #2's medical record revealed the only documented clinical therapy session for the month of January 2019.

On 1/7/19, the same Psychiatrist, who reassured the family member, entered three visits for 12/28/18, 1/3/19 and 1/7/19, after the inspection was initiated. None of the notes were designated as late entries. The documents were all initiated and time/date stamped on 1/7/19; the software allowed clinicians to manipulate the date by scrolling to the date intended for a past entry.

On 1/10/19 at noon, a Registered Nurse (RN) currently working on the PRTF unit indicated the following: The RN was familiar with Patient #2. The RN indicated PAtient #2 should have had SRP precautions. It meant not being in close contact with peers, line of sight/1:1 observation, but it required a physician order. The RN was unaware if the SRP patients had to have their own room, but it usually lasted the length of the stay. The RN was unaware Patient #2 already had two sexually inappropriate incidences within the building.

On 1/11/19 in the afternoon, the Medical Records Director acknowledged and demonstrated the aforementioned entries in the Medical Records Office.

Patient #2's medical record lacked documented evidence of a Treatment Plan for sexually inappropriate behavior until 1/13/19, after the inspection revealed the treatment team failed to design a Treatment Plan for this problem. The Treatment Plan lacked documented evidence of any updates between the 12/10-18/18 plan goals initiated during the first week of post admission and 1/13/19.

On 1/15/19 at 12:30 PM, Patient #2 verbalized the following: The patient wanted a therapist to talk to and felt there should be more therapeutic activities available, but had not seen a therapist in some time because no therapist was assigned, and the previous therapist was terminated. The patient was told the terminated therapist had to take care of a dog. The patient did not want a social worker. The patient was unable to recall the last Psychiatrist visit.

Patient #3

On 12/4/18, Patient #3 was admitted for major depressive disorder.

On 12/13/18, an Incident Report revealed the patient had sex with another patient from the unit in the bathroom. The patient indicated being the initiator. Patient #3 was not placed on SRP precautions. The Risk Manager wrongfully indicated the police did not need to be called because both parties were above the legal age of consent. The perpetrator was of legal age, but the victim was not.

On 12/17/18, Patient #3 was transferred to another unit.

On 12/17/18, a Nursing Admission Assessment revealed the patient was sexually active and did not practice safe sex.

On 12/18/18, a Psychosocial Assessment revealed the patient's sexual abuse history as a victim.

On 12/18/18, the Initial Psychiatric Assessment revealed sexual preoccupation. Patient #3 still was not placed on SRP precautions.

On 12/24/18, a Nursing Progress Note revealed the patient engaged in sexual activity with another patient.

On 12/24/18, an Incident Report revealed the patient had a sexual incident with another patient on the unit. Facility census data showed Patient #3 continued to have a roommate and was still not placed on SRP precautions.

On 12/27/18, a Nursing Progress Note revealed the patient had self harm and a blade was used. The nurse did not find a blade initially. The patient turned the blade in.

On 12/28/18, a Psychiatrist documented a progress note showing awareness of the sexual incident dated 12/24/18. Patient #3 still was not placed on SRP precautions.

On 1/3/19, a Psychiatrist documented a progress note.

Patient #3's medical record lacked documented evidence of a clinical therapy visit except for one documented on 1/4/19.

On 1/4/19, a Nursing Progress Note showed the patient first threatened and then removed shirt and pulled pants down in class when another patient did not apologize for something. An hour later, the patient received emergency Zydis per protocol for agitation, pacing and verbalizing a desire for sex. Patient #3 still was not placed on SRP precautions.

On 1/7/19 in the morning, a patient census report was observed and obtained for patients in the Psychiatric Residential Treatment Facility area (PRTF). Patient #3 was not placed on SRP precautions and was placed with a roommate.

On 1/10/19 at noon, a Registered Nurse (RN) currently working on the PRTF unit indicated the following: The RN was familiar with Patient #3. The RN indicated Patient #3 should have had SRP precautions. It meant not being in close contact with peers, line of sight/1:1 observation, but it required a physician order. The RN was unaware if the SRP patients had to have their own room, but it usually lasted the length of the stay. The RN was unaware Patient #3 already had two sexually inappropriate incidences within the building.

On 1/10/19 at 1:00 PM, the Unit Manager (UM) verbalized the following: The UM Knew of the two incidents with Patient #3. Patient #3 was previously on another unit before being transferred to the present unit. The UM was unable to answer why unit nurses were not informed or why patients were not placed on SRP, except to say the unit relied on a verbal report at the time of transfer from one unit to the next. Treatment plans were supposed to be updated with new problems/interventions as they presented.

On 1/11/19, a Psychiatric Progress Note showed an increase in medication for persistent sexual urges.

Patient #3's medical record lacked documented evidence of a treatment plan for sexually inappropriate behavior until 1/13/19, after the complaint inspection revealed the treatment team failed to assess the behavior and update the treatment plan for this problem.

On 1/15/19 at 12:20 PM, Patient #3 had a difficult time discussing urges with the therapist, but indicated seeing a therapist for a total of twenty minutes so far during the stay.

Patient #7

On 12/13/18, Patient #7 was admitted with recurrent major depressive disorder.

On 12/20/18, a Psychiatric Progress Note revealed patient had a significant history of sexual abuse and neglect. The Psychiatrist did not place Patient #7 on SRP precautions.

On 12/21/18, a Nursing Progress Note showed Patient #7 engaged in inappropriate touching with another patient. Facility census data showed Patient #7 had a roommate and was not placed on SRP precautions.

On 1/7/19 in the morning, a patient census report was observed and obtained for patients in the Psychiatric Residential Treatment Facility area (PRTF). Patient #7 was not placed on SRP precautions and was placed with a roommate.

Patient #7's medical record lacked documented evidence of a treatment plan for sexual abuse history until 1/13/19, after the inspection revealed the treatment team failed to identify the behavior/history as a problem and design/update the treatment plan for this problem.

On 1/15/19 at 12:10 PM, Patient #7 expressed not receiving therapy because the therapist disappeared three weeks ago.

Patient #8

On 9/7/18, Patient #8 was admitted with bipolar disorder.

On 9/8/18, the initial Psychiatric Evaluation showed Patient #8 had a traumatic victim of sexual abuse history.

On 1/7/19 in the morning, a patient census report was observed and obtained for patients in the Psychiatric Residential Treatment Facility area (PRTF). Patient #8 was not placed on SRP precautions.

The successive Psychiatric Progress Notes highlighted the sexual abuse history, but Patient #8's medical record lacked documented evidence of a treatment plan for sexual abuse history until 1/13/19.

Patient #9

Patient #9 was admitted on [DATE] with diagnoses including ADHD, Bipolar I Disorder, Oppositional Defiant Disorder, post-traumatic stress disorder (PTSD). The patient was ordered precautions and observations including assault precaution, sexual aggressor precaution, and sexual reactive precautions (SRP).

On 1/15/19 at 4:00 PM, Patient #9 verbalized frustration there was no treatment plan discussion and no therapist assigned. Nobody discussed accomplishing goals. Groups were run more frequently during the previous stay at the facility.




Patient #26

Patient #26 was admitted [DATE] with diagnoses including dementia and psychotic disorder.

On 1/9/19 at 9:15 AM, Patient #26 was sitting in a wheelchair in the common area of Unit 500. The patient had a laceration to the bridge of the nose, swelling and discolored bruising surrounding the left orbital area a "black eye."

On 1/9/19 in the morning, the charge nurse indicated Patient #26 fell in the bedroom during the night and sustained injuries to the left side of the head, nose and left eye. The nurse also indicated the patient was complaining of of pain to the hips and legs. The charge nurse indicated the fall was not witnessed by any staff and the patient's roommate indicated Patient #26 fell . The patient also indicated a fall occurred in the room. The charge nurse indicated both patients were confused. The charge nurse indicated there was no investigation completed or needed due to what the patients said. The charge nurse indicated Patient #26 and the roommate slept in the same room during the night after the injuries were identified by the staff.

On 1/9/19 at 9:20 AM, Patient #26 was alert and oriented x1 to person only. The patient rambled some incoherent sentences and was asked by the Inspector on how the injuries to the face and head were sustained with no mention of the patient's roommate or any fall during the conversation. The patient indicated the roommate kept taking her things and the roommate wanted to be the boss. Patient #26 indicated the roommate kept hitting her.

The Psychiatric Progress Note form dated 1/8/19 at 18:59 (6:59 PM), documented the patient was confused.

The Nursing Progress Note form dated 1/8/19 at 21:40 (9:40 PM), the patient was found standing in the room with a cut on the nose. The staff interviewed the roommate and the roommate stated Patient #26 fell .

On 1/9/19 at 9:55 AM, Patient #34 (roommate of Patient #26) was alert and oriented x 1-2, to person and place. The patient indicated the year was 1998, was not able to give the month and was aware the city was Las Vegas but was unable to give what building she was in.

On 1/9/19 in the morning, the Quality Assurance Coordinator indicated the facility had no policy regarding investigating injuries of unknown origin. The Coordinator indicated since both residents were confused and no staff witnessed the incident an investigation should have been conducted.

There was no documented evidence an investigation was performed to determine how the patient sustained numerous injuries to the facial area from a single fall. There was no documented evidence interviews were obtained from other possible witnesses due to both patients who were interviewed were known to have confusion to determine if the unwitnessed incident was an actual fall or a physical abuse altercation.

Patient #35

Patient #35 was admitted on [DATE] and discharged on [DATE], with diagnoses including personal history of adult physical and sexual abuse, suicidal ideations and major depressive disorder.

Patient #35 documented on a Compliment/Complaint/Suggestion Form dated 11/11/18, the patient's rights were violated and threatened my a roommate.

An event followup on 11/12/18 1:59 PM, indicated the response to the complaint IR (incident reports were confidential and could not be printed out and the patient had the right to consult an attorney.

On 1/11/19 in the Quality Assurance Coordinator confirmed there was no investigation completed for Patient #35's allegations of being threatened by the roommate and there should have been one conducted.

Complaint #NV 061





A High Risk/High alert Handoff was not completed on admission to identify Patient #9 for behaviors of sexually acting out as an aggressor or victim.

Patient #9's Treatment Plans were not updated to include the patient's inappropriate sexual behaviors. An actual incident of inappropriate sexual behavior occurred on 12/13/18.

Patient #13

Patient #13 was admitted on [DATE] with diagnoses including conduct disorder, group type, unspecified mood affective disorder, and potential harm to others (aggressive and defiant behavior).

Patient #13 was ordered precautions and observations including Sexually acting out precaution, line of sight (LOS) while awake (WA), suicide precaution, observation every (q) 15 minutes, and sexual aggressor.

The staff unit work sheet dated 01/11/19 documented "Watch with [Female Patient]" and indicated the patient was planning to have sex in the bathroom". The patient was not placed on SRP.

An order for precautions for sexually acting and Line of Sight (LOS) was not done or precautions initiated until 01/12/19.

Patient #33

Patient #33 was admitted on [DATE] with diagnoses including attention deficit hyperactivity disorder (ADHD) combined type, bipolar I disorder, family discord, major depressive disorder no-psychotic recurrent, severe, post-traumatic stress disorder (PTSD), social discord, potential for self-harm.

Patient #33 was ordered precautions and observations including sexually acting out precautions, suicide precautions, line of sight while awake, every 15 minute observation, and sexual aggressor precautions.

Patient #33's Treatment Plan not updated to include SRP.

A High Risk/High Alert Handoff dated 01/06/19, documented the patient was sexually acting out (SAO) and an aggressor and a victim. An order for SRP precautions was not initiated until 01/12/19.

Patient #37

Patient #37 was admitted on [DATE] with diagnoses including major depressive disorder and recurrent severe psychosis.

The staff unit work sheet dated 01/11/19 identified Patient #37 as planning to have inappropriate sexual contact with a peer in the bathroom. The Patient #37 was not placed on SRP until it was identified the patient had planned to attempt inappropriate sexual contact with a second peer on 01/13/19.

Patient #10

Patient #10 was admitted on [DATE], with diagnoses including major depressive disorder and recurrent severe psychosis, ADHD combined type , and unspecified mood disorder. Patient #10 was ordered precautions and observations including SRP, LOS WA, q 15 min checks, assault, and suicide.

Patient #10's Treatment Plans were not updated to include the patient's inappropriate sexual behaviors.

On 01/08/19 at approximately 9:10 AM, a Registered Nurse (RN) identified having two patients in the acute pediatric and adolescent unit on sexual reactive precautions (SRP).

On 01/08/19 in the morning, a Registered Nurse (RN) explained the SRP precautions were when a patient was on sexual restrictive precautions, on One-to-One Observation (1:1) and placed in a private room. The RN indicated not being aware of a policy.

On 01/08/19 in the morning, another RN indicated SRP a patient was placed on SRP precautions when a need was identified such as being sexually traumatized. The RN indicated they needed to watch the patient, the patient was roomed by self and monitored with peers. The RN indicated not knowing if the SRP protocol was an official process.

Patient #32

Patient #32 was admitted to the adolescent partial hospital program (PHP) on 12/04/18 with diagnoses including attention deficit hyperactivity disorder (ADHD) predominately inattentive type, anxiety disorder, unspecified, and recurrent major depressive disorder. The patient was discharged on [DATE].

An Initial Psychiatric Evaluation dated 12/04/18, documented the patient claimed being abused sexually (touched inappropriately) at a foster home.

A Psychiatric Progress Note dated 12/12/18, documented Patient #32 disclosed that a peer in the program exposed himself to her in the bathroom a week ago.

Patient #31

Patient #31 was admitted to the adolescent partial hospital program (PHP) on 11/30/18 with diagnoses including attention deficit hyperactivity disorder (ADHD) combined, asperger's syndrome, recurrent depression and mood disorder. The patient was discharged on [DATE].

A Psychiatric Progress Note dated 12/05/18, documented Patient #31 was released from the Acute Unit due to impulsive behaviors and safety concerns.

A Treatment Plan Assessment Update dated 12/12/18, documented Patient #31 did not attend PHP treatment or participate in treatment team meeting. The Treatment Plan Assessment Update indicated to continue current medications as prescribe and discharge with outpatient therapeutic referrals for therapy and psychiatric services.

An incident report dated 12/11/18 documented the allegation was reported to the Las Vegas Metropolitan (Metro) Police Department and Child Protective Services (CPS). Both patients were processed with the therapist. All PHP staff were alerted to the incident, advised to be alert for any ongoing behaviors related to the incident, and the patient interactions were to be monitored closely by staff.

The event description documented Patient #31 asked Patient #32 into the restroom saying that it was an "emergency". Once in the restroom Patient #32 was told to close her eyes. When Patient #32 opened her eyes Patient #31's pants was seated on the toilet with pants down exposing self, and asked Patient #32 to touch him.

The report document of the incident was reviewed by the Director of Compliance Quality and Risk (DCQR) which indicated the staff took the appropriate action in response to the incident. The DCQR indicated the incident did not meet the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) nor the State of Nevada definition of a Sentinel event and did not require a formal investigation, and a formal Root Cause Analysis was not recommended.

On 01/08/19 at 10:35 AM, the Director of Outpatient Services explained the patients were monitored by the Mental Health Technicians (MHT's) along with other assigned staff. The staff not leading the group monitored the patients going to the bathroom. The Director of Outpatient Services indicated the staff who escorted Patient #32 did not escort the patient to the adolescent group, but stood at the exit of the program space and did not see Patient #32 go into the restroom. The Director of Outpatient Services disclosed Patient #32 was told by Patient #31 to close her eyes and Patient #31 pulled his pants down. The Director of Outpatient Services indicated a week later Patient #32 told someone when it was time for her scheduled discharge.

The Director of Outpatient Services indicated the MHT's were responsible for running the group. If therapy staff lead the group there were two staff. The Director of Outpatient Services confirmed a MHT lead the adolescent group and no one monitored the patients going to the bathroom during the time the incident occurred.

On 01/15/19 at 5:33 PM, the Chief Nursing Officer (CNO) explained the outpatient area does their own staffing, but MHT's could have been pulled to cover the outpatient area if needed. The CNO indicated the Director of Outpatient Services should have called if additional staff was needed.

The outpatient area lacked staff to monitor patients for safety and prevent an occurrence of inappropriate sexual behavior between patients.

On 01/08/19 at 10:48 AM, the Director of Outpatient Services explained an investigation was done and the outcome was there was no touching. The Director of Outpatient Services indicated the family, CPS and Metro were called per facility policy. The Director of Outpatient Services indicated the Therapist spoke to the MHT's regarding the incident, talked to the family, the male patient was discharged the next day and we set staffing.

On 01/09/19 at 1:50 PM, the Director of Compliance Quality and Risk (DCQR) confirmed no formal investigation or root cause analysis was done for the complaint. The DCQR indicated not being aware if training was done with the staff in the outpatient area.

A facility policy entitled Critical Event Review and Reporting, 200.14, Effective date: 10/01/16, Revised 09/2017, documented guidelines for communicating, investigating and acting upon critical events. The policy indicated any actual or alleged inappropriate sexual contact between staff and current patients or individuals who were patients within two years from discharge, (to include inappropriate verbal or written communication and/or inappropriate physical contact).

The critical event analysis will completed with 30 days of knowledge of the event, and should include the following:
-A determination of what happened in terms of the details of the event and the areas or services impacted.
-Identification of hwy the event occurred, i.e. was there human error, a missing or weal step in the process, equipment failure, environmental or other external factors that directly affected or influenced the occurrence.
-A flow chart of the process with identification of the steps that may have contributed to the critical event.
-A review of the cause and effect factors contributing to the critical event.
-An analysis of the process to prevent a repeat of the critical event specifically asking "why" multiple times during the review of the following issues.
-The human factor (staffing, staff competencies, performance of the staff involved, in-service education needs of the staff);
-Information management (communication among staff, the availability of accurate,complete, unambiguous information;
-Environmental management(physical environment appropriate to the process performed, emergency preparedness planed and tested , identification of environmental risks such as lighting);
-Leadership (corporate culture conducive to risk identification and reduction, barriers to communication of potential risk factors on the unit/within the facility, priority of prevention of adverse outcomes within the unit/facility; and,
-Any uncontrollable factors.

Complaint #NV 530

On 1/11/19 at 9:00 AM, the Medical Director of the Unit (housing Patient #1, #2 and #3), a Psychiatrist indicated the following: The main part of the job was initial psychiatric evaluations and weekly progress notes for one unit and daily progress notes for the other unit. Sexual restrictive precautions (SRP) meant line of sight observation, single rooms with the precautions reviewed every other day. Patient #2 was known, so Patient #2 was placed on SRP precautions since admission. The rooms were probably full, which would explain why Patient #3 had a roommate when the bureau walked in on 1/7/19. The first incident of Patient #3, dated 12/13/18, was acknowledged. The second incident of Patient #3, dated 12/24/18, was acknowledged. Not everyone with sexually inappropriate behavior history needed to be on precautions. There was no explanation as to why Patient #3 was not placed on SRP precautions, except probably should be now. The Psychiatrist was unable to recall the history of Patient #1, which was documented in the initial Psychiatric Evaluation. The Psychiatrist was unable to recall if Patient #1 was on SRP precautions or a request for the order. [The request was made on 1/10/19]. The Psychiatrist acknowledged notes were entered weekly until hearing three sets of Patient #2's visits were entered on 1/7/19. Then the Psychiatrist verbalized there had been no discussion regarding late notes entered for visits and indicated maybe the scribe was late and it was a trick question.

After the immediate jeopardy was called regarding the protection of patients with sexual inappropriate behavior histories or acting out during their stays on 1/9/19, the facility provided a precaution list for each patient in the building: the facility only identified three patients with sexual restrictive precautions on 1/10/19.

On 1/11/19 from 10:30 AM to noon, interviews were conducted with the following staff:

Chief Clinical Officer (a Clinical Psychologist) who served on the Med-Executive Committee, Quality Committee and Governing Body.

The Director of Clinical Services who oversaw day to day functions of therapists.

The Chief Nursing Officer.

The treatment team designed the full continuum of care. Goals were supposed to be set and individualized at admission with a start date. The target date was set to assess whether the patient accomplished the goal. The treatment team included the Psychiatrist, Medical Doctor, Nurse, Family Members, Patient and Case Worker. The History and Physical was completed within 24 hours of admission. Patients were placed on daily medical log for issues to be seen by a medical doctor. The History and Physical was updated every 30 days. Nurse Practitioners could see patients also. In the Acute Youth unit, patients were seen daily with notes required. The treatment team met weekly. In the PRTF, patients were seen weekly with notes required. The treatment team met monthly. The treatment team discussed the past month. Therapists and nurses were responsible for goal setting/reviewing, usua
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on interview, record review and policy review, the facility failed to ensure its staff members renewed their certifications for providing care for patients in restraint/seclusion.

Findings include:

On 1/9/19 in the afternoon, a Milieu Manager identified the Handle With Care Behavior Management System as the facility's restraint/seclusion training program. Employees were expected to complete an online as well as a practical training session.

On 1/9/19 in the afternoon, the Milieu Manager (who was also a certified instructor for the facility's Handle With Care training) provided a list of employees who had not yet completed their annual training renewals for restraint/seclusion training. The Milieu Manager identified the last day worked with the due date for each employee's renewal training. The following employees lacked documented evidence of Handle With Care renewal training:

An Electroconvulsive Therapy Registered Nurse due 5/2/18 who obtained certification on 7/6/18.

An Admissions Assessment and Referral Specialist due 6/6/18 who continued to work through 11/3/18.

An Acute Adult RA/Mental Health Tech due 6/27/18 who continued to work through 1/7/19.

An Acute CD Adult RA/Mental Health Tech due 8/23/18 who continued to work through 1/7/19.

A PRFT RA/Mental Health Tech due 10/11/18 who continued to work through 1/8/19.

A PRFT Registered Nurse due 10/13/18 who continued to work through 1/8/19.

A PRFT Recreation Therapist due 12/6/18 who continued to work through 1/3/19.

An Acute Geriatric RA/Mental Health Tech due 11/21/18 who obtained a certificate on 12/9/18.

A PRFT RA/Mental Health Tech due 11/21/18 who continued to work through 1/6/19.

A PRFT Recreation Therapy Assistant due 12/24/18 who continued to work through 1/8/19.

An Acute Adult RA/Mental Health Tech due 12/20/18 who continued to work through 12/29/18.

An Acute Adult RA/Mental Health Tech due 12/20/18 who continued to work through 1/3/19.

An Admissions Intake Coordinator due 12/21/18 who continued to work through 1/8/19.

On 1/9/19 at 2:20 PM, the Infection Control Officer and Milieu Manager verbalized the above current information.

Under Staff Education #5 of the Seclusion and Physical or Chemical Restraint policy (1000.57, last revised May/2018), all staff with direct patient contact shall be trained and certified in the use of these procedures during orientation, semiannual Handle With Care skill reviews, and ongoing in-service education. Education will be documented on in-service records, pre and post competency testing, and in staff personnel files.
VIOLATION: QAPI Tag No: A0263
Based on interview and document review, the facility failed to implement and maintain an effective ongoing, hospital wide, data driven quality assessment and performance improvement (QAPI), that reflected the complexity of the hospitals organization and services involving all hospital departments and contracted services. Specifically, the hospital failed to ensure data collected was used to monitor the effectiveness and safety of services and quality of care, data was documented and accurately reported to identify trends related to patient safety (Tag A0273, A0283, A0286, A0297, A0308, A0309); to ensure Radiology Services, Laboratory Services and Anesthesia Services were integrated into the QAPI program (refer to Tag A0528, A0576, A1000).

The cumulative effect of these systemic practices resulted in the failure to deliver statutory mandated care to patients.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on observation, interview, record review and document review, the facility failed to integrate laboratory and radiological services into the facility's Quality Assurance Performance Improvement (QAPI) program.

Findings include:

1) First Addendum to Laboratory Services Agreement form dated October 1, 2015, documented performance expectations. The form indicated the contracted laboratory company would provide monthly reports to the facility regarding compliance with agreed testing procedures for monitoring and evaluation purposes. The following were to be obtained by the facility from the contracted laboratory company:

-Turn around time
-Critical Lab values
-QNS/TNP (quantity not sufficient/test not performed)
-Utilization by test (dollar and units)

There was no documented evidence the facility integrated the laboratory services into the facility QAPI program. There was no documented evidence the facility obtained monthly data from the laboratory contractors for their QAPI program.

On 1/11/19 at 2:00 PM, the Director of Compliance and the Chief Nursing Officer (CNO), indicated laboratory contracted services were not integrated with the facility QAPI program. The CNO and the Director of Compliance indicated they did not request and obtain monthly reports from the laboratory contractor.

2) The Service Agreement form dated January 18, 2018 for radiological services documented the provider (x-ray contractor) agreed to perform quarterly quality assurance/performance improvement studies as requested by the facility.

There was no documented evidence the facility integrated the radiological services into the facility QAPI program to maintain safety for the patients and personnel. There was no documented evidence the facility obtained quarterly data from the radiological contractors for their QAPI program.

On 1/11/19 at 2:00 PM, the Director of Compliance and the Chief Nursing Officer (CNO), indicated radiological contracted services were not integrated with the facility QAPI program. The CNO and the Director of Compliance indicated they did not request and obtain quarterly reports from the radiological contractor.
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on observation, interview, record review and document review, the facility failed to integrate laboratory and radiological services into the facility's Quality Assurance Performance Improvement (QAPI) program.

Findings include:

1) First Addendum to Laboratory Services Agreement form dated October 1, 2015, documented performance expectations. The form indicated the contracted laboratory company would provide monthly reports to the facility regarding compliance with agreed testing procedures for monitoring and evaluation purposes. The following were to be obtained by the facility from the contracted laboratory company:

-Turn around time
-Critical Lab values
-QNS/TNP (quantity not sufficient/test not performed)
-Utilization by test (dollar and units)

There was no documented evidence the facility integrated the laboratory services into the facility QAPI program. There was no documented evidence the facility obtained monthly data from the laboratory contractors for their QAPI program.

On 1/11/19 at 2:00 PM, the Director of Compliance and the Chief Nursing Officer (CNO), indicated laboratory contracted services were not integrated with the facility QAPI program. The CNO and the Director of Compliance indicated they did not request and obtain monthly reports from the laboratory contractor.

2) The Service Agreement form dated January 18, 2018 for radiological services documented the provider (x-ray contractor) agreed to perform quarterly quality assurance/performance improvement studies as requested by the facility.

There was no documented evidence the facility integrated the radiological services into the facility QAPI program to maintain safety for the patients and personnel. There was no documented evidence the facility obtained quarterly data from the radiological contractors for their QAPI program.

On 1/11/19 at 2:00 PM, the Director of Compliance and the Chief Nursing Officer (CNO), indicated radiological contracted services were not integrated with the facility QAPI program. The CNO and the Director of Compliance indicated they did not request and obtain quarterly reports from the radiological contractor.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on interview and job description, the Governing Body failed to ensure the Quality Assurance committee conducted a number of distinct improvement projects annually.

Findings include:

On 1/11/19 at 3:00 PM, the Director of Quality Compliance acknowledged the facility failed to conduct annual improvement projects.

The Director of Quality Compliance position description/job evaluation (last revised 6/22/16) lacked documented evidence the facility required the Director of Quality Compliance to conduct annual improvement projects.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, interview and document review, the facility failed to abide by and enforce its Medical Staff Bylaws, Rules and Regulations regarding treatment plans, adherence to medical staff and facility requirements and care of the patient.

Findings include:

The State Licensing and Certification records for the facility revealed the facility is only licensed as a psychiatric hospital. The facility does not have a separate license or certification as a psychiatric residential treatment facility. Therefore, sections of the Bylaws and Rules and Regulations of the Medical Staff that tried to distinguish different frequencies/levels of obligations on behalf of providers/clinicians as those distinctions applied to in-patients (such as acute patients vs. PRTF patients) would not be applicable. Although the facility's Rules and Regulations above refer to acute care patients, "completing progress notes at least six days per week and other such notes as clinically indicated during the patient's length of stay" would apply to all patients.

None of the patients in the PRTF area had such entries.

Medical Staff Rules and Regulations (January 2018):

Treatment Plan:
8. The multi-disciplinary team shall develop an Individual Comprehensive Treatment Plan that is based on a comprehensive assessment of the patient's needs. This plan will be reviewed at least weekly.

Plans were reviewed monthly for the following patients. The Chief Clinical Officer acknowledged the monthly reviews.

Adherence to Medical Staff and Facility Requirements:
11. Each Attending Medical Staff member on the Active Medical Staff shall attend treatment team meetings conducted concerning patients, and for acute care patients is responsible for completing progress notes at least six days per week and other such notes as clinically indicated during the patient's length of stay.

Care of the Patient:
14. Progress notes shall be made by the attending medical staff member, on the acute care unit at least six days weekly and preferably on each patient visit.
On 1/10/19 at 1:00 PM, the Unit Manager (UM) verbalized the following: The UM Knew of the two incidents with Patient #3. Patient #3 was previously on another unit before being transferred to the present unit. The UM was unable to answer why unit nurses were not informed or why patients were not placed on SRP, except to say the unit relied on a verbal report at the time of transfer from one unit to the next.

Patient #1
Patient #1 was admitted on [DATE] with major depressive disorder and bipolar disorder. Patient #1 had a history of inappropriate sexual behavior during previous stays at the facility.

On 11/30/18, the History and Physical and admitting nursing assessment revealed a history of sexual abuse. On 1/11/19, the patient census report revealed Patient #1 was placed on SRP precautions. Patient #1's medical record lacked documented evidence of a Treatment Plan for sexually inappropriate behavior until 1/13/19.


Patient #2
Patient #2 was admitted on [DATE] with self-harm and placed on sexual restrictive precautions. The History and Physical dated 12/10/18 revealed hypersexuality and sexual abuse.
On 12/11/18, a Psychiatrist documented an Initial Psychiatric Evaluation revealing hypersexuality, and a Psychosocial assessment dated [DATE] revealed Patient #2 was acting hypersexual with an admitted history of abuse/exploitation.

On 12/10-11/18, the Nursing Admission Assessment revealed no connection to the patient's hypersexuality and sexual abuse history. The nurse acknowledged reviewing the Psychosocial Assessment. A Nursing Progress Note, dated 12/21/18, showed Patient #2 engaged in inappropriate touching with another patient.

On 12/22/18, an Incident Report revealed staff saw Patient #2 engaged in inappropriate touching with another patient, but Patient #2 denied it.

On 12/24/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate sexual behavior with a second patient. Facility census data showed Patient #2 had a roommate until 12/25-26/18.

On 12/24-25/18, an Incident Report revealed a patient was told by Patient #2 and another patient the two had sex, but when confronted by staff, the two denied it.

On 1/3/19, a Psychiatric Progress Note revealed Patient #2's family member expressed anger regarding the two sexual incidents. The Psychiatrist assured the facility did its best to ensure the safety of every patient.

Patient #2's medical record lacked documented evidence of a Treatment Plan for sexually inappropriate behavior until 1/13/19. The Treatment Plan lacked documented evidence of any updates between the 12/10-18/18 plan goals initiated during the first week of post admission and 1/13/19.

Patient #3
Patient #3 was admitted on [DATE] for major depressive disorder.

On 12/13/18, an Incident Report revealed the patient had sex with another patient from the unit in the bathroom. The patient indicated being the initiator. Patient #3 was not placed on SRP precautions and was was transferred to another unit on 12/17/18.

On 12/17/18, a Nursing Admission Assessment revealed the patient was sexually active and did not practice safe sex.

On 12/18/18, a Psychosocial Assessment revealed the patient's sexual abuse history as a victim. On 12/18/18, the Initial Psychiatric Assessment revealed sexual preoccupation. Patient #3 still was not placed on SRP precautions.

On 12/24/18, a Nursing Progress Note revealed the patient engaged in sexual activity with another patient. An Incident Report dated 12/24/18, revealed the patient had a sexual incident with another patient on the unit.

A Nursing Progress Note dated 12/27/18, revealed the patient had self-harm and a blade was used. The nurse did not find a blade initially. The patient turned the blade in.

On 12/28/18, a Psychiatrist documented a progress note showing awareness of the sexual incident dated 12/24/18. Patient #3 still was not placed on SRP precautions.

On 1/4/19, a Nursing Progress Note showed the patient first threatened and then removed shirt and pulled pants down in class when another patient did not apologize for something. An hour later, the patient received emergency Zydis per protocol for agitation, pacing and verbalizing a desire for sex. Patient #3 still was not placed on SRP precautions.

On 1/8/19, a Psychiatrist documented a progress note. On 1/11/19, a Psychiatric Progress Note showed an increase in medication for persistent sexual urges.

Patient #3's medical record lacked documented evidence of a treatment plan for sexually inappropriate behavior until 1/13/19, after the inspection revealed the treatment team failed to identify the behavior as a problem and update the treatment plan for this problem.

Patient #7
Patient #7 was admitted on [DATE] with recurrent major depressive disorder.

On 12/20/18, a Psychiatric Progress Note revealed patient had a significant history of sexual abuse and neglect. The Psychiatrist did not place Patient #7 on SRP precautions.

On 12/21/18, a Nursing Progress Note showed Patient #7 engaged in inappropriate touching with another patient. Facility census data showed Patient #7 had a roommate and was not placed on SRP precautions.

Patient #7's medical record lacked documented evidence of a treatment plan for sexual abuse history until 1/13/19.

Patient #8
Patient #8 was admitted on [DATE] with bipolar disorder.

On 9/8/18, the initial Psychiatric Evaluation showed Patient #8 had a traumatic victim of sexual abuse history.

The successive Psychiatric Progress Notes highlighted the sexual abuse history, but Patient #8's medical record lacked documented evidence of a treatment plan for sexual abuse history until 1/13/19.


On 1/11/19 from 10:30 AM to noon the Chief Clinical Officer (a Clinical Psychologist) who served on the Med-Executive Committee, Quality Committee and Governing Body indicated the following:

The treatment team designed the full continuum of care. Goals were supposed to be set and individualized at admission with a start date. The target date was set to assess whether the patient accomplished the goal. The treatment team included the Psychiatrist, Medical Doctor, Nurse, Family Members, Patient and Case Worker. The History and Physical was completed within 24 hours of admission. Patients were placed on daily medical log for issues to be seen by a medical doctor. The History and Physical was updated every 30 days. Nurse Practitioners could see patients also. In the Acute Youth unit, patients were seen daily with notes required. The treatment team met weekly. In the PRTF, patients were seen weekly with notes required. The treatment team met monthly. The treatment team discussed the past month. Therapists and nurses were responsible for goal setting/reviewing, usually 7-14 days initially. Incidents of Suicidal Ideation and Sexual Acting Out should have caused the treatment team to have met sooner to revise the treatment plan. Patients were on unit orientation for the first 2 weeks. The Milieu Manager reported to therapy where patients earned levels of privileges: learning, accepting, willing, succeeding. The panel acknowledged the Admission and Referral Assessment at intake and the Nursing Admission Assessment should have screened patients for potential sexual abuse history, sexual acting out or predatory behavior. The panel acknowledged the facility failed to designate/program SRP patients appropriately.

Procedure #1 of the Treatment Plan Acute Inpatient, Psychiatric Residential Treatment policy (1200.9, last revised October 2018) revealed the initial Treatment Plan involved the identification of all medical and biopsychosocial problems and an assessment of the patient's needs.

Procedure #2 of the Treatment Plan Acute Inpatient, Psychiatric Residential Treatment policy (1200.9, last revised October 2018) revealed treatment planning continued with the development of an individualized plan of care for each active problem identified...

The Medical Director was responsible for the clinical operations of the hospital; for improving patient safety; for continually assessing and improving the activities and quality of patient care; for making recommendations to the hospital's administrative staff regarding the planning of hospital facilities, equipment, routine procedures and other patient care matters.

The Medical Director and any Associate Medical Directors appointed by the Governing Board were responsible for the development and implementation of policies and procedures that guide and support the provision of services, and the continuous assessment and improvement of the care and services provided.

The facility's Rules and Regulations above referred to acute care patients, "completing progress notes at least six days per week and other such notes as clinically indicated during the patient's length of stay", the Medical Staff Bylaws and Rules and Regulations lacked documented evidence of provider frequency obligations for patients in the PRTF, since those patients were not considered acute care patients.

2018 Medical Staff Bylaws, Rules and Regulations.
Article IV: Categories of The Medical Staff:
Each member of the medical staff will:
b. abide by the medical staff bylaws, rules and regulations, and by all other hospital and service area standards, policies, rules and regulations.
d. prepare and complete in a timely manner medical records and all other required records of all patients he/she admits or in any way provides patient care services to in the hospital.









































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VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on interview, record review and document review, the facility failed to: 1) Complete medical records in a timely fashion (Tag A0450); 2) document information necessary to monitor each patient's condition (Tag A0467), and ensure a discharge summary was documented (Tag 0468).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory-mandated care to patients.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview and document review, the facility failed to complete medical records in a timely and accurate fashion for 2 of 37 patients (Patient #2 and #9).

Findings include:

Patient #2

On 12/10/18, Patient #2 was admitted with self harm and placed on sexual restrictive precautions.

On 1/7/19, a Psychiatrist entered three visits for 12/28/18, 1/3/19 and 1/7/19, after the inspection was initiated. None of the notes were designated as late entries. The documents were all initiated and time/date stamped on 1/7/19; the software allowed clinicians/providers to manipulate the date by scrolling to the date intended for a past entry.

On 1/11/19 in the afternoon, the Medical Records Director acknowledged and demonstrated the aforementioned entries in the Medical Records Office.

Article IV: Categories Of The Medical Staff of the 2018 Medical Staff Bylaws, Rules and Regulations provided revealed:

Each member of the medical staff will:

b. abide by the medical staff bylaws, rules and regulations...
d. prepare and complete in a timely manner medical records and all other required records of all patients he/she admits or in any way provides patient care services to in the hospital.

Sections of the Bylaws and Rules and Regulations of the Medical Staff tried to distinguish different a frequency obligation on behalf of providers. Although the facility's Rules and Regulations above referred to acute care patients, "completing progress notes at least six days per week and other such notes as clinically indicated during the patient's length of stay", the Medical Staff Bylaws and Rules and Regulations lacked documented evidence of provider frequency obligations for patients in the PRTF, since those patients were not considered acute care patients.




Patient #9

Patient #9 was admitted on [DATE] with diagnoses including ADHD, Bipolar I Disorder, Oppositional Defiant Disorder, posttraumatic stress disorder (PTSD). The patient was ordered precautions and observations including assault precaution, sexual aggressor precaution, and sexual reactive precautions (SRP).

Precautions and Observations included Assault Precaution, Elopement Precaution, Sexual Aggressor Precaution, Attention deficit hyperactivity disorder, Sexual Reactive Precautions (SRP).

An order for observations every 15-minute checks dated 12/10/18, with a start dated of 12/10/18, indicated routine checks. The Treatment plan indicated a frequency of every 15-minute checked as necessary.

An order for observations for one to one with an order entry date of 12/24/18 and a start date of 12/14/18, indicated routine while awake. The Treatment plan indicated a frequency of one to one observations as necessary.

On 01/14/19 in the afternoon, the Director of Medical Records indicated the electronic medical records (EMR) did not include the frequency column when printed out. The Director of Medical Records reviewed the patient's ancillary orders and treatment plan and confirmed the frequency for the 15-minute checks and the one-to one observations were not accurate.

On 01/14/19 at 3:55 PM, a Registered Nurse (RN) indicated a one-to-one observation was exactly what it meant one-to-one. The RN acknowledged a one-to-one observation was not the same as necessary. The RN explained when the treatment plan was done the staff has the ability to choose from a drop-down box to select the frequency and may have selected as necessary. The RN indicated several staff depending on the order had the ability to update the treatment plan. The RN acknowledged the treatment plan did not have the same frequency as the physician order.

A facility policy entitled Levels of Observation -Every (Q) 15 Minute Checks, Policy Number: .24, Revised 1/2017, indicated the Q 15 minute observations/rounds were the minimum level of observation for all patients. Staff observed the patient and documented on the Patient Observation Record q 15 minutes. The staff constantly rounded when patients showered, changed clothes or used the bathroom. The policy included One-to-One Observation (1:1) which indicted a specified and dedicated staff member stayed within approximately one arm's length of the patient on 1:1 observation. This continuous observation continued even when patients showered, changed clothes or used the bathroom.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview and document review, the facility failed to document information necessary to monitor a patient's condition for 6 of 37 patients (Patient #1, #2, #3, #7, #8 and #25).

Findings include:

On 1/10/19 at 1:00 PM, the Unit Manager (UM) verbalized the following: The UM Knew of the two incidents with Patient #3. Patient #3 was previously on another unit before being transferred to the present unit. The UM was unable to answer why unit nurses were not informed or why patients were not placed on SRP, except to say the unit relied on a verbal report at the time of transfer from one unit to the next. Treatment plans were supposed to be updated with new problems/interventions as they presented.

Patient #1

On 11/30/18, Patient #1 was admitted with major depressive disorder and bipolar disorder. Patient #1 had a history of inappropriate sexual behavior during previous stays at the facility.

On 12/12/18, Patient #1 was transferred to another unit.

The Psychiatrist entered progress notes on 12/21/18, 12/28/18, 1/3/19 and 1/11/19.

On 12/12/18, Patient #1 saw a therapist for a Treatment Plan Assessment.

On 1/11/19, the patient census report revealed Patient #1 was placed on SRP precautions.

Patient #1's medical record lacked documented evidence of a Treatment Plan for sexually inappropriate behavior until 1/13/19.

On 1/15/19 at 12:52 PM, Patient #1 verbalized the following: being told two therapists were terminated, and Patient #1 had not received therapy since.

Patient #1's Treatment Plan initiated in December 2018 revealed the following:

Therapist will assist in developing a safety plan.
Therapist will facilitate groups.
Therapist will assist with support and psychoeducation.
Therapist will assist with identifying role of drugs as means of numbing and escaping feelings.
Therapist will assess for patterns of impulsivity.
Client will be referred for psychological testing.

As of 1/15/19 at 1:43 PM with the Medical Records Director present, Patient #1's medical record lacked documented evidence of having an assigned clinical therapist for individual therapy.

Patient #2

On 12/10/18, Patient #2 was admitted with self-harm and placed on sexual restrictive precautions.

On 12/10/18, the History and Physical revealed hypersexuality and sexual abuse. On 12/11/18, a Psychiatrist documented an Initial Psychiatric Evaluation revealing hypersexuality.
On 12/11/18, a Psychosocial Assessment revealed Patient #2 was acting hypersexual with an admitted history of abuse/exploitation.

On 12/21/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate touching with another patient. Facility census data showed Patient #2 had a roommate.

On 12/24/18, a Nursing Progress Note showed Patient #2 engaged in inappropriate sexual behavior with a second patient. Facility census data showed Patient #2 had a roommate until 12/25-26/18.

On 12/24-25/18, an Incident Report revealed a patient was told by Patient #2 and another patient the two had sex, but when confronted by staff, the two denied it.

On 1/5/19, Patient #2's medical record revealed the only documented clinical therapy session for the month of January 2019.

On 1/7/19, the same Psychiatrist entered three visits for 12/28/18, 1/3/19 and 1/7/19, none of the notes were designated as late entries. The documents were initiated, and time/date stamped on 1/7/19; the software allowed clinicians/providers to manipulate the date by scrolling to the date intended for a past entry.

On 1/11/19 in the afternoon, the Medical Records Director acknowledged and demonstrated the entries in the Medical Records Office.

Patient #2's medical record lacked documented evidence of a Treatment Plan for sexually inappropriate behavior until 1/13/19. The Treatment Plan lacked documented evidence of any updates between the 12/10-18/18 regarding treatment goals initiated during the first week of post admission and 1/13/19.

Patient #3

On 12/4/18, Patient #3 was admitted for major depressive disorder.

On 12/13/18, an Incident Report revealed the patient had sex with another patient from the unit in the bathroom. The patient indicated being the initiator. Patient #3 was not placed on SRP precautions.

On 12/17/18, Patient #3 was transferred to another unit.

On 12/27/18, a Nursing Progress Note revealed the patient had self-harm and a blade was used. The nurse did not find a blade initially. The patient turned the blade in.

On 12/28/18, a Psychiatrist documented a progress note showing awareness of the sexual incident dated 12/24/18. Patient #3 still was not placed on SRP precautions.

On 1/3/19, a Psychiatrist documented a progress note.

Patient #3's medical record lacked documented evidence of a clinical therapy visit except for one documented on 1/4/19.

Patient #3's medical record lacked documented evidence of a treatment plan for sexually inappropriate behavior until 1/13/19.

Patient #7

On 12/13/18, Patient #7 was admitted with recurrent major depressive disorder.

On 12/20/18, a Psychiatric Progress Note revealed patient had a significant history of sexual abuse and neglect. The Psychiatrist did not place Patient #7 on SRP precautions.

On 12/21/18, a Nursing Progress Note showed Patient #7 engaged in inappropriate touching with another patient. Facility census data showed Patient #7 had a roommate and was not placed on SRP precautions.

Patient #7's medical record lacked documented evidence of a treatment plan for sexual abuse history until 1/13/19.

Patient #8

On 9/7/18, Patient #8 was admitted with bipolar disorder.

On 9/8/18, the initial Psychiatric Evaluation showed Patient #8 had a traumatic victim of sexual abuse history.

The successive Psychiatric Progress Notes highlighted the sexual abuse history, but Patient #8's medical record lacked documented evidence of a treatment plan for sexual abuse history until 1/13/19.

Procedure #5 of the Initial Nursing Assessment policy (900.51, last revised January 2017) revealed all assessment data would be reviewed by the nurse including the psychosocial and any clinical information from transferring facilities when determining level of precautions required.

Procedure #1 of the Treatment Plan Acute Inpatient, Psychiatric Residential Treatment policy (1200.9, last revised October 2018) revealed the initial Treatment Plan involved the identification of all medical and biopsychosocial problems and an assessment of the patient's needs.

The Medical Director expressed surprise the Psychiatrist previously interviewed indicated there was no discussion regarding late assessment/progress note entries. For months, the Psychiatrist had been on peer review, and the Medical Director decided just last month to continue reviews and re-education of the Psychiatrist.

The hospital Medical Staff Rules and Regulations, dated January 2018, indicated:

Treatment plan: The multi-disciplinary team shall develop an Individual Comprehensive Treatment Plan based on a comprehensive assessment of the patient's needs. This plan will be reviewed at least weekly.




Patient #25

Patient #25 was admitted on [DATE] with diagnoses including Bipolar Disorder, and was discharged on [DATE].

Patient #25 was admitted to the Psychiatric Residential Treatment Facility (PRTF). Psychiatry Progress Notes were documented weekly on 08/01/18, 08/02/18, 08/09/18, 08/17/18, 08/23/18, 08/3 0/18, 09/05/18, 09/11/18, 09/21/18, 09/28/18, 10/07/18, with the exception of when a Nurse Practitioner documented a medical visit on 09/14/18.

On 01/14/19 at noon, the Medical Director described the physician must document a progress note six days a week for any acute patient, and one or two progress notes a week for PRTF or Partial Hospital Program patients. The Medical Director reviewed the frequency of progress notes for Patient #25 and stated they met the Medical Staff Rules as they occurred about once a week, and the patient was admitted to the PRTF.

On 1/15/19 at 9:17 AM, Patient #25's record was reviewed with the Chief Clinical Officer. The Chief Clinical Officer's responsibilities included oversight of therapist services.

The patient's Treatment Plan, initiated on 07/24/18, included a goal the patient would attend individual therapy for 50 minutes per week.

The 09/06/18 Treatment Plan Assessment documented by the Licensed Clinical Social Worker (LCSW), indicated goals to live in a group home. Guardian treatment goal was to get long term treatment for the patient. The Chief Clinical Officer revealed each patient's treatment plan must be assessed and the assessment documented at a minimum every 7 days, or every 14 days for patients housed on the PRTF, by a team consisting of the psychiatrist and the LCSW. The Chief Clinical Officer revealed Patient #25's treatment plan was not assessed until approximately 6 weeks after admission. The Chief Clinical Officer described this interval as unacceptable, and revealed the LCSW was terminated from employment at the hospital on [DATE] for failing to document therapy case notes, and consistently documenting therapy meetings which did not occur. This was discovered during chart audits performed by the Chief Clinical Officer.

The Therapist Initial Contact Note, dated 07/24/18, indicated this was the patient's second time attending the PRTF, with last visit in March 2018. Patient #25 had a history of attempted hanging in March 2018 with a belt. Denied current suicidal or homicidal ideation. The patient stated her goal was to live in a group home and be emancipated.

Therapy Service Progress Notes were documented by the LCSW. There was no note documented between 08/13/18 and 08/29/18, a period of nine days. There was no note documented between 09/26/18 and 10/08/18, a period of 11 days. The Chief Clinical Officer described documentation indicated the patient did not consistently receive therapy in accordance with the treatment plan.

The Therapy Treatment Summary, dated 09/12/18, indicated it was a summary of the patient's course of treatment. The patient was discharged on [DATE], one month after the summary was written. The Chief Clinical Officer verified the Therapy Treatment Summary should be documented at or near the date of discharge, and not in advance, to ensure the information on the Therapy Treatment Summary reflected a summary of all treatment received.

The Discharge Continuing Care Plan, dated 10/12/18, indicated Patient #25 was discharged to a Case Worker for a state agency at 5:47 PM, to go to a group home. Follow up instructions included contacting the hospital Partial hospitalization Program. The plan indicated Patient #25 was admitted and treated at the hospital for Bipolar Disorder and now denied any suicidal or homicidal ideations, and discharge instructions were given and the patient verbalized understanding. The form included areas for a nurse signature, patient signature, physician signature, and Parent/Guardian signature, indicating by signing below, certify the following information has been reviewed with and provided to me: Discharge/Continuing Care Plan including appointment(s), recommendation(s), and medication information including potential drug-drug interactions, food-drug interactions, side effects, adverse reactions, how to administer medications, importance of continuing medication, and how/when to seek out further treatment. A Registered Nurse signed the plan, but there were no signatures for the patient, physician, and Parent/Guardian. The Chief Clinical Officer verified the plan was a document provided to the patient and guardian upon discharge. The form should have been signed by the patient, physician, and Parent/Guardian indicating the instructions were received.

The record lacked documentation of a safety plan, and list of medication the patient was to take after discharge. The record lacked a Therapy Discharge Note. The Chief Clinical Officer stated these elements should have been in the record but were not.

The hospital policy and procedure titled Discharge and Continuing Care Planning, revised 10/2017, indicated at the time of discharge, the licensed nurse completed the discharge instructions and summary, which included a list of medications the patient was to continue on, and upcoming appointments. Once discharge had occurred the discharge note would then be placed in the progress notes. The therapist would complete the safety plan with the patient, and would write a discharge note. The patient would be provided a copy of the safety plan and their discharge plan.

The hospital Medical Staff Rules and Regulations, dated January 2018, indicated:

Adherence to Medical Staff and Facility Requirements -each Attending Medical Staff member on the Active Medical Staff shall attend treatment team meetings conducted concerning his/her patient, and, for acute care patients was responsible for completing progress notes at least six days per week and other such notes as clinically indicated during the patient's length of stay. Medical staff members would document a progress note at least every seven days for patients in the partial Partial hospitalization Program (PHP).

Treatment plan: The multi-disciplinary team shall develop an Individual Comprehensive Treatment Plan based on a comprehensive assessment of the patient's needs. This plan will be reviewed at least weekly. The attending physician/practitioner would be directly and actively involved in the development of the plan and approve it, noting this approval by signing the Master Treatment Plan and Treatment Plan updates.

Care of the Patient - The facility utilizes the team approach in the treatment of patient admitted for care. The core team consists of the attending psychiatrist, the medical physician practitioner, the patient's therapist, nurse, a recreational therapist, and other disciplines, as indicated. The patient's family and others may be included in this process as indicated by the patient's situation and their consent. All team members are responsible for obtaining and communicating pertinent patient information to one another on an ongoing basis and, in accordance with hospital policy and procedure.

The facility policy and procedure titled Information Management Plan, dated 09/2017, indicated the Health Information Management Department was to coordinate all activities relative to documentation, usage retrieval and storage of all medical records generated at the the facility.

Current and accurate medical records:

- served as a basis for planning individual patient care and furnishing documented evidence for the course of a patient's illness and treatment during each hospital admission.

- were the source documents for the analysis, study and evaluation of the quality of care rendered to patients.

Goals included development of complete and adequate medical records, and verify all records are completed within the time frame specified in the Medical Executive Bylaws.


Complaint #NV 540
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure the patient record documented a discharge summary for 1 of 37 sampled patients (Patient #25).

Findings include:

Patient #25 was admitted on [DATE] with diagnoses including Bipolar Disorder, and was discharged on [DATE].

On 1/15/19 at 9:17 AM, the patient's record was reviewed with the Chief Clinical Officer.
The record lacked a physician Discharge Summary. The Chief Clinical Officer described the physician Discharge Summary should be written and included in the record within 30 days of discharge. The patient was discharged about approximately three months ago.

On 01/15/19, in the afternoon, the Medical Records Specialist was unable to furnish the Discharge Summary, and verified the record lacked a Discharge Summary.

The hospital Medical Staff Rules and Regulations, dated 01/2018, indicated to provide information to other caregivers and facilitate the patient's continuity of care, the patient's attending physician must document a discharge summary which included the care, treatment, and services provided, the patient's condition and disposition at discharge, information provided to the patient and guardian, and provisions for follow-up care. The physician must complete the discharge summary within 30 days of the discharge of the patient.

The hospital policy and procedure titled Information Management Plan, dated 09/2017, documented a goal to verify all records were completed within the timeframe specified in the Medical Executive Bylaws.

Article IV: Categories of The Medical Staff of the 2018 Medical Staff Bylaws, Rules and Regulations provided revealed:

Each member of the medical staff will:

b. abide by the medical staff bylaws, rules and regulations...
d. prepare and complete in a timely manner medical records and all other required records of all patients he/she admits or in any way provides patient care services to in the hospital.

Complaint #NV 540
VIOLATION: RADIOLOGIC SERVICES Tag No: A0528
Based on interview, record review and document review, the facility failed to: 1) integrate radiological services into the facility's quality assurance performance improvement (QAPI) program to provide safety for patients and personnel (Tag A0535); 2) provide radiological services which must be provided only on the order of practitioners with clinical privileges or, consistent with State law, of other practitioners authorized by the medical staff and the governing body to order the services (Tag A0539).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory-mandated care to patients.
VIOLATION: ANESTHESIA SERVICES Tag No: A1000
Based on observation, interview, record review and document review, the hospital failed to: 1) establish criteria for the qualifications for the director of anesthesia services, and appoint one individual as director 2) integrate anesthesia service into the facility's Quality Assessment Performance Improvement (QAPI) program 3) develop a policy and procedure to ensure pre-anesthesia evaluations were completed and documented within 48 hours of administration of anesthesia (Tag A1003).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory-mandated care to patients.

Findings:

On 01/11/19, at 7:30 AM, the Electroconvulsive Therapy (ECT) Nurse Manager indicated the hospital performed ECT therapy for inpatients and outpatients. ECT was a treatment for depression which worked by passing electricity into the patient to cause a seizure. The procedure was performed under anesthesia, provided by contracted anesthesiologists. Approximately 10-12 ECT procedures were performed each week. The ECT Director indicated they reported metrics including adverse effects, number of procedures, and any infections resulting from the procedures to the Chief Nursing Officer and the Quality Director.

On 01/11/19 at 8:04 AM, Patient #22 was admitted to the ECT room and placed on a procedure bed. A cardiac monitor, oxygen mask, and pulse oximeter were placed. The Anesthesiologist put Patient #22 under anesthesia by administering intravenous medications. The Anesthesiologist stated the level of anesthesia was monitored anesthesia. The patient's airway was guarded by a positioning and use of a bite block in the mouth. The patient was monitored by the Anesthesiologist throughout the procedure.

On 01/11/19 at 10:15 AM, the Anesthesiologist verbalized being an independent practitioner with privileges at the hospital, along with other independent practitioners. The Anesthesiologists did not recall reviewing hospital policies regarding the provision of anesthesia, and was not sure who was the director of anesthesia services. The Anesthesiologist had not been asked to submit quality measures to the hospital.

A review of the hospital medical staff organization chart, undated, indicated eight anesthesiologists had privileges at the hospital.

The QI and Performance Meeting Minutes from August, November, and December of 2018 lacked documentation information from anesthesia services was brought forward or discussed.

On 01/11/19 at 2:20 PM, the Director of QAPI reported anesthesiology services were not integrated into the hospital QAPI program. The Director of QAPI indicated the ECT Nurse Manager reported adverse drug reactions. Since 2016 there was some data collection but no program in QAPI.

On 01/14/18, in the morning, review of the position descriptions of the Medical Director and the Internal Medical Director indicated no specific responsibilities for planning, directing and supervising the activities of the anesthesia service, or evaluating the quality and appropriateness of anesthesia services provided to patients as part of the hospital's QAPI program.

On 1/14/19 at noon, the Medical Director indicated there was no appointed director of anesthesia and no job description for a director of anesthesia. The Internal Medicine Director was responsible for directing the internal medicine physicians and the anesthesiologists.
VIOLATION: ANESTHESIA RECORD Tag No: A1003
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review and document review, the facility failed to ensure pre-anesthesia evaluations, including development of the patient's plan of care and discussion of the risks and benefits of the delivery of anesthesia, were completed and documented within 48 hours prior to the the delivery of the first dose of medication(s) given for the purpose of inducing anesthesia, for two of two sampled patients receiving Electroconvulsive Therapy (ECT) (Patients #22 and #23).

During an observation on 01/11/19 at 8:04 AM, Patient #22 underwent an ECT procedure with administration of anesthesia.

During an observation on 01/11/19 at 8:29 AM, Patient #23 underwent an ECT procedure with administration of anesthesia.

On 01/11/19 at 1:50 PM, review of the patient records was conducted with the Electroconvulsive Therapy Nurse (ECT Nurse)

Patient #22 was admitted on [DATE] with diagnoses including depression. A pre-anesthesia evaluation, dated 07/11/18, included evaluation of the airway, lungs, heart, medical history, ASA class, and anesthesia plan. The record lacked additional pre-anesthesia evaluations for ECT procedures performed after 07/11/18, or for the procedure performed on 01/11/19.

Patient #23 was admitted on [DATE] with diagnoses including depression. A pre-anesthesia evaluation, dated 12/12/18, included evaluation of the airway, lungs, heart, medical history, ASA class, and anesthesia plan. The record lacked additional pre-anesthesia evaluations for any ECT procedures performed after 12/12/18, or for the procedure performed on 01/11/19.

On 01/11/19, the Electroconvulsive Therapy Nurse (ECT Nurse) described Patients #22 and #23 had undergone multiple serial ECT treatments at the hospital. The process used was the anesthesiologist would complete a pre-anesthesia evaluation prior to the first treatment of a series. For following treatments, usually at two week intervals, the pre-anesthesia evaluation was reviewed by the anesthesiologist immediately prior to the treatment, but not documented unless there were changes.

The hospital policy and procedure titled General Anesthesia Care during ECT, revised 10/28/14, indicated the pre-anesthesia evaluation would be completed and informed consent obtained prior to the first ECT treatment. The policy lacked guidance regarding completing and documenting a pre-anesthesia evaluation and obtaining informed consent for anesthesia within 48 hours of each following procedure in the series.
VIOLATION: OUTPATIENT SERVICES PERSONNEL Tag No: A1079
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the facility failed to ensure the outpatient program had staff to monitor patients for safety and prevent an occurrence of inappropriate sexual behavior between patients (Patient #32 and Patient #31).

Findings include:

Patient #32

Patient #32 was admitted to the adolescent partial hospital program (PHP) on 12/04/18 with diagnoses including attention deficit hyperactivity disorder (ADHD) predominately inattentive type, anxiety disorder, unspecified, and recurrent major depressive disorder. The patient was discharged on [DATE].

An Initial Psychiatric Evaluation dated 12/04/18, documented the patient claimed being abused sexually (touched inappropriately) at a foster home.

A Psychiatric Progress Note dated 12/12/18, documented Patient #32 disclosed that a peer in the program exposed himself to her in the bathroom a week ago.

Patient #31

Patient #31 was admitted to the adolescent partial hospital program (PHP) on 11/30/18 with diagnoses including attention deficit hyperactivity disorder (ADHD) combined, asperger's syndrome, recurrent depression and mood disorder. The patient was discharged on [DATE].

A Psychiatric Progress Note dated 12/05/18, documented Patient #31 was released from the Acute Unit due to impulsive behaviors and safety concerns.

A Treatment Plan Assessment Update dated 12/12/18, documented Patient #31 did not attend PHP treatment or participate in treatment team meeting. The Treatment Plan Assessment Update indicated to continue current medications as prescribed and discharge with outpatient therapeutic referrals for therapy and psychiatric services.

An incident report dated 12/11/18 documented the allegation was reported to the Las Vegas Metropolitan (Metro) Police Department and Child Protective Services (CPS). Both patients were processed with the therapist. All PHP staff were alerted to the incident, advised to be alert for any ongoing behaviors related to the incident, and the patient interactions were to be monitored closely by staff.

The event description documented Patient #31 asked Patient #32 into the restroom saying that it was an "emergency". Once in the restroom Patient #32 was told to close her eyes. When Patient #32 opened her eyes Patient #31's pants was seated on the toilet with pants down exposing self, and asked Patient #32 to touch him.

On 01/08/19 at 10:35 AM, the Director of Outpatient Services explained the patients were monitored by the Mental Health Technicians (MHT's) along with other assigned staff. The staff not leading the group monitored the patients going to the bathroom. The Director of Outpatient Services indicated the staff who escorted Patient #32 did not escort the patient to the adolescent group, but stood at the exit of the program space and did not see Patient #32 go into the restroom. The Director of Outpatient Services disclosed Patient #32 was told by Patient #31 to close her eyes and Patient #31 pulled his pants down. The Director of Outpatient Services indicated a week later Patient #32 told someone when it was time for her scheduled discharge.

The Director of Outpatient Services indicated the MHT's were responsible for running the group. If therapy staff lead the group there were two staff. The Director of Outpatient Services confirmed a MHT lead the adolescent group and no one monitored the patients going to the bathroom during the time the incident occurred.

On 01/15/19 at 5:33 PM, the Chief Nursing Officer (CNO) explained the outpatient area does their own staffing, but MHT's could have been pulled to cover the outpatient area if needed. The CNO indicated the Director of Outpatient Services should have called if additional staff was needed.

The outpatient program lacked staff to monitor patients for safety and prevent an occurrence of inappropriate sexual behavior between patients.